Key Elements to Consider When Developing Interprofessional Education Experiences

by Chase Board, Pharm.D., PGY1 Community Pharmacy Resident, University of Mississippi School of Pharmacy

My pharmacy school’s curriculum required each student to participate in one interprofessional education (IPE) training session and to write a self-reflection on the experience.  My IPE session occurred during my third year.  Working in a group with nursing and osteopathic students, we were tasked to provide an assessment and develop a treatment plan for a patient case scenario.  The instructors prefaced the activity to encourage us to focus our communication and teamwork skills.  For me, it seemed we struggled to find any purpose in learning how to work as a team.

The Joint Accreditation of Interprofessional Continuing Education defines IPE as events “when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”¹  Highly effective interprofessional teams can improve health outcomes by enhancing the quality of patient care, reducing medical errors, reducing the hospital length of stay, and lowering medical costs.²  In a crossover study evaluating the quality of written transition plans for patients within a healthcare delivery system, treatment plans written by healthcare professionals who collaborated as a team correlated to stronger work quality when compared to healthcare professionals who did not actively collaborate together.³

Thanks in part to this growing body of literature, many academic institutions are implementing IPE.  Indeed, the Accreditation Council for Pharmacy Education (ACPE) requires all colleges/schools of pharmacy to implement IPE in their curricula.  In a January 2018 update, the ACPE Board of Directors clarified guidance to schools of pharmacy curriculum to include IPE experiences involving prescribers, specifically physicians and medical students, in didactic and experiential courses.⁴

Preceptors at the University of Wisconsin-Madison School of Pharmacy implemented IPE with a “dual identity” design.5  Their program trains students to become traditional pharmacists, but they integrate interprofessional learning and socialization with other healthcare disciplines.  The program offers elective experiences allowing students to volunteer at a student-run clinic.  These opportunities allow students to learn and apply interprofessional skills such as cooperation, communication, and coaching.  The aim is to prepare students for their fourth-year Advanced Pharmacy Practice Experiences (APPE) and graduate “career-ready, collaborative pharmacists.”⁵

Preceptors should structure their IPE experiences based on the four core competencies outlined by the Interprofessional Education Collaborative (IPEC).  IPEC is composed of 21 national associations representing nearly all health professions educators, including the American Association of Colleges of Pharmacy (AACP).  IPEC serves to promote and advance the efforts of interprofessional learning experiences.  The recommendations provided by IPEC focus on four core competencies:⁶

1.   Values/Ethics for Interprofessional Practice

Team members should have mutual respect and shared values. This is a cornerstone of effective collaborative practice.

2. Roles/Responsibilities

Individuals should use their knowledge in collaboration with the other members of the team to address patient health care needs.

3. Interprofessional Communication

Team members should promote and maintain the health of their patients by engaging in effective team-based communication.  They should direct their dialogue towards the patient, the patient’s family, other members of the health care team, and the community.

4. Teams and Teamwork

Teams should discuss relationship-building values and team dynamic principles to plan, deliver, and evaluate patient care.

 

For example, during a fourth-year APPE, I served as a facilitator in a structured IPE experience.  Groups of pharmacy, nursing, and osteopathic medicine students were assigned to review a patient case, communicate electronically, and attend a face-to-face session.  The face-to-face activity was intended to simulate an actual patient encounter.  My role as an IPE facilitator was to observe each team during the simulation and record comments based on my observations. I was provided a rubric to assess IPEC core competencies such as communication, professionalism, roles/responsibilities assignments, and team cohesiveness.  At the end of the simulation experience, groups received feedback regarding the written progress notes and electronic communication.  They were asked to write self-assessments based on their individual and team-based performance. I believed this activity represents a good example of how to structure an IPE experience.

There are many assessment tools available to evaluate IPE experiences. When structuring an IPE experience, it is important to identify the type of tools available, as well as determine which tools are most effective.  The Committee on Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes suggests IPE experiences should utilize a mix of qualitative and quantitative assessment tools to evaluate outcomes.  Implementing only one methodology does not fully explore and capture the data that can be obtained by a mixed-methods approach.  A mixed-methods approach can provide insight into both the “what” and “how” of IPE interventions and outcomes.⁷

When selecting tools to use for IPE assessment, the assessment tools should measure attitude, behaviors, knowledge, and skills.⁸ This aligns with the IPEC four core competencies (values/ethics, roles/responsibilities, interprofessional communication, and teamwork).  The IPE experience I helped facilitate during my fourth-year APPE used three assessment tools to evaluate attitudes, perceptions, and behavior.⁸ Assessment tools like these can be found on the National Center for Interprofessional Practice and Education website.

Preceptors should role model effective interprofessional collaboration as a strategy to teach pharmacy students appropriate behavior to uphold during IPE experiences.  Including activities in a rotation whereby students observe and reflect properties can help them develop conscious behavior.⁹  Some strategies preceptors should use include being self-aware of being a role model, reserving time for discussion with students, facilitating reflection on the experiences, and explicitly communicating what is being modeled for the student.¹⁰

I’ve had the opportunity to role model for students at a local free clinic during my residency training.  A medical student was consulted to counsel a patient who was starting insulin therapy.  The medical student said they were struggling to remember subcutaneous injection technique.  I reviewed the proper insulin injection technique with her. Feeling more competent, the student counseled the patient and returned to me to reflect on her experience.

Functioning effectively on an interprofessional team is important.  Thus, we need to teach these skills to students while they are in school.  IPE experiences should be linked to the four IPEC core competencies. When developing IPE assessment, teachers should use quantitative and qualitative methods to evaluate student performances and experiences.  Role modeling can be used by facilitators and preceptors to demonstrate what effective behavior looks like in collaborative practice.

References

1. Definitions. Joint Accreditation Interprofessional Continuing Education website. 2019. Accessed May 15^th, 2019.
2. Buring SM, Bhushan A, Broeseker A, et al. Interprofessional education: definitions, student competencies, and guidelines for implementation. Am J Pharm Educ. 2009;73(4): Article 59.. Accessed May 15^th, 2019.
3. Farrell T, Supiano K, Wong B, Luptak M, Luther B, et. al. Individual versus interprofessional team performance in formulating care transition plans: A randomised study of trainees from five professional groups. J Interprof Care. 2018;32(3):313-320.
4. Clay Kirtley J., Vlasses P. ACPE Update – 2018. Oral Presentation at: American Pharmacists Association Annual Meeting; March, 2018. Nashville, TN. Accessed May 16^th, 2019.
5. Gerhards K. PharmD Program Strengthens Interprofessional Education. University of Wisconsin-Madison School of Pharmacy’s website. 2018. Accessed Mary 17^th, 2019.
6. Interprofessional Education Collaborative. Core competencies for interprofessional collaborative practice: 2016 update. 2016. Washington, DC: Interprofessional Education Collaborative. Accessed May 19^th, 2019.
7. Chapter 5: Improving Research Methodologies. Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. Washington (DC): National Academies of Science. Published December 2015. Accessed May 19^th, 2019.
8. Shrader S, Farland M, Danielson J, Sicat B, Umland E. A Systematic Review of Assessment Tools Measuring Interprofessional Education Outcomes Relevant to Pharmacy Education. Am J Pharm Educ. 2017;81(6): Article 119. Accessed May 19^th, 2019.
9. Cruess S, Cruess R, Steinert Y. Role Modelling – making the most of a powerful teaching strategy. BMJ. 2008;336(7646):718-721.

Assessing Students on Advanced Pharmacy Practice Experiences

by Taylor Loper, Pharm.D., PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-North Mississippi

One thousand, four hundred and forty. That’s the minimum number of Advanced Pharmacy Practice Experience (APPE) hours the Accreditation Council for Pharmacy Education (ACPE) mandates a pharmacy student receive before they graduate.¹  Over the course of at least thirty-six weeks (and sometimes more), these students are exposed to a variety of practice settings, institutions, and situations designed to support the development of their knowledge, skills, and abilities.  Essentially, their competence to practice as a pharmacist following graduation. The ACPE Standards state that the APPEs should be designed to “hone practice skills, professional judgment, behaviors, attitudes and values, confidence, and sense of personal and professional responsibility.” Schools are also required to have a formal assessment of the achievement of APPE competencies using validated assessments. Student performance must be documented at key time points throughout these experiences.

https://pharmacy.uiowa.edu/students/academic-programs/doctor-pharmacy/pep/appe

The CAPE educational outcomes developed by the American Association of Colleges of Pharmacy (AACP) are a set of goals that all pharmacy curriculums should be focused on achieving. These educational outcomes are linked to Entrustable Professional Activities (EPAs) that all pharmacy graduates should be able to perform.² (For more on EntrustableProfessional Activities, see the post by Andrew Mays) Students should have ample opportunity to practice these activities become proficient, and demonstrate mastery before becoming licensed pharmacists. This can be problematic in that the heavily didactic nature of the first three years of the pharmacy curriculum results in few opportunities to practice these EPAs.  Too often students are often being assessed before they have an opportunity to master the EPAs during APPE rotations.

Reflecting back on my experiences as a pharmacy student, the assessment of learning on APPE rotations involved a series of assignments that had to be completed by the end of the rotation.  An example of this would be a set of questions asking you to reflect on interprofessional teams and the benefits of working with different professions at your current practice site. While most assignments were site-specific, several (like the one above) were repeated for multiple rotations. Additionally, specific objectives were set forth and students were asked to provide evidence of assignments or activities they completed that enabled them to meet those objectives. An example of this would be to “evaluate and interpret patient data.” A student could then provide details of working patients up, reviewing medical records, or conducting patient interviews. This gave students an opportunity for reflection while providing concrete examples of progress that the APPE preceptors could then base their end-of-rotation evaluations on. However, completing these assignments and documenting these examples was often time-consuming. By the final APPE, they felt cumbersome, especially the assignments that we had to repeatedly do on multiple rotations.

This process of assessing student performance raises several questions. First, how do we ensure each student meets the required competencies for each rotation? With practices settings and sites varying significantly, assessing each student on basic competencies can be difficult. Moreover, different preceptors have different expectations. All this variability makes it very difficult to create a consistent assessment process that is not dependent on the student’s learning experiences. Second, how do we assure an assessment tool can be applied in a variety of APPE rotations without omissions or redundancy? Requiring the same assignments and reassessing the same set of skills for a student who is taking two community rotations puts a strain on the student and preceptor. But we must find a way to ensure the student is developing on each rotation. Finally, how do we measure competency, such as the EPAs?  Should be rated “acceptable”?  Or “completed”? Should a student be required to “complete” them by the end of each APPE or by the end of all APPE experiences?

Several institutions have tried to address these questions. The System of Universal Clinical Competency Evaluation in the Sunshine State (SUCCESS), is an internet-based APPE assessment tool created by the colleges/schools of pharmacy in Florida.³ Under this system, preceptors rate students as “excellent”, “competent”, or “deficient” for each competency at the end of each APPE. They are also allowed to select “no opportunity” if not observed. These ratings were then converted by the school to determine the student’s grade.  There was a correction factor for students that were earlier along during their APPE schedule. It also allowed preceptors to weigh each competency based on importance and frequency in the practice setting / site. This weight provides preceptors the ability to focus on the learning goals that are most relevant. Another such tool was created by faculty at the University of Colorado Skaggs School of Pharmacy after the addition of 14 ability-based outcomes to their curriculum.⁴ By polling current preceptors, they were able to determine which competencies and outcomes were frequently observed and how important they are to the success of students on each APPE. These responses were used to create APPE-specific tools to ensure students met rotation goals that aligned with the ability-based outcomes of the curriculum.

It’s clear that assessing the performance of APPE students is a crucial, yet complex, task. Based on the two methods documented above, implementing an effective evaluation method requires the active participation of preceptors in developing a tool that is specific to each APPE experience. Preceptor evaluations of students need to be specific to the setting and site but must also relate to the overarching ACPE standards and ACCP outcomes.

I believe that monthly preceptor evaluations of students and their progress toward or achievement of learning objectives are necessary to ensure each APPE experience is helping to develop the student’s competence. However, rather than completing a series of monthly (and sometimes redundant) assignments, a series of unique assignments completed over the ENTIRE year coupled with specific ability-based assessments might be a better strategy.  This can reduce assignment fatigue and still provide appropriate documentation that each student can competently perform the EPAs and other educational outcomes before they graduate. It would great to see some research to determine the validity of this approach.

References

1. Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (Standards 2016). 2015.
2. Haines ST, Pittenger AL, Stolte SK, et al. Core Entrustable Professional Activities for New Pharmacy Graduates. Am J Pharm Educ. 2017; 81(1): Article S2.
3. Reid LD, Nemire R, Doty R, et al. An Automated Competency-Based Student Performance Assessment Program for Advanced Pharmacy Practice Experiential Programs. Am J Pharm Educ. 2007; 71(6): Article 128.
4. Gilliam EH, Brunner JM, Nuffer W, et al. Design and Content Validation of Setting-Specific Assessment Tools for Advanced Pharmacy Practice Experience Rotations. [published online ahead of print March 6, 2019] Am J Pharm Educ. Article 7067.