Advancing Community Pharmacy Practice Through Integrated Course Design

by Joseph Nosser, Pharm.D., PGY-1 Community Pharmacy Resident, University of Mississippi School of Pharmacy and Tyson Drug Company

A wise person once told me, “everyone wants progress, but no one likes change.” In recent years, pharmacy benefit managers (PBMs) have repeatedly reduced reimbursement rates to pharmacies.  For many independent community pharmacies, the traditional dispensing-prescriptions-only service model is no longer viable. Clinical services, such as medication therapy management (MTM), chronic care management (CCM), wellness visits, and immunizations can be (and successfully have been) implemented in community pharmacies to diversify revenue streams. Pharmacy students learn about community pharmacy practice through introductory and advanced practice experiences, as required in the 2016 ACPE educational standards.⁴

A wealth of research supports the effectiveness of experiential learning. However, a call to action has been issued to increase community pharmacy practice exposure in the didactic classroom. A 2011 study found that less than 40% of pharmacy students strongly agreed that they received the necessary education to provide clinical services and only 35% felt strongly confident in their abilities to provide these services in a community pharmacy.⁵ While many community pharmacy advanced pharmacy practice experiences expose students to the delivery of quality clinical service, these results suggest that pharmacy students would benefit from additional didactic instruction through an integrated-curricular design.

James Beane, the author of Towards a Coherent Curriculum, compared a traditional curriculum-based education to a jigsaw puzzle.^1,2 Students have traditionally learned in “disciplinary silos”, moving “from one classroom to another, one time-block to another, one textbook to another, and one teacher to another”.^1,2 Like puzzle pieces, each foundational knowledge course and each practical skill that is learned in a practice lab or experiential course contributes, only partially, to the final outcome. No single learning outcome or “puzzle piece” creates the entire picture needed to become an effective health professional. However, when those “puzzle pieces” in a curriculum are connected-together (in a thoughtful way), it can produce the picturesque mosaic that can truly impact real-world practice. Unfortunately, in most curricula, students gather the pieces of knowledge and skills in a “disconnected, fragmented” manner, and often have difficulty connecting those pieces.^1,2 Moreover, learning in this manner can be like assembling an intricate, 1,000-piece puzzle without the container’s display image.^1,2

In recent years, pharmacy schools have worked toward creating integrated learning experiences and facilitating their students’ assembly of the “puzzle pieces”.¹ Pharmacy education has experienced a paradigm shift to this integrated curricular model away from the traditional disciplinary model where each student was responsible for correlating classroom learning with pharmacy practice.¹ For example, pharmacy students are trained to administer immunizations in their first or second year, while learning about the pathophysiology and pharmacotherapy of diabetes mellitus in their second or third year. However, do students connect their knowledge about immunizations and diabetes mellitus when conducting MTM visits at a community pharmacy? An integrated curriculum intentionally creates a learning environment for students to make meaningful connections between their foundational knowledge and real-world practice.¹

Integrated course design generally includes a careful examination of learning goals, learning activities, and assessment/feedback methods. ³ Instructors for an integrated course must account for situational factors, such as class size, students’ knowledge level, and available resources, which can influence each component. Initially, the team of instructors must develop learning goals that define what students should be able to do in order to achieve success. The instructors use the course goals and resources to create activities and learning experiences that correlate with real-world pharmacy practice. Active learning strategies should be emphasized, which may include facilitated group discussions, group projects, and case-based simulations. Instructors use authentic assessments to measure and evaluate student performance, while also allowing students to provide course feedback for continuous improvement.³

A great example of an integrated course was implemented at the University of North Texas College of Pharmacy.  The goal of the course was to improve second and third-year pharmacy students’ knowledge about clinical and business management skills related to community pharmacy practice. This elective course was created by community pharmacy-trained faculty in collaboration with the university’s Center for Innovative Learning, which supports integrated course design in the classroom. The instructors created course learning goals based on the 2012 NACDS and NCPA competencies for community pharmacists.⁴ Moreover, feedback from community pharmacy residency programs guided their focus to emphasize certain clinical services (i.e., MTMs, CCM, immunizations, wellness visits) in the course content.^4,6 Instructors accounted for situational factors (i.e., class size, student’s prior knowledge) to create meaningful learning experiences. This course was offered to students who had previously completed training in point-of-care testing, patient assessment, and counseling during their first-year. The small class-size enabled student engagement and facilitated discussion.⁴ The course activities included a behavioral change assignment, topic discussions with guest lecturers, quizzes, and a group-based business plan proposal.⁴ The instructors used a pre/post survey to measure changes in the students’ knowledge and confidence. There were statistically significant improvements in student knowledge related to the course learning goals.  Moreover, there was a significant improvement in student confidence to perform these clinical services.⁴ Student feedback identified the guest-lecturing community pharmacists as one of the most valuable components of the course, as they shared real-world experiences that connected clinical knowledge and skills with the clinical services provided in their practices. Students also believed that the business plan proposal and behavioral change assignment helped them to develop the skills needed to implement clinical services and motivate patients towards behavioral change.⁴

The integrated course design model is an intentional process that promotes active learning, connecting students’ foundational knowledge from various disciplines with real-life applications.¹ Instructors should assess students’ abilities to connect and use clinical knowledge and skills across disciplinary boundaries, while also using previous knowledge to make new associations.¹ For example, an assessment could include a case-based, simulated MTM activity with a standardized patient.

While integrated course design has many advantages, several limitations for implementing this model have been identified, including the lack of research evidence regarding its effectiveness and the amount of time and resources required to create course content.¹ However, this model offers a promising alternative method bridging foundation knowledge acquisition to real-world applications.  This form of instruction may be especially when teaching students about community-pharmacy-based clinical services. As the scope of community pharmacy practice evolves, pharmacy programs should use integrated course design to prepare students to effectively implement and perform clinical services in the communities they will serve.

References

1. Pearson ML, Hubball HT. Curricular integration in pharmacy education. Am J Pharm Educ. 2012; 76(10): Article 204. Accessed March 7, 2020.
2. Beane JA. Towards a Coherent Curriculum. Association for Supervision and Curriculum Development. 1995. Accessed March 7, 2020.
3. Mantell A, Moore CS, Barnett A, et al. Composing a course for significant learning. Temple University, Center for the Advancement of Teaching. Accessed March 7, 2020.
4. Bullock KC, Horne S. A didactic community pharmacy course to improve pharmacy students’ clinical skills and business management knowledge. Am J Pharm Educ. 2019; 83(3): 6581. Accessed March 7, 2020.
5. Maynard RA, Wagner ME, Winkler SR, et al. Assessment of student pharmacists’ perceptions on participating in clinical services in the community pharmacy setting. Curr Pharm Teach Learn. 2011; 3: 123–136. Accessed March 8, 2020.
6. Schommer JC, Owen JA, Scime GM, et al. Patient care services provided at primary community pharmacy residency sites J Am Pharm Assoc 2013;53:e125–e131. Accessed March 8, 2020.