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Assoc Prof Martin Henman
Trinity College Dublin
Health Outcomes and Social Pharmacy, Belgrade – March 2018
Contemporary Pharmacist Education –
challenges from society and practice to
academia and vice versa
Trinity College Dublin, The University of Dublin
Current issues in Education
Qualifications Framework
Quantification of learning activity
Integrated curricula*
Competency-Based curricula*
Experiential learning*
Interprofessional learning*
Enabling Research, Innovation & Entrepreneurship
Progression/Link to Professional Practice – Continuing
Professional Development
Accreditation & Continuous Quality Improvement
Trinity College Dublin, The University of Dublin
The challenges that Health Care poses for
pharmacists & for education & for societyComplex & interactive
Demand led
Benefits, risks & consequences
Impact on individuals, small groups & society
Changing while delivering
Diversity, vulnerability & rarity
Ever increasing demand & ever decreasing resources
Trinity College Dublin, The University of Dublin
Complex and interactive
Complicated – a lot to know, a lot to do, a lot to monitor
Interactive – each element interacts with others, so changing one, changes others – over time health status changes
Individual – physiology ↔ pathology ↔ pharmacology
psychology
Group – team, small business
Organisation – hospital, Health Service, National Agency
Trinity College Dublin, The University of Dublin
Consequences of complexity
Hard to understand, & hard to predict
Simplification of knowledge may lead to superficial view
– Scientific view vs biomedicalpsychosocial view
– Structure→ Process → Outcome
Distortion & underestimation
– Knowledge changes behaviour
Unintended and unexpected outcomes
– The least worst option
Difficult to explain
Education = Apprenticeship – observing & working for someone
& learning on the job
Trinity College Dublin, The University of Dublin
Learning & Working in pharmacy …separate cultures?
Academic Environment
•Tradition
•Hierarchy
•Regulation
•Divided by academic discipline
•Research-led
•High quality scientists
•Researchers
•Practitioners in waiting
Practice Environment
•Tradition
•Hierarchy
•Regulation
•Divided by profession
•Demand/Service-led
•High quality practitioners
•Manage demand
•Wish lists
4 years of University education + 1 year of practice, with 6 months
in hospital or community
Trinity College Dublin, The University of Dublin
Pharmacy Education & Practice –
separate worldsAll other Health Care Professions integrate in the undergraduate
course
Because separation is the enemy of learning, of high quality health
care & of quality research in health sciences
Academic Workplace Practice
Trinity College Dublin, The University of Dublin
Integration & ProgressionIndependent
practice in a
supervised
environment
Supervised
practice
Talking to
Patients,
Practitioners
Simulation of
practice
Observation of
practice
Novice
Proficient
Year 1 - Novice
Year 5 - Proficient
Trinity College Dublin, The University of Dublin
Curriculum planningReverse engineering
– What Competencies do our students
need?
– What Learning Outcomes will align
with these?
– What Assessment will provide evidence
of those Outcomes?
– What teaching methods can we use to
deliver the content & prepare students
for the assessment?FIP 2016
Trinity College Dublin, The University of Dublin
Competence-based education
Education
Remember
Appraise
Solve problems
Demonstrate Skill
Simulation, time-limited
Assessment
Practice
Apply
Interpret
Resolve unknowns
Judgement
Experiential, open-ended
Performance
What do you want your students to be able to do?
List the competences required.
Trinity College Dublin, The University of Dublin
Example: Competence - Dispensing
Domain 1
1. Obtains individual patient history
1.1 Accesses patient medication records/notes
Behavioural descriptors:
1.1.1. Effectively uses records on pharmacy
computer/patient medical notes/animal records
1.1.2. Obtains copies of records (computer/hard copy) from
other health professionals
Trinity College Dublin, The University of Dublin
Competence & behaviour
• Competence - the skill and
the standard of performance
attained
- Competences - skills
• Competency – behaviour by
which the competence is
achieved
- Competencies – behaviours
- May be core/generic, or
specific/technical
Irish Core Competency Framework for Pharmacy
6 Domains → 25 Competences → 177 Behaviours!
Trinity College Dublin, The University of Dublin
Learning & Working…different cultures?
Undergraduate Learning
Environment
Peer contact
Defined curriculum
Tutor Access
Regular Appraisal
Guided study
material
Learning
Support
Employees learning in the
workplace
Individualised
Curriculum
Limited Tutor
Support
Infrequent
Appraisal
Unable to identify
learning needs
Limited
Opportunity to
learn
Academic Competences Practice Competences
Competency Framework
Teacher- Practitioner
Adapted from G. Davies
Academic Environment
Tradition, Hierarchy, Regulation
Research-led
Practice Environment
Tradition, Hierarchy, Regulation
Demand/Service-led
Trinity College Dublin, The University of Dublin
Pharmacists’ roles
• Securing & providing medicines & medical devices
• Improving medicines use
• Contribute to health & wellbeing policies
Pharmacists can connect directly to patients in familiar roles
Pharmacists’ contribution to the health system can be increased by changing pharmacists’ roles and the way pharmacists work
To do this, Pharmacy education and Pharmacy Practice must change together
– And the health system itself must be changed
Trinity College Dublin, The University of Dublin
Medication-related Skills
Main Activities
•Counselling patients receiving prescription medicines
•Responding to requests for non-prescription medicinal products
•Responding to symptoms
Additional Relevant Knowledge & Skills
•Dispensing, Prescriptions & Medicines supply schemes
•Communications skills
Trinity College Dublin, The University of Dublin
Medication Related
Consultation FrameworkAbdel-Tawab R, et al, Patient Education
& Counselling 2011 Jun;83(3):451-7.
Sections of a consultation Aims of sections
(A) Introduction “To build a therapeutic relationship with the patient”
(B) Data collection &
Problem Identification
“To identify the pharmaceutical needs of the patient”
(C) Actions & Solutions “To establish an acceptable management plan with the patient”
(D) Closing “To negotiate safety netting strategies with patient”
“natural flow of a consultation”
Trinity College Dublin, The University of Dublin
Medication Related Consultation Framework
Abdel-Tawab R, et al, Patient Education &
Counselling 2011 Jun;83(3):451-7.
Trinity College Dublin, The University of Dublin
Researching more into the Consultation
Our review suggests that sound medication therapy decisions cannot be made without
good insight and attention to Patient Lived Experience with Medicines.
Hence, actively exploring and engaging PLEM when making therapeutic decisions may help
provide individualised care. Mohammed MA, Moles RJ, Chen TF. BMJ Open 2016;6:e010035. doi: 10.1136/bmjopen-2015-010035
Trinity College Dublin, The University of Dublin
Experiential education
• Supervised, structured or semi-structured teaching and
learning activities that take place in a practice setting
• Part of curriculum, and so each placement is responsibility of
University
• Real-life situations and inter-personal interactions with
patients, caregivers
• And with other health professionals
• Work-based learning, Practice-based learning
Education is not an Apprenticeship – observing & working for
someone & learning on the job
Trinity College Dublin, The University of Dublin
Clinical settings for Experiential
Community pharmacies
Hospitals
Nursing/residential homes
Compared to University
Governed by specific rules & norms
Clinical staff – hierarchy & teams
– Setting specific
– Variable range of responsibilities
Teacher-practitioners
Preceptors & Tutors
Krk
USA
TCD
Trinity College Dublin, The University of Dublin
Simulation: learn skills effectively
& without risk to prepare for Experiential- Simulation is a technique, not a
technology
- Replicate elements of practice
- Fully interactive
- Recorded by observation or video
- Allows practice, learning from
mistakes
Therefore simulation is a valuable prior
requirement to Experiential learning.
At each stage of development.
Allows Peer review.
Assessment e.g. Objective Structured
Clinical Examination
Pharmacy – Trinity College Dublin Non-prescription stock shelves (right), EPOS system(centre), General sale stock shelves (left), Dispensary (rear)
Laerdal – UDLA, Santiago, Chile
Trinity College Dublin, The University of Dublin
P/O/C are not equivalent to Experiential
Pharmacist Practitioners lecturing in College
Useful, but it is not practice
Patients lecturing is more valuable
Observation
Visiting a pharmacy is a useful precursor but not a substitute
– aims, objectives & outcomes are required
Clinical visits
Often used to mean any relevant experience
Settings such as regulatory bodies, health service management or even some
industrial practice
Providing the scope of activities, required supporting knowledge and skills
and the need for professional judgement are clearly evident
Trinity College Dublin, The University of Dublin
Experiential learning
Active, focussed process in a prepared environment
Knowledge is ‘apprehended’ (captured) by student
Nor is Experiential simply about being there, or being there and
doing
Thinking & talking about experience may also lead to learning
And the experience of their peers in same/similar setting is
credible & useful
Sofia
Ljubljana
Trinity College Dublin, The University of Dublin
ObservationA crucial skill with people who are unwell
Observing, noting & integrating all of the sensory &
factual information during an encounter, particularly
the unusual – useful skill for clinician and scientist
Observation as a Novice & as one who is Proficient
What is going on here?
What is different about this situation?
What can I see, as opposed to, what am I supposed to
be looking for?
Trinity College Dublin, The University of Dublin
Learning OpportunitiesTaking a patient history – patient’s attitude to medicines
Communication skills - from basic to empathy
Drug-Related Problems – Actual vs Potential
Making decisions on balance of available information
Benefits & limitations of guidelines
Pharmacists’ roles (services)
– Leading Practitioners
Concrete situations in which the evidence base is poor, lacking or contradictory
Tirana
Trinity College Dublin, The University of Dublin
Professional work environmentStudents’ must present their knowledge, make
recommendations to others
They must work with less qualified but more
knowledgeable people
They must meet not only academic standards,
but also professional practice, follow workplace
procedures, co-ordinate with others, account for
their actions
Appreciation of the environment & of meeting
patients helps students learn from the
experience of others
Students bring new ideas & energy
Trinity College Dublin, The University of Dublin
Who can cross from one side to
the other?
Undergraduate Learning
Environment
Peer contact
Defined curriculum
Tutor Access
Regular Appraisal
Guided study
material
Learning
Support
Workplace learning
Individualised
Curriculum
Limited Tutor
Support
Infrequent
Appraisal
Unable to identify
learning needs
Limited
Opportunity to
learn
Academic Competences Practice Competences
Preceptor-Tutor
Teacher- Practitioner
Adapted from G. Davies
Trinity College Dublin, The University of Dublin
Preceptors – Tutors & Teacher PractitionersPersonal expertise & experience
Help to ‘define’ and map competencies
How is the role defined?
Context & significance of generic competencies
When & which specific competences are required
– Particular combination of generic & specific competences
Experiential learning - identification of and access to opportunities
Practicalities of teaching & learning of specific activities
Pragmatic assessment & evaluation
Training & support of Preceptors/Tutors is essential
Measuring
Evaluation Assessment
The process of gathering and discussing information from multiple and diverse sources in order to develop a deep understanding of what students know, understand and can do with their knowledge as a result of their educational experiences.‒Huba and Freed, 2000
The systematic process of
determining the merit, value,
and worth of someone or
something (such as a product,
program, policy, procedure, or
process).
Evaluation Glossary (n.d.) from Western Michigan
University, The Evaluation Center Web site
Trinity College Dublin, The University of Dublin
Aligning the processes of
education to the practice setting
Interprofessional learning
Experiential learning
Simulation
Methods of measurement
Types of Assessment
Competency framework
Trinity College Dublin, The University of Dublin
Preparing for Learning in PracticePractitioner
Demands of learning •Balance work & life responsibilities with learning
•Adaptable & continuous
Role of mentor • Guide & support learning• Assess
Professional & personal life experiences
• Make connections with & between experiences
• Acknowledging, accepting, revising
Purpose for learning • Competence • Capability to deal with uncertainty• Coping with acute, serious events
Permanence of learning • Self-initiated • Long-term
Adapting Knowles’ Learning Theory
Trinity College Dublin, The University of Dublin
Supervision & Questioning aligned
to level of student development
Supervision Level of development Questioning
S1 Coaching & directing Incompetent –
unconsciously or
consciously
What?
What – Remember
Why - Understand
S2 Supporting Consciously competent So what?
Which… - Apply
What do you think
about… - Analyse
How will this affect…
S3 Delegating Unconsciously
competent - Intuitive
Now what?
Evaluate…
Develop… - Create
Barnum, Guyer, Levy & Graham,
2009
Howell & Fleischman, 1982 Barnum, 2008; Bloom’s taxonomy
Trinity College Dublin, The University of Dublin
Feedback- assessed against validated criteria
Confirming/Reinforcing
– Let student know they are doing something well
– Reinforce appropriate behaviours
Corrective
– Modify or improve behaviour to more appropriate form
– Prevent students developing incorrect techniques or accepting inaccurate evaluations/statements
Guiding
– Help student by making clear, suggesting improvements, refinements
Nottingham & Henning, 2014
• Timing
• Specificity
• Content
• Form
• Privacy
Nottingham & Henning, 2014
Trinity College Dublin, The University of Dublin
Interprofessional Learning &
Collaborative practice • Service provision
delivered by multidisciplinary teams with emphasis on health promotion, preventative services and chronic disease management
• The multidisciplinary nature of these services will necessitate health care professionals working together in a more integrated way than ever before WHO 2010
Trinity College Dublin, The University of Dublin
Learning together to work together
Overcoming the problem of education in silos
Accreditation and regulatory bodies require evidence of IPL in professional courses
Developed with collaboration from across the faculty and clinical partners
Refined in response to student/facilitator feedback following workshops
Based on constructivist learning theory
..…..that is students build new knowledge based upon the learning they achieved together
Workshops designed to
facilitate skills and attributes
desirable in health
professionals
Trinity College Dublin, The University of Dublin
Student evaluationsProfessional identify
“Even though I thought I had a good understanding of the disciplines I learned a lot about everyone’s individual roles” Medical student
“Found the session very useful in developing MDT relationships, learning various roles and showing your area of expertise.” Physiotherapy student
Collaboration and teamwork
“It was a great learning experience. Also brought up questions for me about how to explain things that SALT (Speech and Language therapy) do. Helped me try and be concise and to summarise and be relevant with my information” SALT student
“Good insight into the role of other professionals and encourages respect and admiration of the integral and important work other professionals do” Pharmacy student
“Workshops were great and consolidated a lot of things for me. Disheartening however when some group members did not prepare or seem to interact enough” OT student
Trinity College Dublin, The University of Dublin
Interprofessional Learning & ReFEEHSIPL is difficult because, in most countries, the Health Professions
have not agreed what Inter-Professional Practice or
collaboration are – we just look at the clinical outcome
Each profession has not yet addressed this because within each
one the range of views is wide and some are irreconcilable
A national consensus would enable a competency framework to
be developed, but we cannot wait for this
We need to look at standardised patient scenarios in which both
teams and individuals are assessed
We need to consider how more IPL can be introduced
And how it can be delivered in the periods of Experiential
Learning
Trinity College Dublin, The University of Dublin
Stakeholders in Pharmacy Education
In Health Sciences, the technicalities of assuring the quality of the
education are overshadowed by one primary objective, patient safety
Trinity College Dublin, The University of Dublin
Increasing complexity of Health Care
leads to ever increasing demand for
ever decreasing resourcesDemand
– Increased capability
• New knowledge
• New investigative capabilities
– Prevailing attitudes & values
• Political imperative
• Social acceptability
Resources
– More to be done
• More complicated things to be
done
– More people to do it
• More people paid less
• Higher salaries for those paid
more
• More supports & support
people
Trinity College Dublin, The University of Dublin
Consequences of increasing demand and
decreasing resources
Doing more with less – becoming Lean
Using resources to assess costs, benefits, to find inefficiencies
Increasing difficulty of managing
– Current expenditure & budget
– Capital/Investment resources
Alternate facts
Poor Practice
Trinity College Dublin, The University of Dublin
As an individual, I may not be
able to change the System but…Performance
– Do our best, in our setting
– Effective, safe & responsive to patients’ needs and wants
Continuing performance
– Address all of the essential roles that comprise the current scope of
practice of pharmacy & pharmacists
– Meet external standards
– Demonstrate both of the above for each new role/service that is
incorporated into the scope of practice
– Argue, based on the above for the resources to do more
Trinity College Dublin, The University of Dublin
4
4
ReFEEHS ongoing work
Momentum generated by;
– Reform of Higher Education in Serbia.
– International Bologna conferences.
– Erasmus Plus and Tempus Programmes
– Support from Public Health Institute of Serbia
– Networking of Teaching and Learning Competencies
– Postgraduate Cert/Diploma and MA in Teaching and Learning in Higher Education
Maintaining the Momentum;
Make a start with like-minded people.
Keep it simple, at first.
Academic & Pharmacy staff training is the key.
Provide support to all staff.
A team effort.
Trinity College Dublin, The University of Dublin
Education has an impact on Practice
and vice versa
Re-configuration of the curriculum
– Via simulation/action, reflection, patient impact, collaboration
– Nowhere has achieved perfection
Maximising learning opportunities in Practice
– Types of knowledge & settings for learning
– Learning outcomes & assessment
– Reflection & continuous improvement
Re-envisioning of pharmacy
– Academic & Practice pharmacists focussed on providing high quality care
– Meeting needs of patients
– Meeting the needs of pharmacists