Advanced practice pharmacy experiences (APPE) in psychiatric pharmacy
Advanced practice pharmacy experiences (APPEs) are the foundations upon which pharmacy students develop the skills to apply the knowledge gained from their didactic courses. This article describes the APPEs in psychiatric pharmacy that are offered at the Purdue University College of Pharmacy.
Advanced practice pharmacy experiences (APPEs) for pharmacy students are the foundations upon which students build application skills drawn from their didactic learning. Each rotation practice site is unique in the opportunities that it can provide for the student, and this is often based upon the rotation preceptor and his/her engagement with the student. Pharmacy students may learn the most from preceptors who are active in their practice and provide the student with appropriate learning opportunities that enhance their understanding of the environment. In the area of psychiatry, students often gain didactic knowledge during therapeutics courses or elective offerings, but may commonly feel intimidated both by psychiatric drugs and the patient population. For the APPE that I primarily precept, I have found it useful to assign projects that allow the student to make independent content choices based upon their interests in psychiatry or neurology, but not be excessively time-consuming so that the student has a significant portion of the APPE for patient and health care team interactions. Improving their comfort level in talking to patients with psychiatric disorders and gaining confidence in the provision of pharmacy education for these patients, along with increasing drug knowledge and application, is my goal for the students completing my APPEs. I offer both introductory and advanced practice psychiatric pharmacy electives in the Purdue University College of Pharmacy didactic curriculum, so I require students who are assigned to these APPEs to have completed at least the introductory course, with students who take the advanced practice course having priority.
APPE: INPATIENT PSYCHIATRIC PHARMACY
The APPE in inpatient psychiatric pharmacy at Wishard Health Services in Indianapolis, IN is based in a teaching hospital setting with a treatment team consisting of a psychiatrist, psychiatric pharmacist, nurses, case managers, psychiatry residents, and medical and pharmacy students. The pharmacy student is engaged in the treatment team very early in the APPE. I have a co-preceptor, which gives the student the advantage of learning from two different psychiatric pharmacists. Students are engaged on the inpatient psychiatric unit for approximately 75% of the APPE time: walk rounds (25%), table rounds (25%), medication reconciliation (10%), patient assistance programs (5%), and patient education (10%) for our underserved patient population. Schizophrenia, mood disorders, substance dependence, and personality disorders are well-represented in our patient population. Students are required to review their therapeutics and elective course notes prior to starting the APPE; they are also required to complete a 40-question short-answer quiz at the beginning of the APPE to identify any gaps in basic knowledge and provide areas to focus on during the APPE. Required projects for preparation and presentation by the student include one journal club, one topic discussion, and one formal presentation. Topic discussions led by the preceptor(s) and/or pharmacy residents on the APPE at the same time are scheduled throughout the rotation. Students also have the opportunity to observe patient groups, family meetings, and commitment hearings. For each APPE, Purdue requires (at a minimum) a mid-point and final formal evaluation of student performance; informal feedback is provided to the student at varying times during the APPE. Students are relatively independent, allowing them time to engage with patients and the treatment team, with mentoring provided by the preceptor during table rounds, topic discussions, and presentations.
APPE: OUTPATIENT PSYCHIATRIC PHARMACY
The practice site for this APPE is the Prevention and Recovery Center for Early Psychosis at Midtown Community Mental Health and Wishard Health Services. APPE students see patients with the clinical pharmacist preceptor, either for pharmacy intakes or medication management follow-up appointments. The clinical pharmacist provides services under collaborative practice; pharmacy students are able to observe independent pharmacist practice, including medication initiation and discontinuation, dose changes, laboratory monitoring, mental status exams and suicide screenings, and the provision of patient education. Concepts of motivational interviewing are used, allowing the student to see firsthand the value of encouraging the patient to evaluate their perceptions of their illness, available treatments, side effects, and the effect of their illness and treatment on their quality of life. Medication adherence is also discussed with patients, along with engagement in treatment. Outpatient APPE students are assigned the same projects as the inpatient APPE students, with presentations occurring for inpatient and outpatient students together. Because this is an early psychosis patient population, the age of the patient is generally similar to that of the student; I ask students to reflect upon the impact that schizophrenia or a psychotic disorder would have on their life and to translate that reflection to the patients we see. APPE students are also exposed to clinical research. Students attend both clinical and research meetings and are able to observe the process used to review patient research charts, as well as build knowledge regarding rating scales and blinding procedures used in the clinical research setting. Formal performance evaluations are done at the mid-point and end of the APPE, with informal feedback provided as needed. Students are also engaged in clinic projects that are ongoing, including metabolic monitoring, use of antihypertensives, metformin, topiramate, and statins, if needed. Literature evaluation and development of treatment algorithms for the clinic are also performed. Psychiatry residents from the Indiana University Department of Psychiatry are often rotating through the clinic and allow pharmacy students to see patients with them to improve pharmacy student knowledge of the patient evaluation and follow-up management processes.
APPE: AUTISM CAMP
The Autism Camp APPE offered at Purdue for pharmacy students requires the student to spend 2 weeks in a residential camp, 1 week of focused time with the pharmacist preceptor, and 1 week off. The APPE is offered in conjunction with the Indiana University School of Nursing and Riley Hospital for Children. Pharmacy students are required to have completed the advanced practice psychiatric pharmacy elective at Purdue, as well as be approved by the preceptor. The individual student schedule for each week is determined by the camp schedule and the number of students who have been assigned to the APPE. It is an intensive APPE occurring in June each year. In June 2012, 6 students were assigned and separated into two groups of 3 students each (See Table I).
INTENSIVE WEEK WITH PRECEPTOR AT WISHARD
Students are required to prepare and present three projects during this intensive week, the same projects as required of inpatient and outpatient APPE psychiatric pharmacy students (i.e., one journal club, one topic discussion, and one formal presentation), but with a shorter focused time to complete them. The focus of each of the projects is autism, developmental disabilities, or physical disabilities that can accompany developmental disabilities.
RESIDENTIAL CAMP
Students live at the camp with the campers; they are camp counselors with assigned cabins and general camper responsibilities. Pharmacy students are also required to work with the camp nurse (generally IU School of Nursing faculty) and nursing students on the first day of camp to generate medication lists from parents/guardians, verify correct medication strength and directions, verify correct drug, separate medications into camp cabin totes, and set up medications for administration throughout the camp. Pharmacy students may also help nursing students with medication administration during the camp. At least one week of camp is for clients with autism spectrum disorders. The other week of camp may consist of campers with developmental and/or physical disabilities. During this “other week”, pharmacy students are often confronted with issues they may have learned about, but never seen or experienced, including maintenance of gastrostomy tubes, administration of medications in this manner, Nissen fundoplication, wound and contracture treatments, and acute treatment of seizures. Pharmacy students are actively involved in the care of these issues, as health care professionals and as camp counselors. The pharmacist preceptor is not on-site during the camp; the students report to and interact with a nurse practitioner/camp nurse with experience in treating patients with autism spectrum disorders and developmental/physical disabilities in pediatrics. Students are required to send bi-weekly reflections about their experiences at camp to the pharmacist preceptor, what they've learned, and what impact it has had on them, via email.
WEEK OFF
Because this camp requires a residential status for two weeks of the APPE, as well as the intensive week with the preceptor, the student is given one week off to make up for the significant time spent during the other weeks of the APPE.
Students are formally evaluated at the mid-point and end of the APPE. While they do learn about drug therapy, the APPE provides them with a hands-on experience in an area that most do not have the opportunity to learn from. I have found that most students end up reflecting deeply on their perceptions of these patients before and after the APPE, as well as on the impact of a health care professional on quality of life.
SUMMARY
The APPEs in psychiatric pharmacy offered during the P4 year at the Purdue University College of Pharmacy allow students to gain experience in a variety of practice settings, with a diverse population of patients with psychiatric disorders. Each APPE features a strong integration of pharmacy services in the health care treatment teams in providing patient-centered care; the student is provided with a considerable opportunity to work directly with the treatment team and improve their individual interactions with patients with psychiatric disorders in various stages of illness. The pharmacy student is encouraged to identify their areas of interest and/or gaps in knowledge to facilitate both self-assessment and provide the preceptor with areas to focus on during the APPE to maximize the experience. Overall, these APPEs receive high evaluations from students, generally because of the health care team and patient interaction.