Development of a collaborative psychiatric advanced pharmacy practice experience
Introduction: Faculty are required to balance multiple duties, including, but not limited to teaching, precepting, and scholarly activity. Likewise, pharmacy managers with faculty appointments are challenged with balancing teaching and administrative duties. With increasing numbers of pharmacy students enrolled in colleges of pharmacy and the recent economic decline, there are concerns that increased responsibilities of faculty and preceptors may lead to sub-optimal advanced pharmacy practice experiences (APPEs).
Objectives: Describe a collaborate approach in teaching a psychiatric APPE allowing for additional time for other responsibilities while providing a favorable environment for students.
Methods: Pharmacy faculty and managers developed a collaborative psychiatric APPE. The pharmacists divided lectures and case discussions. Students were given many responsibilities (e.g., counseling, intervention documentation). Preceptor evaluations were documented and evaluated.
Results: Sixty-four students were precepted over two years. Student evaluations of APPE preceptors averaged 3.74/4.00. Additionally, faculty and pharmacy managers accomplished other activities.
Conclusion: It appears this collaborative team taught approach succeeded in providing an auspicious environment for students while allowing preceptors to be productive.
INTRODUCTION
The number of College of Pharmacy Programs has increased by more than 27% over the past ten years. Additionally, the number of pharmacy students also continues to grow. At our campus, the student body has increased from 125 to over 250 per class in seven years. Therefore, there has been an increase in the amount of students pharmacy practice faculty are required to precept every year. Currently, each pharmacy practice faculty member at Nova Southeastern University must annually precept a minimum of 14 students during advanced pharmacy practice experiences (APPEs). Concurrently, due to the current economic decline, hospitals have placed budget cuts and hiring freezes in their pharmacies; therefore, pharmacists are expected to take on additional responsibilities. Despite the added responsibilities due to hiring freezes and terminations, departments of pharmacy may still be expected to oversee these students. As a result, pharmacy managers and clinical pharmacists may be challenged with managing both APPE students, and clinical or administrative duties. According to one study, most academic medical centers do not have a framework to adequately provide pharmacy students with a learning environment.1 Therefore, there is concern about the poor quality of APPEs with no direct vision on improving the situation.2 This situation is also worsened by concerns in the number of qualified pharmacy faculty available to educate our students.
Advanced pharmacy practice experiences, which focus on active learning and engaging with patients, are necessary in a pharmacy student's development. Increasing class size and administrative responsibilities may provide a sub-optimal APPE in which some may feel students observe rather than participate in patient care.3 Additionally, there are recent concerns regarding whether APPEs are adequately training pharmacy students.3–5 Many preceptors are discovering there is insufficient time or lack of resources to properly teach our students.25 Despite these challenges and concerns, there are a lack of data reporting ways to maximize time spent with students, specifically on a psychiatric APPE. Therefore, the objective of our study is to describe the effectiveness of a collaborative psychiatric APPE.
METHODS
Development of the Psychiatric APPE
We began with an affiliation agreement between two institutions: Nova Southeastern University (NSU) and Jackson Health Systems (JHS) Behavioral Health Hospital. Two NSU faculty members were given nine months to develop their clinical practice site. During this time, NSU faculty met with two JHS behavioral health pharmacy managers to develop a collaborative APPE. An extensive syllabus was created, and topic discussions were agreed upon (i.e., Introduction to Mental Health, Psychosis/Schizophrenia, Bipolar Disorder, Major Depressive and Anxiety Disorders). Each preceptor chose one topic to teach each month and lead discussions with all the students on the acute inpatient psychiatry APPE during that given month, regardless of whether the students were directly assigned to that preceptor or not. Topic discussion handouts were developed by the preceptor assigned to lead the discussion. Pertinent articles, based on the list provided by CPNP, (http://cpnp.org/_docs/SuggestedReadingsforPsychStudents.pdf) were reviewed and included in the required psychiatric readings. Updated articles were included, if needed. A monthly activities calendar was implemented which included due dates for assignments such as journal clubs, formal drug information questions, clinical intervention documentation, psychiatric-related lectures offered to medical students by psychiatrists, case/topic discussions with preceptor, mid-term/final exam, and a final case presentation. After each topic discussion, the preceptor for that specific topic would provide feedback on students' participation to their primary preceptor. Midpoint and final student evaluations were also provided to the students by the primary preceptor.
Our setting included two acute adult inpatient units with the opportunity to rotate in pediatrics or geriatrics units on particular days. Each NSU preceptor was assigned to one acute adult inpatient unit. Each acute inpatient unit holds approximately twenty psychiatric patients which is divided into two teams, each led by a psychiatric resident overseen by an attending psychiatrist. As a result, each student was assigned to one team and followed approximately ten patients at any given time. Students assigned to the JHS administrators were placed in our unit, and while overseen by the NSU preceptors in the unit, ultimately reported to their primary preceptor. Student responsibilities included proper drug monitoring (e.g., dose, adverse events), laboratory monitoring, patient education, drug information, and/or teaching inservices to the medical residents, attending, and nursing staff. If any recommendations were made, they were to document them in JHS's intervention database. Patients were discussed on a regular daily basis. Students were provided with preceptors' mobile phone numbers and pagers in case the primary preceptor had to be off site (e.g., course coordination, didactic Therapeutic lectures at NSU). At the conclusion of the APPE, students were required to complete evaluation forms of their preceptors. There were 26 evaluation points in areas which included opportunities to interact with patients (e.g., counseling), professional development (e.g., challenged to think critically, identify strengths and weaknesses, give constructive criticism), and professional interaction (e.g., preceptor encouraged student to express ideas, respected student as an individual).
RESULTS
A total of 64 students participated in our APPE elective between June 2007 and May 2009. Both NSU faculty members precepted 54 students from several campus sites (i.e., Davie, International, Puerto Rico, West Palm Beach) over this time period. The behavioral health pharmacy managers precepted ten students from University of Florida and Florida A&M University. The overall score for the grading of the APPE during the first year was a 3.55 out of 4 (n=23) compared to 3.88 out of 4 (n=30) for the second year. The overall score averaged 3.74 (n=53) for both years. Areas which demonstrated the highest scores included: students being challenged to think critically, respecting students as individuals, having the site expand their knowledge, and use of drug information services. Areas of most needed improvements included: providing reasons for grades received during mid-point evaluations, and regularly meeting with students to discuss recent developments or new information in the field of practice.
Over the 24 months, a total of 271 interventions were documented by pharmacy students. The most common interventions included dose recommendations, drug levels/laboratory recommendations, and therapeutic interventions. All interventions were documented utilizing Pharmacy OneSource System, which uses previous data to determine costs associated with the intervention. These interventions provided an estimated cost savings of $15,524.
DISCUSSION
We believe psychiatric APPEs need to be well-defined and established in order to teach and develop pharmacists familiar with the care of mentally ill patients since mental health complications and costs are increasing in the United States (US). Currently, it is estimated that over 26% of the US population may have a diagnosable mental illness with 22.3% of these cases considered serious.6 As a result, 5.8% of the US population is considered to have a severe mental disorder which may require considerable medical intervention and resources. The prevalence of almost 6% alone is higher than heart attacks, breast cancer, or stroke. However, approximately 10% of pharmacy programs do not offer an elective psychiatric APPE.7 Currently, our college offers several psychiatric APPEs that are taken by at least 10% of our student body.
One of the goals for the APPE was that it met standards set forth by pharmacy organizations. As such, the psychiatric APPE follows ACCP recommendations for ensuring a quality experiential rotation.8 Our student: preceptor ratio is no more than 2:1 at any given time for the practice site. Three of the four preceptors have completed a residency and all are board certified in psychiatric pharmacy. The students are graded on a standardized and consistent format through SUCCESS and are challenged to think critically, independently, and recommend treatment plans based on primary literature. SUCCESS is an APPE grading rubric developed and implemented by several Colleges of Pharmacy during an American Association of Colleges of Pharmacy spring training (for more information: http://pharmacy.ufl.edu/experiential/success/). Our College of Pharmacy has been using SUCCESS grading since it addresses many of the competencies necessary to perform well during APPEs. This allows our program to have standardized forms that may provide appropriate unbiased grading.
Students were required to document interventions in a hospital database that supports the cost effectiveness of pharmacists. Students' interventions focused mostly on patient consultation and drug information. The value of having the students document their interventions is based on their ability to justify their value to the hospital. A current study stated students provided not only monetary compensation, but proved to be pharmacist extenders, increasing teaching opportunities to their residents, and overall improve staff satisfaction.1 Also, some encourage that this component be implemented during a student's APPE.3 Additionally, this experience and skill may not only assist those who pursue careers where documentation is necessary (e.g., community, staffing), but those who are pioneering pharmacy involvement in different areas.
According to student evaluations and comments, it appears pharmacy students enjoyed their APPE and felt it was a favorable learning experience. One of the faculty members was recognized as a finalist for their excellence and innovative teaching by the fourth year (APPE) students and was the recipient of the Golden Apple award, which recognizes the best overall professor of the Academic year among the NSU College of Pharmacy.
During this period, faculty members presented 12 abstracts at national meetings. After excluding case reports and letters to the editor (n=2), both faculty members published two manuscript/year which surpasses the recommendations established by NSU's department guidelines for continuing contract. The manuscript/year ratio of 2.0 is also higher than the national average of 0.4 publications/year contributed by pharmacy practice faculty across the country.9 Didactic lectures were done in courses including Therapeutics, Pharmacokinetics, Physical Assessment, Pediatrics, Ambulatory Care, and Women's Health. Both faculty members also coordinated four Therapeutic courses consisting of over 250 students, including three distant sites, during those two academic years. Faculty members served as the Chair of several college committees (e.g., Faculty search, Awards) and one of them served as the advisor for a pharmacy fraternity. The faculty members also participated and presented on five topics for the JHS Pharmacy and Therapeutics committee. NSU faculty feel that these endeavors may not have been possible without the collaborative structure of the APPE.
Based on the collaborative nature of the APPE, pharmacy managers also felt they were still able to offer students a robust rotation while continuing to manage their administrative duties. They implemented a new hospital information system (Cerner), new automated medication dispensing equipment (converted from Pyxis to Omnicell Rx), and a medication order management system (Omnilink). They were also involved in several hospital wide committees including the Medication Safety Committee, Formulary subcommittee of P&T. In addition, they were able to play a more active role in the JMH behavioral health hospital including the Continuous Readiness Committee, Hospital Performance Improvement Council, Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and Mental Health Patient Care Services Council.
Limitations included no evaluations reported by students for the pharmacy managers, because they did not precept any NSU students over the two years. Also, some of our evaluations (n=5) were from other APPEs that we offer (e.g., medical mission, academic) which had different objectives. Nonetheless, these evaluations could not be excluded due to the anonymity policy of NSU.
Based on the evaluations and subjective feedback from the students, changes in the APPE between year one and two included more time counseling patients, viewing electro-convulsive therapy (ECT) procedures, and attending patient court hearings. Perhaps these opportunities led to a slightly better experience for our students between both years.
CONCLUSION
It appears the NSU Pharmacy students had a positive experience during their psychiatric APPE. Additionally, all preceptors felt that the collaborative nature of the APPE has allowed more time for other endeavors (e.g., didactic teaching, publication, administrative affairs) while still providing an auspicious APPE based on overall evaluations. Students also enjoyed interacting with different preceptors and felt it was a more positive learning experience.
Contributor Notes
*Dr. Marino was an Assistant Professor at Nova Southeastern University during the development, implementation, and participation of the APPE. Dr. Marino's contributions to this editorial are her own and were not performed on behalf of her employer (OAPI).