Aiding Transformation from Student to Practitioner by Defining Threshold Concepts for the Pharmacists' Patient Care Process

A Narrative Inquiry of Critical Events Supporting Professional Identity Formation in Introductory Pharmacy Practice Experiences

OBJECTIVE

Professional identity formation (PIF) is the process of internalizing a profession's core values and beliefs so that one begins to think, act, and feel like a member of that profession. PIF occurs over an individual's professional socialization in stages, precipitated by critical moments or experiences. The purpose of this study was to answer the following: (1) What are the critical events for pharmacy student PIF in introductory pharmacy practice experiences?; and (2) How do these events support or challenge PIF?

METHODS

This study used critical event narrative inquiry methodology. A critical event is an experience that creates a change in understanding and affects professional performance. Semistructured interviews were conducted with pharmacy students who completed introductory pharmacy practice experience rotations in community (first year) and hospital (second year) settings. Interviews were coded and analyzed using narrative analysis.

RESULTS

Twelve first-year and 10 second-year students participated in this study. Narratives revealed that common experiential education experiences resulted in a deeper understanding of core role elements (ie, professional autonomy, responsibility, interprofessional collaboration, and patient-centered care), leading to changes in agency, knowledge, and anticipated future behaviors. While first-year participants' narratives mainly focused on understanding pharmacist roles ("what"), second-year participants focused on understanding the process to fulfill those roles ("how to"). Emotions, assuming responsibility, external validation, and preceptor guidance supported these events.

CONCLUSION

Critical events in introductory pharmacy practice experiences affect and shape pharmacy students' PIF. These events are relevant to pharmacy education because these experiences can result in changes in knowledge, agency, or future behaviors for students.

A Qualitative Study of Experiences Contributing to Professional Identity Formation in Recent Pharmacy Graduates

OBJECTIVE

A professional identity has been described as "an individual thinking, acting, and feeling" like a person within the profession. The objective of this study was to learn about professional identity formation (PIF) in recent graduates of a pharmacy program.

METHODS

In-depth interviews were conducted with students graduating from a doctor of pharmacy degree program. Investigators performed a thematic content analysis of interview transcripts.

RESULTS

Participants were from community pharmacy practice (4), residencies (4), industry (1), and ambulatory care (1). At the time of the interview, participants were a range of 5-13 months out from graduation. Analysis of the data revealed 4 thematic findings. First, thinking and acting like a pharmacist occurred frequently while in school but feeling like a pharmacist occurred mostly after graduation. Second, feeling like a pharmacist meant participants felt confident in their knowledge base and ability to independently make decisions. Third, real-world practice is critical to PIF, particularly through interactions with patients. Finally, feedback, mentoring, and reflection support PIF and can aid in reconciling the tensions between concepts taught in school and experiences in practice.

CONCLUSIONS

In this qualitative analysis of data about PIF obtained from recent graduates from a pharmacy school, we found that thinking and acting like a pharmacist preceded feeling like a pharmacist; feeling like a pharmacist involved confidence in the ability to work autonomously; feedback, mentoring, and reflection on experiences supported PIF; and real-world experiences were critical to PIF.

Medication histories to identify medication-related problems through the pharmacists' patient care process in a simulated ambulatory care laboratory

BACKGROUND AND PURPOSE

Assessment of the Pharmacists' Patient Care Process (PPCP) in pharmacy curricula has been reported in a variety of contexts, but results have not described individual student performance in a controlled ambulatory care skills laboratory to purposefully identify medication-related problems (MRP) and develop plans for resolution.

EDUCATIONAL ACTIVITY AND SETTING

One of five MRPs was embedded within standardized medication profiles to facilitate student completion of three graded ambulatory care medication history encounters in a third-year skills laboratory. Data analysis included student performance in aggregate and according to MRP type from the first to the third medication history encounter.

FINDINGS

One hundred thirty-six students completed three medication histories for 408 encounters. Regardless of MRP, the total and subscale scores for adjusted marginal means were significantly higher in Sessions 2 and 3. Performance on MRP scenarios for drug interactions and adverse effects were significantly lower and higher, respectively. Successful collection of patient history significantly influenced marginal mean scores for respective MRPs.

SUMMARY

Improvement in student application of PPCP Steps 1 through 3 may be evident using three simulated ambulatory care medication history patient encounters toward the end of the third professional year, with potential influences by MRP type, MRP repetition, and adequate collection of patient history. Repetition with individualized grading and formative feedback are essential for skill development to identify MRPs in this setting. Confirmation of findings and extension into experiential education with higher complexity are needed to develop consistent and effective application of the PPCP to patient care.

Indicators, influences, and changes in professional identity formation in early experiential learning in community pharmacy

BACKGROUND

Experiential education is a key area in the pharmacy curriculum that professional identity formation (PIF) occurs. However, little is known about PIF influences and supports for pharmacy students during early experiential placements. The study aimed to explore pharmacy student PIF in an early experiential rotation in community pharmacy using reflective writing.

EDUCATIONAL ACTIVITY AND SETTING

First-year pharmacy students completed written reflections describing their professional identity and influencing experiences, before and after a four-week community introductory pharmacy practice experience. Qualitative content analysis of the written reflections was performed using three analytical approaches: (1) deductive coding based on professional identity indicators; (2) inductive coding to identify influences; and (3) inductive coding of field notes to identify changes between pre- and post-written reflections.

FINDINGS

Twelve students participated. All participants described discrete professional attributes and behaviors and valuing a patient-centered approach as part of their professional identity. Participants reported observation of pharmacists, the curriculum, and previous work experience influenced PIF prior to the experiential rotation. A strong influencer of PIF during the rotation was observation of pharmacist preceptors, whereas participants' own experiences were described less often. Changes in professional identity among participants were subtle and categorized as affirmation, acquisition, and growth.

SUMMARY

Pharmacy students' markers and influencers of PIF should be considered when developing curricular experiences and preceptor development that support PIF. The use of professional identity indicators and analysis of written reflections as a method to uncover PIF, shows promise and warrants further investigation.

Pharmacy Students' Experiences of Self-regulated Learning through Simulated Virtual Patients

Objective: Virtual patient (VP) cases are a valuable learning tool for students, used to apply classroom knowledge and develop clinical skills. It is unknown whether exposure to multiple VP cases helps students develop self-regulated learning (SRL). We sought to learn more about how students engaged in SRL as they made goals for approaching patient care during repeated exposure to cases. Methods: Second-year students (N=211) were invited to participate in an online survey. Students were surveyed before and/or after completing three VP cases. Each survey consisted of two open-ended questions. Prior to each case, students were asked "How will you change the sequence of your approach to completing the VP assessment today, if at all?" and after each case, "What more do you have to learn in order to approach similar real-life patient assessments?" A thematic analysis was conducted on open-ended survey responses. Results: One hundred and seventy pre-case and 242 post-case responses were received. The most common themes identified in pre-case surveys were a need for a more systematic approach and specific strategies for executing the patient care process. Some students had no plans for approaching VP cases. The most common themes identified in post-case surveys were knowledge gaps of medical conditions, therapeutics, and lab tests. Conclusion: VPs provided students the opportunity to self-identify gaps in knowledge and plan to strengthen their clinical reasoning skills. More research is needed to understand the relationship between VP cases, instructional guidance for supporting SRL and the realities of the intended benefits to students' learning and practice.

Threshold concepts in health professions education research: a scoping review

Threshold concepts (TCs) are increasingly used in health professions education (HPE) research. TCs are claimed to be conceptual gateways which are often traversed with substantial difficulty. In this paper, we report on a scoping review investigating the following research question: What is the scope and nature of the currently available research on threshold concepts in health professions education literature? We employed Arksey and O'Malley's model for scoping reviews. A search for literature on TCs in HPE research between 2003 and 2020 yielded 999 records of which 59 were included in the review. The data set was subject to quantitative descriptive analysis of article characteristics as well as qualitative thematic analysis of the scope of research on TCs. Among the 59 articles selected for review, there were 30 empirical, 26 conceptual and three reviews. A majority were published in 2015 or later. Almost half of the included articles attempted to identify possible TCs within HPE. Others investigated how TCs can be traversed or suggested how TCs could influence curriculum design. Some critically appraised the framework of TC. Although TCs are increasingly utilised in HPE, the present review identified how researchers came across methodological challenges related to identifying possible TCs and definitional challenges around identifying the essential characteristics of TCs. Before embracing TCs as the next go-to theory for learning in HPE, we acknowledge the need for methodological stringeny and rigour as well as more data to support TCs. Until then, any implementation of TCs in HPE curricula should be done cautiously.

Evaluating a Skills Laboratory Curriculum to Determine the Essential Skills for Pharmacy Students to Learn

The profession of pharmacy is complex and diverse, encompassing a wide range of necessary practice skills. Decisions regarding which skills are essential for students are made by faculty of skills-based laboratory courses, who also determine how these skills are taught and assessed. This commentary aims to further the discussion regarding how the essential skills taught and assessed in skills laboratory curricula are identified, with the intention of preparing student pharmacists for both current and future pharmacy practice. Guidance on essential skills is provided by various organizations and documents, but ultimately each institution has the autonomy to decide what to teach. As such, this piece discusses the importance of frequent curriculum evaluation to determine how to train pharmacists of the future so they will practice at the top of their license rather than simply meet competency with historical skills.

Identifying threshold concepts in postgraduate general practice training: a focus group, qualitative study

OBJECTIVE

To identify threshold concepts (TCs) for physicians undergoing postgraduate medical education (PGME) in general practice.

DESIGN

An explorative, qualitative study with 65 min focus group interviews and thematic analysis was used. Participants were asked to describe their most transformative learning experiences. Heuristical TCs were identified from the thematic analysis.

SETTING

Aotearoa/New Zealand (A/NZ).

PARTICIPANTS

Fifty participants, mostly comprising current trainees and educators from urban centres, and of NZ/European ethnicity.

RESULTS

Twenty TCs covering many aspects of postgraduate general practice experience were derived from themes identified in the data. Presented in medical proverbial form for ease of recollection, these included: Money makes the practice go round; Be a legal eagle; Manage time or it will manage you; Guidelines, GPs' little helpers; Right tool, right word, right place; The whole of the practice is greater than the sum of the parts; The personal enhances the professional; Beat biases by reflection; Chew the Complexity, Unpredictability, Diversity; Embrace the uncertainty; Not knowing is knowing; Seek and you shall find; Waiting and seeing, waiting and being; Look, listen, think between the lines; Treat the patient beyond the disease; No patient is an island; Words work wonders; Hearing is healing; Being you and being there; and; The relationship is worth a thousand consults. These TCs mapped onto core competencies in A/NZ's PGME in general practice curriculum.

CONCLUSIONS

Participants readily identified transformative and troublesome moments in their PGME in general practice. These findings confirmed evidence for a wide range of TCs with many newly identified in this study. All TCs were fundamentally based on the doctor-patient relationship, although often involving the context and culture of general practice. Actively incorporating and teaching these identified TCs in PGME in general practice may enable trainees to grasp these important learning thresholds earlier and more easily and aid in identity and role formation.

Development of a scale to determine student self-efficacy in performing key pharmacists' patient care skills

BACKGROUND

The Pharmacists' Patient Care Process (PPCP) was developed to describe a consistent process in which pharmacists in any setting provide patient care. Faculty at a midwestern university developed and refined an assessment tool which provides an indirect approach to measure student confidence in performing skills essential to the PPCP. The objective of this paper is to conduct a stepwise factor analysis to refine the PPCP survey.

METHODS

Assessing appropriateness of survey response data led to an exploratory factor analysis (EFA) on student confidence data to refine the survey instrument and examine the underlying constructs that influence student responses. Post EFA, the results were presented to the research team that collaboratively reached consensus on inclusion or exclusion of items.

RESULTS

EFA factor loadings identified a 4-factor solution suggesting elimination of 30 items from the original 53 item survey. Team discussions led to eliminating 29 items, combining two items and generation of 5 new items in order to retain important concepts. The outcome was a well-conceptualized and refined 29 item-survey model assessing 4 constructs.

CONCLUSION

To potentially improve patient outcomes, it is imperative to utilize comprehensive yet concise survey instruments, like the PPCP Skills Self-Efficacy Survey, to prepare students to translate PPCP skills to practice.

Unpacking student learning from an early experience with the Pharmacists' Patient Care Process

BACKGROUND

To illuminate learning, a case study approach was used to examine early, authentic experiences within Pharmacists' Patient Care Process (PPCP)-focused practices.

EDUCATIONAL ACTIVITY

Six students were matched with five practitioners and spent five half-days in a primary care clinic in a PPCP-committed health system. Students practiced interviewing, determining the patient's medication experience, and formulating the beginnings of the assessment, as well as observing and debriefing on the completion of the process by a practitioner mentor. The Five R Model was used to prompt student learning reflection. In addition, instructors examined students' work for evidence of transformative learning and observations were captured using forms of reflective practice and collaborative debriefing.

CRITICAL ANALYSIS OF THE EDUCATIONAL ACTIVITY

Reflection performance ratings varied; however, there was strong evidence of transformative learning for all students. Specifically, most student reflections demonstrated a focus on elaborating on existing frames of reference. The most prevalent indicator of transformative learning was exploration of options for new roles, relationships, and actions. The codes from instructors' observations revealed five categories of learning evidence, with the strongest in the patient centeredness category. The process of reviewing student work products, documenting instructor observations, and collaborative debriefing resulted in insights for curricular improvement and explanations for learning difficulties. Further work is needed in understanding student experiential learning intentions and their influence on learning and reflection. Additionally, further research should explore the value of longitudinal assessment of reflection and the value of assessing student work products using criteria beyond traditional reflection criteria.