Innovations in Teaching Innovative Enabling Strategies in Self-Directed, Problem-Based Therapeutics: Enhancing Student Preparedness for Pharmaceutical Care Practice 1

The objectives of this innovation were to enhance student learning in therapeutics taught in a large-group, problem-based format in third and fourth professional years of the program and to increase student preparedness in providing pharmaceutical care. Feedback from students and instructors helped identify some limitations to learning and included limitation of breadth of knowledge learned, increasing students' awareness of the patient's perspective of illness, and students' ability to verbally justify recommendations. Alignment of the courses in relation to students' expected competency were also considered. Strategies to address limitations included development of criterion-based assessments, oral examinations, use of real patients, and development of a web infrastructure. The innovation resulted in an enhancement of student learning in a self-directed problem-based environment and a better understanding of the patient's perspective of illness. It can be concluded that preparedness for pharmaceutical care practice by the student increased motivation to pursue self-directed, life-long learning. INTRODUCTION In 1994, the Faculty of Pharmacy at the University of Toronto changed its existing four-year curriculum to a new 1+4-year undergraduate pharmacy program, leading to a baccaulaurate in pharmacy. The emphasis in the new curriculum was on the students' ability to provide pharmaceutical care upon graduation(1). Therapeutics, taught in a problem-based format and offered in the fourth year of the old program(2) was expanded significantly to two courses, to be taught in the third and fourth year of the new program(1). In addition to the lecture compo-1 Manuscript based on a portfolio submitted to the 2000 Council of Faculties Innovations in Teaching Competition. Am. J. Pharm. Educ., 65, 56-64(2001); received 8/15/00, accepted 1/5/01. 56 American Journal of Pharmaceutical Education Vol. 65, Spring 2001 nent in the courses, five small group seminars on key disease states were incorporated into the two therapeutics courses, Pharmaceutical Care II and III(1). The new Therapeutics courses were initiated in 1996-97 (Pharmaceutical Care IIoffered in third year) and 1997-98 (Pharmaceutical Care IIIoffered in fourth year). During the last semester of fourth year, students undergo 16 weeks of structured practical experience in community and institutional practice sites. Hence, therapeutics plays a significant role in building students' knowledge and skills in preparation for practice. Underlying Principles of Teaching and Learning in Therapeutics Therapeutics is taught in a large-group format of 120 students, using self-directed, problem-based learning. Underlying the courses are also the principles of Pharmaceutical Care(3). Students in the class are divided into groups of eight to facilitate group work. Paper patient cases, along with required readings from course textbook and/or journal articles, are provided in advance. Students, working within their groups, are expected to carry out an assessment of the patient utilizing the pharmaceutical care process(2) and identify and resolve any drugrelated problems, in preparation for class discussion. An expert instructor facilitates the discussion during class time. Each case discussion takes 1.5 hours. The classes are all taught by practicing pharmacists. Development of Knowledge and Skills within the Curriculum Students are evaluated using criterion-based assessment in most of the pharmacy practice courses. In ensuring that students meet the required level of knowledge and skills upon graduation, a well-defined admissions process is used to ensure that students entering the program can perform at the interface of the Uni-and Multistructural level(4) (see Appendix A) of competence in communication skills as a condition of entry. During the first year of the program, a communications course emphasizes listening, verbal and written communication skills at the Unistructural-Multistructural level. Students are also guided through self-assessment skills starting in the first year. The curriculum is aligned with respect to communication skills and students' development of knowledge and skills are built on each other over the four years. The overall goal of the therapeutics courses is to enable students to optimize their knowledge and skills required to provide pharmaceutical care. During the two-year therapeutics courses, students are gradually exposed to therapeutic problems that range from being well-defined and routine (see Appendix B), to ill-defined and non-routine problems, thus ensuring that their knowledge and skills are developed to a multistructural (Appendix A) level in the third year and bridging between a Multistructural and Relational level in the fourth year, in preparation for their practical experience. Upon graduation, students should be at a Relational level of learning. The alignment of skills throughout the curriculum ensures that students entering Pharmaceutical Care II in third year can be expected to function at a beginning Multistructural level of knowledge acquisition and skill. Based on formal and informal student feedback and assessing the knowledge and skills required to be able to provide pharmaceutical care during their practical training period, several limitations to student learning were identified. These include: • In the large group setting, not all students are prepared for class discussions; hence, many times the instructor would have to 'lecture' to complete the course material. Not receiving timely feedback for their participation has been identified as one of the reasons why students are not motivated to increase their participation. • As one case is discussed for each therapeutic topic, students indicated a limitation to the breadth of knowledge learned. • Students were unclear of the expectations of the examinations, based on the one case. • The one patient case did not always give students an understanding for the types of problems seen in patients with that particular disease state. • Students would have liked to have the opportunity to apply their knowledge beyond class discussion. • The need for increased instructor-student interaction in preparation for cases, when needed beyond the usual office hours. • A difficulty for students in sometimes arranging for regular face-to-face group meetings. • Due to the dynamic nature of the material, treatment information learned in third year is sometimes 'out-of-date' by the time students start their practical training during the last semester of fourth year. • Preceptor feedback from clinical training in previous years indicate that students may know the information but are not always able to verbally justify their recommendations. Many of the issues identified relate to the limitations of large group problem-based learning. These include limitation of the breadth of knowledge learned, lack of opportunity to apply knowledge beyond the case discussion, lack of understanding of the types of problems seen in patients beyond the case discussed in class and difficulty in coordinating face-to-face team meetings. Other issues relate to the student's need to gain a better understanding of 'patient issues' related to their illness. In order to address these issues and to optimize student learning, new educational and assessment strategies were integrated into the Therapeutics courses. The Desired Outcomes of the Innovative Strategies • to enhance student learning by identifying and addressing limitations to learning in a large-group, problem-based format; • to increase the student's understanding of the patient's perspective of the illness; To increase the student's ability to 'care' for the patient; • to facilitate the development of verbal communication skills, with respect to discussing therapeutics issues and making recommendations; and • to motivate students to develop self-directed learning skills, thus enabling and promoting life-long learning. The innovative strategies were targeted to address these outcomes. METHODS Changes to the courses were incorporated gradually over the past four years. The following lists the changes that have been integrated into the two courses and the year the change was initially made: American Journal of Pharmaceutical Education Vol. 65, Spring 2001 57 Teaching and Learning Strategies 1. Student learning objectives to be developed for each case (1996) 2. Integrated cases incorporated into the course schedule (1996) 3. Discussion of common drug-related problems within each therapeutic area (1996) 4. Use of real patients for selected cases (1997) 5. Development of a web infrastructure to complement classroom learning (1999)(2000) Changes to Student Assessments 1. Assessment of group contribution to class discussions with timely written feedback (1997-98) 2. Final oral examinations at the end of each year (1996) 3. Case study seminars (small group seminars): change in assessment of performance during seminar (1996-97) 4. Case study seminars-incorporation of verbal and written, self and peer assessment (1996-97) Teaching and Learning Strategies 1. Development of student Learning objectives for each therapeutic case 2. Goals • To increase students' breadth of knowledge learned • To provide students with guidelines on expectations for examinations Rationale Students enter therapeutics in third year at a beginning Multistractural(2) level of knowledge acquisition and skill. They have not yet developed the judgement required to decide on what may be relevant information to learn within each therapeutic area. Often the patient case discussed in class may deal with one main problem. Hence, providing students with specific learning objectives gives them a clear indication of the material that they should be familiar with, within each disease topic, beyond the one problem discussed in class. Additionally, these objectives provide a guideline for examinations, which creates an affective environment that is conducive to learning. Process In addition to the development of the case, the instructor developed a set of clear learning objectives for that specific topic. These provided the students with a guideline on the breadth of information to be learned within that area. The Student Learning Objectives precede the case. In preparation for class discussions and examinations, students are asked to review these objectives and to be familiar with the information covered within the objectives. Learning objectives are incorporated into all therapeutic cases for third and fourth year. Examples • For pneumonia, the case discussed in class could be a patient with community-acquired pneumonia. Students are also expected to understand the pathophysiology and treatment of other types of bacterial pneumonia, such as hospital-acquired pneumonia, aspiration pneumonia, etc. • Acute migraine management may be the focus of the case discussed in class. However, students are also required to be able to assess and recommend prophylactic therapy for a patient with migraine. Incorporation of Integrated Cases Goal To provide students with an opportunity to gain insight into patient problems that are ill-defined and/or non-routine (refer to Appendix II) in nature (i.e. a realistic patient case). Rationale Simulated paper patient cases used for each therapeutic area usually deal with a primary issue related to the disease topic. Although the paper cases are developed from real cases, the patient's other medical conditions and concerns may be simplified to ensure that the application of information related to the new topic is clearly understood. However, in order to prepare students for practice, it is important to expose them to patients with multiple issues and a number of drug-related problems. This emphasizes the interrelationship between conditions and how to set priority in resolution of drug-related problems. Process Integrated cases are scheduled at various times during the two courses and are taught in a three-hour teaching block. The integrated cases usually incorporate one to two new therapeutic areas, along with two or three disease conditions that have already been covered. In addition to teaching students how to deal with multiple problems, the case serves as a review of information already covered, clarifying any issues from previous discussions. Discussion of Common Drug-Related Problems Goal To provide students with an understanding of the types of problems seen in patients with a particular disease state. Rationale As students lack practical experience, the clinical significance of the patient case problem discussed in class is often unclear to them. Hence, providing students with common types of problems encountered by pharmacists related to drug therapy in patients with a particular disease provides a context for understanding of the case problem. Process Upon completion of the case discussion, the instructor provides an insight into the clinical significance of the types of drug-related problems that he/she sees in practice. This provides students with an appreciation for the pharmacist's role in identifying and resolving problems for patients with specific types of illness. With the development of the web site, a discussion of the common types of drug-related problems for each disease area is included on-line for easy student access. Use of Real Patients for Selected Cases Goals • to create authenticity within the problem-based learning environment; • to provide bridging for students between caring for simulated paper cases to real patients during their experiential training; • to provide students with an opportunity to interact and care for patients with ill-defined, non-routine problems. Background Information Students are exposed to graduated levels of complex ity of therapeutic issues over the two years. During the fourth year of the program, students are provided with an authentic experience with patients with complex therapeutic issues. The interaction with patients is correlated with the level of student's knowledge and skills/competencies. Students can be expected to gather, select, process, manage and present issues for patient problems that are well defined and routine. For patients with ill-defined and/or non-routine problems, students can manage patient problems, with the guidance and expertise of the respective care provider. Hence, students interact with the patients at different levels during the course. Process Patients are invited to the classroom to help address four different therapeutic areas. These include cardiology (post-myocardial infarction management), neurology (Parkinson's disease) and Psychiatry (Psychosis and Bipolar Affective Disorders). Earlier in the course, students interact directly with patients with routine and/or welldefined problems. With increasing complexity of the patient's disease, students interact with the patient under the guidance of a health care practitioner, and gain experience in dealing with ill-defined and/or non-routine problems. Cardiology Earlier in fourth year, upon completion of the cardiology block, a patient with multiple cardiac issues is invited to the class and provides the basis for the Integrated Cardiology Case discussion. Prior to class, four student volunteers discuss the interview strategy with the instructor. During the first half of the integrated case, the volunteer students interview the patient in front of the class. The instructor is also present. At the completion of the interview, other students may ask questions of the patient or the interviewers. Information from the patient is gathered and selected. The patient is encouraged to share his/her views on their relationship with health care practitioners, especially pharmacists. The patient then leaves. During the second half of the class, the instructor elicits information from the interviewers and asks them to share their thoughts about the interview with the class. Following this, the instructor facilitates the class discussion on the 'patient case'. Real and/or potential drug-related problems are identified and potential solutions discussed. Following this, the instructor discusses the students' recommendations with the patient and encourages the patient to discuss these with his/her physician. The instructor follows-up with the patient at a later date to determine any alterations to therapy; this information is then shared with the students. Students enjoy this experience very much and get satisfaction in knowing that some changes were made to the patient's therapy based on their recommendations. Neurology -Parkinson's Disease Week 1. Two patients are invited to the class with dramatically different presentations of Parkinson's disease. The pharmacist-instructor conducts the interview with both patients, eliciting information regarding their condition and treatment. Following the interview, students are encouraged to ask questions of the patients or instructor. Students gain an appreciation for issues that impact on the patients' quality of life and the role of drug therapy in their disease management. At the end of the interview, patients leave the room. The instructor provides students with a brief overview of the discussion. Students are required to carry out an assessment of the patient's medical conditions, which will be discussed the following week in class. Students are expected to work within their groups, to identify the patient's drug-related problems and make recommendations to resolve them. Week 2. At the beginning of class, a video is shown to demonstrate the classic symptoms of Parkinson's disease. As patients visiting the class are usually controlled on medications, the symptoms are not obvious. Hence, this visual depiction provides students with a better understanding of the clinical presentation and treatment. The video is followed by an instructor-facilitated discussion of Parkinson's disease and the patient's management. Following the class, the instructor discusses any identified drug-related problems and potential recommendations with the patient. The patient is encouraged to then discuss these with his/her physician. Later, students are provided with an up-date on any changes in therapy that resulted from their recommendations. Psychiatry -Psychosis and Bipolar Affective Disorders Two patients, one with psychosis and one with bipolar affective disorder, are invited to the class, along with their psychiatrist. The pharmacist-instructor is also present. Week 1. The psychiatrist conducts an interview of his/her patients, providing students with a history of the mental illness and various interventions, including drug therapy, that have been tried. Following the interview, students are encouraged to ask questions of the patients or the psychiatrist. This session provides students with an insight into the complexity of psychiatric illnesses, with respect to both diagnosis and treatment. Following the interview, the patients and the psychiatrist leave. The pharmacistinstructor provides an overview of the discussion and clarifies any issues for the students, who are then expected to work-up the two patients, in preparation for class discussion the following week. Week 2. The instructor facilitates the class discussion related to the management of the two patients, in two separate lecture times. Any identified drug-related problems and potential recommendations are discussed with the psychiatrist by the instructor. A follow-up is provided at a later date to students regarding any changes to patient's therapy as a result of student recommendations. Development of a Web Infrastructure to Complement Classroom Learning Goals • to address limitations to student learning in a largegroup, problem-based format; • to enable students to optimize their knowledge and skills required in providing pharmaceutical care. Rationale Several limitations to problem-based learning could be addressed by a well planned web site. Allowing the student to access supplemental information promotes greater understanding of the therapeutic area and supports the development of self-directed learning. It also ensures that students become familiar with information technology resources. The site would allow for easy access to courserelated information. Process Various courseware tools were reviewed and a web framework was designed using the WebCT courseware package. Information is added to the site on an ongoing basis. Each therapeutics course has its own web site. All students registered in the course are given login identification and an initial password to access the site. Student feedback is sought continuously in the development of the sites. The Pharmaceutical Care III site (course offered from September to December) for fourth year students and the Pharmaceutical Care II site (course offered from late October to April) for third year students, went live on September 15, 1999 and January 25, 2000, respectively. The site also has the capability to track student use and posting of student evaluations. The web infrastructure provides information and/or activities related to the following: • learning objectives, cases and required readings; • common drug-related problems experienced by patients with a specific disease; • key treatment principles and/or a brief summary o f key points discussed in class which is made available to students upon completion of class discussion; • mini case scenarios and/or quizzes for practice in each area; • supplemental readings for students who may be interested

Pharmacy patron perspectives of community pharmacist administered influenza vaccinations

The final publication is available at Elsevier via https://doi.org/10.1016/j.sapharm.2018.04.015. © 2018. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/One approach to boost influenza vaccination coverage has been to expand immunization authority. In 2012, the province of Ontario gave community pharmacists the authority to administer the influenza vaccine.This study was conducted as part of the Ontario Pharmacy Evidence Network (OPEN) and funded by the Government of Ontario