Therese I. Poirier

Assessment of Pharmacy Student Professionalism Across a Curriculum

Objectives. To evaluate changes in professionalism across the curriculum among pharmacy students in different classes. Methods. A professionalism instrument was administered early in the first (P1) year, upon completing the introductory pharmacy practice experiences (IPPE) near the end of the second (P2) year, and upon completing the advanced pharmacy practice experiences (APPE) at the end of the fourth (P4) year. Results. The professionalism scale and its subscales were compared for the 3 time points for the class of 2009. Significant differences were noted in professionalism scores between the P1 and P4 years and for altruism, accountability, and honor/integrity subscale scores for the class of 2009. No significant differences were noted when the scores for 4 P1 classes, and 3 P2 classes were compared. Conclusion. An increase in professionalism scores and altruism, accountability, and honor/integrity scores was demonstrated, providing evidence that the curricular and co-curricular activities in the school of pharmacy helped develop professionalism in the class of 2009 students.

Reversible Renal Failure Associated with Ibuprofen: Case Report and Review of the Literature

A report of a probable case of acute, reversible renal failure and hyperkalemia, after an increase in dose of ibuprofen, is presented. Other cases of renal dysfunction associated with various nonsteroidal anti-inflammatory drugs (NSAIDs) are reviewed. The ability of NSAIDs to inhibit prostaglandin synthesis may explain the various renal consequences. Possible predisposing factors to renal deterioration include the amount of drug consumed, presence of compromised renal blood flow, underlying renal insufficiency, nephrotoxic drug combinations, and high urinary prostaglandin excretion. Generally, the renal failure with NSAIDs is acute and reversible, though analgesic nephropathy with papillary necrosis and chronic renal failure are reported. Electrolytes, blood urea nitrogen, and serum creatinine levels need to be monitored in high-risk patients with predisposing factors and for chronic, long-term use of drugs that inhibit prostaglandin synthesis.

Interprofessional ethics learning between schools of pharmacy and dental medicine.

Abstract A case-based interprofessional education (IPE) ethics activity between pharmacy and dental students was developed and evaluated. Eighty-two third-year pharmacy and 51 first-year dental students were divided into teams for two sessions. The IPE activity involved the student teams analyzing two cases at each session utilizing an ethical decision-making process followed by debriefing of each case. Assessments included pre-/post-Readiness for Interprofessional Learning Scale (RIPLS), pre-/post-individual ethics knowledge quiz, pre-team ethics knowledge quiz and post-student perception survey. The results indicated no significant differences in RIPLS scores although scores indicated a high readiness for interprofessional learning including teamwork and collaboration among pharmacy and dental students. When comparing pre-/post-ethics knowledge quiz scores a significant difference was found between individual and team scores as well as between professions. Perception survey results were highly favorable toward the value of interprofessional learning activities. The sessions resulted in enhanced knowledge about ethical decision-making.

Interprofessional Education: Fad or Imperative

There has been increased focus with a call to implement interprofessional leaning experiences for health profession students. Some of the attention has come from highly respected sources, such as the Institute of Medicine.1 In 2011, the Interprofessional Education Collaborative identified 4 core competencies of interprofessional education which include: values and ethics for interprofessional practice, roles and responsibilities, interprofessional communication, and teams and teamwork.2 Last fall, the Accreditation Council for Pharmacy Education sponsored a national conference on “Advancing Quality in Pharmacy Education: Charting Accreditation’s Future” which highlighted the need to implement interprofessional competencies and learning.3 To many in academia, all this attention has been perceived as another trend which schools will frantically need to address in order to meet accreditation standards. Integration of interprofessional education within health profession curricula provides learning opportunities for students in an environment which prepares them to practice. Effective communication and teamwork in providing health-care has demonstrated improved patient outcomes.4 Interprofessional education is an imperative because it is each profession’s responsibility to their patients. The resistance encountered among colleagues can be disheartening, especially for those who buy into interprofessional education as a professional mandate and responsibility to patients. In our experience, students may be more open to the concept than faculty members. Reasons for this include faculty perceive implementation challenges and time commitments as too much work, therefore interprofessional education is not a top priority. Faculties in academia are not known for agile responses when making curricular changes. It took over 50 years from the first suggestions of need for change within the profession’s curriculum to become more patient-care focused to implementing the doctor of pharmacy degree as the first professional degree. Another challenge is the misconception among faculty members that interprofessional education is already occurring because of multidisciplinary collaborations in research efforts. This attitude reflects the lack of understanding of the importance and the nature of interprofessional education.5 Interprofessional education is “when students from 2 or more professions learn about, from, and with each other to enable effective collaborations and improve health outcomes.”6 Faculty members may not be prepared for the cooperative role without professional ego that is required for interprofessional education. Each profession may desire to lead their own interprofessional education efforts. To implement effective interprofessional education, students learning together will need to be matched according to comparable levels of knowledge and skills. If students at a more senior level are matched with novices in the profession, this leads to an imbalance and incompatibility, with the senior-level students dominating the team. Students need to be acculturated to the professionalism responsibilities of their profession. A simple consideration of how they should dress when engaging with other professionals can result in students’ having more respect for the other profession. Performance standards are needed which are similar and cross disciplines. One profession having lower expectations will create another area for imbalance. There is a need to develop validated and sensitive tools that can assess the impact of interprofessional education. In particular, tools for assessing teamwork skills are needed. Logistics such as finding a common schedule and an appropriate size room for interprofessional education collaborations are also challenges. These logistical issues are often the rate-limiting step for implementing interprofessional education. Additionally, sustaining efforts over a longer period of time becomes difficult. As there are many challenges, colleges and schools should start small. Look for opportunities where others are seeking collaborations. Elective offerings may be a good place to start. Accept the notion that even small undertakings are steps in the right direction for the profession of pharmacy and patients served. Recently, Southern Illinois University Edwardsville (SIUE) implemented 2 interprofessional education programs. SIUE is not affiliated with an academic health science center. It has schools of pharmacy and nursing located on the main campus, and schools of dental medicine and medicine located 20 and 75 miles from the campus, respectively. The first interprofessional education program implemented involved pairing third-year pharmacy and first-year dental students in teams to apply ethical decision-making principles to cases. The second interprofessional education program involved second-year pharmacy and sophomore nursing students coming together for cross-cultural communication learning sessions. With each program, students came together for two 2-hour sessions. Although the dose of interprofessional education was low in both of these programs, the potency was high based on student feedback. The pilot programs helped to create a model for future required courses in ethics and cultural competency taught together with other health professional students. Starting in fall 2013, first-year pharmacy students will come together with first-year dental students for a required interprofessional education ethics for health-care course. The course consists of both uniprofessional and interprofessional sessions. Faculty attitudes and knowledge can be addressed by hosting an institutional interprofessional education retreat. The retreat planning committee should be made up of an interprofessional team. To instill teamwork and collaboration, the planning committee could attend 1 of the institutes sponsored by the IPEC. The retreat should consist of showcasing existing institutional interprofessional education efforts as well as active learning exercises to engage faculty members. One example is to have interprofessional teams of faculty members using shared thematic interests, (ie, patient safety, global health, simulations, health promotion, etc) to design an effective interprofessional education experience by applying principles of teaching and learning.7 Bringing together comparable students requires mapping of each profession’s curriculum to determine where courses are taught. Developing validated assessment tools should be a priority research focus in interprofessional education. Scheduling and room challenges can be addressed by exploring creative approaches to collaborations including the use of technology.8 If pharmacy education is to achieve the desired outcomes of interprofessional education, which is improved patient care, then major infrastructure changes to curricula as well as changes in attitude among faculty members will be essential. Not only will colleges and schools need to be flexible and adapt to the needs of other professions, but the culture of how students are educated must change, too. We suggest that the standard for interprofessional education in pharmacy education requires interprofessional education across the curriculum (classroom and experiential) with extensive collaborations in learning so pharmacy students can learn about and with many other health professions. The academy should publish best practices in interprofessional education in the Journal. Funding for the development of innovative interprofessional education models and assessment tools should be a top priority. Clearly, interprofessional education is an imperative for healthcare professional practice and is not a fad.

An interprofessional faculty seminar focused on interprofessional education.

Objective. To evaluate an interprofessional faculty seminar designed to explore the topic of interprofessional education (IPE) as a way to encourage dialogue and identify opportunities for collaboration among health professional programs. Design. A seminar was developed with the schools of pharmacy, nursing, dental medicine, and medicine. Components included a review of IPE presentation, poster session highlighting existing IPE endeavors, discussion of future opportunities, and thematic round tables on how to achieve IPE competencies. Assessment. Fifty-four health professions faculty members attended the seminar. Significant differences in knowledge related to the IPE seminar were identified. Responses to a perception survey indicated that seminar goals were achieved. Conclusion. An interprofessional faculty seminar was well received and achieved its goals. Participants identified opportunities and networked for future collaborations.

Use of humor to enhance learning: bull's eye or off the mark.

Humor as a pedagogical tool can be like walking on a tightrope. If done well, it could enhance learning or at the very least make learning more fun. However, if not done well, it could have disastrous consequences. I remember a few years ago attending a webinar on use of humor and I found it to be so ineffective and boring that it was funny. Fun is 1 of the 5 primary human needs along with survival, belonging, power, and freedom.1 There are various positive ways to incorporate humor into the classroom.2 Humor can include funny stories and comments; jokes (especially self-deprecating ones); professional humor, such as linking content to mnemonic devices; cartoons; puns; riddles; top 10 lists; and comic verses. Humor can be used as an icebreaker, such as having students share their experience about a comical moment in a classroom. Humor can be used effectively to deal with classroom management issues such as instructor’s top 10 peeves. Humor can also be used to deal with sensitive topics to help students feel comfortable discussing those topics in the class. Humor can be useful for tedious and difficult subject matter. These positive ways can hit the target. There are also negative ways to use humor including sarcasm, especially if directed at students. Harmful effects of humor can be distracting in the classroom. Negative humor could dampen students’ motivation for the class and thus hinder learning. Lei summarized the drawbacks of humor on learning which included degrading remarks of students, offensive humor, and excessive humor.1 References to a person’s ethnic or sexual characteristics or to their appearance or a disability are inappropriate. These negative attempts at humor would be off the mark. Chabeli provided guidelines to facilitate learning through the effective use of humor.3 This author stated that students should connect the curriculum with fun. Using humor that is natural and spontaneous is best. Using facial expressions, such as a smile, enhances the effectiveness of humor. Hellman suggested 7 simple steps for using humor in the classroom including be yourself, pick your spots, be politically correct, know your audience, use oxymorons and acronyms, sometimes be quiet, and acknowledge others’ humor.4 Remember faculty members are not stand-up comedians. Humor provides a relaxed atmosphere in the classroom which is an environment conducive to learning, creativity, and critical thinking. It also makes the learning process more fun. When a faculty member is using humor, students need to perceive the faculty member as a caring human being. Appropriate use of humor can enhance a sense of community, foster openness and respect, and could contribute to effective learning. The value of the use of humor is mixed.5 Lei outlined 31 benefits of humor including: psychological, social, and cognitive, in which there is research evidence.1 Many of the benefits are theorized and not substantiated by rigorous research methods. Hackathorn et al showed that humor increases learning at the knowledge and comprehension levels of Bloom’s taxonomy but not at the application level.6 Appropriate use of humor can enhance retention, increase learning, improve problem solving, relieve stress, reduce test anxiety, and increase perceptions of faculty credibility.7 It also enhances students’ attitudes toward the faculty member and can make the faculty member more likeable. Torok reported on the relationship between use of humor and faculty members who were favored by students.7 There are gender differences in student perceptions of effective use of humor. Use of humor by women tends to be less frequently appreciated. This report consisted of faculty members from the disciplines of biology, educational psychology, and theater. This leads us to hypothesize about the role of humor in pharmacy education. Do pharmacy faculty members need to learn how to use humor as an instructional strategy? Does pharmacy education benefit from the use of humor? The paucity of research documenting the value of humor in pharmacy education and also medical education is noted.8 Most of the literature related to use of humor as a tool to enhance learning is found in the nursing literature. The research literature involves 3 categories: (1) use of humor for learning; (2) student evaluations of faculty members who use humor; and (3) effects of use of classroom humor on student performance, especially on examinations. There are numerous challenges for providing clear scientific evidence of the value of humor in pharmacy education. These challenges include the difficulties of controlling for other aspects of the learning environment such as the instructional methods used by faculty members, the academic quality of the students, and student appreciation for humor. There is probably a need for research on the role of humor in pharmacy education as no reports were found in the literature. There is a Humor Orientation (HO) Scale that measures an individual’s predisposition to convey humorous messages.9 Wanzer found that student perceptions of faculty members with a high HO tend to result in higher student perceptions of learning.5 Can faculty members with low HO learn to use humor effectively as a pedagogical tool? There are numerous techniques that can be learned and resources available by Ronald Berk.10,11 Some would argue that as there is contradictory evidence of benefits of use of humor on learning, why would you want to learn to use humor if you are not naturally humorous? Like physicians, pharmacist faculty members desire to have clear scientific evidence to support innovative instructional strategies outside of one’s comfort zone.12 Today’s generation of students expect learning to be enjoyable. At one time, there was no place for humor in the classroom.7 But now, the time for a stern professor as the “sage on the stage” is no longer acceptable. Humor creates a relaxed, engaging, and safe environment. It has been suggested that using humor as a pyromaniac can fuel the fires of curiosity in our students.7 Even if there is a paucity of scientific data proving the benefits of humor in pharmacy education, should we not want to make learning fun? As Thomas Edison said: “I never did a day’s work in my life – it was all fun.”13

Academic pharmacy practice fellowships address challenges of evolving pharmacist roles.

Does the academy have the responsibility of preparing graduates to realize their potential in society? This would include preparing them to practice advanced patient care roles in community and nontraditional practice settings such as medical homes, student health clinics, public health clinics, university based clinics, or community pharmacy wellness clinics, and to prepare future practice faculty members for the challenges of academic positions.1 With new regulations and the impact of the Affordable Care Act on the future of pharmacy, does the academy also have the responsibility to advance the practice of pharmacy in community and other nontraditional health care system settings? More than 10 years ago, an AACP task force provided numerous recommendations for postgraduate training to address the challenges of preparing future practice faculty members.1 The current residency structure for preparing practice faculty members does not adequately prepare residency graduates to assume faculty roles in teaching and scholarship, nor does it prepare them for advance pharmacy practice beyond traditional health care systems.2 Murphy advocated that pharmacy practice faculty members should be prepared to teach and conduct scholarship, in addition to serving as clinical role models.3 Even with teaching programs in existing residency training, there is a need to enhance the teaching and scholarship skills of future practice faculty members. An ACCP committee reviewed how residents are currently trained for academic positions and concluded that there is a need for quality standards for teaching programs, including an accreditation process.4 The academic community has a long history of leading the development of residencies and other postgraduate training for advancing pharmacy practice in healthcare systems and for developing clinical science as a respected academic discipline. However, with the momentum to obtain recognition of pharmacists as health care providers, there is a need for further creativity and innovation to address postgraduate practice needs, which would also help advance practice in community and nontraditional healthcare settings. Creativity and collaboration are essential to meeting these challenges. Colleges and schools of pharmacy should have a mission for engaging in postgraduate pharmacy practice education. The American Society of Health-System Pharmacists’ current accreditation process for residencies is not intended to meet the focus or needs of the academic community, community pharmacy, or nontraditional practice areas. Thus, another organization, such as the Accreditation Council for Pharmacy Education (ACPE), should develop quality standards and accreditation programs targeted to meet these needs. The model for postgraduate medical education might be considered where the schools are accredited but not the practice sites. Colleges and schools can help to achieve the goal of developing advanced practitioners to work in a variety of practice settings. It has been advocated that a tiered medical model for physician education should be followed for postgraduate pharmacy practice education.5,6 A new pathway for creating postgraduate training that specifically meets needs for academic practice faculty members and advances community pharmacy practice should be developed. One model proposed is that the 1-year postgraduate fellowship be set up as an optional year experience affiliated with colleges and schools of pharmacy. In other words, first professional degree PharmD students or pharmacists who desire to practice advanced direct patient care and teach would matriculate into an academic fellowship. In contrast to current models of residency training, where students are paid for the clinical services rendered, an academic affiliated postgraduate fellow would only be paid for teaching services rendered. This would address the challenge of funding residencies without being tied into clinical services provided. It would assist colleges and schools of pharmacy with providing instructors to address curricular requirements for enhanced skills development and practitioners who could develop new types of patient care services in community pharmacy or nontraditional practice areas. Unique practice models, scholarship related to teaching, and expansion of clinical service present opportunities for innovation. This type of academic fellowship would not only be intended to develop patient care skills but also enhance teaching and research skills. It would not be confined to meeting the same rigid standards for healthcare system practice that postgraduate year 1 residency programs must meet, but would allow for affiliation with various types of practice settings, including community practice. An academic fellowship in the colleges and schools of pharmacy would allow the fellow to develop skills in direct patient care, teaching, research, and scholarship, and in pharmacy practice settings other than health care systems. Core competencies for faculty members have already been delineated.1 At Southern Illinois University in Edwardsville, students have the option to pursue a specialized education track within the PharmD program that addresses teaching and learning and the scholarship of teaching and learning.7 Students who complete this track would be ideal for an academic fellowship, because they could apply skills learned in the track and focus on expanding clinical skills in various non-healthcare settings. A recognized accrediting agency like ACPE should be involved with setting quality standards for these academic pharmacy fellowships. This fellowship would be another way for graduates to expand their patient care roles outside of the traditional health care system, serve the needs of the academy by becoming qualified pharmacy practice faculty members with teaching and research skills, and develop advanced patient care roles in community practice and nontraditional healthcare systems.

Time for Consensus on a New Approach for Assessments

With the impending changes in the Accreditation Council for Pharmacy Education (ACPE) Standards projected for implementation in 2016, the academy is at another crossroads with respect to pharmacy education.1 One of the more controversial items is Standard 25.2, relating to standardized and comparative assessments.2 It states that “the assessment plan must include standardized assessments as required by ACPE that allow for national comparisons and college- or school-determined peer comparisons.” Specifically the Pharmacy Curriculum Outcomes Assessment (PCOA) is given as an example of a structured assessment that would help provide preadvanced pharmacy practice experiences (APPEs) assessment of foundational knowledge. The concept of standardized assessment is a response to a call from the Department of Education for more accountability to the public.3 The suggestion of using PCOA for preAPPE assessment of knowledge has generated reactions from the academy including criticism of the PCOA examination’s validity as a tool for curricular revision. Schools contend that each school’s curriculum is unique and that a standardized tool would be too prescriptive and stifle creativity among schools. Others do not like the idea of National Association of the Boards of Pharmacy (NABP) being involved in curricular assessment. Another concern is the additional cost and hurdle pharmacy students would incur. The profession currently regulates entry to practice pharmacy and protects the public with the National Association Pharmacy Licensure Examination (NAPLEX). Even though the blueprint for NAPLEX has evolved, with resulting changes in curricular content, the examination has never been a direct measure of curricular effectiveness nor has it assessed the skills and affective domains required for practice of direct patient-centered care as intended by the curricular outcome standards for the PharmD degree.4 The affective patient-centered skills are even more critical as we prepare for the evolving role of the pharmacist as a health care provider. The academy should be proactive in addressing the need for standardized and comparative assessments of curricular effectiveness. A standardized assessment model that intersects with the licensure to practice pharmacy should be advocated for. The model should assess competencies not only in knowledge, but also in skills and the affective domains to meet curricular outcomes. Most schools of pharmacy having limited resources, it would be more cost-effective for an institution like the NABP to collaborate with the academy and ACPE to focus on a new approach to licensure that would address the need for curricular assessment and address assessment needs for professional licensure to protect the public. The United States Medical Licensing Examination (USMLE), which uses a stepped approach to licensure, is worth considering as a model as both pharmacy’s and medicine’s curricula are intended to prepare graduates for patient-centered roles.5 The USMLE currently consists of 3 steps. Step 1 consists of multiple-choice questions that assess foundational sciences using clinical vignettes. Students complete it at the end of the second year of medical school. Step 2 consists of 2 parts: assessing clinical science knowledge using multiple-choice questions and assessing clinical, communication, and interpersonal skills using standardized patients. Students complete this step at end of fourth year of medical school. The third step is assessment of clinical science and competencies in management using multiple-choice questions and computerized case simulations. Step 3 is completed between the first and third year of residency. The model for pharmacy licensure could similarly be a 3-step approach that assesses knowledge, skills, and affective curricular domains of the ACPE Standards. Instead of administering a separate PCOA tool to assess the didactic curriculum prior to APPEs, the first step in the licensure process could be an assessment of core foundational knowledge administered upon completion of the preAPPE components of the curriculum (Step 1: PreAPPE Examination). Completion of the first step would be required for matriculating into APPEs. The examination would be developed and validated to address foundational knowledge delineated in the ACPE Standards, which would circumvent the issue of a separate PCOA examination. The second step would be to assess skills and the affective domains of the ACPE Standards (Step 2: Clinical and Patient-Care Skills). This step would include objective structured clinical examination (OSCE)-like processes and clinical/patient care case assessments administered upon completion of the APPE curriculum components. The third and final step would be an objective examination assessing knowledge of federal and state law and application of clinical knowledge to patient care (Step 3: Law and Clinical Applications Examination). This step would be completed upon graduation. The NABP could be responsible for creating the blueprint and administering all 3 steps of the examination. Such a model would benefit the academy and provide a stepwise assessment approach that would build on a solid scientific and clinical knowledge base and ultimately culminate in the ability of graduates to apply knowledge to practice. A standardized assessment model such as the USMLE would serve as the gateway for licensure to practice pharmacy, thereby addressing ACPE assessment standards and validating the curricular outcome expectations (knowledge, skills, and affective domains) for PharmD graduates. Moreover, it would address the need to protect the public because not only knowledge but also patient care skills would be assessed. If the academy, ACPE, and NABP can reach a consensus, it would enable the profession to proactively ensure that the public is protected by properly credentialed pharmacists who can competently deliver patient-centered care.

Design and evaluation of interprofessional cross-cultural communication sessions

Abstract The 2013 National Standards for Culturally and Linguistically Appropriate Services (CLAS) call for healthcare professionals to provide quality care and services that are responsive to diverse cultural health beliefs and practices. Accreditation organizations for health professional programs require their curriculum to adequately prepare future practitioners for serving culturally and linguistically diverse populations. Another common curricular need of health professional programs is interprofessional education (IPE). This study presents data that evaluates two IPE culturally competent communication sessions designed for pharmacy and nursing students. Teams of nursing and pharmacy students (n = 160) engaged in case studies focused on developing cross-cultural communication skills, using the LEARN model. Quantitative survey data collected pre-test and post-test measured cultural competency (including subscales of perceived skills, perceived knowledge, confidence in encounter, and attitude) and knowledge related to culturally competent communication. Univariate ANOVA results indicate that actual knowledge as measured by the test and all four Clinical Cultural Competency Questionnaire (CCCQ) subscales significantly increased after the IPE sessions. Pharmacy students scored higher than nursing students on the knowledge pre-test, and nursing students had a more positive attitude at pre-test. The IPE sessions effectively addressed all learning outcomes and will continue in future course offerings. Using cross-cultural communication as a thematic area for IPE program development resulted in educational benefits for the students. To further strengthen nursing and pharmacy students’ interprofessional practice, additional IPE opportunities are to be explored.

Where and How to Search for Evidence in the Education Literature: The WHEEL

An awareness of how and where to search the education literature, and how to appraise it is essential to be a teacher scholar (an academic who takes a scholarly approach to teaching), to develop high quality education research, and to perform the scholarship of teaching and learning. Most pharmacy faculty scholars do not receive training in searching the education literature. Thus, a framework for searching the education literature is needed. The framework presented here on where and how to search for evidence in the education literature, referred to as the WHEEL for teaching, is meant to serve as a guide for faculty members in conducting comprehensive and exhaustive literature searches for the publication of scholarship of teaching and learning projects, educational research, or approaching ones teaching in a scholarly manner. Key resources to search and methods for searching the education literature are listed and described.