PRECEPTING STUDENTS AND RESIDENTS Anne Marie Bott, PharmD, BCOP, BCPS IHS Alaska Area Oncology Pharmacist Infusion Center Pharmacy Manager Alaska Native Medical Center Courtney Klatt, PharmD, MBA, BCPS Pediatric Pharmacist Alaska Native Medical Center
DISCLOSURES No conflicts of interest to disclose.
OBJECTIVES Identify the four preceptor roles as defined by the American Society of Health-System Pharmacists (ASHP) Produce learning objectives for the learning experience Produce learning activities based on the individual preceptor roles Illustrate effective feedback
PRE-TEST 1. What is the correct order of the four preceptor roles as defined by the American Society of Health-System Pharmacists? a) modeling, instructing, coaching, facilitating b) instructing, modeling, coaching facilitating c) modeling, coaching, instructing, facilitating d) instructing, coaching, modeling, facilitating 2. Which of the following is an objective? a) Interact effectively with the health care teams to manage patients’ therapy. b) Participate in daily rounds. c) Identify medication-related problems and address them with the team. d) Make evidence based recommendations.
PRE-TEST CONTINUED 3. Learning activities should: a) Be actionable b) Specific c) Explain how an objective will be met d) All of the above e) B and C 4. Feedback should be ____. a) Given when you discuss an evaluation b) At scheduled times c) Constructive d) B and C e) All of the above
Instructing Precepting Facilitating Modeling Coaching
IMPORTANCE OF PRECEPTOR ROLES Builds clinical reasoning abilities ▪ Defined as “higher order thinking in which the health care provider, guided by best evidence or theory, observes and relates concepts and phenomena to develop an understanding of their significance”.
3 PARTS OF CLINICAL REASONING Pattern recognition/nonanalytic reasoning ▪ Subconscious process ▪ Relate verbal and non-verbal input to a past experience ▪ Recognition of when a pattern doesn’t fit or apply Analytical reasoning ▪ Controlled process ▪ Gathering knowledge – chart review, reading guidelines ▪ Applying logic and inference Prevention of cognitive errors ▪ Awareness of potential biases and personal strengths/weaknesses
NIMMO’S MODEL Image From: Kristin W. Weitzel, Erika A. Walters, James Taylor, Teaching clinical problem solving: A preceptor’s guide, American Journal of Health-System Pharmacy , Volume 69, Issue 18, 15 September 2012, Pages 1588 – 1599, https://doi.org/10.2146/ajhp110521
OBJECTIVES VS. ACTIVITIES Objective ▪ ASHP has these set for residents in the guidelines ▪ Observable, measurable statement describing what the student or resident should be able to do by the end of learning experience ▪ Can be created for students who are on rotation Activity ▪ What the student or resident will do to help achieve the objective ▪ Should be actionable ▪ Specific
EXAMPLE FROM ASHP: Manage aspects of the medication use process related to formulary management. • Review non-formulary drug requests to determine if meet criteria for approval. • When a non- formulary or “patient’s own drug” is prescribed, ensure bar-coding of the medication is completed before dispensing. • Recommend formulary therapeutic alternatives for non- formulary medications, as appropriate. https://www.ashp.org/-/media/assets/professional-development/residencies/docs/learning-activity- examples.ashx?la=en&hash=06B1F8664EB0FB03AFC3A07AC797CE7DBCD467A8
DISCUSSION/ACTIVITY Given the following as an Objective, create two learning activities: Prepare and dispense medications following best practices and the organization’s policies and procedures .
INSTRUCTING Providing information that is necessary to acquire before skills can be applied or performed necessary information foundational learning clear instructions
INSTRUCTING Provides foundational knowledge and skills to apply to patient care Lectures ▪ Can include fictional case-based teaching ▪ Rarely used in clinical setting Assigned readings ▪ Guidelines ▪ Site specific policies and procedures
INSTRUCTING STEPS Recommend guidelines ▪ Look up the most up to date guidelines ▪ If from various sources, compare them ▪ Results ▪ Expands knowledge or provides a refresher to fill in knowledge gaps ▪ Guidelines are applied to patients/disease states ▪ Leads to start of applying script theory
SCRIPT THEORY Application of script theory ▪ Brain organizes memories and knowledge as structures/scripts ▪ Review guidelines ▪ Review patient chart ▪ Apply guidelines to patient case ▪ Refinement and further development of knowledge base ▪ Develops non-analytic reasoning Script Theory continues into the next preceptor role of modeling
STUDENT INSTRUCTING SCENARIO Review medication counseling ▪ Common medications ▪ Compile important information into a document or table for review ▪ Assesses and confirms prior knowledge ▪ Fills in knowledge gaps Counseling expectations are reviewed
RESIDENT INSTRUCTING SCENARIO Resident verifying new orders ▪ Drug – indication appropriate? ▪ Dose: including compounding dilution ▪ Route: IVPB, IV, SQ, IM, PO etc. ▪ Rate ▪ Pre-medications: any necessary? New order verification can also incorporate discussion of guidelines when determining if all of the above are appropriate
MODELING Demonstrating a problem- solving skill or process with verbal cues verbal cues to allow learner to observe skill sets thoughts or problem- solving process. demonstrating important processes
MODELING Providing an example for the learner to follow ▪ Also referred to as “active observation” ▪ Takes place during an actual situation ▪ Rounding ▪ Counseling ▪ Patient case discussion Best used once the learner has foundational knowledge/skills (instructing)
CONTINUATION OF SCRIPT THEORY Think Out Loud ▪ Explain observations and thought processes ▪ Describe patterns and missing information if discussing a patient case ▪ Facilitates further development of scripts that were established during instructing role
STUDENT MODELING SCENARIO Medication counseling Preceptor talks through the counseling process ▪ Reviewing orders and filled medications ▪ Key points to educate patients on ▪ New patients vs those that have been on the medication ▪ Explain the process and thoughts or considerations ▪ Student observes counseling patient with preceptor
RESIDENT MODELING SCENARIO Preceptor models process of verifying orders Making sure to discuss thoughts out loud Making sure to point out why something is not appropriate with an order if it needs to be corrected and why
COACHING Allow learner to guidance perform a skill while observing and providing any feedback necessary feedback. support
COACHING Learner performs a task or skill that was previously modeled for them Provides situations for supervised, practical experiences Provide feedback and direction that allows refinement of skill or knowledge ▪ Make sure to give timely feedback to reinforce good habits and prevent bad habits
FACILITATING Allow the learner to perform independently while remaining provide observe assistance debrief available if needed if needed and for debriefing afterwards.
FACILITATING Observe learner in performing specified duties as appropriate Ensure two-way communication during facilitation ▪ Learner asks questions as needed Engage learner in self-assessment
SELF-ASSESSMENT DURING FACILITATING Continue to perform tasks or skills that were modeled and coached Provide an opportunity for the learner to evaluate their own progress ▪ Helps learners develop a habit of evaluating their own behaviors and clinical skills Leads into feedback
WHAT IS FEEDBACK? Exchange of information from preceptor to student or resident that describes their performance Is not an “evaluation” ▪ Usually done at the end of a learning experience or APPE rotation. ▪ Renders judgement on where the student or resident is in their development/learning Avoid vague or misleading statements
STEPS FOR PROVIDING EFFECTIVE FEEDBACK 1. Timing Agree upon a time for discussion Encourages a team approach 2. Preparation Make notes on strengths/weaknesses and performance Use a grading sheet/scale Examples: rubric, checklist, rating scale 3. Discuss strengths Avoid statements like “you did great” because it makes discussing weaknesses difficult
STEPS FOR PROVIDING EFFECTIVE FEEDBACK 4. Discuss weaknesses Limit the number of weaknesses so they are not overwhelmed and can focus on an area or two 5. Set goals Discuss what to improve on in future Create a plan that will help aid in improvement 6. Follow-up Repeat steps 1-5 emphasizing area for improvement from step 5 the previous time
POST-TEST QUESTION 1 1. What is the correct order of the four preceptor roles as defined by the American Society of Health-System Pharmacists? a) modeling, instructing, coaching, facilitating b) instructing, modeling, coaching, facilitating c) modeling, coaching, instructing, facilitating d) instructing, coaching, modeling, facilitating
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