precepting students and residents · precepting instructing modeling coaching facilitating ... also...
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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
PRECEPTING STUDENTS
AND RESIDENTS
◼No conflicts of interest to disclose.
DISCLOSURES
◼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
OBJECTIVES
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, facil itating
b) instructing, modeling, coaching facil itating
c) modeling, coaching, instructing, facil itating
d) instructing, coaching, modeling, facil itating
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
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
PRE-TEST CONTINUED
Precepting
Instructing
Modeling
Coaching
Facilitating
◼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”.
IMPORTANCE OF PRECEPTOR ROLES
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
3 PARTS OF CLINICAL REASONING
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
◼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
OBJECTIVES VS. ACTIVITIES
EXAMPLE FROM ASHP:
https://www.ashp.org/-/media/assets/professional-development/residencies/docs/learning-activity-
examples.ashx?la=en&hash=06B1F8664EB0FB03AFC3A07AC797CE7DBCD467A8
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.
◼Given the following as an Objective, create two learning
activities:
Prepare and dispense medications following best practices
and the organization’s policies and procedures .
DISCUSSION/ACTIVITY
INSTRUCTING
Providing information that is necessary to acquire before skills can be applied or performed
necessary information
clear instructions
foundational learning
◼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
◼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
INSTRUCTING STEPS
◼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
SCRIPT THEORY
◼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
STUDENT 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
RESIDENT INSTRUCTING SCENARIO
MODELING
Demonstrating a
skill or process with
verbal cues to allow
learner to observe
thoughts or problem-
solving process.
demonstrating important processes
skill sets
verbal cues
problem-solving
◼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)
MODELING
◼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
CONTINUATION OF SCRIPT THEORY
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
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
RESIDENT MODELING SCENARIO
COACHING
Allow learner to
perform a skill while
observing and
providing any
necessary feedback. support
feedback
guidance
◼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
COACHING
FACILITATING
Allow the learner to
perform independently
while remaining
available if needed
and for debriefing
afterwards.
observe provide
assistance if needed
debrief
◼Observe learner in performing specified duties as appropriate
◼Ensure two-way communication during facilitation
▪ Learner asks questions as needed
◼Engage learner in self-assessment
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
SELF-ASSESSMENT DURING FACILITATING
◼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
WHAT IS 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
STEPS FOR PROVIDING EFFECTIVE FEEDBACK
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
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
POST-TEST QUESTION 1 ANSWER
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 tea
d) Make evidence based recommendations.
POST-TEST QUESTION 2
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.
POST-TEST QUESTION 2 ANSWER
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
POST-TEST QUESTION 3
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
POST-TEST QUESTION 3 ANSWER
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
POST-TEST QUESTION 4
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
POST-TEST QUESTION 4 ANSWER
QUESTIONS / DISCUSSION
◼Lynne M Sylvia, A lesson in clinical reasoning for the pharmacy preceptor, American Journal of Health-System Pharmacy , Volume 76, Issue 13, 1 July 2019, Pages 944–951, https://doi.org/10.1093/ajhp/zxz083
◼Required Competency Areas, Goals, and Objectives for Postgraduate Year One (PGY1) Pharmacy Residencies. (2015, March 8). Retrieved January 7, 2019, from https://www.ashp.org/-/media/assets/professional-development/residencies/docs/required-competency-areas-goals-objectives
◼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
◼Melissa S. Medina, Providing feedback to enhance pharmacy students’ performance, American Journal of Health-System Pharmacy , Volume 64, Issue 24, 15 December 2007, Pages 2542–2545, https://doi.org/10.2146/ajhp070316
◼Melissa S. Medina, Assessing student performance during experiential rotations, American Journal of Health-System Pharmacy , Volume 65, Issue 16, 15 August 2008, Pages 1502–1506, https://doi.org/10.2146/ajhp080007
REFERENCES