Structured Practical Experience Program

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SPEP Goals

• Structured Practical Experience Program
• Teaching Associate Educational Program

2
GOALS OF SPEP

• to enable the student to understand the
  professional role of the pharmacist within the
  pharmaceutical care practice model
• to allow the student to further develop the
  skills, knowledge and competency required to
  provide pharmaceutical care

3
What is a typical rotation?

• Structured Practical Experience Program
• Teaching Associate Educational Program

4
Typical Rotation.

• No typical rotation
• Each rotation has unique characteristics
• Part of learning/challenge is adapting to the new
  learning environment and excelling
• Students take responsibility for learning and
  ensuring all activities and evaluations are
  completed

5
Factors that Affect your Learning

• Environment
• Need to establish what is best for learning in
  new environment
• Content
• Move toward application of information
• Facilitator
• Teaching associates will have different ways of
  teaching and learning
• Successful rotation recognize there will be
  differences in learning styles

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Learning Style Inventory

• Kolbs Learning Style Inventory
• 4 Learning Style Types
• Diverging approach situations by observing
  rather than taking action
• Assimilating understanding a wide range of
  information and putting into concise and logical
  form
• Converging good at finding practical uses for
  ideas and theories
• Accommodating learn primarily from hands-on
  experience

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Teaching Styles

• How would you react to the questions posed by
  your TA?
• Uncomfortable (U) to Very Comfortable (VC)
• 1. What is the drug of choice for UTI?
• Amoxicillin is an option for that purpose, but in
  my experience increasing resistance patterns have
  made Septra a better choice.
• How did you arrive at your therapeutic
  recommendation and why?
• 4. Mr. Smith shared some information about his
  illness with you. How did that make you feel?
• Adapted from the Mountain Area Health Education
  Center

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Teaching Styles

• Take 5 minutes to think about these questions
  posed by your TA and rate each question.
• Discuss in groups of 4 or 5 your ratings and
  reason for your ratings of each question.
• Identify if there are differences or similarities
  from the group members.

9
Teaching Styles

• Assertive
• asking for very specific information
• Suggestive
• Information given is supported by experience
• Collaborative
• Explore the reason for the decision
• Facilitative
• Discussing the feelings elicited in a patient
  encounter

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• What is the drug of choice for UTI?
• (Assertive Style for questioning)
• Amoxicillin is an option for that purpose, but in
  my experience increasing resistance patterns have
  made Septra a better choice.
• (Suggestive style)
• 3. How did you arrive at your therapeutic
  recommendation and why?
• (Collaborative style)
• Mr. Smith shared some information about his
  illness with you. How did that make you feel?
• (Facilitative style)

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Application of Teaching Styles

• Be able to recognize different styles
• Observe your TA, other team members
• Discuss with your TA
• Be open to try learning within all types
• Consider when you need to teach and the style
  you will use

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What would you expect during week 1?

• Structured Practical Experience Program
• Teaching Associate Educational Program

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During your first day.

• TA Hi Sally, Im glad you are here. Would you
  mind counselling Mr. Jones on an antibiotic for
  his daughter? Im sure you learned all about
  these drugs at the Faculty. Ill be listening
  over here in case you get stuck

• How would you feel about this situation?
• What would you say to your TA?
• Is this part of your SPEP learning?
• What resources/ references would you rely on?

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Beginning of Rotation

• Meet and greet TA staff at site
• Orientation to site (learn work flow, computers,
  charts, rounds, roles of HCP)
• Discuss TAs expectations of the student
• Discuss the students and TAs responsibilities
  to patients
• Discuss supervision by other pharmacists
• Agree on how problems will be addressed and
  resolved
• Agree to communicate openly honestly

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Other Items for Discussion

• Review the required SPEP activities, identify
  opportunities to fulfill these requirements and
  consider timelines
• Review site-specific professional behaviour (ie
  dress code, confidentiality) and PB8 Form
• Discuss site-specific learning opportunities
  (part of Activity 4)
• Explore other resources/experts at site
• Review TA/E 12 Form
• Start practising pharmaceutical care

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What should be completed by week 2?

• Structured Practical Experience Program
• Teaching Associate Educational Program

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By the end of Week 2.

• PC in its entirety for 4 patients (16 patients
  for each rotation)
• Completed 5 OBS 1A forms
• Draft site-specific learning objectives
• Submit PC1B form, OBS 1A forms, 1 care plan,
  site-specific learning objectives
• Send in on Friday of week 2

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Activity 1 Pharmaceutical Care

• Provision of PC is main focus of SPEP (80 of
  time)
• What is your experience in providing PC?
• Have you observed another pharmacist providing
  PC?
• How confident do you feel providing PC at this
  point?

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Providing PC to Patients

• Select patients with acute and chronic illness
  (list of disease states (p.41))
• Choose appropriate patients with TA
• Patient work-up (often more than 1 DRP)
• Consistent approach to presenting case (ie SOAP
  or other format)
• Example of typical day in hospital

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Patient Information Elements

• 1. ID
• Demographics
• Date of admission
• 2. RFA
• 3. HPI
• 4. PMHx
• 5. Meds PTA
• 6. Allergies
• 7. Social History

• 8. Review of Systems (ROS)
• 9. Labs
• 10. Microbiology
• 11. Diagnostic Tests
• 12. Meds on Admission
• 13. Patient Discussion
• 14. HC Team Discussion

Adapted from UHN, O. Fernandes
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UHN SPEP rotation

• A typical day for an SPEP student
• Tailored to clinical site
• Gen Med
• Morning Report
• Bullet Rounds
• Time to work up patients/ meet with patient/
  team/ make interventions
• Noon Rounds
• Student / Preceptor discussions
• Patients/ Structured Discussions
• Specialty Rounds

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Provision of Pharmaceutical CareObservation
Records(OBS 1A Forms) (p.38)

• coaching tool to receive regular and frequent
  feedback
• provides evidence to support formal biweekly
  evaluations (PC1B form)
• Faculty requires this type of documentation as
  evidence of learning

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Observation RecordsProcess

• minimum of one observation record every 2 days
  (i.e. 5 records every 2 weeks) filled out by TA
• observations are shared with student
• specific actions/behaviours described (effective
  behaviours and areas for improvement)
• Non-TA pharmacist can also fill out records
• Students should receive feedback from the Non-TA
  pharmacist and/or TA

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Observation RecordsCompletion by TA

• categories on Observation Record reflect
  assessment components on the 2-weekly PC
  evaluation form (PC1B)
• TA completes observation records for most parts
  of PC process within each two-week period
• all categories do not have to be completed on
  each Observation Record

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• OBSERVATION RECORD
•  
• Student Name                        
• Date of Observation                   
• Pt. Initials Age Sex M F
•  
• Main Conditions Significant Medications
• (or attach anonymous profile)
•  
•  
•  
• Observations (Check all that apply)
• 1. Development of relationship with a patient ?
• 2. Response(s) to drug/disease question(s)
• arising in the provision of care ?
• 3. Identification of a patients actual or
  potential
• drug-related problem(s) ?
• 4. Collaboration with another health care
  provider ?

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Pharmacy Care Plans
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Care Plans

• Submit 1 care plan every 2 weeks more if
  requested by Faculty
• Format of care plans should meet the criteria
  outline in syllabus (p.42)
• Examples of care plan formats in syllabus at end
  of Activity 1
• If patient has more than 1 DRP, monitor all DRPs
  submit care plan with 1 or more DRPs depending
  on complexity
• Submit photocopy of plan actually used at the
  site (all patient identifiers must be removed)

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Care Plans

• How comfortable are you in developing care
  plans?
• Examples?

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Assessment Criteria for Care Plans (p. 42
Syllabus)

• organized, concise
• relevant patient information included
• other relevant information included
• DRPs listed and prioritized
• plan of action outlined
• evidence that patient perspective considered
• outline of implementation plan
• follow-up, monitoring outcomes
• transfer of care
• reference sources

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Evaluation of Provision of Pharmaceutical
Care(Form PC1B)
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Provision of Pharmaceutical CarePC1B Evaluation
Form (p.39)

• teaching associate provides evaluation at weeks
  2,4, 6, 8
• student provides self-evaluation at weeks 2,4,6,8
  
• Performance based on 7 categories (same as on OBS
  1A form)
• all categories must be completed
• 7 point rating scale with comments

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PC 1B Evaluation Form

• outline students areas of strength and areas for
  improvement in each domain
• include comments on areas that have improved or
  worsened since last evaluation
• ensure sufficient comments to give a complete
  picture of student performance
• Form submitted on-line (preferred)

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Performance Guidelines (p.36)

• Develop effective relationships with patients
• Respond to drug/disease questions
• Identify patients actual and potential
  drug-related problems
• Collaborate with health care providers
• Develop and implement care plans
• Monitor and follow up with patients
• Document relevant information

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Drug/Disease Questions
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Drug and Disease Question (p.43)

• Responses to drug/disease questions routinely in
  provision of care
• Submit one sample response on weeks 4 6
• Outline date, source of question, contact
  information, background information, question,
  response, references
• List all references and search strategy

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Documentation

• What to document?

• DRP justification
• Possible solutions to DRP
• Recommendations justification
• Medication counselling
• Monitoring plan follow-up
• Pharmacokinetic monitoring

39
Documentation Principles

• Content
• Include information that is necessary to make
  decisions
• Presentation
• Logical, coherent
• Include standard components
• SOAP (Subjective, objective, assessment plan)
• FARM (Findings, assessment, resolution,
  monitoring)
• DAP (data, assessment plan)
• Style
• Clear, concise, professional, diplomatic

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Where to Document

• Patient profile (manual, computerized)
• Letter to physician
• Patients health care record in hospital setting
• Multidisciplinary team records
• Third party payers
• Note for patients with instructions
• Check with TA for site-specific process for
  documenting

41
Examples of Documentation Formats

• A - Letter to Physician (p.44)
• Letterhead
• date
• Dear Dr. Collaborative
• introduction
• body
• closing
• Sincerely,
• J. Approachable
• Jane Approachable, B.Sc. Phm

• B - Health Care Record Documentation
• date
• drug-related problem
• rationale
• recommendations /plan
• J. Approachable, B.Sc. Phm

42
Assessment and Feedback

• Teaching Associate Educational Program
• Structured Practical Experience Program

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Video of student and patient

• Watch video and assess student performance
• note positives and areas for improvement
• jot down behaviours observed on OBS form
• assign a rating
• prepare to give feedback to the student on
  components 1,3,5 of the PC process
• assume this interview is occurring midway through
  the 2nd week of Rotation 1

44
Post video exercise

• In groups of 4-5
• discuss your feedback in your group
• how did others state their feedback?
• was it specific?
• note any useful phrases
• what was good/fair/excellent about the behaviour?
• note how ratings may have differed among your
  group

45
Sample OBS - I

• Week 2 Rating Very Good
• List actions/behaviours/phrases that made
  performance effective or ineffective
• Excellent technique made customer feel very
  comfortable small joke at the beginning
• Good knowledge base knew exactly what he was
  talking about and very confident - customer felt
  this and responded wow- you're very thorough"
•  
• Suggestions for improvement
• Remember to get all info at beginning reason for
  use came out but should have been determined
  before counseling on side effects

46
Sample OBS - II

• Week 2 Fair
• List actions/behaviours/phrases that made
  performance effective or ineffective
• I DRPs stated in point form with no
  explanation/relationship to drug therapy.
• E Monitoring plan identifies appropriate
  symptoms and side effects
• I Assessment of alternatives is missing
• ETherapeutic plan contains key points/issues
• E Some values recorded for monitoring
•  
• Suggestions for improvement
• Assessment of alternatives should include a very
  brief list of alternatives (even by class) and
  reasons for ruling out
• Do you want to modify your worksheet to help
  clarify your plans?

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Sample OBS - III
Week 4 G List actions/behaviours/phrases that
made performance effective or ineffective made
patient feel at ease started interaction by
asking what patient would like to know (i.e
identified patients learning goals) good word
selection for explaining how medications work -
when patient did not have many questions did not
adapt structure of interaction to patients
learning needs   Suggestions for improvement -
Have goals for minimum amount of information to
be given, before going into interaction - This
was a challenging interaction to prepare because
the RN led us to believe that the patient had
many questions
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Basic Principles Giving and receiving Feedback

• Structured Practical Experience Program
• Faculty of Pharmacy
• University of Toronto

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Basic PrinciplesGiving and Receiving Feedback

• giving feedback effectively is a skill
• - it can be learned and can be improved
• receiving feedback positively is also a skill
  that can be learned and improved
• SPEP rotations will require participants to both
  give and receive feedback effectively

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In order to be effective feedback must

• be regular and systematic
• be recognized by both the giver and receiver as
  necessary and desirable
• be timely
• use descriptions of specific actions and
  behaviours as examplesnot just good, right,
  wrong
• measure behaviour or action against a standard or
  expected level of performance

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• In order to be effective feedback must
• be individual and personalized
• be sensitive to receivers individual needs and
  ability
• be balanced - area for improvement sandwiched
  between positive reinforcement
• be fair, unbiased - based on accurate
  observations
• be consistent with the givers own behaviournot
  Do as I say not as I do!
• be given privately

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Students who benefit most from feedback

• want to grow and develop
• feel that the feedback has been carefully
  considered
• recognize that skills develop only with practise
• really HEAR the feedbacklisten attentively
• are not defensive about feedback
• seek clarification when necessary to aid
  understanding

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• Students who benefit most from feedback
• have assessed their own performance and are
  prepared to discuss this
• use open, honest, and assertive communication
  techniques
• recognize that giving (and receiving) feedback
  can be challengingand contribute to creating a
  positive environment for this exchange
• explain when feelings (e.g. embarrassment,
  insecurity, sensitivity) are interfering with the
  ability to receive feedback positively
• understand the value of feedback in enhancing
  learning

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What do you need to submit at Week 4?

• Structured Practical Experience Program
• Teaching Associate Educational Program

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Week 4 Submissions

• Activity 1 (PC 1B, OBS 1A, 1 care plan,
  drug/disease question)
• PB 8
• TA review of portfolio

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Activity 8 Professional Behaviour (p.72)

• Standards of Professional Behaviour for Pharmacy
  Undergraduate students
• professional activities will be characterized
  by honesty, integrity, conscientiousness and
  reliability

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Professional Behaviour PB8 Form

• Examples from Section A
• Students must demonstrate
• Empathy and compassion for patients
• Respect for confidentiality of all patient/client
  information
• Appropriate personal conduct

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Professional Behaviour - Continued

• Examples from Section B
• Students must not
• Violate the criminal code
• Fail to accept responsibility and/or communicate
  the need for preventing or resolving a drug
  related problem
• Fail to respect patients/clients rights

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Scenario

• You are training on the general medicine ward.
  During a routine hospital audit of computer
  files, your TA is notified that you have accessed
  a record of a patient in the ER department.
• What actions/issues need to be considered in this
  situation?

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What should be completed by week 6?

• Structured Practical Experience Program
• Teaching Associate Educational Program

61
Week 6 Submissions

• Activity 1 (PC1B, OBS 1A, 1 care plan, drug/
  disease question)
• Form 2/4/6 - (Form completed by TA)
• Activity 2 Ethical Moral issues
• Activity 4 Learning Portfolio
• Activity 6 Interview Community Rotation only
• Form 9/10 (Form completed by TA Student)
• - Activity 9 10 Contributions to
  Pharmaceutical Care

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Submission Week 6 or 8

• Submit Form 3/5/7 (Form completed by TA
  Student)
• Activity 3 Presentation
• Activity 5 Health Promotion Community
  Rotation only
• Activity 7 Team meetings (Institutional
  Rotation only)

63
Activity 2 Ethical, Moral, Social Issues (p.46)

• Identify, discuss document 4-6 issues
• Issues identified by the student or TA
• Document each issue (1-2 lines) and personal
  reflection and insight gained (1-2 paragraphs)
• Submit student documentation and Form 2/4/6
  completed by TA

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Ethical, Moral, Social Issues

• Any examples from your experience?

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Activity 2 example

• A person identifying himself as a police officer
  calls the pharmacy requesting information on the
  drug history of a customer. According to the
  caller, the person is being investigated and has
  some unlabelled vials at home. Should the
  pharmacist provide the information to the caller?