Organizing a Community Advanced Pharmacy Practice Experience

Abstract

Setting up a community advanced pharmacy practice experience can be an overwhelming task for many pharmacy preceptors. This article provides guidance to pharmacist preceptors in developing a complete and effective community advanced pharmacy practice experience (APPE). When preparing for the APPE, initial discussions with the college or school of pharmacy are key. Benefits, training, and requirements should be addressed. Site preparation, including staff education, will assist in the development process. The preceptor should plan orientation day activities and determine appropriate evaluation and feedback methods. With thorough preparation, the APPE will be rewarding for both the student and the pharmacy site.

INTRODUCTION

Setting up an advanced pharmacy practice experience (APPE) site may feel like an overwhelming task. This article will provide the reader with some practical ways to set up the site and prepare the pharmacy and staff members for the student's arrival. Tools provided in this article include lists of topics to discuss with administrators at the college or school of pharmacy in advance of the APPE and with the student during a structured orientation. Preparation of the pharmacy and pharmacy staff will be discussed. The article will also provide preceptors with tips on obtaining feedback and conducting evaluations.

PREPARATION

Preliminary Discussions With the College or School

Before contacting a college or school of pharmacy about establishing an APPE site, the prospective preceptor should understand his/her employer's national or regional policies on precepting students. A discussion with his/her immediate manager or supervisor can begin this process. There are several topics, summarized in Table 1, to address with the college or school of pharmacy before precepting students. Discussing these issues in advance will make the experience more enjoyable for everyone involved. This dialogue helps to set clear, consistent expectations for the students with whom the preceptor will be working. In addition, when difficult situations arise, the preceptor will be better equipped to handle them appropriately. Many colleges have an experiential program coordinator who organizes the APPE and serves as the primary contact person for preceptors. This is the person with whom the prospective preceptor should have some preliminary discussions.

Table 1.

Topics for Prospective Preceptors to Discuss With the College or School of Pharmacy Before Starting an Advanced Pharmacy Practice Experience

A topic that is of interest to most preceptors is that of attaining adjunct faculty position/status for serving as a preceptor. It is important to know if and when this is available, what privileges it includes, and how to access them. Examples of privileges may include library/Web access, special admission rates to cultural and sports events, use of athletic facilities, class audits/educational credit discounts, and bookstore discounts. Many colleges have committees that enable preceptors to provide input to the college, address current issues, and help direct the future of the experiential program as a whole. College resources are another area the preceptor should find out more about. Some colleges may provide APPE sites with various drug information resources (eg, software, books) or there may be a network/listserve of adjunct preceptors that can be helpful for new preceptors. Some colleges provide additional forms of compensation to sites which should be reviewed in advance.

Training may be offered for new preceptors to discuss the policy and procedures manual, APPE goals and objectives, evaluation procedures, online access/resources, software training/palm documentation system training, etc. If there is no official training provided, a policy and procedure manual should be obtained if available. Policies with which the preceptor should become familiar include the schedule of the APPE year, holidays, absences/excused absences, grievances, and professionalism expectations (ie, honor code). It is important for the preceptor to ascertain from the college what training the students must complete before enrolling in an APPE. This would include, but is not limited to, administering immunizations, cardiac pulmonary resuscitation training, blood and universal precaution training, Health Insurance Portability and Accountability Act (HIPAA) training, conducting drug/alcohol screening/background checks, confidentiality statements, health insurance, liability insurance, and internship registration if required by the State Board of Pharmacy.

To meet the college's desired ability-based outcomes for the community APPE, students may be required to complete standardized assignments. The prospective preceptor and APPE site staff need to determine whether they have the resources necessary for every student they precept to meet the requirements and whether the requirements are compatible with site expectations. Overall, both the college and preceptor should agree on the outcomes students are expected to attain. The philosophy of both parties must be congruent to achieve the optimal educational setting.

A method of evaluating student performance that corresponds with the agreed upon ability-based outcomes should be discussed. There may be specific forms, unique grading systems (A-F, pass/fail, competency based), checklists, etc. Depending on the college or school, these may be Web-based or paper systems. Finally, preceptors should identify how they will be evaluated by the students and college in order to receive constructive feedback. Turning to site-specific issues, the availability and cost of housing should be considered for sites located outside of the city where the college is located. How many students can the site accommodate at one time? Are disability requirements met by both the site and available housing? Another consideration is the requirements of the site. These would be similar to items the site would cover for new employees. HIPAA policies, vaccinations, and signed forms indicating that the student agrees to comply with site-specific policies/procedures (ie, confidentiality) are just a few to note. The prospective site should determine how its resources may be utilized to enhance the student's experience and increase the student's understanding regarding the goals of the organization. For example, students may participate in an in-house training program for a specific disease state. Students are not allowed to be paid for fulfilling APPE responsibilities; thus, many colleges have policies indicating that students should not complete APPEs at sites where they are employed.

Preparing the APPE Site

Before the student arrives, it is best to discuss the student's role with the entire pharmacy staff. A meeting might be needed to allow staff members to engage in an open dialogue and ask questions. The goals and objectives of the APPE should be briefly reviewed with the staff and specific details should be discussed. This will enable staff members to understand what activities the student will be participating in that meet the college's objectives. For example, does the preceptor plan to involve the student in the prescription dispensing process? If so, are there set times of the day the student will be working in this role? What are the differences between staff responsibilities and student responsibilities? Should the student be using the cash register (most colleges restrict this activity completely)? Knowing these things in advance can help the student and staff focus on the duties for which each are responsible. Incorporating the student's learning needs into the practice site without utilizing the student as an “extra” staff member to dispense prescriptions is difficult. Committing to the education of the student and enabling the student to grow professionally will likely necessitate reallocation of the preceptor's time and/or the time of other pharmacists. The preceptor should remember that the more time he/she spends as an educator, the more the student will enhance his/her skills as a practitioner.

Orientation Materials

Gathering the materials needed for a successful orientation in advance will not only help preceptors plan the orientation session, but it will also help to structure the APPE. A binder with 4 sections kept at the site is an excellent way of organizing these materials. The first section could include general information regarding the site such as a list of staff members (with pictures, if possible), their titles and job responsibilities, important telephone and fax numbers, store hours, the pharmacy's mission statement, and a description of programs and services the pharmacy offers. Any important store policies and procedures of which the students should be aware should also be incorporated. The second section could include examples of past successful student projects, patient case presentations, newsletters, etc. The next section of the binder may include required reading materials for the APPE. The final section could include the specific goals and objectives for the APPE, an APPE calendar, and any forms the student needs to complete during the APPE.

Orientation Day

One of the key components of a successful experience is the orientation on day 1. Some preceptors find it best to meet the student 30 to 60 minutes prior to their staff's arrival to conduct this session without interruptions and distractions. This is a time when the student and preceptor can become familiar with one another and when clear expectations are conveyed to the student. The preceptor must explain in detail what the expectations are for the student. Remember, the more organized the preceptor, the site, and the APPE, the more likely the student will excel. The preceptor should have clearly stated goals and objectives to discuss with the student that will help explain his/her role over the next few weeks. This will engage the student's interest and commitment from “Day 1” and prevent the student from feeling lost in the shuffle of day to day activities. It is not uncommon for it to take 2-3 weeks for a student to become comfortable. This timeframe can be reduced by a good orientation.

Day 1 should begin with some basic introductions. The preceptor should share with the student his/her background, training, professional goals, and vision for the profession. Using the binder, he/she should describe the pharmacy, the community it serves, the programs and services it provides, and its vision and plans for the future. Discovering more information about the student can help the preceptor to formulate a learning experience that meets the student's needs. Some colleges have students construct a biographical sketch, compile a portfolio, and/or complete a questionnaire for preceptors to view in advance. This can provide preceptors and the staff with the student's background, previous work experience, completed APPEs, and future aspirations. If none of this information is formally provided, a good conversation with open-ended questions can elicit that information. Another aspect to this process is discussing with the student what their expectations and goals are for the APPE. What do they hope to get out of this experience? The preceptor should ask the student what his/her strengths and weaknesses are. How could the student utilize this to enhance his/her professional growth?

The preceptor should orient the student to the basics of the practice site. For example, discuss where the student should park. The student should be shown where he/she can store personal items, such as purses, bags, coats, and books. If employee locker space is available for student use, that might be helpful to keep things organized. The preceptor should take the student on a tour of the pharmacy, and point out areas such as the restroom and break area. Time and duration for breaks, such as lunch, should be discussed. Although it may seem like common sense that a break should not be 2 hours long, such problems can occur if guidelines have not been discussed.

The student's expected work hours should be discussed. Will the student be there from 8:00 AM-4:00 PM? Will the hours vary? If the normal schedule will vary during the APPE due to specific events or activities, the student should be informed of this on the first day of the APPE so he/she can plan ahead and adjust their personal schedule. If the preceptor expects the student to stay beyond normal hours if a patient appointment runs longer than expected, the preceptor should make this clear on the first day. It is not uncommon for patients to be late or appointments to run longer in clinical practice. The student should understand that responsibility for patient care is of primary importance and may necessitate working extended hours. Providing the student with a calendar of activities or having the student create the calendar on his/her first day is a good way for the student, the preceptor, and the staff members to be on the same page throughout the APPE. This calendar can be kept in a prominent area in the pharmacy. The preceptor should review the college's policy on absences and his/her expectations for how an absence will be reported. Is there specific documentation that should take place when a student is absent, such as a form submitted to the Director of Experiential Programs? The student should be made familiar with this process, and asked to contact the preceptor as soon as possible prior to an absence. The student should be told by what means he/she should contact the preceptor and/or the APPE site (phone number, email etc). The preceptor should discuss with the student what he/she will need to do to make up missed time if the student is absent. Identify what holidays the college recognizes. Colleges will have some holidays that are automatically a day off for the student, but some holidays are optional and at the preceptor's discretion. The preceptor should determine what his/her expectations are for the optional dates and address with the student whether he/she is to be at the site.

Day 1 is also a good time to have a conversation with the student regarding professional appearance. Is the student expected to wear a white laboratory coat at all times? Are women allowed to wear open-toed shoes? Should socks or hose be worn at all times? Should men always have a tie on? Keep in mind that each site, preceptor, and student may have a different definition of “professional dress.”

The preceptor should introduce the student to all staff members to help the student to feel a part of the team from the start. The student could shadow different members of the staff the first 2-3 days of the APPE. This is a way for the student to learn the pharmacy workflow and what is normal practice at the site, and helps to set the standard of expectations. This exercise reflects the importance of having staff model for the student the actions and behaviors expected at the site. For example, the pharmacy staff should model appropriate patient confidentiality procedures.

Students should have designated time to review the dispensing system. Although for some colleges, prescription order entry is not the focus of an APPE, students need to be familiar with the dispensing workflow, quality assurance procedures, and how to access and enter needed information. The student will need access to a phone to contact patients. Instruct them on any details necessary to use this phone. Is there a specific number to dial to get an outside line? How do they place a call on hold? Does the phone have the capability to transfer a call to another phone in the pharmacy? Is there a hands-free option? What is the proper way to answer the phone? Is the student allowed to make long-distance calls to patients or the college? The company's policy regarding personal calls and/or cell phone use during working hours should be discussed.

If possible, the student should have a designated workspace that includes a desk with a computer. A desk organizer could serve as a place for the preceptor to leave messages for the student and for the student to file/store projects he/she is still working on. The student should be told to keep the workspace tidy at all times. The student should be told if there is a designated place in which the preceptor would like charts or items that contain patient specific information stored (or shredded). It is important that patient confidentiality is maintained, and if the location of the pharmacy has multiple non-pharmacy staff members, there is a possibility that items left out will be seen by those who should not have access to them. If the site is not located in the same city/town as the college, the preceptor should familiarize the student with local resources such as the public library, video conferencing location, and physician's offices and hospitals.

Often, Internet access is needed for the student to access the college web site and e-mail. The student may also need access to the Internet to perform a variety of tasks, including drug information research. Any passwords needed to access the computer and/or Internet should be given to the student. If Internet access is not available and it will be needed to complete some tasks, the preceptor may consider scheduling some library time for the student to complete some projects.

After the preceptor has covered the logistics listed above, he/she should discuss with the student what the objectives are for the APPE. What will the student be doing over the next 4-5 weeks? In the syllabus, the preceptor should connect the objectives and activities to the college's ability-based outcomes and the evaluation process so the student can see the relationship and identify how the activities they complete will assist in their development. The student should be involved in the selection process of a major project and activities if possible. A project and activities that will be beneficial for the pharmacy but also of interest to the student should be identified to facilitate his/her learning. Due dates for specific projects/activities should be provided. Due dates for submitting an outline and rough draft that are prior to the final due date should also be set. This will allow the preceptor to provide feedback to the student and redirect him/her if necessary to prevent submission of a final project that does not meet the preceptor's expectations. These dates can be added to the calendar.

Overall, an orientation highlights what the next few weeks will hold and allows the student to know in advance what to expect. Remember that a good orientation will reduce the number of questions the student will need to ask and will improve efficiency in getting started. Table 2 provides a checklist of topics to cover during orientation.

Table 2.

Orientation Checklist for Advanced Pharmacy Practice Experience

EVALUATION AND FEEDBACK

During orientation, the methods that will be used for evaluation should be identified. If the college does not have anything developed, the preceptor could develop his/her own evaluation methods. The student should be asked to document the date and description of each assigned activity, time spent on the activity, and the competency/objective this activity satisfied. This is something the preceptor can take a look at a few times each week to survey all of the activities the student has completed and identify future focus areas for the student.

Providing informal feedback on a regular basis and performing written formal evaluations are an important component to the experience. The evaluations can be a mechanism of exposing students to different ways of doing things to expand their horizons. They will work with many different people over the course of their career and need to be prepared to listen and adapt to other ideas. Some general guidelines for providing feedback are listed in Table 3. If multiple pharmacists/staff members work with the student, their feedback should be solicited when performing evaluations. Often, the primary preceptor is not with the student 40 hours per week; therefore, input from others will provide a more accurate assessment of all of the student's activities throughout the APPE.

Table 3.

Guidelines for Feedback Given to Advance Pharmacy Practice Experience Students

The preceptor should consider providing both oral and written feedback to the student. Verbal feedback is more immediate and situational and is often provided following observation of a student in an activity. This is an opportunity to turn ordinary moments into teachable moments. Any feedback given to the student in front of others should be constructive in nature (ie, “you did this very well; however, you might want to consider doing this a little differently next time”). If a site has more than one student at a time, the preceptor might consider involving the students in the evaluation process of their peers. For example, following a case presentation, the preceptor could ask the other students to provide feedback before the preceptor offers his/her own thoughts to the student. For an activity where the student has to counsel a patient about a product, another student could play the role of the patient and then provide feedback on whether he/she would be able to use the product based on the counseling provided.

Written feedback is recommended at the midpoint and final evaluation time points, offering the benefit of additional time for reflection. Many colleges offer written evaluation tools for student and preceptor use. Students can perform written self-evaluations to reflect on their performance over the APPE, identify areas in which they feel competent, and consider areas they would like to focus on for improvement in the future. The preceptor's written feedback and recommendations for the midpoint and final evaluations provide documentation for the college and helps the student identify areas in need of improvement.

The preceptor should discuss the student's progress on the select competencies with him/her and provide constructive criticism for improvement. To tell a student he/she is not performing up to expectations simply leaves the student with a feeling of inadequacy. The preceptor should identify the areas of concern and then show the student how he/she can improve. If there is an opportunity to role model the activity, this should definitely be done. People perform better once they have observed the proper way of doing something. If a specific behavior is expected, the preceptor and/or a staff member should be able to exhibit it for the student. Positive feedback should be included in formal and informal evaluation processes whenever possible. When a student does something well, he/she should be told. A verbal “pat on the back” is a powerful motivator.

Experiential preceptors help to teach and assist in student learning, with the ultimate goal of ensuring the student excels. Saying nothing is a form of silent approval, so if something needs to be done in a different manner, the preceptor must tell the student. Likewise, providing passing scores just to avoid conflict does both the student and the profession a disservice as these students are the future of pharmacy. Both the college and the site's standards should be set for what the expectations are of a new graduate. Final evaluations should be based on final performance. Did they learn and improve upon skills they completed at a lower level initially? Grading criteria should be consistent and utilize the college's grading system as closely as possible. Drake College of Pharmacy utilizes a proficiency scoring system. This system is based on the expectations for a new graduate to practice pharmacy. This scoring system can be found in Table 4.

Table 4.

Drake College of Pharmacy Proficiency Scoring System^*

^*Published with permission from the College of Pharmacy, Drake University

Throughout the APPE, if the preceptor has concerns or questions regarding the progress of a student who is having difficulties, the preceptor should communicate these to the college in a timely manner. If a student is struggling, it is important that the college is aware of this in order to provide assistance to the student and the preceptor and/or site. All information regarding the student should be kept confidential. Their learning experience and progress is something that should only be discussed with the student and with the college. Students should be provided with a form to evaluate the site and provide feedback on how to improve the APPE for future students.

CONCLUSION

The substantial effort put into the preparation of establishing a community APPE is minimal compared to the rewards from the experience. All of the preparatory steps help to attain the ultimate goal of creating an experience that benefits the professional development of the student and enhances the pharmacy site.