Improving Student Professionalism During Experiential Learning

Abstract

The purpose of this paper is to serve as a tool for preceptors to aid in pharmacy students' development of professionalism. Specifically, the article defines professionalism, describes it in the context of contemporary pharmacy practice, discusses the professional socialization process of students, and suggests strategies for preceptors to facilitate improvement in professionalism among students during experiential training. While numerous suggestions are presented, positive role modeling is considered the most important means of improving professionalism among students.

INTRODUCTION

Pharmacists have traditionally been held in high esteem by the public, ranking prominently in polls for trust, ethics, and honesty. As health care providers, we certainly should be held to high standards of practice in the care of patients. This level of professionalism is increasingly important as the health care system and needs of society continue to evolve. The clinical pharmacy movement, which gained momentum in the 1970s, continues to grow and expand. Many pharmacists and practices have embraced and implemented pharmaceutical care to make a significant difference in patients' lives. Opportunities abound to move the profession forward, especially with the potential of Medicare Part D and Medication Therapy Management. Many student pharmacists are engaged in activities to improve the health of their communities as well as actively participate in professional organizations.

Maintaining and enhancing this professionalism can seem rather daunting, as reflected in daily news reports of professionals, celebrities, high-ranking officials, and other role models engaging in some sort of unprofessional, unethical, or even criminal behavior. Apparently no profession is immune as these behaviors have been cited in physicians, lawyers, clergy, accountants, nurses, professors, and others. Couple this trend with the perception of some that today's youth are lazy, apathetic, and demonstrate a sense of entitlement, and it seems there may be a demoralization of society occurring. Some see these same trends occurring in pharmacy: there are accounts of greedy, unethical, or uncaring pharmacists in the press, and reports of student pharmacists who dress unprofessionally, demonstrate a lack of respect, engage in unethical behavior, or are not motivated to learn.

This article defines professionalism in the context of contemporary pharmacy practice, discusses the professional socialization process of student pharmacists, and suggests strategies for preceptors to facilitate the professionalism of the student pharmacists they precept.

PROFESSIONALISM DEFINED

Professionalism is a broad concept that is described in many different ways. It is often easier to discuss what professionalism is not, rather than what it is. Professionalism can be defined by the way it is demonstrated in practice, by its structural characteristics, by the beliefs held by those in the profession, or in a values-based manner. To get a better idea of how professionalism is demonstrated in practice, consider the following definitions:

• “conduct, aims or qualities that characterize or mark a profession or professional person.”¹

• “active demonstration of the traits of a professional…displaying values, beliefs and attitudes that put the needs of another above your personal needs.”^2-3

• “basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health.”⁴

Of these 3, the last definition is the most descriptive and captures the essence of professionalism. In comparison, the original concept of professionalism studied by sociologists in the 1950s and 1960s distinguished professions from occupations based on structural characteristics. They determined professions were altruistic in nature; considered vital to the functioning of society; upheld as prestigious within society; based on specialized knowledge, education, and training; guided by a code of ethics; governed by peers; and represented by professional associations. Additionally, members were required to be licensed or certified to practice legally, and most importantly, they maintained individual, covenantal relationships with clients/patients.^5-9 One of these sociologists also described beliefs held by professionals, and stated that the extent to which a professional espoused these ideals determined his/her level of professionalism.¹⁰ These included belief in service to the public, belief in self-regulation, a sense of calling to the field, autonomy, and use of the professional organization as a major reference.

Academic medicine has described professionalism in more of a values-based manner, including attributes such as accountability, excellence, duty, service, caring, respect for others, honor, integrity, and commitment.¹¹ Pharmacy has often focused on more behavioral aspects of professionalism, such as initiative, empathy, appearance, courtesy, lifelong learning, responsibility, exceeding expectations, and pride in the profession.^12-13 One author concluded:

“Professionalism is displayed in the way pharmacists conduct themselves in professional situations. This definition implies a demeanor that is created through a combination of behaviors, including courtesy and politeness when dealing with patients, peers, and other health care professionals. Pharmacists should consistently display respect for others and maintain appropriate boundaries of privacy and discretion. Whether dealing with patients or interacting with others on a health care team, it is important to possess--and display--an empathetic manner.”¹²

There is certainly overlap among these definitions and attributes, and the lists presented above are not exhaustive. This presentation of various traits and definitions is meant to demonstrate the breadth of the concept and how difficult it may be to arrive at a concise definition or set of behaviors.

PROFESSIONALISM IN PHARMACY PRACTICE

Professionalism manifests itself in many ways in practice. From facilities and inventory to the competence and attitudes of the staff, the level of professionalism is usually readily apparent to those who interact with the practice. First consider the practice environment: are the facilities clean, neat, organized, and up-to-date, or dirty, disheveled, crowded, and in disrepair? Does the inventory promote health and well-being, or products of convenience and high profit margins? Is the practice environment spacious, well-lit and inviting? Is there a comfortable and pleasant waiting area? Are there areas for private patient consultations and clinical activities? The physical layout and other structural characteristics go a long way in promoting the level of professionalism of the practice. Even the name of the pharmacy can convey an image. Consider “Drugs-R-Us” versus “Professional Pharmacy.”

Other “messages” in the pharmacy can also help to promote professionalism. Most pharmacies have a sign posted that reads something to the effect “a generic equivalent will be substituted for a brand name product unless the prescriber or patient requests otherwise.” What would happen if a sign was posted that read something like:

“WE CARE ABOUT YOUR HEALTH. Our pharmacists spend several minutes preparing your prescription to ensure it will be safe and appropriate for you. This includes double-checking that the medication prescribed and the dosing schedule are appropriate for your treatment, and that there are no interactions with other medications you are taking or with other matters of your health. We appreciate your patience during this very important process.”

A pharmacist who posted a sign like this was amazed at how the level of impatience decreased in his waiting area. A sign about patient counseling might have a similar effect:

“WE CARE ABOUT YOUR HEALTH. We want to make sure that your medication will be safe and effective for you. We would appreciate a few moments of your time to discuss your new or refill medications, as well as answer any questions you may have about them. This will help you to understand exactly what the medications are for, best ways to use them, and what to expect while taking them. It also helps us to monitor how well the medications are working for you.”

And what about signs in the nonprescription drug aisles? “Unsure which product is best for you? Ask one of our pharmacists to assist you.” These sorts of messages are good public relations for pharmacy and can help to improve the professionalism of the pharmacy. Services provided by the pharmacy also promote its level of professionalism. If a pharmacy is able to provide services beyond dispensing, such as extensive counseling, medication therapy management, health screenings, compounding, or durable medical equipment, they are promoting a more positive image of that pharmacy and the profession at large.

The pharmacists and staff are equally important, if not more important, in establishing a professional practice environment. Are they respectful and caring toward one another? Toward other health care providers and patients? Is their appearance and demeanor professional? Are they competent and well-trained? Are there regular meetings to communicate important issues among them? All pharmacy personnel promote (or detract from) the pharmacy's image, from the cashier to the pharmacists to the top administrator. Even conversations that take place supposedly out of patients' earshot are part of the culture of the practice (for example, consider the negative impact that derogatory discussions about patients or prescribers would have if overheard). Conversely, consider the positive impact of a pharmacy adopting a needy family during the holiday season or being involved in other charitable events. It stands to reason that professional behavior demonstrated by pharmacy/store staff contributes toward a higher level of professionalism of the practice.

All of these factors – facilities and environment, services provided, and the people involved – come together to create the professional image of the pharmacy. This image gives observers an impression of the level of practice and quality of care provided. This message is also transmitted to and absorbed by the students who come to learn at the site.

STUDENT PROFESSIONALISM

In discussions about students and professionalism, one question that often arises is whether professionalism can be “taught.” There is certainly a body of knowledge about professionalism that can be learned, but does that ensure that the learner will demonstrate professional behaviors? Probably not. Professional socialization, however, which is the process by which students learn and adopt the values, attitudes, and practice behaviors of a profession, can be taught or at least influenced. It is understood that formal curricula, including experiential learning, help to socialize students, hopefully in a positive direction. “Hidden curricula” (ie, attitudes and behaviors that are not formally taught) and experiences outside of a formal curriculum also help to socialize students in positive or negative directions. In medicine and nursing, several longitudinal studies identified factors that were most predictive of students' practice behaviors after they concluded their training^14-16:

• The values, attitudes and behaviors of the students when they entered the program,

• The environment in which they learned, and

• The role modeling of those from whom they learned.

To translate this to experiential learning in pharmacy, consider the background the student brings to the specific experience: his/her beliefs, attitudes, previous pharmacy experience, knowledge base, skill set, and professional behaviors (or unprofessional behaviors). If preceptors were able to learn about these traits prior to or at the beginning of the learning experience, then perhaps they could tailor the experience to maximize the student's strengths and improve upon his/her weaknesses. Sometimes the school can provide preceptors with this information, or preceptors can create their own questionnaire or interview of the student to obtain at least some of this information prior to or at the beginning of the learning experience. Several preceptors have published information about the tools and processes they use.^17-21

Preceptors should also consider their practice environment, not only in the ways described in the previous section, but also the kind of learning environment that is created for the student. Is the student considered an important part of the practice, or is he/she just another pair of hands, or worse yet, in the way? Is quality time spent with the student to guide his/her learning and providing constructive feedback on his/her performance? Some students may need more structure, guidance, and feedback, while others may have the initiative, experience, and maturity to function more independently. Even for the latter, however, providing constructive and specific feedback is still important, if for no other reason than to let the student know that he/she is doing an excellent job and to “keep up the good work.”

So what about the most influential factor from the research above: role modeling? Does the preceptor practice in a manner that consistently provides the highest quality patient care? Does he/she treat staff members and other health care providers with respect? Do other staff members with whom the student interacts demonstrate professionalism? What does the “hidden curriculum” at the site teach the student? How would a student need to adapt his/her attitudes, beliefs, and practice behaviors in order to fit in at the site? These are all important questions to consider when thinking about the quality of learning that occurs during experiential education. It is incumbent upon the pharmacists to emulate the highest standards of practice and behavior for the student, other staff members, and patients. Preceptors are extremely influential in shaping the attitudes and behaviors of these future pharmacists.

IMPROVING PROFESSIONALISM DURING EXPERIENTIAL LEARNING

There are numerous techniques to help students develop positive professional behaviors during experiential learning. Preceptors may already be employing some of these and may have additional ideas that have worked at their sites. Some ideas are described in detail below.

State Explicit Expectations

One of the first strategies is to make explicit both the site and preceptors' expectations for the student. Traditionally, the college/school of pharmacy provides students with a set of objectives or competencies they are expected to achieve during a learning experience, but it may not include language about professional behavior. Some preceptors may feel that they should not have to talk to students about their behavior; that at this point, students should know how to behave in a practice setting. Although we would like to believe this and for many students it is true, there are always exceptions. It is better to be up front about the behavior that is expected during the learning experience, in addition to the knowledge and skills students are expected to develop. Some examples of expectations to review with the students related to their professionalism may include policies related to dress code, tardiness, patient confidentiality, and cell phone use. One variation of this is to have the student help to define what should be expected of him/her during the rotation, as well as what his/her expectations are for the preceptor(s) and the site. This exercise can create a meaningful dialogue between the student and preceptor about what is expected of both parties, as well as establish a positive learning environment where the preceptor cares about the student's opinions and demonstrates respect toward him/her. This strategy also creates buy-in from students: if they are involved in the process of determining what is expected of them, they are more likely to meet or exceed those expectations. It is important to document these expectations in writing so they can be revisited. Some sites/schools may even have the student and preceptors sign an affidavit or “statement of understanding” of the expectations of both parties, to formalize its importance.

Set High Standards for Students

Another strategy is to establish high standards toward which the student can aspire to achieve. Appropriately challenging the student in the experiential learning process is important so that he/she can work toward achieving his/her potential. A support system should be in place, however, to aid the student. Standards and expectations should not be set so high that the student becomes routinely overwhelmed or frustrated. Recognizing that each student is different is also important. Preceptors may need to adjust their standards to maximize the learning and development of certain students.

Treat Students Respectfully

Preceptors should treat students with respect and as future colleagues. If preceptors demonstrate that they care about students' learning and are willing to help them learn, then students are more likely to work hard and learn as much as they can from the preceptors and the experience. Respect the knowledge and experience that students bring to the site; challenge them to apply these to the practice, help to improve it, and learn as much as possible from the experience to improve their future practice. Along these same lines, spend time with the student. Some students have described experiences where they meet the “preceptor” on the first day of an APPE but do not see him/her again until the end of the experience. The student is “delegated” to other staff members and has limited interaction with the preceptors who are meant to guide the student's learning.

Frequent, Timely, Specific Feedback to Students

Preceptors should provide frequent, specific, and real-time feedback to students, both positive and constructive. If the student does something very well, the preceptor should let the student know immediately and specifically indicate why it was good. Similarly, if the student performs in a manner that is below stated expectations, the student should be taken aside as soon as possible and asked about his/her impression of the situation. The preceptor should then provide his/her assessment of the situation, and together they should create a plan for preventing similar situations from recurring. It is important never to degrade a student in front of others, and to provide constructive feedback as opposed to criticism. For some students it might be the first time that a particular behavior has ever been pointed out to them.

Evaluation of Students' Professional Behavior

The student evaluation process should reflect the importance of demonstrating professional behaviors. Some programs may fail a student if unprofessional behavior has been demonstrated repeatedly, even though the student achieves all of the traditional learning competencies. Similarly, students may be able to achieve “honors” grades in experiential learning if they not only achieve traditional learning competencies but also exceed expectations for professional behavior. The important idea here is that evaluation instruments and the weighting of items/competencies need to reflect what the preceptors and school deem important.

Many preceptors find it difficult to objectively discuss students' professional behaviors with them. There are tools available to make this easier, such as the Behavioral Professionalism Assessment form.²² This instrument contains items ranging from time management to appearance to ethical behavior. This tool can be used by the student as a self-assessment of his/her professional practice behavior, as well as by the preceptor to assess the student's behavior. Students and preceptors can then compare each other's evidence and rationale for their respective ratings and have a meaningful discussion about the student's strengths and areas to improve. Many schools have included items about professional behavior on their student evaluation forms. Granberry and colleagues queried 50 schools about professionalism competencies on their acute care clerkship evaluation forms. They found that 58% of responding schools used a separate section to evaluate professionalism, and that on average, 16% of students' clerkship grades were derived from the assessment of professionalism.²³ As mentioned earlier, it is important to provide the student with real-time feedback about their behavior and not just during formal evaluation periods such as midpoint and end of the experience.

Student Feedback to Site and Preceptors

In the same vein, students should be provided with multiple opportunities to provide constructive feedback about preceptors and sites. This creates a climate where the students' opinion is valued, and the preceptors and sites are willing to improve their learning environment. These opportunities can occur during impromptu teachable moments as well as scheduled times. A teachable moment may occur when the student observes the pharmacist engaging in a difficult encounter with a patient. Asking the student for his/her input about what went well and what the preceptor could have done differently can be a valuable learning experience for both. Scheduled conversations to solicit student input could occur in weekly or bi-weekly meetings with the student to discuss progress toward meeting learning goals and other expectations. Some preceptors have students keep a daily or weekly learning journal to help document this progress. Beck et al also described a process that allows the student to express his/her perspectives about a particular topic or issue. Although the preceptor may have more knowledge and expertise in the area, by listening carefully to the student and providing feedback, “the instructor has the opportunity to clarify misinterpretations that might otherwise go undetected. Students can learn significantly from these new understandings.”²⁴ If students' comments about the experience are not phrased in a constructive manner, encourage them to develop strategies for improving the observed deficiencies.

Role Modeling

Above all, role modeling is the most important strategy for improving professional behavior. Students look to their preceptors to model the appropriate behavior expected of practitioners. Do preceptors and staff members abide by the same standards and expectations set forth for students? If not, then inconsistent messages are being sent to the student (“do as I say, not as I do”), which usually results in the student “doing as you do.” This is not to suggest that preceptors and staff members must behave perfectly at all times, but it does underscore the importance of being aware of how one's behavior can impact the learning of a developing professional. Additionally, role modeling goes beyond direct patient care. Students also recognize and learn from observation of preceptors actively engaging in professional association activities, community involvement, continuing education, and other demonstrations of professionalism.

Some helpful resources about precepting and professionalism are the American Association of Colleges of Pharmacy (AACP)/American Pharmacists Association - Academy of Student Pharmacists (APhA-ASP) Professionalism Toolkit (which includes a specific section about experiential education), the Leadership and Professionalism section of the APhA-ASP web page, and the September/October 2002 issue of Pharmacy Student magazine.^25-27 Additionally, preceptors can contact their local pharmacy schools as well as consult the references provided in this article.

SUMMARY

This article describes the concept of professionalism and how it relates to pharmacy practice, and suggests strategies for how preceptors can further develop professionalism in the students they precept. The professional socialization process can be thought of like the socialization process of a child into adulthood: factors that seem to be the most powerful in shaping children's behaviors are their genetic predisposition, the environment in which they are growing up, and the role modeling that they are mimicking subconsciously. Preceptors can influence students' professionalism most positively by working with the individual student's background, strengths and weaknesses, providing a positive learning environment, and by modeling those behaviors that allow one to successfully practice pharmaceutical care.