Development of a Coprecepting Model for a Preceptor-in-Training Program for New Practitioners

Abstract

Background: Preceptor development is a focus of pharmacy residency programs across the country. Graduation from residency into the role of preceptor can be a challenge, as it is one of many transitions junior practitioners make in their early careers. Literature in recent years has brought attention to the need to establish preceptor development programs that adequately allow newer preceptors to develop their skills in experiential education, for both pharmacy residents and students. Furthermore, many preceptor development programs as implemented are often didactic in nature, and include readings, webinars, and other passive learning regarding the art of precepting. Objective: Given the need to develop a preceptor development program in our service line that met the needs of preceptors-in-training and full preceptors, we offer a description of our preceptor development program in the intensive care unit. Methods: We focused on active development of preceptor skills for multiple layers of resident and student learners. In addition, this model incorporated instructing, modeling, coaching, and facilitating, as the relationship between full preceptor and preceptor-in-training evolved. It also offered the opportunity for real-time feedback and discussion on precepting performance. Conclusions: We describe our coprecepting model as an opportunity that succeeded for us in helping to transition our preceptors-in-training to full preceptors. It met the needs of our department, staff, and patients, and we believe it has the potential to be valuable as a tool extrapolated to the preceptor development programs of other institutions.

The American Society of Health-System Pharmacists (ASHP) has put forth standards that govern preceptor qualifications for accredited pharmacy residency programs. In the 2016 Postgraduate Year (PGY) 1 and 2017 PGY2 updates to these standards, ASHP restructured requirements for preceptors, delineating a full preceptor from a preceptor-in-training (PT).^1,2

To be a full preceptor, one must meet all requirements from standards 4.6 to 4.8, including having appropriate experience and ability to execute preceptor responsibilities.¹ PTs are pharmacists new to precepting who either do not have the appropriate years of experience or do not meet the specified qualifications of a full preceptor. Accreditation standards of ASHP require PTs to have a qualified preceptor assigned as a coach or advisor, and have a documented preceptor development plan to achieve full preceptor status within 2 years.^1,2

Residency program directors (RPDs) have the responsibility of establishing the preceptor development plan for their program preceptors. There is no formal outline mandated from ASHP to accomplish this goal; creating, implementing, and evaluating a preceptor development plan is left to the individual residency program. Precepting is an important skill for residents to develop during their training given survey findings that the majority of residents accept positions where precepting and/or teaching is required.³ In addition, barriers such as lack of time during the residency program for the resident and lack of availability of preceptors available to mentor the residents in precepting commonly hinder the development of residents as preceptors during residency training.³ A 2012 survey of pharmacy residents and preceptors revealed that less than half of preceptor respondents (45.6%) reported their institutions had a policy outlining specific requirements for preceptor development.⁴ The most commonly reported methods of preceptor development were self-study (61.1%) and continuing education sessions at professional meetings (56.2%).⁴ Based on summary responses from established PT programs, a prior commentary has offered recommendations regarding the administration of these PT programs from an institution-wide perspective.⁵ It has been acknowledged that the optimal way to administer these PT programs is unknown, including at the level of the individual PT, and innovative approaches to PT development offer the opportunity for knowledge sharing and a future path toward standardization.⁵

Critical care pharmacists at University of Kentucky HealthCare sought to expand on the idea of a preceptor development plan by introducing a coprecepting model with PTs to provide experience and feedback in an observed setting. University of Kentucky HealthCare is a 945-bed academic medical center that serves as the tertiary referral center for the state and surrounding areas. The residency program is comprised of 13 different residency programs encompassing approximately 25 residents annually. More than 80 preceptors are classified as full preceptors across the PGY1 and PGY2 residency programs.

For our particular service line in the Medical Intensive Care Unit (MICU), we identified 5 PGY2 trained critical care pharmacist new hires as PTs. A team of 4 clinical pharmacists, including the current PGY1 RPD, PGY2 Critical Care RPD, and full preceptors for both residency programs, developed a plan to help onboard these new pharmacists and incorporate them into the residency programs as preceptors.

Program Description

Our coprecepting plan focused specifically on precepting skills in action. Each PT was paired with an experienced mentor for their overall preceptor development training, who was a qualified preceptor according to ASHP standards. Each PT was then assigned 3 scheduled MICU months to coprecept alongside a full preceptor. The primary full preceptor of the MICU rotation (for which the PT was assigned) may or may not have also been the assigned mentor for the overall preceptor development plan. If the mentor was not coprecepting that particular learning experience that month with the PT, they were encouraged to attend daily patient and topic discussions as desired. This program was implemented over the course of 1 year, with 3 distinct months of coprecepting opportunities for the PT, interwoven with independent time on service.

Ideally, the PT would have an incremental escalation in each learner’s skill level. The first coprecepting month involved precepting a PGY1 pharmacy resident, the second coprecepting month a PGY2 noncritical care resident, and finally, the third month coprecepting a PGY2 critical care resident (Figure 1). The full preceptor and mentor utilized the 4 precepting roles (direct instruction, modeling, coaching, and facilitation) as the backbone of providing this learning opportunity.⁶ For example, the first few days of the first coprecepting month were characterized by full preceptor direct instruction and modeling, which quickly evolved to coaching and facilitating during the remainder of the coprecepting experience. The full preceptor retained the preceptor of record responsibility for the learning experience and served to support the PT, provide feedback, and to help grow their precepting skills.

Figure 1.

Longitudinal coprecepting structure in the preceptor development plan.

Note. PT = preceptor-in-training; PGY = postgraduate year.

The focus of this preceptor development training was primarily on precepting pharmacy residents. However, when students were on rotation, they were integrated into the layered learning model and interacted with the pharmacy resident and/or PT during rounds as well as patient and topic discussions. The PT directly observed and coached the resident, where applicable, on their precepting of the student within the layered learning model.

Expectations

From the PTs perspective, the coprecepting model served as an opportunity to practice precepting skills while benefiting from the expertise and mentorship of an experienced preceptor. It was anticipated that the full preceptor support the PT in learning the nuances of the institution, as well as the established precepting model. PTs expected to identify many growth opportunities in this role given most had greater experience precepting students rather than residents. It may be a challenge for a new practitioner PT to precept a resident just 1 year junior in experience. The coprecepting model was expected to be especially helpful in this regard, ensuring that students and residents at different experience levels were engaged and challenged appropriately while the PT gained more experience.

From the full preceptor’s standpoint, the coprecepting model allowed for additional time spent with the PT to serve as a continuation of orientation. It was anticipated that this additional time spent together would uncover variations in practice among pharmacists, while also serving as an informal setting to learn more about the local practices and protocols present for various clinical scenarios. From a precepting standpoint, it was anticipated that navigating the layered learning model, particularly ensuring students and residents were engaged at an appropriate depth during patient and topic discussions, would be the most challenging aspect of precepting for the PTs.

Roles and Responsibilities

The role of the PT was to take the lead in precepting the pharmacy resident and pharmacy student, assuming the functions of a primary preceptor for rotations. The PT met with the full preceptor prior to the start of the rotation to discuss the oncoming resident’s goals, strengths, and challenges, and to create a schedule for the month. The PT responded to immediate patient care issues and completed full patient profile review. Depending on resident seniority and clinical progress, the PT may have rounded with the resident if warranted. The PT served as the primary lead for patient and topic discussions, with input from the full preceptor as described below. Finally, the PT led the delivery of verbal feedback to the student and resident in weekly evaluations, in addition to helping complete end of rotation evaluations.

The role of the full preceptor was to be present for the majority of patient discussions and for all topic discussions. If time allowed, the full preceptor would complete patient profile review, and may also have been covering an additional service in addition to their coprecepting responsibilities. During the course of the training program, the full preceptor’s role evolved as the PT progressed through the month and the program. As the PT grew in this experience, the full preceptors made intentional efforts to interject the conversation only when an important point needed to be made, for example, providing historical perspective, institutional perspective, or additional teaching points or pieces of primary literature pertinent to the patient or topic at hand. The full preceptor was available to answer questions from the PT, facilitated learner questions through the PT, and contributed add-on points as needed in discussion. Specific ways the full preceptor helped the PT prior to the first month (and throughout the experience) were to (1) review the practice style and challenges of the attending physician/unit for the month, (2) review resident expectations (of the institution and specific program), (3) review previous feedback and possible learning needs for the specific resident, (4) provide guidance on appropriate topic discussions, (5) extend the PTs library of primary literature (if needed) to facilitate topics, and (6) provide tips on good versus poor approaches to questioning learners.

Assessment and Feedback

Following weekly feedback discussions with learners, there was a heavy focus on PT self-evaluation with feedback from the full preceptor. This included feedback on patient care discussions, topic discussions, and progress of the overall precepting experience. This allowed for an opportunity for one-on-one discussion with the PT and facilitating access to any additional training resources as appropriate, whether that be an institutional protocol, piece of primary literature, or other precepting resource.

Successes and Opportunities

Upon evaluation of the coprecepting model, several strengths were noted. We believe the model succeeded in serving as an active application of precepting skills, as opposed to passive learning experiences such as viewing a webinar, listening to a lecture about precepting, or other nondirect precepting development activity such as a workshop about precepting.⁵ This environment allowed for a breadth of exposure to the different skill levels of residents that rotate through the MICU practice site. The PT experience was supervised to some extent, which provided the opportunity for the PT to receive feedback on their precepting skills from more established preceptors in the area. The learners on rotation, both residents and students, provided generally positive feedback on the coprecepting model. In particular, they enjoyed the accessibility and continuity of the PT as well as the expertise and different perspective of the full preceptor. Overall, the full preceptors and PTs felt the coprecepting model was successful in further developing the PTs and moving them forward in the goal of becoming a full preceptor.

One of the possible downsides noted was that the coprecepting model at times provided a safety net in terms of precepting for the PT. Although this is generally a good thing for the PTs, learners, and patient care, to some extent, we believe there is great value and growth potential that stems from ownership of carrying the sole responsibility for patient or topic discussion.

Similarly, despite intentional attenuation efforts by the full preceptors, this model struggled not to reinforce a hierarchy among clinical pharmacists. Our pharmacy practice model does not currently differentiate between levels of clinical pharmacists, and at times, the nature of this model served to reinforce the perceived hierarchy between the full preceptors and the PTs rather than breaking down the perception of such. Another recognized challenge was the variation in precepting styles among the different full preceptors and mentors in their interactions with PTs. Although we feel exposure to various styles is beneficial for overall precepting growth, we acknowledge this as a limitation given variation in expectations, the balance of participation and observation of the full preceptor in patient care and topic discussions, and feedback style to the PT. Looking forward, we hope to limit this variation and also improve our documentation of PT growth and progression by completing a written, standardized feedback template during each learning experience. This will also help outline clear milestones for PT progression and develop a plan for remediation and reevaluation when such milestones are not met. Finally, the PTs had inconsistent exposure to contributing to written evaluations of residents and students. As a final opportunity for future renditions of this model, the PTs will be given consistent exposure to providing appropriate written feedback to supplement the verbal feedback they were providing to resident and student learners.

Conclusions

Creating and implementing a preceptor development program with a coprecepting component can augment traditional preceptor development plans, allowing for a layered integration of PTs into the preceptor roles of varying residency programs.