precepting students and residents · precepting instructing modeling coaching facilitating ... also...

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