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To implement a Learning Bridge tool to improve educational outcomes for pharmacy students as well as for preceptors and faculty members.
Pharmacy faculty members collaborated to write 9 case-based assignments that first-year pharmacy (P1) students worked with preceptors to complete while at experiential sites.
Students, faculty members, and preceptors were surveyed about their perceptions of the Learning Bridge process. As in our pilot study,1 the Learning Bridge process promoted student learning. Additionally, the Learning Bridge assignments familiarized preceptors with the school's P1 curriculum and its content. Faculty teamwork also was increased through collaborating on the assignments.
The Learning Bridge assignments provided a compelling learning environment and benefited students, preceptors, and faculty members.
Experiential education plays a significant role in pharmacy education and allows for practical application of principles covered in classroom courses. However, a significant amount of time elapses between the classroom learning and the experiential component and a potentially synergistic learning opportunity is lost. As an analogy, this is similar to teaching a student the theory behind baking a loaf of bread, but not providing the opportunity to bake a loaf of bread until a much later date, forgoing the chance to increase understanding of the theory through practical application. Therefore, an effective pharmacy curriculum should support and integrate, wherever possible, concurrent didactic learning and experiential application. True curricular integration requires faculty members, administration, and preceptors to collaborate proactively to provide an optimal learning environment for students.1 Because the experiential and classroom curricula are delivered by 2 sets of educators (preceptors and faculty members), without a system/plan in place to integrate the content of classroom and experiential curriculums, students may not make the necessary connection between knowledge acquisition and knowledge application. Faculty members may be unaware of details regarding the experiential activities students perform at introductory pharmacy practice experience (IPPE) or advanced pharmacy practice experience (APPE) sites. Similarly, preceptors may be unclear about the order in which curricular topics are presented to students. The more preceptors and faculty members know about what their students have learned and how, the better they can assist students in integrating their knowledge. Accreditation agencies for healthcare professional programs emphasize the important role that such integration plays in student learning.2-4 The Accreditation Council for Pharmacy Education (ACPE) Standards clearly emphasize the important roles that experiential and classroom curricular integration and preceptor training play in pharmacy education.5 Similarly, the American Association of Colleges of Pharmacy's (AACP) Center for the Advancement of Pharmaceutical Care (CAPE) supports the idea that both faculty members and colleges and schools of pharmacy need to refine their curricular outcomes to meet the evolving needs of pharmaceutical care.6
Pacific University School of Pharmacy is a learner-centered environment where the didactic and experiential curricula occur in parallel to promote a comprehensive and practice-oriented educational experience for students.1 The curriculum is delivered within a 3-year program and emphasizes active learning, critical thinking, and teamwork. The first 2 years (P1 and P2) are comprised of a series of didactic and concurrent IPPE blocks. During the first IPPE in P1, students learn the responsibilities of pharmacists and the operation of a pharmacy. Students are assigned to a single preceptor and are at an experiential site for 8 hours every other week. To integrate the classroom and experiential curricula more purposefully, we pilot tested a “Learning Bridge” strategy in the fall 2008, with a series of 4 assignments generated by faculty members and completed by P1 students at their IPPE sites. After receiving positive feedback from this pilot study, we refined the Learning Bridge process, using only case-based assignments and providing preceptors with an answer key to improve their ability to guide students at the site.1 We then assessed the hypothesis that the Learning Bridge process could improve the educational outcomes for all involved: not just students, but preceptors and faculty members as well. Simply put, by better informing preceptors and faculty members about what students were doing in the classroom and in experiential settings, we hoped that both groups of educators would be enabled to help students build a “bridge” between concepts learned in class and tasks performed in the pharmacy, and in the process, increase their own knowledge.
In our pilot study, we implemented 4 Learning Bridge assignments that were effective in bridging students’ learning from the classroom with the practical experience they gained at their IPPE sites.1 We generated 9 additional case-based Learning Bridge assignments that, similar to our pilot study, applied science concepts to patients, drugs, and disease states commonly encountered in a retail pharmacy setting (Appendix 1 and Appendix 2). Based on feedback received from students who completed the pilot study, the design of the assignments was altered to include patient cases.
The desired outcomes of this second study were to: (1) enhance student learning by bridging the IPPE with the classroom curriculum; (2) facilitate introduction of the P1 classroom curriculum to preceptors; (3) invigorate preceptors’ knowledge of biomedical and pharmaceutical sciences; and (4) enhance teamwork among faculty members.
Before creating the Learning Bridge assignments, nonpharmacist faculty members consulted with pharmacist faculty members concerning “real world” details of the patient cases, appropriateness of the questions for a community pharmacy setting, and the feasibility of completing the assignment within the desired timeframe (1-2 hours) at the experiential site.1 Students were required to complete each Learning Bridge assignment while at the community pharmacy site and to consult with their preceptor concerning the assignment for additional input and learning. An answer key for each Learning Bridge assignment was provided to each preceptor via e-mail prior to each day of the IPPE, to facilitate preceptor involvement with the student concerning the assignment even if the science material was not familiar. Students submitted their responses to the faculty member who authored the assignment for review and grading via Blackboard (Blackboard Inc, Washington, DC). Finally, faculty members facilitated a 20-minute wrap-up session to P1 students in the classroom with the pharmacist faculty member present to close the “learning loop.” These sessions provided general feedback about the assignment to students and facilitated discussion about responses to the questions.1
After a full year of implementation, the course instructor conducted a series of assessment activities to collect students’, faculty members’, and preceptors’ input about the role the Learning Bridge process played in student learning (the survey instrument is available from the author). In addition, faculty members and preceptors were asked to reflect on the contribution, if any, of the Learning Bridge process to the dynamic of faculty teamwork and precepting success, respectively. The Blackboard tool was used to collect responses from students, and SurveyMonkey (SurveyMonkey, Portland, OR) was used to administer the preceptor and faculty surveys. Quantitative and qualitative questions were included in each survey instruments. Quantitative responses were based on the following Likert scale: strongly agree, agree, neutral, strongly disagree, and disagree. We considered a combined score of strongly agree and agree equal to or greater than 75% to be a desired and acceptable level of agreement. The Pacific University Institutional Research Board approved the study and the 3 survey instruments.
In addition to completing survey items about the benefits of the Learning Bridge assignments, all 3 groups were asked questions about student learning. Because student learning is difficult to assess objectively and student perceptions may not accurately assess the intended learning outcomes,7 we felt it was important to assess student learning from multiple viewpoints. The following definitions were included on the student survey instrument to ensure that we collected accurate student perceptions.
Critical-thinking skills: intellectual skills to critically interpret and evaluate a concept or a problem in order to synthesize or find an accurate answer to a question.
Self-directed learning: students are self-guided and know how to use their knowledge and resources to complete assignments.
Active learning: students utilize and refer to their own knowledge to answer a question and also actively seek and explore other resources and gather relevant information to improve or find a better answer.
The above definitions also were included on the preceptor survey instrument in the pilot study, but not on the faculty survey instrument because the definitions had been discussed frequently in faculty development workshops. Student, preceptor, and faculty responses to the quantitative survey questions assessing student learning outcomes are summarized in Table Table11.
Completion of the student survey instrument was mandatory and therefore had a 100% response rate (n = 92). Submission of the preceptor survey was not mandatory, and 26 preceptors completed the survey (28% respondent rate). In addition, 12 faculty members familiar with the Learning Bridge process (7 pharmacist faculty members and 5 PhD nonpharmacist faculty members completed the faculty survey [71% response rate]).
Eighty-two percent of students, 96% of preceptors, and 82% of faculty members believed that the Learning Bridge assignments facilitated student learning of both didactic and experiential materials (Table (Table1).1). Many qualitative comments from all 3 surveyed groups also supported this outcome (Tables (Tables22 and and33).
Seventy-six percent of students, 92% of preceptors, and 64% of faculty members agreed that the Learning Bridge assignments promoted students’ self-directed learning skills (Table (Table1).1). The remaining 36% of the faculty members selected “do not know.”
The school's curriculum emphasizes the use of active-learning components during the first 2 classroom lecture years.1,8 Seventy-seven percent of students, 92% of preceptors, and 73% of faculty members agreed that the Learning Bridge assignments promoted students’ active-learning skills (Table (Table1).1). All faculty members who did not agree chose “do not know” rather than disagreeing with the statement.
Ninety-two percent of preceptors and 81% of students believed that the Learning Bridge assignments promoted student critical-thinking skills. A majority of faculty members (64%) agreed with the role the Learning Bridge process played in promoting critical-thinking skills (Table (Table1),1), while the rest were unable to answer.
Eighty-nine percent of preceptors agreed that the Learning Bridge discussions with their student improved their awareness of the school's first-year curriculum, and several mentioned this as a significant benefit of the Learning Bridge process (Table (Table3).3). We also explored whether the introduction of the curriculum afforded by the Learning Bridge process improved the preceptors’ ability to precept P1 students. Eighty-four percent of preceptors believed the Learning Bridge process improved their ability to precept P1 students as a direct result of the increased preceptor knowledge of the P1 curriculum. In addition, 69% of preceptors felt they were an active member of the school's academic community as a result of the Learning Bridge process.
Eighty-eight percent of preceptors believed the Learning Bridge assignments invigorated their knowledge of biomedical and pharmaceutical sciences. In addition, 82% of preceptors agreed that they learned something from the Learning Bridge assignments that they did not know before or had long forgotten.
One hundred percent of nonpharmacist faculty members and 86% of pharmacist faculty members agreed that effective teamwork among faculty members was a major benefit of the Learning Bridge process. In addition, all nonpharmacist faculty members (100%) stated that generation of their Learning Bridge assignment was a teamwork effort in which they consulted the pharmacist faculty members in order to produce an effective Learning Bridge assignment and that consultation with pharmacist faculty members improved their understanding of how to integrate classroom learning and experiential areas into Learning Bridge assignments.
88% of preceptors indicated that Learning Bridge assignments were effective at assessing learning strengths and weaknesses for their students, 100% of faculty members agreed that Learning Bridge assignments assessed and promoted student learning.
Ninety-three percent of students agreed that classroom lectures/content made them confident to discuss the Learning Bridge assignments with their pharmacy team (Table (Table1).1). One hundred percent of faculty members also agreed with the above statement. Ninety-two percent of preceptors agreed that their students became more confident during their conversations as a result of having the Learning Bridge assignment to discuss. Benefits of the Learning Bridge to students, preceptors, and faculty as indicated by the results of the 3 surveys are summarized in Figure Figure11.
Pharmacy students must be able to interpret a question or problem, identify appropriate resources to research it, and evaluate the information in those resources in order to come to a solution. Thus, pharmacy students need to develop their active-learning, self-directed learning, and critical-thinking skills. The Learning Bridge provides a way to hone these essential learning skills while integrating learning materials and experiential training to provide a comprehensive educational experience. Data collected in this study provided compelling evidence of the effectiveness of the Learning Bridge process in overcoming some of the challenges to integration and the benefits that this process brought to students, faculty members, and preceptors as reflected in both quantitative and qualitative responses from all 3 groups. Perceived benefits of the Learning Bridge (Tables (Tables22 and and3)3) included faculty teamwork, student learning, and preceptor learning of the curriculum, which were all goals of the Learning Bridge process, and the comments reflect all 4 components of Fink's Taxonomy: incorporating foundational knowledge, application, integration, and caring.9 Figure Figure11 summarizes benefits that the Learning Bridge process brings to students, preceptors, and faculty members.
With encouragement from the ACPE (Standard No. 11),5 many US colleges and schools of pharmacy are actively engaged in a learning process that assists students in developing active-learning,1,8,10,11 critical-thinking,1,12,13 and self-directed learning skills.1,14 The results of the present study confirmed the results from the pilot study,1 with a majority of students, preceptors, and faculty members agreeing that the Learning Bridge process promoted development of all 3 of these skills in participating students (Table (Table1).1). Furthermore, 71% of preceptors agreed that the Learning Bridge assignments were an effective tool they could use to assess how well their students were learning the practice of pharmacy, though the Learning Bridge is not intended to address all aspects of pharmacy practice.
Approximately 30% of faculty members and 5% of preceptors were not able to assess the Learning Bridge's effect on student's active-learning, critical-thinking, and self-directed learning skills. One explanation for the difference between faculty members’ and preceptor's ability to assess these skills is that faculty members were not present at experiential sites to directly observe students’ engagement in completing the assignments. Additionally, while nonpharmacist faculty members (100%) and preceptors (96%) agreed with the statement that Learning Bridge assignments facilitated student learning of both didactic and experiential materials (Table (Table1),1), only 67% of pharmacist faculty members agreed, while the others chose “do not know.” This difference may have been because some of the pharmacist faculty members surveyed were not regularly involved in giving lectures to P1 students.
Due to different experiences, responsibilities, and tasks that preceptors and faculty members have at their respective work sites, a preceptor may experience student learning and progress differently than a faculty member. A comparison of faculty and preceptor views about the ways in which the Learning Bridge process made a difference in pharmacy education for students shows that these groups do have different viewpoints (Table (Table2).2). While faculty members commented primarily on the integration between classroom and experiential materials, preceptors also mentioned the opportunities for dialog that the Learning Bridge activities opened between them and their students.
Many preceptors would agree that the more they know about a program's curriculum the better they can assist the program's students with their learning and progress. Since the biweekly Learning Bridge assignments were based on concurrent didactic materials, the text of the assignments and answer keys as well as discussions between preceptors and students could assist preceptors in identifying faculty members’ expectations and which didactic curricular topics were delivered. In other words, the Learning Bridge assignments could paint a picture of what the P1 curriculum was about. In the busy pharmacy environment, preceptors are challenged to provide patient-centered care while facilitating student skill development with little time to develop educational materials for students. The Learning Bridge assignments provided clear learning goals and expectations for each experiential session and assisted the preceptor in providing a learning experience that was “in line” with the curriculum without having to spend preparation time that could potentially detract from patient care responsibilities. The majority of preceptors felt that the Learning Bridge positively benefitted student learning and considered the integration of didactic and experiential education highly valuable. Preceptors felt better able to gauge the strengths of their students because they had a better understanding of educational expectations. In addition, a few preceptors suggested shorter assignments or more applicable assignments. A majority of preceptors felt that the Learning Bridge process integrated them into the school's academic community. The latter result can be further improved by providing preceptor training and emphasizing the significant role preceptors play in student education by implementing the Learning Bridge process.
Because the foundational sciences that comprise the majority of the P1 curriculum at the school change over time, with new topics such as pharmacogenetics entering the curriculum only recently, and were studied by most preceptors 5 or more years ago, interaction with the Learning Bridge assignments and answer keys could be expected to refresh or expand the knowledge of many preceptors. Our provision of answer keys to the Learning Bridge assignments provided preceptors with an opportunity to review pharmacy-related topics and therefore refresh or enhance their own learning. The majority of preceptors did take advantage of this opportunity and learned something from the Learning Bridge assignments that they did not know before or had long forgotten. In addition, some preceptors commented in their responses to qualitative questions that the assignments provided enhanced professional satisfaction from their increased ability to be an integral part of the student learning process due to increased understanding of the curriculum (Table (Table3)3) and from witnessing student confidence in discussions on the topics of the assignments. By ensuring that preceptors acquire knowledge about the pharmacy curriculum, the Learning Bridge process assists preceptors in enhancing their supervision and assessment of their students.
While many colleges and schools of pharmacy encourage their students to work in a team and/or assist them in teambuilding skill development, little emphasis is given to encouraging faculty members to work as a team, particularly across pharmacist and nonpharmacist lines. The 13 biweekly Learning Bridge assignments generated over the course of an academic year were written by faculty members representing pharmaceutical science, pharmacy practice, and 2 social/administrative sciences. Faculty members were encouraged to work together to generate effective Learning Bridge assignments that integrated classroom and pharmacy concepts and practices and could be performed with the resources available at a retail pharmacy within the desired timeframe. As was mentioned earlier, 92% of faculty members agreed that one of the main keys in the success of the entire Learning Bridge process was effective teamwork among faculty members. The nonpharmacist faculty members unanimously stated that consultation with pharmacist faculty members improved their understanding of how to integrate didactic and experiential concepts and practices into Learning Bridge assignments. The generation of Learning Bridge assignments can be used at colleges and schools of pharmacy to encourage nonpharmacist faculty members, particularly from pharmaceutical sciences departments, to be familiar with what students learn at experiential sites, which may in turn encourage them to make their didactic materials more integrative to further enhance student learning.
Building a learning bridge was a manageable curricular task with significant benefits to student learning that outweighed the costs of faculty time required to implement it. However, we did encounter a few barriers to assessment and also implementation of the Learning Bridge. Despite multiple e-mail reminders to preceptors, our response rate to the preceptor survey was low (28%). Despite the low response rate, we believe the results are still valuable as they confirmed many of our observations from the pilot study.1 However, the responses obtained may be skewed toward the preceptors with the most positive opinion of the Learning Bridge assignments, while those who were less enthusiastic may have been unmotivated to complete the survey instrument. The low response rate could be explained by limited access to the Internet, heavy patient-care workload, and/or preference for survey instruments in paper form. To address this barrier, we may use a paper form that does not require Internet access for future preceptor surveys. Also, there were 2 preceptors who consistently marked “disagree” across all survey questions, indicating that they did not like the Learning Bridge assignments. Seeking buy-in from preceptors, and not just faculty members and students, is important. Second, a few student Learning Bridge submissions were identical to the preceptor's answer key. Therefore, it is important to clarify our expectations with both students and preceptors to ensure that adequate time is set aside for the Learning Bridge activity at the experiential site. We also plan to ask students to cite their literature sources in their responses to discourage them from using the preceptor's answer key. If the IPPE is split into community pharmacy sites and health system sites, generating a universal Learning Bridge assignment that is practical to implement at both types of sites will be challenging. To avoid this, 2 different assignments could be generated to meet desired student learning outcomes at both types of experiential sites. Finally, a few faculty members marked “do not know” in answer to a few quantitative questions; assessing the reasons behind those statements will be important.
The Learning Bridge process is now a formal component of our PharmD curriculum. Clinically relevant cases that are focused on pharmaceutical science content also can be used in other ways. For example, an independent study student on temporary leave from the school was assigned to write Learning Bridge-style case studies as a means to retain curricular knowledge. Preliminary data show that the student learned a significant amount by generating the cases. This result initiated a discussion among faculty members to allow P2 students, under faculty supervision, to generate Learning Bridge assignments for P1 students, thereby helping both groups of students in learning and retaining their science knowledge.
Faculty members generated a series of pharmacy-related Learning Bridge assignments designed to be completed by students at a pharmacy site. The students’, preceptors’, and faculty members’ perceptions, combined with our observations, indicated that the Learning Bridge process played an instrumental role in promoting student learning and confidence in discussions with their preceptors, familiarized preceptors with our P1 curriculum, assisted them in invigorating their knowledge of the curricular topics, and increased their ability to precept P1 students, and increased the dynamic of faculty teamwork. The Learning Bridge process integrates classroom and experiential realms, and the results were sufficiently encouraging to incorporate the Learning Bridge process into P1 and P2 curricula.
We sincerely thank Pacific University Oregon P1 preceptors and the class of 2011 who diligently participated in this study. In addition, we extend our heartfelt thanks to our colleagues Ms. Becky Shipman and Professors Joe Bonnarens, Amber Buhler, Fawzy Elbarbry, Jeff Fortner, Brad Fujisaki, John Harrelson, Mike Millard, Vedavalli Pokala, Sigrid Roberts, and Susan Stein who contributed to the success of the Learning Bridge process.
The role of pharmaceutics and physicochemical properties of active and inert ingredients in compounding a suppository to treat epilepsy
Amy Johnson is a newly registered pharmacist who has been working in a compounding pharmacy for one week. Today she received a physician prescription order to compound 20 diazepam suppositories (10 mg diazepam in each) for a 20-year-old man with epilepsy. Amy remembered from pharmacy school that making suppositories is a piece of cake because what she needed to do was to mix an appropriate amount of diazepam (valium) with a melted base and use a rubber or metal mold that could hold 2 g/suppository.
The prescription order is:
Rx: Diazepam suppository 10 mg
M. & ft. Suppositories #20 Base q.s.
Sig: insert one suppository rectally prn
Although Amy was good at using her compounding skills, she did not remember much about pharmaceutics. Therefore, Amy didn't know what suppository base she should use. However, she remembered that the following fat and water soluble bases are routinely used for formulating suppositories:
A. Cocoa Butter
B. MBK base
D. Polyethylene Glycol (PEG 1540)
Based on the physical nature and chemical structure of the drug substance, diazepam, your preceptor knows that only one of the above bases will work for the requested rectal dosage form. However, your preceptor wants you to help Amy. Please help Amy to survive her first week at the compounding pharmacy by answering the following questions and discussing your answers with your preceptor: