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A demonstration study comparing “role-emergent” versus “role-established” pharmacy clinical placement… Kassam, Rosemin; Kwong, Mona; Collins, John B Aug 5, 2013

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RESEARCH ARTICLE Open AccessA demonstration study comparing “role-emergent”versus “role-established” pharmacy clinicalplacement experiences in long-term care facilitiesRosemin Kassam1*, Mona Kwong2 and John B Collins3AbstractBackground: Increasing challenges to recruit hospital sites with full-time on-site pharmacy preceptors forinstitutional-based Advanced Pharmacy Practice Experiences (APPE) has made it necessary to consider alternateexperiential models. Sites with on-site discipline specific preceptors to supervise students have typically beenreferred to in the literature as “role-established” sites. In British Columbia, long-term care (LTC) facilities offered aunique opportunity to address placement capacity issues. However, since the majority of these facilities are servicedby off-site community pharmacists, this study was undertaken to explore the viability of supervising pharmacystudents remotely – a model referred to in the literature as “role-emergent” placements. This paper’s objectives areto discuss pharmacy preceptors’ and LTC non-pharmacist staff experiences with this model.Methods: The study consisted of three phases: (1) the development phase which included delivery of a trainingprogram to create a pool of potential LTC preceptors, (2) an evaluation phase to test the viability of the LTC role-emergent model with seven pharmacists (two role-established and five role-emergent) together with their LTC staff,and (3) expansion of LTC role-emergent sites to build capacity. Both qualitative and quantitative methods wereused to obtain feedback from pharmacists and staff and t-tests and Mann–Whitney U tests were used to examineequivalency of survey outcomes from staff representing both models.Results: The 76 pharmacists who completed the training program survey rated the modules as “largely” meetingtheir learning needs. All five role-emergent pharmacists and 29 LTC participating staff reported positive experienceswith the pharmacy preceptor-student-staff collaboration. Preceptors reported that having students work side-by-sidewith facility staff promoted inter-professional collaboration. The staff viewed students’ presence as a mutually beneficialexperience, suggesting that the students’ presence had enabled them to deliver better care to the residents. As adirect result of the study findings, the annual role-emergent placement capacity was increased to over 45 by the endof the study.Conclusions: This study demonstrated that role-emergent LTC facilities were not only viable for quality institutionalAPPEs but also provided more available sites, greater student placement capacity, and more trained pharmacypreceptors than could be achieved in role-established facilities.Keywords: Residential care, Long-term care, Pharmacy, Clerkship, Clinical education, Clinical practice, Non-traditionalclinical placements, Role-emergent, Role-emerging, Institutional, Experiential* Correspondence: rosemin.kassam@ubc.ca1Faculty of Medicine, School of Population and Public Health, University ofBritish Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the article© 2013 Kassam et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Kassam et al. BMC Medical Education 2013, 13:104http://www.biomedcentral.com/1472-6920/13/104BackgroundAccreditation standards in Canada and the US specifythat schools of pharmacy must ensure that patient-centered and population-based care competencies serveas the basis for curriculum development and change.These standards also stipulate that experiential learningshould embody the critical curriculum components togive students opportunities to practice and master thesecompetencies [1-3].In the Canadian province of British Columbia, the re-sponsibility for designing and implementing experientialsites falls to the University of British Columbia’s (UBC)Faculty of Pharmaceutical Sciences as the sole post-secondary institution graduating pharmacists. At UBC,these experiential learning segments consist of threeseries of community pharmacy-based experiences: two160-hour series of introductory pharmacy practice expe-riences (IPPE) completed at the end of the second andthird years of the four-year curriculum and one 320-hour series of advanced pharmacy practice experiences(APPE), and an additional institutional-based 160-hourseries of APPE delivered in the final year of the curricu-lum. This paper focuses on the school’s efforts to buildgreater placement capacity for its institutional-basedAPPE.In keeping with traditional practice in pharmacyschools across North America, UBC places students intoexperiential learning segments only at sites with full-time on-site pharmacy preceptors who can provide con-tinuous and direct student supervision. Placement siteswith an on-site discipline specific preceptor to superviseand model the professional role to the student havetypically been referred to in the literature as “role-established” sites [4,5]. In British Columbia, the onlyinstitutional settings offering continuous on-site pharma-cist supervision were tertiary and community hospitalsettings -- mostly in acute care in-patient wards and somelong-term care wards. Most other institutional settingssuch as outpatient clinics and stand-alone long-term carefacilities had only limited pharmacy coverage, and as suchwere traditionally not considered to be eligible experientialsites for pharmacy students. However, over the past sev-eral years, numerous factors converged to make it increas-ingly challenging to continue to recruit and retainsufficient hospital sites to provide all UBC students withan institutional-based APPE. Contributing factors in-cluded: increased student enrolments, increased length ofthe institutional APPEs, increased emphasis on patient-centered activities and less on drug distribution services,shortages of hospital pharmacists, downsizing and amal-gamation of institutional facilities, and increased expecta-tions for hospital pharmacy departments to expandservices such as: participating on ward-based and out-patient inter-professional teams to promote formularypolicies and effective and safe medication use, routine al-lergy assessment and screening, review of medicationcharts, conducting discharge medication counselling, andimplementing self-medication management programs forhigh risk patients prior to discharge. Similar challengeswere also reported by other schools of pharmacy [1,6,7].Under these circumstances, hospital pharmacists found itdifficult to maintain their own employment and profes-sional responsibilities while simultaneously assistingschools to provide students with patient care learningopportunities. This resulted in fewer hospitals willing tocommit to precepting, making it difficult for the school tomeet accreditation expectations requiring student expos-ure to institutional patient care practice. Consequently,the school has needed to consider alternate experientialmodels to meet this mandate.With studies confirming the benefits of pharmacy-based patient care services to promote appropriate, safeand effective use of medications among elderly patients,expanding the institutional APPE sites to include Long-Term Care (LTC) facilities seemed a sensible solution toaddress capacity issues [8-14]. However, including LTCfacilities as APPE sites remained problematic since themajority were serviced by off-site community pharma-cists offering medication dispensing services remotely,with on-site time limited to once a week for patient careservices. Experiential sites lacking on-site preceptors tosupervise students have often been labelled in the alliedhealth literature as “role-emergent”, “self directed”,“long-arm supervision”, “independent community place-ments”, or “non-traditional placement sites” [4,15,16].Given the role-emergent nature of the LTC facilities,UBC’s pharmacy leadership, faculty members and pro-spective pharmacy preceptors were reluctant to fully en-dorse this non-traditional model without evidence itcould provide comparable experience to that of the trad-itional role-established model. These questions were dif-ficult to answer in the absence of any published reportsdiscussing pharmacy preceptors’ and facility staff experi-ences within such settings.This current demonstration study explored the viabil-ity of role-emergent LTC APPEs at sites which had trad-itionally not served as placement locations for pharmacystudents. The specific objectives of this paper are to: (1)outline the support and training necessary for new pre-ceptors, (2) discuss pharmacy preceptors’ and LTC non-pharmacist staff experiences with the new model, (3)compare their experiences with those at the more trad-itional role-established LTC APPE sites, and (4) docu-ment gains in numbers of available role-emergent sitesas a consequence of the study’s findings. Project start-upcosts were funded through the British ColumbiaAcademic Health Council and included costs of add-itional support staff and program overhead to developKassam et al. BMC Medical Education 2013, 13:104 Page 2 of 11http://www.biomedcentral.com/1472-6920/13/104and deliver the preceptor training program and to designand evaluate the LTC role-emergent model.MethodsDesignThis demonstration study was designed as a comparativestudy to understand the experiences of both pharmacypreceptors and of non-pharmacy facility staff participat-ing in the newly implemented role-emergent modelversus the traditional role-established LTC APPE model.This study occurred over three academic years (August2005 to May 2008) and consisted of three phases: (1) de-velopment phase between August to November 2005,(2) evaluation phase from January 2006 to May 2008,and (3) role-emergent placement expansion phase at theend of the study. Ethics approval was obtained from theOffice of Research Services at UBC for research with“individuals whose data, or responses to interventions,stimuli or questions by a researcher are gathered or uti-lized for the purposes of a Research project” [17].Recruitment of LTC preceptors and facilitiesPurposive sampling (where subjects are selected becauseof some distinguishing characteristic) was used toidentify pharmacy preceptors and their affiliated LTC fa-cility from a list that exemplified best LTC pharmacypractice models within British Columbia created bycommunity and hospital pharmacy managers [18]. Thesefacilities consisted of both role-established sites with on-site hospital pharmacists and role-emergent sites whosepharmacy requirements were contracted to a local com-munity pharmacy. The first seven preceptors, two role-established and five role-emergent -- who agreed toparticipate were recruited. Table 1 summarizes the char-acteristics and staff composition of the LTC facilitiesrecruited for this study. While the role-established phar-macists had previous histories of serving as preceptorsfor the traditional institutional APPEs, the communityrole-emergent pharmacists had no such experiences.The role-established preceptors participated in the de-velopment phase to define a LTC APPE syllabus basedon their previous experiences and expertise. In thispaper, “preceptor” means the pharmacy preceptor andall other LTC non-pharmacy personnel are referred to as“staff”. Since the aim of this study was to build institu-tional capacity using LTC role-emergent sites, all facil-ities served as evaluation sites to test the viability of thisnew model for pharmacy. As part of our school’sTable 1 Characteristics of long-term care facilities participating in the study (N=7)Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6 Facility 7RoleestablishedRoleestablishedRoleemergentRoleemergentRoleemergentRoleemergentRoleemergentAffiliationHospital √ √Community Pharmacy √ √ √ √ √OwnershipProprietary - - √ √ - - √Religious √ - - - - √ -Not for Profit √ - - - - - -Government √ √ - - √ - -Level of Care† 3 3 3 2 3 3 2Number of Beds 221 150 38 103 80 200 115Ancillary Services(Number) Type of Services* (6) DT, Pod, OT,PT, ST, SW(5) DT, OT,Pod, PT, SW(3) DT,Pod, PT(4) PT, DT,Pod, OT(3) DT,Pod, PT(5) DT, OT,PT, ST, SW(3) DT, Pod, PT(Number) Type of non-pharmacystudents*(5) DMD, DT,MD, OT, PT0 0 (1) Aide 0 (3) DT, RN,OT(2) Aide, RNCare provided by resident’s physician √ √ √ √ √ √ √Care provided by house physician - - - - - - √Patient Care Conferences √ √ √ √ √ √ √Resident’s Chart Available toPharmacists for Documentation√ √ √ - - √ Separate Careplan inserted*RN Registered Nurse, Aide Nurse’s Aide, DMD=Dentistry, DT Dietician, MD Medicine, OT Occupational Therapist, Pod Podiatrist, PT Physical Therapist, ST SpeechTherapist, SW Social Worker.†Level 3 care: clients need 24 hour professional nursing care and supervision, medical and therapeutic care in required, and a minimum 2.5 hours of personal careis needed. Level 2 care: clients need 24 hour of personal care, medical and, or nursing care is required, individual care may range from 1.2-2.5 hours per day.Kassam et al. BMC Medical Education 2013, 13:104 Page 3 of 11http://www.biomedcentral.com/1472-6920/13/104remuneration policy, all pharmacies received a stipendof $50.00 CDN for a four week student experience. Allrole-emergent LTC affiliated pharmacists and non-pharmacy staff participating in this study were assuredtheir identity would remain confidential for the purposeof this study, and they were free to withdraw from thestudy at any time.Preparation: training program for potential LTCpreceptorsSince the APPEs for role-emergent LTC locations wereexpected to be less structured - thus requiring studentsto be more self-directed, preceptor preparation was es-sential to ensure the APPE’s learning outcomes weremet [4,15,16]. An education program was introduced tohelp preceptors acquire basic knowledge and skillspertaining to care of elderly patients. Those invited tothe program included all pharmacists who were affiliatedwith a LTC site (emergent or established) and interestedin enhancing their competence for providing care to se-nior patients and in increasing their confidence to men-tor students within such a practice. While the school didnot require an immediate commitment from the phar-macists to take a LTC APPE pharmacy student, the invi-tation was extended to all those who were open toexploring the possibility of creating future LTC APPEplacement within their affiliated sites. The program wasinitially piloted with LTC APPE preceptors participatingin the first cycle of the evaluation phase (January – May2006) and was delivered over one-half day. The programfeatured a case-based approach using lectures, smallgroup discussions, and exercises requiring pharmaciststo identify drug and non-drug related issues and to de-velop care plans for these issues. During subsequent cy-cles (September 2006-May 2008), the program wasextended to a full day and was open to all communityand institutional APPE preceptors who were interestedin developing future APPE content specific to the careof older adults in their practices. A Jeopardy®-like gameand an expert panel of inter-professional health pro-viders from pharmacy, occupational therapy, physiother-apy and nursing was introduced to promote a moreinteractive delivery of the case content. The case wasbuilt on an existing “Care of Elders Delirium Module”developed at the University of British Columbia for pro-moting inter-professional collaboration [19]. The modulefacilitated learning about commonly encountered condi-tions among elderly patients in LTC facilities including:delirium, depression, dementia, urinary incontinence,urinary tract infection, anemia, pain control, chronicheart failure, atrial fibrillation, stroke, renal failure andalcohol withdrawal. The case also allowed participants todeal with implications of physiological changes in theaged, and provided an overview of common geriatricassessment tools. Writers and reviewers with advancedclinical training were retained to develop a participant’seducational tool kit which included completed care plansfor all drug-related issues within the case and evidence-based summaries for the management for all drugrelated issues that arose in the case. Because of the scar-city of geriatric pharmacology textbooks, the kit wassupplemented with learning resources from the primaryand secondary literature.LTC preceptor supportConsistent with the school’s other APPE program, bothLTC APPE students and preceptors recruited for theevaluation phase received the same 150-page APPEmanual, which includes a list of learning activities that isspecific to the APPE setting. The manual is organizedinto several sections intended to facilitate teaching andlearning process during APPEs. The first section pro-vided an overview of the APPE, a list of expected com-petencies and outcome-based objectives so that thestudents and preceptors understood the expectations ofthe APPE, a list of learning activities to meet theintended objectives and a week-by-week activity calendarproposing how the student learning activities could bedistributed throughout the weeks allotted to the APPE.For the LTC APPE, the list of learning activities isoutlined in Table 2. The subsequent sections of the man-ual served as a resource to guide students and precep-tors through the APPE and included: an orientationchecklist to be followed when new students came tothe site; a policy and procedure section that outlinedrules on attendance, attire, preparedness, professional-ism; an evaluation form and evaluation procedure de-tailing the components to be considered for the finalgrade; and patient care documentation tools to facilitatedelivery of care and to guide discussions between pre-ceptors and students. The school’s APPE faculty metwith the preceptors to discuss the content of the man-ual, and all preceptors were supported by the schoolthrough site-visits, telephone communication, and writ-ten e-mail/ webmail communications on an as-neededbasis. Contact with preceptors was made on averageonce a week.To ensure adequate learning support for students, theschool proposed all preceptors schedule a one-day orien-tation session at the start of the APPE to introduce theirstudent to the facility staff, to provide students with atour of the facility and its programs, and to provide thestaff with an overview of the students’ learning activities.Preceptors also scheduled regular face-to-face meetingtimes with their students for at least one-half day perweek to monitor students’ progress, to provide directsupervision, and to carry out formal assessments of thestudent’s findings. Preceptors were available to studentsKassam et al. BMC Medical Education 2013, 13:104 Page 4 of 11http://www.biomedcentral.com/1472-6920/13/104at all times via telephone and email to discuss students’proposed patient care interventions and drug informa-tion responses, before they were disseminated to healthcare team members.Data collectionAt the end of the educational program, pharmacistswere asked to report using a 15-question survey - howwell the Care for Elders Delirium Module had met theirTable 2 Student learning activities at the long-term care facilities (4-week experience)Learning activities Minimums1. Provide Comprehensive pharmaceutical care: 3-5 patients over 4-weeks● Assess for drug-related problems (DRPs)● Identify and list all actual and potential DRPs● Create an initial care plan for each DRPs and discuss with pharmacy preceptor● Collaborate with physician/ facility staff and, or patient to resolve or prevent the DRPs.● Provide follow-up to all patients2. Participate in Drug Review Process: 2-8 hours over 4-weeks● Participate in daily drug review process by reviewing patients’ medication profiles on designated unit● Assess for DRPs● Identify and list all actual and potential DRPs● Create an initial care plan for each DRPs and discuss with pharmacy preceptor● Collaborate with physician/ facility staff and, or patient to resolve or prevent the DRPs.3. Conduct Allergy Assessments: 4-5 patients over 4-weeks● Assess patients for drug allergies● Discuss allergies with pharmacy preceptor● Discuss allergies with physician/ facility staff● Document all allergies on the form provided4. Provide Medication Teaching: 4-5 patients over 4-weeks● Provide medication teaching to patients and their families5. Provide Presentations to the facility staff: 1 of each type of presentationover 4-weeks● On a patient case to which comprehensive pharmaceutical care has been provided● On a topic of interest6. Conduct Critical Appraisal of the Literature: 1 critical review over 4-weeks● Critically review one article relevant to care of your patients and discuss with pharmacy preceptor● Document the appraisal on the form provided7. Provide Drug Information: 3 drug information workupsover 4-weeks● Work-up patient specific drug information questions raised by staff at the facility● Document all drug information questions on the form provided8. Engage in Inter-professional Collaboration: Daily and on-going● Participate in patient care-conferences9. Participate in Drug Distribution at the long-term care facility: Daily and on-going● Discuss drug distribution system with pharmacy preceptor● Observe Nurse and Unit Clerk in distribution process● Participate in processing and clarification of medication orders at the designated unit10. Understand Medication Management Processes and Protocols at the facility: No minimum, as time permitting● Discuss programs at the institution to improve the quality of drug use, for example: drug utilizationprograms, adverse drug reporting protocols, etc.● Discuss formulary system11. Participate in other activities identified as appropriate by pharmacy preceptor No minimum, as time permittingKassam et al. BMC Medical Education 2013, 13:104 Page 5 of 11http://www.biomedcentral.com/1472-6920/13/104own learning needs on a 5-point scale (5=Totally,4=Largely, 3=Fairly, 2=Poorly, 1=Not at all). Those phar-macists who participated in the role-emergent APPEalso participated in a follow-up telephone interview toobtain their viewpoints on the APPE. Similarly, the non-pharmacy facility staff was invited to share their experi-ences using a seven question survey that requiredselecting responses from predefined 4-point scale:(4=Very, 3=Somewhat, 2=Only a little, 1=Not at all).Additionally, staff were encouraged to share theirthoughts using open-ended response formats in thespaces provided the end of the survey. Pharmacy precep-tors handed out the surveys to staff at their facilities onone of their on-site visits and instructed them to depositthe completed survey in a receptacle box. Staff were as-sured that their responses would be delivered directly tothe research office without being read by the site phar-macists and the survey return boxes were labelled ac-cordingly. UBC’s Office of Research Services permitsresearch data to be collected only from research partici-pants who provide written Informed Consent to allowuse of their data by the study team.AnalysisPreceptors and LTC facility staff reports of their percep-tions and experiences were transferred onto a spreadsheet(Microsoft Excel 2000) then uploaded to SPSS Ver. 18(IBM, 2011). Descriptive statistics (frequencies, means andstandard deviations) on the LTC facilities characteristicsand survey questions were computed and quantitativelyanalyzed. Differences of opinion between staff in role-established versus role-emergent facilities were examinedvia t-tests with significance set at p<.05 and confirmed(for ordinal data) with Mann–Whitney U tests. Free-formand open-ended responses were categorized thematicallyand analyzed. All identifiers were removed to maintainanonymity of participants.ResultsIn all, 88 pharmacists participated in the training pro-gram, 7 pharmacists (n=2 role-established and n=5 role-emergent) were recruited to serve as LTC preceptors forthe evaluation phase and 29 non-pharmacy LTC staffparticipated in the demonstration study. We report re-sults from this study in five sections; (1) pharmacists’ ex-periences with the education program, (2) characteristicsof the facilities and preceptors where the APPEs were lo-cated, (3) pharmacy preceptors’ experiences during fivecycles of the APPE itself, (4) experiences of non-pharmacy facility staff in working with the APPE, and(5) gains in numbers of role-emergent placements at theend of the study.Pharmacists’ experience with the education programEighty six percent (n=76) of pharmacists completed the15-question survey on how well the Care for Elders De-lirium Module had met their own learning. Given theanonymity of the surveys, the data could not be catego-rized into those who participated in the evaluation phaseversus those who remained potential recruits. Respon-dents assessed the module as “largely” meeting theirown learning needs (4.3 out of 5) and reported the Jeop-ardy® Game to be equally “largely” effective for learning(4.5 out of 5), 75% found the content to be relevant totheir practice, 87% indicated the case embodied prob-lems and issues typically encountered in practice, and57% reported they had gained a better understanding ofthe roles and responsibilities of the different health pro-fessionals within residential care settings (Table 3). Themost frequently cited new knowledge included: the dif-ferences between delirium, depression and dementia;relevance of laboratory values; the roles of other healthcare professionals; the relevance of physiological andpharmacokinetic parameters in managing drug therapy;and strategies to develop and implement care plans. Theone-day education program was delivered two monthsprior to beginning actual APPE rotations in January2006, and was offered twice: once on a weekday andthen again on a weekend to accommodate pharmacists’work schedules.Characteristics of role-emergent and role-established LTCAPPE facilitiesThe seven LTC facilities participating in the evaluationphase – two role-established and five role-emergent, to-gether created 23 LTC APPE placements from January2006 to May 2008. One placement represents one stu-dent. While the ownership and the ancillary services dif-fered across facilities; with the exception of one facility,all residents residing in these LTC facilities had access toa physiotherapist, dietician, podiatrist, nurse and medicalcare provided by an off-site primary care physician(Table 1). The resident’s chart served as an importanttool for pharmacists to document their care at all buttwo role-emergent LTC facilities. The single key differ-ence between the role-established and role-emergentLTC facilities was the availability of an on-site pharmacypreceptor. At the role-emergent sites, students and pre-ceptors had to schedule regular meetings to discusslearning and care activities. On days when the role-emergent preceptor was absent, the allied health andnursing staff played an instrumental role in providingstudent oversight.Role-emergent APPE pharmacy preceptors’ experiencesOverall, preceptors expressed positive experiences withthe APPE. Post-APPE follow-up interview data revealedKassam et al. BMC Medical Education 2013, 13:104 Page 6 of 11http://www.biomedcentral.com/1472-6920/13/104that preceptors believed the students had learned sub-stantially from this experience and confirmed participa-tion in future LTC APPEs. Their comments includedsuch observations as “Just wanted to say how great it hasbeen to have the student … (student) is an awesome re-source for the nurses and a help to me in following up onthings I wish I was there to do.” Another preceptor said“I think (the student) is getting an amazing learning ex-perience - interacting with patients, nurses and physi-cians and problem solving. (The student) has helped toresolve some nursing issues … helped managed an insulinstart … conducted an in-service to the nurses … attendeda medication safety advisory committee meeting and anursing medication incident meeting … I don't think shehas had a boring day yet!, while a third said “It might betoo soon to say this, but I wish I could have a student ateach of my facilities!” A particularly summative com-ment came from a role-emergent preceptor who said “Ithink this was the best facility for a pharmacy student …I hope the next batch of students will have as rewardingan experience.”Some preceptors did note that their LTC site offeredstudents limited exposure to certain traditional hospitallearning activities such as conducting allergy assess-ments and providing one-on-one patient education.However, generally all expressed that other opportunitiesunique to LTC - such as working side-by-side with thefacility staff to enhance residents’ care and access toextensive medication and health record to review andassess for drug related issues, made up for thesedeficiencies.Non-pharmacy facility staff experiences at role-emergentand role-established APPEAdditional post-APPE surveys were completed by 29staff: 8 at role-established and 21 at role-emergent sites(Table 4), and consisted primarily of registered nurses,care aides and licensed practical nurses. Non-pharmacystaff reported overall positive experiences (Table 5).There were no statistically significant differences be-tween staff experiences in role-established versus role-emergent facilities on any of the 7 features althoughTable 3 Pharmacists’ learning needs met by the care of elders module (N=76)Questions* Mean ± SD1. The material provided was presented in an understandable manner. 4.4 ± 0.72. The program has met the stated learning objectives effectively. 4.4 ± 0.73. The jeopardy game was helpful and effective for learning 4.3 ± 0.84. How realistic and true-to-life was the case? 4.3 ± 0.85. Did the case embody problems and issues typically found in actual practice? 4.2 ± 0.86. Did the case complexity or difficulty level challenge you? 4.1 ± 0.97. Is the case complexity and difficult level appropriate for entry-level health personnel? 3.9 ± 0.88. Did you have sufficient knowledge from your own previous experience? 3.7 ± 0.89. How much new information about health/medical issues did you learn? 3.9 ± 0.810. How much did you learn about different professional roles and responsibilitiesin interdisciplinary settings?3.9 ± 0.911. Did the panel provide new, critical information as needed? 4.2 ± 0.712. How much did you learn that is relevant to your own practice? 4.0 ± 0.813. Did the facilitator help your group to develop relevant pharmacy care plans? 4.5 ± 0.614. The jeopardy game was helpful and effective for learning 4.3 ± 0.715. Overall Assessment on a 1 to 5 scale 4.3 ± 0.716. Please suggest two or three things you learned today that werenew information to you● Delirium vs. Dementia vs Depression● Interpreting laboratory values in seniors● Role of other Health Professions in senior care● Physiology and pharmacokinetic considerations that need to be madere – drug therapy in seniors● Process for developing care plans17. Please name two to three changes in your own practicethat you will implement as a result of what you learned:● Incorporate comprehensive patient care process for seniors, such asthorough assessment and monitoring● Incorporate inter-professional collaboration and referral processes● Will be able to better support students*Response Scale: 1=Not at all, 2=Poorly Met, 3=Fairly Met, 4=Largely Met, 5=Totally Met.Kassam et al. BMC Medical Education 2013, 13:104 Page 7 of 11http://www.biomedcentral.com/1472-6920/13/104there were minor variations: staff at role-emergent siteswere slightly more familiar with the students’ purpose attheir site, knew how to refer patients to students, foundstudent services to residents to be helpful, developedtheir own better understandings of the pharmacist role,and found students to have provided helpful services atthe placement site. In contrast, staff at role-establishedsites reported fractionally more opportunities for studentinter-collaboration and more professional communica-tions and interactions with residents. Across all sites,more than half of the respondents remarked that eventhough they were initially uncertain of how to referresidential patients to the students, they made deliberateeffort to engage students in the patients’ care; and 64%indicated the services provided by the students were veryhelpful to the patients. A similar 64% also reported thatstudents’ services benefitted them directly and 25% sug-gested they now had a better understanding of the roleof the pharmacist at their facility as a consequence ofworking with the students. Three staff from different in-stitutions spoke about the benefits of pharmacy studentsat the role-emergent facilities: “If we have questionsabout medications, they are available right away. Wecan collaborate with them. By listening to themTable 4 Characteristics of staff survey respondents (N=29)Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6 Facility 7Role established RoleestablishedRoleemergentRoleemergentRoleemergentRoleemergentRoleemergentDistributionRegistered Nurse (RN) 3 RNs 1 RN 2 RNs 2 RNs 2 RNs 3 RNs -Nurse’s Aide (Aide) - - 4 Aides 1 Aide - - -Licenced Practical Nurses(LPN)- 1 LPN 1 LPN - - - 5 LPNsOther 2 Pastoral Care;1 Dietician- 1 (notspecified)- 1 Administrator - -Shifts WorkedDays 2 RNs; 2 Pastoral Care;1 Dietician1 RN; 1 LPN 5 RNs 1 RN 2 RNs;1 Administrator3 RNs 2 LPNsEvenings - - 2 RNs - - - -Graveyards - - - - - - -Mixtures 1 RN - - 2 RN; 1 Aide - - 3 LPNsEmployment StatusFull-time 3 RNs; 2 Pastoral Care;1 Dietician7 RNs 1 RN 2 RNs;1 Administrator1 RN 3 LPNsPart-time 1 RN; 1 LPN 1 RN 2 RNsCasual 1 Aide 2 LPNsTable 5 Responses to the staff survey (N=29)Staff responses* Role-establishedfacilities (n=8)Role-emergentfacilities (n=21)Significance of thedifferenceNumber of respondents Mean±SD Median Mean±SD Median t-test** MWW**How familiar were you with the purpose of the students at your setting? 3.13 ± 0.64 3 3.29 ± 0.78 3 ns nsDid you know how to refer residents to the student? 2.74 ± 1.16 3 3.24 ± 0.94 3 ns nsWere the students professional in their communications and interactionswith the residents?3.86 ± 0.38 4 3.75 ± 0.55 4 ns nsWere the services provided by students helpful to residents? 3.57 ± 0.54 4 3.67 ± 0.48 4 ns nsAre there opportunities for student to collaborate with other studentsat your LTC facility?3.43 ± 0.54 3 3.34 ± 0.82 4 ns nsBy interacting with the students, did you develop a better understandingof the pharmacist’s role?3.25 ± 1.04 4 3.38 ± 0.67 3 ns nsDid you find the services provided by the students helpful to you? 3.43 ± 0.79 4 3.57 ± 0.60 4 ns ns*Response Scale: 1=Not at all; 2=Only a little; 3=Somewhat; 4=Very.**Significance set at p<.05 and confirmed (for ordinal data) with Mann–Whitney U (MWW).Kassam et al. BMC Medical Education 2013, 13:104 Page 8 of 11http://www.biomedcentral.com/1472-6920/13/104(pharmacy students) teaching a patient, we were able tolearn from them.” Another said, “When a new ordercame around I was unfamiliar with, I found the phar-macy student very knowledgeable of said drugs … indica-tions, etc.… plus when dealing with pharmacy she (thestudent) helped the process out by providing informationin dealing with them (community pharmacy staff ), ques-tions they would ask to make the process smoother.” Staffalso recognized that successful APPEs result not only instudent learning but also in improved care for residents,“She (the student) helped us in reducing loxapine 10 mgwith our resident by suggesting to the doctor the taperingprocess, thus reducing dyskinetic effects of loxapine. Goodjob …!”There was overall consensus by both pharmacy pre-ceptors and facility staff that successful institutionalAPPEs could be located in role-emergent LTC settings,with equal effectiveness as in role-established settingsand with additional benefits of exposure to a growingsector of health services to the elderly.Gains in numbers of role-emergent placements at the endof the studyAs a direct consequence of this study, the school wasable to expand its institutional-based APPE placementcapacity by recruiting from the already trained pool ofpreceptors. Figure 1 shows that opportunity for growthand expansion of LTC placements was much more evi-dent at role-emergent sites than at role-established ones.This was not surprising since the majority of the newlytrained preceptors were affiliated with role-emergentthan role-established facilities. Together, the role-emergent preceptors represented about a dozen differentLTC establishments, some single-site but many multi-site. The numbers of placement per LTC establishmentranged from one to 12 students, spread over the aca-demic year (from September through April). Together,this increased annual student placement capacity at therole-emergent LTC facilities from zero at the study’s out-set to a total of 46 by the end of the study.DiscussionIt has long been recognized that the healthcare needs ofseniors residing in LTC facilities are complex and requirethe attention of a variety of healthcare providers. Severalstudies have confirmed that the presence of pharmacistwithin these facilities contributes to improved drug ther-apy management [8-13]. Academic-based studies have alsodemonstrated that pharmacy students under the directsupervision of pharmacy preceptors contribute effectivelyto patient care during their practice education experiences[20-22]. However, experiences involving pharmacy stu-dents within role-emergent settings have been lacking,and findings from this study provide some understandingto this end. This study demonstrated that role-emergentLTC facilities are a viable option for institutional APPEs.Within these settings, inter-professional collaboration nat-urally manifested itself with many nursing staff taking onthe role of surrogate preceptors while the pharmacy pre-ceptor was off-site. In this paper, the term “preceptor” isreserved for the pharmacy preceptor and LTC facility staffreferred to as “staff”. The pharmacy preceptors communi-cated routinely with the LTC staff both during theirweekly visits to the facilities and by phone as necessary.Student supervision was the responsibility of these phar-macy preceptors, but with occasional input from facilitystaff. Direct pharmacy preceptor-student-staff collabora-tions became integral to supporting both pharmacy pre-ceptors in their efforts to provide students with relevantpatient care opportunities and to the nursing staff in theirefforts to provide optimal patient care.Reviewing the staff surveys, it was apparent that mosthealth care providers viewed students’ presence at theLTC facilities as a mutually beneficial experience. Manyfelt that they delivered better care to residents as a resultof the services provided by the students to the residentsand to themselves. A large number of staff indicatedFigure 1 LTC placements capacity over four-academic years for role-emergent versus role-established sites.Kassam et al. BMC Medical Education 2013, 13:104 Page 9 of 11http://www.biomedcentral.com/1472-6920/13/104they had developed a better understanding of the phar-macist’s role through their interaction with the phar-macy students. When asked what changes they mightsuggest to the APPE activities, the staff suggested: par-ticipating in regular bed-side medication rounds withthe staff, setting aside more time to serve as resource forthe nursing staff, increasing their involvement with se-niors who have questions about their health/medica-tions, and providing education to nursing staff on topicsrelated to medications and their safe administration.Some staff also suggested that future students should oc-casionally work the night shifts to enhance their learningand to support nurses during that shift. Hence, overall,the students’ presence and their engagement in APPEactivities contributed towards shaping and expandingthe pharmacist’s role at these LTC facilities. Others haveshared similar reciprocal staff-student learning within aninter-professional experiential environment [5,23].The time committed by the school at the beginning ofthe study to support preceptors through discussions andworkshops, and preceptors’ efforts to orient the studentsto the facility and its staff prior to the start of the APPEwere likely important factors contributing to the successof these experiences. In their feedback, preceptors notedthat the educational support extended to them had in-creased their awareness of how to structure studentlearning within their LTC facilities. Moreover, the oppor-tunity to interact with the inter-professional panel dur-ing the Care of Elders Delirium Module workshop hadprovided them with useful strategies for promotinginter-professional collaboration at their sites, whichmanifested in a rich learning environment for their stu-dents. Examples of some of these activities include:shadowing nurses during medication administration,providing in-services for the staff on relevant medicationissues, providing information on questions about pa-tients’ medications, and assisting with medication ordersthat required clarification. Preceptors also reportedlearning new knowledge, skills and processes by partici-pating in the Care of Elders Delirium Module, whichthey believed would help them guide their students.Additionally, as part of the APPE expectations, all place-ments began with a tour of the facility provided by thepreceptor where students were introduced to most ofthe staff and programs available at the LTC. Preceptorsand students met face-to-face at least one-half day perweek during which time preceptors provided directsupervision and carried out formal assessments of thestudent’s findings, care plans, and recommendations.Written care plans, drug information responses and con-sultation notes to the physician were emailed to the pre-ceptor for feedback prior to dissemination. Preceptorswere available to students at all times via telephone andemail to discuss proposed interventions, before theywere discussed with health care team members. Hence,despite the seemingly unstructured nature of these role-emergent APPE placements, there was sufficient struc-ture for checks and balances to ensure appropriate,effective and safe care by students.LimitationsLike any study, certain limitations still exist. The first isthe small sample size of staff who responded to the sur-vey. Given that this was a demonstration study and thatthe sample represented the majority of the disciplines atthe LTC facilities, feedback provided valuable insight onthe impact of the APPE on staff. However, future studiesshould aim to validate the findings with other disciplinesnot represented here. Second, role-emergent placementswere limited to senior year pharmacy student APPEs.These students had previously completed two placementexperiences – one in their second year and another intheir third year. It remains untested whether such ex-periential models offered earlier in students’ academicprograms would have the same success.ConclusionThe analysis of pharmacy preceptors’ and facility staffdata has provided a greater understanding of the role-emergent experiential model in pharmacy education.Within the context of our school, the role-emergentmodel provided a beneficial experience for both precep-tors and staff. Prior to this study, there had been no ex-posure of pharmacy students to role-emergent LTCfacilities, and this model was seen as an attempt to fill ashortage of role-established institutional sites. However,the study results have shifted this view, and now suchsites are being recognized as offering legitimateinstitutional-based learning experiences [4]. We hopethese findings will serve as a catalyst for greater adop-tion of role-emergent approaches and will stimulate fur-ther research to examine whether similar successes canbe achieved within different contexts.Based on the pharmacy preceptors’ and facility staff ’spositive experiences, two of the participating role-emergent sites offered to increase their original studentplacement number from one to five and six students peracademic year, respectively. In addition, the school con-firmed two new role-emergent LTC facilities at the endof the study for subsequent academic years, and regis-tered six other facilities as potential future placementsites. Together, this increased student placement cap-acity at the role-emergent LTC facilities from none toover 45 by the end of the study - a number well exceed-ing expectations.AbbreviationsAPPE: Advanced pharmacy practice Experience; IPPE: Introductory pharmacypractice Experience; LTC: Long-term care; UBC: University of British Columbia.Kassam et al. BMC Medical Education 2013, 13:104 Page 10 of 11http://www.biomedcentral.com/1472-6920/13/104Competing interestsThe authors report no conflicts of interest in this work. The authors meet thecriteria for authorship as recommended by the International Committee ofMedical Journal Editors. John B. Collins received consultancy fees for analysisand interpretation of the study data. The authors received no compensationrelated to the development of the manuscript.Authors’ contributionsRK conceived the design of the study, implemented the study, andinterpreted the data. MK participated in the design, implementation,collation and data analysis of the study, and JBC participated in the analysisand interpretation of the data. All authors contributed to drafting themanuscript and read and approved the final version of the manuscript.AcknowledgmentsThis study was funded by the British Columbia Ministries of Health andEducation through the British Columbia Academic Health Council. We wouldlike to acknowledge Dr. Peter Jewesson for his editorial contribution to thegrant proposal; Dr. Angela Kim-Sing - in her role as institutional experientialcoordinator, with student/ preceptor recruitment and preparation; Dr. MarthaDonnelly for permission to use the Care of Elders Delirium Module; Dr. AaronTejani, Dr. Rhonda Malyuk, Dr. Kiran Ubhi, Dr. Arun Verma, Ms. Mandeep Kooner,Dr. Kim-Sing and Dr. Marianna Leung for assisting with the preceptor educationprogram; Ms. Lenora Ho for assisting with literature review, Ms. Yvonne Sin forassisting with data collation, and all pharmacy preceptors, students and LTCstaff who participated in this demonstration study.Author details1Faculty of Medicine, School of Population and Public Health, University ofBritish Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada. 2HoweStreet Pharmacy, 1070 Howe Street, Vancouver, BC V6Z 1P5, Canada.3Department of Educational Studies, University of British Columbia, 2044Lower Mall, Vancouver, BC V6T 1Z2, Canada.Received: 30 October 2012 Accepted: 25 July 2013Published: 5 August 2013References1. 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Obreli-Neto PR, Guidoni CM, de Oliveira BA, Pilger D, Cruciol-Souza JM,Gaeti-Fanco WP, Cuman RK: Effect of a 36-month pharmaceutical careprogram on pharmacotherapy adherence in elderly diabetic andhypertensive patients. Int J Clin Pharmacol 2011, 33(4):642–649.13. Lau E, Dolovich L: Drug-related problems in elderly general practicepatients receiving pharmaceutical care. Int J Pharm Pract 2005,13(3):165–177.14. Haddad AR, Coover K, Bramble JD, White L: Knowledge of pharmacygraduates of consultant pharmacy practice. Am J Pharm Educ 2004,68(2):51.15. Huddleston R: Clinical placements for the professions allied to medicine.Part 2. Placement shortages? Two models that can solve the problem.BJOT 1999, 62(7):295–298.16. Lekkas P, Larsen T, Kumar S, Grimmer K, Nyland L, Chipchase L, Jull G,Buttrum P, Carr L, Finch J: No model of clinical education forphysiotherapy students is superior to another: a systematic review.Aust J Physiother 2007, 53(1):19–28.17. The University of British Columbia Board of Governors: Research involvinghuman participants. Policy 89. Revised June 2012. http://www.universitycounsel.ubc.ca/files/2012/06/policy89.pdf.18. Patton MQ: Qualitative evaluation and research methods. 2nd edition.Newbury Park, CA: Sage Publications; 1990.19. Care for Elders Education Group, University of British Columbia: Aninteractive guide to the treatment of delirium. http://www.careforelders.ca.20. Kassam R, Kwong M: An enhanced community advanced pharmacypractice experience model to improve patient care. Am J Pharm Educ2009, 73(2):25.21. Hata M, Klotz R, Sylvies R, Hess K, Schwartzman E, Scott J, Law AV:Medication therapy management services provided by studentpharmacists. Am J Pharm Educ 2012, 76(3):51.22. Nuffer W, McCollum M, Ellis SL, Turner CJ: Further development ofpharmacy student-facilitated diabetes management clinics. Am J PharmEduc 2012, 76(3):50.23. Charles G, Bainbridge L, Copeman-Stewart K, Kassam R, Tiffin S: Impact ofan interprofessional rural health care practice education experience onstudents and communities. J Allied Health 2008, 37(3):127–131.doi:10.1186/1472-6920-13-104Cite this article as: Kassam et al.: A demonstration study comparing “role-emergent” versus “role-established” pharmacy clinical placementexperiences in long-term care facilities. BMC Medical Education 2013 13:104.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitKassam et al. BMC Medical Education 2013, 13:104 Page 11 of 11http://www.biomedcentral.com/1472-6920/13/104

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