Pharmaceutical Sciences, Faculty of
DSpace
UBCV
Nemir, Arwa
Master of Science - MSc
University of British Columbia
Background Patient-centred health professional teaching requires learners to develop skills that consider patientsâ preferences and needs. Accordingly, patient input is fundamental to enhance learner skill development. Objectives Phase 1: To map the existing evidence on how real patients participate in workplace-based assessment of health professional trainees across various health disciplines. Phase 2: To compare and contrast patientsâ and pharmacy learnersâ perspectives on patient involvement in assessing pharmacy learner skills. Methods Phase 1: Scoping review of patient participation in workplace-based assessment of health professional trainees. Phase 2: A qualitative study informed by interpretive description methodology and situated in an outpatient pharmacist-led clinic that serves as a teaching site for pharmacy learners. I conducted virtual semi-structured interviews with ten patients who were cared for by a pharmacy learner and ten pharmacy learners who were completing clerkship training. Data analysis was iterative, occurring as interviews proceeded and used a thematic approach. Findings Phase 1: There is limited evidence on patient involvement in health professional trainee assessment, particularly in the pharmacy discipline; with most studies in medicine and nursing. Phase 2: Addressing the knowledge gap revealed in Phase 1 on lack of patient involvement in pharmacy learner assessment. Patients expressed interest in giving feedback on pharmacy learner skills while learners regarded patient feedback as an asset to their educational journey. Overall, I identified two overarching themes 1) Humanistic aspects of pharmacy learner care; and 2) Intrinsic aspects of pharmacy learner care. There was marked divergence when comparing and contrasting patientsâ and pharmacy learnersâ data. Subthemes further revealed that humanistic aspects include rapport, simple language, and active listening as pharmacy learner skills patients felt they could assess. Conversely, pharmacy learners expected patients to predominantly assess their intrinsic pharmacy skills including knowledge and optimization of health. Conclusion This thesis provides insight into how real patients could participate in the assessment of pharmacy learners and how this participation was perceived by learners themselves. I propose an inclusive approach to pharmacy learner assessment, informed by patient perspectives and demands, to guide pharmacy educators in developing patient-centred feedback techniques that would ultimately enhance learnersâ training as future frontline clinicians.
âHonouring the Knowledge They Possess; It Is Time We Let the Patient Assessâ BRINGING THE PATIENT VOICE INTO WORKPLACE-BASED ASSESSMENT OF PHARMACY LEARNERS: AN INTERPRETIVE DESCRIPTION STUDY by Arwa Nemir PharmD, Qatar University, 2018 B.Sc., Alexandria University, 2014 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Pharmaceutical Sciences) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August 2021 © Arwa Nemir, 2021 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis entitled: âHonouring the knowledge they possess; it is time we let the patient assess.â Bringing the patient voice into workplace-based assessment of pharmacy learners: an interpretive description study. submitted by Arwa Nemir in partial fulfillment of the requirements for Examining Committee: Dr. Kerry Wilbur Associate Professor and Executive Director, Entry-to-Practice Education, Faculty of Pharmaceutical Sciences, University of British Columbia Supervisor Dr. Jillian Reardon Coordinator, Quality Care, Pharmacists in PCN Program, Pharmacist, The UBC Pharmacists Clinic, and Lecturer, Faculty of Pharmaceutical Sciences, University of British Columbia Supervisory Committee Member Dr. A. Fuchsia Howard Associate Professor, School of Nursing, University of British Columbia Additional Examiner Additional Supervisory Committee Members: Dr. Marion Pearson Professor, Faculty of Pharmaceutical Sciences, University of British Columbia Supervisory Committee Member Dr. Mary De Vera Associate Professor, Faculty of Pharmaceutical Sciences, University of British Columbia Supervisory Committee Member the degree of Master of Science in Pharmaceutical Sciences iii Abstract Background Patient-centred health professional teaching requires learners to develop skills that consider patientsâ preferences and needs. Accordingly, patient input is fundamental to enhance learner skill development. Objectives Phase 1: To map the existing evidence on how real patients participate in workplace-based assessment of health professional trainees across various health disciplines. Phase 2: To compare and contrast patientsâ and pharmacy learnersâ perspectives on patient involvement in assessing pharmacy learner skills. Methods Phase 1: Scoping review of patient participation in workplace-based assessment of health professional trainees. Phase 2: A qualitative study informed by interpretive description methodology and situated in an outpatient pharmacist-led clinic that serves as a teaching site for pharmacy learners. I conducted virtual semi-structured interviews with ten patients who were cared for by a pharmacy learner and ten pharmacy learners who were completing clerkship training. Data analysis was iterative, occurring as interviews proceeded and used a thematic approach. Findings Phase 1: There is limited evidence on patient involvement in health professional trainee assessment, particularly in the pharmacy discipline; with most studies in medicine and nursing. Phase 2: Addressing the knowledge gap revealed in Phase 1 on lack of patient involvement in pharmacy learner assessment. Patients expressed interest in giving feedback on pharmacy learner iv skills while learners regarded patient feedback as an asset to their educational journey. Overall, I identified two overarching themes 1) Humanistic aspects of pharmacy learner care; and 2) Intrinsic aspects of pharmacy learner care. There was marked divergence when comparing and contrasting patientsâ and pharmacy learnersâ data. Subthemes further revealed that humanistic aspects include rapport, simple language, and active listening as pharmacy learner skills patients felt they could assess. Conversely, pharmacy learners expected patients to predominantly assess their intrinsic pharmacy skills including knowledge and optimization of health. Conclusion This thesis provides insight into how real patients could participate in the assessment of pharmacy learners and how this participation was perceived by learners themselves. I propose an inclusive approach to pharmacy learner assessment, informed by patient perspectives and demands, to guide pharmacy educators in developing patient-centred feedback techniques that would ultimately enhance learnersâ training as future frontline clinicians. v Lay Summary Health care practice and education are strongly interconnected. Todayâs health professional trainees are tomorrowâs health care providers. Correspondingly, pharmacy programs aim to graduate pharmacists with patient-centred skills that respect patient preferences, needs, and values. The goal of my thesis is to understand patient participation in providing feedback to health professional trainees in general and pharmacy learners in specific. To do this, I conducted two studies. The first study highlighted a gap that led to completion of a second study. Firstly, I looked at research studies on how patients participate in assessing health professional trainees who care for them. Secondly, I interviewed patients and pharmacy learners asking them, âwhich pharmacy learner skills do you think patients could comment on?â and âwhat are your preferences for feedback delivery?â This thesis offers patient- and pharmacy learner-informed suggestions for including patients in pharmacy learner assessment to prepare future pharmacists for their roles as patient-centred frontline care providers. vi Preface The entirety of this thesis including literature review, study design, preparation and submission of ethics application, participantsâ recruitment, collection, analysis and interpretation of research data, and writing is the original work of Mastersâ Candidate, Dr. Arwa Nemir. Thesis writing was done by Dr. Nemir and revised based input received from research supervisor, Dr. Kerry Wilbur, committee members, Drs. Jillian Reardon, Marion Pearson, and Mary De Vera, and external examiner, Dr. A Fuchsia Howard. None of this work has been published to date. Chapter 2: Preliminary results from the scoping review study (abstracts) were accepted as oral presentations and were presented in the following research events either as live or pre-recorded presentations: 1. *[Nemir, A.], Pearson, M., Kitchin, V., Wilbur, K. (2021). Patient Participation in Workplace-Based Assessment of Health Professional Trainees: A Scoping Review. An International Association for Medical Education (AMEE) 2021 The Virtual Conference. UK. August 27th â August 30th, 2021 * Accepted abstracts will be available in the conference abstract book and in the conference app. 2. [Nemir, A.], Pearson, M., Kitchin, V., Wilbur, K. (2021). Patient Participation in Workplace-Based Assessment of Health Professional Trainees: A Scoping Review. UBC Pharmaceutical Sciences Graduate and Postdoctoral Research Symposium (GPRS). Vancouver, BC, Canada. May 6th, 2021 vii 3. *[Nemir, A.], Pearson, M., Kitchin, V., Wilbur, K. (2020). Patient Participation in Workplace-Based Assessment of Health Professional Trainees: A Scoping Review. 2020 The Centre for Health Education Scholarship (CHES) 10th Annual Celebration of Scholarship. Vancouver, BC, Canada October 6th, 2020 *Accepted abstracts were available in the 2020 CHES Celebration of Scholarship abstract book which was available online and was shared with all attendees. I took the lead in this scoping review study, and I was responsible for all the key decisions regarding the study design, database screening, data acquisition, abstraction, analysis, and interpretation of the data, writing of the review, and presentation of results. Ms. Vanessa Kitchin, research librarian at the University of British Columbia, assisted in conducting the literature search and contributed to the search strategy, running the database searches and the revision of the review draft. Drs. Pearson and Wilbur contributed to the database screening independently reviewing identified records according to pre-specified inclusion criteria as well as revision of the review draft. Chapters 3-6: Ethics approval to conduct this interpretive description study was provided by the University of British Columbia (UBC) Behavioural Research Ethics Board (H19-04038). My role as the lead research coordinator involved taking responsibility for the main decisions that pertained to the study design, data collection (virtual interviews), analysis, and interpretation in addition to presentation of findings at research events while working collaboratively with Dr. Reardon (co-/site investigator) and Dr. Wilbur. Drs. Reardon and Wilbur offered vital intellectual contributions and guidance during this study. Dr. Reardon also played a key role in participant recruitment owing to her position as a clinician and preceptor at the study site. viii Preliminary results from this study (abstracts) were: 1. Accepted as an oral presentation, [Nemir, A.], Wilbur, K., Reardon, J. (2021). Let the Patient Teach: Patientâs Voice in Workplace-Based Assessment of Pharmacy Learners. 2021 The Centre for Health Education Scholarship (CHES) 11th Annual Celebration of Scholarship. Vancouver, BC, Canada October 6th, 2021 2. *Presented as a poster, [Nemir, A.], Wilbur, K., Reardon, J. (2021). Let the Patient Teach: Patientâs Voice in Workplace-Based Assessment of Pharmacy Students. 2021 American Association of Colleges of Pharmacy (AACP) Annual Meeting Virtual Pharmacy Education 2021.USA, July 19th â July 22nd, 2021 *Poster was displayed in the Virtual Poster Gallery and was accessible by all registrants and attendees. ix Table of Contents Abstract .................................................................................................................................... iii Lay Summary ............................................................................................................................. v Preface ...................................................................................................................................... vi Table of Contents ..................................................................................................................... ix List of Tables ......................................................................................................................... xvii List of Figures ....................................................................................................................... xviii List of Abbreviations .............................................................................................................. xix Acknowledgements ................................................................................................................ xxi Dedication ............................................................................................................................ xxiv Chapter 1: Introduction ............................................................................................................. 1 1.1 Overview of Thesis Chapters ......................................................................................................... 1 1.2 Patient-Centred Care ....................................................................................................................... 3 1.2.1 Defining Patient-Centred Care within Health Professions Education ........................................... 3 1.2.2 The Notion of Patient-Centredness within the Pharmacy Profession .............................................. 5 1.3 Patient Involvement in Health Professions Education ............................................................. 7 1.3.1 Patient Involvement in Learner Training and Education .............................................................. 7 1.3.2 Patient Involvement in Workplace-Based Assessment of Learners ................................................ 8 1.4 Value and Impact of Patient Participation in Learnerâs Workplace-Based Assessment ..... 10 1.4.1 Value and Impact on Patients ................................................................................................... 10 1.4.2 Value and Impact on Pharmacy Learners ................................................................................. 11 x 1.5 Research Questions and Thesis Objectives ............................................................................... 12 Chapter 2: Patient Participation in Workplace-Based Assessment of Health Professional Trainee: A Scoping Review ..................................................................................................... 13 2.1 Chapter Overview .......................................................................................................................... 13 2.2 Background and Rationale ............................................................................................................ 13 2.3 Methods ........................................................................................................................................... 14 2.3.1 Search strategy ........................................................................................................................... 14 2.3.2 Citation management ................................................................................................................. 15 2.3.3 Study screening and selection ...................................................................................................... 15 2.3.4 Data extraction ......................................................................................................................... 16 2.3.5 Data synthesis and analysis ....................................................................................................... 16 2.4 Findings ........................................................................................................................................... 16 2.4.1 Overview of Included studies ....................................................................................................... 16 2.4.2 Aspects of Patient Participation in Health Professional Trainee Assessment ............................... 17 2.4.2.1 Patient Perspective ........................................................................................................... 17 2.4.2.1.1 Patient Satisfaction ........................................................................................................ 17 2.4.2.1.2 Assessing Patient Experiences, Opinions, Perceptions, and Perspectives ........................... 18 2.4.2.1.3 Health Professional Trainees Eliciting Patient Feedback ................................................ 20 2.4.2.2 Patient Versus Stakeholder Perspectives ...................................................................... 20 2.4.2.2.1 Triangulation as Multi-Source Feedback ........................................................................ 20 2.4.2.3 Influence on/of Patient Perspective ............................................................................. 21 2.4.2.3.1 Evaluating an Educational Intervention ......................................................................... 21 xi 2.4.2.3.2 Nature of Patient Feedback and Its Impact on Trainees ................................................. 22 2.4.2.4 Patient Perspective Relative to Other Factors ............................................................. 22 2.4.2.4.1 Association with Patient- or Trainee-Related Information ............................................... 22 2.4.2.5 Intertwined Aspects of Patient Participation ............................................................... 23 2.5 Discussion ....................................................................................................................................... 23 2.6 Conclusion ...................................................................................................................................... 27 Chapter 3: Research Methods ................................................................................................. 43 3.1 Chapter Overview .......................................................................................................................... 43 3.2 Description and Rationale for Applying Interpretive Description Methodology ............... 43 3.3 Research Paradigm ......................................................................................................................... 46 3.4 Theoretical Framework ................................................................................................................. 47 3.5 Study Site ......................................................................................................................................... 48 3.5.1 Pharmacy Education Context .................................................................................................... 48 3.5.2 Pharmacy Practice Context ........................................................................................................ 49 3.6 Research Team ............................................................................................................................... 51 3.7 Study Design ................................................................................................................................... 51 3.7.1 Study Sample ............................................................................................................................ 52 3.7.2 Participant Recruitment ............................................................................................................. 54 3.7.3 Data Collection ......................................................................................................................... 55 3.7.3.1 Pilot Interviews ................................................................................................................. 55 3.7.3.2 Semi-Structured Interviews ............................................................................................ 55 3.7.3.3 Participant Demographics and Characteristics ............................................................ 57 xii 3.8 Mitigating Strategies in Response to the Corona Virus Disease (COVID-19) Pandemic .. 57 3.9 Data Analysis and Interpretation ................................................................................................. 58 3.10 Reflexivity ........................................................................................................................................ 62 3.11 Ethical Considerations .................................................................................................................. 64 3.12 Security and Access to Data ......................................................................................................... 66 Chapter 4: Patient Perspectives on Patient Involvement in Pharmacy Learner Skill Assessment .............................................................................................................................. 68 4.1 Chapter Overview .......................................................................................................................... 68 4.2 Patient Participants ........................................................................................................................ 68 4.3 Overarching Themes ..................................................................................................................... 69 4.3.1 Theme #1 - Humanistic Aspects of Pharmacy Learner Care ..................................................... 71 4.3.1.1 Subtheme #1.1 - Atmosphere of The Patient-Learner Encounter .......................... 71 4.3.1.2 Subtheme #1.2 - Pharmacy Learners Recognizing Patientâs Humanity .................. 74 4.3.1.3 Subtheme #1.3 - Pharmacy Learners as Patient-Centred Communicators ............ 76 4.3.2 Theme #2 - Intrinsic Aspects of Pharmacy Learner Care .......................................................... 78 4.3.2.1 Subtheme #2.1 - Pharmacy Learners as Patient-Centred Medication Therapy Experts ............................................................................................................................................. 78 4.3.2.2 Subtheme #2.2 - Pharmacy Learners Acknowledging Their Capabilities ............... 82 Chapter 5: Pharmacy Learnersâ Perspectives on Patient Involvement in Pharmacy Learner Skill Assessment ...................................................................................................................... 85 5.1 Chapter Overview .......................................................................................................................... 85 5.2 Learner Participants ....................................................................................................................... 85 xiii 5.3 Overarching Themes ..................................................................................................................... 86 5.3.1 Theme #1 - Intrinsic Aspects of Pharmacy Learner Care .......................................................... 88 5.3.1.1 Subtheme #1.1 - Pharmacy Learners as Medication Therapy Experts ................... 89 5.3.1.2 Subtheme #1.2 - Pharmacy Learners as Patient-Centred Team Players ................. 93 5.3.1.3 Subtheme #1.3 - Pharmacy Learners Providing Exemplary Patient Care .............. 97 5.3.1.4 Subtheme #1.4 - Professionalism Is a âState of Mindâ ............................................. 99 5.3.2 Theme #2 - Humanistic Aspects of Pharmacy Learner Care ................................................... 102 5.3.2.1 Subtheme #2.1 - Pharmacy Learners as Patient-Centred Communicators .......... 103 5.4 Learner Perspectives on Patient Versus Preceptor Feedback ............................................... 106 5.4.1 Theme #1 - Patient Feedback Is Humanistic and Perceptive, Preceptor Feedback Is Evaluative and Instructive ........................................................................................................................................... 107 5.4.2 Theme #2 - Patient Feedback Is Not Only Valuable, But Also Legitimate ........................... 109 Chapter 6: Establishing Patient Feedback Norms ................................................................ 113 6.1 Chapter Overview ........................................................................................................................ 113 6.2 Understanding Patient Preferences for Feedback Delivery .................................................. 114 6.2.1 Patient Willingness and Comfort in Giving Feedback .............................................................. 115 6.2.2 Supervisor/Preceptor Involvement in the Patient-Learner Feedback Loop ................................. 116 6.2.2.1 Patient Feedback Given Directly to The Learner in Presence of The Preceptor 116 6.2.2.2 Patient Feedback Given Directly to The Preceptor in Absence of The Learner . 118 6.2.3 Means of Patient Feedback ...................................................................................................... 120 6.2.3.1 Verbal Patient Feedback ............................................................................................... 120 6.2.3.2 Written Patient Feedback .............................................................................................. 121 xiv 6.2.3.3 Patient Feedback Means is Situational ........................................................................ 122 6.2.4 Timing of Patient Feedback ..................................................................................................... 124 6.2.5 Possible Factors Influencing Patient Feedback .......................................................................... 126 6.3 Understanding Pharmacy Learner Preferences for Patient Feedback Delivery ................. 131 6.3.1 Means of Patient Feedback ...................................................................................................... 131 6.3.2 Timing of Patient Feedback ..................................................................................................... 134 Chapter 7: Discussion and Recommendations ..................................................................... 137 7.1 Chapter Overview ........................................................................................................................ 137 7.2 Integration of Research in Education and Practice ................................................................ 137 7.2.1 Contextualizing Chapter 2 Key Findings ................................................................................. 137 7.2.2 Contextualizing Chapters 4 and 5 Key Findings ..................................................................... 139 7.2.3 Contextualizing Chapter 6 Key Findings ................................................................................. 144 7.3 Strengths ........................................................................................................................................ 146 7.4 Limitations .................................................................................................................................... 148 7.5 Research Implications for Pharmacy Education and Practice .............................................. 149 7.6 Future Research Directions ........................................................................................................ 151 7.7 Conclusion .................................................................................................................................... 154 References ................................................................................................................................................... 156 Appendices ................................................................................................................................................. 185 Appendix A ................................................................................................................................................ 185 Appendix A-1: Definitions of Patient Roles in Health Professional Education .......................................... 185 Appendix B ................................................................................................................................................. 186 xv Appendix B-1: PRESS - Search Submission & Peer Review Assessment ................................................. 186 Appendix B-2: Search Strategy ................................................................................................................. 190 Appendix B-3: Data Extraction Form ..................................................................................................... 193 Appendix C ................................................................................................................................................. 194 Appendix C-1: Definitions of the AFPC Educational Outcomes .............................................................. 194 Appendix C-2: Letter of Initial Contact (Patient Participants) .................................................................. 195 Appendix C-3: Letter of Initial Contact (Learner Participants) ................................................................. 196 Appendix C-4: Consent Form (Patient Participants) ................................................................................. 197 Appendix C-5: Consent Form (Learner Participants) ............................................................................... 200 Appendix C-6: Interview Topic Guide (Patient Participants) ..................................................................... 203 Appendix C-7: Interview Topic Guide (Learner Participants) ................................................................... 205 Appendix C-8: Mapping the Research Questions and Study Objectives within Patient Interview Questions 208 Appendix C-9: Mapping the Research Questions and Study Objectives within Learner Interview Questions 210 Appendix D â Patient Participants ......................................................................................................... 213 Appendix D-1: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Care Provider) .......................................................................................................................... 213 Appendix D-2: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Communicator) ......................................................................................................................... 215 Appendix D-3: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Collaborator) ............................................................................................................................ 217 Appendix D-4: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Scholar) .................................................................................................................................... 218 xvi Appendix D-5: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Professional) ............................................................................................................................. 219 Appendix E â Learner Participants ........................................................................................................ 220 Appendix E-1: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Care Provider) .......................................................................................................................... 220 Appendix E-2: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Communicator) ......................................................................................................................... 221 Appendix E-3: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Collaborator) ............................................................................................................................ 222 Appendix E-4: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Health Advocate) ..................................................................................................................... 224 Appendix E-5: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Scholar) .................................................................................................................................... 225 Appendix E-6: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Professional) ............................................................................................................................. 227 xvii List of Tables Table 2-1 Summary of Scoping Review Inclusion and Exclusion Criteria ............................................. 28 Table 2-2 Characteristics of Included Studies in the Scoping Review (n=78) ....................................... 29 Table 2-3 Literature on Patient Participation in Health Professional Trainee Assessment ................. 30 Table 4-1 Patient Participantsâ Characteristics ............................................................................................ 83 Table 5-1 Learner Participantsâ Characteristics ......................................................................................... 111 xviii List of Figures Figure 2-1 Flow Diagram for The Scoping Review Process ..................................................................... 41 Figure 2-2 Map Demonstrating Different Aspects of Patient Participation in Health Professional Trainee Assessment ......................................................................................................................................... 42 Figure 4-1 Thematic Map of Identified Themes and Corresponding Subthemes of Patient Perspectives ....................................................................................................................................................... 84 Figure 5-1 Thematic Map of Identified Themes and Corresponding Subthemes of Learner Perspectives ..................................................................................................................................................... 112 Figure 6-1 Diagram Mapping Patient Feedback Components ............................................................... 136 xix List of Abbreviations AFPC Association of Faculties of Pharmacy of Canada BSc Pharm Bachelor of Science in Pharmacy CAT Communication Assessment Tool CL Collaborator CM Communicator COVID-19 Corona Virus Disease CP Care Provider EMT Emergency Medical Technician HA Health Advocate ID Interpretive Description LM Leader-Manager MSF Multi-Source Feedback PharmD Doctor of Pharmacy PGY Post-Graduate Year PR Professional PRESS Peer Review of Electronic Search Strategies PSQ Patient Satisfaction Questionnaire OSCE Objective Structured Clinical Examination REB Research Ethics Board xx SC Scholar SOAP Subjective, Objective, Assessment, Plan SP Standardized Patient TCP Tri-Council Policy UBC University of British Columbia UK United Kingdom USA United States of America WBA Workplace-Based Assessment xxi Acknowledgements âScience knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world. Science is the highest personification of the nation because that nation will remain the first which carries the furthest the works of thought and intelligenceâ ~ Louis Pasteur *** There are no words to express my sincerest and utmost gratitude to my incredible supervisor, Dr. Kerry Wilbur. Dr. Wilbur is an exemplar as a brilliant educator, enthusiastic researcher, empowering colleague, extremely supportive mentor, and kind human being. She believed in me when no one else did. She saw the potential in me and changed my life, not once but twice. First, in 2016, when she offered me a position as post-baccalaureate student in the Doctor of Pharmacy program at Qatar University College of Pharmacy. Then, three years later, when she chose me to be her first graduate student at UBC. This thesis would not have been possible without Dr. Wilburâs tremendous encouragement and thought-provoking questions and ideas as she continuously challenged my thoughts and writing and paved the way for me to be an independent researcher and educator. Dr. Wilbur has genuinely motivated me not only in my training but also my professional and personal life. I could not have wished for a better advisor. I would also like to acknowledge that Dr. Wilburâs support went above and beyond her role as my graduate research supervisor. She is not just my supervisor; she is also family and âhome away from home.â Her heart-warming kindness and big heart helped ease my transition as an international student relocating to Canada as she supported me through my emotional struggles. As my mum always says, âKerry is Allahâs [Godâs] soothing reward and precious gift to you after all the hardships you have been through.â And yes, xxii she is. I am truly honoured and humbled to have been Dr. Wilburâs student for the past five years and I am forever grateful to have crossed paths with her. I would also like to extend my deepest appreciation for my supervisory committee members for their ongoing support and continuous guidance from the first day I joined the Faculty of Pharmaceutical Sciences at UBC. To Dr. Jillian Reardon, an integral member of my research team, for her continuous motivational words and support as well as valuable contribution and insights throughout this project as a pharmacist, researcher, and educator, specifically during participant recruitment and data analysis. To Dr. Larry Lynd, for chairing my committee meetings with utmost professionalism and a delightful sense of humour and for always challenging me with his thought-provoking questions and perspectives. To Dr. Mary De Vera, for her professional and personal support over the course my graduate studies, invaluable feedback to help me become a better researcher and academic writer, and generosity, kindness, and compassion (Mary the fairy). To Dr. Marion Pearson, who has imparted immeasurable knowledge throughout this thesis, especially during the literature review and study design, for her dedication and commitment, generous feedback, and insightful comments, which helped shape the final thesis product. Much gratitude also goes out to Dr. Abby Collier for her kind support and our weekly Zoom check-ins to catch up as we were both working from home during the COVID-19 pandemic. I would also like to thank Dr. Anita Kapanen for her valuable consultation on my ethics application. Thank you to the incredible UBC Pharmacists Clinic team, who were my support system during participant recruitment. Heart-warming thanks to Monyca and Valery Szabo, Dr. De Veraâs gorgeous daughters and my adorable little chef friends, who showered me with love through their mouth-watering home baked goods. xxiii I am grateful for the funding provided by the Canadian Foundation for Pharmacy to support this thesis as a well as the financial recognition I received as a graduate student researcher at UBC through Douglas and Jean Bailey Scholarship and ImpactBC Scholarship in Health Care Research and Development. Most importantly, I want to acknowledge my research participants who are the heart and soul of this thesis. My thesis would not have come to life if it were not for the patients and pharmacy learners who devoted their valuable time to share their experiences and perspectives and who trusted me with their stories. Finally, to my wonderful family and friends who have always supported me in my academic endeavours and encouraged me to keep going. I am forever indebted to my mother, Dr. Manal Elkoreny, and father, Professor Mohamed Taher Nemir, for their unconditional love and support and for always putting their faith in me and my work. No words could ever express how lucky I am to have supportive and loving parents like you. To my younger sister, Maram Nomir, younger brother, Omar Nemir, and my friends in Canada, Emily Logan, Lisa Cheng, Michael Doerksen, and Wajiha Mehdi, for their continuous support, words of encouragement, and for believing in me. xxiv Dedication I dedicate my dissertation to my beloved Palestinian grandmother, Teita Soubheya, and mother, Dr. Manal Elkoreny, who are both exemplars as strong and independent women refugees. They taught me resilience, perseverance, courage, and kindness through life. 1 Chapter 1: Introduction 1.1 Overview of Thesis Chapters The aim of this thesis is to provide an understanding of patient involvement in assessing the health professional trainees who care for them. Accordingly, this thesis comprises two research studies. The first study highlighted a gap that fueled conducting the second one. Therefore, the two studies complement each other with respect to aspects of patient participation assessment of health professional trainees in general (Chapter 2) and pharmacy learners in particular (Chapters 3-7). In Chapter 1, I provide background information regarding the thesis topic which includes introducing the reader to the patient-centred approach, patient roles in health professional education, and how the concept of patient-centredness is positioned within health professions education and the pharmacy profession. In this chapter, I also emphasize the rationale and significance, on both patients and pharmacy learners, of involving patients in health professions education with a specific focus on pharmacy education and training. I finalize Chapter 1 by outlining the research questions and specific thesis objectives. In Chapter 2, I review the first study, a comprehensive scoping review of the existing literature by screening over 8,700 studies for evidence of patient and/or caregiver participation in the workplace-based assessments of health professional trainees who provide them with care. Findings from the scoping review demonstrate a significant research gap which informed conducting the second study discussed in Chapters 3-6. 2 In Chapter 3, I describe the qualitative research methods which I implemented in the interpretive description study presented in Chapters 4-6. The chapter also includes an explanation for the chosen research methodology (interpretive description) and the rationale behind it, theoretical framework, research paradigm, study site, study design (study sample, participant recruitment, data collection methods, data analysis, and reflexivity), ethical considerations, and privacy and data security measures. In Chapter 4, I report findings of the interpretive description study that I undertook to gain insight into patient perspectives on pharmacy learner skills they could observe and assess. This chapter presents the âwhatâ component of this thesis with respect to aspects of patient involvement in pharmacy learner skill assessment, from the patient perspective. In Chapter 5, I report findings of the interpretive description study that I undertook to gain an insight on pharmacy learner skills patients could observe and assess, from pharmacy learnersâ point of view. This chapter presents the âwhatâ component of this thesis with respect to aspects of patient involvement in pharmacy learner skill assessment, from the learner perspective. In Chapter 6, I present findings from the interpretive description study that pertain to the logistics and practicality of patient participation in pharmacy learner workplace-based assessment from the perspective of patients and pharmacy learners. This comprises the âhowâ, âwhenâ, and âwhoâ components of patient feedback to learners. Specifically, Chapter 6 demonstrates patient and pharmacy learner preferences for feedback delivery including feedback means, timing, and preceptor involvement. 3 The thesis concludes with Chapter 7 where I 1) provide an integrated discussion of key findings derived from the research presented in Chapters 2-6; 2) contextualize findings in Chapter 2 (scoping review) within Chapters 4 (patient perspectives) and 5 (learner perspectives; 3) situate findings in Chapters 4-6 within existing supporting evidence; and 4) compare and contrast findings highlighted in Chapters 4-6. The concluding chapter also outlines the inherent strengths and limitations of the interpretive description study in addition to addressing implications for pharmacy education and practice and recommendations for future research initiatives informed by the conclusion of my thesis work. Notes on language and nomenclature: Throughout this thesis, I use the term âlearnerâ interchangeably with the terms, âtraineeâ and âstudentâ to refer to a health care professional in training. I also use the terms âsupervisorâ, âpreceptorâ, and âclinical educatorâ interchangeably to refer to the individual supervising the health professional in training during the care provision. 1.2 Patient-Centred Care 1.2.1 Defining Patient-Centred Care within Health Professions Education Patient-centred care is a pivotal contemporary approach to health care delivery that acknowledges and respects patientsâ individual expectations, needs, preferences, and values (Stegers-Jager & Themmen, 2015; Stojan et al., 2016) while serving their best interests (Scambler et al., 2015). It seeks to empower patients, their families, and/or their caregivers to take an active part in shared- decision making with health care providers (Stojan et al., 2016). The notion of patient centredness is revolutionary and has witnessed a tremendous growth in health care provision with the aim to 4 evolve beyond the previously prevailing paternalistic means of delivering care to address and attend to patientsâ personal values and needs (Kuluski et al., 2016). The term âpatient-centredâ lacks a universal agreed upon definition (Cliff, 2012); however, as proposed by the Institute for Health care Improvement (2011): âCare that is truly patient-centred considers patients' cultural traditions, their personal preferences and values, their family situations, and their lifestyles. It makes the patient and their loved ones an integral part of the care team who collaborate with healthcare professionals in making clinical decisions ... When care is patient-centred ... unneeded and unwanted services can be reduced.â (para. 2) Since the notion of patient-centredness places patients at the forefront, patients are not solely regarded as recipients of healthcare but their unique individual experiences with their medications and medical conditions are recognized as contributing factors to the health care process (Mead & Power, 2000). Existing literature shows that the concept of patient-centred care has existed for over sixty years (Balik et al., 2011; Cliff, 2012) but for unknown reasons was not a mainstream culture until recently when patient-centredness is a typical practice in health care provision (Cliff, 2012). An opposing model of patient-centred care would be one which overlooks patient autonomy and informed choice (Boggiano et al., 2017), whereby patients are passive recipients of their own care rather than actively collaborating in it. The future of a nationâs health care is shaped by todayâs health professional learners. We need learners who are competent and well-equipped to keep up with the changing and challenging landscape of health care delivery. Health professional education programs are responsible to society and accountable to the individuals graduates serve. Therefore, contemporary health professions programs are expected to graduate learners capable of providing patient-centred care that respects patientsâ individual perspectives and needs. Since the notion of patient-centredness has been widely 5 emphasized as a means of empowering patients to be involved in their own health care (Stojan et al., 2016), health professional education programs have been designing curricula to equip learners with patient-centred skills and competencies across diverse educational contexts (Towle & Godolphin, 2011). Training programs aim to prepare learners as future patient-centred practitioners while offering more accountability to patients and their family members and care givers. 1.2.2 The Notion of Patient-Centredness within the Pharmacy Profession Patients are essential members in their own health care team and the expression "nothing about me without me" explicitly conveys this message (Barry & Edgman-Levitan, 2012). Accordingly, patient-centred teaching has become a priority for multiple health professions educational programs and the pharmacy profession is indeed no exception. Pharmacy education has evolved and continues to grow in the movement towards a patient-centred competency-based education (Frankel et al., 2014; Paradis et al., 2018; Waite et al, 2006) to meet accreditation standards. This movement is reflected in the shift of pharmacy programs within North American programs from the Bachelor of Science in Pharmacy (BSc Pharm) to the Doctor of Pharmacy (PharmD) degree (Frankel et al., 2014; Paradis et al., 2018; Waite et al, 2006). The PharmD degree reflects the expansion in pharmacist roles from compounding and dispensing medications (Frankel et al., 2014; Waite et al, 2006) to clinical services (Paradis et al., 2018) with prescribing authority in multiple North American settings. The pharmacy profession within Canada has witnessed an ongoing transition into more patient care-focused roles over the past twenty years (Gobis et al., 2020). Patient-centred pharmacy care, in particular, aims to contribute effectively to the process of health care by taking direct responsibility for each patientâs medication-related requirements and needs (Sánchez, 2011). As described by de Oliveira (2003), pharmacy care provision entails that, âthe practitioner must not only meet a patientâs drug-related needs and resolve drug therapy problems, but also attend to the meanings patients ascribe to 6 their illness as well as to their medicationsâ (p. 188). Pharmacist contributions and responsibilities have extensively progressed over the past decades to a role as a medication therapy expert and frontline health care provider with more direct patient contact (Paradis et al., 2018). Pharmacists now play a central role in managing patientsâ medication needs such as drug therapy monitoring, adherence, lab work, and any drug or disease-related problems (de SÃ¡ Borges et al., 2010; Khaira et al., 2020). Pharmacy education and practice are strongly intertwined. Pharmacy programs strive to train their learners to skillfully integrate textbook evidence-based learning into practice not only affecting their current training but also the future workforce. Todayâs pharmacy learners are tomorrowâs frontline care providers. As part of their pharmacy training and as required by their programs, learners engage in experiential education where they provide direct supervised patient care. Pharmacy learners are expected to keep up with the changing needs of the communities they serve and to focus on what matters the most to each individual patient and to society at large. Additionally, pharmacy learners are trained to adopt a life-long appetite for learning and a mindset of adapting and accommodating patientsâ personal circumstances, needs, values, desires, demands, and preferences. As far as the pharmacy profession is concerned, the patient-learner relationship strives to achieve a therapeutic alliance (Hasan, 2008; Sánchez, 2011). Sánchez (2011) eloquently describes the alliance between patients and pharmacy professionals as one that, âfocuses on the whole person and not simply a biological, organ system, disease state, or drug product in any reductionist sense. It is based on trust, respect, authenticity, and commitmentâ (p. 56). A therapeutic alliance is a relationship of collaboration created between a patient and their pharmacist with the goal of improving the patient's pharmacy care and the patientâs experience with their drug therapies (Hasan, 2008; Sánchez, 2011). The alliance between patients and pharmacy learners, like other kinds of human relationships, needs to be nurtured with mutual contribution where both parties expect a seat at the table to share their 7 perspectives. Accordingly, the patient-pharmacist therapeutic relationship strives to facilitate the mutual exchange of information and knowledge, so that patients would get the most out of their medications (Strand et al., 1991; Sánchez, 2011). 1.3 Patient Involvement in Health Professions Education 1.3.1 Patient Involvement in Learner Training and Education Patient involvement in health professions education traces back to the early 20th century as proposed by Sir William Osler, a well-recognized Canadian physician (Towle & Godolphin, 2011). Sir Osler proposed the concept of having the âpatient as a teacherâ, a concept that has been not only adopted but also continuously evolved in the training programs of diverse health care disciplines (Towle & Godolphin, 2011). Health professions d- education programs incorporate patients in multiple aspects of learnersâ training and educational processes such as curriculum development (Towle, 2006) and delivery (Bollard et al., 2012), storytelling of lived experiences (Rowland & Kumagai, 2018), and bedside teaching (Monrouxe et al., 2009). Examples of patients involved in health professional education include standardized patients, simulated patients, patient volunteers, virtual patients, patient partners, patient tutors, or real patients (Hudson & Ratnapalan, 2014; Towle, 2006) (see Appendix A-1). A ârealâ patient is defined as, âsomeone who has a direct lived experience with the disease and/or condition they sought to displayâ (Rowland et al., 2019, p. 602). This description distinguishes real patients from individuals who do not actually have a condition or a disease and who have been trained to represent it or ârole-playâ (Towle et al., 2010). Engaging with patients is an integral component of traineesâ educational and professional growth and this justifies why training should be centred around patients, the heart of health care. A trainee-patient encounter provides an authentic space where trainees can integrate experiential training with didactic 8 knowledge. Real patients are thus in an ideal position to play a key role in shaping learnersâ training and educational experience. Research also shows that patients deem their contribution to learner training and educational experience as an altruistic means of giving back to their community (Morgan & Jones, 2009; Wykuruz & Kelly, 2002; Suikkala et al., 2018). 1.3.2 Patient Involvement in Workplace-Based Assessment of Learners While the contribution of patients to health professions education has been explored, research demonstrating their role in traineeâs workplace-based assessments is scarce. Workplace-based assessment (WBA) is defined as multiple assessment techniques combined with the provision of competency-based feedback for the evaluation of learners in a clinical setting (Guraya, 2015; Moreau et al., 2019). Observation of learner clinical performance through clinical evaluation exercises or direct observation of procedural skills, case-based clinical discussions, and multi-source feedback are all WBA modalities (Guraya, 2015). The aspect of observation of the learner performance in an authentic real-world setting, coupled with appropriate feedback, is a hallmark of WBA, promoting reflective practice (Guraya, 2015). In the clinical learning environment, health professional learners typically receive performance feedback from a supervisor such as a preceptor or a clinical educator (Bridge et al., 2014). However, alternative evaluation methods to support providing optimal feedback to learners have not been well explored. In addition, multi-source feedback, also known as 360-degree evaluation, is one form of workplace-based assessment which involves peers, educators, patients, family members, or caregivers as assessors for learners (Braend et al., 2010; Garra et al., 2011; Riveros et al., 2016). Nevertheless, the perspectives of patients, their family members, or caregivers are often a missing component in multi-source feedback provision (Moreau et al.,2019). 9 It is the duty of health professions educators and preceptors to support learners in mastering patient-centred competencies. Therefore, providing patients with spaces to voice their feedback of learners is essential to the provision of a holistic patient-centred care to align with patientsâ individual values, needs and preferences. A patient-generated perspective reflecting learnerâs expertise and skills is a compelling and critical supplement to the pedagogical model of training through augmenting the existing evaluation and assessment strategies. Soliciting patient feedback is an indispensable opportunity to focus on patientsâ values and expectations (Freed et al., 2010) while serving as a potential patient-focused means of recognising areas of future improvement for learners (McMahon-Parkes et al., 2016). As Bartlett and colleagues (2017) remind us, âEducational feedback is amongst the most powerful of all learning interventionsâ (p. 1). Fostering patientsâ active involvement in health professional workplace-based learning is paramount in facilitating learnersâ smooth transition into practice in the movement towards advocating for and being congruent with the philosophy of patient-centred care. Active involvement is a term used to: âDescribe the involvement of people who are engaged in teaching, assessment or curriculum development because of their expertise and experiences of health, illness or disability and who are aware that they have designated teaching roles, but not to describe the involvement of people who role-play patients to express symptoms or conditions they do not actually have (simulated patients [SPs])â (Towle et al., 2010, p. 65). It is compelling to prepare future health professional learners who are capable of providing high-quality patient-centred care that respects patientsâ preferences and expectations. Health professions educators must work hand-in-hand with patients to define the skills required by health professional learners to optimize patient-centred care and improve health outcomes (Earnest & Brandt, 2014). Health professional educational institutions and programs are accountable to the society and the individuals they serve. From an ethical and moral perspective, patients should be 10 provided with the opportunity to be involved in making decisions about their health. They are the experts when it comes to their own health and have a unique experience with their medical condition; therefore, their voices should be an integral component in the practice of patient-centred health care (Rycroft-Malone et al., 2004). 1.4 Value and Impact of Patient Participation in Learnerâs Workplace-Based Assessment 1.4.1 Value and Impact on Patients It is crucial to highlight the importance of empowering patients by approaching them as a person rather than a treatment subject. Providing patients with an opportunity to, for example, participate in health professional learnersâ skill assessment would provide one outlet to ensure that their voices are heard. An inclusive approach to practice-based education means putting patients at the forefront while ensuring the patient perspective of the care that learners provide them with are represented is an essential component of respecting the patient autonomy. Additionally, humanizing and understanding the patient experience with the care delivered by health professional learners is a vital aspect of providing individualized care that evaluates the safety and effectiveness of the patientâs medications. Appreciating patients' perceptions of their medical conditions, their values, and beliefs with regards to medications, and how these impact treatment recommendations offer patients a chance to learn more about their therapies augmenting the provision of an individualized, effective, and humanistic care. When health professional education is tailored to patientâs expectations and preferences, it enhances patientâs health outcomes while aligning with patient-specific treatment goals (Bornkessel et al., 2014; LaVela & Gallan, 2014). This includes improving patientsâ understanding of their diagnosis, medical therapy, and improving satisfaction with and adherence to treatment. Furthermore, it is an indispensable opportunity to enable patients to share 11 their perspectives and make decisions that best fit their individual needs. It also strengthens the relationship between patients and their health care providers in an attempt to advance the patientâs recovery by boosting the patientâs self-confidence (Fadden et al., 2005; Masters et al., 2002; Monrouxe et al., 2009; Rees et al., 2007). Therefore, an inclusive approach to health professions education that highlights the importance of empowering patients by making sure their perspectives of health professional learners are expressed is necessary. 1.4.2 Value and Impact on Pharmacy Learners It is unreasonable to claim that we are preparing health professional learners to be patient-centred practitioners if we overlook the patient perspective in our educational programs. Patient participation in learnersâ workplace-based assessment is indeed fundamental to the development of the competent health professionals that our society not only expects but also deserves and needs. For health professional learners, as future health care providers, the patient perspective is essential to enrich their practice-based education and support their patient-centred skills and competencies while working in collaboration with patients (Suikkala et al., 2018). Pharmacists are considered to be the most accessible health care providers (Khaira et al., 2020; Manolakis & Skelton; 2010). Consequently, as future pharmacists, pharmacy learners are expected to attend to patientâs needs, preferences, and expectations. Patient feedback would provide learners with insights into the care they provide and how it is experienced and viewed by patients. This enables learners to question and improve their own practice and improve while meeting patientsâ expectations and needs. As the primary recipients of care, patients would have complementary contributions and unique viewpoints of a pharmacy learner. Including patients, their family members and/or their caregivers as part of the feedback loop will help train the next generation of competent pharmacy learners, preparing them for what they will inevitably face as 12 practicing professionals. The onus is on health professions educational programs and academic institutions to ensure that learners are provided with a sound education that integrates patientsâ expectations, values, and needs so they are well prepared for the evolving demands of health care. 1.5 Research Questions and Thesis Objectives Prior research indicates unanswered questions concerning patient participation in pharmacy learner workplace-based assessment. However, rather than forcing the possibility of being part in pharmacy learner assessment and feedback procedures on patients, I decided to first investigate which components of pharmacy learner care patients could willingly and comfortably assess. Accordingly, the three research questions guiding my thesis are 1) What evidence exists regarding real patient involvement and/or participation in the assessment of health professional trainees in a workplace-based context? 2) What skills, demonstrated by pharmacy learners during patient interactions, are patients capable of observing and subsequently assessing? and 3) What are patientsâ and pharmacy learnersâ preferences for patient feedback delivery? Particularly, my thesis objectives are to compare and contrast patient and pharmacy learner expectations, perspectives, and preferences for research questions number 2 and 3. My thesis also aims to provide an initial understanding, based on views from patients and pharmacy learners, on establishing patient feedback norms including patient willingness and comfort, feedback means and timing, preceptor involvement in the patient-learner feedback loop as well as gain insight into potential factors which could influence the feedback process. 13 Chapter 2: Patient Participation in Workplace-Based Assessment of Health Professional Trainee: A Scoping Review 2.1 Chapter Overview In this chapter, I present the scoping review I conducted to locate and map the evidence on aspects of patient participation in the assessment of health professional trainees with a real-life/ workplace-based setting across a diverse of health care professions. This review represents important foundational work for my thesis as it informed undertaking the interpretive description study presented in Chapters 3-6. 2.2 Background and Rationale Health care provision is cultivated by training future health professionals who are geared towards our nationâs current and forthcoming health care needs. Trainees must be well-equipped to address the changing and challenging landscape of health care, and educational programs must respond to societal needs. Education is important to how health professional trainees practice, communicate, and contribute to patient care quality and safety. Preparing health professional trainees to meet the evolving demands of health care delivery and provision requires fundamental changes to training and education. These changes are only possible if academic and health care institutions align with the expectations of the communities they serve. Health professional education programs are responsible for equipping trainees with patient-centred competencies to align with patientsâ needs and demands. Additionally, it is imperative to foster an educational process that is consistent with patientsâ expectations and perspectives. The aim 14 of this scoping review is to outline the existing landscape of the ways real patients participate in the workplace-based assessment of trainees across diverse health care professions. 2.3 Methods Because my aim was to identify a body of emerging evidence (Munn et al., 2018) and offer a broad perspective of a topic in question (Pham et al., 2014), I conducted a scoping review. The scoping review was guided by the broad research question, âWhat evidence exists regarding real patient involvement and/or participation in the assessment of health professional trainees in a workplace-based context?â and conducted using the framework initially proposed by Arksey and OâMalley (2005), and subsequently adapted and refined by Levac and colleagues(2010) . The framework consists of a five-step process: (1) composing with the research question; (2) identifying potentially eligible studies; (3) selecting relevant studies according to a predefined criterion; (4) charting the data; and (5) collating, summarizing, and reporting the findings. 2.3.1 Search strategy A search strategy was developed in collaboration with a research medical librarian to identify published studies and conference proceedings using the following electronic databases, MEDLINE, EMBASE, CINAHL, ERIC, Web of Science, and PsycINFO. The medical librarian performed a search in Medline (Ovid) and that search went through a Peer Review of Electronic Search Strategies (PRESS) (see Appendix B-1). Once the PRESS was completed, the search strategy was translated to all other databases with adaptions to all identified keywords, subject headings, and index terms, using the characteristics and properties available within each database (see Appendix B-2). A combined search was conducted for medicine and nursing disciplines whereas searching 15 within the following health care professions was collectively undertaken; pharmacy; dentistry; physical therapy; occupational therapy; dietetics/nutrition; Emergency medical technician (EMT)/paramedics; respiratory therapy; and social work. The search was carried out between January 2020 and May 2020 without applying any geographical limits. To ensure that the search was as exhaustive as possible, additional studies were identified by hand-searching and screening the reference lists of the full-text articles selected and included in the review. 2.3.2 Citation management All the references were exported into a RefWorks ProQuest. Articles were grouped together according to the database and health profession, either medicine + nursing or other health professions. Duplicates were removed manually and using the deduplication feature in RefWorks ProQuest. 2.3.3 Study screening and selection A two-phase screening process was used. In phase one, I independently screened titles and abstracts for relevance based on the following criteria, 1) empirical studies and conference proceedings published in English language; 2) had an available abstract; and 3) included descriptions of systems or experiences whereby patients received care from a health professional trainee in a workplace-based setting and participated in performance assessment of the trainee. In phase two, full-text articles were reviewed independently by two researchers, with me as the first screener and one of either KW or MP (committee members) as second screeners. Inclusion and exclusion criteria which we applied in our screening are summarized in Table 2-1. Conflicts were resolved through further discussions and consensus (AN, KW, and MP). 16 2.3.4 Data extraction I extracted relevant data from the eligible papers using a predesigned data extraction form (see Appendix B-3) and the following information was collected, 1) citation; 2) study location/country; 3) study setting (discipline, site/context, study participants and inclusion criteria); 4) study objectives; 5) methods (study design, theoretical framework, data collection tools, and analysis); 6) outcomes; 7) results; and 8) conclusion. 2.3.5 Data synthesis and analysis I conducted inductive content analysis for the included studies. Because my analysis is of descriptive nature, I combined qualitative, quantitative and mixed-methods in the same analysis (Suikkala et al., 2018) and categorized the included studies based on their objectives and aims. 2.4 Findings 2.4.1 Overview of Included studies I included 78 articles in this scoping review after excluding 8,693 articles (See Error! Reference source not found.) The majority of published experience for patient involvement in workplace-based assessment is found within physician training programs (n = 66; 84.6%) followed distantly by nursing education (n=7; 9%). More than half of the articles identified were situated in the United States (n= 44; 56.4%) (See Table 2-2). The description or evaluation of patient involvement in workplace-based assessment of health professional trainees was not always the main objective of the included studies. Seeking the patient perspective of traineesâ demonstrated skills was interconnected with other study aims such as its association with trainee self-assessment, validating and examining the feasibility of an assessment tool, or assessing the impact of an educational 17 intervention such as a workshop, curriculum, or module. In many studies, patients were predominantly asked for their feedback on specific trainee skills such as communication, interpersonal skills, and professionalism. Moreover, heterogeneous strategies were used to obtain patient feedback and inconsistencies existed within and across health disciplines. Varied means of soliciting patient feedback included the administration of surveys or questionnaires formatted to collect data on patient satisfaction, formative or summative assessment data from patients sometimes collected via interviews, or a mix of surveys and interviews. 2.4.2 Aspects of Patient Participation in Health Professional Trainee Assessment In this section, I mapped the findings according to aspects of patient participation in the assessment of the health professional trainees who cared for them into five main categories and corresponding subcategories 1) patient perspective; and corresponding subcategories; 1.1) patient satisfaction; 1.2) assessing patient experiences, opinions, perceptions, and perspectives; and 1.3) health professional trainees eliciting patient feedback; 2) patient versus stakeholder perspectives; 2.1) triangulation as multi-source feedback; 3) influence on/of patient perspective; 3.1)evaluating an educational intervention; and 3.2) nature of patient feedback and its impact on trainees; 4) patient perspective relative to other factors; 4.1) association with patient- or trainee-related information; and 5) intertwined aspects of patient participation (see Table 2-3 and Figure 2-2). 2.4.2.1 Patient Perspective 2.4.2.1.1 Patient Satisfaction One of the most common aspects of patient involvement in health professional traineesâ assessment is nested within the objective of examining patient satisfaction (Canales et al., 2019; Dalia 18 & Schiffman, 2010; Sherbuk & Barakat, 2019). Patients and/or their families and caregivers were asked about their satisfaction with the quality of their care encounter which included a participating trainee (Oskay et al., 2015; Turner et al., 2016) or how patient satisfaction varies in presence and absence of the trainee (Beard et al., 2020; Li et al., 2018). Questions related to trainee performance and competency such as professionalism (Niedermier et al, 2017), communication (Niedermier et al, 2017; Oda et al., 2014; Stewart et al., 2011), and interpersonal skills (Niedermier et al, 2017; Oda et al., 2014) and were gathered using a standard tool (survey or questionnaire) such as the patient satisfaction questionnaire (PSQ) (Nouri et al., 2018). Patient satisfaction was also examined in relation to other factors such a trainee level of training (Dudas et al., 2010), post-graduate year status (Nadkarni et al., 2014), trainee satisfaction, quality of care, or workload (Francis et al., 2014). Other researchers used survey questionnaires to measure patient satisfaction with care provided by a health professional trainee within a trainee-run clinic (Riddle et al., 2014; Witherspoon et al., 2019). 2.4.2.1.2 Assessing Patient Experiences, Opinions, Perceptions, and Perspectives The objective of several studies was to test the feasibility and importance of collecting assessment data from patients to gain an insight into patientsâ perspectives (Bridge et al., 2014) and such objective was sometimes achieved using an assessment tool that was handed to patients. Some studies also captured the patient experience with the care they receive from health professional trainees by examining the facilitators of and barriers to obtaining feedback from patients about the trainees (Mahoney et al., 2019), or developing and validating a new patient feedback tool (Debyser et al., 2020; Dine et al., 2014; Reinders et al., 2009; Sripada et al., 2011). Davies and Lunn (2009) recruited patients to take part in traineesâ formative assessment and examined the potential role of patients in participating trainee assessment from the traineesâ point of view. In addition, Diachun 19 and colleagues (2012) studied patientsâ and caregiversâ ability to complete an evaluation for trainee performance after they were cared for by the trainee. Ward and Benbow (2016) sought to collect information about trainee performance through patientsâ own words using a feedback form. In the same study, the researchers also examined how patient feedback would reflect the qualities patients deem as valuable when receiving care from a health professional trainee (Ward & Benbow, 2016). A more general concept of patient participation in health professional traineesâ assessment, was sometimes incorporated using a standard tool to assess patient perceptions (Le Comte et al., 2016). In other more specific circumstances, patients were asked about their perceptions of certain aspects of traineesâ communication skills (Khan et al., 2016; Newcomb et al., 2017; Wen et al., 2012), shared understanding between patients and trainees (Khan et al., 2016), and trainee knowledge and the clinical care patients received (Pecha et al., 2015). Moreover, using questionnaires, patient opinions of the education they received during challenging consultations by health professional trainees was compared to that of their supervisors (Wouda et al., 2015). Another study aimed to gain an insight into patient perspectives of the communication and clinical decisions made by trainees during primary care visits (Schoenborn et al., 2017). In one study, Wiggins and colleagues (2009) solicited patient perceptions on whether trainees demonstrated professionalism through certain behavioral, communicative and personal characteristics. Another study examined the experiences patients had in an education ward where health professional trainees were involved in direct patient care and compared it with how patients experienced care in a regular non-education ward (Scheffer et al., 2013). 20 2.4.2.1.3 Health Professional Trainees Eliciting Patient Feedback Speers and colleagues had an aspiring objective of involving health professional trainees in the process of obtaining patient feedback (Speers & Lathlean, 2015). The researchers designed, evaluated, and examined a feedback system that helps trainees with seeking the patient perspective. 2.4.2.2 Patient Versus Stakeholder Perspectives 2.4.2.2.1 Triangulation as Multi-Source Feedback Patient experiences were sought as part of multi-source feedback (MSF) initiatives in workplace-based assessment with the aim of soliciting the perspectives of stakeholder such as patients, patientsâ families, carers, preceptors, mentors, administrators, nurses, physicians, peers and/or trainee themselves on trainee skills (Braend et al., 2010; Garra et al., 2011; McMahon-Parkes et al., 2016; Riveros et al., 2016, Tiao et al., 2013). Patient feedback was triangulated with trainee self-assessment (Braend et al., 2010; Persson et al., 2013), assessment from trainee and faculty (Keister et al., 2017), clinician and non-clinician (Murphy et al, 2009), faculty and non-faculty evaluators (Warm et al., 2010), or grades assigned by the traineeâs tutor (Santiago et al., 2017). A combined stakeholder feedback was also solicited to obtain a multi-focal perspective for multiple purposes 1) develop and implement a multisource assessment method (Sharma et al., 2012; Wener et al., 2011); 2) examine the reliability and/or feasibility of a validated MSF tool (Garra et al., 2011; Murphy et al., 2009); 3) adapt an existing MSF instrument and examine its validity and feasibility (LaMantia et al., 2017); 4) associate patient feedback on trainee communication skills with trainee self-perception (Dickson et al., 2012; Ford et al., 2014); 5) evaluate the feasibility and acceptability of video supervision (Groener et al., 2015); or 6) assess the degree of patient-centredness in a care clinic (Mazanec et al., 2015). Noordman et al. (2019) specifically evaluated 21 trainee patient-centred skills such as communication and empathy from a trifocal point of view through feedback offered by patients, observes and the trainees themselves. Hall and colleagues (2020) also examined the correlation between traineesâ scores on standardized video interviews with faculty and patient rated scores of communications, professionalism, and interpersonal skills. Another study compared perspectives of standardized patients with that of actual patients to see how closely they agreed on rating trainee communication skills and professionalism (Sattler et al., 2017). Additionally, Debyser and team (2011) examined how patient feedback on trainee performance was consistent with feedback solicited from the trainee and their educators. In one study, the researchers compared how patients and their families perceived bad news delivered by health professional trainees with how the bad news was perceived by physicians (Toutin-Dias et al., 2016). 2.4.2.3 Influence on/of Patient Perspective 2.4.2.3.1 Evaluating an Educational Intervention In some instances, patient feedback was collected to assess the impact of an educational intervention (Schoenborn et al., 2016) on health professional traineesâ competencies and skills, sometimes using a validated assessment tool or a patient satisfaction questionnaire (Oda et al, 2014). This involved the creation of an educational experience such as coaching (Rassbach et al., 2019), education curriculum (Canales et al., 2019; DeBlasio et al., 2019; Dubosh et al., 2019; Mitchell et al., 2016; Niedermier et al., 2017; Oda et al, 2014), training program (Bylund et al., 2018; Latta et al., 2013; Schutte et al., 2018; Yu et al., 2018) or an educational module (Lin et al., 2013; McElroy et al., 2014) where patients were surveyed about their perspectives to verify the improvement in trainee 22 performance and skills such as history taking, communication, confidence, interpersonal skills, and professionalism. 2.4.2.3.2 Nature of Patient Feedback and Its Impact on Trainees Patient responses on questions about trainee communication were elicited to determine its nature, how valuable the patient opinion would be as a means of providing feedback for trainees (Gharib et al., 2017) and how it was perceived by trainees (Grieveson et al., 2011). Researchers also explored the process of collecting feedback from patients and how the feedback could be used as a potential learning opportunity for future practice (Masters & Forrest, 2009; Pearl et al., 2018) and whether the feedback contributed to trainees passing or failing (Pearl et al., 2018). 2.4.2.4 Patient Perspective Relative to Other Factors 2.4.2.4.1 Association with Patient- or Trainee-Related Information The demographics of patients and their families such as socioeconomic status or race/ethnicity were assessed in relation to patient ratings of the care they received from a health professional trainee to examine the potential contextual influences on patient feedback (Long et al., 2014). Additionally, there were other studies that examined the correlation of patientsâ and/or caregiversâ attitudes towards trainees with trainee-related characteristics such as post-graduate year (PGY) status (Nadkarni et al, 2014), level of training (Myerholtz et al., 2010; Dudas et al., 2010), trainee gender (Myerholtz et al., 2010), first language (Myerholtz et al., 2010), trainee photographs (Dudas et al., 2010), or patient and trainee demographics (Persson et al., 2013). Ratelle and colleagues (2020) investigated, using a validated tool, the correlation between patient assessment of trainee professionalism with patient demographic data such as sex, race/ethnicity, education level, and resident characteristics like sex, age, and previous medical training. 23 2.4.2.5 Intertwined Aspects of Patient Participation Some studies had several objectives that were mapped into more than one of the categories discussed above. For instance, communication assessment tool (CAT), a validated instrument developed for patient assessment of the interpersonal communication skills of physicians (Makoul et al., 2007), was used by several researchers for multi-faceted purposes. Sometimes, patients were asked to fill out a CAT to evaluate the effectiveness of certain training received by health professional trainees (Yu et al., 2018) or assess the impact of curriculum on traineesâ performance using patient feedback (DeBlasio et al., 2019; Dubosh et al.,2019). In other circumstances, the CAT was used to solicit patient feedback on traineesâ communication and confidence (Newcomb et al.,2018) or to examine if trainee-related characteristics would influence patient ratings of communication (Myerholtz et al., 2010). Newcomb and colleagues (2017) also elicited standardized and real patientsâ perceptions using CAT to develop and validate a feasible process for assessing traineesâ communication. 2.5 Discussion To my knowledge and to this date, this is the first scoping review to map the existing literature regarding aspects of patient participation in workplace-based assessment of health professional trainees according to health care discipline and research location. Patient involvement in the assessment of health professional traineesâ performance over the past decade is an underutilized strategy which reflects a passive role of the patient in traineesâ education and learning process. Although patient perspectives are crucial to traineesâ skill development and professional growth, evidence of formalized patient roles in health professional trainee feedback and assessment is lacking. There is limited evidence of patientsâ participation in competency-based feedback of 24 trainees in medicine and nursing fields and even more alarming lack of incorporation of patientsâ perspective in the feedback process of other health professional trainees. On the other hand, extensive research has been done on standardized patient (SP) involvement in the assessment of health professional trainees in simulated scenarios such as objective structure clinical examinations (OSCEs) or role playing (Berg et al, 2011; Riopel et al., 2018; Riopel et al., 2019; Ryan et al., 2010; Schelgel et al., 2012; Webster et al., 2012). Sherman and Johnson (2019) examined the improvement in patient care and documentation skills of third professional year (P3) student pharmacists during a skills laboratory course at the University of Mississippi School of Pharmacy. The students were evaluated by a standardized patients during a sequential system of case scenarios using a checklist/rubric and a subjective, objective, assessment, plan (SOAP) note grading rubric with standardized patients playing the role of evaluators. The standardized patient checklist rubric assessed several aspects of student pharmacistsâ patient care skills including interpersonal, data gathering, physical exam, and counselling skills in addition to patient satisfaction. Direct assessments performed by standardized patients showed that student pharmacists demonstrated a great improvement in their communication skills, confidence, and SOAP note writing during the practice skills course. The value of obtaining feedback from real patients has been compared with feedback derived from standardized patients to highlight and emphasize the impact of the former. Chua and Bogetz (2018), acknowledged the distinct educational significance of obtaining feedback from standardized patients as compared to real patients. Additionally, while feedback from standardized patients is considered to be more âstructuredâ than real patient feedback, the latter is viewed as more authentic and a true reflection of patientsâ experiences since it is solicited in a more spontaneous and realistic manner (Bokken et al., 2009; Bokken et al., 2010, Chua & Bogetz, 2018). In addition, feedback obtained from real patients was 25 found to make âa more profound impression on the studentsâ (Bokken et al., 2009; Bokken et al., 2010; Dammers et al., 2001, and Chua & Bogetz, 2018). Research reveals several benefits of involving patients in health professional traineesâ assessment which includes enhancing traineesâ partnership, advocacy, and communication skills (Crawley & Frazer, 2015) in addition to detecting potential areas of improvement in the teaching and learning process. The responsibility of teaching health professional trainees the value and benefits of involving patients in their assessment is mostly shouldered by health professions educational institutions and programs. The use of patient-centred approaches to health professions education is continuously evolving and health professions curricula are the best place to start incorporating more patient perspectives. Health professions educators must adjust their curricula to meet the dynamic and critical changes in the health care environment. Having the patient voice is a valuable addition to the curriculum by augmenting the tools and processes for assessment of experiential and workplace-based learning. In rapidly changing clinical and educational settings, patient feedback is a valuable asset in curriculum design, evaluation, and improvement to maintain course quality and promote trainees learning outcomes. Grujich and colleagues sought the perceptions of psychiatry residents at the University of Toronto on the current evaluation methods of professional competency and using multi-source feedback as an assessment tool. Over seventy-percent of the residents thought that patients/family members should contribute to the evaluation process along with their supervisors as part of a multi-source feedback process. Another study by Duygulu and Abaan (2013) used self-administered questionnaires to document Turkish nursing studentsâ opinions on involving service users in clinical practice assessments. Almost seventy-percent of the students favoured the involvement of service users in their assessment process and sixty-percent thought that it would be beneficial to have service users as part of the assessment during clinical placement. Students justified 26 their preferences by stating that service users spend considerable time with them in the practice setting. Alternative evaluation methods to support providing optimal feedback to trainees have not been well explored. It is crucial to consider that, in some instances, there are other individuals involved with patients in their health care process such as caregivers or family members. For instance, the perspectives of patientsâ family members, or caregivers are often a missing component in multi-source feedback provision (Moreau et al., 2019). Their experiences and views are also vital to enrich health professional traineesâ learning and training as they might hold additional opinions of traineesâ performance. There are several factors that are also worth taking into consideration before soliciting patient feedback to ensure ethical aspects are employed and maintained. These include patientâs anonymity, confidentiality and vulnerability which must be respected along with the patientâs capability, and timing when requesting their feedback (Suikkala et al., 2018). Accordingly, this scoping review also proposes an avenue for future research by considering the possibility and feasibility of coaching patients to be involved in the assessment of health professional trainees. Strengths and limitations of this scoping review warrant discussion. A comprehensive search strategy was developed with a medical research librarian that covered multiple reference databases across a wide range of health disciplines. Having three researchers (AN, KW and MP) working independently on the screening and analysis processes also ensured reliability. However, the search strategy was limited to studies published in English language; therefore, I cannot guarantee I located all available evidence regarding patientsâ active participation in the workplace-based assessment of health professional trainees. Over 50% of the included studies were conducted in the United States likely due to limiting our search to English-language articles only. As educational scholarship is an 27 evolving field, it is possible that publications exploring patient involvement in health professional trainee assessment are limited. It is also likely that there could be academic institutions and faculties incorporating the patient input into their curricula without disseminating their research work and findings. 2.6 Conclusion This scoping review reveals that formal patient roles in health professional trainee feedback and assessment is inconsistent including the ways patient feedback is elicited and the different outcomes assessed. Additionally, the existing landscape of the ways patients participate in workplace-based assessment of trainee across diverse health professions is heterogenous. To the best of my knowledge, evidence regarding patient involvement in the assessment of health professional trainees in a workplace-based context is lacking. Published experiences are mostly in literature from medicine and nursing educational contexts where both professions have diverse and concrete means for patient assessment of trainees compared to other health professions. Disappointingly, ârealâ patientsâ involvement in other health professional traineesâ workplace-based assessment including pharmacy trainees has received scant attention. Gaps in the literature are evident pointing to the need for changes in the existing pedagogical techniques of workplace-based assessment. 28 Table 2-1 Summary of Scoping Review Inclusion and Exclusion Criteria Criteria Inclusion Exclusion Language English Non-English Type of publication Full-text articles, thesis/dissertation, conference proceedings, posters, and book chapters Review articles Study population Real patients, their family members and/or caregivers OR service users AND cared for by a learner in training (undergraduate student, graduate student, trainee, intern, resident, or fellow) Standardized, simulated, trained, volunteer, or role-playing patients, patient partners, patient tutors, health mentors, or health educators OR care providers who were practicing health care professional such as attendings, supervisors, faculty members, preceptors, specialists, or consultants Intervention assessment/evaluation/ feedback/opinion on care provided by a health professional trainee AND focused and directed at an individual trainee general and unfocused perceptions of health professional trainee involvement in patient care Setting learning context OR clinical learning environment OR competency-oriented OR workplace-based Objective Structured Clinical Examination (OSCE) OR classroom teaching 29 Table 2-2 Characteristics of Included Studies in the Scoping Review (n=78) Characteristics No. (%) Health Profession/Discipline Medicine Nursing Dentistry Social Work Radiotherapy 66 (84.6) 7 (9.0) 3 (3.9) 1 (1.3) 1 (1.3) Research Location USA Europe UK Canada Asia Australia and New Zealand Brazil 44 (56.4) 1 (14.1) 9 (11.5) 5 (6.4) 4 (5.1) 3 (3.9) 2 (2.6) Database MEDLINE CINAHL EMBASE PsycINFO Web of Science 42 (53.9) 17 (21.8) 13 (16.7) 4 (5.1) 2 (2.6) 30 Table 2-3 Literature on Patient Participation in Health Professional Trainee Assessment Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Davies & Lunn (2009) UK Medicine Mixed methods (qualitative + quantitative) To investigate the potential for the involvement of service users (patients) and their carers in the assessment of students Murphy et al. (2009) UK Medicine Pilot, quantitative, questionnaire To investigate the reliability and feasibility of six potential workplace-based assessment methods in general practice training: which included multi-source feedback from clinical and non-clinical colleagues and patient feedback (the CARE Measure) Reinders et al. (2009) The Netherlands Medicine Quantitative, questionnaire To assess the face and content validity, the construct validity, and the internal consistency of a new patient feedback on consultation skills (PFC) questionnaire Wiggins et al. (2009) USA Medicine Quantitative, descriptive, cross-sectional To identify which behavioural, communicative, and personal presentation characteristics most closely represent patientsâ views of professionalism and to determine whether patients perceive resident doctors as displaying these characteristics Braend et al. (2010) Norway Medicine Mixed Methods (qualitative + quantitative), questionnaire To triangulate feedback using patient questionnaires, written self-assessment and teachersâ observation-based assessment, and to describe the content of this feedback Brennan et al. (2010) USA Medicine Quantitative, survey questionnaire 1) To gather initial benchmarking data for the use of the communication assessment tool (CAT) in family medicine residency programs 2) To examine differences in patient ratings of family medicine residents in six programs, based on the residentâs year in training, gender, and native language (native English speaking versus non-native English speaking) Dalia & Schiffman (2010) USA Medicine Quantitative, survey questionnaire To judge patient satisfaction and to determine who patients believe is their ââmain physicianââ on the teaching service 31 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Dudas et al. (2010) USA Medicine Prospective, mixed methods (qualitative + quantitative) To determine if an information sheet containing photographs and explanations of the training level of medical providers would impact parental attitudes toward trainee involvement and patient satisfaction Masters & Forrest (2010) UK Nursing Qualitative To examine how service user involvement in the assessment of professional practice could be further developed Myerholtz et al. (2010) USA Medicine Quantitative, survey questionnaire To examine differences in patient ratings of family medicine residents in six programs, based on the residentâs year in training, gender, and native language using the communication assessment tool (CAT) Warm et al. (2010) USA Medicine Quantitative, survey questionnaire To describe the assessment and feedback procedures to evaluate residents in the ambulatory setting with particular interest in the rankings provided by self, peer, staff, attending physician, and patient evaluations Debyser et al. (2011) Belgium Nursing Qualitative, explorative, semi-structured interviews To examine to what extent is a client's feedback on the student's work performance, consistent with feedback from the mentor (nurse from the ward), the teacher and the student Garra et al. (2011) USA Medicine Quantitative, prospective, questionnaire To determine the feasibility of a multi-source (MSF) program and evaluate the intraclass and interclass correlation of a previously reported resident professionalism evaluation, the Humanism Scale (HS) Grieveson et al. (2011) UK Dentistry Quantitative patient assessment questionnaires 1) To evaluate the effectiveness of workplace-based assessments (WPAs) in dental foundation training (formerly vocational training [VT]) 2) To investigate the perceived impact of reflection and feedback associated with WPAs on clinical practise and improving patient care Sripada et al. (2011) USA Medicine Quantitative, questionnaire To develop and evaluate a feedback method for reducing empathic errors in psychotherapy Stewart et al. (2011) USA Medicine Quantitative, survey questionnaire To examine whether resident communication skills evaluated through patient satisfaction surveys demonstrate evidence of decline through the 3 years of internal medicine residency 32 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Wener et al., (2011) Canada Dentistry Mixed methods (qualitative + quantitative), surveys (Patient Communication Assessment Instrument (PCAI) and Student Communication Assessment Instrument (SCAI)) and focus groups To assess studentsâ clinical communication skills and how a holistic approach, with input from key stakeholders including patients, was used to produce two communication skills assessment instruments Diachun et al. (2012) Canada Medicine Quantitative, survey To determine whether patients/caregivers could accurately complete a post-assessment evaluation of traineesâ clinical performance Dickson et al. (2012) USA Medicine Observational, quantitative, survey To investigate the strength of association between traineesâ self-assessments of the quality of their end of- life communication skills and the assessments of their patients, patientsâ families, and clinician-evaluator Sharma et al. (2012) Canada Medicine Mixed methods (qualitative + quantitative), questionnaire To describe the development, implementation, and evaluation of a team-based, multi-source method of assessment in which students on a clinical clerkship were provided with feedback on their performance as observed by physicians, residents, nurses, peers, patients and administrators. Wen et al. (2012) USA Medicine Quantitative, Survey questionnaire, interviews To obtain patient feedback and assess the communication abilities of resident physicians with a standard tool Latta et al. (2013) New Zealand Medicine Mixed Methods (qualitative + quantitative) To evaluate an Ambulatory Medicine Programme and determine patientsâ perspectives to gauge their level of satisfaction, make improvements where necessary and provide an opportunity to provide feedback as partners in the teaching process Lin et al. (2013) USA Medicine Mixed Methods, (qualitative + quantitative), survey To create an educational module to instruct physical medicine and rehabilitation residents in the evaluation and appropriate treatment of patients and to verify acquired competencies in neuromuscular using patient surveys 33 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Persson et al. (2013) Canada Medicine Quantitative, questionnaire To examine medical student self-assessment of their skills and compare these to parent assessment of the medical student and to determine parent attitudes towards medical students in the pediatric ambulatory setting and to examine if demographic factors of either parents or students could account for these attitudes Scheffer et al. (2013) Germany Medicine Quantitative To compare the experiences of patients on the Clinical Education Ward to those of patients on the regular internal medicine wards with respect to patient centredness: (a) physician-patient interaction, (b) physician empathy, and (c) patient enablement Tiao et al. (2013) Taiwan Medicine Questionnaires To evaluate the outpatient communication skills of medical students via multisource feedback, which may be useful to map future directions in improving physician-patient communication Bridge et al. (2014) Australia Radiotherapy Pilot study, mixed methods (qualitative + quantitative) To determine the value of anonymous patient feedback for students, gain patient perspectives on the process and appraise the feasibility of data collection Dine et al. (2014) USA Medicine Pilot, Quantitative, survey questionnaire To assess the feasibility and validity of a new 16-item tool developed to assess patientsâ perspectives of internsâ communication skills and professionalism and the teamâs communication Francis et al. (2014) USA Medicine Cross-sectional, quantitative, survey To examine the relationship between patient satisfaction and other practice variables, such as continuity, ambulatory workload, utilization, resident satisfaction, and quality of care across participating programs Ford et al. (2014) USA Medicine Prospective, observational, survey To determine whether physician traineesâ self-assessments of their communication skills in religious/spiritual discussions were associated with assessments obtained from patients under their care Long et al. (2014) USA Medicine Randomized trial, survey To examine the association of race/ethnicity or socioeconomic status with patientsâ and families âratings of end-of-life care and communication about end-of-life care provided by physicians-in-training 34 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) McElroy et al. (2014) USA Medicine Quantitative To propose an educational module to instruct pain medicine fellows in the appropriate performance of interventional pain management techniques and verify acquired competencies using patient surveys and 360 global rating scales) Nadkarni et al. (2014) USA Medicine Cross-sectional, Quantitative survey To assess relationship between doctor post-graduate year (PGY) status and patient satisfaction with provider interpersonal skills and humanistic qualities using an American Board of Internal Medicine (ABIM) questionnaire Oda et al. (2014) Japan Medicine Multiphase cross-sectional study, patient satisfaction questionnaire To evaluate fifteen years of undergraduate medical education curriculum by measuring medical studentsâ communication and interpersonal skills with a patient satisfaction questionnaire Riddle et al. (2014) USA Medicine Quantitative, survey To provide a detailed description of the processes by which a student-run free clinic adopted elements of the PCMH model into an existing experiential learning program using patient satisfaction surveys Groener et al. (2015) Germany Medicine Quantitative, questionnaire (post assessment) To evaluate the feasibility and acceptability of video-based, on-ward supervision for final year students in a clinical context with real patients using an oral feedback loop including student, patient and supervisor feedback on communicative and procedural aspects of skills performed Mazanec et al. (2015) USA Medicine Quantitative, survey (Patient Perception of Patient Centredness (PPPC) instrument) To describe how an interprofessional cancer care clinic is training health care professionals in patient-centred care using an instrument is designed to capture patient and provider perceptions of the providerâs patient centredness Oskay et al. (2015) Turkey Nursing Quantitative, cross-sectional, descriptive To evaluate patient satisfaction with the care provided by nursing students on a perinatology ward Pecha et al. (2015) USA Medicine Randomized, quantitative, double-blind survey To investigate patientsâ perception of orthopaedic knowledge and clinical care provided by orthopaedic medical residents and athletic trainers (ATs) 35 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Speers & Lathlean (2015) UK Nursing A 2-year study, encompassing five cycles of participatory action research (PAR). Qualitative, Semi-structured interviews + questionnaires To design, evaluate and refine a system enabling students to seek feedback from service users by involving stakeholders (mentors, service users and a lecturer). The feedback concerned mental health studentsâ interpersonal skills Wouda et al. (2015) The Netherlands Medicine Quantitative, survey questionnaire To compare supervisorsâ and residentsâ patient-education competency in challenging consultations Kamangar et al. (2016) USA Medicine Quantitative, survey questionnaire To evaluate and compare patient and nursing staff satisfaction with regards to provider quality of care and its concordance with physician self-assessment Khan et al. (2016) USA Medicine Prospective cohort, written reports (5-point Likert scale) To evaluate prevalence and predictors of lack of shared understanding between parents and nighttime residents about the reason for admission and care plan for hospitalized children. Le Comte et al. (2016) New Zealand Medicine Mixed-methods (focus-groups, semi-structured interviews, and surveys) To establish the value of house officers (HOs) general practice attachments and assess patient perceptions of the HOs using patient surveys Mitchell et al. (2016) USA Medicine Pre- and post- surveys To implement a simulation and web-based curriculum in communication for anesthesia residents and use a patient survey to detect changes in patient feedback on residentsâ communication skills after the curricular intervention McMahon-Parkes et al. (2016) UK Nursing Exploratory qualitative, interviews To evaluate patients', carers', mentors' and adult field nursing students' experiences of patients and carers Riveros et al. (2016) USA Medicine Two-group randomized clinical trial (quantitative, questionnaire) To evaluate the effect of a Multisource feedback (MSF) on resident's professional behavior and to assess the effect of faculty feedback on resident performance Toutin-Dias et al. (2016) Brazil Medicine Mixed Methods (qualitative+ quantitative), survey To assess patient and family membersâ perception of bad news received in the ED and compare these with physiciansâ perceptions 36 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Turner et al. (2016) USA Medicine Cross-sectional, quantitative, survey To measure the rate at which medical students use six targeted communication elements with patients and association of element use with patient satisfaction Ward & Benbow (2016) UK Nursing Prospective, observational, survey To describe how service-user feedback on undergraduate student nursesâ performance gives an insight into the qualities service users value in student nurses and to capture the reality of the studentsâ performance through the service users' own words Gharib et al. (2017) UK Dentistry Qualitative To evaluate the nature of patient responses to determine its value in providing undergraduate dental students with feedback on their clinical performance Keister et al. (2017) USA Medicine Mixed Methods (qualitative+ quantitative), Using scores from multiple perspectives to quantify the ability of graduate medical learners at various stages of residency to assess their own competence in relationship-centred care (Triangulation of Faculty and Patient Feedback) LaMantia et al. (2017) USA Medicine Retrospective case study, surveys To adapt existing multisource feedback (MSF) instruments for emergency department implementation, measure feasibility, and collect initial validity evidence to support score interpretation for learner assessment. Newcomb et al. (2017) USA Medicine Prospective, quantitative (Rating Scale) To develop a feasible data collection process that generates objective clinical performance information to guide training activities, inform, and validate assessment instruments using standardized and real patient perception of communication with the resident using the 14-item Communication Assessment Tool (CAT) Niedermier et al. (2017) USA Medicine Quantitative (Instrument) To provide residents with information about the concepts of patient satisfaction and experience using a curriculum while focusing on the competencies of professionalism and interpersonal and communication skills using patient surveys 37 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Santiago et al. (2017) Portugal Medicine Observational study, quantitative To verify the correlation between the patientâs evaluation and the tutorâs grades regarding both the performance and the fluency of performance of students in the practical component within a general practitioner/family physician visit framework Sattler et al. (2017) USA Medicine Mixed Methods (Likert-scale surveys + open-ended comments) To compare actual patients (AP) and standardized patients (SP) assessments of medical studentsâ communication skills and professionalism. Schoenborn et al. (2017) USA Medicine Pre- and post- single arm intervention, quantitative, questionnaire To assess how internal medicine residents incorporated prognosis to inform clinical decisions and communicated prognosis in primary care visits with older patients after an educational intervention, and resident and patient perspectives regarding these visits Bylund et al. (2018) USA Medicine Quantitative, survey To rigorously evaluate a 4-year institutionally based patient communication skills program for oncology post-graduate trainees Li et al. (2018) USA Medicine Quantitative, survey To look at the impact of resident involvement on patient satisfaction and to determine if there was variation in patient satisfaction with and without resident involvement among various surgical subspecialties Newcomb et al. (2018) USA Medicine Cross-sectional, quantitative, survey To assess surgical residents' communication confidence and skills using patient feedback via the communication assessment tool (CAT) Nouri et al. (2018) Iran Medicine Qualitative To explore the validity and reliability of the Persian version of the patient satisfaction questionnaire (PVPSQ) specifically addressing the communication skills section of the PSQ 38 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Pearl et al. (2018) UK Social Work Quantitative patient evaluation/feedback questionnaires To explore Service User and Carer feedback: how its gathering is viewed and undertaken, whether the feedback is seen more as a pass/fail issue or as an opportunity to learn from, if there are better ways to gain constructive feedback for students, conditions that enable students to learn from the feedback that is gathered, the extent to which the service user and carer feedback gathered contributes to a student passing or failing and whether it has the potential to be used as a learning tool for future practice Schutte et al. (2018) The Netherlands Medicine Randomized, quantitative, questionnaire To describe and evaluate a student-run cardiovascular risk management (CVRM) programme that was set up to offer primary prevention to patients with known risk factors in a general practitionerâs practice Yu et al. (2018) China Medicine Quantitative, survey questionnaire To determine the effect of using standardized parent training history-taking on the quality of medical records and communication skills among pediatric interns using patient feedback via the communication assessment tool (CAT) Canales et al. (2019) USA Medicine Observational, cross-sectional, quantitative (scale) To describe the development and implementation of a humanism curriculum for anaesthesiology residents, and evaluate whether it improved physician perceived empathy translating into improved patient pain, anxiety, and overall satisfaction Bernardo et al. (2019) Brazil Medicine Prospective, controlled, quantitative (survey) To investigate the associations between self-assessed empathy levels by physicians in training and empathy levels as perceived by their patients after clinical encounters and to examine whether patient assessments were valid and reliable tools to measure empathy in physicians in training DeBlasio et al. (2019) USA Medicine Prospective, randomized, pilot mixed methods (quantitative + qualitative), survey + free responses To determine the impact of a curriculum that included parent feedback, via the Communication Assessment Tool (CAT), on resident communication skills 39 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Dubosh et al. (2019) USA Medicine Randomized controlled trial (RCT), mixed methods (survey + open ended questions) To develop a multimodal curriculum including direct patient feedback and assess whether it improves communication skills as measured by the Communication Assessment Tool (CAT) in fourth-year medical students during an emergency medicine (EM) clerkship Mahoney et al. (2019) USA Medicine Pilot, pretest-post-test, quantitative, questionnaire To assess the feasibility and acceptability of patient feedback collection and to accurately characterize existing barriers to collecting patient feedback as well as factors that facilitate successful feedback collection Noordman et al. (2019) The Netherlands Medicine Randomized controlled trial (RCT), mixed methods (survey + open ended questions) To evaluate residentsâ training âpatient-centred communication and empathyâ from a tri-focal Perspective (patients, observers and residents themselves) Rassbach et al. (2019) USA Medicine Quantitative, survey To assess the effect of coaching on residentsâ self-confidence in communication, and patient rated communication skills. Sherbuk & Barakat (2019) USA Medicine Quantitative, cross-sectional, questionnaire To assess patient satisfaction with HIV providers, both trainees in an HIV Primary Care residency program and HIV-specialists Witherspoon et al. (2019) Canada Medicine Mixed Methods (qualitative + quantitative), focus groups and survey questionnaire To describe the implementation of a urology resident-run clinic (RRC) and report assessments of both resident performance and patient satisfaction 40 Table 2-3 â Continued Authors and Year Location Discipline Study Design and Data Collection Methods Aim(s) Beard et al. (2020) USA Medicine 3-phased validation psychometric study, mixed methods (interviews + instrument) To determine whether longitudinal student involvement improves patient satisfaction with care and if patients cared for by a Veterans Affairs Longitudinal Undergraduate Medical Education (VALUE) student had (1) increased satisfaction with their overall care and (2) whether these patients would be willing to work with VALUE students in the future Debyser et al. (2020) Belgium Nursing Pilot, retrospective, quantitative, questionnaire To develop and validate an instrument that enables patients to evaluate nursing students during their internship Hall et al. (2020) USA Medicine Prospective cohort, quantitative, survey To determine whether there is a correlation between the standardized video interview (SVI) score that assess residentsâ professionalism, communication, and interpersonal skills and both faculty and patient ratings of these competencies in emergency medicine (EM) applicants Ratelle et al. (2020) USA Medicine Observational study, Quantitative To investigate relationships between patient, resident, and hospital-encounter characteristics and the results of patient assessments of IM resident professionalism 41 Adapted from Page et al., (2021). Figure 2-1 Flow Diagram for The Scoping Review Process Records identified from Databases (n = 10,966) Records excluded as duplicates using RefWorks automation tool (n= 2,196) Records screened for inclusion by title and/or abstract (n= 8,770) Records excluded as title and/or abstract not relevant (n = 7,993) Full-text articles reviewed and assessed for eligibility (n=778) Full-text articles excluded based on exclusion criteria and/or unobtainable (n=700) Full-text articles included in the review for analysis (n=78) Identification Screening Included 42 Figure 2-2 Map Demonstrating Different Aspects of Patient Participation in Health Professional Trainee Assessment 43 Chapter 3: Research Methods 3.1 Chapter Overview Findings from the scoping review presented in Chapter 2 point to the need for an inclusive approach to workplace-based assessment that would necessitate reconsideration and expansion of current pedagogical techniques to ensure patient feedback of the pharmacy learners who care for them is better represented. In this chapter, I describe research methods for the study comprising the original research component of my thesis. The overall goal of this qualitative research study is to establish the basis for bridging the gap between education and practice, particularly those I identified in the scoping review. This qualitative study also has a dual purpose, to serve as an innovation in pedagogical strategies with a high emphasis on patient involvement in pharmacy education and provide tangible recommendations to inform improvement in educational practice. 3.2 Description and Rationale for Applying Interpretive Description Methodology I conducted a qualitative research study informed by interpretive description (ID) methodology. As Hole (2014) describes, âat its core qualitative research is a practice of empirical inquiry focused on naturally occurring phenomenaâ (p. 166). In qualitative research, the researcher tries to make sense of or interpret occurrences through the meanings individuals assign to them (Denzin & Lincoln, 2011; Hole, 2014). The researcher also strives for an in-depth knowledge and understanding through individualsâ own accounts and experiences (Hole, 2014). The contextual, in-depth processes linked with qualitative research inquiry allow for extensive study and excavation of complex social experiences and phenomena (Hole, 2014). And while quantitative research aims to quantify, predict, and explain correlations, qualitative research, on the other hand, focuses on the meanings and contexts of the phenomena in question (Hole, 2014). 44 Interpretive description is a contemporary qualitative approach developed by Thorne and colleagues and is extensively adopted in nursing research (Thompson Burdine et al., 2020; Thorne, et al., 1997). The methodology is derived from nursing epistemology (Thorne, 2019). As Moon & Blackman (2014) state, âepistemology is concerned with how people create knowledge and what is possible to knowâ (p. 4). Interpretive description was established to fulfill the needs of nursing researchers in investigating the gaps found in their literature (Kahlke, 2014). However, it is applicable to research in health care and education (Hunt, 2009). For this reason, interpretive description is relevant to the multidisciplinary nature of my research theme, pharmacy education, which integrates health sciences with educational research (social sciences). The birth of interpretive description was in response to the ongoing interest and efforts of health researchers to explore research questions beyond the restrictions of other qualitative methodologies (phenomenology, grounded theory, and ethnography) (Hole, 2014; Thorne, 2008). It is a generic qualitative approach that offers flexibility to conduct research in health professions education while retaining and maintaining rigor and structure. Research adopting a generic qualitative research approach is defined as a study that, âis not guided by an explicit or established set of philosophic assumptions in the form of one of the known [or more established] qualitative methodologiesâ (Caelli et al., 2003, p. 4). Therefore, interpretive description does not adhere to a single criterion and is not strictly bound to the guidelines offered by the foundational and frequently used qualitative research methodologies, including phenomenology, grounded theory, and ethnography (Kahlke 2014; Thorne, 2008). Instead, interpretive description borrows from and builds on existing tools and boundaries offered by those commonly employed methodologies. Moreover, interpretive description is an appropriate methodology when the focus is to enhance the knowledge regarding the educational experience without jeopardizing the integrity of the research (Thompson Burdine et al., 2020). As Thorne (2008) states, âinterpretive description was a way for researchers to liberate 45 themselves from using strictly normative methodologiesâ (Bertero, 2015, p. 1) or as Sandelowski (2000) says, a means for researchers to be free from ââtyranny of methodââ (p. 334). Notably, âinterpretive description has the potential to generate new conceptualizations or to inform refinements on the attributes and operational elements we understand in relation to existing conceptsâ (Thorne. 2016, p. 189). My rationale for employing interpretive description is that neither my research questions nor my study objectives fit within major qualitative methodologies. My study did not aim to explore cultures or practices as in ethnography (Hole, 2014), or explain the âbasic social processesâ and âunderlying social structuresâ of a phenomenon (Dey, 1999; Glaser, 2001, as cited in Hole, 2014) through developing theories via grounded theory (Glaser & Strauss, 1967, as cited in Hole, 2014), or analyzing lived experiences (Hole, 2014), and gaining an essence and âa deeper understanding of the nature or meaning of our everyday experiencesâ (van Manen, 2001, p. 9, as cited in Hole, 2014) as phenomenology seeks. It was not possible to confine my study within any of these long-established methodologies. I required an accessible approach that is flexible enough to accommodate the experiential nature of my research questions while offering applicable avenues and practical implications (Thompson Burdine et al., 2020). Research guided by interpretive description reflects on evidence derived from clinical practice and transfers it back to be applied in the clinical setting (Kahlke, 2014; Hunt, 2009; Thorne et al., 1997, Thorne et al., 2004). Researchers using interpretive description âseek understandings of clinical phenomena that illuminate their characteristics, patterns, and structure in some theoretically useful mannerâ (Thorne et al., 2004, p. 3). Researchers can also adopt interpretive description to identify themes, patterns, and commonalties among subjective viewpoints while taking individual differences into consideration (Hunt, 2009; Thompson Burdine et al., 2020). Therefore, interpretive description aligns well with my research questions and study objectives by seeking to bridge the theory-practice gap (Kahlke, 2014) through comparing and contrasting patient 46 and pharmacy learner perspectives, which does not fit within the other commonly employed methodologies. 3.3 Research Paradigm It is crucial to provide an explanation of the research paradigm (Guba & Lincoln 1994 as cited in Moon & Blackman, 2014; Morgan 2007) also known as worldview (Creswell & Creswell 2017) and philosophical perspective (Moon & Blackman, 2014) which I adopted in the interpretive description study since it plays a key role in deciding how my methodological choices might affect how findings from this study are constructed and perceived. Accordingly, my epistemological stance in this thesis was drawn from a social constructivism worldview (Moon & Blackman, 2014) which is congruent with the assumptions of interpretive description methodology. A social constructivism worldview adheres to a subjectivist epistemology, which recognizes that the researcher together with the research participants co-construct and shape the understanding and perception of reality and the meaning that results from it (Chilisa & Kawulich, 2012). In addition, this worldview assumes that: âDifferent individuals construct meaning of the same object or phenomenon in different ways; how an individual engages with and understands their world is based on their cultural, historical, and social perspectives and thus meaning arises through an interaction with a human communityâ (Crotty, 2020; Creswell & Creswell, 2017, Moon & Blackman, 2014, p. 6). Research conducted in a constructivist paradigmâwhere subjectivist attitudes pose a great influenceâ strives for theoretical and/or naturalistic generalizability (Varpio et al., 2021). Subjectivist research, like constructivist research, is characterized by a focus on the particularities of individual instances through locating a select number of study participants according to prespecified 47 criteria (more details in Section 3.7.1 below) (Varpio et al., 2021). Accordingly, through this worldview, my goal was to rely as much as possible on the participantsâ subjective perspectives of the topic in question which is co-constructed through their interaction with others to inductively develop a pattern of meaning (Creswell & Poth, 2007). I also believe that as a researcher, I am part of their world and have to engage with those participants to be able understand the research question of interest (Crotty, 2020; Groenewald, 2004). 3.4 Theoretical Framework To guide my study, I applied a competency-based framework based on AFPC Educational Outcomes. Specifically, in 2017, the Association of Faculties of Pharmacy of Canadaâs (AFPC) outlined Educational Outcomes for First Professional Degree Programs in Pharmacy across Canada according to seven main categories of pharmacist competencies of: Care Provider (CP), Communicator (CM), Collaborator (CL), Leader-Manager (LM), Health Advocate (HA), Scholar (SC), and Professional (PR) (Association of Faculties of Pharmacy of Canada, 2017) (see Appendix C-1). These Educational Outcomes were adopted from and inspired by the CanMEDS, a competency-based framework used in medical education (Frank et al., 2015). The 2017 AFPC Educational Outcomes represent a revised version of the Educational Outcomes published in 2010 based on stakeholder feedback and peer review (Faculties of Pharmacy across Canada, national and provincial pharmacy organizations, and external stakeholders) in addition to review of pharmacy literature and other health care professions (Association of Faculties of Pharmacy of Canada, 2017). The revised 2017 AFPC Educational Outcomes reflect a paradigm shift in the concepts and expressions of the 2010 AFPC Outcomes and how each of the seven pharmacist roles mentioned 48 above interrelates and is interconnected to one another (Association of Faculties of Pharmacy of Canada, 2017). The AFPC Educational Outcomes showcase how the evolution of pharmacist roles pertains to a greater societal accountability (Association of Faculties of Pharmacy of Canada, 2017). The Educational Outcomes also highlight how pharmacist exercise their medication expertise by being one of the most accessible health care practitioners and how pharmacists repositioned themselves as frontline health care workers providing direct patient care (Paradis et al., 2018). Additionally, the AFPC Educational Outcomes provide a framework for curriculum design and are implemented to advance pharmacy practice through enhancing pharmacy learnersâ core competencies and skills to be âfit to practiceâ as patient-centred medication therapy experts (Association of Faculties of Pharmacy of Canada, 2017). The interpretive description study has been guided by both the 2010 and 2017 AFPC Educational Outcomes as the competency-based frameworks since I found they complement one another and provide a more comprehensive and thorough guidelines of pharmacist roles when combined. 3.5 Study Site 3.5.1 Pharmacy Education Context The Entry-to-Practice Doctor of Pharmacy (PharmD) Program at the UBC Faculty of Pharmaceutical Sciences (âthe Facultyâ) is a four-year professional program. (Entry-to-Practice PharmD Degree, Faculty of Pharmaceutical Sciences, n.d.). The program meets the academic requirements set by the College of Pharmacists of British Columbia and has been accredited by the Canadian Council for Accreditation of Pharmacy Programs (Entry-to-Practice PharmD Degree, 49 Faculty of Pharmaceutical Sciences, n.d.). The PharmD program at UBC embraces a competency-based curriculum. Such curriculum equips future pharmacists with the knowledge, skills, and qualifications they need to thrive in the several health care settings of pharmacy practice such as hospital, primary care, ambulatory care and community/retail pharmacy in addition to specialized areas like industry and government (Entry-to-Practice PharmD Degree, Faculty of Pharmaceutical Sciences, n.d.). UBC PharmD students receive a patient-centred teaching approach which combines didactic learning with experiential education during practicum rotations to optimize health care delivery (Entry-to-Practice PharmD Degree, Faculty of Pharmaceutical Sciences, n.d.). In addition, descriptions of the AFPC Educational Outcomes are outlined in the formal evaluation forms assigned by the Office of Experiential Education at the UBC Faculty of Pharmaceutical Sciences. All pharmacy learners enrolled in the UBC PharmD Program have been provided with assessment instruments that specify the programâs expectations of learner skills and competencies throughout their training program, as defined and advised by the AFPC. 3.5.2 Pharmacy Practice Context The study was conducted with the UBC Pharmacists Clinic at the Faculty over a seven-month period. The UBC Pharmacists Clinic (the âClinicâ) is a licensed, pharmacist-led patient care university-affiliated clinic (Pharmacists Clinic, Faculty of Pharmaceutical Sciences, n.d.). The Clinic provides consultative comprehensive medication management services to patients (Gobis et al., 2016). Patients are eligible to receive no-cost care regardless of the number or type of medications they are prescribed, their medical conditions, geographical location or health plan status (Gobis et al., 2016). There are five models of patient care provided by the UBC Pharmacists Clinic and these include; 1) Consultation Model: care received from a pharmacist located at the UBC 50 Pharmacists Clinic site; 2) Co-Located Model: care received from a pharmacist located in a medical practice; 3) Telephone: care received from a pharmacist by telephone; 4) Telehealth: care received from a pharmacist by secure telehealth/videoconference; and 5) Community-Based: care delivered to patients in remote communities from a pharmacist via telephone, telehealth, and at in-person community visits (Pharmacists Clinic, Faculty of Pharmaceutical Sciences, n.d.). Typically, patients referred to the UBC Pharmacists Clinic are complex, have diverse health conditions, and are taking multiple medications (Gobis et al., 2016). Sixty percent of referrals received at the Clinic come from physicians (mostly family doctors) and forty percent are self-referrals or from another health care providers such as occupational therapists and physiotherapists. The volume of patient visits at the UBC Pharmacists Clinic is typically 2000 patient appointments per year for one-on-one care in the Clinicâs appointment-based model. However, there are additional patient-pharmacist interactions which are not factored in the number of appointments per year such as outreach initiatives, group appointments, and immunization clinics. The Clinic also offers pharmacy learners enrolled in the PharmD Program at UBC a unique opportunity to build on their pharmacy training and grow professionally while developing and mastering core competencies and skills (Pharmacists Clinic, Faculty of Pharmaceutical Sciences, n.d.). Overall, the UBC Pharmacists Clinic is a living laboratory and a hub for pharmacy practice innovation and serves as an experiential education site for training pharmacy learners (undergraduate, graduate and practicing pharmacists) within Canada (Pharmacists Clinic, Faculty of Pharmaceutical Sciences, n.d.). Altogether, the UBC Pharmacists Clinic was selected as the study site for the following reasons, 1) the Clinicâs feasible location; 2) pre-existing relationships between the study researchers and the Clinic team since they work within the same Faculty; 3) the teamâs familiarity with 51 precepting pharmacy learners; 4) the relative ease of access to the research participants (patients and pharmacy learners); 5) the potential to build trusting relationships between me and the research participants; 6) the ambulatory nature of the care provided at the Clinic and the appropriateness of recruiting non-acutely ill patients; and 7) the possibility of saving time on data collection procedures (Marshall & Rossman, 2014). 3.6 Research Team § Principal Investigator and Research Supervisor: Dr. Kerry Wilbur, Associate Professor and Executive Director, Entry-to-Practice Education at the UBC Faculty of Pharmaceutical Sciences § Co-investigators: 1. Dr. Arwa Nemir, MSc Candidate and Graduate Research Assistant at the UBC Faculty of Pharmaceutical Sciences 2. Dr. Jillian Reardon, Coordinator, Quality Care, Pharmacists in Primary Care Network (PCN) Program, Lecturer at the UBC Faculty of Pharmaceutical Sciences and Clinical Pharmacist at the UBC Pharmacists Clinic (study site). Dr. Reardon was assigned as the site investigator for this project owing to her experience working at the Clinic, supervising pharmacy learners, and providing direct patient care 3.7 Study Design This was a single-centre, qualitative research study employing virtual semi-structured interviews (phone or video calls) and informed by interpretive description methodology. 52 3.7.1 Study Sample The study population is composed of patients and pharmacy learners. I implemented convenience sampling to recruit study participants within a subpopulation that met the following inclusion criteria: 1) For patients § 18 years of age or above § able to understand and express themselves in English to avoid any loss of meaning through the interpretation process (Mukumbang & Adejumo, 2014) § received direct supervised care from a pharmacy learner at the UBC Pharmacists Clinic 2) For pharmacy learners: § student pharmacists and/or pharmacy residents § trained at the UBC Pharmacists Clinic between September 2020 â April 2021 There are multiple categories of learners who train at the UBC Pharmacists Clinic, and these include: § fourth-year direct patient care rotations (PHRM 473: Selected Advanced Pharmacy Practice Experience) § fourth-year non-direct patient care rotations (project, research, health promotion, indigenous health, leadership, etc.) (PHRM 473) § hospital pharmacy residents § post-baccalaureate PharmD students Despite the fact that traditional and specific criteria exist for calculating participant recruitment number in quantitative studies, there is no such equation for research informed by qualitative methods (Malterud et al., 2016). Qualitative research studies seek a deep and thick description of data through establishing relationships and connections with research participants 53 rather than aiming for statistical significance or proving causality (Marshall & Rossman, 2014). Therefore, my standards for determining participant recruitment number were dictated by convenience factors and site-specific variables such as feasibility and time constraints (Marshall & Rossman, 2014) while considering a reasonable variation in our study population (Dobbert,1982, as cited in Marshall & Rossman, 2014) in order to preserve the credibility and trustworthiness of our data (Marshall & Rossman, 2014; Tracy, 2010). It is important to note that because the applied and practice disciplines realize that human experience can theoretically have limitless diversity, data saturation is not a desirable outcome or aim in interpretive description in general (Thompson Burdine et al., 2020) and specifically in this study. Instead, the emphasis is on gaining a better understanding of participant perspectives while acknowledging that there might be differences in perceptions and outliers (Abdul-Razzak et al., 2014; Thompson Burdine et al., 2020). Additionally, the intention of research findings from qualitative studies, as the case with this study, is not to generalize to a larger population (Marshall & Rossman, 2014). This study, on the other hand, attempts to offer insights through transferability, emulating experiences in other domains (Varpio et al., 2021). Marshall & Rossman (2014) describe the concept of transferability in qualitative research studies as, âways the studyâs findings will be useful to others in similar situations, with similar research questions or questions of practiceâ (p. 479). Transferability can also be explained as applying findings about the study population to another population presumed or believed to share mutual context and/or characteristics that would warrant that application to other contexts or settings (Marshall & Rossman, 2014). Therefore, because several subjectivities are prioritized, the realities of research participants within this study might or might not necessarily extrapolate to the realities of people outside of the study sample (Smith, 2018; Varpio et al., 2021). 54 3.7.2 Participant Recruitment Prospective patients were identified by the UBC Pharmacists Clinic staff (pharmacists providing direct patient care) since they had permission to use the UBC Pharmacists Clinic database for research purposes. The pharmacists checked the Clinic's daily scheduled appointments for patients who met the study inclusion criteria and gave eligible patient participants an overview of the study. Patients then verbally consented to be contacted for further information. Afterwards, the pharmacists informed me of potential patient participants whom I then contacted via email to ask about their willingness to participate. Prospective pharmacy learners who met the study inclusion criteria were identified by JR at the start of their training rotation at the UBC Pharmacists Clinic. JR informed the learners about the study and asked to connect them with me after which I approached those learners via email to ask about their willingness to participate. I communicated with eligible participants (patients and learners) via email providing them with a study package that included a letter of initial contact (see Appendices C-2 and C-3) and an informed consent form (see Appendices C-4 and C-5). I explained the study to eligible participants in simple language addressing any questions or concerns they had and mentioning the purpose and procedures of the study, the role of the investigators in terms of data collection and analysis, their role as participants, and the procedures that were implemented to protect confidentiality (Kaiser, 2009). All participants (patients and pharmacy learners) were informed that they had up to 48 hours to decide whether they would be willing to participate or not. 55 3.7.3 Data Collection 3.7.3.1 Pilot Interviews To determine the feasibility of my study, predict any potential unforeseen difficulties, provide an estimate of interview duration and further refine the robustness of the interview topic guides (Hassan et al., 2006), I piloted the interview topic guides prior to study initiation with participants who were not involved in the actual study. I recruited one patient from the UBC Pharmacists Clinic in addition to two third-year undergraduate PharmD students at the UBC Faculty of Pharmaceutical Sciences according to the predetermined inclusion criteria. I determined this number while considering the possibility that not all eligible patients and learners would agree and/or consent to participate. My rationale for conducting pilot interviews was that patients and learners are the primary interviewees for the proposed study; therefore, their perspectives are essential to determine the flow of the questions, appropriateness of prompts, clarity of the wording, and identify any other potential flaws with the interview topic guide. Furthermore, I anticipated making changes to the interview topic guide while identifying ambiguity, if any, based upon the participantsâ feedback (Dudas et al., 2010). This helped me refine the interview questions and make the appropriate improvements (Majid et al. 2017) according to the intervieweesâ comments which I utilized when I implemented the interview guide in the full study. 3.7.3.2 Semi-Structured Interviews Data were collected through virtual semi-structured interviews. As proposed by Qu & Dumay (2011) the semi-structured interviewing process involves, âprepared questioning guided by identified themes in a consistent and systematic manner interposed with probes designed to elicit more elaborate responsesâ (p. 246). Semi-structured interviews have the advantage of flexibility and accessibility (Qu 56 & Dumay, 2010) making them the most convenient and effective research method of data gathering (Kvale and Brinkmann, 2009, as cited in Qu & Dumay, 2010). I developed and adapted the semi-structured interview topic guides (see Appendices C-6 and C-7) based on a review of the literature (Eady & Moreau, 2017; Moreau et al., 2016; Moreau et al., 2019) and discussions among other research team members, while making sure to nest our research questions and study objectives within the interview questions (see Appendices C-8 and C-9). Questions from the topic guide covered the following areas 1) skills learners demonstrate during patient encounters including aspects of pharmacy learner care patients prioritize; and 2) the specifics of patient feedback delivery including comfort, willingness, and timing and means of feedback. The interview topic guide was followed and complemented by scheduled and unscheduled prompting and follow up questions (Qu & Dumay, 2010) for clarification and/or elaboration, stimulation of deeper description (Manio, 2018) and to grasp a fuller picture of the participantâs narratives (Qu & Dumay, 2010. The interview guide evolved as interviews proceeded. New ideas and perspectives that arose while interviewing a participant were noted and added to the following interviews. I asked additional questions to subsequent participants as a way of elaborating on earlier interviews. A table summarizing the 2017 AFPC Educational Outcomes (Association of Faculties of Pharmacy of Canada, 2017, p. 3) was shared with all pharmacy learner participants before the interview to reorient them to the pharmacist roles as outlined by the AFPC. It was also intended to serve as a reference for learners during the interview process since the AFPC Educational Outcomes represent the competencies and skills pharmacy graduates in Canada are expected to demonstrate in practice. 57 3.7.3.3 Participant Demographics and Characteristics Demographic data were collected for patient and pharmacy learner participants to interpret and contextualize the findings with respect to sample population characteristics (Manio, 2018; Morse, 1991; Thorne, 2016). Providing basic descriptive data about study participants like age and gender is an important aspect of undertaking qualitative research in order to establish transferability and credibility of study findings through âsituating the sampleâ (Elliott et al., 1999, p. 221) in addition to adhering to ethical guidelines of conducting research (Elliott et al., 1999). It also provides guidance on the specific circumstances of research participants to assist the reader in determining the spectrum of people and situations to which the study findings might apply or in other words, transferability of findings (Elliott et al., 1999). The following patient demographics were collected by JR who has access to the UBC Pharmacists Clinic database for research purposes, 1) date of birth/age in years; 2) gender; 3) number of chronic medical conditions; 4) number of medications; and 5) occupation/ level of education. During the interviews, pharmacy learners were asked about; 1) their stage of training (pharmacy year); and 2) types of patient care they were involved with at the UBC Pharmacists Clinic (direct/non-direct and in other settings (ambulatory care, community, or hospital). My aim was to present participant demographics as compiled overall characteristics of study population and not to link any data to a specific participant. 3.8 Mitigating Strategies in Response to the Corona Virus Disease (COVID-19) Pandemic The UBC Pharmacists Clinic supports the academic progress of pharmacy learners by providing them with hands-on experience and a chance to bridge the theory-practice gap in addition to connecting learners to pharmacy practice with course participation, case studies, and course 58 resource materials. Normally, pharmacy learners would participate in all five patient care models offered by the Clinic as discussed in Section 3.6. However, due to suspension of in-person patient visits and learner instruction in the UBC Pharmaceutical Sciences building according to UBCâs adherence to the Public Health Agency of Canadaâs recommendations and Provincial Health Orders regarding COVID-19 pandemic, pharmacy learners were providing supervised consultation-based care via telephone calls or telehealth visits. Additionally, because the COVID-19 pandemic circumstances hindered our ability to have in-person interactions, interviews were conducted virtually through telephone calls, or audio/video conference call via Zoomâ¢ platform, depending on participant preference. 3.9 Data Analysis and Interpretation All interviews were audio-taped then transcribed verbatim using an encrypted software named Descript, Inc. (Version 14.0.0-release.20210514.16). I then verified all transcripts where I listened to the recording while reading and revising the transcribed text, word by word. It is advised that researchers develop their own transcripts since âtranscription is regarded as analysis within the perspectiveâ (Hutchby and Wooffitt, 1998 as cited in Davidson, 2009). This proceeded in tandem with having all interviews conducted by me and was an opportunity to immerse myself in the interview transcripts as I tried to grasp a deeper insight into the data. To preserve participant anonymity, names and identifying information were removed and/or changed in transcripts (Phinney et al., 2013). Even though the interview questions were framed to guide my inquiry, I adopted an open mind throughout the data collection and analysis processes. I welcomed unplanned ideas and topics introduced by my research participants (not added to the initial version of the interview topic guide). Upon analysis, relevant and thought-provoking ideas were used to refine the 59 interview topic guide and were added as prompts and discussed with other participants during subsequent interviews. Data analysis, as informed by an interpretive descriptive lens, is âinherently experientialâ (Thorne et al., 2004, p.7) and aims for a thick description (Manio, 2018) and a ârigorous conceptual workâ (Thorne, 2016, p. 185) with a strong and coherent narrative using inductive qualitative reasoning (Thorne, 2016). In interpretive description, the researcher is the one âdriving the interpretive process (Morse, 1994; Thorne, 2016, p. 185). Accordingly, I carried out an interpretive analytic process striving towards a final analytic product with a high level of abstraction and conceptualization and of distance from the raw data (Thorne, 2016), what Sandelowski and Barroso (2003) describe as a âconceptual or thematic descriptionâ (p. 913). My analysis evolved from a descriptive level (coding) to a more conceptual and interpretive means by linking and clustering the codes into broader categories and sub-categories then themes and subthemes. I also employed reflexive thematic analysis to inductively develop the final themes and subthemes. In reflexive thematic analysis, the coding process is important to theme formation where analytic outputs are derived from codes through the researcherâs active engagement with their raw data (Braun & Clarke, 2006; Braun & Clarke, 2021). Accordingly, themes are inductively generated through coding or in other words, themes are an âoutcome' of this coding process (Braun and Clarke, 2021). In this study, data analysis was dynamic, evolving, on-going and iterative, occurring simultaneously with data collection. Data analysis occurred separately for each participant population (patients and pharmacy learners). Analysis began after two patient and two pharmacy learner interviews had been completed and was performed in multiple sequential phases. Overall, analysis was done in iterative cycles using a constant comparative approach (Boeije, 2002). I carried out within-case analysis by immersing myself in and reviewing each individual transcript in addition 60 to a cross-case analysis by making comparisons across the transcripts, exploring both the contrasts and commonalities (relationships) between the experiences of the research participants (patients and pharmacy learners) (Ayres et al., 2003; Phinney et al., 2013; Thompson Burdine et al., 2020; Thorne, 2016). The initial phase of data analysis involved a descriptive approach using conventional content analysis and coding to try to capture meanings in order to get a âfirst senseâ of what is happening to identify patterns and similarities within and between interviews (Neubauer et al., 2019; Phinney et al., 2013). I started by reading and immersing myself in the interview transcripts to gain a sense of the raw data trying to grasp the meaning of participant responses (Erlingsson and Brysiewicz, 2017), adding interpretive notes and comments supplemented by my field notes/memos which I took during participant interviews. The next phase of data analysis involved more in-depth reading of interview data while going back and forth between transcripts. This was done while reflecting on and mapping participant responses within the 2010 and 2017 AFPC competency-based frameworks. Transcripts were analyzed using the framework approach nested within the 2010 and 2017 AFPC Educational Outcomes to identify recurrent themes and subthemes. Mapping matrices were created to keep track of participantsâ responses within each theme and subtheme in relation to the AFPC framework in an easily visualised format. Unmappable responses were tagged for coding outside of the AFPC framework using a coding framework which I derived and developed from the data itself. Constant comparative analysis of the interview transcripts was carried out while using interpretive strategies to inductively develop logic themes and subthemes that would best answer the research questions while gaining an in-depth insight into the raw data (Manio, 2018; Morse, 2015; Thompson Burdine et al., 61 2020). Themes and subthemes were further refined through collaborative discussions with research supervisor, KW and committee members, JR, MDV, and MP. Moreover, I wrote analytic memos along the way in the form of descriptive notes and interpretive reflections based on my in-depth readings of the complete data set for each participant while considering how the data or parts of them contribute to understanding the whole picture (Neubauer et al., 2019). The memos also served as a record of how the study data were considered relative to the 2010 and 2017 AFPC competency-based frameworks. My strategy for triangulation to enhance the credibility, rigour, and trustworthiness of my findings (Tracy, 2010) was by having three research team members (AN, KW and JR) who are pharmacists and educators with experiential knowledge contribute to the data analysis process and create the analytical framework (Thompson Burdine et al., 2020). Specifically, JR offered a unique contribution and vital input to the data analysis process being an experiential researcher, practicing clinician, and preceptor at the study site. The researchersâ experiential knowledge and disciplinary orientation (pharmacy education) were both assets to this study, an applied research informed by interpretive description methodology (Thompson Burdine et al., 2020; Thorne, 2016). Meetings were regularly scheduled with KW for coding, discussing analytic memos and to offer feedback on the progress and structure of the analysis process. Analysed data were extracted to a spreadsheet and exported to a data management software called NVivo 12TM (QSR International Pty Ltd. Version 12.6.1). Exporting to NVivo software is advised to be done at the later/final stages of data analysis as per interpretive description (Thorne, 2016). The methodology stresses on having the researcher the initial and main driving force of the data analysis, performing the interpretation and conceptualization of data before using a software 62 that has biased previously set algorithms (Thorne, 2016). As Jennings (2007) reminds us, ââit is âpeopleware,â not software, that analyses qualitative dataâ (p. 483). 3.10 Reflexivity Positioning the researcher, also known as reflexivity, is a crucial and intrinsic element of qualitative research and social constructivism in particular to ensure integrity, rigour, and sincerity are well-maintained throughout the research study (Manio, 2018; Thorne, 2016; Tracy; 2010). In addition, the social constructivist paradigm I adopted in this study has subjective foundations, as previously discussed in Section 3.3, which acknowledges that, because knowledge is subjective, research inquiry is guided by the researcher's values, experiences, and beliefs (Chilisa & Kawulich, 2012). Accordingly, I recognize the importance of situating myself within this thesis. It was important for me as a researcher, instead of silencing my biases, to acknowledge my sense of voice. It was also crucial to reflect on, be transparent about, and identify any subjective values, preconceived notions, or perceptions I had towards the topic in question and that might interfere or influence the research process. I thereby acknowledge the potential influences that my training experiences as a former pharmacy learner and my role and identity as an aspiring pharmacy educator and early career pharmacy researcher might have on the data collection, analysis, and interpretation of findings (Manio, 2018; Marshall & Rossman, 2014). Therefore, to maintain the sincerity of my work and my credibility as the researcher who was predominantly responsible for collecting and interpreting the data (Thorne, 2004; Tracy, 2010), I jotted down analytic memos to consider my position throughout the data collection and analysis periods. As an applied researcher, the analytic memos served as a record of self-reflexivity notes about my subjective biases and inclinations, and preliminary reflections and interpretations to enhance my credibility as a researcher in mapping and constructing the findings (Manio, 2018; Tracy, 2010). 63 Pezalla and colleagues (2012) describe a qualitative interview as, âa collaborative enterprise, an exchange between two parties, reflecting on the ways in which the interviewer affects the organization of this talk-in-interaction and the processes by which the talk is producedâ (p. 166). Since the researcher is regarded as the principal instrument during semi-structured interviews (Guba & Lincoln 1981; Merriam 2002, as cited in Pezalla et al., 2012) in studies that adopt interpretive description as their methodology (Thorne, 2016), I acknowledge that my unique researcher attributes might have a potential influence on the data collection process, conversational spaces created during the interview process (Pezalla et al., 2012) in addition to the flow of the conversation. If I were to describe my approach and characteristics as an interviewer, I would use the following terms, âenergeticâ, âinterpretiveâ, and âaffirmingâ (Pezalla et al., 2012). Participants are the heart and soul of health professional research and specifically my study. My thesis would not have come to life if it were not for the patients and learners who devoted some of their valuable time to contribute to this study. I acknowledge the importance of building a connection with the research participants prior to conducting the interviews. Especially because all the interviews were carried out virtually, establishing rapport was not only compelling but also enhancing. Participating in virtual interviews with a total stranger is not something that I expect participants to do in their day-to-day lives. I noticed some participants were craving a social connection even if it is just through a computer screen (Zoomâ¢) or over the phone. Breaking the ice before starting the recorder by chatting for a couple of minutes, asking general questions about life and how they were doing helped ease into the conversation and made the participants more open to share their perspectives. One cannot dive into asking the interview questions and focusing on technicality aspects while forgetting that an interview involves a human interaction and a conversation between two people. It was important for me to make participants feel safe, respected, 64 and that they are not just a bucket of information I am aiming to collect but rather a very valued member of my study. The following interview excerpts demonstrate the rapport and connection that was built and established with some of the patient participants: âItâs not relevant to the interview, but you're really great at reflecting back what people are saying and clarifying, did you practice for qualitative interviews? It comes through. I noticed when we were going through and I thought I would definitely tell her that do it, without really thinking about it, but that's partly how I was, you know.â (Patient 4) âSince weâre talking about giving input. I just want to tell you that I think you're fabulous. I think that you have a wonderful way of communicating with people. You're very upbeat. You're very uplifting. And I think that's just fantastic.â (Patient 9) âAnd I also think, because of COVID, we're living in this world where we're communicating through Zoom or whatever other program, and it takes away from a little bit about, although I didn't feel that with you at all, I think all those things create barriers that to some degree. I had a great talk with you today, Arwa. I really enjoyed our interactions. So, thank you.â (Patient 10) 3.11 Ethical Considerations Ethical approval was granted from UBCâs Research Ethics Board (UBC REB), UBC Ethics ID# H19-04038. In addition, I have completed the Canadaâs Tri-Council Policy, TCPS2: CORE (Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans â Course on Research Ethics) and made sure to implement the policies, procedures, and guidelines throughout the study. âRespect for Personsâ, âConcern for Welfareâ, and âJusticeâ are the three core principles 65 declared in and mandated by Canadaâs Tri-Council Policy (TCPS2) for ethical practice of research involving humans. Minimal risk research is defined in TCPS 2 (2018)) as: "research in which the probability and magnitude of possible harms implied by participation in the research is no greater than those encountered by participants in those aspects of their everyday life that relate to the researchâ. It is also important to consider the vulnerability of research participants and the research risk itself when judging a research study to be of minimal risk. Vulnerability is defined as: âA diminished ability to fully safeguard one's own interests in the context of a specific research projectâ (TCPS 2 (2018)). Even though the interpretive description study was estimated to be of minimal risk since it did not involve any at-risk participants, it was anticipated that participants' vulnerability might be of medium level because they were receiving care or training at the study site (The UBC Pharmacists Clinic). However, the data collection was done through non-invasive procedures (virtual semi-structured interviews) and the likelihood of participants experiencing discomfort associated with any questions (psychological harm and/or social harm) was low. A solid plan was prepared to mitigate any potential participant concerns by doing the following, 1) confidentiality safe guards in place were outlined and all participants (patients and pharmacy learners) were informed that they could refuse to respond to any of the interview question/s; 2) patients were informed that they would not be asked to disclose actual information about any individual learner; 3) patients were also assured that their decision to participate in this study would not affect the level or quality of care they receive at the UBC Pharmacists Clinic; and 4) pharmacy learners were assured that their academic standing or evaluations as a pharmacy learner at the UBC Faculty of Pharmaceutical Sciences would not be affected by their choice of participation in the study. Moreover, all participants (patients and learners) were assured that 1) any data that they provide would remain confidential and would not be 66 shared with any of the team members working at the UBC Pharmacists Clinic except with co-investigator, JR; 2) they may choose to withdraw their participation at any stage without undue harm and their relationship with the UBC or the UBC Pharmacists Clinic would not be changed in any way; and 3) they may request withdrawal of their data if they choose to withdraw their participation at any stage during the study. The following measures were implemented to ensure that privacy was maintained on both ends (participants and interviewer) during the data collection phase, 1) using personal phones; 2) using personal internet connection; 3) using personal email address (participants) and professional email address (interviewee); 4) being in a private location during the interview; and 5) communicated via a private platform that uses end-to-end encryption such as Zoomâ¢. The Zoomâ¢ invitation was password protected so no uninvited participant could join. All participants were asked to join the Zoomâ¢ call using their assigned code. Participants were also informed that they can turn off their cameras and mute their microphones during the interview (if not needed). All Zoomâ¢ and phone recordings were stored on my password-protected device. 3.12 Security and Access to Data All participants were assigned an alphanumeric code (L for learners, P for patients combined with a number reflecting the sequence of interview date). A master list was created to link codes to names. The master list was password protected and encrypted and only two of the research team members (AN and KW) had access to it through the UBC's official sharing cloud platform (Workspace 2.0). This study did not use any names or personal identities of participants. Participants were not identified by name in the written transcripts. Anonymous codes were applied to participants in the transcription process. Any data provided by individual participants remained confidential and were not shared with any of the team members at the UBC Pharmacists Clinic 67 except for a small, selected sample of aggregate anonymized and blinded data that were shared with co-investigator, JR, for coding and analysis purposes. Anonymized electronic copies of the signed consent forms and interview recordings were stored on an encrypted password-protected hard drive owned by me. Only two of the study team members (AN and KW) had access to raw data (interview audio-recordings and written transcripts) through the UBC Workspace 2.0 file sharing platform and are both previously oriented to the confidentiality, security, and privacy issues. 68 Chapter 4: Patient Perspectives on Patient Involvement in Pharmacy Learner Skill Assessment 4.1 Chapter Overview The study findings reported in this chapter represent the patient perspective on addressing research question number 2, âWhat skills, demonstrated by pharmacy learners during patient interactions, are patients capable of assessing?â. As described in Chapter 3, Section 3.7, data were collected by interviewing patients who received direct supervised pharmacy care from a pharmacy learner at the UBC Pharmacists Clinic. All interviews were conducted virtually via phone or Zoomâ¢ calls because of COVID-19 restrictions halting all in-person interactions. It is important to acknowledge that patients were reflecting on their experiences and chronicled their perspectives of being provided with pharmacy learner care within the context of a primary care clinic (The UBC Pharmacists Clinic). This is worth highlighting when interpreting and considering the transferability of the study findings since the Clinic has a unique model of pharmacy care provision as discussed in Chapter 3. 4.2 Patient Participants Altogether, I interviewed ten patients as participants, whose characteristics are summarized in Table 4-1. Patient interviews lasted on average 53 minutes and were all conducted virtually, mostly via Phone calls (6 interviews) or Zoomâ¢ (4 interviews). Patient participants had a mean age of 66 years (range 40 to 73 years) and ninety-percent of them self-identified as females. Eighty-percent of patient participants had a diagnosis of six or more chronic medical conditions and hundred-percent of all patient participants were receiving five or more medications (See Chapter 3, Section 3.5 for further details on study site and patient population). Forty-percent of patient 69 participants have health professional background for which they received training either through a post-secondary education degree (30%) or employment (10%). Randomized participant numbers (i.e., Patient 1, Patient 2) are used to categorize the narratives and emphasize the diversity of perspectives (Manio, 2018). The conventions some (defined as 1 to 3 participants), many (4 to 7 participants), and most (8 to 10 participants) are used to indicate the weight of consensus within separate findings presented within the themes below (Manio, 2018). All names and pronouns that were occasionally present within patientsâ responses when reflecting on their interaction with a pharmacy learner were removed and replaced with [the learner]. 4.3 Overarching Themes Findings associated with each theme are based on framework- and data-driven coding and presented as a hybrid of concepts that were either mapped within the 2010 and 2017 AFPC competency-based frameworks and/or unmappable concepts which were tagged for coding outside the AFPC framework. Patient participants shared their perspectives and views on pharmacy learner skills which was nested within the aspects of care they received from the pharmacy learner. I was able to read the patientsâ responses and derive findings into themes regarding what prevailed within and across patient interviews. Altogether, the two themes and corresponding five sub-themes were constructed: § Theme #1 Humanistic aspects of pharmacy learner care â¢ Subtheme #1.1 Atmosphere of the patient-learner encounter â¢ Subtheme #1.2 Pharmacy learners recognizing patientâs humanity â¢ Subtheme #1.3 Pharmacy learners as patient-centred communicators 70 § Theme #2 Intrinsic aspects of pharmacy learner care â¢ Subtheme #2.1 Pharmacy learners as patient-centred medication therapy experts â¢ Subtheme #2.2 Pharmacy learners acknowledging their capabilities The humanistic aspects of pharmacy learner care describe the skills that pertain to the learnerâs identity as a human being engaging in an interaction with another human (patient) aside from the learnerâs identity as a health professional in training. The humanistic aspects of care predominantly relate to the learnerâs communication skills which include the learner introducing themselves, establishing rapport, actively listening, showing empathy, and using simple language. In other health care disciplines, such as medicine, scholars refer to these humanistic skills as ânon-technicalâ (Moreau et al., 2016). On the other hand, the intrinsic aspects of pharmacy learner care refer to the learnerâs inherent formal pharmacy skills which they acquire through education and training, such as knowledge and professionalism, and which plays an integral role in shaping their identity as pharmacy professionals in training (see Figure 4-1 for a thematic map of identified themes and corresponding subthemes of patientsâ perspectives). While patientsâ narratives of the pharmacy learner skills they could assess were mostly embedded within the communication aspect of the interaction, their responses sometimes reflected descriptions of other pharmacist roles outlined by the AFPC such as âCare Providerâ, âCollaboratorâ, âScholarâ, and âProfessionalâ. I also indicated when these patient perspectives did blueprint back to stated APFC Educational Outcomes as key or enabling pharmacist competencies (see Appendices D-1 - D-5). The following sections explain the findings related with each theme, with illustrative excerpts added to contextualize the patient participantsâ viewpoints and perspectives. 71 4.3.1 Theme #1 - Humanistic Aspects of Pharmacy Learner Care Patients provided several insights that pertained to their ability to observe and provide feedback on the way the learner carried themselves and how this reflected on their interaction with the patient. Several aspects of care that patients regarded as something they could assess were intertwined with their expectations when receiving care from a health care professional, in this case a pharmacy learner. Patients described aspects of care that humanized their experience, encompassing the whole patient-learner interaction, from the very first moment they met the learner, during, and until the end of the encounter. Patient perspectives indeed depicted the basic facets of any human contact, which is no different from a patient-learner professional care encounter. 4.3.1.1 Subtheme #1.1 - Atmosphere of The Patient-Learner Encounter Some patients thought they could have an opinion on the general atmosphere of their encounter with the pharmacy learner during which the patient could observe and provide feedback on specific pharmacy learner skills. Starting off the interaction by greeting the patient, providing the patient with a self-introduction while acknowledging their role as a pharmacy learner, and demonstrating sincere efforts to establish and maintain rapport with the patient with all taking place in a comfortable and safe patient-learner encounter were skills patients stated they would be capable of recognizing and talking about. In this subtheme, I was able to map the patientsâ narratives within the pharmacist patient care responsibility, âCollaboratorâ Educational Outcome, as outlined by the AFPC even though patients did not consistently refer to the specific Educational Outcome by its name (see Appendix D-3). 72 One of the patient participants described their ability to assess the sequence of events when they initially interacted with the learner and how it was interconnected with being confident in receiving care from this specific learner: âIntroducing self and the positive way of talking first. Once when you see the patient first of all greeting and explaining self and self-introducing. So that's all the things that will help the patient to get the confidence with [the learner].â (Patient 3) Another patient mentioned that they could recognize whether the learner began the encounter by establishing rapport with the patient which would in turn make the patient feel comfortable: âI guess it really comes down to like the rapport theyâre able to build the comfort they create.â (Patient 4) This patient further shared that they would observe and assess the learnerâs demeanour and approach when interacting with them and if the learner walked the patient through the care process: âI guess their manner of interaction, how they approach how they interact, definitely on how they interact with me as a patient. Their manner, how they approach everything, how they explain what they're doing and why.â (Patient 4) Patient 4 also argued that the learnerâs self-introduction when initiating an interaction with the patient was something they would be able to observe and comment on when receiving care from any health professional in training and not necessarily a pharmacy learner: âIt's not totally relevant, but it really annoys me when students don't identify themselves as students and explain why they're there. I mean, that's for any professional. Because sometimes somebody comes up and starts asking or doing, and you're like, who are you? What are you? Like what's your role?â (Patient 4) Explicit here is how overlooking self-identification and explanation of oneâs position by some learners were not only observable but also a source of frustration for the patient. 73 Some patients also mentioned they would be able to tell if they were provided with a comfortable and safe atmosphere to receive care. Even though patients did not explicitly label it as such, patients felt they could assess whether their interaction with the learner was entrenched in the patient-centred care model, where they felt welcomed, allowed the space and time to have a back-and-forth conversation with the learner, addressing their questions and concerns and inviting questions from patients. Such perspective requires the learner to acknowledge and recognize the power dynamics in the patient-learner encounter to establish a relationship that is built on confidence and maintained by trust. As Patient 6 described: âIt's just mostly the way they treat you and the way they come around to getting answers to their questions because that's what as a patient, that's what you would notice. You wouldn't notice that they gave you a medication, you know, you wouldn't know if there was something better, they could have done for you, you have to trust that they have that knowledge, but it's more just the way they treat their patients I think.â (Patient 6) A comfortable encounter where the patient felt they were given enough time to answer questions, and were welcomed to share their perspectives when interacting with a pharmacy learner was what Patient 8 believed they would be able to observe and subsequently assess: âBut in my situation, I felt very comfortable that the questions that were asked I was allowed the space and the time to be able to answer them and not feel rushed. And even in my sessions, I understand you can have a 30-minute or a one-hour telehealth appointment. And I take the full hour up every time. But I appreciate the fact, even when with the student is there and the questions asked that there is the time to let me ramble or say what I need to say or that information that's required that the pharmacist or the student needs to hear that I'm able to share, that I've got the time to be able to.â (Patient 8) 74 Reflecting on Patient 8âs response, a patient-centred encounter, even though not overtly defined as such, seemed to prevail in the patientsâ narratives when asked about the pharmacy learnersâ skills they could recognize and comment on. Here Patient 8 expressed their ability to pick up on if they were allowed to use their appointment time to have a conversation with the pharmacy learner rather than being talked at in a one-way encounter predominately handled by the learner. 4.3.1.2 Subtheme #1.2 - Pharmacy Learners Recognizing Patientâs Humanity Recognizing their contributions to the learner training and educational journey, patients understood the educational significance of their interactions with pharmacy learners and how important it was for learners to practice their pharmacy care practice skills. Patients not only understood but also expected learners to ask questions, so they were able to address the patientâs needs and concerns. Nevertheless, patients thought they could comment on the flexibility of the learner during the patient encounter, listening to what the patient had to say and not strictly abiding by a structured script which could jeopardize the flow and smoothness of their conversation with the patient, were all skills that many patients felt they could comment on. In addition, some patients believed they could assess whether they felt included in their pharmacy care process by having the learner acknowledge, respect, and recognize the patientâs experience with their medical conditions and medications. In this subtheme, I was able to map the patientsâ narratives within the pharmacist patient care responsibilities, âCare Providerâ, âCommunicatorâ, âCollaboratorâ, and âProfessionalâ Educational Outcomes, as outlined by the AFPC (see Appendices D-1, D-2, D-3, and D-5) even though patients did not consistently refer to the specific Educational Outcome by its name. Specifically, Patient 4 reflected on their own previous encounter with a pharmacy learner and explicitly stated how interacting with a learner who welcomed questions would foster a âconnectionâ with the patient. Patient 4 could also tell if their role was solely as learning 75 apparatuses or platforms from which learners would obtain information while overlooking the fact that the patient is a âpersonâ who would appreciate being âheardâ: âOpenness to questions. Cause that would be for any student in pharmacy or not like how their therapeutic rapport is, that's something I could comment on. If they're open to questions not just trying to get through an interview or whatever, but making sure to really connect with the person, listening. Cause I've been there myself too. I'm sure when you have students and they have an assessment or list of questions and they kind of push through without checking in, or sort of allowing conversation to move a bit and you feel like you're just answering questions and they're just there to get the information and go, and they don't really see you as a person, but that's not relevant to what they're doing.â (Patient 4) Similarly, Patient 9 expressed their ability to recognize whether the learner was paying attention to the patientâs words which, according to the patient, would be reflected in the learnerâs response: âI think probably the most important thing was the ability to not only listen but hear and be responsive that way. I guess what I'm trying to say is being more personable and rather than just, okay, well I know this and, you know being.â (Patient 9) Being validated and having the learner respect the patientâs lived experience with their medical conditions and how this would contribute to the patientâs understanding and knowledge about their own disease was what Patient 10 thought they were capable of discerning and subsequently assessing when being provided with care by a pharmacy learner. In the narrative below, Patient 10 expressed their perspective reflecting on a previous interaction they had with a pharmacy learner: âOh, Arwa, [the learner] was very respectful. And that's really important. Here's a side comment, as a myeloma patient, sometimes doctors and health care professionals, not all, sometimes people dismiss you 76 because it's a terminal disease. And I work very hard to take good care of myself and I want to be treated as if I'm a regular person, not a person with a disease. So, [the learner] was very good with me. I didn't feel at any time when I was speaking that [the learner] was dismissing me. [The learner] was respectful, listened to my questions.â (Patient 10) 4.3.1.3 Subtheme #1.3 - Pharmacy Learners as Patient-Centred Communicators Pharmacy learners are trained to avoid using pharmacy acronyms and medical jargon when providing care to the general public. Learners are also expected to be able to shift between clinical and lay language according to the circumstances they are in and the people they interact with. Another aspect of pharmacy learner care that some patients expressed they would be able to assess when communicating with a pharmacy learner was the learnerâs means of communicating with the patient which would be reflected in the learnerâs expressions and conveying of information to the patient. According to some patients, such aspect would be presented in the learnerâs use of lay language while avoiding sophisticated medical jargon that might seem confusing or overwhelming to the patient. Even though not explicitly expressed in patientsâ narratives, communicating with patients in a language they are able to comprehend indeed goes in tandem with the concept of patient-centred care. In this subtheme, I was able to map the patientsâ narratives within the pharmacist patient care responsibilities, âCare Providerâ, âCommunicatorâ, âCollaboratorâ, and âProfessionalâ Educational Outcomes, as outlined by the AFPC even though patients did not consistently refer to the specific Educational Outcome by its name (see Appendices D-1, D-2, D-3, and D-5). Some patient participants mentioned they would be able to generally pick up on the learnerâs language skills and their use of patient-friendly terms. Patient 6 felt they could comment on how the learner paraphrased their words to align with the patientâs understanding: 77 âThe way they come around to getting answers to their questions, just the way you are doing in rewording catching something because I realize every patient's level of understanding is different.â (Patient 6) Patient 6 elaborated that assessing the patientâs knowledge base and accessibility needs through having a dialogue with the patient and tailoring the learnerâs communication accordingly was another aspect they would be able to appreciate and subsequently provide feedback on: âWell, just through conversation, if you have time to have a short conversation, you can get a sense of what people's knowledge base is. And then from that you can tailor the way you describe things to them maybe they are hard of hearing or maybe have a short attention span or a low IQ. I think every person has to be treated differently.â (Patient 6) Moreover, for Patient 8, it was not only about the pharmacy learner conducting a thorough assessment to get a full picture of the patientâs condition and address an aspect of care the patient might have missed to share, but it was also about the learnerâs comfort level in asking those questions: âThat the students would ask questions, that they would feel comfortable being able to ask questions. I don't know if they're necessarily in the situation of being able to give advice or to speak in front of the patient. But that they would ask leading questions that might help in the understanding of the patient's situation where their current health situation is, where they are emotionally and mentally, where they're physically particularly during COVID. I think that it's critical because so many people maybe that are immunocompromised or people that have health conditions in which they need to stay clear or separate from others that are out in the community, they might be isolated. So, I think that it's a real positive right now to have the interaction and that I quite enjoy that because often sometimes when you have somebody coming from a different point of view, it might tweak something that you might have forgotten to write down.â (Patient 8) 78 4.3.2 Theme #2 - Intrinsic Aspects of Pharmacy Learner Care In this theme, patients acknowledged their roles as followers of pharmacy care and advice provided by learners, and this was in turn reflected in their narratives on their contribution to pharmacy learner assessment. Formal pharmacy skills and intrinsic roles of pharmacy learners were what many patients felt they could talk about [within some limits]. Patientsâ recognition of formal pharmacy skills included knowledge base that pertained to discussing with the patient the indications, efficacy, side effects, and drug interactions, proposing options for the patient to choose from, or deprescribing medications that no longer serve a purpose in the patientâs care plan. Such narratives highlight and reinforce the notion of patient-centredness as something patients would be able to observe and assess, even if patients would not necessarily be able to explicitly characterize that the learnerâs skill aligned with patient-centred care. Comparatively, some patients expressed their ability to observe and comment on the learnerâs appreciation of their knowledge limits and how the learner would seek assistance when needed instead of providing patient with misinformation. 4.3.2.1 Subtheme #2.1 - Pharmacy Learners as Patient-Centred Medication Therapy Experts Patients rely primarily on their pharmacist to provide evidence-based medication information to support them in making informed decisions about their therapy. Consequently, patients are placed in a unique position to attest to pharmacy learnerâs skills in providing them with the guidance to consider all available treatment options. In this subtheme, I was able to map the patientsâ narratives within the pharmacist patient care responsibilities, âCare Providerâ, âCommunicatorâ, âScholarâ, and âProfessionalâ Educational Outcomes, as outlined by the AFPC 79 (see Appendices D-1, D-2, D-4, and D-5) even though patients did not consistently refer to the specific Educational Outcome by its name. The above concept is reinforced by Patient 10âs response when asked about the pharmacy learnerâs skills they could provide feedback on. The patient reflected on an interaction they had with a pharmacy learner, and how they were able to recognize the research the learner did on their particular medical condition to address the patientâs questions about the different treatment options they could choose from: âSo, [the learner] was, I think did a lot of research on what my specific issues were, and that had to do with bone medication. So, multiple myeloma affects the bones, and I was asking, I really wanted to know what the right course would be, which medication should I go with given my own personal situation. And I think in [the learnerâs] case, [the learner] had to do the research and had done research.â (Patient 10) Patient 6 felt they would not only able to comment on the fact that the pharmacy learner provided them with a thorough description regarding their medications but also whether the learner was considerate of the patientâs specific circumstances and provided their options relative to the patientâs factors such as financial burden: âSay, for example, discussing a type of medication and maybe giving you an option of a different one that has different side effects and also being respectful of the cost of the medications. There are different medications that do the same things at different costs, for sure. Kind of give you the pros and cons.â (Patient 6) Even though the patient did not refer to it as such, but Patient 6âs observation would fall within the pharmacy learner practicing patient-centred care which takes into consideration the patientâs circumstances, preferences, values, and needs. Patient 8âs perspective of the pharmacy learner skills they would recognize was very specific and exclusive to pharmacist medication therapy knowledge which encompassed, according to the 80 patient, the learnerâs unique expertise in drug interactions as compared to physicians. In addition, Patient 8âs narrative implied a patient-centred care approach where the patientâs firsthand knowledge with their medications and medical conditions would complement the scientific knowledge of the learner to help guide the learner during the patient care process specifically with medication choice and side effects: âI'm always really interested in drug interactions. I know that physicians arenât necessarily well versed in knowledge about medications, maybe the cause and effects of how they help in certain situations and certain health conditions and the drug interactions. And in that situation, I've always even referred my own patients to the pharmacist to ask those specific questions. So, that's always really important to me. I definitely think that whether have training within the school of pharmacology of having the one-on-one with a patient. And being able, I don't know necessarily if I would be incorrect in saying patient led but being able to recognize what the patient is trying to communicate to the pharmacist but I think it's important because, if you're not aware of all the health conditions of the individual or you're able to mitigate the cause and effect of some medicationsâ side effects, that somebody might be taking a drug that they don't necessarily need or might be the wrong one because it interacts.â (Patient 8) An intriguing perspective that was brought up by Patient 9 affirmed what was shared earlier by Patient 8 about the patientâs experiential knowledge. Here Patient 9 argued their position and credibility in assessing the learnerâs knowledge base since the patient had a lived experience with their medications and diseases that should be acknowledged rather than dismissed by the pharmacy learner and were also proactive in their care by doing their own research: âMostly my own experience. When you experience something firsthand for yourself, you know what you're feeling, you know what issues you're dealing with. I have had a couple of doctors tell me about, certainly with my headaches, that about migraines and telling me wrong information that I had known for years and years 81 that is true and they're telling me something that's not true, you know kind of thing, so it's basically based on my own experience, but also my own research because I do like to research a lot of different things and I do go to places like medical journals and like PubMed and even government websites to find information.â (Patient 9) For Patient 3, their testament of pharmacy learner knowledge was not exclusive to the learnerâs medication therapy expertise, and how they explained or proposed multiple drug options for the patient to choose from. It also involved the pharmacy learner offering non-drug related recommendations that would help the patient manage their medical condition: âGiving some suggestions. And on the other hand, about the treatment, not only with the medication as a kind of treatment modality, what we can take. So, that is other learning curve for me to explain other ways. For example, for me, I have headache. Just telling there are the things that you can maintain a diary or go for a walk, like kind of extra, other than the medication thing. So, [the learner] was giving me more way of treatment that how to manage the headache. So, even though [the learner] was a student, [the learner] was very knowledgeable, was explaining to me, explaining all about the medication and the other non-pharmacological explanation and moreover the people always accept the person by explaining each and everything by talking and in a good way of representing the things that for the patient will all help.â (Patient 3) On the other hand, Patient 4 was open about the limitations of their role in assessing pharmacy learner knowledge. According to the patient participant, commenting on the learnerâs knowledge was limited to the patientâs understanding of what the learner said rather than the content of the information provided or whether it was right or wrong: 82 âIn terms of knowledge, obviously that wouldn't be my area. Some stuff I just wouldn't be able to know if they gave me a good, comprehensive answer. I mean, I could maybe tell them like what I'd understood them to say, but I couldn't comment on the accuracy or the knowledge necessarily.â (Patient 4) 4.3.2.2 Subtheme #2.2 - Pharmacy Learners Acknowledging Their Capabilities Evident in many patientsâ responses presented above was how the patient would be able to assess multiple facets of pharmacy learnerâs knowledge. In addition, some patient participants mentioned they could provide feedback on how the learner acknowledged their competencies and capabilities, overcoming their ego, and consulting their supervisor when they lacked knowledge about a certain topic. In this subtheme, I was able to map the patientsâ narratives within the pharmacist patient care responsibilities, âProfessionalâ Educational Outcome, as outlined by the AFPC even though patients did not consistently refer to the specific Educational Outcome by its name (see Appendix D-5). For some patient participants, a learner recognizing their knowledge limits was an act of professionalism and integrity. The patients mentioned they would be able to observe whether the learner sought assistance when needed rather than providing the patient with nonsense information Specifically, Patient 7 described their perspective as an act of professionalism from the learner in order to serve the patientâs best outcomes and needs: âI'm just thinking back to the experience that I had, I think that involving the supervisor when there is some degree of uncertainty that this pharmacy student is not totally competent or confident about saying or recommending. I think that professionalism takes many forms, but certainly with a student, it's a question of knowing what you don't know. And, not having the ego that stands in the way of the best care for the patient but the ability to say this is what I think, what do you think to the supervisor?â (Patient 7) 83 Table 4-1 Patient Participantsâ Characteristics Characteristics n =10 (%) Age, in years Range 40-73 (Mean=66) Gender Male 1 (10%) Female 9 (90%) Number of chronic medical conditions (Range) 1-5 2 (20%) 6-10 11-15 7 (70%) 1 (10%) Receiving five medications or more (polypharmacy) Participants with a health care professional background/training Nursing Allied health care professional Medical assistant 10 (100%) 4 (40%) 2 (20%) 1 (10%) 1 (10%) 84 Figure 4-1 Thematic Map of Identified Themes and Corresponding Subthemes of Patientsâ PerspectivesSubtheme #2.1 Pharmacy learners as patient-centred medication therapy experts Subtheme #2.2 Pharmacy learners acknowledging their capabilities Subtheme #1.1 Atmosphere of the patient-learner encounter Subtheme #1.2 Pharmacy learners recognizing patientâs humanity Subtheme #1.3 Pharmacy learners as patient-centred communicators 85 Chapter 5: Pharmacy Learnersâ Perspectives on Patient Involvement in Pharmacy Learner Skill Assessment 5.1 Chapter Overview The study findings reported in this chapter represent the learner perspective on addressing research question number 2, âWhat skills, demonstrated by pharmacy learners during patient interactions, are patients capable of assessing?â As described in Chapter 3:, Section 3.7, data were collected by interviewing learners who received supervised training at The UBC Pharmacists Clinic. All interviews were conducted virtually via phone or Zoomâ¢ calls because of COVID-19 restrictions halting all in-person interactions. 5.2 Learner Participants Altogether, I interviewed ten pharmacy learners who characteristics are summarized in Table 5-1. Learner interviews lasted on average 65 minutes and were all conducted virtually, mostly via Zoomâ¢ platform (8 interviews) or phone calls (2 interviews). All participating pharmacy learners were in their fourth year of the PharmD program except for one pharmacy learner who was completing their post-baccalaureate PharmD degree. 90% of learners were involved in non-direct patient care at the UBC Pharmacists Clinic which included administrative work, shadowing pharmacists during patient appointments, research and policy development, immunization, or health promotion/community outreach (health clinics) (see Chapter 3, Section 3.7.1 for details of learner participantsâ inclusion criteria). When interpreting and considering the transferability of the findings presented in this chapter, it is important to acknowledge that most learners who participated in this study despite 86 being recruited from the UBC Pharmacists Clinic, spent the biggest portion of their in-person pharmacy training in a community pharmacy practice setting during their Entry-to-Practice Doctor of Pharmacy rotations/experiential training courses (16 weeks or more) and/or working as pharmacy assistants. Therefore, when asked about their perspectives on pharmacy learner skills patients would be able to observe and consequently assess, learners were compelled to draw upon their experiences from settings other than the Clinic, predominantly caring for patients in a community pharmacy. Typically, pharmacy learners who receive direct patient care training at The UBC Pharmacists Clinic would provide pharmacy care while having in-person supervised patient encounters. However, due to the constraints dictated by COVID-19 pandemic, all in-person patient-learner interactions were disrupted and shifted to virtual care via telephone calls or telehealth as discussed in Chapter 3:, Section 3.8. Randomized participant numbers (i.e., Learner 1, Learner 2) are used to categorize the narratives and emphasize the diversity of perspectives (Manio, 2018). The conventions some (defined as 1 to 3 participants), many (4 to 7 participants) and most (8 to 10 participants) are used to indicate the weight of consensus within separate findings presented within the themes below (Manio, 2018). 5.3 Overarching Themes Findings associated with each theme are based on framework- and data-driven coding and presented as a hybrid of concepts that were either mapped within the 2010 and 2017 AFPC competency-based frameworks and/or unmappable concepts which were tagged for coding outside the AFPC framework. Learner participants shared their perspectives and views on pharmacy learner skills they believed that patients could assess which was rooted within the aspects of care the 87 patients receive from the pharmacy learner. On many occasions, learners specifically referred to a certain AFPC Educational Outcome by reflecting on the 2017 AFPC Educational Outcomes table that was shared with them during the virtual interview as I discussed in Chapter 3, Section 3.7.3.2. Subsequently, when discussing with learners several pharmacy learner skills that patients could observe and assess, I could indeed map pharmacy learnersâ narratives to specific 2010 and 2017 AFPC Educational Outcomes, even when learners did not consistently refer to the specific Educational Outcome by its AFPC-labelled name. I also indicate when these learner perspectives did blueprint back to stated APFC Educational Outcomes as key or enabling pharmacy learner skill (see Appendices E-1 - E-6). I was able to read the learner responses and inductively derive findings into themes regarding what prevailed within and across learner interviews. The following two themes and five subthemes were constructed: § Theme #1 Intrinsic aspects of pharmacy learner care â¢ Subtheme #1.1 Pharmacy learners as medication therapy experts â¢ Subtheme #1.2 Pharmacy learners as patient-centred team players â¢ Subtheme #1.3 Pharmacy learners providing exemplary patient care â¢ Subtheme #1.4 Professionalism is a âstate of mindâ § Theme #2 Humanistic aspects of pharmacy learner care â¢ Subtheme #2.1 Pharmacy learners as patient-centred communicators The humanistic aspects of pharmacy learner care describe the skills that pertain to the learnerâs identity as a human being engaging in an interaction with another human (patient) aside from the learnerâs identity as a health professional in training. The humanistic aspects of care predominantly relate to the learnerâs communication skills which include the learner introducing 88 themselves, establishing rapport, actively listening, showing empathy, and using simple language. In other health care disciplines, such as medicine, scholars refer to these humanistic skills as ânon-technicalâ (Moreau et al., 2016). On the other hand, the intrinsic aspects of pharmacy learner care refer to the learnerâs inherent formal pharmacy skills which they acquire through education and training, such as knowledge and professionalism, and which plays an integral role in shaping their identity as pharmacy professionals in training (see Figure 5-1 for a thematic map of identified themes and corresponding subthemes of learnersâ perspectives). In addition, the last part of this chapter illustrates some of the perspectives proposed by learner participants in response to the question âHow do you think the feedback that you receive from patients compare to the feedback, either formal or informal, that you received from other sources?â In their narratives, the learners highlighted the importance and value of patient feedback in addition to comparing and contrasting the key differences between the feedback they receive from patients versus their preceptors. These findings are organized into two overarching themes, Theme #1 Patient feedback is humanistic and perceptive, preceptor feedback is evaluative and instructive and Theme #2 Patient feedback is not only valuable, but also legitimate. The following sections explain the findings related with each theme, with illustrative excerpts added to contextualize the learner participantsâ viewpoints and perspectives. 5.3.1 Theme #1 - Intrinsic Aspects of Pharmacy Learner Care Reflecting on their interactions with patients, many pharmacy learners believed that patients would be able to assess their integral and intrinsic role as pharmacy professionals in training. The learnersâ perceptions of this role entailed several formal pharmacy skills 1) medication therapy experts 89 providing evidence-based information; 2) collaborating with the patient and other members of the health care team; 3) optimizing the patientâs health; and 4) acting professional. 5.3.1.1 Subtheme #1.1 - Pharmacy Learners as Medication Therapy Experts In this subtheme, many pharmacy learners perceived that patient could comment on the intrinsic aspects of pharmacy care which, according to the learners, implied three core formal skills of the discipline of pharmacy 1) knowledge base; 2) patient education; and 3) evidence-based pharmacy practice. When discussing these formal pharmacy skills as something patients could observe and assess, I was able to map the learnersâ narratives within the pharmacist patient care responsibilities, âCare Providerâ and âScholarâ Educational Outcomes, as outlined by the AFPC even though learners did not consistently refer to the specific Educational Outcome by its name (see Appendices E-1 and E-5). Knowledge base was an intrinsic pharmacy skill pertaining to the medication therapy expert role of pharmacists that learners thought patients could provide feedback on. Specifically, some learners used a broad term as âknowledgeableâ, without going into specifics, associating the learnerâs knowledge base with establishing a trusting relationship with the patient. Learner 1 described: âPatients are able to figure out if you know what you're talking about. If you're knowledgeable, if you're feeling comfortable sharing information, they can pick up on that right away. And I think this is one of the most basic things being knowledgeable about your field and if patients think that their care provider is not knowledgeable, they're not going to trust anything.â (Learner 1) Nevertheless, according to other pharmacy learners, patients assessing their knowledge base was situational and was not about the âcontentâ of the knowledge itself. It was more about how the knowledge or information was conveyed and communicated to the patient. As Learner 1 followed 90 up on their earlier comment, âIt's, it's how you say it. Itâs how you communicate it,â referring to a learnerâs knowledge base. Such intriguing perspective was brought up in subsequent interviews with other pharmacy learners. I specifically asked learners of the factors they thought would contribute to patientâs capability of assessing a learnerâs knowledge base and educator role. Among the patient-related factors voiced by many learners were the patientâs: 1) health literacy; 2) educational level; 3) occupation (inside or outside health care); 4) number of years taking medications and/or living with medical conditions; 5) inherent motivational level and desire to educate themselves and do their own research; 6) lived experience with their medication conditions and medications; and 7) awareness about the pharmacist role and scope of practice As Learner 4 described: âScholar's definitely something that patients, well, I guess it really depends on like their knowledge level, but they're able to, I guess patients might not know if it's right or wrong, but they're able to kind of deduce if they asked a question, did the pharmacist have an answer to it or did they have to go away and look that up and provide information later. Like, were they knowledgeable enough to provide that evidence and that information to them at that time?â (Learner 4) Since patients seek pharmacy care primarily for pharmacist medication expertise, pharmacy learners are expected to educate patients on medications. Learners believed patients could attest to the educational aspect of the encounter and learnersâ role as âteachersâ about medicines. According to learners, patients could determine whether they were offered adequate explanations about their drug therapy regimen/s. Such explanations include any changes that were made by their doctors instead of being dismissed while clueless about their care plan. This perspective goes in tandem with the notion of patient-centred care by having the patients fully informed about their therapy and pharmacy learners proactively attending to patientsâ questions and/or concerns. 91 Learner 6 described and justified their perspective on patients assessing the learnerâs âeducatorâ role: âCommunicating what we need the patient to know just so they're taking the medication safely. It's just like part of it. And then patients come, and they ask questions. We're the most accessible health care provider. And they come to us for any small questions.â (Learner 6) However, similar to some learnersâ perspectives on patients assessing their knowledge base skill as discussed above, having patients provide feedback on the pharmacy learnerâs educational role is restricted, according to some learners. Some learners argued that patients would be capable of assessing the absence or presence of the educational information they were provided with rather than the accuracy or appropriateness of the âcontentâ of the information. According to these learners, it was only legitimate to assume that patients could provide feedback on the pharmacy learnerâs teaching skills and their ability to convey the medication-related information. Nevertheless, whether the information provided was right or wrong was something patients might not be able to assess, according to some learners. Learners justified that the patient education aspect of the encounter is niche and very specific to being a pharmacist that sometimes it is even difficult for fellow pharmacists to comment on. As Learner 9 argued: âScholar is very difficult because it's very specialized. Itâs hard for pharmacists to do that too. Itâs hard for a healthcare professional in general to. I guess the point SC4: teach other pharmacy team members and healthcare professionals, you could assess a person's ability to teach. Technically, you don't need a pharmacy degree to do that. In fact, a lot of people without pharmacy degrees can do that better. So, there's a role there, but I think it' one of those things that's very specific, your ability to determine a drug therapy problem is very specific to being a pharmacist.â (Learner 9) 92 The third skill embedded within the medication therapy expert role and which, according to learners, patients could appreciate and assess was pharmacy learners as evidence-based practitioners. This skill was also intertwined with pharmacy learners as âeducatorsâ where learners would apply evidence to support the information provided to patients. Some learners believed that patients could tell if the learner backed up their recommendations with the most up-to-date evidence. Typically, patients seek pharmacy care when they have questions, sometimes relating to a newly introduced medication, vaccination, or a controversial dietary/herbal supplement they saw on TV or came across on a social media platform. Therefore, pharmacy learners need to be aware of the most recently available evidence, so they are able to attend to patient needs. Learner 6 commented: âMaybe scholar, they can see. Maybe they do see us as like a little bit of a scholar, just because sometimes they do see students in pharmacies and they see preceptors, pharmacists, preceptors helping us and teaching us their expertise and their knowledge. Times when we counsel, we also talk about there's not much evidence based on this, not much evidence based on that, or just giving a lot of knowledge to them. So, I guess for me, a scholar kind of overlaps with being a health advocate maybe that one is observable by patients.â (Learner 6) Moreover, Learner 10 reminded us of what patients could observe hence comment on when it came to pharmacy learners being practice-based practitioners addressing patientsâ controversial questions: âIf you're using resources and using evidence, then that scholar aspect of it, they can definitely I guess communicate that you're applying evidence, when they ask for vitamins and stuff, sometimes a lot of the times they think something works, but the evidence shows it doesn't actually work. So, just making them aware 93 that the most up-to-date evidence might not necessarily support the social media whatever social media might be saying. So, deconstructing myths and stuff.â (Learner 10) 5.3.1.2 Subtheme #1.2 - Pharmacy Learners as Patient-Centred Team Players Collaborative care provision was another skill that most learners thought patients would be able to recognize and give feedback on. Such skill also pertained to the notion of âpatient-centrednessâ and âinter- and intra-professional collaborationâ. On most occasions, learners explicitly referred to the AFPC Educational Outcome âCollaboratorâ when discussing this skill (see Appendix E-3). However, even though it was implicitly stated, other learnersâ responses were rooted within some aspects of the âCare Providerâ and âProfessionalâ Educational Outcomes (see Appendices E-1 and E-6). Some pharmacy learners agreed that patients could witness and in turn provide an insight on the âteam playerâ role of the learner, if the learner was working in partnership with other health care providers such as physicians, nurses, or fellow pharmacists. Learner 5 offered this example: âI think actually patients can definitely assess how you conduct yourself within the health care team. So, they can maybe make some sort of judgment on how myself as a pharmacy learner communicates with their nurse my preceptor, pharmacist, or the physician, that's an aspect of professionalism as well that patients can assess you on. I think patients can assess to a certain degree; patients can provide feedback on that. So, whether I can give you specific examples, maybe a patient can comment on how you are able to loop their family physician, fax the physician or call the physician to provide information on this or they might be able to possibly observe how you interact within the hospital, how you interact with the pharmacist or how you interact with the nurse. They can assess on those aspects. So, it's more of the communication part.â (Learner 5) 94 Evident in Learner 5âs narrative is how they intertwined collaboration, communication and professionalism as foundational aspects of patient care. Here the learner described how patients could comment on the pharmacy learnerâs collaborative role as they observe them communicate and interact professionally with the learnerâs preceptor, fellow pharmacists, and the patientâs other health care providers. Learner 10 also shared their justification of why they thought patients would be positioned to assess the learnerâs collaborator role. The learner reflected on their medication expert role as the bridge between the patient and their physician: âWeâre a lot of the times being that bridging person between their doctor and them so whether that's updating them on any dose changes on any medication changes, brand changes, formulation changes, that kind of thing. I think they'll also see whether, I guess as a collaborator, like it says be able to hand over the care to another pharmacy team member when appropriate. So, they definitely can witness and observe that you know this person is able to acknowledge if they don't know something as much as they would like to. So, they're comfortable in handing or asking their senior or another team member, like they're not too shy to do that or too stubborn to do that. So, I think they can definitely observe that and provide feedback on that.â (Learner 10) Another thought-provoking perspective offered by Learner 10 above when discussing patientâs involvement in assessing the âteam playerâ skill of learners was how patients could observe the channeling of work between members of the pharmacy team. According to Learner 10âs narrative, collaboration here goes beyond working together with another team member. Here it invokes an impression on patients that the learner was able to acknowledge the boundaries of their capabilities and seek support when needed through what is known as âintraprofessional collaborationâ. 95 Correspondingly, Learner 3 believed that if patients saw the learner as someone working together with them, they would be under the impression that that learner will likely collaborate with the patientâs health care providers. The learnerâs perspectives inferred the notion âonce a collaborator, always a collaboratorâ: âIf you're collaborating with them, their family, they might be able to get a sense of whether you've been collaborating with their other health care providers, their physicians, other members of their team.â (Learner 3) For some learners, working collaboratively was not exclusive to working together with the other members of the patientâs care team also known as âinterprofessional collaborationâ, but also involving the patient by having them at the centre of the care process. In their responses, the learners described the synergistic nature of the patient-learner relationship and how collaborating with patients was for the patientâs own benefit as someone with firsthand experience with their medications: âI think that means like patient-centred care. So, ensuring that it's not you, who is making the decision that you and the patient are making the decision about their health. So, coming together with them, giving them a bunch of options, giving them various alternatives in terms of whether that be drug or non-drug therapy, and then posing these to them, presenting them to them, and then allowing them to ask questions to you and make a decision together.â (Learner 4) âInvolving them in your decision making, so for example, I have some sort of therapeutic recommendation that I have in my mind which I think is evidence-based, it meets the guideline recommendations. But then at the end of the day, it's the patient that's going to be taking this medication, itâs the patient that's going to be 96 incurring the costs and the practical side of things. They have to remember to take of medication. So, always trying to involve the patient in the decision-making is my number one thing.â (Learner 5) Many learners believed that patients would be able to assess whether they felt included in the decision-making process which, according to learners, meant providing patients with an opportunity to share their thoughts, preferences, and expectations rather than having their opinion discounted and/or dismissed. When asked about their perspective of pharmacy learner skills patients could observe and provide feedback on, Learner 3 clearly referred to collaborating with patients as a âpatient-centredâ encounter acknowledging that patients might not necessarily label it as such: âIf they think it was patient centred. I don't know if they would specifically know what that term is, but if they felt like they were part of a discussion and they felt involved in their care. I think that that's something they could tell you about because it's almost in this subway a feeling, did they feel involved or not? So, working effectively with the patient. I think the patient could tell you if they think that the pharmacist was working effectively with them.â (Learner 3) Even though not explicitly mentioned but affirmed here was that patients could directly discern if the concept of paternalistic care provision was abandoned and instead a two-way conversation with the patient was invited. Here the learner emphasized the patientâs role in recognizing whether they felt included in their care and invited to take part in making decisions about their health. Another learner overtly responded describing how they understood working together with patients being the cornerstone of patient-centred care: âBut from a patient centred care perspective, I mean, that's kind of with communication and being able to loop the information, loop the patient into the decision making. I think that is something that patients can 97 definitely assess because they're the ones that are receiving it. They can like tell you, I felt like I was included in that decision, or I felt like I was heard, they can provide those kinds of feedbackâ (Learner 5) 5.3.1.3 Subtheme #1.3 - Pharmacy Learners Providing Exemplary Patient Care According to most learners, patients would be able to recognize and comment on the efforts the learner exerted as they implemented their formal pharmacy skills to advance and optimize the patientâs health, in what learners understood and referred to as health advocacy. In this subtheme, I was able to map learnersâ responses within the âhealth advocateâ and âscholarâ Educational Outcomes outlined by the AFPC (see Appendices E-4 and E-5). Some learners expressed how patients could recognize the learnerâs responsibility as a health advocate. Based on the learnersâ understanding of this role, advocating for the patient meant attending to the patientâs individual needs, which implicitly implied patient-centred care provision. The learner believed patients would be capable of assessing the learnerâs health advocate role which would be embedded in the intrinsic responsibility of pharmacy learners as medication experts. Specifically, Learner 4 briefly described situations where the learner would demonstrate health advocacy in their encounter with the patient. Those situations involved the learner communicating, on the patientâs behalf, with the other health care providers to serve the patientâs medication-related needs: âI definitely think health advocate is something that patients can also provide feedback about. I think it's very clear and very visible when a pharmacist is advocating for someone else's health, when they tell them they're going to go speak to the prescriber about changing it or speak to the doctor about renewing the prescription. I think it can be very clear to patients when your health care provider is advocating for you.â (Learner 4) 98 Learner 6 also thought that having patients comment on their role as a health advocate would be an observable task for patients owing to the nature of work and type of patient care pharmacy learners are involved in. According to Learner 6, exhausting all available resources to optimize patient health was something entrenched in their training and professional background as pharmacy professionals which would in turn enable patients to recognize and assess: âI think health advocate is definitely one. I was reading the thing here, so I guess it says pharmacy graduates demonstrate care for individual patients. And I think this is just very evident in what we do, that we are caring for patients and we're just trying to help them achieve like the most optimal health. And everything we do is to make sure that they're healthy. This is our entire job is to advocate for their health and doing med reviews, doing flu shots, doing counseling. It's all just to advocate for their health. And then having health, heart health clinics, having diabetes clinics, all the posters.â (Learner 6) Other learners conceptualized health advocacy as something they would willingly do beyond their âexpectedâ pharmacist roles and without having the patient anticipate or request it. These learners believed patients would be able to pick up on the learnerâs unsolicited efforts in attending to patientâs needs, As Learner 10 responded: âI think they can definitely look at the health advocate part of it. So, a lot of the times, we can give them advice beyond just their medication, whether that's non-pharm, whether that's lifestyle interventions, whether that's their dietary, habits, so they can give feedback on whether you're going above and beyond other than just the medication listed on the prescription and you're giving them advice beyond just that, so they can give you feedback on whether they feel like you really took the time out to actually go above and beyond what they were just there for.â (Learner 10) 99 For Learner 9, it was particularly patients belonging to minority groups based on race, gender, or medical conditions, who would be well-positioned to assess if health advocacy occurred or not and whether the learner advocated on the patientâs behalf: âHealth advocate, I guess, technically anybody, I guess patients could do health advocate because for example, I guess I'm just thinking about transgender people because it's related to my research, but also just the smoking cessation, anyone that's a smoker could be, hey, you could help advocate for tobacco cessation. Anybody who is transgender could be, hey, you know, this person did a good job of advocating for the fact that our population may have higher rates of HIV or other conditions, for example, you could say even from the perspective of being minorities of race and stuff like that too, minority has like higher rate of this and, so you're advocating for that.â (Learner 9) 5.3.1.4 Subtheme #1.4 - Professionalism Is a âState of Mindâ Demonstrating professionalism through exhibiting a professional demeanour, ethically practicing pharmacy care, and maintaining a sense of integrity reflected in the learnersâ attitude was another skill many learners believed patients could recognize and provide feedback on. Learners thought that patients looked up to pharmacy learners as professional health care practitioners demonstrating professionalism through behaving according to high ethical standards. The overarching AFPC Educational Outcome here, as explicitly prevailing in learnersâ responses, was âprofessionalâ (see Appendix E-6). Commenting on observable and easy to spot aspects of professionalism such as the learnerâs professional presentation which would be demonstrated through the learnerâs dress code and hygiene were what Learner 5 felt patients could do: 100 âMaybe your presentation, in terms of your dress code and how you kind of present yourself, are your hair and nails, your hygiene and aesthetics are professional looking.â (Learner 5) For other pharmacy learners, professionalism extended beyond how the learner chose to dress. Displaying a professional attitude and an ethical behaviour when interacting with patients was embedded in their training as future health care professionals which, according to those learners, would make it effortless for patients to recognize and provide feedback on. Learner 6 described professionalism, through the patientâs eyes, as a multifaceted observable skill which, according to the learner, involved respect, trustworthiness, and high standards of ethical practice demonstrated by the pharmacy learner during their patient encounters: âI think maybe professional, that's definitely something they can observe. I guess most people, from my understanding, they view pharmacists as a respected professional and trustworthy and we practice based off of high standards and regulations and we're ethical and that's definitely something that they can observe in what we do like observable, meaning like they can see it they can experience it. So, the professional, just from the way that we act and the way that we communicate, they see us in the pharmacy doing what we do. They see us in like white coats. And there has to be some sort of trust there because they know that we are professionals for them to come to us. That's why for me, it's something that's very observable that we are professionals.â (Learner 6) Learner 6 elaborated on their perspective by sharing how they viewed professionalism as a pharmacy learner and how it was more than the apparent visible aspects of care such as a learner wearing their white coat. Professionalism, as defined by Learner 6, meant holding the learner accountable of their actions in what Learner 6 labelled as âprofessional integrityâ: âLike personally, I feel like being professional is not just the very superficial, like being on time, like dressing professional and like sneaking in professional terms, it's more like integrity thing. That I expect people to 101 kind of own up, you know, it's not just doing these superficial things to seem oh, I'm a professional and I'm wearing a white coat. It's if I make a mistake, in the pharmacy, I'm going to own up to my mistakes quickly and let people know. I think that's for me being very professional in what you do and having that professional integrity.â (Learner 6) When asked about their thoughts of what pharmacy learner skills patients would be able to observe and comment on, Learner 1 also interconnected the term âethicalâ with a professional pharmacy learner. The learner then provided a description of how patients could pick up on the fact if they are interacting with a professional pharmacy learner through their communication style. It is also important to note that the learnerâs narrative is contextual since they were specifically referring to patient care within the community pharmacy setting where patients expect to be provided with a positive service: âAre they ethical? So, this will fall in their profession as well. Be able to say someone is professional or not, by the way they communicate by the way, they themselves look by the service that they're getting. Community pharmacy is very much retail. It's very much customer service as well. So, are they getting good customer service or are they feeling they're being taken care of?â (Learner 1) Learner 2 explained the potential impact of a professional pharmacy care on patientâs satisfaction and how the patient would be able to explicitly provide verbal feedback through positive comments as a subtle affirmation to the learner that their professional behaviour was well received by the patient: âAnd the patient walks away satisfied. So, saying simple words, like thanks for doing a great job, you know, like throwing out those little compliments. And I think that is sort of an indirect feedback to the pharmacist that yeah their professionalism was met.â (Learner 2) 102 On the other hand, Learner 9 expected and welcomed receiving feedback from patients regarding professionalism. However, Learner 9 expressed how the patientâs ability to comment on professionalism of the pharmacy learner they interact with was conditional: âProfessional I guess it depends on the patient's expectations and understanding of what is or isn't acceptable practice. So, a pharmacist may ask a piece of information that may be relevant to their assessment and the patient might be like this unprofessional of you because I don't want, you know, itâs a random question, but maybe it is relevant. So, there are challenges there, but I think overall, I would want a patient's feedback of professional, if I'm displaying professionalism or not.â (Learner 9) In their response, Learner 9 provided an explanation for their perspective which, according to the learner, commenting on the specifics of professionalism required a patient who had awareness and understood the pharmacist scope of practice to help them decide what was regarded as a professional encounter. 5.3.2 Theme #2 - Humanistic Aspects of Pharmacy Learner Care Communication is a foundational aspect of any human interaction, and the pharmacy learner-patient encounter is no exception. Communication is also key to an optimal patient-centred pharmacy care and an integral part of pharmacy learnerâs interactions with their team members and the patientâs other health care providers. All ten learners unanimously identified âcommunicationâ as a skill patients would intuitively recognize and assess owing to the nature of interactions the patients have with pharmacy learners. In this theme, the learners shifted their narratives from discussing skills that pertained to their inherent formal roles as pharmacy professionals in training to talk about communication as a multi-dimensional social construct concerning the learner as a human being irrespective of their profession or occupation. 103 5.3.2.1 Subtheme #2.1 - Pharmacy Learners as Patient-Centred Communicators This subtheme encompassed 1) communication style expressed through the learnerâs demeanour; 2) efficacy and efficiency of communication, and 3) communication as a multi-dimensional skill, according to what learners expected patients to observe and assess accordingly. Besides, certain acts of professionalism, as outlined by the AFPC, were conveyed in some of the responses provided by the learners even though the learners did not explicitly label them as professional skills (see Appendix E-6). Learner 6 emphasized the pivotal role communication plays in mediating the delivery of information, which the learner had acquired, to the patient: âCommunicator. I feel like communication is a huge part of what we do. If the communication part was completely removed from the practice of pharmacy, we're basically just pill counters and we're basically not providing much like healthcare towards the patient. It's every part, every step of the way of even just dispensing a medication, requires communication from drop off to pick up, and even in between and it's not just communicating with the patient about what they want and what they need. It's communicating with them about their medical history or their medication history. And if it's not right, it's communicating with their prescriber to see what we can do. And it's also communicating with like our colleagues to make sure the task is done, right. I guess I'm trying to say that without the communication part weâre basically like we are not even pharmacists, that's all we learned in like in our labs, tutorials, our IAs [integration activities], we're just learning how to communicate. And get information across because I think that's what we are as pharmacists. We have so much information that we know, and we're just trying to get it across to the patient.â (Learner 2) Another learner participant added that patients could spontaneously comment on the learnerâs communication irrespective of their professional background. In their response, the learner 104 did not refer to the specifics or the content of what they communicate to the patient rather than the act of communication itself: âCommunicator, because I think we all speak like everybody's goals on that is the same. And technically for communication to be successful, you need two people. So, it's very easy for a second person to be. no, you're not taking this right. Or you're not doing this you should not be doing it because I'm not getting what you're saying. That's very, I think very straightforward for them, for anyone who doesn't have a healthcare background to look at that and clearly assess.â (Learner 9) In particular, Learner 4 referred to the specifics of the pharmacy learner communicator role that patients would be capable of observing and assessing. Learner 4 felt that owing to the patientâs experience in interacting with a pharmacy learner, they could talk about the learnerâs use of language while they communicate with the patient: âThose are definitely things that you're able to just see and experience with the pharmacist and between pharmacist and patient directly within an interaction. So, communicator, you'll see that patients can provide feedback on the types of language they were using, if they were effective at communicating.â (Learner 4) Additionally, Learner 2 provided other examples on the specific aspects of communication that patients could appreciate and consequently comment on such as the pharmacy learnerâs demeanour such as empathy and assertiveness. According to Learner 2, patients could provide feedback on the learnerâs demeanour and communication style and would expect the learner to improve accordingly: âI think the communication is the biggest one. Just because patients observe, as you've mentioned the question and they can pick up on things. For example, the style of the communication. Some pharmacists are more assertive than others. Some pharmacists are more compassionate than others. So, I feel if the patient didn't like the style of communication that the pharmacist sort of has, and they can sort of provide feedback on that 105 basis. So, saying for example, oh, you could talk nicer you could talk, oh, for example, for me again, back to my situation where the patient asks me to smile less, right? Yeah. I guess they could be involved that way.â (Learner 2) One the other hand, for Learner 10, it was not only about how they communicate or the ways they interacted with patients, but the learner also believed that patients could pick up on the how the learner would provide an efficient response without wasting the patientâs time. The learner also offered ways on how they could communicate pharmacy care to patients in a timely fashion. According to Learner 10, an efficient learner-patient interaction is established during the information gathering process and achieved through asking the appropriate questions to help address the patientâs issues and/or concerns: âI think they can definitely comment on so for sure, I don't know which one this fits into, but the efficiency of our communications. So, whether weâre, you know, asking them the relevant questions and not using too much of their time, which may be limited, but actually asking them the relevant questions that ultimately lead to a solution to whatever it is they're asking or whatever problem it is that they're presenting. So, in a way, like kind of efficiently solving the problem, as opposed to kind of going in circles and not really getting anything done. So, at the end of the day, they look for whether we can offer them a timely solution of that.â (Learner 10) As discussed earlier, communication is not a stand-alone skill and goes hand-in-hand with other elements of a patient-learner interaction. Given its complexity as a multi-dimensional core skill imperative for all human dealings, some learner participants associated communication with several factors, when commenting on the patient position in assessing the pharmacy learner communicator role. The learners expressed how such factors would support establishing a patient-learner relationship. For instance, Learner 5 expressed how their communicator role was intertwined with 106 exhibiting professionalism when providing patient care. The learner thought that the patient could assess whether the learner demonstrated respect and communicated appropriately which, as perceived by the learner, would be according to the patientâs disposition: âProfessionalism, I think would be like one well, communication, I think is also part of professionalism. So, you know, respectful communication just in the way Iâm speaking that it is appropriate from a patient to their provider point of view.â (Learner 5) Learner 6 also provided an affirmation, even though implicitly, that the communication aspect of their encounter with the patient was interconnected with other aspects of care, in their response it would be collaboration, that patients could observe and subsequently provide feedback on. Learner 6 explained their perspective reflecting on the chain of events that occurred during the patient care process where the learner would be involved in collaborating with their team members and the patientâs other health care providers: âIt's just communicating with them about their medical history or their medication history. And if it's not right, it's communicating with their prescriber to see what we can do. And it's also communicating with our colleagues to make sure the task is done right.â (Learner 6) 5.4 Learner Perspectives on Patient Versus Preceptor Feedback Bringing the preceptor into the patient-learner feedback interface was unplanned yet inevitably took place during my conversations with some of the learner participants owing to the preceptorâs role as a predominant assessor in the learnerâs training experience. The learners identified differentiating points between the feedback they receive from their preceptors versus the feedback they would get from the patients they care for. These points mainly included 1) the focus and content of the feedback; and 2) the learnerâs perception of the feedback. Theme #1 below discusses the focus 107 of the patient versus preceptor feedback whereas Theme #2 describes the learnerâs personal views on the value of the feedback they would receive from the patient as compared to the feedback their preceptors offered. Collectively, learners considered patient feedback as an important supplement, complementing the feedback their preceptors offer. 5.4.1 Theme #1 - Patient Feedback Is Humanistic and Perceptive, Preceptor Feedback Is Evaluative and Instructive Some learner participants pointed out key differences, comparing and contrasting the patient versus preceptor perspectives with respect to the nature, content, and focus of the feedback. According to both learners, patient feedback held an emotional and personal aspect, pertained to the patientâs experience with pharmacy care from a subjective point of view, and mirrored the patientâs feelings during their interaction with the pharmacy learner. On the other hand, both learners thought that since their preceptors held an educator role, they provided feedback from an evaluation standpoint: âI think it might come from a more humanistic, how do I say it? It's coming from more emotional side, if it was just like your peers, your peers usually don't really give good feedback. I think peers just write to write something. I think preceptors usually try to give you really good feedback. They observe you more and they usually talk about, oh, you're professional, the way you communicate and things. But they, sometimes we neglect how patients actually feel. So, then if patients are able to tell you about specific things that they noticed, especially because patients don't have the entire picture of what's going on. So, I think they come from maybe a more subjective point of view.â (Learner 6) âI think the patient themselves would be the ones that would say why they would have a greater appreciation for how they felt after receiving that information. And especially if they're nervous about taking a medication 108 or something and if you helped to make them feel more comfortable, I think that in itself is more important than telling them maybe a side effect that isn't that important or that you could even call them and follow up and just remind them, if you have any other questions, call me. I think that's why the receiving part is a little more important than the delivery or, I mean, they're both important. I think sometimes patients obviously, don't know, exact everything you had a hit on the head to [medication group name] counseling, for example, where a preceptor would I think the expectation of the patient is okay well, I got educated on certain points and I feel good about walking away from this counter.â (Learner 7) Learners 6 and 7 also argued that while patients would focus on the atmosphere and general impressions of their interaction with the learner, their preceptors would pay attention to the specifics of the patient encounter including the content of the care delivered to the patient such as education and knowledge pieces, something that was highlighted several times in this chapter. Learners attributed their perspectives to the assessorâs position arguing that patients being care recipients would have different expectations, priorities, and needs. Comparatively, learners perceived their preceptor whose professional background and expertise as a pharmacist, intention and role as an educator was to observe the logistics and technicalities of the pharmacy learner care delivered to the patient and provide feedback accordingly: âI think it would be different in what they focus on. So, if there was a counseling interaction, for example, I don't think patient would be focused on all the information I was giving. I think they would be more focused on the way I was talking or the way I was smiling at them or how my voice sounded and how I was able to help them and how fast I was. And how much time I was able to help them. But I think my preceptor would kind of think about other things, did I cover, did I collect patient identifying factors? Did I talk about the side effects did I talk about this interaction or how long did I spend here? Did I document this? So, it's more logistical stuff. So, I think what they would comment on would be different topics.â (Learner 6) 109 âSo, I think your preceptor obviously holds experience and knowledge in terms of therapeutics, perhaps. So, if there's feedback in terms of, I think you missed this maybe you need to say this next time. I think the preceptors are a bit more on how you can improve in terms of the things you're educating a patient on. Whereas a patient, their feedback is more of how it was delivered, and received. Oh, sorry actually, I'll say it's more of how it's received, and the preceptor will give you feedback more on how it was delivered. But I think sometimes, preceptors will say, oh, you know, maybe try not to talk to the patient that much. And I'm, well, that's, that's against who I am. So, I'm not doing that. I do think that they have different expectations cause they expect you to make, I think they are the ones who mostly want to see that you're not forgetting an important piece, education and knowledge, of course.â (Learner 7) 5.4.2 Theme #2 - Patient Feedback Is Not Only Valuable, But Also Legitimate While explaining their perspectives on patient and preceptor feedback with respect to its nature and content, some learner participants shared their personal views and perceptions on what the patient feedback represented to them as health care professionals in training. In particular, Learners 6 and 10 discussed the significance and value of patient input, arguing that obtaining patient feedback on pharmacy learner skills in combination with the feedback the receive from the preceptors would help them achieve the patient-centred pharmacy care approach they strive for: âI think I would take it more seriously because it's actually a patient and that's ultimately who is kind of receiving our care. So, I would take it more to heart and take it more seriously and think about it more and think about how I can change. So, I think it helps you become aware of how people have different opinions, and the patients are all different and they can view things in different ways. So, it kind of broadens your perspective because if you're just receiving feedback from your peers, we're all the same. Everyone in pharmacy's kind of similar in at least one or two ways. And everyone in the field of pharmacy, we're all similar that's why we're all like pharmacists. So, our scope or our viewpoints are kind of narrower, but if 110 weâre getting feedback from patients, I think it really helps us like expand our horizon or our perspectives and itâs something to open our eyes to.â (Learner 6) âI would think that in a way, they're both valuable, but I think the one from patients is especially valuable because at the end of the day, weâre in the profession of healthcare and everything we do is supposed to be centred around the patients. So, then obviously their feedback's important because we're just going off of what we think, what we learned in school or what our practices are at our workplace, but we're not actually considering what if it works for them or not. And the only way to figure that out is to ask them. So, I feel like their voices need to be part of the picture for feedback, for sure. And I think a lot of the times we don't actually have that right now, which is kind of strange because we keep saying patient centred care patient centred care, but we don't actually know if it's patient-centred, unless we should take the time to ask them, do they truly think it is. So, I think both are valuable.â (Learner 10) 111 Table 5-1 Learner Participantsâ Characteristics Characteristics n =10 (%) Stage of pharmacy training Fourth year PharmD Post-Baccalaureate PharmD 9 (90%) 1 (10%) Involvement at the UBC Pharmacists Clinic Direct patient care Non-direct patient care 1 (10%) 9 (90%) 112 Figure 5-1 Thematic Map of Identified Themes and Corresponding Subthemes of Learnersâ PerspectivesSubtheme #1.1 Pharmacy learners as medication therapy experts Subtheme #1.2 Pharmacy learners as patient-centred team players Subtheme #1.3 Pharmacy learners providing exemplary pharmacy care Subtheme #1.4 Professionalism is a âstate of mindâ Subtheme #2.1 Pharmacy learners as patient-centred communicators 113 Chapter 6: Establishing Patient Feedback Norms 6.1 Chapter Overview In Chapters 4 and 5, I addressed research question number 2, âWhat skills, demonstrated by pharmacy learners during patient interactions, are patients capable of observing and subsequently assessing?â, by presenting the âwhatâ component of the interpretive description study by discussing with patient and pharmacy learner participants their perspectives on pharmacy learner skills in addition to aspects of pharmacy learner care that patients could have an opinion about. In this section, I address research question number 3, âWhat are patientsâ and pharmacy learnersâ preferences for patient feedback delivery?â, by discussing, through the lens of patients and pharmacy learners, the specifics of patient feedback which includes the âhowâ, âwhenâ, and âwhoâ components of patient participation in workplace-based assessment of pharmacy learners (see Figure 6-1 for a diagram mapping patient feedback components). In this chapter, I first present patientsâ preferences for feedback delivery (see Section 6.2) categorized as 1) patient willingness and comfort in offering their feedback to pharmacy learners; 2) âhowâ component of patient participation in learner feedback which pertains to supervisor/preceptor involvement in the feedback loop, patient feedback means (verbal or written), as well as potential factors that might influence feedback means; 3) âwhenâ component which pertains to timeliness of patient feedback in relation to the timing of patient-pharmacy learner encounter (promptly or later); and 4) âwhoâ component which includes potential patient-related factors that might influence patient feedback. In the second part of this chapter (Section 6.3), I present pharmacy learnerâs preferences for feedback delivery categorized as 1) âhowâ component of patient participation in learner feedback which pertains to supervisor/preceptor involvement in the feedback loop and patient feedback 114 means (verbal or written); and 2) âwhenâ component which pertains to timeliness of patient feedback in relation to the timing of patient-pharmacy learner encounter. The conventions some (defined as 1 to 3 participants), many (4 to 7 participants) and most (8 to 10 participants) are used to indicate the weight of consensus within separate findings presented below (Manio, 2018). 6.2 Understanding Patient Preferences for Feedback Delivery Each patient is different which means that every patient would have their own personal needs and would present with their individual circumstances. Accommodating patientsâ preferences is an integral principal of patient-centred care. When asking patients about their thoughts on contributing to pharmacy learner skill assessment, I needed to also understand patient willingness and comfort level in doing so instead of imposing the prospect of being involved in learnerâs assessment and feedback processes on patients. Additionally, it was important to gain an understanding of patient preferences of the circumstances and means by which they would like to provide feedback. My rationale was that I was aiming to grasp the patient perspective instead of assuming the elements that would facilitate or hinder the feedback process for patients. I asked patients to imagine a situation or a scenario where they interacted with a pharmacy learner after which they were requested to give their feedback or opinion on that particular learner who cared for them. Specifically, I asked patients the following four questions regarding the feedback process 1) âWould you be willing and comfortable to give your opinion or feedback about a learner who cared for you?â; 2) âHow would you like to give your opinion or feedback, to the learnerâs supervisor or preceptor or directly from yourself to the learner? And why?â; 3) âWhich way would you like/prefer to give your opinion or feedback, in writing (like by filling out a form) or by speaking to someone? And why?â; and 4) âWhat about the timing of your opinion or 115 feedback, would you prefer to give it immediately after interacting with the learner or at later time? And why?â 6.2.1 Patient Willingness and Comfort in Giving Feedback All patient participants expressed willingness and most of them felt comfortable to take part in the pharmacy learner assessment process; however, some patients specified certain conditions for giving their opinion on the learner who cared for them. Patient 5 expressed no objection against being involved in providing feedback for the pharmacy learner under the condition that they would be previously informed, so they would be attentive to what happened during their encounter with the learner: âI think so as long as I knew beforehand so that I could pay attention.â (Patient 5) On the other hand, Patient 10 had a different perspective from the rest of the patient participants. The patient mentioned they were willing to participate in the pharmacy learner assessment process; however, they would be uncomfortable doing so. When asked to explain the discomfort they expressed towards participating in assessing the pharmacy learner who provided them with care, Patient 10 was concerned about the pharmacy learnerâs emotional response and reaction to the patient feedback. The patient themselves did not want to be a source of discomfort or negativity for the learner when they would hopefully be contributing to the learner training by voicing their feedback: âWilling but not comfortable. I don't know if I'd be comfortable, but I would be willing to do it. I wouldn't want to hurt anybody's feelings.â (Patient 10) 116 6.2.2 Supervisor/Preceptor Involvement in the Patient-Learner Feedback Loop 6.2.2.1 Patient Feedback Given Directly to The Learner in Presence of The Preceptor Recognizing their positions as recipients of pharmacy care, patients also acknowledged the role of the pharmacy learnerâs supervisor/preceptor as someone inevitably present during the patient care encounter. Admittedly, the possibility of having the learnerâs supervisor be part of the patient feedback process was brought up in my conversations with the patient participants especially when asking them about how they would prefer to provide their feedback. Comparatively, some patients did not have a specific preference on giving their feedback directly to the pharmacy learner or solely to their preceptor recognizing the advantages and disadvantages of both situations. The patientsâ overall aim was for their feedback to be a chance for learning and point of improvement for the pharmacy learner. Many patient participants preferred to voice their feedback directly to the pharmacy learner and did not mind the preceptorâs presence in the feedback loop, welcoming any follow-up comments from the preceptor regarding the learnerâs performance with the patient. The patients felt they owed it to the learner, therefore, they wanted to express their gratitude to the person who directly provided them with pharmacy care while recognizing their efforts. The patients also thought that conveying their opinion to the person who provided the care would help the learner make the best out of the patientâs feedback. Moreover, some patient participants expressed their concern that some aspects of the feedback might accidentally get lost in translation if the learner was dismissed from the patient feedback encounter and instead had their preceptor delivering the patientâs message. Those patients felt it was crucial that the pharmacy learner received the feedback firsthand to ensure what the patient said was what was exactly conveyed to the learner. 117 For instance, Patient 4 preferred that the learner would predominantly be involved during the patient feedback interaction in the presence of the learnerâs preceptor. The patient acknowledged the impact of having multiple people with a diverse level of experience (learner and preceptor) in the patient-learner feedback loop. Being a preceptor themselves, Patient 4 recognized the patient feedback as an educational opportunity for the pharmacy learner. The patient believed it was important for the pharmacy learner and their preceptor to have a discussion while sharing each otherâs perspectives of the patient feedback encounter: âMaybe to the student with the preceptor present, the student taking the lead probably, but preceptor partly, so the students could ask for clarification or ask questions and then with the preceptor they can always step in and ask questions as needed or clarify it. And then afterwards, the two could compare to their how they thought it went before and then the patient feedback to see if it matched their perceptions. Cause the preceptor and the student will have different perspectives on how something went, given the difference in experience. I guess that's me personally, as a preceptor, I always find it interesting to see how the student thinks something went and the feedback they got versus how I see it, plus being different for people, you'll see different things. It would be useful for learning to compare the perspectives.â (Patient 4) For Patient 9, it was also important to involve the learnerâs preceptor in the patient-learner feedback loop. The patient believed that if both the pharmacy learner and their preceptor were present when the patient provided their feedback, this would provide a room for conversation and discussion afterwards. Patient 9 acknowledged that both the pharmacy learner and the preceptor might hold different perceptions hence complementing each otherâs understandings and made an analogy with when the patient had a family member accompanying them during a medical appointment: 118 âSo, my husband and I do that all the time now. Because both of us can't remember everything. So, we go into each other's appointments a little harder now with COVID, and I find both of us find that same thing is that I hear stuff he hears stuff, but we both don't hear everything. So, after the appointment, well, I heard this and then I heard that. And so, you get more of the complete picture I think that way. And I think by doing that, then both teacher and student get a clearer understanding of the full message of what the patient was trying to say.â (Patient 9) 6.2.2.2 Patient Feedback Given Directly to The Preceptor in Absence of The Learner On the other hand, many patients expressed their personal preferences for providing their feedback on the pharmacy learner whom they interacted with directly to the learnerâs preceptor or supervisor without having the learner present. The patients described different reasons for their chosen preference; however, there was one common explanation provided by those patients which was ensuring that their feedback was communicated to the learner in an articulate and well-phrased manner. When asked about their preference, Patient 7 commented they would like the learner to be absent from the feedback loop. The patient recognized the position of the supervisor as some who established a relationship with the learner which might not always be the case for the patient. Another intriguing perspective shared by Patient 7 pertained to the supervisorâs role as an educator who, according to the patient, had an experience in structuring and providing educational feedback for the learnerâs best interests: âI think it's better to be done through the supervisor. I think that I don't have a relationship with the student, and I would assume that the supervisor does. And then it's the supervisor's responsibility to work with the student. And the supervisor would have a better sense of how to phrase constructive criticism in a way that it would be well-received. I think that when you get criticism from a stranger, the immediate response is a defensive one. I think it's very hard for people to hear something negative from somebody that they don't 119 know, and somebody who's not in a professional supervisory capacity. I have no credibility with the student as an analyst of their skills. I can provide feedback and I can say it to me it felt like X but I think more effectively if I said to the supervisor the same thing, this was what my experience was I would have preferred whatever.â (Patient 7) Similar to what was shared by some patients, Patient 7 acknowledged their position as a non-educator and discussed how the supervisor could act as a filter, articulating and validating the patientâs feedback for the learnerâs educational benefit and to enhance its receptiveness by the learner. In addition, Patient 8 thought their feedback would be a better learning opportunity if it was offered through a third party, in this case the learnerâs supervisor. The patient was concerned that their feedback might result from a misjudgement on their part, and they acknowledged the role of the learnerâs supervisor as an educator with the knowledge and expertise. For these reasons, Patient 8 thought it would be more beneficial to have the learnerâs supervisor validate the feedback and convey the patientâs message to the learner which would enhance its receptiveness: âPersonally, I think that it would be more effective through the supervisor. I believe so. And the reason why is they're able to communicate the whole, and they might be able to do it in a more concise fashion, than the patient in an articulate sense. The supervisor might be able to articulate it in a much more concise way, a much more effective way. But the whole point isn't missed because again across the board. As humans, we tend to shut off when we feel we've been criticized, and we might not hear what might be a value to us.â (Patient 8) Another reason why Patient 8 preferred the learnerâs supervisor to communicate the patientâs feedback on their behalf was to depersonalize the feedback so it would hopefully be 120 regarded by learners as an opportunity to improve rather than a personal attack on or a criticism of their behaviour: âAnd the reason why I say that is that sometimes when an individual is giving advice or recommendations that sometimes generally and I speak across the board, we tend to shut off when somebody is giving us advice. Cause we always look at it as being critical. So, personally I think that the most effective way of giving effective advice or opinions is through a supervisor. So, then it can be communicated in a way that that individual will be receptive because everybody receives information differently. I think that's the best. And I say that because you don't want the point missed. You don't want the person there who you're being critiquing or giving an opinion up or communicating what improvements could happen or what the positives are. You don't want them shutting off before they hear what you're trying to say.â (Patient 8) 6.2.3 Means of Patient Feedback Typically, feedback is offered by various means including verbal or written through filling out a form or questionnaire. Therefore, when asking patients about their thoughts on participating in the pharmacy learner assessment process, it was important to understand the patient preferences for how they would like to offer their feedback. Some patients expressed interest in giving their feedback by talking to someone, many preferred to answer questions in writing, whereas others felt it depended on the situation and/or patient-related factors. 6.2.3.1 Verbal Patient Feedback Some patient participants thought that by offering feedback verbally, it would be a chance for them to listen to what the learner and their preceptor had to say about the feedback creating a better learning experience for both the learner and the patient: 121 âOn the phone, I think by speaking to someone because then if they have more questions, they can ask it. Whereas as if I put it in paper then it's totally my opinion. And it's not listening to their thoughts of my opinion. Because I feel it would offer more feedback from both of us. I think that would be a better learning experience for both of us, not just [the learner] but me too.â (Patient 1) Here Patient 1 reflected on their phone appointment with the pharmacy learner and their preceptor at the UBC Pharmacists Clinic arguing that verbal rather than written feedback provided room for conversation between the patient and the learner who might want to ask questions and share their perspectives on the feedback. Additionally, other patient participants argued that using a written document to record feedback would be restrictive and the content might not align with what the patient experienced during their encounter with the learner: âProbably speaking sometimes like the ticky boxes or the answers it's sometimes it's hard to fit your experience into that depending on what level of feedback is being sought. I mean some stuff the little ticky boxes and short forms are good. I don't know how revealing they are versus talking to someone.â (Patient 4) While Patient 8 did not have a specific preference for the means by which they would like to offer their feedback, the patient reminded us of a patient-centred accommodation aspect by which verbal feedback might be more accessible to patients with visual impairments: âEither is okay for me but also, I think verbally is probably easier at this point in time cause I have visual impairments.â (Patient 8) 6.2.3.2 Written Patient Feedback Some patient participants favoured the option of providing their feedback in a written form and each patient shared their own (personal) explanation to justify their choice. 122 Patient 4 argued that the key for an efficient feedback was to ask patients specific rather than general questions regarding their perspectives on learners in order to direct and guide their thought process and to avoid receiving irrelevant information from patients: âAnd also, they might not know what's relevant. Cause they could tell you things that sure that's their opinion, but it has nothing really to do with the services you're providing. Something like rant about the doctor or something not necessarily useful to what you're trying to do. And it helps people because sometimes if you ask too broad a question, they're like, I don't know.â (Patient 4) For Patient 10, it was the time factor as they thought that being provided with a form to fill in their feedback would be a chance for them to think about what they would like to say instead of being restricted by time if they were to offer their feedback verbally. The patient argued that offering their feedback in a written form has superior efficacy as compared to verbal feedback. According to the patient, written feedback would have the perk of giving them time to process their interaction with the pharmacy learner and write their feedback accordingly: âI think either or, Arwa. I think I'd be willing to do it, you know, maybe putting it in writing is more effective because sometimes you need to stand away and reflect on a discussion and you have more. Sometimes there's some value in having time to reflect on a conversation.â (Patient 10) 6.2.3.3 Patient Feedback Means is Situational Some patient participants did not specify a preferred option regarding the feedback means, whether verbal or written. Other patient participants had a personal preference that they recognized might not be a universal or generalized perspective that would be shared by other patients. These patients were either comfortable offering their feedback in any format, felt it depended on the situation they were in or some patient-related factors, or proposed having an integration of both verbal and written means. 123 For instance, Patient 7 did not have a specific choice when they were asked about how they would prefer to give their feedback on the pharmacy learner they interacted with. However, the patient believed that their personal perspective might not be generalizable to other patients Specifically, Patient 7 argued that written feedback might be a favourable option for patients who would like to offer criticism and who would not be a source of discomfort if their feedback was voiced verbally. The patient also perceived written feedback as a means to retain their anonymity: âEither. I think for some people, the written feedback is more comfortable because people don't like to say something negative to somebody else but I don't have an issue with that.â (Patient 7) While Patient 9 mentioned they preferred to provide their feedback of the pharmacy learner by speaking to someone, the patient argued that it would be effective to be offered with a hybrid means of feedback (verbal + written). In their response, Patient 9 acknowledged that offering their feedback verbally might pose a challenge for them and for that reason the patient felt it would be a better option to express their feedback in writing then speak about what they wrote. Here the patient shared a thought-provoking perspective where patient-specific factors would dictate how the patient would be able to provide their feedback on the pharmacy learner they interacted with: âI would prefer oral because I think that way people can hear the determination in your voice and how you mean things. However, because of my lack in that area, I can articulate myself way better in writing than I can verbally. So, perhaps a combination would work better.â (Patient 9) Despite the fact that Patient 4 personally preferred to offer their opinion of the pharmacy learner who provided them with care by an oral means, as previously discussed, the patient argued that there were certain factors that needed to be taken into consideration when deciding. These factors included the type of patient care setting, length, and depth of encounter with the pharmacy learner, and patientâs personal preference: 124 âI think there's room for both. Some settings would be more superficial, like a more short paper form might be more suitable, but if it's a longer interaction, more in depth then, you know, asking or giving the option for people, because there's some people that don't want to give feedback or don't want to say anything, other people who would love to tell you exactly what they think.â (Patient 4) Personally speaking, Patients 4 mentioned that another contributing factor to their chosen means of feedback would be the patientâs psychological, mental, or emotional state before, during, or after their interaction with the pharmacy learner: âIt would depend on my state of mind. If I had gotten frustrated with, generally, I'm not frustrated with the pharmacist, it's more the doctors, but if I'm really frustrated, then I don't want to provide verbal feedback, but generally I'm happy to. Depending on how you see the world.â (Patient 4) 6.2.4 Timing of Patient Feedback Time is a core element of human interactions, and the patient-pharmacy learner encounter is no exception. Among the important specifics of patient feedback was âwhenâ patients preferred to offer their feedback regarding they pharmacy learner they interacted with. As much as it was crucial to understand patientâs comfort level in providing feedback on pharmacy learners, it was also important to recognize the temporal element of the feedback according to what patient participants preferred. Offering their feedback on the pharmacy learners who cared for them is a societal expectation and an aspect of the patientâs civic duty as a recipient of pharmacy care. Therefore, respecting the patientâs time through seeking their perspectives on their preferred feedback timing would honour the patientâs contribution to the pharmacy learner assessment process. Specifically, I asked patients if they would like to offer their opinion immediately after they interacted with the pharmacy learner or later in addition to asking the patients to explain their chosen preference. 125 Some patient participants preferred to offer immediate feedback, so their memory would serve them, and they were able to recall what happened during their encounter with the pharmacy learner and subsequently provide their opinion. Other patient participants preferred to be given the option to offer their feedback at their convenience and not immediately after they finished their encounter with the pharmacy learner and provided an explanation for their choice. Those patients felt that not offering their feedback right way would give them an opportunity to process their interaction with the learner, reflect on what happened while avoiding jumping into conclusions or making untrue presumptions. For Patient 7, providing their feedback immediately after their encounter with the pharmacy learner might pose a mental and physical burden, according to the patient. The patient expressed how hard it would be for them if they were to offer their opinion right after their appointment when the patient would be exhausted. The patient believed that immediate feedback might not truly reflect their opinion of the pharmacy learner they interacted with. Patient 7 also felt that a postponed feedback offered at a reasonable interval not too far after their encounter with the pharmacy learner would give the patient enough time to reflect back while still being able to recall their impressions on the encounter: âI think in a later time, I think after right afterwards I was spent. And I might check out some boxes on a form, but I certainly would not be willing to do what we're doing right now. And I think that the time lapses, so it's almost a week now. So, I remember it well enough to be able to refer back to it, but I'm not remembering the whole detailed chronology of the conversation or whatever, I have impressions from it now. And I think thatâs what you're looking for rather than the actual well, he said this, and I didn't like.â (Patient 7) 126 An intriguing perspective which was brought up during my conversation with Patient 4 was the timing of the feedback relative to the stage of the patient care encounter. The patient mentioned that if the pharmacy learner were to solicit the patient feedback themselves, it was important for the learner to first check in with the patient if it was an appropriate time for them. Patient 4 reminded us how their perspective was in tandem with patient-centred care approach by acknowledging the patient as a person and that they were coming first and foremost to seek pharmacy care: âSo, I don't want to measure the temperature of the person, so to speak before you immediately push the feedback or the request for, I guess. Then you want to be, patient-centred not just focused on the student and their learning. I think a lot of people are happy to help the students in whatever way, but I mean, itâs always good to be acknowledged as a person first.â (Patient 4) 6.2.5 Possible Factors Influencing Patient Feedback While discussing their preferences for different specifics of their feedback to pharmacy learners, many patients recognized their feedback to pharmacy learners would be subjective and based on their individual circumstances and perceptions. Patients identified multiple patient-related factors to be mindful of and recognized as factors with potential influence on the patient feedback process (content, means, and timeliness). It is noteworthy that patients did not necessarily associate these factors with themselves, but they identified these factors from a general perspective or hypothesis. These factors included the patientâs; 1) occupation, profession, or education; 2) experience with their medical conditions, medications, and with the health care system; 3) mental, psychological and/or emotional state; 4) physical state; 5) age; 6) gender; 7) ethnicity; 8) personal life experiences; 9) culture; and 10) inherent personality as well as the number and depth of patient-learner encounters. Moreover, as presented in Chapter 4, eighty-percent of patient participants had 127 six or more medical diagnoses, something that would likely shape the depth and nature of the patientâs experience in the health care system in addition to the degree of patient involvement in their own health care. Additionally, since some participants proposed that the mental health of the patient at the time of their interaction with the learner might have a potential influence on the feedback delivery (timing and/or means), this prompted me to check the demographics of the patient participants to further contextualize my findings. I found that thirty-percent of participating patients were diagnosed with a mental health condition. In particular, Patient 4 acknowledged their unique position not only as a health care professional (occupational therapist) but also as an educator and preceptor who was familiar with giving feedback to the learners they supervised. The patient recognized that not all patients would have the same level of literacy and familiarity with feedback provision, therefore, the patient proposed a suggestion to support patients with guiding questions would help facilitate the feedback process for them: âProbably cause I have expectations in general of what a student should be like and do. And whenever I interact with a student, I can't really completely take off my preceptor hat. Sometimes they even ask questions that I know the answer to just to make the student feel like they're contributing. I might be someone outside the average there though, because with my own students, I have to give a lot. I do give a lot of feedback. That's the way I learned where I went to OT [occupational therapy] school, always giving a lot of feedback and if student has to in the debriefs, they have to provide their own feedback. And then I will give them feedback. So, giving people feedback is not unusual for me to do, but I know if you're not used to doing it, that could be difficult without guided questions or something.â (Patient 4) Some patient participants argued that a temporal factor would have a prominent impact on the patientâs feedback shaping their perspectives and views which would in turn be reflected in the 128 feedback they offer to pharmacy learners who provide them with care. For some patients, time meant the amount and depth of encounters a patient had with a pharmacy learner in order to form a longitudinal connection based on comfort and trust, which might influence the feedback the patient would give to pharmacy learners. Other patient participants perceived time as oneâs experience within the health care system and/or the number of months or years they have lived with their medical conditions: âAnd I think especially, length of time they've been dealing with the healthcare system, because there's people with chronic conditions that have you know, seen 50 specialists and not had good interactions or answers. So, some people come in with a negative view of the system and some people don't, so I think previous interactions built what they expect or understand the healthcare system or how they understand it to work would also definitely influence their views.â (Patient 4) Patient 9 expressed their ability to generally observe and comment on the communication piece of their interaction with the pharmacy learner. However, the patient honestly acknowledged their boundaries and qualifications when assessing aspects of care received from a pharmacy learner and how their health challenges might create a barrier hindering the patientâs ability to provide feedback on certain pharmacy learnerâs skills: âI have to qualify for that because where I am in my life and is that my brain doesn't really work a lot. When I know something, I know something, so it's easy, but when I'm trying to formulate an answer like off the top of my head, I have a hard time. So, I guess for me would be feedback on how well they communicated to me. I like to be able to give feedback, the reason I'm hesitating is because of the way I speak now. Like I said, if I've researched something and I know if I've got it down packed and I kind of understand things and I know things, I'm fine in talking some most of the time. But when I'm being asked questions and having to formulate an answer that's where the difficulty comes in. So that's my hesitation is. I don't want to come 129 across like I'm sounding like a bumbling idiot. A lot of times that's what I think I sound like because my brain just doesn't work like itâs supposed to anymore. So, even with you, some of my answers, I'm thinking to myself, gee, I must sound like an idiot. My brain works in terms of thinking where the disconnect is between my mouth and my brain. (laughs).â (Patient 9) Here Patient 9 recognized their cognitive challenges as a potential barrier which would not necessarily influence the concept of the patient giving feedback in the first place but rather the content, means, and timing of feedback. The patient was honest about their credibility and capability to give feedback which would only include an aspect of pharmacy learner care they experienced, observed, and could talk about in spite of their challenges. Such intriguing perspective shared by Patient 9 as they openly acknowledged their health limitations emphasizes how the notion of patient-centredness and attending to patientâs individual circumstances should be an integral component not only of pharmacy learner care but also when including patients as part of the pharmacy learner assessment process. Besides, Patient 7 elaborated on other possible health challenges, noting that psychological, mental, and/or emotional factors could impact the patientâs assessment of the pharmacy learner: âAnd there's also my psychology, that's involved with it, [the learner] may have pushed a button for me. I don't know what the current term triggered, they say now, [the learner] may have triggered an emotional response for me and my feedback may be an emotional response to that trigger.â (Patient 7) Age, gender, and ethnicity were also among the demographics mentioned by some patients as potential contributing factors in the patient feedback process. The patient believed these variables might skew the patient perceptions of pharmacy learner skills: 130 âAge and gender as well because I think probably the younger generation feel much more comfortable with being outspoken of what they want and where they're at, where I think somebody of an older generation might be a lot more reserved. And ethnicity, I think there's a multitude of things that fall in that.â (Patient 8) Other intriguing viewpoints shared by some patient participants concerned inherent patient factors and the patient individual personality. For instance, Patient 8 argued that a patientâs prior personal experience in speaking up and sharing their thoughts and how that was received by others in addition to their upbringing and cultural norms could potentially impact their comfort level in providing their opinion on the pharmacy learner they interacted with: âAs well as how that people reacted to them or treated them with respect or not is a huge barrier, I think. Also, oneâs experience with being heard in general in life, if there's someone that's able to orally communicate in a way that they're feeling heard or feel comfortable in doing that because I know a lot of people don't even feel comfortable with communicating. Some people feel that they might offend somebody, they are maybe raised not to just speak outwardly to individuals in that way.â (Patient 8) Additionally, patient 9 acknowledged that giving input that could be construed as criticism might cause discomfort for patients who like to avoid confrontational situations. The patient believed that the onus lied on patients themselves to feel comfortable in delivering their feedback to pharmacy learners in a compassionate manner: âTheir level of comfort. people in general do not like conflict. So, it's easy to say to somebody, you did a great job and you're fabulous and so on and so forth, right? Those things are easy. What's not easy is critiquing another person, okay well, you could stand a little bit of improvement in this area. And I think in order for a patient to be able to do that, they themselves inside need to have some level of self-security where they feel comfortable to do that, but in a very caring fashion, not in a fashion that says, well, if you had done this, that goes nowhere. So, I think that part is strictly upon the patient themselves.â (Patient 9) 131 6.3 Understanding Pharmacy Learner Preferences for Patient Feedback Delivery Correspondingly, I discussed with participating pharmacy learners their preferences on âhowâ and âwhenâ they would like to receive feedback from the patients they provided with care. In particular, I proposed the following questions to the learner participants, âWhat do you feel is the ideal way and timing to obtain feedback from patients and/or families? And Why?â 6.3.1 Means of Patient Feedback Pharmacy learners expressed diverse preferences for how they favoured to receive patient feedback. Some learners preferred the feedback would be provided to them verbally, most expressed value in having the patient feedback in a written format while others did not have a specific preference. Learner 7 eloquently acknowledged that each feedback means had its value, âWell written is always more permanent. Verbally is a little more personal.â In their responses, learner participants often intertwined their preferred format of patient feedback with or without the involvement of the learnerâs supervisor or preceptor in the patient-learner feedback loop. Whether that meant having the patient feedback provided as a direct conversation between the pharmacy learner and the patient they interacted with or involving the learnerâs preceptor as a go-between who would filter and package the patientâs feedback before communicating it to the learner. Learners who favoured a direct patient feedback often thought it would be ideal to have it verbally communicated whereas those who thought their preceptor should be involved in the feedback process mostly appreciated documented feedback through surveys or questionnaires. Moreover, some learner participants preferred to solicit the patient feedback themselves by directly asking the patient their thoughts and perspectives on their encounter with the learner. The learners argued the values of engaging in such interaction with the patient would be a direct 132 affirmation to the learner of their performance or might give an impression to the patient about the learnerâs potential to improve and grow. Comparatively, other learner participants were keen to have authentic feedback provided by the patient, which in some circumstances might highlight areas of critique of the learnerâs performance. Therefore, those learners believed it was imperative to withdraw the learner from the feedback loop not to impose any conflicts or sensitivities on the patient. The learners also preferred to spare the patient from any discomfort that might be created if the patient were to give feedback directly to the learner and thought that the ideal way to obtain feedback from the patients was via their supervisor and in a written form. Learner 2 argued the impact of engaging in a straightforward interaction with the patient as they directly provide the learner with their feedback. The learner believed it would be a personable experience to engage with the patient who was the primary recipient of care as they discussed their perspectives with the learner, observing their body language, and hearing the patientâs tone as they voiced their feedback to the learner: âHonestly, I think verbal. I guess it's just that when I listen to the feedback verbally, I can hear and see two things. I can hear the words coming out from the patient, and I can read their facial expressions because if it was a feedback that was verbally given about something very simple, then that's okay. But if they were super concerning and the patient really was frustrated, or they just needed to emphasize their feedback. If I see it in person, I see their facial expressions, I hear their tone. I hear their words. I feel I can take that more seriously and that'll have an impact on me. I feel this is just my, as a learner, I've seen that impact me. I think body language is a good word, the body language of the patients and the feedback from that really has an impact on me.â (Learner 2) While some learner participants also thought conversational patient feedback provided verbally would be superior to a written format such as a survey or questionnaire, those learners 133 believed that their preceptor was better positioned to receive the feedback from the patient on learnerâs behalf: âI think directly talking to them. I think having questions, like how you're asking me questions, better semi-structured but also open-ended, I think asking them those kinds of questions. And then I think because I donât think online or surveys, not everyone is engaged when doing those and not everyone will have the incentive to actually give their response this thoroughly. So, I think more so in a conversation setting. I think a middleman would be helpful especially if the patient feels comfortable giving them their honest feedback when you're right in front of them. Could be supervisor, preceptor, but I dunno if ethically, would they be influenced by that? I don't know what the purpose of that would be, if it's simply just for how to communicate, how to improve your communication and like the preceptor is the middleman, then that's fine but it shouldn't affect like your grading.â (Learner 10) Here Learner 10 raised a thought-provoking aspect of having their preceptor as a participant in the patient-learner feedback loop. The learner welcomed their preceptorâs contribution as long as the patient feedback had nothing to do with the learnerâs formal evaluation or jeopardize their position as pharmacy professional in training. Evident in their response is how Learner 10 appreciated receiving patient feedback as a learning opportunity if provided within in a safe space and non-threatening environment. Conversely, Learner 3 was concerned that communicating the patientâs feedback verbally via their supervisor might pose a risk of having the patientâs words lost in translation if unintentionally misinterpreted, simplified, or censored by the learnerâs supervisor, a concern that was shared earlier by one the patients: ââ¦versus having them, for instance, telling my supervisor that, oh, I did this and that. And then the supervisor translates it to me. I can't be fully sure that what's being translated to me is the actual feedback, 134 because maybe as a learner, my preceptor doesn't want me to hear the negative side of it and maybe just sort of feed it to me in two three simple words when in fact it's something bigger.â (Learner 3) Learner 6 appreciated a written patient feedback and thought it would have a superior advantage if their preceptor were involved. As some patient participants expressed earlier, the learner felt that their preceptorâs position as an educator would play a role in articulating the patientâs feedback for the learnerâs best interest making it an opportunity for training and improvement. Learner 6 argued that documented patient feedback via the preceptor would retain its authenticity while providing patients with a chance to communicate their perspectives in a more comprehensive manner as compared to verbal feedback: âMaybe not something verbal to the pharmacy learner. I think something written would be better, so they can be more detailed about it. And then they won't feel so uncomfortable if they want to give negative feedback, it would be easier to write it down. They can be more honest too if they write it down. It doesn't have to be anonymous, but I think written down is better than saying it verbally. I think it should be given to a third party. I think if it's given to a preceptor or supervisor, this preceptor and supervisor can look through first and see what do they mean by these points. Cause I think sometimes patients might not have the full picture, but I think preceptors and supervisors, they kind of have a better picture of whatâs happening. And they're probably able to pinpoint what the patient is trying to say. So, they can communicate this in a better way to the learner and give them tips also to help them improve. But if you give it to the student and they don't really know what they mean, and they don't know how to improve, it might be kind of pointless.â (Learner 6) 6.3.2 Timing of Patient Feedback Another aspect of pharmacy learner perspectives on patient feedback specifics was when learners thought would be a good timing to receive the feedback relative to the learnerâs encounter 135 with the patient. Some learners appreciated an instant patient feedback, not necessarily on the spot but one that would be obtained shortly after their interaction with the patient. For instance, Learner 7 argued the value of having immediate feedback rather than a delayed one so both the learner and the patient would have a good memory on what happened during the patient encounter making it more beneficial for the learner: âI would say within a day because it's fresher in your mind, if you had an interaction with a patient and a week or two later, you heard about it, you wouldn't be able to reflect as well as what you did, right or what you maybe didn't do right when itâs fresher in your head.â (Learner 7) Even though Learner 10 did not necessarily label it as such, their perspective on how they felt an ideal timing for patient feedback would be was congruent with the notion of patient-centred care. The learner believed that choosing a good time to ask patients for their feedback on the pharmacy learner who provided them with care depended on the individual patientâs circumstances Particularly, the learner thought it was the patient who should be asked about their preferences for the feedback timing: âTiming, I guess like probably when they aren't in a rush. So, they should be given the option, whether they have the time to give you that feedback. So, I think a lot, whatever is convenient for them. So, probably when they're coming to the pharmacy with a question or whether it, when they're picking up a medication or following up on a question. So, I think when they're there and it's just works for them, and they have some time.â (Learner 10) 136 Figure 6-1 Diagram Mapping Patient Feedback Components 137 Chapter 7: Discussion and Recommendations 7.1 Chapter Overview In this final chapter, I will discuss key findings arising from Chapters 2, 4, 5, and 6 as well as situate the findings within existing literature, review strengths and limitations of the interpretive description study presented in Chapters 3-6, highlight the contributions and implications of my thesis, and propose future directions by offering inclusive patient-informed suggestions which could be the foundation to shape future research initiatives aimed at involving patients in pharmacy learner assessment. Specifically, I contextualize the keys findings from Chapters 2, 4, 5, and 6 by discussing how findings from Chapter 2 informed the interpretive description study which I presented in Chapters 3-6. In addition, I compare and contrast key findings from Chapters 4, 5, and 6 by discussing the similar and conflicting perspectives shared by patients and pharmacy learners on patient participation in pharmacy learner assessment and feedback processes. 7.2 Integration of Research in Education and Practice 7.2.1 Contextualizing Chapter 2 Key Findings In Chapter 2, I conducted a scoping review where I mapped the existing evidence on real patient involvement in the assessment of health professional trainees in a workplace-based setting including aspects of patient participation. To the best of my knowledge, there has been abundant evidence on patient involvement in assessing medical professionals in training and to a lesser extent nursing trainees. Regrettably, patient participation in the assessment of other health professionals in training, specifically pharmacy learners, in a workplace-based context has been neglected. 138 Analysis of the studies included in the scoping review revealed that patients were predominantly asked for their feedback on the communication and interpersonal skills and professionalism of health professional trainees. Additionally, the patient perspective was sometimes requested solely, combined with other sources of feedback such as the traineeâs supervisor or preceptor, elicited in relation to patient-related demographics such as sex, ethnicity, and educational level, or solicited directly from the patient by the health professional trainee. Moreover, heterogeneous strategies were used to obtain patient feedback and inconsistencies existed within and across health disciplines. Varied means of soliciting patient feedback included the administration of surveys or questionnaires formatted to collect data on patient satisfaction, formative or summative assessment data from patients sometimes collected via interviews, or a mix of surveys and interviews. Notably, the overall aims of the studies included in the scoping review were to assess pre-determined aspects and domains of health professional trainee skills by including patients as part of the feedback process. In these studies, the researchers assumed (on the patientâs behalf) which health professional trainee skills patients could assess rather than investigating the potential of patient involvement in trainee assessment by trying to gain an understanding of patientâs capabilities and willingness to take part in the assessment process. Extensive research has been done on standardized patient (SP) involvement in the assessment of health professional trainees in simulated scenarios such as objective structure clinical examinations (OSCEs) or role playing (Berg et al, 2011; Riopel et al., 2018; Riopel et al., 2019; Ryan et al., 2010; Schelgel et al., 2012; Webster et al., 2012). The value of obtaining feedback from real patients has been compared with feedback derived from standardized patients to highlight and emphasize the impact of the former. Chua and Bogetz (2018), acknowledged the distinct educational significance of obtaining feedback from standardized patients as compared to real patients. 139 Additionally, while feedback from standardized patients is considered to be more âstructuredâ than real patient feedback, the latter is viewed as more authentic and a true reflection of patientsâ experiences since it is solicited in a more spontaneous manner (Bokken et al., 2009; Bokken et al., 2010, Chua & Bogetz, 2018) while providing a sense of reality. In addition, feedback obtained from real patients was found to make âa more profound impression on the studentsâ (Bokken et al., 2009; Bokken et al., 2010; Dammers et al., 2001, and Chua & Bogetz, 2018). Resultant findings from the scoping review in Chapter 2 highlight the need for an inclusive approach to workplace-based assessment, which would involve a rethinking and expansion of current pedagogical approaches in order to properly represent real patient input on the pharmacy learners who care for them. Accordingly, I argue that the conventional means of providing feedback has been proxied on the patientâs behalf (Bridge et al., 2014) by the learnerâs supervisor/preceptor whereas patients themselves are able to bring insightful perspectives, owing to their direct interactions with learners. Altogether, these findings illuminated areas for further research which subsequently informed the research question, objectives, and design of the interpretive description study outlined in Chapters 3-6 to address and challenge the knowledge and practice gaps that have been highlighted in the review. 7.2.2 Contextualizing Chapters 4 and 5 Key Findings As previously highlighted in Chapter 2, there is no empirical evidence on the pharmacy learner skills patients could observe and subsequently assess. Findings from Chapter 2 prompted the need to involve patients in pharmacy learner assessment. For this reason, I decided to be proactive and took an innovative initiative by conducting the interpretive description study presented in Chapters 3-6 while exhausting my research abilities and skills as an aspiring health 140 professions educator and researcher. I designed, conceived, and collaborated on implementing this single-centre study that used semi-structured interviews to contribute to bridging the education and practice gap. Subsequently, findings from the scoping review in Chapter 2 were used to inform the research question, objectives, and design of the original qualitative study described in Chapters 3-6 which focused on gaining an understanding of stakeholder perspectives (patients and pharmacy learners) on pharmacy learner skills that patients could observe and assess. Unlike the focus of the studies included in the scoping review, I did not ask patients to assess a specific pharmacy learner who cared from them. Instead of imposing the prospect of being involved in pharmacy learner assessment and feedback processes on patients, the aim of the interpretive description study was to explore, with patients and pharmacy learners, their perspective on the aspects of pharmacy learner skills that patients would be capable of, willing to, and comfortable discussing. Overall, I analysed pharmacy learner skills, based on patient and pharmacy learner narratives, into two main themes 1) Humanistic aspects of pharmacy learner care and 2) Intrinsic aspects of pharmacy learner care. Patients and pharmacy learners shared diverse perspectives within two main themes which was reflected in the different corresponding subthemes presented for each participant group (see Figures 4-1 and 5-1). Reflecting on the patient participantsâ findings presented in Chapter 4, patients thought they were capable of assessing a multitude of pharmacy learner skills Subtheme #1.1 Atmosphere of the patient-learner encounter, Subtheme #1.2 Pharmacy learners recognizing patientâs humanity, and Subtheme #1.3 Pharmacy learners as patient-centred communicators, some of which I was able to map within the Educational Outcomes outlined by the AFPC including Care Provider (CP), Communicator (CM), Collaborator (CL), Professional (PR), and to a lesser extent the Scholar (SC) role. While not explicitly stated, patient responses and observations of the pharmacy learner skills that they thought 141 they could assess aligned with the concept of patient-centredness. The study findings revealed that patients were predominantly able to observe and provide their opinion on a human pharmacy learner. Specifically, patients mostly spoke about pharmacy learner communication skills that pertained to the learnerâs humane identity and attitude as a human being engaging in an ordinary conversation with another human, preceding the learnerâs role as a health professional in training. Patients thought they could comment on the cascade of events that took place during their interactions with pharmacy learners, from initiating their meeting with the patient by a welcoming attitude, appropriately introducing themselves as a pharmacy professional in training while explaining their role in the patientâs care process to making the patient feel comfortable during the encounter through establishing rapport with them. Davies and Lunn (2009) identified communication skills as primary area for health education research owing to their innate characteristics as âcore transferable skillsâ and foundational for any clinical practice setting that involves patient interactions. Other humanistic facets of pharmacy learner communication that patient participants identified as skills they could assess were the learnerâs efforts to connect with the patient by engaging in a two-way conversation using simple language while actively listening to what the patient had to say, internalizing, and then processing the patientâs words before reiterating it back to the patient. Explicitly validating and acknowledging the patientâs lived experiences were aspects of pharmacy learner skills that patients mentioned they could appreciate and were regarded by patients as a sign of respect. In contrast, patients felt they would be able to identify if the learner communicated in a condescending manner while dismissing the patient as an information source. Patient participants attributed all these communication skills to establishing a patient-learner alliance that was built on trust and confidence, something that would subsequently influence the patientsâ abilities to be receptive of the care pharmacy learners provide them with. In comparison with the 142 humanistic pharmacy learner skills, patients thought they were more restrictively positioned to provide feedback on the pharmacy learner intrinsic role as a medication therapy expert who were mindful of their boundaries as a health professional in training, employed evidence, and collaborated with the patient to provide them with patient-centred pharmacy care, Subtheme #2.1 Pharmacy learners as patient-centred medication therapy experts, and Subtheme #2.2 Pharmacy learners acknowledging their capabilities. Correspondingly, patients acknowledged the mutually valuable relationship and symbiotic alliance they had with pharmacy learners, where patients were essentially active recipients of care during which learners got to practice and refine their clinical, professional, and interpersonal skills. On the other hand, in Chapter 5, pharmacy learners primarily thought that patients were positioned to assess their intrinsic and formal pharmacy skills as clinicians with medication expertise, Subtheme #1.1 Pharmacy learners as medication therapy experts, Subtheme #1.2 Pharmacy learners as patient-centred team players, Subtheme #1.3 Pharmacy learners providing exemplary patient care, and Subtheme #1.4 Professionalism is a âstate of mindâ. After analyzing the learnerâs narratives, I was able to map their perspectives within the pharmacist Educational Outcomes outlined by The AFPC which included Care Provider (CP), Communicator (CM), Collaborator (CL), Scholar (SC), Professional (PR), and to a lesser extent the Health Advocate (HA) role. Specifically, learners identified their formal pharmacy skills as 1) medication therapy experts (knowledge base, patient education, and implementation of evidence); 2) collaborators with the patient and their other health care providers; 3) clinicians optimizing patient health; and 4) professional health care providers (presentation, integrity, respect, trust, and ethical practice). However, learners recognized the patientâs role in assessing their knowledge would sometimes be limited to the communication aspect of it or in other words the means of the knowledge conveyed rather than its actual content. 143 Accordingly, learners acknowledged the importance of their communication skills and assumed that, owing to the nature of interactions with patients, patients could observe some components of the learnerâs humanistic role as a communicator, Subtheme #2.1 Pharmacy learners as patient-centred communicators. These components encompassed empathy, language, assertiveness, efficiency, clarity, timeliness, and style of communication. Overall, learners welcomed the formative assessment role of the patient perspective on their skills and acknowledged its value, credibility (Moreau et al., 2019) and complementary role to preceptor feedback as long as it was nonthreatening, nonjudgmental, had no bearing on the learner's formal evaluation, or jeopardized their position as a pharmacy professional in training (Davies & Lunn, 2009). Learners also deemed the patient perspective as real-world feedback rather than just reiterating theoretical principles and pharmacy concepts to their preceptors reflecting Wykurz and Kelly's (2002) value-added impact (Davies & Lunn, 2009). With this in mind, it is notable that some of this study findings are affirmed by research conducted by Moreau and colleagues (2016) where parents of pediatric patients expressed their capability to assess what the authors termed ânon- technicalâ skills of the medical trainees who cared for their children. Similarly, parents expressed their capability to assess the medical trainee communication skills which included trainee self-identification, active listening, and use of non-jargon plain language when interacting with parents (Moreau et al., 2016). In the same study, medical trainees echoed the caregiver perspectives regarding their position in assessing the âcommunicator roleâ of the trainee (Moreau et al., 2016). Additionally, findings from a study by Coelho and team (2018) are consistent with this thesis work where patients also believed they were âbest placedâ to provide feedback and comment on the communication skills of the dental trainees who treated them. Altogether, these findings support the idea that patient feedback might provide useful and unique insight into pharmacy learner communication skills. A recent paper by 144 Schuwirth and van der Vleuten (2020) discusses the future demands of the health care workforce with respect to health professional skills and how such needs would dictate a rethinking of our assessment strategies. The authors argued that in future circumstances, patients will almost certainly require someone to collaborate with them and assist them in navigating their sickness, as well as someone to help them make sense of their medical condition (Schuwirth & van der Vleuten, 2020). For this purpose, health care professionals will need to possess a variety of skills, abilities, and competencies, most likely in the humanistic realm (Schuwirth & van der Vleuten, 2020). 7.2.3 Contextualizing Chapter 6 Key Findings The work presented in Chapter 6 was guided by findings highlighted in Chapter 2 with respect to patient feedback delivery specifically feedback means (verbal or written) and patient-related factors with potential influence on the feedback process. Maintaining an equilibrium with respect to patient and learner participantsâ preferences on feedback delivery seems challenging. This was demonstrated in the conflicting areas presented in Chapter 6 where patient and pharmacy learner participants shared mixed opinions on feedback practicalities, each arguing with their personal justification, on 1) the feedback means (verbal or written); 2) timing (prompt or delayed); and 3) supervisor involvement in the feedback loop. Offering their feedback in a written/documented format was the preferred means for patients who had disclosure issues around anonymity (Coelho et al., 2018) or appreciated having questions to guide their thought process. Other patients chose to avoid any bothersome or uncomfortable circumstances that might be created if they were to offer their feedback verbally and directly to the learner who cared for them. On the other hand, some patients perceived verbal feedback to provide more autonomy and a room for conversation with the pharmacy learner. In terms of feedback 145 timing, some patients preferred to provide instant feedback so that their memory would aid them in recalling what occurred throughout their meeting with the pharmacy learner. Conversely, many patient participants appreciated postponing their feedback to a later time. Either because it was difficult for them, both mentally and physically, to provide comments right after their interaction with the pharmacy learner or they believed time would allow them to evaluate their engagement with the learner, reflect on what occurred, and avoid leaping to conclusions or making false assumptions. Few patients welcomed giving their feedback directly to the learner whom they interacted with and thought it would be a more beneficial learning experience doing so. Nevertheless, other patients showed some vulnerability to offering their feedback firsthand to the learner. The patients voiced certain concerns and challenges around discomfort and confrontational sensitives and believed preceptor support would be needed to increase the feedback credibility and acceptability by the learner. According to these patients, in order to boost the feedback legitimacy, they wanted the preceptor to take ownership of the feedback process rather than themselves, delivering the feedback to the learner on the patientâs behalf (Coelho et al., 2018). Comparatively, learner participants frequently intermingled their preferred means of patient feedback with or without the learner's preceptor presence in the feedback loop. Verbal feedback straightforwardly voiced from the patient to the learner was favored by learners who regarded it as a personal learning experience, were concerned if the preceptor would accidentally miscommunicate the patient's comments, the patient's words might then be lost in translation, or were seeking a direct affirmation from the patient on the learner performance. On the contrary, echoing the same perspectives shared by some patient participants, learners appreciated a written patient feedback via the preceptor either to maintain the patient anonymity and subsequent comfort level or to allow for 146 learner progress and improvement by having the preceptor assist the learner in articulating the patient's words for the learner's best interests. Overall, the practicality of feedback norms should be in tandem with the notion of patient-centred care taking into consideration patient-related factors and characteristics which were comprehensively discussed in Chapter 6 Bleakly and Bligh (2008) proposed a constructive framework for clinical education that shifts from the traditional paternalistic viewpoint in which the supervisor (as the teacher) communicates with the student (as the learner) with the patient (passively) providing a supportive role to one in which the patient (as the educator) and the student (as the educator and co-learner) actively work together while the supervisor provides support (Coelho et al., 2018). In this situation, however, patients are primarily viewed as co-educators rather than patient educators, and supervisors are included for their supportive role owing to their expertise (Coelho et al., 2018). 7.3 Strengths There are notable strengths and limitations associated with my thesis that are worth highlighting and considering when interpreting the thesis findings. A reminder that the specific strengths and limitations of the scoping review study are discussed in Chapter 2, Section 2.5. To begin with the strengths, the work presented in this thesis is of sequential nature since the research question and interview topic guide of the interpretive description study in Chapters 3-6 were both informed by a comprehensive and an extensive scoping review of over 8700 published studies as presented and discussed in Chapter 2. In terms of the qualitative study design, the convenience sampling strategies that I implemented during participant recruitment phase maximized diversity across study participants (Manio, 2018). The interviewing approach provided me with an 147 exceptional opportunity to gather rich data from multiple stakeholders, comparing and contrasting the perspectives of both patients and pharmacy learners (Manio, 2018). It also allowed for time for reflection and communication of insights of participant perspectives on numerous aspects of patient feedback on pharmacy learner skills (Manio, 2018) and illuminated additional thought-provoking findings beyond the scope of this thesis. Additionally, qualitative interview data collection techniques can allow for deep contemplation and insights, allowing for affirmation of practices and lobbying for change when necessary (Manio, 2018; Qu & Dumay, 2011). Both interview topic guides (patients and pharmacy learners) were developed after a thorough literature review and were adopted from research done in medical education which involved navigating patient and medical trainee perspectives on patient participation in the assessment of medical trainees (Eady & Moreau, 2017; Moreau et al., 2016; Moreau et al., 2019). Moreover, piloting the interview topic guides with non-participants before implementing the full study helped me determine issues with the clarity and wording of the interview questions where I subsequently adjusted according to the intervieweesâ feedback. This facilitated the technicalities and flow of the interviewing process with the study participants. A major strength of this thesis is the triangulation efforts (Tracy, 2010) and collaborative work undergone by the research team members throughout the research process, including literature review, study design, data analysis, and interpretation of findings. Each team member contributed differently with their unique expertise and vast knowledge as academics, educators, clinicians, preceptors, and researchers. Specifically, including three researchers during the literature review, analysis, and coding phases enhanced the credibility, rigour, and trustworthiness of my thesis findings. 148 7.4 Limitations Among the limitations of the interpretive description study presented in Chapters 3-6 and that is important to acknowledge, despite being unavoidable, pertains to accessibility issues due the virtual nature of the data collection and participant recruitment processes as dictated by COVID-19 restrictions halting all in-person and social interactions. Since the initial contact with potential research participants (patients and pharmacy learners) was done via email communications, my recruitment was limited to individuals with internet access and technology literacy. Another limitation of the interpretive description study is the characteristics of the patient participants who are receiving care at the study site (UBC Pharmacists Clinic). Similar to research questions answered using qualitative research approaches, it is worth acknowledging that this study findings are contextual and should be interpreted as such, respective of the study site and participant demographics and information. As previously mentioned in Chapter 3, patients seen at the UBC Pharmacists Clinic are ambulatory, complex and were diagnosed with several medical conditions for which they are receiving multiple medications. Therefore, patient participants in my study share a unique characteristic of having an extensive experience as care recipients within the health care system who interacted with multiple health care professionals across their patient care journey. However, because this thesis only involves ambulatory patients, the opinions of acutely ill patients who require hospitalization, their family members, or caregivers on their needs and choices for learner feedback involvement might differ from those of the patient participants represented here. Additionally, forty-precent of patient participants received health professional training which might have played a role in shaping their perspectives of the pharmacy learner skills as discussed in Chapter 6. Another reminder that all research participants (patients and pharmacy learners) willingly and voluntarily joined the study without any prespecified obligations or mandates. It might be that 149 the study participants were more proactive, motivated, outspoken, or had a particular interest in the research topic (Moreau et al., 2016) that fueled their willingness to be part of the study. For this reason, I cannot eliminate the possibility that the individuals who participated in my study held different perspectives and views compared to those who did not (Moreau et al., 2016). Furthermore, as stated in Chapter 5, participating pharmacy learners chronicled their perspectives on their skills that they thought patients could assess based on their patient care experience within the community pharmacy practice where the patient care operates at different logistics and pace as compared to other pharmacy settings. On the other hand, as presented in Chapter 6, patient participants drew upon their interactions with the pharmacy learners in an outpatient care site (The UBC Pharmacists Clinic). An ambulatory care setting such as the Clinic fosters longitudinal patient-pharmacy learner relationships in comparison with the community pharmacy where pharmacy learners might not necessarily have subsequent interactions with patients. Consequently, the specific dynamics of the pharmacy care setting might have an influence on shaping the patient perspectives of the pharmacy learner skills in addition to the relationships the patients establish with the learner. 7.5 Research Implications for Pharmacy Education and Practice This thesis contributes to understanding how patients are already involved and included in assessing health professional trainees specifically in medicine, nursing, dentistry, social work, and radiotherapy disciplines, as discussed in Chapter 2, in addition to offering potential and new opportunities for how patients could participate in pharmacy learner assessment and feedback processes as presented in Chapters 3-6. Specifically, the interpretive description study is unique in that it is the first of its kind not only in Canada but also in North America to provide real patients with a space to voice their perceptions of pharmacy learner skills. This study did not only have a 150 single but dual pioneer purpose, informing patient-centred pharmacy education and practice driven changes through emphasizing patient involvement in pharmacy learner assessment process. The study also proposes a potential avenue of pharmacy learner assessment grounded in real-life circumstances by including the patient perspective as part of the feedback process complementing feedback pharmacy learners receive from other sources (preceptor/supervisor). Accordingly, findings from this study break ground towards better ways to training the next generation of competent pharmacy learners and contribute to shaping the future direction of competency-based assessment (Delisle & Nash, 2017). Overall, this thesis has broader educational and societal implications for learning routes and revising university curriculums such as course design and delivery to be congruent with patientsâ expectations, preferences, and needs in addition to offering guidance on preparing pharmacy learners for their roles as future patient-centred frontline care providers, so that society will benefit more fully from our training programs. As discussed in Chapter 3, Section 3.4, the AFPC defined ideal societal pharmacist contribution by providing Educational Outcomes for the Entry-to-Practice Pharmacy degrees in Canada. Ideally, pharmacy learners across Canada are trained to abide by the expectations outlined by The Association of Faculties of Pharmacy of Canada (AFPC). The overall aim of pharmacy programs is to graduate patient-centred pharmacists in Canada who would occupy clinical patient care positions within the health care system with the aid of their medication therapy expertise (Association of Faculties of Pharmacy of Canada, 2017). While Canadian pharmacy programs claim they are implementing patient-centred pharmacy teaching and training within their curricula, the patient perspective on the learnerâs assessment, a core component of the learnerâs educational process, has been neglected until this thesis work. Comparing and contrasting the 151 patient and learner perspectives, findings from my study shed light on several humanistic aspects of pharmacy learner care where the AFPC Educational Outcomes fall short. 7.6 Future Research Directions The interpretive description study offers novel insights to establish a roadmap for future research and provide a fertile ground for soliciting direct patient feedback of the pharmacy learners who care for them. The data collected for this research illuminated additional findings beyond the scope of this thesis. These data suggest that the practicalities around the process and implementation of patient feedback systems are further areas for exploration in future research. As pharmacy educators, we should focus on informing patient-driven changes in the training of future pharmacists, so patients are offered with high-value patient-centred care that they not only expect but also deserve. In addition, future research should investigate preceptor-mediated coaching sessions, in which preceptors would help pharmacy learners comprehend patient feedback by discussing their reactions to it and supporting development of resulting action plans (Moreau et al., 2019; Sargeant et al. 2011). I wholeheartedly believe that it is our collective responsibility as health professions educators and institutions, and we owe it to our patients and our community at large. Specifically, the onus is on pharmacy educators, curriculum designers, and policy makers to not only bring patient and community voices into pharmacy education but also to align their training programs with patientsâ expectations and needs. Therefore, to be congruent with the patient-centred teaching pharmacy programs in Canada pride themselves on, educators must address the highlighted mismatch between the pharmacy learner skills patients appreciate versus what pharmacy learners are trained to achieve and demonstrate as outlined by the AFPC. This thesis provides a starting point 152 for enhancing pharmacy curricula and the AFPC Educational Outcomes to include the patient voice in pharmacy learner skill assessment. Therefore, when considering the training of the next generation of pharmacists, it is important for pharmacy educators, researchers, curriculum designers, and policy makers to diversify pharmacy training and education accounting for inclusive assessment opportunities that would invite the patient perspective. 1) Pharmacy curriculums and training programs are the first and best places to start. Based on my interpretive description study findings, I call for fundamentally restructuring the pharmacy curricula and training programs to include structured patient perspectives in competency-based assessment of pharmacy learners. The thesis findings should encourage educators to synchronize patient perspectives with the content and curricula of their pharmacy training programs, a key to providing a patient-centred pharmacy care that aims to acknowledge patient preferences and respect their values and needs. In addition to the importance of having patients actively involved in pharmacy learner assessment, this thesis provides guidance on how much active involvement of patients is feasible (Suikkala et al., 2018). 2) I suggest the translation of findings into program level change in pharmacy practice and education towards implementing a patient feedback process/tool informed by the patient and pharmacy learner perspectives while considering the factors discussed within this thesis that might contribute to or constrain the patient feedback process. This is particularly important given that findings of the interpretive description study have demonstrated a mismatch between patient and learner perspectives on pharmacy learner skills patients could 153 assess. Accordingly, the feedback process/tool should account for the humanistic domains of pharmacy learner skills highlighted by patient participants in Chapter 4 together with the formal intrinsic pharmacy skills outlined in the AFPC Educational Outcomes and shared by learner participants in Chapter 5. As highly emphasized in this thesis, the patient feedback process should be patient-centred. Therefore, when implementing patient feedback, pharmacy programs should also consider the components of patient feedback delivery previously discussed in Chapter 6 such as patient willingness, comfort level, preceptor involvement, feedback means, timing, and patient-related factors (see Figure 6-1). One important factor to also consider is having the patient input as an enabler rather than a barrier, deterrent, or potential threat for the pharmacy learner education and training process. This was indeed underlined in learnersâ perspectives presented in Chapter 5. With that said, the patient perspective should be solicited in the form of a low stakes feedback without the intention of having it graded or included in the formal pharmacy learner evaluation. Involving patients in pharmacy learner assessment and feedback processes should be an opportunity for learner professional growth and improvement while in tandem with the notion of patient-centredness. 3) On a broader level, the findings warrant system level change. The thesis emphasizes an imminent need for the members of the AFPC Task Force, representatives from individual Faculties of Pharmacy within Canada as well as pharmacy stakeholders to revisit the AFPC Educational Outcomes integrating patient informed AFPC Educational Outcomes rather than having patients as bystanders. Regrettably, most of the aspects of pharmacy care proposed by the AFPC entailed the intrinsic clinician role of future pharmacists whereas, 154 based on this thesis findings, patients could principally observe and subsequently comment the role of pharmacy learners as humans. Some of the gaps in the AFPC Educational Outcomes that were highlighted based on the perspectives of the patient participants fall under the pharmacy learner communication skills which include 1) welcoming and greeting the patient; 2) pharmacy learner self-identifying and describing their role; 3) building rapport with the patient; 4) flexibility and adopting an open mind; 5) making the patient feel comfortable; and 6) acknowledging the patientâs lived experiences as information resources. 7.7 Conclusion Despite movement towards patient-centred teaching, real patient involvement in the education of pharmacy learners, beyond their role as recipients of pharmacy care, has been overlooked. While there has been great emphasis and extensive work on patient involvement in the assessment of medical and nursing trainees, little attention has been paid to pharmacy learners in training. In spite of some overlap, I would argue that patients would not necessarily hold similar expectations of pharmacy learners owing to the differences in the nature of interactions as compared to medicine and nursing training professionals. Pharmacy curricula and training programs must reflect patient care within the real clinical practice setting (Sánchez, 2011) and this can only be achieved by integrating the patient perspective within pharmacy programs. This in turn underlines how engaging patients in pharmacy learnersâ educational experience through soliciting their insights of learnersâ skills would tackle a pivotal element in the journey of pharmacy care delivery. The interpretive description study provides an initial understanding of and demystifies how patients could participate in pharmacy learner workplace-based assessment. 155 Findings from this thesis, together with future research, can help create and execute patient feedback processes/tools. They can also aid in the promotion of the use of patient input for assessment of pharmacy learners in a workplace-based context. In addition, the interpretive description study findings imply that pharmacy programs should take into account not only the process of gathering feedback but also how it is communicated to pharmacy learners (Bogetz et al., 2017). The outcomes of this study taken together (patient and learner perspectives), support the argument that patient input can provide useful and unique insight into pharmacy learner skills. 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Medical Teacher, 40(2), 188â192. https://doi.org/10.1080/0142159X.2017.1395833 185 Appendices Appendix A Appendix A-1: Definitions of Patient Roles in Health Professional Education Patient Role Definition Standardized or Simulated Patients (SPs)* *The terms simulated and standardized are often used interchangeably (Hudson & Ratnapalan, 2014) â¢ âTrained actors portraying real patients in the clinical settingâ (Kalet, 2017) â¢ âSpecially trained laypersons who present learned symptoms or diseases in a standardized, non-varying manner for didactic purposesâ (Krautter et al., 2017, p. 2) â¢ Patients who do not actually have a condition or a disease and whose portrayal of either is part of role-playing or training they have received to represent a certain illness or medical condition they do not have (Towle et al., 2010) Patient Volunteers âPatients who volunteer for educational purposesâ (Hudson & Ratnapalan, 2014, p. 674) Virtual Patients Patients used in medical education in the form of online tools for trainees to learn clinical skills (Hudson & Ratnapalan, 2014) Patient Partners âA patient (or caregiver or other person with lived experience) who is a partner or collaborator on a research teamâ (Richards et al., 2020, p. 1) Health Mentors/Patient Tutors/Patient Educators âAn adult with one or more chronic conditions or impairments currently receiving care from one or more healthcare providersâ (Umland et al., 2016, p. 219 and 220) âSomeone with a chronic condition (an 'expert by experience')â (Towle et al., 2014, p. 301) Real Patients âSomeone who has a direct lived experience with the disease and/or condition they sought to displayâ (Rowland et al., 2019, p. 602) and is receiving care for this condition 186 Appendix B Appendix B-1: PRESS - Search Submission & Peer Review Assessment SEARCH SUBMISSION: THIS SECTION TO BE FILLED IN BY THE SEARCHER Name of searcher: Vanessa Kitchin E-mail: vanessa.kitchin@ubc.ca Date submitted: 2020-Mar-27 Date needed by: ASAP Note to peer reviewers â please enter your information in the Peer Review Assessment area Scoping review title: Patient Participation in Workplace-based Assessment of Health Professional Trainees: A Scoping Review This search strategy is â¦ x My PRIMARY (core) database strategy â First time submitting a strategy for search question and database My PRIMARY (core) strategyâ Follow-up Review NOT the first time submitting a strategy for search question and database. If this is a response to peer review, itemize the changes made to the review suggestions. SECONDARY search strategy â First time submitting a strategy for search question and database SECONDARY search strategy â NOT the first time submitting a strategy for search question and database. If this is a response to peer review, itemize the changes made to the review suggestions. Database & Interface (i.e. Ovid MEDLINE, EBSCO CINAHLâ¦): [mandatory] Ovid MEDLINE Research question (Describe the purpose of the search) [mandatory] The purpose of this scoping review is to understand how patients participate in the assessment of trainees in health professions education. 187 PICOS format (Outline the PICOS for your question, i.e Patient, Intervention, Comparison, Outcome, and Study Design, as applicable) P medical students/health professions students I patient participation & patient feedback C N/A O assessment S N/A Inclusion criteria (List criteria such as age groups, study designs, etc. to be included) [optional] Exclusion criteria (List criteria such as study designs, date limits, etc. to be excluded [optional] Date limit = 2009 Was a search filter applied? NO If YES, which one(s)? (e.g., Cochrane RCT filter, PubMed Clinical Queries filter) Provide the source if this is published filter [mandatory if YES to previous question] Other notes or comments (that might be useful for the peer reviewer)? [optional] This search is looking at undergraduate medical education specifically. Please âcopy and pasteâ your search strategy below (exactly as run, including the number of hits per line) [mandatory] Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions(R) <1946 to present> 1 exp Students, Medical/ 2 "Internship and Residency"/ 3 resident*.mp. 4 medical undergraduate*.mp. 5 (medical adj2 student*).mp. 6 Education, Medical/ 7 educat*.mp. 8 teach*.mp. 9 learn*.mp. 10 competenc*.mp. 11 skill*.mp. 188 12 train*.mp. 61123 13 Patient Participation/ 14 ((patient or parent or caregiver or guardian) adj2 (assess* or participat* or involve* or inclusion or feedback or evaluat*)).mp. 15 service user*.mp. 16 or/1-5 17 or/6-12 18 or/13-15 19 16 and 17 and 18 20 OSCE.mp. 21 19 not 20 22 limit 21 to yr="2009 -Current" PEER REVIEW ASSESSMENT: THIS SECTION TO BE FILLED IN BY THE REVIEWER Statement of Confidentiality I agree to hold all information contained in this worksheet and submission form as confidential and understand that materials may not be shared outside PRESS forum or used for any competing purpose without the written permission of the librarian who submitted the search for peer review. Type âyesâ to indicate agreement): Yes Peer reviewerâs name: T Fyfe Date completed: May 21, 2020 Please select the one most appropriate answer for each element No revisions Revision(s) suggested Revision(s) required 1. Translation of research question x 2. Boolean & proximity operators x 3. Subject headings x 4. Text word searching x 5. Spelling, syntax & line numbers x 6. Limits and filters x Overall evaluation* * If one or more ârevision(s) requiredâ is noted above, overall evaluation must be ârevision(s) requiredâ Additional comments: 189 Subject Headings: - Consider adding the following MeSH: patient satisfaction/ or feedback/ Text word searching: Line 3: change resident* to residen* (for residency or residents) Line 14: truncate âpatient* or parent* or caregiver* or guardian*â Syntax: Line 21: what is the rationale for notting OSCE? Limits: Line 22: What is the date limit rationale? 190 Appendix B-2: Search Strategy Table B-1 - Search Terms Used in Scoping Review Categorized by Databases and Health Care Professions *Limits: English Language and Time Frame (2009-2020) Database Search Terms* MEDLINE Medicine Students, Medical/ OR âInternship and Residency"/ OR resident* OR medical undergraduate* OR (medical adj2 student*) AND Education, Medical/ OR educat* OR teach* OR learn* OR competenc* OR skill* OR train*AND Patient Participation/ OR ((patient or parent or caregiver or guardian) adj2 (assess* or participat* or involve* or inclusion or feedback or evaluat*)) OR service user* NOT OSCE Nursing + Other Health Professions Students, Health Occupations/ OR ((nurs* or pharmacy or dentistry or dental or physical therap* or occupational therap* or dietician or dietetic* or nutrition* or paramedic or EMT or respiratory therap* or social work*) adj2 (student* or school or education)) OR education, pharmacy/ or education, pharmacy, graduate/ or pharmacy residencies OR Education, Nursing OR education, professional/ or education, dental AND educat* OR teach* OR learn* OR competenc* OR skill* OR train* AND Patient Participation/ or quality improvement/ or caregivers OR ((patient* or parent* or caregiver* or guardian*) adj2 (assess* or participat* or involve* or inclusion or feedback or evaluat*)) OR service user* NOT OSCE EMBASE Medicine medical student OR resident OR resident* OR medical undergraduate* OR (medical adj2 student*) AND medical education/ or residency education OR educat* OR teach*OR learn* OR competenc* OR skill* OR train* AND patient participation OR ((patient or parent or caregiver or guardian) adj2 (assess* or participat* or involve* or inclusion or feedback or evaluat*)) OR service user* Nursing + Other Health Professions (nurs* or pharmacy or dentistry or dental or physical therap* or occupational therap* or dietician or dietetic* or nutrition* or paramedic or EMT or respiratory therap* or social work*) adj2 (student* or school)) OR pharmacy student AND dental student AND nursing student AND physical therapy student AND occupational therapy student AND paramedical student AND social work student AND educat* OR teach* OR learn* OR competenc* OR skill* OR train* OR nursing education OR dental education AND patient participation OR ((patient or parent or caregiver or guardian) adj2 (assess* or participat* or involve* or inclusion or feedback or evaluat*) OR service user* NOT OSCE 191 Database Search Terms* (Continued) CINAHL Medicine + Nursing ("Students, Medical") OR (âStudents, Nursing+") OR resident* OR (medical OR nurs*) undergraduate* OR (medical or nurs*) AND student* AND ("Education, Medical+") OR (âEducation, Nursing+") OR educat* OR teach*OR learn* OR competenc* OR skill* AND ("Consumer Participation") OR (patient or parent or caregiver or guardian) AND (assess* or participat* or involve* or inclusion or feedback or evaluat*) OR service user* NOT OSCE Other Health Professions ("Education, Pharmacy") OR dental education OR ("Education, Dental") OR health profession* education OR (pharmac* or dentistry or dental or physical therap* or occupational therap* or dietician or dietetic* or nutrition* or paramedic or EMT or respiratory therap* or social work*) AND (student* or education) AND educat* OR teach* OR learn* OR competenc* OR skill* OR train* AND (patient* or parent* or caregiver* or guardian*) AND (assess* or participat* or involve* or inclusion or feedback or evaluat*) OR ("Consumer Participationâ) NOT OSCE ERIC Medicine + Nursing ("Medical Students") OR (âNursing Students") OR resident* OR (medic* OR nurs*) (undergraduate* OR resident* OR student* OR intern* OR educat*) AND ("Medical Education") OR (âNursing Education") OR educat* OR teach* OR learn* OR competenc* OR skill* OR train* AND "Feedback (Response)" OR (patient* OR parent* OR caregiver* OR guardian*) N2 (assess* OR participat* OR involv* OR inclusion OR feedback OR evaluat* OR "service user*" Other Health Professions (âDental Education") OR (pharmac* or dentistry or dental or physical therap* or occupational therap* or dietician or dietetic* or nutrition* or paramedic or EMT or respiratory therap* or social work*) N2 (student* or education or residen* or intern*) OR health profession* education AND educat* OR teach* OR learn* OR competenc* OR skill* OR train* OR "Feedback (Response)" AND (patient* OR parent* OR caregiver* OR guardian*) N2 (assess* OR participat* OR involv* OR inclusion OR feedback OR evaluat* OR âservice user*" Web of Science Medicine + Nursing ((medical OR nurs*) OR (undergraduate* OR student*)) AND (educat* OR teach* OR learn* OR competenc* OR skill*) AND ((patient or parent or caregiver or guardian or âservice user*â) AND (assess* or participat* or involve* or inclusion or feedback or evaluat*)) 192 Database Search Terms* (Continued) Web of Science Other Health Professions (Pharmacy or dentistry or dental or physical therap* or occupational therap* or dietician or dietetic* or nutrition* or paramedic or EMT or respiratory therap* or social work*) AND (educat* OR teach* OR learn* OR competenc* OR skill* OR train*) AND ((patient or parent or caregiver or guardian or "service user*") AND (assess* or participat* or involve* or inclusion or feedback or evaluat*)) PsycINFO Medicine + Nursing ("Medical Students") OR ("Nursing Students") OR resident* OR (medical OR nurs*) undergraduate* OR (medical or nurs*) AND student* AND (âMedical Education" OR âMedical Residency") OR (âNursing Education") OR educat* OR teach* OR learn* OR competenc* OR skill* OR train* AND (patient* or parent* or caregiver* or guardian*) AND (assess* or participat* or involve* or inclusion or feedback or evaluat*) OR "Feedback" OR service user* NOT OSCE Other Health Professions (pharmac* or dentistry or dental or physical therap* or occupational therap* or dietician or dietetic* or nutrition* or paramedic or EMT or respiratory therap* or social work*) AND (student* or education) AND educat* OR teach* OR learn* OR competenc* OR skill* OR train* OR (âDental Education") OR health profession* education AND (patient* or parent* or caregiver* or guardian*) AND (assess* or participat* or involve* or inclusion or feedback or evaluat*) NOT OSCE 193 Appendix B-3: Data Extraction Form CITATION COUNTRY STUDY SETTING AND PARTICIPANTS â¢ Discipline: â¢ Site/Context: â¢ Study Population: â¢ Inclusion Criteria: STUDY OBJECTIVES METHODS â¢ Study Design: â¢ Theoretical Framework: â¢ Data Collection: â¢ Data Analysis: OUTCOMES RESULTS CONCLUSION 194 Appendix C Appendix C-1: Definitions of the AFPC Educational Outcomes Role Definition and Key Competencies Care Provider (CP) Pharmacy learners provide patient-centred care while continuously contributing to the improvement of patient safety and quality of health care Communicator (CM) Pharmacy learners communicate effectively in a team-based approach using professional and simple language Collaborator (CL) Pharmacy learners work collaboratively with patients and other health professionals to provide efficient and safe health care Leader-Manager (LM) Pharmacy learners engage with others to optimize the efficiency and quality of health care while demonstrating leadership and management skills Health Advocate (HA) Pharmacy learners use their pharmacy expertise and background to respond to and advance the health needs of individual patients as well as communities Scholar (SC) Pharmacy learners integrate medication therapy expertise with the best available evidence to teach fellow pharmacists, students, other health care professionals and the public Professional (PR) Pharmacy learners have high behavioral standards in delivering pharmacy care to patients while considering ethical aspects Adapted from the AFPC (2017) Educational Outcomes for First Professional Degree Programs in Pharmacy in Canada 2017. 195 Appendix C-2: Letter of Initial Contact (Patient Participants) INVITATION TO PARTICIPATE IN A RESEARCH STUDY TITLED: âLet the Patient Teach: Patientâs Voice in Workplace-Based Assessment of Pharmacy Learnersâ Researchers at the UBC Faculty of Pharmaceutical Sciences are inviting you to take part in this study because you have been provided with a supervised care by a pharmacy student at the UBC Pharmacists Clinic. The purpose of this study is to learn more about which skills demonstrated by pharmacy students can patients provide feedback on and assess. This study is being conducted as part of a masterâs graduate student research. Your perspectives will contribute to pharmacy studentsâ training and skill development. Your participation in this study is entirely voluntary and your decision to participate will not affect the level or quality of care you receive at the UBC Pharmacists Clinic nor your relationship with the UBC or the UBC Pharmacists Clinic. If you are interested to know more about the study, a researcher will provide you with further information. If you decide to participate, we will kindly ask you to sign an informed consent form. A researcher will then conduct a virtual interview with you at your convenience through a telephone call or online via a secure and private platform called Zoomâ¢ (audio or videoconference calls) depending on your preference. Participants will be offered a 25$ gift card as a token of appreciation for their time. The gift card will be sent to participants following their participation in the virtual interviews. You may choose to withdraw your participation at any stage and your relationship with the UBC or the UBC Pharmacists Clinic will not be changed in any way, and you may request withdrawal of your data If you have any questions or you would like to participate, please contact either, 1. Dr. Arwa Nemir â arwa.nemir@alumni.ubc.ca Master of Science Student at the UBC Faculty Pharmaceutical Sciences OR 2. Dr. Jillian Reardon - jillian.reardon@ubc.c Clinical Pharmacist at the UBC Pharmacists Clinic Principal Investigator: Dr. Kerry Wilbur 196 Appendix C-3: Letter of Initial Contact (Learner Participants) INVITATION TO PARTICIPATE IN A RESEARCH STUDY TITLED: âLet the Patient Teach: Patientâs Voice in Workplace-Based Assessment of Pharmacy Learnersâ Researchers at the UBC Faculty of Pharmaceutical Sciences are inviting you to take part in this study because you have been training at the UBC Pharmacists Clinic. The purpose of this study is to learn more about pharmacy students' perspectives regarding what feedback they think patients can provide on pharmacy studentsâ skills. This study is being conducted as part of a masterâs graduate student research. Your perspectives will contribute to pharmacy studentsâ training and skill development. Your participation in this study is entirely voluntary and your decision to participate will not affect your academic standing or evaluations as a pharmacy student at the UBC Faculty of Pharmaceutical Sciences nor your relationship with the UBC or the UBC Pharmacists Clinic. If you are interested to know more about the study, a researcher will provide you with further information. If you decide to participate, we will kindly ask you to sign an informed consent form. A researcher will then conduct a virtual interview with you at your convenience through a telephone call or online via a secure and private platform called Zoomâ¢ (audio or videoconference calls) depending on your preference. Participants will be offered a 25$ gift card as a token of appreciation for their time. The gift card will be sent to participants following their participation in the virtual interviews. You may choose to withdraw your participation at any stage and your relationship with the UBC or the UBC Pharmacists Clinic will not be changed in any way, and you may request withdrawal of your data. If you have any questions or you would like to participate, please contact either, 3. Dr. Arwa Nemir â arwa.nemir@alumni.ubc.ca Master of Science Student at the UBC Faculty Pharmaceutical Sciences OR 4. Dr. Jillian Reardon - jillian.reardon@ubc.c Clinical Pharmacist at the UBC Pharmacists Clinic Principal Investigator: Dr. Kerry Wilbur 197 Appendix C-4: Consent Form (Patient Participants) Study Title: âLet the Patient Teach: Patientâs Voice in Workplace-Based Assessment of Pharmacy Learnersâ Who is doing this study? Principle Investigator: Dr. Kerry Wilbur Associate Professor. & Executive Director, Entry-to-Practice Education Faculty of Pharmaceutical Sciences, the University of British Columbia Co-investigators: Dr. Arwa Nemir Master of Science (MSc) Student Faculty of Pharmaceutical Sciences, the University of British Columbia Dr. Jillian Reardon Clinical Pharmacist and Lecturer UBC Pharmacists Clinic Faculty of Pharmaceutical Sciences, the University of British Columbia While reading this consent form please, keep in mind the following: â¢ Your participation in this study is completely voluntary and it is entirely up to you whether you would like to participate in this study or not â¢ If you choose not to participate, your relationship with the University of British Columbia (UBC) and the UBC Pharmacists Clinic will not be affected in any way â¢ We would also like to assure you that your decision to participate in this study will not affect the level or the quality of care you receive at the UBC Pharmacists Clinic â¢ You may choose to withdraw your participation at any stage and your relationship with the UBC or the UBC Pharmacists Clinic will not be changed in any way, and you may request withdrawal of your data The rest of this form describes the study. You are encouraged to discuss any questions you might have about the project with any of the study investigators. Why are we doing this study? â¢ The study investigators are inviting you to participate in a research project exploring which skills demonstrated by pharmacy students can patients provide feedback on and assess â¢ As someone who has been cared for by a supervised pharmacy student at the UBC Pharmacists Clinic, your input is valuable â¢ This study is being conducted as part of a masterâs graduate student research 198 What happens if you take part? â¢ If you agree to participate, you will be asked to sign two copies of this informed consent form either as an electronic signature or, if possible, you could print the consent forms to sign as hardcopies then scan them â¢ You will send a copy of the signed consent form to one of the co-investigators, Dr. Nemir, via email while the other copy will remain with you â¢ Dr. Nemir will conduct a virtual interview with you through a telephone call or online via a secure platform called Zoomâ¢ (audio or videoconference calls) depending on your preference â¢ If you prefer to use Zoomâ¢, you will be asked to log in using only a nickname or a substitute name or research code that will be given to you ahead of time by Dr. Nemir. Also, you can turn off your camera, and you can mute your microphone (if it is not needed) â¢ The interview will take approximately 30-40 minutes at the date and time most convenient to you â¢ You will then be asked a series of questions relating to the pharmacy studentsâ skills â¢ The interview will be audio-recorded and transcribed into written text â¢ The research project findings will be shared with all participants at the studyâs conclusion Who can participate? â¢ Adult English-speaking patients â¢ Have received a direct supervised care from a pharmacy student (undergraduate pharmacy student and/or pharmacy resident) at the UBC Pharmacists Clinic What are the benefits, risks, and discomforts from joining this study? â¢ Participants will be offered a 25$ gift card as a token of appreciation for their time â¢ The gift card will be sent to participants following their participation in the virtual interviews â¢ Although you may not directly benefit from participating in this study, your perspectives will contribute to pharmacy studentsâ training and skill development â¢ There are no physical risks or harms in participating in this study â¢ You will not be asked to disclose actual information about any individual student How will we maintain privacy and confidentiality? â¢ We will implement the following to ensure that privacy is maintained on both ends (patients and interviewee) 1) use personal phones; 2) use personal internet connection; 3) use personal email address (patients) and professional email address (interviewee); 4) be present in a private location during the interview; and 5) communicate via a private platform that uses end-to-end encryption such as Zoomâ¢. The Zoomâ¢ invitation will be password protected so no uninvited participant can join â¢ The audio-recorded interview will be transcribed by a third-party (professional transcription company/software) and verified by Dr. Nemir â¢ This study will not use any names or personal identifiers of participants â¢ You will not be identified by name in the written transcripts â¢ Anonymous codes will be applied to participants in the transcription process 199 â¢ The interview audio-recording and written transcript will not be accessed by anyone except for the primary investigator (Dr. Kerry Wilbur) and one of the co-investigators (Dr. Arwa Nemir) â¢ Any data that you will provide us with will remain confidential and will not be shared with any of the team members at the UBC Pharmacists Clinic â¢ You will not be specifically identified as a study participant in any reports or publications of this research, but anonymized interview data may be used for future reports or publications of this research Have questions or problems? â¢ In the event that you have any questions about this study you can contact the Principal Investigator, Dr. Kerry Wilbur (kerry.wilbur@ubc.ca) or any of the coinvestigators, Dr. Arwa Nemir (arwa.nemir@alumni.ubc.ca) and Dr. Jillian Reardon (jillian.reardon@ubc.ca) at the Faculty of Pharmaceutical Sciences, the University of British Columbia â¢ If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e- mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598. 200 Appendix C-5: Consent Form (Learner Participants) Study Title: âLet the Patient Teach: Patientâs Voice in Workplace-Based Assessment of Pharmacy Learnersâ Who is doing this study? Principle Investigator: Dr. Kerry Wilbur Associate Professor. & Executive Director, Entry-to-Practice Education Faculty of Pharmaceutical Sciences, the University of British Columbia Co-investigators: Dr. Arwa Nemir Master of Science (MSc) Student Faculty of Pharmaceutical Sciences, the University of British Columbia Dr. Jillian Reardon Clinical Pharmacist and Lecturer UBC Pharmacists Clinic Faculty of Pharmaceutical Sciences, the University of British Columbia While reading this consent form please, keep in mind the following: â¢ Your participation in this study is completely voluntary and it is entirely up to you whether you would like to participate in this study or not â¢ If you choose not to participate, your relationship with the University of British Columbia (UBC) and the UBC Pharmacists Clinic will not be affected in any way â¢ We would also like to assure you that your decision to participate in this study will not affect your academic standing or evaluations as a pharmacy student at the UBC Faculty of Pharmaceutical Sciences â¢ You may choose to withdraw your participation at any stage and your relationship with the UBC or the UBC Pharmacists Clinic will not be changed in any way, and you may request withdrawal of your data The rest of this form describes the study. You are encouraged to discuss any questions you might have about the project with any of the study investigators. Why are we doing this study? â¢ The study investigators are inviting you to participate in a research project exploring which skills demonstrated by pharmacy students can patients give feedback on and assess â¢ As a pharmacy student who is training at the UBC Pharmacists clinic, your perspective is valuable â¢ This study is being conducted as part of a masterâs graduate student research 201 What happens if you take part? â¢ If you agree to participate, you will be asked to sign two copies of this informed consent form either as an electronic signature or, if possible, you could print the consent forms to sign as hardcopies then scan them â¢ You will send a copy of the signed consent form to one of the co-investigators, Dr. Nemir, via email while the other copy will remain with you â¢ Dr. Nemir will conduct a virtual interview with you through a telephone call or online via a secure platform called Zoomâ¢ (audio or videoconference calls) depending on your preference â¢ If you prefer to use Zoomâ¢, you will be asked to log in using only a nickname or a substitute name or research code that will be given to you ahead of time by Dr. Nemir. Also, you can turn off your camera, and you can mute your microphone (if it is not needed) â¢ The interview will take approximately 30-40 minutes at the date and time most convenient to you â¢ You will then be asked a series of questions relating to what feedback do you think patients can provide regarding pharmacy studentsâ skills â¢ The interview will be audio-recorded and transcribed into written text â¢ The research project findings will be shared with all participants at the studyâs conclusion Who can participate? â¢ Pharmacy students (undergraduate pharmacy students and/or pharmacy residents) who are training at the UBC Pharmacists Clinic What are the benefits, risks, and discomforts from joining this study? â¢ Participants will be offered a 25$ gift card as a token of appreciation for their time â¢ The gift card will be sent to participants following their participation in the virtual interviews â¢ Although you may not directly benefit from participating in this study, your perspective will contribute to pharmacy studentâs training and skill development â¢ There are no physical risks or harms in participating in this study â¢ You will not be asked to disclose actual information about any individual patient How will we maintain privacy and confidentiality? â¢ We will implement the following to ensure that privacy is maintained on both ends (students and interviewee) 1) use personal phones; 2) use personal internet connection; 3) use personal email address (students) and professional email address (interviewee); 4) be present in a private location during the interview; and 5) communicate via a private platform that uses end-to-end encryption such as Zoomâ¢. The Zoomâ¢ invitation will be password protected so no uninvited participant can join â¢ The audio-recorded interview will be transcribed by a third-party (professional transcription company/software) and verified by Dr. Nemir â¢ This study will not use any names or personal identities of participant â¢ You will not be identified by name in the written transcripts â¢ Anonymous codes will be applied to participants in the transcription process â¢ The interview audio-recording and written transcript will not be accessed by anyone except for the primary investigator (Dr. Kerry Wilbur) and one of the co-investigators (Dr. Arwa Nemir) 202 â¢ Any data that you will provide us with will remain confidential and will not be shared with any of the team members at the UBC Pharmacists Clinic â¢ You will not be specifically identified as a study participant in any reports or publications of this research, but anonymized interview data may be used for future reports or publications of this research Have questions or problems? â¢ In the event that you have any questions about this study you can contact the Principal Investigator, Dr. Kerry Wilbur (kerry.wilbur@ubc.ca) or any of the coinvestigators, Dr. Arwa Nemir (arwa.nemir@alumni.ubc.ca), and Dr. Jillian Reardon (jillian.reardon@ubc.ca) at the Faculty of Pharmaceutical Sciences, the University of British Columbia â¢ If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e- mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598. 203 Appendix C-6: Interview Topic Guide (Patient Participants) 1. I understand you have met a pharmacy student at the Clinic before, was this the first time you have met a pharmacy student as part of your care? 2. Approximately, how many visits do you think you have made to the UBC Pharmacists Clinic? How many virtual appointments? 3. In the pharmacy program, we are training learners to develop different skills so they can provide quality care to patients. If you think about a pharmacy student in general, not necessarily the specific one/s you met through the UBC Pharmacist Clinic, what sorts of things about their care for you were important? And why? 4. Supervisors give their opinion or feedback to pharmacy students after seeing them interact with patients in the appointment in order to help the student improve for next time. What sorts of things about the appointment or the care you received from a pharmacy student do you think you could also have an opinion about? 5. What do you think are some factors that would influence/play a role in how patients comment on the studentâs knowledge? 6. If you think about communication in particular, what do pharmacy students need to do to communicate well with you? 7. How do you think pharmacy students can improve their communication with patients and their accompanying family member/caregivers? 8. How would you define âprofessionalismâ when receiving care from a pharmacy student? 9. Has a pharmacy student asked for your opinion(s) and input in making decisions about your own care? â¢ Follow- up question: If yes, how did you feel about that? 204 â¢ Probing question: If no, in what ways would you like to be involved in your own care? 10. In what ways do you think/would you like to be involved in the studentâs training? 11. Would you be willing/comfortable to give opinion or feedback about a student who cared for you? 12. If yes, which way would you like/prefer to give this opinion or feedback? In writing (like by filling out a form) or by speaking to someone? And why? 13. How would you like to give the opinion or feedback? To the studentâs supervisor or preceptor or directly from yourself to the student? And why? 14. What about the timing of your opinion or feedback? Would you prefer to give it immediately after interacting with the student? Or at a later time? And why? 15. What do you think are some factors that would influence/play a role in how patients provide feedback? 16. In what ways do you think pharmacy students could use patient opinions or feedback? 17. Is there anything else you would like to share with me or talk about? Note: the bolded questions were not part of the initial interview topic guide and were added to subsequent interviews during data analysis which occurred simultaneously with interviews as relevant, rich, and thought-provoking perspectives were introduced by patient participants. 205 Appendix C-7: Interview Topic Guide (Learner Participants) 1. Tell me a little more about yourself, which year are you in? â¢ Probing question: How many patients have you cared for? â¢ Probing question: What type of patient care you were involved with at the Clinic? Probing question: Describe the types of encounter that you might have with a patient that you see in the pharmacy/clinic? 2. What is your idea of effective communication with patients? What are your approaches? 3. What are your strengths in communicating with patients? Why? 4. What challenges do you face when communicating with patients? How do you approach them? â¢ Probing question: What is the most challenging part for you during an encounter with a patient? 5. How do you think you can improve your communication skills with patients and their families/caregivers? 6. What does collaborating with patients mean to you? Shared decision making? 7. From a pharmacy learner perspective, how would you define âprofessionalismâ? 8. In your opinion, which pharmacist skills are patients able to observe & provide feedback about? Why? 9. What do you think are some factors that would play a role in how patients comment on the studentâs knowledge? 10. Which pharmacist skills are patients not able to observe and provide you feedback about? And why? 11. What pharmacist skills do you think matters the most to patients? And why do you think that? 206 12. Have you ever received/asked for feedback from patients or their caregivers? Can you talk about it more? 13. If yes, â¢ Describe how you reacted to the feedback you received from the patients? Internally & externally. â¢ How did you react to positive feedback from the patients? How did you react to negative feedback from the patients? â¢ Were you surprised by any of the feedback that you received from the patients? Please explain. â¢ Please describe examples, if any, of specific changes that you made in your clinical practices as a result of this feedback from the patients? 14. If yes and/no â¢ What type of feedback on your skills would you like to receive from a patient? â¢ What kind of feedback from a patient and/or family member would be most valuable to you? â¢ What do you feel is the ideal way and timing to obtain feedback from patients and/or families? Why? â¢ If you were to receive feedback from patients/caregivers, how would you use that feedback? â¢ Would you prefer your supervisor/preceptor to be involved in this process? And why? 15. What do you think are some factors that would influence/play a role in how patients provide feedback? 207 16. How do you think the feedback that you receive from patients compare to the feedback, either formal or informal, that you received from other sources? 17. Is there anything else you would like to share with me? Is there anything else on this topic that you would like to talk about? Note: the bolded questions were not part of the initial interview topic guide and were added to subsequent interviews during data analysis which occurred simultaneously with interviews as relevant, rich, and thought-provoking perspectives were introduced by learner participants. 208 Appendix C-8: Mapping the Research Questions and Study Objectives within Patient Interview Questions Patient Interview Questions Comments and Linking to Research Questions and Objectives 1) I understand you have met a pharmacy student at the Clinic before, is this the first time you have met a pharmacy student as part of your care? Icebreaker #1 to establish rapport with patients and get an overview and estimate of their experience in interacting with pharmacy learners in general and not necessarily at the UBC Pharmacists Clinic. 2) Approximately, how many visits do you think you have made to the UBC Pharmacists Clinic? How many virtual appointments? Icebreaker #2 to establish rapport with patients and get an overview of their experience at the UBC Pharmacists Clinic and in interacting with pharmacy learners virtually. 3) In the pharmacy program, we are training learners to develop different skills so they can provide quality care to patients. If you think about a pharmacy student in general, not necessarily the specific one/s you met through the UBC Pharmacist Clinic, what sorts of things about their care for you were important? And why? These questions relate to research question #2 âWhat skills, demonstrated by pharmacy learners during patient interactions, are patients capable of observing and subsequently assessing?â 4) Supervisors give their opinion or feedback to pharmacy students after seeing them interact with patients in the appointment in order to help the student improve for next time. What sorts of things about the appointment or the care you received from a pharmacy student do you think you could also have an opinion about? 5) What do you think are some factors that would influence/play a role in how patients comment on the studentâs knowledge? 6) If you think about communication in particular, what do pharmacy students need to do to communicate well with you? 209 7) How do you think pharmacy students can improve their communication with patients and their accompanying family member/caregiver? 8) How would you define âprofessionalismâ when receiving care from a pharmacy student? 9) Has a pharmacy student asked for your opinion(s) and input in making decisions about your own care? Follow- up Question: If yes, how did you feel about that? Probing Question: If no, in what ways would you like to be involved in your own care? These questions set the stage for research question #3 by soliciting the patient perspective on their involvement in assessing and giving feedback to pharmacy learners 10) In what ways do you think/would you like to be involved in the studentâs training? 11) Would you be willing/comfortable to give this opinion or feedback about a student who cared for you? These questions relate to research question #3 to gain insight into patient preferences for feedback delivery with the objective of eliciting patient perspectives on feedback specifics and norms 12) If yes, which way would you like/prefer to give this opinion or feedback? In writing (like by filling out a form) or by speaking to someone? 13) How would you like to give the opinion or feedback? To the studentâs supervisor or preceptor or directly from yourself to the student? 14) What about the timing of your option or feedback? Would you prefer to give it immediately after interacting with the student? Or at a later time? 15) What do you think are some factors that would influence/play a role in how patients provide feedback? 16) In what ways do you think pharmacy students could use patient opinions or feedback? 17) Is there anything else you would like to share with me or talk about? Closing question as an attempt to elicit more ideas or perspectives in case the patient would like to add an extra information that they remembered and might have missed during the interview. 210 Appendix C-9: Mapping the Research Questions and Study Objectives within Learner Interview Questions Pharmacy Learner Interview Questions Comments and Linking to Research Questions and Objectives 1) Tell me a little more about yourself, which year are you in? Probing questions: â¢ Approximately, how many patients have you cared for? â¢ Describe the types of encounter that you might have with a patient that you see in the pharmacy/clinic? Icebreaker to establish rapport with learners and get an overview and a rough estimate of their experience in interacting with patients in general and not necessarily the patients they see at the UBC Pharmacists Clinic. 2) What is your idea of effective communication with patients? Approaches? To get an overview of learnersâ experience and their skills, as proposed by AFPC, in interacting with patients in general and not necessarily the patients they see at the UBC Pharmacists Clinic. 3) What are your strengths in communicating with patients? 4) What challenges do you face when communicating with patients? How do you approach them? Probing question: What is the most challenging part for you during an encounter with a patient? 5) How do you think you can improve your communication skills with patients and their families/caregivers? 6) What does collaborating with patients mean to you? Shared decision-making? 7) From a pharmacy learner perspective, how would you define âprofessionalismâ? 8) In your opinion, which pharmacist skills are patients able to observe & provide feedback about? Why? These questions relate to research question #2 âWhat skills, demonstrated by pharmacy learners during patient interactions, are patients capable of observing and subsequently assessing?â 9) What do you think are some factors that would play a role in how patients comment on the 211 studentâs knowledge? 10) Which pharmacist skills are patients not able to observe and provide you feedback about? Why? 11) What pharmacist skills do you think matters the most to patients? And why do you think that? 12) Have you ever received/asked for feedback from patients or their caregivers? Can you talk about it more? Follow-up to previous questions to understand pharmacy learnersâ perceptions on receiving patient feedback on their competencies. 13) If yes, â¢ Describe how you reacted to the feedback you received from the patients? Internally and externally. â¢ How did you react to positive feedback from the patients? How did you react to negative feedback from the patients? â¢ Were you surprised by any of the feedback that you received from the patients? Please explain. â¢ Please describe examples, if any, of specific changes that you made in your clinical practices as a result of this feedback from the patients? Follow-up to questions 8-11 to explore with pharmacy learners their approaches to communicating and engaging with patientsâ feedback. 14) If yes and/no, â¢ What type of feedback on your skills would you like to receive from a patient? What kind of feedback from a patient and/or family member would be most valuable to you? These questions relate to research question #3 to gain insight into learner preferences for feedback delivery with the objective of eliciting learner perspectives on feedback specifics and norms. 212 â¢ What do you feel is the ideal way and timing to obtain feedback from patients and/or families? â¢ If you were to receive feedback from patients/caregivers, how would you use that feedback? â¢ Would you prefer your supervisor/preceptor to be involved in this process? And why? 15) How do you think the feedback that you receive from patients compare to the feedback, either formal or informal, that you received from other sources? This question builds up upon the previous questions relating to pharmacy learnersâ perceptions about patientsâ feedback on their skills and how the patient feedback compares to feedback they receive from their supervisor/preceptor. 16) What do you think are some factors that would influence/play a role in how patients provide feedback? These questions relate to research question #3 with the objective of eliciting learner perspectives on feedback specifics. 17) Is there anything else you would like to share with me? Is there anything else on this topic that you would like to talk about? A closing question as an attempt to elicit more ideas or perspectives in case the learner would like to add an extra information they remembered and might have missed during the interview. 213 Appendix D - Patient Participants Appendix D-1: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Care Provider) AFPC Educational Outcome: Care Provider (CP) Themes Theme #1 Humanistic Aspects of Pharmacy Learner Care Theme #2 Intrinsic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #2.1 Subtheme #2.2 2010 AFPC Educational Outcomes 1.1 Develop and maintain professional, collaborative relationships required for patient care. 1.1.2 demonstrate that the patientâs goals are the priority 1.1.4 acknowledge and respect the roles and responsibilities of the pharmacist, the patient and/or caregivers, and the patientâs other health care professionals 1.2 Elicit and complete an assessment of required information to determine the patientâs medication related and other relevant health needs. 1.2.1 elicit the reason(s) for the patientâs visit to the pharmacy or encounter with the pharmacist 1.2.2 obtain and evaluate relevant history from the patient, his/her chart, caregivers and other health care professionals 1.3 Assess if a patientâs medication-related needs are being met. 1.3.1 evaluate the safety and effectiveness of a patientâs medications with consideration of the patientâs values and preferences, characteristics, conditions, functional capabilities, other medications and access to health care/monitoring 1.4 Determine if a patient has relevant, priority health and wellness needs. 1.4.3 recognize problems with activities of daily living important to the patientâs well-being 1.6 Develop a care plan that addresses a patientâs medication-therapy problems and priority health and wellness needs. X X X X X X X X X X X 214 1.6.3 assess alternative strategies and negotiate the therapeutic option best suited to the patient 1.6.7 determine if a patient requires information or other support to facilitate his/her management of needs related to activities of daily living, health promotion or well-being 1.7 Implement the care plan. 1.7.4 convey information on maintaining and promoting health 1.7.5 convey information about available social support services to assist with daily living 1.8 Elicit clinical and / or lab evidence of patient outcomes 1.8.2 evaluate the efficacy of the care plan relative to the desired goals 1.8.3 evaluate the safety of the care plan including the presence of adverse drug reactions or effects 2017 AFPC Educational Outcomes CP2 Provide patient-centred care CP2.1 Collect, interpret and assess relevant, necessary information about a patientâs health-related care needs CP2.2 Formulate assessments of actual and potential issues and in collaboration with the patient and other health team members as appropriate, prioritize issues to be addressed in a given patient encounter X X X X X X X X X X X X 215 Appendix D-2: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Communicator) AFPC Educational Outcome: Communicator (CM) Themes Theme #1 Humanistic Aspects of Pharmacy Learner Care Theme #2 Intrinsic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #2.1 Subtheme #2.2 2010 AFPC Educational Outcomes 2.1. Communicate non-verbally and verbally with others. 2.1.1 use active listening skills and respond appropriately X X 2.1.2. exhibit empathy, tact and respect in their dealings with others 2.1.5 tailor the content of their communication to specific contexts and audience X 2.1.6 adapt their communication techniques to facilitate efficient and effective clinical encounters X 2.3. Present information 2.3.3 respond to and manage interaction with the audience X X 2017 AFPC Educational Outcomes As Communicators, pharmacy graduates communicate effectively in lay and professional language, using a variety of strategies that take into account the situation, intended outcomes of the communication and diverse audiences. CM1 Communicate in a responsible and responsive manner that encourages trust and confidence CM1.3 Express facts, evidence, opinions and positions accurately and effectively, with clarity and confidence. CM1.4: Listen, actively solicit and respond appropriately to ideas, opinions and feedback from others CM1.5: Use language, pace, tone and non-verbal communication that is suitable for: a) the intended outcomes of the communication, and b) the X X X X X X X 216 complexity, ambiguity, urgency and/or difficulty of a situation, conversation or conflict. CM1.6 Seek and synthesize relevant information from others in a manner that ensures common understanding and where applicable, clarifies and secures agreement and/or consent X 217 Appendix D-3: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Collaborator) AFPC Educational Outcome: Collaborator (CL) Themes Theme #1 Humanistic Aspects of Pharmacy Learner Care Theme #2 Intrinsic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #2.1 Subtheme #2.2 2010 AFPC Educational Outcomes 3.1. Function as members of teams 3.1.2 actively make their expertise available to others and willingly agree to share relevant information, using language that can be understood by all 3.1.5 make their points of view known, listen to and respect the opinions of others, defend points of view if necessary 3.3 Work collaboratively with the patient and his/her health care professionals to provide care and services that facilitate management of the patientâs health needs 3.3.7 communicate and review the care / services provided and patient status / outcome X X X X 218 Appendix D-4: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Scholar) AFPC Educational Outcome: Scholar (SC) Themes Theme #1 Humanistic Aspects of Pharmacy Learner Care Theme #2 Intrinsic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #2.1 Subtheme #2.2 2010 AFPC Educational Outcomes 6.1 Demonstrate a thorough understanding of the fundamental knowledge required of pharmacists and apply this knowledge in daily practice 6.1.1 rationalize their recommendations and decisions with appropriate, accurate explanations and best evidence 6.2 Provide drug information and recommendations. 6.2.1 identify needs for information, recommendations and decisions on medications 6.2.2 conduct a systematic search for evidence using a variety of search methods and tools 6.2.3 critically analyze information including primary research articles 6.2.4 determine plausible solutions and select the most appropriate recommendation 6.2.5 communicate information / recommendations 6.3 Educate regarding medications and appropriate medication use, including the pharmacistâs role 2017 AFPC Educational Outcomes SC2 Integrate best available evidence into pharmacy practice. SC2.3 Critically appraise health-related research and literature SC2.4 Incorporate best available evidence in the decision-making process X X X X X X X X X 219 Appendix D-5: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Professional) AFPC Educational Outcome: Professional (PR) Themes Theme #1 Humanistic Aspects of Pharmacy Learner Care Theme #2 Intrinsic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #2.1 Subtheme #2.2 2010 AFPC Educational Outcomes 7.1 Demonstrate professionalism throughout patient encounters 7.1.1 show respect for patients by acknowledging the patient as a person, listening actively, and considering their needs and expectations 7.2 Practice in an ethical manner which assures primary accountability to the patient. 7.2.1 involve the patient in decision-making, respecting their right to make their own choices 7.3 Maintain their competence to practice through lifelong learning 7.3.5 recognize their limits of competence and seek assistance 7.4 Practice in manner demonstrating professional accountability 7.4.4 fulfill their professional tasks and commitments to patients in a diligent, timely, reliable, respectful manner 7.4.7 maintain a professional image, using appropriate language and demeanour X X X X X X X 2017 AFPC Educational Outcomes PR1 Committed to apply best practices and adhere to high ethical standards in the delivery of pharmacy care. PR 1.1 Exhibit professional behaviour whether face-to-face, in writing or via technology-enabled communication. Professional behaviour includes but is not limited to a) demonstrating honesty, integrity, humility, commitment, altruism, compassion, respect and respect for diversity and patient autonomy b) being accessible, diligent, timely and reliable in service to others e) maintaining professional composure, demeanour and language even in difficult situations X (a, b) X (a, b, e) X (a) 220 Appendix E - Learner Participants Appendix E-1: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Care Provider) AFPC Educational Outcome: Care Provider (CP) Themes Theme #1 Intrinsic Aspects of Pharmacy Learner Care Theme #2 Humanistic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #1.4 Subtheme #2.1 2010 AFPC Educational Outcomes 1.1 Develop and maintain professional, collaborative relationships required for patient care 1.1.4 acknowledge and respect the roles and responsibilities of the pharmacist, the patient and/or caregivers, and the patientâs other health care professionals 1.6 Develop a care plan that addresses a patientâs medication-therapy problems and priority health and wellness needs. 1.6.8 negotiate the responsibilities of the pharmacist and patient, and when other health care professionals should be contacted. 1.7 Implement the care plan 1.7.2 educate the patient regarding the care plan to facilitate understanding and adherence 1.7.3 facilitate continuity of care through referral and communication with relevant care providers 2017 AFPC Educational Outcomes X X X X CP2 Provide patient-centred care CP2.2 Formulate assessments of actual and potential issues and in collaboration with the patient and other health team members as appropriate, prioritize issues to be addressed in a given patient encounter CP2.4 Implement plans in collaboration with the patient and other health team members as appropriate, including: CP2.4.5 engaging the patient or care-giver through education X X X 221 Appendix E-2: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Communicator) AFPC Educational Outcome: Communicator (CM) Themes Theme #1 Intrinsic Aspects of Pharmacy Learner Care Theme #2 Humanistic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #1.4 Subtheme #2.1 2010 AFPC Educational Outcomes 2.1. Communicate non-verbally and verbally with others. 2.1.1. use active listening skills and respond appropriately 2.1.2. exhibit empathy, tact and respect in their dealings with others 2.1.4. when speaking, use organized processes and appropriate, precise expressions and vocabulary 2.3. Present information 2.3.2. are organized and can set and adhere to appropriate time limits 2017 AFPC Educational Outcomes As Communicators, pharmacy graduates communicate effectively in lay and professional language, using a variety of strategies that take into account the situation, intended outcomes of the communication and diverse audiences CM1 Communicate in a responsible and responsive manner that encourages trust and confidence CM1.2 Provide timely, clear responses that are tailored to the context and audience CM1.3 Express facts, evidence, opinions and positions accurately and effectively, with clarity and confidence X X X X X X X 222 Appendix E-3: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Collaborator) AFPC Educational Outcome: Collaborator (CL) Themes Theme #1 Intrinsic Aspects of Pharmacy Learner Care Theme #2 Humanistic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #1.4 Subtheme #2.1 2010 Educational AFPC Outcomes 3.1. Function as members of teams 3.1.2 actively make their expertise available to others and willingly agree to share relevant information, using language that can be understood by all 3.1.5 make their points of view known, listen to and respect the opinions of others, defend points of view if necessary 3.3 Work collaboratively with the patient and his/her health care professionals to provide care and services that facilitate management of the patientâs health needs 2017 AFPC Educational Outcomes X X X As Collaborators, pharmacy graduates work collaboratively with patients and intra- and inter-professional teams to provide safe, effective, efficient health care, thus fulfilling the needs of the community and society at large CL1 Work effectively with members of the health team including patients, pharmacy colleagues and individuals from other professions. CL1.3 Join with others in respectful, effective shared decision-making CL2 Hand over the care of a patient to other pharmacy team members and non-pharmacy team members to facilitate continuity of safe patient care CL2.1 Determine when and how care should be handed over to another team member X X X 223 CL2.2 Recognize, respect and honour the negotiated shared and overlapping responsibilities of patients, pharmacy team members and other health team members when handovers occur. X 224 Appendix E-4: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Health Advocate) AFPC Educational Outcome: Health Advocate (HA) Themes Theme #1 Intrinsic Aspects of Pharmacy Learner Care Theme #2 Humanistic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #1.4 Subtheme #2.1 2010 AFPC Educational Outcomes 5.2 Promote the health of individual patients, communities, and populations 5.2.1 facilitate patientâs interaction with the health care system through advice, education and/or guidance 5.2.2 support patientâs access to required health services by representing or speaking on behalf of patients 2017 AFPC Educational Outcomes As Health Advocates, pharmacy graduates demonstrate care for individual patients, communities, and populations by using pharmacy expertise to understand health needs and advance health and well-being of others HA1 "Respond to an individual patientâs health needs by advocating with the patient within and beyond the patient care environment." HA2 "Respond to the needs of communities or populations they serve by advocating with them for system-level change in a socially accountable mannerâ "HA2.1 âWork with a community or population to identify the determinants of health that affect themâ X X X X X 225 Appendix E-5: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Scholar) AFPC Educational Outcome: Scholar (SC) Themes Theme #1 Intrinsic Aspects of Pharmacy Learner Care Theme #2 Humanistic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #1.4 Subtheme #2.1 2010 AFPC Educational Outcomes As Scholars, pharmacy graduates have and can apply the core knowledge and skills required to be a medication therapy expert, and are able to master, generate, interpret, and disseminate pharmaceutical and pharmacy practice knowledge 6.1 Demonstrate a thorough understanding of the fundamental knowledge required of pharmacists and apply this knowledge in daily practice. 6.1.1 rationalize their recommendations and decisions with appropriate, accurate explanations and best evidence 6.2 Provide drug information and recommendations 6.2.1 identify needs for information, recommendations, and decisions on medications 6.2.3 critically analyze information including primary research articles 6.2.4 determine plausible solutions and select the most appropriate recommendation 6.2.5 communicate information / recommendations 6.3 Educate regarding medications and appropriate medication use, including the pharmacistâs role 2017 AFPC Educational Outcomes X X X X X X X As Scholars, pharmacy graduates take responsibility for excellence by applying medication therapy expertise, learning continuously, creating new knowledge, and disseminating knowledge when teaching others. To educate regarding medications and appropriate medication use, including X X 226 the pharmacistâs role: individual and groups of patients, peers, pharmacy, and allied health care SC1 Apply medication therapy expertise to optimize pharmacy care, pharmacy services and health care delivery SC2 Integrate best available evidence into pharmacy practice. SC2.2 Use systematic approaches in the search for best available evidence SC2.4 Incorporate best available evidence in the decision-making process SC4 Teach other pharmacy team members, the public and other health care professionals including students. SC4.1 Provide effective education to others X X X X 227 Appendix E-6: Mapping the Themes and Subthemes within the 2010 and 2017 AFPC Educational Outcomes (Professional) AFPC Educational Outcome: Professional (PR) Themes Theme #1 Intrinsic Aspects of Pharmacy Learner Care Theme #2 Humanistic Aspects of Pharmacy Learner Care Subtheme #1.1 Subtheme #1.2 Subtheme #1.3 Subtheme #1.4 Subtheme #2.1 2010 AFPC Educational Outcomes 7.1 Demonstrate professionalism throughout patient encounters. 7.1.1 show respect for patients by acknowledging the patient as a person, listening actively and considering their needs and expectations 7.1.2 accept responsibility for recognizing and meeting patientsâ medication therapy needs 7.2 Practice in an ethical manner which assures primary accountability to the patient. 7.2.1Involve the patient in decision-making, respecting their right to make their own choices 7.2.3 integrate patient preferences related to culture, beliefs, and practice 7.2.4 use ethical frameworks as one component of professional judgement 7.3 Maintain their competence to practice through lifelong learning. 7.3.5 recognize their limits of competence and seek assistance 7.4 Practice in manner demonstrating professional accountability 7.4.2 respect and fulfill professional standards of practice 7.4.4 fulfill their professional tasks and commitments to patients in a diligent, timely, reliable, respectful manner 7.4.5 accept responsibility for their decisions and recommendations with patients and colleagues X X X X X X X X X X X X 228 7.4.7 maintain a professional image, using appropriate language and demeanour 2017 AFPC Educational Outcomes As professionals, pharmacy graduates take responsibility and accountability for delivering pharmacy care to patients, communities and society through ethical practice and the high standards of behaviour that are expected of self-regulated professionals PR1 Committed to apply best practices and adhere to high ethical standards in the delivery of pharmacy care PR1.1Exhibit professional behaviour whether face-to-face, in writing or via technology-enabled communication. Professional behaviour includes but is not limited to b) being accessible, diligent, timely and reliable in service to others PR2 Able to recognize and respond to societal expectations of regulated health care professionals. PR2.1 Take responsibility and accountability for actions and inactions X X X X X
Thesis/Dissertation
eng
Pharmaceutical Sciences
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Wilbur, Kerry
âHonouring the knowledge they possess; it is time we let the patient assessâ : bringing the patient voice into workplace-based assessment of pharmacy learners : an interpretive description study
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