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May/June 2018 - Preceptor Development: Layered Learning in Pharmacy Practice

21 May 2018 12:36 PM | MSHP Office (Administrator)

Authors: Angela Brownfield, PharmD: UMKC School of Pharmacy at MU and Barb Kasper, PharmD, BCACP: UMKC School of Pharmacy at MU


Background

With the experiential program comprising at least 30% of the pharmacy curriculum, pharmacy preceptors may make use of the layered learning model (LLM) as an effective tool to juggle the demands of experiential instruction and patient care responsibilities at clinical sites.1 At its most basic level, the LLM allows learners at varying levels of instruction to educate and learn from each other.  LLMs include various combinations of the following participants:  attending pharmacist (i.e. pharmacy preceptor), postgraduate year 1 (PGY-1) or postgraduate year 2 (PGY-2) pharmacy resident, Advanced Pharmacy Practice Experience (APPE) students, and Introductory Pharmacy Practice Experience (IPPE) students.2-9 

Across settings, the pharmacy preceptor oversees all teaching and patient care responsibilities of the learners.  Senior learners assume increased teaching and patient care oversight of the junior learners, depending on their place in the hierarchy of the LLM.  Senior learners also assume an increased volume of direct patient care responsibilities, up to the entire workload of the preceptor.  However, individual direct patient care tasks may differ between acute and ambulatory care practice settings.  Differences in responsibilities may include the type of task and manner of delivery.  Table 1 outlines the potential learners and responsibilities involved in LLM.

Table 1

Learner

Acute Care Responsibilities

Ambulatory Care Responsibilities

PGY-2 Resident

  • Responsibility for all aspects of patient care and oversight/teaching of learners listed below
  • Responsibility for all patients on service
  • Responsibility for all aspects of patient care and oversight/teaching of learners listed below
  • Responsibility for all patients on service

PGY-1 Resident

  • Responsibility for all aspects of patient care listed for APPE and IPPE students
  • Oversight/teaching of APPE and IPPE students
  • Responsibility for a greater number of patients than APPE or IPPE students
  • Responsibility for all aspects of patient care listed for APPE and IPPE students
  • Oversight/teaching of APPE and IPPE students
  • Responsibility for a greater number of patients than APPE or IPPE students
APPE
  • Responsibility for all aspects of patient care listed for IPPE students
  • Oversight/teaching of IPPE students
  • Clinical consultation to rounding teams
  • Pharmacokinetic monitoring
  • Responsibility for a greater number of patients than IPPE students
  • Responsibility for all aspects of patient care listed for IPPE students
  • Oversight/teaching of IPPE students
  • Clinical decision-making
  • Responsibility for a greater number of patients than IPPE students

IPPE

  • Completion of medication histories/medication reconciliation
  • Provide patient education
  • Documentation in EMR
  • Responsibility for a limited number of patients
  • Assess patient vital signs
  • Completion of medication histories/medication reconciliation
  • Provide patient education
  • Documentation in EMR
  • Responsibility for a limited number of patients

Benefits

The benefits of the LLM are quite extensive.  A few highlights of the advantages of LLM include: 

  • Enhanced Patient Care and Learning
When multiple learners are in the same environment, a combined effort toward effective patient care may produce a sum greater than its parts.  By working together, the quality of patient care, as well as learning, may be augmented as different learners approach a situation from varying angles yet work collaboratively toward the same endpoint.  In the process, learners have the opportunity to process, explain, and/or discuss approaches with each other.  This, in turn, could lead to opportunities to adopt new approaches to patient care and/or increase comprehension of drug/disease state knowledge and patient care skills.  In addition, through modeling by senior learners, junior learners are able to observe expectations for future patient encounters and learning experiences.10
  • Increased Availability of Patient Care Experiences for Learners

In order to provide optimal learning experiences for pharmacy learners, the LLM allows for increased availability of patient care experiences by overlapping learners at the clinical site.2-5, 9, 11-13  Both time and energy are maximized when junior and senior learners appropriately share patient care responsibilities (Table 1).  The LLM affords learners the ability to apply didactic knowledge and learned skills in a dynamic environment within the construct of existing patient workload.

  • Extension of Patient Care Activities for Clinical Institutions

“Win-Win” is the overall goal for both the academic and medical institutions involved in the LLM.  Preceptors optimally use learners as extenders of patient care and thus, increase services that were once not possible with existing manpower.2, 3, 5, 6, 11, 14  This may include such services as medication reconciliation and high-risk patient counseling for a greater patient population than was previously possible. 

  • Increased Efficiency for Pharmacy Preceptors

The LLM allows for improved balance of student learning and clinical site responsibilities for pharmacy preceptors.  By concurrently placing varying levels of learners at a site, preceptors may maintain an appropriate level of experiential oversight while addressing demanding patient care responsibilities.  Senior learners are able to provide higher-level patient care while modeling and coaching junior learners in the process.  This allows the preceptor to still engage in the LLM as the primary educator while allowing greater flexibility in ensuring clinical responsibilities are met.10  

Potential Barriers and Mitigation Strategies

While the LLM can provide a number of benefits to preceptors, barriers to successful implementation are also important to address.  Below are some common barriers to LLMs and opportunities to overcome them:

  • Inadequate Space and Resources  for Increased Learners
Having limited numbers of computer stations could be overcome by providing learners with remote computer access.  Learners are able to access electronic medical records on personal devices, allowing for greater flexibility in the physical location needed to complete this task.  Within the ambulatory care setting, exam room space limits the number of learners who can see a patient at one time.  Pairing learners for complementary components of the patient encounter can serve several purposes. Pairing learners allows for modeling and coaching to occur.  Additionally, this strategy can minimize redundancies in the patient interviewing process when each learner needs the information gathered to make clinical decisions.
  • Complexities of Coordinating Multiple Learner Schedules
Coordinating each learner’s schedule can be a complicated task and is best completed in a systematic manner.  Although scheduling requires time and advance planning, mapping each learner’s schedule will ensure learner overlap occurs in a logical sequence and aligns with direct patient care opportunities.  Preceptors should consider the amount of time needed for senior learners to orient to the rotation before assuming teaching responsibilities.  Additionally, preceptors should allow for flexibility in scheduling, based on individual learner needs.
  • Inconsistent Availability of Direct Patient Care Opportunities

Despite advanced planning and scheduling, unpredictable situations may not afford equitable distribution of direct patient care opportunities across learners.  For example, a hospital may have an unusually low census or patients may not show for clinic appointments.  Having a contingency plan will be important in these situations to maintain quality learning experiences.  Some examples of contingency plans could include the following:

  • Convert clinic appointments to phone appointments if a patient does not show
  • Utilize senior learners to lead topic discussions with junior learners
  • Utilize senior learners to guide junior learners in population health management initiatives or other projects
  • Assist colleagues with direct patient care responsibilities

Conclusion

As pharmacists continue to engage in experiential learning, the LLM offers one approach to help maximize student learning while balancing patient care responsibilities.  Its design is flexible as it offers numerous approaches to the inclusion of various, overlapping learners where instruction and learning can coexist.  As with any pedagogical design, the LLM comes with both benefits and limitations that every preceptor must consider.  Yet, in order to increase learners’ knowledge, skills, and abilities, the LLM can serve as an effective mechanism for instruction as well as the delivery of patient care.2-14  

References

  1. Accreditation Council for Pharmacy Education: Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree ("Standards 2016"). Available from: 〈https://www.acpe-accredit.org/pharmd-program-accreditation/〉; 2015. Accessed 7 February, 2018.
  2. Bates JS, Buie LW, Amerine LB, et al. Expanding care through a layered learning practice model. Am J Health-Syst Pharm. 2016;73:e603–e609.
  3. Delgado O, Kernan WP, Knoer SJ. Advancing the pharmacy practice model in a community teaching hospital by expanding student rotations. Am J Health-Syst Pharm. 2014;71(21):1871–1876.
  4. Bates JS, Buie LW, Lyons K, et al. A study of layered learning in oncology. Am J Pharm Educ. 2016;80(4) 68.
  5. Soric MM, Glowczewski JE, Lerman RM. Economic and patient satisfaction outcomes of a layered learning model in a small community hospital. Am J Health-Syst Pharm. 2016;73(7):456–462.
  6. Kalich BA, Cicci JD, Shah S, Reed BN. From pilot to practice: feasibility & impact of a layered learning practice model experience in cardiology [abstract]. Pharmacotherapy. 2013;33(10):e250.
  7. Leong C, Battistella M, Austin Z. Implementation of a near-peer teaching model in pharmacy education: experiences and challenges. Can J Hosp Pharm. 2012;65(5):394–398.
  8. Cameron K, Fernandes O, Musing ELS, Raymond C. Increasing capacity for experiential rotations for pharmacy learners: lessons learned from a multisite teaching hospital. Can J Hosp Pharm. 2016;69(1):23–29.
  9. Loy BM, Yang S, Moss JM, Kemp DW, Brown JN. Application of the layered learning practice model in an academic medical center. Hosp Pharm. 2017;52(4):266–272.
  10. Kasper B, Brownfield A. Evaluation of a Newly Established Layered Learning Model in an Ambulatory Care Setting.  Curr Pharm Teach Learn. (In Press).
  11. Masterson J, Rafferty A, Michalets E. The Clinical Training Center: a layered-learning rotation model to meet hospital goals and standards of practice [abstract]. Pharmacotherapy. 2016;36(12):e287.
  12. Smith WJ, Bird ML, Vesta KS, Harrison DL, Dennis VC. Integration of an introductory pharmacy practice experience with an advanced pharmacy practice experience in adult internal medicine. Am J Pharm Educ. 2012;76(3) Article 52.
  13. Kessler TL, Vesta KS, Smith WJ, Dennis VC, Bird ML, Harrison DL. Students' attitudes and perceptions of a structured longitudinal introductory pharmacy practice experience (IPPE) medicine rotation. Curr Pharm Teach Learn. 2011;3(1):2–8.
  14. Cobaugh DJ. Layered learning: the confluence of pharmacy education and practice. Am J Health-Sys Pharm. 2016;73(24):2035.


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