Pharmacists are interdisciplinary health providers involved in the psychosocial dynamics of pharmaceutical care. Pharmacy students can best learn these dynamics when educators integrate the scientific and interpersonal aspects of care. This paper illustrates how social workers can partner with pharmacy faculty members to strengthen the psychosocial and interpersonal content of the pharmacy curriculum. Service-learning is a promising vehicle for engaging pharmacy students. Students’ reflections indicated that they believed this service-learning course developed their understanding of the social issues that influence their provision of health care. Pharmacy students value experiential learning, reflection activities, and group discussion that enable a supportive and nonjudgmental exploration of stereotypes. These pharmacy students developed their empathy and professional commitment, which will benefit the public. They incorporated a sense of social responsibility into their profession through team visits to residents of a federally subsidized housing facility. Through in-class evaluations and pretests and posttests, the students expressed their changing attitudes toward a group of people who represented a population of future patients. There is educational benefit from integrating a strong commitment to science with a strong sense of civic responsibility.
Like all health disciplines, pharmacy is undergoing considerable change. The educational preparation required for pharmacy careers in hospital and community pharmacies, teaching and research, and managed care has expanded, as has that required for direct involvement in the care of patients. Increasingly, pharmacists are serving as core health providers who become involved in the psychosocial dynamics of care. As members of interdisciplinary teams, pharmacists must address a range of patient issues, many of which are psychosocial in nature. It is these issues, in particular, that influence access to pharmacological care and the appropriate use of medication. Income, functioning, and cultural issues are the most salient.
Pharmacists are those professionals best educated to address the cognitive behavioral dynamics of medication management. They help people to understand, manage, and use their medications appropriately. Pharmacists are the most appropriate professionals to facilitate patient understanding and proper use of medications. Pharmacy educators integrate the scientific and interpersonal aspects of care into its core curriculum so that pharmacy students can grasp the psychosocial dynamics of medication management.1
While service-learning is a relatively new area of teaching and active learning for pharmacy educators and students, this form of pedagogy has increased in popularity as many colleges and universities recognize the importance of preparing students to be engaged professionals, involved in a variety of practice and service settings. Service-learning (S-L) has become a vehicle for helping students to become more aware of their future roles, and to rethink how they best serve citizens who must cope with poverty, social devaluation, and marginalization.2 For pharmacy students, service-learning requires rethinking their roles as professionals and, perhaps, expanding their concept of practice to include interacting with patients as educators, counselors, and sources of support in the management of illness.
Service-learning in schools and colleges may promote an attitude of caring by requiring service-learning experiences.3 Service-learning requires pharmacy students to interact with people who cope with serious social issues in a variety of settings. Through this form of pedagogy, pharmacy students can step out of the traditional pharmacy role, and interact with people who may be medically at risk. Service-learning helps pharmacy students learn about people, explore their diversity and cultural differences, and challenge stereotypes, topics that other pharmacy courses may not include.
The emphasis on diversity and cultural competency has not been a traditional element of pharmaceutical education, and the emergence of service-learning in pharmacy reflects the considerable change ongoing within the profession as pharmacy care becomes increasingly identified as a core aspect of health care. Such skills are also central to the preparation of social workers; therefore, social work has much to offer pharmacy. Pharmacy students must learn about how to interact with patients effectively as well as the social, interpersonal, and individual differences that can influence how people use medication to cope with their illness, impairment, and/or disability.
The purpose of this paper is to describe how social workers can partner with pharmacy faculty to expand the scope of a service-learning course (see Appendix 1) by strengthening the psychosocial and interpersonal content of the curriculum.
Challenges Facing Pharmacy Education
The emergence of pharmaceuticals that require vigilant monitoring make pharmacists central to health care delivery. They interact with the public on a regular basis and may be one of the most trusted groups of health care professionals today.4 Along with such adulation, citizens will likely assign great responsibility and expectations to the profession. Pharmacists, who have the shortest amount of time of all health care professionals to interact with patients, must use this time efficiently. The pharmacy students need to learn to develop a patient-professional partnership that will help them to better serve and respond to patients who want a greater understanding of their medication and more control over their health care. Clinical practitioners who are members of care teams must become more attuned to psychosocial issues that may be a barrier to medication management. Those pharmacists involved in the delivery and therapeutic monitoring of these drugs must get to know a person, often times in depth. The therapeutic relationship is more important than ever in health care, and pharmacists must refine their skills for interacting with people whose degree of cognition, behavior, emotion, social skills, and language vary considerably. The Report of the Janus Commission5 includes the following recommendation: “Require the incorporation of community outreach or service learning activities that stress the core values throughout the curriculum and with corresponding standards for ACPE” (American Council on Pharmaceutical Education).
Pharmacists may be reluctant to interact with their patients, especially in ambulatory settings, outside of the delivery of basic prescriptions. This reluctance may stem from the pharmacist having an innate reserved communication style, a lack of time, or a lack of knowledge. Thus, the pharmacist must move from a mechanical style of service, that in which they only formulate, measure, and dispense appropriate medication properly, to relationship-based service, which requires them to interact, educate, support, and counsel people who are often different in some important way from themselves.
Like other health professionals, it is easy for pharmacists to adopt negative stereotypes, particularly about members of devalued populations that influence their attitudes and interactions with people. Disparities between the qualities, characteristics, and social standing of health care professionals and people who experience diminished health status and require care may foster considerable social distancing of this group. Negative stereotypes are counterproductive. An important way of reframing these stereotypes is to bring pharmacy students into closer contact with people who are different and thereby increase their understanding of the consequences negative stereotypes create for the people health care providers serve. Thus, through such contact, pharmacy students can gain insight into the social circumstances of people, and develop empathy for their situations.
Social Work Contributions to Pharmacy Education
Social workers can guide pharmacy students in the development of interaction skills. The design of service-learning can place pharmacy students into pedagogical situations to work with the elderly, those coping with disabilities, and people who have diminished health care. Engaging pharmacy students in relationship building and helping them to reflect on the implications of what they learn through service to these individuals can expand the scope of pharmacy practice and prepare them for situations that now require an unprecedented range of psychosocial competencies.
Social work faculty members have extensive knowledge of the aging process. They can lead the students in experiences like visiting isolated homebound older adults, interacting with people with serious disabilities, or interviewing migrant workers. These interactions offer opportunities for students to learn by reflection that addresses their feelings, uncertainties, or attitudes about aging. Throughout this process social workers can help pharmacy students broaden their learning about elderly individuals as people and increase their awareness about the social context in which medication is prescribed and administered.
In the classroom, the social work faculty member introduces knowledge about the psychosocial dynamics of professional-patient interaction. Social work professionals spend 6 hours of class time enlightening pharmacy students about how social factors influence interaction. They encourage discussion of how the consequences of serious illnesses shape the way patients form relationships, develop expectations, experience health care delivery, and engage the process of their care. Social workers focus on relationship factors, and the importance of affective, cognitive, and social differences in fostering either strong or weak treatment alliances between the pharmacist and the patient.
For example, social work faculty members noted specifically that many elderly patients are very capable of handling medication issues when the pharmacist provides written guidance, such as assistance with enrolling in a drug program. Some pharmacists may be reluctant to start the conversation out of concern they will have to direct the older patient through all the steps of enrollment.
Faculty members from social work and pharmacy can further integrate pharmacy practice content with psychosocial factors of the elderly, thereby influencing the students’ ability to provide effective health care. Such interdisciplinary courses often plant the seeds for future collaborative projects. For example, pharmacists and social workers can work together to provide services such as “Ask the Pharmacist” programs, health fairs, and programs for helping those who are medically underserved.
Service-learning elements have been translated into a course for pharmacy students at the Eugene Applebaum College of Pharmacy and Health Sciences (EACPHS) at Wayne State University in Detroit, Michigan. This urban, research-intensive university houses 13 colleges with an enrollment of more than 35,000 students. EACPHS is home to ~800 students enrolled in more than 20 degree and certificate programs in 9 major categories: nurse anesthesia, clinical laboratory science, mortuary science, occupational and environmental health sciences, occupational therapy, physical therapy, pharmacy practice, pharmaceutical sciences, and physician assistant studies. This 2-credit elective course introduces pharmacy students to a mutually beneficial collaboration in which students and community members become learners and teachers simultaneously. Almost 50 students in the Bachelor of Science pharmacy program and Doctor of Pharmacy programs have taken the course, which also is open to students in the other health sciences programs. The course is team-taught by 1 pharmacy practice faculty member and 1 social work faculty member.
The course involves students in service to elderly people who are coping with isolation and diminished quality of life in addition to having complex health care needs. This service-learning course helps students transfer their affective learning to pharmacy practice.
At the end of this course, the student is expected to:
Be able to define service-learning and reflection;
Recognize the importance of community service as a means of better understanding future patients;
Be more aware of patients’ needs for social support;
Be able to form relationships across human differences;
Prepare a written account of their experience at the end of the semester.
Importance of Orientation
Each service-learning course has a theme based on a particular health care need, a segment of the community (eg, the Hispanic Latino community), or a demographic group (eg, the elderly). Whatever the topic or theme, all students are given a scholarly orientation to the area in which they will serve and learn. For example, if the focus is the elderly, the orientation will include a thorough introduction to the dynamics of aging, and to the integration of a biological, social, and cultural perspectives on the issue. Social work professionals have the education and experience to describe this unique population and to identify how these factors can create impasses in the provision of health care. The pharmacy practice faculty member presents specific practices and procedures for addressing the dynamics of aging in the provision of pharmaceutical care and how service-learning influences the students’ future practice.
Visitation
Visitations and subsequent reflections are the cornerstones of the S-L course. Teams of 2 pharmacy students scheduled 2-hour weekly visits during the last 6 to 8 weeks of the 15-week semester. The teams met with the volunteer resident of a publicly subsidized housing facility for people who generally were between the ages of 50 and 70 years of age, although some were older. The student teams introduced themselves to the resident manager just before their visit. The resident manager enlisted the volunteers and was given a list of all students and the names of the resident they would visit. Each student team visited the same resident for the entire semester. At each visit, the student team had a general conversation with their resident and observed the person’s behavior. Later they reflected on their interactions. This type of visit was termed a “friendly visit” and no pharmacy-oriented activities took place. Students focused only on developing a professional relationship with the resident.. Previous participants have been in their first, second, or fourth professional year of either their BS pharmacy program or PharmD program.
Electronic Journal
Students were required to complete an entry in their personal electronic journal for each visit. Although, students were in teams while in the field, the journal entries were personal and private and shared only with the 2 faculty members. For each visit, the students recorded the events that transpired, their observations about the events, and their feelings about the visit. The journal entries could be written at any time, but had to be submitted by e-mail on the Monday before class. Students were encouraged to submit the journal entry as an e-mail attachment.
Reflection
Weekly opportunities for private reflection in an electronic journal facilitated a continuous learning process in which students documented the situations they experienced and processed personal issues and challenges. Both pharmacy and social work faculty members reviewed the electronic journals in advance of the bi-weekly group reflection sessions. During the group reflection, each student provided a verbal synopsis of their visit and then led a group discussion about it, answering questions from other students.
Group reflection sessions offered the students opportunities to review their visits and discuss their experiences in a group format and process what they were learning. This group reflection and evaluation also allowed students to review the experiences of other teams and compare and contrast the other teams’ experiences and impressions with their own.
The faculty members served as facilitators, listening to the students’ experiences and identifying issues the residents were facing such as poor health status, improper medication, and lack of certain services. This served to catalyze the discussion and allowed the faculty member to introduce other issues, such as health care delivery, social policy, ethics, and access to health care. By so doing, the faculty members helped students to connect service-learning and pharmacy practice, highlighting the importance of relationship building in the delivery of pharmacy care.
Summative Paper
This service-learning course concluded with a 10-page summative and integrated essay describing the educational preparation, the visits, the journals, their reflection, and the impact of the experience on the student’s professional attitude. The students were asked to include both immediate applications and future implications of the course in terms of their professional development in pharmacy.
Making connections between pharmacy practice and the research literature is an important aspect of service-learning.6 Good service-learning presents students with an intellectual challenge and helps them translate theory into practice. Service-learning can help students increase their understanding of how social issues influence the lives of the people they serve. Pharmacy has significant and recent literature7-13 describing themes of S-L and care provision. The Internet offers a wealth of resources14 for health care professions as a basis for creating or modifying a service-learning course in pharmacy. Students and faculty can review these resources for more extensive information and link service with the literature, amplifying student understanding of how the social issues they witness influence a specific group and how they may create serious challenges for effective pharmacy practice.
This course includes a pretest and posttest to foster reflection and maximize the students’ experiences. (Copies of these tests are available by e-mail from the corresponding author.) This is an excellent opportunity for the student to identify and modify stereotypes and change attitudes. Within this course, students can improve their basic helping skills and review methods of interviewing and interacting with older persons. The course, therefore, revisits modules from other courses, including health care communication and relationship development and assessment.
Students in their first professional year (P-1) of the pharmacy program are socialized into a scientist-practitioner model where they gain considerable insight into the science of pharmacy. At the end of the second professional year (P-2) they are educated to assess patients’ medication regimens. They have some exposure to the interpersonal aspects of care and the interface between pharmacists and other professionals and their models of care. However, the second and third professional years are filled with clinical content, and the emphasis only on intellectual mastery of those topics may restrict the students’ concept of pharmacy practice.
This S-l course offers the opportunity for the pharmacy students to step back and reflect on their interactions with people and on the role of pharmacists as care providers. Service-learning sensitizes students to their own family issues and, importantly, students can assess their basic values and attitudes about people without the immediate focus on therapeutics and pharmacology. This course is designed to engage students in both self-reflection and group reflection. Given the need for faculty to integrate service, reflection, academic content, and practice content, the scope of teaching is quite broad and results in the adoption of several roles to achieve these ends including preceptor, facilitator, mentor, content guide, and role model.
There is considerable documentation that personal transformation is a highlight of service-learning courses.15 To further demonstrate achievement of this transformation, comments were obtained from students through an in-class evaluation (see Appendix 2). Students’ reflections through their journals, in papers, and in group sessions indicated that they viewed the course as a way of developing their understanding of pharmacy practice and of the social issues that influenced the provision of health care. They reported more sensitivity to aged individuals and to how people must cope with the constraints of isolation, diminished health care, and poverty. Students valued experiential learning and highlighted the importance of multiple approaches to reflection including a personal and private modality that they share with faculty members who are sensitive to the challenges they face in making sense out of their visitations. Students reported that reflection in group sessions enabled the supportive and nonjudgmental exploration of stereotypes they may hold of elders.
Some students underscored the importance of interacting with people with whom they do not share similar qualities or characteristics. Differences in race and culture between students and elders are salient in students’ narratives. They contemplated how their awareness and understanding of someone who is different, yet who may be dependent on them for health care, influences their action as pharmacists. They considered how they communicate, how they interact, the extent of their comfort, and their anxiety aroused by going into a new and unfamiliar situation, one that they may perceive as unsafe. All of these issues are fundamental today in health care settings, and service-learning becomes a portal through which to anticipate these challenges that will be so influential in shaping pharmacy practice in community and institutional settings.
Some students indicated that their learning was more linked to the reflective context than to any other component. Several students noted that the group situation helped them to listen better, open up, share their perspective, and invite feedback. In this sense, the reflective group sessions may share certain qualities with group practice in which team members must learn about one another and anticipate how each other thinks. Learning from one’s colleagues and understanding them professionally, cognitively, emotionally, and culturally may be important outcomes that the service-learning situation can foster. Indeed, perhaps service-learning can heighten awareness of diversity and prepare pharmacy students for a collaborative form of practice that will increasingly incorporate cultural differences and variations in linguists, ethnicity, religion, and education among and between those offering health care and those receiving it.
The interactions with the community, the resident, and the patient begin to affect the students’ professional esteem, and the students’ professional identification may be enhanced as a consequence. One S-L class addressed the educational needs of youth, in which pharmacy students had an experience that placed them in roles to manage and resolve conflicts and to teach prosocial skills. The community sees pharmacy students as both caregivers and health care professionals who have important knowledge to offer youth. The positive response by community members and youth shapes how the students come to see themselves, that they are professionals of the future who are more than pharmacists and who also have learned something that makes them more effective as health care professionals.
The students enjoy the weekly visits with senior citizens or the tutorial sessions with the elementary and junior high school students. They provide community service and their lives are likely enriched. However, how does service-learning prepare students for being professionals in the practice of pharmacy? How will we identify the issues that have influenced their academic, personal, and professional lives? Of course, in an academic setting, there are written assignments that can be used to demonstrate learning. The final paper brings together information learned, discussed, and observed throughout the semester. This essay pertains to classroom discussion, visitation, personal journal, and research, and how these elements affect the student’s practice of pharmacy. The final essay is designed to encourage students to combine the literature and their personal experiences into a summative reflection. It required the students to integrate, contemplate, and indicate how this particular learning experience influenced them as people, health care professionals, and future pharmacists.
Additionally, there are elements of the class that expose students to progressive learning models so that they will experience the principles of service-learning. As the students enter the area of research and development, they create new tools to facilitate pharmacy practice with elderly persons. This research may be a patient fact sheet, referral procedures, or resource directories useful within the context of pharmacy practice.
One element that hampers practicing pharmacists, especially those in community practice, is the immediacy of questions or problems posed by patients. When a pharmacist understands that a patient can be given well-prepared information, a fact sheet, or resource directory for use at home, the pharmacist/patient relationship continues to thrive without the pharmacist doing the work for the patient. When pharmacists provide a resource from their professional background it empowers the elderly patient to take action. The pharmacists’ knowledge creates tools that support patient referral, education, and pharmaceutical self-management.
In a collaborative practice model, such as the one seen in this class, pharmacists and patients understand how social workers practice with elderly persons and the scope of that practice. The social work professional takes adequate time to resolve the issues with their client as part of their service. A pharmacist/social worker team serves the patient well and holds promise for the continuous improvement of health care delivery.
As pharmacy students learn about the elderly from social work professionals there is a potential for education in empathic understanding of the elderly through the purposeful use of interpersonal skills. When a practicing pharmacist meets with an elderly patient, it is especially important to maintain friendly eye contact while respecting the patient’s cultural background. In this educational setting, the body language of the professional is important as well as observing the same in the patient. Clear verbal communication is essential in both pharmacy practice as well as service to the community. Service-learning students can learn the importance of listening carefully and being comfortable while interacting with elderly patients. One aspect of this service-learning class is that pharmacy students visit as a 2-person team, giving each an opportunity to observe while the other student is talking with the resident. Students can pace their verbal communication and alter the timing and speed of the conversation.
Creative problem solving about medications involves professional assessment and business management. Pharmacists and social workers are schooled in patient assessment and must broaden their assessment to include the process that includes drug information and professional referral. However, there are ways of including others as an effective resource, especially family members or caregivers. When professionals establish and develop relationships, there are mutually beneficial advantages of cooperation and trust and mutual investment of affection and support. This good will leads to a more obvious benefit of sensitivity to the diversity of those involved and an acceptance of the other person.
The pharmacy student’s experience of interpersonal change is best described as a conscious use of “self” directing interaction with patients, especially the elderly. Can pharmacy students embrace the empathetic approach to medication management and therapeutic drug monitoring after a service-learning experience? This empathy will serve the graduates, their patients, and other professionals well.
A change in professional self-concept can be derived from the service activity itself or from reflection on it. Some students complete the course with a new sense of themselves as care providers. While the term “pharmaceutical care” is progressive and appropriate, it is a paradigm shift in the public role of a pharmacist. Pharmacists who view themselves as public servants and bring to health care knowledge with a spirit of service are useful in helping people manage their own health. The integration of these 3 elements reflects a paradigm shift in pharmacy education.
Service-learning is a movement in higher education that is rapidly growing. Certainly, pharmacy is well positioned among the health care professions to offer students outstanding careers with considerable responsibility, respect from other disciplines, a strong identity in science, and competitive salaries for entry-level practitioners. But to confine education to these rewards and outcomes somehow negates the meaning of professionalism in contemporary society. Engaged pharmacy professionals may begin to ask critical questions about the quality of health care in their communities, they may advocate for the needs of those who experience diminished health care or limited access, and they may demonstrate public outrage about the consequences of limited or nonexistent medical benefits.
These questions will come from those pharmacists who not only see themselves as scientists, but also who value themselves as primary and specialized providers of health care in their communities. But how will these professionals acquire their empathy and their commitment to public benefit? Will some naturally come by it from family upbringing? Of course, some will. Others may come by it because of their education and the integration of a strong commitment to science with a strong sense of civic responsibility. Integrating service-learning into the pharmacy curriculum may facilitate the development of the pharmacy student as a professional.
1.
Health professions education: A bridge to quality. Greiner AC, Knebel E, eds. Committee on the Health Professions Education Summit; Institute of Medicine of the National Academies. The National Academies Press, Washington, DC; 2003:76.
2.
Farris MC, Kelly S. The Salem Signature: Self-discovery, and community service. In: DeVitis JL, Johns RW, Simpson DJ, eds. To Serve and Learn: The Spirit of Community in Liberal Education. New York: Peter Lang; 1998.
3.
Roche V. National Association of Boards of Pharmacy/American Association of Colleges of Pharmacy District 7 & 8 Meeting, Tucson, Ariz; September 22, 2000.
5.
Approaching the Millennium: The Report of the AACP Janus Commission. American Association of Colleges of Pharmacy Washington, DC. October 1997.
6.
McEwen MK. Enhancing student learning, and development through service-learning. In Jacoby B and associates, eds. Service-learning in higher education: concepts, and practices. San Francisco, Calif: Jossey-Bass; 1996.
7.
Nickman NA. (Re)learning to care: Use of service-learning as an early professionalization experience. Am J Pharm Educ. 1998;62:380-387.
8.
Lamsam GD. Development of a service-learning program. Am J Pharm Educ. Spring. 1999;63:41-45.
9.
Barner JC. Implementing service-learning in the pharmacy curriculum. Am J Pharm Educ. 2000;64:260.
10.
Barner JC. First-year pharmacy students perceptions of their service-learning experience. Am J Pharm Educ. 2000;64:266.
11.
Nichols-English GJ, White C, Brooks PJ. Bridging community based pharmacy outreach with service-learning principles. Am J Pharm Educ. 2002;66:124.
12.
Brown MC, Lind PR, Sorensen TD. Early pharmacy education with community teachers (EPhECT). A longitudinal service-learning experience. Am J Pharm Educ. 2002;66:443.
13.
Carter JT, Cochran GA. Service-learning projects in a public health in pharmacy course. Am J Pharm Educ. 2002;66:312.
15.
Gottlieb K, Robinson G, eds. A practical guide for integrating civic responsibility into the curriculum. Community College Press, Washington, DC.
Corresponding Author: Wynefred Schumann, MS Address: Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI 48201 Tel: 313-577-1719 Fax: 313-577-5589 E-mail: w.schumann@wayne.edu
Schumann W, Moxley DP, Vanderwill W.
Integrating Service and Reflection in the Professional Development of Pharmacy Students.
Am J Pharm Educ. 2004; 68(2):article 45.
