Preceptors, Interns, and Newly Registered Pharmacists' Perceptions of New Zealand Pharmacy Graduates' Preparedness to Practice

INTRODUCTION

Internationally, pharmacy education shares common areas of teaching and professionalism. Each country has specific requirements for its pharmacy graduates, and pharmacy programs must prepare students for practice in their respective countries.¹

Pharmacists in New Zealand must be registered with the New Zealand Pharmacy Council in order to practice. A pharmacy preceptor is a pharmacist who has been registered and practicing in New Zealand for at least 3 years and who has agreed to provide guidance to pharmacy students and interns. Each preceptor must complete Workplace Assessor Training Unit Standard 4098 on the New Zealand Qualifications Authority framework and the pharmacy site must meet certain criteria, including offering a comprehensive range of pharmacy services and products.² (Registration to practice as a pharmacist for overseas pharmacy graduates is not discussed here and the reader is referred to the Pharmacy Council Web site for additional information.³)

In New Zealand, pharmacists are required to have successfully completed an undergraduate pharmacy degree program of a minimum of 4 years' duration from an accredited university and an approved internship program lasting a minimum of 44 weeks, prior to undertaking preregistration assessment supervised by the New Zealand Pharmacy Council. After successful completion of the assessment, an intern may apply for registration as a pharmacist. In order to register, interns must meet the competence requirements for pharmacists.⁴ Preceptors are required to evaluate the progress of interns on a regular basis by providing feedback on the level of competence according to a 4-point scale of “well below,” “below,” “meets,” or “exceeds” the required standard. A copy of each evaluation is submitted to the Intern Training Program of the Pharmaceutical Society of New Zealand. At the end of the internship year, competence is assessed using an objective structured clinical examination (OSCE) that incorporates a variety of scenarios covering different aspects of practice.

Competence is defined by the pharmacy profession in New Zealand as “the ability to do a task to a set standard on a repeatable basis.”⁴ In comparison, competency incorporates skills, attitudes, and other attributes including values and beliefs.⁵ Although the terms are sometimes used interchangeably, competence is the “ability to perform a task” whereas competency is “ability based on behavioral trends.” For the purposes of this paper, competence as defined by the New Zealand Pharmacy Council will be used and refers to the 7 Competence Standards (Table 1) which were ratified by the Council in 2001.

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Table 1.

Bachelor of Pharmacy Graduates and Preceptors' Perceptions of Graduates' Preparedness for Entering Pharmacy Practice

Undergraduate pharmacy programs have to be accredited in order for their graduates to enter a registered internship program. Accreditation of pharmacy programs in New Zealand occurs through a national body, the Australian Pharmacy Council (APC), which was established in 2008 and of which the New Zealand Pharmacy Council is an Associate Member. Prior to 2008, the APC was called the Council of Registering Authorities (COPRA) and the committee managing accreditation was called the New Zealand and Australia Pharmacy Schools Accreditation Committee (NAPSAC). New Zealand and Australia are 2 independent countries but are linked through the Trans-Tasman Mutual Recognition Act of 1997.⁶ In the pharmacy profession, this facilitates registration of pharmacists between the 2 countries, although New Zealand and the 7 states within Australia each has specific requirements for pharmacy registration. New Zealand only offers the 4-year BPharm degree as entry into a recognized internship program, while some Australian universities also offer a graduate-entry master of pharmacy (MPharm) degree.

The accreditation process provides assurance that a graduate who has successfully completed an accredited BPharm or master's degree program will possess the knowledge, skills, and attributes to enter the preregistration training period or internship. Accreditation of a pharmacy program involves assessment of program content, structure and delivery, and resources and scholarly environment, and also gathering information on the performance of graduates in the practice setting. New and established pharmacy degree programs undergo interim, preliminary, provisional, and full accreditation through the Australian Pharmacy Council Accreditation Committee. A requirement for full accreditation (which is the final stage of the process for all new pharmacy programs) is to provide evidence of “effective feedback on graduate preparedness from the initial cohort of graduates, after they have been in the workforce for [at least] a year, as well as from the employers” (e-mail correspondence, NAPSAC representative, 2005). Full accreditation can only be sought once graduates have achieved registration as pharmacists and then worked for at least 12 months in pharmacy practice.⁷ The first cohort of BPharm students from the University of Auckland graduated in 2003, and most of them undertook an internship in 2004. This study was undertaken in 2006 when the first cohort of graduates had entered their second year of practice as registered pharmacists.

The objective of this study was to elicit the perceptions of preceptors and former students regarding the preparedness of pharmacy graduates to enter the profession.

METHODS

A 16-item questionnaire was created based on the 7 Competence Standards for the Pharmacy Profession, Pharmacist Level⁴ (Table 1), including 5 statements related to English communication. In a previous study undertaken to elicit qualitative feedback regarding the new pharmacy program,⁸ concerns about the English communication skills of some graduates became apparent and it was therefore considered important to gain information on how graduates were communicating with other pharmacy staff members, health professionals, patients, customers, business associates, and the preceptor. Although students had to have New Zealand permanent residence status for entry to the pharmacy program, many were born outside New Zealand and English was not their first language.

The questionnaire items did not repeat the Competence Standards word for word. For example, the item assessing the Standard “Provide primary health care” was worded “Completion of the Auckland BPharm degree enabled graduates to respond to symptoms and supply nonprescription medicines and refer patients as appropriate.” Three of the standards (standards 1, 4, and 6) required more than 1 statement to elicit sufficient information. The responses were rated using a 5-point Likert scale (strongly agree, agree, neutral, disagree, strongly disagree) plus a “not applicable” option. Data were entered into a Microsoft Excel 2003 spreadsheet for analysis. An “open” section for voluntary comments was included at the end of the questionnaire to allow preceptors and graduates to provide additional information. Thematic analysis of responses was undertaken.

Anonymous questionnaires were mailed in July 2006 (mid-year) to all preceptors (n=141) who had supervised graduates over the 2-year period during which the graduates had been in the workforce. Preceptors were asked to reflect on their overall satisfaction of graduates' performance rather than on individual performance. The following statement also was included in the cover letter sent with the questionnaire: “… please bear in mind that the pharmacy degree is intended to prepare the graduates …with the knowledge, skills, attitudes and competencies to enter general pre-registration training. It cannot claim to produce a fully-fledged pharmacist without the additional practical experience of the internship program.” A second mailing was conducted a few weeks later with an appropriately revised cover letter.

Questionnaires were personally distributed to interns (41.6% of graduates; n = 72) by the Pharmaceutical Society during one of its intern training days; interns could decline to participate. Ethical approval for the study was obtained in 2006 from The University of Auckland Human Participant Ethics Committee.

RESULTS

One hundred ninety-five survey instruments were returned, giving a response rate for preceptors of 54.6% (77/141); interns, 100% (72/72); and registered graduates, 45.5% (46/101). Where appropriate, interns and registered pharmacists were referred to collectively as graduates.

The majority (87.4%; n=2,556) of responses were positive and represented agreement or strong agreement with the statements. The responses were calculated as a percentage of the total possible answers (eg, 15 statements × 195 respondents = 2,925). Interns gave more neutral responses (9.7%; n = 105/15×72) than preceptors (8.5%; n = 99/15×77) or registered graduates (7.2%; n = 50/15×46). The highest proportion of disagreement with statements was found among preceptors: 53 ‘disagree’ responses reflected 4.6% of preceptors (n = 53/15×77) compared to 3.3% of interns and 3.8% of registered graduates (n = 36/15×72 and n = 26×15×46).

Table 1 contains a summary of responses (%) from graduates and preceptors; newly registered graduates are reported separately from intern responses because the latter were still practicing under supervision of experienced pharmacists. There was a higher correlation (0.78) between the perceptions of newly registered pharmacists and interns than between preceptors and newly registered pharmacists (0.56), and preceptors and interns (0.67).

More preceptors (28.4%) and newly-registered pharmacists (29.3%) wrote free-text comments compared to interns (12.5%). Qualitative analysis of the comments revealed 4 main themes (Table 2), including the need for additional skills in extemporaneous compounding (mentioned more frequently by graduates than preceptors) and improvement in English communication among graduates who did not speak English as a first language (mentioned by preceptors). A few preceptors felt that research skills had been fostered at the expense of clinical or practical skills and that some graduates were “arrogant” or “overconfident” and did not demonstrate sufficient personal and/or professional independence.

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Table 2.

Graduates' and Preceptors' Comments About a New Bachelor of Pharmacy Program

DISCUSSION

This paper shares the findings of a new school of pharmacy on the perceptions of the first 3 cohorts of pharmacy graduates and of the preceptors who supervised them as interns. In Competence Standard Three (Primary Health Care), most preceptors (73%) agreed or strongly agreed that graduates were competent, compared to 91% and 90% of newly registered graduates and interns respectively. Variances can be explained because different stakeholders (in this case, the preceptors and the graduates) hold different perceptions of competency, which in turn are based on the stakeholder's specific needs and wants.⁹ In the current study, graduates were required to self-assess their preparedness for practice; self-assessment (or self-evaluation) needs to progress through various stages.¹⁰ Arguably, new pharmacy graduates have started only recently on the journey of professional self-assessment and may be inexperienced in its application. Characteristics reported to influence self-assessed competence include age and gender, with younger females perceiving themselves as more competent than older pharmacists.¹¹ The majority of graduates were female, comprising 72.2%, 83.3%, and 77.0% of the 2003, 2004, and 2005 graduate cohorts, respectively. Most of the graduates were younger than their preceptors, as the latter had to be practicing for at least 3 years.

Professional behavior and interpersonal skills are accepted as essential for all-round competence in health professions.¹² Interestingly, more preceptors (90%) indicated favorable responses to the graduates' organizational skills than either newly registered pharmacists (76%) or interns (79%). The relevant statements in the questionnaire included “taking responsibility,” “professional development” and “contributing to the organization as an effective team member.” Possibly, graduates were still at a more task-oriented level and not able to perceive their behaviourally related competencies to the same extent as the more experienced preceptors.¹³ In addition, many preceptors had the added responsibility of running a business, which may have caused a conflict of interest, and they may have perceived competence from a different perspective.¹⁰

More preceptors perceived graduates to be competent in dispensing a prescription than in extemporaneous compounding, which was the competence rated lowest by all 3 groups of respondents. This may have been due to compounding skills being taught in the junior years (years 1 and 2) of the 4-year program, while counselling and dispensing of proprietary products and aseptic/sterile compounding were the focus of dispensing in senior years. Revision of extemporaneous compounding skills is required to maintain competence and reduce the potential for errors as this is an area of pharmacy in which many errors can occur.¹³

The few comments that were received from interns provided useful feedback, such as “I have great research skills…but clinical skills were lacking” and “…extemporaneous compounding in fourth year as a refresher will be quite helpful.” Curriculum changes were made as a result of this study including additional education in extemporaneous compounding in the final year of the pharmacy program.

From an educational perspective, the findings could indicate a need for undergraduate pharmacy students to develop the skills of self-assessment; this skill could be beneficial for graduates because the New Zealand Pharmacy Council requires evidence of continued competence for renewal of pharmacists' Annual Practicing Certificates. Additional practical undergraduate training could be undertaken through tailored experiential placements. However, this would require preceptor training and the associated costs of implementing and monitoring such an experiential program would be expensive.

CONCLUSIONS

The study elicited the perceptions of graduates of a new pharmacy program and from their preceptors regarding the graduates' preparedness for and performance in, the workplace. Graduates felt that they were more prepared for practice than the preceptors perceived them to be in most areas of competence, professional behavior, and interpersonal communication skills. However, preceptors felt graduates were more organized than graduates perceived themselves to be. Improved skills, including English communication, professional attitudes, and additional training in extemporaneous compounding, were identified from free-text comments.

ACKNOWLEDGEMENTS

Sarah Case, for data entry and analysis, and Mridula Dhogra, for assistance with the compilation of the report. The authors would also like to thank the Pharmacy Council of New Zealand for assistance and advice. The ideas expressed in this manuscript are those of the authors and in no way are intended to represent the position of the Pharmacy Council of New Zealand or the Pharmaceutical Society of New Zealand Inc.