Abstract
Objective. To assess preceptor teaching challenges and development programming design preferences through a qualitative needs assessment of Doctor of Pharmacy student and resident preceptors.
Methods. In 2018, 148 experiential education stakeholders across North Carolina (eg, preceptors, residency program directors, experiential faculty administrators, and practice site administrators) were invited to participate in a 60-minute semi-structured interview as part of a broad preceptor development needs assessment. Interview questions focused on: precepting challenges, positive and negative features of development programs, and preferences for program design. Interview transcripts were coded using thematic analysis.
Results. Forty-two participants completed interviews, including preceptors from various rotation types, residency program directors, experiential faculty administrators, and institution administrators. Participants identified numerous teaching challenges related to learners, preceptors, and institutional level factors. Participants often noted there was inadequate time, resources, and support to effectively teach. Desirable preceptor development program features included practical strategies, collaboration with preceptors, delivery by education and practice experts, and topics specific to precepting experience. Participants identified live, on-demand, and webinar formats as acceptable if collaboration and engagement were included. Participants also desired unique training opportunities such as online platforms, coaching programs, and simulated learning environments.
Conclusion. Preceptors for pharmacy students and residents face numerous challenges and require sufficient time, support, and resources to develop their skills. Participants requested training that included on-demand, frequent sessions delivered through various modalities, collaboration opportunities, a choice in topics and delivery formats, and sessions from educational and practice experts.
INTRODUCTION
Experiential curricula comprise a significant proportion of Doctor of Pharmacy (PharmD) curricula and all of pharmacy resident training. Therefore, it is essential to identify preceptors’ needs and to tailor development programs to achieve desired outcomes. Programs should be designed by understanding the primary end users: preceptors. Preceptors are faced with balancing practice site and precepting priorities, leaving little time to develop as educators.1 There is also an assumption that individuals with clinical expertise can readily function effectively as preceptors; however, preceptors may lack foundational knowledge and skills related to evidence-based pedagogical practices.1,2 Furthermore, preceptors of both students and residents may have unique development needs or additional time constraints, such as simultaneously teaching different levels of learners. These issues are compounded by continued pressures health systems face to improve quality and reduce costs using existing resources.3
In addition to understanding needs of preceptors, coordinators of preceptor development programs should seek advice of other pertinent stakeholders, including experiential education administrators and residency program directors, who must adhere to preceptor development standards of accrediting bodies.4-6 It is also critical to consider perspectives of institutional administrators, such as pharmacy managers and directors of pharmacy, who influence support for practitioner engagement in teaching. Learning more about pertinent stakeholder perspectives may help align scarce resources with needs.
Literature is sparse regarding desirable pharmacy preceptor development program attributes from a comprehensive stakeholder perspective that includes preceptors, residency program directors, experiential education faculty, and institutional administrators. While limited literature is available regarding residency program and pharmacy education perspectives, the viewpoints of institutional administrators have not been adequately explored.7-11 When surveyed, residency program directors and health-system personnel identified a need for more resources for preceptor development.7 Cited challenges of resident preceptors include insufficient time, difficulty balancing precepting and workload responsibilities, inability to provide effective feedback and perform evaluations, and insufficient assistance to manage challenging learner situations.8,9 Learner issues, which require significant time to address, have also been recognized as a challenge for experiential education administrators in addition to concerns of expanding administrative responsibilities.10,12-14 Identifying and addressing learner challenges may provide efficiencies that would benefit preceptors, organizations, and experiential administrators.
The Professional Affairs Standing Committee of the American Association of Colleges of Pharmacy (AACP) recognized the importance of standardizing preceptor development in its 2016-2017 report.15 In addition, recommendations for a national preceptor development prototype emerged from work of the Canadian Experiential Education Project for Pharmacy, providing guidance for designing preceptor development platforms.11,16 While development resources are available through other platforms, they may be more limited in delivery modalities or scope, have cost limitations, or have solely a clinical focus. As a comprehensive national preceptor development platform is not available at the time of this writing, and the ease and cost of access to such a platform is unknown, pharmacy programs must provide development resources to their preceptors. The purpose of this study was to describe perceived challenges and preferences for preceptor development programming from a broad stakeholder group, including preceptors, preceptors with administrative roles, and experiential faculty administrators.
METHODS
In 2018, 148 preceptors of the University of North Carolina (UNC) Eshelman School of Pharmacy were invited to participate in a one-hour semi-structured interview. Invitees were identified as high performing preceptors (ie, recommended for student awards, high evaluation markings, and frequently requested rotations) at academic medical institutions and other partnership sites across seven geographic regions in North Carolina. A sampling of high-quality preceptors was used to refine the sample size given the qualitative nature of the study and to help ensure feedback was from self-aware, engaged, and knowledgeable participants. Approximately 10 preceptors were initially recruited in each of the following categories: health-system administration, community pharmacy administration, health-system operations (eg, distribution), inpatient clinical (including a mix of general and specialty practice), ambulatory care, community pharmacy (eg, independent, chain, and other), non-direct patient care (eg, industry, managed care, informatics), experiential faculty administrators (eg, individuals involved in experiential administration and student scheduling across the state), and residency program directors. Additional participants were recruited if volunteers per group were less than three. To capture more diverse perspectives than those closely associated within the school, full-time faculty preceptors, who comprised approximately 0.01% of school preceptors, were not invited to participate.
Resources provided by the school at the time of the study included: eight 15- minute online videos covering the school’s mission, curriculum, experiential syllabi, and policies and procedures; biannual one-hour preceptor development programs, sponsored by the Office of Experiential Programs and an educational research center at the school; annual 15- to 30-minute online operational/procedural training updates; quarterly newsletters; access to the university’s digital library resources; annual regional in-person recognition and continuing education events in collaboration with regions when requested; and an experiential manual. Additional curriculum resources were available in the experiential management system, such as a list of disease states and when covered in the curriculum. Preceptors also received annual access to their de-identified student evaluations if they precepted three or more students. Further, preceptors had access to an online referral system for academic, health/well-being, professionalism, and discrimination/harassment concerns and access to a 24-hour on-call system for serious issues necessitating immediate school intervention. Faculty in the Office of Experiential Programs aimed to meet with sites annually as feasible and with new sites during onboarding. Sites could be visited more frequently if significant concerns arose. Of note, the school underwent a curriculum change two years prior to this study that increased the number and length of early practice experiences, including addition of an early direct patient care experience.
Semi-structured, open-ended interview questions were developed by the research team in collaboration with the Office of Experiential Programs to ensure items addressed gaps in literature while accomplishing organizational understanding of preceptor challenges.9,15-17 Questions focused on: teaching challenges encountered while precepting and barriers to preceptor development, positive and negative features of attended preceptor development programs, and preferences for preceptor development programming. Interview questions were broad and applied to any preceptor development programming, including those from schools of pharmacy, their institution, or a professional organization. An educational researcher specializing in qualitative methods served as an interviewer and provided training to the two additional interviewers. Demographics collected were number of years precepting, practice area, geographic region, and number and type of learners precepted. Sessions were held via video teleconference, and audio was recorded and transcribed. One research team member checked de-identified audio transcripts for accuracy by listening to each recording.
One team member was responsible for initial thematic analysis of qualitative data and created a codebook using inductive coding of salient themes across transcriptions. Themes were confirmed by other team members.18,19 To ensure coding was consistent across team members, an inter-rater reliability (IRR) was calculated at the question level during the coding process. The IRR represents percent agreement that coders identified the same codes when analyzing transcripts for a specific question posed to participants.18 When the IRR for a section of data was below 80%, discrepancies were discussed and resolved. The average IRR was 94.4%; all discrepancies were resolved among team members.
Following final coding, one team member consolidated coded data through a thematic analysis; these findings were confirmed by another research team member. A summary of major ideas was shared with the team to review and approve. The goal was to identify a robust and succinct list of ideas that minimized duplication for ease of dissemination. The frequencies and prevalence of utterances were not tabulated as the research goal was exploratory and aimed for a broad perspective that could inform preceptor development programming design. In addition, subgroup analyses based on participant practice, location, or region were not conducted because the sample sizes per group were too small. Descriptive statistics were used to analyze participant demographics using Excel and were reported as frequency (n), percent, and mean and standard deviation. The study was deemed exempt by the university’s institutional review board.
RESULTS
Forty-two participants from a variety of regions and practice areas in North Carolina participated in interviews (Table 1). The most frequent practice areas included health-system administrators (n=7, 16.7%), inpatient clinical practitioners (n=6, 14.3%), and experiential faculty administrators (n=6, 14.3%). Participants had an average of 10.7 years (SD=7) of precepting experience and an average of 11 learners (SD=7.9) on rotation per year. Results are reported to reflect the ideas expressed by the larger participant group rather than those of specific stakeholder groups. This was because of the low number of participants in each group and the desire to gain holistic information from a range of participants, not to inform programming for specific groups.
Demographics of Preceptor Participants in Pharmacy Preceptor Development Needs Assessment
Participants identified various challenges to precepting and participating in preceptor development, which referred to learner, preceptor, and institutional factors (Table 2). The following are a list of examples to provide more context regarding some of the themes identified. At the learner level, participants described inappropriate attitude or behaviors such as learners not being “particularly motivated or engaged” or professionalism challenges with learners who “do not communicate well or don’t collaborate well” or who are having “issues transitioning from a student to a professional.” Concerns about learner knowledge deficits were shared such as “they struggle with some of the mechanism of action and pharmacology of a lot of drugs they should know.” Well-being was also recognized as a growing concern: “student wellness is a really big issue… I try to look for signs of depression. I think that I am able to see signs of depression more than I used to because I actually look for it.”
Challenges at the Learner, Preceptor, and Institutional Levels Identified by Pharmacy Preceptorsa
At the preceptor level, participants often discussed challenges in their ability to execute teaching requirements due to insufficient time. For example, one participant described challenges with scheduling and finding opportunities to teach given regular administrative and clinical activities, noting, “it’s a time commitment that…is extraordinarily difficult because my calendar is double-booked and triple-booked every day.” Participants also found it difficult to find time for preceptor development such as time to self-assess development needs, attend development, and implement new ideas. For example, a participant stated, “time to think about how I’m precepting, whether or not I’m doing it the best way… it’s just not something I have a lot of time to sit and reflect on.” They also identified challenges accessing preceptor development resources and expressed a desire to have a central location for resources.
Participants also described the challenges of teaching learners at different levels. One participant shared that “…every student is so different, and some students come in and they excel in counseling, but they can’t formulate a SOAP note or vice versa.” This participant described difficulty identifying and addressing each learner’s nuanced areas of growth in a short amount of time. Participants also noted a lack of knowledge about the school’s curriculum. One shared, “We don’t understand what a learner knows or what we think they know…we’ve made assumptions about some of the training they had received...” Other preceptors described the desire to better understand what is happening in the didactic setting after curriculum change noting, “our preceptors are needing to engage more in understanding what happens in the classroom so that we can emphasize the things...taught in the classroom.”
Participants also shared that receiving mentoring from others is a significant challenge as there are barriers to accessing perspectives from other preceptors or from experts in educational practices. For example, one participant desired preceptor coaching or evaluation noting, “I don’t have a lot of people evaluating me besides learners who don’t necessarily have the same perspective as a preceptor.”
At an institutional level, participants cited concerns about institutional support and work culture. They shared they do not have adequate support from sites to dedicate time to teaching and are expected to do more with less resources. Moreover, one participant shared, “as institutions we’ve got to tackle the problem of assigning value to education, putting clear value on it, and demonstrate to the preceptor that we value the time they spend having dedicated time to teaching.” Participants also described barriers to accessing preceptor development resources, citing a lack of site support from a financial, staffing, and value perspective.
Participants also described positive and negative features of previously attended preceptor development programming from any source (Table 3). Participants identified the following useful features: opportunities for interaction and collaboration with other preceptors, a variety of delivery formats that included continuing education credit, and topics that addressed novice and expert needs. For example, a participant described the value of learning with and from other preceptors, noting, “there can be a lot of power in talking to other people and understanding their experiences.” Participants suggested multiple delivery formats due to logistical challenges; “as much as live training programs sound good, it logistically doesn’t work easily because people can’t get to places… and we need to have a very timely component to it, so that’s where I think the module or webinar-based or self-directed learning [comes in].” Participants also appreciated programming that identified resources and support for preceptors. In addition, they valued programming that included topic experts.
Positive and Negative Features of Preceptor Development Programming that Participants Have Previously Attended
Features of less desirable preceptor development program included those that had more lecture focus or were more theory rather than application based. Participants also struggled with programming that was not designed for seasoned preceptors and shared concerns that, “a lot of preceptor development is geared at new preceptors and that’s not as relevant to me” or that some programing is, “redundant.” Further, participants found recorded modules challenging because of the inability of the viewer to share ideas. One participant noted, “you’re not engaged because you’re doing other things”, while another mentioned, “as a learner [it is] hard to stay focused on that thing for so long.” Moreover, participants did not value short notice about upcoming programs, infrequent availability, required training without a choice of options, limited offerings, outdated information, or delivery formats that did not support interaction.
Finally, participants suggested design features for preceptor development programs (Table 4). In general, participants identified electronic delivery methods (eg, webinars, websites, and podcasts) as viable options. Others preferred live preceptor development sessions at their respective practice sites. The emphasis was on interactive and on-demand resources that could be readily accessible to meet individual preceptor needs. Participant suggestions for program frequency were highly variable, ranging from weekly to every three years. The desired frequency was often linked to the program type (eg, annual in-person, required programs vs quarterly, online optional programs). Participants shared that emails, online calendars, websites, and social media were effective notification strategies. Unique design suggestions included a comprehensive online portal or mobile application with preceptor development resources, online preceptor forums to exchange ideas, objective structured teaching experiences (OSTEs), as well as a preceptor mentoring or coaching program. Suggested topics were diverse and related to multiple aspects of teaching practices (Table 4).
Participant Suggestions for Preceptor Development Program Design Including Topic Suggestions, Delivery Methods, Frequency, Notification Strategies, and Novel Opportunities
DISCUSSION
This is one of the first studies to include perspectives from multiple stakeholders, including preceptors from a range of practice sites, various years of practice experience, administrators, experiential faculty administrators, and residency program directors. The results demonstrate that preceptors in this study faced numerous challenges and they had creative ideas on how to improve preceptor development programming. There was substantial variability in topic interest for preceptor development program content; therefore, soliciting local preceptor needs and interests may be most helpful to increase motivation and engagement.20,21 Participants in this study and other studies frequently identified addressing difficult teaching and learning situations as a desirable focus (eg, learner well-being, knowledge deficits, and attitude issues).1,16,22,23 Table 4 offers a starting point for programming and content should integrate explicit strategies to emphasize the application in clinical teaching.24
Another finding was that preceptors desired orientation to schools’ curricular structures and expectations for learners—this is also an ACPE requirement.5 When surveyed about preceptor training and development programs by O’Sullivan and colleagues, experiential educational administrators agreed that reviewing where students learn specific knowledge and skills in the curriculum and what to expect of students are attributes of successful preceptor development programs.1 Though curriculum resources were available, preceptors in this study indicated a desire to have additional information. Factors that may have influenced preceptors’ opinions include recent major experiential curricular changes and/or the lack of awareness of existing resources. Providing preceptors access to resources that provide granular details about the curriculum can help them know what to reinforce and build upon in experiential settings.1 While this effort may be time-intensive and difficult to create, involving preceptors in the design of these tools may help ensure their usability. One strategy to accomplish this is to establish an experiential advisory committee to inform the content and format of curriculum resources and vet the tools once created.
The study findings also indicate a need for development resources at different preceptor competence levels (eg, novice to expert). Partnering with divisions or centers at schools focused on evidence-based education approaches to teaching is one approach our institution has used to help identify new teaching strategies in a variety of modalities appropriate for preceptors’ level of experience. This is supported by Steinert and colleagues’ systematic reviews that identified “evidence-informed educational design” and a “diversity of educational methods” as some of the essential features of faculty development programs.24,25 Incorporating motivational theory constructs of autonomy (choice) and task value (importance) in development offerings may encourage participation.26
In addition, study findings support the use of educational experts and experienced preceptors to facilitate programming, which confirms health-system personnel’s perspectives that education experts are beneficial in pharmacy education models.7 Access to and funding for educational experts may be limited. One option is a “train the trainer” model where a group of professionals develop educational expertise through faculty development workshops.27 The goal is for these individuals to become well-versed in education theory and evidence-based techniques to be applied in clinical settings.24 Another option is to form shared collaborations wherein identified experts join a pool of speakers to share resources at participating organizations.1
Study findings suggest that other design features should include high levels of interaction and collaborative learning. Self-study or written resources that lack preceptor engagement may be less appealing to preceptors, which aligns with theories of learning.20,21,24 Of note, live, in-person programming to facilitate engagement may be challenging because of limited resources as well as accessibility (eg, time). Offering development on site, such as “moving the workshops to the workplace,” is one way to increase the accessibility of programming and engagement.24,25 Previous research revealed that preceptors find networking and peer support opportunities through online and in-person communities valuable.16,28 If on-demand or recorded modules are used, program designers should incorporate cases, online preceptor forums, or question and answer sessions to support discussion and learning from others.
Other delivery elements include choice of formats (ie, virtual or on-site programs). Currently, there is limited data to suggest one delivery format leads to better outcomes beyond participant satisfaction or preference.16,29 Schools and colleges of pharmacy may differ in their abilities to provide multiple formats. A 2017 survey found that experiential education programs with more than a $10,000 per year investment in preceptor development offered a variety of delivery formats more frequently.1 The study authors suggested collaborations within experiential consortia, professional organizations, and other health professions schools as a way to overcome resource barriers.1 Programs should also develop a consistent notification strategy (eg, email listserv, online calendar, multiple notifications) that provides sufficient notice of offerings. Listservs have been suggested as a delivery mode in other literature describing preceptor development programs.16
Another key finding was that participants desired more unique opportunities for preceptor development such as preceptor mentoring/coaching programs, comprehensive online portals, mobile applications, and objective structured teaching examinations (OSTEs). Some preceptor training programs integrate coaching (ie, someone observes and provides feedback), while others use mentors who offer teaching strategies and assist with planning.30,31 Time, coordination, and available personnel are frequent challenges;31 however, assessment tools, such as the Habits of Preceptors Rubric, can support and standardize these efforts.32 OSTEs—similar to objective structured clinical examinations (OSCE)—use a standardized preceptor encounter with a learner that is observed and critiqued for training purposes.33 Available evidence on the feasibility of OSTEs in medical education is generally favorable.33-35 This type of peer assessment of experiential teaching can be beneficial for preceptors, and collaboration with OSCE designs can aid OSTE design and effectiveness.36-38 OSTE challenges, however, can include observation anxiety and scheduling concerns.37 Preceptor input in the development of the assessment instrument used in peer evaluation is critical for success.38 In general, these unique opportunities may require extensive resources and collaboration with other health professions training groups may be useful to implement effectively.
Of note, providing quality programming based on stakeholder needs does not ensure preceptors will participate due to time and practice constraints. Housing all preceptor resources in a central location could reduce some of the barriers to access and use. The findings from this study also underscore a need to determine the institutional value of preceptor time required for teaching and personal development. Multiple studies cite the value learners bring to institutions such as practice model and pharmacy services improvement, increased scholarly dissemination, cost avoidance, and savings.39-43 However, little is known regarding the impact of precepting behaviors and time spent teaching on patient care and institutional outcomes. Maximizing preceptor time is a complex issue that may require multiple solutions in collaboration with sites.
This study has several limitations, and results should be interpreted with caution. First, the study represents findings from preceptors associated with one school; however, the study included broad perspectives from participants across North Carolina. While similar numbers of stakeholders from all practice settings were invited to participate in interviews, some groups had higher representation, such as health-system administration. Therefore, the results could favor the needs of more represented groups. However, the large number of stakeholders who worked in inpatient settings (40.5%) represented in this study is similar to the largest category of pharmacy preceptors at UNC in 2018-2019 (approximately 42%) and nationally based on respondents to the 2018 AACP National Preceptor Survey (34.9%).44 Future studies should include more stakeholders from all categories. Another limitation is that the views of the high-quality preceptors sought out for this study may not represent those of all preceptors. Preceptors who are consistently rated lower in evaluations may be unaware of needing assistance (ie, Dunning-Kruger) and the perspectives included may be only those interested in engaging.45 Interviews were conducted prior to the COVID-19 pandemic and recent sociopolitical shifts (eg, Black Lives Matter protests of 2020). Preceptors may now face new challenges, such as engaging learners in virtual or telemedicine environments, shifting responsibilities within their institutions due to staff shortages, and overall impacts on their ability to effectively conduct educational activities in inclusive learning environments. Additional research is warranted to understand preceptor challenges and needs in the evolving pandemic and sociocultural climate.
Because of the exploratory and qualitative focus of the study, the aim was to develop a comprehensive list of preceptor challenges and ideas for programming rather than reach a consensus on which challenges were most frequent or needed immediate attention. Next steps should include the design of a survey (eg, a Delphi study) to evaluate the incidence of these challenges and those that should be prioritized. The study should also evaluate the generalizability of our findings and whether challenges may be more impactful in specific experiential education settings (eg, inpatient, ambulatory care, community). Moreover, the survey could confirm design principles that can inform how individuals prefer preceptor development programming be developed and implemented. Additional research can establish an agenda for local and national preceptor development programming initiatives that are broadly applicable. The focus of future research could also include comparing the study findings to preceptor self-assessments and student evaluations of experiences in order to support the findings and provide additional insight into the development needs of preceptors.
CONCLUSION
Results from this qualitative, exploratory needs assessment showcase the teaching challenges preceptors face at the learner, preceptor, and institutional levels. Preceptors identified that optimal preceptor development programing should include on-demand and frequent sessions delivered through various modalities such as webinars, websites, podcasts, and live sessions at practice sites. In addition, preceptors prefer opportunities to collaborate with others, choice in topics and delivery formats, and learning from educational and practice experts. Preceptors expressed desire to integrate new technologies into training as well as coaching and assessment programs. The results of this study, in conjunction with adult learning pedagogy, can inform the design of future preceptor development programs.
ACKNOWLEDGMENTS
The authors wish to acknowledge the assistance of faculty from the Office of Experiential Programs at UNC Eshelman School of Pharmacy for preceptor participant recommendations and review of questionnaires. The authors also acknowledge Philip T. Rodgers, PharmD, FCCP, for his contributions in assisting with reviewing the manuscript.
- Received October 30, 2020.
- Accepted May 26, 2021.
- © 2021 American Association of Colleges of Pharmacy
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