Abstract
The profession of pharmacy is complex and diverse, encompassing a wide range of necessary practice skills. Decisions regarding which skills are essential for students are made by faculty of skills-based laboratory courses, who also determine how these skills are taught and assessed. This commentary aims to further the discussion regarding how the essential skills taught and assessed in skills laboratory curricula are identified, with the intention of preparing student pharmacists for both current and future pharmacy practice. Guidance on essential skills is provided by various organizations and documents, but ultimately each institution has the autonomy to decide what to teach. As such, this piece discusses the importance of frequent curriculum evaluation to determine how to train pharmacists of the future so they will practice at the top of their license rather than simply meet competency with historical skills.
INTRODUCTION
During the COVID-19 pandemic, the topic of essential workers has been discussed frequently, and pharmacists certainly fit into that category. When determining what makes an individual’s occupation or role essential, one must evaluate the job responsibilities and skills those individuals perform as well as their impact and importance. During the pandemic, the Centers for Disease Control and Prevention (CDC) defined essential workers “as those who conduct a range of operations and services in industries that are essential to ensure the continuity of critical function in the United States.” 1
The question for pharmacy education is not whether pharmacists are essential but, instead, what skills are essential to being a pharmacist. Decisions about which skills are essential are made by faculty of skills-based laboratory courses, who also decide how these skills are taught and assessed. The standards determined by the Accreditation Council for Pharmacy Education (ACPE) (Standards 2016), specifically Appendix 1, outline the broad category of Clinical Sciences as one of the required elements of the didactic Doctor of Pharmacy curriculum. 2 This category includes health information retrieval and evaluation; medication dispensing, distribution, and administration; patient assessment; and public health. The clear expectation embedded in Appendix 1 is that students will develop comprehensive knowledge required to be “practice ready,” and students will be able to retain, recall, build upon, and apply that knowledge to deliver quality patient care in a variety of practice settings. Moreover, Standards 2016 also allows for creativity and flexibility. Specifically, Key Element 10.4 states, “the curriculum is rigorous, contemporary, and intentionally sequenced to promote integration and reinforcement of content and the demonstration of competency skills required to achieve the Educational Outcomes articulated in Section 1” of Standards 2016. 3
Skill development occurs in many courses throughout pharmacy curricula but is the primary focus of pharmacy practice skills laboratories. Skills laboratories have varying titles and organizational structures depending on the institution, as they can be combined with didactic courses, be standalone courses, or have ties to experiential coursework. Interestingly, skills laboratories are not specifically mentioned in Standards 2016. However, the separate but corresponding ACPE document developed to support efforts to enhance the quality of PharmD programs, called Guidance 2016, cites “practice laboratories” as an approach to achieve learning and documentation of student performance on the Pre-APPE Core Domains listed in Appendix A. 3 Students should demonstrate achievement in the domains and on associated abilities prior to entering advanced pharmacy practice experiences (APPEs). However, the question of which skills are essential and should be taught and assessed in these courses remains.
This commentary aims to further the discussion on how essential skills that are taught and assessed in skills laboratory curricula are identified, with the intention of preparing student pharmacists for both current and future pharmacy practice. Institutions should examine skills laboratory curricula frequently and choose skills with purpose. We encourage institutions to refrain from being complacent with their skills laboratory content and instead be nimble and anticipate continuous adjustments to prepare students for advance pharmacy practice.
DISCUSSION
What does the literature say about essential skills?
Skills laboratories are courses designed with the intent to provide students an opportunity to strengthen their skill development and apply knowledge learned through their coursework. 4 Moreover, skills laboratories provide a curricular structure for embedded performance-based assessments to demonstrate student achievement of educational outcomes as well as propagate data for programmatic assessment. 5
In 2015, a group of skills laboratory faculty surveyed APPE preceptors from the United States regarding essential skills for pharmacy graduates. 6 This study found that preceptors ranked verbal and written communication as the most essential skill and created a list of other important skills. A more recent study by Frenzel and colleagues focused on developing a list of laboratory-focused items that could be taught and assessed in the skills laboratory to ensure graduates were practice ready in the areas of community pharmacy, health-system pharmacy, ambulatory care pharmacy, and managed care pharmacy. 4 The authors mapped the identified items to domains of Entrustable Professional Activities (EPAs). 7 Furthermore, Bellottie and colleagues in 2018 reviewed published literature, activities, and assessment methods that could be adapted and implemented in practice laboratory courses to achieve the abilities outlined within the Pre-APPE Core Domains and that could serve as a resource for skills laboratory faculty who want to create or make improvements to their skills laboratory coursework. 8
Who decides what essential skills are taught?
Many different sources provide guidance on what is taught in a skills laboratory curriculum. As discussed previously, Standards 2016 provides guidance for APPE-ready and practice-ready graduates. 2 Additional guidance comes from the pre-APPE domains of the 2007 version 2 (2011) accreditation standards, the EPAs, the Educational Outcomes of the Center for the Advancement of Pharmacy Education (CAPE), and the Pharmacists’ Patient Care Process (PPCP) of the Joint Commission of Pharmacy Practitioners, all of which inform the knowledge, skills, and attitudes that are taught in a skills laboratory curriculum. 9-12
Furthermore, when determining which skills should be included in a PharmD program, one should consider stakeholders’ input. 13 Internal stakeholders could include faculty, staff, students, administrators, and others on campus. External stakeholders who can inform current and future pharmacy practice include preceptors, alumni, pharmacists, employers, other health care professionals, and patients. Additional information and guidance could be gathered from advisory councils and state or national organizations.
The COVID-19 pandemic has led to changes in pharmacy practice that also need to be considered when determining pharmacists’ essential skills. 14 Pharmacists have a critical role in providing COVID-19 vaccinations and other routine immunizations. In 2020, the Public Readiness and Emergency Preparedness (PREP) Act included several declarations that authorized pharmacists to prescribe vaccines, pharmacy interns and qualified pharmacy technicians to administer vaccines in specific circumstances, and pharmacists to order and administer COVID-19 tests. 15 Additionally, states have passed changes to pharmacy practice acts that authorize pharmacists to do more than previously allowed. Telehealth and telepharmacy have also increased during the pandemic, and many predict they will likely continue after the pandemic. 14
With these changes in practice, pharmacists are continuing to use the same PPCP skills but may be using them in different ways. 12 For example, point-of-care testing is not a new skill for pharmacists, but COVID-19 testing became a new service provided by pharmacists. Additional recent changes outside of the pandemic include prescribing naloxone and oral contraceptives. While prescribing may be new for some pharmacists, many underlying components, such as collecting information, assessing the patient’s medication profile and medical history for drug-related problems, determining a plan, monitoring and following up with the patient, and communicating that information to the patient and other health care providers, remain consistent with what they have done previously.
Furthermore, modifications to skills may be occurring in pharmacy practice. For example, student pharmacists historically have been taught manual blood pressure and heart rate measurements. However, anecdotally, pharmacists in many settings do not perform these skills on a regular basis and, if they perform the skills at all, use an automated cuff. Therefore, the question arises as to whether manual blood pressure and heart rate measurements should be taught and assessed. One could argue that programs should be teaching students more about automatic blood pressure monitoring, educating patients about self-monitoring, and hypertension management, as these skills and topics may be encountered more frequently in practice than taking blood pressure manually.
How do we prepare student pharmacists for the future of pharmacy practice?
When determining which skills to prioritize for skills laboratory curricula, consideration must be given to expected advancements in pharmacy practice. As the role of the pharmacist evolves, education must advance to maintain or surpass current practice to adequately prepare future practitioners. In a 2020 article, DiPiro proposed that the next generation of pharmacists will be both health care providers and change agents. 16 As the science of medicine and biomedical technology advance, schools must reexamine curricula to ensure that future pharmacists will be trusted leaders and interprofessional collaborators with excellent communication and critical thinking skills. Skills laboratories are often the courses that are charged with teaching and assessing these integral “soft skills.”
Another approach for determining the direction of the future of pharmacy was proposed by Shcherbakova and Desselle, who suggested examining the past to look for historical and emerging trends. 17 Previous predictions for the future of practice were often found to be accurate, although the results were not always achieved in the expected way. 17 Similarly to DiPiro, Shcherbakova and Desselle suggested that technology will be a driving force for future practice; indeed, digital health, increasing user interest in pharmacogenomics, and the automation of pharmacy operations shape pharmacists’ day-to-day work. 17 Skills laboratories offer student pharmacists the opportunity to use digital health and practice performing pharmacist roles in a safe environment where no patient will be harmed during the learning process. For student pharmacists to be successful during experiential learning experiences, skills laboratory faculty must ensure students have the skills to navigate the new technology they will encounter in experiential practice.
CONCLUSION
We are not advocating for the creation of prescriptive standards or a detailed list of specific essential skills. Accordingly, the existing standards and guidance documents are written at a broad enough level to allow faculty the autonomy to decide what and how to teach. As pharmacy practice is continuously changing, a list of specific essential skills could quickly become outdated. However, we propose that each school and college of pharmacy create a routine, proactive process to review the skills curriculum at their institution and undertake a thoughtful approach in deciding which skills to teach. Typically, this process would include skills laboratory faculty and instructors that meet periodically throughout the academic year to review the curriculum, discuss recent practice advancements, and determine what curricular changes are needed. When developing a process, it may be helpful for the skills laboratory team to ask and answer key questions (Table 1).
Key Questions to Consider When Evaluating Essential Skills Teaching and Assessment
While the structure and purpose of regional and national collaborations may not be arranged for ensuring success and accountability in such a review process, they can be helpful with building connections throughout the Academy and discussing topics and issues. As different states have differing practice levels, it is important to be connected to state societies and advocacy efforts to stay current.
This process is unlikely to be a simple one. Determining an essential skills curriculum is a complex task with many considerations, challenges, and opportunities. First, examining what is being taught, why it is being taught, and whether it makes sense is important while considering curricular shift or curricular drift. As individuals, we like to teach what is familiar and what we’re excited about teaching, which could introduce bias into course content decisions. Like many other courses, curricular hoarding is an issue. 18 Skills-based courses have limited time and resources, and not every skill can be taught. It is impossible to keep adding to the skills-based curriculum without removing something: deciding what to take out is just as important as deciding what to keep in. Collaboration and coordination with experiential education faculty can also assist in this process.
Other considerations must be discussed throughout this process. Threshold concepts should be assessed, where students test out or achieve competency for a skill, such that it no longer needs to be covered in the curriculum. 19 Additionally, faculty who do not routinely practice may not be as up to date with the skills needed in practice. Which skills taught in the classroom may also depend on limitations on time and resources (ie, time for faculty to assess students, cost for standardized patients), and these decisions may be influenced by different beliefs among faculty regarding the importance of topics and skills as well as the depth of training needed for a pharmacy graduate.
Additionally, we must consider how to teach students to be lifelong learners. For example, rather than teaching students how to use every type of inhaler currently available, teaching students how to read and understand package inserts and general concepts for inhaler techniques may create lifelong learners who can flexibly adapt and evolve with pharmacy practice. Finally, we are all human and change can be difficult; however, it is important to fully acknowledge when change may be best.
Routinely analyzing what is being taught and thoughtfully evaluating what should be included in skills-based courses is critical for pharmacy programs. Because of changes in pharmacy practice, frequent curriculum assessments and modifications are needed to train future pharmacists who will practice at the top of their license rather than simply meet competency standards using historical skills.
- Received September 3, 2021.
- Accepted September 11, 2021.
- © 2022 American Association of Colleges of Pharmacy
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