Characterization and Impact of Pharmacy Student Participation on Hematology/Oncology Advanced Pharmacy Practice Experiences

Matthew J Yacobucci, PharmD, BCOP
Assistant Professor, Albany College of Pharmacy and Health Sciences
Albany Medical Center Hospital
Albany, NY

Christina L Lombardi, PharmD
Cancer Care Service Line & Research Clinical Pharmacist
St. Peter’s Health Partners
Albany, NY

Laurie L Briceland, PharmD, FASHP, FCCP
Professor
Albany College of Pharmacy and Health Sciences
Albany, NY

Introduction
Oncology pharmacists practice in varied settings including inpatient hospitals, ambulatory care clinics, infusion centers, specialty pharmacies, and investigational drug services.1,2 Within these settings, many oncology pharmacists offer an Advanced Pharmacy Practice Experience (APPE), providing student pharmacists the opportunity to participate in collaborative team-based patient care, patient education, and clinical guideline development.

Literature characterizing the extent of participation and added value of APPE students to the oncology practice site, as well as the impact of the learning experience on the student pharmacist, is scarce. Two studies reported positive contributions of student pharmacists in assisting preceptors with oncology medication reconciliation or medication history-taking services.3,4 A survey of pharmacy practice department chairs reported that students on oncology rotations performed patient care work-ups, drug information requests, journal club presentations, and patient chemotherapy counseling.5

The value of student pharmacists’ contributions to patient care outcomes in diverse settings has been documented, though is lacking in the oncology setting.6-8 Documenting the full scope of activities and the associated value of the student to the practice site would provide useful information. Characterizing the professionalization impact of the student’s participation on oncology APPEs would provide equally useful information, as student pharmacists may enter the APPE lacking confidence in their abilities in the challenging oncology setting, and/or espousing preconceived notions that the rotation will be emotionally depressing and expose the student to dangerous chemicals.9,10 One study reported that student pharmacist learners in an oncology setting, upon participation in patient care services, gained a self-awareness of their purpose, and began to view themselves as a valuable health care team member, which furthered their professional identity formation.11

The purpose of our study of student pharmacist participation in hematology/oncology (hem-onc) APPEs was to characterize the scope of participation and impact of this participation upon the practice site, and upon student professionalization.

Methods
All students who completed a 6-week, hematology/oncology APPE, defined as inpatient or ambulatory care hem-onc, malignant hematology, or pediatric hematology, during 2016-2019 were retrospectively identified. For each hem-onc APPE, specific information from the student’s final APPE evaluation was extracted, including student-reported rotation activities, and 300 to 500-word self-reflections describing the meaningful impact of the APPE on the student. Rotation activities were grouped into like categorizations under two overarching classifications: Direct Patient Care and Education, or Guidelines, Policies, Standards, and Advocacy.12

To assess the impact of student contributions on the practice site, an electronic survey employing a 5-point Likert scale was developed and disseminated to the 33 preceptors of hem-onc APPEs. Preceptors ranked five activities from a list in which students had most impact and provided specific examples of what the site gained from having a student pharmacist. Preceptors also rated the level of entrustability typically placed upon student pharmacists who engaged in various activities at the practice site. The levels of entrustment range from observing only (Level I) to supervising junior colleagues (Level V), and at a minimum, literature suggests pharmacy students should graduate with the ability to complete activities with reactive supervision (Level III).13-15 APPE grades were reviewed from the preceptor final evaluations to serve as evidence of student aptitude in providing pharmacy services.

To determine the professionalization impact of the hem-onc APPE, each student’s APPE self-reflection was reviewed and no more than three themes of impact were extracted and categorized under one of the following groupings:16

Professionalization: career development; community service; leadership development; professionalization [confidence-building; self-directed learning; motivation; preceptor role model]; mentored others; self-awareness/habits of mind, including empathy, striving for accuracy; clarity/precision; and continuous learning);

Acquiring new/honing practice skills: immersion into new field of study; practice skills development; research; Patient counseling/communication skills: patient interactions; communication skills; teach/educate others; Collaborative teamwork: team-based pharmacy care; interprofessional education.

Results
Over the 3-year study period, 171 students completed hem-onc APPEs at private or hospital-affiliated ambulatory care settings (133; 77.8%) and/or inpatient (38; 22.2%) hospitals. All but seven students (>99%) earned a grade of ≥ B+, with no students failing a rotation.

The student collective self-reported 932 distinct participatory activities (5.5 per student), with the most common categories being: evaluating patient pharmacotherapy (209), providing in-service education to medical staff (132), providing patient counseling (non-chemotherapy) (99), answering drug information questions (96), and providing patient counseling (chemotherapy) (82). Most activities (89%) involved direct patient care and education.

Preceptor surveys were completed by 16 preceptors (48.5% response rate). Activities that preceptors entrusted students to perform with reactive supervision (level III) were medication reconciliation (46.7%) and in-service educational presentations to medical staff (53.3%). Activities that required direct supervision and specific instruction (level I) were chemotherapy patient counseling (37.5%) and research endeavors (33.3%). Three student activities that were most impactful to the site were: evaluating pharmacotherapy, providing medication education/adherence resources, and providing in-service educational presentations. The most common activities that would have occurred less frequently or not at all without students were in-service educational presentations to medical staff (50%), answering DI questions (41.7%), and research endeavors (41.7%).

There were 392 reflection themes of impact (2.3 per student) extracted and categorized from student self-reflections, distributed among the four overarching domains of professionalization (39.3%), which included self-awareness, developing empathy, confidence building/self-directed learning, and career development/ learning about oncology pharmacists’ roles; patient counselling/ communication skills (27.8%), which included patient interaction/ patient care activity; development of practice skills (20%), including learning a new field of study; and collaborative teamwork (13%), which included interprofessional education/team-based collaboration.

Discussion and Key Take-Aways
The majority of hem-onc APPEs were provided in the ambulatory care setting (77.8%). During their hem-onc APPEs, student pharmacists were involved in a broad range of direct patient care and educational activities, including evaluating and recommending pharmacotherapy, providing in-service education to medical staff, counseling patients, and researching drug information queries; our comprehensive compilation of participatory activities augments that reported in the literature.5 While this scope of student self-reported duties is not surprising, given that it mirrors much of the scope of practice of the oncology pharmacist,2,17 it was important to note that student pharmacists were given authentic direct patient care and education experience, comprising 89% of APPE activity. Not only is direct patient interaction an expectation of contemporary pharmacy APPE education,18 the provision of authentic patient care experiences is one underpinning of the development of professional identity formation in student pharmacists.19

Surveyed preceptors identified that the most impactful student activities included evaluating patient-specific pharmacotherapy, providing medication education/adherence resources directly to patients, such as filling pill boxes and compiling calendars, and educating healthcare colleagues by providing in-service presentations, which also was listed by 50% of preceptors as the most frequent activity to occur explicitly because of the presence of the student pharmacist. In addition, 42% of preceptors indicated that student pharmacists were instrumental in answering drug information queries and participating in clinical research, which would not have happened (or would have occurred less frequently) without the students’ presence.

These data indicate that preceptors found value in students’ day-to-day participation in patient care and education in the oncology setting and noted that some of these activities would occur less frequently (if at all) had it not been for the students’ presence. Further, preceptors entrusted students to perform medication reconciliation (46.7%) and in-service educational presentations to medical staff (53.3%) with reactive supervision (level III), which is the expected level of expertise of a pharmacy graduate.14,15

Others have also noted that students are well-positioned to provide medication reconciliation services, even in their early stages of clinical education, with appropriate supervision.3,17 Not surprisingly, activities that required direct supervision and specific instruction (level I) were chemotherapy patient counseling (37.5%) and research endeavors (33.3%), both of which would be considered patient-facing higher stakes activities in which the Hematology/Oncology Pharmacy Association recommends that pharmacists performing such activities be oncology-board certified (or gained the equivalent through practice).1,2 This information gathered from our oncology preceptor survey supports the contention that student pharmacists on hem-onc APPEs were entrusted contributors to the healthcare system.

Participation in hem-onc APPEs proved to be extremely impactful upon the professional identity formation of student pharmacists, as evidenced by student self-reflections on domains of professionalization, practice skills development, counselling/ communications skills, and collaborative teamwork. Professionalization was most prevalently extracted from student reflections, with a number focusing on self-directed lifelong learning opportunities, a critical strategy that students need to hone, especially in the dynamic cancer care environment.20

A number of students chose empathy as their theme of impact, noting that the frequent patient interactions/counseling provided great opportunity to develop empathy; students also expressed that the rotations were not melancholic, but rather uplifting and inspirational. Through our own experiences and those reported by Weingart,21 we have found many oncology patients to be upbeat and generally willing to openly communicate with the pharmacy team, owing to the high-stakes illness and treatments, longitudinal nature of the illness and frequent visits to the team, and involvement of family/support network. In sum, all themes of impact identified by student self-reflections meaningfully contributed to the student’s professional identity formation.

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