Int J Clin Pharm DOI 10.1007/s11096-015-0082-7
COMMENTARY
Implementing clinical pharmacy within undergraduate teaching in Namibia Nicola Rudall • Francis Kalemeera Timothy Rennie
•
Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015
Abstract Clinical pharmacy is currently not practised in Namibia. To introduce the concept and skills pertinent to this area of practice, pharmacy undergraduates at Namibia’s new School of Pharmacy are introduced to clinical pharmacy from their second year, and progress from theory to practical application on the wards. This approach has led to students having a greater understanding of clinical pharmacy and how it can be applied in practice. Introducing clinical pharmacy progressively at an undergraduate level may help to stimulate interest in the speciality for future career progression. Keywords Clinical pharmacy Namibia Pharmacy education Undergraduate education
Impacts on practice •
•
Clinical pharmacy experience can be successfully introduced at undergraduate level, developing skills as the course progresses. Implementing clinical pharmacy teaching at undergraduate level may help shape future practice in SubSaharan Africa.
Introduction Namibia, an upper-middle-income African country, has a population of around 2.3 million [1]. Following
N. Rudall (&) F. Kalemeera T. Rennie School of Pharmacy, University of Namibia, Private Bag 13301, Windhoek, Namibia e-mail: [email protected]
independence in 1990, Namibia has borne a heavy burden of HIV and tuberculosis (TB) and its healthcare system—as well as donor funding—has targeted the reduction of prevalence of these two diseases. With a high Gini coefficient, the economic disparity is evident in the healthcare system, with over 80 % of the population accessing public sector care, due to a lack of medical aid or insurance and only 12.13 % of government funding allocated to healthcare [2]. However, public healthcare in Namibia is hugely underresourced from a staffing point of view and the government, which spends 22.4 % of its budget on education, has invested a considerable amount in establishing a School of Pharmacy to train Namibians as pharmacists in-country [3]. The public healthcare system currently has around 25 pharmacists within its employ, and anecdotal evidence suggests retention is poor. From necessity, these pharmacists generally focus on the day-to-day running of the pharmacy and medicines supply and clinical pharmacy, as practised routinely in countries such as the UK and US, is not practised on the wards.
Aims of implementing clinical pharmacy teaching With the first cohort (14 students) of the University of Namibia (UNAM) School of Pharmacy due to graduate in 2014, the aim is to attract a large portion of the graduates into the public sector, boosting the existing workforce, and allowing pursuit of further training and specialisation of the pharmacist. Currently pharmacists can register as either a pharmacist or a specialist pharmacist, so the number of pharmacists who consider themselves clinical pharmacists is unknown. Only one specialist pharmacist, with a speciality in forensics, is registered in Namibia, and the path to becoming a specialist is not clearly defined. One possible future
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Int J Clin Pharm Fig. 1 How the concept of clinical pharmacy is introduced through the undergraduate course
Internship and future career Clinical rotaon two – 4th year Clinical rotaon one – 4th year Hospital placement – 3rd year Introducon to clinical pharmacy – 2nd year
specialism is clinical pharmacy, with the pharmacist becoming a necessary and valued part of the multidisciplinary clinical team, essential to the provision of high quality healthcare in Namibia. Clinical pharmacy was defined, in 2008 by the American College of Clinical Pharmacy, as, ‘‘…as that area of pharmacy concerned with the science and practice of rational medication use.’’ [4] By teaching this and Hepler and Strand’s concept of pharmaceutical care [5], to the pharmacy student, the specialism can be introduced and these roots built on as the pharmacist progresses through their career. This approach has been adopted in Namibia, and pharmacy undergraduates are exposed to a range of pharmacy specialities, many of which are reinforced with practical placements. This, coupled with a strong inter-professional component gives students ample opportunity for shared, team-based learning with medical students. Clinical concepts are introduced to students gradually, with generic clinical skills taught alongside medical students in the second year and lectures delivered on the role of the clinical pharmacist, as well as skills such as patient counselling. Pharmacotherapy, built on the Subjective–Objective–Assessment–Plan (SOAP) framework, is introduced to the students in the third year and continued into their fourth and final year (see Fig. 1 for a stepwise diagram of clinical teaching). At the end of their third year, students have a four-week hospital placement incorporating all aspects of the hospital pharmacist role, including dispensing, stock management, formulary and ward visits. In 2013, following the first hospital placement of the programme, it became apparent that supervision needed strengthening to demonstrate the role of a clinical pharmacist. In evaluation, students reported a lack of clarity as to how a pharmacist should or could contribute to the clinical care of a patient and what their role was in the multidisciplinary team.
Clinical teaching structure In 2014, a pharmacy clinical instructor was employed by the School of Pharmacy in Namibia, whose purpose was to
123
introduce the concept of clinical pharmacy and teach the final year students clinical review skills, as well as to develop a post-graduate pharmacy practice Masters degree. The aim was to use the knowledge gained from the pharmacotherapy modules (and at a later point in the year, clinical toxicology and clinical pharmacokinetics modules) and apply it in practice, identifying pharmaceutical issues and subsequently any interventions that could be made. A clinical pharmacy tool, incorporating the SOAP approach, was developed by the pharmacy practice team of the School, to assist students in gathering relevant information and processing it, in conjunction with the prescription chart and patient notes, in a logical manner. In the first semester, the clinical rotations were divided between the TB wards and the intensive care unit (ICU) of two local hospitals, with one supervisor per area. These areas were chosen because of instructor expertise and background, but also because the staff were very receptive to having pharmacists and pharmacy students in their areas. With TB being a considerable health issue in Namibia, and ICU having a wide case mix, the students were able to review patients with a broad range of disease states, comorbidities and medications. In groups of three or four, final year students spent 2 weeks each in both clinical areas, spending 90 min each morning reviewing patients, completing care plans (using the clinical pharmacy tool) and discussing pharmaceutical issues with the clinical instructor. The TB rotation had a particular focus on interprofessional learning and students were taught in conjunction with medical and nursing students who also rotate there. Any interventions highlighted by the student were first reviewed with the instructor, and then discussed with the doctor or other appropriate healthcare professional. A workbook, with clinical questions relating to the specialities, was also given to the students to complete throughout the rotations. Following each rotation, students had to present a case study, write it up as a care plan and additionally submit a reflective journal. Other tasks, such as observation of adherence counselling and taking a medication history were also part of the training and
Int J Clin Pharm Table 1 Teaching and assessment tools used in the clinical rotation training Tool utilised
Role
Ad-hoc questioning on ward
Teaching relevant to current situation
Assessed observation (e.g. medication history taking/adherence counselling)
Assessment of skills
Care plan tutorials
Teaching of care plan production
Case study presentation
Assessment of knowledge and application
‘Mock’ patient in ‘mock’ ward environment
Assessment of knowledge and skills
Production of care plan
Assessment of clinical review skills
Reflective journal
Student assessment of experience
Workbook
Self-directed learning of basic knowledge
assessment (Table 1 shows the teaching and assessment tools used in the clinical rotations). Students were asked to complete a feedback questionnaire following the first rotations, consisting of such questions as whether they had learnt a lot, understood what clinical pharmacy was, enjoyed the rotations, felt the structure of the rotations worked and whether they felt they made a contribution to patient care. They were also asked to comment on the good and bad aspects of the rotations as well as having the opportunity to add further comments should they wish to. Questions were graded on a Likert scale from one to five (one being ‘strongly disagree’ and five being ‘strongly agree’) and results were generally very positive with all answers graded three or above and, in particular, those pertaining to learning and understanding of clinical pharmacy graded four. All students responded, as it was stressed that the feedback would be used to review and improve future rotations. Comments highlighted that they had learned new clinical review skills and a lot of new knowledge, made contributions to patient care and, significantly, had an understanding of what clinical pharmacy was. Building on the previous semester’s teaching, the second semester rotations broadened and shifted their focus, so final year students also learnt about HIV, oncology and psychiatry, with time spent in all of these areas, in addition to those from semester one. The piloted clinical pharmacy tool was reviewed and adjustments made to the structure, in order to make data collection and clinical review more efficient. A refresher session on review technique was held prior to the next rotation, and another workbook for the new specialist areas was developed. Assessment has been formalised, with more detailed case presentations and the
introduction of an assessment based on a mock patient. Marks from the assessments make up 50 % of the final coursework mark for a clinically-related module (the pharmacotherapy module in the first semester and the clinical toxicology module in the second). The ultimate aim of the training is that students develop a robust and consistent system for clinically reviewing patients, and gain an enthusiasm for clinical pharmacy which will hopefully progress into a future career path. Acknowledgments Mr Dan Kibuule, Head of Department, Pharmacy Practice and Policy, for his support and assistance in implementing the clinical training within the programme. Funding The position of the clinical instructor was funded by a grant from the US Centers for Disease Control and Prevention. Conflicts of interest The authors have no conflicts of interest to declare.
References 1. The World Bank [Internet], Washington DC, c.2014 (cited 2015, January 6th). http://data.worldbank.org/country/namibia. 2. USAID & PEPFAR, Commercial prospects for donor-funded Namibian non-governmental organizations, SHOPS (Strengthening Health Outcomes through the Private Sector), June 2013. 3. Trading Economics [Internet], New York City, c.2014 (cited 2015, January 6th). Available from: http://www.tradingeconomics.com/ namibia/public-spending-on-education-total-percent-of-govern ment-expenditure-wb-data.html. 4. American College of Clinical Pharmacy. The definition of clinical pharmacy. Pharmacotherapy. 2008;28(6):816–7. 5. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47(3):533–43.
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COMMENTARY
Implementing clinical pharmacy within undergraduate teaching in Namibia Nicola Rudall • Francis Kalemeera Timothy Rennie
•
Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015
Abstract Clinical pharmacy is currently not practised in Namibia. To introduce the concept and skills pertinent to this area of practice, pharmacy undergraduates at Namibia’s new School of Pharmacy are introduced to clinical pharmacy from their second year, and progress from theory to practical application on the wards. This approach has led to students having a greater understanding of clinical pharmacy and how it can be applied in practice. Introducing clinical pharmacy progressively at an undergraduate level may help to stimulate interest in the speciality for future career progression. Keywords Clinical pharmacy Namibia Pharmacy education Undergraduate education
Impacts on practice •
•
Clinical pharmacy experience can be successfully introduced at undergraduate level, developing skills as the course progresses. Implementing clinical pharmacy teaching at undergraduate level may help shape future practice in SubSaharan Africa.
Introduction Namibia, an upper-middle-income African country, has a population of around 2.3 million [1]. Following
N. Rudall (&) F. Kalemeera T. Rennie School of Pharmacy, University of Namibia, Private Bag 13301, Windhoek, Namibia e-mail: [email protected]
independence in 1990, Namibia has borne a heavy burden of HIV and tuberculosis (TB) and its healthcare system—as well as donor funding—has targeted the reduction of prevalence of these two diseases. With a high Gini coefficient, the economic disparity is evident in the healthcare system, with over 80 % of the population accessing public sector care, due to a lack of medical aid or insurance and only 12.13 % of government funding allocated to healthcare [2]. However, public healthcare in Namibia is hugely underresourced from a staffing point of view and the government, which spends 22.4 % of its budget on education, has invested a considerable amount in establishing a School of Pharmacy to train Namibians as pharmacists in-country [3]. The public healthcare system currently has around 25 pharmacists within its employ, and anecdotal evidence suggests retention is poor. From necessity, these pharmacists generally focus on the day-to-day running of the pharmacy and medicines supply and clinical pharmacy, as practised routinely in countries such as the UK and US, is not practised on the wards.
Aims of implementing clinical pharmacy teaching With the first cohort (14 students) of the University of Namibia (UNAM) School of Pharmacy due to graduate in 2014, the aim is to attract a large portion of the graduates into the public sector, boosting the existing workforce, and allowing pursuit of further training and specialisation of the pharmacist. Currently pharmacists can register as either a pharmacist or a specialist pharmacist, so the number of pharmacists who consider themselves clinical pharmacists is unknown. Only one specialist pharmacist, with a speciality in forensics, is registered in Namibia, and the path to becoming a specialist is not clearly defined. One possible future
123
Int J Clin Pharm Fig. 1 How the concept of clinical pharmacy is introduced through the undergraduate course
Internship and future career Clinical rotaon two – 4th year Clinical rotaon one – 4th year Hospital placement – 3rd year Introducon to clinical pharmacy – 2nd year
specialism is clinical pharmacy, with the pharmacist becoming a necessary and valued part of the multidisciplinary clinical team, essential to the provision of high quality healthcare in Namibia. Clinical pharmacy was defined, in 2008 by the American College of Clinical Pharmacy, as, ‘‘…as that area of pharmacy concerned with the science and practice of rational medication use.’’ [4] By teaching this and Hepler and Strand’s concept of pharmaceutical care [5], to the pharmacy student, the specialism can be introduced and these roots built on as the pharmacist progresses through their career. This approach has been adopted in Namibia, and pharmacy undergraduates are exposed to a range of pharmacy specialities, many of which are reinforced with practical placements. This, coupled with a strong inter-professional component gives students ample opportunity for shared, team-based learning with medical students. Clinical concepts are introduced to students gradually, with generic clinical skills taught alongside medical students in the second year and lectures delivered on the role of the clinical pharmacist, as well as skills such as patient counselling. Pharmacotherapy, built on the Subjective–Objective–Assessment–Plan (SOAP) framework, is introduced to the students in the third year and continued into their fourth and final year (see Fig. 1 for a stepwise diagram of clinical teaching). At the end of their third year, students have a four-week hospital placement incorporating all aspects of the hospital pharmacist role, including dispensing, stock management, formulary and ward visits. In 2013, following the first hospital placement of the programme, it became apparent that supervision needed strengthening to demonstrate the role of a clinical pharmacist. In evaluation, students reported a lack of clarity as to how a pharmacist should or could contribute to the clinical care of a patient and what their role was in the multidisciplinary team.
Clinical teaching structure In 2014, a pharmacy clinical instructor was employed by the School of Pharmacy in Namibia, whose purpose was to
123
introduce the concept of clinical pharmacy and teach the final year students clinical review skills, as well as to develop a post-graduate pharmacy practice Masters degree. The aim was to use the knowledge gained from the pharmacotherapy modules (and at a later point in the year, clinical toxicology and clinical pharmacokinetics modules) and apply it in practice, identifying pharmaceutical issues and subsequently any interventions that could be made. A clinical pharmacy tool, incorporating the SOAP approach, was developed by the pharmacy practice team of the School, to assist students in gathering relevant information and processing it, in conjunction with the prescription chart and patient notes, in a logical manner. In the first semester, the clinical rotations were divided between the TB wards and the intensive care unit (ICU) of two local hospitals, with one supervisor per area. These areas were chosen because of instructor expertise and background, but also because the staff were very receptive to having pharmacists and pharmacy students in their areas. With TB being a considerable health issue in Namibia, and ICU having a wide case mix, the students were able to review patients with a broad range of disease states, comorbidities and medications. In groups of three or four, final year students spent 2 weeks each in both clinical areas, spending 90 min each morning reviewing patients, completing care plans (using the clinical pharmacy tool) and discussing pharmaceutical issues with the clinical instructor. The TB rotation had a particular focus on interprofessional learning and students were taught in conjunction with medical and nursing students who also rotate there. Any interventions highlighted by the student were first reviewed with the instructor, and then discussed with the doctor or other appropriate healthcare professional. A workbook, with clinical questions relating to the specialities, was also given to the students to complete throughout the rotations. Following each rotation, students had to present a case study, write it up as a care plan and additionally submit a reflective journal. Other tasks, such as observation of adherence counselling and taking a medication history were also part of the training and
Int J Clin Pharm Table 1 Teaching and assessment tools used in the clinical rotation training Tool utilised
Role
Ad-hoc questioning on ward
Teaching relevant to current situation
Assessed observation (e.g. medication history taking/adherence counselling)
Assessment of skills
Care plan tutorials
Teaching of care plan production
Case study presentation
Assessment of knowledge and application
‘Mock’ patient in ‘mock’ ward environment
Assessment of knowledge and skills
Production of care plan
Assessment of clinical review skills
Reflective journal
Student assessment of experience
Workbook
Self-directed learning of basic knowledge
assessment (Table 1 shows the teaching and assessment tools used in the clinical rotations). Students were asked to complete a feedback questionnaire following the first rotations, consisting of such questions as whether they had learnt a lot, understood what clinical pharmacy was, enjoyed the rotations, felt the structure of the rotations worked and whether they felt they made a contribution to patient care. They were also asked to comment on the good and bad aspects of the rotations as well as having the opportunity to add further comments should they wish to. Questions were graded on a Likert scale from one to five (one being ‘strongly disagree’ and five being ‘strongly agree’) and results were generally very positive with all answers graded three or above and, in particular, those pertaining to learning and understanding of clinical pharmacy graded four. All students responded, as it was stressed that the feedback would be used to review and improve future rotations. Comments highlighted that they had learned new clinical review skills and a lot of new knowledge, made contributions to patient care and, significantly, had an understanding of what clinical pharmacy was. Building on the previous semester’s teaching, the second semester rotations broadened and shifted their focus, so final year students also learnt about HIV, oncology and psychiatry, with time spent in all of these areas, in addition to those from semester one. The piloted clinical pharmacy tool was reviewed and adjustments made to the structure, in order to make data collection and clinical review more efficient. A refresher session on review technique was held prior to the next rotation, and another workbook for the new specialist areas was developed. Assessment has been formalised, with more detailed case presentations and the
introduction of an assessment based on a mock patient. Marks from the assessments make up 50 % of the final coursework mark for a clinically-related module (the pharmacotherapy module in the first semester and the clinical toxicology module in the second). The ultimate aim of the training is that students develop a robust and consistent system for clinically reviewing patients, and gain an enthusiasm for clinical pharmacy which will hopefully progress into a future career path. Acknowledgments Mr Dan Kibuule, Head of Department, Pharmacy Practice and Policy, for his support and assistance in implementing the clinical training within the programme. Funding The position of the clinical instructor was funded by a grant from the US Centers for Disease Control and Prevention. Conflicts of interest The authors have no conflicts of interest to declare.
References 1. The World Bank [Internet], Washington DC, c.2014 (cited 2015, January 6th). http://data.worldbank.org/country/namibia. 2. USAID & PEPFAR, Commercial prospects for donor-funded Namibian non-governmental organizations, SHOPS (Strengthening Health Outcomes through the Private Sector), June 2013. 3. Trading Economics [Internet], New York City, c.2014 (cited 2015, January 6th). Available from: http://www.tradingeconomics.com/ namibia/public-spending-on-education-total-percent-of-govern ment-expenditure-wb-data.html. 4. American College of Clinical Pharmacy. The definition of clinical pharmacy. Pharmacotherapy. 2008;28(6):816–7. 5. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47(3):533–43.
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