How to support pharmacists during hospital rotations

For the first few years of their career, newly qualified pharmacists working in hospitals usually rotate between different ward specialties and areas in the pharmacy department, such as aseptic services and medicines information. Undertaking rotations exposes pharmacists to a wider variety of scenarios than they would usually experience by only working in one area. These varied experiences can help pharmacists develop their clinical knowledge, skills and understanding of different directorate and organisational pressures. Providing consistent, structured rotations can be challenging, as staff turnover and shortages affect service delivery and the level of support that can be provided​[1]​. 

Trainee pharmacists working in hospitals will also rotate between different ward areas and sections of the pharmacy department. Reforms to the initial education and training of pharmacists has triggered an expansion of placement provision during the undergraduate pharmacy programme and this requires employers and universities to consider how to provide a meaningful learning experience and assess the students’ performance in the workplace​[2]​.

The principles discussed in this article can be applied or adapted to undergraduate placements, especially if these have a longitudinal format. Feedback on tasks completed during placements can be used as evidence towards ‘entrustable professional activities’, which are units of clearly defined professional activities that a learner can complete with a level of supervision linked to their level of competence’​[3]​. This article will provide practical advice on how to facilitate and support high quality rotations for pharmacists and trainees, highlighting how pharmacists undertaking rotations can identify opportunities for completing supervised learning events.

Rotation leads

Each rotation should have an assigned lead who assumes the role of practice supervisor, assesses supervised learning events (SLEs) and acts as a consistent point of contact for the rotational pharmacist. Advanced (or even consultant) pharmacists often oversee ward-based rotations, but other areas, such as the dispensary and aseptic services, may be supervised by a senior pharmacy technician. Practice supervisors supporting rotational pharmacists can use this experience to demonstrate achievement of outcomes 4.2 and 4.3 of the Royal Pharmaceutical Society (RPS)’s ‘Core advanced pharmacist curriculum’ (see Box)​[4]​. 

Providing an induction session

The rotational pharmacist and their practice supervisor should meet a week or two before a rotation starts, if possible, to have an early discussion about objectives and expectations. The rotational pharmacist might find that sharing feedback from completed SLEs with their new practice supervisor will highlight achievements and help individualise development goals for the next period of practice. Providing the rotational pharmacist with a list of essential references and resources can also help them prepare beforehand. 

On the first day of the rotation, rotational pharmacists should be shown the layout of the ward, location of the printer, medicines storage room, information leaflets and any bespoke documentation for that specialty (e.g. prescription charts). They should also be provided with a list of contact and bleep numbers and introduced to the ward staff and informed when ward (and board) rounds and other multidisciplinary team meetings take place.

Setting objectives

Pharmacists undertaking rotations are not expected to know everything straight away and will undoubtedly ask questions and require support. It is not feasible to provide individual didactic teaching sessions during rotations, so a combination of learning materials — such as directed reading and e-learning packages — and supervised learning events should be used. Producing a set of objectives gives the rotation structure and identifies priority areas for the pharmacist to focus on; however, pharmacists will commence rotations with varying levels of baseline knowledge and may therefore need individualised objectives.

To help rotational pharmacists identify priority development needs, ask them to:

• Reflect on their prior experience managing patients with specific conditions they are likely to encounter during this rotation. For example, even if they have not worked on a respiratory ward before, a previous rotation on the medical admissions unit may have given them experience in managing pneumonia and acute exacerbations of asthma;
• Highlight topics that those studying a postgraduate diploma in clinical pharmacy (or equivalent) will have covered already so that knowledge can be contextualised during the rotation. It is impossible to align a programme’s study days with everyone’s rotations, but online materials provided by the university can help consolidate learning during this period;
• Complete (or update) a learning needs analysis (e.g. using the RPS’s e-portfolio). This analysis should be considered an evolving record that can help identify priority actions for the rotational pharmacist to address during their next rotation.

Supervised learning events

Rotational pharmacists may need guidance on when and how often SLEs should be completed. Although a minimum number of each SLE is not required for those working towards post-registration foundation credentialing, those studying towards postgraduate diplomas may have specific requirements that can be aligned with rotations​[5]​. Completing at least one SLE per month will provide rotational pharmacists with regular feedback and help them to include a variety of scenarios in their portfolio.

Table 1 provides a suggested blueprint for supervised learning events during a clinical rotation, to help space them out and maximise their educational value. The plan should be adapted based on the specific rotation and as a pharmacist becomes more proficient at specific tasks and skills (see ‘Case study 1‘ and ‘Case study 2‘ for examples). The rotational pharmacist should be responsible for organising these, but practice supervisors may need to send reminders during earlier rotations or if the individual pharmacist is not engaging with the process.

As pharmacists become more experienced, it may be more appropriate for them to negotiate with their practice supervisor which SLEs they will complete, to allow them to obtain evidence that they lack for specific credentialing curriculum outcomes.

At the start of a new rotation, a pharmacist may need to significantly adapt their approach to managing workload and prioritising patients to fit the context of their new rotation. For example, a patient on a cardiology ward will have different medicines-related needs compared with a patient admitted to an orthopaedic ward for a total hip replacement. Therefore, completing an acute care assessment tool (ACAT) and mini-clinical evaluation exercise (mini-CEX) four to six weeks into a rotation can provide pharmacists with useful feedback on their approach to working in their new clinical area.

If a pharmacist has been struggling, a repeat assessment can be arranged in a few weeks’ time to see whether the pharmacist has addressed the development needs identified. Waiting until the later stages of a rotation to use these tools is a missed opportunity to offer early support to a pharmacist, and the patients on that ward might have received a poorer level of care during that time. 

Case-based discussions enable the supervisor to assess the rotational pharmacist’s clinical reasoning and the depth and application of their clinical knowledge. Completing these towards the end of a rotation allows the pharmacist to show how their knowledge has developed during this period and identify a more challenging patient (to maximise the educational value of the assessment). There is an argument that an extra case-based discussion in the early part of a rotation could identify gaps in knowledge; however, although mini-CEXs are not intended to assess knowledge in depth, they may still be able to identify baseline knowledge in a therapeutic area.

Multi-source feedback

Multi-source feedback (MSF) involves collating opinions on a pharmacist’s practice. This can be coordinated by the practice supervisor (using an in-house survey) or the rotational pharmacist can use the tool within the RPS e-portfolio — a user flow diagram demonstrating how to facilitate this is available on the RPS website​[6]​. By the end of a rotation, a pharmacist should have worked regularly with a range of healthcare professionals of differing levels of seniority and experience, who can provide informed feedback about the pharmacist’s performance. The pharmacist should discuss their chosen list of peers with their practice or educational supervisor to ensure a sufficient range of individuals have been chosen and there are no potential conflicts of interest such as selecting their friends. 

Other SLEs focus on non-clinical skills and can be completed at any time during a rotation. Some tasks may be directly aligned to a rotation (e.g. a direct observation of non-clinical skills for checking and release of products made in an aseptic unit), whereas others may be completed when a suitable opportunity arises (e.g. a teaching observation for delivering medicines management training at staff induction).

Regular progress checks

Regular (monthly) meetings between a pharmacist and their practice supervisor allow progress and any difficulties to be discussed. A form is available in the RPS e-portfolio to record outcomes; some points to help guide discussions are listed below:

• Encourage the rotational pharmacist to reflect on their progress to date (including what they have learnt during the past month and areas that they are still unsure about); 
• Review the SLEs that have been completed to identify areas of good practice and/or development needs, and any barriers encountered by the pharmacist in completing them;
• Summarise the actions that were agreed to address ongoing development needs and any concerns about engagement or performance.

End-of-rotation review

The rotational pharmacist and their practice supervisor should meet at the end of the rotation to discuss progress made with the rotation objectives, highlight key achievements and identify areas for further development during future rotations. The pharmacist should be given an opportunity to provide feedback on their rotations and encouraged to complete a reflective account of their experiences, so improvements can be made for future iterations.

The following case studies demonstrate how rotations can result in the completion of different supervised events based on the needs of individuals and opportunities available during a period of practice.

Case study 1

Peter is a newly qualified pharmacist working in a large teaching hospital. He completed his foundation trainee pharmacist year in community pharmacy. His first rotation is in orthopaedic surgery and he agrees the following objectives with his practice supervisor:

• Advise on medicines that need withholding before surgery and in the immediate post-operative period;
• Identify patients requiring extended venous thromboembolism (VTE) prophylaxis after orthopaedic surgery;
• Critically review postoperative analgesia in patients after orthopaedic surgery.

Three weeks into Peter’s rotation, an acute care assessment tool (ACAT) shows that he is struggling to prioritise patients and delegate tasks to his ward-based pharmacy technician. The agreed action plan recommends that Peter shadow his practice supervisor to see how they prioritise patients.

A follow-up ACAT two weeks later shows that Peter’s prioritisation and delegation skills have improved. During the ward visit, the practice supervisor suggests a patient admitted for an elective left knee replacement is used for a mini-CEX. This assessment highlights that Peter was aware the patient would need their ramipril withheld on the day of surgery and would require rivaroxaban for 14 days for extended VTE prophylaxis. A priority area for development is identified: management of diabetes during the peri-operative period.

Towards the end of the third month, a case-based discussion is completed, involving a patient admitted for an elective total hip replacement that Peter had managed. Peter demonstrated that he had incorporated feedback from the mini-CEX by advising the staff on how to step down from a variable-rate IV insulin infusion to the patient’s usual insulin regime. He also had good knowledge of post-operative pain management. One of the development needs identified was that Peter review the evidence base for extended VTE prophylaxis, so that he could develop a better understanding of how decision statements in clinical guidelines have been made.

At the end of the rotation, an MSF survey is circulated to a ward-based pharmacy technician, three ward nurses, the ward manager, two foundation year 1 doctors and one foundation year 2 doctor. According to the feedback, Peter’s strengths are his communication skills and organisation (providing further evidence that he has addressed feedback from his first ACAT). One of the agreed actions is to use more senior doctors or surgeons in future MSFs to evaluate how he interacts with these individuals.

Peter completes a reflective account at the end of the rotation to evaluate progress made with his objectives. He also refers to the SLE feedback forms to demonstrate how feedback has been addressed, which helps triangulate the evidence for outcomes 4.1, 4.2 and 4.3 of the RPS ‘Post-registration foundation pharmacist curriculum’.

Case study 2

Mira has been working as a hospital pharmacist for 14 months and has completed rotations in care for older people, general surgery and acute medical admissions. Her portfolio includes three ACATs, four mini-CEXs and four case-based discussions and she performed well in all of them, sometimes exceeding the performance expected of a post-registration foundation pharmacist. She is due to commence a rotation in aseptic services. She has not worked in this area since she was a trainee pharmacist, therefore the following objectives are agreed:

• Perform accurately the necessary checks on aseptically prepared products and complete the documentation required prior to their release;
• Discuss the principles of environmental monitoring in aseptic units;
• Complete the department’s intrathecal training package to allow entry on the trust’s intrathecal register.

The lack of ward time makes completing ACATs and mini-CEXs difficult; however, Mira’s previous performance in these assessments means more are not crucial for this rotation. As a result, she focuses on completing a direct observation of non-clinical skills related to the release of total parenteral nutrition bags and intrathecal chemotherapy (to support her first and third objectives). 

Pharmacists from the aseptic unit deliver a presentation on the role of aseptic services at one of the regional trainee pharmacists’ study days on injectable medicines. Mira volunteers to deliver this and is observed by her practice supervisor from the aseptic unit, who completes a teaching observation feedback form, which provides evidence towards outcomes 4.3 and 4.5 of the RPS ‘Post-registration foundation pharmacist curriculum'[4].

An opportunity arises for Mira to update the standard operating procedure on preparing total parenteral nutrition bags. A leadership assessment skills (LEADER) assessment is then completed, which provides evidence for outcomes 3.5, 3.6, 3.9 and 3.10 of the ‘Post-registration foundation pharmacist curriculum'[4].

At the end of the rotation, Mira receives MSF from the pharmacists and pharmacy technicians she has worked with. Previous MSFs have included feedback from a range of doctors and nurses, so it is not important that they do not contribute this time.

Mira’s reflective account helps her to recognise that she could have completed a further teaching observation when she had an undergraduate pharmacy student completing a placement in the aseptic unit. As part of the feedback provided to the rotation lead, Mira highlights how it would have been useful to have attended the nutrition ward round and suggests this could be considered for future rotations.

Conclusion

Providing structured rotations on a consistent basis is challenging in the current climate. Although this article offers one approach to embedding SLEs within rotations of different durations, it can be adapted based on requirements of the organisation and post-registration foundation pharmacist.