Caregivers' treatment-seeking behaviors and predictors of whether a child received an appropriate antimalarial treatment: a household survey in rural Uganda.

BACKGROUND: This study responds to a rural community's concern that, despite national initiatives, malaria management in young children falls short of national guidelines in their district. This study aimed to: (1) describe caregivers' treatment-seeking behaviors in the rural district of Butaleja, (2) estimate the percentage of children who received an appropriate antimalarial, and (3) determine factors that maximized the likelihood of receiving an appropriate antimalarial. Appropriate antimalarial in this study is defined as having received only the Uganda's age-specific first-line malaria treatment for uncomplicated and severe malaria during the course of the febrile illness. METHODS: A household survey design was used in 2011 to interview 424 caregivers with a child aged five and under who had fever within the two weeks preceding the survey. The survey evaluated factors that included: knowledge about malaria and its treatment, management practices, decision-making, and access to artemisinin combination therapy (ACT) and information sources. Bivariate analysis, followed by logistic regression, was used to determine predictors of the likelihood of receiving an appropriate antimalarial. RESULTS: Home management was the most common first action, with most children requiring a subsequent action to manage their fever. Overall, 20.9 % of children received a blood test, 68.4 % received an antimalarial, and 41.0 % received an ACT. But closer inspection showed that only 31.6 % received an appropriate antimalarial. These results confirm that ACT usage and receipt of an appropriate antimalarial in Butaleja remain well below the 2010/2015 target of 85 %. While nine survey items differentiated significantly whether a child had or had not received an appropriate antimalarial, our logistic regression model identified four items as independent predictors of likelihood that a child would receive an appropriate antimalarial: obtaining antimalarials from regulated outlets (OR = 14.99); keeping ACT in the home for future use (OR = 6.36); reporting they would select ACT given the choice (OR = 2.31); and child's age older than four months (OR = 5.67). CONCLUSIONS: Few children in Butaleja received malaria treatment in accordance with national guidelines. This study highlighted the importance of engaging the full spectrum of stakeholders in the management of malaria in young children - including licensed and unlicensed providers, caregivers, and family members.

Caregivers' treatment-seeking behaviors and practices in Uganda-A systematic review (Part II).

Prompt treatment with artemisinin combination therapies (ACTs) remains the cornerstone for managing uncomplicated malaria caused by Plasmodium falciparum. In accordance with global initiatives to curb malaria, the Ugandan government pledged to increase the proportion of children under five to receive the first-line antimalarial treatment to 85% by 2010. To achieve this, Uganda has implemented several initiatives to improve prompt access to ACTs. While several studies have evaluated various aspects of caregivers' treatment-seeking and its impact on malaria management in children since the advent of ACT, this is the first systematic review to synthesize the Uganda literature since 2004. A comprehensive search employed key web search engines databases. A total of 19 studies met the inclusion criteria. This review found that although most Ugandans associate mosquitoes with malaria, misconceptions about the cause of malaria is common. Home management continues to be a common first response, with most caregivers seeking subsequent treatment if the child does not improve. A major concern arising from this review was that an increase in ACT knowledge does not always translate into a child receiving an ACT. While 84% of caregivers in a recent national study spontaneously named ACT as the antimalarial of choice, only half of the children were reported to have received an antimalarial and only 44% received an ACT. As with ACT usage, prompt use of ACT fell significantly short of the 2010 target. Given the on-going popularity of home management, future research is needed to examine the diversity and adequacy of home management for malaria and the sequence of care provided from the moment of recognition of initial symptoms. Considering the pervasive use of polypharmacy to manage malaria, further research is needed to quantify the proportion of children who receive an appropriate antimalarial - defined as receiving only the first-line treatment. Finally, given children's reliance on caregivers to seek out appropriate care on their behalf, future studies need to examine specific assets and challenges influencing caregivers' treatment-seeking behaviors in order to positively influence decision-making at the household level.

Narrative review of current context of malaria and management strategies in Uganda (Part I).

In accordance with international targets, the Uganda National Malaria Control Strategic Plan established specific targets to be achieved by 2010. For children under five, this included increasing the number of children sleeping under mosquito nets and those receiving a first-line antimalarial to 85%, and decreasing case fatality to 2%. This narrative review offers contextual information relevant to malaria management in Uganda since the advent of artemisinin combination therapy (ACT) as first-line antimalarial treatment in 2004. A comprehensive search using key words and phrases was conducted using the web search engines Google and Google Scholar, as well as the databases of PubMed, ERIC, EMBASE, CINAHL, OvidSP (MEDLINE), PSYC Info, Springer Link, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched. A total of 147 relevant international and Ugandan literature sources meeting the inclusion criteria were included. This review provides an insightful understanding on six topic areas: global and local priorities, malarial pathology, disease burden, malaria control, treatment guidelines for uncomplicated malaria, and role of the health system in accessing antimalarial medicines. Plasmodium falciparum remains the most common cause of malaria in Uganda, with children under five being most vulnerable due to their underdeveloped immunity. While international efforts to scale up malaria control measures have resulted in considerable decline in malaria incidence and mortality in several regions of sub-Saharan Africa, this benefit has yet to be substantiated for Uganda. At the local level, key initiatives have included implementation of a new antimalarial drug policy in 2004 and strengthening of government health systems and programs. Examples of such programs include removal of user fees, training of frontline health workers, providing free ACT from government systems and subsidized ACT from licensed private outlets, and introduction of the integrated community case management program to bring diagnostics and treatment for malaria, pneumonia and diarrhea closer to the community. However despite notable efforts, Uganda is far from achieving its 2010 targets. Several challenges in the delivery of care and treatment remain, with those most vulnerable and living in rural settings remaining at greatest risk from malaria morbidity and mortality.

A demonstration study comparing "role-emergent" versus "role-established" pharmacy clinical placement experiences in long-term care facilities.

BACKGROUND: Increasing challenges to recruit hospital sites with full-time on-site pharmacy preceptors for institutional-based Advanced Pharmacy Practice Experiences (APPE) has made it necessary to consider alternate experiential models. Sites with on-site discipline specific preceptors to supervise students have typically been referred to in the literature as "role-established" sites. In British Columbia, long-term care (LTC) facilities offered a unique opportunity to address placement capacity issues. However, since the majority of these facilities are serviced by off-site community pharmacists, this study was undertaken to explore the viability of supervising pharmacy students remotely - a model referred to in the literature as "role-emergent" placements. This paper's objectives are to discuss pharmacy preceptors' and LTC non-pharmacist staff experiences with this model. METHODS: The study consisted of three phases: (1) the development phase which included delivery of a training program to create a pool of potential LTC preceptors, (2) an evaluation phase to test the viability of the LTC role-emergent model with seven pharmacists (two role-established and five role-emergent) together with their LTC staff, and (3) expansion of LTC role-emergent sites to build capacity. Both qualitative and quantitative methods were used to obtain feedback from pharmacists and staff and t-tests and Mann-Whitney U tests were used to examine equivalency of survey outcomes from staff representing both models. RESULTS: The 76 pharmacists who completed the training program survey rated the modules as "largely" meeting their learning needs. All five role-emergent pharmacists and 29 LTC participating staff reported positive experiences with the pharmacy preceptor-student-staff collaboration. Preceptors reported that having students work side-by-side with facility staff promoted inter-professional collaboration. The staff viewed students' presence as a mutually beneficial experience, suggesting that the students' presence had enabled them to deliver better care to the residents. As a direct result of the study findings, the annual role-emergent placement capacity was increased to over 45 by the end of the study. CONCLUSIONS: This study demonstrated that role-emergent LTC facilities were not only viable for quality institutional APPEs but also provided more available sites, greater student placement capacity, and more trained pharmacy preceptors than could be achieved in role-established facilities.

Promoting direct patient care services at community pharmacies through advanced pharmacy practice experiences.

OBJECTIVES: To determine the relative benefits of three different models of advanced pharmacy practice experience (APPE) in successfully integrating the delivery of direct patient care into students' final year community pharmacy clerkships. METHODS: All fourth-year pharmacy students at the University of British Columbia were divided into one of three study arms for their community APPE: a 2 × 4-week rotation in a traditional format, a 1 × 8-week rotation where their preceptors had experienced a 2-day education course and a 1 × 8-week rotation with both preceptor education plus a 5-day pre-APPE in-store orientation and peer debriefing. KEY FINDINGS: All 123 students conducted patient consultations and documented their care. Students in the pre-APPE + preceptor education arm provided nearly double the number of direct patient consultations than did students in the preceptor-education-only arm or the traditional 2 × 4-week arm. Numbers of drug-related problems identified and interventions performed per patient consult did not differ across study arms. CONCLUSIONS: Pre-APPE orientation activities provided an enhanced learning environment, promoted greater student engagement, provided care to more patients, increased preceptor preparedness and enhanced in-store patient-centred care practice. Certain of these learning activities can also form part of third- and fourth-year introductory pharmacy practice experiences to prepare students for their final-year APPE.

Validation of a global assessment of arthroscopic skills in a cadaveric knee model.

PURPOSE: The purpose of this study was to determine whether a global assessment of arthroscopic skills was valid for blinded assessment of cadaveric diagnostic knee arthroscopy. METHODS: A global skills assessment for arthroscopy was created using a published theory of the development of expertise. Faculty surgeons, fellows, and residents were consented and enrolled in this institutional review board-approved validation study. All participants were oriented to the equipment and procedures for diagnostic arthroscopy of the knee. After reviewing the anatomic structures to be visualized, participants were allowed 10 minutes to complete a diagnostic arthroscopy of the knee. The hands and arthroscopic view were recorded during this attempt. Resident participants completed a second filmed diagnostic arthroscopy 1 week after the initial attempt. Five blinded reviewers watched the synchronized videos and assessed arthroscopic skills with a procedure-specific checklist and the newly developed global skills assessment. The agreement between reviewers was determined by intraclass correlation coefficient. Internal consistency was determined with Cronbach's α. Test-retest reliability was measured by correlating repeated arthroscopies by residents. The ability of the global assessment to discriminate skill levels was determined with between-group Mann-Whitney U tests. RESULTS: The agreement between global assessment scores was strong (I.C.C. = 0.80, 95% C.I. 0.68-0.92). The internal consistency of evaluations was excellent (Cronbach's α = 0.97), and the test-retest reliability was strong (r = 0.52). The global assessment score was shown to be able to discriminate between skill levels by an analysis of variance indicating the difference in means among the various levels of training (P < .0001). CONCLUSIONS: The Objective Assessment of Arthroscopic Skills is a useful adjunct to arthroscopic educators and learners and could be used for in-training evaluations. CLINICAL RELEVANCE: The Objective Assessment of Arthroscopic Skills is an instrument that can be employed to measure the impact of skills curricula, including but not limited to simulation.

Clinical reasoning in dentistry: a conceptual framework for dental education.

This study presents a conceptual framework for clinical reasoning by dental students. Using a think-aloud method with six vignettes, the researchers interviewed eighteen dental students from two stages of training about oral health-related problems influenced by biopsychosocial factors. Verbatim transcripts of the interviews were analyzed to identify the processes and strategies of clinical reasoning used by the students to produce treatment plans. The process included 1) rituals to collect information; 2) forward and backward reasoning to generate and test clinical hypotheses; 3) pattern recognition from integrated scripts of knowledge and experience; and 4) decision trees to assess options and outcomes. The process was supplemented by scientific, conditional, collaborative, narrative, ethical, pragmatic, and part-whole reasoning strategies. Senior students showed a keen awareness of the contextual determinants of care and emphasized patients' motivations for treatment. In contrast, junior students focused more on problems associated with individual teeth as they struggled to integrate the information within each vignette. In this article, the processes and strategies for reasoning used by both groups of dental students are abstracted and then illustrated by a model of clinical reasoning that accommodates the complicated contexts in which clinical problems usually arise.

Patient satisfaction with pharmaceutical care delivery in community pharmacies.

BACKGROUND: The purpose of this study was to validate previously published satisfaction scales in larger and more diversified patient populations; to expand the number of community pharmacies represented; to test the robustness of satisfaction measures across a broader demographic spectrum and a variety of health conditions; to confirm the three-factor scale structure; to test the relationships between satisfaction and consultation practices involving pharmacists and pharmacy students; and to examine service gaps and establish plausible norms. METHODS: Patients completed a 15-question survey about their expectations regarding pharmaceutical care-related activities while shopping in any pharmacy and a parallel 15 questions about their experiences while shopping in this particular pharmacy. The survey also collected information regarding pharmaceutical care consultation received by the patients and brief demographic data. RESULTS: A total of 628 patients from 55 pharmacies completed the survey. The pilot study's three-factor satisfaction structure was confirmed. Overall, satisfaction measures did not differ by demographics or medical condition, but there were strong and significant store-to-store differences and consultation practice advantages when pharmacists or pharmacists-plus-students participated, but not for consultations with students alone. CONCLUSION: Patient satisfaction can be reliably measured by surveys structured around pharmaceutical care activities. The introduction of pharmaceutical care in pharmacies improves patient satisfaction. Service gap details indicated that pharmacy managers need to pay closer attention to various consultative activities involving patients and doctors.

Effects of visible and UV light on the characteristics and properties of crude oil-in-water (O/W) emulsions.

The effects of visible and UV light on the characteristics and properties of Prudhoe Bay (PB) and South Louisiana (SL) emulsions were investigated to better understand the role of sunlight on the fate of spilled crude oils that form emulsions with a dispersant in the aquatic environment. Before irradiation, crude oil emulsions showed the presence of dispersed crude oil micelles in a continuous water phase and crude oil components floating on the surface. The crude oil micelles decreased in size with irradiation, but emulsions retained their high degree of polydispersity. UV irradiation reduced the stability of emulsions more effectively than visible light. The reduction of micelles size caused the viscosity of emulsions to increase and melting point to decrease. Further, irradiation increased acid concentrations and induced ion formation which lowered the pH and increased the conductivity of emulsions, respectively. Ni and Fe in PB emulsions were extracted from crude oil with UV irradiation, which may provide an efficient process for metal removal. The emulsions were stable toward freeze/thaw cycles and their melting temperatures generally decreased with irradiation. Evidence of ˙OH production existed when emulsions were exposed to UV but not to visible light. The presence of H(2)O(2) enhanced the photodegradation of crude oil. Overall, the changes in emulsion properties were attributed to direct photodegradation and photooxidation of crude oil components.

An online module series to prepare pharmacists to facilitate student engagement in patient-centered care delivery: development and evaluation.

INTRODUCTION: Accreditation bodies across North America have adopted revised standards that place increased emphasis on experiential education and preceptors to promote and demonstrate patient-centered, pharmaceutical care practices to students. Since such practices are still evolving, challenges exist in recruiting skilled preceptors who are prepared to provide such opportunities. An online educational module series titled "A Guide to Pharmaceutical Care" (The Guide) was developed and evaluated to facilitate this transition. The objectives of this paper are: (1) to describe the development of the modules; and (2) to present the evaluation results from its pilot testing. METHODS: The Guide was developed as an online, self-directed training program. It begins by providing an overview of patient care (PC) philosophy and practice, and then discusses the tools that facilitate PC. It also provides a range of tips to support students as they provide PC during their experiential learning. Pharmacists participating in the pilot study were recruited using purposive and snowball sampling techniques. A pre-post quantitative survey with additional open-ended questions was used to evaluate the modules. RESULTS: THE MODULES INCORPORATED A VARIETY OF TEACHING STRATEGIES: self-reflection exercises, quizzes to review important concepts, quick tips, flash cards, and video clips to illustrate more in-depth learning. Thirty-two pharmacists completed the pre-post assessment and reported significant increases in their confidence because of this training. The most influenced outcome was "Application of techniques to facilitate learning opportunities that enable pharmacy students to practice pharmaceutical care competencies." They also indicated that the training clarified necessary changes in their teaching techniques as well as increased their own practice skills. CONCLUSION: The study results indicated that a series of self-paced online modules with appropriate content improved the pharmacists' confidence to nurture students' experiential learning for PC practice as well as enhanced their PC knowledge and skills within their own practices.

"Teaching as a Competency": competencies for medical educators.

Most medical faculty receive little or no training about how to be effective teachers, even when they assume major educational leadership roles. To identify the competencies required of an effective teacher in medical education, the authors developed a comprehensive conceptual model. After conducting a literature search, the authors met at a two-day conference (2006) with 16 medical and nonmedical educators from 10 different U.S. and Canadian organizations and developed an initial draft of the "Teaching as a Competency" conceptual model. Conference participants used the physician competencies (from the Accreditation Council for Graduate Medical Education [ACGME]) and the roles (from the Royal College's Canadian Medical Education Directives for Specialists [CanMEDS]) to define critical skills for medical educators. The authors then refined this initial framework through national/regional conference presentations (2007, 2008), an additional literature review, and expert input. Four core values grounded this framework: learner engagement, learner-centeredness, adaptability, and self-reflection. The authors identified six core competencies, based on the ACGME competencies framework: medical (or content) knowledge; learner- centeredness; interpersonal and communication skills; professionalism and role modeling; practice-based reflection; and systems-based practice. They also included four specialized competencies for educators with additional programmatic roles: program design/implementation, evaluation/scholarship, leadership, and mentorship. The authors then cross-referenced the competencies with educator roles, drawing from CanMEDS, to recognize role-specific skills. The authors have explored their framework's strengths, limitations, and applications, which include targeted faculty development, evaluation, and resource allocation. The Teaching as a Competency framework promotes a culture of effective teaching and learning.

Biosynthesis of iron and silver nanoparticles at room temperature using aqueous sorghum bran extracts.

Iron and silver nanoparticles were synthesized using a rapid, single step, and completely green biosynthetic method employing aqueous sorghum extracts as both the reducing and capping agent. Silver ions were rapidly reduced by the aqueous sorghum bran extracts, leading to the formation of highly crystalline silver nanoparticles with an average diameter of 10 nm. The diffraction peaks were indexed to the face-centered cubic (fcc) phase of silver. The absorption spectra of colloidal silver nanoparticles showed a surface plasmon resonance (SPR) peak centered at a wavelength of 390 nm. Amorphous iron nanoparticles with an average diameter of 50 nm were formed instantaneously under ambient conditions. The reactivity of iron nanoparticles was tested by the H(2)O(2)-catalyzed degradation of bromothymol blue as a model organic contaminant.

Do spouses know how much fatigue, pain, and physical limitation their partners with rheumatoid arthritis experience? Implications for social support.

OBJECTIVE: To determine whether perceptions of clinical manifestations (fatigue, pain, and physical limitation) of rheumatoid arthritis (RA) differ between spouses and their partners with RA, and to determine whether the differences are associated with the perception of beneficial and problematic spousal social support. METHODS: English-speaking adults with RA of ≥ 6 months' duration and their spouses (n = 222 couples) completed standardized questionnaires for fatigue, pain, physical limitation, beneficial spousal support, and problematic spousal support. Spouses completed questionnaires based on their perception of their partner with RA. Agreement scores for fatigue, pain, and physical limitation were calculated by subtracting spouse scores from the scores of the partner with RA. Agreement levels were defined a priori: agreement (within ± one-half of a minimum clinically important difference [MCID] unit), overestimator (< one-half an MCID), and underestimator (> one-half an MCID). Separate hierarchical linear regression models were used to measure the association between beneficial support and problematic support after adjusting for RA duration, physical health, sex, educational level, relationship duration, and satisfaction. RESULTS: Response rate for couples was 82%. Relative to participants with RA, spouses overestimated fatigue (26%), pain (29%), and physical limitation (39%), and underestimated fatigue (11%), pain (17%), and physical limitation (34%). After statistically controlling for demographic, disease, and psychosocial variables, participants with RA whose spouses underestimated fatigue received more problematic support (R(2) = 3.7%, P = 0.002), as did those whose spouses underestimated or overestimated physical limitation (R(2) = 3.4%, P = 0.017). CONCLUSION: Persons with RA perceived more problematic spousal support when their spouse underestimated fatigue, or underestimated or overestimated physical limitation levels.

Guided autobiography's developmental exchange: what's in it for me?

The developmental exchange is a central feature of social development, interpersonal dynamics, situated learning, and personal transformation. It is the enabling process in Guided Autobiography (GAB) settings that promotes the achievement of personal goals and group accomplishments. Nevertheless, these exchanges are embedded in the GAB structures of time, events, participants, themes, perspectives, medium, and quest for relevance. Ongoing research studies are gradually clarifying the actual, ideal, and social image of self as well as the processes, outcomes, and specific learning topics achieved during the GAB experience as they unfold through the listening, participating, and diversifying structures of the developmental exchange.

Comparison of patients' expectations and experiences at traditional pharmacies and pharmacies offering enhanced advanced pharmacy practice experiences.

OBJECTIVES: To compare patients' expectations and experiences at pharmacies offering traditional APPE learning opportunities with those offering enhanced APPEs that incorporate pharmaceutical care activities. METHODS: A survey of anchored measures of patient satisfaction was conducted in 2 groups of APPE- affiliated community pharmacies: those participating in an enhanced APPE model versus those participating in the traditional model. The enhanced intervention included preceptor training, a comprehensive student orientation, and an extended experience at a single pharmacy rather than the traditional 2 x 4-week experience at different pharmacies. RESULTS: While patient expectations were similar in both traditional and enhanced APPE pharmacies, patients in enhanced pharmacies reported significantly higher in-store satisfaction and fewer service gaps. Additionally, satisfaction was significantly higher for patients who had received any form of consultation, from either pharmacist or students, than those reporting no consultations. CONCLUSION: Including provision of pharmaceutical care services as part of APPEs resulted in direct and measurable improvements in patient satisfaction.

High-fidelity simulation in anesthesiology training: a survey of Canadian anesthesiology residents' simulator experience.

PURPOSE: The objective of this survey was to explore Canadian anesthesiology residents' educational experience with high-fidelity simulation and to improve understanding of the factors perceived to have either a positive or a negative effect on residents' learning. METHODS: In 2008, all Canadian anesthesiology residents (n = 599) were invited to complete a ten-minute anonymous online survey. Survey questions were derived from two sources, a literature search of MEDLINE (1966 to present), EMBASE (1980 to present), and the Cochrane and Campbell collaboration libraries and the experience of 25 pilot residents and the lead author. RESULTS: The survey response rate was 27.9% (n = 167). Junior residents (PGY1-3) responded that it would be helpful to have an introductory simulation course dealing with common intraoperative emergencies. The introduction of multidisciplinary scenarios (where nurses and colleagues from different specialties were involved in scenarios) was strongly supported. With respect to gender, male anesthesia residents indicated their comfort in making mistakes and asking for help in the simulator more frequently than female residents. In accordance with the ten Best Evidence Medical Education (BEME) principles of successful simulator education, Canadian centres could improve residents' opportunities for repetitive practice (with feedback), individualization of scenarios, and defined learning outcomes for scenarios. DISCUSSION: Anesthesiology residents indicate that simulation-based education is an anxiety provoking experience, but value its role in promoting safe practice and enhancing one's ability to deal with emergency situations. Suggestions to improve simulation training include increasing residents' access, adopting a more student-centred approach to learning, and creating a safer learning environment.

Developing anchored measures of patient satisfaction with pharmaceutical care delivery: Experiences versus expectations.

BACKGROUND: A pilot study was undertaken to evaluate patients' satisfaction with pharmaceutical care (PC) activities delivered at community pharmacies. The objectives of the study were to: (1) operationalize patient satisfaction in terms of the advanced pharmacy practice experience (APPE) PC activities, (2) conduct psychometric analysis of the satisfaction instrument, and (3) assess the sensitivity of the instrument to detect any differences that may exist between what patients expect to receive versus what is actually experienced. METHODS: Pharmacies affiliated with two national chains were recruited to participate. Asthma patients at each of these sites were invited to complete a survey designed to assess their expectations of and their experiences with PC at the respective site. RESULTS: One hundred forty-seven surveys were completed from patients in 19 community pharmacies. Psychometric analysis confirmed the survey's internal reliability and sensitivity to be very high. Data analysis suggested that most patients expect more from PC services than they actually experienced. CONCLUSION: Unlike other PC satisfaction surveys, this instrument allows patient experiences to be anchored against their expectations. The results suggest that most patients would be willing to engage in PC activities outlined in the survey.

Validation of a survey instrument to evaluate students' learning during community-based advanced pharmacy practice experiences.

OBJECTIVE: To develop and validate a preceptor/student self-report survey instrument to distinguish between different advanced pharmacy practice experience (APPE) models based on pharmaceutical care competencies. METHODS: The survey instrument's psychometric properties and differential impacts of 3 community-based APPE models were evaluated retrospectively. RESULTS: Five dimensions characterized APPE learning: importance of 14 pharmaceutical care competencies; agreement with pharmaceutical care procedures in practice; gains in perceived pharmaceutical care abilities; and learning climate and preceptor support. Most of the survey instrument scales detected student/preceptor differences as well as differences in APPE model structures. A streamlined, 30-item short form was validated against the full 78-item survey instrument. CONCLUSIONS: This study confirms that APPE learning can be quantified to: (1) identify high-risk students, (2) train new or continuing preceptors, (3) promote skills-training for select pharmaceutical care competencies, (4) add clarity and structure to APPE learning objectives, and (5) provide students and preceptors with common frameworks for negotiating the APPE experience.

The power of one: looking beyond the teacher in clinical instruction.

BACKGROUND: Research on clinical teaching in medicine tends to focus on preceptors and senior attending physicians as the primary source of learning for medical students. As a result, there is an artificial separation of 'teacher' from context in much of the research on clinical teaching in medicine. AIMS: The central aim of this study was to challenge the taken-for-granted assumption that student learning can be attributed primarily to a preceptor or attending physician on a rotation. METHODOLOGY: Twenty-two medical students and forty-one clinical faculty members generated explanations for a study that showed a positive effect on NMBE results for 3rd year clerkship students who had at least one highly effective clinical teacher during their clinical rotation in medicine. RESULTS: Student and faculty explanations resulted in fourteen factors and six propositions describing the nature of highly effective clinical teaching. Students believed contextual factors influenced their own learning, but did not comment on that possibility in the study (Griffith CH, Georgesen JC, Wilson JF. 2000. Six-year documentation of the association between excellent clinical teaching and improved student examination performance. Acad Med 75(10): October Supplement). Most clinical faculty did question the assumption that one teacher could have that effect. CONCLUSIONS: We recommend refocusing research on clinical instruction toward engagement within a community of professionals, rather than attributing 'power' to a single clinical teacher.

Development of an instrument to assess the impact of an enhanced experiential model on pharmacy students' learning opportunities, skills and attitudes: a retrospective comparative-experimentalist study.

BACKGROUND: Pharmacy schools across North America have been charged to ensure their students are adequately skilled in the principles and practices of pharmaceutical care. Despite this mandate, a large percentage of students experience insufficient opportunities to practice the activities, tasks and processes essential to pharmaceutical care. The objective of this retrospective study of pharmacy students was to: (1) as "proof of concept", test the overall educational impact of an enhanced advanced pharmacy practice experiential (APPE) model on student competencies; (2) develop an instrument to measure students' and preceptors' experiences; and (3) assess the psychometric properties of the instrument. METHODS: A comparative-experimental design, using student and preceptor surveys, was used to evaluate the impact of the enhanced community-based APPE over the traditional APPE model. The study was grounded in a 5-stage learning model: (1) an enhanced learning climate leads to (2) better utilization of learning opportunities, including (3) more frequent student/patient consultation, then to (4) improved skills acquisition, thence to (5) more favorable attitudes toward pharmaceutical care practice. The intervention included a one-day preceptor workshop, a comprehensive on-site student orientation and extending the experience from two four-week experiences in different pharmacies to one eight-week in one pharmacy. RESULTS: The 35 student and 38 preceptor survey results favored the enhanced model; with students conducting many more patient consultations and reporting greater skills improvement. In addition, the student self-assessment suggested changes in attitudes favoring pharmaceutical care principles. Psychometric testing showed the instrument to be sensitive, valid and reliable in ascertaining differences between the enhanced and traditional arms. CONCLUSION: The enhanced experiential model positively affects learning opportunities and competency acquisition, as measured by a new instrument showing sound psychometric properties.