Case Scenario 

Kateryna, 40 years old and new to your pharmacy, presents seeking advice. She has been feeling anxious, irritable and tired, and requests valerian tablets from the intern pharmacist. The intern conducts the consultation with the patient in the counselling room. You (the preceptor) and the intern agree this would be a good activity for a case-based discussion. Away from the dispensing area, the intern presents the case to you verbally using the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) format. They cover the patient’s age, gender, symptoms, medicines, medical conditions, rationale for determining valerian was not appropriate and their recommendation to refer the patient to their GP.

Learning objectives

After reading this article, pharmacists should be able to: 

  • Discuss the rationale and purpose of workplace-based assessment 
  • Describe workplace-based assessment methods and associated tools being introduced into the supervised practice period 
  • Provide practical tips for implementing the workplace-based assessment tools in pharmacy workplaces. 

Competencies addressed (2016): 1.1, 1.4, 1.5, 1.6, 4.1, 4.2, 4.3, 4.6, 5.1

 

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Introduction 

For intern pharmacists, the transition from student to pharmacist involves the successful completion of a period of supervised practice. During this time, interns are faced with a range of situations to which they apply their knowledge and continue to develop their professional skills. This workplace-based education provides the opportunity for interns to put theory into practice while under the guidance of an experienced pharmacist. 

The Pharmacy Board of Australia (PharmBA) stipulates that preceptors are responsible for the overall supervision and development of the intern by guiding them through an experiential education program that is essential for them to become a competent pharmacist.1 The day-to-day activities undertaken by preceptors in the practice setting are underpinned by competency standards for the pharmacy profession, including those relating to the delivery of education and training.1,2 The 2020 PharmBA report on intern and preceptor experiences of intern training indicated that a majority of interns and preceptors found the supervised practice period to be useful. However, there is a common concern related to inconsistencies in the quality of training and supervision.3

Workplace-based assessment (WBA) is a process that involves observation and feedback of how the intern is performing in the workplace. Importantly, WBA provides an evidence-based framework for preceptors to provide supervision and support that is tailored to the learner.4,5 When used appropriately, WBA can help ensure equity and consistency in intern training and supervision. 

The implementation of WBA aims to improve the quality of supervised practice, but all stakeholders, including preceptors, interns and intern training program providers, must actively participate and understand their roles. 

This article describes a series of recently developed WBA tools6 that are now part of intern training programs (ITPs) and can be used as a guide for how to effectively use WBA in pharmacy workplaces. 

Overview of workplace-based assessment 

WBA is not unique to health professionals. It has been the key element of traditional apprenticeship programs for trades and occupations which require a person to demonstrate they can do something, often in highly complex and variable real-world contexts.7 These concepts have been adopted into health professional training whereby a trainee is observed performing the tasks that will be required of them as an independent practitioner. This enables the trainee to further refine and develop their skills under the supervision of a registered health professional, while also safeguarding patient safety.8 One of the essential aims of training is to ensure that trainees become competent healthcare professionals and can be trusted to perform clinical tasks. 

Psychologist George Miller described four levels for assessing clinical competence, referred to as Miller’s pyramid.9 He argued that no single assessment can be used to determine competency, and that a variety of assessments should be used. At the bottom of the pyramid, the focus of assessment is on testing knowledge (‘knows’), whereas at the highest level, assessment focuses on observing performance in a real-world environment (‘does’).9 WBA is at the top of the pyramid and provides evidence that a learner has integrated the knowledge and skills required to perform tasks in a real-world environment. 

More recently, Ten Cate et al extended this theory to suggest that registration of a healthcare professional should not only be based on what we observe them do in practice but also on the level of trust we have that they can perform the clinical task unsupervised in the future.10 Making such decisions relies on a collection of information in the workplace to help assess current performance and our trust in a trainee’s future performance.11

Context for change 

In 2020, the Australian Pharmacy Council (APC) published a Performance Outcomes Framework as part of a suite of documents to accompany revised accreditation standards.12 The framework details expected performance at two key milestones along the pathway to pharmacist registration. First, at the point of graduation from a pharmacy degree program, then on completion of supervised practice. 

The framework encompasses all entry level competencies outlined in the National Competency Standards Framework for Pharmacists in Australia (2016)2 and is now the basis for intern performance assessment. 

The Intern Year Assessment Blueprint (IYB) specifies the most appropriate method for assessment of the performance outcomes required to be demonstrated by intern pharmacists.13 As most of these assessments are best performed in the workplace, a suite of WBA tools are being introduced as part of ITPs. 

Making workplace-based assessment a meaningful learning tool 

A variety of WBA tools for health professional training have been developed. WBA tools that may be familiar to pharmacists include the mini-clinical evaluation exercise (mini-CeX) and, direct observation of procedural skills (DOPS) among others. 

When coupled with self-reflection and effective feedback, WBA also serves as a learning tool to structure intern development.4,5

The key features that make WBA meaningful for learning are5: 

  • Observation
    • Observing the intern performing a task in the workplace (whether directly through prospective observation or indirectly through retrospective discussion of an episode of care). In some cases, observation may also include analysis of a completed product demonstrating application of skill into practice (e.g. dispensed item or extemporaneously prepared product). 
  • Reflection 
    • Encouraging the intern to self-reflect on their performance. As a key element of WBA, good intern reflective practice deepens the learning experience. 
  • Assessment 
    • Assessing the intern’s performance, usually against a set of standards or criterion. 
  • Feedback 
    • Providing the intern with meaningful and timely feedback about their performance. 
  • Development planning 
    • Encouraging the intern to create a plan to maintain or improve their performance of a given task. 

Below, we describe three WBA methods and associated tools which will be integrated into ITPs: 

  • Entrustable professional activities (EPA) 
  • Case-based discussion (CbD) 
  • In-training assessment activities (ITA-act): specifically reflective practice activities and health promotion activities. 

A range of support material that includes videos, guidelines and exemplars, and associated templates have been developed by the APC with funding from the PharmBA to assist interns and preceptors in their understanding of how to use the tools. Support material and tools can be accessed for free on the APC website. 

Entrustable professional activities 

An EPA is defined as ‘a unit of professional practice (a discrete task or group of tasks) that can be fully entrusted to an individual, as soon as he or she has demonstrated the necessary competence to execute this activity unsupervised’.14

In the context of pharmacy, an EPA is a professional task that forms part of daily work, and we trust a pharmacist to perform (e.g. dispensing). Establishing trust requires the supervisor to not only confirm that the intern can perform the task but to also make a judgement call that the intern can be trusted to perform the task independently in different contexts when they become a registered pharmacist. Supervisors make decisions about the extent to which a learner (in this case an intern) can be assigned responsibility for a given task (EPA). 

This concept of entrustment is the underlying basis of assessment of EPAs for determining intern readiness to practice.15,16 To learn more about EPAs, refer to Assessing Intern Performance and Readiness to Practise using Entrustable Professional Activities (EPAs) on the APC website.17

One WBA tool that can be used to inform an entrustment decision is a short practice observation where the supervisor is directly observing the intern perform an EPA (task) and evaluating their performance.18 As with other WBA tools, following this, the intern should be provided an opportunity to reflect and be given timely feedback from the supervising pharmacist. 

The intern is also engaged in a more in-depth discussion (termed ‘entrustment discussion’) following the observation. An entrustment discussion is like a CbD in that the supervisor is probing the intern’s rationale for the decisions made. This helps add extra evidence to inform the decision that the intern can perform the EPA autonomously in the future. 

Additionally, the use of ‘what if’ questions during this discussion can help establish how the intern would respond in future unobserved scenarios. 

The following is an example of the steps involved in the assessment of a dispensing EPA18: 

  1. Short practice observation 
  • Intern is observed by the supervising pharmacist receiving a prescription, deciding if a prescription is appropriate to dispense, processing the prescription and checking the final dispensed product. 
  • Using the short practice observation template, the supervising pharmacist notes what is observed and documents their feedback. 
  1. Reflection 
  • Intern is asked to self-reflect on their performance. 
  1. Entrustment discussion 
  • Intern and supervising pharmacist engage in a discussion where the intern shares their self-reflection, and the supervising pharmacist shares their feedback. During this discussion, the supervising pharmacist asks ‘what if’ questions to establish how the intern may respond in a different scenario (e.g. what if you suspected that this was a forged prescription?). Adding this element helps to better make an assessment that the intern can be entrusted to perform this EPA in different circumstances. 
  1. Entrustment decision 
  • The supervisor makes an entrustment decision and explains why they have chosen the supervision level. 
  1. Development plan 
  • From the feedback and discussion, the intern creates a development plan to maintain or improve their performance. 

Case-based discussions 

CbDs are retrospective explorations of a case in which the intern was actively involved in the provision of care. In this process, an intern discusses the management of a recent patient encounter with their supervisor.19

One of the most important roles of the supervisor in a CbD is to use questions to probe the intern’s reasoning in relation to the case by prompting the intern to defend their decisions or recommendations. 

One of the temptations to avoid as a supervisor in a CbD is to ‘lecture’ the intern by telling them the right approach to the case straight away. It is also a misconception that CbDs need to involve a case that has a medicine-related problem requiring pharmacist intervention. There is still value in the intern discussing a case with safe and reasonable therapy. The value of the CbDs relates to the learner defending why they have made this evaluation. 

Tips for using CbD in practice: 

  • Help the intern select a case that is tailored to their stage of progress and presents some challenges that stretch the intern. 
  • Set time aside. Even 5 minutes is enough. 
  • Avoid surprising your intern. Let them know what you are expecting them to demonstrate or learn from the case.
  • Ask questions that will elucidate the intern’s reasoning and decision making (e.g. why did you choose medicine A over medicine B?). 
  • Instead of telling the intern the answer to your questions, guide them to resources that will help them establish their own responses. 

In-training assessment activities 

ITA-act involve direct or indirect observation of the intern performing a workplace activity. ITA-act are training strategies that have been part of ITPs and are designed to facilitate learning in the workplace and the acquisition of competencies relevant to the pharmacy context.20

The health promotion and reflection ITA-act are part of the suite of WBAs, and new templates have been developed to help structure how these activities are undertaken and assessed.

Health promotion 

Interns are required to demonstrate that they are independently competent in and committed to endorsing and participating in health promotion activities, health services and public health initiatives intended to maintain and improve health.12,13

The purpose of this activity is to provide interns with structured guidance on which to base the design, implementation and evaluation of a specific health promotion, service or public health initiative which is intended to maintain and/or improve the health of members of the public. 

The intern is not expected to run the activity alone, but a degree of autonomy is expected in ensuring it is appropriately delivered. The supervisor is expected to observe and provide feedback to the intern at three key phases of the health promotion activity: design, implementation/execution and evaluation.21

Reflection 

Reflection is the process of thinking back on experiences, learning from what happened and planning what could be done differently in the future, and it is integral to the practice of healthcare.22 At the point of general registration, interns are expected to demonstrate competence in, and commitment to, engaging in regular and systematic reflection to enhance professional learning and practice.12,13

Reflection in this context involves an indirect observation of the intern’s experience and performance of workplace activities. 

A reflection template for use by interns accompanied by an assessment and feedback form has been developed to encourage reflective practice and ensure any gaps in reflective practice can be addressed by the preceptor.23

Knowledge to practice and top tips for workplace-based assessment 

With competing work pressures, implementing WBA tools as part of intern training can appear to be a daunting task. Observing interns’ practice and providing feedback takes time but is a necessary component of workforce development and is an opportunity to shape the future of pharmacy practice. 

Supervisors often ask how to avoid WBAs becoming a ‘tick box’ exercise. 

The following are useful tips for implementation: 

  • Observation of interns may be conducted by anyone who is nominated to provide clinical supervision for an intern.1 With one’s practice observed by different supervisors, it can strengthen feedback for the intern and maximise opportunity for professional development. 
  • Interns should regularly self-reflect on their performance, as well as the feedback received, and develop a plan to improve.22,23
  • Interns and supervisors should agree on the expected standard of performance before assessment is carried out. Achievement of expected standard of performance varies from individual to individual. Therefore, it is alright if an intern develops faster or slower than their peers in some areas. 
  • Feedback by supervisors should be provided in a timely manner and be specific, honest and constructive.4,5 Structure the feedback around what was observed by using specific objective statements rather than subjective statements (e.g. ‘I observed that you dispensed medicines for multiple patients at the same time’ rather than ‘I feel that you were distracted’).4
  • During the development planning stage, the intern should discuss reflections and the feedback received to develop a plan to maintain or improve their performance in relation to the observed task. To make this a more actionable and measurable plan, interns should be encouraged to formulate this as a SMART (Specific, Measurable, Achievable, Time-bound) goal.

Conclusion

WBA facilitates progress from observation to participation, supervised execution and then independence.10 WBAs should occur as a natural part of the training environment to foster self-directed learning by interns, supported by observation and feedback from supervisors.

Case Scenario Continued 

After the case is presented, you engage in a discussion with the intern to probe their reasoning for the clinical decision made and their general understanding of the conditions and treatments covered in the case, including referral criteria. You agree with the intern’s decision and provide verbal and written feedback, including what they did well and areas for improvement. You also complete the CbD feedback and assessment form. You note the intern is meeting most expectations for their stage of training. Following this, the intern documents their reflection and development plan to maintain or improve their performance in relation to this task.

 

Key Points 

  • Workplace-based assessments (WBAs) provide an evidencebased framework for preceptors to provide supervision and support to intern pharmacists. 
  • WBAs are a key element in assessing an employee’s workplace-based skills. 
  • A suite of WBA tools have been introduced by the Australian Pharmacy Council to assess intern pharmacist workplace-based skills and structure development during the required supervised practice period. 
  • Key features that make WBA a meaningful learning tool include observation, reflection, assessment, feedback and development planning.

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References

  1. Pharmacy Board of Australia. Intern pharmacist and preceptor guide. Australian Health Practitioner Regulation Agency. 2021. At: www.pharmacyboard.gov.au/Registration/Internships.aspx  
  2. Pharmaceutical Society of Australia. National competency standards framework for pharmacists in Australia. 2016. At: www.psa.org.au/wp-content/uploads/2018/06/National-Competency-Standards-Framework-for-Pharmacists-in-Australia-2016-PDF-2mb.pdf 
  3. Pharmacy Board of Australia. The intern training experience from perspective of the intern and preceptor – a large scale study. 2020. At: www.pharmacyboard.gov.au 
  4. Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach 2007;29(9):855–71.
  5. Hurst YK, Prescott-Clements L. Optimising workplace-based assessment. Clin Teach 2018;15(1):7–12.
  6. Maundu J, Galbraith, K, Croft H, et al. Development of workplace-based assessment tools to support postgraduate training of provisionally registered pharmacists in Australia. J Am Coll Clin Pharm 2022. Epub 2022 Oct 22.
  7. Pratt, D, Johnson J. ‘The apprenticeship perspective: modelling ways of being’ in Pratt, D. (ed.) Five perspectives on teaching in adult and higher education Malabar FL: Krieger Publishing Company (1998). 
  8. Rassie, K. The apprenticeship model of clinical medical education: time for structural change. NZ Med J 2017;130(1461):66–72.
  9. Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65S63–7. 
  10. Ten Cate O, Carraccio C, Damodaran A, et al. Entrustment decision making: extending Miller’s pyramid. Acad Med 2021 92(2):199–204.
  11. Witheridge A, Ferns G, Scott-Smith W. Revisiting Miller’s pyramid in medical education: the gap between traditional assessment and diagnostic reasoning. Int J Med Edu 2019;10:191–2.
  12. Australian Pharmacy Council. Accreditation standards for pharmacy programs in Australia. Performance Outcomes Framework. 2020. At: www.pharmacycouncil.org.au/
  13. Australian Pharmacy Council. Intern year assessment blueprint 2020: Performance outcomes framework. 2020. At: www.pharmacycouncil.org.au/
  14. Ten Cate O, Taylor DR. The recommended description of an entrustable professional activity: AMEE Guide No. 140. Medical Teacher 2021;43(10):1006–1114. 
  15. Hauer KE, Ten Cate O, Boscardin C, et al. Understanding trust as an essential element of trainee supervision and learning in the workplace. Adv Health Sci Educ Theory Pract 2014 Aug;19(3):435–56. 
  16. Ten Cate O, Hart D, Ankel F, et al. International competency-based medical education collaborators. Entrustment Decision Making in Clinical Training. Acad Med 2016;91(2):191–8. 
  17. Australian Pharmacy Council. Assessing intern performance and readiness to practise using entrustable professional activities. At: www.pharmacycouncil.org.au/workplace-based-asessment/
  18. Australian Pharmacy Council. Workplace-based assessment tool. Entrustable professional activity (EPA) 1: Dispensing medicines. Preceptor and intern user guide. At: www.pharmacycouncil.org.au/workplace-based-assessment/ 
  19. Australian Pharmacy Council. Workplace-based assessment tool. Case-based discussion (CbD) Preceptor and intern user guide. At: www.pharmacycouncil.org.au/workplace-based-assessment/
  20. Australian Pharmacy Council. Intern year assessment blueprint 2018: Competency standards. At: www.pharmacycouncil.org.au/
  21. Australian Pharmacy Council. Workplace – based assessment tool. In-training assessment activity (ITA) activity health promotion: Preceptor and intern user guide. At: www.pharmacycouncil.org.au/workplace-based-assessment/
  22. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sc Educ 2009;14:595–621.
  23. Australian Pharmacy Council. Work-place based assessment tool. In training assessment (ITA) activity Reflection. Preceptor and intern user guide. At: www.pharmacycouncil.org.au/workplace-based-assessment/

Authors

DR HAYLEY CROFT (she/her) PhD, BPharm, GradCertDiabetes, AACPA, MPS is an accredited consultant pharmacist and teaching and research academic at the University of Newcastle, NSW. 

STEVEN WALKER (he/him) BPharm(Hons), MClinPharm is a senior lecturer and Intern Programs Manager for the Faculty of Pharmacy and Pharmaceutical Sciences at Monash University, Vic. 

JOSEPHINE MAUNDU (she/her) BPharm(Hons), MPH, PharmD, MPS is currently Director of Policy and Projects at the Australian Pharmacy Council. 

Acknowledgement

SALLY MAROTTI (she/her) BPharm, MClinPharm, AdvPractPharm from SA Health.

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