Developing consensus on the competency and assessment of pharmacist preceptors

Abstract

Background

Pharmacist preceptors facilitate the professional development of students and interns during preregistration training. Evaluating preceptor competency is essential for ensuring the quality and consistency of the training process. For effective evaluation to occur, consensus is needed to establish which preceptor competencies require assessment as well as the method of assessment and who should perform the assessment.

Methods

The Delphi method was used to develop a consensus among experts in pharmacy education, accreditation, and practice settings. The study involved three rounds of anonymous surveys in REDCap, focusing on the necessity, feasibility, and methods of assessing preceptor competencies. A previous literature review identified 16 evidence-based competencies that formed the basis of the survey. An agreement level of 70% was set as the threshold for consensus.

Results

Among the 59 invited experts, 22 completed the first round, 13 completed the second round, and eight completed the last round. Consensus was achieved on 17 competencies, with 16 deemed feasible to assess. Eight were considered mandatory for assessment, and four were preferable. Consensus on assessment methods and suitable assessors was achieved for these patients. Four competencies were feasible to assess but lacked consensus on the method or assessor. A multimodal assessment approach, including preceptee surveys, self-assessments, and peer observations, was identified as suitable.

Conclusions

Using a Delphi consensus method, by expert opinion, our study supports the perceived feasibility of assessing pharmacy preceptor competencies via a multimodal approach and clarifies who should assess each competency and how. Implementing these assessments can enhance preceptorship quality, facilitating consistent experiential placements for preceptees. The incorporation of preceptor assessment into accreditation standards should be considered essential to promote high-quality preceptorship and support the ongoing professional development of preceptors.

Introduction

Preceptorship is a form of supervision undertaken in many health professions, such as medicine [1, 2], pharmacy [3, 4] and nursing [5, 6], where there is a defined term of supervision between a practising clinician (preceptor) and a student or intern (preceptee). In Australia, pharmacy education is traditionally a four-year undergraduate (or two-year postgraduate) degree followed by a one-year internship. Both the degree and the internship require a period of supervised practice. Pharmacy preceptors facilitate the professional development of students and interns during their supervised practice. Preceptors help new graduates transition from novice to independent professionals through supervision, providing opportunities to learn with feedback and role modelling. The quality of a placement or internship experience has been shown to have a lasting impact on the development of professionalism throughout a practitioner’s career [7], and interaction with preceptors increases the clinical competence and confidence of practitioners [8]. The influence of the work environment, the people in the workplace and the subsequent variability in preceptorship experienced by preceptees was explored in a 2016 study by Jee and colleagues on professional socialisation [9]. This highlights the variation between hospital and community pharmacy preregistration training with respect to exposure to more complex medication issues, role models and levels of responsibility, raising issues of equity, consistency and quality assurance. Preceptors also play a critical role in professional identity formation, cultivating a sense of inclusion in the professional environment and guiding learners to think, act and feel like pharmacists through a combination of relational (intrinsic) and practical (extrinsic) support strategies [10].

Despite the importance of the preceptor role, an Australian 2017 independent review of accreditation systems for health professions noted that there are no minimum requirements for preceptors. The review also noted a lack of oversight in the appointment of preceptors, which may introduce variability into the quality of the preceptorship experience [11]. With increasing focus on experiential education, reaching consensus on preceptor competencies and how they could be assessed constitute a foundational step toward enhancing preceptor development and the quality assurance of preceptors. However, experiential education needs to be sustainable, and as preceptors are generally not compensated for their role, balancing the learning needs of interns and students with regulatory requirements placed upon preceptors with their available time and clinical roles is an important consideration [12].

Several health professions have adopted preceptor assessment tools to aid professional development, but how these tools are used in terms of accreditation as a preceptor varies considerably. The American Speech Language and Hearing Association uses a self-assessment tool for preceptors to reflect on their competency [13] and mandates two hours of continuing education on precepting as part of their accreditation as a preceptor; however, they do not have a requirement to revisit this once completed. The Royal Australasian College of Physicians recommends self- and peer assessment for professional development [14], but this is not mandated. A literature review of health profession accreditation practices (2018) provided some insight into how various jurisdictions use preceptor assessment and training as part of their accreditation processes [15]. The accreditation standards of the General Pharmacy Council (UK) include feedback from interns on preceptors [16]. The Pharmacy Council of New Zealand currently requires preceptors to complete a free preceptor training program, pass a post training assessment and recertify every three years, or every six years if the preceptor has an intern every year. In contrast, the Pharmacy Board of Australia’s registration standards recommend suitable training or experience for pharmacy preceptors without mandating any oversight provisions or accreditation [17]. This represents a gap between recommendations to accreditation bodies in both Australia and internationally [15] and the process of becoming a preceptor in Australia.

While many authors have examined preceptorship or supervision in a range of health professions, particularly psychotherapy, nursing and medicine [18, 19], these studies have focused primarily on the importance of effective supervision and evaluation of supervisor training and development programs [20, 21]. Previous research has also identified the competencies of preceptors and evaluated the evidence for preceptor competencies across health professions [3]. L’Ecuyer et al. [22] discuss the role expectations of preceptors and how better understanding preceptor competencies can aid in the selection, training and development of preceptors in nursing [3]. Preceptor training is highlighted as essential to quality preceptorship [23]. Ensuring a consistent and high-quality experience for preceptees necessitates the assessment of preceptor competency via a consistent set of competencies [19, 24, 25]. What has been missing from the literature is a discussion of the methods of assessment of each competency. Consensus is required on the competencies related to pharmacy preceptorship, if they should be assessed, along with the method of assessment and the lens through which the assessment should occur, that is, preceptee assessment, peer assessment, self-assessment, or by a third party such as an accrediting body.

The Delphi process is a method of arriving at a consensus position on an issue or statement through several rounds of structured questionnaires [26]. During each round, a panel of experts may anonymously provide comments or opinions, which are used to refine the questionnaire after each round, with the ultimate aim of reaching a consensus by a predetermined percentage of agreement. This technique has been used in various modified forms to arrive at consensus positions on therapeutic treatment protocols, definitions, policy positions and curriculum development, among others [26]. As panellists do not interact with each other, any bias produced by a dominant personality or opinion is minimised [27], and panel composition rather than panel size is a significant factor [28]. Overall, the objective of this process is to provide an evidence base for decision making and the implementation of guidelines or policies.

Aim

To develop an expert consensus on the assessment of pharmacy preceptor competencies.

Objectives

For each competency:

1. 1.

Determine whether an assessment of preceptor is needed.

2. 2.

Determine if the assessment of the preceptor is feasible.

3. 3.

Determine who should perform the assessment of preceptors and the preferred method of assessment.

Methods

Ethics approval for this study was obtained through the University of Sydney (project number: 2020/643).

To develop a consensus, the Delphi method was utilised, comprising an anonymous questionnaire developed in REDCap (Research Electronic Data Capture) [29, 30], version 9, hosted by the University of Sydney. REDCap is an online tool designed to capture data in a secure environment and facilitate easy export to other platforms for analysis.

Survey development

A previous literature review that generated 16 evidence-based preceptor competencies along with how they were being assessed in practice formed the basis for discussion [3]. A summary of the findings from that review is included in Supplementary file. The questionnaire was developed for this study and consisted of questions asking about the wording of the competency, the necessity of assessing each competency (mandatory, preferable, or unnecessary), the feasibility of assessment, the appropriate assessors (preceptee, peer, or self), the method of assessment (student survey, self-assessment, peer assessment, or other), and the identification of any additional competencies not previously identified. In the context of this study, “Mandatory” competencies were defined as those essential for ensuring effective preceptorship. “Preferable” competencies, while not strictly essential, would be beneficial for enhancing preceptorship. “Unnecessary” competencies would be those having minimal or no impact on the preceptorship experience. The questionnaire, consisting of multiple-choice selections and options for free-text input, was developed in REDCap and was initially piloted with two experienced pharmacy researchers. Minor modifications were made, including refinement of the wording of the questions to improve clarity and corrections to the branching logic to improve the flow of the survey. The survey instrument is available as a supplementary file.

Panel selection

A panel comprising experts from stakeholder organisations such as The Pharmacy Guild of Australia and The Pharmaceutical Society of Australia, professional and academic roles, and individuals involved in policy settings related to professional development and intern or preceptor/preceptee training programs was assembled. A purposive recruitment strategy was employed, whereby key opinion leaders were invited to be on the panel on the basis of expertise and extensive experience in the field, ensuring a diverse and knowledgeable representation that provided insights into various aspects pertaining to pharmacy preceptor competencies. All participants were involved in preceptorship as either an active preceptor, a previous preceptor, or an administrator or regulator of preceptorship programs. Consideration was given to the number of years served as a preceptor in either hospital or community pharmacy settings, roles within professional organisations relating to pharmacy preceptors or intern training, roles in educational institutions (e.g., placement coordinators), and pharmacy regulators with experience and interest in accreditation and training. The invitation included a participant information statement that informed participants that completion of the questionnaire was considered consent to participate in the research study.

Survey rounds

All the responses were anonymous, and the email addresses collected were used only to invite participants for further rounds and were not linked to survey responses. The survey was held over three rounds, with a consensus threshold determined at 70% agreement, as suggested by the literature [31]. However, in cases where consensus narrowly missed this threshold, such as a level of agreement of 69% without meaningful support for other options, we adopted a flexible approach. After the initial round, the data were analysed in Microsoft Excel via descriptive statistics, including the proportion of agreement, and to refine and discuss any amendments to any participant-suggested wording where agreement was not met, these could be integrated into the second-round survey. The second and subsequent rounds of surveys highlighted areas where consensus had been reached and highlighted those where consensus had not been achieved, allowing participants to rerate these options. This process was repeated to produce a third round. At the conclusion of the third round, the results were analysed and summarised to identify areas of consensus. The Delphi process is outlined in Fig. 1.

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Results

A total of 59 invitations were initially distributed to various experts, and 22 participants completed the first round. These 22 participants were subsequently invited to complete the second round, with 13 completing the questionnaire. Among the 13 participants who were invited, eight completed the third round. The characteristics of the participants are presented in Table 1.

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In the initial round, 16 competencies were proposed. Two additional competencies, “assessment skills” and “conflict resolution,” were suggested by the participants during the round. The participants noted that “is approachable and flexible” and “adapting to the learning needs of preceptees” essentially describe the same content. Therefore, these were combined into one single competency, “Provides an accessible learning environment”. At the conclusion of the Delphi process, a final list of 17 competencies was proposed. These competencies are described in Table 2, and the full results are available in Supplementary file.

Of the 17 identified competencies, eight reached a consensus on being mandatory for assessment, and an additional eight competencies reached a consensus on being preferable for assessment. One competency reached a consensus that assessment was not necessary. Sixteen of the 17 competencies reached a consensus on being feasible to assess (Table 2).

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Of the 16 competencies judged feasible to assess, 12 competencies reached a consensus on at least one method of assessment and on at least one person (i.e., either preceptee, peer, or self) suitable for assessing competency (Table 3). Four competencies that reached a consensus on being preferable to assess did not reach a consensus on either who should assess the competency or the method of assessment.

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Discussion

Through this Delphi process, we determined by a consensus of expert opinion that assessing preceptor competencies is feasible. This research provides guidance on aligning the competency that is being assessed with the individual who may be best placed to assess it, along with the method of assessment. While a consensus was reached on the best person to assess and at least one method of assessment for 12 competencies, five did not reach a consensus. Among these 12 competencies, eight could be considered mandatory to assess and four could be preferable. The eight competencies that should be mandatory for assessment may be considered the critical skills and knowledge areas that all preceptors must develop, whereas the four competencies identified as preferable to assess are areas that may enhance the quality of preceptorship. Two of these competencies were proposed during the Delphi process and failed to reach a consensus position; therefore, further refinement may be needed. Feasibility, along with consensus for how preceptor competencies should be assessed, helps to form a foundation for the development of a preceptor assessment framework. Feasibility ensures that a preceptor assessment framework is not only conceptually robust but also implementable from a practical perspective within clinical and educational settings and therefore sustainable. A sustainable and implementable tool could address the need for consistent preceptorship experiences along with the quality assurance recommended previously [15].

The identification and assessment of preceptor competencies play a vital role in professional development and have been a focus of research in pharmacy practice and other health professions. Walter et al. (2017) discussed developing preceptor competency frameworks as the basis for preceptor development programs [4]. Their study did not delve into specific assessment methods but instead focused on competencies and their performance indicators, whereas our study, while using a similar consensus approach, concentrated on how competencies should be assessed and by whom. Another study across 12 health professions, including psychology, social work and nursing, developed a free validated assessment tool for both supervisors and supervisees to measure the competency of supervision. The authors recognised the importance of assessment to the development of both the supervisor and the supervisee and that the lack of accessibility of assessment tools was a barrier to good assessment practices [32]. Factor analysis was used to refine and validate an assessment tool, the Generic Supervision Assessment Tool (GSAT), across a broad range of practice settings. The tool development followed a robust method with competencies identified from the literature review and resulted in 21 items developed with a diverse expert panel. The competencies identified were similar to the 17 items proposed in this study, with the added inclusion of some competencies relevant to the supervision context. Notably, while this study of 12 health professions demonstrated the validity of the tool from two perspectives, supervisors and supervisees, it did not examine which competencies are best assessed from different perspectives. Our study fills a gap in the literature by addressing how identified competencies should be assessed.

What is apparent from the results of our study is that a single method of assessment does not adequately capture all competencies of preceptorship, and a multimodal approach is needed. There were competencies that were associated with only one preferred method of assessment. For example, a survey completed by the preceptee would not capture a demonstration of reflective practice, in which self-assessment would be preferred. A flexible and pragmatic approach to preceptor assessment is needed to account for the variation in the practice setting in which preceptorship is occurring. Previous research has shown that peer assessment is not acceptable across all practice settings [33]. Those in community pharmacies may find it more intrusive and inconvenient, whereas in a hospital setting, peer observation is accepted and often part of performance review processes. Taking into consideration the acceptability of how competencies are assessed, one solution to ensure a multimodal approach is, at a minimum, that preceptor competencies should be measured by a survey completed by the preceptee, in conjunction with preceptor self-assessment, and where practical, supplemented by peer observation.

Moving forward, our research sets the stage for further investigations. Future work should focus on developing more granular descriptions of these competencies and creating aligned and validated assessment tools. To provide the appropriate oversight as recommended in the 2017 independent review into accreditation practices in health professions [34] and the Health Profession Accreditation Practices International Literature Review (2018), we propose the adoption of minimum accreditation requirements to become a preceptor and to maintain accreditation as a preceptor. Preceptor development training should be mandated as part of the accreditation process to become a preceptor. Furthermore, ongoing assessment of competency should be used to identify training and development opportunities that could form a set number of Continuing Professional Development (CPD) hours in line with education being part of the preceptor’s scope of practice. The assessment should consist of, at a minimum, a survey tool completed by the preceptee, along with the completion of a self-assessment survey or reflection, all of which would be mapped to the competencies identified as suitable for assessment by these methods. In addition, a peer assessment included as part of a portfolio of evidence should be included if practical or if the preceptor was seeking recognition in a role as an educator.

Additionally, it is crucial to examine the impact of more stringent requirements on the pool of preceptors willing to fulfil this role. It may also be worth investigating other aspects of preceptor assessment programs, such as the ideal timing and frequency of competency assessment. Understanding the current preceptor assessment practices of pharmacy education providers could provide invaluable practical insights, offering a comprehensive view of how these enhancements might affect both educational outcomes, preceptor acceptance and availability.

Strengths and limitations

The strengths of this study were that a broad range of participants with expertise in experiential education, industry experience and accreditation participated. The Delphi process reduces bias by facilitating individual voices without influence from dominant participants. The iterative nature of the Delphi process allowed for refinement of the items being discussed over the rounds.

Limitations included the decrease in the number of participants as rounds progressed due to the length of time that the Delphi process took, which may have changed the balance of opinions expressed. Hospital preceptors were overrepresented in the initial round; however, this evened out over the course of the study. Additionally, the geographical location of the participants was not collected as part of the survey, which, owing to differences in educational and regulatory approaches to preceptorship, may influence the interpretation of the study results. These limitations may affect the acceptability of the final pharmacist-preceptor competency assessment framework. This study was undertaken via rounds of an online survey, which may reduce the amount of active discussion between participants. The agreement level was set at 70%, which is arbitrary even though based on the literature, choosing a different agreement level may have changed the outcomes.

Conclusions

Using a Delphi consensus method has provided a basis for a preceptor competency assessment framework that not only provides clarity on the competencies as well as their relevance but also incorporates modes of assessment and feasibility. The results suggest that a multimodal approach to assessment utilising, at a minimum, a preceptee survey of preceptor competency along with self-assessment of preceptor competency is ideal, with the addition of peer assessment where possible. Importantly, the competencies identified could inform future recommendations from accrediting bodies on preceptor standards. Integrating preceptor assessment into accreditation standards for pharmacy preceptors should be considered to promote high-quality preceptorship and professional development of preceptors.

Data availability

Data is provided within the manuscript.

Abbreviations

CPD:

Continuing Professional Development

GSAT:

Generic Supervision Assessment Tool

REDCap:

Research Electronic Data Capture

AB:

Andrew Bartlett

IU:

Irene Um

CS:

Carl Schneider

IK:

Ines Krass

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