A Diabetes Education Program for Pharmacy Students

Transcription

1 A Diabetes Education Program for Pharmacy Students Peggy Soule Odegard, Linda Lawless LaVigne and Allan Ellsworth School of Pharmacy, University of Washington, Box , Seattle WA This paper describes a novel education program for doctor of pharmacy students about diabetes, a chronic disorder of glucose metabolism affecting an estimated 16 million people in the United States. The Diabetes Program (DP) incorporates didactic learning, web-based case evaluation, and role play into a two-week comprehensive module on diabetes care. In the DP, students are placed in the role of the diabetes patient for one week and the diabetes pharmacist for one week using clinical faculty as preceptors for this case-based learning. Classroom education is provided in lecture format with laboratory learning in the format of a standard outpatient diabetes education class. The DP has earned positive evaluations from students and faculty. Student knowledge and confidence in self-care management of diabetes were improved by the program. INTRODUCTION In schools of pharmacy across the country, education about diabetes may be a standard part of the curriculum although the depth of coverage or the extent students are able to apply what they learn may vary. In this publication, we describe a program, for third-professional year students, partnering didactic instruction on diabetes with life experience as both a mock patient with diabetes and as a pharmacist taking care of a patient with diabetes. Diabetes Mellitus (DM) is a chronic disorder of glucose metabolism affecting an estimated 16 million people in the United States. If not controlled, diabetes can have devastating consequences resulting in significant, debilitating morbidity and even mortality. A 1997 report by the American Diabetes Association estimated annual costs for diabetes in the United States at 98 million dollars with much of this cost associated with the long-term complications of uncontrolled diabetes(1). Glucose control near the range of normal for individuals without diabetes or "tight control" continues to show the greatest benefit in reducing the risks of long term complications of diabetes(2-4). While the costs of poor control are both financially and personally high, control of diabetes is often not achieved or only achieved temporarily by the individual patient. Effective management involves a complex treatment regimen including modification of lifestyle-related factors like nutrition, exercise, stress, smoking; the use of medications; and, ongoing invasive monitoring of blood glucose. Coordinating all of the components of treatment is not an easy task and requires education, support, monitoring, and motivation. Treatment complexity may pose a challenge to the patient's ability to adhere to the regimen resulting in poor control, symptom relapse, progression of complications, and resulting frustration. Studies evaluating interventions to improve the control of diabetes continue to support the use of educational approaches with several studies demonstrating value when education is provided by a pharmacist or when a pharmacist is part of the diabetes care team(5-7). As health care providers with knowledge of the illness, its treatments, and monitoring tools, pharmacists are vital members of the diabetes health care team in both the outpatient (retail, clinic, day health) and the inpatient (hospital and long term care) settings. Nationwide, pharmacists can obtain certification as diabetes educators (CDE) with many of those certified practicing in multidisciplinary settings of diabetes care and providing a high-level of support to the individual with diabetes. Pharmacists are available as consultants in rural as well as urban settings and often during "off-hours" thus creating excellent access to care for the individual with diabetes(8). Given these factors, adequate preparation and training of the pharmacist are critical to assure that patients receive the level of care required. One can assume the general health care consumer with diabetes expects the pharmacist to possess a minimum level of knowledge and skill in the area of diabetes management given the prevalence of this disease. The ideal way to train pharmacy students so that they may provide the support, counseling, education, monitoring, and follow-up needed by patients with diabetes has not been studied. For individuals with DM, group education with skills practice and return demonstration are well supported by the literature as effective instructional methods.(9) To reflect this Am. J. Pharm. Educ, 66, (2002); received 4/29/02; accepted 7/21/02. American Journal of Pharmaceutical Education Vol. 66. Winter

2 instructional format for pharmacy students, we synchronized role play throughout a two-week period and group education in a simulated diabetes education center with the core therapeutics course lectures on diabetes. In this program, lab instructors acted as preceptors, and students as both patients and pharmacists. Our goal was to develop a more comprehensive training program that would provide a better core level of knowledge and, at the same time, expose the student to experiential learning about diabetes. Specific objectives in developing the University of Washington pharmacy diabetes curriculum were to: (i) improve student knowledge about diabetes; (ii) improve student confidence in providing diabetes care; and (iii) improve integration of the didactic lectures on diabetes provided in the therapeutics course with the problembased learning cases and patient assessment laboratory. METHODS Baseline Assessment The diabetes program (DP) was developed in the endocrine/cardiovascular quarter of the Therapeutics course, a 29-credit course for third-professional year doctor of pharmacy students. Prior to development of the module, the course provided four hours of lecture about diabetes. Lecture topics included pathophysiology, classification, complications, and treatment of type 1 and type 2 diabetes. Evaluation of student learning employed a mix of multiple-choice and short answer case-based questions. Problem-based learning cases were given to students in small groups (eight or less) to solve over 1-2 weeks time (4-8 hours) with required problem-oriented SOAP noting for evaluation. The patient assessment laboratory provided two weeks (four hours) of practical instruction on glucose monitoring devices, foot care, nutrition, and administration of insulin or glucagon with associated skills testing prior to passing the section. Student evaluations and focus groups reported that while the information learned was valuable, redundancy of material and excessive evaluation and busy work seemed to bog down the learning. To develop the new DP, the primary diabetes course instructors worked together to implement an integrated approach for the therapeutics course, problem-based groups, and assessment lab. Pilot Program Initially, the 2000 diabetes curriculum was designed with the idea that lectures would continue to provide the background information on diabetes and the lab would continue to provide practical instruction. The primary change was made in the casebased learning using a homework role-play. The role-play relied on the use of web-based technology linked with case details to enable students to observe daily glucose values for a case patient. The web-based program was designed to allow clinicians to view blood sugars entered by their patients via the internet. This program ( Rose Technologies, Colorado. 2000) was selected for use during the project because of the availability of local programming support and training facilitating ease of use and the ability to make modifications for the diabetes project. The program enabled viewing of a patient's blood sugars in report formats (e.g., charts or graphs) to observe trends in blood sugar and to determine opportunities for improved DM management. Mock patients were created in the system for the students to follow. Approximately 70 pharmacy students participated in the pilot project. Although the web-based case provided students with the opportunity to experience new technology, evaluations Fig. I. Diabetes program flowchart. Table I. Orientation curriculum Topic Role of case patient and pharmacist Timeline for module Use of web-based technologies Patient confidentiality rules and regulations Blood born pathogens, Universal Precautions Voluntary aspects of project (e.g., voluntary mock self injection of insulin) completed by the students at the end of the project revealed a request for even greater integration and practice with the case experience. In response, a fully integrated model was developed and implemented in The pilot program was evaluated by the students using a standard course evaluation tool, anonymous written input, and discussions with program faculty, students, and staff. Program Development General Description. In 2001, the revised DP integrating lecture, problem-based cases, role-play, the assessment lab, web-based learning, and the dispensing lab was implemented. As described in Figure 1, DP learning was initiated during winter quarter with the start of a six-hour didactic series on diabetes including lecture on the pathophysiology, classification, treatment, cost and potential complications of the disease, and specific management of both type 1 and type 2 DM. During the initial lecture, students were provided with an orientation (approximately 30 minutes) to the DP (Table I). Following the initial three-hour lecture that included the orientation, students attended their assigned two-hour weekly Therapeutics Course skills lab session (16 students per lab) transformed for the course module into the "Diabetes Education Center," a group-learning center. At the door of the center, students were presented with their actual case assignments and linked with another student as a project partner. During one of the two-weeks in the project period, each student partner acted as the "case pharmacist" while the other member of the pair acted the role of the "case patient. Each student pair was assigned a meter and supplies, case descriptions, and prescriptions to 392 American Journal of Pharmaceutical Education Vol. 66. Winter 2002

3 Table II. Electronic mail messages and alerts Learning point Message Hypoglycemia "You are feeling sluggish, shaky, and sweaty... what do you do? Mixing Insulin "You need to mix your insulin in one syringe... how wilt you do this? Can you mix your evening syringe now?" Hidden Carbohydrates 'identify the extra carbohydrates when a diabetic chooses to put sugar in their coffee or syrup on their pancakes. Where would you be willing to give up some carbs if necessary?" Exercise "Give advice to a diabetic using insulin who wishes to start exercising. Notice how much extra planning and preparation is required for them to just go out and run." filled for the patient cases. Students were paired with a partner in their geographical home locale to minimize long distance care needs. All students resided in the Puget Sound area. Student partners did not share patient cases but rather had separate cases for their role-play as the patient in order to allow each student new information and case challenges. There were four different diabetes cases used in this role-play portion of the DP. In the Diabetes Education Center, students assumed the identity of the newly diagnosed diabetes case they were assigned. The Diabetes Education Center experience included four learning stations at 30-minute intervals. School of Pharmacy Clinical Faculty experts, most with certification as diabetes educators, assisted with lab instruction. Stations included glucose monitoring, insulin and glucagon administration, nutrition (meal planning and hypoglycemia rescue), and foot care (daily care and clinical foot exam). The philosophy of the education center was to provide the students with a level of group education similar to that provided to new patients in a diabetes education series in accordance with American Diabetes Association guidelines for selfmanagement educa-tion(x). The education provided in the center was also geared to familiarize students with a standard set of pharmacist clinical skills for provision of diabetes care. Getting Prescriptions Filled. After receiving initial diabetes education, student "patients" proceeded to the dispensing lab where first year pharmacy students filled their DM prescriptions and provided counseling on medication use as part of the first year, Pharmacy Practice course. Sugar-free or sugar-filled candy was used for tablets or capsule dosage forms based on patient preference or allergies (e.g. chocolate) reported in the history. Normal saline for injection was used for mock insulin dispensed with 30 gauge insulin syringes. A one-hour lecture on DM, general mechanism of action and counseling tips for the medications to be used by the case patients, and an orientation to the module were provided to the first year students as part of the Pharmacy Practice course prior to the DP. A DP faculty member was available to answer questions and facilitate the project the day of the actual dispensing lab in order to optimize project communication. Taking Care of the Patient. During one of the two weeks of the case period, the student acted as the case pharmacist for his or her case partner. Students were allowed flexibility to decide which of the pair would act in the role of the patient or pharmacist first. At the end of the first week of the two-week period of the DP, student pairs shifted roles and initiated the second patient case at a time convenient for the students to trade meter supplies. When acting in the role of the case patient, students checked blood sugars multiple times daily, administered subcutaneous normal saline to mimic insulin injections and candy to simulate medication as defined in their case. Electronic mail was used to notify case pharmacists and patients of events occurring throughout the week such as hypoglycemia and decision-making regarding exercise and nutrition (Table II). Students were advised to check their electronic mail at least once daily during the project period. This notification system was used to standardize some of the experiential learning so that all students addressed certain features of diabetes care during the DP. The web-based blood glucose monitoring system was available for case pharmacists to follow case patient progress throughout the project period. Case pharmacists were instructed to clarify trends in or extreme blood glucose values observed via the web-based program by calling their case patient (i.e. student project partner) at least once daily during the case period for a phone interview. During the phone interview, case patients opened sealed envelopes containing a case update scenario provided to them as part of the case assignment and then described the scenario to their case pharmacist. The scenarios provided a source of new developments in the case. An example scenario involved a patient with a painful, red, oozing blister on the bottom of his foot with accompanying elevation in blood glucose. Students were encouraged to provide consultation to the case patient (phone or in-person, if preferred) throughout the case period in order to reinforce teaching, encourage self-management skills, answer questions, and provide motivational support. Any recommendations or changes in diabetes care made by the case pharmacists were to be documented in a SOAP note and presented, discussed, and turned in at the lab section, week two of the DP. During this second week of the DP lab section, case pharmacists were provided with a written blood glucose log book for their case patient and met, in person, with their case patient for a progress update. Case patients were provided with new scenario updates to share if queried appropriately during the pharmacist-patient interview. Case pharmacists were given time (20 minutes) in this second lab session to interview their case patient about the scenario update and to provide counseling or feedback to the patient on further management of the diabetes given the new scenario update. All students participated in this section by acting both in their role as the case patient and the case pharmacist, each in a 20-minute shift, so that all would get a chance to perform the in-person interviews of their case patient. Following this, case pharmacists met for 20 minutes with the other four case pharmacists in their lab section who cared for the same case patient to share findings and ideas for effective management. Then, these case pharmacist teams presented their patient's history, progress, and collective recommendations to the entire lab section (16 students) for discussion the last hour of the second therapeutics lab section of the DP. American Journal of Pharmaceutical Education Vol. 66. Winter

4 Table III. Self-care confidence, 1-5 scale with 5 "very confident" Confidence domain Median score pre-module Median post-module P value for change score comparison 3 Diet Exercise Blood glucose monitoring Taking medications Coping a Wilcoxon signed-rank test. RESULTS AND DISCUSSION Assessment of Student Learning At the start and the end of the DP, students completed a brief diabetes knowledge and confidence questionnaire. This brief questionnaire is based on the target learning domains outlined by the American Diabetes Association for diabetes selfmanagement education(x). The tool evaluates patient pre and post knowledge about diabetes and confidence to perform selfcare. For the third year pharmacy students (N=57 respondents), mean test scores for diabetes knowledge were 5.54 (six points possible, SD 0.74) prior to the module and 5.89 (SD 0.31) after completion of the module (P = ). Treatment of hypo-glycemia and sick day management were the two most frequent knowledge deficits identified by the pretest. Self-care confidence prior to the DP was rated highest for "checking blood sugar" and "understanding and taking medications." Post-test evaluations revealed greatest confidence in "understanding and taking medications." Confidence in DM self care was significantly improved in all areas (Table III) except for blood glucose monitoring. In some cases, students who rated high levels of confidence in self-care prior to the module had dramatic shifts downward in confidence after completion of the DP. Overall, 51 percent of students experienced an improved sense of confidence (increase of at least 0.5 on 1-5 scale), 13 percent, a decrease in confidence (decrease of at last 0.5 on 1-5 scale), and 36 percent no significant change in their confidence in performing self-care duties to manage diabetes (change less than +/- 0.5 on 1-5 scale) although the trend was toward improved confidence in this group. The measure of 0.5 change on the scale of 1-5 has not been validated but was determined by the authors to be a clinically meaningful change for this analysis based on discussion with faculty diabetes educators. On the post-test comments, students (6/15) who commented on their reduction in self-care confidence explained this result by an improved understanding of the difficulty encountered daily in managing diabetes, therefore shifting their earlier confidence from the pre-test. Specific comments these students made with regard to the difficulty in self-management involved pain and fear in performing finger sticks or injections and challenge with respect to meal planning and maintaining an exercise routine. Overall student learning for the diabetes component of the Therapeutics Course was assessed by written short answer case and multiple choice written examination, graded evaluation of project SOAP notes, and pass/fail skills assessment in lab. The written examination portion of the DP evaluation was incorporated into the normal Therapeutics Course final examination. Successful completion of the DP was tied to achievement of a passing grade for the Winter-quarter Therapeutics Course and Skills Lab. Diabetes Program Assessment This module, developed with faculty and student input, received positive evaluations and will be continued in future years with some minor operational adjustments to improve communication and time management for both students and faculty. Initial faculty time to develop the DP was approximately 40 hours. Following the initial pilot, faculty preparation and contact time for the DP has substantially decreased with preparation taking approximately eight hours each year in addition to the usual time required to prepare the therapeutics lab and lectures. The majority of this extra faculty time is required to coordinate supplies for the case role-play section and schedule clinical faculty time in the lab sections. To minimize faculty time overseeing the first-year students filling and dispensing prescriptions for the case patients, and, to reduce third-year case patient wait time in the dispensing lab, these prescriptions will be called in the week ahead of the project so that the first year students have plenty of time to review the medications and fill the prescriptions without feeling rushed. In course evaluations, students reported "usefulness of the DP for developing a better clinical understanding of diabetes" (median 3.94 on a 1-5 scale with 5 being "excellent"), "usefulness of the DP for improving your knowledge about the use of diabetes drug therapies" (median 3.84 on a 1-5 scale with 5 being "excellent"), "attitude about a patient with diabetes who fails to follow advice will be different in the future" (3.31, scale of 1-4 with 4 being "strongly agree"), ease of web-based log book (3.27, scale of 1-4 with 4 being "strongly agree"). These scores were improved from the phase 1, year 2000 pilot DP. SUMMARY The DP has accomplished the goals set forth for improvement of the diabetes therapeutics curriculum integrating the didactic and the practical aspects of learning. The DP has been well received by students and faculty with evaluation scores increasing over the two-year pilot phase. Although the program requires a commitment of planning and coordination each year by faculty and students, interest in the module continues to improve each year. In light of the prevalence of diabetes and the complexity of managing this illness, we feel it is imperative that pharmacy students gain an adequate understanding of the management of this disease in the core curriculum. While elective coursework and clerkships are beneficial for additional training, each pharmacy graduate should possess a basic knowledge about diabetes that fosters appropriate triage, counseling, medication support, and empathy for patients with diabetes. References (1) Fox Ray, N., "Economic consequences of diabetes mellitus in the U.S. in 1997," Diab. Care, 21, (1998). (2) The Diabetes Control and Complications Trial Research Group, "The effect of intensive treatment of diabetes on the development and pro gression of long-term complications in insulin-dependent diabetes melli tus," N. Engl. J. Med., 329, (1993). (3) UK Prospective Diabetes Study (UKPDS) Group, "Intensive blood-glu- 394 American Journal of Pharmaceutical Education Vol. 66. Winter 2002

5 cose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)," Lancet, 352, (1998). (4) Ohkubo, Y., Kishikawa, H., Araki, E., et ah, "Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: A ran domized prospective 6-year study," Diabetes Res. Clin. Pract., 28, (1995). (5) Sadur, C.N., Moline, N., Costa, M., et al, "Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits," Diabetes Care, 22, (1999). (6) Berringer, R., Chibley, M.C.H., Cary, C.C., et al, "Outcomes of a com munity pharmacy-based diabetes monitoring program," J. Am. Pharm. Assoc. 39, (1999) (7) Gerber, R.A., Gordon, L. and McCombs, J.S., "Impact of pharmacist consultations provided to patients with diabetes on healthcare costs in a health maintenance organization," Am. J. Man. Care., 4, (1998). (8) Knapp, K.K., Paavola, FG. and Maine, L.L., "Availability of primary care providers and pharmacists in the United States," J. Am. Pharm. Assoc.,39, (1999) (9) Rickheim, P.L., Weaver, T.W., Flader, J.L., et al. "Assessment of group versus individual diabetes education: A randomized study," Diab. Care, 25, (2002). (10) Mensing, C, Boucher, J., Cypress, M, et. al., "National standards for diabetes self-management education diabetes care," ibid., 25, (2002). American Journal of Pharmaceutical Education Vol. 66. Winter

6