Model for clinical clerkship site development in the visiting nurse association

American Journal of Pharmaceutical Education, Summer 1998 by Catney, christine M, Arthur, Christal L, Fleckenstein, Lawrence L, Scavone, Joseph M

Christine M. Catney,2 Christal L. Arthur,3 and Lawrence L. Fleckenstein

College of Pharmacy, The University of Iowa, 115 S. Grand Avenue, Iowa City IA 52242

This report describes a clerkship which integrated pharmacy student clinical activities into a Visiting Nurse Association (VNA) office and established a mechanism for supervision by off-site preceptors. The procedures for providing drug regimen review, for charting and communicating with other health professionals, and for documenting and tracking these activities are described. The clerkship provided rich opportunities for student growth and pharmacy service development and was successfully managed by off-site preceptors. The procedures constitute a model for extending a preceptor beyond a single clerkship site or for offering a supervised clinical clerkship to non-traditional PharmD students in a distance education program.

INTRODUCTION

A study by Draugalis and colleagues recently reported information about agreements between clerkship sites and colleges that offer a PharmD program(1). The authors reported a significant increase in the median number of clerkship placements needed by schools since publication of a similar survey in 1993(2). The number of clerkship placements is likely to continue to increase as more schools implement either entry-level or nontraditional PharmD programs. Furthermore, the pressure to develop new sites will increase as schools modify their curricula to adapt to new ACPE accreditation standards.

As programs change to accommodate more students in advanced clinical clerkships, the same number of faculty or preceptors may be responsible for a larger number of students, and schools will need to find new ways of developing primary care clerkship sites. In the survey results reported by Draugalis and colleagues, an ambulatory care clerkship was found to be required in more than half of the entry-level programs responding. However, sites for these clerkships were identified as difficult to find by 36 percent of respondents(1).

This pressure is occurring at a time when academic health centers are downsizing and when hospitals of all types are shifting emphasis from inpatient to outpatient care. Managed care organizations are growing. Primary care is being emphasized to a greater extent than in the past in the education of all health care providers. At the same time, pharmacies with distinct pharmaceutical care practice components are developing in the community. These factors may produce a decrease in the number of faculty or preceptors available in the traditional hospital-based sites as well as a shift in focus from acute care to chronic care and to health promotion and disease prevention strategies in the community at large.

The purpose of this report is to describe a set of procedures developed during the implementation of a clinical clerkship in a VNA office. The authors hope to illustrate how implementation of these or similar procedures in other VNA sites could permit the development of clinical clerkship sites with these characteristics:

1. supervision and management of the student by an offsite preceptor;

2. opportunities for students to monitor and assess drug therapy during home visits;

3. possible extension of a single preceptor to more than one site;

4. possibility for a nontraditional PharmD program student to obtain a supervised clinical clerkship experience close to home.

THE VISITING NURSE ASSOCIATION

The Visiting Nurse Association (VNA) is an organization with offices in all 50 states. In Iowa, each of 99 counties is served by a VNA office. Like hospitals and home care pharmacies, the VNA is subject to accreditation by JCAHO. The VNA places a high value on personal individual independence and restoration of health. The primary mission4 of the Visiting Nurse Association of Johnson County, Iowa is "to improve the quality of life to persons in its service area by assisting individuals and families to achieve the highest level of independent living appropriate to the persons involved." As the VNA strives to carry out its mission, it provides skilled nursing care, links clients with community services, identifies unmet health needs, and provides health promotion and disease prevention programs.

The VNA employs a variety of health care professionals. At the VNA office that was the site of this clerkship, the staff includes registered nurses, a medical social worker, and nurse practitioners specializing in psychiatry, maternal-child care, and enterostomal therapy. A physical therapist, an occupational therapist, a speech therapist, and a dietitian are available on a part-time basis for referrals. In addition, the VNA provides non-nursing services rendered by home care aides.

In a tradition consistent with its emphasis on independence, wellness, and restoration of health, individuals served by the VNA are referred to as "clients" rather than patients. To maintain consistency within this text, the term, "client" will be used in place of the word, "patient." throughout this report, except in the phrase, "patient education." All residents of the service area of a VNA office are regarded as potential clients, irrespective of age, race, gender, ethnicity, religion, sexual preference, or socioeconomic status. The service area of this VNA office extends throughout Johnson County, Iowa, which has a population of approximately 97,000(5) . Most of the clients served are elderly members of the community living independently. Other client groups of significant numbers included persons with AIDS, mothers and their newborns, persons with psychiatric diagnoses, and recently discharged hospital patients who qualify for skilled nursing care.