clinical problem solving in pharmacy

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Teaching clinical problem solving: a preceptor's guide

Affiliation.

• 1 College of Pharmacy, University of Florida, P.O. Box 100486, Gainesville, FL 32610, USA. [email protected]
• PMID: 22935942
• DOI: 10.2146/ajhp110521

Purpose: Instructional methods to help pharmacists succeed in their growing role in practice-based teaching are discussed, with an emphasis on techniques for fulfilling the four key preceptor roles.

Summary: The American Society of Health-System Pharmacists (ASHP) and other organizations advocate ongoing efforts to develop the teaching skills of clinician-educators serving as preceptors to pharmacy students and residents. The broad model of teaching clinical problem solving recommended by ASHP emphasizes the creative and flexible application of the four major preceptor roles: (1) direct instruction, (2) modeling, (3) coaching, and (4) facilitating. A variety of teaching methods used in the fields of medicine and nursing that can also be adopted by practice-based pharmacy educators are presented; in particular, the advantages and disadvantages of various case-presentation formats (e.g., One-Minute Preceptor, SNAPPS, patient-witnessed teaching, "Aunt Minnie," "think-aloud") are reviewed. Other topics discussed include the appropriate use of questioning as an educational tool, strategies for providing constructive feedback, teaching learners to self-evaluate their skills and progress, and integrating residents into teaching activities.

Conclusion: The ASHP-recommended approach to teaching clinical problem-solving skills can be applied within the educational frameworks provided by schools of pharmacy as well as pharmacy residency programs. A wide range of validated teaching strategies can be used to tailor learning experiences to individual learner needs while meeting overall program goals and objectives.

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How to approach challenging scenarios in primary care pharmacy

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After reading this article, you should be able to:

• Understand the need to prioritise patient safety when faced with a crisis situation or patients who are at risk of harm;
• Consider appropriate follow-up questions when a patient discloses risk of harm;
• Better understand how and when to refer patients for specilialised services or crisis support when faced with complex scenarios.

As healthcare becomes increasingly complex, the pharmacy profession must develop additional skills and competencies in line with its growing responsibilities.

Working with patient’s who are in crisis or at risk of harm is a reality of practice and these situtaions require an ability to appraise the available information, evidence and guidance, alongside a skilled reading of the specific situational context.

This article introduces three typical scenarios from primary care requiring professional judgement. In each case, the intention is not to provide definitive answers but to consider the questions raised by each scenario and how you might approach them if faced with a similar situation. The purpose of sharing these examples is to encourage reflection and initiate conversation, considering all possible approaches and why individual practice may be different. Each example is based on real cases with details changed to protect the identity of the individuals. The scenarios discuss topics of suicide, addiction and sexual violence.

Scenario 1: Depression, addiction and suicide ideation

A man aged 27 years comes in for a depression review follow-up. He has been diagnosed with moderate-to-severe depression and started antidepressants about eight weeks ago. During his appointment, he tells you the following information:

• He is a gambling addict with approximately £30,000 of debt and is unable to stop using gambling sites;
• He is actively suicidal: he thinks about suicide daily and is unsure what stops him from following through. He has a plan to overdose on tablets at home;
• He uses drugs recreationally, most commonly marijuana, but will “try anything he can get his hands on” as intoxication makes him feel less depressed. Quite often, when he takes recreational drugs, he accesses gambling sites.

What would you do if you saw this patient in a consultation?

With a patient disclosure such as this, one of the first challenges is to react appropriately. How can you ensure your response comes across in a non-judgmental way? It is difficult for anyone to admit that things are going wrong, and feeling judged will deter them from telling the truth.

It is important to learn more about the patient’s support network. This will provide additional context into the risk of suicide and their ability to access help. You could start by asking if they have shared what they have told you with anyone else or if they have people (e.g. friends or family) in their life with whom they can talk. Consider also signposting the patient to organisations, such as the Samaritans, regardless of what support network he might have.

What are the most significant risks for this patient?

• Suicidality — when a patient expresses suicidal ideation, an immediate appraisal of risk is required. There are some effective screening questions that can be asked to help establish this. For example, are you having suicidal thoughts right now? Do you have a plan in place? Do you think you will go ahead with a suicide attempt? The way a patient answers these questions can help guide what you decide to do next;
• Financial risk — accumulating levels of debt could spiral further, worsening their levels of depression and increasing their vulnerability;
• Use of recreational drugs — the patient’s use of recreational drugs potentially increases the risk of harmful behaviours and altered perception of reality.

What are the management options?

There are two things to consider here: depression and addiction. For depression, prescribers could increase the dose of the current antidepressant — this may be appropriate if the patient is not experiencing side effects or has tolerable side effects, and the patient’s dose is within a licensed range. You could also try switching to an alternative antidepressant : this may be warranted if the patient is experiencing intolerable side effects, if increasing the dose of the original antidepressant would take them to an unlicensed dose, or if the patient has not seen any therapeutic effects. Non-pharmacological management routes could also be investigated, such as cognitive behavioural therapy (CBT); however, this requires engagement from the patient to be effective so would require further investigation to establish if talking therapy is a viable strategy at this stage.

You could also alert the mental health crisis team and arrange follow-ups at shorter frequency, dependent on your assessment of the level of risk.

For gambling addiction, the patient could speak to banks or other institutes to obtain support for debt and help with debt recovery. He could also contact gambling sites and ask them to block his account. As with depression, the patient is likely to benefit from long-term counselling to tackle their addiction.

He may also benefit from being signposted to an organisation that can help him manage his use of recreational drugs.

This case is complex owing to gambling addiction, severe depression, suicidal ideation and use of recreational drugs.

Hearing a patient disclose suicidal intentions can be an overwhelming experience, particularly if it is the first time encountering this during your practice. It can be difficult to know what type of language and tone of voice to adopt. Being clear and direct when asking follow-up questions can encourage patients to talk openly about how they are feeling. Displaying empathy  is important but the priority is the patient’s safety and wellbeing; if hard questions are avoided, it may affect the patient’s capacity to speak openly and honestly about suicide. In addition, knowing what to do if the patient is high risk can be difficult. If you are unsure of what action to take, there is usually a colleague you can call upon to help you work through your decision making.

Treating patients with these conditions can be complex for healthcare professionals. Finding the right balance of empathy while staying within professional boundaries can take some practice. Debriefing about these scenarios with other healthcare professionals can provide valuable opportunities for reflection and acknowledgement of any emotional toll it may have taken.

For more on how to deal with suicide disclosure, see ‘ Suicide: how to recognise the warning signs and deal with disclosure ‘.

Useful resources

• GambleAware

Scenario 2: Sexual assault and safeguarding

A patient aged 15 years has booked an appointment for emergency hormonal contraception. It is her first time requesting contraception. She appears to be worried and dishevelled. During the consultation, it emerges that:

• This was her first time having sexual intercourse;
• She does not have a regular partner;
• She has bruises on her wrists. When asked, she says she was attacked.

What should you do next in this consultation?

Be as empathetic as possible. Although only basic facts are known at this stage, it is clear that the patient has been through a distressing and traumatic experience. Build trust  by showing that you recognise this and allow her to talk further. You can better judge what to do next as you gather more information.

What else should you ask the patient?

The immediate priority is establishing risk and you can start by asking whether the patient would be safe once they leave the appointment. You could provide reassurance that she would not get into trouble by talking to you. It will be necessary to explore who the perpetrator is; for example, if it was someone known to her, she may still be at risk.

It will be helpful to ask about her support network by asking questions, such as whether she has told anyone else or reported the incident to the police. There may also be opportunities to signpost her to further sources of support and explain the options available to her.

The next priority is preventing pregnancy and the patient’s request for emergency hormonal contraception. You will need to ask questions sensitively to ensure the safe supply of a suitable emergency contraceptive, making sure to explain the purpose of the questions.

Should you notify anyone? If so, who?              

With the agreement of the patient, a referral to the nearest NHS Sexual Assault Referral Centre (SARC) can be made. These centres specialise in providing support to victims of sexual assault, which includes access to specially trained police officers, as well as arranging to safeguard referrals where appropriate, including for children. You could provide the patient with details of the nearest centre, ensure she has the ability to access it and encourage her to invite a friend or family member to go with her.

At this stage, details are limited, but if you judge that the general public may be at risk, it may be necessary to notify the police.

If this is the first time that you have managed a situation such as this, it may be appropriate to seek advice from a colleague. It is also helpful to run through your rationale with a third party to sense-check your actions and see whether they can identify anything you have not yet considered.

With scenarios such as this, it is important to be clear about the legal and professional obligations and the patient’s rights. A doctor or other healthcare professional can provide contraceptive advice and treatment to those aged under 16 years without parental consent ​[1]​ . The Care Quality Commission has a useful summary page of things to consider when treating anyone aged under 18 years, including a summary of when there may be safeguarding concerns. It is aimed at primary care but the principles can be transferred to other care sectors. 

As long as the emergency hormonal contraception was not contraindicated, and the patient has been judged to have the required level of competence to give informed consent, a prescription may be a viable option in this situation.

What other support might the patient require?

The patient is likely to benefit from the support of a friend or family member and it may be appropriate to encourage them to seek this out if they have not done so already.

If emergency hormonal contraception is chosen, patient education will be required, including a verbal explanation of how this might affect the patient’s menstrual cycle, as well as written information to read once she has processed the event.

The patient could also be signposted to other support services (see Useful resources  section for examples).

There are many things to consider in this scenario. The immediate physical elements, as mentioned previously, include the patient’s safety and preventing pregnancy. There is also the likelihood that a serious crime has been committed against a child and consideration needs to be given to the viability of collecting physical evidence for a potential prosecution. The sooner this is gathered, the better the chances of collecting reliable samples, so encouraging the patient to visit a SARC would be a priority. Referring to a SARC would also ensure the most appropriate channels for safeguarding referrals were made.

The patient could react in a number of ways and it may be that you can emphasise to the patient that visiting a SARC would not necessarily mean she must report the incident to the police, and that what happens next is her choice.

The psychological effects of sexual assault will have the most extended impact. The patient is likely to benefit from specialist support and advice, and should ideally access these as soon as possible. The best things to do in this situation are to remain empathetic and non-judgemental, reinforce to the patient that the assault was not their fault, and ensure they understand the different options available and are able to access the best available support services.

• NHS rape and sexual assault referral centre search
• Rape Crisis
• Rape Crisis support line

Scenario 3: Health beliefs, adherence and patient preference

A male aged 43 years presents for an asthma medicines use review. He knows one of his asthma triggers is his cat but he has a strong bond with his pet and is not willing to relinquish ownership. He considers himself an expert patient and has researched asthma extensively. His previous medical notes are sparse, but include that he is prescribed Relvar Ellipta (fluticasone furoate, vilanterol trifenatate; GSK) every 3–4 months. He has also had four exacerbations in the past 12 months where antimicrobials and oral prednisolone have been prescribed. During the consultation, it emerges that:

• The patient considers their asthma to be well controlled as they do not need their inhaler daily;
• They do not allow the cat into certain rooms of the house to minimise symptoms.

What would you do if you were the consulting pharmacist?

A good initial step may be to further explore the patient’s perception that their asthma is well controlled and build up your understanding of how it affects him day to day. You could ask questions from the asthma control test to establish this.

Other questions could focus on his inhaler use, including frequency of use, and what stops him from using them daily.

It could also be helpful to explore how he felt during an exacerbation and see if he can make connections between his asthma control, the frequency of exacerbations and inhaler use.

Spending some time getting to know what is most important for this patient will help you to frame your advice and relate this to his asthma/breathing. We know his pet is important to him, and that he is unwilling to give up ownership despite the health impacts, but it is important to establish what other changes he may be willing to make.

The most considerable risk for this patient could be that his perception of disease control is leading to continued exacerbations and long-term lung and airway damage. His control is unlikely to improve (and may worsen) if he continues to believe his asthma is well managed despite experiencing regular exacerbations.

The patient has formed fixed beliefs about his asthma, which means he may be reluctant to adopt a new treatment plan. Although he has already stated he will not relinquish ownership of his cat, it is worth checking whether he would temporarily trial living without it to see if he notices a difference in his breathing. This may allow him to explore the option in the future.

There may also be other things the patient can do to minimise symptoms if he would like to keep his cat. For example, removing any carpets to prevent the accumulation of allergens, the use of air purifiers, vacuuming more frequently and, depending on the type of cat, grooming may also help to reduce allergens.

The patient’s inhaler technique should be checked at every opportunity ​[2]​ . Finding out more about the patient’s inhaler preferences could provide further insight and the benefits of adherence could be discussed with the patient, with connections made as to how this will help improve his lung health and prevent exacerbations.

Asthma UK has an extensive range of asthma plan templates that can be used and tailored to patients ​[3]​ . These templates could be used as the basis of an agreement with the patient over how to manage his asthma going forward, including acute exacerbations.

What other support might he require?

Since the patient has shown capacity to learn about his condition, you could direct him to resources that will further improve his understanding of asthma. It may be possible to jointly explore what the evidence says about the harmful effects of uncontrolled asthma and regular exacerbations.

Asthma is a condition commonly treated or managed by pharmacists. One of the largest components of managing asthma is successful adherence to treatment,[5] making the profession ideally placed to improve outcomes for patients. This means effective inhaler prescribing — prescribing the right product at the right frequency.

Patients today have access to vast amounts of information about their condition and are likely to have formed fixed beliefs about it, some of which may be inaccurate or potentially harmful. Tailoring your communication approach is important here. Consider how a patient may react if they are bluntly told that they are wrong. Spending some time getting to know the patient, understanding what is important to them, and using this to help convey how certain changes can benefit them, will likely have a better impact. Look to use the knowledge they have gained as a starting point and explore together the consequences and impact of different approaches to the management of their condition.

Patients have the right to choose how to live their lives. They will have priorities outside of their condition, which, as in this case, can negatively affect disease control. Pets are often viewed as part of the family and some patients can become offended if it is suggested that they give them away. This discussion should be approached sensitively so the patient does not feel dismissed.

Using the ICE (Ideas, concerns, expectations) consultation model can be beneficial in scenarios such as this. There are specific models and techniques, such as motivational interviewing, that have been developed to promote positive health behaviour changes, which could be used to help this patient. The article ‘ Motivational interviewing to improve medicines adherence ’ explores this topic in more depth.

• Asthma control test
• RSPCA — Grooming your cat

Tips for improving your ability to deal with complex situations

Knowledge and experience are two critical components of effectively managing challenging situations, but there are several guiding principles that you can draw from to help you improve your ability to identify options and make good decisions. 

Be person-centred

Whatever consultation model you follow, ensure you can tailor it to the patient. Thinking back to Scenario 3, if looked at from a purely medical perspective, the best solution for the patient’s asthma control would be to give up owning a cat. A person-centred approach, however, allows us to consider the full consequences of decisions and work with patients to identify the option that is best for them. Being person-centred also helps the practitioner to be responsive to unusual patient circumstances. If you are considering patients individually and avoiding assumptions, you are less likely to be thrown off balance when patients tell you something unexpected or that you have not come across before.

It can be helpful to develop a hierarchy of elements to focus on when faced with a professional dilemma. For instance, ensuring the immediate safety of the patient is the first priority. From there, you can take a triage approach to the different components of the scenario and work with the patient to plan next steps.

The more information you have, the better your judgement is likely to be and it is important to allow the patient to tell you as much as possible. Avoid interrupting them prematurely (e.g. employ the ‘golden minute’ at the start of a consultation) and probe into details as necessary.

Use reflection to build your competence

Understanding the clinical rationale for a decision is incredibly important when it comes to increasing your scope of practice safely. Decision making and clinical judgment are something that practitioners should continuously look to improve. The ability to gather information and work logically through a clinical problem in a patient-centred way requires skills that can be improved over time. A significant amount of learning comes from reflecting on decisions and speaking to other healthcare professionals about what they would do and why.

Be clear on your rationale and produce effective documentation

With complex cases, you may be required to explain the course of action taken and justify specific decisions. For instance, in Scenario 1, the pharmacist may need to provide evidence that they assessed the patient to be ‘Gillick competent’ before prescribing emergency hormonal contraceptives. Written notes can act as an audit trail for decision making. Always document the reason for a decision, especially if it involves taking action outside of standard operating procedures. This advice applies regardless of the sector in which you practice.

Be prepared

Although it is impossible to predict every clinical situation, there is value in using your experience and judgment to anticipate queries and challenges and prepare for certain situations. Developing your digital literacy is also important: being able to quickly search for required information in real time during a consultation can improve effectiveness and lead to better decisions and outcomes.

Become comfortable dealing with uncertainty

With healthcare becoming increasingly complex, challenging situations are to be expected. Pharmacists must develop the ability to deal with uncertainty and risk effectively. Working through dilemmas and emotionally-charged situations provides an opportunity to grow professionally and can be highly rewarding. If it does become necessary to refer to another clinician, review their notes after the patient has been seen and, if possible, discuss the case with the other clinician. Reflect on the experience and consider making the topic a continuing professional development priority so that you feel more prepared for similar future cases.

• 1 0–18 years: guidance for all doctors. General Medical Council. 2023. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/0-18-years (accessed Sep 2023).
• 2 Asthma: diagnosis, monitoring and chronic asthma management. National Institute for Health and Care Excellence. 2021. https://www.nice.org.uk/guidance/ng80/chapter/Recommendations (accessed Sep 2023).
• 3 Adult asthma action plan. Asthma + Lung UK. 2023. https://www.asthmaandlung.org.uk/sites/default/files/2023-03/your-asthma-plan-a4-trifold-digital-july22.pdf (accessed Sep 2023).

I hope you don't mind me adding that Zero Suicide Alliance (https://zerosuicidealliance.com/) provide some excellent, free and concise training on how to engage with patients like those described in this article.

I found the scenarios very interesting.. Now I understand what person-centred really means, putting the person at the centre of care and practice. thank you

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• Kathryn J. Smith, PharmD Kathryn J. Smith Correspondence Corresponding Author: Kathryn J Smith, The University of Oklahoma, College of Pharmacy, 1110 N Stonewall Ave CPB 229, Oklahoma City, OK 73117. Tel: 773-368-9711. Contact Affiliations The University of Oklahoma, College of Pharmacy, Oklahoma City, Oklahoma Search for articles by this author
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Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process . 2014. https://jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdf Accessed March 10, 2021.

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Developing Critical Thinking Skills in Pharmacy Students

Adam m. persky.

a Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

b Associate Editor, American Journal of Pharmaceutical Education , Arlington, Virginia

Melissa S. Medina

c College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

Ashley N. Castleberry

d College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Objective. To review the importance of and barriers to critical thinking and provide evidence-based recommendations to encourage development of these skills in pharmacy students.

Findings. Critical thinking (CT) is one of the most desired skills of a pharmacy graduate but there are many challenges to students thinking critically including their own perceptions, poor metacognitive skills, a fixed mindset, a non-automated skillset, heuristics, biases and the fact that thinking is effortful. Though difficult, developing CT skills is not impossible. Research and practice suggest several factors that can improve one’s thinking ability: a thoughtful learning environment, seeing or hearing what is done to executive cognitive operations that students can emulate, and guidance and support of their efforts until they can perform on their own.

Summary. Teaching CT requires coordination at the curricular level and further to the more discrete level of a lesson and a course. Instructor training is imperative to this process since this intervention has been found to be the most effective in developing CT skills.

INTRODUCTION

Critical Thinking (CT) is one of the most desired skills of a pharmacy graduate because pharmacists need to think for themselves, question claims, use good judgment, and make decisions. 1,2 It is needed in almost every facet of pharmacy practice because pharmacy students need to evaluate claims made in the literature, manage and resolve patients’ medication problems, and assess treatment outcomes. 3 While pharmacy educators may agree that CT is an essential skill for pharmacy students to develop, it must be consistently defined because the definition determines how it is taught and assessed. 4 While many definitions of CT exist, 5 it is most commonly defined as automatically questioning if the information presented is factual, reliable, evidence-based, and unbiased. 2 In simpler terms, it is reflecting on what to believe or do. 6

To operationalize the CT definition, six core CT skills have been proposed: interpretation, analysis, evaluation, inference, explanation, and self-regulation (directing one's actions automatically). 7,8 Interpretation includes understanding and communicating the meaning of information to others. Analysis includes connecting pieces of information together to determine the intended meaning. Inference is recognizing elements of information one has and using those elements to reach reasonable conclusions or hypotheses. Evaluation involves making a judgment about the credibility of a statement or information. Explanation includes adding clarity to information one shares so it can be fully understood by another person. Self-regulation is the ability to control one’s own thoughts, behavior and emotions.

Besides the six core skills, CT is more than a stepwise process. It is a summation of attitude, knowledge, and knowledge of the CT process (Attitude + Knowledge + Thinking Skills = Critical Thinking). 9 All three components are necessary. First, individuals need an attitude that aligns with CT. This attitude includes a willingness to plan, being flexible, being persistent, willingness to self-correct, being mindful and a desire to reconcile information. 9 If the attitude is not there, it is unlikely that the individual will engage in the actual process. Second, CT requires knowledge or something to think about. The more knowledge the individual has, the better their process and answer. Thus, acquiring foundational, requisite knowledge is important in CT. The final part is the knowledge of the CT process. Knowing the steps and following them is key to success. Not following the steps can lead to incorrect answers. Skipping steps is one of the barriers to CT. When these three components are present, CT can occur at a deep level.

While CT is used often, it is important to differentiate CT from other processes. Problem solving, clinical reasoning and clinical decision-making are related higher-order CT skills and while the terms may be used interchangeably, there are distinguishing features. Problem solving is a general skill that involves the application of knowledge and skills to achieve certain goals. Problem solving can rely on CT but it does not have to. 10,11 The steps of identifying a problem, defining the goals, exploring multiple solutions, anticipating outcomes and acting, looking at the effects, and learning from the experience are all steps that can benefit from eliminating assumptions or guesses during the problem-solving process. 12 In comparison to general thinking skills, clinical reasoning and clinical decision-making depend on a CT mindset and are domain-specific skills that are used within pharmacy and other health sciences. 4 Clinical reasoning is the ability to consider if one’s evidence-based knowledge is relevant for a particular patient during the diagnosis, treatment, and management process. 4,13 Clinical decision-making happens after the clinical reasoning process and is focused on compiling data and constructing an argument for treatment based on the interpretation of the facts/evidence about the patient. 14 Overall, the process of thinking like an expert by considering the evidence and making correct decisions about a patient to solve a patient’s problems is a skillset that students should practice so it becomes automatic. See Figure 1 for a visual representation.

Schematic of Critical Thinking and its Relationship to Other Types of Thinking

White boxes represent the thinking type while gray boxes provide descriptions of each type and show how the skills build upon each other

Barriers to Critical Thinking

There are several challenges to students thinking critically: perceptions, poor metacognitive skills, a fixed mindset, heuristics, biases and because thinking is effortful. The first barrier is students’ perceptual problem – students believe they know how to solve problems, so often, they do not understand why they are being re-taught this skill. Educators teach students how to monitor their thinking and become better problem solvers by giving them a framework to be more thoughtful thinkers.

The next challenge is students’ weak metacognitive skills. The relationship between CT and metacognitive skills has been noted in the literature. 15 Metacognition refers to an individual’s ability to assess his/her own thinking and actual level of skill or understanding in an area. Metacognition helps critical thinkers be more aware of and control their thinking processes. 15 Students who are weak at metacognition jump to conclusions without evaluating the evidence, thinking they know the answer, which ultimately interferes with CT.

A third reason CT is difficult for students is that they may have a fixed mindset or a belief that their intelligence cannot change. 16 If students believe CT is an innate skillset that occurs naturally, they may not invest the effort to develop it because they believe that no matter how hard they try, they will never get it.

Heuristics can get in the way of CT. Heuristics are our shortcuts to thinking – they are a strategy applied implicitly or deliberately during decision-making where we use only part of the information we might otherwise want or need. This results in decisions that are quicker and less effortful because the individual may be using the best single piece of data to make a more frugal approach. 17-19 In a classic study, participants were asked, “If a ball and bat cost $1.10, and the bat is $1 more than the ball, what was the cost of the ball?” 20 The most popular answer is $0.10, which is incorrect (the correct answer is the ball costs $0.05, the bat then is $1.05 or $1 more. If the ball was $0.10, the bat is only $0.90 more than the ball). We take cognitive shortcuts because thinking is effortful and if we can get a quick response that fits our current needs, we will do it. Kahneman referred to two systems of thought: System 1 and System 2. 19,21 System 1 is a fast decision-making system responsible for intuitive decision-making based on emotions, vivid imagery, and associative memory. System 2 thought processes is a slow system that observes System 1’s outputs, and intervenes when “intuition” is insufficient. 21

Another challenge that makes CT difficult for students is their inherent biases. One major bias is confirmation bias or the tendency to search for information in a way that confirms our ideas or beliefs. 22 Confirmation bias happens because of an eagerness to arrive at a conclusion, so students may assume they are questioning their assumptions when they are only searching for enough information to confirm their beliefs. 22 When we want to think critically, we want the evidence against our view to better inform our decision. See Appendix 1 for a list of cognitive biases that may affect our thinking.

CT is difficult and does not develop automatically. It takes practice and effort. Experts think critically without conscious thought, which makes it effortless. However, developing expertise is estimated to take 10 years or 10,000 hours (or more) of deliberate practice, so it is a time consuming activity. 14,23 In a study of thinking using the game Tetris, it was shown that initial game learning resulted in higher brain glucose consumption compared to individuals with experience playing and those watching someone play. 24 Similar results are seen when comparing experts to novices. Functional MRI studies show that experts use less of their brain to solve a problem than novices, partly because a problem for a novice is not a problem for an expert. 25 It is experience that has led to muscle memory and heuristics. Students do not have a lot of experience thinking critically and therefore, do not want to do it because it is difficult and time consuming; they would rather do things that are automatic and effortless.

Developing Critical Thinking Skills

Developing CT skills is difficult but not impossible. CT is a teachable skill and is often discipline-specific because it relies on discipline-specific knowledge. Research and practice suggest several factors that improve thinking: a thoughtful learning environment (eg, integration), seeing or hearing what is actually done to executive cognitive operations one is trying to improve (eg, model behavior), guidance and support of one’s efforts until he or she can perform on their own (eg, scaffolding); 26 and prompting to question what is thought to be known (eg, challenging assumptions). 27 These are general, key points that instructors can do to help students develop CT skills.

Creating a thoughtful learning environment is not limited to just letting students make mistakes. Table 1 compares features of thoughtful classrooms to traditional classrooms that do not emphasize CT. The first piece of this thoughtful learning environment is helping students to integrate their knowledge. Integration allows students to build on previous experiences, provide developmentally appropriate opportunities for the individual to produce optimal performance, and lay a foundation for further development. By intentionally creating an environment that allows students to integrate previous and current knowledge, they can begin to evaluate how the concepts are related and make decisions on how to apply that knowledge to future, and likely different, situations. Integration can take many forms and does not necessarily mean courses need to be integrated or aligned in time. Integration can take the form of integrating the cumulative knowledge gained over the curriculum.

Major Features of Thoughtful and Traditional Classrooms 26

Modeling expert thinking is another way to help students see CT in action and begin to use these steps themselves. Instructors should verbalize their executive cognitive operations for students to hear or see when addressing a problem or issue that requires CT. No single step is too insignificant to point out. Learners are novice and assumptions should not be made that they understand or know how to perform a seemingly simple set in the thinking process. By watching the experts process information, learners begin to form those thinking skills as well.

Scaffolding is another general method that can facilitate development of CT skills. Scaffolding is a temporary support mechanism. Students receive assistance early on to complete tasks, then as their proficiency increases, that support is gradually removed. In this way, the student takes on more and more responsibility for his or her own learning. To provide scaffolding, instructors should provide clear directions and the purpose of the activity, keep students on task, direct students to worthy sources, and offer periodic assessments to clarify expectations. This process helps to reduce uncertainty, surprise and disappointment while creating momentum and efficiency for the student.

Thinking begins when our assumptions are violated. Driving to work requires little effort. We do it all the time and sometimes we may wonder how we got to work because our thoughts were elsewhere. On a daily basis, you assume your drive will be normal and unimpeded. Now imagine there is traffic. You move from auto-pilot to thinking mode because your assumptions were violated. When our assumptions are violated, we start to think and we see this thought process as early as a few weeks from birth. 28 In the classroom, we must identify and challenge students’ assumptions. As an example from self-care instructors, when students are asked to recommend a product for cough associated with the common cold, any student pharmacist with community pharmacy experience may answer “dextromethorphan.” This may be what they have seen in practice or what they received as a child from their parents. They have experience in this context. However, this answer is not supported by the guidelines, 29,30 but the students will argue it is correct because of their experience. The cognitive dissonance – not expecting something to happen that you thought would – starts the cognitive thinking process. From an instructional standpoint, it may be important to initiate the critical thinking process by having students make predictions on outcomes and showing how their predictions may be correct or incorrect.

Developing CT requires a 4-step approach. 9 The first step is explicitly learning the skills of CT. The second is developing the disposition for effortful thinking. The third step is directing the learner to activities to increase the probability of application and transfer of skills. The final step is making the CT process visible by instructors making the metacognitive monitoring process explicit and overt. These four steps should be included both at the broad curricular level and down to the more discrete level of a lesson and a course.

Curriculum.

College has shown to increase CT skills when CT is measured through standardized assessments of CT skills (four years of college = effect size of 0.6). 31 While part of this growth in college may be due to maturation and increase in knowledge, developing CT skills requires curriculum-level coordination. Just like a military action will fail if the individual units do not play their role, CT development will fail if individual units do not play their respective roles. One way to develop CT skills is to use a two-fold approach. 1,32 The first step is to have a course in the curriculum that teaches the general thinking skill process and starts to develop the dispositions. The second step is to have individual courses reflect that process within the context of the subject matter. Ideally courses have explicit learning objectives and make the thinking process equally as explicit; this is called the infusion method. Table 2 shows the effect sizes (difference in performance relative to the standard deviation) of these types of interventions. Typically effect sizes under 0.2 are considered small, over 0.4 are considered educationally significant, and over 0.7 are considered large. 33,34 To note, these effect sizes come from a variety of study types, durations and outcome measures. For example, one study in nursing used a standardized assessment of CT (California Critical Thinking Skills Test) to compare lecture to problem-based learning (PBL) in a pre/post design. 35 Examining pre-to-post changes, PBL showed an effect size of 0.42 whereas lecture was 0.010. When comparing the post-scores from PBL to lecture, the effect size was 0.44. Alternatively, undergraduates were placed in dyads across four different conditions outlined in Table 2 : general, infusion, immersion and control. 36 The outcome was a rubric developed by the instructor and research team. Compared to control, the general (.46), infusion (1.1) and immersion (.97) all showed positive and moderate-to-large effect sizes. Relatively, infusion was better than general (.60) as was immersion (.49) with very little difference between infusion and immersion (.12). Although the effect sizes in Tables 2 and 3 should be interpreted with some caution as the context varies, they represent effects across a variety of disciplines, outcome measures and study designs, thus suggesting a more generalizable effect.

Effect Size and 95% Confidence Intervals for Types of Interventions to Develop Critical Thinking. 1,32 (Effect sizes may include: pre-post design, quasi experimental design, or true experimental design. Outcome measures may include standardized critical thinking tests, instructor-developed critical thinking assessments, researcher-developed critical thinking assessments or some combination thereof. Study durations range from short – 1 hour to 2 days – to greater than 1 semester.)

Effect Size for Pedagogical Grounding of Intervention. 1 (Effect sizes may include: pre-post design, quasi experimental design, or true experimental design. Outcome measures may include standardized critical thinking tests, instructor-developed critical thinking assessments, researcher-developed critical thinking assessments or some combination thereof. Study durations range from short – 1 hour to 2 days – to greater than 1 semester.

Within a course structure, collaborative learning (ie, peer teaching, cooperative learning) helps develop CT more than other activities. One meta-synthesis that attempted to integrate results from different but interrelated qualitative studies on critical thinking found an effect size of 0.41 for promoting CT skills when collaborative learning was used. 1,32 Collaborative learning provides feedback to learners and puts learners in a setting that challenges their assumptions and engages them in deeper learning to solve a problem. However, if learners receive minimal guidance, they may become lost and frustrated or develop misunderstandings and alternative understandings. 32,36 Students’ CT improves most in environments where learning is mediated by someone who confronts their beliefs and alternative conceptions, encourages them to reflect on their own thinking, creates cognitive dissonance or puzzlement, and challenges and guides their thinking when they are actively involved in problem solving. This guided participation role may be implemented by learners in structured activities with the guidance, support, and challenge of companions. 26

Individual lessons should be designed with CT in mind by intentionally providing learners opportunities to engage in complex thinking. Appendix 2 offers a guide to developing these types of opportunities for students. The goals of the activities should be made clear and instructors should acknowledge that effortful thinking is required while recognizing that the learning environment allows students to make mistakes. Instructors should explicitly model their expert thinking and actively monitor how students are learning. Adjustments to teaching should be made reactively as instructors notice trends in student thinking. Providing enough time to think and learn during these activities is crucial. Expect novice students to take at least double the time it would take you as an expert to complete the activity. Appendix 3 ) provides a worksheet that students can use to develop their CT skills during an activity.

Instructors.

While the curriculum structure can have a large effect, it relies heavily on the individual instructor. Instructor training has been found to be the most effective intervention in developing CT skills ( Table 3 ). This training, however, must go beyond having students observe others think critically. This facilitation requires the appropriate material (eg, cases), facilitation skills and mentoring skills. 32 Appendix 4 provides a rubric to help instructors assess students’ problem-solving skills on a problem-solving activity. Though difficult, instructors should often remain silent during the activity. When necessary, instructors can ask probing questions that require students to clarify, elaborate, explain in more depth or ask more questions, which are related to metacognition. Instructors can signal acceptance of the student’s assertions by paraphrasing, providing a friendly facial expression, or writing responses for all to see. The key is to facilitate learning and not “do” the learning for the students.

Recommendations

A common model for the process of CT should be used in each pharmacy school curriculum. Ideally, a course should be required for all students early in the curriculum that addresses the definition, common model, and dispositions of CT and then provides an opportunity for students to actively practice these skills on general subject matter content. As students’ knowledge of pharmacy specific content grows, courses need to explicitly use the process outlined in the general course with application to the subject specific content. The repetition of these skills in multiple courses or course series will help students practice this skill. Additionally, all instructors should learn the model taught to students and learn how to create and facilitate activities to encourage CT in their content areas.

While there may be many templates for CT, we propose a 4-step cycle: generation, conceptualization, optimization and implementation. 37,38 In the generation phase, learners identify the problem and find facts. This is followed by the conceptualization phase when learners define the problem and draft ideas that could explain the defined problem. In the optimization phase, learners evaluate and select an idea then design a plan. Finally, the implementation phase involves accepting the plan and taking action. The cycle restarts with finding a new problem. For example, during a patient encounter, a learner would enter the generation phase, find all the problems and facts (laboratory values, past medical history, etc.). Then the learner would define the problem(s) and generate ideas as to why the problems are occurring. For example, the patient is complaining of fatigue and the learner would have to come up with reasons why fatigue might occur (anemia, lack of sleep, pregnancy, poor diet). The learner then uses the facts to evaluate each potential cause and consider what further tests may be necessary to exclude some of the potential causes. After selecting the cause, the learner formulates a plan and decides his or her next action. Once the learner discovers the patient is anemic, the cycle restarts with treatment options. This cycle can be used along with the Joint Commission of Pharmacy Practitioners Pharmacists' Patient Care Process. 39

Critical thinking skills (interpretation, analysis, evaluation, inference, explanation, and self-regulation) are important for health care providers, including pharmacists. While some students and instructors may think that CT skills are fixed, CT can be developed and augmented through a process of attitude alignment, absorption of knowledge, and learning new thinking skills. CT is also developed when one learns to combat potentially hazardous CT roadblocks such as bias, heuristics (thinking shortcuts), and simply not wanting to go through the effort of thinking on a higher level. Pharmacy educators can foster the development of CT skills in the wide scope of curricular design, in the narrowest interactions between professor and student, and everywhere in between. It is important to note that the methods described in this paper do not have to be added to an already compressed curriculum but rather can be used with existing materials to cover the content in a deeper and more meaningful way. By modeling expert thinking and using scaffolding techniques to support students’ CT development, pharmacy educators can instill both the desire and the drive for students to begin thinking critically. Regardless, it is noteworthy to point out that teaching CT skills requires time and effort at the potential expense of other skills. Thus, gains in critical thinking during a PharmD curriculum may be a function of our need to develop a multitude of other skills like teamwork, empathy, adaptability, communication, and initiative.

Appendix 1. List of Biases That May Impact Critical Thinking 40

Appendix 2. Generating Thoughtful Questions to Engage Students in Critical Thinking 26

Select a topic

• a. Rich enough detail, depth of detail, implications and interconnections and relationships inside and outside of area.
• b. Open to diverse interpretation and methods of inquiry.
• c. Capable of being entered at any variety of points.
• d. Requires guidance of an instructor.
• e. Is one that instructors are likely to spend lots of time on instead of rushing through it.
• f. Contributes to the development of meaningful and significant key ideas, explanation, principles, concepts, and generalizations.
• g. Can be learned about in the context of realistic problems.
• h. Fits into the overall curriculum and course

Begin at the global level

• i. Focuses on big picture.
• j. Focuses on ill-defined rather than precisely delineated topics.
• k. Requires students to pose and then answer numerous subordinate questions as they seek to define and probe the initial question and implications.

Word the question provocatively

• l. Helps invite student engagement; questions that present unusual, unanticipated, or unconventional points of view bother people, agitate thinking, spark curiosity, and demand response.

Engage the students

• m. Focus on the “non-present” – predicting or planning future conditions or events, reconstructing past events.
• n. Have students reflect about questions before they attempt to answer them or before examining the answers they generate.

Appendix 3. Critical Thinking/Making an Argument Worksheet

Adapted from Halpern’s Thought and Knowledge: An Introduction to Critical Thinking . 9

• 1. State your conclusion.
• 2. Give 3 reasons (or some other number) that support your conclusion. Rate each reason (weak, moderate, strong, very strong).
• 3. Give 3 counterarguments (or some other number) that weaken your conclusion. Rate how much each counterargument weakens the conclusion (little, moderate, much, very much).
• 4. List any qualifiers (limitations on the reasons for or against).
• 5. List any assumptions.
• 6. Are your reasons and counterarguments directly related to your conclusion?
• 7. What is the overall strength of your argument? Weak, moderate, strong, very strong

Appendix 4. University of Oklahoma College of Pharmacy Problem Solving Rubric

Created by Dr. Melissa Medina

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Evaluation of the effectiveness of educational medical informatics tutorial on improving pharmacy students’ knowledge and skills about the clinical problem-solving process

Main article content.

Clinical problem-solving process, Pharmacy, Informatics, Online learning

Objective: To investigate the effectiveness of an online tutorial and its impact on improving knowledge and skills of pharmacy students in the clinical problem-solving process that is necessary to implement pharmaceutical care. Methods: This is a prospective interventional study conducted during the COVID-19 pandemic restrictions using four novel templates. The first two levels of Kirkpatrick’s Model (Reaction and Learning) were used. Results: 129 participants completed all of the online training parts. The findings indicated a significant improvement in the students’ knowledge and skills. The participants achieved higher score following the tutorial than the baseline, with a statistically significant difference (p < 0.001). There was a significant improvement in the number of detected treatment-related problems. The majority of students were satisfied with the overall training process and stated a high evaluation score out of 10 (mean = 7.93 ± 1.42, median = 8.00). Conclusion: The educational intervention achieved a substantial positive impact on decision-making skills of participating students and was considered effective in helping them attain basic skills such as teamwork, peer assessment, communication and critical evaluation. Healthcare providers must work together to ensure accurate medication use during care transitions. Pharmacists, as medication experts, play an important role in the implementation process. Pharmacy educators must prepare pharmacy student to use pharmaceutical care in their future practice.

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16 Community Pharmacist Skills for Your Career and Resume

Learn about the most important Community Pharmacist skills, how you can utilize them in the workplace, and what to list on your resume.

Community pharmacists are responsible for providing medication and other health-related products to patients. They also offer advice on the use of these products and services. Community pharmacists need to have a wide range of skills to be successful in their jobs. These skills include customer service, communication, organization, and more.

Clinical Services

Problem solving, pharmacy operations, third party billing, patient education, inventory management, customer service, patient counseling, supervisory skills, medication therapy management, regulatory compliance, decision making, compounding, attention to detail, communication, organization.

Community pharmacists often provide clinical services to patients, including treatment for minor health conditions and advice on how to manage chronic illnesses. Clinical skills include the ability to assess patient needs and prescribe medications that can help them feel better. Community pharmacists also use clinical skills when they conduct research into new drugs or drug combinations.

Community pharmacists often solve problems for their patients. They may help them find the right medication or dosage, answer questions about how to take medications and suggest lifestyle changes that can improve a patient’s health. Community pharmacists also use problem-solving skills when they’re trying to identify an unknown substance someone has taken.

Pharmacists use their knowledge of pharmacy operations to ensure that they can operate a community pharmacy efficiently. This includes knowing how to manage inventory, track sales and maintain the pharmacy’s physical space. Community pharmacists also use their skills in pharmacy operations when interacting with insurance companies or other health care providers who send them prescriptions.

Community pharmacists often bill insurance companies on behalf of their patients. This is an important skill because it allows them to receive payment for the medications they dispense and ensures that their patients can afford their treatment. It’s also a necessary part of maintaining a successful business, as most community pharmacies rely on third-party billing to stay in operation.

Patient education is an important skill for community pharmacists to have because it allows them to educate patients on how to use medications properly and safely. Community pharmacists often provide information about the side effects of certain medications, what to do if a patient experiences those side effects and any other relevant information that may be helpful to their patients.

Community pharmacists often manage inventory for their store, which requires them to know how to track and organize the supplies they have. They also need to be able to identify when they’re running low on a product so they can order more before they run out. This is important because it ensures customers are able to get the medication they need.

Customer service skills are important for community pharmacists to have because they interact with patients and customers regularly. Customer service involves providing information, answering questions and resolving issues that customers may have. Community pharmacists should be friendly and welcoming when interacting with their patients so they can help them understand the medications they’re taking or any side effects they may experience.

Community pharmacists often work with patients to help them understand their medication and how it works. They may explain the side effects of a drug, what to do if they experience those side effects or if they have any questions about their treatment plan. Patient counseling skills allow community pharmacists to educate patients on how to use medications safely and effectively. This can also help patients feel more comfortable when taking prescription drugs.

Community pharmacists often supervise pharmacy technicians and other staff members. Supervisory skills include the ability to delegate tasks, provide feedback and manage time effectively. Community pharmacists also need to instruct patients on how to use their medications properly and safely. They may also train new employees or act as a mentor for current employees.

Medication therapy management is the ability to assess a patient’s medication needs and create an individualized treatment plan. Community pharmacists often work with patients who have complex medical conditions that require several medications to treat different symptoms. For example, a patient may need one medication for high blood pressure and another medication to control their diabetes. A pharmacist can help determine which medications are most effective for each condition and ensure the patient understands how to take all of their medications correctly.

Regulatory compliance is the ability to follow all laws and regulations regarding medication. Community pharmacists must be aware of any changes in laws or regulations that may affect their practice, as well as how to apply these laws and regulations when filling prescriptions for patients. For example, a pharmacist should know what information they need to collect from a patient before filling a prescription and how to store medications safely.

Community pharmacists often need to make decisions about the medications they dispense. They may decide which medication is most effective for a patient’s condition or whether a medication is safe for a certain age group. Pharmacists also use decision-making skills when deciding how to handle an emergency situation, such as if a customer has taken too much of a drug and needs medical attention.

Compounding is the process of mixing ingredients to create a medication. Community pharmacists often use compounding skills to prepare medications for patients who need unique dosages or forms of treatment. For example, some patients may require liquid medication while others may need pills. A pharmacist can compound these medications by combining different ingredients and adjusting their proportions.

Community pharmacists must be able to accurately measure and mix medications. They also need to ensure that they enter the correct information into a patient’s medical records, including dosage instructions, side effects and potential drug interactions. This ensures that patients receive safe treatment and helps pharmacists monitor their patients’ progress.

Community pharmacists often work with patients to explain the medications they provide. They also communicate with other medical professionals, such as doctors and nurses, about patient care. This requires strong written and verbal communication skills so community pharmacists can send emails and make phone calls effectively. It’s also important for them to be able to clearly explain medication instructions to patients so they understand how to use their prescriptions properly.

Organization is the ability to keep track of multiple tasks and responsibilities. Community pharmacists often have many duties, including filling prescriptions, answering customer questions about medications and providing advice on health topics. Having strong organizational skills can help them manage their workload and prioritize their time effectively. It’s also important for community pharmacists to be organized when handling medication so they can ensure patients receive the correct treatment.

How Can I Learn These Community Pharmacist Skills?

Community pharmacists typically gain their skills through on-the-job training. However, there are a few ways that you can learn these skills outside of the traditional work setting. One way is to take courses offered by your local community college or university. These courses will give you the opportunity to learn about the different aspects of community pharmacy and how to perform your duties in this type of setting. Another way to learn these skills is to shadow a community pharmacist in your area. This will allow you to see firsthand how community pharmacists interact with patients and perform their duties.

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