Experiences of Supervision at Practice Placement Sites

Background. Whilst placement supervision and clinical education programmes are of significant value in shaping the behaviours of undergraduate healthcare students, appropriate provisions which are efficacious to the learner are somewhat lacking, particularly for students studying on UK MPharm programmes. Objectives. To explore and explain the value of placement supervision to the personal development and employability of undergraduate pharmacy students.Methods. Students participated in a week long community pharmacy pilot programme, a result of a collaborative effort between the School of Pharmacy and Life Sciences and a small consortium of community pharmacies. Students and stakeholders were asked to evaluate their experiences via separate questionnaires which had been developed to elicit views and attitudes. Key Findings. Feedback from students and stakeholders towards the experience was overwhelmingly positive with multiple benefits being reported. Of particular prominence was the emphasis in student feedback on the value of placement supervision to their professional and personal development. Findings were indicative of a development in clinical practice proficiencies, core skills, and improvement in decision-making practice.Conclusions. The benefits of clinical supervision to the professional and personal development of MPharm students are well documented, although attracting professional pharmacy supervisors is proving a problematic task for educational providers in the UK.


Introduction
Guidance on the "seven-star pharmacist, " as provided by the World Health Organization [1], indicates that all qualified pharmacists should routinely incorporate teaching into their clinical practice [2].These standards are in line with those other healthcare professionals who are working in the United Kingdom for the National Health Service (NHS), where participation in mentorship or clinical education programmes is a core responsibility [3,4].It has been suggested that mentorship and clinical education programmes are of significant value in shaping the behavioural intentions and processes of learners within the healthcare professions [5].Various models of adult learning exist to explain the process of knowledge acquisition in educational environments including Bandura's Social Learning Theory [6] and Vygotsky's Social Development Theory [7].The tenets suggest that behaviour is acquired by a process of observation within a role specific social environment.Behavioural stature is achieved via role modelling whereby learners emulate the social and technical skills of a person held in high regard.Integration is dependent on repeated exposure to those perceived as being superior and sustenance, reliant on the internalisation and subsequent adoption of the behaviour as one's own [8][9][10].
The paradigm has proved to be a viable model of behavioural learning and has been supported in a variety of contexts.Notably, the NHS and researchers have utilised Bandura and Vygotsky's theories as the raison d'être for adopting mentorship into a variety of professional roles in the healthcare context [11][12][13][14].In pharmacy, however, the role of the pharmacist in educating the next generation has, until recently, been limited to preregistration tutors who commit to working with one individual, subsequent to completion of their undergraduate course, for a training year.In addition, some schools of pharmacy have utilised professionals from a nonacademic background in their undergraduate teaching by enlisting their specialist clinical expertise to assist in onand off-campus delivery.Although the scope of external involvement in undergraduate teaching has not historically extended beyond this, recent guidance issued by the General Pharmaceutical Council (GPhC) and the Modernising Pharmacy Careers panel is set to change the role of the contemporary pharmacist in line with the service needs of users [15].

Education Research International
Whilst experiential placements are of significant value in providing undergraduate students with first-hand experience of a working environment [16][17][18], it has been suggested that they are of equal worth to stakeholders and policy planners.The Centre for Workforce Intelligence paper [19,20] report that although there has been an increase in the number of students enrolled on pharmacy undergraduate programmes in England, there is uncertainty over the forecast for the future of preregistration places: it is posited that, in the absence of recruitment linking, the supply may exceed the demand for preregistration places and increase competition for posts.The authors ascertain that it is imperative that this risk is accurately evaluated and preregistration places are aligned with the expected number of graduates.Inaccuracies in linking the workforce with enrolling procedures could jeopardise the future of the availability of pharmacy services if institutions fail to enroll adequate numbers or alternatively could lead to disproportionate unemployment levels in pharmacy as a consequence of overrecruiting [19,20].
Given the uncertainty of the future of pharmacy, it is evident that academic institutions have a front line responsibility in providing the new generation with the requisite education and experience required to cope with the ever increasing expectations of the healthcare services [20,21], elements of which can be addressed through the provision of quality placements and via consultation of appropriate frameworks.The five-year course, proposed in England and Wales, could address some of these issues; however, the Centre for Workforce Intelligence [20] and Smith and Darracott [15] caution that the future implications on the workforce are uncertain.Whilst the benefits of clinical supervision to students [22][23][24] and to ones' professional practice [24][25][26] are widely reported, schools of pharmacy can face difficulties in attracting stakeholders who are willing to provide experiential opportunities to undergraduates.
With the hope to embed quality-assured experiential opportunities, the School of Pharmacy has been actively involved in researching, piloting, developing, and evaluating a range of professional clinical experiences to implement what could be considered as the optimum placement for undergraduate students.This research was primarily to identify whether the students and stakeholders benefitted from these placements before developing a more structured placement provision programme.This paper will present the main outcomes of a week-long community pharmacy placement pilot opportunity from both the student and stakeholder perspective; the focus will centre on the overall benefits of the experience and the value of clinical supervision to students' learning.

Methods
Third year MPharm students were invited to participate in a week-long community pharmacy pilot placement opportunity organised by the Robert Gordon University in collaboration with a consortium of independent pharmacy contractors.Community pharmacies were recruited via the independent pharmacy group and students offered placement opportunities in various locations across Scotland.
Students were housed in seventeen individual pharmacies in various locations throughout Scotland.
In an effort to quality assure each placement, students were required to complete a practice learning agreement which assessed standard procedures and covered elements pertaining to the health and safety of students whilst in attendance.Providers were required to submit a risk management questionnaire which aimed to identify any potential hazards.Learning outcomes, relevant to the MPharm stage curricula, were established from the outset and students were expected to complete these in partnership with their community pharmacy supervisors.All activities pertaining to the learning outcomes were completed under the supervision of a community pharmacist or other suitably qualified member of pharmacy staff.Additional on-placement forms included an induction checklist (to assure adequate assimilation); the role of the student on placement; the role of the tutor on placement; the role of the link supervisor on placement; the role of the practice teacher on placement.Upon completion, providers submitted a placement report, which assessed the student's practice, and students submitted a report detailing their placement experience and achieved learning outcomes.
In addition, students ( = 18) were asked to complete a series of mixed methods questionnaires in relation to their placement.Each received an email, inviting them to complete a 54-item postplacement web-hosted questionnaire.The postplacement survey tool was based on the published literature [16,23,[27][28][29][30] and further developed to align with the aims and scope of the placements.Domains focused on experiences, views and attitudes, identification of facilitators and barriers (post), and demographics.The tool was pretested for face and content validity (by an expert panel of academics, pharmacists, preregistration pharmacists, and students).Each community pharmacy placement supervisor ( = 15) was emailed via a third party contact and asked to complete a 16-item mixed methods questionnaire.Questions were designed to identify any practical issues or barriers, to determine the suitability of the placement for third year students, and to assess the competencies of each student.

Data Analysis.
Quantitative questionnaire data was analysed using SPSS 19.0 for Windows and qualitative elements of the questionnaire, prior to being subject to thematic analysis, were read through multiple times to familiarise the researcher (KG) with the content.Upon familiarisation, the data was coded and analysed in accordance with the thematic analysis approach [27,28].

Ethics. The project conformed to the current Robert
Gordon University School of Pharmacy and Life Sciences standard operating procedure for good research practice.The project proposal was approved by the Ethical Review Panel, School of Pharmacy and Life Sciences, Robert Gordon University.The Local NHS Ethics Committee was also contacted but confirmed that the project did not necessitate further review.

Results
Of those who participated in the pre-placement questionnaire just less than half completed the post placement questionnaire ( = 8).Students were distributed uniformly in various community pharmacy locations across Scotland: Aberdeenshire; Tayside; Lothian; Strathclyde; Central.Over half of stakeholders ( = 7) responded to the invitation requesting that they complete a questionnaire.

The Student Learning
Experience.The majority of students agreed that their professional experience was, at the very least, probably relevant to their future practice (highly relevant:  = 7; probably relevant:  = 1) and the MPharm course (highly relevant:  = 6; probably relevant:  = 2) and, similarly, probably influential to their future practice (highly relevant:  = 6; probably relevant:  = 2) and future careers (highly relevant:  = 3; probably relevant:  = 3).
The feedback from the cohort on the clinical components of the experience was positive and tended to focus on appreciation of the experience and on the opportunity to assimilate knowledge into practice: "I thought it was a great learning opportunity and was great to put into place everything learned so far in university" (Participant 7).The cohort felt adept in their clinical environment and although some were not confident that all aspects of each learning outcome were within their competencies, they noted an improvement: "There were some drugs which I had not come across before however the ones I did know I coped with" (Participant 7).Furthermore, respondents, in their answers to various questions, expressed that the placement had enabled them to develop, contextualise, and consolidate their academic knowledge into community practice: "I can now put into practice some of the skills I have learned in MIHI and CPT 2" (Participant 1).
The majority of the cohort ( = 6) stated that their confidence in clinical competencies had increased, as a result of their clinical experiences.It was noted and widely recognised that the contextualisation of knowledge led to an improvement in clinical confidence: "I feel more confident, as I now know more about what pharmacists can do legally and I learnt more about how to deal with non-textbook situations which has made me more confident to deal with every-day matters" (Participant 3).Students reported that their competencies were developed as a consequence of practical exercises and tasks that they were required to undertake in their clinical environments or as a product of role observation.Moreover, patient centredness and awareness of the importance of incorporating this ethic into clinical practice emerged as an important theme.Students were conscious of the patient's perception and the importance of patient inclusive treatment plans, with some noting active incorporation into their practice whilst on placement: "It is important to listen to the patient and treat the patient rather than just the symptoms" (Participant 6).
Furthermore, a recurring theme throughout the data was the propensity for the professional experience to inform a student's revision.Students, as a consequence of their placement and the tasks completed, were able to identify areas which required further revision or where they would like to expand their knowledge to aid their future practice: "I identified that I could do more to improve my knowledge of minor ailments and the various health services provided by community pharmacies" (Participant 2).Overall, the majority of students concurred (strongly agreed or agreed) that they felt more confident ( = 8), competent ( = 8), and organised ( = 7) to go out on placement and, similarly, felt very satisfied with the clinical experience as a whole ( = 6, do not know:  = 2).

The Effects of Placement Supervision.
The data attained demonstrated the positive effect of observation and participation on the acquisition of practical clinical skills: "Got to see how they clinically assess prescriptions and especially how they make changes to care plans coming from nursing homes to improve patients' medication regimes" (Participant 6).In addition, observation of placement supervisors permitted students to witness the use of interpersonal skills in practice: "I could shadow and watch how the pharmacist carries out their daily tasks, what these tasks are and how they deal with difficult situations" (Participant 7).
Moreover, as a result of witnessing their facilitator's approach to decision-making in practice, a significant proportion of the cohort noted that the experience had changed the way in which they would consider making clinical decisions.Students note that they are now aware of the importance of taking their time during the decision-making process, "I learnt its okay to take as much time as you need to make decisions, and that it is acceptable as long as you can justify what you did" (Participant 3), and of employing use of logical methods to guide the course of action, "I have a better, more stepped approach I feel to clinical decisions that covers a broad area" (Participant 1).
Students articulated that the experience enabled them to develop their practical clinical skills and competencies, ". ..and to develop skills for example, communication skills which are hard to develop by just reading textbooks in university" (Participant 3), whilst allowing for the opportunity to contextualise their preexisting academic knowledge to practice in a supported environment, "I really enjoyed it; the pharmacist I was working with was very supportive and was keen to let me see and do as much as possible.I saw every aspect of the Pharmacy service and was involved in nearly every patient interaction that the pharmacist was involved in throughout the week.As a result, I gained experience that I would never have got at university" (Participant 3).Skills were developed as a result of observation and engagement in activities and related to communication; technological processes; decision-making in practice; and core community pharmacy skills.

Future Placements.
According to the cohort, the AlbaPharm placement should be a requisite professional experience embedded in the curriculum ( = 7) and students were keen that more placements, of similar length or longer, should be available to future year groups: "I definitely think that the pharmacy course should have an integrated placement within its duration.This placement should be three consecutive days at a pharmacy or longer.Although I appreciate this would be hard to organise, I believe the experience would be invaluable to most students" (Participant 1).

The Stakeholder Perspective.
Feedback on whether students possessed the appropriate skills of a pharmacist, according to elements of the General Pharmaceutical Council criteria, was positive.The majority of pharmacy placement supervisors ( = 5) agreed, to an extent, that students had both appropriate clinical knowledge ( = 3) and knowledge of legislative frameworks ( = 3).Opinions of RGU students soft skills were also high; the popular belief was that undergraduates' communication skills were appropriate ( = 4) and that they displayed apposite levels of professionalism throughout the duration ( = 3).
The sample ( = 7) agreed that they would recommend future placements for students on the MPharm course with the majority commenting on the value of experiential education to the student, "extremely beneficial for the student."Whilst the respondents did note their positive thoughts on the value of placements to the undergraduate education programme, one stated that the experience "Needs to be a win-win placement to ensure continued support.Good quality students who are able to contribute to the pharmacy will encourage participation by pharmacies" (Participant 3).
Suggestions for future placements centred on the time scale in which pharmacies were informed, "More advanced notice from the University on student details and modular content would improve forward planning by the pharmacy, leading to a better experience for the student" (Participant 1), the scheduling of the placement, "These hols are often a time when key pharmacy staff are on holiday including the regular pharmacist" (Participant 7), and the importance of feedback in the future, "I would let these run for a couple of years then hold a wee workshop or teleconference" (Participant 6).

Discussion
The week-long community pharmacy placement pilot was received well by students who participated in the evaluation, with all communicating positive experiences before completion.The opportunity, which was articulated, permitted students to develop their understanding of the workings of a community pharmacy and to contextualise and consolidate existing knowledge into practice.Participants highlighted the value of interacting with "real" patients, outwith any simulated setting, and noted the consequential effect of exposure on informing practice, particularly on the development of patient centredness.Students, throughout the week, identified areas which required further revision or which were specifically relevant to community practice and which would be beneficial to a career in this particular setting.The experience was perceived to be relevant to those considering a future in community pharmacy practice and it was noted that employability could be enhanced as a consequence of participation.Stakeholders provided further support of this notion and felt that experiential opportunity was highly beneficial to students.The benefits of participating were congruent with the evaluations attained from previous studies on the experiences of pharmacy students and are, perhaps, indicative of the educational value of the opportunity [16][17][18].
Placement supervision, according to student evaluations, was a critical component of the placement and any subsequent learning.Vygotsky, as a social learning theorist, would attribute such conclusions to a process based on constructivist theory.The zone of proximal development paradigm ascertains that the preceptor plays a key role in determining the success of a placement.It has been suggested that facilitators can engage students and encourage them to work outwith their comfort zone via a process commonly referred to as scaffolding.Scaffolding requires the facilitator to engage the student in a task and gradually withdraw assistance to a point whereby the individual is able to execute the task without aid [29].Participants in this study note such an effect, whereby observation of clinical supervisors and participation in scaffolding activities were deemed to be beneficial to an individual's skill development.Students, as a result of engaging in scaffolding, report an improvement in their interpersonal skills and clinical confidence.Synonymous with findings published by Ting et al. [18], the supervising pharmacist was deemed to be of significant importance in ensuring that the learner acquires or develops the requisite skill base of a pharmacist.Further, collaborative working with placement supervisors permitted students to witness the reality of making a decision in practice.An increased awareness of the role of the patient and restrictions of legal frameworks were noted and considered to impact clinical decisions and future considerations.Students felt they were able to make informed practice decisions and were appreciative of the importance of ensuring adequate time is taken and of incorporating structure approaches which would not have previously been considered.
Moreover, students statements were supportive of the tenets of Social Learning Theory [6] and consistent with the theoretical basis of the paradigm.The discourse supported the practice of observation and suggested that occurrence would enable participants to internalise appropriate behaviours.This was evidenced by frequent reference to phrases inclusive of proactive terms which were suggestive of an increase in knowledge, skills, and competencies: know; learn; identify; see; gain; do.Furthermore, students communicated that they felt the opportunity had permitted advancement of their technical and soft skills.Although the feedback is supportive of the paradigm, Bandura ascertains that if the learner is to remain on the continuum and behaviours fully integrated into practice, students would require multiple exposures to experiential environments which reinforced similar professional styles [6].As the theorist suggests, repeated exposure would be necessary to ensure full adoption and, perhaps, could further support the promotion of mentorship within the healthcare professions.Mentorship requires a long term commitment from the mentor with NHS Scotland Guidance Series defining the role as follows: "Mentoring is a learning and development process which allows a mentee to discuss any issues or development needs they may have with a more experienced and senior mentor.As a result of the arrangement the mentee will learn and develop through reflective thinking, benefiting from the mentor's knowledge.The mentee may be looking to develop their understanding of the NHS, workforce, service or finance planning and a mentor would be able to help by encouraging their development." MPharm engagement in mentorship programmes could greatly enhance the calibre of pharmacy graduates and could perhaps address some of the forecasted workforce issues such as oversupply.As reported by this sample and further supported by the body of evidence [22][23][24], placement supervisors have a notable effect on a learners practice and collaboration with a longer term mentor could further enhance the skill base of students.Moreover, evaluation from a pilot mentorship programme in Australia details the multiple benefits experienced by participating students and concludes that engagement in mentorship programmes could reduce "transition-shock" [30].Furthermore, the Centre for Workforce Intelligence [20] paper predicts that competition between candidates for pharmacy positions will further increase over the coming decades and thus it would be hugely beneficial if graduates can demonstrate that they are in possession of the skills required to ensure a smooth transition from student to pharmacist.As demonstrated, integration of a mentorship and placement programme could prove to be a valuable addition to the MPharm education, and although stakeholders from this study rate the students skill base relatively well, they do caution that educators need to ensure the programme will be beneficial to providers to encourage participation.
Whilst the data attained from the community placement project is demonstrative of the benefits of placement supervision, the study is not without limitations.The small numbers of students and community pharmacists involved in the pilot experiential experience will not permit broad generalisations to be made but have, however, been used to evidence the observations of the existing literature.Furthermore, this evaluation was a component of a larger scale placement project and was used to help develop a more robust framework.Each placement was linked to a specific module, forming a common core of placement activity, and aimed at providing students with a continuous placement experience.The project did not intend to provide an answer to the current placement situation experienced by MPharm courses throughout UK.

Conclusion
The cohort, as was also reported in Nation and Rutter's study [23], was eager that additional opportunities, such as this experience, should be requisite components embedded in the MPharm curricula citing that experiential learning is invaluable to student's learning and vital in accelerating the knowledge-transfer process prior to qualifying.Bandura's Social Learning Theory [6] paradigm is supportive of repeated exposure to professionals who act as mentors, ascertaining that multiple observations are required for integration of behaviours to occur.
Furthermore, the benefits of placement supervision to the personal development of MPharm students are well documented, although attracting professional pharmacy mentors is proving an onerous task for educational providers in UK.Stakeholders reported multiple benefits to the learning process of participants but emphasised the importance of safeguards, which related to university provision of structured learning outcomes and appropriate scheduling, in ensuring that continued support is maintained.Whilst the positive aspects of incorporating clinical placements into the MPharm curricula have been acknowledged, it was ascertained that opportunities need to be beneficial for both the student and the supervisor to ensure the sustenance of future provisions.Since this initial pilot, the programme has now become embedded in the MPharm course; however, the recruitment and retention of community pharmacy mentors have continued to be a problem with a heavy reliance on informal networks to build capacity.