“I have no Structured Rotation – how do I Learn Effectively?”
After two years since the pandemic has started I have reflected on how it has impacted on pharmacists' rotations in hospitals and how to address potential perceived barriers to learning.
An ideal scenario?
Many hospital Trusts operate a rotational programme for early career pharmacists, with individual rotations typically lasting three to four months for band 6s and six to twelve months for band 7s. In an ideal world, these rotations would:
Be planned at least a year in advance so that pharmacists know which areas they will be working in
Run without interruptions or time reduced in that area to cover other gaps in the rota
Have clear objectives set at the beginning and meetings to review progress during and at the end of the rotation
Allow pharmacists to have some input into the areas where they will work
An article published in the Pharmaceutical Journal in 2011 (How to get the most out of your clinical rotations) offers some useful advice on how rotations can aid your development, but this tends to focus on situations where structured rotations are in place.
We don’t work in an ideal world
Pressures on service delivery may result in pharmacists spending less time in their rotational area to cover gaps in rotas and in some cases their rotation may be pulled completely. Some pharmacists may not have an official rotation or be given what is referred to as a “cover” or “float” rotation. Whilst working in postgraduate education I’ve had conversations with students and tutors about this and it appears that the COVID-19 pandemic has made this situation worse, both due to staff shortages and more frequent changes to wards to accommodate the fluctuating number of in-patients testing positive for the virus. Students have highlighted that they have had difficulties compiling portfolio evidence when rotations have been interrupted (or non-existent), therefore I have reflected on what advice I could offer them and identified five top tips.
Tip 1: Every patient you encounter represents a potential learning opportunity
Since no two patients are the same, management of an individual condition may be straightforward for one and identify gaps in your knowledge and skills base for another. Routine tasks (e.g. medicines reconciliation) can also be complicated by individual patient factors (e.g. communication problems). Keep a notebook to summarise these scenarios as they could be used for a supervised learning event (see Tip 5), contribution to care records or a planned continuing professional development record (required for revalidation).
Tip 2: Think beyond just learning about one clinical specialty at a time
Whilst bigger hospitals usually offer more clinical specialties, many still won’t be able to offer experience in all areas. Some pharmacy departments are also unable to offer services such as aseptics or medicines information. When these issues are combined with the duration of rotations and the number of other early career pharmacists employed by an organisation, even a well-planned rotational programme will leave you without experience in certain areas. However, if you undertake a cardiology rotation but not ones in respiratory or gastroenterology, think about how you can still develop knowledge and experience in these areas whilst in the workplace by:
Reviewing the management of patients’ other co-morbidities and identify gaps in your knowledge to work on. Specialists can overlook the management of other co-morbidities, so this provides you with an opportunity to apply your learning to practice
Managing outliers – these patients may present with conditions that you and the ward staff are familiar with, thus providing you with further opportunities for learning in practice. If you need to contact the specialist team to discuss a patient’s management, you could also use this as an opportunity to ask the specialist questions about aspects of the patient’s management you are unsure about
Tip 3: “Cover / float” rotations can expose you to a more varied case load
In my experience these rotations are usually met with negative perceptions. However, these may provide you with an opportunity to cover a clinical specialty that you would not otherwise undertake a rotation in, and practice-based portfolios benefit from evidence covering a wider variety of scenarios. Working on different wards each day will also help you to become more adaptable, which aligns with domain nine of the Royal Pharmaceutical Society (RPS) Foundation Pharmacy Framework and domain three of the Post-registration Foundation Pharmacist Curriculum.
Tip 4: Identify key resources to support learning
Departments offering structured rotational programmes may have objectives, recommended reading lists and training packs to support development in that area. If your department has these, ask for copies of those relating to areas that you haven’t rotated through but are interested in developing your knowledge in. Other useful resources include:
Materials provided as part of a postgraduate diploma in clinical pharmacy. It is impossible to align the topics to everyone’s rotations, so enquire whether you can access materials for a future topic earlier
Webinars are provided by the RPS and United Kingdom Clinical Pharmacy Association
Podcasts (e.g. Aural Apothecary, Pharmacy in Practice and the common journals) are available on most streaming platforms and can offer “CPD on the move” due to their audio format
Tip 5: Think supervised learning events!
Perhaps my most important (and most challenging) tip is this last one. Supervised learning events (SLEs) provide opportunities to obtain feedback on your strengths and areas for development as well as providing evidence for practice-based portfolio used as part of postgraduate qualifications, appraisals and credentialling schemes. I could (and may well) write a series of blogs on these but will focus on some key points to help you maximise the use of these when you do not have a structured rotation.
Familiarise yourself with the purpose of each tool
Can conversations you have had with colleagues about patients be turned into a SLE? I’ve had students with no or limited SLEs in their portfolio tell me about such discussions taking place, without them realising that they would have satisfied requirements for SLEs, e.g.:
Mini-CEXs can be conducted at any part of the patient’s admission. If you are unsure about advice to give to a nurse or prescriber, could this be used as a Mini-CEX? Rather than just asking the question over the phone, could your senior colleague come to the ward and observe you review the patient’s information, formulate a management plan and discuss your advice with members of the ward team? If they can’t come to the ward, could the review be conducted over a video conference call (electronic prescribing and notes would make this easier)?
Case-based discussions do not have to involve you managing the patient from admission to discharge. Challenging patients that you have only managed for one day and on-call queries can also be used. If you have kept notes of scenarios encountered in practice (see Tip 1), could these be used for a case-based discussion?
Peer assessment / multisource feedback can be a useful tool for gaining opinions about your overall practice rather than how you have managed individual scenarios or tasks. I recommend that my students complete these at the end of a rotation but if you haven’t had structured rotations try to identify peers that you have worked with on a recurring basis (e.g. at least every 1-2 weeks). Are there doctors or nurses you have provided advice to whilst on-call or at weekends in addition to when you’ve worked on their ward on an ad-hoc basis? Do you tend to work with the same team of pharmacy staff on late nights or at weekends? If so, you could ask them to complete the feedback form
Whilst staff shortages will impact on the availability of assessors, if other colleagues have easy access to assessors for SLEs and you don’t then I would advise raising this (respectfully) with either your line manager or clinical lead. You could also identify external assessors for case-based discussions such as a university tutor (if you are studying a postgraduate qualification) or mentor (e.g. via RPS scheme).
Final thoughts
Even within an individual organisation, no two pharmacists will have the same rotational experiences (both in terms of areas covered and support provided). The lack of structured rotations can still provide opportunities for learning by keeping an open mind and taking a proactive approach.
•“Learning is not a spectator sport. Students do not learn much just by sitting in classes listening to teachers, memorizing pre-packaged assignments, and spitting out answers. They must talk about what they are learning, write about it, relate it to past experiences, apply it to their daily lives. They must make what they learn part of themselves”. Chickering, AW, Ehrmann SC. Implementing the Seven Principles: Technology as Lever. AAHE Bulletin 1996: 3-6