Impact of Experiential Education on Pharmacy Students Perceptions of Health Roles

Impact of Experiential Education on Pharmacy Students Perceptions of Health Roles Kimberly S. Plake and Alan P. Wolfgang School of Pharmacy and Pharmacal Sciences, Purdue University, 1335 R. Heine Pharmacy Building, West Lafayette IN 47907-1335 Role expectations can have a significant impact on the effectiveness of interdisciplinary collaboration in health care delivery. This project was designed to determine: (i) fifth-year students perceptions of professional roles and attitudes toward other health care workers prior to externship/clerkship experiences; and (ii) changes in their perceptions and attitudes after their externship/clerkship experiences. In the Spring of 1994 data were collected from 147 fifth-year pharmacy students in one school of pharmacy prior to and at the conclusion of their experiential program. It was determined that students perceptions of and attitudes toward health care professionals did change after completing the program. Specifically, students attitudes toward physicians were more positive. In addition, student perceptions regarding health care roles shifted toward a perception of increased sharing of responsibility between health care professionals. The results emphasize the importance of incorporating interdisciplinary health care issues into pharmacy school curricula. INTRODUCTION In recent years, health care has become very complex. In fact, the crises facing the health care system, such as AIDS and the increasing elderly population, are so complex that it does not seem reasonable to expect one single health profession to respond to all these problems. According to Mariano, this requires a comprehensive approach and necessitates that professionals relate to many client-institutional systems and collaborate with many professions (1). In addition, Leininger claims that many of our health care problems are related to a lack of understanding of and appreciation for the actual and potential contributions of different health disciplines. Consequently, the talents and skills of practitioners in some health disciplines are either grossly underutilized or overutilized (2). Collaborative relationships established between health professionals could provide greater continuity of care and more appropriate use of health personnel, thus possibly increasing the efficiency of health care delivery(1,3). Role expectations, however, could have significant effects upon the effectiveness of the interdisciplinary team in the provision of health care services. Although health professionals frequently interact with one another in health care settings, members of different professions may not understand each other s functions or roles. A role refers to the activities or behaviors that are performed by anyone occupying a status (4) and is based on both self-expectations and expectations of others. When a given health professional s self-expectations and the expectations of other health professionals are in agreement, there is no role conflict within the team. Health team members roles often overlap, however, which can cause conflict within the team, especially between the members sharing a given role. This is especially likely to occur when the overlap results from specific technical expertise, training, or long established tradition of a particular discipline(5). As Lister stated, confusion about roles most often arises when a task seems likely to belong to two disciplines (5). Pharmacy is currently in a position which could foster role conflict. With the increased emphasis on clinical functions for pharmacists and the move toward the PharmD degree, for example, pharmacists have more opportunities to directly interact with other health care professionals. In the past, however, communication between the pharmacist and other health care professionals, especially physicians, typically has taken place over the phone. Since there has been little face-to-face contact in most practice settings, many other health care professionals may not understand the role of more clinically oriented pharmacists and it may be more difficult to develop strong collaborative relationships. If students have no experience collaborating or interacting with other health professionals, it may be difficult for them to interact once they are in professional practice. Although many health professionals realize that collaboration would improve patient care, it requires special skills that have not always been emphasized in their education. In order to establish effective and efficient collaborative relationships, health professional students should be trained in teamwork skills so that they can use them when they enter practice. In addition, information should be provided about other health care professionals and their roles within the health care environment. According to Wessell, understanding the nature of health professions, capability in communication with other health professions, and at least foundational competence in interdisciplinary collaboration is important for beginning practice(6). However, many professionals do not receive this training. In most health profession programs, students are prepared to function as individuals in the health care system rather than as team members. In addition, during their didactic experiences, students in one discipline often are isolated from other health profession students(7-9). The lack of interdisciplinary education during didactic experiences may foster preconceived attitudes toward and perceptions of other health professionals. These preconceived notions often prevent the student from receiving the full benefits of interdisciplinary interaction(10). Thus, it has been suggested that interdisciplinary education should be American Journal of Pharmaceutical Education Vol. 60, Spring 1996 13

established early in the professional curriculum. Since interdisciplinary education can help prepare health profession students for their future professional practices, it is necessary to evaluate and assess students knowledge and skills in this area. Health profession education needs to establish if students: can effectively collaborate with others (e.g., patients and health workers), have preconceived perceptions of and attitudes toward health care workers, and receive the educational experiences and interactions needed to be successful practitioners. In this project, the focus was upon assessing students perceptions of and attitudes toward other health care professionals. The study objectives were to determine: (i) fifth-year students perceptions of professional roles and attitudes toward other health care workers prior to externship/clerkship experience, and (ii) changes in their perceptions of professional roles and attitudes toward other health care workers after externship/clerkship experiences. METHODS To fulfill graduation requirements, Purdue University students must complete a structured experiential program. This program begins in January of the students last semester and lasts 15 weeks. Of the 15 weeks, two externship periods of six weeks each are required at both a community and hospital site. The remaining three weeks are devoted to a clerkship rotation which is usually in a hospital setting. A brief explanation of this project was presented in Fall 1993 semester to 147 fifth-year students preparing to enter the externship/clerkship portion of the BS Pharmacy program. The pre-experiential questionnaire was administered the week after an externship orientation meeting during the recitation sections of a required therapeutics course. After completing the questionnaire, students returned it to the instructor of the recitation. The post-experiential questionnaires were distributed to the students to be completed and mailed at the end of their final rotation using a preaddressed stamped envelope. The experiential questionnaires administered to the students consisted of two main sections: (i) health professionals responsibilities, and (ii) health professionals descriptors. The first section, health professionals responsibilities, listed various roles commonly viewed as responsibilities of health professionals. Roles used in the questionnaire were obtained through several literature sources. Two sources in particular were utilized: the Project Porvenir rural health program initiated by the University of New Mexico(11); and a study of University of Illinois Hospital pharmacists and nurses attitudes toward their responsibilities in the drug treatment process(12). The students were asked to identify the health care professional(s) responsible for each of 39 roles. The primary focus was roles performed by physicians, nurses, and pharmacists, even though some of the roles could be performed by other types of the health care professionals. Realizing this, the following scale from the Project Porvenir rural health care program was used to identify responsibility for the roles: 1=physician primarily; 2=nurse primarily; 3=pharmacist primarily; 4=physician and/or nurse; 5=physician and/or pharmacist; 6=nurse and/or pharmacist; 7=physician, nurse, and/or pharmacist; and 8=none of the above(11). The second section, health professionals descriptors, was used to evaluate the students attitudes toward pharmacists, nurses, and physicians. These perceptions were evaluated through the use of a modified version of the Interprofessional Perception Scale (IPS)(9). The IPS utilizes 15 true/false statements to determine an individual s perceptions of his own profession and other professions. The statements concern perceptions of individuals on issues such as ethics, competence, and health professionals relationships with other health professionals. The IPS typically asks an individual to respond to the statements as a member of another profession evaluating his own profession. Because some of the students may not have extensive work experience in a pharmacy prior to externship/clerkship, the IPS was modified so that the students did not respond to the statements as an individual in another profession. In modifying the IPS for this study, students were asked to respond to the statements with respect to the medical, nursing, and pharmacy professions. The pre-experiential questionnaire also included a section for the students demographic information. This information included: gender, prior pharmacy experience, future practice site preference, and familial associations with health professionals. All data were coded and entered using the Statistical Analysis System (SAS) data entry screens. Frequencies and chi-square tests were used to analyze the data. An a priori significance level of one percent was established for all analyses. RESULTS The sample consisted of 101 females (69.2 percent) and 45 males (30.8 percent); one student did not indicate his or her sex. The majority of students had some professional practice experience. Of the 147 students initially surveyed, only four indicated that they had no practical pharmacy experience before the externship/clerkship. Over 40 percent of the students planned to practice in a chain community pharmacy setting upon graduation. Thirty percent were undecided about their plans after graduation. In the first section, health professionals responsibilities, students were asked to indicate which of the health professionals were responsible for each of the 39 roles. As can be seen in Table I, for most of the roles pertaining to medication use and information, over 50 percent of the students agreed that the pharmacist was primarily responsible. These roles included assessing patient compliance with drug therapy, assessing and monitoring patients for adverse reactions to drug therapy, and reviewing patient medication record systems to screen for potential drug interactions and to determine if treatment matched assessment. There were some roles dealing with medications that the majority of students did not believe were entirely a pharmacist s responsibility. These included monitoring patients responses to hyperalimentation and other IV fluids and adjusting dosages accordingly, preparing and recording medications administered during cardiopulmonary resuscitation (CPR) attempts, assessing and monitoring patients responses to drug therapy, collecting and documenting data on medication/allergy history, and developing drug treatment plans. For these roles, the students tended to believe that the pharmacist shared the responsibility with another health professional such as a nurse or a physician. Students exhibited a high degree of agreement on several other items, one of which was the role of health professionals 14 American Journal of Pharmaceutical Education Vol. 60, Spring 1996

Table I. Responses to health professional responsibilities items on pre-experiential program questionnaire a (n=147) Responses (percent) 1 2 3 4 5 6 7 8 Monitor patient s response to hyperalimentation and other IV 9.7 2.1 7.6 9.7 40.0 11.7 19.3 0.0 fluids and adjust accordingly Inform and talk with the family of a patient taken to the hospital 48.6 3.4 0.7 34.9 2.7 1.4 8.2 0.0 in an emergency situation Give follow-up care to patients by making 4.8 46.6 3.4 5.5 6.8 13.7 8.9 10.3 home visits Regularly attend meetings of a community health council 2.1 0.7 2.1 4.1 2.1 88.4 0.7 0.0 Design a comprehensive treatment and rehabilitation program 16.4 0.0 2.1 4.8 52.1 0.0 22.6 2.1 for a patient with multiple chronic conditions Instruct patients about the use of medical devices and equipment 0.0 1.4 43.8 0.7 8.9 24.7 20.5 0.0 Counsel a patient going through an emotional crisis in 13.0 1.4 7.5 8.2 21.9 13.7 24.7 9.6 connection with menopause Interview patients about their family and home situation 11.1 25.0 2.1 14.6 9.7 6.3 19.4 11.8 Assess patient compliance with drug therapy 0.0 0.0 69.9 0.7 14.4 2.1 12.3 0.7 Instruct patients on the use of birth control pills and other forms 0.0 0.0 45.9 0.7 28.8 4.1 20.5 0.0 of contraception Counsel the family of an alcoholic patient 22.6 1.4 4.1 12.3 11.0 4.1 15.8 28.8 Assess and monitor patients for adverse reactions to drug 0.7 0.0 51.4 0.0 17.8 7.5 22.6 0.0 therapy Assess minor illnesses of patients by interview to determine 10.3 2.1 57.5 1.4 4.8 17.1 6.8 0.0 need for self-medication or referral to specialized care facilities for treatment Plan and deliver community health education programs 0.7 1.4 13.8 0.7 10.3 8.3 63.4 1.4 Upon request of a family member, visit someone who is very ill 8.9 8.9 6.8 11.0 6.8 6.2 45.2 6.2 but refuses to seek medical treatment Review patient medication record system to screen for potential 0.0 0.0 86.3 0.0 8.9 0.0 4.1 0.7 drug interactions and to determine if treatment matches assessment. Serve as a drug information source 0.0 0.0 89.7 0.0 6.2 0.7 3.4 0.0 Administer immunizations 4.1 51.4 0.7 33.6 0.0 2.7 7.5 0.0 Discuss treatment plans with patients having difficulty 3.4 1.4 25.3 2.1 24.7 7.5 35.6 0.0 understanding them. Discuss community resources with the patient and family 1.4 5.6 8.3 2.8 13.9 10.4 56.9 0.7 Prepare and record medications administered during CPR 3.5 32.6 20.8 5.6 1.4 22.2 12.5 1.4 attempts Take vital signs 0.0 76.0 0.0 10.3 0.7 2.7 10.3 0.0 Instruct patients about their medications 0.0 0.7 53.8 0.0 24.1 4.1 17.2 0.0 Document professional activities on patients charts 7.0 26.8 3.5 9.2 2.8 2.1 48.6 0.0 Select drug(s) to be prescribed based on diagnosis 30.8 0.0 11.0 0.7 55.5 0.7 1.4 0.0 Provide in service education for other health professionals 1.4 0.0 10.3 0.0 19.3 6.9 62.1 0.0 Instruct patients with special dietary needs 5.5 11.7 2.8 8.3 13.1 8.3 31.0 19.3 a Response Categories: 1=physician primarily; 2=nurse primarily; 3=pharmacist primarily; 4=physician and/or nurse; 5=physician and/or pharmacist; 6=pharmacist and/or nurse; 7=physician, nurse, and/or pharmacist; 8=none of the above. in regularly attending meetings of a community health council. Most students believed it was a responsibility of nurses and/or pharmacists to attend these meetings. Over 60 percent of the students felt that physicians, nurses, and/or pharmacists were responsible for planning and delivering health education programs. The majority of students also felt that providing inservice education was a responsibility of all three professionals. Taking vital signs was perceived to be a nursing role according to 76 percent of the students. While the students agreed that multiple health professionals could be responsible for some roles, they did not always agree on which health professionals should perform those roles. For example, over 68 percent of the students perceived counseling a patient going through an emotional crisis in connection with menopause as a responsibility for multiple health professionals. However, 8.2 percent of those students felt it was the responsibility of a physician and/or nurse while 21.9 percent felt it was responsibility of a physician and/or pharmacist. An additional 13.7 percent believed it was the role of a pharmacist and/or nurse and another 24.7 percent thought the counseling could be handled by all three health professionals. In the second section, health professionals descriptors, students were asked to respond true or false to a list of descriptive statements for each of three professions, pharmacy, nursing, and medicine. As shown in Table II, for pharmacy, 90 percent or more of the students were in agreement on seven of the statements. These statements indicated that pharmacists: (i) are competent; (ii) understand the capabilities of other professions; (iii) are highly American Journal of Pharmaceutical Education Vol. 60, Spring 1996 15

Table II. Responses to health professional descriptor items on pre- and postexperiential program questionnaire (n=147) Pharmacy (percent) Nursing (percent) Medicine (percent) True False True False True False Are competent. 99.3 0.7 92.5 7.5 97.3 2.7 Have very little autonomy. 38.7 61.3 57.7 42.3 16.1 83.9 Understand the capabilities of other professions. 91.8 8.2 66.0 34.0 40.4 59.6 Are highly concerned with the welfare of the patient. 98.6 1.4 97.2 2.8 94.4 5.6 Sometimes encroach on others professional territory. 54.1 45.9 75.3 24.7 75.9 24.1 Are highly ethical. 98.6 1.4 85.5 14.5 75.0 25.0 Expect to much from other professions 14.6 85.4 27.8 72.2 31.2 68.8 Have a higher status than other professions. 47.9 52.1 13.8 86.2 87.0 13.0 Are very defensive about their professional prerogatives. 56.6 43.4 72.9 27.1 93.1 6.9 Trust others professional judgements. 89.7 10.3 85.4 14.6 47.2 52.8 Seldom ask for others professional advice. 7.6 92.4 14.6 85.4 66.9 33.1 Fully utilize the capabilities of other professions. 69.9 30.1 60.3 39.7 15.2 84.8 Do not cooperate well with other professions. 7.6 92.4 29.6 70.4 46.5 53.5 Are well trained. 99.3 0.7 86.3 13.7 100.0 0.0 Have good relations with other professions. 88.9 11.1 80.4 19.6 57.3 42.7 Table III. Health professions responsibilities: Significant differences between the pre- and post-experiential questionnaire response a (n=106) Responses (percent) One Two Other Chi square P Design a comprehensive treatment and rehabilitation program for a patient Pre 19.8 56.6 23.6 16.65 0.001 with multiple chronic problems Post 23.6 30.2 46.2 Assess and monitor patients with Pre 54.7 26.4 18.9 9.44 0.009 adverse reactions to drug therapy Post 37.7 25.5 36.8 Prepare and record medications Pre 63.2 23.6 13.2 9.78 0.008 administered during CPR attempts Post 44.3 43.4 12.3 Take vital signs Pre 82.1 11.2 6.6 14.47 0.001 Post 62.3 33.0 4.7 Do routine blood pressure checks on hypertensive patients Pre Post 34.0 16.0 33.0 37.7 33.0 46.2 9.48 0.009 Clarify medication order problems Pre 60.4 32.1 7.6 13.65 0.001 Post 45.3 28.3 26.4 a One= physician primarily, nurse primarily, and pharmacist primarily. Two=physician and/or nurse, physician and/or pharmacist, and pharmacist and/or nurse. Other=physician, nurse, and/or pharmacist, and none of the above. concerned with the welfare of the patient; (iv) are highly ethical; (v) ask advice of other professionals; (vi) cooperate well with other professions; and (vii) are well-trained. While the students were in agreement on most of the statements when applied to nursing, on only two of the statements were at least 90 percent of the students in agreement. Almost all the students perceived nurses as competent and concerned about the welfare of the patient. For medicine, over 90 percent of the students agreed on four descriptive statements that indicated that physicians: (i) are competent; (ii) are highly concerned with the welfare of the patient; (iii) are very defensive about their professional prerogatives; and (iv) are well-trained. There were some major differences across the professions. When there were differences across the professions, the students tended to perceive pharmacists in a more positive light than the other two professions. For example, 91.8 percent of students agreed that pharmacists understand the capabilities of other professions. However, only 66 percent of the students felt nurses understand these capabilities and only 40.4 percent felt that physicians understand. In addition, students were more likely to perceive nurses (75.3 percent) and physicians (75.9 percent) as encroaching on others professional territory than pharmacists (51.4 percent). In addition, changes in students attitudes or perceptions after completing externship and clerkship were evaluated. Changes were interpreted as significant differences using a chi-square analysis comparing answers from the prequestionnaire to answers from the postquestionnaire. Due to small cell frequencies, role responsibility responses were collapsed into three categories: one profession, two professions, and other. The one profession category included responses which indicated that roles were the responsibility of one profession (i.e., physician primarily, nurse primarily, and pharmacist primarily). Responses which indicated that the role was shared by two of the professions (i.e., physician and/or nurse, physician and/or pharmacist, and pharmacist and/or nurse) were included in the two professions category. The other category consisted of all three 16 American Journal of Pharmaceutical Education Vol. 60, Spring 1996

Table IV. Health professional descriptors: Significant differences between the pre- and post-experiential questionnaire responses (n=106) Medicine (percent) True False Chi square P Seldom ask advice of other professionals Pre 63.5 36.5 8.52 0.009 Post 43.3 56.7 Do not cooperate well with other professions Pre 46.7 53.3 8.75 0.003 Post 26.9 73.1 Have good relations with other professions Pre 59.2 40.8 13.55 0.001 Post 82.5 17.5 health professionals and none of the specified health professionals. In analyzing these changes, the students responses from the prequestionnaire were linked to their responses for the postquestionnaire. Those students who did not return a prequestionnaire and/or postquestionnaire were not included, thus data from 106 students were used in this analysis. In the health professionals responsibilities section of the questionnaire, six significant differences were identified (Table III). For each of these differences, there was a shift toward a perception of sharing of responsibilities among the professions. For example, before externship/clerkship, the majority (56.6 percent) of students believed designing a comprehensive treatment and rehabilitation program for a patient with multiple chronic problems was a responsibility shared by two professions. After completing their rotations, only 30.2 percent of students continued to agree that the role was the responsibility of only two professions (χ 2 =16.65, P=0.001). A greater percentage (46.2 percent) of students perceived the role to be a responsibility of those professionals in the other category. Similar shifts also occurred in the students perceptions of assessing and monitoring patients for adverse reactions to drug therapy (χ 2 =9.44, P=0.009), preparing and recording medications during cardiopulmonary resuscitation (CPR) attempts (χ 2 =9.78, P=0.008), taking vital signs (χ 2 =14.47, P=0.008), performing routine blood pressure checks on hypertensive patients (χ 2 =9.48, P=0.009), and clarifying medication order problems (χ 2 =13.65, P=0.001). In the health professionals descriptors section, there were three significant differences (Table IV). Generally, students had more positive perceptions of physicians after completing their externship and clerkship rotations. One of these differences pertained to physicians relations with other professions (χ 2 =13.55, P=0.001). There was an increase in true responses, indicating that more students perceived physicians having good relations with other professions after completing their rotations. In addition, a greater proportion of students felt that physicians do ask others professional advice (χ 2 =8.52, P=0.004). After finishing their rotations, more students also believed that physicians cooperate well with other professions (χ 2 =8.75, P=0.003). DISCUSSION Prior to externship/clerkship, there were several roles that students felt were the primary responsibility of the pharmacist. For the most part, these roles pertained to medication use and information. However, these roles might be interpreted by others as roles that health professionals share. Such roles include assessing patient compliance with drug therapy, instructing patients about their medications, and ensuring that a patient has received and is instructed about discharge medications. Since their perceptions seemed to indicate individual responsibility, one might wonder if students will feel threatened when they encounter another health professional performing these activities. Part of the problem in health professional relations or interactions deals with role expectations and role confusion. According to Lister, When expectations of the physician and the other status occupants are in agreement, then the mutuality of role expectations tend to lead to a balanced homeostatic social system. When there is a lack of agreement as to role expectations, however, conflict, either latent or manifest, usually occurs in the social system (5). Such interprofessional conflicts could decrease the effectiveness of the health care system. Of the 39 roles, there were four roles on which over 40 percent of the students perceived that a pharmacist and physician shared responsibility and six other roles where a pharmacist, physician, and nurse shared the activity. This seems to indicate that the students perceived the pharmacist s role as one in which he/she is an active participant in the health care team. However, there was just one role in which the students indicated that nurses shared responsibility with only a pharmacist or only a physician. The role-sharing in nursing was seen only with both a pharmacist and physician. In addition, roles in which over 40 percent of the students felt that nursing had the primary responsibility included giving follow-up care to patients by making home visits, administering immunizations, taking vital signs, performing routine blood pressure checks on hypertensive patients, and ensuring the physician order sheet reaches the pharmacy. Of the five roles, four pertained to physical or technical activities, as opposed to therapeutic duties. With very few therapeutic primary role responsibilities and role-sharing activities associated with nursing, it seems that students may not have perceived the nurse as an active participant in the health care team. They may have perceived pharmacist-nurse interaction only occurring in technical matters such as a missing dose, a physician order sheet, or approval of refills. In a participant-observation study by Mesler, he found that pharmacy s expanded roles did not significantly overlap with nursing responsibilities(13). Instead, it seemed that pharmacists were aligning themselves with nurses and used their expanded clinical roles to address issues of concern for the nurses. As one pharmacist stated in the study, Nurses get hammered from all sides; pharmacists help take some of their responsibility. Alternatively, expanded pharmacy roles did appear to cause role boundary conflicts with physician roles. Initially, it may appear that these observations are contrary to the findings of the present study. American Journal of Pharmaceutical Education Vol. 60, Spring 1996 17

However, in responding to role responsibility items, students indicated that there was not much sharing of roles between nurses and pharmacists. Perhaps students perceived pharmacists working in conjunction with nurses to relieve some of the burden from nurses. In addition, students indicated more role sharing between pharmacists and physicians. Role-sharing could increase the potential for role conflict between health professionals as observed by Mesler. In the health professional descriptors section of the prequestionnaire, students responded to a series of statements which described attributes of a health care professional. In general, students had a very positive image of pharmacists. Most students indicated that pharmacists were competent and ethical, understood the capabilities of other professions, were concerned with the welfare of the patient, did not expect too much from other professions, trusted others professional judgements, asked advice of other professionals, fully utilized the capabilities of other professions, cooperated well with other professions, were well-trained, and had good relations with other professions. Students did not have the same positive attitudes toward nursing and medicine. Although the majority of students may have viewed nurses favorably on a given attribute, it was usually to a lesser degree than for pharmacists. Students attitudes toward physicians, on the other hand, were often negative. The majority of students felt that physicians did not understand the capabilities of other professions, encroached on others professional territory, were defensive about their professional prerogatives, did not trust advice of other professionals, and did not fully utilize the capabilities of other professions. When the majority of students did indicate positive attributes toward physicians, it usually was to a lesser degree than for pharmacists. Robbins, however, found that pharmacists had no strong positive or negative feelings for physicians(13). From his study, he concluded that they somewhat agreed that pharmacists respect community physicians, disagreed somewhat that physicians tend to be conceited and aloof, and disagreed somewhat that physicians are competent and well-informed about prescription drugs. Unlike those pharmacists, students in the present study indicated that physicians were well-trained and did not have good relations with other professions. After the externship/clerkship experience, their attitudes toward physicians improved. Perhaps, as the students gained experience and became more like pharmacists, their attitudes became closer to the pharmacists in the Robbins study. Another possible explanation could relate to the increased contact between pharmacists and physicians in recent years, especially in the hospital environment. Since the Robbins study was conducted at a time when pharmacist-physician contact was relatively limited, the attitudes of pharmacists in that study may have been different than the pharmacists and pharmacy students of today. The positive attitudes exhibited in the present study toward pharmacists, combined with the relatively negative attitudes toward other health professionals, could influence pharmacists interactions with other health professionals in several ways. First, they may perceive themselves as not being responsible for conflicts with other health professionals. In addition, the very favorable self-image of pharmacists may influence the way in which pharmacists perceive interactions between health care professionals. For instance, if there is a conflict with a physician on a recommendation from a pharmacist, the pharmacist may perceive the physician as not being able to trust his/her judgement or cooperate with him/her. Both of these can lead to misunderstandings between the pharmacist and other health professionals. In a health care institution, this could decrease the effectiveness of an interdisciplinary team. As Frank stated, Obviously if each person in a team of interdisciplinary or interprofessional practitioners relies on the concepts and assumptions of his discipline or profession and expresses these in whatever he says and does, his attempts at communication to the others will be likely to fail, especially if he is not wholly aware of his own preconceptions and ignores those of his colleagues (15). After completing externship/clerkship, students exhibited changes in their perceptions of health care professionals, with a shift toward increased sharing of role responsibility. There are two possible explanations for this shift in perceptions after externship/clerkship. First, students may have seen health professionals performing these roles while on their externship/clerkship. For instance, they may have seen a physician taking vital signs on a patient or experienced a physician and/or nurse assessing and monitoring patients for adverse reactions to drug therapy. Secondly, the students could have discussed various roles with other health professionals during informal conversations. For example, a pharmacist could have talked to the student about a nurse calling the pharmacy regarding an adverse reaction to drug therapy. Although there was still a large number of students responding in the one profession category for some of the roles, the significant changes in perceptions indicate that more students became aware of various role responsibilities that health professionals share. There also were significant changes in students attitudes toward health professionals. In general, students had a more positive image of the medical profession after completing their rotations. Prior to their rotations, students may have had little or no interactions with physicians. During externship/clerkship, however, students may have had a number of interactions with physicians. In their clerkship rotations, many students participated in patient review rounds with physicians and medical students, which may have enabled them to establish integrative working relationships. This contact with the medical profession could have influenced students overall attitudes with respect to physicians. Although students still had some negative images of physicians, they generally had a more positive image of physicians following externship/clerkship. In the future, these improved attitudes toward physicians may lead to better relationships between physicians and pharmacy practitioners. Students indicated no significant changes in attitudes toward nursing. One possible reason for this is that students may have had different types of interactions with nurses than with physicians. During their clerkships, they may not have had the same opportunity to establish working relationships with nurses on patient review teams. In addition, their interactions with nurses during hospital and community externships could have been more oriented to resolving technical problems such as a missed dose or refill authorization. Often these types of interactions take place on the phone, which may hinder effective communication. 18 American Journal of Pharmaceutical Education Vol. 60, Spring 1996

CONCLUSIONS AND RECOMMENDATIONS While it cannot be assumed that the results of this study can be generalized to all schools of pharmacy, the findings do have important implications for the education of pharmacy students. It is difficult to determine where students perceptions of and attitudes toward health care professionals originated. Because many of the initial attitudes toward other health care professionals, specifically physicians, were not favorable, it may be especially important to determine the origin of these attitudes. They could come from variety of sources such as other pharmacists, media, or family members. Another possibility is that students may develop these attitudes and perceptions from the content and design of the pharmacy curriculum. Considering the lack of formal interdisciplinary training in their curriculum, students may have perceived that learning the roles of other health care professionals was not important in the overall scheme of the health care system. In addition, by not presenting this information, preexisting negative images cannot be dispelled about nurses, physicians, or even pharmacists. One also must consider the possibility that students receive these messages from pharmacy educators. Is information regarding other health professionals and their relationships with pharmacists presented in the most accurate and beneficial light? Interdisciplinary education should be utilized to give students more information about professional relationships and interactions with other health care professionals. Such education could include information about health care professionals roles, teamwork skills, and interaction with other health professional students. According to Mariano, education could reduce role conflict often experienced in practice. She feels that preprofessional and professional team training where students come together with various disciplines to learn principles and skills of collaboration; explore role specificity and role generality; examine the unity of knowledge and connections among disciplines, should be instituted to help decrease the problems of role conflict in professional practice (1). The training should be emphasized during the entire educational process. As Kindig noted, this is more effective than a one-time course. Since it may be difficult to change these attitudes, he feels that reinforcement is required for behavioral changes to occur (7). This supports the belief that clerkship and externship alone are not adequate for preparing students to interact effectively with health care professionals in a collaborative environment. Essential to an interdisciplinary program is the interaction among different health profession disciplines. When students are able to interact with other health professions, they may feel more comfortable relating to these individuals during their externship and clerkship. It has been stated that space and physical proximity can influence the functioning of an interdisciplinary team. If team members rub elbows, communications can be enhanced(1). If students rub elbows during their professional education, perhaps communications in professional practice could be promoted and enhanced. Considering current conditions within the health care arena, pharmacists need to be prepared for the changes that will occur in the future. With the increasing focus on comprehensive care and interdisciplinary health care teams, students should be prepared to interact with different health care professionals. The American Pharmaceutical Association has taken the initiative in this area by modifying its Code of Ethics to include aspects of collaboration with other health care professionals. It indicates that a pharmacist respects the values and abilities of colleagues and other health professionals (16). This implies that other health professionals have unique backgrounds and specialties, and that pharmacists should respect such differences when collaborating with these individuals in caring for patients. Pharmacy schools need to evaluate their curricula to assure that they are preparing students to adapt to these types of changes in the practice of pharmacy. Am. J. Pharm. Educ., 60, 13 19(1996) received 6/20/95, accepted 10/23/95, References (1) Mariano, C., The case for interdisciplinary collaboration, Nurs. Outlook, 37(6), 285-288(1989). (2) Leininger, M., This I believe about interdisciplinary health education for the future, ibid., 19(2), 25-29(1971). (3) Johnson, N., Collaboration An environment for optimal outcome, Crit, Care Nurs. Q., 15(3), 37-43(1992). (4) Lister, L., Role training for interdisciplinary health teams, Health Soc. Work, 7, 19-25(1982). (5) Lister, L., Role expectations of social workers and other health professionals, ibid., 5, 41-49(1980). (6) Wessel, M., Learning about interdisciplinary collaboration, J. Nurs. Educ., 20(3), 39-44(1981). (7) Kindig, D., Interdisciplinary education for primary health care team delivery, J. Med. Educ., 50(2), 97-110(1975). (8) Szasz, G., Interprofessional education in the health sciences, Milbank Mem. Fund Q., 47, 449-475(1969). (9) Robertson, K.E. and McDaniel, A.M., Interdisciplinary professional education: A collaborative clinical teaching project, Am. J. Phar. Educ., 59, 131-136(1995). (10) Ducanis, A.J. and Golin, A.K., The Interdisciplinary Health Care Team, Aspen Systems Corporation, Germantown MD (1979). (11) Weise, W.H., Howard, C.A. and Stephens, J.A., Augmentation of clinical services in rural areas by health sciences students, J. Med. Educ., 54, 917-924(1979). (12) Thompson, D., Attitudes of pharmacists and nurses toward their responsibilities in the drug treatment process, Am. J. Hosp. Pharm., 46, 257(1989). (13) Mesler, M., Boundary encroachment and task delegation: clinical pharmacists on the medical team, Sociol. Health Illn., 13, 310-331 (1991). (14) Robbins, J., Pharmacy: A Profession in Search of a Role, Navillus Publishing Corp., Stamford CT (1979). (15) Frank, L.A., Interprofessional communication, Am. J. Public Health, 51, 1798-1804(1961). (16) Code of Ethics Review Committee, Proposed: Code of ethics for pharmacists, Am. Pharm., NS34(8), 79(1994). American Journal of Pharmaceutical Education Vol. 60, Spring 1996 19