Children learn to use symbols, combining their oral language, pictures, print, and play into a coherent mixed medium and creating and communicating meanings in a variety of ways. From their initial experiences and interactions with adults, children begin to read words, processing letter-sound relations and acquiring substantial knowledge of the alphabetic system. As they continue to learn, children increasingly consolidate this information into patterns that allow for automaticity and fluency in reading and writing. Consequently reading and writing acquisition is conceptualized better as a developmental continuum than as an all-or-nothing phenomenon.
But the ability to read and write does not develop naturally, without careful planning and instruction. Children need regular and active interactions with print. Specific abilities required for reading and writing come from immediate experiences with oral and written language. Experiences in these early years begin to define the assumptions and expectations about becoming literate and give children the motivation to work toward learning to read and write. From these experiences children learn that reading and writing are valuable tools that will help them do many things in life.
The beginning years (birth through preschool)
Even in the first few months of life, children begin to experiment with language. Young babies make sounds that imitate the tones and rhythms of adult talk; they "read" gestures and facial expressions, and they begin to associate sound sequences frequently heard words with their referents (Berk 1996). They delight in listening to familiar jingles and rhymes, play along in games such as peek-a-boo and pat-a-cake, and manipulate objects such as board books and alphabet blocks in their play. From these remarkable beginnings children learn to use a variety of symbols.
In the midst of gaining facility with these symbol systems, children acquire through interactions with others the insight that specific kinds of marks print also can represent meanings. At first children will use the physical and visual cues surrounding print to determine what something says. But as they develop an understanding of the alphabetic principle, children begin to process letters, translate them into sounds, and connect this information with a known meaning. Although it may seem as though some children acquire these understandings magically or on their own, studies suggest that they are the beneficiaries of considerable, though playful and informal, adult guidance and instruction (Durkin 1966; Anbar 1986).
Considerable diversity in children's oral and written language experiences occurs in these years (Hart & Risley 1995). In home and child care situations, children encounter many different resources and types and degrees of support for early reading and writing (McGill-Franzen & Lanford 1994). Some children may have ready access to a range of writing and reading materials, while others may not; some children will observe their parents writing and reading frequently, others only occasionally; some children receive direct instruction, while others receive much more casual, informal assistance.
What this means is that no one teaching method or approach is likely to be the most effective for all children (Strickland 1994). Rather, good teachers bring into play a variety of teaching strategies that can encompass the great diversity of children in schools. Excellent instruction builds on what children already know, and can do, and provides knowledge, skills, and dispositions for lifelong learning. Children need to learn not only the technical skills of reading and writing but also how to use these tools to better their thinking and reasoning (Neuman 1998).
The single most important activity for building these understandings and skills essential for reading success appears to be reading aloud to children (Wells 1985; Bus, Van Ijzendoorn, & Pellegrini 1995). High-quality book reading occurs when children feel emotionally secure (Bus & Van Ijzendoorn 1995; Bus et al. 1997) and are active participants in reading (Whitehurst et al. 1994). Asking predictive and analytic questions in small-group settings appears to affect children's vocabulary and comprehension of stories (Karweit & Wasik 1996). Children may talk about the pictures, retell the story, discuss their favorite actions, and request multiple rereadings. It is the talk that surrounds the storybook reading that gives it power, helping children to bridge what is in the story and their own lives (Dickinson & Smith 1994; Snow et al. 1995). Snow (1991) has described these types of conversations as "decontextualized language" in which teachers may induce higher-level thinking by moving experiences in stories from what the children may see in front of them to what they can imagine.
A central goal during these preschool years is to enhance children's exposure to and concepts about print (Clay 1979, 1991; Holdaway 1979; Teale 1984; Stanovich & West 1989). Some teachers use Big Books to help children distinguish many print features, including the fact that print (rather than pictures) carries the meaning of the story, that the strings of letters between spaces are words and in print correspond to an oral version, and that reading progresses from left to right and top to bottom. In the course of reading stories, teachers may demonstrate these features by pointing to individual words, directing children's attention to where to begin reading, and helping children to recognize letter shapes and sounds. Some researchers (Adams 1990; Roberts 1998) have suggested that the key to these critical concepts, such as developing word awareness, may lie in these demonstrations of how print works.
Children also need opportunity to practice what they've learned about print with their peers and on their own. Studies suggest that the physical arrangement of the classroom can promote time with books (Morrow & Weinstein 1986; Neuman & Roskos 1997). A key area is the classroom library a collection of attractive stories and informational books that provides children with immediate access to books. Regular visits to the school or public library and library card registration ensure that children's collections remain continually updated and may help children develop the habit of reading as lifelong learning. In comfortable library settings children often will pretend to read, using visual cues to remember the words of their favorite stories. Although studies have shown that these pretend readings are just that (Ehri & Sweet 1991), such visual readings may demonstrate substantial knowledge about the global features of reading and its purposes.
Storybooks are not the only means of providing children with exposure to written language. Children learn a lot about reading from the labels, signs, and other kinds of print they see around them (McGee, Lomax, & Head 1988; Neuman & Roskos 1993). Highly visible print labels on objects, signs, and bulletin boards in classrooms demonstrate the practical uses of written language. In environments rich with print, children incorporate literacy into their dramatic play (Morrow 1990; Vukelich 1994; Neuman & Roskos 1997), using these communication tools to enhance the drama and realism of the pretend situation. These everyday, playful experiences by themselves do not make most children readers. Rather they expose children to a variety of print experiences and the processes of reading for real purposes.
For children whose primary language is other than English, studies have shown that a strong basis in a first language promotes school achievement in a second language (Cummins 1979). Children who are learning English as a second language are more likely to become readers and writers of English when they are already familiar with the vocabulary and concepts in their primary language. In this respect, oral and written language experiences should be regarded as an additive process, ensuring that children are able to maintain their home language while also learning to speak and read English (Wong Fillmore, 1991). Including non-English materials and resources to the extent possible can help to support children's first language while children acquire oral proficiency in English.
A fundamental insight developed in children's early years through instruction is the alphabetic principle, the understanding that there is a systematic relationship between letters and sounds (Adams 1990). The research of Gibson and Levin (1975) indicates that the shapes of letters are learned by distinguishing one character from another by its type of spatial features. Teachers will often involve children in comparing letter shapes, helping them to differentiate a number of letters visually. Alphabet books and alphabet puzzles in which children can see and compare letters may be a key to efficient and easy learning.
At the same time children learn about the sounds of language through exposure to linguistic awareness games, nursery rhymes, and rhythmic activities. Some research suggests that the roots of phonemic awareness, a powerful predictor of later reading success, are found in traditional rhyming, skipping, and word games (Bryant et al. 1990). In one study, for example (Maclean, Bryant, & Bradley 1987), researchers found that three-year-old children's knowledge of nursery rhymes specifically related to their more abstract phonological knowledge later on. Engaging children in choral readings of rhymes and rhythms allows them to associate the symbols with the sounds they hear in these words.
Although children's facility in phonemic awareness has been shown to be strongly related to later reading achievement, the precise role it plays in these early years is not fully understood. Phonemic awareness refers to a child's understanding and conscious awareness that speech is composed of identifiable units, such as spoken words, syllables, and sounds. Training studies have demonstrated that phonemic awareness can be taught to children as young as age five (Bradley & Bryant 1983; Lundberg, Frost, & Petersen 1988; Cunningham 1990; Bryne & Fielding-Barnsley 1991). These studies used tiles (boxes) (Elkonin 1973) and linguistic games to engage children in explicitly manipulating speech segments at the phoneme level.
Yet, whether such training is appropriate for younger-age children is highly suspect. Other scholars find that children benefit most from such training only after they have learned some letter names, shapes, and sounds and can apply what they learn to real reading in meaningful contexts (Cunningham 1990; Foorman et al. 1991). Even at this later age, however, many children acquire phonemic awareness skills without specific training but as a consequence of learning to read (Wagner & Torgesen 1987; Ehri 1994). In the preschool years sensitizing children to sound similarities does not seem to be strongly dependent on formal training but rather from listening to patterned, predictable texts while enjoying the feel of reading and language.
Children acquire a working knowledge of the alphabetic system not only through reading but also through writing. A classic study by Read (1971) found that even without formal spelling instruction, preschoolers use their tacit knowledge of phonological relations to spell words. Invented spelling (or phonic spelling) refers to beginners' use of the symbols they associate with the sounds they hear in the words they wish to write. For example, a child may initially write b or bk for the word bike, to be followed by more conventionalized forms later on.
Some educators may wonder whether invented spelling promotes poor spelling habits. To the contrary, studies suggest that temporary invented spelling may contribute to beginning reading (Chomsky 1979; Clarke 1988). One study, for example, found that children benefited from using invented spelling compared to having the teacher provide correct spellings in writing (Clarke 1988). Although children's invented spellings did not comply with correct spellings, the process encouraged them to think actively about letter-sound relations. As children engage in writing, they are learning to segment the words they wish to spell into constituent sounds.
Classrooms that provide children with regular opportunities to express themselves on paper, without feeling too constrained for correct spelling and proper handwriting, also help children understand that writing has real purpose (Graves 1983; Sulzby 1985; Dyson 1988). Teachers can organize situations that both demonstrate the writing process and get children actively involved in it. Some teachers serve as scribes and help children write down their ideas, keeping in mind the balance between children doing it themselves and asking for help. In the beginning these products likely emphasize pictures with few attempts at writing letters or words. With encouragement, children begin to label their pictures, tell stories, and attempt to write stories about the pictures they have drawn. Such novice writing activity sends the important message that writing is not just handwriting practice children are using their own words to compose a message to communicate with others.
Thus the picture that emerges from research in these first years of children's reading and writing is one that emphasizes wide exposure to print and to developing concepts about it and its forms and functions. Classrooms filled with print, language and literacy play, storybook reading, and writing allow children to experience the joy and power associated with reading and writing while mastering basic concepts about print that research has shown are strong predictors of achievement.
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Knowledge of the forms and functions of print serves as a foundation from which children become increasingly sensitive to letter shapes, names, sounds, and words. However, not all children typically come to kindergarten with similar levels of knowledge about printed language. Estimating where each child is developmentally and building on that base, a key feature of all good teaching, is particularly important for the kindergarten teacher. Instruction will need to be adapted to account for children's differences. For those children with lots of print experiences, instruction will extend their knowledge as they learn more about the formal features of letters and their sound correspondences.
For other children with fewer prior experiences, initiating them to the alphabetic principle, that a limited set of letters comprises the alphabet and that these letters stand for the sounds that make up spoken words, will require more focused and direct instruction. In all cases, however, children need to interact with a rich variety of print (Morrow, Strickland, & Woo 1998).
In this critical year kindergarten teachers need to capitalize on every opportunity for enhancing children's vocabulary development. One approach is through listening to stories (Feitelson, Kita, & Goldstein 1986; Elley 1989). Children need to be exposed to vocabulary from a wide variety of genres, including informational texts as well as narratives. The learning of vocabulary, however, is not necessarily simply a byproduct of reading stories (Leung & Pikulski 1990). Some explanation of vocabulary words prior to listening to a story is related significantly to children's learning of new words (Elley 1989). Dickinson and Smith (1994), for example, found that asking predictive and analytic questions before and after the readings produced positive effects on vocabulary and comprehension.
Repeated readings appear to further reinforce the language of the text as well as to familiarize children with the way different genres are structured (Eller, Pappas, & Brown 1988; Morrow 1988). Understanding the forms of informational and narrative texts seems to distinguish those children who have been well read to from those who have not (Pappas 1991). In one study, for example, Pappas found that with multiple exposures to a story (three readings), children's retelling became increasingly rich, integrating what they knew about the world, the language of the book, and the message of the author. Thus, considering the benefits for vocabulary development and comprehension, the case is strong for interactive storybook reading (Anderson 1995). Increasing the volume of children's playful, stimulating experiences with good books is associated with accelerated growth in reading competence.
Activities that help children clarify the concept of word are also worthy of time and attention in the kindergarten curriculum (Juel 1991). Language experience charts that let teachers demonstrate how talk can be written down provide a natural medium for children's developing word awareness in meaningful contexts. Transposing children's spoken words into written symbols through dictation provides a concrete demonstration that strings of letters between spaces are words and that not all words are the same length. Studies by Clay (1979) and Bissex (1980) confirm the value of what many teachers have known and done for years: Teacher dictations of children's stories help develop word awareness, spelling, and the conventions of written language.
Many children enter kindergarten with at least some perfunctory knowledge of the alphabet letters. An important goal for the kindergarten teacher is to reinforce this skill by ensuring that children can recognize and discriminate these letter shapes with increasing ease and fluency (Mason 1980; Snow, Burns, & Griffin 1998). Children's proficiency in letter naming is a well-established predictor of their end-of-year achievement (Bond & Dykstra 1967, Riley 1996), probably because it mediates the ability to remember sounds. Generally a good rule according to current learning theory (Adams 1990) is to start with the more easily visualized uppercase letters, to be followed by identifying lowercase letters. In each case, introducing just a few letters at a time, rather than many, enhances mastery.
At about the time children are readily able to identify letter names, they begin to connect the letters with the sounds they hear. A fundamental insight in this phase of learning is that a letter and letter sequences map onto phonological forms. Phonemic awareness, however, is not merely a solitary insight or an instant ability (Juel 1991). It takes time and practice.
Children who are phonemically aware can think about and manipulate sounds in words. They know when words rhyme or do not; they know when words begin or end with the same sound; and they know that a word like bat is composed of three sounds /b/ /a/ /t/ and that these sounds can be blended into a spoken word. Popular rhyming books, for example, may draw children's attention to rhyming patterns, serving as a basis for extending vocabulary (Ehri & Robbins 1992). Using initial letter cues, children can learn many new words through analogy, taking the familiar word bake as a strategy for figuring out a new word, lake.
Further, as teachers engage children in shared writing, they can pause before writing a word, say it slowly, and stretch out the sounds as they write it. Such activities in the context of real reading and writing help children attend to the features of print and the alphabetic nature of English.
There is accumulated evidence that instructing children in phonemic awareness activities in kindergarten (and first grade) enhances reading achievement (Stanovich 1986; Lundberg, Frost, & Petersen 1988; Bryne & Fielding-Barnsley 1991, 1993, 1995). Although a large number of children will acquire phonemic awareness skills as they learn to read, an estimated 20% will not without additional training. A statement by the IRA (1998) indicates that "the likelihood of these students becoming successful as readers is slim to none This figure [20%], however, can be substantially reduced through more systematic attention to engagement with language early on in the child's home, preschool and kindergarten classes."
A study by Hanson and Farrell (1995), for example, examined the long-term benefits of a carefully developed kindergarten curriculum that focused on word study and decoding skills, along with sets of stories so that children would be able to practice these skills in meaningful contexts. High school seniors who early on had received this type of instruction outperformed their counterparts on reading achievement, attitude toward schooling, grades, and attendance.
In kindergarten many children will begin to read some words through recognition or by processing letter-sound relations. Studies by Domico (1993) and Richgels (1995) suggest that children's ability to read words is tied to their ability to write words in a somewhat reciprocal relationship. The more opportunities children have to write, the greater the likelihood that they will reproduce spellings of words they have seen and heard. Though not conventional, these spellings likely show greater letter-sound correspondences and partial encoding of some parts of words, like SWM for swim, than do the inventions of preschoolers (Clay 1975).
To provide more intensive and extensive practice, some teachers try to integrate writing in other areas of the curriculum, like literacy-related play (Neuman & Roskos 1992), and other project activities (Katz & Chard 1989). These types of projects engage children in using reading and writing for multiple purposes while they are learning about topics meaningful to them.
Early literacy activities teach children a great deal about writing and reading but often in ways that do not look much like traditional elementary school instruction. Capitalizing on the active and social nature of children's learning, early instruction must provide rich demonstrations, interactions, and models of literacy in the course of activities that make sense to young children. Children must also learn about the relation between oral and written language and the relation between letters, sounds, and words. In classrooms built around a wide variety of print activities, then in talking, reading, writing, playing, and listening to one another, children will want to read and write and feel capable that they can do so.
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The primary grades
Instruction takes on a more formal nature as children move into the elementary grades. Here it is virtually certain that children will receive at least some instruction from a commercially published product, like a basal or literature anthology series.
Although research has clearly established that no one method is superior for all children (Bond & Dykstra 1967; Snow, Burns, & Griffin 1998), approaches that favor some type of systematic code instruction along with meaningful connected reading report children's superior progress in reading. Instruction should aim to teach the important letter-sound relationships, which once learned are practiced through having many opportunities to read. Most likely these research findings are a positive result of the Matthew Effect, the rich-get-richer effects that are embedded in such instruction; that is, children who acquire alphabetic coding skills begin to recognize many words (Stanovich 1986). As word recognition processes become more automatic, children are likely to allocate more attention to higher-level processes of comprehension. Since these reading experiences tend to be rewarding for children, they may read more often; thus reading achievement may be a by-product of reading enjoyment.
One of the hallmarks of skilled reading is fluent, accurate word identification (Juel, Griffith, & Gough 1986). Yet instruction in simply word calling with flashcards is not reading. Real reading is comprehension. Children need to read a wide variety of interesting, comprehensible materials, which they can read orally with about 90 to 95% accuracy (Durrell & Catterson 1980). In the beginning children are likely to read slowly and deliberately as they focus on exactly what's on the page. In fact they may seem "glued to print" (Chall 1983), figuring out the fine points of form at the word level. However, children's reading expression, fluency, and comprehension generally improve when they read familiar texts. Some authorities have found the practice of repeated rereadings in which children reread short selections significantly enhances their confidence, fluency, and comprehension in reading (Samuels 1979; Moyer 1982).
Children not only use their increasing knowledge of letter-sound patterns to read unfamiliar texts. They also use a variety of strategies. Studies reveal that early readers are capable of being intentional in their use of metacognitive strategies (Brown, & DeLoache 1978; Rowe 1994) Even in these early grades, children make predictions about what they are to read, self-correct, reread, and question if necessary, giving evidence that they are able to adjust their reading when understanding breaks down. Teacher practices, such as the Directed Reading-Thinking Activity (DRTA), effectively model these strategies by helping children set purposes for reading, ask questions, and summarize ideas through the text (Stauffer 1970).
But children also need time for independent practice. These activities may take on numerous forms. Some research, for example, has demonstrated the powerful effects that children's reading to their caregivers has on promoting confidence as well as reading proficiency (Hannon 1995). Visiting the library and scheduling independent reading and writing periods in literacy-rich classrooms also provide children with opportunities to select books of their own choosing. They may engage in the social activities of reading with their peers, asking questions, and writing stories (Morrow & Weinstein 1986), all of which may nurture interest and appreciation for reading and writing.
Supportive relationships between these communication processes lead many teachers to integrate reading and writing in classroom instruction (Tierney & Shanahan 1991). After all, writing challenges children to actively think about print. As young authors struggle to express themselves, they come to grips with different written forms, syntactic patterns, and themes. They use writing for multiple purposes: to write descriptions, lists, and stories to communicate with others. It is important for teachers to expose children to a range of text forms, including stories, reports, and informational texts, and to help children select vocabulary and punctuate simple sentences that meet the demands of audience and purpose. Since handwriting instruction helps children communicate effectively, it should also be part of the writing process (McGee & Richgels 1996). Short lessons demonstrating certain letter formations tied to the publication of writing provide an ideal time for instruction. Reading and writing workshops, in which teachers provide small-group and individual instruction, may help children to develop the skills they need for communicating with others.
Although children's initial writing drafts will contain invented spellings, learning about spelling will take on increasing importance in these years (Henderson & Beers 1980; Richgels 1986). Spelling instruction should be an important component of the reading and writing program since it directly affects reading ability. Some teachers create their own spelling lists, focusing on words with common patterns, high-frequency words, as well as some personally meaningful words from the children's writing. Research indicates that seeing a word in print, imagining how it is spelled, and copying new words is an effective way of acquiring spellings (Barron 1980).
Nevertheless, even though the teacher's goal is to foster more conventionalized forms, it is important to recognize that there is more to writing than just spelling and grammatically correct sentences. Rather, writing has been characterized by Applebee (1977) as "thinking with a pencil." It is true that children will need adult help to master the complexities of the writing process. But they also will need to learn that the power of writing is expressing one's own ideas in ways that can be understood by others.
As children's capabilities develop and become more fluent, instruction will turn from a central focus on helping children learn to read and write to helping them read and write to learn. Increasingly the emphasis for teachers will be on encouraging children to become independent and productive readers, helping them to extend their reasoning and comprehension abilities in learning about their world. Teachers will need to provide challenging materials that require children to analyze and think creatively and from different points of view. They also will need to ensure that children have practice in reading and writing (both in and out of school) and many opportunities to analyze topics, generate questions, and organize written responses for different purposes in meaningful activities.
Throughout these critical years accurate assessment of children's knowledge, skills, and dispositions in reading and writing will help teachers better match instruction with how and what children are learning. However, early reading and writing cannot simply be measured as a set of narrowly-defined skills on standardized tests. These measures often are not reliable or valid indicators of what children can do in typical practice, nor are they sensitive to language variation, culture, or the experiences of young children (Shepard & Smith 1988; Shepard 1994; Johnston 1997).
Rather, a sound assessment should be anchored in real-life writing and reading tasks and continuously chronicle a wide range of children's literacy activities in different situations. Good assessment is essential to help teachers tailor appropriate instruction to young children and to know when and how much intensive instruction on any particular skill or strategy might be needed.
By the end of third grade, children will still have much to learn about literacy. Clearly some will be further along the path to independent reading and writing than others. Yet with high-quality instruction, the majority of children will be able to decode words with a fair degree of facility, use a variety of strategies to adapt to different types of text, and be able to communicate effectively for multiple purposes using conventionalized spelling and punctuation. Most of all they will have come to see themselves as capable readers and writers, having mastered the complex set of attitudes, expectations, behaviors, and skills related to written language.
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Exploring the Requisite Skills and Competencies of Pharmacists Needed for Success in an Evolving Health Care Environment
a University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
b School of Nursing, University of North Carolina, Chapel Hill, North Carolina
Corresponding Author: Jacqueline E. McLaughlin, University of North Carolina Eshelman School of Pharmacy, CB #7574, Beard 327, Chapel Hill, NC 27599-7574. Tel: 919-966-4557. E-mail: ude.cnu@nilhgualcm_iuqcaj
Author information ►Article notes ►Copyright and License information ►
Received 2016 Jun 30; Accepted 2016 Aug 23.
Copyright © 2017 American Association of Colleges of Pharmacy
Objective. To identify and describe the core competencies and skills considered essential for success of pharmacists in today’s rapidly evolving health care environment.
Methods. Six breakout groups of 15-20 preceptors, pharmacists, and partners engaged in a facilitated discussion about the qualities and characteristics relevant to the success of a pharmacy graduate. Data were analyzed using qualitative methods. Peer-debriefing, multiple coders, and member-checking were used to promote trustworthiness of findings.
Results. Eight overarching themes were identified: critical thinking and problem solving; collaboration across networks and leading by influence; agility and adaptability; initiative and entrepreneurialism; effective oral and written communication; accessing and analyzing information; curiosity and imagination; and self-awareness.
Conclusion. This study is an important step toward understanding how to best prepare pharmacy students for the emerging health care needs of society.
Keywords: collaboration, communication, adaptability, jobs-to-be-done, competencies
The US health care system needs change to improve the quality of care, enhance the patient experience, and reduce health care costs.1 Care is fragmented and poorly coordinated, and interprofessional, team-based care is not where it needs to be to facilitate the delivery of high quality care. Further, a critical component of improving national health care centers is the need to improve the safe and effective use of medications. Numerous calls have emerged for reform in health professions education and highlight ongoing concerns about the ability of current curricula to prepare students for the continual improvement of health and health care.2-6 Employers within and outside health care are increasingly seeking graduates who are able to think critically, work in highly collaborative environments, communicate clearly, ask good questions, and solve complex problems.7 Medicine, nursing, and pharmacy schools are further challenged with educating students amid rapidly expanding information about health and medicines, increasingly complex health care systems, ongoing shifts in legislative and regulatory requirements, and emerging models of care delivery and payment reform. Embedded in this challenge are the evolving roles of health care providers who must effectively respond to these changes and work collaboratively to proactively identify solutions that promote and improve the health and well-being of patients.
Although a growing body of evidence highlights the importance of designing practice models to achieve interprofessional care that is patient-centered and effective, many health care professionals do not fully understand the capabilities of other health care team members and often struggle to effectively capitalize on the expertise and talents of each other.6 The Interprofessional Education Collaborative (IPEC) identified roles and responsibilities as a core interprofessional collaborative practice competency domain for collaborative practice, proposing that providers “use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of the patients and populations served.”6 Understanding the skills and competencies needed by members of the health care team is critical for ensuring that educational experiences and curricula are structured to prepare aspiring health professionals for contemporary health care challenges. Further, elucidating the skills desired from specific health professions disciplines will facilitate work aimed at optimizing the roles and responsibilities of team members serving to improve patient care.
Across multiple health professions, curriculum accreditation standards are emphasizing interprofessional education (IPE) to better prepare students for the challenges of real world practice. The Liaison Committee on Medical Education (LCME), for example, mandates in Standard 7.9 that “the faculty of a medical school ensure that the core curriculum of the medical education program prepares medical students to function collaboratively on health care teams that include health professionals from other disciplines as they provide coordinated services to patients.”8 In addition, the Accreditation Council for Pharmacy Education (ACPE) details in Standard 11 the need to prepare all “pharmacy students to provide patient-centered care in a variety of practice settings as a contributing member of an interprofessional team with competency in team expectations, education, and practice,” and the American Association of Colleges of Nursing (AACN) includes “interprofessional communication for improving patient outcomes” as a critical component of undergraduate and graduate accreditation.9,10 The National League for Nursing (NLN) has challenged nurse educators to collaborate with other health professions to develop meaningful interprofessional education and practice opportunities for students as part of undergraduate and graduate learning experiences.11
Meeting the health care needs of society, optimizing team-based care, and developing effective programs that foster interprofessional education and care will require a more rigorous and nuanced understanding of the knowledge, skills, and abilities of graduates emerging from health professions curricula and the job to be done by specific members of the health care team. Literature that describes the qualities and characteristics requisite for success in the various health professions appears largely descriptive and positional in nature. In pharmacy, recent white papers propose core competencies for pharmacy practice. Jungnickel and colleagues, for example, projected future practice competencies in a white paper for the American Association of Colleges of Pharmacy (AACP) that included professionalism, self-directed learning competencies, leadership and advocacy, interprofessional collaboration, and cultural competency.12 In an American College of Clinical Pharmacy (ACCP) white paper on clinical pharmacist competencies, Burke and colleagues identified and advocated for clinical problem-solving, judgment, and decision-making; communication and education; medical information evaluation and management; management of patient populations; and therapeutic knowledge.13 The Center for the Advancement of Pharmaceutical Education (CAPE) 2013 Educational Outcomes, derived from a literature review and vetted with various stakeholders, included foundational knowledge, essential for practice and care, approach to practice and care, and personal and professional development.14
For many professions, there remains a need for research that examines the contemporary skills associated with 21st century health care. The purpose of this study was to identify and describe the core competencies and skills deemed essential for success of pharmacists in today’s health care system. As described below, this research is framed by Christensen’s jobs-to-be-done theory,15 analyzed according to Tony Wagner’s New World of Work and the Seven Survival Skills16 and presented within the context of interprofessional health care and education. Identifying these qualities provides critical insight into curriculum design and practice innovation for pharmacy and other health professions striving to improve patient care and care delivery.
In his book, Wagner describes a core set of skills identified as necessary for success in today’s workplace.16 These skills, Wagner argues, define a “new and very different kind of worker (p. 41)” and that those without these skills are “unprepared to be active and informed citizens…who will continue to be stimulated by new information and ideas (p. 14).”16 Specifically, the seven survival skills include: critical thinking and problem-solving, which is reflected by asking good questions, dealing with vast amounts of information, deciding what’s accurate and what’s not, and having a plan of action; collaboration across networks and leading by influence, which includes working in teams, making your own decisions, understanding and respecting difference among people, leading and influencing the people around you; agility and adaptability, characterized by working with disruptions, using various tools to solve new problems, ability to work when there isn’t a right answer, and adapting to constant change; initiative and entrepreneurialism, which means being proactive, actively looking for ways to improve systems, courage to try and fail, generating your own answers and solutions; effective oral and written communication, which includes clear and concise writing and speaking, discretion for using different levels of communication, and presentation skills; accessing and analyzing information, which encompasses finding and synthesizing information, using information from a variety of sources, and understanding and responding to how rapidly information is changing; and curiosity and imagination, which is reflected by the ability to continually ask great questions (eg, “What if…?”), dreaming, searching for unique solutions, dissatisfaction with the status quo, and empathy.16,19
The University of North Carolina (UNC) Eshelman School of Pharmacy is implementing a redesign of its doctor of pharmacy curriculum using a process called curriculum transformation.17 A hallmark of the curriculum transformation to date has been applying the principles of Clayton Christensen’s jobs-to-be-done theory.15 This theory challenges educational leaders to articulate what it is that graduates will be hired to do. In other words, what is the job to be done by pharmacy graduates in the year 2020 and beyond? Christensen argues that if you do not understand what your products (ie, graduates) should be hired to do, you cannot develop the best product for the market. The idea then is to design a curriculum that facilitates student development toward the endpoint, which aims to promote better understanding of the content or processes that are essential to learning. We believe that this theory is a critical exercise for effectively designing and implementing educational opportunities that enable pharmacy students to develop the skills and competencies necessary for contemporary health care.
To identify the job to be done by pharmacists as integral members of the health care team, we interviewed 103 preceptors, pharmacists, students, and partners assembled for the UNC Eshelman School of Pharmacy’s Second Annual Preceptor and Partnership Symposium in January 2015, Preparing for Curriculum 2015: Re-engineering Experiential Education. One goal of the symposium was to engage participants in thinking about the job to be done by pharmacists in as much the same way we have engaged our campus-based faculty in this discussion as a part of our curriculum transformation efforts. Specifically, six breakout groups of 15-20 preceptors, pharmacists, and partners engaged in a facilitated discussion about the qualities and characteristics relevant to the success of a pharmacy graduate in today’s health care system (Appendix 1). Each group had a trained facilitator and a note-taker.
All breakout group discussions were audio recorded and subsequently transcribed verbatim. Standard qualitative methods were used to analyze the transcriptions. Two research team members analyzed the data using qualitative content analysis, in which themes and subthemes were identified.18 The first step of analyzing the data included reading and re-reading the transcripts to become familiar with the data. The researchers then used a constant comparative method to code the data according to the categories and subcategories elucidated by Wagner.16
The researchers worked together to compare findings and reach consensus on emerging themes and subthemes. Preliminary reports were presented to additional research team members for peer-debriefing and to participants from the symposium for member-checking. These qualitative research steps (ie, multiple coders, peer-debriefing, member-checking) promote trustworthiness of the findings. The study was reviewed by the UNC Institutional Review Board and was classified as exempt.
One-hundred and three symposium attendees participated in breakout groups with each group composed of participants from various site types, gender, and positions. Fifty-eight participants were from inpatient practice sites (56.3%), 17 from community practice sites (16.5%), 17 from the school (16.5%), and 11 from ambulatory care sites (10.6%). Thirty-six participants were male (35%). Twenty-seven held on-campus or experiential faculty positions (26.2%), 50 served as pharmacy preceptors for students (48.5%), 10 were students (9.7%), seven were residents or postdoctoral fellows (6.8%), and nine were other (eg, hospital administration, school staff) (8.7%).
Eight overarching themes were identified from the data. The first seven themes were represented by Wagner’s seven survival skills,16 while the eighth theme emerged inductively: critical thinking and problem-solving; collaboration across networks and leading by influence; agility and adaptability; initiative and entrepreneurialism; effective oral and written communication; accessing and analyzing information; curiosity and imagination; and self-awareness. Table 1 provides illustrative quotes from a composite description of a pharmacy graduate provided by a participant, organized by theme. Additional quotes from various participants are provided in-text, with a collection of quotes also provided in Appendix 2. The pharmacy content associated with these comments focused on medication therapy expertise, patient care optimization, and health care infrastructure.
Illustrative Quotes From a Composite Description Provided by a Participant, Organized by Theme
Critical thinking and problem solving included asking and anticipating good questions, dealing with vast amounts of information (eg, most frequently used drugs, prevalent diseases, managing large groups of patients), prioritizing responsibilities and managing time, and having the ability to differentiate between accurate and inaccurate information. One participant said, “…we have to teach…future graduates what is the right question to ask for us to be able to move forward.”
Participants also identified collaboration and leadership by influence as noteworthy characteristics; specifically, the ability to foster relationships across interdisciplinary teams in both virtual and face-to-face settings and having a sense of accountability, ownership, and responsibility of decisions. Participants mentioned specifics such as working through disagreements and committing to a plan of action.
Theme three, agility and adaptability, encompassed the ability to quickly adapt to constantly changing environments and patient care situations and working with disruptions. The participants emphasized the importance of navigating the multiple roles a pharmacist may serve such as clinician responsible for managing drug therapy, consultant, patient educator, and care coordinator. The participants also commented on the importance of taking initiative and having a spirit of entrepreneurialism, theme four. The participants indicated the pharmacist of 2020 and beyond should be proactive. For example, one participant said that they should “be a self-starter, a knowledge-seeker, a work-seeker.” Additional traits such as serving as an advocate for the profession while actively searching for ways to improve it and having the confidence to try new things and fail also were expressed. Furthermore, as one participant said, future pharmacists should be “proactive within that system to participate in the recognition [of the problem] and the solution.”
The fifth theme, effective oral and written communication skills, includes the ability to communicate clearly and concisely. As one participant said, “Sometimes all you have is an opportunity to do a two-minute elevator pitch…how do you do that?” An additional subtheme highlighted one’s capacity to recognize how and when to use different levels of communication. For example, a participant said, “There may be a phone call that’s required over sending an email, especially if you’re not very happy, or maybe you just need to go down to someone’s office and have a face to face. There is body language; you can read it.”
The sixth theme was the ability to assess and analyze information. One participant said that a future pharmacist should have “…a good understanding of where to go and what is quality literature, or guidelines to review for a given disease state, or problem.” Related, the participants also promoted the importance of recognizing how rapidly information is changing in health care and having the ability to deal with these changes as they emerge. For instance, one participant noted that a future pharmacist must be aware of new drugs and have the ability to incorporate them and prioritize them into practice. Curiosity and imagination was the seventh theme. Participants described the importance of asking great questions, never being satisfied with the status quo, exhibiting empathy, and searching for unique solutions. As one participant said, “It's about not being satisfied with answering a question but being able to answer their question and let that lead you someplace else.”
Self-awareness, the final theme, included the ability to both accept and receive feedback from others and having awareness of one’s impact. For instance, one participant said that the future pharmacist should have “…a certain self-awareness of where their own deficits, where the sum of them lie, and [accept] that.” In reflecting on previous discussions with residents, another participant said, “…one of the key things that I talk to residents about…is how they’re able to self-evaluate their own work and judge the quality of it.”
It is worth noting that while the overarching themes emerged as distinct from one another, they were not always mutually exclusive, and some subthemes occasionally overlapped. For example, a subtheme from theme one, “decide what’s accurate and what’s not,” had common characteristics with a subtheme from theme six, “find, evaluate, and synthesize information.”
Preparing aspiring health professionals to deliver high quality, team-based care is imperative for improving patient care and meeting health care needs. This study found that the skills and abilities believed to be critical for the job to be done in pharmacy align with Wagner’s research on skills for success in work, learning, and citizenship. As stated by Wagner, “the most successful companies in the emerging economy need a new and very different kind of worker who teams with others to continuously reinvent the machine as well as the products and services it creates (pg. 41).”16 The results of this study suggest that the participants also envisioned this new and very different kind of worker as necessary for the job to be done by pharmacy graduates. Further, research from the American Association of Colleges and Universities (AACU) supports the importance of these “cross-cutting capacities” to employers, who indicated they want more emphasis on critical thinking, complex problem-solving, written and oral communication, and applied knowledge in a real world setting.7
These findings have important implications for pharmacy education as well as other health professions. The proliferation of curriculum reform and new health professions schools, coupled with ongoing changes in health care, make this work timely and relevant. All too often, curricula emphasize vast amounts of discipline-specific knowledge at the expense of skills essential to survive in an increasingly competitive and global society. Being a professional requires specialized knowledge and skills; however, much of what is learned as a student in the classroom changes over time. Consequently, schools must foster in students the skills needed to become self-directed lifelong learners who strive for personal and professional development, thus positioning themselves for continual and positive impact on health and health care. With a rapidly evolving health care landscape, students must develop habits of mind that embrace curiosity, agility, and collaboration, and they must demonstrate the ability to lead and manage change. We also need to teach our students about their own roles, unique skillsets, and the profession’s expectations so that our graduates are better positioned to articulate what the profession can offer.
The skills identified in this study – critical thinking and problem-solving; collaboration across networks and leading by influence; agility and adaptability; initiative and entrepreneurialism; effective oral and written communication; accessing and analyzing information; curiosity and imagination; and self-awareness – are important, timely, and relevant skills for pharmacists for several reasons. First, ensuring the safe, effective, and affordable use of medications is critical if we are to improve national health care. This requires that pharmacists assume more responsibility for optimizing medications as a means toward improving care and care delivery, which, in turn, requires that pharmacists be open and adaptable to shifting away from traditional ways of working to arrive at new and creative solutions that better position them to play a much more direct role in optimizing medication use. It also requires them to be effective communicators and function in a highly, collaborative environment to advance care. Skills such as critical thinking and problem-solving are essential to arrive at new, sustainable models of care delivery that demonstrate the value-added role of pharmacists as integral team members who positively impact the quality and cost of patient care.
Preparing students for the realities of real-world health care delivery permeate conversations about curricular change as accreditors promote curriculum design.8-10 This research also contributes to a growing body of literature on the need to foster interprofessional education, including the interprofessional collaborative practice competencies from IPEC.6 Although participants in this study were not asked specifically about teamwork and interprofessional care, several of the study themes and subthemes (eg, collaboration across networks and leading by influence) reflect key behavioral expectations from IPEC, including engage diverse health care professionals who complement one’s own professional expertise, choose effective communication tools and techniques, recognize one’s limitations in skills, knowledge, and abilities, and reflect on individual and team performance. For learners of different disciplines to be ready for collaborative practice, students and instructors must better understand what the respective disciplines are emphasizing that will prepare students for practice; and work toward creating intentional programs within their curricula to foster relationships and promote the development of interprofessional collaborative practice competencies.6
Collaboration, communication, and critical thinking and problem-solving are common in interprofessional care and education models and have been emphasized as important competencies for many years. The literature on each of these competencies is vast, spanning a wide range of disciplines and educational levels.20 In The Ten Principles of Good Interdisciplinary Team Work, for example, researchers identified supportive team climate and communication strategies and structures as characteristics underpinning effective interdisciplinary work.21 Given the salience of these constructs, their presence as themes in this study is not surprising.
While collaboration, communication, and critical thinking have a long and rich history of emphasis in health professions, other themes reflect emerging ideas about education and success such as initiative and entrepreneurialism and agility and adaptability. The need to foster these characteristics likely starts early in the educational process for the professional student. Schools and faculty need to create engaged and active learning experiences, both in the classroom and in the practice setting, that emphasize initiative, innovation, critical thinking, and adaptability so that students are mindful of the importance of these skills and are assessed accordingly throughout their education and training. Preceptors and faculty alike should be able to observe these qualities in students, and have appropriate assessment instruments in place to both measure and document the level to which students demonstrate these qualities in the applied, real-world setting.
This study is an important step toward understanding how to best prepare pharmacy students for the emerging health care needs of society. At our own school, this work has enabled us to establish a common language and philosophy among our preceptors about the job to be done by pharmacists in 2020 and beyond. Having a shared philosophy helps to ensure that we are collectively designing a curriculum toward a common endpoint or outcome upon graduation from the professional program. In addition, this exercise has informed the refinement of our core competencies for the doctor of pharmacy degree program, the development of our transformed curriculum, our plans for assessment of student learning, and will continue to inform preceptor engagement and development. Further research will be critical for understanding how to best integrate the teaching, learning, and assessment of these skills within the curriculum.
The main limitations of this study are related to the sample, as participants were associated with a single school and state (North Carolina) and represented only one discipline. However, many participants engage with other pharmacists, health care professionals, and organizations by the nature of the work that they do. Given that the participants are associated with the school, it is also possible that they were previously influenced by Wagner’s framework because it has been used to help guide the school’s curriculum transformation for some time. Surveying participants prior to the breakout groups about their knowledge of Wagner’s framework could have provided additional insight into the extent to which participants may have adopted these principles.
In light of these limitations, future work could be aimed at exploring the perspectives of other disciplines to determine input from multiple professions into the job to be done by pharmacists in the future. In addition, similar research in other health professions will provide insight into the relationship of these skills with the jobs to be done in other disciplines. While this study focused specifically on pharmacist skills, it advances the efforts of health professions schools working toward identifying effective educational strategies and opportunities that adequately engage students across disciplines. In addition, it will be critical for other health professions disciplines to understand the value-added role of pharmacy in the provision of high-quality, team-based, patient-centered care. This, in turn, will promote a health care workforce that is prepared to function collaboratively in patient care and will move us closer to transforming practice and meeting the health care needs of society.
Understanding the skills and competencies needed by pharmacy graduates is critical for ensuring that educational experiences and curricula prepare them for the job to be done in today’s rapidly evolving health care system. By elucidating those skills seen as core to the pharmacist’s role by professionals, partners, and educators, this research contributes to a growing body of literature concerning the evolving roles of health care providers and provides insight into curriculum development needs in pharmacy education. Further research should examine the operationalization of these skills and their intersection with other health care professions.
This study was funded by a 2015 AHEC Innovation Grant.
Appendix 1. Breakout Group Script
During the symposium, participants were asked to consider the job to be done by pharmacy graduates in 2020 and beyond. In the breakout groups, discussion was facilitated with a semi-structured script using two questions. These questions were written to help participants envision the job to be done by graduates of the school’s new curriculum (ie, 2020 and beyond):
1. If we aspire to create students who look like a post-graduate year 1 (PGY1) resident six months into training (“PGY 0.5”), what are those qualities and characteristics that define these individuals?
2. What do they know (knowledge), how do they behave (behaviors), what is it that they do (skills)?
Appendix 2. Example themes, subthemes, and quotes from the January 2015 UNC Eshelman School of Pharmacy preceptor symposium
THEME 1: CRITICAL THINKING AND PROBLEM-SOLVING
Ask good questions(or anticipate good questions)
○ “…anticipate the intuitive question ahead of time…”
○ “…Somehow, we have to teach these future graduates what is the right question to ask for us to be able to move forward…”
Deal with vast amounts of information (Including the most frequently used medicines and prevalent diseases)
○ “…managing large group of patients. I guess what that really means is in your brain you’re able to keep pieces of discrete information kind of on hold… .RAM is the term that comes to mind like recording. [W]hat was your RAM capacity? Or what is your ability to have multiple windows open at one time without computer loss?”
○ “One thing that was unpopular when I was in school and probably still unpopular but I think extremely important is some of the traditionally medical pieces of knowledge like terminology, some diagnostics, entry level diagnostics, medical abbreviations.”
○ “I think that [my students who are halfway through] have a rich understanding of drug therapy in the most common disease states that they’re seeing.”
Figure out what’s important and what’s not(Including developing a plan of action, prioritizing projects, and managing time)
○ “…when it comes [to] recommendations or working with the team, understanding this is important. This is not as important. This is something I can put onto the side and ask.
○ “If they were to the point of being halfway through a residency year, then I would expect them to be able to handle that entire volume of patients and be able to go back to the prioritization issue. Figure out what’s important to cover in clinic today. What can we table for next time? Let’s make sure that clinic stays on time and on track and patients’ needs are being covered. I think that volume issue is something that I would look for.”
Decide what’s accurate and what’s not
○ “…recognizing when what’s in evidence-based medicine may not exactly fit your patient’s scenario…The ability to critically evaluate and apply.”
THEME 2: COLLABORATION ACROSS NETWORKS AND LEADING BY INFLUENCE
Work in teams, face-to-face and virtually(Including the ability to foster relationships across interdisciplinary teams)
○ “…Just recognizing the importance of interdisciplinary relationship, building with those relationships, more competent/aware relationships building…”
○ “I think that would be helpful for them to have worked through or seen or experienced a disagreement in the professional setting and how do you go from beginning to end and still work together and still affect patient care.”
Make your own decisions (Including having a sense of accountability, ownership, and responsibility)
○ “I think we want to create people who do actively see it as their personal responsibility to ensure that the patient gets their medication, and be responsible for that whole medication use process.”
○ “I think it’s about in terms of…committing sometimes. Sometimes our students or early residents will be given a consult to say, ‘What do you think we should do in this situation?’ And you’ll get a note that says, ‘You can do one of these seven things.’ … I think this is the best choice. Committing to a plan of action.”
○ “Because I think to me, we need practitioners who are ready to make decisions on day one. I think that is again what I find to be a differentiating factor in learners is, somewhat it’s how they approach pharmacy to begin with, but then it is also their skills status. Are they ready to take ownership and make decisions and advocate for interventions or are they still kind of a spectator or at least still on the evolution from being a spectator?”
THEME 3: AGILITY AND ADAPTABILITY
Adapt to change
○ “I think one thing I noticed in myself and I see in other residents is they progress through a PGY1 year is becoming more quickly adaptable to new patient care situations. You get a lot of practice moving between very different care environments.”
○ “…there are times for our residents that they might be serving in a CPP role. There are other times that they might be serving in a consultant role or a patient educator role or a care coordination role.”
○ “…adapt the way they engage with the patient based on what they’re hearing from or seeing from the patient.”
Work with disruptions
○ “I've heard this mentioned now three times in our discussion about that adaptability and being able to recognize when you need to go, maybe you’re going to do something in the clinic room or the patient room or wherever that’s totally different than what you thought and you don’t even do that, that you thought you were going to do. Students do have trouble changing rails on that sometimes.”
THEME 4: INITIATIVE AND ENTREPRENEURIALISM
○ “They're not just sitting there waiting for it to be told what to do.”
○ “…I think being proactive within that system to participate in the recognition [of the problem] and the solution.”
Actively look for ways to improve the systems around you (Including advocating for the profession and professional development)
○ “…what about graduates who recognize opportunity for change? Try to come up with better solutions for improving whatever, whether it’s patient care, the system they’re working in….Advocates for advancing the profession.”
Not be afraid to try and fail (Including having confidence and being “appropriately assertive”)
○ “…the confidence in yourself and the ability to question other health care providers when something doesn’t seem right.”
○ “I think it’s almost the ability to fail, so most of us come out of school having never failed and so residency takes a candidate who has succeeded over and over and then finally reaches capacity and you have to deal with personal failure.”
THEME 5: EFFECTIVE ORAL AND WRITTEN COMMUNICATION
Clear and concise writing, speaking, and presenting with focus, energy, and passion
○ “…get their charting done, which involves good communication. It involves efficiency. It involves the ability to document effectively and to ask for help when they need it.”
○ “Sometimes all you have is an opportunity to do a two-minute elevator pitch, and how do you do that? Maybe note both written and verbal communication that’s concise and compelling, and effective and appropriate.”
Know how and when to use different levels of communication
○ “I think some of our subgroups have also talked about the ability to distinguish between which ones are appropriate at what times. There may be a phone call that’s required over sending an email, especially if you’re not very happy, or maybe you just need to go down to someone’s office and have a face to face. There is body language; you can read it.”
○ “There’s also communications with patients, providers, and pharmacists. Students understanding both the language, the complexity and the depth that you go into, when you’re explaining a concept to a physician who asked a question and really what they want to know is the endpoint. But when you’re talking to your preceptor, you can go through your entire thought process, being able to give the same message to three people very differently based on who your customer is.”
THEME 6: ACCESSING AND ANALYZING INFORMATION
Find, evaluate, and synthesize information
○ “… has a good understanding of where to go and what is quality literature, or guidelines to review for a given disease state or problem.”
○ “…a commitment to understanding what the health care system looks like and recognizing that part of understanding the health care system is not just learning it once. It’s keeping up with it.”
Understand how rapidly information is changing and be able to deal with that
○ “…New drugs as they come out, how to incorporate them and prioritize them into your practice. Where they’re going to fit into your steady guideline. Am I going to add this or am I going to revise it or not. I guess, it’s capability to acquire knowledge as it evolves.”
THEME 7: CURIOSITY AND IMAGINATION
Never be satisfied with the status quo
○ “It’s about not being satisfied with answering a question but being able to answer their question and let that lead you someplace else.”
○ “The ones who are most successful are those who take the guidelines that I support to give them, but they ask the further question, why?”
○ “…have an appreciation for our patients, because you’re going to encounter barriers they have to go through due to Medicare, diversity, that kind of complexity.”
○ “…teaching the student that the patient’s at the center, and it doesn’t matter the practice site.”
THEME 8: SELF-AWARENESS
Self-awareness (Including receiving/accepting feedback from others and awareness of one’s impact)
○ “…a certain self-awareness of where their own deficits, where the sum of them lie, and accepting that. How do you identify that, because we’re prepping them to be able to speak to their vulnerabilities or deficiencies that they have, that conversation prior to getting to the site.”
○ “…do they recognize their strengths and their limitation and their areas of improvement and things like that.”
○ “…one of the key things that I talk to residents about at this point is how they’re able to self-evaluate their own work and judge the quality of it.”
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