21.Wk1Dis

RESEARCH - EDUCATION

Improving prescribing practices: A pharmacist-led educational intervention for nurse practitioner students Jennifer A. Sabatino, PharmD, BCACP (Clinical Pharmacist)1, Maria C. Pruchnicki, PharmD, BCPS, BCACP, CLS (Associate Professor)2, Alexa M. Sevin, PharmD, BCACP (Assistant Professor)2, Elizabeth Barker, PhD, CNP, FAANP, FACHE, FNAP, FAAN, FNP-BC (Professor Emeritus of Clinical Nursing)3, Christopher G. Green, PharmD (Specialty Practice Pharmacist)4, & Kyle Porter, MAS (Senior Consulting Research Statistician)5

1Department of Pharmacy, Memorial Hospital Medication Therapies Center, Marysville, Ohio 2Division of Pharmacy Practice and Science, The Ohio State University College of Pharmacy, Columbus, Ohio 3College of Nursing, The Ohio State University, Columbus, Ohio 4Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio 5Center for Biostatistics, The Ohio State University, Columbus, Ohio

Keywords Pharmacotherapy; education; prescriptions;

students; pharmacists; nurse practitioner;

advanced practice nurse.

Correspondence Maria C. Pruchnicki, PharmD, BCPS, BCACP,

CLS, Division of Pharmacy Practice and Science,

The Ohio State University College of Pharmacy,

500 West 12th Avenue, Columbus, OH 43210.

Tel: 614-292-1363; Fax: 614-292-1335; E-mail:

[email protected]

Received: 22 May 2016;

accepted: 6 January 2017

doi: 10.1002/2327-6924.12446

Previous presentations: Poster presentation at

the American Pharmacists Association Annual

Meeting, March 2014, Orlando, Florida.

Encore poster presentation at the Ohio

Pharmacists Association 136th Annual Meeting,

April 2014, Columbus, Ohio.

Podium presentation at the Ohio Pharmacy

Resident Conference, May 2014, Ada, Ohio.

Encore podium presentation at the Celebration

of Educational Scholarship “Advances in Health

Sciences Education” at The Ohio State

University College of Medicine, November

2014, Columbus, Ohio.

Encore poster presentation at the American

Pharmacists Association Annual Meeting,

March 2015, San Diego, California.

Abstract

Background and purpose: To assess impact of a pharmacist-led educational intervention on family nurse practitioner (FNP) students’ prescribing skills, per- ception of preparedness to prescribe, and perception of pharmacist as collabora- tor. Method: Prospective pre–post assessment of a 14-week educational interven- tion in an FNP program in the spring semester of 2014. Students participated in an online module of weekly patient cases and prescriptions emphasizing legal requirements, prescription accuracy, and appropriate therapy. A pharmacist fa- cilitator provided formative feedback on students’ submissions. Participants com- pleted a matched assessment on prescription writing before and after the module, and a retrospective postsurvey then presurvey to collect perceptions. Conclusion: There was significant improvement in performance on error iden- tification and demonstration of prescription elements from preassessment to postassessment (+17%, p < .001). The mean performance on both assessments was less than the 70% passing score. Students reported significant positive changes in perceptions, including all statements regarding their preparedness to prescribe and those addressing willingness to collaborate with pharmacists. Implications for practice: Formative education on prescribing enhanced stu- dents’ understanding of safe and effective medication use with improved recog- nition and avoidance of prescribing errors, although it did not result in compe- tency. Exposure to pharmacist expertise in this area may encourage collaboration in practice.

Introduction

Like physicians, nurse practitioners have prescriptive authority within the scope of their practice (Newhouse et al., 2011). In the 2009–2010 American Association of Nurse Practitioners Sample Survey of 13,562 nurse practitioners, 97.6% reported prescribing medications to

patients, averaging 22 prescriptions per day in full-time practice (Goolsby, 2011). However, studies have shown that new prescribers often do not feel adequately prepared (Hilmer, Seale, Le Couteur, Crampton, & Liddle, 2009; Rauniar, Roy, Das, Bhandari, & Bhattacharya, 2008). Evaluation of errors in various settings has determined

248 Journal of the American Association of Nurse Practitioners 29 (2017) 248–254 C©2017 American Association of Nurse Practitioners

J. A. Sabatino et al. Improving prescribing practices

that most preventable adverse drug events occur as the result of errors made in the prescribing stage (Thomsen, Winterstein, Søndergaard, Haugbølle, & Melander, 2007). A study by Kuo, Phillips, Graham, and Hickner (2008) reported that 70% of errors made in primary care physi- cians’ offices were prescribing errors. Medication selection and dose were the most common types of prescribing er- ror, with the most error-prone factors being incorrect drug selection, contraindications such as medication allergies, incorrect dosing, and including insufficient information on the prescription. In the study, pharmacists were re- sponsible for preventing the errors from reaching patients the majority of the time, consistent with their training and expertise. However, pharmacists may not be routinely utilized to their potential by nurse practitioners. In the Nurse Practitioner Sample Survey, the reported frequency of pharmacist consultation by nurse practitioners was weekly (30.3%), monthly (29.9%), one to two times per year (29.7%), daily (6.9%), and never (3.2%, Goolsby, 2011). Yet incorporation of pharmacists into the patient care team has been identified as a healthcare strategy with positive outcomes for patients, including improvement in clinical markers such as hemoglobin A1c, LDL cholesterol, and blood pressure and reduction in adverse drug events (Chisholm-Burns et al., 2010).

This is the first study to assess the impact of a pharmacist educating nurse practitioner students on the elements of appropriate, safe, and complete prescription writing with weekly online patient cases. We hypothesized that the incorporation of a pharmacist in nurse practitioner stu- dent learning could improve preparedness to prescribe as well as encourage collaboration with pharmacists as part of an interprofessional healthcare team. The purpose of this study was to evaluate an existing educational inter- vention in the family nurse practitioner (FNP) curriculum to assess the impact on: (a) students’ clinical and proce- dural accuracy of prescribing, (b) students’ perception of preparedness to prescribe, and (c) students’ perception of a pharmacist as a collaborator.

Methods

This study was a prospective pre–post assessment of a 14-week educational intervention designed to improve technical and clinical aspects of prescribing of FNP stu- dents. This research was determined to be exempt by The Ohio State University Institutional Review Board.

Educational intervention

In an effort to expand interprofessional learning beyond experiential educational settings, our faculty–practitioner team developed and implemented a pharmacist-directed

prescribing intervention, delivered as a 14-week online education module for FNP students. The intention of the program was for a clinical pharmacist to educate students at The Ohio State University (Ohio State) and provide them longitudinal practice for appropriate prescribing habits, including the identification and correction of the factors commonly associated with prescribing errors. The technical aspect of appropriate prescribing requires the provider to include all necessary elements for a legally complete and accurate prescription. Clinical prescribing errors have a greater potential to cause patient harm and involve medication choice and dosing with respect to indi- cation as well as patient specific factors including concur- rent medications or comorbidities (Velo & Minuz, 2009).

FNP students enrolled in a clinical practicum during spring semester 2014 participated in an online mod- ule delivered using the course management platform at Ohio State (Carmen; [email protected]). Each week, the pharmacist facilitator posted a patient case to the discussion board and students were asked to review a corresponding prescription for accuracy and appropriate- ness or to generate a prescription for the patient. The weekly exercises emphasized legal requirements and ac- curacy (technical elements) as well as patient safety considerations (clinical elements). A summary of the various clinical prescribing issues addressed in the weekly exercises is provided in Table 1. Students were asked to identify any errors in the prescription, provide three pa- tient counseling points for the medication prescribed, and then demonstrate a correct prescription for the patient. Each week, the pharmacist posted a response that pro- vided formative feedback on errors commonly identified and/or missed by the students, addressed any miscon- ceptions from the class, and answered additional ques- tions that had been raised by the class. The exercises were graded as satisfactory/unsatisfactory based on student participation.

Assessments

Prescribing skills before and after the didactic interven- tion were assessed using an original assessment tool, de- veloped with input from Ohio State’s University Center for Advancement of Teaching (a campus-wide teaching cen- ter). The assessment was reviewed for face validity and content validity by the investigator team and the collabo- rating educational consultants, respectively. Students were given limited time (20 min) to complete each assessment in order to simulate the limited decision-making and pre- scribing time that is available in practice. Research as- sessments were administered at predetermined times dur- ing the study protocol, specifically before and after the 14-week online educational intervention. All students

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Table 1 Description of clinical prescribing issues addressed in intervention

Case number Clinical issues addressed

1 Prescribing a medication without a clinical indication

Medication allergy to prescribed agent

Medication dosed incorrectly

Quantity prescribed does not cover duration of

treatment

Drug–drug interaction

2 Topical formulation prescribed when oral formulation

indicated

Ambiguous directions contributing to inaccurate dosing

Refills inappropriate as patient should be reevaluated

3 Drug–disease state interaction

Maximum safe daily dose exceeded

4 Drug–age interaction

Drug–disease state interaction

Alternative drug choice more appropriate based on

patient-specific factors

5 Inappropriate dosage form for pediatric patient

Dose inaccurate based on patient weight

Refills inappropriate as patient should be reevaluated

6 Additional medication not indicated based on

therapeutic goals

Maximize current therapy before adding additional

agent

Alternative drug choice more appropriate based on

patient-specific factors

Dose too high

7 Drug contraindicated in pregnant patient

Refills inappropriate as patient should be reevaluated

Stepwise dose increase more appropriate

8 Drug–disease state interaction

Maximize current therapy before adding additional

agent

Stepwise dose increase more appropriate

9 Ambiguous directions contributing to inaccurate dosing

Dose inaccurate based on patient weight

10 Dosing of medication inappropriate due to narrow

therapeutic index

11 Patient requires additional work up before prescribing

12 Medication allergy to prescribed agent

13 Prescribing medication without accompanying

prescription for supplies

Alternative drug choice more appropriate based on

guidelines

Drug choice and cost considerations

Ambiguous directions making accurate dosing

challenging

were required to complete the assessments as part of the course requirements, but only those consenting to the re- search had their responses included in the study. All stu- dents enrolled in the course were eligible to participate in the study.

The preassessment consisted of questions regarding four prescription cases and a demographic survey. Cases 1–3 asked the students to identify any clinical or technical

errors in the corresponding prescriptions. Case 4 prompted the students to write a prescription on the prescription blank provided. Demographic questions targeted baseline characteristics of participants: age, gender, primary lan- guage, prior exposure to pharmacists or pharmacy stu- dents, and the number of prescriptions written prior to the activity.

The postassessment included the identical prescription cases and a retrospective postsurvey then presurvey, which was used to collect information on the students’ perceived preparedness to prescribe, willingness to collab- orate with pharmacists, and perception of the pharmacist as the educator. The retrospective postsurvey then presur- vey differs from the more common presurvey then post- survey design in that respondents complete both surveys at the conclusion of the intervention. This is done to address the fact that respondents who have little experience with a subject prior to an educational intervention are unable to accurately assess their perceptions of the subject on a presurvey (Rockwell & Kohn, 1989). This tool was chosen to allow the students to self-report their perceived change over time using the same scale for pre- and postresponses and without the potential bias introduced by a traditional pretest. The 11 perception questions or statements were rated on a 4-point Likert scale ranging from “strongly dis- agree” to “strongly agree” and from “highly unlikely” to “highly likely,” as appropriate. In answering the postsur- vey then presurvey, students were asked to provide a re- sponse to each question or statement first with what their perceptions were at the point of conclusion of the educa- tional intervention and then think back to the point prior to starting the educational intervention.

Data analysis

Errors to be identified in the assessment were grouped by type (i.e., technical or clinical), level of impact (i.e., pa- tient harm, inconvenience, or minimal impact), and cat- egory of error (i.e., directions, dosing, patient elements, medication elements, etc.). Four practitioner investigators individually assigned the groupings of each error and then met to achieve consensus on the final groupings prior to administration of the preassessment. The prescription as- sessment was scored for each student as the percentage of errors correctly identified/avoided, both overall and within each specific category of errors. Competency was assessed by comparing the overall score to 70%, a standard passing score for a graduate nursing program. Improvement from preassessment to postassessment was measured as the in- crease in percentage correct for each category. Preassess- ment, postassessment, and change scores are reported as median with interquartile range (first quartile to third quartile) across the 26 students. Nonparametric Wilcoxon

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sign rank tests were applied to the change scores to as- sess within-student improvement overall and within er- ror type, severity of impact, and category using SAS 9.3 (Cary, NC). For the retrospective postsurvey then presur- vey, responses were reported as frequency and percent- age. The primary questions measuring student perceptions by signed rank test were assessed with the null hypothesis being zero change. No adjustments were made for multiple comparisons.

Results

All of the 30 FNP students enrolled in the course consented for the study. Of those, two students were ineligible due to nonattendance at the administration of the preassessment and two more students withdrew from the course before the postassessment was administered, resulting in a final participant pool of 26. The majority of participants were female, aged 25–30, spoke English as a primary language, and were registered nurses. Work ex- perience was the most common exposure to pharmacists or pharmacy students (Table 2).

Prescribing ability

The overall performance on the prescription cases from the preassessment to postassessment showed improvement with a median increase of 17% (p < .001); the overall median score for the postassess- ment was 57% (Table 3). Identification of errors and demonstration of clinical and technical pre- scription elements from preassessment to postassess- ment also improved (p < .001). Individually, two of 26 students (8%) had an overall score greater than 70% on the postassessment, compared to zero students on the preassessment.

The performance on technical elements was consis- tently greater than the performance on clinical elements, with legal requirements of controlled substance pre- scribing showing the least improvement from preassess- ment to postassessment. When errors to be identified were grouped by potential patient impact, the improve- ment was significant from preassessment to postassess- ment across all three levels of potential impact: harm (p < .001), inconvenience (p < .001), and minimal impact (p = .01). Improvement from preassessment to postassessment on categories of errors was signif- icant for those pertaining to directions, dosing, pa- tient elements, prescriber elements, medication elements, and other required elements (see Table 3). Only the change in performance from preassessment to postassess- ment on error-prone abbreviations was not significant (p = .17).

Table 2 Demographic characteristics of 26 family nurse practitioner studentsa

N (%)

Age

<24 years 3 (12)

25–30 years 13 (50)

31–35 years 6 (23)

>35 years 4 (15)

Gender

Female 22 (85)

Primary language

English 25 (96)

Other 1 (4)

Credentials earned

RN 20 (77)

BSN 13 (50)

Other 1 (4)

Exposure to pharmacists or pharmacy students

Work experience 13 (50)

Part of a required course 10 (38)

Experiential rotations 7 (27)

Part of an elective course 4 (15)

Volunteer experience 3 (12)

No previous exposure 2 (8)

Student organization 2

Family member or close friend who is a pharmacist

Yes 9 (35)

Number of prescriptions written

<10 prescriptions 1 (4)

11–50 prescriptions 8 (31)

51–100 prescriptions 12 (46)

>100 prescriptions 5 (19)

aThe Ohio State University, 2014.

Perceptions

On the retrospective postsurvey then presurvey, the students reported statistically significant increases in the perception ratings on all statements that addressed their preparedness to prescribe. Following the educational intervention, there was an increase in agreement that classroom education and clinical rotations prepared the students for prescribing (p = .03 and p = .04, respectively) and that nurse practitioners should have formal training on writing prescriptions (p = .03). The largest positive change was seen in response to the statement, “I feel completely prepared to prescribe medications” (p < .001). Students who reported having written fewer prescrip- tions prior to the online prescribing module showed a significantly larger positive change from preassessment to postassessment in response to the statement, “I feel completely prepared to prescribe medications” (p = .01).

A similar trend was seen on all statements that ad- dressed the pharmacist as the educator, as students agreed that a pharmacist-led prescribing activity is helpful in

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Table 3 Family nurse practitioner student performancea on assessmentsb

Median (IQR) Preassessment Postassessment Changec p-Value

Overall 38% (30–47%) 57% (49–66%) 17% (11–23%) <.001

Type of error

Clinical 27% (18–36%) 45% (36–55%) 16% (5–23%) <.001

Technical 44% (36–60%) 68% (60–76%) 20% (12–28%) <.001

Patient impact

Harm 30% (22–39%) 48% (35–57%) 15% (4–26%) <.001

Inconvenience 50% (39–67%) 72% (67–78%) 25% (11–33%) <.001

Minimal impact 33% (17–50%) 50% (33–83%) 17% (0–33%) .01

Category of error

Directions 19% (13–38%) 44% (25–50%) 19% (0–38%) .003

Dosing 25% (0–50%) 50% (25–50%) 25% (0–50%) .02

Error-prone abbreviations 25% (0–25%) 25% (0–50%) 0% (0–25%) .17

Patient elements 80% (60–100%) 100% (80–100%) 10% (0–40%) .004

Prescriber elements 40% (40–60%) 80% (80–100%) 40% (20–60%) <.001

Medication elements 50% (38–63%) 63% (63–75%) 13% (13–25%) <.001

Other required elements 33% (17–50%) 67% (50–83%) 17% (0–50%) <.001

aPerformance measured as percentage of possible errors identified for each category and reported as median and interquartile range (IQR: first and third

quartiles) across all 26 students. bThe Ohio State University, 2014. cChange reported as median of individual differences calculated from preassessment to postassessment for each of 26 students.

preparing nurse practitioners to prescribe (p = .01) and that pharmacists are qualified to educate nurse practition- ers on prescribing (p = .03). Significant positive changes in perception were also demonstrated on three out of five statements that addressed their willingness to collaborate with a pharmacist in practice (Figure 1).

Discussion

In our study, a pharmacist-led educational intervention resulted in significant improvement in prescribing abilities

for FNP students, almost entirely across the spectrum of abilities assessed. The prescription cases in the assessment highlighted examples of factors most commonly associated with prescribing errors, including dosing and other med- ication elements. Students demonstrated significant im- provement in their ability to identify/avoid these errors, suggesting that instruction in both the technical and clin- ical components of prescribing supported appropriate and safe prescription writing. In particular, there was signifi- cant improvement in identification and avoidance of er- rors that were categorized as having potential for patient

Figure 1 Family nurse practitioner student perceptions regarding collaboration with pharmacist in practices.

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harm. In general, improvements on items related to tech- nical proficiency were greater than those related to clinical performance, with the exception being the legal require- ments of controlled substance prescribing which remained very low on both assessments.

Unfortunately, the overall postassessment average remained below the standard passing score for a graduate nursing program, and a >30% error rate would be far from acceptable in patient care. This suggests that longitu- dinal, online learning activities are effective in improving prescribing abilities; however this single module was not sufficient in itself. Our results are consistent with findings of a published systematic review that examined the impact of various therapeutic tutorials and workshops on new practitioner knowledge and prescribing skill (Kamarudin, Penm, Chaar, & Moles, 2013). In the included studies, a range of interventions were studied with many showing improvements in prescribing performance, including those incorporated into structured academic curricula. However, subjects were most commonly medical interns and the intervention was typically a single session without the opportunity for prescribing practice or formative feedback. The study in the review most similar to our research utilized an 8-week intervention for medical students com- prised of four 1-h physician and pharmacist-led tutorials and eight 1-h practical sessions on prescribing (Sandilands et al., 2011). Students were given a pretest and posttest to assess incidence of prescribing errors and self-reported confidence. Those investigators demonstrated improved performance and confidence, but also with continued prescribing errors made on the posttest and overall mean posttest performance �70%.

To build upon previously studied interventions, we designed our online prescribing module to provide both longer-term (longitudinal) practice and formative feed- back on prescribing. Students specifically had regular practice with repeated exposure to technical elements of prescription writing (which showed the greatest im- provements), while each clinical element was addressed only a maximum of three times over 14 weeks (Table 1). The importance of practice as a research-based learning strategy is well-known. In the book How Learning Works: 7 Research Based Principles for Smart Teaching, authors note that both sufficient quantity of practice and practice over time (accumulating practice) are needed (Ambrose, Bridges, DiPietro, Lovett, & Norman, 2010, pp. 133–136). Typically, instructors and students alike underestimate how much practice is needed. Therefore, additional cases focused on clinical components related to patient factors, errors with potential for patient harm, error-prone abbre- viations, and legal requirements of controlled substance prescribing would likely have benefited the study partici- pants, and may have resulted in greater change. A strategy

for continuing the online exercises throughout the FNP didactic curriculum could be explored and studied further.

The retrospective postsurvey then presurvey examined the impact of the intervention as perceived by the stu- dents, with the greatest significant increase in percep- tion rating from preassessment to postassessment on the statement, “I feel completely prepared to prescribe.” Af- ter completion of the educational intervention, 81% of students agreed that they were completely prepared to prescribe medications, compared to only 27% of students who agreed with the statement prior to completion of the educational intervention. Those students who had writ- ten fewer prescriptions prior to the intervention showed a significantly larger positive change on the survey state- ment regarding feeling completely prepared to prescribe. Though the general perception of preparedness is not con- sistent with our objective results, an expected benefit of targeted feedback is to help students more accurately dis- cern change in learning behaviors and assess their own progress. The “nonpassing” postassessment scores may suggest that students did not review all of the posted feed- back from the weekly exercises. Online posting of the feedback with student-directed review cuts down on the time investment required from the pharmacist facilitator and allows for broader application with limited resources. Kamarudin et al. suggest that prescriber feedback in the form of “provider letters” is a cost-effective teaching strat- egy (Kamarudin et al., 2013), but the heavy reliance on student independence and student inexperience may have limited the learning gains in our format.

Despite the poor prescribing performance on the pre- assessment, students ranked highly their previous instruc- tion for prescribing (i.e., prescribing activities in previ- ous classes and during clinical rotations, provided before this educational intervention). This was unexpected, as we believed students would recognize that they were not highly prepared at the time of the preassessment. How- ever, students were never given the results of, or solu- tions to, the preassessments in an effort to prevent re- call bias. Therefore, the students did not seem to clearly differentiate between the respective impact of the studied educational module versus prior classroom education and clinical rotations. Module enhancements such as provid- ing the students with the objective scores on the preassess- ments and postassessments, conducting formal review ses- sions, and/or having the weekly feedback being facilitated as asynchronous online discussions should be considered to encourage students to rework cases, consider alterna- tives, and self-assess.

Ninety-six percent of students agreed with the state- ment, “Involving a pharmacist in the prescribing pro- cess would result in better patient outcomes” with no change from the preassessment to postassessment ratings.

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Although the students also strongly agreed that pharma- cists should be involved in prescribing, there was actually the least change in perception on the statement, “How likely are you to consult a pharmacist for help writing a prescription?” (69% on the preassessment vs. 77% on the postassessment). Though positive, this trend was not found to be significant. A possible explanation for this is that the students may not have anticipated requiring help writing a prescription after the educational interven- tion (i.e., expecting they were now proficient). Percep- tions regarding collaboration with a pharmacist in prac- tice prior to the educational intervention may have been confounded by consistent promotion of interprofessional collaboration by nurse practitioner educators within the curriculum.

Though the tools utilized were not validated, a major strength of the study is that the assessments were designed and implemented collaboratively between pharmacist and nurse practitioner researchers and educational/assessment experts. The use of the retrospective postsurvey then presurvey was intended to reduce response shift bias as a threat to internal validity (Rockwell & Kohn, 1989). Self-reporting is generally vulnerable to bias as learners may respond in the way that they believe their educator wants them to. Another limitation specific to the retro- spective design of the survey was the potential inaccuracy of student recall when responding to the statements based on what their perceptions were prior to the activity. Finally, the study was limited by the small population included, especially in that the results may not be directly applicable to teaching and learning strategies for other professional students. Repeating the study with the use of a control group may more accurately demonstrate the impact of the intervention.

Future directions include evaluation of the duration and timing of the educational intervention in FNP student cur- ricula, to optimize outcomes and also to identify the point at which incorporation of pharmacist-provided prescribing practice would be most meaningful, for example, in didac- tic versus experiential coursework. Broadening the appli- cation to prescriber training in other disciplines should also be explored.

Conclusions

Formative education on appropriate prescribing, includ- ing the opportunity for longitudinal practice, enhances preparedness of future nurse practitioner prescribers. Well-prepared prescribers would be expected to make fewer prescribing errors, leading to fewer preventable ad- verse drug events and reduction in delays initiating or op- timizing drug therapy. Exposure of the nurse practitioner

students to pharmacist expertise in this area during train- ing may also encourage future collaboration in practice, which could further reduce errors and impact outcomes for patients.

Acknowledgments

The authors wish to thank Stephanie Rohdieck and Teresa Johnson of The Ohio State University Center for the Advancement of Teaching. Jennifer Sabatino, Maria Pruchnicki, Alexa Sevin, Elizabeth Barker, and Christopher Green developed the instrument and performed data analysis; Jennifer Sabatino administered the instrument, collected data, and wrote the initial draft of the article; Kyle Porter provided statistical analysis; all authors developed the research project and revised the article for final submission. There is no funding to disclose.

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