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This guide outlines the Case-based Discussion (CbD) workplace based assessment (WBA).
On this page:
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Abbreviation |
Term |
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APC |
Australian Pharmacy Council |
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CbD(s) |
Case Based Discussion(s) |
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ISBAR |
Identify-Situation-Background-Assessment-Recommendation |
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ITP |
Intern Training Program |
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WBA |
Workplace-based assessment |
This guide is to be used by pharmacist interns, preceptors, supervising pharmacists and Intern Training Program (ITP) providers.
The guide outlines the Case-based Discussion (CbD) workplace based assessment (WBA) tool developed by the Australian Pharmacy Council (APC) for use in the assessment of Australian pharmacy interns. The tool is intended to assist with the assessment of an intern’s achievement of one or more of the performance outcomes listed in the Performance Outcomes Framework 2020 which accompanied the 2020 Accreditation Standards for Pharmacy Programs in Australia.
Interns will use the tool and the template for preparing and presenting a review of a case encountered in the workplace for discussion with their supervisor.
Preceptors and supervising pharmacists (collectively referred to as Supervisors) will use the tool and template for assessing the intern’s performance, providing feedback to the intern, and jointly formulating a plan for future development with the intern.
Intern Training Program providers will incorporate the tool into the Intern Portfolio. The portfolio is the compiled record of the intern’s achievements during the intern year and is used as the basis for determining whether the intern has achieved the performance outcomes required at the point of general registration. ITP providers may choose to use the completion of CbD as part of the formal requirement of the ITP.
Familiarity with the following documents is recommended and they should be read in conjunction with this User Guide.
1. Intern pharmacist and Preceptor Guide. Current version. Published by the Pharmacy Board of Australia.
2. Performance Outcomes Framework 2020. Published by the Australian Pharmacy Council (APC).
3. Intern Year Assessment Blueprint. Current version. Published by the Australian Pharmacy Council (APC).
As interns participate in workplace activities, they will be actively engaged in the provision of care to patients and/or carers. Initially, interns’ contributions may be limited only to certain aspects of a case, but as they gain more experience, they are likely to be given increased autonomy and responsibility, and also to be engaged in cases of greater complexity. To obtain the greatest benefit from their engagement with patients and the associated critical thinking and problem-solving, debriefing with a more senior colleague is very important. This facilitates future skills development through reflection on areas of strength and areas where improvements could be made.
Case-based discussions are retrospective explorations of cases or scenarios by interns and supervisors. Ideally, the chosen case should be one in which the intern was actively involved, as this provides a richer learning opportunity. However, it is recognised that some interns may not encounter a sufficiently broad range of cases, and therefore it may be valuable to base some discussions on cases carefully selected by the supervisor but in which the intern was not involved. These may be historical or contemporary cases. In addition to providing a broader range of cases and scenarios than might be experienced in an individual workplace, this approach may also be used to provide an increased consistency of learning experiences for interns.
CbD typically involves a comprehensive clinical review of a case, where the learner researches and presents the outcomes of delivering care and engages in a structured discussion with the supervisor who provides feedback and offers prompts for further consideration by the learner.
CbD facilitates the development of critical knowledge, skills and attitudes underpinning person-centred care and is ideally designed to promote learning in addition to acting as a formative and/or summative assessment. It is suitable for the simultaneous assessment of multiple performance outcomes and a range of interdependent skills including clinical reasoning, critical thinking, decision-making, professional judgement, implementation of decisions and follow-up. To reflect these characteristics of CbD, a single tool has been developed which can be used flexibly to facilitate assessment of multiple performance outcomes, individually or in an integrated manner.
The purpose of this tool is to provide interns and supervisors with structured guidance to scaffold learning and facilitate assessment from discussion of a case encountered in the workplace.
The tool comprises the following elements:
1. A user guide for preceptors and interns.
2. An Intern Assessment and Feedback Form.
3. A quick reference guide.
In general, on completion of the activity, the intern is expected to have demonstrated achievement of, or progress towards achievement of, the following performance outcomes.
The activity may also provide evidence relating to other performance outcomes, and this should be recorded in the Case Based Discussion: Intern Assessment and Feedback Form.
The flowchart (Figure 1) details the steps which comprise the CbD activity.
Figure 1: CbD Process
The first step in the process is to choose an appropriate case on which to base the CbD. This should generally be done by the supervisor in conjunction with the intern and should be tailored to the intern’s current stage of progress. The case will be a clinical case focusing on the therapeutic aspects of patient care and should also align with one or more of the performance outcomes against which the intern is being assessed. To maximise the potential for learning, the case should ideally be one which was within the intern’s capacity, but which presented some challenges and stretched the intern.
Case Complexity
It is expected that as an intern proceeds through their period of supervised practice, their capacity to review cases of increasing complexity will increase. It is not possible to define unambiguously what a low, medium, and complex case might entail as it is largely subjective; however, supervisors should use their judgement to guide interns to cases which are likely to stretch them at the current point in their development.
Complexity may involve co-morbidities, polypharmacy, age-related factors, patient-related factors (e.g., swallowing ability), cultural and/or communication barriers, presence of disabilities, and other factors which create a level of uncertainty and require significant clinical judgement skills. In addition, both supervisors and interns should ensure that a reasonable VARIETY of cases and issues are included.
The relative complexity of a case can also be increased by asking the intern to consider the effect of hypothetical changes to some of the parameters. For example, the supervisor could ask the intern what would have changed if the patient had different co-morbidities, or a language barrier.
Increased complexity may also be reflected in increased responsibility and autonomy granted to the intern in managing the case. Interns are expected to demonstrate increasing sophistication in the way that they ask questions, consider options, and make decisions as the year and intern experience progresses.
The intern should spend some time gathering as much relevant information about the case as possible, reviewing the case and preparing a summary of the key aspects, from history taking and information gathering, through to follow-up and self-management strategies, identification and prioritisation of any medication-related problems, and recommendations.
While this tool is not specifically designed to account for legal and/or ethical issues arising from the case, these elements could also be included in the case summary if relevant. Similarly, pharmacological and/or pharmacokinetic aspects are not specifically accommodated but should be included where they have a bearing on the case. The Case Based Discussion: Intern Assessment and Feedback Form provides space for additional elements to be added by the supervisor, and pharmacological/pharmacokinetic/legal/ethical and any other relevant issues could therefore be included in the assessment and feedback process.
Once the case has been prepared, the intern should reflect on the process of preparing the case, and complete Section 1 of the Case Based Discussion: Intern Assessment and Feedback Form.
The intern and supervisor should set aside sufficient time for the intern to present the case summary to the supervisor, and for follow-up discussion and feedback from the supervisor. The time allowed for discussion between the intern and supervisor should be at least 30 minutes, although more complex cases may require longer, and the discussion should take place in an area with minimal distraction. During this time, the intern should present the case, including aspects such as presenting condition or clinical problem, medical and medication history, identification and prioritisation of any medication-related problems, evidence-based approaches to treatment including pharmacological and non-pharmacological therapies, need for referral, follow-up, monitoring and self-management. The presentation can take any appropriate form; however, a written summary should be provided by the intern as the basis for the presentation and subsequent discussion.
While there are different ways that an intern can choose to structure the case presentation, the following is offered as a helpful general approach.
It should be noted that interns may be familiar with specific approaches to the evaluation of a case, such as the Identify-Situation-Background-Assessment-Recommendation (ISBAR) approach.
The ISBAR framework, which was introduced to structure and facilitate effective communication between health care professionals, particularly when time constraints are apparent, can also be used as the basis for a case-based discussion.
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Introduction or Identify |
Who you are, your role, where you are and why you are communicating |
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Situation |
What is happening at the moment? |
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Background |
What are the issues that led up to this situation? |
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Assessment |
What do you believe the problem is? |
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Recommendation |
What should be done to correct this situation? |
Following the case presentation, the supervisor should engage in discussion and provide feedback to the intern. This feedback can cover the clinical aspects of the case as well as the way that the intern prepared and presented the case.
The supervisor should question the intern to probe understanding, critical thinking, and professional judgement skills, and to encourage additional reflection on the case.
The supervisor should complete Section 2 of the Case based Discussion: Intern Assessment and Feedback Form following the case presentation, provide feedback to the intern, and agree with the intern on the areas in which the intern needs development. As a guide to providing feedback, it is helpful to focus on promoting future learning and development, and this is facilitated by specific, timely and realistic feedback. It may be convenient to structure the feedback using categories
Exemplars which have been used as the basis for the development of the assessment and feedback template include those developed by Monash University, South Australia Pharmacy, the Royal Pharmaceutical Society, the Royal Australian College of Physicians, and the Royal Australian and New Zealand College of Psychiatrists.
The criteria included in the assessment rubric are:
The basis for assessment judgements is that of the extent to which the intern Meets expectations for their level of experience and stage of internship. This means that considerable judgement is needed by the supervisor in assigning ratings; further, what constitutes meeting expectations will clearly change as the internship progresses. Supervisors are encouraged to reflect in advance of the discussion phase on their own expectations, and to be realistic in their assessments, particularly in the early stages of the intern year.
Three rating levels are included, namely Below expectations, Borderline, and Meets expectations. The following table is a guide to the use of these ratings. It is important for both interns and supervisors to have a shared understanding of what is expected at different stages of the intern year, and these should be discussed before the intern commences the activity. Expectations should therefore be set RELATIVE to the intern’s current experience. These expectations will therefore change over the course of the intern year, and it may be that an intern will meet expectations on a simple case early in the year but fall below expectations with a more complex case later in the year.
Expectations in relation to at least two aspects of the intern’s performance should increase with increased experience:
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Below expectations |
Intern’s performance meets expectations in few, if any, aspects of the criterion; major concerns exist about the intern’s demonstrated performance |
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Borderline |
Meets expectations for some aspects of the criterion but not others; some concerns exist about the intern’s demonstrated performance |
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Meets expectations |
Comfortably meets expectations for most or all aspects of the criterion; no major concerns exist with the intern’s demonstrated performance |
By the end of the intern year, the intern is required to demonstrate performance which would meet the expectations of a pharmacist who has newly gained general registration.
Following the intern’s case presentation, and feedback from the supervisor, the final stage should be the joint creation by the intern and supervisor of a SMART (refer below) development plan. The plan should outline the actions needed for the intern’s further development. This planning may take place as part of the same session, or the intern may wish to reflect further on the feedback received, and create the Development Plan at a later date. The supervisor should review the Development Plan once the intern has finalised it.
This plan should include strategies for improvement of any areas which were rated as Borderline or lower, but should also consider areas where the intern met expectations as well. It is likely that the intern may be able to finetune their performance in these latter areas, and build on the strengths that they demonstrate earlier in the intern year. Outcomes from the development plan can form part of the discussion for subsequent case presentations.
A SMART plan is characterised by being Specific, Measurable, Attainable, Relevant and Time-bound.
A Specific plan or goal considers what specifically needs to be accomplished – for example, the documentation of the medication history needs to be more clearly correlated with the medical history.
A Measurable plan or goal is one which can be assessed or evaluated in a tangible way – for example, the next case presentation will set clear priorities for addressing medication concerns.
An Attainable plan or goal is one which is realistically achievable in the current circumstances and within a reasonable timeframe – for example, the next case study will focus more significantly on non-pharmacological management strategies.
A Relevant plan or goal is one which is important enough to pursue – for example, I will seek to address patient compliance concerns in the next case.
A Time-Bound plan or goal is one which has a defined endpoint in time – for example, the next case based discussion will take place in 6-8 weeks.