A hospital pharmacy foundation residency training program has been introduced in Australia, modelled on residency programs established in other countries. The program aims to support the professional development of early-career hospital pharmacists, in both clinical and non-clinical roles. Pharmacy educators are usually tasked with the implementation and maintenance of this program. This qualitative, longitudinal study aimed to investigate hospital pharmacy educators’ expectations, perceptions and experiences with implementing and developing their residency program.Qualitative data were collected at two timepoints, approximately 24 months apart, using either focus groups or interviews with pharmacy educators who were directly involved in the implementation of the residency program at their respective hospitals. During the early phases of implementation, and approximately 24 months later, participants were asked about their experiences and expectations of the residency program as well as any changes that had occurred within the residency program over time.Four focus groups and three semi-structured interviews were held with pharmacy educators and senior pharmacists from different hospital settings. These were audio recorded and transcribed verbatim. Transcripts were inductively analysed via thematic analysis. Fifteen hospital pharmacy educators and senior hospital pharmacists participated in the initial focus groups and interviews, and seven educators were retained for follow-up. Four main themes were established from the discussions: participants had great expectations of a positive impact of the residency on their workplace and residents’ professional development; substantial effort, support and resources were needed to implement and maintain a residency program; self-motivation and engagement is needed by residents to succeed and experience timely completion and career acceleration; and lastly a balance between standardisation, consistency and flexibility in delivering the residency needs to be found. The role of educators changed with the implementation of a residency, with the addition of more managerial and supervisory aspects.The Australian hospital pharmacy foundation residency program is a complex workplace training program with multiple factors and prerequisites influencing its implementation, development and outcomes. Pharmacy educators are central to the successful implementation and ongoing sustainability of a residency program. They may benefit from formal training and qualifications to support their role.The online version contains supplementary material available at 10.1186/s12909-022-03497-2. Over the last decade the number of registered pharmacists in Australia has increased by 36%, with at least 20% of pharmacists working in hospital settings –3. In paUndergraduate and graduate entry pharmacy degrees may not adequately prepare pharmacy graduates for the increasing role diversity and complexity of contemporary healthcare, especially in hospital settings. Experiential and work-integrated learning, during undergraduate studies, often focuses on preparing graduates for community pharmacy practice as this is where the majority of the pharmacy workforce is based .To support and maintain the professional development of hospital pharmacists in the early phases of their career various strategies, including structured residency and other workplace-based training programs, have been developed, particularly in the United States of America and the United Kingdom –13. SincThis two-year program consists of three six-months rotations in medical, surgical and operational areas, as well as one six-month elective in an area of interest. During their residency, resident pharmacists (‘residents’ from hereon) are required to complete multiple clinical or practice-based and non-clinical assessments and tasks. The clinical and practiced-based assessments are described in Table Participation by hospital pharmacies in the residency is voluntary, but an individual site must submit an application to SHPA demonstrating their capabilities in education, training, research, and prove they have the necessary organisational resources to become a provisionally or fully accredited residency sites . HospitaThe role of a hospital pharmacy educator (‘educator’ from hereon) and their scope of practice varies between different hospitals. Educators in Australia typically have supervisory roles as preceptors for intern pharmacists and students in their organisation, they often assess clinical assessments and conduct, organise or manage departmental education events , 29. TheFor this study, we defined hospital pharmacy educators as pharmacists who have the designated role of overseeing education at their hospital site, this may be in either a full- or part-time capacity, and oversee the educational aspects of residency programs. For example, in some smaller hospitals senior pharmacists take on a part-time educator role, whereas bigger, tertiary hospitals often have the resources to employ educators in a more permanent and full-time capacity.This qualitative, longitudinal study aimed to investigate educators’ expectations, perceptions and experiences with implementing and developing their residency program over time.Findings may inform future implementation of and adjustments to existing residency programs and identify potential support needed by pharmacy educators.This study was approved by The University of Queensland, Human Research Ethics Committees . All participants provided written, informed consent before voluntarily participating in this study.Reporting of this study follows the Standards for Reporting Qualitative Research Checklist . Semi-structured interviews were conducted via phone or Zoom when participants were unable to attend in person due to geographical location, scheduling or social distancing requirements. While there are both advantages and disadvantages for participation in focus group or semi-structred interview, the investigators ensured that all participants were provided opportunities to express their views freely regardless of the mode. Utilising both modes also improved the attendance of participants and ensured reach to a more diverse group of educators . The priAll focus group and interviews were audio recorded and transcribed verbatim by either professional transcription services or the main investigator (CW), who also checked the accuracy of professionally transcribed transcripts.The baseline data collection started in late 2018, continuing into 2019 to capture late initiators of residency, and to ensure most participants had experience in implementing or managing their residency for a year. Transcripts of both focus groups and interviews were reviewed iteratively and data collection ended when this review showed that participants did not offer new insights and answers to interview questions and it was anticipated that no new themes were able to be generated from the data . Follow As the questions were the same for focus groups and interviews, transcripts from each round of data collection were combined for the data analysis. Microsoft Excel was used to sort and categorise data. An inductive data-driven approach to thematic analysis of the transcripts was followed, where all investigators reviewed the transcripts and independently developed preliminary themes. Main themes were established via frequent group discussion, after which three investigators  established codes for all themes and then independently coded all transcripts , 33. RegOver the course of the study four focus groups and three semi-structured interviews were conducted. Two focus groups and two semi-structured interviews were undertaken at the first stage of data collection, two focus groups and one semi-structured interview collected follow-up data. On average, each focus group lasted approximately 60 minutes and interviews were approximately 40 minutes in duration. The discussions encouraged a wide range of responses, participants shared their experiences and views freely. Overall, 15 stakeholders from 10 different hospital sites, and different hospital settings, participated. The participants were recruited from three different States in Australia. They were representing one third of all the early adopting sites of the Australian program. The majority of respondents represented hospitals from the one State which during the early phases of implementation in 2017 had the highest uptake of residency. All partipants were pharmacy educators, working either in a full- or part-time capacity, while some may also have been a designated program lead for periods of time, their substantial role, as they described it, was in education. All participants were involved in the implementation and introduction of residency programs at their hospital or health service and identified as the person with the most significant educational role in their local residency programs.n = 13) worked in tertiary hospitals  see themselves more superior. They are fully aware of the timeframe, and they don’t want to be seen as not complying with the program requirements. Yes, ours are probably less comfortable with failing, the idea of failing. I would like to hear what they actually say but they definitely have this feeling of superiority, I can tell you.’ E4, FG1‘They  get the best rotations.’ E15, FG3‘… It's still an issue, and as much as I've tried to combat that with every resource I can think of, but it's a little bit of the elitism, a bit of the golden child. … They . A potential lack of research skills by those supervising residents in their quality assurance or research projects was also highlighted, this created challenges in providing sufficient support or guidance to residents.These initial challenges changed significantly over time. At the follow up focus-groups and interviews, educators described the various strategies they used to resolve or mitigate these issues. Within one of the more centralised hospital health services, the residency was implemented using a hub and spoke model, with residents rotating through various hospitals that were able to offer specific rotations that were not necessarily available within one individual hospital. The residency program was also aligned with a local university-based post-graduate program. Collaboration with a university added educational capacity to the residency program, with university academic staff conducting some practice-based assessments in the workplace and supervising residents’ research projects. These strategies resolved potential issues associated with time constraints and skill deficits in workplaces.All educators experienced greater engagement from all staff over time, with mentoring becoming more normalised for senior clinical staff. Importantly, pharmacists who had completed the residency program and remained on staff supported new residents as mentors and program experts. They actively committed to assisting educators in maintaining their residency program by conducting assessments and supervising research projects. For many educators these developments made the initial work and resources they had to direct to the residency worthwhile.residency) does give them that opportunity but… it just is how they use those opportunities.’ E4, FG1‘...I do feel that  that just want to rock up... it’s not a guarantee that, if you are in the same program, that you will all come out the same’. E5, FG1‘I think that somebody could be spat out at the other end with no change to them at all, because we see that with standard rotations ... We can see those . Outcomes were perceived to depend on how the resident participated in the program.Educators also learnt to elicit and align everyone’s expectations of the residency. Some residents had unrealistic expectations about the level of commitment needed to successfully complete their residency. In the early stages of implementation mismatches in expectations of responsibilities between residents and educators often lead to unsatisfactory experiences for both parties, and in some instances discontinuation of a resident’s training (subtheme 3.2).E3, FG1‘You may not excel at that but then you will know that is not my cup of tea…’ The educators believed that having an early exposure to a variety of potential pharmacy career pathways, inherent to the structure of the residency, was important for the residents’ future career development as it allowed them to identify their personal learning interests and potential career goals. Residency potentially shortened the time residents needed to explore their preferred career pathways.senior pharmacist), permanent (senior pharmacist) positions. We were devastated when they left, but yeah, so I think it just equips people to a level where they're just ready to get onto, to take on, well, they all, their practice is at an (senior pharmacist) level.’ E3, FG3‘… we've had people move on to . Adjustments were more often driven by workplace needs and capacity rather than by residents’ needs. One commonly reported adjustment overt time was a reduction in the frequency of the resource-intensive, practiced-based assessments as these were found to be time consuming and staff with appropriate skillsets required was not always available.Reconciling workplace needs, SHPA standards and residents’ development needs remained challenging for educators. Educators confirmed that some positive changes occurred based on feedback by educators to SHPA, for example by giving residents the freedom to choose one of the two compulsory seminars according to their learning needs and interests. From the educators’ perspective some of the program activities lacked clear learning and training objectives, which raised questions about the purpose of some of the residency activities and requirements (subtheme 4.2).While some flexibility was needed to allow each residency site to cope with the program requirements, the educators were concerned that this flexibility had led to significant program variation between different sites, which may, over time, affect the credibility, validity and cohesiveness of the program and importantly, the quality of residents’ experiences (subtheme 4.3).E7, FG2‘… it has been two years now, and it’s time, they maybe did have feedback sessions or groups like these, maybe to see what program leaders and residents are thinking about the program and what could be done better.’ Educators also emphasised the need for SHPA to evaluate and provide further guidance on reviewing and developing the residency curriculum.This qualitative study of pharmacy educators’ experiences with the SHPA foundation residency in Australia elicited many of the challenges educators faced in the early phases of program and in some cases continue to face up to 2 years later.The study described the strategies some educators had used to overcome these challenges, and pointed to changes in the educator role throughout the implementation and maintenance of the program. Currently, literature investigating pharmacy educators’ experiences implementing a residency at a national level is limited. Most studies reported on the experience in single healthcare services and longitudinal observations on how experiences change over time are lacking –36. TheyEducators’ experiences showed that the SHPA’s intended aim of hospital pharmacy workforce development via a residency program is achievable, and can facilitate the career transition of junior pharmacists from internship to more advanced practice. Educators described the residency as a valuable, but resource-intensive, workplace training program, that to succeed required skilled educators and other senior pharmacists with the time to devote to the program. Their experiences showed that drawing on locally available skills, by either keeping graduated residents on staff, or collaborating with other hospital pharmacies or universities, mitigated potential resource limitations and skill shortages. The extension of residency implementation from tertiary hospitals to smaller, usually less well resourced, secondary hospitals could be facilitated by exchanging residents for rotations and having senior pharmacists or academics from tertiary hospitals or universities provide additional educational support. Engaging additional experience and expertise to support residents in more complex areas, such as research, either from other hospital departments or externally, would also enhance the residents’ learning and supervisory experience. Aligning the program with postgraduate study could further distribute workload and assessment requirements throughout the residency. This would allow for a broader implementation of residency programs across Australian hospitals, at the same time raising the skill level of a greater proportion of the hospital pharmacy workforce and avoiding concerns of selectivity and exclusivity educators raised.Educators described having a pivotal role and influence in the residency, which supports the SHPA stipulation of a designated educator at a site as a program requirement. While the educator role has always included the supervision of students and interns, developing and organising site specific training, and supervision and educational events, with the implementation of a residency program their role has been extended. Taking responsibility for the implementation of a structured workplace training program, which prescribes a curriculum with regular assessments and formalised activities potentially demanded additional skills and expertise. In the early phases of residency uptake, educators were learning and exploring how to best implement and adjust the program to their workplace, developing their own strategies and skills in facilitating training of registered pharmacists. Changes they described to their role extended to the enlistment, support and supervision of senior pharmacists who were training and assessing residents, motivating residents, negotiating expectations and learning needs, and getting involved in curriculum development and program evaluation. These may become more challenging once residencies are offered more widely to all early-career pharmacists, including those who may be less motivated and engaged than current residents.While SHPA outlined desirable competencies for pharmacy education almost a decade ago, there is limited consensus on how these may be achieved or what prerequisite qualifications would be useful –39. ClinIn this study, about one-third of educators who participated in the initial discussions were no longer working in the education space 3 years later, suggesting that the educator role may be considered a short-term, temporary rotation in some hospitals.Formal training and qualifications may allow educators to understand, critique and modify the residency program informed by adult and workplace-based learning theories, reconciling changes seemingly driven by organisational needs with residents’ learning needs.New challenges posed by the implementation of residency, the addition of responsibilities of developing and adjusting the curriculum of a new workplace training program suggest that formal recognition of the role and skill of pharmacy educators in clinical and workplace settings could align more closely to the role of a medical educator, many of whom practice clinical education as a subspecialty of medical education, and it may be beneficial to create permanent, specialised pharmacy educator roles –42.The experiences of medical and other health professional educators’ show that they take on more responsibilities than simply sharing clinical knowledge and skills as a clinical supervisor . EducatoEducators flagged the need for evaluation and modification of the residency, as it became evident that individual programs have been evolving independently. Variations between residency sites, while necessary at times, jeopardise the benefits that a standardised workforce development program promises. Regular evaluations of the consistency of program implementation and reviews of contemporary learning needs of early-career pharmacists could lead to evidence-informed adjustments to ensure sustainability and wider uptake of the residency.This study was a preliminary qualitative study of pharmacy educators involved in the implementation and development of the initial roll-out of the pharmacy residency program. It did not take into account the views of other key stakeholders, including management and the residents themselves, which are explored separately. Participants were from different States and practice settings in Australia, however, a significant proportion of participants were drawn from one State, because the residency program was initiated there earlier than in others. Participants primarily worked in tertiary hospital settings. This was expected as tertiary hospitals are often better resourced to implement new programs, and thus may be more willing to trial a new training program early compared to smaller or rural hospital pharmacies . Hence, Pharmacy educators described the residency as a useful program to accelerate professional development but also as a complex workplace training program with multiple factors influencing its development and outcomes. Educators are central to the successful implementation and ongoing sustainability of a residency program and may benefit from formal training and qualifications to support their role and the ongoing evaluation and modification of the residency program across Australia. As the hospital pharmacy workforce expands, clinical pharmacy education could be established as a speciality as are the clinical aspects of medical education, with similar prerequisite training as is required for roles in other pharmacy specialty areas.Additional file 1.


Intramuscular ganglion cyst (IMGC) is a very rare lesion with an unidentified pathogeny that originates within the muscle. We encountered a case of 49-year-old man who complained of intermittent claudication in the right lower limb for 2 months. An intramuscular ganglion cyst in the biceps femoris muscle was diagnosed and located by Computed tomography angiography (CTA) and magnetic resonance imaging (MRI), which compressed the popliteal artery and resulted in ischemia in the right lower limb. Six months after surgical resection, there was no recurrence of the cyst and the popliteal artery was patency. We describe this case with a review of the relevant literature. A ganglion cyst is a common tumor-like lesion arising from various soft tissues that is generated by mucoid degeneration of the joint capsule, tendon, or tendon sheath . It usuaA 49-year-old male was admitted to hospital with intermittent claudication of the right lower limb for 2 months, with a limping distance of 100 m and no resting pain (Rutherford III), which is an indication for surgery . His pasPhysical examination revealed that the popliteal, dorsalis pedis, and posterior tibial arteries were not observed. His skin color, skin temperature, and lower limb appearance were basically normal, and the capillary filling time of the bilateral toes was < 2 s.Ultrasound showed reduced flow velocity in the right lower limb artery, superficial femoral artery (34 cm/s), popliteal artery (24 cm/s), anterior tibial artery (20 cm/s), posterior tibial artery (17 cm/s), and peroneal artery (24 cm/s), with absent triphasic waves . CTA sugExploration of the right popliteal artery and cystectomy were performed under epidural anesthesia. The popliteal artery was connected to a tendon sheath cyst on the medial aspect of the long distal head of the biceps femoris tendon with a smooth, tough wall, and jelly-like contents . After cAt the 6-month postoperative follow-up, the patient had no intermittent claudication, good arterial pulsation in the lower limbs and no significant ultrasound abnormalities.Ganglion cyst (GC) is a common and frequent clinical condition, but cases of tendon cysts compressing the surrounding blood vessels are rarely reported. Ganglion cysts that occur within the muscle belly and are associated with popliteal artery compression are extremely rare. Limited data available make them prone to misdiagnosis and underdiagnosis, and preoperative imaging to determine their origin and nature can be difficult. Moreover, previous studies were unable to generate valuable research to develop a uniform and effective treatment due to the small number of cases included , 8–14.Entrapment neuropathy is a frequent clinical symptom because of its anatomical location. Also, the popliteal vascular components are subject to compression, including the vein, which is next most medially located and easily compressible compared with the artery, which is most lateral and least frequently involved . The popThe primary differential diagnosis is cystic adventitial disease (CAD), which typically occurs in otherwise healthy, middle aged male patients, causing symptoms of sudden-onset progressive intermittent claudication. Although four theories have been proposed, the etiology of CAD is still not fully understood , 22. DurThere is controversy regarding the final diagnosis of the disease. Popliteal artery depression syndrome (PAES) is defined as a group of symptoms in which there is a congenital anatomical abnormality between the popliteal artery and its surrounding muscles or bundles of tendons and fibrous tissues . ClassifPopliteal cysts are also known as Baker cysts, a general term for synovial fluid cysts in the popliteal fossa that occur in the medial head of the semimembranosus bursa . Secondary popliteal cysts are most often seen in adults and the cysts tend to be connected to the knee joint cavity. Sansone et al. performed a retrospective analysis of 1,001 cases of MRI for various reasons and found popliteal cysts in 4.7–37% of these cases, all of which communicated with the joint cavity. The patient in this case originated within the biceps femoris muscle belly and was not a synovial bursa of the medial head of the semimembranosus and gastrocnemius muscles and did not communicate with the joint cavity and was not strictly a popliteal cyst .Several treatment options are available if the diagnosis of PAES has been made, with the treatment objective being to release the popliteal artery from compression and preserve popliteal arterial flow . ConventHere we describe a patient with an IMGC of the biceps femoris muscle compressing the popliteal artery, which could not be diagnosed preoperatively and highlighted the necessity and difficulty of differential diagnosis. Intraoperative exploration and postoperative histopathology are key to the diagnosis of IMGC. In our case, intraoperative ultrasound did not reveal any abnormality in the popliteal artery and there were no clinical symptoms at the 6-month follow-up, and the follow-up ultrasound was normal. In cases where the popliteal artery has been compressed for a short period of time and where there is no thrombosis, intimal thickening, or aneurysm formation, intraoperative ultrasound can be used to determine the flow velocity and flow in the popliteal artery, and if the flow is normal, decompression of the popliteal artery alone can be performed without wall repair or saphenous vein grafting.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.Written informed consent was obtained from the participant/s for the publication of this case report. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.KZ, WY, WZ, and CL contributed to conception and design of the study. KZ wrote the first draft of the manuscript and drew the illustrative figures. WY, HR, SW, and MS had the acquisition, analysis or interpretation of clinical data for the work. All authors contributed to manuscript revision, read, and approved the submitted version.


Background: Yale New Haven Health (YNHH) implemented a pharmacy technician training program in 2016. The curriculum includes 14 weeks of combined didactic and simulation hours , followed by 360 h of experiential learning. MyDispense, an online pharmacy simulation, allows students to develop and practice their dispensing skills in a safe environment with minimal consequences for mistakes. We describe a novel innovation, expanding the functionality of MyDispense to the training of pharmacy technicians. Methods: Technician training coordinator, supervisor, faculty members with experience in MyDispense, and experiential pharmacy students created cases within the MyDispense software that were targeted towards pharmacy technician activities. Activities were aligned with current American Society of Health-System Pharmacists (ASHP)-Accreditation Council for Pharmacy Education (ACPE) Accreditation Standards for pharmacy technician education and training programs. Results: A total of 14 cases were developed to be utilized in student technician training, and account for approximately 14 h of simulation. Conclusions: MyDispense is an innovative software that could allow students to access and complete exercises, and to continue developing dispensing skills in a safe, remote environment. We identified similarities between activities performed by student pharmacists and student pharmacy technicians, expanding MyDispense to a new learner group to practice, develop and be assessed on dispensing skills within their scope, as part of a formal technician training program and in preparation for the Pharmacy Technician Certification Examination (PTCE). In the American Society of Health-System Pharmacists (ASHP)’s Practice Advancement Initiative 2030 (PAI), multiple recommendations have been made for pharmacy technician education and training that will assist in advancing pharmacy practice in health systems ,2. A colThe ASHP/ACPE Accreditation Standards curriculum requirements are outlined in three main educational components: the didactic, simulation, and experiential. Each component has a minimum number of hours whether developing an entry or advanced-level program, with flexibility to add additional hours to certain areas . SimulatMyDispense, an online pharmacy simulation platform, was developed in 2010 by faculty of Pharmacy and Pharmaceutical Sciences at Monash University in Australia for the purposes of pharmacy student education. This platform allows students to develop, practice and be assessed on their dispensing skills in a learning environment without real-world consequences of mistakes . MyDispeIn addition to the customizability of MyDispense, benefits can be seen for both the instructors and students. For instructors, these simulations update automatically, without instructors needing to manually update or set up the materials for the simulation. Additionally, for both faculty and students, MyDispense cases allow for remote learning via simulation (which is key in a post-COVID era), which allows flexibility of learning environment to fit the health and life needs of the faculty and students. MyDispense also alleviates the pharmacy team from having pharmacy technicians’ first dispensing opportunities occur in the pharmacy wherein patient care may potentially be impacted. While MyDispense was designed for pharmacy students, its adaptability and customization to an independent program’s needs allows the potential for it to expand to other teaching and learning environments with similar training objectives, as has been seen in nursing programs  and mediThe Pharmacy Technician Training Program at YNHH was established in 2016, as a product of blending ASHP/ACPE national standards with the needs of their hospital system ,19. The Our project occurred over three phases. During phase one, faculty members from UConn further brainstormed the idea during a research collaboration session at the MyDispense Global Symposium, in collaboration with faculty from VCU, who are implementing a new technician training program to meet the need for accredited pharmacy technician programs in Virginia. Starting in July 2022, all pharmacy technicians in Virginia must receive their training from a program accredited by ASHP and ACPE ,22. ThisOnce contact was established with leadership within the program at YNHH, phase two began with forming a development group, which consisted of a pharmacy technician training coordinator (1) and supervisor (1), faculty members from UConn (2) and VCU (2), experiential pharmacy students (2) and a research pharmacy student (1) from UConn. A plan to create or modify pre-existing MyDispense cases to meet ASHP/ACPE standards and program objectives was established. Development meetings were held weekly, starting in September of 2022 for four weeks, then monthly thereafter until the anticipated implementation into the program’s simulation curriculum in January 2023.Pharmacy students completing their Health Systems experiential rotation worked closely with coordinators to review ASHP/ACPE Outpatient Pharmacy Learning Objectives that are integrated into the simulation portion of the program curriculum in phase three of the project. Objectives that would be addressed utilizing MyDispense activities were identified. A blueprint was created  to highlA total of 14 cases were developed in MyDispense to be utilized in student technician training. Twelve standards/objectives were met by utilizing the developed cases, and account for 14 h of simulation within the program’s curriculum. Cases that were modified from the MyDispense online repository  originatThis project offered a unique opportunity for pharmacy student involvement, and incorporated two fourth-year pharmacy students completing experiential rotations and a second-year pharmacy research student. The total combined time spent by the three pharmacy students developing the blueprint and carrying out MyDispense case building and modification was around 112 h. The collaborative meetings between faculty, pharmacy technician training program staff and students accounted for 4.5 h of the workload.As the basis of this paper was to describe an innovative use within the MyDispense platform, our group has many goals for future directions. Our first pilot was done with a cohort of six students, and included simulation exercises alongside an assessment portion which incorporated many learning objectives. At time of this publication, simulations were completed over 8 total hours allotted within the course. Feedback sessions are planned and will allow for us to adjust any exercises. We plan to collect data to further describe the use of simulation exercises and assessments within the technician training program on a larger sample size. With that, we aim to analyze and assess achievement of learning objectives and first-pass success of board examinations after multiple cohorts of the technician training program have utilized this MyDispense functionality.Although simulation is a required component of the ASHP/ACPE Accreditation Standards curriculum’s educational requirements, published reports of the simulation types employed in pharmacy technician training programs are limited to inpatient settings or customer interaction in the community pharmacy setting ,9. This The functionality of MyDispense, with its ability to have the learner communicate with patient or providers and identify when a pharmacist needs to become involved, collect patient information, process prescriptions , and prioritize tasks, is aligned with many of the ASHP/ACPE Model Curriculum for Pharmacy Technician Education and Training Programs’ outpatient pharmacy learning objectives. Furthermore, MyDispense offers a platform to eliminate some of the gaps in simulation opportunities that currently exist within pharmacy technician training programs, such as (1) processing and handling of medications and medication orders (2) procurement, billing, reimbursement, and inventory management, and (3) patient and medication safety.We did encounter some limitations to our project. At this time, simulation activities are limited in scope to the outpatient community setting; therefore, technician roles that are prominent in the inpatient hospital setting are unable be simulated at this time. However, an inpatient version of MyDispense is in development. Additionally, the scope was limited within certain outpatient scenarios, as students in training are unable to practice prescription processing through various insurance or billing scenarios because this is not a feature available via MyDispense. While the repository does allow for sharing of cases nationwide by participating colleges of pharmacy, we still needed to develop four cases to suit the simulation needs of the program. As disclosed in the results section, case modification and development can take a significant amount of time, which was completed by fourth-year pharmacy students as part of their experiential rotations. However, administrative tasks were completed by a faculty member and training program coordinator, which did require some workload commitments and should be considered when deciding to implement such programs. Finally, navigation of institutional cybersecurity and information technology support service requirements is needed when implementing MyDispense, which does require an initial investment of time . While hA recent survey of 204 pharmacy technicians showed that over 60% of pharmacy technicians prefer to learn using kinesthetic learning methods  . MyDispeAnother benefit of using MyDispense in a technician training program is a reduction in faculty workload. Typically, the medication dispensing process is taught in-person or during an experiential rotation, thus requiring the faculty and learner to be onsite within a classroom or pharmacy. However, MyDispense can allow the student to practice many of these skills asynchronously . The facIn conclusion, MyDispense has the ability to fill a gap that currently exists in many pharmacy technician training programs: simulation of processing and dispensing a prescription in a community pharmacy setting. MyDispense is an innovative software that could additionally allow students to access exercises and continue to develop dispensing skills in a safe, remote environment. It can be not only useful for completion of a formal technician training program either synchronously or asynchronously, but also in preparation for the PTCE. It can contribute to reduced faculty workload and provide additional educational learning opportunities that in other settings have been shown to improve educational outcomes. As our program is implemented, we will seek to evaluate learning outcomes with the use of MyDispense for technician training, expand exercises to achieve all learning objectives related to community pharmacy, and allow for technician learners to practice these prior to taking the PTCE exam.


Despite the long-standing faculty development initiatives for improving teaching skills in the health professions, there is still a growing need for educators who are formally trained in educational theory and practice as health professions schools experience dramatic demand and growth. Graduate programs in health professions education (HPE) provide an avenue for health professions’ faculty continuing professional development to enhance their knowledge and skills for teaching and curriculum leadership roles. There has been a proliferation of certificate, master’s, and doctoral programs in HPE over the last two decades to respond to the growing need for well-prepared faculty educators and program leadership. The purpose of this study was to identify and describe current HPE doctoral programs in United States (U.S.) and Canada.The study first examined doctoral programs in HPE identified in earlier studies. Next, we searched the literature and the web to identify new doctoral programs in the U.S. and Canada that had been established between 2014, when the prior study was conducted, and 2022. We then collated and described the characteristics of these programs, highlighting their similarities and differences.We identified a total of 20 doctoral programs, 17 in the U.S. and 3 in Canada. Of these, 12 programs in the U.S. and 1 program in Canada were established in the last 8 years. There are many similarities and some notable differences across programs with respect to degree title, admission requirements, duration, delivery format, curriculum, and graduation requirements. Most programs are delivered in a hybrid format and the average time for completion is 4 years.The workforce shortage facing health professional schools presents an opportunity, or perhaps imperative, for continuing professional development in HPE through certificate, master’s, or doctoral programs. With the current exponential growth of new doctoral programs, there is a need to standardize the title, degree requirements, and further develop core competencies that guide the knowledge and skills HPE graduates are expected to have upon graduation. Health professions will face dramatic workforce and faculty shortages nationally due to several converging factors: an aging workforce, a growth in care needs of an aging population, and expanding healthcare coverage . For exaTo combat looming attrition due to workforce aging, admissions and enrollment increases are evident across fields, from medicine, nursing, to physician assistants –9. This Indeed, a majority of faculty in the health professions have little to no formal training in educational theory and practice, despite more than three decades of calls to develop and reward medical education teachers for their educational work . This gaIn systematic reviews of FD literature, researchers reported numerous studies on initiatives designed to improve teaching effectiveness and leadership abilities in medical education –19. TheyIn nursing education, research on FD initiatives found an increase in participants’ knowledge and skills as well as improved preparation for clinical teaching –23. WithDespite the faculty development initiatives for improving teaching practices, challenges remain in improving teaching skills and educational knowledge among health professions educators who may benefit. In response to the challenge, there is a proliferation of graduate programs in health professions education (HPE) to address the need for educators who are formally trained in teaching and learning , 28. AddOver the last two decades, the number of graduate programs in HPE has grown tremendously including certificate, master’s, and doctoral programs. The master’s degree has been the most chosen credential  and has Our analysis began with examining HPE doctoral programs identified in earlier work . We thenOur inclusion criterion was HPE doctoral programs in the U.S. and Canada because we wanted to understand the similarities and differences of North American programs. We excluded programs that did not focus on education in the health professions. We collected the characteristics of the programs from each program’s website. In the cases where information was no longer available online for programs that were identified in the previous study, we contacted administrators at these institutions to verify whether the program was still being offered. We organized program information in a table consisting of the following 10 fields: name and location of institution, degree title, admission requirements, published program duration, credit hours, graduation requirements, delivery format, program cost, academic location, and website link.We identified 20 doctoral programs, 17 in the U.S. and 3 in Canada  in HPE, three programs offer an educational doctorate (EdD) in HPE, two programs offer a PhD in Health Sciences, and one offers a Doctor of Health Professions Education (DHPE). There were other notable variations in offerings and title of the degree. These differences include: Eastern Virginia Medical School (EVMS) offers both an EdD and PhD in Medical and Health Professions Education, University of Houston (UH) offers an EdD in Professional Leadership for Health Science Education, University of Illinois Chicago (UIC) offers a PhD in Education with a concentration in Critical Pedagogies and Urban Teacher Education and a specialization in Health Professions Education. The University of Texas at El Paso (UTEP) offers a PhD in Interdisciplinary Health Sciences, University of Ottawa offers a PhD in Education with a concentration in HPE, whereas the University of Calgary offers a PhD in Community Health Sciences with a specialization in Medical Education.The criteria for admissions also varied across institutions. Nineteen programs (95%) require a master’s degree or higher for admission. UIC also admits students with a bachelor’s degree, however these students must complete additional coursework. Ten programs require a grade point average (GPA) of 3.0 and above, one program requires a minimum GPA of 2.6 and another requires a minimum GPA of 2.5. Seventeen programs require a statement of purpose, 16 require a curriculum vitae, 15 require letters of recommendation, and 5 require a writing sample. Interviews are required for four programs and may be required for two programs. Four programs require the Graduate Record Examination (GRE) scores, one program recommends GRE scores if available, and 17 programs require the Test of English as a Foreign Language (TOEFL) scores for international applicants.The duration of these programs ranges from 3 to 8 years depending on whether students are enrolled full-time or part-time. The required credit hours across the U.S. programs averages 58 credit hours, with a range of 48–70 credit hours. One outlier that was not factored into our average requires 144 credit hours. The Uniformed Services University (USU) courses are based on quarter credit hours instead of semester hours, thus, 144 credit hours are equivalent to 96 semester hours. The wide difference in the credit hours is because the USU program requires more courses, as well as more credit hour requirements, for a practicum (20) and dissertation (30). The required credits for the three programs in Canada range from 1.5 credits (courses only) to a minimum of 18 credits. Western University has three mandatory half-credit courses and the rest of the courses are seminars.Within curricula, most programs include core content areas for HPE programs as previously reported . These iGraduation requirements typically include completing required courses, which range from 6–24 courses across the programs, completing a research project, or dissertation/thesis. Three online programs have a residency requirement and onsite seminars. In six programs, students complete a teaching or leadership practicum/internship/preceptorship. The USU program requires students to assemble a comprehensive portfolio that demonstrates they have achieved each HPE program competency.The delivery format of the programs varies. Nine programs offer the degree in a hybrid format, combining online and face-to-face instruction. Seven programs are online, and four programs offer only face-to-face instruction. The average cost of U.S. programs is $894 (USD) per credit hour and is $6,685 (CAD) per year in Canada. The current cost of U.S. programs ranges from $505 to $1,354 per credit hour, with the face-to-face program having the least expensive in-state tuition. Of the three programs in Canada, the least expensive one is about $3,464 (CAD) per year and the costliest one is approximately $8,499 per year for citizens/residents and $8,081 - $9,219 per year for international students.Five programs are hosted in the college/school of medicine, four programs in the college/school of health sciences, two programs each are in the college of education and the college/school of health professions. The remaining seven programs vary or include more than one college or school. One program each is housed in a graduate school, center for interprofessional studies and innovation, school of nursing, college of graduate health studies, school of health and medical sciences, and college of health and human services. The UIC program is co-hosted by the colleges of education and medicine.This study examined trends in the number and characteristics of doctoral programs in HPE, comparing their similarities and differences. We found that there were 10 programs in the U.S. and Canada in 2014 and we identified 13 new programs that had been established since that time – more than 100% increase in a span of 8 years. Our search revealed, however, that three of the initial eight programs in the U.S. no longer offer a doctoral degree in HPE. It is unclear why two of the programs discontinued the HPE concentration and one program stopped offering the degree completely.Most programs in the U.S. are in the Southern region with the Western region having the fewest programs. It is worth noting that using the same geographic classification system, we classified U.S. medical schools  and the There are many similarities across programs with respect to the admission requirements, duration, delivery format, curriculum, and graduation requirements. Almost half of the programs are delivered in a hybrid format, with program duration ranging from 3 to 8 years. Most programs require completion of core courses, elective courses, and either a research project or dissertation/thesis. Of note, there were four unique courses required in some programs including, cultural competence and multicultural education; diversity in healthcare education; finance and fiscal management/budgeting; and professional, ethical, and legal issues in HPE.While two programs have stand-alone courses in cultural competence and diversity, it is possible that other programs cover these content areas longitudinally across their courses. Since HPE doctoral programs are not overseen by an independent accreditor, there is no “gold standard” for the learning outcomes and the curriculum structure. There is a lot of institutional leeway in the curriculum elements, admissions criteria, program length, and graduation requirements. The variation in curricula begs the question of whether there should be formal standardized competencies for HPE graduates. With the current growth of recent programs, there is a growing need for developing a core body of knowledge or competencies to provide guidance on the knowledge and skills all HPE graduates should possess. Researchers recently proposed seven domains of competence for the HPE doctoral curriculum, including professional expert, research and scholarship, teaching, interdisciplinary collaboration, leadership and management, professionalism, and personal and professional development . AnotherAs described earlier, there is a wide variation in the current titles given to HPE programs. For example, PhD in Medical Education, PhD in Health Sciences, EdD in Professional Leadership for Health Science Education, and PhD in Community Health Sciences: Medication Education. Some of the titles may not be noticeably clear to prospective applicants regarding the focus of the degree. This was sometimes unclear to the authors without carefully reading the program and course titles or descriptions. We recommend that the naming convention of the degree be standardized to include “Health Professions Education” in the title.In recent articles, several authors have contended that HPE should be considered as its own field because 1) it meets Boyer’s four criteria of a mature scholarly discipline namely discovery, integration, application, and teaching , and 2) We also recommend that the interprofessional team of faculty who teach in HPE programs includes faculty with expertise in educational theory and practice, in addition to faculty from the health professions fields. Faculty with a background in education can contribute to teaching courses in which they were trained such as, learning theories, curriculum development and instructional design, instructional strategies, and assessment. These are the anchor courses present in most curricula we examined in HPE programs and warrant being taught by subject matter experts.This study has several limitations. First, it only looked at doctoral programs in U.S. and Canada, which does not provide the complete landscape of doctoral programs worldwide. A second limitation is that the information presented was mostly extracted from program websites and it is possible that this information may not be current for that program. Information about some of the programs was not easy to find on the program websites, which for advancing HPE education, may discourage or limit the number of potential HPE applicants. As much as this article has attempted to provide accurate details about current programs, new programs already in development will emerge in the next few years making this information obsolete. In fact, during this study, we realized that one program had been discontinued after identifying it in our initial search, and then we found four new programs in subsequent searches.As health professions experience dramatic demand and growth, the pressing problem of faculty shortages continues to persist. This workforce problem presents an opportunity, or perhaps imperative, for continuing professional development in HPE through certificates, master’s, or doctoral programs. In addition, doctoral programs prepare independent researchers to advance educational theory and practice through research and scholarship. While the current HPE doctoral programs in the U.S. and Canada have many similarities, there are some notable differences with respect to the admission requirements, duration, delivery format, curriculum, cost, and graduation requirements. There is a need for standardizing the degree requirements, title, and developing core competencies to provide guidance on the knowledge and skills HPE graduates are expected to have upon degree completion. Future studies should examine the outcomes from these programs and the impact graduates are making in the HPE field.


The COVID-19 pandemic has posed an ongoing threat to the mental wellbeing of countless individuals worldwide, with healthcare workers at particularly high risk. We developed the STEADY staff wellness program prior to the pandemic based on the available literature and input from stakeholders, guided by the Knowledge-to-Action (KTA) Implementation Science Framework. We quickly adapted the STEADY program for implementation in selected high-need units within Canada’s largest trauma hospital during the pandemic’s first wave. This brief report describes implementation of the STEADY program, retroactively applying the structure of the Knowledge-to-Action Implementation Science Framework to the practical steps taken. We identified the importance of more frequent, shorter contact with HCWs that occurred in-person, with an emphasis on peer support. A flexible approach with strong support from hospital leadership were key facilitators. Our findings suggest that a flexible approach to practical program implementation, theoretically underpinned in best-practices, can result in an acceptable program that promotes increased HCW wellbeing during a pandemic. Healthcare workers (HCWs) are at high risk of occupational stress injuries, with greater proportions of burnout, post-traumatic stress injury (PTSI) and suicide reported in this population than in the general public. PTSI and burnout severely impact work and home life for HCWs and harm their relationships with family and friends . AdditioPremature implementation of a healthcare innovation can contribute to its failure or lack of future uptake, even if it is evidence-based, theory-driven, and/or efficacious in previous trials ,18,19. TThere is a growing body of literature regarding knowledge translation and implementation science, with many frameworks, theories and models created to guide researchers and policymakers through the development and implementation of healthcare innovations. The Knowledge-to-Action (KTA) Framework is widely recognized, employed, and promoted worldwide by organizations such as the Canadian Institutes for Health Research . The KTAUsing a structured, iterative knowledge translation and implementation science approach, such as the KTA framework, encourages end-users  to engage in knowledge exchange with researchers/program developers. Such interactions, wherein end-users can share their experiences and perspectives of practical program implementation with researchers and policy makers, allows for mutual learning and iterative program adaptation to best suit the needs of the target population.Gathering data regarding program implementation and effectiveness may not be well-planned during a crisis; many who implemented programming in response to COVID-related distress would not have evaluated outcomes. Prior research systematically evaluating the feasibility of implementing mental wellness programs in HCWs and the effectiveness of such programming is sparse, especially during disasters/pandemics. Most work has been conducted in ‘normal,’ non-pandemic times, or months-to-years following a disaster. HCW mental health programs developed or implemented using knowledge translation and implementation science frameworks is limited; the literature in the field is sparse.Our team spent approximately three years prior to the COVID-19 pandemic developing the evidence-informed Social Support, Tracking Distress, Education And Discussion, communitY (STEADY) program, completing the Knowledge Creation component of the KTA framework . LiteratOur team was involved in a response to staff wellness needs during the first wave of the COVID-19 pandemic at Sunnybrook Health Sciences Centre (SHSC), Canada’s largest trauma centre. This led to the implementation of the STEADY Program in select units at SHSC. Aspects of the KTA were considered throughout implementation, though the crisis-situation limited the capacity for a planned, structured approach. Our team implemented STEADY at SHSC as part of a Quality Improvement Project over one year of the COVID-19 pandemic. This narrative report describes the teams’ experience of practical implementation, describing steps taken in chronological order and retrospectively applying the KTA Cycle throughout, with embedded lessons learned and actionable recommendations.Following the COVID-19-related lockdown in Toronto, Canada, in March 2020, HCWs’ need for emotional support in coping with pandemic-related distress became evident to leadership. Our team was engaged in the response to wellness needs as part of the Hospital Emergency Operations Committee. We established a staff wellness working group which included psychiatrists, spiritual care providers, organizational development associates, occupational health and safety staff, hospital leadership, and members of the STEADY research team. We created a list of supportive resources  to be sent to anyone requesting support, and a centralized email account to help staff access these resources. This included virtual one-on-one peer support session offerings with volunteers from the Department of Psychiatry. Volunteers provided times of the week that they were generally available, and we scheduled in those needing support.To add structure to the response, we applied the previously developed STEADY framework to support HCWs within the context of the pandemic. We had already completed the “identify the problem,” “determine the know/do gap” and “identify, review, and select knowledge” steps of the KTA Cycle while creating STEADY. Therefore, this project began at the “adapt knowledge to the local context” step of the action cycle. In order to do so, we needed to build a deeper understanding of staff needs in the context of the pandemic.We previously amalgamated validated questionnaires of mediators of PTSI, anxiety, depression, and quality of work life (described in ) to makeLimeSurvey housed the Brief Wellness Assessment. Submissions were confidential, though participants could choose to provide their email address to receive tailored responses. A response algorithm was developed according to possible distress profiles; responses included a summary of results  and suggested resources. In the first month (April 2020), there were 947 submissions, with 282 respondents providing their email addresses.The research team consulted with the working group and other organizational leaders to adapt the other elements of STEADY  to the current context, considering pandemic-related restrictions . We presented our initial project plan [described below] to the Senior Leadership Team at SHSC and applied for research funding. A limited amount of organizational funding was allocated to our team to begin responding to high-needs units while we worked to secure grant funding to implement and evaluate the use of STEADY across a larger population, with Senior Leadership support.This section outlines the initial plan created in March-April 2020. We proposed implementing the full STEADY program ; the project underwent peer-review during the grant review process. Funding was acquired in May 2020 to implement STEADY in eight of the highest distress units at SHSC  for a six month period. We selected five units at SHSC’s acute care site and the entire rehabilitation site  for program implementation.Moving clockwise on the KTA action cycle, we “assessed barriers/facilitators to knowledge use” by meeting with managers and/or staff delegated by the managers of each target unit to gauge which elements of STEADY they believed would be most acceptable to their group, while gathering logistical details of potential barriers to implementation. Throughout this process, we considered constructs within the “inner setting” domain of the CFIR, including “culture” and “implementation climate.” We asked how open the group might be to different types of support, how and where the team preferred to gather for sessions, and for the manager/delegate’s opinions on our plans. Feedback was used to “select, tailor, and implement interventions,” by informing the implementation logistics, such as the best method of peer partnering, and realistic frequencies for offering peer support sessions and education workshops. Resulting plans for implementation looked slightly different between groups .Monthly team meetings were planned, as a way for the team to accomplish the “monitor knowledge use” step of the KTA cycle. We planned to log provision of partner assignments, surveys, workshops, and peer support groups, as well as number of attendees at each STEADY session, as a proxy for program feasibility and acceptability, and to “evaluate outcomes” (another step on the KTA Cycle).Six individuals  acted as STEADY peer support facilitators at the time of initial program implementation, two others joined this initiative during the process. Two STEADY peer support facilitators co-led programming in each unit . One facilitator, who also acted as the program manager [MBK], worked with all participating units.We began programming with each unit as soon as preparatory meetings were completed for that group, due to the urgent nature of the pandemic. STEADY was introduced to each participating unit via an e-mail sent to the group by their patient care manager (using a template provided by the STEADY program manager) between May and October 2020. Introductory e-mails included a general introduction to the programming, an offer to pair up individuals with a partner  and access to both the brief and extended versions of the wellness assessment via LimeSurvey. Research assistants checked LimeSurvey for submissions on each weekday and reviewed scores to determine whether an individual scored positively according to the evaluation criteria for each validated measure used. Research assistants sent a response to any individual that provided their e-mail address, according to their combination of scores. For example, if they scored negatively for all areas of interest, respondents were told that their scores indicate that they are coping well, they were reminded to practice self-care and provided general resources created for healthcare workers or for managing stress during the pandemic. Response templates can be accessed by contacting the corresponding author. Clinical STEADY team leaders were engaged whenever individuals included concerning comments or requested specific types of support, and when scores were consistently high.Introduction to Self-Care;Introduction to Meditation and Mindfulness;Mindfulness Practice (Continued);Becoming a Reflective Practitioner: Personal Practice and Reflective Communication;Having Difficult (Death and Dying) Conversations with Patients;Understanding and Overcoming Burnout and Compassion Fatigue;Grief and Bereavement as a Healthcare Provider;Normal Stress Reactions versus Acute and Post-traumatic Stress Disorders;Skills for Coping and Resilience-Building;Managing Anger (in yourself and in patients);Tackling COVID-19- Related Stress;Coronasomnia: Sleep and Mental Health;Moral Distress.Select facilitators  and research staff were involved in workshop material development. Topics were identified based on past work, challenges highlighted by the literature, themes that arose in conversation with participants, and suggestions from other facilitators, participating HCWs or leadership. Each topic was offered two or more times on each unit, to increase accessibility. The final list of workshop titles was as follows:Participation was strictly voluntary; individuals could pick and choose elements of the program that they wished to participate in. Informal conversations between program facilitators , HCW attendees, unit leaders and STEADY Team members were crucial in accomplishing the “monitor knowledge use” step of the KTA cycle. Having one consistent facilitator who acted as the STEADY Program Manager across all units (working with varying co-facilitators in each group) was beneficial for knowledge synthesis and change management. Some changes were made to adapt to HCWs’ needs and preferences across multiple units, while other changes were unit-specific. For instance, one-hour education workshops were deemed unrealistic across all units since HCWs were unable to take this time away from their clinical duties, especially considering increased clinical demands created by the pandemic. We adapted the frequency and duration of these workshops from biweekly one-hour to weekly thirty-minute workshops. Other adaptations were made to increase uptake or respond to specific units’ needs  as we learned more about their staff, unique unit practices and cultures. For instance, the Acute Care Inpatient Unit described in The “community” element of STEADY was difficult to implement consistently due to lack of structure. In some areas where leaders actively planned holiday events, we were welcomed to participate in or co-host these celebrations, thereby working with leaders to bolster group interaction and sense of community. In other areas, leaders attended education workshops to encourage staff attendance and model vulnerability. However, this element was not implemented in all STEADY units until we decided to create communal “Gratitude Trees” for each participating group, with manager consent. This idea arose from the monthly working group meetings. These meetings created the opportunity for interdepartmental conversations about the various wellness initiatives being run and unaddressed needs across the organization, in addition to discussing progress with STEADY.It quickly became clear that remote/virtual program implementation was not acceptable to most groups, with minimal or no uptake of remote workshops or peer support sessions. To address this, we received organizational approval for one facilitator to attend sessions in person, following infection prevention and control protocols, and “zoom in” the second facilitator. This hybrid approach allowed one facilitator to build relationships with individuals during casual conversations in their area, even if they had not yet attended programming. It helped to maintain physical distancing and to increase accessibility, as staff on target units could choose to attend from home on days off. The extra time needed to make these in-person changes, build trust with staff and gain traction on the units led to a project extension beyond the initial planned six months to approximately eight-to-12 months. Other challenges faced and solutions implemented are outlined in Specific protocols for responding to high-distress areas were developed in real-time. Where increased distress was identified by a unit manager or team member, the STEADY team met with leadership/management, wherever possible, to determine how to prioritize and target interventions for their staff. This often included a Group Wellness Assessment, using a peer support model to engage staff and normalize conversations about distress, validate their experiences, and identify issues. Further supports were suggested based on identified issues or reported desires. For example, where staff described experiencing burnout and the desire for more opportunities to connect as peers, we offered the workshop on “understanding and overcoming burnout and compassion fatigue” and created the opportunity for peer support discussions during these sessions. Other departments were engaged when concerns fell outside the scope STEADY. For instance, the Department of Organizational Development and Leadership was engaged for team-building interventions where team dynamic issues were described.In the absence of other evaluative strategies to gather impact data from participants, we collected comments and feedback that were offered spontaneously over the course of programming. Feedback was virtually entirely positive; Program implementation required iterative bi-directional movement across four parts of the KTA Action Cycle: (1) Adapt Knowledge to Local Context, (2) Assess Barriers/Facilitators to Knowledge Use, (3) Select, Tailor, Implement Interventions, and (4) Monitor Knowledge Use. Feasibility and acceptability data are being analyzed, though analysis is complicated by the iterative adaptations of programming across the participating units over time. Though this may have been due, in part, to the responsive nature of program implementation and need for expediency to address growing staff distress, it is in keeping with the rationale for the bidirectional arrows on the KTA Action Cycle. If possible, future program implementation might benefit from a prolonged planning stage wherein a larger number of the target population are surveyed or consulted to identify barriers/facilitators to knowledge use and ways to tailor implementation . Nonetheless, future work should include extensive logs with findings from informal conversations regarding barriers/facilitators to knowledge use and ways to tailor interventions, dates that each adaptation was implemented, and observations of program facilitators/end-users related to these adaptations. This would allow teams to evaluate differing iterations of their program/intervention to better understand team needs and guide future improvements.Lack of reminders: Frontline HCWs do not typically sit at a desk with an open calendar. The large number of competing clinical demands sometimes results in staff “catching up” on charting and entering data into systems at the end of the day, and they are likely to forget that sessions are happening at a specific time during busy shifts, especially if they have not logged into their emails to receive the reminders sent electronically;Limited capacity to connect to Zoom: Prior to the pandemic there was no need for webcams and/or microphones on computers in patient care areas. Delays in installation during the pandemic limited the capacity for remote access for those working in patient care areas (compared to management or administrative staff);Lack of familiarity with facilitators: Facilitators did not have the chance to build rapport with target groups before asking them to login to sessions and discuss personal topics. The lack of trust and comfort with facilitators may have prevented individuals from joining;Stigma: Logging into a session is, in essence, asking for emotional support, and one might feel that this is “admitting weakness.” Staff spaces in patient care areas are communal, and one might not feel comfortable logging in on a shared computer with other individuals around;Frustration: Some groups expressed frustration in hearing messages that “we are all in this together,” when they felt that they were risking their safety by coming in to work every day while others stayed at home. This led to individuals rejecting online programming, feeling there was no genuine sense of caring and understanding of their situation shown through this mode of intervention.The largest initial barrier to program implementation experienced by facilitators was a lack of engagement in virtual sessions. Our team arranged with someone on-site to connect a communal computer to Zoom, or for a space where staff could go to connect to Zoom, making staff aware of this location through e-mail invitations for sessions. Rates of participation were relatively low, if any, but this increased slightly after having built relationships with staff who could then announce to the group that the sessions were happening . Based on the feedback received from participants, as well as the facilitators’ observations/ understanding, and in keeping with the literature, likely explanations for this include the following:Having at least one facilitator on-site was effective in increasing program uptake. Other effective strategies included being flexible in coming to the staff and working around their schedules and identifying “Peer Champions” from the unit who could encourage spread awareness, remind their peers, and co-facilitate sessions.Some units were more open to programming than others. The construct of “culture” as part of the “inner setting” domain of the CFIR was experienced by facilitators to be particularly important with this type of program. It was important to try to understand each unit’s individual culture and offer programming in ways that would be acceptable based on unit norms. We observed greater difficulty breaking into the culture on trauma units . A facilitator of implementation in these, and other, units was the support and encouragement of local leadership. Facilitators felt that it was easier to build trust in a group when leaders welcomed us in, introduced us to the group, spoke positively to staff about our work, and modelled vulnerability or openness to having conversations related to emotional wellbeing.Despite challenges faced, we slowly gained traction, earned their trust, and became “part of the team,” to the point that some staff would reach out to us if they were distressed on days that we were not coming to their unit. Additionally, individuals reported missing us on weeks we were not there, and an overwhelming number of additional requests were received from other teams based on positive word-of-mouth. To accommodate this, we began to offer a weekly organization-wide workshop series via Zoom.Informal peer support sessions  were particularly successful. As many staff had recognized us as peer support facilitators by the time these were implemented, they quickly opened-up when we came to them. The more intimate and informal setting seemed to help staff feel comfortable openly discussing their wellbeing.Gratitude trees were implemented in response to the theme identified by STEADY facilitators of a lack of gratitude/appreciation felt by staff. This consisted of our team hanging a large cut-out of a tree on a wall in the unit and providing paper ‘leaves’ for staff to fill out, by writing down something that they were grateful for, and add to the trees. This ‘community-building activity’ was very successful on most units—we even saw patients and their family members adding leaves with messages of gratitude for staff. Many of these trees are still posted, continuously added to, and valued. Other groups continue to request gratitude trees in their areas or advice in making them.We continue to receive an abundance of positive feedback. There was no natural stopping time, as stressors continuously arose with the ongoing pandemic (including new variants and increased acuity of non-COVID patients), adding to the pre-existing (non-pandemic related) heightened risk for adverse mental health outcomes in HCW. Staff also became accustomed to having our facilitators provide peer support and expressed disappointment and frustration when we reminded them that the initiative would be ending. As a result, organizational funding was granted to extend the project timeline twice, and we were asked to transition programming to the organizational Wellbeing Committee for long-term sustainability.We plan to adapt STEADY to create a peer-led version (STEADY-P), with less external support. This would enable teams to “sustain knowledge use” in the long-term and increase capacity for rapid upscaling to offer more widespread support to HCWs and potentially other high-risk groups.Peer Champions: Include and/or train staff from the target groups to help run programming, for program acceptability and long-term sustainability. External facilitators should be involved alongside Peer Champions to bring objectivity and encourage the sense of a formal peer support environment, rather than that of ‘friends talking.’ Though this is recommended, we should note that during times of staffing shortages and high patient volumes (like the conditions during the pandemic), it might not be possible to train Peers Champions. From our experience, having unit staff advocate for programming and ‘co-facilitate’ by modelling vulnerability and sharing their own experiences helps to increase unit buy-in;Find allies in leadership: Unit and organizational leaders played a crucial role in paving the way for STEADY to be implemented, and in facilitating program uptake. Leadership modelling their trust in program facilitators seemed to encourage frontline staff to trust in the facilitators. In non-crisis situations, groups should take the time to engage leadership and build relationships with management in any target area;If you build it, they won’t necessarily come: Whenever possible, teams should go to the target unit rather than expecting them to come to you, ideally directly to where staff are already working. This gives staff the opportunity to engage in an informal, unpressurized way, and helps to overcome practical, logistical challenges  and cultural challenges ;Maintain a flexible program structure: Structure is important to maintain fidelity and ensure that elements are not forgotten in busy work environments , but flexibility regarding both date/time and method of delivery have proven to be key to the feasibility and acceptability of programming;Keep calm and carry on: Gaining traction takes time, and even once staff have bought in there may be days where only one individual will engage in a session. It is important not to take this personally or jump to conclusions regarding staff not needing or wanting support. Over time, we gained traction, saw the remarkable value and meaning in the smaller group conversations, and heard from many that they felt supported just knowing we were there and in seeing us on the unit;Consider whether and how to end: We implemented STEADY to respond to COVID-19 related distress and did not consider that distress may be even higher after the pandemic. We found that COVID-19 magnified longstanding issues, and as staff experienced the effects of cumulative stress, distress grew, leaving staff needing more support (rather than less). Though, theoretically, using a peer support approach and training staff within the unit should be sustainable, creating this infrastructure amidst a pandemic/period of heightened stress and workload was particularly difficult. We did not find a “natural stopping point,” and relied on organizational resources to continue offering support to staff.STEADY implementation was continuously adapted over approximately sixteen months of the COVID-19 pandemic. Many lessons were learned as we moved from theoretical program planning to practical, real-world implementation. Many of these learnings may be applicable to implementation of other HCW mental wellness programs (beyond STEADY). We will now summarize key lessons that should be considered when conducting similar work:Based on feedback received and our observations over the course of programming, we conclude that this project was highly successful. We hope that reported lessons learned through the iterative process of program adaptation and actionable recommendations made will support others in similar endeavours.


Entry into the field of clinical medical physics is most commonly accomplished through the completion of a Commission on Accreditation of Medical Physics Educational Programs (CAMPEP)‐accredited graduate and residency program. To allow a mechanism to bring valuable expertise from other disciplines into clinical practice in medical physics, an “alternative pathway” approach was also established. To ensure those trainees who have completed a doctoral degree in physics or a related discipline have the appropriate background and didactic training in medical physics, certificate programs and a CAMPEP‐accreditation process for these programs were initiated. However, medical physics–specific didactic, research, and clinical exposure of those entering medical physics residencies from these certificate programs is often comparatively modest when evaluated against individuals holding Master's and/or Doctoral degrees in CAMPEP‐accredited graduate programs. In 2016, the AAPM approved the formation of Task Group (TG) 298, “Alternative Pathway Candidate Education and Training.” The TG was charged with reviewing previous published recommendations for alternative pathway candidates and developing recommendations on the appropriate education and training of these candidates. This manuscript is a summary of the AAPM TG 298 report. Moreover, it has long been recognized that breadth in the educational background of those entering our profession enhances contributions to the medical community. However, the increasing complexity of clinical demands within the respective subfields of medical physics has led to additional emphasis placed on the standardization of the underlying training, for example, Paliwal et al.The current CAMPEP accreditation standards for graduate training in medical physics requires a strong foundation in basic physics.Have the educational requirements for alternative pathway candidate's entry into clinical training programs been adequately defined? That is, are the core elements specified in AAPM Report 197S sufficient?In what environment should certificate programs exist?Can a trainee gain adequate clinical exposure and professional understanding through training in a certificate program?If online training is acceptable, in which format should it be delivered , and for which courses? As an example, this question was particularly relevant during the initial 6–12 months of the COVID‐19 pandemic.Should a trainee be permitted to concurrently complete a non‐CAMPEP‐accredited PhD and certificate program?How are we evaluating the potential success of the certificate program in formalizing the alternative pathway, in preparing alternative pathway candidates for entry into the profession, and, ultimately, in contributing to advancements in the science and clinical application of medical physics?Is this approach consistent with attracting the best possible scientists to our field?Should the alternative pathway be expanded, contracted, or remain at its current capacity?Since the approval of AAPM Report 197SAAPM TG 298, “TG on Alternative Pathway Candidate Education and Training,” was established to review previous recommendations for alternative pathway candidates and to provide recommendations on how to optimize the practical implementation of the alternative pathway in the interest of both our profession and potential future entrants into it.2Although the benefits of preserving a diverse array of backgrounds within medical physics is a widely held sentiment within the field of medical physics, a well‐defined and accredited training pathway for those seeking entry into clinical medical physics is necessary. When the American Board of Radiology (ABR) first announced the 2012/2014 initiative, which was strongly supported by the AAPM due to concerns regarding the board passing rates, it restricted entry into the medical physics ABR certification pathway to candidates enrolled in CAMPEP‐accredited programs.prior to matriculating into the program. In the absence of an undergraduate or graduate degree in physics, the student must have the equivalent of a minor in physics. A certificate program must address the following six core topicsRadiological physics and dosimetryRadiation protection and radiation safetyFundamentals of imaging in medicineRadiobiologyAnatomy and physiologyRadiation therapy physicsAccording to CAMPEP standardsCurrently, certificate programs can reside in one of two settings. The certificate program may be contained within a CAMPEP‐accredited graduate program. As of July 2022, ∼83% of certificate programs (25 of 30) follow this structure. The accreditation process for such a program requires (i) a listing of the specific courses within the accredited graduate program that sufficiently address the six core topics listed earlier, and (ii) an attestation from the graduate Program Director that the courses reviewed for the accreditation of the graduate program are the same as those used for the certificate program. The second current setting is to house the certificate program within a CAMPEP‐accredited residency program that is associated with a higher education institution, even if that institution does not offer a medical physics graduate program. For this option, the accreditation process requires completion of the graduate application template by the program to demonstrate that the six core topics are addressed with detailed descriptions of the courses offered. Normally, a site visit will be required to evaluate the courses, to seek input from existing or potential students (where available), and to review teaching faculty and the educational environment. Association of a certificate program with a residency might allow, for example, an institution to admit PhD graduates from other disciplines of physics, to prepare them through the didactic certificate training, and then to consider them for their own residency training program.Although the support of the alternative pathway through accredited certificate programs has been generally well adopted within medical physics, several concerns have arisen over the past years regarding structure and delivery of certificate programs described as follows.Although CAMPEP standard 7.4 states that all students, including those in certificate programs, “shall have access to appropriate clinical and research facilities and the program shall demonstrate that clinical facilities and equipment are used in the teaching of practical aspects of core topics,”An example of graduate standards waived for certificate students are attendance and participation at conferences, seminars, and journal clubs to allow “students to practice their presentation and oral communication skills,” as well as a set of 24 curricular standards under the headings of professionalism, leadership, and ethics. These exceptions are, in fact, in keeping with the requirement for addressing only the six curricular areas listed earlier. With regard to professionalism and ethics topics, the CAMPEP standardsAnother potential concern relates to the timing of certificate admission and completion of the coursework. Although the original intention of the certificate program was to provide an avenue into the medical physics profession for PhD graduates from non‐medical physics specializations of physics, the expectation was—and the requirement remains—that those entering a certificate program already hold doctoral degrees. Some institutions have advocated for allowing concurrent enrollment in certificate courses with a non‐medical physics doctoral program, which is not permitted according to current CAMPEP requirements,3In 2021, there were a total of 111 applicants and 62 enrollees in certificate programs.p = 0.008 using a T‐test for proportion), it is unclear whether this is associated with characteristics of the certificate pathway itself  or with characteristics of individual applicants and/or programs that may have affected the overall result. Therefore, it should be clear that one cannot make inferences from these data about either the certificate pathway itself or about any individual program. We encourage individual programs to evaluate their own pass rate data and encourage CAMPEP to evaluate this aspect of program performance.Objective evaluation of the success of the alternative pathway is challenging but the ABR certification examination represents one potentially relevant metric. As the quality of a candidate's performance on parts 2 and 3 of the ABR exam should be largely determined by their residency training, a review of the ABR part 1 pass rates may provide insight into the relative preparedness of alternative pathway candidates for entry into residency programs, which could then be used to help drive program improvements. Pass rate data from the 2016–2022 ABR part 1 exams were compared between those who graduated from a certificate and those who did not.Beginning in 2019, CAMPEP included a question on the academic background  of newly accepted students in their annual graduate program evaluation to help provide insight those in certificate programs. However, with several years of data, one cannot discern whether the intent of allowing the alternative pathway as expressed in Section 2 of this document is being achieved  is recommended to assure the certificate student receives exposure to experiential, clinical medical physics.4.5Task Group Recommendation. We recommend that students enrolled in a certificate program should have a terminal PhD degree in physics or related field, consistent with the CAMPEP standards and policies as of the submission of this report (July 2022). Moreover, it is not acceptable for a student to be enrolled in a non‐medical physics PhD and enrolled in a certificate program at the same time.4.6Task Group Recommendation. We recommend follow‐up investigations and surveys to determine the success of the certificate program initiative. As the certificate program is explicitly designed to provide a mechanism for preparation for an accredited residency training program, evaluations of such programs should include, at a minimum, the success rate in placing graduates into these positions. Additional evaluations should include an assessment of the certificate program's success in meeting the stated goals of their program. Programs should request ABR part 1 data for their certificate and graduate students and residents for comparison and evaluation of trends. Consistent with CAMPEP's graduate standards, we recommend programs post the subsequent positions of their graduates  on their program's website for transparency.Although we cannot currently comment on whether the alternative pathway approach will attract the best possible scientists to our field, or whether we need to adjust the number of certificate programs, we hope these questions can be addressed in the future by continuing to monitor and evaluate alternative pathway programs and the successes/accomplishments of their graduates . Further, we acknowledge that there may be other solutions that address the concerns discussed in this report, which may result in changes in future recommendations of certificate program/alternative pathway candidate education and training.All authors contributed to developing the recommendations detailed in this report, as well as writing the report. As the Task Group (TG) chair, Dr. Seibert organized and led the TG meetings, as well at the structure of the report. The preamble was developed by Drs. Burmeister and Robar. Dr. Prisciandaro maintained the running draft of the report and led efforts in the editing of the report.The authors declare they have no conflicts of interest.