Interpretation of findings

Pharmacists are well positioned to engage in AMS interventions in a variety of practice settings. In addition to their traditional dispensing role, expanding the role of pharmacists in prescribing for minor ailments furthers their ability to influence antimicrobial use. ^{Reference Wu, Khalid and Langford16} In the current survey results, all programs taught AMS content in their core curriculum, which is encouraging given that inclusion in the core curriculum guarantees exposure for all students. This finding is consistent with surveys conducted in the United States and the United Kingdom, in which most programs included AMS content in the core curriculum. ^{Reference Kufel, Jeffres, Macdougall, Cho, Marx and Williams11,Reference Castro-Sánchez, Drumright, Gharbi, Farrell and Holmes12} However, our survey results showed that the content was not consistent or comprehensive. On average, programs taught 68% of previously described AMS topics. This variability in content has also been described in the United Kingdom, where pharmacy programs taught 61.5% of the AMS topics included in a questionnaire. ^{Reference Castro-Sánchez, Drumright, Gharbi, Farrell and Holmes12} However, a direct comparison is difficult because the UK questionnaire included mostly task-oriented AMS topics.

In our survey results, Canadian programs consistently taught topics within the care provider role, that is, topics that relate to the provision of direct patient care. Because the care provider role is described as the core of the discipline of pharmacy, it is encouraging that pharmacy graduates are taught the necessary content to fulfill this role. ¹⁰ However, to provide quality care, pharmacy graduates are expected to be able to integrate additional professional roles into their practice, such as communicator, collaborator, leader–manager, scholar, and health advocate. ¹⁰ Communication and collaboration skills are critical for pharmacist participation in interdisciplinary AMS discussions and interventions, as well as patient counselling. With many programs not covering topics that fulfill these important roles, a potential gap exists in the readiness of pharmacy graduates to apply their knowledge and patient care skills.

Gaps in the roles of communicator and collaborator likely reflect the teaching of AMS content and assessment of learning. Programs are predominantly using didactic methods of content delivery and student assessment, such as lectures and multiple-choice questions, respectively. Both approaches could limit students’ ability to develop effective communication and collaboration skills. A scoping review of literature surrounding AMS teaching in pharmacy curricula has endorsed active learning as the preferred strategy for the achievement of the necessary learning outcomes. ^{Reference Nasr, Abbara and Wilby17} Incorporation of active learning activities, such as simulation, role-playing, and small group discussions, may foster the development and facilitate the assessment of communication and collaboration skills.

Outside the United Kingdom, which reported a median of 12 hours dedicated to AMS instruction, surveys in other countries have identified that most pharmacy programs dedicate <5 contact hours to AMS in the required curriculum. ^{Reference Kufel, Jeffres, Macdougall, Cho, Marx and Williams11–Reference Khan, Kritiotis, Coetzee, McCartney and Boschmans13} These findings are similar to those of our survey, in which 8 of the 10 programs reported spending ≤5 hours teaching AMS content in the core curricula. Khan et al ^{Reference Khan, Kritiotis, Coetzee, McCartney and Boschmans13} recommended that a minimum of 1–4 hours be devoted to AMS instruction, but they suggested that a greater number of hours (eg, 10–19) would likely be more beneficial, if permitted.

Although the median number of contact hours was low, a vast range of 0.66–65 hours was reported. This expansive range was also reported among pharmacy programs in the United Kingdom, where an interquartile range of 7–25 contact hours was identified. ^{Reference Castro-Sánchez, Drumright, Gharbi, Farrell and Holmes12} The heterogeneity in this metric may reflect different approaches to delivering an AMS curriculum. Some programs may devote a limited yet focused number of hours to AMS-specific instruction, whereas others may aim to integrate AMS principles into infectious diseases courses or other components of the curriculum, such as laboratory simulations. Further research is needed to determine the optimal approach for integration of AMS content.

In our study, programs offering an elective course in AMS were able to offer more contact hours for AMS instruction and to employ diverse teaching strategies and assessment methods. Although offering content in elective courses can be a valuable way to enhance student learning, we advocate greater inclusion of AMS content in the core curriculum. Elective content can be offered to students interested in furthering their knowledge in this area; however, having a strong foundational AMS curriculum in required courses will ensure that all graduates can provide patient care with a focus on AMS.

It has been previously demonstrated that an interprofessional AMS curriculum improves knowledge and attitudes toward antimicrobial use among both pharmacy and medical students. ^{Reference MacDougall, Schwartz, Kim, Nanamori, Shekarchian and Chin-Hong18} Nevertheless, in our survey, only 1 Canadian program offered the opportunity to learn AMS content alongside students from other health professions. AMS experts have noted that skills in interprofessional interaction are deficient among pharmacy students and practicing pharmacists. ^{Reference Khan, Kritiotis, Coetzee, McCartney and Boschmans13} Expanding opportunities for interprofessional education could be a means of addressing gaps in the development of communicator and collaborator roles.

Similar to interprofessional education, experiential education opportunities can enhance AMS-related knowledge and skills, including interprofessional collaboration. It is encouraging that most programs offer student placements with a focus on AMS; however, these opportunities are not available to all students. A lack of preceptor availability in this field has been identified. ^{Reference Kufel, Jeffres, Macdougall, Cho, Marx and Williams11} With limited availability of AMS-specific rotations, programs and preceptors are encouraged to incorporate AMS teaching into other experiential practice rotations, given that antimicrobials are prescribed throughout the continuum of care. For example, when an AMS checklist and reflection activity was incorporated into student placements in inpatient, ambulatory, and community pharmacy settings, students’ understanding of AMS techniques increased, and students reported being more likely to implement AMS techniques in their careers. ^{Reference Revolinski, Pawlak and Beckers19}

The most commonly perceived barrier to enhancing AMS instruction was a lack of time in the curriculum, which was similarly reported in a recent survey exploring cannabis content in Canadian pharmacy curricula. ^{Reference Tang, Schwarz, Lok and Wilbur20} An additional barrier raised by one respondent was the “lack of integration of AMS principles in the rest of the infectious diseases curriculum.” This finding suggests a need for a standardized set of core AMS competencies, so that instructors can ensure that key AMS principles are taught. Another barrier raised was the “lack of a formalized AMS program in the region/province.” This deficiency could preclude the opportunity for students to engage in AMS interventions in the experiential curriculum, and it further highlights the importance of having this content in the core curriculum. Particularly in areas lacking formalized programs, Canadian pharmacists will need to be well trained and confident in the area of AMS to act as champions for AMS interventions.

Strengths and limitations

To our knowledge, this was the first survey to examine AMS pharmacy education in Canada. With responses received from all 10 Canadian programs, our findings provide a comprehensive look at what is being done at the national level. Additionally, participants included both content experts and faculty leadership, providing a more holistic view of the AMS curriculum. However, an important limitation of our survey was that questions addressing curriculum content used AMS topics developed in the United States as the benchmark, given the lack of Canadian-specific standards. Nevertheless, those topics were felt to be the best available benchmark, given the many similarities between the landscape of pharmacy education in Canada and the United States and the strong alignment of the AFPC educational outcomes and the Centre for the Advancement of Pharmacy Education educational outcomes. ^{Reference Stupans, Atkinson, Meštrović, Nash and Rouse21} A second limitation was that our survey was not designed to capture a detailed picture of AMS in the experiential curriculum, which could offer additional opportunities for knowledge and skill development.

Implications and future directions

The survey findings highlight important gaps in AMS pharmacy education, which course instructors and curriculum designers should address. Overall, little time is devoted to AMS instruction, and the optimal approach to incorporate AMS content is still unknown. Key competencies may not be addressed with the predominant use of didactic methods for content delivery and student assessment. Specifically, learning activities that promote the development of communicator and collaborator roles should be leveraged to enhance graduates’ ability to engage in collaborative AMS interventions. Similarly, opportunities for learning AMS alongside students from other health professions should be explored.

The heterogeneity of content and time devoted to AMS instruction highlights the need for a common AMS curriculum with standardized educational outcomes. Curriculum planning and evaluation of educational interventions in AMS has also been recommended in prior literature. ^{Reference Nasr, Abbara and Wilby17} Curriculum planning has been done to optimize the instruction of pharmacy informatics in entry-to-practice pharmacy curricula through the development of competencies for pharmacy graduates. ²² A similar approach could be utilized for AMS instruction. The findings from our survey can serve as a baseline for building an AMS competency framework for pharmacy graduates. Our findings also highlight some of the current gaps and barriers to be addressed.

An opportunity remains for further research regarding the synchronization of AMS teaching with other curriculum topics related to resource stewardship and quality improvement. For example, deprescribing and opioid stewardship are other areas in which pharmacists can play an important role, and where similar principles of resource stewardship may apply. Synchronizing the instruction of these topics could be an effective way to reinforce important skills and principles despite curricular time constraints.

In conclusion, pharmacists can make significant contributions to AMS interventions. Therefore, it is essential that pharmacy students develop the knowledge and skills required to employ AMS principles in a variety of practice settings. The findings from this survey have established a baseline for the status of AMS instruction in Canadian entry-to-practice pharmacy programs and can aid in the advancement of AMS pharmacy education.