INTRODUCTION

Pharmacist preceptors shape the future of pharmacy by mentoring students during their experiential learning experiences. It is not uncommon for preceptors to encounter challenging situations and difficult student behaviors that can ultimately test a preceptor’s skills and patience. A faculty preceptor once said, “Students don’t usually fail rotations because they don’t know brand and generic drug names; they fail because of behaviors incompatible with the pharmacist’s professional identity. No one becomes a preceptor to hunt for students and force them to go to rounds!”

By addressing diverse behaviors and challenges that preceptors commonly encounter, this activity will empower preceptors to address troublesome behaviors effectively.

PAUSE AND PONDER: What types of difficult behavior have you encountered in the students you precept in the past?

TYPES OF DIFFICULT BEHAVIOR

Preceptors report a variety of challenging student behaviors during introductory pharmacy practice experiences (IPPE) or advanced pharmacy practice experiences (APPE) rotations. This continuing education activity explores the following behaviors as they relate to experiential education; failure to answer introductory emails, dressing inappropriately, cursing, poor language choices, disrespectful oral or written language, tardiness, and making excuses for unacceptable behaviors.

Failure to Send Introductory E-mail

Schools of pharmacy typically notify students about their IPPE or APPE rotations several months in advance, often in April for the latter. The timing for reaching out to preceptors may differ for IPPE and APPE students. For example, some schools require IPPE students to contact their preceptors shortly after receiving their site match notification. They may also expect APPE students to introduce themselves and address any site requirements approximately two weeks in advance of the first scheduled day unless the preceptor contacts them sooner. Students should take the initiative and reach out to their preceptors first. This communication serves multiple purposes, including introducing themselves, demonstrating awareness of the start date, confirming the student’s ability to fulfill the expected hourly commitment of the rotation, and addressing any scheduling adjustments. Students spend 120 to 160 valuable hours under the preceptor’s guidance. A student’s failure to initiate or answer introductory emails can significantly impact the student-preceptor relationship and hinder early establishment of effective communication channels.

When students fail to communicate, it opens the door to discuss the importance of good communication in the workplace. Preceptors can use a few techniques to encourage better communication from students^1,2:

• Create an electronic reminder on your calendar that will notify you one week before a student is expected. If you haven’t heard from the student, use the contact information the school provided for the student and send a brief message. Something like, “My calendar indicates you are scheduled for your rotation at (INSERT LOCATION) starting Monday. I haven’t heard from you. Are you still scheduled or has your situation changed?”
• Consider copying the school’s Office of Experiential Education (OEE) and asking if the preferred contact method has changed.
• Know that 47% of e-mail is opened or deleted based on the subject line. Be sure to use a specific subject line, like “IMMEDIATE RESPONSE NEEDED: Your April 2024 rotation.” Experts recommend starting with a command and using seven or few words so the subject line will be visible on a phone. Using four or fewer words increases the likelihood e-mail will be opened, so a subject line of “TIME SENSITIVE: IPPE Rotation” might be even better.
• When the student responds, reply promptly (modeling good communication), providing information like start time, hours, dress code, and other essential information as you would with any student. Ask for a reply confirming the student received the information.
• If the student does not reply, resend the communication, and copy the OEE. Add a sentence at the start of the communication (and consider highlighting it) that says, “I haven’t heard from you. Is this your preferred method of communication?”
• When the student reports, discuss the need for prompt responses, underscoring that preceptors are busy and do not have time to track students down.

Inappropriate Dress and Hygiene

Schools of pharmacy and preceptors expect students to adhere to professional dress standards during their experiential rotations. Dressing appropriately can improve the student’s self-perception and confidence and also improves the public’s confidence and perceptions of a pharmacist’s abilities.³ Preceptors can explain to students that dressing professionally also reflects the workplace institutional culture. Dressing appropriately can improve the likelihood of career advancement.^4,5 Table 1 lists examples of appropriate and inappropriate attire for pharmacy students.

Consider the case of Ally, a P2 pharmacy student on her first IPPE rotation at a large, well-recognized health system. Ally always reported for her shifts wearing dress pants and a turtleneck of sorts under her white coat. One day, Ally joined her preceptor for a meeting with the organization’s medical directors and the room was quite warm. Ally removed her white coat, which revealed the fact that her top was a crop-top and exposed her torso. Ally had always appeared to dress professionally before but always kept her white coat on.

While conversations about dress are sensitive and may be uncomfortable, it’s important to address issues early when appropriate. Experiential rotations may be the first time a student has ever needed to dress professionally. It may take some students time to assimilate to professional dress standards.^4,5 Providing feedback supports the students ability to make a positive first impression and aids in overall career readiness.

After the meeting ended, the preceptor (who was also female) privately addressed Ally’s attire. She suggested that Ally dress professionally daily for any occasion with or without her white coat. If the preceptor had been male, he could ask another female pharmacist to speak with Ally. The key is to address these issues in private and with discretion.

Hygiene is often closely related to attire. Students who have poor hygiene and noticeable body odor often fail to launder, repair, or replace their clothes when they should. Talking with students about hygiene problems is embarrassing for everyone involved. Here, too, it’s often less embarrassing for the student if the person who addresses the issue is of the same gender. The discussion also needs to be conducted in private and with absolute discretion. Some students may have underlying medical conditions that contribute to the problem, like lack of smell or difficulty with executive functioning or organization.⁷ Preceptors can point out that a lack of proper hygiene can lead to social problems with peers and patients and sometimes increases the likelihood of illness. Clothing like white coats that aren’t washed often harbor bacteria and accumulate odors.⁸ Students may need very specific direction. For example, the preceptor may need to tell the student that white coats must be washed every week, or that showering and washing hair at least every other day is the expectation. They can also suggest that students establish routines and incorporate hygiene activities into their routines, like showering every evening if students tend to run late in the morning.⁷

A growing concern in workplaces is the use of fragrance.⁹ More than one-third of Americans report scent sensitivity.¹⁰ The reason: artificial fragrances can be irritating to individuals who have allergies and asthma. Colognes and perfumes are not the only problem. Products like lotions, soaps, hairsprays, laundry detergent, and dryer sheets designed to reduce static can also trigger allergies and asthma. For individuals who have sensitivities to fragrances, exposure can lead to headache, respiratory distress, itching/burning eyes, runny nose or congestion, and nausea. The end result is presenteeism, meaning they are present in the workplace but unable to perform as well as they might. ⁹ For this reason, some workplaces have policies indicating that employees may not wear any fragrances while on duty.

Here, too, the best intervention is to discuss the problem directly with the student as soon as it's noticed. Since about one-third of workplaces include individuals who have scent sensitivities, establishing a fragrance-free policy is prudent. Consistency is important. Site supervisors who ask one employee or student to stop wearing fragrance should make sure that the rule applies to everyone. Again, it’s often more comfortable for students if the person who approaches them is of the same gender.

PAUSE AND PONDER: What types of difficult behavior might stem from little exposure to professional environments and lack of experience?

Profane or Poor Language Choices

Patients often complain about profanity in healthcare, as they expect professionals to remove these words from professional discussions. But it’s a fact that people—all kinds of people—curse. Experts indicate that people use profane words in two ways: (1) in casual conversation, and (2) in anger.¹¹ Students sometimes use profanity or inappropriate language, and in some cases, they are unaware that the words or phrases they choose are offensive, unprofessional, or incomprehensible. Some students simply use words that they grew up hearing and using, and they believe the words are acceptable. These words usually refer to biologic functions. One pharmacist was surprised when she heard her technician talking to a patient about diarrhea using the *s*-word to describe feces. When she approached the technician, the technician said with all sincerity, “That’s what it is! (The *s*-word)!”  And while the *s*-word is unprofessional, students will need to know patient-friendly terms because “feces” is too high level for many patients. (Suggest bowel movement, stool, or even poop.) Students may also be accustomed to using curse words in casual conversation and simply swear habitually. Unfortunately, others may overhear even casual conversations between coworkers and be offended, so using profanities at work (even in casual conversation) should be avoided.¹¹

Using profanity in anger is a different issue.¹¹ Employees and students usually curse in anger when they are frustrated or arguing with someone. Usually, the person is in a heightened emotional state and the conversation is loud. The cursing affects everyone who hears the profanity, and patients are especially likely to be affected. Humans translate loud conflict as a survival threat and it activates the fight or flight response, raising others’ emotional states, too. Such a change can affect the performance of those involved in or witnessing the conflict for the next few hours. It’s possible that the incident could affect patient outcomes.¹¹

Preceptors should consider a  “No Swearing Policy.” Such policies should be enforced with a well-defined managerial plan for disciplinary action or possible termination for employees and specific repercussions for students (discussed below). While swearing, in and of itself, may not constitute serious misconduct, understanding its context and the potential harm it can cause is crucial.

When preceptors observe a student breaching a no swearing policy, they should consider several factors¹²:

• Intention: Determine whether the student accidentally used profanity as an outlet for frustration or used swear words to voice abuse or threats.
• Delivery: Assess the specific words being used, the volume, and the student’s tone when swearing.
• Context: Examine the circumstances in which an individual swore and the motivations behind it.
• Workplace Environment: Consider the nature of your workplace, including the type of work being performed and the overall atmosphere.

With employees, the recourse is corrective or disciplinary action. With students, the recourse is documentation in the next evaluation and if the event is serious enough, failing the student in  the professionalism section of the evaluation (which in some schools precipitates a failing grade for the entire rotation).

It's important for preceptors to recognize when a student’s behavior may be considered unsafe or harmful to themselves, to patients, or other health care personnel. In cases when a student displays behavior that endangers others, preceptors should

1. Involve the student’s school immediately.
2. Provide timely, constructive, and actionable feedback. Identifying and sharing concerns as soon as they arise offers students the opportunity to correct the behavior promptly. Students may not receive a tremendous amount of feedback on their professionalism. It’s important to be transparent about a student’s progress or standing in a rotation.
3. Inform students that they are breaching workplace policies and the types of disciplinary action that may follow.
4. Document the date, time, and specific details of any concerning behavior. For situations in which students are at risk of a low to failing grades, documenting behaviors with dates can help justify grading decisions and address concerns with the OEE.

Similar steps can be taken when students violate other polices like dress code, attendance, workplace harassment, cell phone use, etc.^13,14

Disrespectful Language

Another type of inappropriate communication is biased language. Clearly, abusive language, hate speech, and racist or sexist remarks are never appropriate, but biased language may occur without the student being cognizant of it.¹⁵ Preceptors should address the student immediately and explain why what the student said or how the student said it is inappropriate. Some students may come from environments at home or socially where inappropriate language is normalized. These students may voice opinions that reflect their cultural biases, political persuasion, or religious beliefs, or demean others who believe differently. They may also use language that has been common and accepted by society but has now fallen from favor.¹⁵ For example, referring to the technicians as “the girls who run the register,” needs gentle correction. Similarly, labeling patients crazy, drug addict, and senile should prompt preceptors to suggest kinder, gentler terms. These terms have been replaced by mentally ill, person who uses drugs, and person with dementia, respectively. Explaining why negative words may be hurtful can help students develop empathy. It’s also an opportunity to explain how these conditions, like all medical diagnoses, are not the patient’s fault.^16,17

Finally, elderspeak is something pharmacy staff often use unintentionally to demonstrate support for the elderly patient.¹⁸ Elderspeak may become obvious as students encounter older adults. It’s a kind of speech adjustment—often called “baby talk” or “pet talk”—that young people may use when talking with an elder. Table 2 provides some examples of elderspeak.¹⁸

Table 2. Examples of Elderspeak¹⁸

• Changing the delivery of verbal information to
  • Raise the pitch and tone
  • Speak in a singsong tempo
  • Exaggerate words
  • Speak more slowly
• Shortening sentence length
• Simplifying sentence complexity by using limited (and sometimes condescending) vocabulary
• Repeating or paraphrasing what the elder just said
• Using terms like "dear," "honey," “old buddy,” or “young lady”
• Using statements that sound like questions
  • Ending sentences with a negative question (e.g., You want to take this medicine as directed, don’t you?”)

In short, elders often find elderspeak condescending and patronizing.¹⁸ Elderspeak can have a significant impact on specific patient populations. For example, patients with dementia or Alzheimer’s may experience progressive symptoms of aphasia as they age. Many caretakers and healthcare providers resort to language that is simple and limited to alpha commands, or language that is concise, straightforward, and direct. While elderspeak may help compensate for natural changes in older adults’ cognitive abilities, it may consequently cause older people to question their abilities and reinforce negative stereotypes about aging. Because opportunities for communication using elderspeak are constrained (often can be answered with yes or no or the communication invites a “correct” answer or no answer at all), older adults may perceive elderspeak negatively. It may cause reduced self-esteem, depression, and withdrawal from social interactions. Pointing out the problem when students use elderspeak is often enough to correct the behavior. Some students, however, will need coaching. Some strategies to minimize elderspeak include repeating and paraphrasing what you are saying, simplifying phrases, actively listening, and asking appropriate questions.^18,19

It’s essential for students to communicate effectively, maintaining a professional and positive demeanor at all times. Rotations with patient interaction are excellent opportunities to help students communicate their thoughts and feelings effectively. Poor language choices reflect poorly on the student, the school of pharmacy, and the pharmaceutical profession.  

Other Specific Behaviors

While the list of challenging student behaviors may be endless, this section touches on some of the other most common difficult behaviors preceptors encounter. This includes tardiness, boundary violations like practicing beyond one’s scope, inappropriate cell phone use, lacking accountability, lacking initiative and motivation, sloppy work practices, and gossiping. Employing effective strategies to manage these behaviors foster a more professional and productive educational experience.

Last to Arrive, First to Leave

Students are expected to be punctual and arrive at their rotations 15 minutes early. These standards are in place to replicate the pharmacist’s obligations and duties. While students aren’t responsible for opening a pharmacy at 8:00 AM, students must demonstrate their ability to be held accountable to such standards in the future. Students must adhere to their agreed scheduling commitments and communicate any delays or absences promptly. Tardiness creates lost productivity. Being 10 minutes late each day is equal to a week's paid vacation by year’s end!  It can also inconvenience others if they need to delay meetings or events.

Students who have chronic tardiness problems usually have time management issues. It’s a habit that's difficult to defeat. Preceptors can use a number of interventions, described in Table 3.²⁰

Table 3. Dealing with Tardiness^20,21

1. Encourage punctuality with a clear policy. Communicate the policy to students when they arrive (and consider putting it in your introductory email) and enforce it consistently.
2. Send reminders of early meetings or events. Send an e-mail reminder the evening before or 30 minutes before every meeting. Remind participants to be on time. Do not backtrack to fill them in on missed discussions if they are late.
3. Deal with tardy individuals privately. Meet with the student, revisit company policies, and ask about extenuating circumstances or logistics problems. Clarify the consequences for being late, which may include asking the school to reassign the student.
4. Describe punctuality as a choice. Convey to students that attendance is not an option, but a critical component of their professional training. They have a choice: To be punctual or the school will have to be notified immediately.
5. Document, Document, Document. Keep written documentation of all incidents of tardiness, detailing the date and time. This will provide an accurate report to the OEE regarding the student’s behavior.
6. Keep the pharmacy school involved and aware.

Tardiness doesn’t just affect the student but the entire workplace dynamic. As one professor commented, “When you are late, it makes us ALL late. This is because, even if you think you’re just a student, you have a job here. When you don’t show up on time, you can’t do all the things we count on you.” This statement emphasizes the cascading effects of lateness and the importance of punctuality as just one way to demonstrate professionalism and teamwork.

Addressing Boundary Issues and Protocol Deviation

Students may fail to adhere to established procedures when the pharmacist is not present. For instance, students may provide patient counseling without the pharmacist present or verify medications without the pharmacist’s supervision to speed up workflow. This is called performing outside the scope of training or practice.²²

Some pharmacy employees are tempted to perform outside the scope of training or practice. Sometimes students feel pressured or justified to perform beyond their scope, but doing so violates professional guidelines, risks patient safety, and may violate state or national laws and regulations.²² Pharmacists might also choose to overlook or fail to confront boundary crossing. However, if allowed once, it sets a precedent for the future. Preceptors need to be clear that emergencies and staffing shortages happen, but all employees including students need to work within their scope of practice. Preceptors need to address mismatched expectations (i.e., that a student thinks it’s OK to counsel if the preceptor is busy) and ensure that the workplace has adequate supervision.²²

Preceptors can coach students that while they are on rotation and after they are licensed, they need to be aware of exactly what they can and can’t do. Students should watch for key phrases that signal danger which include

• I’ll just do this first and then (show the pharmacist, call the doctor, convince the patient) later, I’m sure he won’t mind…
• We do this all the time…
• I know how to do this, it’s no big deal.

When they start thinking like that, they need to stop and make sure they are practicing within their scope of practice.

Practicing outside the scope aligns with another ethical concept known as incrementalism. Incrementalism suggests that as individuals repeatedly observe unethical behavior, they perceive it as less wrong, eventually normalizing it or deeming it acceptable. As the mind struggles to detect subtle changes over time, people may engage in unethical behavior more readily through a gradual process of minor infractions, ultimately escalating unethical behaviors. Unethical or challenging behavior typically doesn’t arise as a conscious decision to violate ethical standards; instead, it often occurs incrementally along a slippery slope, in tandem with peer interactions.

Using cell phones at inappropriate times

Cellphones, tablets, and other electronic devices can help students access pertinent information to better support their pharmacy practice experience. However, engaging with these devices in ways not related to their practice, such as unnecessary texting or browsing on social media, is inappropriate.

Social media encompasses Internet-based tools that facilitate networking and collaboration, and real-time sharing of information, photos, videos, and more. Social media can be referred to as “social networking” or “Web 2.0.”²³ These platforms can have positive and negative consequences on a student’s performance. While cell phones can be an indispensable tool for communicating and information access, misuse, or excessive use, can also be a source of distraction. When social media is excessive, it can lead to social media addiction (which is not yet a recognized medical condition). As with substance use, social media addiction can negatively impair physical and psychological health and cause behavioral disorders such as depression, anxiety, and mania. Researchers have not identified a threshold that would suggest what levels of social media use is considered to have poor outcomes. It’s clear poor management of social media use presents many concerning consequences on students’ academic performance and interpersonal relations ^24-26

As the technology landscape is always changing, consequences are unpredictable. Some practical solutions to supporting a student’s management of social media use can include:

1. Set clear expectations: Early on, practice settings need to communicate and enforce guidelines about cell phone use. A simple approach is to set parameters in the syllabus.
2. Suggest time management tools: Encourage students to use timers to manage their engagement with social media effectively. In the settings app on most phones, students can set a time limit that alerts the user when the time has been met.
3. Be informative: Preceptors can encourage students to join online medical communities to access news articles, expert insights, and stay up to date on research and trends. Some students may simply have never thought to do so. Examples of social networking sites available for pharmacists include the following:

• ASHP Connect (connect.ashp.org )
• APhA (www.pharmacist.com)
• The Pharmacist Society (www.pharmacistsociety.com)
• LinkedIn

4. Connect with students: Preceptors might also share readings, blogs, or podcasts that relate to the experiential rotation with students. As a supplement, following up on these materials can also exercise a student’s communication skills and their proficiency in relaying medical information.

Lack of accountability and dishonesty

At times, it may be necessary to address a student’s challenging behavior by discussing it privately. Many reactions can emerge from such conversations. Honesty and accountability should be prioritized – students should openly acknowledge their actions or lack thereof. As aspiring licensed pharmacists, they must uphold principles of integrity and accountability from the early stages of their advanced pharmacy practice experiences. Lack of accountability and dishonesty are character flaws that preceptors should consider quite serious.

Let's talk about a student, Jeff, who started his IPPE rotation in a chain pharmacy location. Jeff's school of pharmacy has experienced recurring issues with him. He often fails to respond to emails in a timely manner if at all. Staff in the experiential education office has to nag at him constantly to update records about vaccinations, license renewals, and similar necessary documentation. He is often flippant about why OEE needs any of this information. On the first day of his rotation, his  preceptor asked if he was up to date with all of his vaccinations and licensure renewals, to which he responded, “Of course. I wouldn't be here if I wasn't!” Over the first few days that Jeff worked at the store, the preceptor noticed some incongruities in several of Jeff’s explanations. He had unusual explanations for tardiness, was very defensive when he didn't know the answer to a question, and he was caught using the photocopier for personal purposes even after he had been told not to.

Several days later, the person who was responsible for tracking documentation in the OEE called and asked to speak with Jeff. She had heard that Jeff reported to this site even though the school had told him not to until his vaccinations were current. Jeff took the phone off to a corner of the pharmacy and spoke in hushed tones. When he was done, he told the preceptor that unfortunately he had an emergency and had to leave, and he would let him know when he would return. When the preceptor expressed concern, Jeff said that he had not submitted his vaccination documentation. When pressed further, Jeff confessed that he actually had failed to receive his vaccinations.

Dishonesty is unacceptable in a professional setting. When encountering similar situations, the preceptor should consider the following:

• Preceptors should report dishonesty to the OEE as soon as they notice it. Often, preceptors think that this may be a one-off instance of a student’s bad judgement, or preceptors think they may not understand something. Usually, however, this is a behavior that the school of pharmacy has been tracking and other people have noticed also.
• Documentation is critical. It needs to be thorough and clear. Preceptors should document what they saw or heard, how they disproved or came to realize that the information was dishonest, and when exactly it happened. They should not wait till the final evaluation to make note of the problems. It should occur in the very first evaluation and it's acceptable to do an immediate interim evaluation.
• If the preceptor decides to pass a student who showcased moments of dishonesty on a rotation, they should document in writing that they are passing the student, but they experienced professionalism problems during the rotation.
• At some schools that use a pass-fail system, professionalism violations are an immediate “fail.” We don't want people who have this magnitude of dishonesty entering the profession.

PAUSE AND PONDER: What kinds of behaviors would improve with discussion and direction, and what kind of behaviors would improve with more practice?

Inability to take initiative and unwillingness to participate in activities

Some students may appear frustrated, bored, underprepared, and distracted. This lack of engagement may manifest in communication styles aimed at minimizing interactions or diverting attention away from meaningful conversations. An essential component of professional development is the student’s capacity to engage proactively in various learning activities.

A particularly concerning sign is a student’s lack of motivation, which may be evident in their reluctance to engage in self-directed learning or displaying disinterest in the rotation site, assigned activities, or patient care. To address this issue, Table 4 outlines several coaching strategies designed to re-engage students lacking motivation.

Table 4. Strategies to Engage Students Lacking Motivation^27,28

• Discuss your observations regarding their disinterest and lack of motivation with the student.
• Encourage the student to create a personal success plan, including:
• Self-assessment of performance areas needing improvement, as identified by the preceptor
• Development of a concrete, actionable plan for improvement
• Engagement in critical reflection
• Revisit the learner’s professional and rotational goals to realign the students focus
• Consider setting mutual goals with the student, focusing on how to use discretionary time during the rotation to meet their unique needs and interests.

Students may distance themselves for several reasons. This could be due to finding a topic uninteresting, lacking understanding of situational expectations, or facing difficulties engaging with an interprofessional team or among cross-generational groups. By allowing students the opportunity to receive feedback and create their own success plan, they can incorporate a self-directed learning process. This approach provides a scaffold in developing essential self-awareness skills.

Consider Sally, who was two weeks in her rotation at Rosemary Hospital. Her preceptor, Dr. Unconfrontational (“Dr. U”), observed that Sally was unengaged, asked no questions, and kept disappearing in the break room for long stretches of time. Five days into the rotation, Dr. U asked Sally if she had read the assigned chapter the evening before. She said she did. When he asked questions about its content, she couldn’t answer. He needed to take a phone call, and she slipped away. He found her in the break room with the book open to the chapter (but she seemed to just stare at the pages). Dr. U was disappointed that Sally wasn’t interested in what he considered the most fascinating—but not the most difficult—part of his specialty. He decided that it was easier to stop assigning reading to Sally because she seemed uninterested. At the rotation’s end, he passed her with a C.

Cases like this demonstrate that precepting can be difficult and students can be puzzling. Although it’s hard to tell if Sally read the chapter, her behavior suggests she did not. The way that Dr. U interacted with Sally provides little information about the root of the problem. Dr. U could have done a number of things when he noticed Sally’s lack of enthusiasm^29-31:

• He could have educated himself about disengagement. It’s usually not directed at the preceptor. It could be poor self-esteem, difficult home situations, or the need to work after hours to support oneself. It may be that the student doesn’t see the assignment as challenging. Or, the student may be bored and need more—rather than less—work.
• He could have spent time asking Sally about her interests and what she hoped to learn in his rotation. While getting to know her, he could have asked if she had concerns or obligations outside of the rotation that he should know about. Ice-breaking activities are critical with students and should reveal students’ talents, passions, questions, and challenges. Asking questions like, “How do you learn best?” or “Would you rather read about a topic, watch a video, or do both?” can also provide good information.
• He could have examined his own expectations to make sure they were SMART (specific, measurable, achievable, realistic, and time-tagged). Was he asking too much?
• He could have asked her what she learned in pharmacy school related to his specialty, and what she liked and disliked about it.
• He could provide “hooks” to start her thinking about what’s coming next. This is the practice of providing just a little bit of attention-grabbing information about a topic. Preceptors can make a controversial statement (“Some people believe that gargling with bleach kills COVID. We’ll talk about how to respond to that kind of talk next week.”), asking a provocative question (“Why do you think that more than half of patients don’t take their medication? Do you think that statistic is accurate?”), or telling a good story (“I keep this x-ray on the bulletin board because it reminds me of a child who had nausea, vomiting, diarrhea, and low copper levels. It all came down to those things you see in his gut! Anyway…think about that and we’ll talk about it next week)
• He could have asked her to develop three goals for the rotation, and three sub-goals for each of the main goals so she could plan her own learning. If she couldn’t do this activity (which would explain much about why she is disengaged), he could work with her to develop goals.
• He could have asked her to create a deliverable as she read the chapter. Asking her to write down 10 interesting facts or use sticky notes to mark the pages she found most interesting and least comprehensible would have added an interactive element to the assignment.
• He could have asked her if she has had any experience with patients or family members who have diagnoses related to his field. This often provides some real-world relevance to learning.

Sloppiness

Health professionals including pharmacy students are held to rigorous standards of cleanliness, organization, and adherence to site-specific protocols. These protocols are not merely procedural formalities but are fundamental to maintaining quality standards and preventing pharmacy errors.

Pharmacy students, through their education and practical experiences, should be well-versed in these high standards. In compounding labs, for instance, faculty emphasize meticulous attention to detail and stringent adherence to procedures. As future pharmacists, they will prepare or verify medications that are often ingested orally, where the risk of contamination carries potentially severe consequences. Table 5 shares examples of how a student may exhibit sloppy behavior.

Table 5. Examples of the Sloppy, Disorganized, and Nonadherent Student

• Poor medication management: This can include incorrect labeling, improper storage of drugs, or disorganized inventory management. These practices can lead to medication errors, altered drug metabolism, or even possible harm to patients.
• Lack of attention to detail: This can manifest in several ways such as making calculation errors, misinterpreting prescriptions, or failing to recognize important patient information. Again, this is a patient safety issue.
• Failure to clean up: Leaving behind clutter and the detritus of pharmacy work for others to clean not only disrupts workflow but also reflects a lack of professionalism and responsibility.
• Improper waste disposal: Disregarding proper guidelines for drug disposal of expired or unused medications, sharps, and other waste can pose environmental and safety repercussions.
• Improper recycling practices: In hospital and community pharmacy settings, waste bins are often color-sorted for proper disposal. For example, disposing patient information in a regular trash bin instead of its designated bin violates HIPAA regulations.

Addressing these issues in educational settings is imperative for students to be aware of their habits and actions. This involves reinforcing the importance of these standards early, modeling these behaviors, and holding students accountable when necessary.

Gossiping

During rotations, some students may seamlessly connect with other staff members. In some cases, students may observe instances when coworkers engage in gossip and complaints about the workplace and colleagues. While it might be tempting to indulge in such discussion, setting boundaries is crucial when displaying leadership. This includes no gossiping or destructive criticism, and showing empathy when other coworkers present difficult behaviors.  Students should be embedded in the healthcare team with a healthy sense of belonging. As students practice mirroring the pharmacist’s actions, they learn to act as mediators in workplace conflict.

One way to discuss gossip with students is to ask them if they know what Socrates said about repeating information.³² This Greek philosopher said that before speaking, people need to ask themselves three questions about the information they plan to convey: Is it true, is it kind, and is it necessary? These questions are filters. Asking these questions guides the honest person to engage in ethical thinking and decision-making. Taking a few minutes to shift the discussion from the juicy tidbit of gossip to the related and more important topic of truth, kindness, and necessity can (but doesn’t always) help people who gossip develop some insight into their behavior. Emphasizing that these questions help individuals develop nurturing, trusting, empathetic relationships is key. This technique is useful with students and coworkers and can often start the process of reducing gossiping.³²

LEARNING THEORY TO ENHANCE ROTATIONS

Canadian psychologist Albert Bandura is widely recognized for introducing the concept of social cognitive theory.³³ He postulated that learning of any type occurs through observation, imitation, and modeling with influence from the learner’s attention, motivation, attitudes, and emotions. It means that the environment interacts with the individual’s cognitive makeup as learning occurs. Preceptors can use his tenets to help students engage and learn. Bandura’s observational learning theory moves through four key cognitive processes^33,34:

1. Attention: Learning starts with an individual’s engagement and focus on a particular behavior or task. The ability to imitate a behavior hinge on the accessibility of role models, behavior complexity, and perceived value of behavior. Ultimately, students need to perceive a model, or their preceptor, as someone worth imitating.
2. Retention: Students should register and retain information that they observe from their model preceptor. Learners retain information in a symbolic form of imagery and verbal elements. When preceptors perform actions repeatedly, they enhance the student’s retention.
3. Motor reproduction: As students are assigned to new tasks or behaviors associated with being a pharmacist, they will use clues from imagery and verbal elements to guide their actions. Frequent motor reproduction exposes students to new situational contexts and empowers them to adapt and refine their behaviors in future interactions. Role models who demonstrate positive behaviors subtly influence others’ actions and responses.
4. Motivation, reinforcement and punishment: Attention, retention, and motor reproduction all contribute to the ability to imitate a behavior. To stimulate positive reinforcement of behavior, the motivation and will to perform is often based on the rewards and punishment that result from modeling those actions.

Preceptors who understand another theory—that of unconscious learning—will also be able to assess students based on their past experiences and present materials appropriately. It describes the acquisition, access, and application of knowledge without deliberate and controlled attention. It’s the opposite of studying for an exam. It’s basically the “learn by doing” model, students are unaware it’s happening, and it, too, has four stages.^35,36

1. In the first stage, unconscious incompetence, students are unaware of how little they know about a subject. These are entry level students who have little experience. They may think they know more than they actually do.
2. In the second stage—conscious incompetence—students are able to recognize knowledge deficits. Preceptors can think of this as the point where students experience that AH-HA! moment of enlightenment.
3. Learning begins to accelerate and coalesce in the third stage—conscious competence. Students will begin to see patterns and store that information. An example would be learning the top 200 drugs after processing prescriptions or orders, rather than just memorizing them.
4. In the fourth stage, students develop unconscious competence. A task or process becomes second nature. Preceptors will not need to remind students to complete steps. Students will simply do the right thing.

Learning barriers can contribute to student difficulties, so understanding learning theory can assist preceptors to support students and reduce difficult behaviors. Exposure to a variety of situations in the workplace will help students learn unconsciously.³⁶ Fear and anxiety are barriers to unconscious learning (and contributors to difficult behaviors), so creating a learning environment that is comfortable (and maybe even fun) can speed the process. So can asking students to take a few moments and visualize processes and procedures before starting.³⁶

In the unconscious incompetence stage, preceptors will need to look for signs that students are recognizing they don’t know what they don’t know.³⁷ Having students repeat processes until they can do them without error is essential. Asking students how they think they are doing may stimulate some self-awareness. Encouraging them to periodically question what they think they know is also good.³⁷ These steps break down learning barriers gradually.

When students reach conscious incompetence, preceptors need to be observant. It’s the step where students, frustrated with their deficits, may want to give up. Preceptors who provide encouragement and additional practice can help them move on. Students need positive feedback to progress to the last step of unconscious competence, or mastery.

PAUSE AND PONDER: Think about a student whose behavior was difficult to address in the past. After taking this continuing education activity, how would you have addressed the issues differently?

CONCLUSION

When students are on rotations, they are in certain respects on their own and need oversight from preceptors and the preceptors’ team. Students benefit from preceptors who engage with their students. Oversight and feedback are needed consistently during this crucial time because preceptors want their students to succeed in the profession and the workplace. Pharmacy preceptors who explore the effectiveness of managing tardiness and use strategies to reinforce accountability and motivation will find the precepting experience more fulfilling. A thorough understanding and application of social cognitive theory and stages of learning will enhance a preceptors response to difficult student behaviors. They can use the interventions they develop to build better pharmacy student experiences. Before giving up on the student, they should ask for help from the pharmacy school’s OEE and reach out to people with good supervisory skills.

Why does early intervention on the preceptor’s part to correct difficult student behaviors matter? Developing good workplace behaviors is critical to prepare students for the rigors and responsibilities of the pharmacy workplace. Precepting students is a phenomenal opportunity to practice life-long learning and working mantras.

Download CE Activity

INTRODUCTION

Some pharmacy students have visible or invisible disabilities that require accommodation (a change or adaptation to adjust a situation to meet the student’s unique needs). Anecdotally, faculty at the University of Connecticut School of Pharmacy report that between 5% and 12% of students in a typical class in the last 10 years need accommodation. In terms of physical disabilities, institutions of higher learning have almost always built or altered existing buildings to accommodate students with disabilities with ramps, elevators, wide doors, and similar structural changes. Preceptors who work in larger organizations may have support teams that address or have already addressed physical disabilities. Those who work in smaller organizations or older buildings may be intimidated by the need to accommodate but will find that the law requires “reasonable” accommodation.

Pharmacy preceptors are more likely to encounter students who have chronic disease (e.g., asthma, autoimmune syndromes, diabetes, etc.) or learning disabilities, including those who are neurodivergent (the SIDEBAR explains the concept of neurodiversity). While taking classes, pharmacy schools often (and are legally required to) provide accommodation for students with learning disabilities (see Table 1). They may provide double time or access to a quiet room during exams, permission to take breaks during class, or notetakers to help them depending on the disability type. Students with learning disabilities acquire, organize, retain, comprehend, or use verbal or nonverbal information differently than others. They have impaired perception, thinking, remembering, or learning processes.¹

Table 1. Types of Learning Disabilities^1-7

SIDEBAR: Emerging Terminology and Necessary Understanding: Neurodiversity^8-11

Neurodiversity refers to the diversity of all people, but is often used in the context of autism spectrum disorder (ASD), neurological or developmental conditions, and learning disabilities. It is neither a medical term nor a diagnosis; it’s a descriptor used to replace the tendency to think of behaviors as normal or abnormal or to marginalize certain people based on their behaviors. When thinking about neurodiversity, it’s critical to remember that there is no one right way of thinking, learning, and behaving, and all differences are not necessarily deficits. Neurodiversity is not preventable, treatable, or curable. It’s the result of normal variation in the human genome. The term is used to promote equity and social justice for people who are members of a neurologic minority.

Students who are neurodivergent experience and interact with the world around them in many different ways. Common characteristics among students who are neurodivergent include eye contact, facial expressions, and body language that are different than many other people’s.

Students may or may not disclose (or even know) they are neurodivergent. When students do, it is important for preceptors to acknowledge neurodiversity and ask directly about a person’s preferred communication style and accommodations, many of which are described in the text of this continuing education activity. Many of the accommodations for people who are neurodiverse also help other students and employees who do not fall into neurologic minority categories, including

• Offering or allowing individuals to make small adjustments to the workspace
• Avoiding sarcasm, idioms, euphemisms, and implications
• Providing concise instructions
• Posting information about due dates and meetings as far in advance as possible
• Treating all people with respect

Preceptors should foster environments that are conductive to neurodiversity, and to recognize and emphasize each person’s individual strengths and talents while also providing support for their differences and needs. It’s also helpful to know that many large companies are now adjusting their hiring processes to attract people who are neurodivergent. They’ve found that although some people have trouble navigating the hiring process, their unique abilities are valuable, increase the company’s productivity, and often lead to remarkable product and process improvements.

This continuing education activity is designed to help preceptors who encounter pharmacy students with disabilities develop workable plans. Preceptors should start by acknowledging a critical fact: accommodation isn’t special treatment. Accommodation levels the playing field so student pharmacists (and employees) can learn and do their best work.

PAUSE AND PONDER: You’re a preceptor for your state university. In April, the experiential education office notifies that you have one student per month from June through April. Shortly after, a staff member from the experiential education office calls and tells you that the student scheduled for August needs accommodation. What should you expect going forward, and what is the best time to plan?

Providing Reasonable Accommodation

Institutions of higher learning usually have entire departments that develop policies, document the student’s type and degree of disability, and develop student-specific accommodation plans. When students who have disabilities go on clinical rotations, rotation sites may have no processes or policies to provide the same accommodation. Preceptors may not know how to cater to their needs. Often, practice sites need only to make minor adjustments to their environments, policies, and procedures. Once the organization makes the changes, the policies will be ready for future students! A PRO TIP is that an astute student who has disabilities may be willing to help edit and adjust policies; this insight can be valuable. However, the student may not want to help as this can be an added burden that other students don’t have.

Five basic principles help schools ensure that clinical rotation sites provide reasonable accommodation for students on clinical rotations^1,11,12:

• Before going on rotation, it is critical for the school to document the student’s disability with a reliable diagnosis. The school’s department for students with disabilities usually does this.
• All parties will need to work together to identify elements of the student’s disability that would cloud the preceptor’s ability to assess the student’s competence. Any accommodation should mitigate those elements.
• Preceptors should work with the school to develop accommodation tailored to the specific rotation site and tasks to be accomplished at that site.
• Three hundred sixty-degree communication is essential. Preceptors, students, school and rotation site administration, and disability service staff must collaborate and communicate.
• Throughout the whole process, all parties must protect the student’s privacy.

Students with disabilities are subject to a great deal of stigma not only from the outside world but also from preceptors. Ideally, schools should match these students with rotation sites and preceptors with prior experience accommodating students with disabilities.¹³ However, this may not always be possible. In ideal situations, preceptors are sympathetic and the relationship between the student and preceptor is open, non-judgmental, friendly, and relaxed. These characteristics set the stage for students to disclose their learning needs without fear of discrimination.¹⁴

The school, however, must identify sites and preceptors based on the student’s accommodation needs without disclosing student-specific accommodation descriptions. Open and honest communication between students, the experiential education team, and representative(s) of the school’s disabilities office before they develop the rotation schedule can prevent problems later.¹³ Once the school confirms the student’s sites, it can share very basic student-specific details with the preceptor but only the student can share specific health information.¹ In other words, the school can communicate the accommodation the student needs, but not the underlying diagnosis; that is private and only the student may disclose it.

A challenge for students with physical disabilities is needing accommodation through multiple sites, which requires significant coordination and planning. A solution is providing multiple rotations at a single site where accommodation is available. When this solution is available, students can acclimate once.¹³ This can provide the best possible experience for the student, providing a level of comfort in the environment; conversely, this solution may force disabled students to stay at one site while their peers rotate from site to site and experience different healthcare teams. In institutions without pre-existing policies, schools would benefit by working with preceptors and the sites to develop guidelines for accommodating students. For students with physical disabilities, guidelines should address different types of mobility devices, physical dimensions of hospital facilities, safety requirements of the pharmacies, and access to particular areas.¹³ The preceptor should do this before the student begins working at the site. It would be unfortunate if a student arrived at a site only to find it was inaccessible.

Step-by-Step to Accommodation

Using a stepwise approach on site helps preceptors ensure that they provide reasonable accommodation to students.

1. Raising awareness among the clinical team regarding disabilities, accommodation, and inclusive learning environments is a prudent first step. The team is able to do this by reviewing the literature, laws, and regulations. The Americans with Disabilities Act (ADA) Titles I, II, and III and the Rehabilitation Act (see Table 2) are the constellation of laws that prohibit discrimination and govern accommodation in pharmacy experiential education.¹⁵ Individual states may also have additional laws that protect disabled students.

Table 2. Federal Laws and Regulations that Protect Students with Disabilties¹⁵

One area that all employers and employees need to understand is that accommodation can include variations on the workspace or equipment needed to complete various tasks, how work is assigned and communicated, the specific tasks, and the time and place that the work is done.¹⁶

2. Establishing essential learning activities and outcomes for students helps all students, not just those with learning or physical disabilities. This means specifying essential functions, minimum competencies, expectations, and procedures that all students must be able to perform by the end of the rotation.¹⁵ Preceptors should note that accommodating a student’s needs does not mean lowering expectations.¹ A PRO TIP here is that sometimes a student can meet the expectation with only small changes in the preceptor’s style. For students who have information processing issues, asking questions and then pausing for five seconds to allow the student to answer is better than rapid fire questions.¹ (This is actually an approach that all preceptors and teachers need to use more in all situations. Pausing benefits everyone, including people who are not native English speakers.)

3. The rotation site should make reasonable accommodation based on a reliable diagnosis that the student has documented via the school’s office of student disabilities. The pharmacy school’s office will also provide documentation of the requested accommodation to preceptors; students who have disabilities should not make the requests to preceptors on their own; they may, however, provide the accommodation letter and any information they want to share with the preceptor and copy the school’s director of experiential education if that is the school’s policy. One area that can be difficult for preceptors is the student’s healthcare appointments.¹ A PRO TIP is to ask the student at the beginning of the rotation if you need to be aware of any scheduled appointments. Preceptors should also be very clear that the student must notify them of unanticipated appointments as soon as possible (or even before they call to schedule the appointment). If students miss time at rotations, they are responsible for making up the time.

Documenting and discussing reasonable accommodation with the individual student who has a disability may be an uncomfortable or unfamiliar task for preceptors but will avoid problems later. Preceptors should meet with students to discuss exactly what they need in relation to their experiential outcomes (using the aforementioned list of specifying essential functions, minimum competencies, expectations, and procedures), asking questions such as^1,15

• What limitations do you anticipate experiencing on the rotation?
• What tasks will you find problematic?
• What have you done in the past to reduce or eliminate these limitations?
• Do you anticipate needing us to make any modifications while you are here?
• What will you do if you encounter an unanticipated obstacle?

Here’s another PRO TIP: Knowing a few ways to accommodate disabilities will help preceptors help the student. For example, a student who has severe anxiety will find many rotations difficult and threatening. A preceptor can suggest that the student observe or “preview” activities before requiring interaction, especially if the site is fast-paced or chaotic. Allowing the student to arrive early may also help. Students who are challenged organizationally may benefit from one (not multiple) outline of what to expect every day.¹

4. The student should self-assess and document how the disability affects each general competency and how accommodation could mitigate each concern.¹ Figure 1 describes the process of preceptors choosing accommodation.

The preceptor and student should develop an accommodation plan together and document it in writing. An ideal plan would list the intervention or accommodation and how it supports the student, those involved in creating the accommodation, and the parties responsible for any financial costs (discussed below). ¹¹ For example, in a pharmacy setting where a great deal of business is conducted over the phone using headphones, a student who has difficulty hearing may need a phone amplifier. If the student wears hearing aids, headphones may interfere with her ability to hear. The plan should also include specific days/times for periodic check-ins so the student and preceptor can assess whether the intervention/accommodation meets the students’ needs and is still reasonable for the site.¹¹

A PRO TIP for preceptors is to stay abreast of technology changes.¹⁶ If students have difficulty reading or writing—these are students with dyslexia or dysgraphia—many programs now have read-aloud or voice-to-text programs that are remarkably accurate. Some calculators will talk. Encourage students to use them. Asking students to listen to their work using a read-aloud program will also help them catch errors.

PAUSE AND PONDER: You meet with your new APPE student and learn that he has serious visual impairment. He indicates he needs to use assistive devices (supplemental lighting, a magnifier). How would you initiate a discussion about who will secure these devices?

The last step, which overlaps with the previous steps to some extent, is providing reasonable accommodation. Readers may read the term “reasonable accommodation” and wonder what is considered reasonable. Accommodation should not pose an undue financial or administrative hardship to the practice site.¹⁵ The law would not consider an accommodation reasonable if it decreased quality or posed safety issues to patients or imposed undue financial or administrative burden on the institution. It would also be unreasonable to change curricular elements or alter course objectives substantially. Preceptors might reach out to the school’s experiential education office who can contact the university’s legal department to determine whether a specific accommodation is reasonable. Or, preceptors can contact their own legal representatives. Preceptors and students need to communicate openly and honestly to determine reasonable accommodation together. Table 3 describes some examples of reasonable accommodation.

Table 3. Examples of Reasonable Accommodation in Clinical Experiential ^{Learning8,15-17}

Emphasis on Planning Ahead

Before rotations start, students with disabilities and preceptors should complete a practice walk-through at the rotation site to identify, modify, and make necessary adjustments.¹³ The experiential team must also understand the student’s career aspirations. Frank discussion will help all involved with rotation planning. The experiential team and the preceptor can address the students’ and preceptors’ concerns, needs, and goals in advance. Also, the person coordinating this process should identify and discuss costs and financial resources for the accommodation plan with all parties involved and determine who is responsible for the costs. This creates clear expectations. ¹³

If during the check-in or at any time a situation changes, the plan needs revision to find a more acceptable or effective reasonable accommodation or an urgent concern arises, the student or the preceptor should contact the school immediately.¹³

CONCLUSION

Preparing and executing accommodation can be challenging. Preceptors who develop skills in this area help student pharmacists develop communication, collaboration, and planning skills they will use and improve all during their careers. Preceptors also assess the actual barriers associated with the student’s disability in a controlled environment and help students learn how to mitigate the challenges associated with their disabilities in future employment. A PRO TIP is to keep in mind that many employees have disabilities or have slightly different learning styles. Learning how to accommodate them from students and schools of pharmacy will benefit your entire work force. It may even help you!

Download CE Activity

INTRODUCTION

Let’s begin this continuing education activity with some questions. What makes a nurse a nurse? What makes a nurse a good or exceptional nurse? What makes an electrician an electrician? What makes an electrician a good or exceptional electrician? What makes a pharmacist a pharmacist? What makes a pharmacist a good or exceptional pharmacist? Those questions are no doubt difficult to answer. Preceptors may be making a list mentally of the qualities that the ideal nurse, electrician, or pharmacist should possess. Certainly, for each of these professions, education will be the foundation. Here’s a harder question: Is it possible to be a good or exceptional nurse, electrician, or pharmacist but a terrible person? And is it possible to be a good and loyal pharmacy employee, but not such a good pharmacist? All these questions speak to the concept discussed here: professional identity.

Discovering what it truly means to be a healthcare provider goes beyond knowledge acquisition and education for pharmacy students; it demands a transformative journey of professional identity formation (PIF) starting even before introductory pharmacy practice experiences (IPPE) (perhaps with acceptance into a pharmacy program or during professionalism ceremonies) and continuing past graduation and over an entire career. As the introduction hints, preceptors must distinguish between education, professionalism, and professional identity. A quick way to differentiate between the latter two is that a student’s professionalism is outwardly observable. Professional identity, however, is defined by a student’s internal thinking, feeling, and acting like a member of the pharmacy profession and its community.¹

Pharmacists can use their extensive, science-based education to assume many professional identities; they may work in community, hospital, health-system, research, information technology, marketing, or a vast number of other positions. Viewing the history of the profession in just the last century, various identities have accumulated (rather than shifted) over time.² The typical pharmacist’s main responsibility was once compounding. As the industrial revolution made it possible to produce dosage forms en masse, compounding fell out of favor and dispensing manufactured products became the primary focus of a typical pharmacist. Within just the last 20 years, pharmacists have made major inroads into establishing their role as necessary health care professionals rather than just retailers.³ Pharmacists have been shown to be key in improving therapeutic outcomes with a new focus on patient focused intervention.⁴ Pharmacists’ employment opportunities are growing and adapting to a changing field but the profession’s fundamental or core values are somewhat fixed. Table 1 lists the pharmacy profession’s current core values as promulgate by the American Pharmacists Association.

Table 1. The Pharmacist’s Core Values^5,6

PAUSE AND PONDER: Look at Table 1. What other values would you add to the table?

As the profession’s identity evolves, pharmacists’ identities and their core values must follow suit. While pharmacists must be lifelong learners and adapt over time to new conditions, change is most readily achieved in the initial learning process as pharmacy students. In other words, you can teach old dogs new tricks, but it’s easier to teach puppies. In class, faculty teach students information a pharmacist should know and address how to outwardly act like a professional, but the profession demands something more: the development of a professional identity. We rely on our community of pharmacist preceptors to augment the various didactic courses to cultivate new pharmacist graduates who identify strongly with our core values.

PIF is a crucial aspect of pharmacy experiential education. Students require experiential learning and immersion into the profession to assimilate the qualities that make pharmacists unique and different from other healthcare providers. The Accreditation Council for Pharmacy Education (ACPE)-required IPPE rotations provide students with important opportunities to influence PIF, and the PIF process continues during a student’s advanced pharmacy practice experiences (APPE).⁷

The Pharmacy Student’s IPPE Rotation

IPPE rotations serve a much broader purpose than students fulfilling educational requirements and completing dreaded 50-page workbooks that some schools use that aim to help them reflect on or consolidate learning. IPPE rotations should introduce students to the way front line pharmacists navigate real-world pharmacy practice situations. Students primarily relegated to counting pills and organizing stock in the back of a pharmacy are unlikely to develop professional identities. If students perceive that preceptors think of them as free labor or burdensome obligations, they will not engage in the deeper discussions about the preceptor as a person fulfilling professional obligations. Students should observe and actively take part in various aspects of the profession, applying theoretical knowledge acquired in classrooms to real-world situations. Practical knowledge gained through these experiences helps students to develop essential professional skills and test their learning.

Experiential learning rotations should also expose students to different types of pharmacist positions and responsibilities. By observing different practice settings and interacting with pharmacists, patients, and other healthcare professionals, students can explore their interests, while realizing their strengths and developing professional values.

Step-by-Step to Professional Identity

Throughout pharmacy education, faculty members encourage students to exhibit professionalism; they may

• suggest more productive ways to present ideas
• prompt students to elevate or refine language or speak in ways patients will understand, or
• suggest that certain clothing choices can diminish peoples’ view of them and their credibility

While classroom faculty can teach and model the concept of professionalism, preceptors have the responsibility of supporting students in their PIF journey. Teaching starts the learning process; ultimately, students will need to “create their own adventures.” In other words, they must learn to apply aspects of specific material and explore different experiences to develop a professional identity. Relating to the definition of PIF, a pharmacy student’s PIF process must involve thinking, feeling, and acting like a pharmacist.

To discuss professional identity, preceptors and all pharmacists who influence the student’s learning process must acknowledge the steps inherent in PIF. Personal identity is based on an individual’s concept of who they are and how others perceive them.⁷ Individuals develop personal identity in stages starting at birth but personal identity begins at birth and continues throughout life. Professional identity develops in a similar but slightly different way.

Robert Kegan, a Harvard psychologist, developed a framework for longitudinal development of the self into a moral meaning-making entity that has had lasting impact on PIF in education of professionals.^3,8-10 His framework includes six stages with stage 0 beginning at birth. Stages 0 and 1 concern young children’s development of basic motor function and sensing the physical world around them (and are not discussed here).⁸

In relation to PIF, the health professional must pass through at least stages 2 through 4 of the framework: imperial, interpersonal, and institutional.¹⁰ This framework, with steps 2 through 5 shown in Table 2, defines the personal characteristics and related professional context of an individual in continuous stages of development. Individuals who reach the final stage, stage 5, or the inter-individual self-transforming stage, open themselves to multiple identities and other value systems, achieving full personal autonomy.⁸ Research shows that not all individuals reach stage 5.^10,11 However, with effective socialization partnered with experience in the pharmacist’s potential identities, students may reach this level during their careers.

Table 2. Kegan’s Stages of Personal and Professional Identity Development­^8,10

The constantly evolving pharmacy profession and the lack of a specific list of steps for PIF makes it challenging for students to define an identity (and preceptors to help them). As the profession continues to develop to offer a wide range of opportunities for pharmacists, preceptors will observe students finding varying paths of PIF. Different pharmacists will define the profession differently depending on their experiences. Pharmacy students might generally navigate this list of steps, common among many young people developing professionally^12-15:

1. Exploration: In any career path, exploration is the first step in PIF. In pharmacy, the American Pharmacists Association offers the Career Pathway Evaluation (https://www.pharmacist.com/Career/Career-Pathways) to help aspiring pharmacists find a path forward. IPPE and APPE rotations should ideally provide students with opportunities to explore various pharmacy practice settings and work with pharmacists with a range of responsibilities. Students need to augment their existing identities—formed by their upbringing and personal beliefs—as they begin their pharmacy education and careers. Students come from diverse backgrounds with varying past experiences, cultural values, learning styles, and personal characteristics.
2. Reflection and integration: Educators should encourage students to reflect on their experiences, strengths, values, and areas for improvement. Reflection helps students align personal and professional values, shaping their professional identities. Self-reflection and reflection from preceptors during IPPE rotations is necessary for growth. For example, a technician told Jayne, a pharmacist for a chain pharmacy, that a patient was in the counseling room and ready for an immunization. Jayne took her student with her to observe. Jayne asked the student to review the necessary paperwork and make sure the patient, a 17-year-old adolescent, met all the criteria for the human papilloma virus vaccine. The student said he did. When Jayne reviewed the paperwork, she found one problem. She asked the patient, “Which of your parents is here with you today?” In Jayne’s state, the legal age of consent was 18. When contacted by phone, the parent agreed to come in immediately and Jayne administered the vaccination. After all was done, she spent just a few minutes talking to the student about the duty to protect and comply with the law, describing a couple of other instances when she encountered similar situations.
3. Commitment and advocacy: Commitment to the pharmacy profession and dedication to lifelong learning are essential elements in the development of a professional identity. Pharmacy students will become spokespeople for the profession and advocate for the inevitable change from retail-based to clinically- or service-based work. Pharmacists with solid professional identities will be lifelong learners and educators.

Students who have never worked in a pharmacy or observed a pharmacist at work (and some who have) may have inaccurate ideas about the profession. Preceptor Eddie encountered a curious situation when Adam, a P2 student, reported for an IPPE rotation. Adam was more than self-assured; Adam had an exaggerated sense of self-worth. He was bumptious (self-important or smug), so Eddie needed to work around Adam’s personal identity. Adam told Eddie that his older brother was a pharmacist who had told him that pharmacy schooling is pretty worthless. Adam said, “All you need to do is pass and you’re on your way to a darned good salary.” Eddie was astounded. Adam needed help reaching Step 2 of the PIF model—he was putting his own needs and beliefs first and disregarding others’ views. Eddie created a plan to help Adam develop more insight.

Each day when Adam came to work, Eddie presented two or three situations from his work experience that required more than just a body behind a computer. He would ask Adam to work through the problems and present the answers by the end of the day. In this way, he educated Adam about professional responsibility and clarified the difference between a person with a pharmacy degree and an exceptional pharmacist. PIF’s goal is for students to move from playing or imagining the pharmacist’s role to internalizing the pharmacist’s identity and acting as pharmacists at the unconscious level. The process shifts emphasis from ‘doing’ to ‘being.’ While professionalism can be put on and taken off like a white coat, professional identity stays with the healthcare professional at all times. Eddie was able to improve Adam’s professionalism, which was poor at the rotations start, and contribute to Adam’s professional identity.

PAUSE AND PONDER: When you were a student, which preceptors influenced your core values and how did you internalize them?

Activities that Develop Professional Identity

Preceptors who work in different types of positions need to acknowledge their personal and professional strengths and limitations to determine what they can realistically offer to students. Before taking on the preceptor’s or mentor’s responsibilities, professionals must be familiar with their own skillsets.^7,14

• The first step preceptors should take is to embrace self-reflection. Just as preceptors should encourage students to engage in reflective practice, pharmacy is a profession in which preceptors must be lifelong learners. Established pharmacists will continue to accumulate PIF-related experiences over time to aid their effectiveness in guiding others.
• Preceptors will then need to plan intentionally and commit to helping students develop professional identity. A reluctant or unprepared preceptor usually cannot teach students effectively. Sometimes pharmacists with extensive work experience on the frontlines might feel that students come with a more contemporary knowledge base and therefore, they have nothing to teach them. However, that pharmacist could be well-positioned to support the student’s PIF by embracing how their professional experiences led to a deeper understanding of their profession and the pharmacist’s role in supporting patient outcomes.

PAUSE AND PONDER: What are the most efficient ways to help your students develop professional identity in your practice location? What are the most important ideas you can teach? Are they the same?

PIF is a gradual process that revolves around socialization, not classroom lecture. IPPE rotations provide an ideal platform for students to engage in activities that promote professional development. Preceptors can work with students to facilitate PIF during an IPPE rotation in several ways. ^7,16,17

Patient interactions: Direct patient interaction during IPPE can help students apply theoretical learning and develop communication skills, empathy, and a patient-centered approach to care. These experiences help students internalize a sense of responsibility toward patient well-being and strengthen trust in the caregiver-patient relationship.

Preceptors should expose students to patient counseling sessions as observers as often as possible. Consider Leonard, a preceptor who frequently tells students, “I am not going to bring you into this counseling session because it is too complicated. You won’t understand what’s going on.” This is a mistake. IPPE is an opportunity for students to be exposed to difficult real-life examples before they have to handle them alone. These experiences help develop professional identity and may even stimulate an “ah-HA!” moment about pharmacist responsibility for the student. Preceptors who ask students a few open-ended questions (e.g., What did you see that surprised you? What three points did I emphasize? What counseling techniques will you remember from this?) prompt students to engage. Inviting students to see a situation that requires pharmacists to work at the top of their license introduces step 4 (institutional)  and epitomizes PIF. Leonard has the opportunity to show his version of an independent and talented pharmacist who contributes to healthcare positively.

PIF opportunities need not be complicated. Sometimes PIF occurs concurrent with simple everyday tasks. Preceptors who walk students through their thought process when processing an order (i.e., Why does this document go here in the electronic medical record? Why am I looking at that lab before processing the order?) introduce students to the necessity of questioning routinely as a professional function. They can also ask students to find or calculate doses, explore drug interactions, and then provide the information to another interdisciplinary team member.

Not all patient interactions are pleasant or welcome, but they may be professionally necessary. Alex, the pharmacist, was dismayed when a technician came to him and said, “Mrs. Royce is here and wants to talk to you,” while rolling her eyes. Mrs. Royce was notorious for being loud, disrespectful, and a know-it-all. Alex didn’t answer immediately. The technician said, “Shall I tell her you are busy?” Alex said he would talk to her and briefed the IPPE student on Mrs. Royce’s personality. He said he was concerned because Mrs. Royce had recently had surgery, had a reaction to the opioid that was prescribed, and was switched to tramadol. He explained that regardless of his personal feelings, he needed to deal with the situation. When he asked Mrs. Royce how he could help her, she said, “The oxycodone made me sick as a dog. My friend up the street who is a nurse says the tramadol I am taking now is not worth anything. I am taking it and it is super mild but at least it’s something. I have an anti-inflammatory, too. I know this is a first-world problem since this was an elective surgery, so I should not complain. I am just a whiner with pain.” Alex reassured her that no one deserves pain, even if the surgery was elective. Alex counseled the patient with these points^18-20:

• Tramadol is a funny drug. People with certain genetic variations called CYP2D6 deficiencies get less relief from it. It gets a bad reputation because many clinicians don't know that. Take it if it helps. And it sounds like it helps a bit.
• Schedule your anti-inflammatory around the clock. Don't wait until the pain is horrible. Take it every four to six hours for a few days. Eat a little something when you take it.
• Use warm or cold compresses if they help but use them only for 10 minutes at a time once every hour. (You don't want to fry or freeze your skin.) If warm helps, use warm. If cold helps, use cold.
• Move around as much as you can. It increases blood flow to the area.
• Have you tried some acetaminophen? Some people find that taking a couple of acetaminophen once or twice a day for a couple of days helps--it won't address the inflammation but it may help with pain.
• Consider finding an acupuncturist and/or a massage therapist who specializes in pain.

After the session, Alex explained that dealing with patients like Mrs. Royce is an obligation, as is not showing whether he likes her. This attitude aligns with the “interpersonal” step of PIF (step 3)—balancing multiple perspectives and putting others’ needs first. He said that all pharmacists encounter difficult patients. He also said that he planned to check in on her by phone the next day. He asked the student if anything surprised her, and she said, “Yes. You didn’t say anything about the nurse’s bad advice!” Alex explained that professionals don’t speak badly of each other, especially when the information from Mrs. Royce was hearsay. He said he trusts that Mrs. Royce, the consummate know-it-all, will talk to the nurse and the nurse will call if she wants more information. The student was able to teach-back the key points of professional identity:

• Treat all patients with respect, even when they don’t return the favor
• Counsel carefully
• Do not disparage other healthcare providers (talk to them directly if you have a concern about their advice)
• Follow-up.

When the student asked this preceptor for a letter of reference several months later, the preceptor said, “Remember Mrs. Royce? Her attitude is entirely different now. She’s kind and respectful when she comes in.”

Collaborative Practice: Preceptors can highlight interdisciplinary healthcare experiences, demonstrating teamwork, collaboration, and the ability to contribute effectively within a healthcare setting. In a health system setting, for example, many different pharmacists work in the same organization with varying responsibilities. A health system may include an inpatient and outpatient, specialized clinical, emergency department, investigational drug service, and oncology pharmacy. Each position requires modified professional identities and collaboration with different healthcare professionals. A preceptor can join forces with other pharmacists—a model that is increasingly popular and often called team precepting—to ensure students receive a well-rounded education in the short period of time provided.

Exposure to eustress (healthy, stimulating kind and level of stress): A preceptor should take the time to facilitate a learning environment that optimizes the likelihood that PIF will occur. Preceptors can discuss situations that present ethical dilemmas during IPPE rotations, prompting critical thinking, ethical decision-making, and the development of moral reasoning. As students are exposed to common ethical dilemmas, they will begin to develop problem solving skills; build confidence; and think, act, and feel like pharmacists. Students who have not yet assimilated the second step of PIF—the imperial—may be more concerned with packing up to leave at their assigned quitting time than finishing a task. Helping students learn that sometimes the clock should not dictate decisions also develops professional identity.

Exposure to unanticipated, stressful misadventure. Marguerite was precepting a student when a technician came behind the bench with arms raised and a robber holding a gun behind her. The four other employees and the student froze, and Marguerite handled the situation, emptying the vault into the robber’s duffel bag. After the robbery, everyone was shaken but no one was hurt. Although the store manager’s opinion was to send the student home, Marguerite insisted on a post-incident stress debriefing. It gave everyone the opportunity to vent and identify what they did well and what they could do better, and reduced the likelihood of post-incident stress.²¹ As they met, the police returned and said they had apprehended the robber because Marguerite had placed a tracking device in the duffel bag. Marguerite has traversed all the steps of PIF. She considered others in her decisions, balanced multiple perspectives, and maintained her standards.

Although this is an extreme example that underscores the meaning of “unanticipated,” the student reported feeling better and understanding more about the pharmacist’s responsibilities. Other unanticipated events that can convey PIF include dealing with irrationally irate customers, diffusing the situation with a vaccine refuser who wants to espouse her opinion loudly to other patients, or dealing with a patient or employee medical emergency in the workplace. Appropriate and deliberate use of emotion can also focus learners and enhance learning, especially when the material is moving or highlights the patient’s perspective. Preceptors should employ emotion as a teaching tool carefully, since negative emotion (e.g., anger, embarrassment) erodes trust and can disenfranchise students.

Professional involvement: If time allows, preceptors can encourage students to engage with professional organizations. Attending conferences, workshops, state pharmacy board meetings, or seminars that promote professional growth, networking, and exposure to current trends in the pharmacy field builds professional identity. Preceptor Eddie, discussed previously, took Adam to a Board of Pharmacy meeting. Adam seemed uninterested until the Board discussed disciplinary action against a pharmacist who had failed to perform due diligence, leading to a patient’s death and a pharmacist with a drug abuse problem. Adam was less bumptious in the car on the way back to work, and Eddie took time to ask open-ended questions to mold Adam’s professional identity. He asked, “What questions do you have for me?” Adam said, “What is the chance they will get their licenses back?” It created a chance to talk about professional responsibilities and how state boards monitor and ensure public safety. Eddie asked a question of his own “What do you think the patients who experienced poor care or unprofessional behavior from those pharmacists think about the profession of pharmacy? In the world of social media, how far do you think those negative sentiments about pharmacists can spread?" This discussion moved Adam further through Step 2, and away from a preoccupation with self-interest.

Formative feedback (feedback that helps students recognize knowledge gaps and molds the student’s beliefs and values; see the SIDEBAR) and encourage reflection. Preceptors should⁷

• Provide students with regular feedback, but also schedule time for check-ins and reviews mid-rotation. As students’ professional identities develop, they will become their own sources of feedback.
• Employ teaching methods such as using teach-back and open-ended questions.
• Schedule time for students to work on workbooks or other tools for reflection and encourage discussion and questions.
• Assign meaningful work to help students integrate ethical principles, evidence-based practice, effective communication, and patient-centered care.

SIDEBAR: Formative Feedback^22,23

Formative feedback

• refers to informal constructive feedback provided throughout a learning process
• is ongoing and proactive
• is specific and actionable
• helps to develop self-awareness and independence
• gives students the opportunity to reflect and adjust without being graded
• and is not summative feedback (a method of assessment where students are evaluated and/or graded on their overall performance usually at the end of a learning period)

Open ended questions are important in formative feedback. Just as healthcare professionals are encouraged to ask patients open-ended questions, preceptors should do the same with their students. Open-ended questions

• give students the opportunity to participate in discussion actively and gain a deeper understanding of a topic or situation
• can help the preceptor identify gaps in a student’s understanding
• develop students’ critical thinking skills and autonomy to further their PIF
• are especially useful after patient counseling or other interaction.

Teach-back, or the "show-me" method, confirms whether a person—a patient or in this case, a student—understands the topic being explained. Pharmacists and other healthcare providers use the teach-back in patient counseling to facilitate better communication between patient and provider. This tool allows a healthcare provider to assess patient understanding by having a patient explain, or teach-back, what they took away from the counseling session. The healthcare provider can gently correct misunderstandings. Using teach-back with students is especially effective when

• Students observe a complicated counseling session or process
• Students are learning about a new medical device or a medication with an unusual administration route or schedule
• Students need to research a topic that is new to them and may have missed some critical information
• Students witness a situation that is emotionally charged or creates a safety concern

Demonstrating vulnerability. Preceptors often want to hide their deficiencies, limitations, or weaknesses from students so students will have greater confidence in the preceptor’s expertise. Students need to see how mistakes happen and lead to improvement. They also need to see the ethical challenges that are inherent in pharmacy practice. Preceptor Terry received a phone call from a pharmacist who worked at another of her chain’s locations. She knew the pharmacist quite well, and the pharmacist said she had received a prescription for a patient well known to them for hydromorphone 8 milligrams. They were out of hydromorphone and the pharmacist asked if Terry had any 8 milligram tablets. Terry said she did, and the pharmacist said she would send the patient over and to expect him within 30 minutes. When the patient arrived, Terry filled the prescription and being alone with just the IPPE student, prepared to dispense it at the cash register. As required by law, she asked the patient for identification. Much to her surprise, the person presented his driver’s license and he was not the patient. In fact, the identification card was for the prescriber who had written the prescription, a medical resident at a local hospital. She asked the prescriber why he was picking up the prescription and he said that he was helping out the patient who was in terrible pain. It was late in the day, and Terry had received this referral from a colleague who she trusted. She dispensed the prescription despite her misgivings.

The next day when the IPPE student arrived, Terry explained the immediacy of the situation and conflicting professional interests led to dispensing the prescription yesterday, but she still had some nagging doubts. With the prescription volume a bit slower now, she decided to do some follow up. She found that the “patient” had a number of prescriptions filled over months, most of which were filled at her colleague’s pharmacy. However, the initial prescriptions were filled in a town 40 miles away. She eventually called the hospital, found the name of the residents’ supervising physician, and contacted him. After brief discussion, he indicated that he would handle it going forward and that he appreciated the information. Although the supervising physician did not say outright that he suspected this resident of wrongdoing, the implication was that was the case. The supervising physician did follow through and eventually, the state requested documentation. Terry was able to talk through the situation with the student and explain the pharmacist's responsibility in cases like this. Terry exemplifies Step 4 of PIF. She was secure in her identity and despite the way others had handled this situation, she was concerned and confident enough to do the right thing.

Teach-back is useful in many situations, but especially when processes are involved. In one busy pharmacy, a man approached the pharmacy student at counter. He said, “Can I get a shingles vaccine today?” The student, having no prior experience in a community pharmacy, politely asked the patient to wait while she asked the pharmacist. Her preceptor said quickly, “Get the patient’s insurance information and enter him into the system.” With the patient’s insurance card in hand, she began to enter his information. Unsure how to proceed, she asked the pharmacist for assistance again. A line began to form behind the man, so the pharmacist said, “Don’t worry, I’ll do it and you can watch.” The intern watched and thought the process looked easy enough. The pharmacist asked if she understands (a close-ended question), and she said yes. Later in the day, a new patient came in and the student began to enter the patient’s insurance information. She hit a point where she was unsure how to continue. But earlier she told her preceptor that she understood how to do it! She really thought she did know how! The student, becoming flustered, was embarrassed to ask for help again on something she had just learned. How could this situation have been avoided? If the preceptor had asked the student to describe the process, correcting any inaccuracies in recollection, and explained why pharmacies need to provide accurate information, the student would have been in a better position to help.

Overall, preceptors need to provide students with the best experience possible with available time and resources. For example, a student may be in a health systems rotation in a department that has little patient interaction and plenty of down time. The preceptor may worry he cannot give the student the experience she deserves. This preceptor could assign the student to review a journal article on a relevant subject and present it to an interprofessional team of nurses, pharmacists, and doctors. Subsequently, the student may realize the pharmacist’s potential impact and help the student internalize what it means to be a pharmacist.

PAUSE AND PONDER: Can you recall a time when you were taught how to do something, told your teacher you understood it, then could not perform the action on your own? As a preceptor, how would you avoid this situation with your own student?

Finally, let's return to the questions asked at the beginning of this continuing education activity. In particular, the question of whether a pharmacist can be a good employee, but a bad pharmacist, is of tremendous interest right now. The situation it brings to mind is that of the good employee pharmacist whose supervisors urge him to dispense opioid prescriptions as written and avoid asking too many questions. Doing so makes customers happy, increases prescription volume, and reflects positively in the store’s metrics. Many pharmacists conducted themselves this way for many years, despite the fact that they probably had an inkling that they should be checking more closely or perhaps turning some prescriptions away. These pharmacists were not necessarily bad pharmacists, but their employers considered them good employees because they followed directions and turned a blind eye to a developing opioid epidemic.

In November 2021, a federal jury in Ohio found three of the nation's largest pharmacy chains liable for contributing to the U.S. opioid crisis.^24,25 The jury found that the prosecution provided ample evidence that some medications dispensed at chain pharmacies legally were sold on the black market. That finding has resonated nationally as state after state filed similar lawsuits. In December of 2022, two chain pharmacies agreed to share a $10.7 billion fine to settle allegations that they failed to oversee opioid analgesic prescriptions adequately. These funds are being distributed to states, local governments, and federally recognized tribes to improve opioid crisis abatement and remediation programs. Both chains agreed to improve their controlled substance compliance programs and provide mandatory training to pharmacists. Expediency in the short term and compliance with procedures that are unethical seldom avoid long term consequences.

Other states have also secured settlements from pharmacies, and independent pharmacies have also been prosecuted. Discussing situations related to pharmacy that appear in the media is another way that preceptors can introduce discussion of our professional values. The nation is hopeful that pharmacists everywhere have learned that part of our professional identity is the necessity to speak up and to challenge our employers when they ask us to do things that walk the line of professionally ethical behaviors. Starting discussions with students about newsworthy events like this in which preceptors talk about self-interest, other people’s perception of pharmacy and pharmacists, and maintaining standards can advance our profession. Pharmacists are part of a complex system of drug distribution. We need to establish our core values and uphold them to keep society’s respect.

CONCLUSION

Pharmacy educators, preceptors, and mentors must realize the significance of IPPE and APPE rotations and their influence in shaping future pharmacists’ professional identities. Professional identity formation is essential for students’ transformation into successful and compassionate pharmacists. IPPE rotations with effective preceptors enable students to observe, participate, and reflect on various aspects of pharmacy practice. Often these exercises take very little time, and small actions can have tremendous impact. Through exploration, reflection, and commitment to the profession, students can develop professional identities that align with the core values and beliefs of the pharmacy profession and their own personal values.

As students grow throughout their educational and professional careers, they will internalize what it means to be a pharmacist. Changes may not be apparent in the short amount of time a preceptor is with a student. If students are comfortable with the idea, preceptors can connect with them on LinkedIn, stay in contact through email, and be open to being a mentor to the student after the rotation ends. Pharmacy is a profession of many interconnected individuals with unique and valuable professional identities.

Download CE Activity

INTRODUCTION: A PATIENT CASE

JM, an 8-year-old white male presents to your clinic. It’s a pediatric care clinic located in an area where many financially challenged families live. After talking with his parents, you learn he was recently diagnosed with central precocious puberty (CPP). His endocrinologist recommends initiating therapy and would like to know what treatment you recommend. His parents also have questions.

Your spry pharmacy student jumps at the opportunity to write a SOAP note using the “PPCP.” To you, PPCP sounds like an illegal drug that was abused in the 1980s. She explains that the Pharmacists’ Patient Care Process (PPCP) is a standardized model for collaborative medication management. She clarifies what it entails and how to apply the process in a clinical setting.

PPCP’s Importance

Schools of pharmacy have taught the PPCP for the past few years. Preceptors who are unfamiliar with the process may find it helpful to review the PPCP as many students will take this approach when addressing clinical problems in the workplace.

PPCP: THE DETAILS

Teamwork in healthcare has achieved major goals for many patients (although we have room for improvement): accessible, affordable, and high-quality care. In addition to the many healthcare team members, pharmacists are critical contributors to care plans. Medication expertise equips pharmacists with the knowledge to reduce drug adverse events, prevent medication errors, and provide invaluable input for decision-making.¹

In 2014, the Joint Commission of Pharmacy Practitioners (JCPP) developed a standardized process for medication management that could be used across interdisciplinary teams and dubbed it PPCP. JCPP’s members developed the approach using principles of evidence-based practice. The five steps—collect, assess, plan, implement, and follow-up—are tied together with careful communication and documentation.² Pharmacists can remember the steps as the pneumonic “CAP-IF.”

SOAP Notes

The subjective, objective, assessment, and plan (SOAP) note provides a method of documentation for the collect, assess, and plan steps of the PPCP. SOAP notes are probably familiar to most preceptors, as clinicians have used them for roughly 50 years.³ Table 1 highlights the key components of SOAP notes.

Table 1. Components of a SOAP Note¹

Collect

Thorough collection of the right information supplies pharmacists with tools to make safe, effective decisions. A combination of objective and subjective information paints a more complete picture of a patient’s clinical status. If possible, pharmacists should obtain and verify their information across multiple sources. Past medical records, active medication lists, and laboratory results are great places to start.

When soliciting subjective information, pharmacists should use open-ended questions. Prompting patients with questions formatted to avoid “yes” or “no” answers allow providers to obtain more information in less time, prioritize chief complaints better, and minimize implicit assumptions.⁴

Back to the Case

Your head is spinning trying to sort all the “P’s” in PPCP, CPP, and JCPP, but your student assures you that she will start with collecting relevant clinical information. First, you and your student perform a physical assessment of JM including taking his height and weight. JM takes no medication except an occasional antihistamine, but if he took other chronic medications, this would be the time to direct your student to perform a medication reconciliation. Next, you prompt JM’s parents with open ended questions, and they recall JM’s past medical history. You should ask your student if JM needs to be involved in the discussion (see SIDEBAR). After meeting with JM and his parents, here is the relevant information your student jots down:

Subjective information

• At age 5, JM frequently soaked through his underarm clothing with pungent perspiration, so since then, he uses a strong deodorant
• He is starting to develop pubic and underarm hair
• He has some acne on his face and upper back
• JM occasionally tells his parents he feels “different” than his classmates because he is so much bigger and taller
• He has no past surgeries or hospitalizations
• Takes OTC multivitamins daily and loratadine for allergies in the spring

Objective Information

• Height = 4’8” inches
• Weight = 102 pounds
• DHEA Sulfate = Tanner stage III - 60 ug/dL (N = < 28 ug/dL)
• Clinical exam findings = testicle size indicates puberty
• X-ray bone age hand and wrist = greater than 2 standard deviations, 156 months (expected = 108.9 months)
• Luteinizing hormone (LH) = 0.4 units/L (N = < 0.3 units/L)

SIDEBAR: Pediatric Involvement in Healthcare Decisions^5,6

In pediatric cases, clinicians may choose to consult only parents when making decisions regarding their child’s medical care. However, this practice, which is rooted in legal precedence, should shift to involve affected children to some extent. The American Academy of Pediatrics advocates that adolescents actively participate in decisions based on their ability and maturity. ⁵ While research is lacking on how exactly to assess a child’s aptitude to participate in decision making, some studies show that children can participate as young as age 5.⁶ Regardless, it doesn’t hurt to ask children if they have questions or concerns. In the case, JM is 8 and has voiced his concern previously about his height and size. Therefore, including him in the conversation is a possibility if his parents agree.

Preceptors can and should provide tangential learning when working with special populations. Reminding students that adolescents, older adults, people who have cognitive decline or dementia, and people for whom English is a second language will need careful counseling. Pharmacists and pharmacy staff will also need to select their words carefully and accommodate these patients’ needs. Assigning students to do some research on the various needs in these populations is an excellent way to help them develop skills and a professional identity.

Upon looking at your student’s notes so far, you assure her she has done well. However, you still have some questions. You remind her that sometimes information like height and weight requires additional evaluation and ask her to calculate JM’s BMI; she finds that it’s 22.9. You ask your student, “How does JM’s height and weight compare to the expected height and weight of boys his age?” To which she replies, “Pediatric growth charts will give us a better idea!” After consulting the growth charts, she determined and documented that JM falls within the 112th percentile for both measurements.

To make learning comprehensive, you could ask the student if the only kind of precocious puberty is central in nature. This will help your student learn to differentiate among different forms of similar diagnoses.

Assessment

An assessment of comprehensive patient information helps prioritize the problems that require attention. Pharmacists should consider all information when identifying the problem, the rationale, and the goals of therapy. Some example questions pharmacists can consider include¹

Medication appropriateness

• What is the indication for each medication?
• What is the correct dosing?
• What are the common adverse effects?
• What are the possible drug interactions?

Factors that impact access to care

• What cultural factors create barriers to care?
• What socioeconomic factors impact the patient?
• What is the patient’s level of healthcare literacy?
• What goals does the patient or his parents have?
• What barriers impact patient adherence?

Additional services

• What preventive care measures does the patient qualify for?
• Which immunizations has the patient received?
• What other concerns does the patient have?

THE CASE RESUMED...

After compiling the objective and subjective information on JM, the student finds guidelines in the Journal of Clinical Endocrinology for the management of CPP.⁷ Due to JM’s symptoms and lab values showing consistencies with CPP, the guidelines recommend initiating a gonadotropin releasing hormone (GnRH) analog. Depending on JM’s and his parents' preferences, the endocrinologist can choose either an injectable (leuprolide) or long-acting implantable device (histrelin) provided the insurance covers it or the cost is manageable.

Once again, you should have some questions for your student. For example, asking the student to list the search terms and search engines she employed can shed light on her process. Another question might be, “Are these the only guidelines available?” You can show her that you used PubMed, as she did, but when you used Google Scholar, you found an excellent review article that lists five other publications. You suggest she look at them since expert recommendations can vary. She might also contact the endocrinologist and ask if he plans to follow the guidelines she identified, and if not, why not.

The endocrinologist messages back saying he agrees leuprolide and histrelin are both reasonable options to consider for first-line therapy. However, he also cites a 2019 update published on Hormone Research in Paediatrics. These guidelines recommend a third U.S. Food and Drug Administration (FDA)-approved option for the treatment of CPP, triptorelin.⁸ He says the student should consider this choice as a potential treatment for JM as well.

After reading the endocrinologist’s note, you emphasize to your student the importance of citing multiple guidelines when drafting an assessment. In this case, the FDA approved an additional treatment, triptorelin, in 2022. You walk through your student’s process of finding clinical information to identify more ways she can improve next time. Furthermore, you point out how the endocrinologist’s insight exemplifies the importance of interdisciplinary care.

Simultaneously, you and your student read through all three monographs and discuss the major differences you’d like to share with his parents. You ask the student to practice her delivery of the information, and she says, “Leuprolide is a long acting injectable administered intramuscularly (IM) or subcutaneously. Your doctor will administer the IM formulation every month, three months, or six months. “Triptorelin is similar to leuprolide, but is only available as a six month IM formulation. The other option is for your doctor to administer the subcutaneous formulation every six-months.⁹ On the other hand, histrelin comes as a long-acting 1¼ inch implant surgically placed into the upper arm every 12 to 24 months. For the first 24 hours after the surgery, JM should avoid swimming or bathing. As long as JM avoids heavy play or exercise for the first week, he will not have to worry about any further restrictions after that. The implant also requires surgical removal.”¹⁰

Now, you prompt the student to recall that JM’s parents expressed concern about what would happen if JM experienced an adverse reaction to the long-acting implantable device. They asked, “What is the procedure like?” and “If JM has a reaction to the implant, must he continue to wear it for 12 months or can the doctor remove it easily before then?”

The student does more research and says she will assure JM’s parents that this outpatient procedure lasts only 10 minutes, though the appointment may last 60 to 90 minutes. Most surgeons will just numb the area; however, children may undergo sedation if necessary. The surgeon will insert the narrow implant into a small approximately 5 mm opening made in the skin on the inner surface of the arm. With this option, JM can return to school the same day. The student plans to mention that complications don’t commonly occur, but minor discomfort and bruising may.¹¹ The student plans to continue, “The implant may be removed immediately if JM presents at any time a severe allergic reaction or adverse effect. However, this is not common.”

Before you and the student document the assessment section of your SOAP note, the student indicates she will ask JM if he has questions. He shares that he “HATES needles” but is also scared of the surgery hurting.” The student plans to tell him not to worry because he won’t feel any pain during the operation. He can also choose to sleep during the surgery if he prefers.

Here, the preceptor should step in with gentle corrections about patient-appropriate language. First, most Americans have no idea what a 5 mm incision will look like. You ask her to calculate its length in inches and explain it by comparing it to something the child will recognize, like the size of small dice or a stack of 20 playing cards. Next, it’s critical to remind the student that we must never tell patients that something won’t hurt. This is a lesson students should learn during immunization training and creates an opportunity for cross training (applying this principle to other areas of pharmacy) that applies regardless of patient age. Healthcare professionals should never say, “This will not hurt a bit!” or anything similar. People have different pain thresholds making it impossible to predict whether it will hurt. Student pharmacists need to develop language they are comfortable with and use it. A good response if people ask if it will hurt is, “It may hurt or sting a little but just for a minute or two.” In this case, the preceptor suggests saying, “The doctor will numb the area.”

Finally, the preceptor may point out that “operation” can be a scary word for children. The student needs to use a word like “procedure” or find a way to avoid either of those words.

The preceptor should also point out that JM’s parents had also said they were worried about two things: (1) potential side effects and (2) the cost of care. They heard on the news that expenses associated with these medications can add up quickly. The cost of care and determining what the patient’s insurance will cover is probably foremost in the endocrinologist’s mind, too.

In terms of potential side effects, your student says that both GnRH analogs have similar side effect profiles. From the pediatric studies she read on GnRH adverse effects, she shares that signs of puberty may increase transiently with therapy before growth velocity eventually slows down. Some children experience weight gain, changes in appetite, body aches, headaches, gastrointestinal (GI) symptoms, or signs of a common cold. Parameters like physical growth and bone mass density may decrease during treatment but usually return to normal one year after treatment discontinuation.^{9, 10}

Before selecting JM’s treatment option, it’s critical to evaluate insurance coverage since it’s on the forefront of everyone’s concerns. The student needs to determine if they have insurance and what the plan covers. She starts by finding information on ballpark cost. She reports a histrelin implant costs around $40,000. If the patient requires mild sedation when the doctor inserts the implant, the cost may increase. However, in some cases, the implant may be used for up to two years. Leuprolide’s median annual cost ranges from $20,000-$40,000 depending on the formulation.¹² A single injection of triptorelin costs roughly $19,000, making the annual cost nearly $40,000 as well. Then says she will remind JM’s parents that while this may give them an idea, the cost may vary outside of that range.

Plan

Following the assessment, pharmacists work to develop a personalized patient care plan in collaboration with other healthcare professionals. The plan should reflect recommendations from the most recent evidence-based clinical practice guidelines. Pharmacists should focus on optimization of care in a safe, effective, and cost-effective manner.

1. Address medication-related problems and optimize medication therapy
2. Set specific, measurable, achievable, realistic, and timed (SMART) goals in the context of the patient’s healthcare goals and access to care
3. Involve patients to engage in education, empowerment, and self-management
4. Support non-pharmacologic interventions as appropriate

SMART Goals. When creating an action plan for patients, pharmacists should aim to set goals that are SMART.

• Specific instructions provide other clinicians with accurate information about the patient.
• Measurable outcomes provide clinicians the ability to evaluate the patient’s progress and whether the plan requires adjustments
• Achievable and realistic goals
• A timeline for the plan ensures healthcare providers routinely follow up with their patient

A PLAN FOR JM

After you document JM’s main problem, rationale, and goals for care in the assessment section, you move on to create his plan. Following careful consideration of the assessment, you and your student decide to recommend starting histrelin to treat his CPP since his insurance will cover it once the endocrinologist completes prior authorization forms. (Here, you suggest that the student find the prior authorization forms and volunteer to complete as many sections as she can for the endocrinologist. You explain that she can expedite the process and this is a skill she can apply to many different pharmacy practice locations.) Choosing histrelin is also a needle-free option, which may make JM happy. You remind your student that the plan should also include scheduling necessary appointments and follow-ups with JM’s other providers in addition to counseling on the specific adverse effects of the medication detailed in Table 2.

Table 2. Example SOAP note for JM ⁷

Implement

During the implementation phase, pharmacists set the action plan into motion. This may include the administration of vaccines, initiating or discontinuing a medication, or scheduling the next follow-up appointment. Pharmacists, primary care physicians, or caregivers work together to provide care based on the goals made in the planning step.¹

Follow-up and Monitor

The pharmacist in collaboration with other health care providers should follow-up with the patient as recommended in practice guidelines and referring back to the SOAP note. Continuous monitoring of medication appropriateness, adherence, safety, laboratory results, and patient concerns will indicate if the plan requires revision. Routine medication reconciliations, check-ups, or conversations with patients improve outcomes and help to achieve goals of therapy.

Putting it All Together

Upon completion of the SOAP note, you send the endocrinologist your recommendations. You contact JM’s parents to discuss scheduling a follow-up appointment in three months with the endocrinologist and counsel on histrelin.

IMPLICATIONS FOR PRECEPTORS

The Benefits. The PPCP model creates a reproducible framework that demonstrates clinical pharmacists’ contributions to medication-related outcomes.¹³ In addition to improving the quality and completeness of patient medical records, SOAP notes give pharmacists a place to start when working up a new patient. As students practice developing SOAP notes, preceptors should emphasize how the lessons they learn in one case can apply to future cases.

The Drawbacks. As more pharmacy programs integrate PPCP into their curriculum, new students will have access to courses that teach the model. But because the PPCP model is relatively new, many licensed pharmacists have not yet familiarized themselves with the process. Extracting the necessary information to write quality SOAP notes can also be time consuming. Depending on the setting, pharmacists may not have enough time to walk through every step with students. Finally, the PPCP method does not encompass all clinical situations. The framework relies on pharmacists to exercise clinical judgment and reasoning to modify the model as needed.

Uncomfortable Topics. Students often have little exposure to difficult topics. These may include end-of-life issues, psychiatric diagnoses, cultural or ethnic differences, drug abuse/misuse, and gender-related topics. In this case, students may feel strong discomfort in discussing matters related to sex and sexual development. Preceptors need to help students reduce their hesitancy when communicating with you and the patient because improper communication can lead to poor collection of relevant information. Keep in mind strong note-writing skills facilitate good care. Two things help: (1) practice, and (2) finding resources designed to help with difficult topics. The Conversation Project (https://theconversationproject.org/resources/healthcare/) is one such resource that can help students become more comfortable with difficult topics.

In addition, students may have implicit and explicit biases for uncomfortable topics such as the use of hormone blockers, which may bring to mind their use in transgender children. Creating a safe place for your student to share opinions provides a great opportunity for you to teach students how to avoid these biases. Preceptors need to remember that learning—especially if it changes a student's perspective or points out a student's mistake—can be threatening, and students can feel vulnerable while learning. It’s an emotional experience.⁶

To help guide students through these experiences, the SIDEBAR provides 10 additional tips preceptors can use when supervising the PPCP.

SIDEBAR: PRO TIPS for Preceptors Who Supervise the PPCP

(1) Don't let the acronym scare you! This is a new name for a process you've probably used knowingly or unknowingly for years.

(2) Encourage independence. Hand over the problem to the student once you've described the problem and fielded the student's questions. Establish a time for the student to be prepared to discuss it but check in periodically to see if the student is having trouble.

(3) Rescue when necessary. Some students will need more support than others. If a student is clearly flummoxed, spend more time and provide more direction.

(4) Promote interdisciplinary communication. Having students discuss a clinical problem with another clinician, either with you or on their own, fosters interdisciplinary care. Students will also learn from the other clinicians, which will lighten your load!

(5) When students present findings, always ask them to describe things like the search terms and search engines they used or the obstacles they encountered. Help them refine their processes to reduce barriers or find more appropriate resources.

(6) Consistently prompt students to determine if the case is typical or unusual. Asking questions based on a modification of the case can help students learn more globally.

(7) Don't "stay in your lane"! In this CE, the practice site is an ambulatory care location specific to pediatrics. The lessons a student learns in this rotation, if they go beyond pediatrics, will be invaluable. Helping students develop communication skills or analyze how disease states present or are treated in adults or other special populations will increase their clinical acumen in future rotations.

(8) Address implicit biases or misconceptions. Students may not know that an attitude or opinion is biased, incorrect, or simply rude.

(9) Debrief. After the PPCP is done, provide feedback, ask others who may have been involved to provide feedback, and ask the student to perform a self-assessment.

(10) Appreciate reverse mentoring. Remember that students often teach us new things!

Common Sources of Error

Collecting too little information. Not all the information pharmacists need to collect will be obvious. In the patient case, the student collected important objective information like height and weight. However, without something like growth charts to evaluate JM’s height/weight compared to other kids his age, the information does not help in the assessment. Preceptors can aid students who are new to documenting SOAP notes when they are required to dive deeper into collected information. Students should not make assumptions as to what other clinicians know off the top of their heads. In this case, other areas where the preceptor helped the student included directing her to seek other expert opinions like the endocrinologist. That puts the “inter” in “interdisciplinary” care!

Collecting too much information. Pharmacists and students should collect information worthy of appraisal. In other words, only collect the necessary information that will contribute to the identification, prevention, and resolution of either the chief complaint or medication-related problems. If pharmacists/students do not actively use collected information to make the assessment or plan, they should omit it in the note. Documenting more information does not equate to better information. This leads to overly lengthy or confusing SOAP notes. Here, as in the previous error, preceptors should ask students to examine and explain their processes.

Not verifying information. All information should be verified across multiple sources like when performing traditional medication reconciliations. This prevents possible errors in note-taking that may arise from outdated documentation.

Sourcing one guideline. Depending on the disease state, the frequency in which guidelines are updated can vary. Preceptors should emphasize the importance of looking for multiple guidelines and paying attention to their publication dates. Occasionally, the FDA may approve new treatment options after the release of clinical guidelines or updates. In this case, the student completely missed an additional treatment option as a result of sourcing a single guideline from 2013. Similar to how preceptors should encourage students to verify collected information across multiple sources, preceptors should also encourage students to cross-check sources that aid in their assessment.

The assessment lacks evidence. As mentioned above, the assessment should communicate the assessor’s thought process. The information collected by the pharmacist/student should justify why the problem is a problem. If there is no subjective or objective information to back up the assessment, the assessment has no basis.

Forgetting recommendations on current medications. Pharmacists/students should not forget to include instructions for the patient’s current medications, not just the newly prescribed medications.

Forgetting non-pharmacologic recommendations. The plan section also encompasses non-pharmacologic interventions such as referral to another provider, ordering additional laboratory tests, education, or counseling on lifestyle interventions. Pharmacists/students should remember that not all patients require initiation of a new medication.

Being vague. When initiating new therapy appropriately, pharmacists/students should always provide specific recommendations with the drug name, dose, and frequency. Vague instructions such as “Initiate hormone blocker therapy” are unhelpful. Similarly, instead of “monitor for side effects,” pharmacists/students can list the specific symptoms that present most commonly.

Poor communication. Errors due to poor communication directly hinder the PPCP. Furthermore, clinicians with experience are not necessarily better communicators. Therefore, pharmacists should engage in education/training to constantly improve communication skills. SOAP notes should effectively communicate the pertinent information used to create a plan and document important details for the patient’s medical record.

Setting it and forgetting it. The PPCP is not a linear process. While this framework provides clinicians a place to start and a checklist of sections to complete in order, pharmacists should remember to review and revise all sections at any given time. For example, pharmacists may identify new information they should go back to collect as they work on their assessments. Preceptors should encourage their students to occasionally step back and evaluate the completeness and coherence of the SOAP note. Sometimes patient cases will require students to revise sections of the SOAP note they already completed.

And a New Case

Just before the end of the month, the endocrinologist sends yet another patient with precocious puberty to you. The patient LD is a 9-year old Hispanic female. Her endocrinologist recently diagnosed her with idiopathic precocious puberty and wants to know which treatment you recommend. Her parents also want to know why this is happening to their daughter. Before taking LD’s family from the clinic waiting room, you decide to let your student take charge of this case while you supervise. You ask your student “Now that you have practiced writing SOAP notes and know a little about this disease state, how will you approach the PPCP this time?”

The student says to you...

“I stored all my notes from the last case on precocious puberty from earlier this month. I have a document containing the guidelines from the Journal of Clinical Endocrinology along with several updated publications that cite all additional first-line medications approved after the original guideline’s release. I will start with the collection of subjective information such as LD’s symptoms and medical history followed by objective information, specifically pertaining to her growth statistics. I should calculate BMI and her height/weight percentiles since precocious puberty is usually associated with accelerated growth. Next, I will examine her relevant lab values. Since the patient is female, I will be looking out for progesterone levels this time. If possible, I shall cross-reference all of the information I collect across multiple sources.”

“Before I move onto making an assessment, I understand LD’s parents may feel very concerned about their daughter's condition. I don’t want to forget to address their question. I will explain that idiopathic precocious puberty does not have a definitive cause. To help them better understand, I’ll mention that idiopathic cases may result from anything ranging from a head injury in childhood to exposure to certain chemicals. Regardless of the cause, I will assure them there are several treatment options that may be appropriate for LD at this time. I can walk them through the pros and cons of all the available options.”

“Next, I would prompt LD’s parents with open-ended questions to learn more about their major concerns, potential barriers to medication therapy, and insurance eligibility. I know these are important considerations for my assessment. It would also be appropriate for me to engage with LD using appropriate language for a 9-year-old girl. I realize the topic may be uncomfortable to discuss, but without taking initiative of the discussion I may forget to include pertinent details in my SOAP note.”

“Finally, using the information I collected about the family’s preferences and LD’s medical history, I will draft the chief complaint, rationale for treatment, goals of therapy, and eventually a completed plan. The plan will include which treatment I recommend along with the dose, frequency, and which adverse effects are most common. I will write when I recommend a follow-up with her endocrinologist and make note of which lifestyle modifications may support her specific treatment. If the endocrinologist is on board, then we can collaboratively implement and follow-up with the patient as appropriate.”

You are overjoyed to hear that your student has taken what she learned from the previous case and applied it to this case as well. Although some of the parameters were different, such as the patient’s sex, she was able to anticipate how the changes may impact her SOAP note this time. While you identify a few areas in which she can improve, you are happy that she is continuing to expand her clinical pharmacy knowledge.

Conclusion

The PPCP model can be applied to any healthcare setting in which pharmacists practice. This comprehensive approach to patient-centered care has established a streamlined method of documenting patient information to be shared among healthcare teams. As the PPCP continues to grow in clinical settings, practicing pharmacists should become familiar with its methods and applications.

Download CE Activity