Dealing with Difficult Students: Simple(ish) Solutions to Common Problems

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