Preceptors Edition (PDF)

Professionalism for Preceptors

Exemplary Preceptors

Challenging Cases

Residents and Precepting

Guide to Preceptor Professionalism

by Debra W. Kemp and Leigh Foushee

Modeling is an important, and perhaps the most important, element in developing professionalism. While didactic instruction on professionalism provides useful guidance, it is the interaction with faculty and preceptors that most significantly influence student professionalism. Since more than 25% of the PharmD curriculum is delivered through experiential education, the role of preceptors as models of professional behavior is of the utmost importance.

The APhA-ASP-AACP Dean's Council's White Paper on Pharmacy Student Professionalism defines a professional as someone who displays the following traits:

• Knowledge and skills of a profession
• Commitment to self-improvement of skills and knowledge
• Service orientation
• Pride in the profession
• Covenantal relationship with the client
• Creativity and innovation
• Conscience and trustworthiness
• Accountability for his/her work
• Ethically sound decision making
• Leadership

Professionalism is a broad, constantly evolving concept influenced by a person's perspectives and experiences. Most students embark on their introductory and advanced practice experiences eager to demonstrate and apply the concepts of professionalism to the practice setting, but often find this transition challenging. Seamlessly integrating into the practice requires the ability to demonstrate all of the professional traits noted above.

Preceptors are crucial to this development process as the practice environment is a permanent professional situation that mandates student pharmacists to conduct themselves in a professional manner. Preceptors are there to help instill the attitudes, practice behaviors and values of the pharmacy profession, a process known as professional socialization.

Preceptors can employ a variety of techniques to professionalize pharmacy students during experiential training, many of which have been summarized in various resources available to faculty and preceptors.

Teaching Point 1: Set Expectations
Professional development begins with the establishment and clear articulation of expectations. In addition to establishing specific learning goals and activities, it is important to address behavioral standards. Though we often expect students to have a general understanding of dress code policies, attitude, punctuality, patient confidentiality and internet and cell phone use, we easily forget that the average student has had minimal exposure to professional practice settings or that specific norms may vary somewhat from practice to practice. Preceptors may find it beneficial to discuss their philosophy of practice and provide specific examples of expected versus intolerable behaviors during orientation to familiarize students with the culture for that particular site.

Teaching Point 2: Provide Feedback
To positively reinforce professional behaviors, preceptors should provide real-time, constructive feedback throughout the experience regarding both positive and negative aspects of the student's professionalism, and provide students with opportunities for reflection and self-assessment of their professionalism. Constructive feedback will often encourage students to openly discuss professional issues with their preceptor. This can provide a valuable opportunity for the preceptor to share his/her personal experiences and discuss various "what if" scenarios to further develop the student's professional traits.

Just as the preceptor is expected to provide feedback, the learner should also share feedback with the preceptor regarding the rotational activities. Open dialogue during the experience allows the preceptor to tailor the rotation to the student pharmacist's needs. In addition, conducting an exit interview with the student after the final evaluation can provide useful insights to the preceptor into areas that could be improved.

Asking the student about aspects of the rotation that should be added, deleted, modified or maintained will ultimately strengthen the experience for future student pharmacists and communicates to the current learner a sense of professional respect and value. Communicating these ideas openly and face-to-face provides another avenue for professional socialization as learner begins to identify tactful approaches to challenging issues they may face in practice and develop a sense of ownership in the profession.

Teaching Point 3: Do what I do
Crucial to the message of professionalism in experiential training is remembering that we reproduce what we are. Role modeling is often considered the most critical strategy for inculcating professional behavior. Students look to us to embody the traits of a professional and to abide by the same professionalism expectations set forth for them. Preceptors and site staff must lead by example. In essence, we too are accountable for professionalism throughout the experience. Preceptors can advocate professional volunteerism by leading discussions on organizational involvement, professional aspirations, credentialing opportunities, grassroots advocacy, the value of networking, work-life balance, and other similar topics.

Student pharmacists appreciate having preceptors expose them to professional activities beyond the expected scope of the rotation such as, attending association or committee meetings, participating in special projects, attending continuing education programs with the preceptor, and providing networking opportunities. Modeling the attitudes and behaviors of professionalism prepare student pharmacists to be positive and engaged contributors to the profession.

Our goal for the pharmacy profession is not only for it to sustain itself, but to thrive. To successfully promote this, it is paramount that we coach our student pharmacists, as they transition from the academic setting, about the professional realities that await them and the efforts that are needed to advance the profession.

While the degree of adherence to general practice site behaviors and expectations are the traditional professional attributes assessed during a student's performance appraisal, professional socialization goes much deeper. As preceptors, we must be strong and dedicated role models with the willingness to be open and instill a sense of pride and responsibility for the future of the profession.

For more information

• APhA-ASP/AACP-COD Task Force on Professionalism. White paper on pharmacy student professionalism. J Am Pharm Assoc. 2000;40:96-102. Also available at http://www.aphanet.org/students/leadership/professionalism/whitepaper.pdf.
• Hammer, D. Am J Pharm Ed. 2006;70(3) Article 59.
• Cuellar LM and DB Ginsburg. Preceptor's Handbook for Pharmacists. American Society of Health-System Pharmacists, 2005.

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What makes an exemplary preceptor

by Kim Leadon and Kelly Scolaro

Experiential education accounts for more than one-quarter of a student pharmacist’s education. It is critical for preceptors to understand the importance of their role in teaching and shaping future colleagues, and the strength of influence that their behavioral modeling has on developing pharmacists. Introductory (IPPEs) and advanced pharmacy practice experiences (APPEs) provide hands-on learning opportunities are based on learn by doing principles.

At the heart of these experiences preceptors serve as mentors, teachers, motivators, and "keepers of the flame" of the profession. Preceptors are key links in the translation of didactic knowledge into practice, helping students frame and apply their classroom learning to patient care.

Precepting students can be challenging for many reasons including patient loads, budget constraints, and wide variations in student attitudes, knowledge and skills. This article outlines some tips to help all preceptors be exemplary and enable student pharmacists to excel in the experiential portion of their training.

The Relationship, Communication and Role-Modeling
Instructors and preceptors are by far the most powerful motivator for student learning. This influence goes beyond what you say but what you do and how you do it. An exemplary preceptor:

• is accessible and attentive to student
• communicates with students
• actively listens (i.e. listen more than talk, avoid multi-tasking while student is talking, ask clarifying questions, repeat back what they have heard)
• is aware of his/her non-verbal communication (i.e. eye contact, open body language, proximity to student)
• demonstrates warmth, interest, compassion, enthusiasm
• fosters a trusting and collegial relationship with student
• demonstrates a positive attitude and positive outlook for the profession
• shares personal and professional experiences
• orients students to practice site and to rotation requirements
• provides resources and encourage self-directed learning
• empowers students to achieve their goals by motivating and encouraging students to do their best worksetting students up for success rather than failure; and recognizing and rewarding successes; providing constructive feedback and encouraging students when best work isn't produced;
• acts with honesty and integrity
• maintains and demonstrates professional competence

The Rotation Structure & Teaching Skills

Being a good clinician is a necessary but insufficient quality for being a good preceptor. Preceptors also must also understand and apply principles of good teaching. A good teacher:

• has a plan for student learning; is organized and well-prepared (e.g. a syllabus and calendar are provided for the student)
• defines and discusses learning goals and expectations with student at start of rotation
• provides challenging learning opportunities and is willing to adapt rotation to challenge the student
• assesses knowledge and skills by using tools that align with the objectives (e.g., observes and critiques counseling skills against established criteria rather than using a pen and paper test to assess)
• uses school systems (PEMS) to document progress
• provides appropriate guidance
• provides frequent feedback that is constructive, timely, balanced with both positive and constructive comments, concise, and focused on specific performances related to goals and expectations of the rotation. Preceptors should communicate feedback in private, especially if it is negative or if corrective action is warranted
• encourages students to self-reflect (verbally or in writing) on his/her performance
• understands that translating knowledge from didactic training into actual practice is complex and requires multiple opportunities to practice and refine.

The Practice Site

Part of good teaching and good precepting is setting up an environment that is conducive to learning. An effective practice site:

• promotes leadership by exhibiting loyalty, humility, respect, and fairness toward others; has a "do as I say and as I do" attitude
• develops good management practices and fosters teamwork by being organized, setting goals, delegating, treating everyone fairly, and "picking battles wisely" (right place, right time, and for the right reasons)
• demonstrates ethical and respect covenantal relationships between patient and pharmacist; promotes the well-being of every patient in a caring, compassionate and confidential manner
• provides a positive and safe environment for learning, reflection and assessment (i.e. students can make and learn from mistakes and can openly express themselves)

The need for skilled and energetic preceptors has never been greater. To be an effective preceptor, a pharmacist should demonstrate clinical competence; possess excellent communication and relationship-building skills; plan and facilitate challenging learning opportunities; and create a positive learning environment at their practice site. Please contact the Professional Experience Program at the UNC Eshelman School of Pharmacy (919-966-3023 or kim_leadon@unc.edu) if you would like assistance in developing your precepting skills.

For more information:

• Hammer DP, Berger BA, Beardsley RS, et al. Student professionalism. AJPE. 2003;67(3).
• Cuellar LM and Ginsburg DB. Preceptor’s handbook for pharmacists. ASHP. 2005.
  

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Challenging Cases in Precepting: Roundtable

by Kristen Campbell, Mollie Scott and Bill Hitch

Much like pharmacy, the world of education presents new and unique situations and challenges. Some of the challenges can be solved by our natural instincts while others require thoughtful consideration beyond, and sometimes counter to, our first instincts. Here we present various challenging cases and suggestions for handing them.

On the last day of the rotation for which you serve as preceptor, you sit down with your student for a final feedback session and to go over the evaluation/grading form you have completed in PEMS. The student expresses concern that any grade less than Honors will hurt his chance of getting the residency of his choice. He asks you to change your evaluation of his performance by giving him higher marks. How do you handle this situation?

Campbell: First, I would stress that it is inappropriate for a student to ask for a grade change unless he feels that the evaluation is inaccurate based on true self-evaluation of his performance and the feedback / explanation of grading discussed during this final feedback session. In that situation, he can contact his AHEC faculty or the Professional Experiential Education office to discuss further. Next I would be sure to explain my grading methodology (which I usually start every evaluation with). I consider a score of 5 to be equivalent skill to that of a practicing pharmacist and a score of 3 to be equivalent to that of an average student. Early in the academic year I give very few 5's because students are so new to the rotation experience; they should not be expected to practice at the skill level of a pharmacist but in some instances where the students are achieving at a practice level early on, it is appropriate for students to earn a 5. After this explanation I would explain that residency programs consider many more aspects than grades when reviewing applicants. They are very interested in work experience and extracurricular activities (both inside and outside of pharmacy school). Additionally, they focus strongly on the application essay questions, letter of intent, and recommendation letters. I would try to reassure the student that Passing is a good grade that he should be proud of. The most important thing to be concerned with during rotations should be the knowledge gained during that time it is absolutely irreplaceable.

Scott: Students are used to receiving rewards for performance in the form of grades. Part of transitioning from student mode to professional mode is leaving grades behind, and focusing on whether you made a difference in the lives of your patients. As a residency director, I consider many things other than grades when I am interviewing and selecting candidates. Potential residents do need to demonstrate academic excellence, but they also need to exhibit strong communication skills, commitment to the profession, and have clear career goals. I would discuss with the student their strengths and weaknesses, and help them to focus on goal setting for improvements that are tangible and measurable and that are not based upon grades. It is important to model for students that being a professional is about patient-focused instead of grade-focused.

The student you are precepting, who has strong feelings about smoking, is eager to try his patient education and counseling skills to influence patients to stop smoking. Another pharmacist comes to you saying that the student has upset several patients by "lecturing" them. How do you handle the situation?

Hitch: When giving constructive feedback, it is important to identify and encourage the positive while redirecting the negative. The student has displayed enthusiasm and passion for a subject. Helping a smoker to become free from tobacco addiction will have a tremendous impact on that patient's life. The student has taken initiative to seek out patients and practice his patient counseling skills. These are all very positive things. What should be addressed is that his intention for the intervention and the patient's perception of the intervention are likely very different. He intended to be helpful and provide education but was perceived as lecturing. I would have the student place himself in the shoes of the patient and reflect on what parts of his intervention may have created the negative perception. He can brainstorm about ways to improve his approach. I would tell him about how I approach talking to patients who use tobacco. Anyone who receives unsolicited advice may react defensively, especially someone who is aware that they have an addiction that jeopardizes their health. Instead of lecturing them about how they shouldn't smoke, I prefer to let my patients know that I am an advocate and a resource for them whenever they are ready to quit smoking. Those who are interested in quitting will ask questions and those that aren't ready to quit yet can leave without a lecture. Discussing what has worked for me in the past may give the student ideas about how to improve in the future.

Scott: Fourth year students often know a great deal of facts and have solid critical thinking skills. The APPE year is all about learning to apply knowledge and skills as they care for real patients. It is important that student pharmacists learn how to communicate with patients in a compassionate manner that considers individual patients needs, culture, health literacy, and personal goals. In this case, the student likely thought that he was being helpful by sharing with the patient why smoking is harmful. The student should be praised for his desire to help patients stop smoking, but should also be taught that lecturing patients rarely changes behavior. Teaching the student about effective ways to change behavior through readings and discussion of techniques such as motivational interviewing, goal setting, and patient coaching would help the student make the leap from knowing facts to effectively communicating with patients.

The pharmacy student you are precepting is of a different ethnic background from most of the patients you see in your clinic. Some of your patients have refused to let her examine them or otherwise participate in their care. How do you handle this situation? In particular, how do you help the student learn to anticipate and deal with racial or cultural prejudice from patients?

Hitch: I would start by addressing the patient and discussing the rights of patients and the rights of health care professionals. Health care professionals have the right to work in an environment free from verbal abuse, whether foul language or racist remarks or implications. The patient has the right to receive their care wherever they see fit. If the patient would like to receive care at our clinic, then they must be willing to work with our team, regardless of the cultural makeup of that team. When talking with the student, it is crucial to be direct and honest about the situation. The student has the right to know the specifics of the patient's comments and how we responded to those comments. Ignoring the patient's actions or pretending they did not occur could only make the situation worse. It is very important to provide support during this encounter, since this may be very stressful and difficult for the student. This is also a good opportunity to talk about treating difficult patients. It is important that patients and providers are aware of the established rules of conduct at your facility and that they are followed. Patients should be aware that certain actions will lead to the termination of the pharmacist-patient relationship and they must avoid these actions. But it is also important for pharmacists to remember that we are not always aware of the current circumstances of our patients. They may be dealing with a new or difficult diagnosis, stressful economic or social situations, depression, or pain. Even if the patient is difficult to connect with, abrasive, rude, or expresses beliefs contrary to our own, it is our responsibility as pharmacists to provide optimal health care in a patient, non-judgmental fashion.

The student you have precepted for the past several weeks tells you that she was interested in your community practice until seeing the demands it makes on you, professionally and personally. Now she is uncertain of her career goals. How do you advise her?

Campbell: Balancing your professional and personal lives can be very difficult but it is so important to try to achieve. Ultimately you need to choose a career path that you will be happy and satisfied with. I have come to realize that it is especially difficult to find fulfillment and balance when you don't enjoy what you do. This lack of satisfaction tends to spill over into your personal life. On the other hand, if you leave work feeling satisfied, that feeling will extend into your personal life. Of course there are always bad days, but you should be able to say that you enjoy your job, at least most of the time. If you don't, then it may be time to look for something else. I would ask this student what her career goals are. Is she looking to work full time or part time? Does she want to work for a large chain or small independent pharmacy? What is most important to her when she goes to work? What will it take to make her feel accomplished at the end of a work day? The answers to these questions will enable her to make the right career decisions for her. I would also remind her that what one person considers to be the right balance, may not be the same for her and that is okay.

You are the preceptor for both a student and a pharmacy resident during the same month. The student performs well when you are on rounds, but during the last week the resident is responsible for co-precepting the student. The resident comes to you to say that the student is not coming to rounds prepared, and that when he assigned some readings to the student the student retorted: "But you are not my preceptor" What can you do to ensure that the resident receives adequate teaching experience (a requirement of the residency) while ensuring that the student has a positive experience?

Scott: Setting expectations for both the student and the resident at the beginning of the experience is key. It is important for the resident to understand his/her own role in teaching. Tips for preparing the resident for a co-precepting role include providing a preceptor training workshop specifically for residents, reviewing the requirements of the student experience, anticipating pitfalls for resident preceptors, and mentoring the resident as they precept. The Pharmacists Letter has great online resources for new preceptors, and requiring that residents complete precepting modules and discuss them with you is a great way to teach novice preceptors about basic teaching skills. It is also important for the student to understand the role of the resident in co-precepting them. The student needs to understand that they can learn a great deal from a resident about drug therapy as well as their own professional choices, and that the resident can serve as a resource for them during the month. Setting aside time during the midpoint and final evaluation to allow the student and the resident to undergo self-reflection and provide feedback about the co-precepting experience helps both learners to be engaged in the process.

Campbell: This situation requires a great deal of communication, both at the beginning of the rotation and throughout the month. Students should be informed that it is important to the resident's learning experience to work in the preceptor rol e. They cannot gain the experience to be a good preceptor without putting themselves in the situation during their training. However, as the assigned preceptor, I still consider the student to be my responsibility and I still have a commitment to be present and involved with their rotation. I generally approach this situation by taking a backseat position. I am present for all discussions but allow the resident to lead them. I tend to interject as little as possible but am certainly available if needed. This allows me to supervise everything and still have firsthand knowledge of the student's progression. I also encourage the student to talk with me if they feel they are not getting the experience they hoped for I have the resident assist with evaluations but ultimately I still ensure that I have been present enough to make a fair evaluation myself.

Summary
One of the themes from these cases is communication. Communicating expectations in the beginning and throughout the experience is important. Students, like most people, do not necessarily hear all they need to hear the first time around. Repetition is needed because, just like the smoker case, there are times when a student is more open to such communications. The second theme is a safety. When students feel they are in a safe environment, they are more willing to share fears, expectations, etc. Setting an environment where students can openly talk about their experience is one of the most important things a preceptor can do.

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Using residents to help precept students

by Bruce Canady and Holly Knight

Pharmacy residents enter programs to further their own learning and skill sets. Teaching others can be a valuable part of this experience. The question arises however, how do you structure the experience to get the best learning for both the resident and student? While teaching responsibilities will be highly individualized, explaining to residents some basic tenets of teaching and their responsibilities with respect to teaching others can be the way to start. While articles like "Exemplary Precepting Behaviors" provide guidance on what makes a good preceptor, many of the same behaviors make for great resident teachers - with some additional guidance of course. Here are the dos and don'ts of using residents to help precept students.

The Dos

Do model teaching. Spend some time modeling the teaching behaviors you think are important for the resident to learn. Discuss why you teach the way you do as well as the resident's personal views on teaching.

Do set expectations and give objectives. It's hard to know you got there if you don't know where you are going. Set objectives for what you expect residents to do and assess their progress, Do the same with the students. Discuss and decide with the resident what you would like them to do. Be sure it is a decision that you are both comfortable with. Some might be comfortable having residents meet with students one on one; others may prefer all members meet together. Make sure the resident feels comfortable with his or her role.

Do start slow. Start simple and build. Start the resident-student interaction on simpler terms e.g., working up a patient or have the resident bring up an important point or two for the student's benefit (this can be planned ahead). Progress these behaviors so they become more in-depth and regular. Eventually, you may have the resident take over most of your day-to-day activity while you play more of an observer role.

Do prime the students. Clarify for your students the resident's role and how the resident will be of value to them. Also explain what your role in the relationship will be. Make the students comfortable so that they can come to you with any issues or problems that arise. Setting the environment is one the most important things you can do.

Do manage everyones time. Consider how you will balance your time with the resident, your time with the students, and resident-student time so everyone benefits. Remember residents need time for their own learning. Watch how much teaching responsibility you put on the resident.

Do respect authority. Students need to respect the resident as a person, as a professional, and as a reliable source of knowledge. Undermining the resident's authority in front of the students can be detrimental to the learning process.

Do provide feedback. Even if residents or students practice and practice, it doesn't mean they will learn unless they get feedback. Provide feedback in a constructive manner. Give them feedback on things they do well and areas they need to improve on: "You did a very good explaining the side effects of the medication. One area you need to work on is to be a little more empathetic about the patient's situation. Overall though, you did a good job." The sandwich technique is a good way to offer feedback: offer something that gets done well, mention an area for improvement, and end on a positive note.

Do reflect on what you are doing. Talk to the student and resident about what is working and what is not and what can be done to optimize their experiences.

Do show your face. Knowing that you are around and available is an important aspect of the process. Students ultimately want to know their preceptors, maybe more than they do their residents. Don't be MIA.

The Don'ts

Don't just tell. Telling is not teaching. Many new preceptors are guilty of committing the cardinal sin of simply supplying an answer when presented with a student's blank look or "don't know." Sometimes you may have to tell the answer, but look for other ways to get to it or have the student research it and get back to you at a later time. We learn much more by doing.

Don't criticize personality (but you can criticize behavior). Don't tell a student or resident something like "You are too shy or lazy or unmotivated." Tell them that they need to ask more questions, they are not around when they are needed, or they need to volunteer when asked. They can't change their personality, but they can modify their behavior.

Don't forget to smile. Attitude is everything, and enthusiasm is contagious.

Don't make yourself unavailable. As stated earlier, you still need to have a presence in the training

Don't forget to include residents in assessments. Allowing the resident to participate in the student assessment is an important lesson in constructive feedback.

Summary
Residents can deepen their own mastery by helping students acquire new knowledge. Preceptor-mentors can help themselves and their learners by facilitating the resident's learning to teach. Teaching, particularly clinical teaching, does not come naturally to most residents, but practice and mentoring can move the resident from hesitant novice to confident teacher over the course of a residency. Finally, using residents is not meant to save the preceptor time or effort. In fact if done correctly, it will probably take more time and effort. Remember you are ultimately responsible for the resident and student learning: their failures are your failures.

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