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Preceptor Development: The Perfect Recipe for Handling Difficult Student Situations

18 Mar 2019 1:15 PM | Deleted user

Author:  Gloria Grice, PharmD, BCPS
Director, Office of Experiential Education, St. Louis College of Pharmacy

It's Friday, the last day of a rotation, and I get a phone call that starts with “I’m so sorry to bother you, but I need some advice about my current student”.  The preceptor proceeds to describe how the student has not met any of the deadlines for the rotation, has been late multiple times, absent a handful of times for various reasons, and was caught sleeping during a meeting, all the while seemingly disengaged from the rotation in general.  A recipe for disaster.

What I love about this phone call is that the preceptor reached out for advice.  All too often, I learn about challenging student situations well after the student finished the rotation; or that same student goes on to a later rotation, continuing the same behavior and that preceptor is befuddled at how the last preceptor didn’t address these things and wonders “is it only happening on my rotation?”.  What I wish about this phone call is that I received it weeks ago.  As preceptors, if you involve your Office of Experiential Education early in a difficult student situation, they are more likely to be able to help both you and the student have a positive outcome. 

In my experience, difficult student situations can be classified into one of four categories: knowledge deficits, communication deficiencies, professionalism issues, or health-related.  This is supported by the literature that suggests the most common rotation performance deficits are professionalism, time management, communication, punctuality, work ethic, organization, and knowledge deficits.1-3  Each of these types of difficult student situations has nuances that should be handled differently, but in general, the recipe for managing these difficult student situations can be summarized with four main ingredients: 

  1. Expectations
  2. Conversations
  3. Referrals
  4. Documentation


The first ingredient is expectations.  Whenever a student is not meeting your expectations, first check that your expectations are fair.  Often, new preceptors have high and sometimes unattainable goals for students since they themselves have probably just recently finished clinical post-graduate training.  Even seasoned preceptors can sometimes create an ambitious calendar of activities and projects for a student with an excessive amount of work to be done during the rotation hours and beyond.  It’s best to limit assignments/projects to the quantity that the school recommends since they have taken into consideration a reasonable load of work for students.  It’s also important to remember that many students have multiple ‘outside of rotation’ demands.  And while clerkship learning is their top priority, it isn’t their only priority.  Several students must work during the week for financial stability for themselves or their family; those with families have a whole host of additional evening family obligations (e.g. Bobby’s soccer practice and Jane’s dance recital); and several are also studying for a second degree, such as an MBA or MPH.  Having said all this, we do not want preceptors to make the learning a “rotation-lite” for students with competing demands.  Rather, understanding that they exist will ensure that the expectations for learning and performance are reasonable.  In some student situations, a more focused performance improvement plan can be created and implemented between the student and the preceptor with specific goals for the week so that the expectations can be “chunked” to allow for students to work on things at a slower pace and to ensure the student is continually progressing.4  These can often be developed with the assistance of your Office of Experiential Education

In addition to being reasonable, the expectations should be clear.  Students could be not meeting your expectation because they don’t fully understand what it is or confuse it with expectations from their prior preceptor (it’s not easy to have a new boss every 4-5 weeks).  The easiest way to make your expectations clear are: 1) have a rotation syllabus that is specific to you and your site that outlines goals, expectations, a calendar for the rotation, and maybe even samples of work you expect; 2) have a very thorough and detailed orientation where you can review everything verbally; 3) utilize the four preceptor roles well, particularly the modeling role so the students can visually see what is expected; and 4) routinely review the expectations at the first sight of a student not meeting them.5-7


The second ingredient is having timely, productive, and caring conversations.  Trust me, I know having these hard conversations isn’t enjoyable.  If you haven’t read the book “Crucial Conversations”, I would suggest that as a must read for anyone who is a preceptor (or even if you aren’t).8  This book helps prepare individuals for having tough conversations when the stakes and emotions are high.  There is an art to having these conversations and it begins with trying to understand the other person, making the conversation safe, sharing what you are observing, and establishing mutual goals moving forward.  There are many dangerous things we can do without having these conversations such as making up our own story about why the student is performing poorly, or assuming the student will change behavior as the rotation advances, or giving up too early on improving the behavior.  There are also many dangerous things we can do if we have these conversations poorly.  Knowing ourselves and how we handle conflict is the backbone of these conversations; focusing on wanting to see the student succeed is the heart of it.  Communication is key!


The third ingredient is knowing when and whom to refer the student to.  Many times, students that are displaying professionalism issues and even academic concerns can have underlying personal issues.  “Lazy” or “poor performance” could be from social stressors affecting home life (which affects professional life), or diagnosed/undiagnosed mental health or other health conditions.4,9  As a preceptor, you are at the front lines mentoring and coaching students and can be the first to recognize a potential personal issue that could be contributing to their performance.  The best thing to do is to talk to the student and ask them questions about how they are doing outside of the rotation.  Good questions to ask are “how would you say your home life is?” or “how are things at home?” or even “what stressors do you deal with day to day? And have those increased lately?”.  I usually start by asking permission to ask these more personal questions.  I’ve noticed that students are usually grateful that someone took the time to ask them about their situation versus just pointing out all the ways in which they are not meeting expectation.  Depending on what information they share, you can refer them to many of the campus resources including the Counseling Center, Student Affairs personnel, or even the Life Crisis Hotline.  When in doubt, let the student know that you are concerned for them and will be reaching out to the Office of Experiential Education for additional support services for the student.  It could also be that the student does not have any personal circumstances impacting them, but the referral to the Office of Experiential Education and the Counseling Center can emphasize coping skills and resiliency messaging as well as reiterate the urgency of the situation for them to begin taking the rotation more seriously if they want to be successful.


The final ingredient is remembering to document everything.  This can be done in a separate file, and/or in the student’s evaluation.  Without very specific written examples of the concerning behavior, it will be more challenging later for the student to reflect back on the justification for their poor performance, or for the school to uphold a preceptor’s evaluation if a student files a grade appeal, or for a subsequent preceptor to look back and identify if the student has been struggling with the same issues across multiple rotations (this depends on whether your school has an open portfolio for preceptor evaluations).  Additionally, students process things by seeing them written versus hearing it verbally.  With very difficult student situations that require lots of documentation, we also advise to document how the verbal conversations went and documentation of the multiple opportunities that were given to the student to improve the behavior/issue.  Don’t forget to document positive areas of performance as well!  As the age old saying holds true, “it didn’t happen if it wasn’t documented”.

In summary, we know it isn’t easy to take time out of your day to teach, mentor, and coach the next generation of pharmacists on top of the expectations of you as the pharmacist.  The tag line for the Preceptor’s Handbook for Pharmacists by Cuellar and Ginsburg (which, by the way, every preceptor should own and is full of precepting nuggets of wisdom) is “Being a preceptor is hard work”.10  We say that precepting should be a win-win where students win from hands-on learning experience and preceptors win from having students participate in delivering patient care.  When any one situation begins to take over the majority of your time and the win-win feels less and less like anyone is winning, it takes a major toll on preceptors.  Using these four ingredients, a dash of patience, and help from your sous-chefs (Office of Experiential Education) will make for the best possible outcome for you and for students.


  1. Bodenberg MM, Koehler JM. Customizing student learning during advanced pharmacy practice experiences. Curr Pharm Teach Learn. 2015;7(4):519-525.
  2. Boyle CJ, Beardsley RS, Morgan JA, Rodriguez de Bittner M. Professionalism: a determining factor in experiential learning. Am J Pharm Educ. 2007;71(2):Article 31.
  3. Hauer KE, Teherani A, Irby DM, Kerr KM, O’Sullivan PS. Approaches to medical student remediation after a comprehensive clinical skills examination. Med Educ. 2008; 42(1):104-112.
  4. McLaughlin K, Veale P, McIlwrick J, de Groot J, Wright B. A practical approach to mentoring students with repeated performance deficiencies. BMC Med Educ. 2013;13(1):56.
  5. Jackson LD. Can Pharm J. 2015 Nov;148(6):308-313.
  6. Cuellar LM, Ginsburg DB. Preceptor’s handbook for pharmacists. 3rd ed. Bethesda: ASHP;2016
  7. Four Preceptor Roles.  ASHP.  Accessed March 11, 2019 at: http://www.ashpmedia.org/softchalk/softchalk_preceptorroles/softchalk4preceptorroles_print.html
  8. Patterson, Grenny, McMillan, Switzler.  Crucial Conversations: Tools for talking when stakes are high. 2nd ed. Mcgraw-Hill. 2007.
  9. Martin RD, Wheeler E, White A, Killam-Worrall LJ.  Successful Remediation of an Advanced Pharmacy Practice Experience for an At-risk Student. Am J Pharm Educ. 2018; 82(9):Article 6762.
  10. Cuellar LM, Ginsburg DB.  Preceptor’s Handbook for Pharmacists.  3rd ed. ASHP. 2016.

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