Preceptor's Guide

Develop a learning experience description.

Be prepared.

• Plan for learning opportunities outside of patient care activities (e.g., journal club, in service, lecture, medication-use evaluation).
• If possible, review the learner’s previous learning-experience evaluations. This can shed light on a learner’s specific strengths and weaknesses observed during past learning experiences.
• On the first day, review and set clear expectations. For example:
  • A pharmacy or medical resident may be responsible for covering 50% of the internal medicine service on week one, but cover 100% of the service by week four.
  • A pharmacy student may fill IV orders on week one, but fill IV and unit dose orders by week four.
  • A pharmacy technician may fill 25% of the pending prescriptions on week one and increase by 25% each week.
• Get to know the learner. Ask about things like:
  • career goals
  • learning style (e.g., auditory [podcasts], visual [graphics or charts], learning by doing [case studies or simulations])
  • personal areas for improvement
  • previous learning experiences
• Come up with ways to integrate learners into your routine tasks. For example, quiz learners on brand and generic names of medications while putting up the order or share clinical pearls while reviewing morning labs for patients on your service.

Be a good role model.

• Demonstrate professionalism in character (personal reliability), connection (interpersonal compatibility), and competence (professional capability).³ Examples of professionalism for each domain include:³
  • character: honesty, integrity, humility, responsibility, service, and moral courage
  • connection: compassion, empathy, self-control, kindness, and influence
  • competence: self-directed learning, knowledge, applied skill, proactivity, and wisdom
• Use the appropriate professional code of ethics or conduct to help you demonstrate, model, and encourage ethical practice.⁴

Use teaching tools.

• ASHP reviews the four preceptor roles for precepting pharmacy residents. However, these could be applied to any learner. See ASHP’s Starring Roles: The Four Preceptor Roles and When to use Them, for information on when and how to use the four preceptor roles (http://www.ashpmedia.org/softchalk/softchalk_preceptorroles/softchalk4preceptorroles_print.html). These roles include:²
  • instructing: If learners display a knowledge gap, refer them to an appropriate resource to gain knowledge. For example, assign articles for the learner to read to expand their knowledge. Follow up to check their understanding of the material.
  • modeling: Demonstrate skills or processes while “thinking out loud” so learners can see and hear your problem-solving process.
  • coaching: Provide ongoing feedback while observing the learner perform a skill.
  • facilitating: Allow learners to perform tasks independently. Be available in case they need help or guidance.
• SNAPPS is a learner-centered teaching approach involving six steps, often used for medical students or residents. These steps include:²¹
  • S: summarize the history and findings. For example, “The patient is a 5-year-old male with a fever of 101.2°F complaining of right ear pain for two days. Physical exam reveals a red inflamed ear drum.”
  • N: narrow the differential to two or three possibilities. For example, “I believe acute otitis media is the most likely diagnosis, but before examining the patient I was also considering otitis externa.”
  • A: analyze the differential, comparing and contrasting the possibilities. For example, “Since the patient does not have redness or swelling of the ear canal, I am learning more toward acute otitis media.”
  • P: probe the preceptor by asking questions about uncertainties, difficulties, or other approaches. For example, the learner may ask “Is there anything else that you would include in the differential?”
  • P: plan the management of the patient’s issue. For example, “I would recommend using oral amoxicillin for five days.”
  • S: select a case-related issue for self-directed learning. For example, “I would like to learn more about antibiotics that cover infections caused by Streptococcus pneumoniae.”

Communicate effectively.

• Encourage open communication. Request feedback from learners (e.g., on precepting style, teaching methods, rotation activities, feedback).⁵²
• Demonstrate and teach effective communication with patients and healthcare professionals.
  • Some learners may be uncomfortable communicating via telephone.⁴⁷ Teach telephone skills using simulations with real-time feedback, repetition, and structured reflection.^46,47
  • Discuss what to do when there is a language barrier (e.g., allow more time for consultations, provide visuals, utilize facility interpreter services).^48,49 Advise learners to avoid use of translation apps unless they have been approved by your institution.⁴⁹ They should not rely upon colleagues who speak the language or patient family members except in an emergency.⁴⁹
  • Provide tips for talking to older patients: https://www.nia.nih.gov/health/health-care-professionals-information/talking-your-older-patients.
  • Provide tools to navigate cultural differences that might affect patients’ perspective of their illness or treatment (e.g., Arthur Kleinman’s Eight Questions: https://thinkculturalhealth.hhs.gov/assets/pdfs/resource-library/arthur-kleinmans-eight-questions.pdf).

Have students practice the SBAR method of communication.

SBAR is a tool for organizing verbal or written communication that enhances accuracy, clarity, and efficiency of communication, thus reducing the risk of errors.^27,29,30

SBAR stands for:^27,28

• Situation: Briefly state the problem and identify yourself (e.g., name, pharmacy, position) and the patient (e.g., name, date of birth).^27,28 Example: “This is Avery, a pharmacy student at Main Pharmacy. I am calling about Hugh Morris, date of birth April 19, 1954. We received a new prescription for Entresto for him from a hospitalist, and I am calling to let you know because he has an active prescription for lisinopril. This combination is contraindicated.”
• Background: Provide pertinent clinical information and context (e.g., significant medical history, labs).²⁸ Example: “He was discharged today after a heart failure exacerbation.”
• Review pertinent resources (e.g., the medical record, prescribing information, treatment guidelines) before initiating communication to make sure you can provide more background information if requested and respond to any drug-related questions that may arise.
• Avoid unnecessary information unrelated to the current situation.³⁰
• Assessment: State your clinical impression or concern.²⁷ Example: “Taking both meds could increase his risk of hypotension, hyperkalemia, or kidney impairment.”
• Recommendation: Give your advice, and clearly state what you need, including a timeframe for response.²⁷ Example: “I recommend that one of these medications be discontinued. Please ask the prescriber which one of these medications the patient should take. I can hold, or you can call me back today at this number.”

Select a feedback method

• Use a feedback method that you find helpful and easy to use (if it’s not easy, you are less likely to use it).
• Some examples of feedback methods include:
  • Ask-Tell-Ask (https://paeaonline.org/wp-content/uploads/imported-files/Ask-Tell-Ask-Feedback-Model.pdf)
  • One-Minute Preceptor (https://paeaonline.org/wp-content/uploads/2017/02/One-Minute-Preceptor.pdf)
  • ARCH (www.mitemmc.org/uploads/Walsh_monthly_tip.pdf)
  • Start/Stop/Continue (https://www.smartsheet.com/sites/default/files/2022-09/IC-Start-Stop-Continue-Performance-Review-11582_PDF.pdf)(This method can also be used for students to provide feedback to the preceptor.)
  • Plus/Delta (https://mcblogs.montgomerycollege.edu/thehub/fundamentals-of-teaching/instructor_resources/a-means-to-effective-peer-to-peer-feedback-plus-delta-method/)
  • Pendleton (https://www.exult.co.nz/articles/giving-feedback/)
  • What?/So What?/Now What? (https://www.experientiallearning.org/blog/what-so-what-now-what-reflection-model-and-reflection-questions/)

Provide formative (ongoing, regular) feedback.

• Provide feedback in a private setting, to facilitate discussions.
• Start with learner self-assessment; “How do you think that went?” and “What would you do differently next time?”
• Formative feedback is:^2,5,19
  • objective: supported by specific examples.
  • actionable: provides the learner with direction on what to focus on.
  • balanced: includes what was good and why, as well as what could be improved and how.
  • fair: considers knowledge, performance, abilities, and skill level of the learner with reasonable expectations.
  • timely: given in “real-time” or soon after the learning activity. Aim for daily feedback. At a minimum, consider using something like “Feedback Fridays” to ensure ongoing feedback and avoid surprises at the end.
    • For learners who are struggling, early feedback is especially important to allow time for improvement, and for assignments and tasks to be adjusted to target problem areas.
• Consider limiting feedback to one or two items at a time, and balance constructive with positive feedback.
• Have learners summarize the feedback to ensure understanding. Clarify anything that was misunderstood.

Provide summative feedback.

• Summative feedback is a summary of formative feedback given during the learning experience (i.e., nothing should be a surprise at this point).
• Discuss progress toward achieving assigned educational goals and objectives.
• Use this as an opportunity to ask about ways to make the learning experience even better for future learners.

Address the needs of high-performing learners
(i.e.,performing above the curve)

• Individualize expectations. There are minimum expectations for all learners. Consider going beyond the minimum for high performers. If learning experiences are not challenging enough, high performers may become bored.¹⁷
• Communicate regularly. It may seem natural to give high performers more autonomy. But keep in mind that autonomy is not synonymous with a lack of communication. Learners may feel neglected if not meeting with preceptors on a regular basis.¹⁷
• Encourage learners to self-assess. Self-assessment reveals how learners view their own abilities. Some high performers may be overly critical of themselves, dismiss positive feedback, or constantly strive for perfection.
  • Use discussions about self-assessments as an opportunity to correct any inaccuracies.¹⁷
  • During their self-assessments, encourage those constantly striving for perfection to reflect on at least one thing that went well.
• Provide feedback appropriately:^16,17
  • Set the stage. Explain that your job as a preceptor is to provide feedback to learners performing at all levels. Remind learners that the purpose of each rotation or learning experience is to grow, learn, and develop personally and professionally.
  • Give more than just praise. High performers also need constructive feedback.
    • Consider a feedback method with both types of feedback already built in (e.g., ask-tell-ask method).^18,19
    • Praise high performers when they exceed expectations.
    • Provide constructive feedback with suggestions and strategies to help them move beyond success toward mastery. High performers often fear failure. They also may not have had much (or any) constructive feedback. Be prepared that they may respond with anger, defensiveness, denial, devastation, or tears.
      • Work to shift the focus from the learner’s actions to the patient experience or outcome.²⁰
• Discourage comparing themselves to others (e.g., other learners, you, other preceptors).¹⁷ Provide perspective:¹⁷
  • Share your professional timeline (i.e., how long it took you to get where you are).
  • Talk about professional mistakes and failures and what you learned from them. Help learners see their own failures as learning opportunities and encourage self-acceptance.
  • Explain that even though you are a preceptor, you continue to learn, grow, and develop your skills.

Handle challenging learning situations or challenging learners.

• Challenges can occur because of many things. Common reasons for challenges involve knowledge and skill deficits, attitude, and poor time management.¹⁰ Be alert for other reasons (e.g., miscommunication, anxiety, burnout, family problems, substance use).¹²
• Repeatedly having to handle challenging learners is a predictor of preceptor burnout.⁵³ Employ strategies to prevent problems before they occur.⁵¹
  • Set expectations (and consequences) on the first day.⁵¹ Consider incorporating “top 10 rules” into the syllabus.⁵¹
  • Ensure that students understand that informal feedback or “sandwiched” feedback is feedback that should be taken seriously.⁵² 
• As with other feedback, continue to ask learners to self-assess, even during challenging situations.⁵¹
• Identify problems and manage problems one-on-one and early (i.e., don’t wait until a scheduled midpoint or final evaluation if you have concerns.¹⁰ Consider using the SCOPE model when addressing concerns or having a difficult conversation.⁷
  • S: Use sensitivity when phrasing things (e.g., “It may be helpful,” “I’d like to suggest,” “I wonder if,” “My perception is”).
  • C: Be constructive by working together to develop a measurable plan for improvement.
  • O: Provide an objective and specific example of the problem, including documentation, if possible.
  • P: Focus on performance-based behaviors, not personal characteristics.
  • E: Provide equalized feedback by balancing positive and negative.
• Rehearse difficult conversations ahead of time to practice and prepare.¹¹
• Ask learners if this is new feedback or has this type of feedback been provided before. It can be helpful to know if it’s not new, as this may indicate the learner doesn’t have the knowledge or tools to improve.
• Consider the Situation-Behavior-Impact model to get clarity on intent (https://www.uab.edu/humanresources/home/images/LearnDev/PerformanceMgmt/_Tools.Learning.STAFF/Feedback_Model_SBI.pdf).
• Ask for help when warranted.⁵¹ Document and follow procedures to communicate with others, if necessary (e.g., residency program director, school administrator).⁷
• For ideas on how to handle challenging learning situations and tips for giving difficult feedback see Addressing the Needs of Challenging Learning Situations at https://studylib.net/doc/18531398/pharmacy-practice-experiences---american-pharmacists-asso.
• When remediation is needed, follow appropriate remediation policies for:⁹
  • frequency of feedback
  • documentation requirements
  • other customizable interventions (e.g., extended rotation, repeat rotation, probation, counseling [referring residents to your employer’s Employee Assistance Program when appropriate]).

Help students improve time management skills.

• Suggest time tracking to identify specific problems to target.³⁵
• Technology distractions can be minimized by checking email only at set times and turning off notifications.³¹ Set boundaries with family and friends regarding texting during work hours.
• If poor concentration is an issue:
  • share the Pomodoro technique: set a timer to focus on a task for 25 minutes, followed by a three- to five- minute break, then repeat.³³ This method is also associated with improved mood.³³
  • suggest they jot down “to-do” items, questions, or ideas on paper or a notes app so that these thoughts do not affect focus.³⁷
• Watch for maladaptive perfectionism, a paralyzing fear of imperfection that can lead to long hours and procrastination in starting projects.^35,38
• To improve prioritization, recommend triaging tasks by importance and urgency and clarifying deadlines.³⁶ (Be aware that perfectionists may see all tasks as equally important.³⁹) But if a task takes less than two minutes, recommend completing it right away.³¹
• To keep long-term projects on track, suggest an online project management tool such as Microsoft Planner or Trello.³⁶ These can help create timelines and break longitudinal tasks into bite-sized pieces.
• Share tips to improve efficiency.
  • Encourage setting a block of time for each task.³⁴
  • Focus on one task at a time. Discourage multitasking, which is linked to errors, lower productivity, and mental exhaustion.³²
  • Encourage reaching out early for clarification if they are confused about an assignment so they don’t waste time going down the wrong path.
• Be aware that assignment overload may be the problem. Encourage openness about workload. Stagger project deadlines.

Build resilience in longer-term learners (e.g., residents).

• Share the following resources with learners:
  • ASHP’s State Affiliate Toolkit Well-Being and Resilience (https://www.ashp.org/State-Affiliates/Affiliate-Resources/State-Affiliate-Toolkit-Well-being-and-Resilience)
  • National Academy of Medicine’s Clinical Well-Being Knowledge Hub (https://nam.edu/clinicianwellbeing/)
• Consider initial and ongoing assessment of resilience with an existing tool (e.g., Connor-Davidson Resilience Scale [http://www.connordavidson-resiliencescale.com/])
• Consider expanding your program’s discussions to include resilience topics (e.g., combating impostor syndrome [feeling like a fraud], creating a mantra, finding balance, gratitude, mindfulness).^6,14,15
• Embrace the phrase “It takes a village” by providing a culture of connection and support.¹³ Examples of ways to do this might be:
  • including family or significant others in parts of resident orientation to foster an understanding of what is involved in the residency with a goal of leading to encouragement at home.
  • providing an informational email or pamphlet for residents to share specifically with family or significant others.
• Provide opportunities to build comradery organically (e.g., a snack station), or arrange quarterly social events.⁵⁰ Don’t overdo it; for some learners, out-of-work social events can just feel like extra work.⁵⁰
• Celebrate successes to build confidence (e.g., staff meeting or newsletter recognition, personal note, text, or email).¹³
• Tailor resident development plans to incorporate goals and build on existing personality types and individual strengths.¹³Consider having residents complete a personality assessment (e.g., Myers-Briggs [https://www.mbtionline.com/], DiSC profile [https://www.discprofile.com/]) and/or a strength assessment (e.g., StrengthsFinder 2.0or CliftonStrengths [https://www.gallup.com/cliftonstrengths/en/252137/home.aspx]) and use the results. For example:
  • if a resident has “arranger” as a strength, helping to organize activities for pharmacy week might be a good fit.
  • a resident who aligns with the “INTP” Myers-Briggs’ personality type is typically curious, enjoys solving problems, and works methodically). Capitalize on this; involve the resident in helping a student understand a complicated concept or patient case.
• Keep tabs on resident well-being by asking about stressors and encouraging self-care (e.g., sleep, healthy eating, exercise).¹³

Address Impostor Syndrome

• Impostor syndrome involves chronic feelings of inadequacy plus dread about being exposed as a fraud despite evidence of success.¹⁴ It is common in high achievers.⁴⁵
• Impostor syndrome can lead to anxiety, distress, or fear of being evaluated.^42,44 It can even impact physical health.⁴⁵
• Symptoms of impostor syndrome may include self-doubt, feeling undeserving of praise, or attribution of accomplishments to external factors or luck, and perfectionism.^40,42 People with impostor syndrome may take on extra work to prove their worth, second-guess themselves frequently, apologize for asking questions, or eschew challenging opportunities or promotions because they feel unqualified.^40,41
• The Clance Impostor Phenomenon Scale can be used to gauge the likelihood and intensity of impostor syndrome.⁴¹ (https://paulineroseclance.com/pdf/IPTestandscoring.pdf).
• Bring awareness to impostor syndrome by discussing it openly.¹⁴ Share personal experiences with impostor syndrome, and explain that it can happen even to experienced clinicians.¹⁴
• Combat impostor syndrome encouraging objective self-assessment; learners can make a list of their strengths and reflect on accomplishments each day.^14,40,45 Remind learners that it is ok to not know everything.⁴³ Encourage students and colleagues to embrace new roles or challenges.⁴⁰ Pair residents with a student to mentor to increase self-confidence.⁴¹
• Use positive reinforcement, and encourage acceptance of compliments.^40,41

Manage burnout.

• Streamline responsibilities by involving learners in projects you are working on as part of their learning activities (e.g., data collection, developing policies or patient education materials, leading topic discussions, participating in journal club, in-services).
• If possible, use layered learning if you are precepting a student and resident at the same time. This allows the resident to participate in some of the precepting responsibilities of the pharmacy student. For ideas see this preceptor development presentation on layered learning for ideas of how to incorporate this into your practice (https://pharmacy.uconn.edu/wp-content/uploads/sites/2740/2020/03/HO-6-per-page-Layered-Learning-final.pdf).
• Incorporate time for learners to work with other professions (interprofessional learning) and support staff (e.g., understand all roles within the practice).

Growth and professional development.

• Engage in ongoing professionalism, including a personal commitment to advancing the profession, as part of your preceptor requirements. This is met by completing at least three professional activities (e.g., manuscript reviewer, poster presentation, active participation in professional organizations, publications, etc) in the last five years.⁸
• Strive for continual growth and development as a preceptor. Review The Habits of Preceptors Rubric (https://www.habitsofpreceptors.org/) for ideas on how to assess and develop your own or your learner’s precepting skills.
• Encourage participation in professional organizations. US Pharmacist provides a sample list, including links, to national, state, and other pharmacy organizations at https://www.uspharmacist.com/professional-organizations.
• Talk about the benefits of and opportunities for board certification (www.bpsweb.org).
• Share professional development information for things such as:
  • board certification resources (e.g., live reviews, recertification courses)
  • continuing education
  • professional certificate programs (e.g., emergency medicine, nutrition support)
  • residency information
• Share websites on professional development (e.g., www.acpe-accredit.org/continuing-professional-development/) for additional guidance, including a worksheet to use to keep track of professional development activities.
• Encourage participation in professional meetings.

Research projects

• Pharmacy residents often conduct a research project, but other learners may also conduct research projects.
• Understand and address research barriers, such as time constraints and limited experience for both learners and preceptors.
  • Brush up on areas related to research, including IRB submission, study design, statistics, etc.
  • Ensure dedicated and protected time for research. For example, administrative time for research preceptors and time for learners (e.g., one day per month, short blocks near holidays).
• Gather topic ideas to provide to residents to choose from.²²
  • Topic ideas can come from a variety of sources (e.g., preceptor suggestions, departmental needs)
  • Prioritize topics before presenting the list to incoming residents.
  • Consider sending potential topics before residency starts or during orientation to start the research process early.
  • Align resident interests with research topics to avoid disinterest as a research barrier. For example, ask residents to rank their interest in potential research topics.
• Use a formalized research process.²²
  • Consider involving or developing a research committee.^23,24 Research committees:²⁴
    • can provide tools (e.g., data collection forms, protocols).
    • may offer constructive/actionable feedback; help anticipate and overcome barriers; and improve research quality.
  • Provide classes and discuss research and related processes at orientation and throughout the year (e.g., IRB process, interpreting results, manuscript writing)
  • Provide residents with a structured timeline.
    • Ensure selected research projects are realistic to complete within the timeline.
      • Most resident projects will need to be completed within six to eight months. However, larger projects may be an option in some cases (e.g., completing PGY-1 and PGY-2 residency at the same site).
      • Alternatively, outgoing residents could complete the first half of a research project, including project design, IRB submission, etc) while incoming residents could complete data collection and analysis.
    • Ensure deadlines allow for mentor/preceptor review prior to submission.
• Collaborate and engage expertise.²²
  • Collaborate with other residents or residency programs or involve students.²⁵ For example:
    • Students can assist with data collection allowing for a larger sample size.
    • PGY-2 residents may be able to help mentor PGY-1 residents through the research experience.
  • Engage expertise (e.g., college of pharmacy, research committee, colleagues who have completed a research corticate program).
    • Consider participating in a research certificate program.²⁶ For example, The American College of Clinical Pharmacy offers a Research and Scholarship Certificate Program (https://www.accp.com/academy/researchAndScholarship.aspx).
• Have residents share their results to highlight their hard work and practice presentation skills. This can be done internally to administration or the Pharmacy & Therapeutics Committee or externally at an appropriate conference (e.g., regional residency conference).