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New Resource for 2024-2025

This handbook is designed to help students navigate remediation as an opportunity to improve their performance in EL. In some cases, remediation can also help students identify different ways to learn and demonstrate their knowledge, skills, and attitudes in order to meet expectations.

The content on this webpage is meant to provide general information and guidance about remediation in EL. It is not prescriptive nor meant to be interpreted as policy, process, or procedure. Remediation in other areas of the PharmD program may be approached differently (e.g., rewriting an exam, repeating a skills lab, etc.). Students are encouraged to seek information about remediation in non-EL courses by talking directly to their instructor.

Each student's remediation experience will be unique. Questions about a specific student's remediation plan should be directed to the EL Office.

Acknowledgement
The content for this handbook was created in collaboration with PharmD Student, Jenna Harris, during a PHAR 484 APPE rotation within the Experiential Learning (EL) Office.

Introduction

This handbook is a supportive resource designed to guide students and preceptors through remediation in Experiential Learning (EL).

Hearing the word “remediation” may make students feel nervous, scared, overwhelmed, or even defensive. We have found that students often have misconceptions about what we mean by “remediation” in the EL context.

The purpose of this handbook is to demystify and destigmatize the remediation process, reducing the negative feelings students may feel toward remediation and replacing them with more neutral thoughts.

It should empower students to feel more confident and in control of their remediation plan by offering ideas and strategies that they can try out along their journey.

Objectives

This handbook should help students to:

  • Explain what “remediation” is in the context of EL
  • Describe why remediation should not be viewed as punishment or failure
  • Use self-assessment and reflection skills to identify why they may require remediation
  • Compare and contrast the roles and responsibilities of the student, preceptor, and EL Office in remediation
  • Create a personal remediation plan

Self-Assessment and Reflection

Self-assessment and self-reflection are critical to remediation success. Embedded within this handbook are self-assessment questions and reflection prompts to help students practice these skills.

Look for the yellow boxes labelled with a question mark icon ().

Remediation is not meant to be punishment; rather, it is a step in the journey to becoming a successful pharmacist.

Defining Remediation in EL

Remediation can be defined many ways. 

In EL, we like to describe remediation as supportive interventions that ensue when a student is identified either by themself or others to be at risk of not meeting course expectations.

Remediation provides a guided opportunity for students to identify:

  • what areas (i.e. competencies, skills, etc.) they are struggling with
  • why they are struggling
  • why it matters
  • how to improve their performance
  • how to measure their success

Remediation is not just aimed at helping a student pass a course. Other important goals include:

  • permanently correcting knowledge gaps
  • enhancing independence in completing tasks and activities
  • improving consistency in demonstrating expectations
  • boosting confidence
  • recalibrating and ensuring accurate self-assessment and reflection
  • developing self-directed learning skills
  • strengthening professional identity

Self-Assessment

Can you describe remediation in EL in terms of the who, what, when, where, why, and how?

Try to answer the following questions before checking your answers in the drop down menu below.

Students, preceptors, and the EL Office all have roles and responsibilities in remediation. Ultimately, students are responsible for their own success. Preceptors and the EL Office are involved to provide feedback, support, and opportunities to demonstrate growth.

Remediation is the process of a student seeking, accepting, and implementing additional feedback, support, and learning opportunities in an effort of increasing their chances of succeeding. It usually involves a structured plan and timeline.

At any time! Remediation ensues once a student is identified to be at risk of not meeting the expectations for the course. This may be prompted by a preceptor or student requesting support of the EL Office and is not limited to follow up from midpoint and final evaluations. The EL Office may also request to meet with a student and preceptor if concerns are flagged in an evaluation.

Meetings with the EL Office can happen virtually or in person. In IPPE and APPE rotations, the student can usually remain on site to engage in remediation activities and demonstrate growth. For other types of placements, remediation may take place at the University or at home. Students should expect to put in additional time at home on their remediation plan and associated activities to increase their chances of success.

Pharmacy students need to be competent at an entry-to-practice level by the time they graduate. Performance expectations for each EL course need to be met to ensure that students achieve critical milestones along the way, confidently and competently. If a student does not demonstrate the expected skills and knowledge in Year 1, those problems are likely to compound by Year 4.

Students are provided feedback about concerns with their performance and are given opportunities to reflect in meetings between the student, preceptor, and EL Office. A remediation plan is introduced and discussed. In many cases, this involves the student creating a personal learning plan in which they identify and commit to actions that they will take to demonstrate the expectations of the course.

Reasons for Remediation

There are many reasons why a student may struggle during EL and benefit from remediation, including:

  • gaps in foundational knowledge
  • difficulty applying knowledge and skills
  • challenges with communication or conflict
  • professionalism and professional identity concerns

A student may experience difficulty meeting expectations due to a combination of these reasons or something entirely different. More information about each of these scenarios, potential factors underlying them, implications for future practice, and prompts for students to reflect on their own performance are outlined below.

Gaps in Foundational Knowledge and Skills

EL challenges students to recall baseline knowledge gained in the classroom and skills labs. A strong theoretical foundation is critical to accurate and safe application of knowledge in real-world scenarios.

When students struggle with recalling foundational knowledge in EL or have gaps or inaccuracies in that knowledge, it may be due to one or more of the following reasons:

  • studying to pass an exam instead of studying to understand
  • lack of engagement in the content when it was delivered
  • insufficient practice solidifying new knowledge by applying it
  • problems retaining knowledge and skills from year to year
  • feeling overwhelmed by information overload and remembering only bits and pieces of concepts
  • memory issues, learning disabilities, fatigue, stress, or anxiety

While students might feel embarrassed about struggling to recall foundational knowledge and want to try to push through the placement, masking their knowledge gaps can impose risks to the safety of patients and others as well as have the potential to cause other negative outcomes like damage to the preceptors' or site's reputation. 

Reflection

If you are having challenges with gaps in foundational knowledge, reflect on the following questions:

  • Can you identify specific topics or concepts that you have difficulty recalling? 
  • Can you envision a scenario where your lack of underlying knowledge could lead to errors that have the potential to cause patient harm?
  • How might your lack of knowledge or ability to apply knowledge affect your trustworthiness as a healthcare professional? With your preceptors? With colleagues? With prescribers? With patients?
  • At the end of the day, would you feel competent to practice on your own with this current level of understanding of the foundational knowledge required?

Difficulty Applying Knowledge or Skills

Thinking about applying foundational knowledge in EL might make students think of what they learned in their therapeutics courses. However, throughout all of their classroom-based courses and skills labs, students have learned essential skills and how to apply their theoretical knowledge. Students have also gained practice applying foundational knowledge and skills in other areas such as problem solving, critical thinking, communication, collaboration, and leadership and are expected to demonstrate this in EL.

When students struggle with applying knowledge and skills in EL, it may be due to one or more of the following reasons:

  • superficial understanding of underlying concepts
  • previous focus on memorization without understanding the context
  • approaching activities without a systematic process
  • difficulty with adaptability and flexibility
  • inability to look holistically at the situation and apply critical thinking
  • challenges with time management and prioritization
  • underconfidence
  • performance anxiety

The purpose of EL is to provide opportunities for students to demonstrate their knowledge and skills in action and to be evaluated on their ability to meet performance expectations. If a student is struggling to apply knowledge or skills, it is their responsibility to seek and accept help as early as possible in the placement so that they may have ample opportunity to consistently demonstrate the expected level of performance.

Remediation, however, should not be seen as an activity of "teaching" the student something new. EL requires students to apply knowledge and skills previously gained in the PharmD Program, so remediation efforts often focus on refining and solidifying the student's thinking processes.

Reflection

If you are having challenges with applying knowledge or skills, reflect on the following questions:

  • Can you identify specific concepts or skills you find difficult to apply in practice?
  • How well do you feel you understand the concepts related to the tasks you are performing? 
  • How comfortable are you adapting to different scenarios?
  • Can you think of a time when not following a systematic process led to a mistake or oversight?
  • What can you learn from this experience to prevent it in the future?

Challenges with Communication or Conflict

Some students who have a strong understanding of baseline knowledge and skills, and can apply them in EL, still struggle to meet performance expectations. This may be due to challenges effectively communicating. In some cases, this can cause tension and conflict, which can exacerbate the problem.

Students may experience challenges communicating effectively due to one or more of the following reasons:

  • underconfidence or self-consciousness
  • different expectations arising from cultural differences
  • language barriers
  • generational differences in communication style
  • interpersonal dynamics and personality differences
  • weak conflict resolution skills
  • lack of emotional intelligence, learning disabilities, mental health concerns

All students are expected to demonstrate communication skills that, at minimum, ensure effective and safe patient care and satisfactory completion of other activities in EL. Leaving communication challenges unaddressed can cause misunderstanding, conflict, distress, and other negative consequences. This may ultimately affect the way a preceptor views a student's performance. Proactive management is important to success.

Reflection

If you are having challenges with communicating effectively, reflect on the following questions:

  • What kind of feedback have you previously received on your communication skills and style? How does that relate to your performance in EL?
  • How comfortable do you feel adapting to other peoples' communication styles?
  • Can you envision a scenario where communication challenges could lead to errors that have the potential to cause patient harm?
  • How might your challenges communicating effectively affect other's perceptions of the quality of your work?

Professionalism and Professional Identity Concerns

Remediation is sometimes required when students' behaviour does not align with expectations in the professionalism and professional identity domains. Just as important as demonstrating the expected knowledge and skills, demonstrating the ability to think like, feel like, and act like a pharmacist is critical to students' success in EL.

Lapses in professionalism, whether actual or perceived, may be due to one or more of the following reasons:

  • conflicting personal values and morals
  • weak or nonexistent motivation to partake in the learning experience
  • ignorance or unawareness about expectations, including from cultural differences
  • overconfidence and/or reluctance to accept feedback
  • personal biases and previously-formed habits
  • lack of self-awareness or weak self-reflection skills
  • external distractions, competing priorities, mental health struggles

To succeed in the PharmD program, a student needs to be internally motivated to always put their best foot forward. Performance slip-ups happen when students do not see the bigger picture or feel motivated to represent the profession. If a student receives feedback that their behaviours could be considered unprofessional, it is important to pause, reflect, and seek support.

Reflection

If you are struggling with putting your best foot forward in terms of professionalism, reflect on the following questions:

  • Why did I choose pharmacy?
  • Are there specific concepts, activities, or practice models that I find particularly rewarding and engaging?
  • What areas do I dislike about pharmacy, and what causes me to dislike them?
  • What is missing from my experience?
  • What can I do to make this part of the journey more motivating and enjoyable for myself?
  • How might my actions be perceived by others (e.g., patients, preceptors, colleagues, faculty, EL Office staff, etc.)?
  • What is the impact of my actions on others?

Other Factors

The reasons for remediation presented in this section of the handbook are certainly not all-encompassing. Students can struggle to meet performance expectations in EL for many other reasons, which sometimes include:

  • learning disabilities
  • physical, mental, and spiritual health concerns
  • personal life stressors
  • burnout
  • resource limitations
  • ...any many other unpredictable factors

Remediation is not a discriminatory nor punitive process. If anything at all is prohibiting a student from performing at their very best in EL, they are encouraged to talk to the EL Office. If factors out of the student's control are affecting their ability to meet expectations, help is available. The EL Office is often able to connect students with student support services that can help address these barriers, like mental health concerns.

Remediation is more common than one might think. Everyone learns differently, so some students' paths to their PharmD degrees might look a bit different at times.

Roles in Remediation

Remediation is a shared endeavour between the student, preceptor, and EL Office. While each party plays important roles in the process, the student is ultimately responsible for their own success.

The image below identifies some of the key responsibilities of students, preceptors, and the EL Office (click to enlarge).

diagram outlining shared responsibilities

Self-Assessment in Remediation

No student wants to remediate, but it is critical for a student to be honest about their own performance to get the most out of the learning experience and increase their chances of success.

Accurate self-assessment is critical to effective remediation in EL.

Some students may be able to self-identify gaps in their performance, but it is not uncommon for preceptors to determine that a student is not performing as well as they think they are. It might feel surprising or even unbelievable to hear this news. If a student feels they are doing well and meeting expectations, it can be hard to hear and accept that they need to remediate. 

Reflection

How well does your self-assessment of your performance align with feedback received from your preceptor(s) and the EL Office?

Preceptors have years of experience as a professional, know what the expectations of an entry-to-pharmacist are, and have been trained to assess and evaluate students based on these criteria. Essentially, they have the benefit of seeing the "bigger picture"; where a student is at on their journey to becoming an entry-to-practice-ready pharmacist. In the moment, a student's self-assessment might be biased by their relatively limited practice experience and unconscious incompetence - the fact that they simply don't know what they don't know yet. 

Understanding the limitations of a student's own self-assessment, recognizing that this is often a normal part of professional growth, is key to receiving and implementing the additional support offered through remediation.

The Pharmacy Professional Growth Pathway

The EL Office developed the Pharmacy Professional Growth Pathway to help students and preceptors discuss and compare their assessments of the student's performance to date. This tool prompts the student to self-reflect on their demonstrated initiative, knowledge and skills, and judgement and decision-making. Their preceptor will do the same.

If a student finds that their point of view is misaligned with their preceptors, there is a mismatch that needs to be sorted out. The EL Office can often mediate a discussion about what has been demonstrated so far and where it fits within the pathway. Looking at this framework with honesty and humility can open a student's eyes to the "bigger picture" and help them more accurately assess if they are meeting the required expectations.

pharmacy professional growth pathway chart Click the image above to open a downloadable pdf of this graphic

Other Helpful Frameworks

In addition to the Pharmacy Professional Growth Pathway, it can be helpful to review another framework to understand the "bigger picture". These frameworks illustrate how preceptors and the EL Office view performance expectations in EL and the milestones students are expected to reach during the journey from first-year student to practicing pharmacist.

Explore the different frameworks below to gain a better understanding of the "bigger picture".

Students must demonstrate the expected knowledge, skills, and attitudes throughout the PharmD program to advance from course-to-course. It is important that students understand how their knowledge, skills, and attitudes are evaluated.

Miller’s Pyramid of Clinical Competence provides a visual model for looking at how students are being evaluated at each stage of their learning journey. This model helps to see how a student grows from knowing facts to being able to apply and demonstrate knowledge and skills in real-world settings. At the top of the pyramid, a student should be able to demonstrate being; embodying the pharmacist's professional identity in their work. 

miller's pyramid

Breaking down this model into its five levels is helpful to understand the expectations for student performance in the PharmD program as knowledge, skills, and attitudes are gained and developed.

Knows

This is the foundation. At this level, students have the basic knowledge and facts about pharmacy practice. When they learn about different disease states and medications, their knowledge can be assessed through multiple choice exams and quizzes.

This knowledge recall is important, but not enough alone to be an effective pharmacy intern in EL.

Knows How

Next, students are expected to know how to use the knowledge by applying in different contexts. For example, they might learn about person-specific factors that influence the medication and the dose they might select. Their ability to know how to use knowledge is tested through more complex multiple choice questions, short-answer questions, case-based assignments, or essays.

Knowing how to use this information is part of a solid foundation for EL, but still not enough alone to be successful.

Shows How

Once students demonstrate that they know the information and how to apply it, they will have to show that they can do it correctly. This can be demonstrated and evaluated in the skills lab and immersions with simulated cases that they participate in as the pharmacy intern. Before students go into a dynamic and unpredictable practice setting in EL, their ability to show that they can apply their knowledge is assessed through skills lab and immersion assessments as well as OSCEs.

It is not feasible to assess demonstration of a student's knowledge application across sufficiently diverse scenarios in the skills lab and immersions alone. This is when EL rotations (IPPEs and APPEs) are introduced for the next steps.

Does

To assess their ability to accurately and consistently apply their knowledge in different contexts and scenarios, we need to observe and evaluate students' performance in actual practice settings. Evaluation forms used in EL courses describe what knowledge, skills, and attitudes a student must demonstrate. There are often many ways students can demonstrate most of these competencies in any practice setting. The important thing is that they take intiative to do these things in their EL rotation. When students take initiative to apply their knowledge and do it well, they are demonstrating that the base of their pyramid is solid.

EL is an essential component of the PharmD program because it provides students the opportunity to do the things they have been trained to. We can only assess their ability to do these things in the real-world setting of EL.

Is

At the top of the pyramid is the "Is" level. Beyond doing the things expected of them in EL, we also need to see students embody the role and identity of a pharmacist in their being. In EL, students demonstrate their ability to think, feel, and act like a pharmacist by how they conduct themselves. In the classroom or skills lab, they may primarily think of themselves as pharmacy students rather than emerging professionals. Focusing on good marks and obtaining a PharmD degree on time is a common motivator in those settings, but EL asks instead that students focus on being motivated by becoming the best pharmacist they can be.

Preceptors are asked to assess who the student "is" as future pharmacist. In action, students are expected to demonstrate this in EL by approaching the learning opportunities with professionalism, self-awareness, a growth mindset, and other qualities expected of pharmacists.

The Bottom Line: Understanding Miller’s Pyramid helps students see that becoming a competent pharmacist isn’t just about passing exams. It’s about applying knowledge they have gained and demonstrating that they can do and be what is expected at different milestones throughout the PharmD program. 

References:

  • Cruess RL, Cruess SR, Steinert Y. Amending Miller's Pyramid to Include Professional Identity Formation. Acad Med. 2016;91(2):180-5. doi: 10.1097/ACM.0000000000000913.
  • Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;65(9 suppl):S63–S67. Available at: https://winbev.pbworks.com/f/Assessment.pdf.

There are many ways for students to demonstrate the knowledge they are gaining in their courses, from remembering facts to creating something brand new by combining several concepts together. In fact, faculty and instructors are very intentional about the verbs to use in learning objectives to make it explicitly clear to students what the expected outcome of gaining new knowledge should be.

Bloom’s Taxonomy is a helpful framework that outlines the different levels at which a student can demonstrate a concept, with higher levels representing deeper understanding of the concept. While there are many opportunities for students to demonstrate knowledge at each of these different levels throughout the PharmD program, evaluation in EL focuses on the top levels. Bloom's Taxonomy can even help students write their own personal learning objectives!


blooms taxonomy graphic

Examining how knowledge can be shown within each of these six levels can help students identify active verbs to describe how they are demonstrating knowledge in EL.

Remembering

This is the foundation. When you first learn a new concept, you likely focus on remembering basic facts and key aspects of the lesson to recall later. Memorizing drug names, mechanisms of action, and side effects is a remembering task. This body of information serves as the knowledge base for performing more higher level tasks.

While remembering facts is important, it is not alone sufficient to demonstrate what is expected in EL.

Understanding

Going beyond memorization, you should be able to understand the meaning of the information and be able to explain concepts in your own words. This would include explaining why a side effect may occur based on a drug's pharmacology. Being able to describe and paraphrase knowledge is an important skill to demonstrate to your preceptor that you actually understand what you are talking about. 

In EL, however, interacting with patients involves more than just explaining concepts in isolation. It requires application of this knowledge to unique situations, often bringing multiple concepts together, and thus higher levels of knowledge demonstration in this pyramid.

Applying

Once you are able to explain your understanding of a concept, you can apply that knowledge in real-world situations. For example, you could apply your knowledge by counseling a patient about a new medication or calculating a dose based on a child's weight. 

Application is the minimum expected level of knowledge demonstration in EL rotations (IPPEs and APPEs). 

Analyzing

Analyzing involves breaking down information into parts and examining relationships and outcomes. This is the basis of Pharmaceutical Care. To identify the relevance of drug interactions, you would have to analyze a medication profile and patient-specific factors. 

To provide effective and person-driven care, students need to analyze many, often unpredictable, factors. This cannot always be simulated in the skills lab, so it is expected to be demonstrated and assessed in EL rotations (IPPEs and APPEs).

Evaluating

Evaluating is a higher level demonstration of knowledge because it requires a firm foundation in the levels below it. Examples of evaluating include working with a patient to determine if the current treatment plan is effective or requires adjustment, or using evidence-based medicine skills to appraise an article. 

This level of thinking and demonstration of knowledge is expected in EL, particularly as students progress through the program. Students need to become confident and capable of evaluating problems posed in real-world practice. 

Creating

The highest level of the pyramid involves combining elements to create something new. In pharmacy practice, this could be creating a care plan, developing educational materials, or conducting research. At this level, you showcase your ability to pull together knowledge and skills to generate something useful. This requires that you have a deep understanding of concepts and are capable of applying, analyzing, and evaluating contexts in which you use it.

Students must demonstrate knowledge at the create level in EL rotations (IPPEs and APPEs). After all, as a pharmacist, you will be generating new things all the time!

The Bottom Line: Using Bloom's Taxonomy can help a student better understand what is expected of them in EL. It is not enough to simply remember information or explain their understanding of it. Students need to be able to apply, analyze, evaluate, and ultimately create with it! The expectation in all EL courses is that students demonstrate their knowledge in active ways that contribute productively to the practice site.

Reference:

  • Krathwohl DR. A revision of Bloom's taxonomy: An overview. Theory into Practice. 2002;41(4):212. doi: https://doi.org/10.1207/s15430421tip4104_2.

Entry-to-practice pharmacists must demonstrate the ability to think for oneself and make decisions independently. When entering the PharmD program, however, most students are far from being able to practice as an autonomous and self-regulated professional. Their learning experiences to date have heavily relied on authority figures (e.g., teachers, instructors, parents/guardians, peers, etc) to influence their perception of what is right and what is wrong. 

Self-Authorship Theory describes a developmental process that students experience as they transition from relying on authority figures for learning and identity to being capable and confident to self-direct their learning and define their own identity. It describes how students develop maturity in both thinking processes and personal beliefs as they prepare for a professional adult life.

self-authorship theory graph

There are four sequential phases in this framework describing how a student's ability to navigate challenges, make decisions, and form their professional identity grows over time.

Phase 1: Following Formulas

When starting out on your journey in the PharmD program, you may have been used to following formulas for success. You completed the prerequisite courses for the PharmD program by studying the material as it was instructed to you and passed the exams by providing the right answers. Your identity as a University student was likely influenced heavily by following the formula to successfully get into pharmacy school. In this phase, a student might strictly follow guidelines or use class notes to provide patient care in EL because they have been told this is where to find the "right" answer. They expect a preceptor to model pharmacist's behaviour and await instruction to complete tasks.

Because EL is a dynamic environment and no two patients are the same, following formulas can be dangerous. Futhermore, it is the student's responsibility to take initiative to find appropriate activities on site to allow them to demonstrate the expectations of the course. 

Phase 2: The Crossroads

After gaining some real-world experience in EL, students begin to accept responsibility for being self-directed, but still largely look to authority figures. You might find yourself at a crossroads; thinking more about whether or not you agree with others. Instead of blindly trusting authority figures, you might notice that their behaviours and beliefs contest with yours. In EL, this might look like observing a preceptor counselling a patient and thinking to yourself, "I would have approached that differently, but what do I know?". Your internal voice becomes stronger and you start thinking more about the pharmacist you want to be.

The moments that cause students to arrive at a crossroads often happen in EL. It is therefore essential for students to demonstrate critical thinking skills in EL. Preceptors are present to help students navigate the application of their knowledge in different scenarios and who they are becoming as future pharmacists, but students should no longer require modelling for every behaviour and belief.

Phase 3: Becoming Self-Authored

It is impossible to teach every possible topic and expose students to every possible professional challenge that may be seen in EL during the classroom-based portion of the PharmD program. Recognizing the need for continued professional growth through self-directed learning, students become self-authored. You might realize in this phase that knowledge is uncertain and contextual, and that many different perspectives may be valid. This would prompt you to solidify your own beliefs and values, forming your unique identity. Self-awareness and self-reflection skills strengthen. In this way, you would find new ways to relate to others as a care provider and colleague.

This is the phase in which students are expected to be performing by Year 4 of the PharmD program. Students are expected to demonstrate critical thinking skills to apply knowledge in context of the unique problem they face with minimal reliance on their preceptor to guide them. Professional identity is also assessed in EL as, at this point, students should be demonstrating behaviours consistent with the pharmacist's professional identity without prompting and modelling.   

Phase 4: Internal Foundations

A practicing pharmacist should have a strong internal foundation for both decision-making and their professional identity, based on their unique and personal perspective. Knowing who you are and what you have to contribute to the world as a pharmacy professional is paramount to self-authored practice. This requires regular self-reflection, active engagement in practice change, and collaboration with others.

By the end of the PharmD program, students should be reaching this phase and demonstraing internal foundations for their continued personal and professional growth. This is observed in EL as students demonstrate unprompted critical reflection on their practice with a growth mindset. It is also observed in the way students demonstrate pride in the profession, consistently and confidently applying internalized values in their professional actions. This is apparent in the way they care for patients, interact with colleagues, and fulfil their roles and responsibilities.

The Bottom Line: Becoming a pharmacist takes more than gaining and applying knowledge and skills. It is essential that students also form their own professional identity and internal decision-making framework before graduation. In EL, this means that students need to use their internal voice to guide their behaviours and beliefs rather than awaiting direction and guidance from preceptors for each action.

 

References:

  • Johnson JL. Self-authorship in pharmacy education. Am J Pharm Educ. 2013;77(4):69. doi: 10.5688/ajpe77469. 
  • Johnson JL, Chauvin S. Professional Identity Formation in an Advanced Pharmacy Practice Experience Emphasizing Self-Authorship. Am J Pharm Educ. 2016;80(10):172. doi: 10.5688/ajpe8010172.

Reflection

How does being told that you require remediation make you feel?

If the thought of remediation brings up automatic negative feelings or even negative thought spirals (i.e. ruminations), practice reframing them. For example, your automatic thought might be, "I'm going to be pulled from the rotation and have to repeat it again.". Pause to challenge that thought by examining the evidence for it. You might tell yourself instead, "No one has said I am going to be pulled from the rotation. I have been told this is an opportunity to get help. They want me to succeed.". Check out this resource for more practice.

Steps in Remediation in EL

Remediation can be intimidating when students do not know what to expect. While each student's remediation experience is entirely unique, there are usually some key elements involved:

Formative Feedback

Before the EL Office gets involved, remediation almost always starts with the preceptor giving constructive formative feedback to the student. Preceptors are trained to assess students' performance based on established criteria. Most often, when preceptors notice that a student is performing below expectations, they try to offer support on site by offering constructive feedback.

Involving the EL Office

Preceptors may choose to involve the EL Office if they are concerned with a student's performance, if the student seems to be struggling to understand and implement the feedback, or if they feel that extra support would be beneficial to help the student succeed. Sometimes it is apparent that a student will require remediation and other times it is not. We encourage preceptors to reach out even if they have a small suspicion that the student might be experiencing difficulty.

Students should involve the EL Office if they feel that they would benefit from additional support. As of 2024, each fourth-year APPE block has a Reflective Day built into the fourth week so that students have dedicated time to reflect on their experiences and seek support from the EL Office if they feel they are at risk of not meeting expectations by final. Students in IPPE rotations, immersions, or service learning are encouraged to reach out to the EL Office at any time to arrange a support meeting.

The EL Office may reach out to students and/or preceptors to inquire about the student's performance to date. This may be prompted by results of midpoint evaluations, past performance, or at random. EL Office outreach is never meant to be threatening. Early intervention has been shown to improve student success rates, so we simply want to ensure we do not miss the opportunity to offer support to students.

Gathering More Information

Once the EL Office is made aware that a student may benefit from remediation, more information is gathered about the preceptor's and/or student's concerns. In some cases, meetings are held individually with the student, the preceptor, or both parties together. This can occur over the phone, video call, site visit, or email communications. 

Student/Preceptor/EL Office Meetings

Usually, a meeting is promptly set up with the student and preceptor(s) to summarize the concerns that have been raised, share all perspectives, identify the root of why the student is struggling, and agree upon a plan for remediation. This meeting is critical to ensure everyone is on the same page. The EL Office may use tools or frameworks, like the Pharmacy Professional Growth Pathway, in this meeting to help facilitate a productive conversation.

Reflection

To help best prepare for a meeting with the EL Office and your preceptor, reflect on the following questions:

  • What do you hope to get out of this rotation?
  • How will this rotation impact your future career as a pharmacist?
  • What factors do you think are affecting your ability to succeed in this rotation?
  • What sort of additional supports or resources might you benefit from?
  • What do you hope to get out of this meeting?
  • Do you want to have a separate meeting with just the EL Office?

Learning Plan

A student may be asked to complete a learning plan. The EL Office has carefully created a learning plan template (available for download in the CORE Document Library) that guides students through a critical self-reflection process to identify and create their own actionable plan to improve their performance. This is a common practice in remediation. Some schools call this document a learning contract or action plan. It serves the purpose of keeping the student focused on realistic and relevant goals by breaking them down into actionable pieces. The EL Office provides feedback to students on their learning plans to help strengthen their reflection and critical thinking skills.

Action and Follow Up

Ultimately, it is the student's responsibility to implement the action items in their learning plan so that they can demonstrate the necessary improvements. This often involves putting in extra time outside of the rotation hours for self-study and practice activities at home as time on site should be dedicated to participating in the day-to-day activities of the site. Students are often encouraged to use an activity tracking log (available for download in the CORE Document Library) to document what they are doing, how well they are doing it, and how it has enabled them to demonstrate the expectations of the course. The EL Office and preceptor(s) continue to support the student. This might be by offering additional resources, learning opportunities, or feedback. Students are always encouraged to ask for the support that they need.

Assessment and Evaluation

Part of a remediation plan might include more frequent assessments before the final evaluation. Students are encouraged to thoroughly document in their self-evaluations how they believe they have demonstrated the expectations for the course so that their perspective can be carefully considered in evaluation. The outcome of the rotation is ultimately determined by the preceptor's evaluation and the discretion of the EL Office based on evidence collected of what has been demonstrated by the student. 

Course Outcome

Very often, students can be successful in completing an EL course following remediation. In other scenarios, the student may not pass the rotation, but that does not mean that remediation was a waste of time. While it is incredibly challenging for a student to hear that they were unsuccessful in an attempt to pass a course, it can be a catalyst for personal and professional growth. In these scenarios, the EL Office and faculty will help students navigate next steps on a case-by-case basis.

Examples of Remediation in EL

Sam has completed two APPE rotations in community pharmacy settings. She is now in her first hospital experience since PHAR 285.

In the first week of the rotation, Sam was surprised by how much she struggled with gathering information and working up patients’ primary concerns. She didn’t remember the patients being so complicated in PHAR 285. She constantly felt the need to ask her preceptor to help guide her to the next step.

By the end of week two, her preceptor reminded her that the expectation was that she should require minimal guidance moving forward. In week 3, Sam continued to feel overwhelmed and became increasingly frustrated by how much constructive feedback she was getting. Her preceptor suggested she contact the EL office to arrange a meeting to discuss her performance ahead of midpoint. Sam was not concerned about the meeting as she was proud of her work ethic and willingness to learn new things. She emailed the EL Office to set up a meeting when she and her preceptor were available.

During the meeting, her preceptor said, “Sam, I’m concerned about the implications on patient safety. I can’t trust that you can make sound decisions because you are missing important details about the patient when you gather information.”. Sam was struck by this comment and would not consider herself to be a risk to patient safety. She explained her perspective, giving examples of how she uses a secondary identifier when talking to patients and identifies potential side effects as safety checks. Sam’s preceptor said, “Sam, I’m not sure you understand the concern I have.”.

The preceptor explained to Sam that the issue is not that she is practicing recklessly or is inconsiderate of safety precautions. The issue is that her process for gathering information and working up patients is not as thorough as it needs to be without significant guidance. The EL Coordinator asked Sam how she felt about these skills, and she responded, “It’s all so overwhelming and complicated. I don’t know where to begin some days. I don’t picture myself being a hospital pharmacist. It’s too high pressure.”.

The EL Coordinator said, “It sounds like you are having trouble applying foundational skills in hospital pharmacy. Even if you don’t plan to be a hospital pharmacist, we need to ensure that you have a solid process to work up any patient with minimal guidance moving forward so that you can adapt to any clinical area.” The EL Coordinator reminded Sam that in year 4, she should be able to gather information and make sound decisions with minimal guidance. Without gathering all the information to look at the situation holistically, it is impossible to make an appropriate and safe decision.

The preceptor(s) and EL Office have to be confident that students are competent to go out and practice safely as pharmacists, without the safety net of preceptors, after graduation. She asked Sam, “If your preceptor wasn’t on site tomorrow, and you had to pick up a new patient to care for, how confident are you that you would identify the most important things to focus on?”. Sam admitted that she would be comfortable working up disease states they have already covered together in this rotation, but she would feel lost knowing how to workup other disease states without her preceptor. The EL Coordinator responded “We have concern with that nearly halfway through the rotation, Sam, that you are not meeting expectations. We need to ensure that you have a solid process to work up any patient with minimal guidance so that you can use that process in your future practice to adapt to any clinical area.”.

The EL Coordinator introduced the idea of a learning plan and provided Sam with a template. Together, they identified two competencies Sam should develop a plan for. Sam committed to completing the learning plan over the weekend and sharing it with her preceptor and the EL Office on Monday to seek feedback. Sam felt that it was a good reflection exercise. She looked at her situation with humility and honesty. In the plan, she outlined a structured process for systematically gathering information and prioritizing problems. She referred to her notes from Complex Cases and sought additional support from a mentor.

As Sam implemented this plan and assessed her progress on a scheduled basis, she noticed an improvement in her confidence and competence. By week 5, she was able to work up a new patient with minimal guidance. She was excited to report back to the EL Office that she had made improvement. In her week 6 check-in, her preceptor said, “Sam, you are doing better, but I need to see more consistency in your performance in the last two weeks.”. Sam did all that she could in the last two weeks of the rotation to show her preceptor she could complete tasks with minimal guidance. The daily feedback she was getting from her preceptor reinforced she was on the right track.

By the end of the rotation, she reflected in her self-evaluation that she had not only addressed her gaps in knowledge and skills due to a lack of process, but had also developed a more resilient and adaptive learning approach. Her preceptor was proud to agree and felt that she demonstrated consistent performance in the last two weeks at the expected level.

Sam realized that pushing through the rotation, relying heavily on her preceptor for guidance, would have hindered her potential professional growth as a pharmacist. She needed to examine her performance deficiencies and feel in control of a plan to address them. Sam went on to complete her last rotation with more confidence, improved self-awareness, and a stronger professional identity.

Ken, a first-year pharmacy student, was excited to complete his first IPPE rotation. He had never worked in a pharmacy before, but really enjoyed his experience in the community immersions during first year.

Early in the rotation, Ken found interpreting and entering prescriptions to be challenging. He also struggled to confidently answer medication questions from patients, his preceptor, and other healthcare professionals because he was not sure what they were really asking. He constantly felt the need to rely on his preceptor to help. Despite bringing several repeat order entry errors to his attention and lots of ongoing feedback and discussion in the first two weeks, Ken continued to make the same errors so his preceptor contacted the EL office to arrange a meeting to discuss his concern.

Ken felt like since he was only in his first year, his mistakes would be overlooked and he could convince his preceptor he would try harder. During the meeting, his preceptor said, “I am worried about the level that Ken is at. While I understand that this is his first year and he still has lots of time to grow, I feel like he lacks the baseline foundation essential to be successful at this point and is also not aware of the impacts of the mistakes he has made.”. After a discussion about how these mistakes pose a risk not only to patient safety Ken worked on a learning plan to focus his efforts on improving the knowledge and skills required to demonstrate the competencies he was struggling with. The EL Office followed up with Ken and his preceptor at the end of week 3 and found that Ken was still making the same types of major mistakes as before with little to no awareness of their impact. The EL Office offered more guidance on his learning plan and reminded Ken that in order to be successful in the rotation, he needs to consistently demonstrate each competency to the expected level, which may be difficult with only one week left in the rotation.

In the middle of week 4, Ken’s preceptor reached out to the EL Office to express that he felt Ken’s performance was still too inconsistent to meet expectations and he ultimately failed the rotation. In follow-up, the EL Office discussed with Ken that while it seems early in the program to make these decisions, if he continues without a firm foundation, he will likely continue to struggle throughout the pharmacy program. As part of his remediation plan, it was determined that the best way for Ken to build a stronger foundation was to remediate by retaking a skills lab course and a pharmacy practice class. Ken felt disheartened by this. He had worked hard to get into pharmacy. The EL Office assured Ken that remediation is not meant to be a punishment, but rather to help him build a stronger foundation to be successful.

As Ken progressed through his remediation plan, he started to strengthen his skills and knowledge. Ken was later able to reattempt his rotation feeling more prepared and confident. He found herself more capable of handling tasks with some guidance after receiving initial direction from his preceptor. He made very few mistakes and addressed those that arose promptly, reflecting his improved self-assessment of his performance. Throughout his 4-week rotation, Ken was able to consistently perform to the expected level required for his rotation. While Ken was reluctant and upset with having to remediate, he realized more and more as he progressed through the program that the foundational gaps would have likely led to further struggles and potential failure later on.

Self-Assessment

True or False: Can you identify which of the following statements are true and which are false?

Try to answer before checking your answers in the drop down menu below.

FALSE

A lot of students view remediation as a punishment. This is not how it is supposed to be viewed. Instead, it should be viewed as an opportunity to improve their performance with additional support and guidance so that they are able to succeed in their rotation.

TRUE

Remediation gives students an opportunity to intentionally reflect on improving their application of foundational knowledge and skills. Feedback will help students identify what needs to improve and how to improve. This is critical not only for progressing through the PharmD program, but a requirement for them to be able to practice independently as a pharmacist.

FALSE


Students are given opportunities to remediate on-site, unless there are extraordinary circumstances, such as risks to patient safety or severe professional misconduct.

TRUE

Students should not be waiting until midpoint to realize they are performing below expectations. The sooner the need for remediation is identified, the more time the student will have to create and implement a plan to succeed. Students and preceptors can proactively reach out to the EL Office if concerns are apparent before midpoint.

FALSE

Remediation does not only address gaps in knowledge, but can also help with skill-building and shifting perspectives and attitudes. Other common reasons students remediate are discussed in this handbook.

Developing a Personal Learning Plan

Completion of a learning plan is often incorporated into a student's remediation plan when they struggle to meet expectations in an EL course.

The EL Office has created a learning plan template for students to use as a tool to help them identify the root cause of what they are struggling with, why it matters, and how they will address it.

A personal learning plan can be a helpful tool for any learner because it facilitates action-orientated planning for success. When clear intentions and goals are set in a learning plan, it serves as an accountability tool.

Students should follow the steps below when creating and implementing a personal learning plan:

 Download the template from the CORE Document Library.

To quickly find it, use Ctrl+F to search within the Document Library for the word "learning plan".

 Identify the context for creating the learning plan and write it in on page 1.

This is the reason for creating the learning plan. Some reasons might be to:

  • identify how to demonstrate expectations in specific areas of difficulty
  • set learning and performance goals for a specific placement
  • implement feedback from one placement to the next
  • develop a longitudinal professional development plan

Read the prompts across the columns from left to right, keeping in mind the context for creating the learning plan.

If the relevance or application of any of the prompts requires clarification, read through the examples provided on page 2. If anything is still unclear, reach out to the EL Office for support.

Identify what to focus on in this version of the personal learning plan.

It may be intuitive to start at the top of the template by completing one row at a time for each area to focus on. However, starting instead by identifying the areas in which to improve (left-most column) before moving on to the rest of the columns can help to recentre the bigger picture of what is expected and the overlap of many areas. This can make the whole process more efficient as some reflections and plans will fit better in different areas.

Start filling in the chart, frequently referencing the reflection prompts as a guide.

If it is overwhelming to unpack a broad area like application of fundamental knowledge or critical thinking, try thinking of a time that feedback was provided regarding the opportunity to improve in that area. Explore whether that feedback applies more generally and, if so, start by writing down where those challenges come from in the second column. It is critical to identify a "why" before diving into planning for change. Reviewing the reflection prompts embedded throughout the "Reasons for Remediation" section of this handbook above may also stimulate some thoughts around the "why".

Be as specific as possible with action items.

The How and When columns should contain specific and observable action items. For example, "I will do a better job researching answers to questions" is not specific nor observable. Instead, a student should write out their own step-by-step process to describe how they will approach research questions moving forward. Steps should not be omitted, even if they seem obvious. A good approach is to outline the process as if you were trying to teach someone else how to do it, and do it well.

Check for relevance and feasibility.

Action items need to be realistic to be meaningful in the learning plan. A good check is to ask, "On a scale of 1-10, how confident am I that I can do this in the timeline I have specified?". If the answer is less than 8/10, explore what the barriers might be and consider rewriting the action plan to what is feasible. It is important to remember that while improvement is one of the goals of remediation, demonstrated improvement may not be enough to consistently meet the performance expectations of the course. 

 Seek feedback on the learning plan.

When a learning plan is assigned as part of a remediation plan in EL, the EL Office asks that students submit their completed learning plan for review and feedback. Feedback from the EL Office is usually focused on prompting deeper reflection or making action plans more tangible and/or realistic. Students can also seek feedback from mentors and peers on their personal learning plan to provide other perspectives and insights, in addition to considering feedback from the EL Office and preceptor(s). 

 Put the plan into action.

A learning plan must be put into action to be successful. Once a student starts implementing the action items in their personal learning plan, they should keep track of activities that demonstrate growth and improvement in those areas. Use the PharmD Student Activity Tracker (available for download in the CORE Document Library) to keep track of these activities and real-time feedback gathered.

 Seek feedback on an ongoing basis and revise the learning plan accordingly.

A personal learning plan is a living document that can and should be updated as circumstances change. Using the action items identified in the right-most column as a checkpoint, a student should be able to determine whether or not they are achieving what they planned to on the established timeline. Revising the learning plan over time ensures this column always stays up to date and the student can continue to move forward with continuous improvement as a goal.

Resources and Tools

For Students

Shifting from a Fixed Mindset to a Growth Mindset

Developing a Personal Remediation Plan: From Goal-Setting to Taking Action

Practicing the Pharmaceutical Care Process

Accessing Mental Health Supports

Related Policies and Procedures

For information about College of Pharmacy and Nutrition policies and procedures related to student performance, remediation, removal from EL site, and failures of EL courses, please see the college's Academic Policies and Policy Related Documents.