Using “Threshold Concepts” to Enrich Teaching of the Pharmacists’ Patient Care Process

By Claire Kolar, PharmD, PhD

Take a moment to think about the ways students learn to become patient care practitioners at your institution. Are they taught to use the Pharmacists’ Patient Care Process? Do they practice performing patient assessments and writing care plans? Do they practice their skills with simulated and/or real patients and are ‘checked off’ if they meet minimum competency? Furthermore, are these methods the best way to prepare our students to become patient care practitioners? Or are there better approaches to help transform our students into competent patient care practitioners?

Learning to become a patient care practitioner is unlike other learning in pharmacy school. It is different than learning the pharmacology of a class of medications; it is different than learning the application of guidelines to a patient case or the way to compound a medication. Becoming a patient care practitioner requires students to adopt a specific way of thinking and acting. Additionally it is the mastering of the Pharmacists’ Patient Care Process which contributes to a learner’s identity as a pharmacist.

One approach to the training of students to become patient care practitioners is through the use of ‘Threshold Concepts.” The idea of “Threshold Concepts” originated in economics, but has been used in many disciplines including biochemistry,1 palliative medicine,2 and occupational therapy.3 A Threshold Concept is an idea or piece of information that transforms the learner’s way of thinking about a certain topic or discipline and is necessary for a student to progress in his or her learning.4

Threshold Concepts have five defining characteristics:

  1. Transformative; involving shift in personal identity or values
  2. Irreversible; unable to return to the previous way of thinking
  3. Integrative; exposes the interrelatedness of something
  4. Bounded; interfaces with the boundary of where one discipline ends and the next begins
  5. Troublesome; troublesome for many reasons, e.g. counter-intuitive, from an alternative perspective, incoherent

How do (or can) Threshold Concepts Apply to Pharmacy?
Through my own dissertation research I was able to identify five different Patient Care Threshold Concepts associated with learning the Pharmacists’ Patient Care Process.5 These touched upon everything from patient-centeredness to the medication experience, each contributing an integral component of learning patient care.5 One of the five identified Threshold Concepts was to conceptualize and articulate the pharmacists’ unique patient care process. Pharmacists now have a standardized process (PPCP), using common language and integrating clinical knowledge, to provide patient care in a way that is distinct, yet complementary, to other health professions. Mastering this process and developing an understanding of its uniqueness to pharmacy are essential in transforming pharmacy students into patient care practitioners—to help them across the threshold.

How do we Incorporate Threshold Concepts into the Teaching Process?
Incorporating the Patient Care Threshold Concepts into teaching the PPCP gives educators additional tools and language to use in order to go beyond simply teaching the skills of patient care and checking off students once they perform the skills. Just as an example here are some Threshold Concept considerations for when students are being taught patient assessments:

  • Student pharmacists can be taught the questions to ask when doing an assessment with a simulated patient, but are they able to see how the questions they ask are different from a nurse or physician?
  • Student pharmacists can be given opportunities to practice performing patient assessments in lab settings and on rotations, but can they articulate to a patient the unique way pharmacists do their assessments?

As pharmacy educators teaching the Pharmacists’ Patient Care Process, we need to do more than provide students with a checklist approach to patient care. They may be able to perform tasks and skills associated with the PPCP, but are they able to conceptualize and understand the uniqueness of the process used by a pharmacist? We must transform student pharmacists into practitioners and employing Threshold Concepts is one way to enrich teaching of patient care skills. What other ways might Threshold Concepts be useful to transform learning of student pharmacists?


  1. Loertscher J, Green D, Lewis JE, Lin S, Minderhout V. Identification of threshold concepts for biochemistry. CBE Life Sci Educ. 2014;13(3):516-528.
  2. Wearn A, O’Callaghan A, Barrow M. Becoming a different doctor: identifying threshold concepts when doctors in training spend six months with a hospital palliative care team. In: Land R, Meyer JHF, Flanagan M, eds. Threshold Concepts in Practice. Rotterdam, The Netherlands: Sense Publishers; 2016.
  3. Tanner B. Threshold concepts in practice education: perceptions of practice educators. Br J Occup Ther. 2011;74:427-434.
  4. Meyer JHF, Land R. Threshold Concepts and Troublesome Knowledge: Linkages to Ways of Thinking and Practising within the Disciplines. ETL Project Occasional Report 4. Edinburgh, Scotland; 2003
  5. Kolar CK. Across the Patient Care Practitioner Threshold: Identifying Threshold Concepts and Evaluating the Teaching of the Pharmacists’ Patient Care Process [dissertation]. Minneapolis, MN: University of Minnesota; 2017.

Clair Kolar

Claire Kolar, PharmD, PhD, was a graduate student at the University of Minnesota College of Pharmacy at the time this project was done. Research interests include patient care instruction, program evaluation, and threshold concepts. In her free time, Claire enjoys reading novels and playing tennis.


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