Project Profile: Across the Patient Care Threshold

This Project Profile highlights the first aim of Dr. Claire Kolar’s dissertation research, in which she attempts to discover more about the transformation students undergo when learning the Pharmacists’ Patient Care Process (PPCP) by identifying threshold concepts.  An introduction to Dr. Kolar’s dissertation project can be found here.

Why are Threshold Concepts important to pharmacy education?

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Claire Kolar

Imagine the transformation a student goes through when becoming a practitioner.  In some ways, it may be like  crossing a threshold. Once across, the learner fully understands the discipline and is irreversibly transformed. A threshold concept is “akin to a portal, opening up a new and previously inaccessible way of thinking about something. It represents a transformed way of understanding, or interpreting, or viewing something without which the learner cannot progress.” (Meyer & Land, 2003) In essence, threshold concepts are the concepts, or big ideas, a learner must master to transform his or her understanding of a discipline.

According to Meyer & Land, threshold concepts have five defining characteristics. They are:

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

These five characteristics not only help identify threshold concepts in a discipline, they can also help us understand student development as they learn to identify as pharmacy practitioners.

Why are Threshold Concepts important in teaching the patient care process?  

Students at the MN-COP have been taught patient care skills, such as developing a care plan and making a plan for follow-up, for many years. I observed the teaching and learning of these skills is very good. However, I wondered if there was more to the learning of the PPCP than simply mastering the skills. What else happens, or needs to happen, for students to transform into patient care practitioners?

After reading about threshold concepts, I thought this framework could help pharmacy educators discover the transformation associated with learning the PPCP. Indeed, my research identified five Patient Care Threshold Concepts based on input from focus groups of pharmacy students, residents, faculty, and practitioners. The Patient Care Threshold Concepts were then confirmed by an Expert Consensus Panel using the Nominal Group Technique to reach consensus.

Once identified, how can Threshold Concepts be used to advance curricula?

The Patient Care Threshold Concepts can be used to inform teaching and assessment strategies and influence curricular decision-making. For example, one Patient Care Threshold Concept identified was:

Patient Care Threshold Concept #4: Discern a patient’s medication experience and incorporate his or her individual knowledge and beliefs into the care provided

Pharmacists recognize each patient has a unique view of their medications and distinct medication taking behavior. Regardless of how one appears on paper, pharmacists do not make assumptions about patients’ understanding of medications or their expectations of care. Pharmacists work with patients to uncover the individual complexities of their life and their goals related to medications and use this information when providing care.

This idea of the medication experience can be intentionally introduced when teaching the PPCP and woven throughout a pharmacy curriculum, including in experiential education settings. Learning activities, patient encounters, and assessment strategies can be created to ensure students experience and achieve this threshold concept regarding a patient’s medication experience.

In addition, threshold concepts for other areas of pharmacy education can be identified and utilized in course and curriculum design. For example, threshold concepts associated with leader development or interprofessional education could be pursued.

The second aim of Dr. Kolar’s dissertation research applied the Patient Care Threshold Concepts to a curricular evaluation instrument. This aspect of her work will be profiled in the near future. Stay tuned!



Meyer JHF, Land R. Threshold concepts and troublesome knowledge: Linkages to ways of thinking and practising within the disciplines. Improv Student Learn – Ten Years On. 2003;4:1-16