NP Clinical Preceptors: Challenges and Opportunities
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP
Preceptors are an essential part of NP education. In the preceptor role, NPs teaching students in a one-to-one relationship provide the vital link between the NP curriculum and clinical application. Over the past 20 years, however, as NP programs have grown, the number of available NP preceptors has not kept pace with the number of students seeking qualified preceptors.1 The shortage of clinical preceptors is attributed not only to increased NP student numbers, but also to declining ability among NPs to precept.
The Preceptor Role
The disincentives and barriers to precepting are well established and familiar to many NPs. In a recent survey study exploring the benefits, incentives, and barriers associated with precepting, lack of time was the most commonly identified reason for not precepting among the 4,500 NP respondents; barriers also included lack of support from employers, lack of space, electronic health record issues, and inadequate staff support.2,3 Other commonly cited reasons why NPs choose not to precept include concerns about loss of productivity and reimbursement while precepting, inexperience or not feeling prepared for the preceptor role, patients’ expectations for the provider’s attention, and prior negative experiences as a preceptor.4
Although time crunch and performance requirements are considerable challenges in health care, teaching tomorrow’s NPs remains essential to the ongoing success of the NP profession. The current model of NP education relies on clinical educators who volunteer their time and energy in guiding students on their way to becoming competent providers. Preceptors and clinical rotations provide the role models and environment students need to safely learn how to function in real practice settings. In addition, studies have shown that precepting does not necessarily require longer days and more time spent with patients, nor does it necessarily decrease productivity.5 Strategies for addressing these barriers to precepting are discussed below.
Teaching in the clinical setting places multiple demands on the preceptor, but it has important benefits as well. Benefits of precepting that were reported in the Roberts et al. study include learning opportunities, access to educational programs, developing relationships, and continuing education (CE) credit for precepting.2 Teaching students can help NPs stay current with evidence-based practice, as students’ questions and insights foster critical thinking and reflection on our practice strategies. Many NP programs offer preceptors adjunct faculty appointments (which often includes library privileges).6 Precepting also provides an opportunity to create change in health care by building relationships with our future peers in the NP profession. Studies have documented that NP students’ professional development and practice strategies are influenced by their preceptors.4 By precepting, you can share your vision of the NP profession and pass on practice strategies and values that help students become safe, competent, compassionate, caring clinicians with a focus on health promotion and prevention.3 Regarding CE credit, the American Academy of Nurse Practitioners Certification Board allows NPs who recertify by clinical practice hours and CE to use hours providing patient care while serving as a preceptor to replace up to 25 nonpharmacology CE credits.
Strategies for Successful Preceptorships
There is not a standardized, formal approach to preparing NPs for the preceptor role, and feeling unprepared for preceptorship hinders some NPs from getting involved in clinical education. However, resources are available for NPs interested in precepting (see Resources).1,4-6 Several themes associated with successful preceptorship are outlined here.5
Expectations. The preceptor should have an understanding of the program’s expectations for the clinical education experience, including the level of practice expertise the student has achieved (beginner or on their last rotation, experienced registered nurse or new to the profession?), the objectives for the course, and the number of hours the student is expected to spend with the preceptor.4
Communication. Prior to the start of the clinical experience, the preceptor should communicate or meet with the student to establish the shared expectations for the clinical experience and review basic details about the practice such as directions, dress code, charting parameters, practice routines, and a general overview of the patient population.4 During this meeting, the student’s learning style and the preceptor’s teaching style can be discussed. A tour of the site and introduction to staff is also helpful.5 A clear line of communication with the faculty at the student’s program also should be established, and plans for faculty visits (number and timing) should be set.
Preparation. All members of the practice should know the student’s daily schedule and the duration of their clinical rotation in the setting. Day-to-day practice issues such as scheduling patients, arranging examination room availability, providing space for charting, and planning for student access to patient records must be addressed as well.5
Teaching. Teaching strategies used in the clinical education setting include modeling and observation, case discussions, direct questioning, and assigned readings.4 With regard to case discussions, Medicare rules state that a student can document only the review of systems and the past medical, social, and family history, while the preceptor must document the history of present illness and physical exam. Given the Medicare rules, one general approach is for the student to obtain the pertinent histories and perform the physical exam while the preceptor sees another patient. The student then presents the findings when the preceptor returns, and depending on their level of practice expertise, generates differential diagnoses and develops management plans. This approach allows teaching points to be discussed after the exam and allows the preceptor to alter the direction of the visit as needed.4,5
Preceptors can develop their own approaches to discussing cases with their students, but several models designed for this purpose are discussed in the literature. The American Association of Nurse Practitioners’ Preceptor Toolkit recommends the “One Minute Preceptor” (or “Micro Skills for Precepting”) model for getting students to think and talk about their patient encounters (see Box 1).6,7 SNAPPS is a collaborative model for case presentations that was developed for the outpatient setting (see Box 2).8
Box 1. Micro Skills for Precepting
- Get a commitment: “What do you think is going on?”
- Probe for supporting evidence: “What led you to that conclusion?”
- Teach general rules: “Many times when…”
- Reinforce what was right: “You did an excellent job of…”
- Correct mistakes: “Next time this happens, try this…”
Box 2. SNAPPS Collaborative Model
Summarize briefly the relevant history and physical exam findings
Narrow the differential to two or three relevant possibilities
Analyze the differential, comparing and contrasting the possibilities
Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches
Plan management for the patient’s health issues
Select a case-related issue for self-directed learning
Scheduling. Scheduling strategies aimed at helping NPs maintain productivity while precepting include focused half days and wave scheduling. The focused half day is useful for inexperienced students or on busy clinic days. With this strategy, the preceptor selects one or two patients from the day’s schedule and the student spends time before and after their patient arrives studying the chart and looking up material related to the focus of the day and the care of the patient.5 With wave scheduling, two or three patients are scheduled at the same time followed by a break of 10 to 15 minutes. The student sees one patient while the preceptor sees the others, and the break is used for seeing the student’s patient and precepting.5,6
Evaluation. Evaluating students is a critical part of precepting and can be stressful, but it is important to remember that providing timely feedback is necessary for the student’s development as a clinician. The Preceptor Toolkit recommends that evaluations should be constructive, based on skill development, and consistent with the student’s level of development.6 The assessment should be communicated to the faculty at the student’s program.
Preceptors are necessary to ensure continuing excellence in the NP profession. All NPs should be open to taking on this role, remembering that precepting can be as beneficial to the preceptor as it is to the student.