A question for NP's - What if our school preceptorship isn't so great?

medic97RN09 · Nov 1, 2012

You (personally) have to make the best of your clinical exposure! I am getting ready to leave the house in less than 5 mins to spend all day in GYN clinical. I am a male A/GNP student in a GYN setting. I feel like a fox in a hen house. I have to fight and claw for every patient encounter that I get. Now don't get me wrong, the staff is great and my preceptor is awesome but as soon as the patients see a male they are like "NO! I don't want to see a (male) NP student". Thats Ok, I make the best of my clinical every time I show up. I listen, I spend time on the microscope practicing, I review charts, I overhear a patient has XYZ and I start looking it up on UpToDate to become more familiar, and I am constantly picking my preceptors brain about any GYN guidelines, medications, etc.

If I was in your shoes, I would take one of the harder patients after they were reviewing and perform a chart audit. Look up every diagnosis, medicine, etc and then ask questions. Why did you do XYZ, why not this. What were your differentials, etc.

Hope this helps.

tryingtohaveitall · Nov 1, 2012

Great suggestions from MedicRN...

Not all of my clinical rotations were what I'd hoped. One area had a lot of cancellations, no shows but I/we did just as was suggested. We would discuss different clinical situations, she'd tell me about interesting patients she'd seen, etc. I'd also use the time to study. While it would have been nice to have laid hands on more actual patients, I do feel like my time was beneficial. Honestly, the patients I'd see in her clinic for follow-up usually had nothing wrong with them at all by that point, they were just completing a long course of ATB. So I really did learn more from reading their history and treatment course.

Advanced Practice Columnist / Guide · Nov 1, 2012

My question would be how such an intellectually unchallenging clinical rotation could affect your future role preparation. Is an acute rehab setting something you see yourself working in as a nurse practitioner or just a rotation you couldn't wait to get over with? It's different when we say that not being able to do pregnancy exams in an OB setting is alright (or in my personal experience not being able to perform pelvic exams in an ED that has a predominantly Muslim female patient population). The point is, it's not the field I was interested in nor something I would pursue as a nurse practitioner anyway. If it really concerns you and it is an experience you think is valuable for your future there are a few things you can do other than initiate self-directed learning on your own.

One, discuss your learning goals with the preceptor. You should have learning objectives that must be met at the end of the rotation -- this is a requirement in all NP programs. If one of the objectives is to be able to care for complex patients, then your preceptors should make accommodations for this to happen. Two, discuss it with your NP faculty clinical coordinator or program director. If it has to come to you being placed somewhere else where you will learn more than you are doing now so be it. I wouldn't let a school continue utilizing a site that does not offer essential competencies to NP students both from the students perspective and for the program's sake. BTW the statement "I really won't learn "the real deal" until I'm out" to me, is a cop-out on that preceptor's part to dismiss the responsibility to go in-depth into teaching you in the clinical setting.

goofeegirl · Nov 2, 2012

I agree that the preceptor saying that you won't learn "the real deal" until out of school is faulty. I was lucky to have preceptors who would make me see all the patients and experience the true practical role of a NP by thinking through the problems and then presenting the patients to them. I would speak up and let the school know that your clinical is not fulfilling your goals and perhaps they can reconsider using them in the future. You will be doing a service for future students by saying something now. I really believe I learned a lot for the boards in my clinical experiences and you should be getting the same.

SoundofMusic · Nov 2, 2012

I will have to say, out of fairness, that my preceptors encouraged me to obtain the Fitzgerald review and look at it now, so I'd do better in clinical and on the boards. They are trying to do what they can in the short time they have ...but I feel if preceptors really don't have time to teach, they probably shouldn't accept a student, in all fairness.

Why can't we have NP's who are paid to precept in the best way possible without having to carry their own patient loads? Isn't this how medical students are taught? I feel the process really needs some reform if we are going to be educated and prepared properly for the role.

Advanced Practice Columnist / Guide · Nov 3, 2012

Actually medical education works a bit different. First, their clinical training has to be housed within an academic setting. The typical arrangement is that medical students work as sub-interns under the direction of residents in an academic setting such as a hospital. Ultimately attending physicians who teach in the residency program also serve as faculty in the medical school. In out-patient settings where there are no residents, the attending physician faculty member is responsible for training the medical student.

I don't see a reason why NP education can not follow this model. In the setting where I work (an ICU service in an academic medical center), our NP students and medical students have their own assignments and function as sub-interns equally (NP supervises NP student, Resident supervises medical student). Both NP student and medical student present their patients on rounds including their assessment and plan to the attending. They are pimped equally during rounds. I think this is a great way to learn through the problem solving process of medicine.

allnurses Guide · Nov 3, 2012

Can't you just ask them to give you some of their patient load? I'm not sure how advanced you are, but my preceptors would just split their assignment with me, have me work up the H&P, present them on rounds, go over with them what my plan for the day was (and give me hints and tips for stuff I'd missed or not thought of), enter all my orders into the EMR (they had to sign off on them), write the note (they reviewed and then signed off on them). That way I took some of their workload, and in going over my plan etc, we had time for teaching. Sometimes I think preceptors do want to "go easy" on you, and you have to push to get more experience or more patients, or whatever clinical exposure you need. Don't overwhelm yourself, but feel free to say "I can take more" or ask why they aren't giving you more, if you feel it's a deliberate plan of theirs. Maybe they have a reason and it will be a chance to discuss.

I agree if you can't resolve yourself, talk to your faculty advisor.

SoundofMusic · Nov 4, 2012

Can't you just ask them to give you some of their patient load? I'm not sure how advanced you are, but my preceptors would just split their assignment with me, have me work up the H&P, present them on rounds, go over with them what my plan for the day was (and give me hints and tips for stuff I'd missed or not thought of), enter all my orders into the EMR (they had to sign off on them), write the note (they reviewed and then signed off on them). That way I took some of their workload, and in going over my plan etc, we had time for teaching. Sometimes I think preceptors do want to "go easy" on you, and you have to push to get more experience or more patients, or whatever clinical exposure you need. Don't overwhelm yourself, but feel free to say "I can take more" or ask why they aren't giving you more, if you feel it's a deliberate plan of theirs. Maybe they have a reason and it will be a chance to discuss.
I agree if you can't resolve yourself, talk to your faculty advisor.

Eh, I guess I'm just not that advanced yet ...i'm trying to GET to be this advanced - and that is where I feel it's just falling short. What happens is they are basically allowing me to assess and examine, and then I present my findings to them -- yet they come in and just DO the diagnosis and orders, and I can't say they always discuss that with me every single time. Most times, it's just onto the next patient. We might have time at the end of the day to discuss each plan, but sometimes not. I just usually fervently try to print out the notes so I at least GET the Assessment and plans ...and try to learn from it.

My professor has just suggested that I OFFER my plan as I present to them -- and even if I'm a mile off, to just offer it anyway to get the process going that way.

Nurcpou · Nov 11, 2012

I think that the clinical experience is very valuable in terms of future practice. Preceptors can't just wave away clinical by saying that you won't learn the "real deal" until you start to work. I saw complicated patients from the second day onward - now, I often run into situations and disease processes that I did not encounter during my clinical rotations, but I'm glad I got as much exposure and experience as I did. My preceptors were faculty for a residency program, so I got the benefit of learning from physicians who were passionate about teaching. If you have the opportunity, spend as many hours as possible in a county clinic or a location that serves low-income populations - it is quite rewarding work, the variety is interesting, and the staff are often eager for more help. Interjecting your plan as part of presenting the patient is an excellent idea, and maybe you'll get more feedback.

mrmedical, ASN, BSN · Nov 11, 2012

Can't you moonlight somewhere as a shadow or in a non-program affiliated fashion. At least you would get the experienc and exposure, and I'd wager that would count for so much more. I'd be time consuming, but you'd be doing yourself and your patients a service by trying to aggregate that experience.

Psychcns · Nov 11, 2012

Do what Ghilbert suggests above--start with one pt then 2. Practice diagnosing and making plans for care.