internship supervision by preceptor

[dimama, MSN, APRN]

Having begun my internship experiences I have seen a wide range of technique and oversight by my preceptors. I have reviewed the literature, but there seems to be a lot of ambiguity defining supervision, what it is and how close it needs to be. Clearly, the student becomes more independent as they progress through the program. But how independent? Do those of you who are preceptors always exam all patients that your student evaluates, or is verbal report at some point sufficient? What level of oversight do you utilize and still feel comfortable co-signing the chart?

[newFNP2015]

As I am a student rather than a preceptor, I can give you the other perspective. I think it depends on many factors.

Factors I have seen: The preceptor's level of experience in practice and in precepting students, the preceptor's understanding of NP education, the student's level of knowledge of the patient population, preceptor's level of confidence in the student based on patient encounters, etc.

I have had preceptors who see patients with me in real time (as in they are just in the room listening and watching) and I have had preceptors who essentially require a verbal report and a short pop-in to verify any findings and reinforce plan of care.

This is my 3rd semester with a clinical attached and it varies more by preceptor than my level of knowledge in my experience. My first clinical I felt that I had more autonomy than I had knowledge. My second rotation I felt that I had more knowledge than I had autonomy. My current rotation is a great compromise where I feel I am on par with the balance.

I believe there is a lack of uniformity within NP education as a whole and preceptorship is no exception to that rule. For my school, preceptors can be NPs, PAs, or MDs, and I find very few criteria that need to be met except for patient population (related to rotation) and saying "yes" to having a student. We present them with a preceptor agreement at the beginning of the semester and discuss our previous experience and goals for the rotation. Usually, they just sign whatever I hand them and I start seeing patients.

[BostonFNP, APRN]

In general terms I always have students progressively take more responsibility.

In the first semester I expect them to take a good history and do a good physical exam, and I am usually in the room with them the whole time for support and so I can observe technique and intervene. Once the patient has left I ask them for their differential and we talk about it. I have then write a full long note and we then correct it together.

In the second semester I expect the student to start owning the patient and I may or may not be in the room the whole time. I am always readily available but if the student is good I let them go alone. I expect them to start evaluating labs. I expect then to present the patient to me with a diagnosis, two differentials, and ideas on the plan and orders. I then see the patient with the student in the room and finish the visit. I have the student write a more focused note and we correct it together.

Third semester I gradually let the student take on near-full responsibility. I expect them to see the patient then present an assessment, differentials, orders, and plan. I have them up them in the EMR and pend the orders on my signature. I quickly see the patient while the student sees the next patient.

Obviously every student is different but that the basic outline. I never sign off on orders without seeing the patient myself; doing so would put both the student and myself at risk.

[futureeastcoastNP]

In general terms I always have students progressively take more responsibility.

In the first semester I expect them to take a good history and do a good physical exam, and I am usually in the room with them the whole time for support and so I can observe technique and intervene. Once the patient has left I ask them for their differential and we talk about it. I have then write a full long note and we then correct it together.

In the second semester I expect the student to start owning the patient and I may or may not be in the room the whole time. I am always readily available but if the student is good I let them go alone. I expect them to start evaluating labs. I expect then to present the patient to me with a diagnosis, two differentials, and ideas on the plan and orders. I then see the patient with the student in the room and finish the visit. I have the student write a more focused note and we correct it together.

Third semester I gradually let the student take on near-full responsibility. I expect them to see the patient then present an assessment, differentials, orders, and plan. I have them up them in the EMR and pend the orders on my signature. I quickly see the patient while the student sees the next patient.

Obviously every student is different but that the basic outline. I never sign off on orders without seeing the patient myself; doing so would put both the student and myself at risk.

Boston, you sound like such a wonderful preceptor! I wish they would standardize NP clinicals across the board, maybe as part of the consensus model, with every preceptor learning to follow an outline very similar to yours. I worry about the complete lack of standardization - I feel there are probably many students who go through their whole clinical rotations with full supervision and really never learn to be their own provider.

[BostonFNP, APRN]

Any quality NP program will have some sort of structure for preceptors to follow, and more importantly, have regular meeting between the student, preceptor, and clinical faculty. Twice a semester ideally.

[futureeastcoastNP]

Any quality NP program will have some sort of structure for preceptors to follow, and more importantly, have regular meeting between the student, preceptor, and clinical faculty. Twice a semester ideally.

Of course any QUALITY program would, but as we all know, those in charge do not seem to be concerned with shutting down or regulating the poor quality programs so most students don't receive anything like you're talking about, especially now that Walden seems to be undertaking the goal to educate every NP in the country.