Stop the preceptor madness!

LessValuableNinja · Feb 1, 2017

This responsibility of providing support for students falls first on the school, not on the body of practicing NPs or the students themselves. Students shouldn't have to be begging for preceptorships, that is not quality education. Our speaking up about this issue is attempting to help future students.

Imagine what a fit the AMA would have (and be interviewed on CNN about) if half the medical schools in the country said, "Sorry, we aren't providing people in clinical situations any more to teach the students. Students, you need to go find your own.. good luck."

Aromatic · Feb 2, 2017

Jules,
Thank you. You actually supported my comment that it doesn't matter which school you go to. What matters is how much work and dedication the student puts into it...I know one student in the local university and she said the program is so easy it's a joke as compared to BSN school. They only accept 20'students per cohort and they place you with preceptors. But that doesn't mean she is getting a great education.
Also, there are not 3 nurses in NP school on my unit. Im the only one. There are 3 practicing NPs that round on my unit and all recommended the school I chose. As far as over saturation, does that mean no one else should pursue their career goals? I don't agree and there are actually over 250 NP job postings in my city alone.
in any way, I'm not here to argue, simply here to state that there is nothing wrong with looking for preceptors and that is ridiculous for someone to get angry that someone is asking for help with that. Also looking for preceptors does not mean you are not going to be a competent, quality provider, which seems to be what everyone is ranting about on this thread.
Im going to leave it at that and exit myself from reading further rude comments.

let me know how it pans out after you graduate.

How does it go again? I keep forgetting...

Person1- "omg im in first semester NP school learning to be a doctor in less time and I can do everything that neurosurgeon can because I worked in the ICU for 5 years blah blah blah doctors are overpaid NP IS THE WAY TO BE!!! yeah nurse power!!!! I am unstoppable and will get paid like 150k bc I am a Dr. Nurse!!! and physicians are overpaid goons!!"

Two months later:

Person 1- "omg guys I cant find a preceptor, Ive called around all over the place but they only take PA/MD students and I am just so busy writing my paper on patient feelings toward breastfeeding while doing yoga and I dont have time to call around all these places, SOMEBODY HELP"

2 years later: "finally graduated but I failed boards omg!!!!! What did i do wrong??? I did all my school work and wrote fine papers, and one even got published in some journal but I cant pass ahhhh"

6 months later- "Passed boards guys!!!! Heres what i did (inserts terrible study strategy topic post) BUT I CANT FIND A JOB O M G!!!!!! Everybody wants 2 years experience but they wont hire us to get the experience ahhhhhh."

8 months later- "Finally got a job but, I AM MAKING LESS THAN I DID AS A NURSE WHERE IS MY 150K SALARY HELP. I AM SEEING 49 patients a day and have to go home and chart for 5 hours per night ahhhhhhh"

Pardon me for the terrible use of parentheses but I have to go study now. TTYL

Also, yeah I know, its not the story for everybody, but lololololololol it is for those who are inept and go to Western Governors University of the Feenix/Kaplan and get a roflable education.

myoglobin, ASN, BSN, MSN · Feb 2, 2017

Thanks, K-Nicole for the supporting perspective that your post embodies. I was so upset by several of the posters above that I typed a two page reply on my phone which was lost when it would not post yesterday. In any case I will revisit some of the relevant points that I tried to make on the "lost" post.

1. While "research" no doubt indicates the importance of the "preceptor" process I'm not aware of any studies that compare "brick and mortar" students with those who find their own preceptors. Even if such research exists it would be quite a challenge to control for variables such as patient population, student characteristics and patient outcomes. Indeed, what the research does definitively demonstrate is that FNP's provide equivalent or superior care to MD's in terms of patient outcomes in primary care. What is more much of this research was done starting in the mid 1990's when standards to become an NP were considerably less than they are now.

2. There exist well defined laws that establish standards for sitting for certification examination. If some of the posters here are upset that they are not sufficient for current graduate students I would assume that they would be even more outraged over those practicing Master's level practitioners who didn't even have to have a specific clinical component or specialized degree who were "grandfathered" in the 1990's. That is because before that time all you needed was a Masters level education and requisite experience to sit for specialty exams such as the Family Nurse Practitioner exam. Now you may only sit for exams where your education specifically matches your certification.

3. So what if finances are a motivation for students and colleges. The hospital that I work for HCA is the largest for profit hospital in the United States and makes billions from patients. Several neurologists that I work with were complaining to me that they paid over $300,000 in taxes and that they earned less than 500,000K for the first time in over a decade. Is there a single major big pharma company that doesn't earn billions? How many executives for major brick and mortar universities earn less than high six figure incomes? Money dictates almost every aspect of our economy in healthcare and otherwise.

4. Many of the best MD's in our hospital were educated in places like Pakistan and did their residencies in hospitals without even MRI machines. In some cases I would trust them with my life or that of my family far more than some of those educated at places like Duke and who did their residencies at places like Hopkins. I detest the elitist attitude that permeates many of the replies in this thread and elsewhere on the forum.

5. We have the power to "be part of the solution". Those of us who become clinical providers at the Masters level and above can volunteer to be preceptors especially at those institutions from where we graduated.

6. I'll start where I began. Online education has both benefits and challenges. I for one am grateful that I could move to Hawaii tomorrow and finish my clinical education there (if only I could convince my significant other to do so), such flexibility would not be possible with a traditional program. Indeed, I witnessed many students who had to drop out of my ASN and BSN undergrad "brick and mortar" programs because clinical preceptor arrangements were changed often with almost no notice, and their places of employment could or would not allow them to change their work schedules. At least in finding my own preceptors have some control over the scheduling. The flexibility of this situation comes with a price.

7. I see many of the hostile attitudes here reflective of the type of "horizontal violence" that has been the subject of research in nursing for decades with few solutions as to it's resolution. I suspect that it will not largely resolve until this generation (including geezers like myself) have been supplanted by a newer generation not imbued with some of the sentiments no doubt at least partially accrued through decades of mistreatment by facilities and peers.

allnurses Guide · Feb 2, 2017

What is more much of this research was done starting in the mid 1990's when standards to become an NP were considerably less than they are now.

This is a joke right? It is considerably easier to be admitted to NP school now that it was 5 years ago, than it was 10 years ago, then it was 20 years ago. The standards for admissions have declined with the exponential increase in NP programs and the access to NP programs has increased considerably. There is good and bad to this, but it is much easier to go to NP school now than it ever has been.

FWIW, forigen medical school graduates have to do an ACGME approved residency in this country before they can practice here; so those physicians have completed two residencies as well as, often, had years of practice experience.

We have the power to "be part of the solution". Those of us who become clinical providers at the Masters level and above can volunteer to be preceptors especially at those institutions from where we graduated.

I think being a NP preceptor is a great experience for practicing NPs, if they are afforded the opportunity to do so and have a desire to do so. I hope that all novice NPs will wait until they have sufficient experience to undertake this responsibility as it affects the future of the profession as well as the safety of patients.

The problem is two-fold: there has been such an exponential increase in NP school matriculation that if it continues at this rate than the dearth of experienced preceptors will get worse. The result we all fear is that novice NPs begin to precept student NPs resulting in poorly-prepared new novice NPs precepting a new batch of student NPs that then end up being even more poorly-prepared novice NPs and the cycle continues.

I see many of the hostile attitudes here reflective of the type of "horizontal violence" that has been the subject of research in nursing for decades with few solutions as to it's resolution. I suspect that it will not largely resolve until this generation (including geezers like myself) have been supplanted by a newer generation not imbued with some of the sentiments no doubt at least partially accrued through decades of mistreatment by facilities and peers.

Having people disagree with you is now "horizontal violence"? Medicine is going to be a tough job for you.

myoglobin, ASN, BSN, MSN · Feb 2, 2017

What is more much of this research was done starting in the mid 1990's when standards to become an NP were considerably less than they are now.

[COLOR=#000000]My point here was that up until the mid 1990's any Masters level graduate could sit for board certification. Thus, many of the FNP's that practice in this area for example did their Master's in Nursing education, and didn't even have graduate level pharmacology or pathophysiology let alone clinical courses in their specialty (and despite this many are excellent clinicians). Now everyone who wishes to sit for board certification must have the matching requisite education that correlates with the examination they wish to take. This represents and important standardization/change.

[/COLOR] Also, it is not the disagreements that I take issue with, but rather the broad characterizations involving essentially all programs that don't provide preceptors or that rely on distance education. I will grant you certain points with regard to program proliferation. On the other hand many studies have shown a projected deficit in primary care providers in part because so many doctors now go into specialized practices rather than primary care. Furthermore, there is a rapidly evolving "baby boom" bubble that is helping to drive this need. I simply ask that you step back and appreciate the diversity of opportunity that exists today and that were it not for the flexibility in educational venues this opportunity would be much less. Indeed, many of the more experienced nurses such as myself (and others with many more years experience than me) would be among the least able to expand their educational horizons (due to work/family/debt obligations and the inability to go full time in a traditional program where assigned preceptors set rigid guidelines with regard to availability). I acknowledge the challenges of the current system and also the benefits of traditional modalities (and indeed will cede the point that for some people they produce superior outcomes), but don't characterize those who chose a different format as in some way inferior to the one I have chosen. My significant other commented recently that going back to when she started her ASN career back in the early 2000's for every nurse and educator who supported her endeavors going back to school first for her BSN and then for her MSN she had at least two or three discourage her from doing so. Still she has done nothing but succeed, and although I'm surely biased I continue to be blown away by the quality of care that she supplies to her clients in terms of medicine management (she doesn't do counseling). I do believe there is room for improvement in "the system". Way to much time is spent on nursing research and dogma that could be better spent on additional clinical themes (patho, pharm ect). The University of North Dakota's program does a good job at this (at the expense of adding about 12 hours to their MSN program) and they still keep it at under $300 per credit hour. However, even the University of Southern Indiana essentially integrates three course of psycho pharmacology into your last three semesters of clinical's after your core "3P's" despite 20 initial credits of what essentially constitute non clinical research type courses.

allnurses Guide · Feb 2, 2017

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Also, it is not the disagreements that I take issue with, but rather the broad characterizations involving essentially all programs that don't provide preceptors or that rely on distance education.

There are some quality online program and there are some horrendous ones, just as there are for B&M programs. There are some things that need to be taught hands-on and require workshops and most quality online programs have these as a requirement.

On the other hand, I don't see any valid reason any program should not assist students with, and ultimately control, clinical experience and education; I do use a broad brush here because professionally I feel the practice is wrong. I challenge you to tell me one good reason that doing this does anything but burden students and decrease quality of education.

Indeed, many of the more experienced nurses such as myself (and others with many more years experience than me) would be among the least able to expand their educational horizons (due to work/family/debt obligations and the inability to go full time in a traditional program where assigned preceptors set rigid guidelines with regard to availability).

Just because a program assists students with preceptorships does not mean that they don't offer part-time track and/or that they have no flexibility with availability. I have a part time student precepting with me this semester who works full time; it is very common.

I acknowledge the challenges of the current system and also the benefits of traditional modalities (and indeed will cede the point that for some people they produce superior outcomes), but don't characterize those who chose a different format as in some way inferior to the one I have chosen.

The only one that can make you feel inferior is yourself.

I do see a stark difference between NP students and medical students when it comes to drive for excellence. Medical students compete for the best schools, the best residency spots, and in the process they put their lives on hold for 6-10 years, move wherever the need to, quit their other jobs, etc. It disheartens me sometimes to see/hear of NP students and perspective students that want the quickest and easiest path with the least amount of sacrifice. On this very thread a comment was made about trying to be simply "adequate". In the end does that effect outcomes in the aggregate? I don't know, perhaps over time it will.

Jules A, MSN · Feb 2, 2017

Still she has done nothing but succeed, and although I'm surely biased I continue to be blown away by the quality of care that she supplies to her clients in terms of medicine management (she doesn't do counseling). .

How exactly are you certain she is an excellent prescriber? Not saying she isn't but as someone who isn't a psych RN, NP or psychiatrist and who I can only assume hasn't reviewed charts or seen outcomes how can you be so sure? I go home and describe single handedly saving lives and stamping out disease on a regular basis to my husband who I bet thinks I'm good but the truth is he has no clue. I've also seen NP students and especially patients who think someone is a great Dr, NP whatever when the truth is they suck.

Something we all should consider is in the case of NP students they learn to prescribe at the side of whoever they end up with as a preceptor. I personally know of several NPs who have graduated within the last year and are already precepting. It is especially concerning because one of the schools has in its handbook they require 3 years of NP experience prior to precepting which is clearly BS. This is the same school that doesn't require peds hours if the student is unable to find a preceptor which I find disgusting. Interesting how nursing schools can bend the rules and change all that "matching requisite education" necessary prior to board certification to suit their needs.

elkpark · Feb 2, 2017

This is a joke right? It is considerably easier to be admitted to NP school now that it was 5 years ago, than it was 10 years ago, then it was 20 years ago. The standards for admissions have declined with the exponential increase in NP programs and the access to NP programs has increased considerably. There is good and bad to this, but it is much easier to go to NP school now than it ever has been.

That was the statement that jumped out at me from the other poster's comment, as well. It used to be easier?? Not quite. Back in the day, there were a limited number of schools, they were all B&M, and most of them required significant years of clinical experience to consider you eligible. Programs were a lot more competitive than they are now, now that there are so many program that will take anyone with a pulse and student loan eligibility and, basically, anyone who wants to can become an NP (from the privacy of their own homes, in their jammies, in their free time). I don't know how it has worked over the years for NPs, but, when I finished my CNS degree in the 1990s, you had to get two years of supervised clinical experience after you finished school, out in the real, working world, to even be eligible for certification.

myoglobin, ASN, BSN, MSN · Feb 2, 2017

I say she is excellent partly because I see her spend hours reviewing Uptodate and Cochrane for the latest clinical guidelines for her patients "off the clock". However, I say it partly because the bar is so low. At the two biggest Psychiatrist MD run offices where she experienced her student experiences written signed scripts were left everywhere and the expectation was that unlicensed personnel including secretaries give these to patients when there were not enough providers. High percentages of patients (maybe 50%) were on benzo's chronically. Few if any tests such as Lithium levels or regular EKG's wee ever ordered for patients chronically on stimulants like Adderrall. Frankly, at least here just doing the basics, and not breaking the law is enough to make you at least way above average. Perhaps, one of the reasons that essentially every study ever published shows equal or better outcomes for NP's versus MD's is not because they "know more" or have had superior education, but because they are more likely to simply follow the basics (this is supposition I know). Just following basic guidelines will probably beat brilliance and optimized education a high percentage of the time.

allnurses Guide · Feb 2, 2017

Something we all should consider is in the case of NP students they learn to prescribe at the side of whoever they end up with as a preceptor. I personally know of several NPs who have graduated within the last year and are already precepting. It is especially concerning because one of the schools has in its handbook they require 3 years of NP experience prior to precepting which is clearly BS.

As above, this is a major problem that is getting compounded with each rolling graduation from some of these programs. We have a local subpar NP program that most experienced NPs won't touch students from, and that program has started telling their students to make sure they start precepting other students as soon as they get into practice: a local internal med office hired one of these NPs that didn't last 3 months due to negligence and then they had a problem with what to do with her student when they fired her.

elkpark · Feb 3, 2017

I say she is excellent partly because I see her spend hours reviewing Uptodate and Cochrane for the latest clinical guidelines for her patients "off the clock". However, I say it partly because the bar is so low. At the two biggest Psychiatrist MD run offices where she experienced her student experiences written signed scripts were left everywhere and the expectation was that unlicensed personnel including secretaries give these to patients when there were not enough providers. High percentages of patients (maybe 50%) were on benzo's chronically. Few if any tests such as Lithium levels or regular EKG's wee ever ordered for patients chronically on stimulants like Adderrall. Frankly, at least here just doing the basics, and not breaking the law is enough to make you at least way above average. Perhaps, one of the reasons that essentially every study ever published shows equal or better outcomes for NP's versus MD's is not because they "know more" or have had superior education, but because they are more likely to simply follow the basics (this is supposition I know). Just following basic guidelines will probably beat brilliance and optimized education a high percentage of the time.

"Excellent" is not supposed to be a relative term; it's supposed to mean more than "a little better than 'incompetent'."

myoglobin, ASN, BSN, MSN · Feb 3, 2017

As I stated above I am biased. However, I will stand upon the assertion that her care equals or exceeds most experienced psychiatrists in the area most of whom I have interacted with at some point over the last eight years. However, that really isn't the point. Rather, it is painting programs with a "broad brush". If you have a problem with a specific school (or schools) then I say fine, lay out what you believe the specific deficiencies as to their approach. Note, that just because we have to find our own preceptors doesn't mean that they are of lower quality. Note that each of the three preceptors that my significant other utilized (who left multiple signed prescription pads around the office and had secretaries renew prescriptions when providers were not available) were all MD's with many years experienced, were board certified and were also used by "brick and mortar programs" including medical schools in the area as residency locations for their students. In addition, I must provide a litany of paperwork, and certifications for my chosen preceptor and there exists multiple written and oral conversations between my instructors back in Indiana and my preceptors here. Again, my goal is to be mediocre, follow the law, and to live in Hawaii. it takes literally everything I'm capable of to barely be mediocre (including not taking more than about ten lunch breaks in the last eight years which I don't get paid for and charting off the clock in the morning since we get in trouble for clocking out more than 15 minutes after the hour) at my current ICU job. I lack my significant others 150 IQ and nearly photographic memory so whatever she is I will probably fall well short. Then again I plan to use the latest integrated technologies such at the diagnostic system now being used by Wellpoint based on IBM's Watson as soon as the technology is available. I also plan to make available something that few if any providers are offering, specifically "after hours" appointments in the 5PM to 2AM range via tele-medicine. White Castle or Taco Bell may not have the best food around, but when it's 0100 you are often happy just to have something decent for under $10.00 that doesn't give you food poisoning (ok perhaps Taco Bell isn't the best analogy given their past problems with food contamination issues, but you get the point). I want to "fill a hole" in the marketplace and cover the "basics" of medical management for mostly stable, preferably mostly adult psych patients. Of course there will be exceptions that is the nature of the business, but if I can get licensed in say four or five states (say Arizona, New Mexico, Hawaii, Wyoming, and say Colorado) I can probably cast a "wide enough" net to not only fill my appointments, but even have several other providers working with me eventually (who I compensate at say 80% of the billed rate, much higher than most tele-medicine sites currently do which typically pay only about 50 to 60% of what they bill). I believe that this can be done both legally and ethically and provide a needed service at reasonable prices to many.