The Failing Preceptor System for Nurse Practitioner Students: A Student's Perspective

It is time that NP programs recognize the importance of the preceptor’s role and provide their students with paid preceptors. Students NP Students News

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The Failing Preceptor System for Nurse Practitioner Students: A Student's Perspective

I recently graduated from a nurse practitioner (NP) program and experienced the infamous preceptor struggle that many students complain about. Like many NP schools, my school does not provide their students any assistance with finding preceptors. Students are expected to find practicing nurse practitioners or physicians willing to precept them for each of their required rotations. I expected the process to be more formal and not as desperate or pathetic as my predecessors described. I was wrong.

Self-Directed Process

To my disappointment, there was no magical database of potential preceptors to tap into when I started my search. There was no list of potential or confirmed preceptor "leads" provided by my school. The process was a self-directed solo mission and was eerily similar to how I perceive a telemarketing sales job would be. The reality is that most nurse practitioners and physicians do not want to precept a student. It takes time away from their workday tasks and all students are not receptive to teaching, nor are they motivated to work. My search to find a preceptor willing and available to precept me quickly became a full-time job of tedious administrative tasks. In the end, securing preceptors required an exhausting combination of sending emails and faxes with my resume and CV to various human resources departments, cold calling clinics and leaving messages with secretaries, and repeatedly asking (bothering) my healthcare colleagues for any potential connections. It was awkward, embarrassing, time-consuming, and often unsuccessful.

Why is This MY Problem?

I have to question how this practice of students finding their own preceptors is considered appropriate or normal. From a student's perspective, it is a menial task of imploring strangers to take an unpaid preceptorship to train you. From an institution's perspective, clinical education should be structured and consistent for all NP students, with required learning objectives that are supervised by educators employed with the school. In other words, how did this ever become the student's problem?

The process of finding preceptors has become so difficult that some students are forced to delay their graduation date while others have had to pay up to $20 per clinical hour for preceptor-matching services to complete their residency. When students are solely responsible for finding their own preceptors, a culture of desperation is created, and the option to be selective is removed. Instead of electing preceptors by their qualifications or student reviews (few reviewing systems exist), students settle for any provider that is willing and available. The NP Program's only qualifying prerequisite for most preceptors is that they have acquired at least one to two years of clinical work experience. It is not uncommon for students to choose their friends or people they work with to precept them. Potential conflicts of interest did not appear to be a concern, as most NP programs prefer not to have any involvement in the student's search. This is not to say that all friend-turned-preceptor arrangements are bad, but are they appropriate?

What's the Incentive?

In student-arranged preceptor agreements, preceptors are not asked to follow any format when teaching an NP student. The preceptor provides background information and credentials to enter into a legal contract approved by the school, yet the direction and structure (if any) of the student's clinical time are up to the preceptor. There are no checklists of clinical skills that must be demonstrated during the student's residency. There are no student-specific protocols provided to the preceptor outside of general safety guidelines. The most well-intentioned preceptors may have heavy patient loads that prevent them from providing an adequate clinical experience for the student. The preceptor can give you as much or as little instruction and guidance as they choose. They are doing the student an unpaid favor, after all.

Healthcare employers do not give preceptors additional time or smaller patient loads when they are training a student. Precepting is considered a volunteer-based commitment. There is no incentive for the preceptor's employer when permitting them to train a student. On the contrary, precepting may be seen as a hindrance to the employer, as the student's presence may be a distraction and impact the preceptor's productivity.

My Experience

I was fortunate enough to work with some outstanding preceptors during my residency, however, the clinical settings were less than ideal. My participation in residency ranged from strictly observing patient-provider interactions to taking patients independently and reporting my diagnoses and treatment plan to the preceptor. I did not have access to electronic medical records (EMR) in any clinical rotation. I was not given a login ID or a computer to use. No workspace was provided. Some of my preceptors shared their desks with me. In one 4–week rotation, I sat in a single chair, writing in a notebook on my lap in between patient appointments.

My only method of documenting patient information was to jot down as many notes as possible on a notepad, which was a practice that seemed to make patients uncomfortable. I would then use what little information I had written to complete full-length, SOAP-style clinical notes when I returned home. My school required these full-length SOAP notes on every patient seen in clinical, including the patients I only observed. My preceptors did not have time to share vital signs and CPT codes, explain rationales and treatment plans, or give me more than a 10–20-second verbal report before we entered a patient's room. With an average of 15–20 patients per 8-hour clinical day, there was little opportunity for notetaking if I wanted to practice any hands-on skills. While I am grateful to have gained the writing skills to complete clinical notes without EMR, I am concerned that NP students learning under this precepting method will have little to no training when it comes to researching or incorporating past medical history when they get into practice. Access to EMR is essential to clinical learning and understanding. Unfortunately, I was not in a position to be demanding amenities like desk space and computer access.

My residency experience is more common than not. The quality of the clinical experience is neither a priority nor a consideration in most programs. While my program required comprehensive clinical notes on every clinical patient, most programs have minimal writing requirements. Residency faculty are not concerned with the details of the student's clinical learning experience or the student's struggle to find and secure preceptors. I find this disconcerting given the high cost of tuition and program fees. Are program administrators not responsible for the quality of the clinical experience because they refuse to participate in or assist the student with the preceptor search? With other aspects of the NP curriculum being so rigorous, intense, and micromanaged, why is the clinical experience not held to the same standard? The clinical residency is just as important to a nurse practitioner's education as the coursework. The practice of precepting should be standardized to meet the objectives of the student's clinical residency experience. It makes little sense why some NP programs are not directly involved in and oversee this practice.

Is it at all surprising that new NP graduates are entering the field unprepared?

Precepting nurse practitioner students should be a PAID role and candidates should be screened for qualifications and interviewed in the same process used to hire other educators. Preceptors ARE educators. They educate students in clinical practice. They prepare students for the clinical setting in an environment with real patient interactions. Preceptors teach skills in residency that cannot be acquired from a textbook or a simulation lab. Precepting is a job, and it is an IMPORTANT job. All nurse practitioners do not possess the skills to be good preceptors. All clinical sites and settings are not ideal for teaching NP students.

FACT: It is time that NP programs recognize the importance of the preceptor's role and provide their students with PAID preceptors who are invested in the student's clinical experience and held to the same performance standards as other course instructors.

DNPgrad2022 has 6 years experience as a ASN, BSN, DNP.

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Specializes in Community health.

Yes, yes, yes.  I am at a brick-and-mortar school, and they do give some assistance to us, so I am in a better position than many.  BUT we are told up and down that the school does NOT guarantee us a preceptor, so we better find our own. 

My first semester, I did that, using a connection I had from work, and it was a nightmare.  As you described, my preceptor (who was an excellent psychiatrist) had no idea what he was doing when it came to precepting. Like you, I had no desk and no EHR access.  The director of the clinic announced that I would be "Observing, with absolutely no involvement in treatment."  The school screened my preceptor only to make sure he was an MD in good standing, but that was the end of their involvement.

The semester was a complete waste of my time.  Currently, my fall semester placement is going great!  But that's exactly the problem-- the experiences are so completely all over the map that there is zero standardization for learning. Some students have done hundreds of hours inpatient and no outpatient. I've done all outpatient.  Some people's experiences are almost entirely centered around substance abuse treatment; some people have had no addiction experience at all. Some people have seen tons of kids, some people have seen only adults. 

It is incredibly embarrassing that when we start our first jobs as NPs, it will be obvious to all the doctors that our training was woefully inadequate.  I can't believe that the governing boards are allowing it-- it is an enormous stain on the reputation of nurse practitioners.  How can people advocate for professional respect equal to that of doctors when our training is (sometimes-- not always-- but for some students in some placements) a joke?

Specializes in MSN, FNP-BC.

Yes! I agree with everything you pointed out on your post. I had a two excellent preceptors: OB/GYN (MD) and Family (NP). The other three were mediocre at best. I had to pay an honorarium for all of them. I knew I was not remotely ready to practice on my own, so I applied to a primary care residency and will start in a couple weeks.

Once I finish it, one of my missions is to advocate for our profession by finding a way to require universities to set up clinicals for their students, just like they must do for undergrad students, and to increase the hours to 2000. Another mission is to require mandatory 1-yr residencies as well, but that will be mission #2. I have a couple other missions, but those two are the most important.

I am proud of our profession and want to elevate it.

Specializes in Community health.
18 hours ago, Freckledkorican said:

Yes! I agree with everything you pointed out on your post. I had a two excellent preceptors: OB/GYN (MD) and Family (NP). The other three were mediocre at best. I had to pay an honorarium for all of them. I knew I was not remotely ready to practice on my own, so I applied to a primary care residency and will start in a couple weeks.

Once I finish it, one of my missions is to advocate for our profession by finding a way to require universities to set up clinicals for their students, just like they must do for undergrad students, and to increase the hours to 2000. Another mission is to require mandatory 1-yr residencies as well, but that will be mission #2. I have a couple other missions, but those two are the most important.

I am proud of our profession and want to elevate it.

Can I sign up for your mission??  I am in total agreement with the changes you want to see.

Guest1144461

590 Posts

What do you mean by residency? Post-grad? Mine was very formal and we were integrated with actual MD residents for a large portion of it.

The NP preceptor is a joke because NP admissions is a joke. When anyone can go online with a BSN and get into most schools of course there is going to be a preceptor problem. NP programs need to cut the excess admission (and money) and do what's right.

A school in NC isn't reasonably going to find preceptors in CA. They need to be honest with themselves and accept local residents only. No more of this half-baked education. EVERY other medical profession does it right except nursing.

The ONLY way for schools to fix this issue to cut down on admitted students and raise the bar for admission. I don't care if its the GRE, pre-reqs or something else but letting everyone in and feeding them to the wolves is not working...

Guest1144461

590 Posts

To further expand, the problem starts with the push for a BSN and BSN programs. Everyone is taught in nursing school that it is almost expected you pursue higher education after your BSN. With this culture comes the expectation that anyone can be a provider. This is ABSOLUTELY not true and both are extremely different skill sets.

Nursing lobbying is very good, particularly in the NP realm. There are many qualified and excellent NPs out there, but I am not convinced it is because of the education. My school was a hybrid format and did find preceptors. My professor did fly out to my clinical site once to talk with my preceptor. This is waaaaaay more than most school, however the education IMO was still substandard. The admissions process was borderline comical with little to no requirements other than LORs, BSN and 1 year of acute care experience. I am almost positive acceptance rates were 90%+ and this was what I consider an OK school. Some I am sure are near 100%.

Some reality needs to be interjected:

1.Not every nurse can be or should be a NP

2.Online is viable to some extent but should only be offered to local students for SOME classes.

3. NP programs need to have full accountability of preceptors and their quality. Students should NOT find or acquire their own.

4. NP admissions need a complete overhaul.  A BSN and a check shouldn't be the only requirements.

5. NP hours need expansion to at least 1500-2000

6. More NP residencies after graduation need to be created with govt assistance just like GME.

Specializes in MSN, FNP-BC.
3 hours ago, Numenor said:

What do you mean by residency? Post-grad? Mine was very formal and we were integrated with actual MD residents for a large portion of it.

Post-grad residency. I've read some of your posts regarding your experience and it sounds just right. I start mine in a couple weeks and I hope I get a chance to train alongside MD residents, too.

1 hour ago, Numenor said:

Some reality needs to be interjected:

1.Not every nurse can be or should be a NP

2.Online is viable to some extent but should only be offered to local students for SOME classes.

3. NP programs need to have full accountability of preceptors and their quality. Students should NOT find or acquire their own.

4. NP admissions need a complete overhaul.  A BSN and a check shouldn't be the only requirements.

5. NP hours need expansion to at least 1500-2000

6. More NP residencies after graduation need to be created with govt assistance just like GME. 

Yes to all six points you raised, starting with #4. To get into med school, the MCAT is one of the requirements. Heck. Undergrad requires the TEAS exam. NP programs should have an entrance exam as well.

Then, definitely #2 followed by the rest. Another thing. The NP board exam needs to be more rigorous. My proposal is that day one is the online portion and day two should be the clinical portion, meaning rotating through different patient encounters and presenting/defending our care plans to proctors.

If we significantly raise the standards of NP education over time, we'll eventually produce quality NP providers rather than quantity.

Specializes in Community health.
3 hours ago, Numenor said:

To further expand, the problem starts with the push for a BSN and BSN programs. Everyone is taught in nursing school that it is almost expected you pursue higher education after your BSN. With this culture comes the expectation that anyone can be a provider. This is ABSOLUTELY not true and both are extremely different skill sets.

Nursing lobbying is very good, particularly in the NP realm. There are many qualified and excellent NPs out there, but I am not convinced it is because of the education. My school was a hybrid format and did find preceptors. My professor did fly out to my clinical site once to talk with my preceptor. This is waaaaaay more than most school, however the education IMO was still substandard. The admissions process was borderline comical with little to no requirements other than LORs, BSN and 1 year of acute care experience. I am almost positive acceptance rates were 90%+ and this was what I consider an OK school. Some I am sure are near 100%.

Some reality needs to be interjected:

1.Not every nurse can be or should be a NP

2.Online is viable to some extent but should only be offered to local students for SOME classes.

3. NP programs need to have full accountability of preceptors and their quality. Students should NOT find or acquire their own.

4. NP admissions need a complete overhaul.  A BSN and a check shouldn't be the only requirements.

5. NP hours need expansion to at least 1500-2000

6. More NP residencies after graduation need to be created with govt assistance just like GME.

Yes to every single one of these.

subee, MSN, CRNA

1 Article; 5,368 Posts

Specializes in CRNA, Finally retired.
On 9/15/2022 at 3:39 PM, CommunityRNBSN said:

Can I sign up for your mission??  I am in total agreement with the changes you want to see.

If schools don't want to provide preceptors, then they shouldn't be charging tuition since they are offering no service to the students.  We are just cranking out mediocrity in the name of increasing providers.  Schools want to get the students in and, as quickly as possible get them out so they can capture other sources of tuition and get those seats filled.  It stuns me that our accreditors allow this farce to happen.  Would you want to be put asleep by a CRNA who had such shabby educational standards?  The patients don't deserve some of the unprepared people we are putting out there.

Guest1144461

590 Posts

1 hour ago, subee said:

If schools don't want to provide preceptors, then they shouldn't be charging tuition since they are offering no service to the students.  We are just cranking out mediocrity in the name of increasing providers.  Schools want to get the students in and, as quickly as possible get them out so they can capture other sources of tuition and get those seats filled.  It stuns me that our accreditors allow this farce to happen.  Would you want to be put asleep by a CRNA who had such shabby educational standards?  The patients don't deserve some of the unprepared people we are putting out there.

With on another thread a new NP told me that RN experience was just as good as a medical residency. So they are teaching them something in school at least, delusional propaganda.

Specializes in Med nurse in med-surg., float, HH, and PDN.

I once saw a new NP, in lieu of my PCP at the time. The base of my thumbs had (I guess) arthritic pain. The NP looked at my lateral wrists, where I have prominent bones, and said "Oh my gosh, what happened to you here?" He wanted to get x-rays right away. I felt bad telling him that everyone in several generations of my family has "those wrists". I knew he was embarrassed. I think he was one of those unfortunate NP grads with inadequate education or no one to precept him, and he was sprung into his practice unprepared. That's sad, and not right at all!

subee, MSN, CRNA

1 Article; 5,368 Posts

Specializes in CRNA, Finally retired.
5 hours ago, Numenor said:

With on another thread a new NP told me that RN experience was just as good as a medical residency. So they are teaching them something in school at least, delusional propaganda.

Arghhh!

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