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.
