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The Significance of the NP Preceptorship Shortage

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Angie McInnis, DNP, APRN, ENP, FNP-BC
Tanya Schlemmer, DNP, MHA, APRN, AGACNP-BC, FNP-C, CCRN-CMC, RN-BC
Barbara Chapman, DNP, APRN, FNP-C, EBP-C

Abstract

Nurse practitioner (NP) students are often unaware of the difficulties they will face finding preceptors. Many graduate programs lack a network of preceptors, forcing students to reach out to anyone who will agree to precept. Nursing and other healthcare provider programs often compete for the same clinical sites and preceptors. In this article, we offer a comparison of clinical education models by provider and briefly discuss current concerns that impact NP students, such as opposition for practice autonomy and the COVID-19 pandemic, as they seek to complete the required clinical hours to graduate. Also included is general information about the NP preceptor, with a description of requirements and responsibilities of the role. Our discussion suggests several philosophical dilemmas of NP preceptorship, including pay for preceptors, and considers expectations for the future.

Citation: McInnis, A., Schlemmer, T., Chapman, B., (January 31, 2021) "The Significance of the NP Preceptorship Shortage" OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 1, Manuscript 5.

DOI: 10.3912/OJIN.Vol26No01Man05
https://www.doi.org/10.3912/OJIN.Vol26No01Man05

Key Words: nurse practitioner, advanced practice registered nurse, preceptor matching, preceptorship, preceptor shortage, nursing education, clinical rotation, clinical experience, clinical hours, clinical contract, clinical placement, pay for preceptors, Sawyer Initiative, COVID-19 pandemic

Imagine being a graduate nursing student, freshly minted with a degree plan, financial aid, supportive family, and books in hand. Maybe you have finished your didactic courses and are embarking on your first clinical course that will feature pediatrics or women’s health. You are excited because you have always loved taking care of children as a nurse, or maybe women’s health speaks to your heart. Either way, you know you must find a preceptor for roughly 500-700 hours of clinical/patient care.

NP students are often unaware of the difficulties they will face finding preceptors.You put out feelers for preceptors, but everyone is either booked, their facility does not allow students, or they just do not want to precept. More than half of your emails and calls go unanswered, and the semester starts in two weeks. You have now made multiple efforts to find a preceptor, knowing that you must complete these clinical hours. Your full-time employer is requesting your work schedule. That job is vitally important to your ability to feed your family. You are beginning to panic and feel hopeless. Eventually, you really need a schedule and school starts tomorrow, but you still do not have a preceptor.

What do you do? You decide that you will just have to sit out this semester and wait until you can find a preceptor. You are discouraged because you are financially invested in your school. You want to finish on time and start your new career path.

The 2016 report of the National Task Force on Quality NP Education, (National Task Force on Quality Nurse Practitioner Education, 2016) states that students must complete a graduate program that corresponds to the certification, role, and population. This includes a minimum of 500 clinical hours, including the three separate comprehensive graduate level courses in advanced pathophysiology, advanced health assessment, and advanced pharmacology (National Task Force on Quality Nurse Practitioner Education, 2016). Many programs require more than 500 hours of supervised clinical practice learning.

Medical schools have long had a strong system of support for their clinical rotations.The scenario above is reality for many students in nurse practitioner (NP) programs across the United States (US). NP students are often unaware of the difficulties they will face finding preceptors. According to a report by the National Task Force on Quality NP Education, one problem noted in NP education is a lack of standardized preceptor guidelines and educational policies (National Task Force on Quality Nurse Practitioner Education, 2016). Many NP programs lack a network of preceptors to call upon, forcing students to reach out to anyone who will agree to precept. Medical schools have long had a strong system of support for their clinical rotations.

In this article, we offer a comparison of clinical education models by provider and briefly discuss current concerns that impact NP students, such as opposition for practice autonomy and the COVID-19 pandemic, as they seek to complete the required clinical hours to graduate. Also included is general information about the NP preceptor, with a description of requirements and responsibilities of the role. Our discussion suggests several philosophical dilemmas of NP preceptorship, including pay for preceptors, and considers expectations for the future.

Comparison of Clinical Education Models

The Medical Student
Despite the increasing clerkship shortage, medical students continue to find preceptors... Medical students have predetermined clinical rotations, called clerkships, while in medical school (Howley, 2020). Hospitals often compete for medical students and have an application process completed by the medical school liaison. As a general rule, medical student rotations are provided by their school. Some literature has noted a growing shortage of clerkships for medical students resulting in call to support medical students, in lieu of other graduate healthcare providers, for clinical rotations. Despite the increasing clerkship shortage, medical students continue to find preceptors and are supported by their school throughout their four-year tenure (Howley, 2020).

The Resident
The National Resident Matching Program (NRMP) was created in 1952 as the ranks of physicians grew and it was recognized that classroom, cadaver training, and hospital rounding were not enough to educate the young physician. The NRMP, in conjunction with hospital administrators, created internship placements for graduates of medical schools. This process has evolved into “Match Day” and incorporates opportunities for the many specialties available to physician residents.

The medical student applies to residency programs and undergoes an interview for the position... Fourth and fifth year medical students decide what specialty they wish to pursue and enter “match season.” They decide what area of the United States/residency program they prefer in regard to location and/or family needs. The medical student applies to residency programs and undergoes an interview for the position, which is essentially a job interview. Their medical school liaison assists them to schedule interviews, arrange travel, and with any questions related to the match process. Students pick their top four choices at the end of “Match Season.” On “Match Day,” in a ceremony much like graduation, they open an envelope containing one of the preferred choices. Medical students and their families eagerly anticipate this momentous occasion, rivaled only by graduation from medical school.

During the 2020 “Match Season,” 94.6% of medical students were matched with a residency program, with an 80.8% acceptance rate. Students may choose not to accept matches for a variety of reasons. If a match is not initially made, or accepted, there is a subsequent “scramble week” where residency program directors coordinate with medical school liaisons to place graduates. The 2020 Match Week Supplemental Offer and Acceptance Program resulted in an overall residency match of 99.0% of U.S. medical students (NRMP, 2020).

The NP Student
Key to a discussion of NP related concerns is an understanding about differences between an APRN and an NP.Key to a discussion of NP related concerns is an understanding about differences between an APRN and an NP. The designation APRN can encompass many roles and indicates that a nurse has achieved a Master’s degree and certification in some nursing domain. An NP is a healthcare provider who has achieved a specific set of skills to care for patients, along with a Master’s degree and certification in a specialty area. In other words, an NP is one type of APRN, but an APRN is not always an NP. The American Association of Colleges of Nursing (AACN) delineates the types of APRNs using a regulatory model and titles by specialty. These roles are population focused and divided into four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP) (AACN, 2020b). The focus of this article is on the clinical education of the NP student; however, it is worthy to note that each of these roles requires clinical education hours and thus further complicates the availability of appropriate preceptors.

Experiences of finding a preceptor for the NP student to complete clinical hour requirements is a very different process. Students receive university level guidance that often includes a list of facilities with approved potential preceptors for clinical rotations. They can also inquire as to whether their professor may know of, or will serve as, a preceptor. The onus is on the NP student to place multiple phone calls to introduce themselves and their program; discuss clinical hours needed; and request a placement.

The onus is on the NP student to place multiple phone calls to introduce themselves and their program...Although no current data exist, the NP preceptor landscape appears bleak from an anecdotal perspective. Table 1 data illustrate current numbers of NPs who practice in Texas (Texas Board of Nursing, 2020). Every NP program, and many other graduate nursing tracks, require clinical hours, thus these data are a good representation of current NP/APRN students who will need preceptors. Assuming that not every NP represented by Table 1 can or will serve as a preceptor, and given the number of clinical hours required, these numbers suggest that a shortage will persist.

Table 1. NP Specific Data in Texas (as of 10/8/2020)

Area of Texas

Number of Nurse Practitioners (currently practicing, specialty not specified)

PANHANDLE

388

NORTH

6,706

EAST

1,578

CENTRAL

2,460

UPPER GULF COAST

5,990

SOUTH

3,619

WEST

1,866

UNKNOWN

4,827

TOTAL=

27,434

(Texas Board of Nursing, 2020)

Current Concerns

Consideration of data that illustrates specific concerns for clinical education suggests both positives and negatives. This section briefly reviews current relevant data; provides information about the recent Sawyer Initiative; discusses the early impact of the COVID 19 pandemic; and considers the importance of preceptors to prepare NPs to serve rural and vulnerable populations.

Data
These data appear promising for the role of NPs as future primary care providers. In 2019, NPs chose primary care (89%) as a practice focus in greater numbers than did physician assistants (PAs) (19.1%) or physicians (8%) (AANP, 2020c). These data appear promising for the role of NPs as future primary care providers. However, there still exists a vast lack of information and studies about the number of available preceptors to support NP education.

The Good. The number of nurse practitioners has rapidly increased over the last 10 years, from a modest 91,000 in 2010, to 290,000 employed in 2019 (U.S. Bureau of Labor Statistics, 2020). Of the 89% of NPs certified in family practice, 69% are active as family practice NPs delivering primary care. Over 80% of these NPs take patients with Medicare and Medicaid, making them a valued asset to patients of all ages and income levels needing primary care (AANP, 2020a).

This has resulted in active lobbying by these organizations against autonomous practice for NPs The Bad. Despite the overwhelming support of the Institute of Medicine (IOM), the American Medical Association (AMA) has opposed the expansion of NPs as primary care providers for many years (IOM, 2011; Permut, 2016). The Council of Medical Specialty Societies (CMSS) has asserted that the IOM report of 2010 only included the input of two medical doctors and was not a good representation of the field (IOM, 2011; Cabbebe, 2016; CMSS, 2010). Criticism has been offered by the CMSS (2010) that the promised rural health primary care NPs, who could fill the primary care gap in rural areas, did not materialize in the numbers reported. The CMSS Response to The Future of Nursing (2010) provided numbers of NPs in rural and urban settings showing that NPs still preferred to practice in larger cities (Cabbebe, 2016). Although NP numbers are still on the rise, it appears that these numbers are not sufficient for the AMA and CMSS to support the autonomous practice of NPs in most states. This has resulted in active lobbying by these organizations against autonomous practice for NPs (Cabbebe, 2016).

The Sawyer Initiative
It was thought, at first, that this would change the landscape of what nursing programs were required to do to find preceptors. In 2018, a Facebook group of engaged and disgruntled recent NP graduates and practicing NPs, led by Shea Sawyer, developed the Sawyer Initiative. This initiative was drafted in 2019, calling on the Commission on Collegiate Nursing Education (CCNE) to address the lack of NP preceptors and educational standards across NP programs nationwide. Shea Sawyer successfully lobbied CCNE to change the standards in nurse practitioner programs to provide students with clinical placements. The initiative set forth strong recommendations and solutions, which include CCNE enforcing the 70% completion rate for existing accreditation standards; that distance education programs prepare clinical sites for their students; and specifying that experience and qualifications of preceptors are made to ensure quality clinical sites (CCNE, 2019; Chopra, 2018).

It was thought, at first, that this would change the landscape of what nursing programs were required to do to find preceptors. While changes because of the Sawyer Initiative have benefited NP students as they work to obtain required clinical hours, more conversations, changes, and effort is needed to secure preceptors for every NP student.

The COVID-19 Pandemic
The COVID-19 pandemic has greatly affected citizens of the United States, and the world, since the first case was documented. At this point, there are few, if any, peer-reviewed studies that specifically discuss the implications of the pandemic on the preceptor shortage or the impact felt by NP students. Most available knowledge comes from respected group editorials, opinion pieces, anecdotes, and social media postings. Because the pandemic undoubtedly complicates an already frustrating shortage of preceptors, we will offer discussion about what is known.

Preceptors. Some preceptors found themselves immersed in work in areas hard hit by COVID-19; in other areas they were laid off, furloughed, or part of restructuring that included a change in office location and sometimes even specialty. Preceptors had to worry about the health and financial wellness of their families.

Relationships with students were halted and promises made for the summer and fall semesters could not be kept...Relationships with students were halted and promises made for the summer and fall semesters could not be kept because the future was uncertain. Practice performance metrics abruptly changed. Medicare and Medicaid quality measurements were placed on a hiatus as the ability to gather and transmit that needed data was stopped. Clinics everywhere closed to well visits and some converted primary and urgent care to sites for COVID-19 testing. Telehealth and phone encounters increased, and are expected to be a priority for the sake of reimbursement and continuation of care, particularly for elderly patients and those with co-morbidities (Cricchi & Ganesan, 2020). The global shortage of personal protective equipment (PPE) added stress for preceptors in practice, and also made it less likely that students would be allowed to return in any role (Basen, 2020).

COVID-19 directly impacted primary care providers across the country. Worth noting, it has been found that physician recruitment has decreased by 30% since the end of March 2020, while the number of recruitment searches for NPs and PAs has increased by 54% nationally (Terry, 2020). Patient choice and new telehealth models are two of the main reasons that care has shifted, and physician recruitment may be decreasing. Family practice physicians were still the most recruited specialty, but companies that fulfill physician contracts in hospitals and clinics were down overall, which likely reflects effects of the pandemic (Terry, 2020). This will also affect how students obtain preceptors and the type of future preceptors. The current institutions who certify NPs for boards will need to adjust for telehealth as this becomes more the rule and less the exception.

The COVID-19 pandemic has made the preceptor shortage worse...NP Students. The COVID-19 pandemic has made the preceptor shortage worse by causing justified and widespread concern among the healthcare community. Large, bustling hospital systems removed students of all types in March 2020; some have returned but at a trickle compared to previous numbers. Small medical offices have barred students based on the fear of them as a source of exposure to COVID-19, or a decrease in the productivity of their NPs, with numbers of patients already lagging. While these concerns are understandable, this leaves NP students with even less opportunities to complete clinical hours, and delays in timely graduation.

Their focus had to change from becoming a nurse practitioner to working as a full-time nurse. Nurse practitioner students were hard hit in other ways as well. Many contribute a substantial amount of income to their families. They were going to school to earn a Master’s degree and simultaneously working as an RN. If they worked at a clinic or caring for patients with elective procedures they were often laid off. Their focus had to change from becoming a nurse practitioner to working as a full-time nurse. Nurses in the emergency department and intensive care unit dealt with the real threat of illness to themselves or their loves ones. Becoming a nurse practitioner and networking for a preceptor had to wait.

Nursing Programs. Nursing programs across the United States had differing opinions about what returning to clinical sites would mean for students. Some saw the pandemic as a chance to step in and help. Other institutions agreed with the opinion of the American Association of Medical Colleges and felt they needed to protect students, keeping them from direct patient care until more was known (Basen, 2020).

...university administrators and accrediting bodies had to decide how best to proceed.In the wake of many nursing programs across the nation instructing NP students to remain at home, and the loss of clinical sites in March 2020, university administrators and accrediting bodies had to decide how best to proceed. NONPF and AACN maintained the position that students complete a minimum of 500 clinical hours to graduate and seek eligibility to take board exams (Basen, 2020). Some universities require 750 hours; they had to decide if they were going to reduce those hours to allow for graduation. Clinical hours could include telehealth and a small amount of simulation, but this was limited at best (Basen, 2020). Nursing programs have had to be adaptable at a moment’s notice, making continuous changes; this will likely continue for some time.

The Importance of APRN/NP Preceptors to Rural and Vulnerable Populations
...this shortfall cannot be filled without active participation and partnership of engaged and willing preceptors.NPs provide safe and effective care to nearly every population who require healthcare. For over a decade, the IOM (2011) has aggressively supported the expansion of autonomous practice for advanced practice register nurses (APRNs). The Office of Technology Assessment (OTA, 1986) analysis completed more than 30-years ago indicated that NPs could safely and effectively provide greater than 90% of pediatric primary care services and 75% of general primary care services, and that APRNs have competencies that include the knowledge to refer patients with complex problems to physicians (IOM, 2005; OTA, 1986). Rural communities and vulnerable patient populations face a shortage of primary care providers that NPs can fill. However, this shortfall cannot be filled without active participation and partnership of engaged and willing preceptors.

The NP Preceptor

What is an NP Preceptor?
A preceptorship is defined as “A structured, supportive period of transition from learning to applying a complex skill (e.g., nursing) that requires a long and rigorous period of education. Preceptorship is similar to an apprenticeship and serves as a bridge during the transition from student nurse to practitioner” (Farlex Free Dictionary, 2020, para. 3).

Preceptors are a key component of success for any person learning skills that require hands-on teaching and focused learning. Preceptors are a key component of success for any person learning skills that require hands-on teaching and focused learning. NP students learn didactic content in the classroom; this often includes simulation, standardized patients, and frequent testing, including exit tests. NP preceptors are responsible for supervising NP student direct patient care clinical hours. These are defined as hours in which direct clinical care is provided to individuals or families that relates to one of the six population-focused areas of NP practice (AACN, 2020a).

The role of the preceptor is vitally important to successfully preparing students for graduation. Preceptors are the ones who often observe nervous students performing first-time procedures, although students are also supervised by NP faculty. Preceptors guide students’ care while keeping the patients safe and satisfied.

NP preceptors have an advanced level of clinical acumen and enjoy teaching. The Criteria for Evaluation of NP Programs (National Task Force on Quality Nurse Practitioner Education, 2016) require educational preparation and extensive experience in clinical content areas for preceptors to teach and provide supervision to NP students. In sum, the required clinical hours (National Task Force on Quality Nurse Practitioner Education, 2016) discussed earlier in this article are made available through competent preceptors.

Do Practicing NPs Want to be Preceptors?
...we do not have evidence to suggest whether or not NPs want to be preceptors.The reason this is posited as a question is because we do not have evidence to suggest whether or not NPs want to be preceptors. Other unknowns are whether they feel that serving as a preceptor is a duty; how they might feel about doing this for money; or if they perceive that this service changes their jobs.

There are many factors related to becoming a good preceptor. NPs in practice who agree to precept typically enjoy and/or feel a sense of duty to serve NP programs; find the experience rewarding, and often appreciate the need to maintain the clinical knowledge and skills necessary to be an effective preceptor. Given the ongoing shortage of persons willing and/or able to serve in this role, research is needed to inform what is needed to support the level of need to produce competent nurse practitioners.

Preceptor Requirements and Responsibilities
Clinical experiences vary among specialties. The NP preceptorship experience for each student is also, in part, program-specific. Hours are distributed such that the student will be prepared to care for a designated population. This process depends upon experienced preceptors to support competency development for specific population needs.

Typical requirements for a clinical NP (or APRN) preceptor involve the ability to recognize core knowledge, skills, and abilities of students. Specific requirements include: 1) a formal professional practice; 2) a graduate prepared APRN degree with a minimum of 1-year of clinical experience; 3) educated as a medical doctor (MD) or doctor of osteopathy (DO) physician, NP, or PA; 4) a current, unencumbered license to practice in the state where the practice site is located unless placed in a federal clinical site; and, 5) board certified in the area of practice in which they precept or mentor (APRN Clinical Training Taskforce, 2015). Table 2 summarizes the NONPF (APRN Clinical Training Taskforce, 2015) preceptor responsibilities.

Table 2. Summary of Preceptor Responsibilities

Preliminary Requirements

  • Appropriate communication for request to precept (office manager, practice coordinator, etc.)
  • Orient the student to facility and personnel
  • Assist in completing required documentation, such as:
    • Signing confidentiality form/HIPAA requirements/OSHA requirements
    • Computer access/classes or verification
    • Confirming immunization status
    • Background check
    • Verification of RN license
  • Set-up student clinical schedule (days, hours)
  • Prepare staff for student participation
  • Notify student of practice patterns: common condition, concerns in the practice
  • Assist with student access to patient health records
  • Establish a space for patient encounters
  • Support the student learning for referral processes
  • Confirm the site agreement/legal affiliation agreement with the student program
  • Review clinical objectives with the student

Requirements for Preceptor

  • Submit the requested documents to program, such as:
    • CV/resume'
    • Licensing information & credentials
    • Validation of specialty certifications
  • Provide current contact information to faculty

Communication

  • Be available onsite when student is present
  • Enable student documentation of encounters consistent with the requirements of the clinical site. (If students have limited access to EHR, student may use comparable documentation forms to assist with charting)
  • Discuss problems as they arise with the student and faculty, as indicated

Patient Encounters

  • Ensure student has opportunity for a variety of patients to increase their clinical skills
  • Validate student findings and provide feedback regarding their accuracy and significance
  • Discuss and confirm the decision-making with the student including diagnostics, prescriptions, therapeutics, counseling instructions, and follow-up plans

Evaluation

  • Provide clinical performance evaluation for the student performance, consistent with student agreement and personal objectives and course objectives
  • Confer with student, and faculty or staff, a minimum of two times during the clinical experience to discuss student performance, progress, and learning needs

(APRN Clinical Training Taskforce, 2015; Dumas, 2015)

The Commission on Collegiate Nursing Education (CCNE) accredits graduate nursing programs. This accrediting body determines criteria for completion of the intended degree and preparation for board certification exams upon graduation (CCNE, 2020).

The AACN supplies the Essentials Series, which define the elements and framework necessary to develop a graduate nursing curriculum. The APRN Clinical Preceptor Resources Guide provides information for those engaged in APRN education. Within these guidelines, APRNs, NPs, physicians, PAs, and other health professionals are considered partners in the clinical education of APRN students, to include NPs (AACN, 2020b).

The National Organization of Nurse Practitioner Faculty guides NP faculty in setting standards for all NP programs. Endorsed programs include didactic and clinical competency requirements to meet via mentorship in clinical environments; however, NONPF does not detail how clinical sites are developed and maintained (Dumas, 2015). Table 3 compares requirements for APRN preceptorship from varying certifying and guiding bodies.

Table 3. Guiding Body Requirements for NP/APRN Preceptorship

CCNE Requirements for Preceptorship

New 2019 Accreditation Standards (2020)

AACN Requirements for Preceptorship

NONPF Requirements for Preceptorship

  • The program handles ensuring adequate clinical sites
  • Clinical sites are sufficient, proper, and available to achieve the program outcome
  • Clinical sites are reviewed periodically, and resources are changed as needed
  • A defined process is used to determine the adequacy of clinical sites
  • Clinical practice experiences are supplied for students in all programs, including those with distance education programs

Program faculty will clearly communicate to APRN Clinical Preceptor the level and intended clinical progression and outcome aims for the clinical rotation of student during each clinical rotation

Faculty oversight includes:

  • Design
  • Implementation
  • Evaluation of clinical practice experiences that align to student and program outcomes
  • Communication with clinical preceptor is necessary to ensure curriculum is effectively delivered and outcomes are met

Clinical preceptor creates a safe setting for student to gain experience and develop competency to effectively manage population

Clinical preceptor serves as a role model incorporating evidence-based education best practices ensuring safe and effective patient outcomes

  • Notify appropriate individual of request to precept
  • Arrange for student orientation, including computer access
  • Aid in completing required documentation, and process of consultation and referral
  • Arrange clinical schedule with student
  • Inform and prepare staff for student arrival
  • Inform student of practice characteristics
  • Help with student access to patient health records.
  • Ensure examination space for patient encounters
  • Assist with legal affiliation agreement within student program
  • Review personal and course/clinical objectives
  • Provide proper documents to nursing program/faculty including: CV/resume, professional license information, documentation of specialty certifications, current contact information
  • Discuss problems with student and faculty
  • Enable student documentation consistent with requirements of clinical site
  • Be available onsite when student is present
  • Facilitate access to variety of patients
  • Validate student findings and provide feedback
  • Discuss and approve plan of management, including diagnostic, therapeutic, and follow-up plans
  • Provide formative/summative evaluation document student performance
  • Confer with faculty advisor / student at least two times/experience discuss student progress/learning need

(AACN, 2020a, 2020b; CCNE, 2020; Dumas, 2015; APRN Consensus Work Group, 2008)

Philosophical Dilemmas of NP Preceptorship

As previously noted, there are not a lot of data about NP preceptorships. The California Board of Registered Nursing developed and distributed a very comprehensive survey to NPs holding active licenses in the state in 2017. Of the 1,430 NPs who completed the survey, only 277 answered that they precept students, at a rate of two per month. Nurse practitioners who did not respond to the preceptor portion of the survey were not actively precepting (Spetz, Blash, Jura, & Lela, 2018). This suggests a philosophical dilemma for the nurse practitioner community: Is it a practicing NP’s moral responsibility to help train future NPs? Below are some considerations.

Amongst Providers
Pay for Preceptors. Paying a NP preceptor for clinical hours is not a new concept, but a hotly debated one in academic circles. Many NPs feel that, having been taught themselves by preceptors, it Paying a NP preceptor for clinical hours is not a new concept, but a hotly debated one... is their duty and a moral imperative to precept future NPs. Pay-for-preceptor programs are easily found in an internet search. These programs offer a variety of services, including site agreements, preceptor credentialing and screening as well as placement for a ranging fee. The cost may be a set fee (e.g., $600 – $800 or up to $2000) for clinical hours (80 - 180 hours) or paid per hour (e.g., $3.50 - $15/hour) for a semester (McInnis & Schlemmer, 2019). Federal grants, other payment programs, or credentialing requirements may also incentivize preceptors, but are not standard in any one program. A published study about preceptor incentives found that remuneration was the third most common reason that providers precept NP students (Morgan, Brewer, Buchhalter, Collette, & Parrott, 2018).

In 2017, 43.7% of PA programs reported full or partial compensation for clinical sites (Gardenier et al., 2019). In 2016, The AACN found that 4% of programs acknowledged compensation for preceptors (AACN, 2020b). An unintended consequence of paying preceptors is that for-profit schools and universities with greater financial means would be able to secure more preceptors, creating a competitive advantage over nonprofit schools (Gardenier, Arends, & Selway, 2019). Gardenier et al. also contended that this has already happened when offshore medical schools secured preceptors in the United States for their students by providing them large stipends, thus taking preceptors from American medical students. Preceptors may have conflicts or limitations for preceptorship availability due to employer productivity quotas, compensation rules, and an inability to complete or fulfill site agreements.

Productivity Losses. Preceptors face the challenge of standards of productivity within their facilities. Many view students as a liability to productivity, resulting in fewer satisfied patients due to Many view students as a liability to productivity... wait times and decreased patient encounters per shift. Some employment contracts are tied to both productivity measures and quality of care, contributing to disgruntled healthcare providers when dealing with high-risk, complex, time-consuming patients, or potentially during extended preceptorship hours. Healthcare provider groups consistently address compensation ideologies for fairness, simplicity, transparency, and price-value alignment for productivity, which may deter preceptorship.

Amongst Students
Students also have a variety of concerns about precepted clinical experiences. Perceived barriers reported by students have included concern about student competition at clinical sites, the inability to find preceptors in specialty practice, possible travel time for preceptor location, financial resources to pay preceptors, and lack of program assistance to secure appropriate preceptors (Giddens et al., 2014; Nassar, 2019).

Student Assessment Survey. Barriers to finding and obtaining preceptors for NP students vary, but typically suggest similarities. In October 2017, the authors, seeing that their own area was in a preceptorship crisis developed a Likert-type survey that was sent to 435 graduate-level nursing students.

There were 232 responses to the survey which asked respondents to answer questions about the difficulty of finding a preceptor, if they have ever paid for a preceptor, and if they would be willing to pay for a preceptor. We also questioned how they felt about preceptors being paid and if they found this ethical. It was important to us to determine the perception of the students who were struggling to find preceptors. This question offered a 1–10 scale, with 1 being easy and 10 being extremely difficult. Of the 232 student responses, we found that 61% selected an eight, nine, or ten for the level of difficulty to find a preceptor.

Results were evenly split on whether students believed that a preceptor should be paid... Results were evenly split on whether students believed that a preceptor should be paid, with 53% saying “yes” and 47% answering “no.” Roughly 13% of respondents had been asked to pay for their preceptor at the facility they requested, and 11% had used on online service to secure a preceptor for their clinical experience. The survey respondents were agreeable to a tuition increase (60%) to cover the cost of preceptors and were somewhat agreeable to an out-of-pocket payment (27%) to preceptors (McInnis & Schlemmer, 2019).

Payment for clinical sites and/or preceptors is more common in other healthcare disciplines. While this is not common in nursing, the practice is rising due to the increasing and ongoing need. Additional research and conversations are necessary to inform how to best improve the ability to secure, to preceptors for graduate level nursing students.

Expectations for the Future of Preceptorships

Post Pandemic Preceptorships
It is difficult to ascertain how deeply the COVID-19 pandemic will impact us as a country at this point, let alone how it may continue to affect NP preceptorships. As of this writing, COVID-19 mortality and case numbers have been significant. This will undoubtedly have a temporary negative effect on the preceptor shortage and our students. Preceptors and students alike, will have to focus their attention elsewhere.

Nurse educators can expect to face many challenges in the upcoming months as the impact of COVID-19 evolves. Educators will have to seek creative and meaningful ways to connect with students while nursing programs will need to establish better pathways to secure preceptors. It may be that some of these creative solutions are helpful on a long-term, post pandemic basis.

Questions for Consideration
Clinical preceptors are vital for clinical education by a safe setting for APRN students to gain experience while developing competency. The AACN (2020b) says the APRN/NP clinical preceptor also serves as a role model for incorporating the evidence-based practice education necessary to ensure safe and effective patient outcomes. According to the CCNE, NP programs are responsible for finding a clinical placement for the student after the student has exhausted all resources. This begs some questions of us, as faculty (CNL Careers, 2021).

Should the collective NP programs and certifying bodies adopt a “match” program for NP students? Do we legislate for a tax incentive for preceptor services? Should there be a stipend for preceptor services? Is some sort of contract for clinical sites offering compensation or fringe benefits for student slots necessary or appropriate? Do we develop more NP residency programs to support students upon graduation?

Nurse practitioner students are asking for help in the preceptorship process... Nurse practitioner students are asking for help in the preceptorship process with consistency in education across the board. Standardizing NP education would facilitate a better prepared NP upon graduation. Introducing a universal residency program with paid or volunteer preceptors could ameliorate the clinical placement issue.

Increased Use of Simulation
One avenue to offset demand for the lack of sites is to use alternative encounters. This is generally achieved through simulation that already occurs at many institutions. Simulation has long been used in registered nurse programs and is an effective method of teaching real-life scenarios.

Conclusion

In our experience, students have great anxiety surrounding the NP preceptor shortage. They are told they need to find a preceptor for each clinical course and perform a certain number of hours, but there are not enough preceptors for them to do as asked. How will they be successful?

Two very real, current issues affecting the preceptor shortage are the COVID-19 pandemic and competition amongst disciplinesTwo very real, current issues affecting the preceptor shortage are the COVID-19 pandemic and competition amongst disciplines. The pandemic has created an environment that might not always be safe for learning, and healthcare facilities and nursing programs have reacted accordingly. NP students are in competition with medical and PA students for clinical placement. There is lobbying to prohibit autonomous practice for nurse practitioners and pay-for-preceptor incentives for medical students that offers them an edge in gaining a preceptorship. Autonomous practice for NPs could free many to choose whether or not they precept as they would not be bound by supervising physicians to refuse a student who requests clinical placement.

Remuneration for preceptors, and possibly employing facilities, may be the key to fixing this shortage. There are multiple schools of thought about how to best approach the preceptor shortage, but the most important strategy should be cohesive and universal. NP residency programs would likely be helpful to create better prepared NPs and/or solve the ongoing lack of preceptors. Remuneration for preceptors, and possibly employing facilities, may be the key to fixing this shortage. Continued support for legislation for autonomous practice and educating healthcare consumers about the role of the NP can be helpful to increase the number of NP preceptors. More research is needed to answer pressing questions about the best practices for preceptorships.

The NP preceptor shortage is an ever-present issue that seems larger with each passing semester. Nurse practitioner students are positioned upon graduation to fill the role of primary care provider for thousands of Americans, many of them invulnerable populations. But first, we have to find them a preceptor.

Authors

Angie McInnis, DNP, APRN, ENP, FNP-BC
Email: mmcinnis@uttyler.edu

Angie McInnis is an Assistant Clinical Assistant Professor at the University of Texas at Tyler in the Family Nurse Practitioner (FNP) program. Her education includes a Bachelor of Science in Nursing degree achieved at the University of Texas Medical Branch at Galveston, as well as a Master of Science in Nursing and Doctor of Nursing Practice degree from the University of Texas Health Science Center at Houston. She has been a nurse for 20 years, the last 13 as an and emergency nurse practitioner. Her training includes an emergency medicine program and board certification in family practice. Dr. McInnis has served as a preceptor for students for 12-years in emergency medicine, family practice, and urgent care settings. She continues to practice in both emergency medicine, urgent care, and family practice and precepts one to two students a semester. The preceptor shortage is a passion of hers and she is working towards being part of the solution.

Tanya Schlemmer, DNP, MHA, APRN, AGACNP-BC, FNP-C, CCRN-CMC, RN-BC
Email: tschlemmer@uttyler.edu

Tanya Schlemmer is a Clinical Assistant Professor at the University of Texas at Tyler in the Family Nurse Practitioner (FNP) program and an actively practicing nurse practitioner since 2005 with experience in many roles during her 35-year nursing career. She completed a Doctor of Nursing Practice (DNP) degree from Texas Christian University, a Master of Science in Nursing (MSN) with FNP certificate from Texas Woman’s University, a Post-Master’s Adult Geriatric Acute Care Nurse Practitioner (AGACNP) certificate from Texas Tech University Health Science Center, a Post-Master’s Nurse Educator certificate from the University of Texas at Tyler and a Master’s in Healthcare Administration (MHA) from Des Moines University and maintains the dual AGACNP-BC and FNP-C certifications as well as adult Critical Care Nursing with Cardiac Medicine (CCRN-CMC), and Home Health Nursing (RN-BC) certifications. Dr. Schlemmer is cognizant of factors impacting the nursing profession and is engaged in the clinical preceptorship process, she has conducted scholarly work about various aspects of job satisfaction, the nursing shortage, occupational burnout, preceptor role, and factors affecting preceptorships.

Barbara Chapman, DNP, APRN, FNP-C, EBP-C
Email: bchapman@uttyler.edu

Barbara Chapman is an Assistant Clinical Professor at The University of Texas at Tyler in the Family Nurse Practitioner Program. She is also a Family Nurse Practitioner at the Community Health Care Clinic in McKinney, Texas and the INTUNE Mobile Unit, a collaboration between The University of Texas, at Tyler and Special Heath Resources Texas. She completed her Doctor of Nursing Practice (DNP), Master of Science (MSN), and Family Nurse Practitioner certification (FNP) at The University of Texas at Tyler, her Bachelor of Science (BSN), at Texas Tech University Health Sciences Center, and is also Evidence-Based Practice Certified (EBP-C) from The Ohio State University. Dr. Chapman currently serves with the Texas Nurse Practitioners as an Official Texas Nurse Practitioner Legislative Ambassador for 2020-2021 and on the Texas Nurses Association COVID-19 Task Force, Rural Health, Mental Health and Telehealth Committees.

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© 2021 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2021


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