PRECEPTING NURSE PRACTITIONER STUDENTS: JOYS AND PITFALLS

Eileen R. Giardino, RN, PhD, ANP-BC, FNP-BCAssociate Professor

UT Health - Houston – School of NursingHouston, TX

Program Objectives:

The participant will:• Learn ways to improve the precepting experience

• Improve evaluation of NP student performance

• Understand legal aspects of the preceptor role

• Relate NP study findings of expectations of NP preceptors to clinical practice

 The value of preceptors

Preceptors:• Are valuable resource to every NP program • Are essential to strength & viability of NP programs• Teach students essential clinical skills• Evaluate student competence & performance • Serve as professional role models & socialization experts

• Help students learn how to function in “real world”• Have both positive and negative qualities! (Ulrich,

2011)

Why Be A Preceptor• Part of the professional role

• Teaching/evaluating is part of what we do as NPs (Ulrich, 2011)

• Satisfaction of “giving back” (Lyon and Peach, 2001)

• Essential part of process for NP students to learn their profession (Burns, et al, 2006, Barker and Pittman 2010)

• Students keep us “on our toes” (Suzewits, 2002)

• Enhance quality of clinical practice• Contribute to professional development of SNPs. (Giardino &

Giardino, 2013)

• Preceptors enjoy teaching, want to develop the profession, support NPs in primary care (Giardino & Giardino, 2013)

Preceptor Expectations

Preceptor should expect:• To communicate with or have program faculty visit clinical

site during semester• Support when needed from program faculty• Orientation to student/program curriculum

• Know what students able/expected to do at practice site• Schools send students to site with little to no information about

what student should do or is able to do at their site

• CEU credit for precepting

Precepting Rewards

• Some programs pay stipends, most don’t (GNE Grant)• Some programs offer adjunct faculty appointment• Precepting keeps you sharp and current• Enhances professional reputation• Satisfaction in doing the “right thing”• Assures continuing excellence in NP profession

NP program responsibilities• Understand what preceptors expect from students • Cultivate preceptors• Address preceptor needs & concerns that stem from

student supervision.• Have faculty available to address preceptor concerns• Communicate with preceptor & site for any needed issues • Respect that preceptor/site are graciously working with

your students• Students are ‘guests’ at the site

Patient Expectations

The patient should/must:• Agree that student may participate in visit

• Can inform patients at initial visit that practice educates clinicians

• Having a student is part of the practice philosophy

• Know that visit might take additional time d/t student • Be seen by the provider as well

Often patient impressed that provider is a teacher

Study findings regarding precepting• Liability concerns• Conflicts between student’s educational needs and

practice expectations to increase provider productivity [Lyon & Peach, 2001]

• May face issues they are unaware of or unprepared for when precepting nurse practitioner students (Hayes, 1994)

• Preceptors report greater self-confidence in rating students when they have had training in the precepting process (Aagaard, Teherani & Irby, 2004)

Study Findings - Giardino & Giardino, 2013

• Preceptors felt students weak in generating & prioritizing diff diagnoses• Increase the focus on student generated differential diagnoses throughout the

clinical experience

• Many preceptors do not directly observe the SNPs conducting a physical examination. • Watch SNPs perform physical examination on patients at various times throughout

the clinical experience• Opportunity to offer specific feedback around physical examination skills• Support SNP verbally presenting the patient case using a SOAP format

• Preceptors work with students because• They enjoy teaching• Want to develop the profession• Support NPs in primary care

• Important for NP program to support preceptors through• recognition of willingness to precept• Recognition of commitment to foster next generation of 10 care providers

Logistics of Having Students in Practice

• Space in practice for • extra exam room for student to see patient• talking with student privately• student to be when not seeing patients

• Time factors – Precepting takes additional energy even when it doesn’t take much more

time• Melding time it takes to precept into the productive schedule• Study in rural practice indicated that

• parallel precepting strategy was 12 mins 24 sec per visit • & “regular” consultation (without precepting) was 13 mins, 27 sec

• Walters, Worley, Prideaux & Lange, 2008

• Experienced preceptors take less time per visit with comparable outcomes (Baritt, 1997), (Vinson, 1997)

• The more you precept, the better it gets from a time perspective

Principles for Precepting Success• Different learners, different levels of experience, different

techniques• Often we precept the way we were precepted

• Not necessarily the best way to proceed

• Remember what helped you the most to learn• The larger our repertoire of clinical teaching techniques,

the more likely we are to help students be successful

Techniques To Help Precepting• Determine student’s clinical goals.• Allow student opportunity to interact with patients• Choose appropriate patients for student• Request student to give a case presentation • Question student about case details • Allow student to give differentials and state a plan

Feedback Techniques• Get a commitment

• What do you think is going on?

• Probe for supporting evidence• What led you to that conclusion?

• Teach general rules• Many times when . . .

• Reinforce what was right• ”You did an excellent job of . . .

• Correct mistakes• Next time this happens, try this . . .

• (Neher, Gordon, Meyer, Stevens, 1992)

Principles of Evaluation

• Difficult part of the process• Difficult to tell student that s/he not performing well

• Be honest• Give specific examples of positive and negative situations• Should be constructive and based on skill development• Should be consistent for student’s level of practice• Should be respectful-focus on actions and preparation not

personality• Can be day to day feedback or interval evaluation• Include assignments for further study or improvement• Should include communication to the faculty

Dealing With Challenging Students• Patient safety is a primary concern• Trust your judgment - Go with your ‘gut’ • A failing student will often have limited insight or lack of

personal awareness• Early communication of problems to student & faculty• Expect professional behaviors and professional dress

• Articulate your expectations at outset of experience

• Identify poor professional behavior or boundary breeches • Communicate expectations for change

Dealing With Challenging Student• DOCUMENT, DOCMENT, DOCUMENT• Focus on behaviors rather than personality• Tell Faculty – Expect a site visit • Faculty should be supportive of your evaluation• Suggest strategies for reassignment if necessary

Some Precepting Don’t’s

Don’t:• precept a student when overcommitted & stressed• fail to review your students’ work• assume that student’s documentation is adequate or

appropriate• put student down in front of the patient• hesitate to mention issues that are a source of annoyance

or concern

• From: Paulman, P.M. (2001) Family Medicine 33:10, 730-731

Legal or Liability Considerations• Site needs an affiliation agreement in place

• Know what agreement states

• See patients and review notes• Consider what skills student able to perform• Who is responsible if student gets needle stick or

contracts HBV?

Questions? Comments?