Most nursing schools use preceptors to provide critical elements of practice, instruction, and supervision. Students engage with preceptors in various clinical settings to learn skills, interact with other professionals, and transition from student to advanced practitioner in the arena of choice. Recruitment and retention of qualified preceptors is essential to the ability to offer and sustain a graduate program of study.
Preceptors report that it is becoming more difficult to accommodate advanced practice students due to the demand to meet daily patient visit targets, to address billing and regulatory standards, and to provide complex health care services in a time-intensive environment. The increasing shortage of preceptors has limited the admission rates in some advanced practice programs, and the long-term effect is that there may be a shortage of advanced practice nurses just when the country is moving to a health care system that recognizes and values their role.
It is important to understand the factors that influence preceptors to volunteer their time and expertise. It is also important to understand the barriers, incentives, and supports preceptors experience in their work settings.
The purpose of this survey of advanced practice student clinical preceptors was twofold: (a) to determine the barriers to and the motivators for providing clinical mentoring and evaluation and (b) to determine the need for educational preparation to facilitate their roles as clinical preceptors.
The linchpin of advanced practice education is the opportunity for graduate students to participate in real-world situations under the guidance of a skilled preceptor. For the purposes of this study, a preceptor is defined as “an experienced practitioner who teaches, instructs, supervises and serves as a role model for a student or graduate nurse, for a set period of time, in a formalized program” (Usher, Nolan, Reser, Owens, & Tollefson, 1999, p. 507).
A review of the current literature resulted in several studies within the past 10 years that identified the organizational support for the work of the preceptor (Heale, Mossey, Lafoley, & Gorham, 2009; Henderson, Fox, & Malko-Nyhan, 2006; Hyrkäs & Shoemaker, 2007; Wilson, Bodin, Hoffman, & Vincent, 2009); the rewards, incentives, and disincentives to the assumption of the preceptor role (Campbell & Hawkins, 2007; Heale et al., 2009; Hyrkäs & Shoemaker, 2007; Wilson et al., 2009); the relationship with the school of nursing faculty (Brooks & Niederhauser, 2010; Wilson et al., 2009); and perceived competence to take on the preceptor role (Heale et al., 2009; Henderson et al., 2006; Smedley, 2008).
Preceptors report that they are philosophically supported by their agencies and peers, but they consistently indicate that working with students does not change the time required to complete regular caseloads and that they are expected to maintain their practice productivity at all times (Heale et al., 2009; Henderson et al., 2006; Hyrkäs & Shoemaker, 2007).
Preceptors express that they expect to have time to provide instruction, to role model effective behaviors, and to thoughtfully provide feedback to their preceptees. However, preceptors consistently state they are not given any time away from direct clinical activities to review students’ progression and to address any student concerns (Heale et al., 2009; Henderson et al., 2006).
When preceptors were asked whether the organizations in which they worked acknowledged their work of serving as preceptor, they reported that their job descriptions and performance reviews did not include precepting responsibilities and commitments (Heale et al., 2009).
In summary, preceptors report that they work under difficult circumstances to provide clinical experiences to students. They are often not supported with extra time and resources and are seldom recognized for their extra work with students.
Rewards, Incentives, and Disincentives
Studies document a variety of rewards for precepting, ranging from direct compensation, tuition, and continuing education vouchers; verification of hours toward recertification; access to services and events on campus; tickets to cultural and sports events; and lectures. In addition, faculty members can assist preceptors in professional recognitions by nominating them for awards, providing letters of reference, editing manuscripts, and collaborating on research projects (Campbell & Hawkins, 2007; Heale et al., 2009; Wilson et al., 2009).
Preceptors list the absence of rewards and incentives as disincentives. Failure to receive recognition, lack of acknowledgement, and lack of faculty support often lead preceptors to refuse to take students in future rotations (Campbell & Hawkins, 2007; Heale et al., 2009; Henderson et al., 2006; Hyrkäs & Shoemaker, 2007).
Rewards, incentives, and disincentives are consistent across studies. However, it appears that people respond differently to the offerings and barriers. A menu of rewards and incentives with the option for self-selection may be most effective. The disincentives can be reviewed as opportunities to devise rewards and incentives that can mitigate their effects.
Relationship With the School of Nursing Faculty
Faculty in schools of nursing depend on preceptors to provide clinical education, oversight, and evaluation. Several studies (Brooks & Niederhauser, 2010; Wilson et al., 2009) indicate that faculty have been remiss in cultivating and maintaining relationships with preceptors.
Wilson et al. (2009) surveyed neonatal nurse practitioners who served as either preceptors or program directors to determine which strategies were successful in recruiting and retaining preceptors. Respondents from both categories stressed the importance of faculty support and interaction with the preceptors throughout a clinical rotation.
Preceptors have specific expectations of how university faculty members should conduct themselves (Brooks & Niederhauser, 2010). Preceptors reported that the faculty member should make at least two site visits during the defined experience, should be prepared to ask the preceptor questions about the student’s performance related to the course objectives and the adequacy of the client selection, and should answer preceptor questions related to the evaluation and handling of student problems. Preceptors also reported that they expect all faculty members to follow the same guidelines when conducting site visits (Brooks & Niederhauser, 2010).
Perceived Competence as Preceptors
It cannot be assumed that all practitioners are able to serve as preceptors. Often, this assumption operates when students and faculty are desperately seeking a preceptor relationship.
Henderson et al. (2006) interviewed 36 registered nurse practitioners who had participated in a 2-day workshop for preceptors. All reported that the workshop had been extremely useful in teaching them how to provide positive mentoring, to evaluate students’ learning styles, to give appropriate feedback, and to thoughtfully and knowingly infuse socialization processes. This program used varied teaching and learning strategies, such as role-playing, discussions, and demonstrations of the principles taught in the didactic portion of the workshop.
A formal preceptor program offered at Avondale College in New South Wales, Australia (Smedley, 2008), was built on the principles that preceptor education should include “experience and expertise in the clinical field, good communication and decision-making skills, a desire to teach and undertake the preceptor role, an interest in professional growth, leadership skills, assertiveness, flexibility to change, nonjudgmental attitude toward coworkers and adaptability to individual teaching needs” (p. 185). Interviews with seven graduates of this program indicated that additional information was needed in the areas of “the need for knowledge about adult learning, knowledge of various individuals’ learning styles, skills for teaching and learning in a clinical context, positive attitudes toward students and others in the workplace and patience and the desire to motivate others to learn” (Smedley, 2008, p. 189).
A Canadian study of clinical mentors revealed low confidence across seven disciplines (nursing, medicine, physiotherapy, occupational therapy, speech language pathology, social work, and audiology) in the areas of understanding the expectations of the clinical education program, identifying student learning needs, and assessing student’s performance (Heale et al., 2009).
These studies highlight the need to offer formal training to provide clinicians with the skills and techniques necessary to ensure the best learning environment for students and to enable the preceptors to function in a capable and informed manner.
The following research questions formed the basis of the survey instrument:
- What are the characteristics of the advanced-level preceptors?
- How do advanced-level preceptors perceive organizational support for the preceptor role?
- What are the desired incentives and rewards for advanced-level preceptors?
- What are the perceived disincentives and barriers?
- Which attributes of the faculty and preceptor relationships are most important to preceptors?
- Which aspects of preceptor education do preceptors identify as most important?
This was a descriptive study that used a convenience sample of active preceptors from all graduate programs offered at the study school that utilized preceptors at the time of the project. The study was submitted to the institutional review board for review and was approved as exempt.
The online survey instrument was designed from items developed from the review of the literature and from experience working with preceptors in the academic and clinical settings. Items were submitted to 10 program directors for content validity. A content validity index was calculated for each item, and any item with 80% agreement was retained in the instrument. Consultations with the Office of Research focused on item construction, scale development, and validity as instrument development was finalized.
All program directors of advanced-level programs were solicited to provide a contact list of active preceptors. A sample of 113 viable e-mail addresses was forwarded to the online survey administrator for input into the survey program. All e-mail information was secured by the survey administrator and was not available to the researcher. At the conclusion of the study, all data were deleted from the online survey platform.
The single, one-time online survey was forwarded by the survey administrator to the potential respondents with a cover letter explaining the purpose of the survey, assurance of anonymity, and how the results would be reported.
A total of 53 preceptors (47%) responded to the online survey. An automatic reminder message (e-mailed through the online survey site) was sent to all of the potential respondents midway through the open response time frame. The respondents were not identified by name and the e-mail trail was not available to the researcher. The survey administrator reported that all of the e-mails were viable, and no messages came back indicating that there were any undelivered surveys.
Reliability estimates of the survey instrument yielded an alpha coefficient of 0.87. The respondents represented several types of preceptors: 37% identified themselves as nurse practitioners, 17% as clinical nurse specialists, 13% as educators, 11% as medical doctors, 9% as informaticians, 9% as administrators, and 4% as staff educators.
When respondents were asked how many years of experience they had in the area in which they were serving as a preceptor, the majority of the respondents (49%) reported more than 11 years of experience. These responses indicate that preceptors were highly experienced and well established in their area of clinical expertise.
Most respondents reported that their organization provided support for them in their role as preceptor (87%), that they perceived their coworkers provided support when in their role as preceptor (85%), that they were granted the opportunity to meet with their preceptees in a private setting (88%), and that their job evaluations included recognition of their work as preceptors (60%).
One of the areas of concern reported in the literature and anecdotally was the concern about working harder when preceptees were on site. Respondents reported that they did not have reduced patient and work assignments when they had preceptees (79%), some (29%) stated that they were sometimes to always assigned more patients and projects when they had preceptees, and a majority (66%) of the respondents stated that they worked more time on the days they had preceptees.
For those respondents reporting they worked more time on the days they had preceptees, a question was posed as to the nature of the extra work. The following areas were reported as requiring additional time: documentation, organizational priorities, patient needs, preceptee evaluation, and preparation for the next day of work (Figure 1).
Figure 1. Preceptor activities requiring increased work time on the days preceptees were on site.
Rewards, Disincentives, and Barriers
All respondents reported that they enjoyed their role as a student preceptor and that they believed they were giving back to their profession when they served as a preceptor. The majority (95%) also reported that they believed serving as a preceptor helped them to keep current on clinical and professional issues. Approximately half (45%) expected to receive some form of public recognition for their role as a preceptor. A majority (97%) reported that they have never received extra pay when serving as a preceptor, and most (98%) reported that they never received extra days off when they served as a preceptor. Most (77%) reported that they did not get flexible time to attend outside meetings with their preceptees, and two thirds (66%) did not believe that serving as a preceptor improved their chances for promotion or advancement within the work site.
When asked what forms of recognition they would appreciate from the school of nursing, the respondents reported several choices. Figure 2 provides information on the preferred forms of recognition.
Figure 2. Items that preceptors would like to receive from the school of nursing (SON), by order of preference. Note. CE = continuing education.
Relationships With School of Nursing Faculty Members
One of the potential sources of concerns for preceptors is the relationship with faculty members who serve as the course directors and clinical placement coordinators. For this sample, the majority of the preceptors reported positive relationships with faculty members. Ninety-four percent agreed with the statement that instructors were available when needed, 73% reported that they had routine site visits each semester, and 66% reported that they were assisted with difficult preceptees.
The majority reported that they were actively engaged with the school of nursing faculty (87%), that they knew when they would be getting a preceptee (96%), and that they were informed as to the level of preceptee competence (89%). Most reported getting an orientation to the course objectives each semester (72%), that they understood the evaluation criteria (85%), and that they believed their feedback was incorporated into the assignment of grades to the preceptee (77%). Ninety percent of the respondents felt appreciated by the faculty.
Preparation for Role of Preceptor
The respondents (100%) indicated a high level of confidence in their ability to evaluate student performance. They reported a strong confidence in the knowledge of adult learning principles (95%) and felt well prepared to serve as preceptors (94%). Responses revealed that 87% understood the objectives of the course in which they were providing a preceptorship.
Approximately three fourths (73%) of the respondents reported that they teach as they were taught by their preceptors, and almost half (45%) stated they had received information about the legal implications of their role as preceptors.
The mix of respondents provided a cross-sectional picture of the different advanced practice areas of study. Previous research studies reported in the literature review focused on nurse practitioners and did not include areas such as clinical nurse specialists, administrators, educators, and informaticians. The results of the current study offer insights into the broader issues of graduate-level preceptors.
Responses indicated that preceptors believed they received general organizational support for the preceptor role and that it was accepted by fellow professionals within the work setting. However, when asked about the specific supports that had been identified in the literature as being of concern, respondents indicated they received very little accommodation in their regular job duties and, in fact, were sometimes given extra assignments when they were working with a preceptee. Two thirds of the preceptors reported that they had to invest more time to complete their work when they had preceptees. Responses indicated that preceptors did indeed work longer hours and were expected to carry a full workload in addition to their responsibilities to instruct, guide, mentor, and evaluate their preceptees.
Rewards, Disincentives, and Barriers
The good news is that preceptors report strong internal rewards when they serve as preceptors. They value their roles as preceptors and believe they are giving back to their profession. The challenge of staying current on the latest information and issues provides them with a deep sense of satisfaction and connection to the new practitioners entering their specialty. They seem to value their roles as expert clinicians and take their roles seriously as leaders in their field. Although only approximately half of the respondents expressed the sentiment that they expected recognition and support for their preceptor role, all of the respondents indicated their preference for token rewards offered by the school of nursing. Although some did not expect recognition, they could identify what they would like to receive if recognition was offered.
However, there are disincentives and barriers in the various work settings. Most of the respondents did not receive any additional pay, time off, reduced workloads, release time, the opportunity to attend outside meetings with their preceptees, or any other tokens of recognition from their employing agencies. Two thirds of the respondents did not experience any recognition for their role as preceptors when it came time for promotion or increase in salaries.
Practitioner preceptors have started to report that it is harder for them to accept a preceptee because they have daily client targets and reimbursement goals. As indicated by the responses on this survey, preceptors find themselves having to work more hours to accommodate the additional demands of working with a preceptee. The additional work hours are uncompensated, and schools of nursing are reporting more difficulty in securing and maintaining qualified preceptors with each passing year. Some programs have reported that they have been asked to compensate practices for lost revenue.
Although this picture seems somewhat discouraging, preceptors continue to assume vital roles as clinical teachers. Often, preceptors report that they want to give back to their profession, as they recognize that they were assisted in their educational preparation because someone served as their preceptor. Schools of nursing should emphasize the important role of each preceptor and encourage students to serve as future preceptors. One suggestion to assist students in identifying their potential roles as preceptors would be to have senior students serve as preceptors for the newer students in controlled situations. This activity would assist the students in their identity formation as preceptor and as professional role models.
Relationship With School of Nursing Faculty Members
Respondents to this survey indicated a high level of satisfaction with their relationships with the faculty members of one school of nursing. The advanced practice faculty members in the sample school of nursing have made it a priority to develop strong relationships with each preceptor, to make one to two site visits per semester, to provide contact information, and to respond in a timely manner when contacted. Each preceptor is asked to provide formal student evaluation information, which is factored into the final grade for each course. Preceptors who have students with performance or behavioral problems receive assistance and support to develop an action plan to assist the students in successfully completing the course. The faculty members have worked hard to be consistent and to use the same criteria to evaluate each site.
The literature review indicated there are advanced practice programs where faculty members are not as available, as responsive, or as supportive as the preceptors would like them to be (Brooks & Niederhauser, 2010; Wilson et al., 2009). The actions exhibited by this sample school of nursing indicate that preceptors are appreciative of the efforts to include them in the educational process and to recognize their significant efforts.
Including the preceptor as an important element of the education of advanced practitioner students is an area that could easily be improved and that could yield greater dividends for advanced practice programs. As discussed in the previous section, preceptors are finding it harder to provide the time and effort to work with a preceptee. If they experience a good working relationship with the school of nursing, they may be more willing to accommodate requests.
Preparation for Role of Preceptor
As indicated by the responses to this survey, the preceptors were confident in their ability to provide instruction and evaluation and manage conflicts. They reported that they precept as they were precepted. This information can assist faculty members in developing continuing education programs for preceptors. It would probably be unproductive to offer a program on adult learning theory or on managing conflict with a student. However, if these concepts are considered an area that need addressing, then it would be good marketing to offer them in a way that builds on the preceptors’ knowledge and perceptions.
This sample indicated there was some need for information on the legal implications of serving as a preceptor. Most advanced practice nurses are not familiar with the Family Educational Rights and Privacy Act (1974) regulations and their state board of nursing regulations as they relate to working with a student in a supervisory role. This information could be developed as an online module for the preceptor to access as needed.
With the information provided in this survey, schools of nursing can negotiate with clinical agencies to address some of the issues that preceptors face in the area of workload, time to accomplish required and expected tasks when preceptees are on site, and opportunities to attend offsite meetings with preceptees. Although these are difficult challenges for both work sites and school of nursing faculty members to resolve, it is beneficial to begin the conversation rather than ignore the realities of the relationships. Gains can be made in increments, and the rewards will be worth the efforts. To provide for future educational partnerships, it is important that we advocate for our colleagues.
This was a small sample of advanced practice preceptors at one large mid-Atlantic school of nursing. Preceptors in other regions of the United States may respond differently to the same questions. Not all of the programs at this school of nursing provided e-mail contacts for their preceptors. It is not known whether a more complete representation of the different programs would have produced different results.
This survey provided information from preceptors of advanced practice students in the areas of nurse practitioners, nursing administrators, informaticians, clinical nurse specialists, medical doctors, and educators about the challenges and rewards of serving in the preceptor role. Responses to items in the categories of organizational support; rewards, disincentives, and barriers; relationship with school of nursing faculty members; and preparation for the preceptor role offered insight into the challenges and rewards that preceptors experience in their practice settings.
As schools of nursing grapple with a shortage of advanced practice preceptors, it will be useful to understand some of the issues that impact it. Each school of nursing will need to find ways to recognize and offer token rewards and incentives that are feasible within their economic constraints. As indicated by the preceptor responses in this survey, there was no expectation that large sums of money be offered to preceptors, but sincere forms of recognition are expected and appreciated.
- Brooks, M.V. & Niederhauser, V.P. (2010). Preceptor expectations and issues with nurse practitioner clinical rotations. Journal of the American Academy of Nurse Practitioners, 22, 573–579 doi:10.1111/j.1745-7599.2010.00560.x [CrossRef] .
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- Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g (1974).
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