Scenario one: You are assessing your preceptee (graduate nurse) to complete the medication administration practical. Your preceptee does not meet the required standard.  She is not able to describe indications of use and expected drug action  You need to remind her to wash her hands  She does not give the patient any education  She administers the drug too fast 1. Discuss the scenario within your group 2. Role play the feedback to be given to preceptee 3. After the role play – each person to talk about how the role play went 4. Using the displayed overhead write down what your feedback would be and if further follow up needed – this is for discussion with the larger group W:\CNE\Preceptor SD\COURSE MATERIALS\Day 2 Red Folders\Red 06 Other scenarios.doc Scenario Two: You are preceptoring a second year nursing student and you notice that the student appears to have a lack of knowledge re disease processes and appears disinterested in being on the ward/unit. He does not actively participate in ward/unit activities, does not ask questions and often is late to work or retuning from meal breaks. 1. Discuss the scenario within your group 2. Role play the feedback to be given to preceptee 3. After the role play – each person to talk about how the role play went 4. Using the displayed overhead write down what your feedback would be and if further follow up needed – this is for discussion with the larger group W:\CNE\Preceptor SD\COURSE MATERIALS\Day 2 Red Folders\Red 06 Other scenarios.doc Scenario Three: You are preceptoring a proficient level nurse who has transferred from another area. You come across this nurse on the phone discussing a patient loudly at the nurse’s station in front of visitors. You note that this is not the first time this has occurred. 1. Discuss the scenario within your group 2. Role play the feedback to be given to preceptee 3. After the role play – each person to talk about how the role play went 4. Using the displayed overhead write down what your feedback would be for discussion with the larger group W:\CNE\Preceptor SD\COURSE MATERIALS\Day 2 Red Folders\Red 06 Other scenarios.doc Scenario 4: Your preceptee makes you feel uncomfortable when you ask her questions about the patient care she has planned for patients. Answering with….. “I’m too busy right now”, “I’m fine”, “No I don’t need help”. She does not share information and you are finding it difficult to assess her. 1. Discuss the scenario within your group 2. Role play the feedback to be given to preceptee 3. After the role play – each person to talk about how the role play went 4. Using the displayed overhead write down what your feedback would be for discussion with the larger group W:\CNE\Preceptor SD\COURSE MATERIALS\Day 2 Red Folders\Red 06 Other scenarios.doc Scenario 5: You observe your preceptee talking to an elderly patient who has rung the bell and asked for assistance in the shower. The nurse says, with a hint of attitude “I am too busy love, you are not my only patient you know.” 1. Discuss the scenario within your group 2. Role play the feedback to be given to preceptee 3. After the role play – each person to talk about how the role play went 4. Using the displayed overhead write down what your feedback would be for discussion with the larger group W:\CNE\Preceptor SD\COURSE MATERIALS\Day 2 Red Folders\Red 06 Other scenarios.doc Scenario 6: You have noticed that your preceptee regularly does not introduce himself to the patient or their family. On this day you are with you preceptee to check the PCA pump. He does not introduce himself, does not explain what we are going to do or how long it will take. 1. Discuss the scenario within your group 2. Role play the feedback to be given to preceptee 3. After the role play – each person to talk about how the role play went 4. Using the displayed overhead write down what your feedback would be for discussion with the larger group W:\CNE\Preceptor SD\COURSE MATERIALS\Day 2 Red Folders\Red 06 Other scenarios.doc EDUCATION Becoming a super preceptor: A practical guide to preceptorship in today’s clinical climate ElizabethR.Barker,PhD,FNP,BC,FAANP,FACHE(AssociateProfessor,Clinical)&OraleaPittman,MS,FNP,BC, FAANP(ClinicalInstructor) CollegeofNursing,TheOhioStateUniversity,Columbus,Ohio Keywords Abstract Practicemodels;education;preceptor; students;precepting;primarycare. Purpose: To provide both potential and active preceptors with practical information that will help with the decision to become a preceptor, and Correspondence to develop the preceptor partnership among the preceptor, the faculty, the ElizabethR.Barker,PhD,FNP,BC,FAANP, student,andthepatient.Thearticlesuggestswaystoapplyrealistictechniques FACHE,CollegeofNursing,TheOhioState to assure that the preceptorship is successful in today’s fast-paced practice University,1585NeilAvenue,Columbus, climate. The article also presents successful evaluation strategies for the OH43210. experience. Tel:614-292-5684; Fax:614-292-7976; Datasources: Evidence-based reports, anecdotal experiences, personal E-mail:[email protected] conversations,andreportsofprovenpreceptorshiptechniques. Conclusions: Through a review of available literature and the authors’ Received:July2008; experienceaspreceptorsandfaculty,itisclearthatitispossibletoimplement accepted:August2008 a mutually beneficial preceptor experience even in today’s productivity- doi:10.1111/j.1745-7599.2009.00487.x basedpracticemodels.Preplanninganduseofsuggestedstrategiescanmake preceptinganenjoyableandrewardingexperience. Implicationsforpractice: The education of tomorrow’s practitioners is a mutual professional partnership among the stakeholders in the educational process.Applicationofpracticalstrategiesforenhancingthispartnershipwill maketheexperiencerealisticandrewarding. The need for excellence in the preceptor role has to encompass distance learning, and the need to place been well documented in the literature over the past students in clinical experiences where it is not possible two decades. However, there is little that is current for the academic faculty to observe the students on a and few contributions that present practical tips on firsthandbasisduringtheclinicalportionofthecourses, beingapreceptorintoday’s‘‘productivity’’environment. the role of the preceptor has become essential in the Furthermore, there is little in the current literature that educationalprocess(Burns,Beauchesne,Ryan-Krause,& prepares the newer preceptor to ask the right questions Swain, 2006). A preceptorship is usually a time-defined and plan the appropriate experiences for students. This relationshipwithexternallydefinedobjectives,andhasas article is designed to help the faculty and the preceptor itsgoaltheinstructionofaneophyteintheproficiencies build a professional partnership that will result in a of a new role (Barker, 2006). Within this relationship, positivelearningexperiencefortoday’snursepractitioner the preceptor models the realities of practice for the (NP)student. studentandhelpsguidethestudenttoorganizebehaviors The preparation of nursing students for successful and strategies for effective and efficient patient care. transition to real world role implementation has always In addition, a preceptorship provides the student with been a challenge in nursing education. The use of the opportunity to experience the pressures of day- preceptors as role models and teachers in the clinical to-day relationships with patients, other professionals, setting has been employed for many years. Indeed, the referral system, local, state, and federal rules with the expansion of programs in advanced practice and regulations, and the realities of productivity-based 144 JournaloftheAmericanAcademyofNursePractitioners22(2010)144–149©2010TheAuthor(s) Journalcompilation©2010AmericanAcademyofNursePractitioners E.R.Barker&O.Pittman Becomingasuperpreceptor practice.Preceptorsarethevitallinkbetweentheconcepts Becomingapreceptor and evidence-based approaches to care and the realities Making the decision to become a preceptor is not ofactualpractice. an easy one. Trying to squeeze extra time out of Beingapreceptorisavaluedprofessionalactivityandis an already packed schedule often seems to be an rewardedbythecertificationauthoritiesbygivingcredit for recertification in advanced practice by the American impossible task. Remuneration for the time and energy NursesCredentialingCenter(ANCC,2008).Theimpactof expended is usually low or not offered. What then, the preceptor on the student’s formation has been cited would motivate one to become a preceptor? Research repeatedly in the literature (Lyon, 2001; Hayes, 1994, has supported the notion that that for NPs a powerful 1998;Yonge,2005).Eachoftheseauthorsdescribesways influence on the decision is personal satisfaction and in which the preceptor’s unique position influences the a desire to ‘‘give back’’ to the students to repay those way in which the student forms a basic framework for who invested in their education. Another factor is the practice.Asimportantasthepreceptor’sexperienceison perceptionofthequalityofthecommunicationbetween theformationofthestudent’sprofessionaldevelopment, the faculty and the preceptor. Open dialogue between the relationship is forged in the crucible of a clinical the preceptor and the faculty not only enhances the environmentthatisnotdesignedtoallowforthetimeit preceptee’s experience but also provides the preceptor takestoimplementtheteachingprocess. with much needed peer support and a narrowing of Preceptorshipsarefrequentlyshorttermanddependent the theory–practice gap (Kaviani & Stillwell, 2000; on the length of the student’s course. The time that Lyon & Peach, 2001; Hayes, 1994, 1998). Students and students spend with the preceptor is determined by recent graduates have also indicated that the decision overall clinical hour requirements rather than the to be a preceptor in their careers is also based on student’s individualized learning needs. The availability the experience that they had while being precepted ofthepreceptorandthestudentformutuallyconvenient (E. Koenig, personal communication, January 5, 2008). hoursandthestructureoftheclinic’spatientcarehours Somerecentgraduateshaveconsideredthepreceptorrole arealsoessentialingredientsintheequation.Thisreality because they ‘‘remember how it feels to be a student’’ demandsthatthepreceptorquicklyidentifythestudent’s learning needs and select patient encounters to meet and how helpful a great preceptor had been in their those needs and then fit them into the available time formation. constraints.Thisisadifficultandoftenfrustratingactivity. Negativeexperiencesasapreceptorcanalsoinfluence Students often present themselves to the preceptor decision making. Being ‘‘responsible’’ for the success with few, if any, formal objectives for the experience or failure of a student is a heavy burden. Many aside from the requirements of the course. Most often, potential preceptors are reluctant to undertake the role the preceptor is still expected to maintain the level of because of a perceived lack of skill in techniques to productivity that existed before the preceptorship and manage conflictual situations with a student who is assurethatallregulationsandpoliciesarefollowed.This not performing well. A past history of unsuccessful presents an environment that is not conducive to the preceptorships is also a powerful influence on the developmentofself-efficacyinthestudent(Hayes,1998) decision. Situations in which the preceptor’s input was or enthusiasm on the part of the preceptor. In a recent either not solicited or not used to make progression meetingatalargeadvancedpracticesymposiumin2008, decisionshaveanegativeimpactonthedecisiontorepeat many preceptors reported that a lack of communication the experience. The authors have had the experience of between the professors and the preceptor, a lack of being exhausted at the end of a preceptorship because relationship building efforts on the part of the faculty, the student could not be trusted to see a patient and a generalsense that the professors are not clinically safely, discussions with the student were not fruitful, currentwereidentifiedingroupdiscussionasbarriersto and repeated attempts to contact the instructor were thefaculty–preceptorrelationship. unacknowledged.Whenthestudentpassedthecoursein In spite of all the pitfalls in the preceptorship experi- spiteofdocumentedlackofachievement,discouragement ence, it is possible to construct a rewarding experience for all participants: the student, the clinical preceptor, andangerwerepowerful‘‘demotivators.’’Inthestressful thepatient,thepractice,andthefaculty.Thisarticlewill world of primary care, one less stressor is a welcome describepracticalandeffectivetipsforenhancingtheout- respite. How, then, does one become a successful comesofthepreceptedexperienceandforgingmutually preceptor? What does it take to have interactions with beneficialrelationshipsamongthepeopleengagedinthe students that bring a sense of achievement to both process. parties? 145 Becomingasuperpreceptor E.R.Barker&O.Pittman Precursorsofsuccessful preceptorships Table1 Barrierstopreceptingsuccess First, it is essential that before a clinician agrees to Detrimentaleffectonproductivity be a preceptor, he or she should have some indication Practicenotdesignedtoincludestudents Patients’expectationsforcareprovider’sattention of the expectations of the program for the precepted Discomfortwiththeteachingrole experience. These expectations should include the level Shortdurationofthepreceptingexperience of practice expertise the student has achieved (Are they beginnersorontheirlastrotation?Aretheyexperienced Barrierstoprecepting nurses or new to the profession?). The clinician should askfortheobjectivesforthecourse,thecoursesyllabus, Themostcommonperceptionsofbarrierstoprecepting and the number of hours over a specific time frame the are listed in Table 1. The literature does not have many studentisexpectedtospendwiththepreceptor.Thiswill currenteconomicanalysesofthesefactors;however,one study indicated that community physicians who were provide the focus of the course and help the preceptor precepting third year medical students actually saw 1.4 plan the time the student spends in the practice more fewer patients and spent 51min longer at work than effectively. It is quite appropriate for the preceptor to physicians who did not have students with them (Levy, expectthatthestudentdisplayprofessionalbehaviors,be Gjerde,&Albrecht,1997).Anotherstudyofruralclinics mentallyandphysicallypreparedfortheexperience,and indicated that there was no difference in the billing be willing to supplement the time in clinic with specific charges that were generated between sites that had readings to improve his or her ability to manage the students and those that did not (Amella, 2001). The patient’sconditions. questionofproductivityoftenislargelydependentonthe Second, the preceptor should have some sort of level of the student and the fit between the student communication, either face to face, telephonically, or and the preceptor. This area needs further research, electronically, with the student before the onset of the particularlyintoday’spracticeclimate. preceptorship. Some areas of discussion might include Another perceived barrier is the requirements that mutualexpectationsfortheconductofthepreceptorship Medicare place on the structure of the visit. The including dress code, charting parameters, and urgent regulations state: ‘‘Any contribution and participation of a billable service must be performed in the physical contact information in case either party cannot be presenceofateaching(physicianorresident)inaservice available for an agreed-upon meeting. Additionally, a that meets teaching (physician) billing requirements’’ brief description of the practice routines and a general (Centers for Medicare and Medicaid Services, 2007). sense of the patient population will give the student a (NotethattheguidelinesdonotdiscussNPs,thebrackets bettersense ofhow topreparefortheexperience.Ifthe aretheauthors’notation.) preceptor is specific about these basics, it can eliminate The Center for Medicare Services (2007) rules for poor first impressions and save instructional time in the documentation by students indicate that a student can longrun. document only the review of systems, and the past Third, it is helpful if the preceptor has some medical, social, and family history. The preceptor must understanding of generational differences in learning document the history of present illnessand the physical patterns.Researchindicatesthatthelengthofexperience examination. Initialling the student’s charting is not as a nurse is not correlated with level of competency in sufficienttomeettherequirements.Followingtheserules NPstudents(Rich,2005).Thecombinationofayounger doesincreasethetimeandcomplexityofthevisit. Anotherbarrieristheperceptionthat‘‘thepatientsdo studentwithlimitedornoexperienceinnursingwithan not want to have a student.’’ This is certainly true in experiencedNPwhoisanewpreceptorcanoftenleadto somecases,particularlywhenthereisastrongemotional frustrationonthepartofbothparties.Thisfrustrationcan orintimateproblemoverlaytothevisit.Havingastudent be diminished by open communication of expectations, seethepatientcanoftenextendthedurationofthevisit mutualwillingnesstoofferconstructivefeedback,andthe and the patient may have to endure a second history formationofagoodpartnershipwiththefacultymember. or physical examination session. If the patient refuses Itissuggestedthatthefacultymembermakeatleastone to have a student, the patient’s wishes must always visit per precepting period, either in person (the best be respected. This can be an excellent topic for the strategy) or via telephone. This improves the sense of reflection portion of the student’s day. It is an excellent a teaching partnership and allows for a more satisfying learningexperiencetoassurethatstudentsdonottakethe experience. rejectionpersonallyorasareflectionoftheirexpertise. 146 E.R.Barker&O.Pittman Becomingasuperpreceptor Theauthorshaveoftenhadsuccessinthesecaseswhen Table2 Techniquesforpreceptingstudents thepatientistoldthatheorshewasspecificallychosenas Casediscussions animportantexampleofaskillorconditionaboutwhich Matchingpatientsandthestudentforaspecificlearningexperience thestudentneedstolearnandthatthepreceptorwillbe Directquestioning withthestudenteverystepoftheway.Anotherhelpful Thinkaloudsessions approachisthatthestudentisprovidingfresheyesanda Assignmentofdirectedreadings possible new tacticfora problem thathas beendifficult, Coachingandcheerleading andthatstudentsareexcellentsourcesofthe‘‘latestand Directobservation greatest.’’ Furthermore, the authors have often had the experience of the patient being happy that there is a 1992).Theauthors’experienceisthatittakeslongerthan studentbecausethatimpliesthatthepreceptorissowell oneminute,butitisaneffectiveapproach.Inthisclassic respected that he or she is chosen as a preceptor by the model,therearefivemicroskillsused. academiccommunity.Thisoftengivesenhancedstatusto Whatdoyouthinkisgoingon?(getacommitment) thepreceptorandtothepractice. Whatledyoutothatconclusion?(probeforsupporting Preceptor fatigue is another barrier to effective evidence) preceptorships.Ifapotentialpreceptorisaskedtoprecept Manytimeswhen.....(teachgeneralrules) by medical schools, allied health programs, and nursing Youdidanexcellentjobof.....(reinforcewhat programs,theamountofpersonalsatisfactionforpatient wasright) contact and the experience that one is ‘‘always on’’ can lead to burnout and frustration (S. Hatem, personal Next time this happens, try . . . . . (correct mistakes) communication, January 15, 2008). It is a reality that (p.419) advancedpracticeprogramsareexperiencingincreasesin The advantages of this model are that it allows the enrollmentandthenumberofpreceptedexperienceshas preceptortoundertandstudent’scriticalthinkingpattern, increased as well. Individual tracks within a program as itcommunicatesgeneralrulesofencounterwithpatients wellasmultipleprogramswithinaUniversityorCollege and it provides for immediate feedback about what was or within a geographic area often place the potential goodandwhatneededimprovementintheencounter. preceptor in the middle of a cacophony of requests for There still remains the problem of productivity and theservice.Thisisfrustratingandcanleadtoadesirefor how to get through a busy schedule with a student and ‘‘them all to go away and leave me alone’’ (L. Sedlock, not be at the clinic until midnight. Table3 summarizes personalcommunication,May15,2008). somesuggestionsthathaveworkedfortheauthors.One approach is a focused half day. The preceptor can see the projected schedule and select one or two patients Practicalstrategiesforsuccessful precepting on whom the student can concentrate. The focus can It is human nature to often apply the same strategies berelatedtoage,condition,assessmentskills,oraligned thatwereused‘‘onus,’’eveniftheywerenotparticularly withtheobjectivesforthecoursethestudentistaking.In helpful.Itisimportanttorealizethatdifferenttechniques thisstrategy,studentswillhavetimetoreviewnecessary for different learners should be selected depending on informationfromthechartand/orfromtheevidencebase the student’s and preceptor’s personality and level of sothattheywillbepreparedtoaskthepatientappropriate experience, as well as the pace of the practice. A questionsandperformafocusedexamination.Whilethe constellation of techniques is summarized in Table2. In student ispreparingorwhilethestudent isintheinitial ordertomeetMedicareguidelines,asuccessfulapproach encounter, the preceptor can be seeing other patients is for the student to do the history and physical exam and keeping the schedule on track. Although this only (H&P) while the preceptor sees another patient. When provides for the student to see one or two patients, it the preceptor returns to the room, the student presents gives the student the opportunity to have an in-depth the H&P and the preceptor and student develop the experience and learn approaches that can be used in plan together based on findings from the observed subsequentencounters(Taylor,1998).Thistechniquecan examination. Points for improvement can be discussed after the visit, but the preceptor can amend the pattern Table3 Schedulingstrategiesforprecepting of the examination as it occurs. This demonstrates a collaborativeapproachandeliminatesthepatienthaving Focusedhalfdays tohavethesameexamtwice. Focusedobservation Wave-scheduling Another technique is the so-called ‘‘One Minute Appointmentmodification Preceptor’’ model (Neher, Gordon, Meyer, & Stevens, 147