Contributor: Michelle Alexandre, MSN, ACNS-BC
Nurse practitioner (NP) students are all too often faced with the challenge of securing their clinical preceptors (Doherty et al., 2020). Last year a colleague and owner of an NP preceptor matching company reached out to me offering me substantial monetary compensation to serve as one of their clinical preceptors. I was shocked to find that one of these NP preceptors matching companies charges a minimum fee of $1000 for each clinical rotation (NPHub, n.d.). With 40% of NPs not interested in precepting (Doherty et al., 2020), I cannot help but wonder why. Where have we gone wrong in emphasizing our nursing practice obligation to raise up the next generation of NPs?
Provision nine of the national nursing code of ethics outlines the nurses’ fundamental responsibility to maintain the integrity of our profession by fostering access to and assisting in nursing education and professional development (American Nurses Association, 2015, p. 35). Yet NPs are reluctant to precept because employer’s lack of accommodation for the preceptor’s teaching and a scarcity of preceptor compensation and training (Pleshkan, 2024).
Some institutions have responded to this need by providing NP incentives such as library access and academic titles, however many academic programs offer no NP incentives (Doherty et al., 2020). Due to a paucity in NP program support, 14% of NP students are left to secure their own preceptors (Doherty et al., 2020). Many students resort to paying NP preceptor matching companies to meet their needs.
Advanced Practice Registered Nursing programs require a minimum of 500 clinical hours, with some programs requiring 700 clinical hours (Doherty et al., 2020; National Certification Corporation, 2019). NPs typically complete at least five clinical rotations (Doherty et al., 2020; National Certification Corporation, 2019). However, many students find themselves at a standstill in their education due to a lack of preceptors (American Association of Colleges of Nursing (AACN], American Association of Colleges of Osteopathic Medicine [AACOM], American Association of Medical Colleges [AAMC], & Physician Assistant Education Organization [PAEA], 2014). With clinical preceptor placement rates from ten to more than twelve dollars per clinical hour, paid preceptorships can cost a NP student upwards of $5,000 for their required clinical rotations (National Certification Corporation, 2019; NP Clinical Solutions, n.d.; NP Hub, n.d.).
What bothered me the most about my colleague’s nurse preceptor matching business was that he was a nurse. But then I remembered he was also a businessperson. So, I shifted my focus to business ethics. Business research has recently began exploring the question of “if it’s legal, is it ethical?” (Dacin, et al., 2022). Business entities do this by assessing the intertwined concepts of ethics and sustainability (Haywood, 2023). One could ethically argue that NP matching companies provide a much-needed service for students. If students have the financial resources, is there harm? To answer this question, we must look at sustainability (see Figure 1). Sustainability requires businesses to evaluate their long-term impact on the economy, society, and the environment (Haywood, 2023). In terms of economy, businesses must turn a profit. These companies are paying NP preceptors and have business expenses which justify charging a fee for services. There is no harm to the environment. So that leaves us with protection and the betterment of society (Haywood, 2023).
If NP students do not have preceptors for their clinical rotations, they are in a standstill in their educational journey. This results in financial losses from a delay in NP salary income. Additionally, if these NP students secured loans for their previous courses, they may have to start paying them back on their nursing salary while they are waiting to re-enroll. Thus the financial benefit outweighs the cost. Furthermore, healthcare is relying heavily on NPs to fill the gap in patient care. But we know that NPs have high workloads and few resources which can lead to burnout and job dissatisfaction (Schlak et al., 2022). By providing an avenue for NP students to progress and graduate these companies are bolstering the NP workforce and helping patients get the care they need. Thus, on could also argue that they are bettering society.
After realizing that NP paid preceptorships were not the problem, I began to brainstorm ways to help my colleagues. I remembered that as a graduate student, I developed and taught a preceptor course for undergraduate nurses at my alma mater and received three hours of elective course credit towards my degree. In this elective course we outlined nurses; professional responsibility to bridge the gap between nursing students’ education and practice. By providing nursing preceptor students with the skills and tools needed, we equipped them with foundational knowledge needed in the role of preceptors. Offering an NP preceptor elective at the doctoral level might be the answer we are looking for. Because doctoral programs require electives, this may offset the time restraints reported by 89% of potential NP preceptors (Doherty et al., 2020). Additionally, a NP preceptor elective provides the structure for evidence-based teaching, which addresses the lack of preceptor training reported by potential NP preceptors (Pleshkan, 2024).
Because the expensive fees associated with paid preceptorship can be prohibitive for many NP students, we have an ethical obligation to solve the preceptor shortage to ensure the advancement of NP students in their clinical rotations. The Commission on Collegiate Nursing Education (CCNE) requires that NP programs have resources to achieve the program’s mission, goals, and expected outcomes (CCNE, 2021). It is imperative that NP programs address the NP shortage problem. Nursing educators and nurse practitioners must collaborate to find innovative ways to solve this problem and do our due diligence to mitigate the need for paid preceptorships. A doctoral level preceptorship elective course has the potential to address the clinical preceptor shortage.
References
American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, Association of American Medical Colleges, and Physician Assistant Education Association. (2014). Recruiting and maintaining U.S. clinical training sites: Joint report of the 2013 multi-discipline clerkship/clinical training site survey. https://paeaonline.org/wp-content/uploads/imported-files/Recruiting-and-Maintaining-U.S.-Clinical-Training-Sites.pdf.
American Nurses Association. (2015). Code of ethics for nurses. American Nurses Publishing.
Commission on Collegiate Nursing Education (2021, November 22). Procedures for Accreditation of Nurse Practitioner Fellowship/Residency Programs. https://www.aacnnursing.org/Portals/0/PDFs/CCNE/Procedures-NP-Fellowship-Residency.pdf
Dacin, M. T., Harrison, J. S., Hess, D., Killian, S., & Roloff, J. (2022). Business versus ethics? Thoughts on the future of business ethics. Journal of Business Ethics, 180(3), 863–877. https://doi.org/10.1007/s10551-022-05241-8
Doherty, C. L., Fogg, L., Bigley, M. B., Todd, B., & O’Sullivan, A. L. (2020). Nurse practitioner student clinical placement processes: A national survey of nurse practitioner programs. Nursing Outlook, 68(1), 55-61. https://doi.org/10.1016/j.outlook.2019.07.005.
Haywood, D. (2023, March 2). Operating ethically and sustainably [Video]. YouTube. https://youtu.be/LwklKeZMF4g
National Certification Corporation. (2019). Certification Examination Core Nurse Practitioner Board Certified. https://www.nccwebsite.org/content/documents/cms/exam-np-bc.pdf.
NP Clinical Solutions. (n.d.) https://npsolutions.me/.
NPHub (n.d.). https://www.nphub.com/pricing.
Pleshkan, V. (2024). A Systematic Review: Clinical Education and Preceptorship During Nurse Practitioner Role Transition. Journal of Professional Nursing, 50, 16–34. https://doi.org/10.1016/j.profnurs.2023.10.005
Schlak, A. E., Poghosyan, L., Liu, J., Kueakomoldej, S., Bilazarian, A., Rosa, W. E., & Martsolf, G. (2022). The Association between Health Professional Shortage Area (HPSA) Status, Work Environment, and Nurse Practitioner Burnout and Job Dissatisfaction. Journal of Health Care for the Poor and Underserved, 33(2), 998-1016. https://doi.org/10.1353/hpu.2022.0077
About Michelle Alexandre
I am from a small, three stoplight town in West Texas. While I love “big city” Dallas, I am grateful for my small town, country roots.
I moved to the Dallas – Fort Worth area in 2006 while I was pursuing my master’s degree in nursing. Throughout my career as an undergraduate intensive care nurse, I was dedicated to healthcare delivery excellence. I developed and taught courses for the hospital and my university. After graduating with my clinical nurse specialist degree in 2008, I was able to use my skills as a “change agent” and “expert” to improve healthcare systems.
With over a decade of clinical expertise in acute general and orthopedic trauma management and process improvement, I hope to utilize my professional experience to advance nursing research. I am currently enrolled in the Nursing PhD program at Texas Woman’s University. My research interests include intimate partner violence in trauma and advanced practice provider professional development and retention.
Thank you for the post, Michelle. The issue about NP preceptors (including locating them, paying them (or being unable to pay them), etc.) is an important one to think through. Like so many things health-related, it is multifaceted. From time immemorial, NPs have been touted as a group of professionals who have improved access to health services for those in most need of them. Perhaps, then, using “access” as a conceptual guide might be one approach for understanding how we can improve the pool of NPs qualified and willing to provide invaluable clinical education to students. Levesque, Harris, and Russell’s (2013) conceptual framework for access to health care is a popular reference. Some of the concepts within it might apply to accessing NP preceptors. Norris and Aiken (2006) published a concept analysis about “personal access to health care” which includes four defining attributes: availability, eligibility, amenability, and compatibility. Through some creative revisioning, these might be the starting point for studying access NP preceptors. For example, Norris and Aiken (2006) conclude that “availability” includes both “geographic proximity” and “personal convenience.” These are important issues when students need to find NP preceptors. Here is the reference: Norris, T. L., & Aiken, M. (2006). Personal access to health care: A concept analysis. Public Health Nursing, 23(1), 59–66. https://doi.org/10.1111/j.0737-1209.2006.230109.x
Thank you Timothy for your creative application of the conceptual analysis of access. I have to request “access” (pun intended) to your reference through the library. I am looking forward in learning more and am excited about possibly using this as a guide in future work.
Michelle,
Very relevant topic, and thank you for this post.
I will share my viewpoint in very practical terms:
1) Small businesses and private practices may be more likely to charge and go with paid preceptorship because although teaching& learning activities may not be restricted, these businesses will have to invest their time in clinical teachings on the NP students, which might affect their workflow. Minimal charge on precepting, if present, needs to be from the collaboration with the University, not directly from individual students.
2) Large teaching hospitals and healthcare organizations may provide free clinical placements. Universities need to collaborate with these hospitals/ organizations to guide students through clinical placements. Universities that have NP programs need to have a strong relation with the local healthcare centers so that NP students feel supported for easy placements.
Kunta,
Thank you for your contribution. I agree with your outlined points. My organization works with surgical residents at many of our facilities. The “attending surgeons” receive academic titles and a $200 stipend per shift through the Graduate Medical Education (GME) program. The hospital also receives thousands of dollars for each resident. After many years at teaching hospitals, I personally have chosen to step away from facilities with residents. As seasoned NPs we are responsible for the patients they “manage” in addition to our assigned patients. While I love to teach, I prefer to teach my nursing and advanced nursing staff.
Thank you for bringing this issue to the forefront. I must confess, I had/have a strong reaction to this posting. I completely disagree with with the premise of the post. Nursing has struggled with increased workforce demand > the shortage of practicing nurses at all levels > limited clinical placements > ultimately limiting the ability of programs to admit qualified applicants. Advanced practice placements are even more difficult to secure, resulting in the burden of securing an appropriate placement falling on the student. The commitment to further the profession and support development of future advanced practice nurses is not at issue. The question lies with the how.
The current practice of securing preceptors from a pool limited by availability, financial impact, productivity threats, lack of support from the institution, further positions nursing and nursing education at a distinct disadvantage by tapping into guilt and “responsibility” of a mostly female workforce. The practice also supports the business acumen of those who are taking advantage of a student need that is not being filled by the academic institution, and tries to position embedding preparation of future preceptors as an “option” which students will have to pay for to try and encourage more volunteerism among preceptors.
In my view, the answer lies in advocating for nursing education to have access to CME $$ equal to physician education. A shift of this magnitude will require significant disruption to a system that continues to be reinforced by a medicine centric view of health and healthcare. I agree completely that improved academic practice partnerships can have an impact. Until nursing is viewed as a valid solution to improving access to care with the explicit intent of addressing institutional inequities, advanced practice nursing clinical education will continue to resemble more of an apprentice model. We do have a responsibility to care for vulnerable and marginalized communities. We also have a responsibility to address structural barriers and oppressive systems to improve access to education opportunities that increases the number of advanced practice nurses who can also address those structural inequities as well.
Thank you for insight. It was very enlightening. I have spent the majority of my career improving systems/processes at the hospital level. Unfortunately, I have little knowledge of the academic aspects and implications. I recently took a Power, Politics, and Policy course that challenged me to think bigger. I am grateful for colleagues, such as yourself, that unapologetically highlight the root cause of the issues on a grander scope. I share your passion and look forward to learning more from you and others on this topic.
Thank you, Michelle, for reminding all of us of this ongoing challenge to NP education. I am located in Boston and savvy students are now choosing to attend the NP programs in my state that find preceptors for their students, even when the price of tuition is much higher than other programs.
As a former graduate program director at a university where NP clinical placements fell to the students to obtain, I can say that I am still suffering from PTSD to be associated with such a program, even when CCNE required that programs do so. However, CCNE looked a blind eye and continued to grant accreditation to programs that did not find clinical preceptors. So, there is another ethical dilemma when a gatekeeper does not enforce its own requirements. I suspect that many programs would not receive accreditation if CCNE did enforce the requirement.
I personally witnessed students taking an LOA semester after semester because they could not find a preceptor in their area. There are too many NP students and too few preceptors for all of the reasons mentioned, including productivity, lack of incentive, and their employers not allowing them to precept. Offering library privileges or a DNP course, neither of which they wanted, was no enticement to structural and personal factors. Given the amount of NP, PA, and medical student placements in our state, employers are going to agree more readily when there are financial incentives, which, by the way, the NP preceptor will never see. Some of my students admitted to hiring NP placement companies so they could finish the program expeditiously. Because we ran an online NP program across the nation, it wasn’t only my state where there were challenges.
We could talk about many ethical dilemmas related to NP preceptorship, both within and without of nursing. Thank you for yours and others perspectives. Nursing’s got to solve this. Flooding geographic areas with NP students looking for preceptorships, unable to meet the demands of clinical training, ignoring the accrediting body’s requirement to find placements leading to no consequences, students hiring placement services are signs of larger failures. We bemoan this issue every few years but it never gets the attention it needs. What is the duty of the program to the student?
By the way, I am an NP of 28 years.
Susen,
Thank you for your input. It is encouraging to hear that there are programs out there that successfully place NP students with preceptors. In Dallas – Forth Worth, I am bombarded with preceptor requests from nursing colleagues/NP students from all the neighboring programs and many out of state programs. My team’s dedication to precepting is well known in this area. But even my team has not been able to take on students this year because our staffing has not kept up with the growth/demand in our area. Our staffing shortage is crippling our ability to commit to training students. So I can empathize with my colleagues who just do not have time. But I am pleased to report that facility has recently developed a clinical ladder for leadership (with monetary compensation) for APPs that includes clinical preceptorship criteria.
I hope to eventually design a surgical elective course for NP students in collaboration with my healthcare corporation. A surgical elective course will (1) help NP students and DNP/PhD students meet course requirements, (2) foster educational institution’s relationships with hospital systems, (3) create a hiring pool for qualified NPs who have a proven track record at the facility, and (4) provide NPs with surgical training (eliminating the need to pay >7K for nursing first assist training). I have much to learn about the academic side first though.