Contributor – Julie Durand
DNP, MBA, APRN, PMHNP-BC, FNP-BC

Preceptorship, which includes guided experiential learning and mentorship, is a critical component of healthcare education. As in other healthcare disciplines, clinical preceptorship is a core component of nurse practitioner (NP) education. Unlike medical student preceptorship, which benefits from a more coordinated effort and funding, the identification of NP clinical placement is often the responsibility of the student. The shortage of available nurse practitioner (NP) preceptors is widely felt by practicing NPs, NP faculty, and NP students. Identified barriers to NP preceptorship include limited financial incentives for preceptors, varying levels of student competence, a lack of interest from potential preceptors, a lack of defined preceptor role expectations, and a lack of preceptor support (Henry-Okafor et al., 2023).

As the shortage of available NP preceptors has intensified, a controversial workaround has emerged: students paying directly for clinical placements. This practice, unregulated at the national level, raises important ethical questions for nursing education and the profession as a whole. This article examines the ethics of such a system through the lens of ethical principles, including the four main bioethical principles in healthcare as a framework: justice, beneficence, nonmaleficence, and autonomy (Varkey, 2021). This article argues that allowing NP students to pay for clinical preceptorship creates an ethical dilemma that challenges the profession’s commitments to equity, educational integrity, and accountability.

Justice

Justice and equity are commonly cited ethical principles associated with nursing. For example, the National Task Force on Quality Nurse Practitioner Education (NTF), a coalition of 19 national nursing organizations, mandated in their 2022 publication that NP programs maintain policies and procedures that reflect equitable (and nondiscriminatory) practices. Additionally, the American Nurses Association (ANA) published a revised Code of Ethics in 2025. In this document, Provision Nine states that “Nurses and their professional organizations work to enact and resource practices, policies, and legislation to promote social justice, eliminate health inequities, and facilitate human flourishing.” (ANA, 2025).
A system that allows NP students to pay for preceptorship clearly favors students who can afford to pay for such preceptorship. This practice promotes inequity, as economically disadvantaged students are less likely to afford preceptorship. This should alarm the nurse practitioner community, as this undermines efforts towards diversity of the NP workforce.

Likewise, we must consider whether it is just for preceptors to guide, teach, and mentor NP students without any incentive. If an incentive is to be offered, who should pay for it? Is it just that only select students, who can afford the extra cost, have guaranteed placement? As described above, a pay-for-placement model effectively creates a two-tiered system of access to required clinical education. Alternatively, is it most just for the programs to adhere to accreditation guidelines already in place, and ensure placement through incentivizing preceptors with academic partnerships, allocated FTE, and/or direct payments from the University?

Beneficence

Beneficence is described by Cheraghi et al. (2023) as the core ethical principle of nursing. Many describe beneficence as “doing good”, and other descriptions include providing the “best care” or “maximum benefit to the patient” (Cheraghi et al., 2023). Precepting students is seen by many as a professional responsibility and a way to “give back” to the profession, and in doing so, theoretically is “doing good” on some level. Similar to nurses’ goal of acting in a way that provides a maximum benefit to the patient, nursing educators should support policies that provide the maximum benefit for NP students and their future patients. Framing the question of payment for preceptorship through a beneficence lens, we should consider which practices in NP education best support the student’s journey from nurse to advanced practice nurse.

When a preceptor accepts direct payment from a student for preceptorship, we should consider whether the preceptor is doing as much good and providing as much of a benefit to the student compared to the preceptor not charging the student directly. We should also question if payment for preceptorship objectively results in maximum benefit. At present, there is no evidence that paid preceptorship results in stronger clinical competency, improved transition to practice, or better patient outcomes.

Nonmaleficence

The principle of nonmaleficence instructs us to “do no harm”. If we continue to allow students to pay for preceptorship, the act of precepting becomes transactional, which is not aligned with nursing core values. We should consider the harm to students and the harm to our profession if we allow students to directly pay for preceptorship.

When NP students not only arrange their clinical rotations independently but also directly pay for preceptorship, what motivation does the preceptor have to be accurate in their assessment of the student’s clinical knowledge and skill? Financial transactions between student and preceptor may introduce perceived or actual conflicts of interest in evaluation and feedback, which may translate into a lack of competency for the student and result in future patient harm.

Furthermore, the harm to the profession should be considered. The normalization of pay-for-placement models risks reshaping NP education into a market-driven system rather than a professionally stewarded one. Once clinical education becomes transactional, it becomes difficult to re-establish shared professional responsibility for preparing the next generation of clinicians. For example, would we expect NP students who paid for preceptorship to later precept NP students for free?

Autonomy

There is an argument that students who are not allowed to pay for clinical preceptorship have had their autonomy violated. First, we must examine the logic of this. Do students who pay for clinical preceptorship truly decide to pay for the clinical experience, or are they coerced by a system that has nothing else to offer? If faced with either failing the course or waiting out a semester, paying for preceptorship is not a true, autonomous choice on behalf of the student.

Additionally, there is an argument that not granting students the autonomy to select and potentially pay for their clinical preceptorship will delay the timely graduation of NPs, which may result in fewer patients having access to care. However, this sentiment fails to address the structural cause as to why students currently need to pay NP preceptors.

From a systemic perspective, we should also consider the degree of autonomy granted to students, of any discipline, when it comes to setting educational standards for the profession. We do not allow students to “opt out” of requirements in an effort to preserve their autonomy. Students have limited autonomy, even in an ideal situation, as it is inherent in the role of being a student.

Perhaps even more importantly, we should remember that autonomy is not the primary or only ethical principle that guides our decision-making. Ethical dilemmas should be thoroughly evaluated through competing moral principles (Varkey, 2021).

Accountability & Fidelity

We may also approach the ethical dilemma of payment for preceptorship through several other ethical lenses.According to the American Nurses Association Code of Ethics (2025), nursing alone has authority and accountability over nursing practice. Through the lens of accountability, NP students should not be held responsible for finding their own clinical placements. NP programs, however, should maintain this responsibility and be held accountable by accrediting bodies when placement isn’t found.
Fidelity, an ethical principle related to trustworthiness and integrity, should also be considered. Fidelity can also be described as a commitment to the profession and to the promise made (Husted et al., 2014). NP programs are mandated by accreditation standards to provide adequate and high-quality clinical sites for students. Unfortunately, this standard is often disregarded by programs or not enforced by regulatory bodies. This leads to students finding, securing, and paying for their own placement. Therefore, this practice violates the principle of fidelity. The failure to ensure adequate clinical sites is a failed promise and a failed commitment, on behalf of both nursing leadership and academic programs, to NP students. The lack of transparency (and truth) in this process compounds frustration for students and leads to an erosion of trust between the faculty, the student, and the academic program.

Conclusion

A system that allows and/or promotes NP students to find and pay for their own placement violates the ethical principles of justice, beneficence, nonmaleficence, fidelity, and accountability. The practice of paying to be precepted is not aligned with the core ethics and values of our profession. If nursing leadership asserts authority and accountability over advanced practice education, then it must also assume responsibility for ensuring equitable access to clinical training. Allowing students to independently secure and finance required clinical experiences shifts institutional responsibility onto learners and risks undermining both professional ethics and public trust. Of note, this author is not suggesting that preceptors receive no incentivization, but incentivization from the student directly violates ethical principles. Stronger national guidance, transparent program accountability, and sustainable preceptor support models are urgently needed. The future and integrity of nursing depend on it.

References

American Nurses Association. (2025). Code of ethics for nurses with interpretive statements: Provisions. https://codeofethics.ana.org/provisions

Cheraghi, R., Valizadeh, L., Zamanzadeh, V., Hassankhani, H., & Jafarzadeh, A. (2023). Clarification of ethical principle of beneficence in nursing care: An integrative review. BMC Nursing, 22(1), 89. https://doi.org/10.1186/s12912-023-01246-4

Henry-Okafor, Q., Chenault, R. D., & Smith, R. B. (2023). Addressing the preceptor gap in nurse practitioner education. The Journal for Nurse Practitioners, 19(10), 104818. https://doi.org/10.1016/j.nurpra.2023.104818

Husted, G. L., Husted, J. H., Scotto, C. J., & Wolf, K. M. (2015). Bioethical decision making in nursing (5th ed.). Springer Publishing Company.

National Task Force on Quality Nurse Practitioner Education. (2022). Standards for quality nurse practitioner education (6th ed.). National Organization of Nurse Practitioner Faculties. https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/ntfstandards/NTF_Standards__Updated_Feb_2.pdf

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

About Julie Durand

Dr. Durand is an experienced nurse and nurse practitioner, and a nursing educator at the undergraduate, graduate, and postgraduate levels. Dr. Durand clinically practices as a psychiatric consult-liaison nurse practitioner and has additional clinical experience in the psychiatric emergency and outpatient settings, as well as the Intensive Care Unit. Her research interests include the impact of postgraduate training programs for physician assistants and nurse practitioners, as well as best practices for nursing education.