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Clinical Practicums: More Than Finding a Preceptor

Section Editor(s): Fulton, Janet S. PhD, RN, ACNS-BC, ANEF, FAAN

doi: 10.1097/01.NUR.0000469305.88866.7a
DEPARTMENTS: Editorial
Free

Author Affiliation: School of Nursing, Indiana University, Indianapolis.

The editor reports no conflicts of interest.

Correspondence: Janet S. Fulton, PhD, RN, ACNS-BC, ANEF, FAAN, School of Nursing, Indiana University, 1111 Middle Dr, Indianapolis, IN 46202 (Jan_Fulton@sbcglobal.net).

Thank you. Saying thank you is the starting place for any discussion involving clinical preceptors. Thank you to countless clinical nurse specialists (CNSs) for sharing their time and talent with CNS students. The collective contribution of preceptors to the profession is enormous. The educational standard is for each CNS student to complete a minimum of 500 supervised clinical practice hours. The supervisor for those hours is, for the most part, a volunteer CNS serving as a preceptor. It’s a substantial uncompensated effort for which we are all indebted.

Preceptor-supervised clinical experiences have been part of CNS curricula since the initial programs; however, the number and focus of those clinical hours varied. More recently, 500 clock hours was established as a minimum for achieving core CNS practice competencies. Then as now, CNS students learn to apply classroom content by observing and doing alongside experienced CNSs. After graduation, the novice CNS continues to rely on experienced colleagues to traverse the perils of the first few years of practice. Simply stated, experience matters, but greater attention is needed in shaping how that experience is used to maximize student learning.

Now is a good time to take a step back and look at graduate clinical education. The clinical experience involves 3 different interests working in collaboration: faculty, preceptor, and student. Volunteer preceptors often report struggling to understand the faculty expectations, course requirements, and individual student learning objectives. Preceptors may be unfamiliar with the school’s CNS curriculum or may be uninformed about curricular changes, leaving a preceptor to make decisions in a vacuum. Online learning programs present special challenges for preceptors unfamiliar with a course or program and no local faculty contact person. Preceptors, like faculty, tend to teach as they were taught; thus, decisions about what constitutes a good clinical experience are largely grounded in hidden assumptions influenced by past student experiences.

To maximize student learning in clinical experiences, greater effort should be devoted to preceptor preparation. While individual schools have some great supports in place for preceptors, collectively across CNS education there are many gaps. Universal best-practice guidelines would help. By addressing expectations for preceptor preparation and performance, a more comprehensive approach to preceptor preparation could be crafted. Better preparation would result in preceptors being adequately informed about their responsibilities and ready to facilitate a student clinical experience. Individual schools could use the guidelines to create program-specific preceptor orientation packets, professional development programs, and evaluation parameters for reviewing preceptor effectiveness. Preceptor development programs should offer new preceptors support and coaching by faculty and experienced preceptor mentors. Guidelines should also outline preceptor performance expectations and set a standard that schools provide preceptors with timely feedback about their performance. Precepting students can be a rich and rewarding experience, but it is also very demanding. In general, preceptors need more support for the role, timely feedback, and professional recognition.

Students also have responsibility for ensuring a positive clinical learning experience; however, they are often not well prepared for negotiating the experience with the preceptor. For example, preceptors may be expecting a student to bring a course syllabus, a learning contract, achievement benchmarks, a description of possible student contributions to the agency or organization (eg, evidence-based practice project), and a timeline for the clinical experience. A prepared student should leave the initial preceptor meeting with decisions finalized in writing and ready for faculty review and approval. Guidelines describing expectations for a student-preceptor contract would help structure the clinical experience, which is necessary for evaluating student outcomes.

The link between classroom content and clinical practice competencies often is not well defined, resulting in inconsistencies and gaps between intended and actual outcomes. Assessing student competency achievement is difficult in the absence of defined proficiencies, which can be additionally challenging because of the complex nature of CNS practice competencies. Discrete skills, such as a neurological physical examination, can be easier to evaluate than broad-based skill clusters, such as maneuvering through system-level barriers to change nursing practice. Skills with steps occurring in a logical sequence, such as a physical examination, can be observed in a delimited time and place. Complex skills require integrating varying kinds of knowledge and abilities and can only be demonstrated and evaluated across time. For example, a student’s clinical experience might include analyzing multiple data sources and synthesizing findings into practice change plan in the context of system-level priorities. Evaluation of this clinical work must be broken into smaller bits with progress monitored over time. Course content often focuses on fact-based knowledge—research methods, statistics, pathophysiology, and so forth, with little attention given to teaching strategies for helping students master those complex, highly integrated, system-level competencies. Case studies, simulations, debriefing, and other strategies should be developed by faculty to address complex CNS competency achievement. Preceptors need to understand what is expected in designing experiences to develop these complex, integrated competencies.

Greater attention should be given to evaluating student achievement of core practice competencies and the foundational skills that culminate in mastery of the complexities of CNS practice—skills such as cultivating interpersonal relationships and navigating organizational behaviors. Reliable and valid methods and instruments for measuring and evaluating student clinical performance need to be developed. Improved methods for measuring student performance would assist faculty and preceptors to evaluate competency mastery in the field experience.

Clinical nurse specialist faculty, preceptors, and students are collectively responsible for ensuring that clinical experiences achieve the intended purpose of preparing competent graduates for entry into advanced nursing practice as a CNS. It is time for educators and preceptors, working together, to establish guidelines for preceptor preparation and performance and for structuring CNS student clinical experiences. Most important, it’s time to begin thoughtful work in developing reliable and valid measurement instruments for evaluating performance outcomes.

In the meantime, as the work of improving the clinical practicum continues, here’s another big THANK YOU to all volunteer preceptors!

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