Excellence and quality in clinical training for nurse practitioner (NP) students are goals for the academic faculty and clinical preceptor. As per National Task Force on Quality Nurse Practitioner Education (2016) guidelines, evaluation and assessment of the NP student is a responsibility shared by the faculty and clinical preceptor. This article presents the desired relationship and communication patterns among the NP program, its associated faculty, and the preceptors who teach NP students during a clinical experience.
In early 2018, the National Organization of NP Faculties (NONPF) and the American Association of NPs (AANP) collaborated to develop a tool that addressed the deficiency of relationships between NP faculty and clinical preceptors. This tool resulted in the development of guidance checklists that outlined expectations when establishing clinical rotations for NP students. The Preceptor Expectation Checklist and the Faculty Expectation Checklist include evidence-based suggestions to promote a healthy, ongoing relationship and reduce barriers experienced by the clinical preceptor, NP faculty, or NP student (Figures 1 and 2). Standardization of the clinical placement process is critical, especially in light of the growing trend of distance-based, online education within graduate nursing programs. To continue to advance the NP profession, NP faculty and clinical preceptors must work together to establish a quality standard for the faculty–preceptor relationship.
In 2011, the Institute of Medicine charged the nursing profession with the task of improving its current education system in the areas of recruitment, retention, and preparation of advanced practice registered nurses (Fitzgerald, Kantrowitz-Gordon, Katz, & Hirsh, 2012). This required nursing programs to review and address issues related to the current teaching model in the areas of organizational support, preceptor competency, and relationships between nursing programs and clinical sites (Fitzgerald et al, 2012; Latessa, Colvin, Beaty, Steiner, & Pantham, 2013). The sustainability of the current teaching model is questionable, as enrollment in health profession schools increases while productivity demands on preceptors increase as well (Latessa et al., 2013). Such pressures threaten the clinical experience process traditionally used for NP student skill development, role acquisition, socialization, and transition to practice (Donley et al., 2014; Fitzgerald et al., 2012).
The process of establishing a clinical experience has its internal and external challenges. Internal challenges refer to barriers within educational organization structures or within the nursing profession (e.g., nursing faculty shortage, high enrollments, and noncompetitive educational salaries). In the study by Roberts (2017), the majority of NP program faculty reported concerns about obtaining a sufficient number of willing and qualified preceptors and clinical sites. Nurse practitioner faculty report being frequently overwhelmed with the challenge of establishing clinical experiences in light of limited resources, staff support, and workload (Drayton-Brooks, Gray, Turner, & Newland, 2017). External challenges are those issues that cannot be controlled by the educational institution, such as limited clinical sites or preceptors (Fitzgerald et al., 2012). Burnout, role strain, and productivity challenges due to the continuous responsibility of precepting each semester are contributing factors to this external challenge (Burns, Beauchesne, Krause, & Sawin, 2006; Brooks & Niederhauser, 2010; Forsberg, Swartwout, Murphy, Danko, & Delaney, 2015; Roberts, Wheeler, Tyler, & Padden, 2017; Webb, Lopez, & Guarrino, 2015). More importantly, preceptors attribute a decreased desire to take students to lack of recognition for service and lack of support (Campbell & Hawkins, 2007; Wiseman, 2013). Being that clinical preceptors are critical to the practice, instruction, and supervision of NP students, it is important to understand beliefs of clinical preceptors and NP faculty related to the attributes necessary to foster the desired relationship and successful communication pattern supporting NP students' clinical experiences.
National Organization of NP Faculties and AANP encourage ongoing conversation surrounding the expectations and responsibilities of the NP student clinical experience. An open, transparent conversation among all stakeholders should focus on the development of shared goals and outcomes, the engagement and support of senior leadership, and the benefit of establishing academic practice partnerships (AACN, 2012, NONPF, 2016). The guidance checklists support the building of individual relationships and communication patterns between NP faculty and preceptors, as the literature review demonstrates that this is a gap in the clinical experience process (Figures 1 and 2). It addresses the functionality and importance of two key people in the clinical communication triad, the NP faculty member, and the clinical preceptor. The guidance checklists outline necessary tasks related to the establishment, orientation, experience, evaluation, and completion of the clinical experience and are discussed in the below sections.
The clinical communication triad
Critical to the successful establishment and completion of a clinical experience is a communication pathway among the preceptor, supervising NP faculty member, and student (Norman & Weiner 2004; Norman & Weiner 2003). Communication among this triad is key for each person to understand his or her role in relation to student performance, evaluation, and supervision. The primary role of the supervising NP faculty member is to provide preceptors and students with a comprehensive and concise written overview of clinical course requirements, role expectations, and responsibilities. The primary role of the NP student is to demonstrate the ability to safely manage simple and complex patient cases using current evidence.
A mutual agreement about the mechanism and frequency of communication among the clinical triad is essential early in the relationship. Established communication among the clinical triad assures that students are engaged in relevant, adequate experiences required for certification with clearly defined expectations from the clinical preceptor and supervising NP faculty member. The communication relationship also affords each individual the ability to identify and communicate gaps in the student's experience, knowledge, and education. For example, a clinical experience for a family NP student may lack exposure to the pediatric population. Acknowledgment of this gap by any member of the clinical triad allows for efforts to be directed at securing a clinical experience that allows for this subpopulation exposure.
Establishing the clinical rotation
After identifying a potential clinical site, several measures are to be implemented to effectively and efficiently secure the clinical site for the clinical experience. Once contact between the NP faculty and the clinical preceptor or clinical site point of contact is established, details regarding the start date and duration of the clinical experience must be addressed (Brooks & Niederhauser, 2010; Burns et al., 2006). Nurse practitioner faculty are then responsible for providing preceptors with course-related documents related to the course and its requirements (Lucas & Bischof, 2014). This includes, but is not limited to, a welcome letter, preceptor orientation letter/handbook, clinical hour requirements, course syllabus, course objectives, student credentials, and student clearance paperwork (Burns et al., 2006; Roberts et al., 2017). A verbal exchange, whether face to face, virtually, or through telephone, is recommended to ensure that there is clarity about the expectations revolving around the clinical experience, address best practices for precepting, and review the Family Educational Rights and Privacy Act (Logan, Kovacs, & Barry, 2015; Roberts et al, 2017; Warren & Denham, 2010). Nurse practitioner faculty should also notify clinical preceptors of the frequency, length, and the number of clinical site visits to be conducted during the clinical experience (Roberts et al., 2017; Wiseman, 2013). Finally, NP faculty must provide a direct method of contact in case preceptors have questions or concerns related to student evaluation, performance, or progression (Brooks & Niederhauser, 2010; Stiffler, Arthur, Stephenson, Ray, & Cullen, 2009).
Before an NP student can start a clinical experience, NP faculty must ensure that the NP student is compliant with the identified clinical site requirements including, but not limited to, a valid and unrestricted licensure, documentation of health, background check, or drug screen. Once the clinical site is established and assigned to an NP student, the student must take the necessary steps to be appropriately oriented to the site's organizational policies, charting system, and clinical team (Burns et al., 2006). Next, clinical preceptors are responsible for working with NP students to establish their clinical schedule and access patient records (Giddens et al., 2014; Lucas & Bischof, 2014; Reyes, Close, Rodriguez, & Evans, 2017; Warren & Denham, 2010). Finally, the NP student and clinical preceptor frame the clinical experience by discussing clinical course objectives and requirements, student learning goals, learning activities, and the overall expectations of the clinical experience (Brooks & Niederhauser, 2010; Ferrara, 2012; Lucas & Bischof, 2014; Burns et al., 2006). Clinical preceptors should articulate expectations of student progression from observer to clinical autonomy with minimal intervention (Lucas & Bischof, 2014; Wilson, Bodin, Hoffman, & Vincent, 2009). The orientation should be concluded with a decision to use an informal, formal, or combination approach to teaching and learning during the clinical day (Ferrara, 2012). This conversation allows the clinical preceptor to set the tone for the clinical experience, provide direction for learning opportunities, and target knowledge deficits with the NP student (Ferrara, 2012).
The clinical experience
Invaluable to the learning process is the clinical experience. During this time, clinical preceptors serve as role models for clinical skills, professional activities, and ethical behaviors while including the NP student as a member of the health care team (Brooks & Niederhauser, 2010; Burns et al., 2006). Between NP faculty guidance and clinical preceptor role modeling, NP students are exposed to interprofessional collaboration while participating in direct questioning methods that foster reflection and promote learning (Chen, Rivera, Rotter, Green, & Kools, 2016). The NP faculty and clinical preceptor work collaboratively to supervise and assess student progression through the development of clinical skills, knowledge, and competency achievement throughout the clinical experience (Drayton-Brooks et al., 2017; Wilson et al., 2009). Specifically, NP faculty track student progression in relation to course objectives and requirements (Drayton-Brooks et al., 2017). It is imperative that the clinical communication triad is efficiently operating at this point, as the relationship between the NP program and the clinical site, as well as the student's progression, is dependent on it.
During this time, NP faculty member support the clinical preceptor in evaluating and providing constructive feedback to the NP student in regard to their performance and progression. The NP faculty member stresses the importance of the preceptor's timely submission of all required clinical evaluation documents to promote student progression and improvement, if necessary. This relationship empowers the preceptor to discuss student strengths, weaknesses, and plans for improvement with assistance from NP faculty, as applicable (Johnson, O'Brien, Emerson, & Reed, 2017; Wiseman, 2013). A healthy and supportive relationship among the clinical triad encourages student progression, especially in cases that require student remediation (Burns et al., 2006; Wilson, et al., 2009; Campbell & Hawkins, 2007; Marfell, 2011). Once an area requiring remediation is identified, the clinical triad develops and agrees on a corrective action plan that includes a time frame for improvement and objective, measurable goals to determine whether change occurred. If all three members of the triad are not able to agree on a plan, the NP faculty member must decide whether the student has to withdraw from the course or be relocated to a new site (Burns et al., 2006).
Completing the rotation
Closure of the clinical experience with constructive feedback for all stakeholders is required at the end of the clinical experience. Conclusion of the clinical experience interaction for the NP student occurs once clinical performance evaluations have been received and a grade issued for the clinical course. Simultaneously, the NP faculty is responsible for obtaining all pertinent clinical documentation from the clinical preceptor and the NP student (Burns et al., 2006). This includes any formative or summative evaluations from the clinical preceptor, addressing the student's clinical performance, progression, and clinical decision-making skills. The NP student's evaluation of the clinical site and preceptor should also be collected and reviewed by the NP faculty during this time. This evaluation provides NP faculty with the necessary information to deliver constructive feedback about preceptorship performance from the student's point of view (Campbell and Hawkins, 2007). Finally, the clinical preceptor and/or clinical site is offered a token of appreciation to recognize their contribution to the NP program and service to the profession (Drayton-Brooks et al., 2017).
The importance of building academic practice partnerships
The establishment of academic practice partnerships is essential to the education of NP students. Such partnerships adequately address challenges associated with securing clinical placements while simultaneously positioning academic nursing as a stakeholder in the transformation of health care (American Association of Colleges of Nursing [AACN], 2016). It allows for organizational support of preceptors through accommodating patient loads, allotted time for precepting, and acknowledgment during performance reviews (Wiseman, 2013). Academic practice partnerships provide a rich learning environment for NP students while aligning the mission of the NP program and clinical site (AACN, 2016). As the need for quality NPs continues to increase, it may prove beneficial in considering more innovative practice partnerships as well. This may include partnerships containing a service-learning framework that exposes NP students to health promotion, health assessments, and interventions in other clinically relevant settings outside of the traditional one-on-one preceptor relationship. This would reduce some dissatisfaction clinical preceptors may have with the workload associated with the role and enhance relationships with NP faculty. In addition, academic practice partnerships reinforce the expectations of the clinical communication triad through the increased interaction among clinical preceptors, NP faculty, and NP students.
Clinical training of NP students is a critical component of NP programs that assure the public that students are ready to practice on graduation. Standardizing the process of establishing clinical experiences clarifies practices and role expectations for NP programs, NP faculty, and clinical preceptors. It is imperative that evidence-based, standardized processes continue to be developed, implemented, and modified to continue to advance the NP profession. The use of documents, such as the guidance checklist (Figures 1 and 2), may prove beneficial in ameliorating the issues related to clinical experiences and improving the relationships among all those involved.
Acknowledgments:C. Pitts and M. B. Bigley wrote the initial draft of the manuscript. C. Pitts led the development of the guidance checklists used as figures within the manuscript. All authors revised the manuscript for submission.
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