The Health Resources and Services Administration reported a projected shortage of over 20,0000 primary care physicians by 2020 due to the aging and growing population in our country paired with inadequate numbers of physicians entering primary care practice (Health Resources and Services Administration, 2013). Also contributing to the shortage is the enactment of the Affordable Care Act, which resulted in unprecedented numbers of previously uninsured Americans in search of primary care services (Davis & Fathman, 2018). Nurse practitioners (NPs) are uniquely positioned to alleviate this shortage, increasing patient access to care by closing the primary care workforce gap (Drayton-Brooks, Gray, Turner, & Newland, 2017).
Recognition of the growing demand for primary care providers has led to a significant increase in NP program enrollment (Drayton-Brooks et al., 2017). Enrollment increased 81% between 2010 and 2015 and continues to rise (AACN, 2015). The American Association of Colleges of Nursing (AACN) reported that NP program enrollment increased an additional 7% between 2015 and 2017 (AACN, 2017; 2018). Increasing program enrollment has challenged schools of nursing to secure quality clinical learning opportunities for NP students (Drayton-Brooks et al., 2017).
Growing NP program enrollment, competition among other health care professions, and expansion of NP distance learning programs have contributed to the shortage of preceptors (Davis & Fathman, 2018). Sixty-five percent of NP programs reported an insufficient number of clinical sites and preceptors as a reason for not admitting all qualified applicants in 2017—a 5% increase from the 2016 data (AACN, 2017; 2018). Enrollment in health professions is expected to continue to increase, creating further concern for quality clinical placements in the future (Fisher, Dill, & Orlowski, 2018). These findings emphasize the need for NP programs to create innovative approaches that ensure sustainable and pedagogically sound clinical education opportunities for students.
Based on NP program enrollment and continued difficulty in securing NP student preceptorships, the authors began the process of addressing and meeting this need. A literature review was conducted to look at the barriers to preceptorship. To evaluate and prioritize the issues related to preceptorship within this community, a needs assessment was carried out. Meetings were held with NP providers at two local federally qualified health centers and an underserved clinic in an academic health center to anecdotally discuss individual barriers to preceptorship and current processes for student placement. Barriers to preceptorship identified through this process were consistent with the findings in the literature, including inadequate faculty support and short duration of the clinical experience. The need to address the barriers and streamline the student placement process to create a more positive experience for the preceptor was identified and discussed. Preceptors expressed the desire for a longitudinal experience with students and greater involvement in student selection and placement. Therefore, the purpose of this quality improvement project was to evaluate the impact of a longitudinal immersive clinical experience (ICE) on preceptor perceptions of the experience and willingness to continue in the preceptor role.
Review of the literature
A comprehensive literature review of incentives, barriers, and working models for NP student preceptorships was conducted. Qualitative and quantitative research, discussion articles, literature reviews, and reports related to NP clinical education were reviewed. The search was conducted through CINAHL, PubMed, and Scopus. Key words included “nurse practitioner students,” “preceptorship,” “preceptor incentives,” “preceptor barriers,” “preceptor motivation,” and “graduate nursing education.” Articles meeting inclusion criteria were peer-reviewed, full-text, and published in the English language. Articles published prior to 2007 were excluded. The searches yielded a total of 40 relevant articles, and 18 were reviewed. Of the 18 articles reviewed, specific themes were identified that informed this project: barriers, incentives, and academic practice partnerships (APPs).
The paucity of preceptors is a nationally recognized problem. Barriers and incentives to preceptorship were well documented (Roberts, Wheeler, Tyler, & Padden, 2017). Common barriers included time constraints and use of electronic medical records (Roberts et al., 2017). Lack of administrative support for preceptorship was another barrier because practice managers were concerned that students negatively affect productivity (Germano, Schorn, Phillippi, & Schuiling, 2014). Additional barriers included short duration of the experience and lack of faculty support (Webb, Palan Lopez, & Guarino, 2015). The most commonly reported incentive to precept was the ability to “give back” to the profession followed by financial compensation (Morgan, Brewer, Buchhalter, Collette, & Parrott, 2017; Webb et al., 2015). Acknowledgement of preceptor needs and expectations fostered positive relationships, which led to sustainable clinical learning opportunities for students (Brooks & Niederhauser, 2010).
Academic practice partnerships were proposed as a sustainable, evidence-based solution to the preceptor shortage problem (Drayton-Brooks et al., 2017). The AACN (2015) recognized APPs as a valuable tool to improve NP clinical education and foster positive clinical experiences for students, preceptors, and faculty, as well as develop a cost-effective transition to practice for new graduates. Additionally, recent data suggest that APPs contributed to improved patient outcomes and higher quality of care (Shepard Battle, 2018).
A longitudinal clinical experience was identified as a novel pedagogical approach to NP clinical education. Students who participated in a longitudinal clinical experience demonstrated improved communication and heightened clinical and cognitive skills as compared with students who participated in traditional limited hour rotations (Christner et al., 2016). Extended time in the clinical setting produced greater engagement, resulting in authentic feedback from the preceptor to create a more productive experience for the student (Christner et al., 2016). Clinical supervisors reported improved student contribution in the clinical setting, which led to reduced time constraints (Walters et al., 2012). Longitudinally based clinical experiences were also cost-neutral with successful recruitment of students postgraduation (Walters et al., 2012).
Theoretical framework and conceptual model
Kanter's Theory of Structural Empowerment in Organizations provided the theoretical framework guiding this project. Kanter proposed that individuals who are presented with opportunity and power are more likely to be dedicated to the goals of the organization, resulting in improved work performance (Kanter, 1977). Practical application of Kanter's Theory suggests that if preceptors feel empowered by the opportunity to improve students’ clinical competency and skill, they will demonstrate increased dedication to the preceptor role (Kanter, 1977).
Rosswurm and Larrabee's Model for Evidence-Based Practice Change provided a structured approach to project implementation. This model is composed of six steps uniting quality improvement, team work, and evidence-based strategies to encourage the acquisition of new processes (Melnyk & Fineout-Overholt, 2015). In step 1, the clinician assesses the need for a change in practice. This was accomplished through meetings with potential preceptors at each partner site. Step 2 involved locating the best evidence through a review of literature. The evidence was analyzed in step 3, revealing the three main themes: barriers, incentives, and APPs. Step 4 involved designing a change in practice to address the themes identified in the literature review. The change in practice was implemented and evaluated in step 5. The sixth and final step allowed for continuation of the NP student clinical experiences through a sustained APP. An outline of these steps is depicted in Figure 1.
Participating sites were identified based on previously established APPs. Preceptors were recruited from the partnering organizations through in-person meetings in which the ICE was presented and described. No incentives were offered in exchange for participation in the ICE other than a University of Cincinnati lunch bag, coffee mug, and a preceptor instruction manual. The number of preceptors willing to participate determined the number of students eligible for ICE placement. Based on individuals' willingness to participate, the maximum sample size of preceptors for the study was set as nine. Qualified preceptors included NPs who had been in clinical practice for a minimum of one year. Participating clinical sites and preceptors offered adult or family, pediatric, and women's health services to meet the population-focused clinical requirements for the program.
A three-part validated survey titled “Perceptions of Graduate Clinical Preceptors” was selected to evaluate preceptor perceptions with author permission prior to implementation of the ICE (Donley et al., 2014). This particular tool was chosen because the subsections addressed commonly cited barriers to preceptorship in the review of literature and barriers identified through anecdotal feedback from practice partners. The tool was originally developed to evaluate undergraduate nursing student preceptors and reflects Kanter's assertions related to opportunity and power structures in organizations. It was modified with permission for use with graduate clinical preceptors (Donley et al., 2014). The reliability of the modified instrument was 0.65 using Cronbach's alpha (p < .001) (Donley et al., 2014). The 56-item survey was composed of three parts: Preceptor's Perceptions of Benefits and Rewards, Preceptor's Perception of Support, and Commitment to the Preceptor Role. Survey questions from each part were evaluated according to the 6-point Likert scale in which 1 indicated strongly disagree, 2 indicated moderately disagree, 3 indicated disagree, 4 indicated agree, 5 indicated moderately agree, and 6 indicated strongly agree. The survey concluded with demographic questions. The estimated time to complete the survey was 6 minutes. After approval from the University of Cincinnati's institutional review board and 2 months prior to the start of the first immersive clinical rotation, the “Perceptions of Graduate Clinical Preceptors” tool was electronically distributed using a web-based platform to collect data on baseline preceptor perceptions. One reminder email was sent to preceptors requesting completion of the presurvey. All presurvey results were received prior to the first practicum.
The postsurvey on preceptor perceptions was re-administered to participants at midterm of the final semester of the ICE and end of the three-semester practicum program. Two emails were sent reminding participating preceptors to complete the postsurvey. All postsurvey results were received prior to the completion of the final semester of the ICE.
The ICE program was developed to address and overcome the barriers to preceptorship identified in the literature. Novel approaches to NP clinical education including the longitudinal clinical experience also informed and contributed to the ICE program development. In an effort to structure the selection process for the limited number of student placements available, an application process was established. Qualified students were enrolled in the Family Nurse Practitioner (FNP) program and projected to begin their first clinical rotation in the subsequent semester. Students were recruited from both onsite and distance learning programs through an in-class presentation and email communication. Students with interest in participating in the ICE were required to write a statement reflecting their future career goals as well as their desire to work with the patient population served by the partner site. In addition, students were required to provide a recent resume or curriculum vitae.
Applications were compiled by the faculty member and electronically submitted to preceptors at the designated APP in which the student applied. Preceptors reviewed the applications as a team and selected students whom they felt were the best fit for their clinical institution and patient population. Students were notified of selection results via email.
Students participating in the ICE committed to the organization in which they were selected and rotated between three clinical sites and preceptors for all required program hours spanning the course of three semesters or one academic year. Each organization represented a different APP. Academic practice partnership one consisted of three preceptors and three students, APP two consisted of three preceptors and two students, and APP three consisted of three preceptors and one student. As per our university, our students were required to complete a total of 672 clinical hours to meet FNP program requirements, including 150 hours in a women's health or obstetric setting and 200 hours in pediatric primary care. The remaining 322 hours were spent in primary care; however, 90 clinical hours were approved to be spent in a specialty setting outside of the ICE if the student desired.
A single onboarding process took place within each institution. Requests for preceptorship outside of this design were declined, reducing the clinical site frustration with repeated inquiries for preceptorship. Preceptors were provided an instruction manual that included a copy of the course syllabus, a quick reference guide for accessing the web-based platform used for verification of student clinical hours and evaluations, and an outline depicting student, preceptor, and faculty responsibilities. Direct contact emails and phone numbers for faculty and administrative staff at the college of nursing were also provided. The ICE program consisted of a dual-faculty approach to clinical education, and the process was overseen by the clinical faculty and faculty directing the ICE. The clinical faculty maintained communication with the preceptors related to student performance through email, site visits, or telephone calls over the course of the semester as indicated. The ICE director ensured the preceptor received the tools and support needed to be successful in the role. Using our university's evaluation system, the preceptor completed an evaluation on the student. The online evaluation completed by the preceptor gave the student a grade percentage, which was factored into the student's overall grade. Any level of concern raised by the preceptor allowed for open discussion regarding the student's clinical competency and ability to progress in the FNP program.
Data analysis was performed for each individual survey question by exporting results from the web-based survey platform directly into Microsoft Excel using a password protected network. Data was stored in files on a password-protected computer, and only the primary author had access to the data and survey results. Each participant was assigned a number identifier to correlate pre- and postsurvey results. A paired t-test was conducted to evaluate whether differences between preintervention and postintervention scores were statistically significant. All p values < .05 were determined to be statistically significant. Demographic variables were described using frequency statistics.
Nine preceptors agreed to participate in the ICE program. However, only six preceptors completed both the presurvey and postsurvey. Participants were solely women (100%) with 83% in the age range of 31–50 years. Half of the participants (50%) reported it has been 6–10 years since completing their highest level of education with one participant (16%) reporting 16–20 years, and two participants (33%) reporting 0–5 years. An overwhelming majority of participants (83%) reported a master's degree in nursing as the highest level of education with only 16% reporting a doctoral degree in nursing. None of the study participants reported that preceptor responsibilities were incorporated into their job description, and 83% reported they had no preparation for the preceptor role. A summary of demographic data is outlined in Table 1. Scores for the remaining portions of the survey were analyzed by each section of the Perceptions of Graduate Clinical Preceptors Tool: preceptor perceptions of benefits and rewards, support, and commitment to the role. A final overall score was not determined as the results were analyzed by section.
Part I: preceptor perceptions of benefits and rewards
The first section of the survey, part I: Preceptor's Perception of Benefits and Rewards Scale, included 14 questions related to participants' perception of opportunities for professional growth such as increased knowledge, teaching skills, and contributions to the profession. The results are outlined in Table 2. There was no statistically significant difference in changes of preceptor perceptions of professional benefits and rewards. The lowest mean presurvey scores were related to the participants' perception of the opportunity to achieve promotion/advancement within the workplace (2.67/6), gain personal satisfaction from the preceptorship role (3.5/6), and be recognized as a role model (3.67/6). The highest mean presurvey scores were related to the participants' perception of the opportunity to contribute to the profession (5.5/6), increase professional knowledge base (5.17/6), and teach graduate nursing students (5/6). Postsurvey data revealed positive influence on the perceptions of greater opportunity for benefits and rewards in several areas after participating in the ICE; however, results were not statistically significant. To calculate the percent of change between the pre- and postsurvey, the difference between the average prescore and average postscore was identified, divided by six (which was the highest score possible on the survey), and multiplied by 100. Perception of opportunity to achieve promotion/advancement in the workplace (p = .386) and recognition as a role model (p = .371) increased 2.6%. Perceived ability to gain personal satisfaction from the preceptorship role increased 13.8% (p = .182) and teach graduate nursing students increased 11% (p = .164). Perceived opportunity to contribute to the profession (p = .5) and increase one's own professional knowledge base (p = .5) demonstrated no change between preintervention and postintervention scores. An 8% decrease was noted in participants' perceived opportunity to increase involvement in the workplace (p = .207) and improve organizational skills (p = .148). Perceived ability to influence change in the practice setting decreased 5.5% (p = .394).
Part II: preceptor's perception of support scale
Part II: Preceptor's Perception of Support Scale included 14 questions related to preceptors' perceived level of support from colleagues and faculty, as well as adequacy of preparation and professional development in the role. The results are outlined in Table 3. Presurvey scores indicated the lowest levels of perceived support related to the opportunity to share information with other preceptors (2.5/6), faculty assistance in identifying a student's performance problems (2.83/6), and clarity of program faculty responsibilities in relation to the preceptorship role (2.83/6). The highest mean presurvey scores were related to the participants' perception of support from colleagues (5.17/6), appropriateness of workload (4.17/6), and supervisors' commitment to the preceptorship experience (4/6). Postsurvey scores indicated a 33% improvement in participants' perception of support related to the opportunity to share information with other preceptors (p = .025), 27% improved perception of support from nursing faculty to identify students' performance problems (p = .039), and 30.6% greater clarity in faculty responsibilities related to the preceptor role (p = .018). All three areas reached statistical significance. A nonparametric test for the individual questions was unable to be conducted due to ties in the pre- and postsurvey data which made the sample size smaller. For the overall analysis of part II: Preceptor's Perception of Support Scale (for all the questions combined), the nonparametric test did reach significance at the 0.05 level. A 5% increase was noted for preceptors' perception of appropriateness of the workload (p = .182). Decreases in scores related to preceptors' perception of support from colleagues in the workplace (−11%, p = .051) and in departmental supervisor commitment to the preceptorship experience (−2.8%, p = .396) were noted. However, these results did not reach statistical significance.
Part III: commitment to the preceptor role scale
The third and final section of the survey, part III: Commitment to the Preceptor Role Scale included 10 questions related to preceptor commitment. The results are outlined in Table 4. There was no statistically significant difference in pre- and postsurvey scores related to preceptor commitment. The lowest presurvey scores were related to willingness to put forth additional effort to help the student succeed (4.33/6), enthusiasm about the preceptor role (4.33/6), professional gains by continuing in the role (4.33/6), and satisfaction with the decision to be a preceptor (4.33/6). Loyalty to the preceptor role (4.83/6), values associated with preceptorship (4.83/6), and inspiration for very best performance (4.83/6) demonstrated the highest mean presurvey scores. Postsurvey results indicated an 8.3% improvement in commitment related to the decision to become a preceptor (p = .102). Additionally, postsurvey scores increased 2.8% in the following areas: willingness to put forth effort beyond what was expected to help the student succeed (p = .305), enthusiasm about the preceptor role (p = .385), values associated with preceptorship (p = .385), and professional gains by continuing in the role (p = .348). No changes were noted (p = .5) in loyalty to the preceptorship role and inspiration for very best performance. Mean postsurvey scores decreased by 2.8% for questions related to pride for the preceptorship role (p = .182) and fate of the preceptor role in the workplace (p = .371). An 8.3% decrease was noted in willingness to continue to serve as a preceptor if there were a change in present responsibilities (p = .102).
The most notable limitation included the small sample size of preceptor participants. Despite organized recruitment efforts, preceptors had the opportunity to freely choose to commit to this project resulting in a total of nine participants. The time frame of the follow-up period between conducting the presurvey and postsurvey presented an additional limitation. The results reflected implementation of an ICE with a single cohort of students exposing participants to one cycle of the ICE. A larger sample size of preceptors and students over a greater length of time will allow for prolonged exposure. Additionally, NP graduates should have the opportunity to evaluate the experience to assess adequacy of preparation for practice on graduation and whether clinical experience expectations were met as the study focused on preceptor perceptions, not student perceptions of the experience.
Benefits and rewards
The aim of this quality improvement project was to evaluate the impact of a longitudinal ICE on preceptor perceptions and willingness to continue in the preceptor role. Preceptors who participated held an integral role in this novel approach to NP education. Participants were empowered by the ability to have a voice in student selection and placement. These individual benefits of the ICE program were rewarding for preceptors. Participants reported improved personal satisfaction from the preceptor role at the conclusion of the ICE program. This reinforced findings in the literature, which indicate the most frequently reported incentives are inherent (Morgan et al., 2017; Webb et al., 2015).
Preceptors desire greater support from programs and faculty (Davis & Fathman, 2018). Lack of support is a commonly identified barrier to preceptorship (Davis & Fathman, 2018). Three individual survey questions related to the preceptor's perception of support reached statistical significance, indicating the project positively affected preceptor perceptions of support in the role. Increased perception of support for opportunities to share information with other preceptors indicated that the ICE promoted intraprofessional collaboration among participants.
Preceptors desire information on program curriculum and students' expectations as well as instruction on how to safely accommodate students in the practice setting (Germano et al., 2014). The ICE provided greater clarity in responsibilities of the program faculty outlined in the clinical course guidelines that were provided for the preceptor. Presurvey data indicated an overwhelming majority of the participants did not receive a preceptor instruction manual from educational institutions outside of the University of Cincinnati and the ICE. Limited faculty engagement is a concern among preceptors (Roberts et al., 2017). Improved perception of support from program faculty to identify students' performance problems suggests that the ICE provided necessary tools for preceptors to be successful in the educator role because majority of the participants had no preparation for the preceptor role. Future ICE programs should include opportunities for preceptor development and orientation to recruit and retain preceptors.
A surprising finding, although not statistically significant, was the decrease in mean score related to perceived support from colleagues in the workplace. Preceptors reported colleagues were less supportive of the preceptor experience postintervention. An important consideration in willingness to serve as a preceptor is employer support of the preceptor role. Exploring the influence of employer support is an important area for further investigation. Future research should focus on the impact of the organization on willingness to precept. Less surprising was the decrease in departmental supervisor commitment to the success of the preceptor experience. An important consideration that may affect these findings is that none of the study participants reported that preceptor responsibilities were incorporated into their job description or included in their performance review. Practice administrators often express concern that accepting students negatively affects provider productivity (Germano et al., 2014). However, this concern calls for further investigation because productivity ultimately depends on the student's level of experience and a proper match between the student and preceptor (Barker & Pittman, 2010). This brings into question the lack of organizational support for preceptorships within APPs despite data suggesting that APPs have been shown to improve the cost-effectiveness and patient outcomes, as well as provide a cost-neutral opportunity to fill shortages in the primary care workforce (Porche, Hampton, & Holmes, 2018; Walters et al., 2012).
High baseline scores and minimal improvement in postintervention scores related to preceptor commitment suggest participants were dedicated to the role of preceptorship prior to participation. The results of this project reflect Kanter's theory, suggesting that participants gained satisfaction with empowerment in the preceptor role. Findings suggest the participants' perception of the opportunity to increase student competency and skill and gain power through the support of program faculty increased commitment to the preceptorship role. Although not statistically significant, the increase in perceived support related to the appropriateness of workload further reflects Kanter's theory, suggesting that work performance improved while in the role. A decrease in postsurvey scores related to continuing to serve in the role if the preceptor experienced a change in responsibilities suggests that the preceptor would be less likely to serve in the role if certain elements of their responsibilities changed. Although a change in responsibilities is not defined, this finding indicates that preceptor commitment would be negatively affected.
The substantial growth in NP program enrollment affirms the need for committed preceptors. Securing clinical sites and preceptors for NP students is complex and requires a multifaceted approach. A shortage of dedicated and willing preceptors continues to be a barrier to NP student preceptorship and to the expansion of this innovative approach to clinical education. Identifying increased numbers of clinical sites and preceptors agreeable to participate would allow for the growth of the ICE. Health organizations that provide care to diverse patient populations are ideal for this design. Although APPs provide an effective strategy for implementation of an ICE, NP programs continue to be limited by the lack of organizational interest in partnership.
The longitudinal ICE discussed in this article addressed the barriers to preceptorship, creating sustainable clinical learning opportunities for students. Preceptors and clinical site administrators have committed to a third cohort of students for the coming academic year, demonstrating continued success and sustainability of the ICE. Additionally, new APPs expressed interest in participating in future ICE plans. Potential for expansion rests on the participation of agreeable preceptors. Failure to overcome identified barriers to preceptorship and develop innovative approaches to clinical education poses a threat to the future of NP education and expansion of the profession. A longitudinal ICE can engage students and preceptors in productive learning experiences in which preceptors feel supported and committed to the role of preceptorship.
Acknowledgments:The authors would like to acknowledge the University of Cincinnati College of Nursing for supporting this work including the statistical support provided by Assistant Professor and Biostatistician Dr. Joshua Lambert.
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