APRN Precepting: Providing the Tools for Successful ... Precepting: Providing the Tools for Successful ... guidance from the preceptor ... the Bureau of Labor Statistics projects that
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
• High demand to meet the need for high quality NP student educational experiences
• What does this mean? What skills are needed?– Excellent clinical skills– Effective communication– Flexibility– Provision of feedback and support– Ability to meet the different learning styles of adult students– Ability to evaluate student knowledge & competencies
behalf of faculty and course– Student contacts preceptor directly– Preceptor’s health system may be the gatekeeper– Paid agencies may contact preceptor on behalf of student– Online applications for distance learning students
• The typical requirement for certifying bodies is a minimum of 500 hours of supervised clinical practice in the pediatrics specialty with an experienced APRN or physician in the same specialty
• Individual APRN program requirements vary– Dependent on program and student level (BSN-DNP vs.
• Competition for clinical experiences in various teaching arenas needs to be recognized and addressed to meet all healthcare student demands for future healthcare provider workforce– NP students– Medical students– Residents– Physician Assistants
• Need sustainable processes to recruit, retain and recognize preceptors for NP students
• Overall goal: Partnerships between APRNs and faculty to achieve mutually beneficial outcomes in healthcare 17
• Between educational institution and the clinical site– Number of hours needed by student– Days available– Liability coverage– Basic information about where the student is within the program
• Affiliation agreements or contractual agreements undergo university legal review before being sent to clinical sites for signatures
Defining the Preceptor• Preceptors are experienced clinical practitioners who
teach and role-model clinical and leadership skills to novice practitioners (students, new graduates, practitioners new to their setting, or new employees)
• We need you!!! We value you!!!– Preceptors are critical to the successful development
of the APRN– Important role in guiding clinical practice education– Shared role with university faculty
• High-quality APRN preceptors with expertise in pediatrics– Help students acquire real-time clinical skills – Help validate their competency in these skills– Help students to make the transition from being a “generalist
registered nurse” to pediatric advanced practice nursing specialist
• However…– APRNs are not taught how to be preceptors– Precepting is a new skill set that is learned and developed over time
• Networking opportunities with peds-focused colleagues• Adjunct pediatric faculty appointments• Access to university resources (such as library, pediatric
drug guide, pediatric journal access)• Opportunities to guest lecture on pediatric topics• Peer support through dialogue with faculty• Contributions toward ongoing pediatric program
• Fulfillment of one’s “social contract”/giving back to the profession– Perceptive that we ‘owe it’ to the profession, to the student, to our
patients, and to ourselves
• Personal satisfaction– Despite challenges, precepting is inherently satisfying (Latessa et al., 2013)
• Solidifying one’s identity as a pediatric-focused APRN• Reflecting on one’s own practice through the eyes of the student• Adding interest, challenge, renewal, and enrichment to one’s daily
Making an Informed Decision... Potential Difficulties to Overcome
• Lack of time to actively teach• Lack of time to meet patient needs• Lack of financial incentives• Perception or concern for increased workload• Concern for maintaining productivity standards
– Some studies show that productivity is NOT negatively impacted by students
• Gaps in communication from schools• Need for closer observation of student by nursing faculty
• Common attributes of successful mentors include:– Admirable characteristics such as selflessness and
kindness– Provider of support for NP student’s career– Strong time commitment– Supporter of personal and professional life balance– Encourages NP student to carry on a legacy and become a
mentor when the time is right(Cho et al., 2011; MacLeod, 2007)
• Access to practice resources, career center, continuing education opportunities, policy and position statements
• Special interest groups (i.e. NAPNAP SIGs), committee membership (i.e. NAPNAP Professional Issues Committee) and advocacy opportunities (NAPNAP Capitol Hill Day)
• Preceptor involvement in the AFPNP• Statewide and National Professional Groups
Preparing for the Preceptor/NP Student Pediatric Experience
● Expectations from Academic Institutions● Preceptor Roadmap● Individual Student and Course Objectives● Orientation to the Site● Before Clinical Begins
• Faculty must support the student/preceptor relationship• Match student’s learning style with preceptor’s teaching style• Provide a preceptor orientation• Agree on how to assess student competency• Open communication on student progress
– Determine best method of communication (telephone, email, etc)• Provide periodic assessment of progress in the student-preceptor
• Long term questions– What do I want the student to learn during their rotation with me?– What does the student want and need to learn during the rotation?
• Daily questions– What patients will be seen today?– What does the student want to learn from the experience today?– What objectives have not yet been met?
• Review student’s individual objectives and help monitor the student’s progress towards those objectives– Review objectives to ensure they are appropriate to the site,
realistic, and measurable– E.g. Integrate subjective and objective data in order to identify
pertinent differential diagnoses for children with respiratory concerns by mid semester
• Preceptors should share their own objectives for the student– E.g. Perform a thorough physical exam on an infant within two weeks
• Direct the student to resources and evidence-based assigned readings– Specialty-specific readings – Review of pertinent assessment skills and developmental
expectations– Expectation that student will explore and
share new evidence
• Develop a small toolkit of essential resources for your practice
• History taking and patient/family interview skills• Physical examination skills• Differential diagnosis identification• Treatment, management, developing plans of care• Reporting and presentation skills• Additional skills based on the clinical setting
• Take a positive approach– Introduce as “NP student” NOT a “student NP”– Capitalize on the benefit of the Preceptor-NP student team …
• “This student will be speaking with and examining you/your child prior to our visit. S/he is highly skilled and we will be working together to give you the best treatment possible.”
• Reassure the child/family that they are getting the care they would normally receive PLUS the addition of an intelligent, detail-oriented, and motivated NP student
– “I have an NP student working with me. I am going to have her/him begin asking questions and complete the physical exam, then I will be back in…”
– “An NP student is working with me today. Together, we are going to begin the history, but I am going to have her/him take the lead. I am available to her/him and to you at all times.”
• Patients carefully selected based on student skills – Start with uncomplicated routine well visits – Uncomplicated illness visit – Prior to visit student should:
• Do a complete chart review • Prepares components of anticipatory guidance and health
promotion• Formal pre-visit and post visit counseling with preceptor• Cases increase in number and complexity as student develops• Best suited for a NEW student
• Student is given a variety of patients and sees them independently 1. No visible support 2. Minimal pre-visit teaching 3. Preceptor is ultimately responsible for
decisions4. Preceptor is available for backup 5. Best suited for a FINAL semester student
• Using a formative evaluation process allows for a manageable way of teaching/evaluating NP student progress – Allows for discrimination of rationale behind a student’s thought
process– Asking deliberate questions also helps to distinguish rote memorization
The One-Minute Preceptor (OMP)Evidence-based, Time-efficient, Learner-centered approach
5 ‘Microskills’1. Commitment from NP student regarding differentials for child/adolescent1. Probe for underlying reasoning/supporting evidence for their assessment1. Teach the student “general rules” associated with the patient’s issue1. Provide positive feedback1. Correct errors
• “What do you think is going on?” (gain commitment)• “What led you to that conclusion?” (supporting evidence)• “Many times when ___” (teach general rules)• “You did an excellent job of ___” (positive feedback)• “Next time this happens try ___” (correct mistakes)
SNAPPS ModelMnemonic describes an efficient way for the student to present
patient cases and discuss clinical reasoning
• Step 1: Summarize the history and physical exam findings briefly• Step 2: Narrow the differential diagnoses• Step 3: Analyze the differential diagnoses
• Step 4: Probe the clinical instructor with questions and express caseuncertainties
• Step 5: Plan management for patient case• Step 6: Select a case-related issue for self-directed learning
• Identify where the area of concern is:– Lack of focus– Relating with patient– Communication with patients, preceptor or staff– Decision making, using evidence based practice– Knowing boundaries
• Contact school early on for intervention– Remediation is best handled by faculty; Not the
responsibility of the preceptor to “fix” the problem100
The Graduated Approach• Revisit the objectives at the beginning of each experience
– Set specific parameters to move the student away from sole dependence
• Wean from shadowing preceptor– Joint history & PE x 3 visits; – NP student history alone w/joint PE– Gradually increasing responsibility– Designate time to complete tasks
• The detailed report– Allow detail initially to ensure the student has identified all relevant
information within a given timeframe– Over a designated time guide NP student to focus on pertinent
Engaged Feedback Reflective Inventory:Reflecting on your precepting experience
(Rosa & Santos, 2016)
• Method of effective communication that can aid in self care of the preceptor– Rooted in concepts of shared accountability, respect, and
partnership
• The preceptor engages vulnerability, acts as an authentic presence, manages uncertainty, and finds compassion for the student’s experience– Enhances the preceptor’s ability to listen more effectively– Promotes healthy professional relationship between preceptor and
I’m ready to sit next to you rather than across from you What does my body language reflect as we communicate?
I’m ready to put the problem in front of us Can I look at the challenges objectively?
I’m ready to listen, ask questions, and accept that I may not fully understand the issue
Can I ask for clarification, let go of assumptions, and address concerns ‘in the moment’?
I want to acknowledge what you do well rather than picking apart your mistakes
Can I identify, acknowledge, and celebrate my student’s accomplishments?
I recognize your strengths and how you can use them to address your challenges
Can I help build on the NP student’s strengths? Can I help them use those strengths in facing challenges/obstacles?
I can hold you accountable without shaming/blaming you Can I accept that mistakes are a normal part of the process? Do I provide constructive feedback?
I’m willing to do my part Do I own and express responsibility for my part in the process?
I can genuinely thank you for your efforts rather than criticizing you for your shortcomings
Am I thanking the student for their efforts? Do I thank myself for being available to the NP student?
I can talk about how resolving these challenges will lead to your growth and opportunity
Am I focusing on the student’s growth or failure? Do I resolve challenges quickly or prolong them unnecessarily?
I can model the vulnerability and openness that I expect to see from you
Do I value vulnerability and honesty in professional relationships, or does the concept make me uncomfortable?
• Students with limited or restricted EMR access can document on a form that can help the preceptor complete his/her electronic charting
• SOAP notes on all patient encounters: handwritten or a Word doc– Facilitates acquisition of time management skills– Eases later transition from NP student to APRN
• Student should be planning treatment with preceptor input, choosing medications using best evidence, and calculating dosages/timing/mL equivalents and quantity needed
• APRN typically writes/electronically enters/sign prescriptions
• Discuss impact of prescriptive authority on your practice– DEA registration, drug schedules and limitations– Obtaining pharmacology CE per state/certification requirements
• Medicare payments only cover services provided by physicians and other licensed practitioners – In general, to bill for a service rendered, you must be considered an
eligible provider of care (enrolled in Medicare as a provider or credentialed by the insurance carrier)
• Student can contribute to billable service but it must be done in the physical presence of the billing provider
• Examples of formative evaluation in the clinical setting– Case presentations/discussion– Informal discussion– Informal feedback– Questioning exercises– Mid-term evaluations
• NONPF Competency Domains– Scientific Foundation Competencies– Leadership Competencies– Quality Competencies– Practice Inquiry Competencies– Technology and Information Literacy Competencies– Policy Competencies– Health Delivery System Competencies– Ethics Competencies– Independent Practice Competencies
• Evaluation tools may evaluate students based on “independence” or ability to perform skills “with minimal supervision”
• This is challenging, as many AC PNPs work within interprofessional teams and even the most experienced still are not completely “independent” or “with minimal supervision”
Unique challenges in the pediatric specialty care setting
• Depending on the setting, many specialty care PNPs may not be able to let the student work independently– Procedures may have to be performed by the preceptor with student
Based on what you have learned today, including your past experience, state your philosophy of clinical education in 1-2 sentences.
E.g.: As an APRN in pediatrics, I am committed to providing a supportive learning environment that will foster independence and help the NP student provide individualized, developmentally appropriate care to the children and families they encounter.
ReferencesAagaard, E., Teherani, A., & Irby, D. (2004). Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: Proof of
concept. Academic Medicine, 79(1), 42-49.
American Association of Nurse Practitioners (2017). NP Fact Sheet. Retrieved from: https://www.aanp.org/all-about-nps/np-fact-sheet.
Barker, E. & Pittman, O. (2010). Becoming a super preceptor: A practical guide to preceptorship in today’s clinical climate. Journal of the American Academy of Nurse Practitioners, 22, 144-149. doi: 10.1111.j.1745-7599.2009.00487.x
Bandura, A., (1977). Social learning theory. New York: General Learning Press.
Bengtsson, M. & Carlson, E. (2015). Knowledge and skills needed to improve as preceptor: Development of a continuous professional development course- a qualitative study part I. BMC Nursing, 14(51). doi: 10.1186/s12912-015-0103-9
Brooks, M. & Niederhauser, V. (2010). Preceptor expectations and issues with nurse practitioner clinical rotations. Journal of the American Academy of Nurse Practitioners, 22, 573-579. doi: 10.1111/j.1745-7599.2010.00560.x
Brykczynski, K.A. (2009). Role development of the advanced practice nurse. In A. Hamric, J. Spross, & C. Hanson, Advanced practice nursing: An integrative approach (4th ed.), (pp. 95-120). Philadelphia: Saunders.
Buchel, T. & Edwards, F. (2005). Characteristics of effective clinical teachers. Family Medicine, 37(1), 30-35.
Burns, C., Beauchesne, M., Ryan-Krause, P., & Sawin, K. (2006). Mastering the preceptor role: Challenges of clinical teaching. Journal of Pediatric Health Care, 20(3), 172-183. doi: 10/1016.j.pedhc.2006.10.012.
ReferencesCho, C., Ramanan, R., & Feldman, M. (2011). Defining the ideal qualities of mentorship: A qualitative analysis of the characteristics of outstanding
mentors. The American Journal of Medicine, 124, 453-458. doi: 10.1016/j.amjmed.2010.12.007
Donley, R., Flaherty, MJ., Sarsfield, E., Burkhard, A., O’Brien, S., & Anderson, K.(2014). Graduate clinical nurse preceptors: Implications for improved intraprofessional collaboration. OJIN: The Online Journal of Issues in Nursing, 19(3). doi: 10.3912/OJIN.Vol19No03PPT01
Dreyfus, S. E., & Dreyfus, H. L. (1980, February). A five stage model of the mental activities involved in direct skills acquisition. United States Air Force Operations Research Center Report 80-2.
Facione, P. (1990). Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction. Millbrae, CA: The California Academic Press.
Farrell, K., Payne, C., & Heye, M. (2015). Integrating interprofessional collaboration skills in o the advanced practice registered nurse socialization process. Journal of Professional Nursing, 31(1), 5-10. doi: http://dx.doi.10.1016/j.profnurs.2014.05.006
Farwell, A. L. (2009). Practitioner preceptors: A shortage of willing mentors. Journal of Pediatric Health Care, 23(3), 198-200. doi:10.1016/j.pedhc.2009.02.009
Forsberg, I., Swartwout, K., Murphy, M., Danko, K., & Delaney, K. R. (2014). Nurse practitioner education: Greater demand, reduced training opportunities. Journal of the American Association of Nurse Practitioners, 27(2), 66-71. doi:10.1002/2327-6924.12175
Furney, S., Orsini, A., Orsetti, K., Stern, D., Gruppen, L., & Irby, D. (2001). Teaching the one-minute preceptor: A randomized controlled trial. Journal of General Internal Medicine, 16, 620-624.
Gorton, K., & Hayes, J. (2014). Challenges of assessing critical thinking and clinical judgment in nurse practitioner students. Journal of Nursing Education, 53(3), suppl., S26-S29. doi: 10.3928/0144834-20140217-02
ReferencesGoss, C. (2015). Systematic review building a preceptor support system. Journal for Nurses in Professional Development, 31(1), E7-E14. doi:
10.1097/NND.0000000000000117
Green, J., & Jackson, D. (2014). Mentoring: Some cautionary notes for the nursing profession. Contemporary Nurse: A Journal For The Australian Nursing Profession, 47(1-2), 79. doi:10.5172/conu.2014.47.1-2.79
Heinrichs, S., Vela, L., & Drouin, J. (2013). A learner-centered technique and clinical reasoning, reflection and case presentation attributes in athletic training students. Journal of Athletic Training, 48(3), 362-371. doi: 10.4085/1062-6050-48.2.17
Horton, C., DePaoli, S., Hertach, M., & Bower, M. (2012). Enhancing the effective of nurse preceptors. Journal for Nurses in Staff Development 28(4), E1-E7. doi: 10.1097/NDD.0b013e31825dfb90
Latessa, R., Colvin, G., Beaty, N., Steiner, B., & Pathman, D. (2013). Satisfaction, motivation and future of community preceptors: What are the current trends? Academic Medicine, 88(8) 1164-1170.
Lazarus, J. (2016). Precepting 101: Teaching strategies and tips for success for preceptors. Journal of Midwifery & Women’s Health, 61(supp 1), S11-S21. doi: 10.1111/jmwh.12520.
Leimbach, M. & Wilson Learning Worldwide (2018). Social styles versatile communication avoiding the hidden costs of communication misalignment.Retrieved from: http://www.wilsonlearning.com/wlw/articles/w/hidden-cost-com
Link, D. (2009). The teaching-coaching role of the APN. Journal of Perinatal and Neonatal Nursing, 23(3), 279-283.
Logan, B., Kovacs, K., & Barry, T. (2015). Precepting nurse practitioner students: One medical center’s efforts to improve the precepting process. Journal of the American Association of Nurse Practitioners, 27, 676-682. doi: 10.1002/2327-6924.12265
Macleod, S. (2007). The challenge of providing mentorship in primary care. Postgraduate Medical Journal, 83, 317-319.
ReferencesNational Task Force on Quality Nurse Practitioner Education (2016). Criteria for evaluation of nurse practitioner programs (5th ed.). Washington, DC:
American Association of Colleges of Nursing & National Organization of Nurse Practitioner Faculties.
Neher J., Gordon K., & Meyer B. (1992). A five-step "microskills" model of clinical teaching. Journal of American Board of Family Practice, 5(4), 419-424.
Nilson, L. (2010). Teaching at its best (3rd Ed.). San Francisco, CA: John Wiley & Sons.
Nowell, L., Norris, J., Mrklas, K., & White, D. (2017). A literature review of mentorship programs in academic nursing. Journal of Professional Nursing, 33(5), 334-344. https.//doi.org/10.1016/j.profnurs.2017.02.007
O’Connor, B. (2012). New American Association of Colleges of Nursing data show enrollment surge in baccalaureate and graduate programs amid calls for more highly educated nurses. Journal of Professional Nursing, 28, 137-138.
Onieal, M.-E. (2016). Precepting: Holding students and programs accountable. Clinician Reviews, 11-17.
Pearson, T., Garrett, L., Hossler, S., McConnell, P., & Walls, J. (2012). A progressive nurse practitioner student evaluation tool. Journal of the American Association of Nurse Practitioners, 24(6), 352-357. doi: 10.1111/j.1745-7599.2012.00713.x
Raterink, G. (2016). Reflective journaling for critical thinking development in advanced practice registered nurse students. Journal of Nursing Education, 55(2), 11-104. https://doi.org/10.3928/01484834-20160114-08
Rosa, W., & Santos, S. (2016). Introduction of the engaged feedback reflective inventory during a preceptor training program. Journal for Nurses in Professional Development, 32(4), E1-E7. doi: 10.1097/NND.0000000000000280
Ryan, S., & Rosenberg, S. (2015). Nurse practitioners and political engagement: Findings from a nurse practitioner advanced practice focus group & national online survey. Overland Park, KS: American Nurse Practitioners Foundation.
ReferencesScheffer, B., & Rubenfeld, G. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39(8), 352-359.
https://doi.org/10.3928/0148-4834-20001101-06
Shellenbarger, T., & Robb, M. (2016). Effective mentoring in the clinical setting. American Journal of Nursing, 116(4), 64-68.
Shinners, J., & Franqueiro, T. (2017). The nursing professional development practitioner and preceptor role development. Journal for Nurses in Professional Development. Retrieved from: www.jnpdonline.com
Sims, S., & Swenson, M. (2015). Module III: Preceptor guidelines. In: Dumas, J. (ed.) Partners in NP education: A preceptor manual for NP programs, faculty, preceptors & students (2nd Ed). Washington, DC: The National Organization of Nurse Practitioner Faculties.
Souba, W.W. (1999). Mentoring young academic surgeons, our most precious asset. Journal of Surgical Residency, 82, 113-120.
Swihart, D., & Figueroa, S. (2014). The preceptor program builder: Tools for a successful preceptor program. Danvers, MA: HCPro.
The National Organization of Nurse Practitioner Faculties (NONPF) NP Core Competencies Content Work Group (2017). Nurse practitioner core competencies content. Retrieved from: http://www.nonpf.org/?page=14
Ulrich, B. (2011). Mastering precepting: A nurse’s handbook for success. Indianapolis, IN: Sigma Theta Tau International Honor Society of Nursing.
Venter, E. (2017). Bridging the communication gap between generation Y and the baby boomer generation. International Journal of Adolescence and Youth, 22(4), 497-507. doi: 10.1080/02673843.2016.1267022
Ventola, C. L. (2014). Social media and health care professionals: Benefits, risks, and best practices. Pharmacy and Therapeutics, 39(7), 491–520.
Vrabie, A. (2014). Improve team communication with the social style model. Retrieved from:http://blog.sandglaz.com/improve-team-communication-by-understanding-the-social-style-model/
Weber, R. (2015). The perfect preceptor. The Journal of Craniofacial Surgery, 25(8), 2257-2260. doi: 10.1097/SCS.0000000000002211
Wenger, E., McDermott, R. A., & Snyder, W. (2002). Cultivating communities of practice: A guide to managing knowledge. Boston, MA: Harvard Business School Press.
Wilson, L, (2004). The social styles handbook: Find your comfort zone and make people feel comfortable with you. Portland, OR: Nova Vista Publishing.
Windey, M., Lawrence, C., Guthrie, K., Weeks, D., Sullo, E., & Chapa, D. (2015). A systematic review on interventions supporting preceptor development. Journal for Nurses in Professional Development, 31(6), 312-323. doi: 10.1097/NND.0000000000000195
Wirtz Rugen, K., & Jorbridge, S. (2016). Precepting in a busy clinic. [https://vimeo.com/153056353]. Retrieved fromhttp://www.nonpf.org/?page=PreceptorPortal_Main.
Wolff, A., Regan, S., Pesut, B., & Black, J. (2010). Ready for what? An explanation of the meaning of new graduate nurses’ readiness for practice. International Journal of Nursing Education Scholarship, 7(1), ISSN (Online) 1548-923X, doi: https://doi.org/10.2202/1548-923X.1827
Wolpaw, T., Papp, K., & Bordage, G. (2009). Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: A randomized comparison group trial. Academic Medicine, 84(4), 517-524.