Mastering the Preceptor Role

Mastering thePreceptor Role:Challenges ofClinical TeachingCatherine Burns, PhD, RN, CPNP, FAAN, MichelleBeauchesne, DNSc, RN, CPNP, Patricia Ryan-Krause, MS, MSN, RN, PNP, & Kathleen Sawin,DNS, CPNP, FAAN

ABSTRACT

This article aims to help both experienced and new preceptors become moreeffective teachers while maintaining their clinical workloads. A variety of strategiesis essential to increase teaching effectiveness and decrease stress for the busypreceptor who juggles the roles of teacher and clinician. The article will begin witha review of role expectations and role strain factors for student, faculty, andpreceptor. Principles of clinical teaching will be identified, followed by somestrategies for teaching on busy days and concluding with suggestions for dealingwith difficult students. J Pediatr Health Care. (2006) 20, 172-183.

Guided clinical learning experi-ences are essential to nurse practi-tioner (NP) education. The goal isto prepare clinicians to managecare with optimal health out-comes. The preceptorship hasproved to be a highly useful strat-egy for clinical education. It allowseducation to be individualized,links classroom knowledge to realpatient management problems,and provides for role modeling asthe student develops standardsand strategies for practice.

In the United States, preceptor-ships involve more than 500 hoursof supervised clinical practice inthe particular NP specialty withpreceptors who are either experi-enced NPs or physicians in thesame specialty. The student andpreceptor have a one-to-one rela-tionship. In the typical clinicalpractice teaching episode, the stu-dent does the assessment and pre-sents the case to the preceptorwith diagnosis and plan outlined,the preceptor validates the assess-ment and plan, the student imple-ments the plan with assistance asneeded, and the preceptor helpsthe student reflect on the case andits implications. As the studentworks with the preceptor over anacademic term or more, he or sheis expected to increase knowledgeand skills, refine practice efficiencyand effectiveness, and become in-creasingly independent in manag-ing patient care. The preceptorprovides constant feedback andsupport to the student and evalua-tion data to both the student andfaculty� (National� Organization� ofNurse�Practitioner�Faculty,�2000).

This type of teaching is notwithout� problems,� however.� Irby(1995)�noted� that� teaching� in� theclinical setting often occurs at arapid pace with multiple demandson the preceptor; is variable inteaching and learning opportuni-ties as cases vary unpredictably innumber, type, and complexity; and

Catherine Burns is Professor Emerita, Oregon Health & Science University, Portland.

Michelle Beauchesne is Associate Professor, Northeastern University, Boston, Mass.

Patricia Ryan-Krause is Assistant Professor, Yale University, New Haven, Conn.

Kathleen Sawin is Professor and Joint Research Chair In The Nursing of Children,Children’s Hospital of Wisconsin & University of Wisconsin-Milwaukee.

Reprint requests: Catherine Burns, 15490 SW Bell Rd, Sherwood, OR 97140; e-mail:[email protected].

0891-5245/$32.00

Copyright © 2006 by the National Association of Pediatric Nurse Practitioners.

doi:10.1016/j.pedhc.2005.10.012

172 Volume 20 • Number 3 Journal of Pediatric Health Care

Original Article www.jpedhc.org

has a relative lack of continuity. Ina busy setting, there may be lim-ited time for teaching and feed-back. In turn, the student may notfind learning to be collaborativewith the preceptor, may lack op-portunities and time for reflection,and may find that independentlearning is not at an optimal pacegiven the student’s learning style.

A previous study of the precep-tor� as� mentor� (Beauchesne� &Howard,�1996)�concluded�that�pre-ceptors may need help in identify-ing an individual student’s learningstyle and in determining their ownleadership style. Preceptor devel-opment is worth the time and en-ergy needed because, if it is donesuccessfully, the preceptor, stu-dent, and faculty all will benefitfrom more efficient, less stressfulteaching by preceptors in clinicalsettings.

A�survey�by�Burns�(2003)�for�theAssociation of Faculties of Pediat-ric Nurse Practitioner Faculties of350 preceptors attending the Na-tional Association of PediatricNurse Practitioners Annual Confer-ence found that 89% preceptoredbecause they felt an obligation tothe PNP specialty and 85% did sobecause they liked teaching. Nine-ty-four percent said that theyplanned to continue precepting.Thus, despite the problems, pre-ceptors find this role to be inher-ently satisfying.

This article addresses severalstrategies to increase teaching ef-fectiveness while decreasing stressas the busy preceptor juggles theroles of teacher and clinician. Itreviews role expectations and rolestrain factors for student, faculty,and preceptor; identifies some keyprinciples of clinical teaching; sug-gests a variety of strategies forteaching on busy days; and con-cludes with suggestions for dealingwith the difficult student. The goalis to help both experienced andnew preceptors become more ef-fective teachers while maintainingtheir clinical workloads.

ROLE EXPECTATIONS:STUDENT, FACULTY,PRECEPTOR

The roles of student, preceptor,and faculty must work in syn-chrony for good learning out-comes. The setting also is impor-tant and places limitations on time,space, and access to patients. Thestudent is expected to be an activeadult learner; the faculty is ex-pected to assess the student’sneeds and arrange for a preceptor-ship learning environment consis-tent with program goals and toevaluate the student’s work; andthe preceptor is expected to pro-vide day-to-day clinical teachingwhile meeting clinical practice ex-pectations. Meeting the expecta-tions is not always easy for any ofthe parties. More detailed role ex-pectations as well as pressuresupon role performance are sum-marized�in�Table�1.

Hayes� (1994)� studied� the� pre-ceptor role and identified qualitiesof good preceptors from students’perspectives. Personal characteris-tics included being empathic,warm, respectful, and humorous.Flexibility, fairness, dependability,consistency, and enthusiasm werevalued. Students also looked favor-ably on preceptors who were will-ing to work with the beginning stu-dent, could adapt their teachingstyle as needed, and supported theeducational program. The precep-tor is expected to have currentclinical skills and knowledge, helpstudents recognize their assump-tions and think through their man-agement decisions, and model ef-fective communication with clientsthat emphasizes psychosocial as-pects of care. Successful teachingis a complex process that requiresnot only expertise in clinical con-tent but also positive personalattributes.

BASICS OF CLINICALTEACHING

The following sections describesome general principles of teach-ing as well as specific strategies

that can be used by the preceptorto help the student become a safe,competent, compassionate, inde-pendent, and collaborative clini-cian. This teaching spans thecontinuum from the basics ofhealth promotion to the manage-ment of complex conditions andissues.� Thompson,� Kershbaumer,and�Krisman-Scott� (2001)� suggestthat preceptors teach critical think-ing skills so that the practitioner isa detective in taking a thoroughand focused history, reflectiveabout the information gatheredfrom the history and physical andultimately effective in assessment,management, and follow-up.

Characteristics of AdultLearners

Familiarity with characteristicsof adult learners is critical. ManyNP students come to the clinicalsetting with a wealth of previousnursing experiences, whereas oth-ers may come from a non-nursingbackground with other unique ex-periences to enrich their nursingpractice. Regardless of the type oftheir past experiences, adult learn-ers are interested in sharing theirhistory and merging their past livesinto� their� new� roles� as� NPs� (Ne-braska� Institute� for� the� Study� ofAdult�Literacy,�2005).� It� is� impor-tant to consider previous experi-ence in the planning of clinicalopportunities. Activities shouldinclude new experiences, such ascare of older children for theformer NICU nurse, as well as ap-plication of previous skills to newsituations to help students inte-grate important aspects of theirprevious lives into their NPtraining.

Adult learners are often experi-ential learners who prefer to takean active part in the learning pro-cess rather than being passive re-cipients of information. Ideally,NPs view learning as a problem-solving activity rather than justan information-gathering activity.This problem-solving focus is sig-nificant in the development of es-

173Journal of Pediatric Health Care May/June 2006

sential critical thinking skills. Theyneed to understand the “why” be-hind what they are being taughtand what they are expected to do(Knowles,�1984;�Nebraska�Institutefor� the� Study� of� Adult� Literacy,2005).� For� example,� actually�pre-scribing immunizations is morevaluable than reading about theprocess or watching the preceptorperform the activity. Adults typi-cally learn better when the topic isof immediate value.

General Approaches for AdultLearners

Just as there are principles ofadult learning, there also are prin-ciples of teaching adults in theclinical setting. The most com-monly described teaching methodsare the “sink or swim” approach

and the “manipulated structure”approach�(Davis,�Sawin,�&�Dunn,1993).� Use� of� these� approachesgenerally change over time as thestudent develops more skills andconfidence. In the “sink or swim”approach, the student NP is ex-posed to a variety of patient en-counters and is expected to con-duct visits independently with novisible support. With this approachthere is minimal pre-visit teachingbut, obviously, the preceptor is ul-timately responsible for importantdecisions and is available at alltimes for back up. In the structuredapproach, patients are carefully se-lected, based on the student’s pre-vious experience and skills. Thereis much pre-visit and post-visitconsultation with the preceptor.Cases increase in number and

complexity as clinical skills de-velop. Preceptors generally teachas they like to learn but need torecognize that their students maynot share the same perspectives.

Several important factors mustbe considered when decidingwhich method of teaching to use.It is helpful to consider the level ofthe student. A first-semester, first-year student may function bestwith a structured approach,whereas a final-term student islikely to be ready to “swim.” It isappropriate to ask NP studentswhat approach they prefer. If newstudents opt for the “sink or swim”approach, it is critical that they beclosely monitored until the precep-tor is comfortable with their skills.Observing those students indepen-dently conduct a visit may allow

Table 1. Role expectations and pressures

Student Faculty Preceptor

Role expectationsArrange scheduleDevelop personal learning objectivesAddress course objectivesObserve policies and procedures of agencyConfer with preceptor and faculty about

progress and problemsPrepare for each clinical dayReview and read about past day’s workEvaluate faculty, course, and preceptor

Identify and secure appropriate sites forstudents

Prepare student with necessary clinicalskills

Provide preceptor with courseobjectives

Visit site during student experienceSupport and help preceptor develop

teaching skillsMonitor and evaluate student progressProvide evaluation feedback to

preceptorSolve student and/or preceptor

problems with the rotationGuide student clinical learning through

class, chart reviews, case studies,assignments

Provide feedback to studentTeach clinical reasoning and skills from

own knowledge and experience

Orient student to site, policies, proceduresFacilitate informal, collaborative, respectful

learning environmentBe a positive and effective role modelProvide learning experiences with

appropriate patientsProvide on-going feedbackPace learning experiences to meet

student needsDirect student to resources, readingsNotify faculty of concerns about student’s

behavior, work, or progressionProvide evaluation data to preceptor

Role pressures: potential areas of difficultyMake connections between didactic and clinical

workWork according to prescribed trajectory for

clinical progressBalance adult life with student expectationsAchieve learning needs within a service

environment

Identify preceptors and appropriatesettings that meet student learningneeds in a time of preceptorshortage

Evaluate student progress indirectlythrough written documentation andshort visits to the site

Keep learning expectations fromimpacting too greatly on preceptorservice demands

Orient and develop preceptors withintheir time and interest constraints

Reward preceptors for their work

Teach from experience baseMaintain patient care service expectationsFit clinical teaching into the program’s

curriculumMaintain rapport with patients and families

while involving student in a meaningfulway

Persuade colleagues to assist withstudent education

Convince administration to permitstudents at site


the preceptor to judge their currentabilities and subsequently struc-ture clinical experiences accordingto abilities. Preceptors may findthat consultation with universityfaculty is useful when decidingwhich approach to use. An impor-tant principle to keep in mind re-garding use of teaching styles isthat anxiety may result from alearning situation requiring highindependence with low experi-ence, while frustration occurswhen low independence is al-lowed for students with high expe-rience levels.

Principles of Clinical TeachingAfter determining what specific

teaching approach is best for thestudent and for the clinical setting,it is useful to apply general princi-ples of clinical teaching. Some ba-sic tenets of learning include thefollowing:! Learning is evolutionary.! Participation, repetition, and re-

inforcement strengthen and en-hance learning.

! Variety in learning activities in-creases interest and readiness tolearn enhances retention.

! Immediate use of informationand skills enhances retentionPreparation and planning.

In addition to the personal quali-ties of the preceptor that have al-ready been mentioned, prepara-tion and planning have been notedby several authors to be key com-ponents to a successful experiencefor� all� students� (Fay� et� al.,� 2001;Smith� &� Irby,� 1997;� Usatine,Nguyen,� Randall,� &� Irby,� 1997).The goal is to provide settings andexperiences in which learning canoccur with minimal disruption toagency operations and patientneeds and expectations. Aware-ness of the school’s goals as well asthe student’s personal goals is es-sential. Thus, there needs to becommunication with faculty priorto the student’s arrival and discus-sion of goals with the student be-fore beginning clinical activities.Preparation of the clinical setting,

one important aspect, will be dis-cussed later.

Teaching strategy options.Regardless of whether a “sink orswim” or a “manipulated structure”approach is used, several specificstrategies of teaching are useful forall levels of learners. Modeling isan�effective�teaching�strategy�(Irby,1995).�The�preceptor�demonstrateshis or her clinical expertise whenseeing patients while the begin-ning learner observes this process.This approach allows the studentto see the reality of classroom ed-ucation applied to actual patients.Modeling allows the more ad-vanced learner to observe moresubtle aspects of patient interac-tion, such as how one approachesdifficult issues of potential physicalabuse, problematic behaviors, de-velopmental delays, and seriousillness. Observation and modelingprovide the preceptor and the stu-dent with the opportunity to shareimpressions, think through casestogether, and develop differentialdiagnoses. It is often during thismodeling experience that the pre-ceptor may be challenged to an-swer the “why” questions of adultlearners. However, modeling andobservation are relatively passive;learners need to actually applyskills themselves to achievemastery.

Case presentations reflect thestudent’s ability to obtain criticalhistories, report pertinent physicalfindings, generate reasonable dif-ferential diagnoses, and developfitting management and follow-upplans. Discussing cases allows thepreceptor to determine if the stu-dent is able to incorporate past ex-perience and schemata into newclinical situations and assess thestudent’s level of expertise in deal-ing�with�a�range�of�patients�(Cor-alli,� 1989;� Wolpaw,� Wolpaw,� &Papp,�2003).

Direct questioning is helpful infostering critical thinking skills.Preceptors are most effective whenthe questioning is not perceived as“grilling”� (McGee� &� Irby,� 1997).

Optimally, questions such as“What do you think?” and “Why doyou think that?” stimulate thinkingand allow the student to share ob-servations and interpretations withthe preceptor. The preceptor canhelp the student formulate gener-alizations, which then can betested with multiple patients. Gen-eralizations then become part of aconceptual framework, which willbe�useful�over�time�(Smith�&�Irby,1997).

Two types of questioning meth-ods are discussed in the literature.An especially useful approach toteaching when time is very shortis the “One Minute PreceptorMethod”�described�by�Neher,�Gor-don,� Meyer,� and� Stevens� (1992)and evaluated for effectiveness inseveral�studies�(Aagaard,�Teherani,&�Irby�2004;�Irby,�Aagaard,�&�Te-herani,� 2004).� This� strategy� re-quires the preceptor to get a com-mitment from the student aboutwhat the student thinks is going onafter seeing a particular patient.The preceptor then challenges thestudent to provide supporting evi-dence for the assessment. Thisenables the student to draw fromprevious clinical experiences, aswell as coursework and readings.The preceptor gives immediatefeedback to the student aboutwhat was correct about the as-sessment and helps the studentrecognize some general rules thatapplied in the specific situation(Table�2).

The�“Think�Aloud�Method”�(Lee&�Ryan-Wenger,�1997)�requires�thestudent to provide a rationale forspecific questions that were askedand physical examination tech-niques used to show how conclu-sions were reached. This approachfosters critical thinking and clinicalreasoning skills. It is useful with alllevels of learners but especially forthe beginning student, because itrequires the student to verbalizethoughts and support decisions.For example, the preceptor will


ask, “Why did you ask about fe-ver?” This approach works well inclinical seminars conducted byfaculty.

Assigning directed readings onspecific clinical topics that ariseduring visits is helpful. The litera-ture reinforces general rules andfosters the development of con-ceptual frameworks. Directedreadings are especially importantfor beginners because they maynot have enough experience to de-termine where to find the bestinformation in the nursing ormedical literature. The preceptorsuggests readings and asks for abrief report at the next session.

Coaching is another excellentteaching method. In this process,the preceptor provides verbal cuesto the student as he or she movesthrough a procedure. The intent isto keep the student safe and effi-cient while mastering the steps of askill that may not yet be automaticin nature.

Feedback from preceptors iscritically important, especially with

adult students whose learning isenhanced if they believe they aremaking� progress� (McGee� &� Irby,1997).� Effective� feedback� is� de-scriptive of specific situations andskills and is given soon after thepreceptor’s observation of theseconcrete events. It reinforces whathas been done correctly, reviewswhat needs to be improved, andcorrects mistakes. Feedback is lessjudgmental than evaluation and isbest given informally throughoutthe student’s experience. Feed-back is sometimes more meaning-ful if the student has the opportu-nity to do a self-assessment prior tohearing the preceptor’s comments.For example, a conversation re-garding the question, “How welldo you think you addressed thismother’s concerns?” will give thestudent the chance to share his orher rationale for the approachwhile also prompting the furtherdiscussion about the question,“How could you have done thisdifferently?”

Evaluation. Evaluation is animportant component of the pre-ceptor/NP student relationship.The preceptor needs to be familiarwith the university curriculum, theuniversity’s goals and objectivesfor the specific clinical experience,and the evaluation tool that is re-quired by the school at the conclu-sion of the placement. Having agood sense of what knowledgebase the student is expected tohave will be helpful. In addition tothe expectations of the universityand the preceptor, it is helpful toaddress the student’s personalgoals for the clinical experience.Realistic goals are best met if theyare written down and discussedearly in the experience as well asperiodically throughout the rota-tion. An evaluation session mid-way through the term and at theend of the rotation is essential. Thestudent should be encouraged toself-evaluate as well as to receiveevaluative information from thepreceptor. Of course, the precep-tor’s evaluation also needs to be

Table 2. The One-Minute Preceptor Technique

Learning goal Script Rationale

1. The student is to make adecision regarding the case athand

“What do you think?” This question is helpful throughoutthe decision-making analysis—from making a diagnosis toworking out a plan; the studentis not simply providinginformation to the preceptor tomake decisions

2. Probe for supportive findingsand evaluate the critical thinkingthat led to the decision

“Why do you think that?”“What led you to that conclusion?” or

“What else did you consider and ruleout?”

Diagnose the learner’sunderstanding—gaps andmisunderstandings, poorreasoning or attitudes; do notask for textbook knowledge

3. Tell student what was right in theconclusions and critical thinking

“Specifically, you did a good job of________ . . . and this is why it isimportant. . . .”

State specifically what was donewell and why it was important toreinforce excellent performance

4. Correct student errors “You did well based on your knowledge ofolder children but didn’t factor in theinfant’s development”; “I disagreewith . . .” ; “A more efficient way. . .”

Specific correction will reinforcecorrect ideas and extinguishincorrect ones

5. Teach a general principle/ clarifythe take-home lesson

“The key point I want you to rememberis . . . .”

Point out key ideas, prioritizeessential points among manydetails

6. Your own one-minute reflection “What did I learn about my teaching?”,“What did we learn from this?”

Place exercise into larger contextof patient care and refocus forteaching episodes

Adapted from Neher, Gordon, Meyer, & Stevens, 1991.


shared with the faculty personwho is responsible for grading thestudent’s performance.

Teaching to theDevelopmental Level ofStudents

It is important to remember thatwhile being a preceptor is stress-ful,�so�is�being�a�student�(Yonge,Krahn,� Trojan,� Reid,� &� Haase,2002).� Examining� the� situationfrom both perspectives is one wayto better understand the relation-ship� (Papp,� Markkanen,� &� vonBonsdorff,� 2003).� Ohrling� andHallberg� (2000)� studied� students’lived experience of preceptorship.Four themes emerged as critical tolearning: creating a space for learn-ing with both time and room, pro-viding concrete illustrations, pro-viding for some control over theopportunities and pace of learn-ing, and allowing time for reflec-tion. Taking advantage of students’past experiences and expertise ishelpful. Also, students’ self-esteemis enhanced when they believethey are contributing to care(Hayes,� 1998).� Preceptors� shouldnot feel threatened if students aremore expert in some areas of nurs-ing, but rather, seize the opportu-nity to learn from the student. Be-cause students are experiencingthe stresses resulting from being anexpert in a previous nursing areato now becoming a novice again(Benner,� 1984),� recognition� oftheir expertise is helpful to them.

In order to best apply the basicstrategies of effective precepting, itis important to be familiar withspecific developmental levels ofNP students. As with all students,they fall along a continuum of de-velopment. Students develop atdifferent rates, react differently todifferent patients, and may havevariability in their skills from day today. However, there are generalcategories of students, each withspecific� skill� sets� (Davis� et� al.,1993).

The beginner. Beginning oradvanced beginner students typi-

cally need preceptor support forall facets of clinical learning. Theyhave had core course work inhealth assessment and perhapssome management courseworkbut have had little opportunity toapply classroom concepts to actualpatient care. They may have diffi-culty in transitioning from being anexpert in their previous nursingroles to being a beginner in the NProle. Some students will be reluc-tant to begin assessing patients in-dependently, whereas others maybe very assertive in the clinical set-ting, even without any prior nurs-ing experience, using a “sink orswim” style of learning. A precep-tor can use observation of the stu-dent to determine what studentskills are strong and which needparticular attention during the clin-ical experience.

Several specific strategies are use-ful for beginning students. Observa-tion is a reasonable initial strategy.The student can learn much aboutapproaches to patients as well asclinical content from observing anexpert. Students must not stay in theobserver mode, however. If possi-ble, straightforward, uncomplicated,“routine” well visits should bescheduled with families who are fa-miliar with the beginning NP role.Prior to each visit, beginning stu-dents should spend time thoroughlyreviewing each chart and preparingall components of a health promo-tion or uncomplicated illness visit.Several patients of the same age in asession reinforce developmentalmilestones. General rules and con-ceptual frameworks around differ-ent issues and different ages thendevelop.

The transitional learner.After some initial weeks or monthsas a beginner (depending on theintensity of the clinical experienceand the student’s abilities), it is ex-pected that a student will movefrom beginner status to transitionallearner.�According�to�Thompson�etal.�(2001),�this�is�the�stage�in�whichthe preceptor is able to “stepback.” Transitional learners require

less input from the preceptorabout the basic components of pa-tient care. Thus, pre-visit and post-visit conferences can be more con-cise. The student establishes basicpriorities for each visit, gathersonly essential relevant data, andgenerally conducts visits with bet-ter efficiency and effectiveness(Davis�et�al.,�1993).�The�task�of�thepreceptor in teaching transitionalstudents is to schedule more com-plex patients so that more multi-faceted generalizations developand clinical reasoning skills arestretched to a new level. Case pre-sentations, the “think aloud”method, and assigned readingscontinue to be effective strategiesfor transitional students.

The competent proficientlearner. The final type of studentlearner is the competent proficientlearner. This student has solidskills in history taking, physical as-sessment, evaluation, and manage-ment, as well as increased clinicaljudgment and the ability to relatepast clinical situations to currentsituations�(Davis�et�al.,�1993).�Thisstudent is more flexible in thinkingabout cases because he or she hasprevious experience to draw uponand is more time efficient andcomfortable with the advancedpractice� role.� Thompson� et� al.(2001)�describe�this�stage�as�one�inwhich the preceptor can “stepout.” Competent proficient stu-dents, like all experienced clini-cians, are aware of their limitationsand still ask questions and seek theinput of clinicians with moreknowledge. The focus of precept-ing a competent proficient learneris on pattern development and theuse of schemata or general repre-sentations, seeing which can beapplied across patients. Compe-tent/proficient students should seemore medically and socially com-plex patients within designatedtime frames.

As the student nears the end oflater clinical rotations, it is impor-tant for the preceptor to knowwhen it is time to let go and allow


the student more independence.The relationship with the precep-tor often becomes more collegialand less vertical, mutual trust de-velops, and the preceptor is com-fortable with the student’s skillsand clinical judgments. Strong casepresentation skills in the compe-tent student allow the student tocommunicate well with other pro-viders. It is time to let go when thepreceptor is comfortable with thestudent’s competence with pa-tients, but the student must con-tinue to seek help, ask appropriatequestions, and search for newchallenges.

STRATEGIES FOR TEACHINGWHILE PRACTICING ONBUSY DAYS

A common question posed tofaculty is, “How can we have astudent on a particularly busyday?” The reality is that every dayis a busy day in the clinical setting.Nurses are in short supply, and fac-ulty and preceptors are not the ex-ceptions. Thus, all are assumed tocarry heavy clinical loads. Factorsin the shortage include aging fac-ulty, increased clinical burdensthat lessen time available to teach,and a major emphasis on produc-tivity�in�the�clinical�arena�(Lyon�&Peach,� 2001).� Guberski� (2000)summarizes the dilemma facing allclinical faculty: “The challenge fac-ing current faculty is to worksmarter, not necessarily harder,and to evaluate the cost-benefit ra-tio of our teaching strategies andapplication of technology” (p. 5).

Several studies have dispelledsome powerful myths about pre-cepting. Preceptors do not neces-sarily have a longer day or spendmore time with patients, and havingstudents does not inevitably de-crease�productivity�(McKee,�Steiner-Grossman,� Burton,� &� Mulvihill,1998).�In�fact,�students�may�actuallyincrease�productivity�(Fontana,�De-vine,�&�Kelber,� 2000;�Hildebrandt,2001).�However,�working�with�a�stu-dent undeniably makes a clinicalday more complex. Reducing the

complexity wherever possible is thekey to enjoyment of the day when astudent is there.

Taking the time to develop anoptimal climate for learning willpay off for all persons involved.Students learn best when there isongoing student assessment, closecommunication, quick response tostudent’s stress, trusting relation-ships, mutual respect, and accep-tance� as� part� of� team� (Myrick� &Yonge,� 2001).� Frequently� ex-pressed barriers to being an effec-tive preceptor and a clinician at thesame time include the following:feeling overworked, being unpre-pared for teaching, being mis-matched with students, lackingadequate time, and receivinginsufficient feedback and guidance(Hayes,�2001;�Yonge�et�al,�2002).Avoiding as many pitfalls as possi-ble is important for both preceptorand student.

Preparing for the DayTo be successful on a busy day,

it is essential to do good pre-plan-ning. Preparation of the clinic set-ting is essential. All members of thepractice setting must be aware ofthe student’s arrival and expectedlength of stay both in terms of dailyschedule and length of calendartime to be spent in the setting.Such things as scheduling patients,arranging examination room avail-ability, providing space for chart-ing, and planning for student ac-cess to patient records need to beaddressed.

It will also help to meet thestudent for the first time beforethe first day of the rotation byplanning for a brief student inter-view before the first day begins.Discussion should include a re-view of the student’s goals, learn-ing style, and past experiences.The student can be asked to ar-rive with a questionnaire includ-ing this information and contactinformation already completed.The preceptor also needs toshare some of his or her historyand usual teaching style. The pre-

ceptor should describe theagency, the types of conditionscared for, and the mission of theagency. Any specific standards orguidelines that the site has inplace governing student behavioror NP roles need to be shared atthis time. A tour of the site andintroduction to staff will help.

Each day of the preceptorship,further planning should occur.Review of the appointment listfor the day and identification ofappropriate patients for the stu-dent to be involved with is agood idea. The preceptor needsto communicate clearly to thestudent the expectations with re-gard to numbers and types of pa-tients seen, amount of time avail-able to spend with each patient,and amount of preceptor timeavailable to the student. Clearlydelineated expectations help thestudent perform as optimally aspossible while not compromisingthe care of patients. Explainingwhere the difficulties lie andwhere the learning opportunitieswill likely appear is essential.

The expert preceptor is con-stantly doing “invisible plan-ning”—thinking ahead about otheractivities that will be helpful to thestudent’s�progress� (Skeff,�Bowen,&�Irby,�1997).

Students want to be helpful andinvolved in clinic work. They alsoare using the preceptor as a rolemodel to see how clinicians prob-lem-solve clinic management is-sues. Focus on the student by stat-ing such plans as, “We will reviewthe cases for the morning overlunch,” or “Keep a 3 ! 5 card forquestions you have during the dayand we will address them for 20minutes at the end of the day orwhen we have a break in theschedule.”

Use of Other ResourcesThinking broadly about the stu-

dent’s education is useful. Precep-tors often feel guilty about usingothers’ expertise and resources inthe�practice�setting�(Kaviani�&�Still-


well,�2000;�Yonge,�Ferguson,�My-rick,�&�Haase,�2003).�Yet,�it�is�bet-ter to share the teaching. Studentsbenefit from enriched learning op-portunities. These might includearranging for students to attendrounds, case conferences, or anyother relevant meetings that focuson care. Use the library, audiovi-sual aids, and learning centers.Preceptors can establish a buddysystem with a colleague to sharestudents occasionally. Teachingalso can involve use of online re-sources and exercises. Perhaps

there is another clinician who hassomething special scheduled forthe day. Would a morning with alaboratory technician be helpful?What about a couple of hours withthe nurse doing telephone triageor follow-up? Would it be informa-tive for the student to call somepatients to evaluate care given ear-lier? Creative ways of assessmentand evaluation of learning in addi-tion to direct observation will behelpful, particularly if planned forefficient�use�of�time�(DaRosa�et�al.,1997).

Trimming Time off TeachingActivities

Listed in Box 1 are some strate-gies that can be adopted for teach-ing on busy days. They relate topre-planning, student time withpatients, case presentation time,and finding discussion time.

A scheduling strategy that mightwork in some practices but notothers, at least formally, is toschedule patients in waves—twoin slot 1, one in slot 2, and none inslot 3. That will let the preceptorand student each start off with a

BOX 1. Tips for teaching on busy days

Pre-planning1. Prior to the clinical experience, describe to the student the pressures you face.2. Get to know your student’s learning style and needs before the first day of patients.3. Review the cases for the day with the student and mutually decide where the best learning opportunities are likely to arise.4. Have some other ideas in mind for times when you cannot teach for one reason or another. For example, student can

listen in on triage phone calls, follow-up by phone with cases seen previously, go with another provider who likes to teach,spend time with the laboratory technician or pharmacist, or use the Internet to answer a question that had beenunanswered from a previous discussion.

5. Set priorities for the student to accomplish and activities to complete by the end of the day.

Student time with patients1. Work together with one patient to decrease the time spent and allow the student to see your assessment and care for

efficiency. Have student do the history, and then you do the physical. Rotate tasks for the next patient.2. Help the student recognize what to include in a focused history and examination for the presenting concern without going

onto contextual or tangential issues.3. Assign the student to patients whom you know like extra time.4. Set a time limit on the student: “Get as much of the history as you can in 10 minutes and I will come in.”5. Schedule your patients in waves: two in time slot 1, one in time slot 2, and none in time slot 3. In the first time slot, you

and the student start out in different rooms at the same time. You do a second case in time slot 2 while the student finisheshis or her case and prepares to discuss it with you. Use the break in time slot 3 for completion of the student’s case,charting, and preparation for the next wave. You will have kept your productivity numbers at three cases in three timeslots.

6. Go into the patient’s examination room with the student and chart the history and physical while the data are beingcollected by the student. Then reverse roles and have the student document while you gather the data.

Case presentation time1. Set a limit on length of presentation time. “Tell me the H & P, diagnosis and your plan in 5 minutes.”2. Ask the student to present while both of you are in the room with the patient. (Be careful if there is psychosocial

information or other factors that should be communicated and discussed privately between you and the student first.)3. Assign the student to patients you know well, as this may speed evaluation of accuracy of student data. Also, give the

student background on the patient to help focus the history more efficiently.

Finding discussion time1. Ask the student to keep a file card handy to write down questions for discussion later. Follow up daily for 15 to 20 minutes.2. Use travel time to and from clinic or to lunch to discuss cases.3. Set limits on time for encounters. “I can meet with you for 10 minutes now. You can have 5 minutes to ask me questions

and then I want to give you some feedback on the patient we saw together this afternoon.”4. Ask the student to look up information on three cases you saw during the day, but make it clear that you will ask for a

report the next session on only one of the three cases.5. Jot down patient care pearls that arise from various sources. Collect them on a list and share with the students.6. Honor your appointments with students. Keep them brief but focused.7. Expose students to the complete day. Take them to noon conferences, committee activities, and civic activities.


patient to see (slot 1). The precep-tor can continue with the third casein slot two while the student fin-ishes his or her case. The break inslot 3 will give time for teachingbefore the next round begins. Interms of the whole day, three pa-tients will have been cared for ineach three time slots. Whether for-mally scheduled or not, the princi-ple holds as a way to carve outteaching time in the midst of theclinic work.

It is essential that preceptors berealistic about the amount they at-tempt to teach. Small bits are fine.It is also essential to give feedbackdaily, keeping it short and directedat the care given that day. Varyteaching strategies depending ontime, student need, and level andclinical opportunities.

Evaluating the Teaching DayEvaluation of the teaching day

should occur routinely. One partic-ular example may be called the“End of Day Newspaper Review”technique. Thinking briefly aboutwho was seen, what got done,how the student felt about it,where the student wants to gonext, and why things worked ordid not can be very helpful whendone on a routine basis.

Every preceptor needs somefundamental skills, what may betermed “preceptor know-how.” Askilled preceptor knows how tonavigate the clinical system, knowshow to create a climate for learn-ing, and knows how to get theexpected�work�done�(Mamchur�&Myrick,� 2003;� Myrick� &� Yonge,2002).�Role�modeling,�guiding,�fa-cilitating, and prioritizing are keyconcepts for the busy preceptor tokeep in mind. Strong organiza-tional skills and the ability to setpriorities may be critical factors insuccess for precepting in a busysetting.�Morrow�(1984)�has�clearlydelineated the priority setting pro-cess. A good prioritizer carefullyidentifies the activities that are im-portant, essential, time sensitive,urgent, and/or must be completed

on time. Distinguishing betweenthe activities that must be accom-plished today versus those thatwould be nice to do is an essentialskill.

WORKING WITH THEDIFFICULT STUDENT

Although the preceptorship is apositive experience for all partiesthe majority of the time, problemsoccasionally arise. Skilled precep-tors often can turn difficultiesaround, or at least will take appro-priate steps to resolve issues. Gen-erally, this difficulty is related to stu-dent performance, but occasionallythe issue is one of student dissatis-faction or poor communication, per-haps from lack of a good match be-tween the student learning style andpreceptor style or characteristics ofthe clinic. A “difficult student” maybe frustrated, anxious, bored, over-whelmed, unprepared, distracted,ill, or otherwise having somedifficulties.

Preceptors, faculty members,and students all need to be in-volved with resolution of studentperformance problems in the clin-ical setting. The preceptor’s first re-source is a close working relation-ship with the program faculty, andpreceptors should not hesitate toask for a “diagnostic visit” by pro-gram faculty. Some preceptors, es-pecially inexperienced preceptors,are tempted to wait, sometimes forextended periods, thinking a diffi-cult situation will “get better.”

Communication with faculty isenhanced by a comprehensive as-sessment of factors that seem to con-tribute to the student’s lack of per-formance. However, even ifpreceptors are not able to pinpointspecific factors, they should not hes-itate to send up a “red flag” to pro-gram faculty. Serious problemsshould be addressed that very daywith a call to faculty. Notes shouldbe made regarding the situation ofconcern with dates and specifics, sothat the faculty can be as well in-formed as possible when contacted.

Even when a potential problemseems to be emerging, the precep-tor should maintain quality teach-ing. Opportunities for learning andapplication of knowledge shouldbe provided. Continue to give thestudent specific rather than generalfeedback, share information ratherthan give advice, and, above all,keep� communication� open� (Ben-zie,�1998).�A�key�concept�to�keepin mind is that focusing on behav-iors that can be changed ratherthan personality traits is the beststrategy.

Diagnosing the Learning andPerformance Issues

The diagnosis of clinical learn-ing problems needs to include dataabout the setting and specificcases, the student’s behavior, pre-ceptor efforts and responses bythe student, and the student’s per-ceptions of the situation, all inlight of course expectations. Datashould include both the student’sstrengths and deficits. The precep-tor should expect that the student(a) is prepared each day, (b) dem-onstrates history-taking skills ap-propriate for the situations at hand,(c) demonstrates critical thinkingin data collection, (d) uses goodphysical examination skills togather appropriate additional data,(e) demonstrates health promo-tion knowledge and managementskills, and (f) uses knowledge ofacute illness management to cor-rectly make diagnoses and identifytreatment options at a level appro-priate to the course and curricu-lum. A student should also be ableto maintain a reasonably organizedapproach to patient care and useof learning opportunities. Commu-nication with staff, preceptor, andpatients should be clear, orga-nized, and appropriate. This alsoapplies to written documentationand oral presentations of cases.Usually these elements will beconsistent with clinical course ob-jectives for NP courses. Examplesof problems the preceptor may seeinclude inability to take initiative


and be responsible for parts of vis-its; inability to transfer knowledgefrom one situation to another;problems with communicationwith preceptor, staff, and patients;and failure to improve to the nextlearner developmental stage.

The preceptor and faculty needdata to determine if the issue isrelated to a poor match betweenpreceptor, setting, and student. Forexample, does the preceptor use ateaching style such as “sink orswim” that generates anxiety inthis particular student sufficient toseverely reduce performance? Or,is the setting too hectic, limitedin space, unexpectedly busy, orproviding inappropriate patients?(Benzie,� 1998).� Faculty� and� pre-ceptor will need to discusswhether adequate adaptations canbe made to achieve a fit for thestudent.

The level of performanceshould be specified throughcourse objectives and an under-standing of the course placementin the curriculum (e.g., a last-termcourse should have expectationsapproaching the new graduate’slevel of functioning). Preceptors

may find it useful to document thebehaviors�identified�by�Ahern-Leh-man�(2000)�as�exemplars�that�stu-dents “get it” or behaviors that are“red flags” (see Box 2). Faculty ab-solutely need these data.

As a part of the student assess-ment, the faculty needs to deter-mine if there are other issues fromthe student’s perspective, includ-ing competing demands. The pre-ceptor can provide helpful input tofaculty from information providedby the student. Faculty will need todecide if the student has compet-ing life crises and whether thestudent can realistically put thenecessary effort toward clinicallearning to meet course objectives.It is important that the preceptornot confuse the preceptor rolewith that of counselor. If assess-ment reveals mental health prob-lems, faculty will refer the studentto appropriate mental health ser-vices. In any case, even if the stu-dent is under unusual stress or go-ing through a difficult time, thestudent is disadvantaged if precep-tors and faculty do not have clearexpectations for acceptable perfor-mance. Additionally, having an im-

paired student in the clinical set-ting can be extremely frustrating oreven dangerous.

Additional DiagnosticActivities

If the preceptor’s primary site isnot optimal for evaluation of thestudent having trouble, several op-tions may exist. Many programshave senior preceptor or facultypractice sites to use to diagnosestudent performance. In addition,some program faculty use labora-tory simulations for diagnosticassessment. A simulation is con-ducted in a less intense envi-ronment and is accompanied byextensive analysis and debriefing,which can be helpful in assistingstruggling students.

Implementing a CorrectivePlan

If a “match” or “fit” problem isruled out and a student problem isidentified, a corrective plan needsto be developed by the preceptor/faculty team, a time frame set forcorrective action, and an evalua-tion plan developed to determineif change has occurred. The plan

BOX 2. Indicators that the student is learning in the clinical setting

Behaviors that indicate the student is “getting it”! Presents thorough, focused history and physical! Consistently articulates sound decision making! Develops and implements reasonable plan! Connects with patient interpersonally in caring manner! Is organized, independent, time-efficient! Is self-confident but knows limits; asks for help! Has holistic view of care; includes health promotion and disease prevention! Provides concise charting and oral presentations

“Red flag” behaviors! Is hesitant, anxious, defensive, not collegial! Has uneasy rapport with patient and misses cues! Presents less focused history and physical with excessive incomplete data! Performs physical examination poorly, inconsistently! Is unable to explain reasoning for diagnosis! Is unable to prioritize patient problems! Is unable to create plans independently! Misses health education and disease prevention opportunities in plan! Is unsure of tests to order! Is unable to provide clear charting and presentations

Adapted from Ahern-Lehman, 2000.


must involve preceptor, student,and faculty. Faculty need to deter-mine if the student will drop out,move to a new site, or stay in theenvironment. If the student is tostay at the site, a specific plan toimprove areas of concern must bedeveloped. The plan may includemore closely supervised time infaculty practice site, time observ-ing role models, or extension oftime in clinical setting (dependingon school policies). The studentmust to be willing to make thecommitment and effort to addressthe areas of identified concern. Fi-nally, time for follow-up evalua-tion and criteria that all agree tomust�be�set�(Table�3).

EvaluationWhile implementing a correc-

tive plan, the preceptor needs toreassess the student at each clinicalexperience, determine if the stu-dent is making progress in theidentified areas with the intensifiedinput, and document each visitwith short but specific descriptorsabout specified skills and progressor lack of it. The preceptor shouldlet the student know whereprogress has been made as well asareas that need continued work,and must continue to use faculty ascollaborators.

When the diagnosis is specificand interventions are aimed at the

particular needs of the student, themost common outcome is im-proved performance. If improve-ment occurs and is satisfactory,faculty will need to determinewhat strategies need to continuefor improvement in the next clini-cal. However, if performance con-tinues to be unacceptable withoutcomes not demonstrated in thetime frame agreed upon, a recom-mendation for withdrawal from theclinical rotation or the programmay be appropriate. Skillful aca-demic counseling can oftenachieve this outcome in a way thatprovides the student with other ca-reer options. Faculty greatly appre-ciate preceptors for sensitive anduseful assistance with diagnosis offailures of the student’s perfor-mance to match the expectationsof NP course and, ultimately, theNP role.

Learning DisabilitiesIt is not unusual for the de-

mands of graduate education touncover a learning disability thatthe student has been able to com-pensate for in previous educationor professional practice. If the as-sessment process leads the precep-tor and faculty to suspect a learn-ing disability, referral to theuniversity’s Office for Studentswith Disabilities is recommended.Professionals can assess the stu-

dent and, if necessary, refer thestudent for more in-depth assis-tance to identify the accommoda-tions needed for the student’s suc-cess. In addition, the Office forStudents with Disabilities can pro-vide counseling, coaching on ef-fective strategies for learning, andadvocacy for needed accommoda-tions. Generally, if the student hasa documented learning disability,accommodations are mandated bylaw. A student’s or faculty’s beliefthat a learning disability exists isnot sufficient for accommodation.Documentation of a learning dis-ability by a professional in thisfield is crucial for the student tohave any “legal” right for accom-modations. Preceptors who sus-pect a learning disability need toconvey that information to facultywho, in turn, will work closelywith appropriate academic units.

CONCLUSIONIn conclusion, with appropriate

expectations and some strategies forbasic teaching with adaptations forspecial student and clinic needs,most practicing NPs can function asexcellent preceptors. Preceptors areurgently needed to prepare the nextgeneration of clinicians and to pro-vide the access to patients so impor-tant to clinical learning. In turn, pre-ceptors obtain satisfaction frommeeting a professional obligation.

TABLE 3. Examples of interventions for problematic performance

Problematic performance examples Interventions

Unorganized or incompetent history If the student is not competent, determine if she or he has an organizationalframework for history; if the student lacks a useful framework, re-orient topresentation�basics�(Coralli,�1989)

Lacks effective presentation skills Encourage timing of verbal presentations and convey the expectation ofextensive practice outside the clinical setting; effective strategies includerehearsal and use of a tape recorder; faculty may select and evaluate selecttaped presentations

Difficulty applying concepts covered ineducational program

Give student responsibility to be prepared for one system (or specific problem)and a specific well-client visit for each clinical experience; ask student tooutline the priority concerns, assessments, and decision points in a concise,articulate, and clinical relevant presentation in less than 4 minutes

Persistent difficulty “grasping”organization of problem-orientedchart and generating charting withlogical flow

Refer to Office for Students with Disabilities for evaluation of possible learningdisability


The great majority usually findteaching enjoyable, and they learnfrom the students. There is no “se-cret recipe” for successful precept-ing in a busy environment exceptthe following: find the appropriateplace, provide adequate light, nur-ture, protect and give time to grow!Being a preceptor is a rewarding ac-tivity. If the NP role is to continue,the best and brightest cliniciansneed to be involved with educationof their future peers, and they willfind the preceptor role enriching!

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