Practice Matters

The rewards of extern-preceptor relationships

A strong student extern program produces benefits all around. A healthcare facility can recruit top students, help them become good nurses, and retain them after their first year of practice. The externs gain self-confidence in patient-care skills, develop critical thinking, and enhance their organizational abilities. Preceptors discover the value of their own expertise and of nurturing bright, eager students. And patients benefit from the blend of enthusiasm and skill.

During our experiences with our extern-preceptor program at Danbury Hospital in Connecticut, we’ve seen all these benefits.

Selecting externs

Students who have completed their junior year of college may apply to our 10-week summer program, which combines clinical experience and education. Hospital human resources personnel screen candidates to make sure they meet program criteria. Then, nurse educators from the Department of Nursing Education and Research interview the candidates. The educators make the final choices by focusing on the candidates’ initiative, motivation, enthusiasm, and academic achievement.

These characteristics give the interviewers insight into each candidate’s potential to become a valuable team member. Candidates who are selected by the educators then choose the patient-care unit where they want to work. For the summer program we describe below, 18 externs were chosen.

Education and support

After hospital and nursing orientations, our 18 externs attended mandatory weekly education sessions consisting of lectures from expert clinicians and extern presentations on their chosen topics. To prepare their presentations, externs divided themselves into groups. These externs demonstrated the ability to collaborate with people they just met and provided thoughtful, interesting presentations.

The program also required externs to keep a journal with responses to questions developed by the nurse educators. The questions were designed to initiate conversation about the meaning of the externs’ experiences. At each weekly meeting, externs shared their journal entries and engaged in articulate conversations. They were eager to learn the practical and theoretical components of nursing, and they openly shared and analyzed their experiences.


For example, one journal question was, “Describe your role as a team member in the care-delivery system and give an example of how you’ve demonstrated or maintained a positive attitude this week.” In their journals, many expressed concern about their inexperience and their perceived lack of the intellectual and emotional strength professional nurses must have. They expressed respect for nurses’ technical skills, compassion, and organizational abilities. Externs viewed the know-how of the experienced nurse as “awe inspiring” and for the time being, as beyond their reach.

During the program, a nurse educator met regularly with the externs and preceptors to review the externs’ clinical experiences and performance. These meetings provided an opportunity for the nurse educator to address work-related issues and plan resolutions. The support of a preceptor, the follow-up from the nurse educator, and the weekly education sessions were intended to create a supportive environment in which externs could develop as beginning practitioners.

In their own words

In their journal entries, the externs provided observations about themselves and the role they hoped to assume one day. They expressed anxiety about their ability to master the skills that foster clinical judgment. They also made powerful statements reflecting their determination to reach their goals.

Reading this journal entry, you sense this extern’s growing confidence:

I have learned a lot of nursing theory, and I am very excited to have the opportunity to use that knowledge in actual practice. The two weaknesses that cause me most concern are my inability to respond as quickly as experienced nurses and my occasional hesitancy to speak up and take charge. My plan for improvement is to trust myself and rely on my knowledge and instinct when faced with a new situation. I also plan to practice being more assertive. I know I am capable and want others to have confidence in me.

This entry captures the essence of the extern learning experience:

My preceptor is excellent at seeing the bigger picture. Every morning, we prioritize our patient care. Before report, we make rounds to check our patients, so we know what they may need. For me, prioritizing remains a juggling act and a matter of learning how to differentiate the needs of the patients. I watch carefully to learn and absorb this most important skill. I believe this critical skill defines the outcome of all that nurses do. I understand this more now than I ever have.

Of course, the expertise this extern is talking about is based on long-term engagement. A preceptor can quickly assess situations based on a combination of experience, critical thinking, intuition, and sensitivity to patient cues. A beginner must rely on deliberate consideration of many variables to make an assessment. Such journal entries explore the very meaning of nursing practice and show the beginners’ quest for identity and excellence in nursing.

Our externs demonstrated characteristics that brought new life to their clinical units. They were goal-oriented, self-aware, and honest. And they trusted themselves to take the initiative in their work. They took an active interest in others and were attuned to the group dynamics on their units.

Caring connections

Preceptors and other nurses reported that having externs on the unit gave them a new appreciation of the meaning of their work. Sharing the experiences of caring for patients enhanced their feelings about themselves. When preceptors engaged in the circle of caring, the practice of nursing connected nurse and extern. (See Preceptors’ point of view.)

Our program provided an opportunity for preceptors to discover or rediscover the value of being a role model. It also provided the externs with insights into the role of a registered nurse and new understandings of themselves. And the positive relationships between preceptors and externs ultimately had a positive effect on the quality of relationships between nurses and patients.


Angela DiLillo and Linda Soroff are nurse educators at Danbury Hospital in Connecticut. Jeanette Bjurback-Lupinacci is an assistant professor at Western Connecticut State University in Danbury.

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