Stepping out of the classroom and onto the clinical unit, stethoscopes poised, student nurses are nervously eager and excited to be in a hospital setting—the place where they might spend much of their professional life. Students are given report on patients and paired with a registered nurse (RN) preceptor for the day. The nursing instructor guides the process and, for the most part, administers medications and treatments with the student. But make no mistake; it’s the RN whom the student looks up to as a working, professional role model.
For many, the student/preceptor relationship can be enriching and mutually rewarding. Others may find this time-honored model more stressful and difficult. It may be the case that students don’t fully understand the challenges to an RN’s workday; nurses must precept and oversee a full caseload of patients. Perhaps some RNs forget too quickly what it was like to be a student. The following scenarios represent composite stories from teachers, students, and nurses.
From the student’s perspective
Sonia was assigned to a fast-paced surgical unit in a large city hospital her last semester of nursing school. “It can be tough. Sometimes the nurses seem to ignore us. We are supposed to come in extra early to hear report from the night nurses, and often they start without even telling us. How can we learn from nurses that treat us as though we are invisible?”
Although many students report extremely positive experiences with nurse preceptors, Sonia’s complaint isn’t an isolated incident. Stories of indifference and lack of interest from nurse preceptors aren’t uncommon. Students recall how some nurses avoid contact with them, make excuses not to give shift report, or don’t include them in patient-care activities.
Beth’s clinical experience was uneventful her first semester, but in the middle of her second clinical rotation she ran into problems with one of her assigned preceptors. “My instructor asked my preceptor to allow me to put in a Foley, but after I got all the supplies [the preceptor] said she already did it. Later that morning, I was supposed to administer heparin. When I approached her with my instructor, she said she had done it already. I felt that we spent a lot of the morning chasing my preceptor, who really had her own agenda, and it did not include me.”
Part of the problem, according to Beth, was the structure of the unit. She explained that the floor seemed disorganized, and there was a nurse substituting for the nurse manager, who had left several months ago. Nurses were complaining about not having regular schedules and having to work overtime. Beth felt “cheated” by this clinical experience and added, “I could tell these nurses were unhappy and overworked, but we have such a short time in clinical, I want to make the hours count.”
Helen is graduating from an accelerated program in a few months. “Honestly, it’s like Russian roulette. I would say we had really good preceptors about 50% of the time and those preceptors were wonderful nurses, inspirational and giving. They would pull me along into patient rooms, explain everything, and encourage me to help whenever possible. It’s ironic, but the nurses who were the least helpful seemed to have way too much to do, but I never saw them doing anything. I had to remember my father’s advice about the real world; for some people this is just a job.”
From the nurse-preceptor’s perspective
Maria graduated from nursing school last year and now works on a busy 37-bed telemetry unit. She felt that some students were overly judgmental, especially considering their inexperience: “I don’t mind being assigned a student who works hard and asks relevant questions. In fact, a good student will make my day go much easier. But sometimes I overhear students complaining about our clinical practice. It’s like they are trying to catch us making errors, and that makes me uncomfortable.”
As nursing school enrollments rise, there are proportionately more students on the unit, prompting scenarios like this one: “It’s impossible to precept so many students. Sometimes the instructor assigns two or three students to my cases. We have students on the floor three or four days a week now, and sometimes on the weekends. It’s too much!”
Some nurses talked about the pleasurable and sustaining benefits of precepting, but felt they weren’t recompensed for work they weren’t trained or paid to perform. For the last 4 years, David has worked the dayshift on a busy in-patient rehab unit. He explains: “In orientation, we went to workshops about everything from medication administration and patient safety issues to pressure ulcers and wound care, but no one explained our role as preceptor. I know it’s important to work with students, and I enjoy teaching, but we never receive compensation. It’s nice that students write thank you cards and bring cookies their last day, but it would help if management acknowledged our work.”
Let’s start talking
As we review the issues from both sides, it’s clear that a conversation needs to start between students and the nurses who precept them. Students want recognition that they belong and the opportunities to learn. Nurses may feel they have little time to teach, and aren’t reimbursed for the extra work involved in precepting. In addition, nurses may feel threatened by students who are critical and question their clinical judgment. An added burden is the large number of nursing students. As simulation labs become more popular, we may see less crowding on the floor, but we will also have students anxious to maximize every moment of their experience. A careful review of the issues suggests workable solutions both sides could explore.
Everyone needs to get on board
To develop as sensitive and caring preceptors, nurses need a supportive environment and encouragement from their administrators. Nurse managers should allot time and resources toward professional staff development. Along with encouraging continuing education classes on wound care and safety practices, forward-thinking managers will send their staff on work retreats, reward nurses who precept, and create workshops on leadership competencies, which include preceptor training. To address the burden on the nurse, hospitals may consider a reimbursement system to compensate nurses in preceptor roles. Finally, managers should acknowledge their professional service to students, and present the role of preceptor as a way to further their careers.
All too often, student nurses will undervalue their own relevance while inexperience may lead to overly critical and judgmental behavior. Students need to do their part by being avid listeners and observers while demonstrating strong initiative on the floor.
Good preceptors can show students how to instill a confident approach to their patients as well as in themselves. Nurses should remember that being part of a profession carries an added responsibility to share knowledge and promote excellence.
Ideally, the student/preceptor relationship is mutually beneficial. The student gains knowledge and confidence in growing clinical skills. The preceptor benefits by nourishing another individual while demonstrating expertise and advanced critical thinking.
Encouragement + support + lifetime learning = outstanding leadership
We need to encourage students and nurses to develop individual voices with common professional goals. Even in a stressful climate where nurses are burdened with high workloads, a more powerful group sensibility may emerge, with strong preceptors at the front leading students who can learn from the best.
Here is a summary of key points from both sides:
- Incentivize: Hospital management should consider remuneration for nurses who precept, or equally compensate with additional time off.
- To address time constraints for busy nurses, managers could reduce the workload by at least one patient whenever possible. Heavier cases should be reassigned.
- Nurse managers should include leadership curriculum in continued nursing education classes and encourage outside professional activities.
- Nurses need to acknowledge their preceptor roles and take the roles seriously. Nurses should strive to exhibit leadership qualities, even in stressful situations, and remember that students are looking to the preceptor as a role model.
- Students should take an active interest in their cases. Ideally, students will be proactive and demonstrate initiative during clinical.
- Students must be respectful to preceptors and work with them, not against them; build trusting relationships; and hold off on judging.
- Nursing instructors must be sensitive to the RN’s workload and mediate issues with tact and diplomacy.
If we all work together, we can make the clinical experience a positive one for both students and preceptors.
Karyn Lee Boyar is a clinical instructor at New York University College of Nursing, New York City. She is currently enrolled in the DNP program at Pace University in New York City.