ACUTE, PRIMARY, AND SPECIALTYCARE

PEDIATRIC NURSE PRACTITIONERPRECEPTOR TOOLKIT

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ACKNOWLEDGEMENTS

Special thanks to those who have supported the development of the Preceptor Workshop and

Toolkit:

Association of Faculties of Pediatric Nurse Practitioners

National Association of Pediatric Nurse Practitioners

Contributors

• Beth Heuer, DNP, CRNP, CPNP-PC, PMHS

‐ Children’s Hospital of Pittsburgh of UPMC; Robert Morris University

• Cynthia Danford, PhD, CRNP, PPCNP-BC, CPNP-PC

‐ University of Pittsburgh

• Jay M. Hunter, DNP, RN, CPNP-AC, CCRN, CPEN, CPN

‐ Cook Children’s Health Care System; University of South Alabama

• Jodi Bloxham, MSN, APRN, AC-PNP, PC-PNP

‐ University of Iowa

• Daniel Crawford, DNP, RN, CPNP-PC

‐ Arizona State University

• Shayna Dahan, MSN, CPNP, PMHS

‐ Hudson River Pediatrics

• Jessica Diver-Spruit, DNP, RN, CPNP-AC

‐ Wayne State University

• Amanda Lee, MSN, PPCNP-BC

‐ Access Community Health Network

• Maria Lofgren, DNP, ARNP, NNP-BC, CPNP, FAANP

‐ University of Iowa

• Audra Rankin, DNP, APRN, CPNP

‐ Johns Hopkins University

• Imelda Reyes, DNP, MPH, CPNP-PC, FNP-BC

‐ Emory University

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Table of Contents

Table of Contents 3

Background Information 6

The Growing Demand for Preceptors 6

Student Clinical Hour Requirements 7

A Few Words About Simulation Experiences 7

Affiliation Agreements and Legal Considerations 7

PART I- DEFINING THE PRECEPTOR 9

What is a Preceptor? 9

Roles of the Preceptor 9

Qualities of Good Pediatric Preceptors 9

Why Precept? 10

Professional Benefits of Precepting 10

Personal Benefits of Precepting 10

Paid Preceptor Opportunities 11

Learning to Precept 11

Coaching and Mentoring 12

Mentorship 12

Ideal Qualities of Mentors 12

The minuses to mentorship 13

Coaching Techniques 14

PART II- CONCEPTUAL FRAMEWORK 15

The Preceptor Learning Curve: Novice to Expert 15

Dreyfus Skill Acquisition Model 15

Table: Dreyfus Skills Acquisition Model 16

Bandura’s Social Learning Theory 16

Wilson’s Social Styles and Versatility 17

Table: Social Styles and Communication Orientation 19

Versatility 20

Communication Styles 20

Table - Generational Variations in Work Ethic, View of Time, Skill Building and

Authority 21

Table - Generational Variations in Communication, Motivation, and Mentoring Needs 22

PART III- PRECEPTOR TOOLKIT 23

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What Should Preceptors Expect From Academic Programs? 23

When Do I Call Faculty? 23

Site Visits 24

Student Preparation 25

What to Discuss BEFORE Clinical Starts 25

Information to cover 25

Orienting the Student 26

Expectations for Student and Preceptor 26

Student Skills: Ongoing Development 26

Introducing the NP Student to Patients and Families 27

When Patients Refuse to Work With Students 28

Critical Thinking Skills and Precepting Models 34

Reflective Journaling 35

Special Precepting Tools for Critical Thinking 36

The One-Minute Preceptor (OMP) 36

The SNAPPS model 37

Teaching Problem Solving Skills- Real time questions 37

Tips to Engage the NP Student in Pediatric Patient Encounters 38

Providing Patient Education 38

Encouraging Professional Development 40

Networking 40

Organizational Involvement 40

Table: Networking Strategies For the PNP Student and Preceptor 41

Continuing Education 44

Advocacy for APRNs 45

Professional Contribution 45

What to Do With The Difficult Student 47

Specific Student Types 48

The Shy or Dependent NP Student 48

NP Student Lacking Commitment 48

The Inflexible NP Student 49

The “Know-It-All” Student 49

The Unprepared NP Student 50

Question: Can you “Fire” an NP Student? 50

Self-Care for the Busy Preceptor 51

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Taking Care of Yourself During Busy Clinical Days 51

The Engaged Feedback Reflective Inventory 52

Managing Barriers in the Clinical Site 54

Preceptor Availability 54

Coordination and Communication with APRN Graduate Programs 55

Employer Support 55

On Site Barriers 56

Precepting in a Busy Clinical Setting 56

Precepting on Busy Days: Pre-Planning Activities 56

Precepting on Busy Days: Clinical Setting Considerations 57

Precepting on Busy Days: Time Management Pearls 58

Precepting on a Slow Day 58

Student Space and Electronic Health Record Access 59

CMS Documentation Guidelines for Students/Preceptors: 60

Providing a Well Rounded Clinical Experience 60

Managing Prescriptions and Orders in the Clinical Setting 62

Evaluation 62

Types of Evaluation 63

Formative Evaluation 63

Summative Evaluation 64

Student Red Flags 65

Appendices 66

Appendix: Developing a Philosophy of Clinical Education Statement 66

Appendix: NONPF Nurse Practitioner Core Competencies Content (2017) 67

Appendix: 3 Step Structured Process for Reflective Journaling 72

Appendix: Reflective Journal Rubric Score Sheet 74

Appendix: Mentoring Contract 75

Appendix: Site Specific Agenda and Objectives 77

References 78

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INTRODUCTION

Background Information

Nurse practitioner (NP) students require high-quality clinical hours with expert clinician

preceptors. Most recent available data indicates that an estimated 20,000 students graduated

from nurse practitioner programs in 2014-2015 (AANP, 2017). The number of NP students

requesting pediatric clinical placements exceeds the numbers of clinicians willing and able to

serve as preceptors (Miller & Kennedy, 2016).

According to Fulton, Clark & Dickinson (2017), “The role of the preceptor has become

essential in the educational process… and has as its goal the instruction of a neophyte in the

proficiencies of a new role.” Competent and confident preceptors are in high demand to meet

the need for high quality educational experiences. In addition to excellent clinical skills,

precepting skills include such variables as effective communication, flexibility, provision of

feedback and support, the ability to meet the different learning styles of adult learners , and

the ability to evaluate student knowledge and competencies (Burns, Beauchesne, Ryan-Krause

& Sawin, 2006).

Since these skills are not typically addressed in formal educational programs, preceptors may

lack the necessary skills needed to provide NP students with optimal learning experiences

(Horton, DePaoli, Hertach & Bowe, 2012). Education and training that covers teaching and

learning strategies, reflective and clinical reasoning, communication, and the preceptor role

are vital components of preceptor preparation (Bengtsson & Carlson, 2015; Windey et al.,

2015).

The Growing Demand for Preceptors

There is a great need to provide an exponentially growing number of NP students from

pediatric acute, pediatric primary, family NP, and other medical education programs with high

quality pediatric clinical educational experiences. To meet this need, preceptor demand is at

an all time high.

Competitors for pediatric clinical slots include: NP students, medical students, medical

residents, medical fellows, and physician assistant students. Competition for clinical

experiences in various teaching arenas needs to be recognized and addressed to meet current

and future demands for the healthcare provider workforce. There is a need to create

sustainable processes to recruit, train, retain, and recognize pediatric preceptors for NP

students, as well as developing partnerships between preceptors and NP faculty to achieve

mutually beneficial outcomes in healthcare and academia.

Student and preceptor assignments are established in a variety of ways. Faculty may contact

preceptors directly. Some universities have a designated academic affiliations coordinator

who contacts preceptors on behalf of the faculty and course. Some students are responsible

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for finding their own preceptors, and may put out requests through APRN group list serves, on

social media, or at local and national NP events. A number of health systems and clinics

provide online applications to manage their distance learning students. Some medical centers

act as the ‘gatekeeper’ and use a liaison department to manage student requests for preceptors.

In recent years, a number of paid agencies have been created to supply the demand and

contract preceptors on behalf of students who pay a fee for their services.

Student Clinical Hour Requirements

Students must a meet a minimum requirement of 500 supervised, direct patient care clinical

hours within their specialty during their educational program (National Task Force on Quality

Nurse Practitioner Education, 2016). This requirement is increased to 1,000 clinical hours for

BSN-DNP students. Individual NP program requirements vary, and may be dependent on

program and student level (BSN-DNP vs. MSN-DNP). It is the responsibility of the student

to obtain the clinical hours required for graduation, national certification, and licensure.

Clinical hours must offer a variety of experiences to help students become competent in basic

NP skills. According to Bargagliotti and Davenport (2017), “Simply specifying the number of

hours in clinical practice in certain settings did not consistently predict that all students would

have the opportunity to attain the core clinical competencies.”

A Few Words About Simulation Experiences

High-fidelity simulation educational experiences are utilized in many universities and medical

centers as a way of providing hands-on skills training for students. Using computer-based

mannequins that simulate physiologic responses to interventions, simulation labs can provide

real-time opportunities to practice technical skills and clinical decision making. Research has

demonstrated that simulation experiences enhance knowledge, skill performance, critical

thinking skills, and student satisfaction (Warren, Luctkar-Flude, Godfrey, & Lukewich, 2016).

While simulation experiences may be a key component in preparing NP students for the

advanced practice role, they augment and supplement, not replace, essential clinical hours and

educational experiences that are obtained through working with expert preceptors in the real-

world setting (NONPF, 2015).

Affiliation Agreements and Legal Considerations

Affiliation agreements are developed between educational institutions and clinical sites.

These agreements delineate the number of clinical hours needed by each student, the days that

preceptors will be available, the amount of liability coverage provided by the university for

each student, and basic information about where the student is within the program.

Affiliation agreements or contractual agreements typically undergo legal review by both the

university as well as the clinical site prior to approval. It is important to remember that

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preceptors are responsible for the care that is provided to their patients while they are

precepting students.

Students typically have documentation, training, and other requirements to complete prior to

entering a clinical setting. This may include signing confidentiality forms, verifying

information on immunization status, completion of background checks, and providing a copy

of his or her RN license. These requirements may vary widely among institutions and may

have different completion methods at each facility. Private practices may have the office

manager confirm this information, whereas larger medical institutions may have a student

liaison that works with universities who makes sure that NP students have provided the

required clearances and documents.

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PART I- DEFINING THE PRECEPTOR

What is a Preceptor?

Preceptors are experienced clinical practitioners who teach and role-model clinical skills to

novice practitioners (students, new graduates, or new employees). Development of preceptors

is critical in order to maintain a qualified APRN workforce. NP faculty and students rely on

access to high-quality pediatric preceptors to help students acquire real-time clinical skills and

to help validate their competency in these skills. Preceptors help students make the transition

from generalist-trained registered nurses to pediatric advanced practice nursing specialists.

According to Swihart & Figueroa (2014), preceptors “merge the knowledge, skills, abilities,

and roles of both coaches and mentors to help preceptees develop and mature into strong

practicing professionals…”.

Roles of the Preceptor

Preceptor roles, as described by Ulrich (2011), include:

• Teacher- enhance and expand the student’s knowledge and expertise

• Coach- teach the subtleties about how/when to use skills effectively

• Facilitator- create rich, positive learning environment for the student

• Leader/influencer- show how to use reciprocity within work relationships

• Socializing agent- introduce to the culture within the profession

• Protector- create a safe space for learning and asking questions

• Role model- exemplify what it’s like to know the job and do the job well

Qualities of Good Pediatric Preceptors

Throughout the literature, educators and students describe a number of effective clinical and

personal attributes of good preceptors, and in the case of this document, good pediatric

preceptors. In no particular order, here is a list of commonly described characteristics:

• Clinically competent in pediatrics

• Role model

• Constructive with feedback

• Interprofessional collaborator

• Warm

• Respectful

• Enthusiastic

• Empathic

• Nonjudgmental

• Fair

• Dependable

• Consistent

• Humorous

• Flexible

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Why Precept?

There are many personal and professional benefits to precepting. Some academic institutions

offer financial or other academic incentives, such as faculty titles or library access. Some

employers make precepting a required element for APRNs to apply for promotion. There are

significant altruistic benefits of teaching the next generation of pediatric focused APRNs.

Here is a non-comprehensive list of benefits (please feel free to add your own):

Professional Benefits of Precepting

• Narrowing the theory/practice gap by creating relationships between APRNs and NP

programs/ faculty

• Continuous learning, including updated knowledge of evidence-based care (Hudak,

Enking, Gorney, & Gonzalez-Colaso, 2014)

‐ The student can be a source of updated knowledge to the experienced clinician

• Interaction with faculty can give preceptor much-needed peer support (Barker &

Pittman, 2010)

• Research indicates that precepting can be inherently satisfying (Latessa, et al., 2013)

‐ Enjoyment of the teaching process

• Fulfillment of one’s “social contract”- the idea that we owe it to the student, to our

patients, and to ourselves (in part because these students will one day take care of us

and our families) (Onieal, 2016)

• Ability to reflect on one’s own practice through the eyes of the student

• Solidifying one’s identity as a pediatric-focused APRN

• Being viewed by patients/peers as well-respected and knowledgeable

Personal Benefits of Precepting

• Personal satisfaction

• Adds interest, challenge, renewal and enrichment to one’s daily work (Link, 2009)

• Obtain precepting hours for recertification credit through PNCB and ANCC (see

individual certification agencies for details):

‐ https://www.pncb.org/sites/default/files/resources/PC_CPNP_Recert_Guide.pdf

‐ https://pncb.org/sites/default/files/resources/AC_CPNP_Recert_Guide.pdf

‐ https://pncb.org/sites/default/files/resources/DUAL_CPNP_Recert_Guide.pdf

‐ http://www.nursecredentialing.org/RenewalRequirements.aspx

• Completion of institutional requirements for career ladder advancement

• Building of one’s curriculum vitae (CV)

• Networking opportunities

• Adjunct faculty appointments

• Increased opportunities for guest lecturing and dissemination of one’s work

• Availability of university resources (such as library access, faculty discounts, etc.,)

• Contribute to ongoing program development

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Successful collaboration between clinical settings (hospitals, medical centers, practices,

clinics, etc.) and academic institutions can improve the benefits, rewards, and support for

clinical preceptors. Academic-practice partnerships have the ability to make the preceptor

feel supported and appreciated. They also have the potential to make graduate clinical

precepting more inviting and rewarding to future preceptors, strengthening their commitment

to the role (Donley, Flaherty, Sarsfield, Burkhard, O’Brien & Anderson, 2014).

Paid Preceptor Opportunities

While financial arrangements with clinical sites and preceptors are common among the

profession of medicine, it has not been a traditional practice in nurse practitioner education.

In the medical school community, clinical departments at hospitals may pay lump sums to

ensure that department heads make time for their clinicians to lecture and provide training to

medical residents (Physician Assistant Education Association, n.d.). When it comes to

partnerships with academic institutions and healthcare facilities, a partnership model is likely

to have better long-term positive results than a purely financial relationship.

In recent years, a new business model has emerged that is based upon matching nurse

practitioner students to preceptors for a fee. These businesses screen students, vet preceptors,

and advertise their ability to reduce administrative time for the preceptor and the clinical site.

Clinicians working as preceptors for these businesses are paid a portion of the collected fee

for their clinical time. Some of the paid preceptor services include: www.preceptorlink.com;

www.nursepractitionerclinicalrotations.com; www.npclinicalmatch.com; and

www.clinicaltrainingnetwork.com (Dallas, TX area).

Learning to Precept

Precepting can be and is often done without formal training. However, precepting is best

performed after acquiring a specific set of skills that includes understanding of adult learning

concepts, effective communication practices, clinical teaching techniques, and evaluation

methods. There is a learning continuum for the preceptor, as one moves from novice to

expert. This educational process typically doesn’t happen in the classroom. It comes from

experience in your real life clinical environment. Reflect back on the qualities of your own

preceptors and mentors. How did you learn and grow in your role as an APRN? What

techniques worked effectively for you? What techniques didn’t work? How can you bring

together the best of your experiences to best precept your NP students?

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Coaching and Mentoring

Mentorship

There is a difference between serving as a preceptor and serving as a mentor. The preceptor

relationship is defined by time periods and delineated objectives for clinical learning.

Affiliation agreements are established between the educational institution and the clinical site,

and there are specific legal arrangements within the preceptor/student relationship. On the

other hand, a mentoring relationship is long-term, voluntary, and typically does not have an

established end time (Lazarus, 2016). The mentoring relationship can be formal or informal.

A formal mentoring relationship may include development of a formal contract delineating

expectations for both parties (see Appendix: Mentoring Contract). An informal mentoring

relationship can be as simple as having a respected experienced colleague who provides wise

counsel and guidance as needed. The guidance may be general in nature, or specific to a

particular area in which the mentee seeks guidance from the mentor.

The preceptor/student relationship can morph into a mentor/mentee relationship if there is a

good ‘fit’ between the participants. For the mentee, benefits of this relationship can include:

increased self-confidence, enhanced judgment, improved leadership ability, personal and

professional growth, and a higher level of career commitment. For the mentor, the

relationship can improve collegial relations, increase opportunities for collaboration, create

stronger professional networks, and greatly enhance personal satisfaction (Green & Jackson,

2014). It should be noted that mentors need not be more experienced or knowledgeable in all

areas than mentees. For example, a NP with decades of experience may seek mentorship from

a new NP in the areas of technology use in patient care or contract negotiation in today’s

healthcare market, whereas that same new NP may seek mentorship from the experienced NP

in areas such as interdisciplinary practice or clinical decision making. The relationship can be

fluid and mutually beneficial.

Ideal Qualities of Mentors

Cho, Ramanan & Feldman (2011) reviewed the qualities of admired mentors, and found five

common attributes:

1. Admirable characteristics

a. Included kindness, justness, and outgoing and interactive personalities. One of

the most commonly used descriptors was “selflessness”

2. Mentors provided support and guidance for their mentees’ careers

a. Described as setting high standards and realizing the mentee’s potential,

tailoring/individualizing the support provided, offering numerous opportunities

for recognition and promotion, and engaging in concrete activities to foster

career development

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3. Strength of time commitment

a. Contact was frequent and viewed as high-in-quality; mentors were viewed as

available and provided guidance over long periods (even decades)

4. Support of personal/professional life balance

a. Provided guidance on leading a full, balanced home life; offered support

during times of stress in mentees’ lives

5. Legacy of mentorship

a. Provide guidance as mentees move into mentor role themselves

Mentors may provide guidance in many areas of service, research, education, and leadership.

In a clinical mentoring relationship, the novice can learn to make decisions as a pediatric-

focused APRN. As a mentor in this area, your role includes demonstrating how to assess

clinical situations appropriately using intuition, knowledge, and experience during clinical

reasoning, and exhibiting narrative thinking throughout the decision-making process.

Through narrative thinking, you are describing the situation, providing meaning for your

clinical impressions, and talking through your decision making process based on your

knowledge and experience. You bring your unique life experiences and clinical experiences

to a mentoring relationship, and can offer insights that the mentee may only learn otherwise

by trial and error (Hnatiuk, 2012).

Another way of looking at being a MENTOR (Souba, 1999) is with the following mnemonic:

•Motivate

•Empower and Encourage

•Nurture self-confidence

•Teach by example

•Offer wise counsel

•Raise the performance bar

The minuses to mentorship

In a close interpersonal relationship, there can be arguments and disagreements. Mentoring

relationships can become dysfunctional. The mentor has perceived ‘power’ in the

relationship, and it is essential that the mentor and mentee maintain strong ethical standards.

Unethical behaviors can include taking credit for the mentee’s work, delegating only

undesirable tasks that do not contribute to the mentee’s growth, and intentionally excluding

the mentee from growth opportunities.

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Don’t be a difficult mentor. Green and Jackson (2014) describe 5 types of dysfunctional

mentors:

• Avoiders (not accessible to the mentee)

• Dumpers (letting your mentee ‘sink or swim’)

• Blockers (trying to block the success of the protegee)

• Destroyers/Criticizers (undermine the work of the mentee)

• Smotherers (expecting your mentee to become your ‘clone’

Coaching Techniques

The preceptor takes on the role of coach as the PNP student transitions from the role of the

RN with varied clinical experiences or expertise to the pediatric-focused APRN (Link, 2009).

Coaching is “not just about learning the skill; it’s about how and when to use the skill and how

to use it most effectively…” (Ulrich, 2011)

The goal of the preceptor/coach is to facilitate “safe passage” into the new role. The

experienced APRN helps to develop the NP student’s knowledge and skills, and also inspires

the student’s confidence in the ability to use these skills.

The preceptor/coach should exhibit competence in these 4 areas: 1) clinical competence; 2)

technical competence; 3) interpersonal competence; 4) regular engagement in self reflection.

Clinical and technical competence for the pediatric APRN is mostly self-explanatory.

Preceptors must possess the knowledge and the skills to competently teach advanced practice

students. Interpersonal competence refers to the preceptor’s ability to recognize/accept the

student’s unique needs and personality, respond empathetically to the student, and encourage

information sharing and feedback. Self-reflection on both positive and negative clinical

experiences occurs in two ways. First, ‘reflection in action’ occurs as one discusses care

processes in clinic in the moment. Second, ‘reflection on action’ occurs after completion of

the patient encounter.

There are many professional and sports coaching models offering ‘6 easy steps’ or ‘8 easy

steps’ to coaching others. Key concepts throughout these models include being supportive,

focusing on goals, initiating a plan, and evaluating progress.

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PART II- CONCEPTUAL FRAMEWORK

The Preceptor Learning Curve: Novice to Expert

The learning continuum from novice to expert doesn’t happen in the classroom. It comes

from experience in your real life clinical environment. The ‘From Novice to Expert’ nursing

theory, introduced by Patricia Benner in 1982, is based on the Dreyfus Skill Acquisition

Model. This theoretical framework can help preceptors understand the evolving stages of

clinical competence. Preceptors will evolve in their role as a clinical educator with time and

practice. It is also helpful to understand skill acquisition as it applies to the NP student.

Dreyfus Skill Acquisition Model

The Dreyfus Skill Acquisition Model (Dreyfus & Dreyfus, 1980) gives perspective on the role

transition path that we have all experienced and sometimes still experience. Have you ever

said to yourself, “I thought I was good, but I have so much more to learn. Will I ever be good

enough?” The learning curve vacillating from an expert to novice and building back up is not

an easy one. NP students are somewhere on this trajectory and you as a preceptor may also

find yourself on this trajectory. This learning curve can be a difficult struggle for some NP

students. Students may rely heavily on their previous experiences as an RN, and exhibit

rigidity in various learning opportunities. Finding out where they think they are on their

‘roller coaster ride’ may help you to provide more effective precepting experiences.

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Table: Dreyfus Skills Acquisition Model

Table notes: Typical APN role development pattern. 1a, APN students may begin graduate school as proficient

or expert nurses. 1b, Some enter as competent RNs, with limited practice experience. Depending on previous

background, the new APN student will revert to novice level or advanced beginner level on assuming the student

role. 2, A direct-entry APN student with no experience would begin the role transition process at the novice

level. 3, The graduate from an APN program is competent as an APN student but has no experience as a

practicing APN. 4, A limbo period is experienced while the APN graduate searches for a position and becomes

certified. 5, The newly employed APN reverts to the advanced beginner level in the new APN position as the

role trajectory begins again. 6, Some individuals remain at the competent level. There is a discontinuous leap

from the competent to the proficient level. 7, Proficiency develops only if there is sufficient commitment and

involvement in practice along with embodiment of skills and knowledge. 8, Expertise is intuitive and situation-

specific, meaning that not all situations will be managed expertly. For the purpose of illustration, this figure is

more linear than the individualized role development trajectories that actually occur.

Bandura’s Social Learning Theory

The concept behind Bandura’s Social Learning Theory (Bandura, 1973) is that people learn

new ideas and develop new behaviors and/or skills by observing and imitating others. This

model stresses that behavior, person and environment are the important components in the

learning process, and all of them continually influence each other. Environmental factors may

include social aspects (peers, teachers) and physical factors (the setting in which one is

learning).

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The four components of the modeling process are: attention, retention, reproduction and

motivation.

• Attention simply means that the learner needs to pay attention to learn the new skill

• Retention means that the learned information is retained and can be retrieved by the

learner for later use

• Reproduction means that the learner can then exhibit the skill that has been modeled

for him/her

• Motivation means that the learner wants to continue imitating the behavior

The preceptor/student relationship is a perfect example of social learning theory in action.

The student learns by observation and imitation/repetition of desired skills and behaviors.

The preceptor models exam techniques, critical thinking skills regarding differential diagnoses

and treatment planning, appropriate interactions with the parent-child dyad, and use of

evidence-based practice. The student learns by example, complemented by their didactic

training, previous precepting experiences and their own clinical experiences and world-view.

Wilson’s Social Styles and Versatility

According to Wilson (2004), social style refers to how we habitually communicate and

interact with others. The purpose of the Social Style Model is to help you know others and

yourself better in order to improve your ability to communicate with each other and avoid

misunderstandings.

Social style is a theory created by two psychologists –Roger Reid and David Merrill, who

posited that everyone has natural behaviors and a preferred style of communication. Social

style is based on the perception of one’s behavior by others. It is important to note that there is

no correlation between social style and personality.

This model uses two dimensions, assertiveness and responsiveness, to identify four social

styles on the quadrant.

Assertiveness is the way in which you are perceived to influence the thoughts and actions of

others. Some people tend to be more “ask assertive” while others tend to be more “tell

assertive.”

• People that are “ask assertive” tend to be deliberate and will pause often. They

seldom interrupts and are seldom emphatic. They tend to make conditional

statements. The authors describe that people with this style tend to “lean back”.

• People that are “tell assertive” tend to display quick, firm speech and make

declarative statements. They often interrupt and are quite emphatic. The authors

describe that people with this style tend to “ lean forward”.

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Responsiveness is the way in which you are perceived to express feelings when

communicating with others. Some people are “task responsive” and prefer focusing initial

communications. Others are “people responsive” and prefer to focus on the people working

on the task.

• People who identify as “task responsive” talk about tasks, facts. They make minimal

body gestures, limit facial expressions and avoid exposing their personal feelings.

• Those who are “people responsive” talk about relationships and easily expose their

personal feelings. The make many varied body gestures and exhibit varied facial

expressions.

When you plot your responsiveness and assertiveness against those two dimensions you find

your social style: Analytical, Driver, Amiable or Expressive, as shown in the diagram. Note

that people are generally not good observers of their own behavior. Gathering the perceptions

of others whom you know or work with might be the best way to ascertain your style.

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Table: Social Styles and Communication Orientation

Basic Social Styles and Communication Orientation

Analytical (Process-Oriented)

Communicates about:

● Facts and Figures

● Policies and Organization

● Planning and Forecasting

● Analysis and Control

Controls Driver (Action-Oriented)

Communicates about:

● Getting Things Done

● Objectives and Results

● Performance and

Productivity

● Efficiency and Moving

Ahead

● Decisions and Achievement

Asks ⇅⇆ Tells

Amiable (People-Oriented)

Communicates about:

● Needs and Motivations

● Teamwork and Team Spirit

● Feelings and Beliefs

● Values and Self-Development

Emotes Expressive (Idea-Oriented)

Communicates about:

● Innovation and Change

● New Ways of Doing Things

● Creativity and Possibility

● Alternatives or Options

Typical Characteristics

• Analytical style- Those with this style focus on facts and logic. They will act when

the payoff is clear, and are careful not to commit too quickly

• Amiable style- Prefer to coach and counsel. They provide support and communicate

an air of trust and confidence

• Driver style- Tend to take charge, make quick decisions, and like challenges. They

focus on results

• Expressive style- These people motivate, inspire, and persuade. They create

excitement and foster involvement. They prefer to share ideas, dreams, and

enthusiasm.

There is no right or wrong social style. No particular style is more successful than another

and no one style is better suited for a leadership position than another. The bottom line is that

the ability to adapt to different styles is associated with high performance.

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In general, people are more comfortable interacting with those with a similar styles to

themselves. That’s why you can communicate more effectively if you learn how to be

versatile. In other words, learn how to change your behavior to match the person with whom

you are communicating.

The key is to avoid trying to fit people into one the four boxes or expecting them to behave a

certain way because of their style. Instead, use your understanding of their social style to alter

your own behavior as you communicate with them. Make an effort to adjust your

assertiveness and responsiveness behaviors, and then observe your efforts. Evaluate whether

your efforts to modify your behavior have the intended effect. If not, re-examine your

behavior and try to readjust further.

Versatility

Because about 25% of people fall into each of the social style categories, we most likely share

a social style with only about 25% of the people we meet. So what about the other 75%? This

is where versatility comes into play. Think about adaptability when you hear the term

‘versatility’. Over time we learn to adapt and modify our approach based on interactions and

responses and based on our previous communication experiences. It is a skill that can be

learned, and it is an important skill related to communication.

To understand versatility and how it can affect relationships, consider people with whom you

have regular contact. Do you know someone who is "too reserved" for your taste? Is there a

manager, coworker or family member who seems to you to be "too opinionated," "too

emotional," or "too willing (or unwilling) to compromise?" There is a good chance that your

reactions to these people are an indicator of differences in Social Style—how we habitually

communicate and interact with others. When you find it easy to communicate and work with

someone, there's a high probability you share the same social style. When your

communication is difficult, it is often because of unrecognized social style differences.

Being versatile is the answer to decreasing tension and stress in a relationship that may

adversely influence performance or interaction. It is important to understand differences in

communication preferences and work with others in a way that makes them feel more

comfortable. As the preceptor, you can adapt your style in order to make others more open

and receptive. In doing so, you can foster more effective and productive relationships,

making it is easier to work together with others toward shared goals

Communication Styles

Talking about experiences can help novices reflect on performance, consider alternative

actions, and vent frustrations (Shellenbarger & Robb, 2016). A potential disconnect in

communication is an issue that may need to be resolved. How you think may not be the same

as how the PNP student thinks. Bridging this gap might need to be a joint venture (Venter,

2017). Start off by identifying your communication style and that of the NP student.

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Are you and your student on the same page? When in question it is always good to

consider your social style and work to be versatile. But understanding variations in approach

by generation can also shed light on why your interactions are successful or not.

Understanding these differences can shed light on ways that you identify can become more

versatile.

Table - Generational Variations in Work Ethic, View of Time, Skill Building and Authority

Traditionalists Baby Boomers Generation X Millennials

Birth Year 1900-1945 1946-1964 1965-1980 1981-2000

Work Ethic • Dedicated

• Pay your Dues

• Respect

authority

• Age = Seniority

• Company First

• Driven

• Workaholic - 60

hrs/weeks

• Work ethic =

Worth ethic

• Quality

• Balance:Work

smarter, not

longer

• Eliminate the

task

• Self-reliant,

skeptical

• Want structure/

direction

• Ambitious

• ”What’s next?”

• Multitasking

• Tenacity

• Entrepreneurial

View on Time • Push the clock

• Get the job done

• Workaholics

• Invented 50 hr

work week

• Visibility is key

• Project oriented

• Get paid to get

job done

• Effective

workers; but

gone @ 5 pm

• Work: a gig

filling time

between

weekends

View skill building • Training on the

job

• New skills

benefit the

company not the

individual

• Skills important

to success but..

• Not as important

as work ethic &

“face time”

• More known, the

better.

• Work ethic

important, but

not as much as

skills

• Motivated by

learning; want

immediate

results.

• Training

important; new

skills will ease

stress

Authority Respectful Impressed Unimpressed Relaxed

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Table - Generational Variations in Communication, Motivation, and Mentoring Needs

Traditionalists Baby Boomers Generation X Millennials

Birth Year 1900-1945 1946-1964 1965-1980 1981-2000

Communication • Discrete

• Show respect for

age

• Formal logical

• Protect their time

• Slow-to-warm up

• Hand-written

notes/personal

interaction

• Diplomatic

• In person

• Present options

• Dislike controlling

words/manipulation

• Establish friendly

rapport

• Like consensus

• Blunt/Direct

• Immediate

• Straight

talk/present

facts

• Email as #1 tool

• Informal

• Short sound

bytes

• Tie message &

results

• Polite, positive,

respectful,

motivational

• Email/Voicemai

l #1

• Not good with

personal

communication

• Prefer

technology

Motivated by • Being respected

• Security

• Being valued,

needed

• Money

• Freedom/No

rules

• Time off

• Working with

bright people

• Time off

Mentoring • Support long-term

commitment

• Actions w/ focus

on

standards/norms

• Respect

experience

• Let them define

the outcome both

want

• Need to know they

are valued

• Follow-up, check

in, regularly; do not

micro-manage

• Emphasize strong

team & their role

• Casual

environment

• Allow flexibility

• Hands off

approach

• Work with, not

for you

• Prepared/Ask

“why”

• Information

provider, not

boss

• Welcome &

nurture

• Challenge &

respect

• Offer peer-level

examples

• Provide info &

guidance

• Options: flex

time

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PART III- PRECEPTOR TOOLKIT

What Should Preceptors Expect From Academic Programs?

The preceptor should have reasonable expectations for supervising faculty when agreeing to

take on NP students. The preceptor needs to have both the student’s and the faculty member’s

contact information. Faculty should provide a copy of the course curriculum and provide

access to the syllabi and course content. Access to the curriculum may help the preceptor

identify patient cases that are aligned with the content being covered in that week of their

didactic course.

The preceptor needs to understand the course objectives and the individual student’s

objectives. This will help to determine the types of learning opportunities that will best suit

the student’s needs. The goals and objectives for the semester should be crystal clear.

Different semesters in an academic program represent different time points and progress

throughout the program. It is important to understand if the student should be mastering the

skill of obtaining and documenting a complete history and physical, or if they should be

developing differential diagnoses and describing the evaluation of the patient.

Preceptors need to review the student evaluation tool at the beginning of the semester so that

they can have a sense of what is expected of the student. It will also help the preceptor to

prompt the student’s growth and push them along through the process.

Reasonable expectations from faculty include:

• Faculty supports the student/preceptor relationship

• Faculty (hopefully) matches the student’s learning style with preceptor’s teaching style

• The academic institution provides a preceptor orientation (a preceptor handbook or

website may be sufficient)

• Faculty conveys expectations on how to assess student competency

• Faculty provides open communication on student progress

– Determine best method of communication (telephone, email, etc)

• Faculty provides periodic assessment of progress in the student-preceptor relationship

– Site visits

– Emails specifically to address progress

– Phone calls

– Video conferences

When Do I Call Faculty?

Issues with students can arise at any time, but calling the school/supervising faculty member

can feel like it’s a “drastic” measure. In a caring profession like nursing, we have a tendency

to want to ‘fix’ problems, even the problems of our students. When you precept, faculty are

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there to support you and are ultimately responsible for the student in your clinic. Don’t

hesitate to call for support, advice, or with any concerns. Summarize the concern(s), provide

examples, and include any steps toward resolution. This will help you to determine new

strategies with faculty. Ask for a site visit if you feel that it is necessary.

Here are some examples of appropriate times to reach out to faculty:

• Any concerns about student performance, including poor attendance or

unpreparedness for clinical

– Identification of red flags (See chapter Evaluation: Red Flags for Student

Behaviors)

– Safety issues

– When the student is ‘difficult’ (See chapter What to Do With the Difficult

Student)

• Mismatch with student

– Significant personality differences, and when attempts to resolve are

unsuccessful

• Mismatch of clinical site

– Your site cannot meet the student’s objectives or clinical needs

• When you or the student are receiving insufficient feedback and guidance from the

academic institution

Site Visits

The site visit is meant to focus on the student’s progress and the on the interactions between

the student and the preceptor. The preceptor will want to verify that the types of patients seen

in clinic are suitable, that course/student objectives are being met, and that the student is

performing competently. In addition, faculty can determine if the student and preceptor are

interacting well together. Make sure to schedule the site visits early and at a convenient time

for you, the preceptor. Extra site visits may be scheduled for new preceptors or when students

are experiencing difficulty.

Not all academic programs require site visits from faculty unless state law or other regulations

mandate this, especially in the case of distance learning programs. Communication

technologies, such as video conferencing, email, phone, and group messaging programs, can

be utilized to maintain ongoing contact between faculty and preceptors. Faculty must assess

whether students are seeing suitable amounts and types of patients in distance learning

programs. Detailed clinical documentation records should be maintained by the student for

each of the patients that they have seen, and these should be reviewed by faculty to assess

progress throughout the rotation. Electronic tracking systems (such as Typhon) are often used

by students to help augment this documentation.

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Student Preparation

What to Discuss BEFORE Clinical Starts

Be excited! We were all students once, and having a student can be a great experience.

Before clinical begins, review the student’s syllabus or course objectives. Some schools

prepare a preceptor manual that outlines all of this, or you can ask for guidance on the

student’s current clinical level.

Information to cover

• Contact information, what to do if late, etc.

– Urgent contact information if someone cannot be reached

• Dress code

– Appropriate attire for your setting meeting both academic and clinical

institution requirements

■ Scrubs, lab coat, color requirements

– Appropriate identification meeting both academic and clinical institution

requirements

– Reminder for pediatric students to limit strong smells in the clinical setting

• Scheduling and time management

– Time management skills are essential for the NP student. Learning how to

obtain H&P, develop plan of treatment, educate the child and family, complete

documentation, and manage unplanned events is an on-the-go skill important

for transition from student NP to graduate APRN.

• Rundown of patient encounters

– Clinic setting (well vs sick visits)

– In-patient setting (e.g. rounds, procedures)

• Documentation expectations: how, what, and where to document

• Direct the student to resources and evidence-based assigned readings

– Specialty-specific readings

– Have the student research evidence based guidelines and practice parameters

used in your clinical area (e.g. AAP, American Academy of Sleep Medicine,

American Academy of Child and Adolescent Psychiatry, Centers for Disease

Control, Society of Critical Care Medicine, etc.,)

– Review of pertinent assessment skills and developmental expectations

– Set the expectation that the student will explore and share new evidence

• Develop a small toolkit of essential resources for your practice

– Many preceptors develop a small toolkit of essential articles for their practice;

this can be a valuable tool for students. It is appropriate to expect them to

review some literature prior to the first clinical experience.

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• Provide a small resource guide with commonly-used community resources. This can

be a valuable asset to students as they move into the APRN role.

• Develop a list of objectives that you, as the preceptor, expect students to meet during

their clinical time with you (see Appendix: Site Specific Agenda and Objectives)

Orienting the Student

• Introduce student to staff and colleagues

– Let your colleagues know what education program your student is enrolled in,

the length of their rotation, and their extent of involvement in patient care

• Help student understand the patient population and services

– What types of children are served? Who does what?

• Discussion of organizational policies/protocols

• Post a photo/short bio about the student in staff lounge, waiting room, exam rooms

• Review organizational structure of your hospital, clinic, unit, and/or team as is

pertinent to NP student learning

• Review where pertinent forms, supplies, procedural areas, and other equipment are

located

• EMR training as appropriate

Expectations for Student and Preceptor

• Clear communication about what skills the student possesses and what skills they hope

to develop in that setting

• Ask questions and seek further clarification

• Ongoing feedback

– Discuss positive experiences and encounters

– Review opportunities for further growth

• Integration of evidence-based practice in clinical decision making and treatment

decisions

Student Skills: Ongoing Development

• Always remember that the NP student is already an RN, so NP students should be able

to do anything that they did as an RN from day one without supervision. Examples

include doing vital signs, giving immunizations, administering aerosolized treatments,

etc.,

• History taking and patient/family interview skills

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• Physical examination skills

– The student completes a physical assessment course prior to entering a clinical

rotation, so some basic physical exam skills should be expected. They may not

have mastered skills such as using an ophthalmoscope or otoscope in a small

child, but basic physical exam skills should be well-developed.

• Differential diagnosis identification

– This is often challenging for students early in their clinical education. It is

important to help students consider not only the most obvious diagnosis, but

discuss other possibilities and develop the rationale for selecting one

• Treatment, management, developing plans of care

– This is often one of the later skills mastered in graduate nursing education, and

will improve with the more clinical exposure students have

• Reporting and presentation skills

• Additional skills based on the clinical setting

– Procedures

– Specialty diagnostic modalities

– Simulation laboratory skills practice (if available at your facility)

• Prioritization and time management among scheduled and unplanned events is an

essential skill for NP students in all settings

– Scheduled events may include scheduled visits, progress notes, procedures,

H&Ps, rounds, patient management, education, and meetings

– In the acute care setting, be prepared for unplanned events (such as a

cardiopulmonary arrest), unplanned procedures, emergent patient events, rapid

response calls, and urgent staff support needs

– In the primary/specialty/ambulatory care setting, unplanned events may include

emergent visits, crisis intervention, lengthy visits due to significant illnesses

and medical complexity, and hospital transfers

Introducing the NP Student to Patients and Families

Make sure that you take a positive approach when introducing the student. Introduce him/her

as “NP student” NOT a “student NP”. Referring to the NP student is a subtle but meaningful

difference as the NP student is already an educated nurse. Also avoid referring to anyone as

“my student”.

• 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.”

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• Try to avoid having the family decline the student at the beginning of the encounter.

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 today. 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.”

• Depending on the clinical setting and the student’s level of experience, many

preceptors have the student introduce themselves to the patient/caregiver, tell them

that the preceptor will be in shortly, and start taking the history and performing an

exam.

When Patients Refuse to Work With Students

Tell child/family they were chosen specifically to give the NP student an opportunity to learn

and you will be there every step of the way. Always reassure patients and families that they

are getting the care that they would normally receive PLUS the addition of an intelligent,

detail-oriented, and motivated NP student. Other positive statements for the patient/family

may include telling them that the NP student is providing a “fresh set of eyes” and are an

excellent source for the “latest and greatest” information

Remind the child/family the NP student is an experienced RN who has worked with children

extensively (if they have). If they still refuse, reassure the NP student that it is not personal.

Guiding the NP Student Experience- Using Time Wisely

Appointment Modifications (applicable for ambulatory care settings)

In the clinic setting, it may be feasible to modify appointments so that the preceptor has time

and space to give the student a meaningful educational experience. An appropriate schedule

modification is to remove 1 appointment in the morning and 1-2 appointments in the

afternoon. This may reduce productivity so consult with your office in advance. Ideally,

managers will adjust the productivity equation for preceptors.

Observational experience (ambulatory care or acute care settings).

Depending on the student’s level of education/experience (as well as the clinical setting),

preceptors may choose to have the student observe as you complete the H&P, develop the

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treatment plan, and educate the family. This initial strategy to see how much supervision the

student needs. This is NOT an appropriate teaching strategy for more than the first few days.

Structured Approach (ambulatory and acute care settings)

This approach is best suited for a NEW student. Patients are carefully selected based on

student skills. Start with uncomplicated routine well visits, uncomplicated illness visits, or

scheduled cases and admissions in acute care and inpatient settings. Cases and encounters can

increase in number and complexity as the student progresses.

Prior to encounter, the student should:

• Complete a chart review and review the reason for the encounter, such as a well visit

for primary care or a scheduled operation with postoperative admission for acute care,

discussing pertinent issues with the preceptor

• Prepare components of anticipatory guidance and health promotion (primary care) or

develop an anticipated plan of care prior to the patient’s arrival (acute care). The

preceptor and student complete the encounter together,

• Student and preceptor engage in a formal pre- and post-encounter discussion

Acute Care Exemplar - Inpatient and Intensive Care Settings: “A list of expected

postoperative admissions is typically maintained in intensive care settings. As a preceptor, I

review this list for appropriate cases that would be appropriate for ACPNP students to

manage. I provide the student with the patient information, including the reason they are

having surgery. I have the student review the patient’s chart, discussing any pertinent past

medical history and relevance to the surgical procedure and postoperative plan of care. Next,

I have the student formulate an anticipated plan of care for that patient. We then complete

the postoperative admission together in the pediatric ICU, taking into account any pertinent

perioperative events or other previously undisclosed pertinent medical history. We adjust the

student’s anticipated postoperative plan as necessary, with a discussion of the case following

completion of the encounter.”

• This method can also be applied to anticipated transport admissions, oncology

admissions for chemotherapy or stem cell transplantation, or inpatient admissions that

are pending from the emergency department, just to name a few.

Primary/Specialty Care Exemplar: “I let the student know about how the clinic or clinical

day will run. I usually have the MA or nurse tell my patients that I have a student working

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with me that day and that they might see them for the initial part of the visit, and that nothing

will be done without my oversight and approval. Together we review the patient's chart and

discuss the case. I then have the student enter the room alone and introduce themselves as a

student NP. If the family refuses, the student respectfully accepts the patients request and

notifies me. We will then go in together and I will utilize this visit to observe the students

interactions with the family, ability to take HPI and perform a physical exam to be used for

both formative and summative evaluations. If a patient does not want a student to participate

or observe the visit, I respect the patients request and send the student into the next room to

start the next visit.”

“Typical” Clinical Day (ambulatory or acute care settings; may not be appropriate for some

specialty care settings)

This approach can work well with the beginning-to-advanced NP student. The NP student

assesses the child while preceptor is with another child/family. As the preceptor finishes with

their own patient, the NP student presents his/her the case to preceptor with diagnosis and

plan outlined. The preceptor then validates or modifies the diagnosis and plan with student in

the room. The student then implements plan with assistance as needed.

Primary Care Exemplar: “I have four rooms and will allow the student to enter one room as

I go into another. I am usually able to conduct a visit while my student goes into another

room. The student completes the HPI and PE and starts to develop a differential and plan to

present to me. I pull the student out of the room and have the student give me report, then we

go back in the exam room together. If the student and I have agreed on the plan, the student

reviews the plan with the patient/family and provides patient education. While the student is

wrapping up this visit, I head in to see another patient. When the student is done with their

patient they then start another visit and so on.”

Focused Half-Day (ambulatory and acute care settings)

The preceptor chooses 1-2 patients for the student to concentrate on while preceptor sees other

patients. Focus the encounters so that the student can develop experience with various child

ages, conditions, assessment skills, and treatment plans that match with their course

objectives. The student may use additional time to perform in depth chart reviews and delve

into research guidelines as they develop comprehensive plans of care for these patients.

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• This type of scheduling allows students to have an in depth experience as opposed to

just observation or limited exposure to a higher quantity of patients

• Great if you have a “crazy busy” day

Clinical pearl - Let students give the extra time to your patients who you know need a lot of

education and are time intensive. Have students take the extra time with these patients to

really practice and focus their comprehensive skill set on HPI, past medical history, family

history, social history, ROS, patient and family education, and explanation of the

comprehensive plan of care, etc.

Acute Care Exemplars:

“In emergency settings, give the student a couple of cases to follow that are especially

challenging or that fill an educational gap in their clinical experience. For example, in the

emergency department, the student may follow one complex case with multiple consults,

follow-up of diagnostic tests, etc., while the preceptor sees several other more straightforward

cases.”

“In intensive care settings, choose patients that fill a need in the student’s educational gap. If

the student is studying pulmonology during your rotation, assign the student to a case of

respiratory failure, and the student can focus their time on learning the varying levels of

respiratory support, ventilation modes and strategies, respiratory medications and treatment

modalities, etc.”

• These methods support in-depth rather than limited or observational experiences for

acute care PNP students.

Wave Scheduling (ambulatory care settings; may not be appropriate for some specialty care

settings)

In this approach, two or three patients are scheduled in one time block . The student sees one

patient while preceptor completes one or two patients. The remaining time at the end of the

block is used for feedback/consultation and completion of visit with NP student child/family.

Wave Scheduling Examples

1:00 pm: 2 patients scheduled in 30 minute block (student sees one; preceptor completes one)

1:20 pm: Consultation/feedback with NP student; Wrap up with child

1:30 pm: 2 patients scheduled in next 30 minute block (each see one)

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OR

1:00 pm: 3 patients scheduled in 30 minute block (student sees one, preceptor completes 2)

1:30 pm: Consultation/feedback with NP student; Wrap up with child

1:30 pm: 2 or 3 patients scheduled in next 30 minute block

“Sink or Swim”- Moving Toward Independence (ambulatory care settings)

This approach is best suited for a FINAL semester student. The idea is to simulate the

independent APRN clinical experience. The student is assigned a variety of patients and sees

them independently. The preceptor offers no visible support and there is minimal pre-visit

teaching. However, the preceptor is ultimately responsible for decisions and is available for

backup at all times. The preceptor will closely monitor the student’s progress and decision

making until he/she feels comfortable allowing the student to work independently.

In some acute care settings, this will be more difficult to do. Often, the student presents to a

large team in interprofessional rounds and receives feedback throughout the process. The

preceptor can take a more “hands-off” approach and allow the student to develop their plan

and to get feedback from other team members without first running everything by the

preceptor. The need for supervision is inevitable due to the nature of this complex care and

the involvement of interprofessional teams. The preceptor remains available for back-up and

is ultimately responsible for decisions to the extent that they are usually responsible.

Techniques for the Acute Care PNP Student

Make sure that the student is present and participates during rounds. Students should pre-

round and present patients if care model and patient flow allows. If this is not possible,

develop plans for students to learn these skills

When it comes to special procedures, see one, do one, teach one. Ensure that student knows

the basics (e.g., indications and contraindications for procedure, safety measures, equipment

needed, pain control, age-based considerations, etc.)

Preceptor should work closely with the student performing H&P, writing orders, and

developing the plan of care for new patients.

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Progression of student skills:

• Student shadows preceptor performing H&P and discuss Tx plan/plan of care

development

• Student performs H&P w/ preceptor observing/prompting and Tx plan/plan of care

developed together

• Student performs H&P w/ preceptor observing, allows student to develop Tx plan and

plan of care fully (preceptor then discusses necessary changes and/or further H&P data

that the student missed)

Plan that the student has increased/progressing autonomy as rotation progresses. Of course,

patient status can affect this process. Practice ongoing follow up, evaluation, and

modification of the treatment plan

• Prompt the student

– What are the results?

– What do they mean?

– How do the results change the plan of care?

Acute Care Exemplar: “Your student is working with you in the cardiac PICU. During

rounds, your student suggests ordering an echocardiogram to evaluate the cardiac function of

a patient that she is following. The interdisciplinary team agrees, and an echocardiogram is

ordered during rounds. As the preceptor, you want to give your student more autonomy and

allow them to progress in patient assessment, follow-up, and management decisions. While

your student is obtaining a H&P on a new, more stable patient, you check the EMR and see

that the echocardiogram results are available. You review them, noting that function is

improving, so you decide to continue with the current treatment plan. You then wait for the

student to follow up on the echocardiogram results and present the plan to you.

Did the student follow up? What is her interpretation of the results? Did she discuss the

treatment plan based on the results? How long did it take the student to prioritize this over

the other patients? This is an example of evaluating prioritization and time management in

the acute care setting.”

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Critical Thinking Skills and Precepting Models

All nurses have heard of the importance of “critical thinking” skills, but it is important to

define the concept in order to evaluate whether the student or clinician is engaging in the

behavior. Facione (1990) defined critical thinking as “purposeful, self-regulatory judgment

which results in interpretation, analysis, evaluation and inference as well as explanation of the

evidential, conceptual, methodological, criteriological, or contextual considerations upon with

judgment is based.” While RNs will have developed and utilized critical thinking skills in

their undergraduate educational programs and in their clinical practice, the APRN role takes

these skills to a new level.

Let’s break that down into what the preceptor needs to know to develop advanced critical

thinking skills in the NP student during their clinical rotation, and to measure/evaluate

their growth in those skills.

A 2000 consensus statement (Scheffer & Rubenfeld) identified/defined 10 affective

components (“habits of the mind”) and 7 cognitive components (skills) for critical thinking in

nursing.

Habits of the Mind

1. Confidence (assurance of one’s own reasoning abilities)

2. Contextual perspective (able to look at the whole situation, including the background,

environment and relationships)

3. Creativity (intellectual inventiveness)

4. Flexibility (ability to adapt, accommodate, or modify thoughts, ideas and behaviors)

5. Inquisitiveness (eagerness to know; seeking knowledge)

6. Intellectual integrity (seeking the truth honestly, even if results are contrary to one’s

assumptions)

7. Intuition (insightful knowing without conscious use of reason)

8. Open-mindedness (receptive to divergent views and sensitive to one’s biases)

9. Perseverance (pursuit of an action with determination to overcome obstacles)

10. Reflection (contemplation on a subject, especially for the purpose of deeper

understanding and self-evaluation)

Skills

1. Analyzing (breaking the whole into parts to discover its’ nature, function and

relationships)

2. Applying standards (judging according to established rules or criteria)

3. Discriminating (recognizing similarities/differences and carefully distinguishing

category or rank)

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4. Information seeking (searching for knowledge and evidence by identifying relevant

sources and gathering pertinent data from those sources)

5. Logical reasoning (drawing inferences or conclusions supported by the evidence)

6. Predicting (envisioning a plan at its consequences)

7. Transforming knowledge (changing or converting a condition, form or function of

concepts among contexts)

Stop for a moment and reflect (See? Critical thinking!) on your strengths and your weaknesses

in these areas.

Reflective Journaling

Reflective journaling is a structured way to deconstruct a patient situation and then evaluate

the thinking processes used during the situation. Raterink (2016) discussed the role of

reflective thinking and journaling as a way of helping students in reviewing clinical situations

and inferring from what was learned. Reflective journaling may be assigned by faculty, and

can be encouraged by the preceptor. Reflective journaling may be an adjunct (or alternative)

to writing SOAP notes. When students are unable to document in the EMR because of

program or institutional barriers, having them journal about the patient encounter using the

technique below can be a meaningful assignment.

As part of the student’s journal, the student writes a one-page journal entry about a specific

clinical experience. He or she reviews how they applied critical thinking skill or habit to the

clinical situation. The student reflects on their initial actions and thoughts, and focuses on

enhancing their critical thinking skills to improve clinical decision making. The expectation

is that the student will reflect on what they have journaled and learn from their own

experience (as well as by feedback from the preceptor and/or faculty).

Steps to writing the one-page reflective journal entry:

1. Frame the vignette or clinical scenario based on one element of the critical thinking

definition (may be a habit or skill)

2. Have the student support the actions of the vignette as a demonstration of that element

3. Format provided for the student to decide on how they would act in another (similar)

situation to demonstrate that same critical thinking habit or skill

IMPORTANT: Each step is only one paragraph. The entire journal entry is only one page.

The student practices writing succinctly and identifies only key elements from their

experience. See appendix for an example of a reflective journaling entry and rubric for

reviewing journal entries in Toolkit Appendices.

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Special Precepting Tools for Critical Thinking

Since the preceptor role and skills related to precepting are not taught during formal education

there are easy quick models that have been developed to quickly "teach" preceptors how to

precept effectively. Some examples are the One Minute Preceptor (OMP) and the SNAPPS

model.

Using a model allows for discrimination of rationale behind a student’s thought process.

Critical thinking can be very fluid and dynamic in APRN roles, and NP students will often

have flights of thought associated with this compared to their usual more concrete mode of

thinking in their nursing roles. These tools provide a process where the preceptor can ask

deliberate questions to distinguish rote memorization from applied evidence based practice.

The One-Minute Preceptor (OMP)

The One Minute Preceptor (OMP) is an evidence-based, time-efficient, learner-centered

teaching approach. The OMP is comprised of two phases. The ‘inquiry phase’ allows the

preceptor to probe the learner’s understanding of the case using open-ended questions. The

‘discussion phase’ gives the preceptor the opportunity to make a targeted teaching point and

provide positive/corrective feedback.

The OMP consists of five microskills for probing and guiding student reasoning. These skills

are as follows: 1) get a commitment from the learner regarding what they think is going on

with patient; 2) probe for underlying reasoning and supporting evidence for the learner’s

assessment; 3) teach the student general rules associated with the patient’s issue; 4) provide

positive feedback; 5) correct errors.

Here are examples of real-life questions to ask your student using the One-Minute Preceptor

model:

1. Get commitment to diagnosis and treatment option (ask: “What do you think is

going on? What do you do next?”) which encourages student to process and problem

solve

2. Probe for supporting evidence (ask: “What are major findings that lead you to that

conclusion? Why would you choose that treatment?”)

3. Teach general rules at level of students’ understanding (i.e. “When this happens do

this…”)

4. Give positive feedback (“You did an excellent job of _____________”)

5. Correct mistakes; allow student opportunity to critique their performance first

(ask: “Do you feel you addressed the mother’s questions?”) and provide constructive

feedback (“Next time this happens try ___”)

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The SNAPPS model

The SNAPPS mnemonic describes an efficient way for the student to present patient cases

and discuss clinical reasoning while allowing the preceptor to remain fully engaged in patient

care. This approach is learner-centered, with the student leading the encounter and the

preceptor coaching the student in examining his/her 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 case uncertainties

Step 5: Plan management for patient case

Step 6: Select a case-related issue for self-directed learning

Teaching Problem Solving Skills- Real time questions

In the clinical setting, students need to think fast and to be accurate. Decision making

increases in complexity as the nurse transitions into an advanced practice role. When you

precept, remember what it is like to be the student. The novice. The person who had to think

through things step-by-step instead of intuitively knowing the process. How did you think

through real-time problems? Ask your student the critical thinking questions that you no

longer need to methodically review.

For formulating the diagnosis:

What are the presenting symptoms?

What do I need to know NOW in order to know what to do next?

What assessment strategies must I use?

What do I know from the history? What don’t I know?

What are the physical exam findings telling me? What is abnormal? What is normal?

What are the differential diagnoses?

What further diagnostic information is needed?

Can I make a diagnosis now?

What is the most appropriate treatment?

For medications:

What is the evidence for the best choice in medication?

What are the dosing parameters?

What do I need to know about medication dosing and side effects?

What do I need to teach about medication dosing and side effects?

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For procedures (either diagnostic or treatment):

What has already been done? What were the results?

What is the evidence for suggesting this as the most appropriate procedure?

What do I need to teach about what to expect regarding the procedure?

Do I have the necessary skills and equipment to perform this procedure now?

To whom do I refer the patient?

Who is the best consultant to involve in this patient’s plan of care and treatment?

What information does the patient need to schedule an outside procedure?

How will I follow-up?

Ask questions about the student’s reasoning for the decisions that they’ve made.

Tips to Engage the NP Student in Pediatric Patient Encounters

Remind the NP student to WATCH you. Don’t just focus on the technical skill, focus on how

you interact with the child, elicit the exam, teach the family, and collaborate with other

professionals.

Role model how you approach the child or adolescent

• Sitting on ‘even ground’ with the child

• Using a relaxed conversation style

• Asking open-ended questions

• Tailoring the history and physical exam to the child’s age

• Making the exam fun

Note: This is applicable in all settings - if you don’t get on the child’s level, your success may

be thwarted!

Providing Patient Education

The undergraduate nursing education emphasizes patient education skills, and many NP

students have confidence in this area and find this aspect of patient care especially enjoyable.

Parenting topics, immunizations, explanation of disease processes and treatment plans, and

medication counseling are all essential topics, depending on the clinical setting. In addition,

the pediatric-focused primary care APRN may provide education on topics such as health

promotion, disease prevention, health maintenance, and care specific to disease processes.

The pediatric-focused acute care APRN may provide education on topics such as care specific

to disease processes, the structure of the team caring for the patient, monitoring (noninvasive

and invasive), procedure indications, nutrition, respiratory support, medications, and the daily

clinical decision making process, just to name a few.

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The APRN preceptor will work closely with the student to expand his/her patient education

skills within their new role. Patient education is integrated into all aspects of the child’s care.

The preceptor should identify teachable moments throughout patient encounters and role

model these skills to the student.

A helpful exercise often assigned by school faculty is to have the student complete a

patient/family education project for the clinical site. Pertinent topics for the patient

demographic should be discussed with the preceptor and clinical site in advance. Students

may develop handouts, tri-folds, posters, or bulletin boards with a topic of interest to families

in the clinical setting. Examples can include information on preventing infection, flu shots,

Lyme disease protection, toilet training, bulb suctioning infants, pain assessment, treatment

plan involvement, treating fever and discomfort, or introducing solid food to infants. This is a

value-added project for the site providing the precepting experience for the student.

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Encouraging Professional Development

As an experienced APRN, you bring a wealth of knowledge and experience to your preceptor

role. Your lived-experience can provide valuable information to students and encourage them

to take a more active role in the profession. It is important to discuss professional topics and

how you navigate these issues in your professional (and personal, but not too personal) life.

Topics may include:

Networking

Professional networking is an essential component of graduate education and clinical practice.

Advanced practice nursing students, faculty, and professionals benefit from forming and

maintaining a professional network of peers to bolster connectivity, enhance knowledge

sharing, and identify professional development and collaborative opportunities.

Benefits of networking include:

• Building relationships with APRN colleagues and faculty

– Developing support within pediatric peer group or place of employment

– Utilizing social media to maintain network

• Enhancing knowledge sharing

– Seeking clinical experiences in desired specialty

• Identifying professional development and collaborative activities within pediatric

specialty

– Co-authoring, presenting, research opportunities

Organizational Involvement

Help your student to understand that they can become involved in their professional

organization now and can take advantage of discounted student membership and conference

rates.

Benefits of organizational involvement are outlined in Table: Networking strategies for the

PNP Student and Preceptor)

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Table: Networking Strategies For the PNP Student and Preceptor

Networking Strategies Benefits

Join professional

organizations and

societies

• Access to practice resources, career center, continuing

education, policy statements

• Discounted rates for conferences and other educational

offerings

• Special interest groups (i.e. NAPNAP SIGs),

committee membership (i.e. NAPNAP Professional

Issues Committee) and advocacy opportunities

(NAPNAP Hill Day, Health Policy Summit)

• Medical specialty societies may be inclusive of APRN

membership and leadership

Professional organizations may include:

• National Association of Pediatric Nurse Practitioners

(NAPNAP)

• American Association of Nurse Practitioners (AANP)

• American Academy of Pediatrics (AAP)

• Sigma Theta Tau International (STTI)

• Society of Critical Care Medicine (SCCM)

• American Association of Critical Care Nurses (AACN)

• National Hospice and Palliative Care Organization

• Association of Pediatric Hematology and Oncology

Nurses (APHON)

• State RN/APRN organizations

Comprehensive nursing organization list:

https://nurse.org/orgs.shtml

Attend local, regional,

and national conferences

• Opportunities to network with local, regional, and

national colleagues with shared goals and interests

• Maintain knowledge of most recent evidence-based

clinical practice information

• Professional development and skills training in desired

area

• Opportunity to learn and share practice innovations

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through poster and podium presentations

• Can serve as planning or other committee member

• Often have intrinsic networking benefit

Seek clinical experience

in desired organization or

field of practice

• Become familiar with organizational culture and

practices prior to employment to determine appropriate

fit with student’s professional goals and skills

• Experience navigating organization’s EHR, practice

resources, and workflow will aid in transition into

practice, especially for new graduate PNPs

• Opportunity to start building relationships with

clinic/hospital staff during clinical rotations

Build relationships with

APRN preceptors and

faculty

• Preceptors, faculty may serve as mentors, professional

references

• Can share “behind the scenes” insight into

organization of employment

• May offer guidance, support in transition into practice

• Answer questions related to practice issues, licensing,

navigating practice resources

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Utilize social media to

establish and maintain a

professional social

network

• Following professional organizations, health

organizations, health and policy news sources, and

PNP leaders/innovators allows you to stay connected

with local, regional, and national network with shared

interests in pediatric health and hot topics in healthcare

• Access to social, professional support for those in

subspecialties

• Can engage in dialogue and promote exposure of

pediatric health topics, healthy behaviors, and pertinent

policy issues

• May join discussion groups and gain access to

crowdsourcing

• Universities and organizations enhance recruitment by

increasing visibility through social networks

• Access to local health information, concerns if state

public health department shares updates and patient

education via social media

(Ventola, 2014)

Social Media Platforms

• LinkedIn, Twitter, Doximity (HIPAA compliant), ENP

Network (www.enpnetwork.com), Facebook specialty

groups (Acute Care Pediatric Nurse Practitioner

Facebook Group has 700+ members), Instagram,

NAPNAP TeamPeds member network

(community.napnap.org)

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Develop “Community of

Practice” within peer

group or organization of

employment

• There is a social aspect to knowledge - “experience of

knowing is individual, knowledge is not”

• Community of Practice is defined as a “group of

people who share a concern, set of problems or a

passion about a topic, and who deepen their knowledge

and expertise in this area by interacting on an ongoing

basis”

• The group is informally bound by the participants’

perceived value in learning together

• Serves as support network during transition into

practice through graduate colleagues and within own

health system

• Group shares information, insight and advice, helps

problem solve, and acts as sounding board

• Encourages the contribution of others to complement

and further develop an individual's expertise

(Wenger, et al, 2002)

Continuing Education

To help your student understand how they can incorporate continuing education activities into

their professional life, discuss what CE means to you as a practicing APRN.

• Discuss with your student how many hours are required for your state, your

certification(s), and/or your institution.

• It’s also important for students to learn about required pharmacology and other

mandatory continuing education courses and credits. Talk about how you get these

credits and keep track of them.

• Discuss ways that to obtain CEUs and share your resources

– Grand rounds

– Journals providing CE articles

– Journal clubs

– Local, regional, and national conferences and symposia

– NAPNAP pedsCE

– Local APRN CE events

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• Invite students to attend local or national events to further enhance their knowledge

and to begin networking with other students and colleagues

Advocacy for APRNs

Advocacy is described as “the essence of professionalism” (Ryan & Rosenberg, 2015).

Participation in advocacy efforts is an effective way to create change. Students can begin to

understand the role of advocacy efforts in how they are allowed to practice, and in how it

affects their patients. Discuss scope-of-practice regulations and how they affect daily APRN

practice. Scope of practice issues may include collaborative practice agreements (depending

on your state) and how they are written. Are there limitations to practice or billing issues that

require change in your practice, in your state, or nationally? Discuss your involvement at

local, state, and national levels. As NAPNAP members, participation in grass-roots advocacy

and calls-to-action can lead to policy changes.

Example: “There are so many great things happening around the country with scope

of practice issues and care for our great citizens. In some states, APRN leadership

groups may host “APRN Day” or “Lobby Day” at the State Capitol. These events

help orient students to the legislative process. If you are engaging in legislative

training, invite your student to attend with you. Become involved in your local

professional organization to stay current on issues.”

Professional Contribution

Discuss your experiences and involvement within the profession. Have you held any local,

regional, or national offices? Do you participate in medical mission trips? Do you volunteer

with any outside organizations that benefit from your professional knowledge? Through your

experiences, help NP students learn that they can be involved in bettering society as part of

their APRN career.

Other examples include:

• Volunteerism

‐ Opportunities through NAPNAP’s TeamPeds member network

‐ Community engagement (providing healthcare services at free clinics, shelters,

etc.)

• Nurses on Boards Coalition

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• Writing for publication (peer-reviewed and consumer publications)

‐ Peer-reviewed journal articles

■ Writing original research articles or systematic reviews

■ If not actively participating in research, journals such as the Journal of

Pediatric Health Care and the Journal for Nurse Practitioners need

authors for clinical articles, case studies or continuing education

articles for publications

‐ Consumer publications

■ ‘Ready, Set, Grow’

■ Local parenting magazines

• Participation on journal editorial boards or as a peer reviewer

• Serving as an item-writer for the Pediatric Nursing Certification Board

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What to Do With The Difficult Student

At some point, most preceptors come across a student who poses more of a challenge to

engage and educate. To address the issue, you need to be able to clearly identify the area of

concern. We will discuss these ‘difficult student’ types individually, but they generally fall

into several major categories. Some students lack focus or basic skills. Some make rash

decisions or lack boundaries. Others struggle with development of critical thinking skills or

application of evidence-based practice guidelines. Some have difficulty communicating with

patients, preceptors or staff.

The preceptor can contribute to student difficulty by providing too much or too little guidance

and support.

• When the preceptor provides too much guidance, it can foster a sense of dependence

and keep the student from moving forward toward independence.

• When the preceptor provides too little guidance, the student can begin to flounder, also

inhibiting their ability to become confident and independent.

• Strategies for both of these issues are similar:

– Engage the NP student and review their objectives.

– Have the NP student talk with peers regarding the direction they are receiving

from their preceptors. Have them bring this information back to the preceptor

and strategize a realistic plan.

– Bring in faculty to help with the situation. View this as an opportunity for you

to grow as a preceptor and to enhance your ability to vary your educational

style for different styles of learners.

Another significant issue can be having a ‘mismatch’ with your assigned student. Mismatch

can result due to conflicting personalities, differing career goals (e.g., student is not interested

in your subspecialty), incongruence in understanding the clinical objectives, and differences in

work ethic.

• Strategies for managing mismatch include:

– Identifying and addressing a potential mismatch early

– Seeking faculty support

– Redefining clinical goals and objectives and approach for a successful pediatric

experience

– Asking for an early site visit by faculty to mediate and to help strategize

Do not hesitate to contact school faculty early on for intervention. Remediation is best

handled by faculty. It is NOT the responsibility of the preceptor to ultimately “fix” the

problem.

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Specific Student Types

The Shy or Dependent NP Student

Shy or overly-dependent students may be hesitant to approach the child/family, show little

initiative to seek new experiences, lack confidence, and prefer to shadow the preceptor and/or

other health care providers. If a student is having difficulty working independently to practice

their skills, he/she may need remediation by their academic program. The purpose of clinical

hours is to transition them towards independent practice. It would be an important thing to

notify faculty about this so they can provide additional support to this student so their clinical

hours can be most effective.

Strategies to help include:

• Capitalizing on the student’s strengths

• Encouraging skills-building in simulation labs

• Initially directing the NP student toward children/families that are more open, at an

age range that may be comfortable to the student

• Gradually introducing to patients of other ages

• Providing positive reinforcement

• Graduated approach to history, physical exam, and reporting

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

1. Joint history & PE x 3 visits or encounters

2. NP student history alone w/joint PE

3. Gradually increasing responsibility

4. Designate time to complete tasks

■ The detailed report

1. Allow detail initially to ensure the student has identified all

relevant information within a given time frame

2. Over a designated time guide NP student to focus on pertinent

positives and negatives

NP Student Lacking Commitment

The preceptor may sense a lack of motivation and commitment of NP student for successful

career development. These NP students may be at risk for failing the rotation. When the

preceptor finds that valuable time is being poorly utilized, it can lead to an overall frustrating

experience.

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Strategies to help include: • Discussing your concerns with the NP student to determine the cause. Often there is

another issue underlying the problem

• You may need to question a possible lack of appeal for the NP student’s career focus.

This is an excellent time to bring in your faculty contact to work with the student to

help establish the student’s focus and commitment to the program at this time

The Inflexible NP Student

When you encounter an ‘inflexible’ student, that student may be missing important learning

opportunities. They may exhibit a rigid approach to eliciting the patient history, and may not

be able to be flexible in their physical exam skills. These students have the potential for

unsafe practice. Inflexibility can compromise their interaction with the child/family, leading

to decreased trust.

Strategies to help include:

• Tactfully pointing out examples of inflexibility

• Discussing specific examples and resulting repercussions

• Discussing the effect on child and parents

• Identifying examples of how the NP student can show increased flexibility

• Discuss benefits of improved flexibility in patient encounters

The “Know-It-All” Student

The overly-confident, ‘know it all” student may proceeds too quickly through the child’s

history and physical exam. They are at risk for unsafe practice (e.g., not staying up-to-date on

the evidence, missing pertinent H&P data). The preceptor may question whether the student

can safely manage the child, and have concern that the student may make hasty mistakes. In

addition, these students are at risk for alienating other members of the child’s treatment team.

Strategies to help include:

• Reminding the NP student to provide rationale for differentials, management,

treatment plan

• Kindly pointing out omissions/errors

• Discussing how to maintain best practice

• Revisiting objectives to identify how NP student can improve

• Review ways to enhance intraprofessional collaboration

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The Unprepared NP Student

Above all, unprepared students can compromise the safety of the child in the clinic. These

students also impact time management within the clinic by having inefficient interactions with

child/family and poorly utilizing the preceptor’s time. Their lack of preparedness decreases

their progress toward the role of the professional APRN.

Strategies to help include:

• Reviewing both the NP student’s objectives and preceptor expectations

• Set measurable parameters

• Identifying critical points of preparation

• Reviewing pertinent evidence

• Specifying a realistic time for expected behavior change

• Providing ongoing feedback

Question: Can you “Fire” an NP Student?

Answer: Yes, … but …

Discontinuing the preceptor/student relationship starts with open discussion with the student

and with their assigned faculty member. It is essential that you are able to justify your

decision with evidence. This is often not an abrupt decision, and red flags may have been

noted throughout clinical time together. Remediation may have already been instituted.

Examples of issues that may lead you to terminate the relationship include:

• Lack of ability to followed the specified guidelines presented at the beginning of the

experience

• Inability to follow through or improve following constructive feedback

• Unsafe practice

• Compromising the care of the child/family

• Lack of respect for patients/families and toward other healthcare providers

• Late arrival; early departure

• Inaccurate, deceptive reporting

Typically, the preceptor would not be responsible for ‘firing’ the student. Once the preceptor

has addressed concerns with both the student and with faculty, the university can handle the

logistics of pulling the student from the clinical site.

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Self-Care for the Busy Preceptor

There is a fine balance to precepting, practicing, and having a life outside of your profession.

In finding the balance between productivity and effective clinical teaching, you may need to

modify your approach to precepting and work smarter, not harder.

The three dimensions of work burnout are identified as: emotional exhaustion,

depersonalization, and reduced sense of personal accomplishment (Maslach & Jackson, 1981).

Be aware of these signs in yourself and know when you need to stop and practice some

extreme self-care skills.

Think back to all of the techniques learned in health promotion classes, and try to practice

what you preach. Promote positive self care strategies, such as maintaining a healthy diet,

exercising regularly, using mindfulness and other stress management techniques, practicing

relaxation techniques, maintaining healthy interpersonal relationships and engaging in

meaningful spiritual growth practices.

Your precepting skills are needed in the workforce, so do what you need to do to minimize

experiencing burnout. Explore sharing the preceptor role with a colleague. Consider

precepting for only a half-semester OR offering students a one-day specialty experience in

your clinical setting. Avoid scheduling students every day. If you are truly overwhelmed,

take a semester off. The last piece of advice is a hard piece to give (and an even harder one to

take if you’re extremely driven or feel pressured in your work role). Learn to say ‘no’

sometimes. It’s OK to say ‘no’ if you’re exhausted and can’t provide a good clinical

experience because your heart and mind just aren’t in the precepting experience.

Taking Care of Yourself During Busy Clinical Days

In working with your student, make sure that the student’s contributions enhance the day, not

hinder your work. Remember that while every case can be a teachable moment, not every

case has to be. You and your student can focus on a smaller number of specific educationally-

valuable moments, especially as the rotation advances. By focusing on one or two key

principles each day (specific to the student’s goals), you can help the student learn without

sacrificing productivity.

Another way to stay focused is to set clear expectations up front. Be clear with your co-

workers and manager about what you can and cannot do while you’re precepting for the

semester. Be clear with faculty about what you need from them and when you have any

concerns. And be clear with your student on your expectations, on their progress, and on

whatever limitations may exist for you, your patients, and your clinical site.

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The Engaged Feedback Reflective Inventory

Developed by Rosa & Santos (2016), the Engaged Feedback Reflective Inventory is a method

of effective communication that can aid in self care of the preceptor. Rooted in concepts of

shared accountability, respect, and partnership, the inventory can help preceptors think

effectively about their interactions with students. By asking oneself the questions in the

inventory, the preceptor can think more clearly about his/her interactions and improve one’s

ability to listen more effectively to the student’s needs.

The guiding concept is that the preceptor allows him/herself to exhibit some vulnerability,

acting as an authentic presence and finding compassion for the student’s experience. The

goal is to promote a healthy professional relationship between the preceptor and NP student.

Review the questions below and think about your approach to students during discussions.

Enhanced communication can take some pressure off of the preceptor, making it feel like an

enjoyable experience and not just another task to be completed.

Reflective Question for the Preceptor (by the

Preceptor)

Signs of Readiness to Provide Engaged

Feedback

What does my body language reflect as we

communicate?

I’m ready to sit next to, rather than across from,

the student

Can I look at the challenges objectively? I’m ready to put the problem in front of us

Can I ask for clarification, let go of

assumptions, and address concerns ‘in the

moment’?

I’m ready to listen, ask questions, and accept that

I may not fully understand the issue

Can I identify, acknowledge, and celebrate my

student’s accomplishments?

I want to acknowledge what the student does well

rather than picking apart his mistakes

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Can I help build on the student’s strengths?

Can I help him to use those strengths in facing

challenges/obstacles?

I recognize his strengths and how he can use

them to address challenges

Can I accept that mistakes are a normal part

of the process? Do I provide constructive

feedback?

I can hold the student accountable without

shaming/blaming

Do I own and express responsibility for my

part in the process?

I’m willing to do my part

Am I thanking the student for their efforts?

Do I thank myself for being available to the

student?

I can genuinely thank the student for his efforts

rather than criticizing him for his shortcomings

Am I focusing on the student’s growth or

failure? Do I resolve challenges quickly or

prolong them unnecessarily?

I can talk about how resolving these challenges

will lead to the student’s growth and opportunity

Do I value vulnerability and honesty in

professional relationships, or does the concept

make me uncomfortable?

I can model the vulnerability and openness that I

expect to see from the student

Adapted from Rosa & Santos, 2016

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Managing Barriers in the Clinical Site

Preceptors’ most frequently reported self-identified barriers include “effect on productivity,

patients’ expectations for care by the provider, discomfort with the teaching role, competition

from other programs, space limitations, and short duration of experience” (Webb, Lopez &

Guarino, 2015). These authors conducted a large scale study and corroborated that main

precepting barriers include self-reported time constraints and productivity demands. This

Toolkit section will address these barriers and more, and provide solutions for preventing and

navigating such barriers in primary, specialty and acute care settings.

Commonly mentioned barriers to precepting include:

• Lack of available preceptors

• Gaps in communication from school

• Need for closer observation of student by nursing faculty

• 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

• Lack of support from practice, facility, hospital, or organization

Barriers Prior to Clinical Rotation Assignment

Preceptor Availability

Increased demand for nurse practitioners, including PNPs, and public recognition of their role

in healthcare delivery has lead to increased student enrollment in APRN programs at colleges

and schools of nursing (O’Connor, 2012). Clinical sites are often overwhelmed by requests for

NP student placements. This problem can be compounded by students who are required to

identify their own clinical training sites (Forsberg, Swartwout, Murphy, Danko & Delaney,

2013). In evaluating the greater demand and reduced training opportunities of nurse

practitioner education, Forsberg, Swartwout, Murphy, Danko & Delaney (2013) emphasize

“negotiating NP preceptors via relationships and goodwill are no longer the only viable

methods for securing NP training sites” (p. 71).

Graduate nursing schools should identify and offer incentives as able to engage and retain

clinical preceptors. Webb, Lopez & Guarino (2015) found a majority of preceptors were

incentivized by access to clinical references and resources such as online clinical reference

libraries, adjunct faculty status, tuition vouchers, and stipends were found to be the most

highly ranked incentives in their respective categories. Clinical preceptors are encouraged to

request such incentives and build long lasting relationships with graduate nursing programs,

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providing continuity for students, preceptors, and faculty navigating the clinical precepting

process.

Coordination and Communication with APRN Graduate Programs

Highly rated factors influencing individuals to precept include positive relationships with

faculty, students or nursing schools, and accessibility of program information. Clear

communication with faculty, availability of necessary program information such as copies of

syllabi, course objective, and contact information have all been found to be influential in

preceptors decision to precept (Webb, Lopez & Guarino, 2015). This process has shown to be

challenging if an organization utilizes a “gatekeeper” or clinical placement coordinator as the

lines of communication between faculty and preceptors may be disrupted. Additional

administrative burden lies in securing clinical contracts between schools and individual sites

that are in alignment with each organization’s legal department’s specific terms (Forsberg,

Swartwout, Murphy, Danko & Delaney, 2013).

To enhance communication with programs and avoid pre-precepting barriers, clinical

preceptors should

• Identify the point of contact for graduate program placement within their organization

– Is there a clinical placement or academic affiliations coordinator, or is this

determined independently by preceptors? Or a little of both?

• Be aware of standing contracts in place with programs, who maintains those contracts,

and who to contact when they are in need of establishment or renewal

• Obtain assigned students’ faculty contact information; if students assigned through a

clinical placement coordinator, preceptors should proactively establish relationships

with faculty placing and overseeing their assigned students

Employer Support

Some APRNs have activity restrictions placed by their employer, which may include limiting

or prohibiting precepting (Forsberg, Swartwout, Murphy, Danko & Delaney, 2013). In the

high demand healthcare environment, employers may prioritize areas including NP

contribution to productivity demands, quality improvement project participation, and

supervision of nursing practice.

When advocating for the ability to precept, it is important to highlight to employers there is

negligible relevant data on lost productivity secondary to precepting and that sites often hire

graduates they have precepted (Farwell, 2009 & Forsberg, Swartwout, Murphy, Danko &

Delaney, 2013). Offering clinical experience through precepting serves as a great recruitment

tool and provides a foundation to support new graduate providers’ transition into practice

within an organization.

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On Site Barriers

Precepting in a Busy Clinical Setting

Every day is a busy day in the clinical setting (Burns, et al., 2006). To prepare for managing

this expected reality, Wirtz Rugen & Jorbridge (2016) partnered with the National

Organization of Nurse Practitioner Faculties (NONPF) and outlined strategies for overcoming

precepting barriers related to a busy clinic schedule. To enhance preparation and reduce

administrative burden on a student’s first day at the clinical site, they outlined tasks to

prioritize prior to a students first day in clinic and tips for navigating a busy day in clinic that

are summarized below.

Precepting on Busy Days: Pre-Planning Activities

• Pertinent information to be reviewed prior to start of clinical rotation includes:

– Start date, end date, total hours, and number of days per week in need of

precepting

– Clear guidelines for rotation including preceptor expectations

– Student’s resume, synopsis of past clinical experiences

– Student’s preferred learning style

• Consider developing a questionnaire template for students to complete including a

review of students goals, learning style and past experiences to review with the student

prior to their first day in clinical (Burns, et al., 2006)

• Share information about your practice and expectations for precepting experience in

written form (i.e. handouts, PowerPoint) that can include:

– Details regarding preceptor’s clinical practice, type of patients seen (i.e.

primarily adolescents, full pediatric practice), common medical conditions,

hours of clinic, and contact information

– Typical schedule, pressures faced daily

• Provide orientation to clinic site, policies and procedures PRIOR to the first day of

clinical; arrange tour of facility, introduction of staff (this may be done by

administrative/clerical person in place of preceptor)

• Provide a list of pediatric clinical guidelines and resources to review prior to starting

rotation that may include:

– Preventive Services and Screening

■ American Academy of Pediatrics Periodicity Schedule

■ Bright Futures handbook

■ CDC Immunization Schedule

■ Lead, anemia, tuberculosis screening guidelines

■ Sports Physical screening requirements

– Adolescent right to confidentiality, healthcare services in your state of practice

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– Developmental, ADHD, Depression, Anxiety, Substance Abuse screening tools

– Current treatment guidelines for sepsis, pediatric acute respiratory distress

syndrome, RSV, transfusion recommendations, etc.

– Protocols developed to treat specific disease processes in your clinical setting

• Episodic and Chronic Disease Management

– Antibiotic selection guidelines in common pediatric episodic illness such as

acute otitis media, acute otitis externa, strep pharyngitis, bacterial

conjunctivitis, community acquired pneumonia

– Pediatric dermatology resources for managing common conditions such as

eczema, acne, and common fungal/viral/bacterial rashes such as tinea, hand

foot and mouth, and impetigo

– Asthma guidelines including stepwise approach for managing asthma,

classifying asthma severity and initiating treatment, and assessing asthma

control and adjusting therapy by age and screening forms including the Asthma

Control Test

• Develop template for students for documentation and and case presentations (i.e.

SOAP format) for both episodic and preventive pediatric visits, H&Ps, consultations,

and daily progress notes

• Share templates for routine pediatric health maintenance used at your organization

Precepting on Busy Days: Clinical Setting Considerations

• Consider first day as observational experience

– Student may watch encounter, learn flow of clinic, and EHR

– Preceptor may engage student by allowing to perform some history, physical

exam if new, or observe gathering of history and physical with more advanced

students

• Tell students to arrive early (30 minutes -1 hour prior to start of clinic) with enough

time to review scheduled patients or run a list of expected daily activities

• Select patients appropriate for APRN student based on previous clinical rotations,

experience as RN, and specific learning objectives for current coursework

• Assign student to:

– Patients who do not mind having a longer appointment

– Patients that the preceptor knows well (speeds up evaluation of students case

presentation)

– Patients that augment the student’s clinical educational experience

• Give student brief background of patient, issues needing attention during the encounter

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• In primary care, stress the amount of time student should spend with each patient, and

amount of time available to precept for each patient (i.e. 10 minutes); provide student

with time limit for patient encounters, length of case presentation (i.e. 5 minutes for

review of H&P, diagnosis and plan)

• In acute care, stress prioritization and time management to help balance daily schedule

with possible unplanned activities that may occur; help students to write inclusive but

succinct notes; practice presentation techniques and stress timing to maintain attention

• Share teaching with colleagues by encouraging student to engage in grand rounds,

attend case presentations, observe unique findings by other practitioners in clinical

setting

• Use the One Minute Preceptor Model or SNAPPS Model to facilitate critical thinking

in a timely manner (see Student Engagement and Critical Thinking)

Precepting on Busy Days: Time Management Pearls

• Encourage “just in time” learning by use of smartphones or electronic references to

look things up using high quality, evidence based sources efficiently

• Encourage student to write down questions throughout the day, spend time addressing

questions at day’s end or during breaks or downtime, if feasible

– Schedule 15-20 minutes daily to address questions, if feasible

– Promote self efficacy in more advanced students by encouraging to research

some questions and review together at next clinic day

• To prepare for next clinical experience, give student “homework” such as directed

readings, review assignment prior to seeing patients the following clinical day

• Collect and document patient care pearls that arise from various sources, and share

with students (Burns, Beauchesne, Ryan-Krause, & Sawin, 2006)

Precepting on a Slow Day

There may be days when your patient load is lighter than anticipated. Most preceptors are

torn between catching up on work that they need to complete, phone calls that need to be

returned, and projects that require attention and having a student who may sit around, check

their phone, or waste valuable time when they could be learning something new. Part of the

role of the preceptor is to expose students to their upcoming role as a pediatric focused APRN.

Students can help by completing forms, assisting on projects, creating clinical education, and

participating in patient follow up calls, just to name a few. They may also benefit by spending

time with available, able, and willing interdisciplinary team members such as respiratory

therapists, physical therapists, nutritionists, pharmacists, and the like. These are all valuable

experiences that they will need exposure to in order to become competent to practice.

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Other ideas for ‘downtime’ can include:

• Assign directed reading on specific clinical topics that arise

• Discussion of new pediatric evidence

• Reflective journaling

• Additional materials can be developed by the NP student, such as patient education

materials

• Students may enter their clinical cases into electronic tracking systems

• Additional projects (QI, etc)

• Case discussions

• Update medication knowledge

Student Space and Electronic Health Record Access

Students require clinical space in order to prepare for and actively participate in their clinical

rotation (Burns et al., 2006). It is essential to arrange available exam rooms, provide space for

documentation, and allow access to patient records. Electronic health records (EHRs) can

contribute to site barriers as each clinical site may have different EHRs that require additional

staff support to complete training and develop login-information (Forsberg, Swartwout,

Murphy, Danko & Delaney, 2013).

Preceptors should verify students’ EHR registration prior to the start of the rotation and ensure

all necessary trainings have been completed. Additionally, preceptors should work with

leadership in the clinical setting to identify available space for students’ chart preparation and

documentation during their rotations.

Strategies to manage barriers due to space limitations and EHR access:

• Consider scheduling students on days with the least number of providers scheduled in

clinic

– Ask colleagues if students may use their desk space in their absence

– Coordinate with leadership to have additional exam room for patient care

• Investigate remote access opportunities for chart review prior to clinic arrival or Wi-fi

availability for student to use their own device in the clinical setting*

• If no additional space is available (and if allowed by your institution), allow student to

use your desk/computer for chart review/documentation while you “leapfrog” and see

other patients

• If EHR access is unavailable for student, utilize developed SOAP note and have

student handwrite or type documentation relevant to their patient encounters

*Always plan access to protected health information in accordance with HIPAA regulations

to ensure patient information is accessed appropriately.

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CMS Documentation Guidelines for Students/Preceptors:

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).

The NP student can contribute to billable service but it must be done in the physical presence

of the billing provider. Students can document only: past medical history, social history,

family history and review of systems. To bill for services, the preceptor must then repeat and

document the HPI, relevant PE and medical decision making for that patient.

Students need to learn proper documentation as it relates to the medical record. Their

documentation, however, doesn’t need to be a part of the permanent medical record. Students

should be writing SOAP notes as assigned by their school faculty.

Providing a Well Rounded Clinical Experience

Previous experience must be considered when planning and delegating clinical opportunities

for adult learners. Preceptors should prioritize “new experiences, such as the care of a older

children for the former NICU nurse, as well as application of previous skills to new situations

to help students integrate important aspects of their previous lives into their new NP training”

(Burns, Beauchesne, Ryan-Krause, & Sawin, 2006, p. 173). In addition to guiding learning

experiences in in accordance with course syllabus and objectives, pediatric primary and acute

care preceptors should work to incorporate clinical experiences that include:

• The full age spectrum at their practice site (i.e. birth to 18 or 21 years of age if in

primary care office or hospital setting, or age range of children seen at school based

health or adolescent clinic)

• Preventive services such as:

‐ Developmental screening

‐ Anticipatory guidance provision by age

‐ Immunization schedules

• Range of more commonly seen clinical situations by body system or service type such

as:

‐ HEENT - conjunctivitis, upper respiratory infections, otitis media/externa,

Strep pharyngitis, tonsillar hypertrophy, croup

■ Acute care: head injuries, tracheal reconstruction, tracheostomy

placement and care care, upper and lower airway obstruction

‐ Abdomen - acute gastroenteritis, GERD, constipation, abdominal red flags

including appendicitis, cholecystitis, intussusception, pyloric stenosis,

genitourinary complaints

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■ Acute care: ruptured appendix, NEC, abdominal trauma, bowel

perforation, GI bleed

‐ Skin - newborn rashes, eczema, acne, tinea, viral exanthems

■ Acute care: toxic epidermal necrolysis, Stevens Johnson Syndrome,

skin breakdown, allergic reactions, skin failure, burn management

‐ Lungs - asthma, pneumonia, bronchiolitis

■ Acute care: status asthmaticus, acute respiratory failure, chronic

respiratory failure, pediatric ARDS, ventilator management,

bronchiolitis

‐ Heart - murmurs, hypertension, chest pain, syncope

■ Acute care: congenital heart disease, heart failure, cardiomyopathies,

hemodynamic instability, dysrhythmias, cardiopulmonary resuscitation

‐ Neurological - cluster/tension headaches, migraine, concussion, epilepsy,

infantile spasms

■ Acute care: status epilepticus, hypoxic ischemic brain injury, traumatic

brain injury, Guillain Barre Syndrome, SMA, Muscular Dystrophy,

intracranial pressure management, ischemic and hemorrhagic stroke,

meningitis

‐ Musculoskeletal - congenital hip dysplasia, sprains/strains, scoliosis, Osgood-

Schlatter, SCFE

■ Acute care: postoperative scoliosis repair, traumatic fractures

‐ Hematology - iron deficiency anemia, thalassemia, clotting disorders, sickle

cell, idiopathic thrombocytopenic purpura

■ Acute care: anemia, transfusion management, coagulopathies, clot

treatment

‐ Genetics - newborn screening evaluation and follow up (ACT Sheets,

babysfirsttest.org), when to screen for fragile X, chromosomal abnormalities

■ Acute care: metabolic syndrome management, prognosis in genetic

disorders

‐ Reproductive Health - amenorrhea, irregular menses, menorrhagia,

contraceptive counseling, STI screening & treatment, teen pregnancy

■ Acute care: minimizing iatrogenic harm to reproductive health,

screening for STIs as sources of disseminated infection

‐ Endocrine/Electrolytes- evaluation of short stature, type 1 and type 2 diabetic

management

■ Acute care: DKA, SIADH, DI, electrolyte imbalances

‐ Mental Health - depression, anxiety, ADHD screening and treatment.

screening and treatment of common mood and behavioral disorders

■ Acute care: suicide screening, treating intentional ingestions,

appropriate referral

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‐ Nutrition - transitioning infants to solids, obesity counseling, pre diabetes and

dyslipidemia management

■ Acute care: nutritional needs, enteral vs. parenteral feedings, when to

initiate feedings, weight management

Managing Prescriptions and Orders in the Clinical Setting

Since students may not have EHR access and will not have prescriptive and ordering

privileges until after graduation, an additional task that preceptors take on is helping the

student learn to manage medications and treatment options, and how to write orders and

provide prescriptions to patients and caregivers. Here are some ways to plan ahead and help

your student learn to manage these processes as part of their clinical experience:

• Students should be planning treatment with preceptor input, choosing medications

using best evidence, and calculating dosages/timing/mL equivalents and quantity

needed

• The APRN typically writes/electronically enters/signs orders and prescriptions

• In your precepting role, make sure to discuss the impact of prescriptive authority on

your practice

‐ Encourage DEA registration, and discuss whether the APRN or the employer

covers this cost in your practice site

‐ Review drug schedules and dose limitations

‐ Discuss how you obtain pharmacology and controlled substance CE per your

state/certification requirements

‐ For acute care preceptors, discuss the differences between orders and

prescriptions

Evaluation

Preceptors should be familiar with the curriculum from the academic program, objectives, and

goals of both the student and program, and the evaluation tools to be used (Burns et al., 2006).

Objectives and goals are often directed by both the program and the individual student. These

goals should be reviewed and discussed between the student and preceptor (Burns et al.,

2006).

• Students are often also asked by their program to periodically evaluate themselves

with regard to these goals and objectives.

• If not a program requirement, preceptors should encourage self-evaluation as part of

their clinical rotation (Burns et al., 2006).

• It can also be helpful for preceptors to identify any goals for the student that they may

have and communicate these to the student at the beginning of the rotation.

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Types of Evaluation

Formative Evaluation

Measures progress toward meeting objectives and goals; can help to individualize further

learning to improve targeted areas of need.

Examples in the clinical setting may include:

• Case presentations/discussions

‐ In presenting to the preceptor, students should develop gradual mastery of the

content and should demonstrate understanding of developmental and family

considerations.

‐ In order to encourage students to learn when to ask for help, include in

feedback when/if a second opinion should be considered. If so, from whom,

how, and when (urgent vs. non-urgent).

• Informal discussion

‐ To expand learning, discuss with the student after each patient the worst case

scenario for the presenting symptoms. Students often don’t know the “zebras”

but can demonstrate progress toward learning the signs of one and expanding

differential diagnosis skills.

‐ Some pediatric examples may include:

■ Abdominal pain: appendicitis, peritonitis, bowel perforation, etc

■ Headache: tumor, meningitis, stroke

■ Vomiting & diarrhea: dehydration, cyclical vomiting, abdominal

migraine, GI obstruction

■ Skin lesion: kerion, lipoma, cellulitis, underlying systemic disease, etc

■ Heart murmur/syncope: hypertrophic cardiomyopathy, undiagnosed

congenital heart disease

■ Abnormal movement: seizure, Guillain Barre Syndrome

■ Developmental delay: autism, neurodegenerative disorder

■ Fever: sepsis, RA, lupus, or other autoimmune disorders

■ Respiratory distress: status asthmaticus, pneumothorax, pleural

effusion, etc

• Informal feedback

‐ Giving the student “pointers” in a non-threatening way can allow for prompt

improvement in skills.

• Questioning exercise

‐ Asking students questions on the spot about content they should have learned

or already been exposed to can assess knowledge and critical thinking. For

example, after seeing a child with asthma deemed to be in the “yellow zone”,

the preceptor may ask the student what criteria allowed for that determination

and/or what treatment options should be considered.

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• Mid-term evaluation

– Required by many programs. Often use the same criteria as the final evaluation

and allow for preceptors to discuss with students areas where progress is

needed and also identify the student’s strong skills.

‐ If not required, preceptors can initiate this on their own.

‐ May also be helpful to discuss progress toward student and preceptor

objectives.

Summative Evaluation

Measures achievement of objectives & goals; typically takes place at the end of a rotation or

academic semester.

Examples in the clinical setting may include:

• Formal evaluation tool (most common)

– Tools vary by school but are typically built upon common set of competencies

developed by the National Organization of Nurse Practitioner Faculties

(NONPF) (Pearson et al., 2012).

– NONPF competencies (SEE APPENDIX) cover a variety of domains of

learning related to the APRN role.

■ Independent practice competencies most common in clinical setting.

■ Some settings may also offer experiences with exposure to other

competency domains. If so, these should be addressed in evaluation.

– NONPF and the American Association of Colleges of Nursing (AACN) have

recently looked at creating more standard evaluation tools.

• Student end of semester self-evaluation

• This should be reviewed with the preceptor and the course faculty.

• Preceptor evaluation of student progress toward objectives established by the

preceptor and/or site-specific skills or competencies.

• Student evaluation of site and preceptor

– Universities often choose to not share (or forget to share) this information with

preceptors after the semester has ended. It is very appropriate for preceptors to

ask faculty members for student feedback on the clinical experience. This

information can be invaluable, as it can help the preceptor grow from the

experience and further improve his/her teaching skills.

Communication of evaluations should take place between preceptors and both the student and

faculty (Burns et al., 2006). Open and ongoing communication with faculty encourages

student success and an improved preceptor experience.

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Student Red Flags

What constitutes a ‘red flag’ at the beginning of the NP student program (or the beginning of

the semester ) will differ as the student progresses, but it is essential to identify concerns early

and discuss with faculty, so that remediation can be provided.

• Unable to prioritize care needs

• Missing essential components of history and physical

• Poor communication skills (including defensiveness)

• Unable to independently develop treatment plan

• Unable to present cases clearly

• Missing opportunities for anticipatory guidance and patient/family education

• Unable to determine tests to order

• Any unsafe practices

• Not following standards of practice

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Appendices

Appendix: Developing a Philosophy of Clinical Education Statement

A ‘philosophy of clinical education’ statement is a general affirmation that can be

individualized to emphasize your commitment to helping the students encounter a variety of

ages and a variety of differentials and changing acuity according to your primary, acute or

specialty area.

Writing a simple statement and sharing it with students is a great way to introduce yourself

and to stress your commitment to the student and to your practice. These statements can be as

simple as a sentence or two (see first example) or may be several paragraphs in length (see

second example).

Example 1:

“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.”

Example 2:

“My clinical education philosophy is rooted in my knowledge/expertise in evidence-based

pediatric care, respect for the learner, genuine enthusiasm, and a strong dedication to family-

focused care. I love to teach, and enjoy doing so outside of the formal classroom setting.

Precepting advanced practice providers offers me the opportunity to combine my dedication

as a clinician with the opportunity to prepare students for their role as nurse practitioners.

I bring a high level of respect for other adult learners to my preceptor role. Their time and

experience are valuable, and I learn from my students and from the teaching process every

day as I precept. Student questions often lead to review of new literature and existing clinical

guidelines, so that both the student and I understand the rationale for the care that we

provide. I love to help students to connect the dots between classroom lectures/rote

knowledge, evidence-based guidelines, and real-life patient care.

As a pediatric nurse practitioner, I engage with the child’s caregivers as much as I do with

the child him- or herself. Students get a strong experience in what it means to provide family-

focused care. I am passionate about care of children, and hope that this enthusiasm shines

through as I work with students. ”

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Appendix: NONPF Nurse Practitioner Core Competencies Content (2017)

*and what they mean to the pediatric APRN preceptor…

Keep in mind that, as a clinician and preceptor, you may not be modeling many of these

competencies directly. Not all competencies will be measured in every clinical setting. It is

the responsibility of the educational institution to make sure that students can meet these

competencies.

• Scientific Foundations Competencies

– Critically analyze data and evidence for improving advanced practice nursing

– Integrate knowledge from the humanities and sciences within the context of

nursing science

– Translate research and other forms of knowledge to improve practice processes

and outcomes

– Develop new practice approaches based on integration of research, theory, and

practice knowledge

* If you work in a setting that involves clinical research, expose your student to

protocols, the informed consent process, and data collection. Review evidence-based

practice guidelines (i.e. AAP guidelines) as you discuss treatment planning.

• Leadership Competencies

– Assume complex and advanced leadership roles to initiate and guide change

– Provide leadership to foster collaboration with multiple stakeholders to

improve health care

– Demonstrate leadership that uses critical and reflective thinking

– Advocate for improved access, quality and cost effective health care

– Advance practice through the development and implementation of innovations

incorporating principles of change

– Communicate practice knowledge effective (in both oral and written form)

– Participate in professional organizations and activities that influence advanced

practice nursing and/or health outcomes of a population focus

* The preceptor can role model leadership skills in the practice setting. Precepting

itself is a demonstration of the leadership role. As part of professional development,

encourage participation in professional organizations (such as NAPNAP).

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• Quality Competencies

– Use best available evidence to continuously improve quality of clinical practice

– Evaluate the relationships among access, cost, quality and safety and their

influence on health care

– Evaluate how organizational structure, care processes, financing, marketing

and policy decisions impact the quality of healthcare

– Apply skills in peer review to promote a culture of excellence

– Anticipate variations in practice and become proactive in implementing

interventions to ensure quality

*Discuss how your current practice setting measures quality (including role of

transparency measures such as Press-Ganey questionnaires). If any small QI

projects are underway, introduce this work to the student. There is a Child Core Set

of quality measures that are used by Medicaid and CHIP programs. Students can

review these measures at: https://www.medicaid.gov/medicaid/quality-of-

care/performance-measurement/child-core-set/index.html

• Practice Inquiry Competencies

– Provide leadership in the translation of new knowledge into practice

– Generate knowledge from clinical practice to improve practice and patient

outcomes

– Apply clinical investigative skills to improve health outcomes

– Lead practice inquiry, individually or in partnership with others

– Disseminate evidence from inquiry to diverse audiences using multiple

modalities

– Analyze clinical guidelines for individualized application into practice

*Provide opportunities for student to share new knowledge with staff within your

practice setting, as possible. Assign pertinent clinical guidelines as required reading.

• Technology and Information Literacy Competencies

– Integrate appropriate technologies for knowledge management to improve

health care

– Translate technical and scientific health information appropriate for various

users’ needs

■ Assess patients and caregivers educational needs to provide effective,

personalized health care

■ Coach the patient and caregiver for positive behavioral change

– Demonstrate information literacy skills in complex decision making

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– Contribute to the design of clinical information systems

– Use technology systems that capture date on variables for the evaluation of

nursing care

*Technology plays an important role in primary care, acute care, and subspecialty

care practices. Encourage use of technology to review updated diagnostic criteria,

treatment guidelines, and educational tools for patients and families.

• Policy Competencies

‐ Demonstrate an understanding of the interdependence of policy and practice

‐ Advocate for ethical policies that promote access, equity, quality and cost

‐ Analyze ethical, legal, and social factors influencing policy development

‐ Contribute in the development of health policy

‐ Analyze the implications of health policy across disciplines

‐ Evaluate the impact of globalization on health policy development

‐ Advocate for policies for safe and health practice environments

*Open discussions on the role of health policy as it relates to your patient populations

and ongoing treatment considerations.

• Health Delivery System Competencies

‐ Apply knowledge of organizational practices and complex systems to improve

healthcare delivery

‐ Effect health care change using broad based skills including negotiating,

consensus-building and partnering

‐ Minimize risk to patients and providers at the individual and systems level

‐ Facilitate the development of healthcare systems that address the needs of

culturally diverse populations, providers, and other stakeholders

‐ Evaluate the impact of healthcare delivery on patients, providers, other

stakeholders, and the environment

‐ Analyze organizational structure, functions and resources to improve the

delivery of care

‐ Collaborate in planning for transitions across the continuum of care

*Many preceptors lack opportunities to help the student develop competency in this

area. Offline conversations about organizational structure and healthcare delivery

can provide perspective in a real-world setting. The preceptor can model to students

how to create relationships with other specialists and providers.

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• Ethics Competencies

‐ Integrate ethical principles in decision making

‐ Evaluate the ethical consequences of decisions

‐ Apply ethically sound solutions to complex issues related to individuals,

populations, and systems of care

*Discuss ethical concerns and dilemmas with your student as opportunities arise.

• Independent Practice Competencies

‐ Function as a licensed independent practitioner

‐ Demonstrate the highest level of accountability for professional practice

‐ Practice independently managing previously diagnosed and undiagnosed

patients

▪ Provide the full spectrum of health care services to include health

promotion, disease prevention, health protection, anticipatory guidance,

counseling, disease management, palliative, and end-of-life care

▪ Use advanced health assessment skills to differentiate between normal,

variations of normal and abnormal findings

▪ Employ screening and diagnostic strategies in the development of

diagnoses

▪ Prescribe medications within scope of practice

▪ Manage the health/illness status of patients and families over time

‐ Provide patient-centered care recognizing cultural diversity and the patient or

designee as a full partner in decision-making

▪ Work to establish a relationship with the patient characterized by

mutual respect, empathy, and collaboration

▪ Create a climate of patient-centered care to include confidentiality,

privacy, comfort, emotional support, mutual trust and respect

▪ Incorporate the patient’s cultural and spiritual preferences, values, and

beliefs into health care

▪ Preserve the patient’s control over decision making by negotiating a

mutually acceptable plan of care

▪ Develop strategies to prevent one’s own personal biases from

interfering with delivery of quality care

▪ Address cultural, spiritual, and ethnic influences that potentially create

conflict among individuals, families, staff and caregivers

‐ Educate professional and lay caregivers to provide culturally and spiritually

sensitive, appropriate care

‐ Collaborate with both professional and other caregivers to achieve optimal care

outcomes

‐ Coordinate transitional care services in and across care settings

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‐ Participate in the development, use, and evaluation of professional standards

and evidence-based care

*These are the real nuts-and-bolts competencies that students see in-action in the

clinical setting with their preceptors. Serve as a role model, encourage these skills in

the student, and provide constructive feedback on how to develop confidence and grow

in the role.

NONPF has also listed population focused NP competencies for both primary and acute care

PNPs related to their core competencies that can be reviewed here:

http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/Competencies/CompilationPopFoc

usComps2013.pdf

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Appendix: 3 Step Structured Process for Reflective Journaling

Reflective journaling is a structured way to deconstruct a patient situation and then evaluate

the thinking processes used during the situation (Raterink, 2016). Faculty can assign

journaling as an adjunct (or alternative) to writing SOAP notes. When students are unable to

document in the EMR because of program or institutional barriers, having them journal about

the patient encounter using the technique below will provide a meaningful assignment.

The expectation is that the student will reflect on what they have journaled and learn from

their own experience (as well as by feedback from the preceptor and/or faculty).

IMPORTANT: Each step is only one paragraph. The entire journal entry should only take up

one page. The student practices writing succinctly and identifying only key elements in the

encounter.

1. Frame the vignette or clinical scenario based on one element of the critical thinking

definition (may be a habit or skill)

2. Have the student support the actions of the vignette as a demonstration of that element

3. Format provided for the student to decide on how they would act in another (similar)

situation to demonstrate that same critical thinking habit or skill

Example:

During primary care clinic, I saw a 7 year-old boy whose mother describes teacher concerns

that this child seems to stare off into space during classroom lessons. His mother stated that

she is very worried about his classroom performance- she describes him as very “bright”.

My preceptor and I have discussed ADHD symptoms, and I decided to ask a few questions

that would help me understand if this child may have ADHD. His mother stated that these

problems have only been occurring for maybe about 2 months. I asked if anyone else has

noticed any types of staring spells, and his mother stated that sometimes it seems like her son

is daydreaming for 10 or 15 seconds and then “snaps out of it”. She said that this seems to

happen two or three times a day. I immediately thought of the possibility of absence seizures,

and remembered to ask mom if she thinks that she can get his attention if she touches him.

She thought hard and said that she did not feel confident that she can get his attention, but

that she thought that he was just “lost in thought”. She stated that he can typically complete

his homework worksheets quickly, and that he otherwise does not seem overly distracted or

forgetful at home. I gave him my best possible physical exam, and everything seemed to be

normal. When I stepped out to present this case to my preceptor, I made sure to tell her that

we hadn’t received any Conners or Vanderbilt rating forms, and that his mother hadn’t

brought any grades or teacher reports to help us better understand what was going on in the

school setting. I sensed that this child may not have ADHD and that maybe a neurology

evaluation (or EEG) might be needed, and I shared these thoughts with my preceptor.

When we returned to the room, my preceptor clarified a few aspects of the history (I was so

glad that I was on the right track and hadn’t forgotten much!). My preceptor pulled out a

pinwheel and started hyperventilating the patient by having him take deep breaths and

blowing on the pinwheel. At the count of 23, this child stopped and had a staring spell that

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lasted for about 10 seconds. He quit blowing on the pinwheel and just stared ahead. He then

seemed to snap out of it and looked at my preceptor like he’d forgotten what he was just

doing. I just saw my first absence seizure. My preceptor and I shared a “look” and she then

launched into a discussion with the parents about what she had just seen and how she’d like

for the child to have an EEG and an appointment with one of her colleagues in pediatric

neurology. And she also sent home parent and teacher Vanderbilt rating forms and asked for

the mom to provide a copy of his most recent grades and any comments from teachers. We

want to review this information to make sure that we’re not missing anything else in his

clinical picture.

I felt really excited that I sensed that something else was going on with this child and

remembered to ask more questions. I felt like I was formulating differential diagnoses in my

head as his mom was answering my questions, and I was thinking about whether this child

was just inattentive (was it ADHD?) or was there more to it? I am so glad that my preceptor

helped me to understand what to do next, what to order, and how to best explain this to the

family without worrying them excessively. I might not be able to perfectly do these things on

my own as a student, but I feel like I thought about more of the possibilities. I also might have

forgotten to still get more input from the teachers and parents once we’d seen the child have

his staring spell, but I feel like I learned how to pull the pieces together. I will definitely

remember this experience and use these skills with my future patient encounters.

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Appendix: Reflective Journal Rubric Score Sheet

Student name _______________________________________________________________

Rater______________________________________________________________________

Critical thinking definition skill or habit ___________________________________________

1. Identification- student’s ability to effectively match the actions in the journal vignette

to the skill or habit; how well the vignette describes the skill or habit

4 = clear representation of the skill or habit in the description of actions

3 = partial representation of skill/habit with some difficulty in clear

identification

2 = misidentification of skill/habit based on the vignette; actions are described

but do not match

1 = no understanding of the skill/habit that student thought that he/she was

describing

SCORE ____________________

2. Justification- student’s ability to support the decision about the actions as they match

the skill or habit; why the description of the actions matches the skill or habit

3 = incorporates the definition of the skill/habit and applies to the use in the

vignette

2 = actions described partially justified as representing the skill/habit but no

clear relationship to the definition

1 = actions are not justified

SCORE ___________________

3. Specification- how well the student clearly explains what changes (or not) to behavior

that he/she would take to improve the use of the skill/habit in subsequent patient

situations

3 = detailed description of how the student would use skill/habit better in

subsequent patient encounters

2 = unclear or partial description of changes for the next encounter

1 = no description of changes the student would make to improve use of

skill/habit in the future encounter

SCORE _____________________

Comments of rater:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

(adapted from Rubenfeld & Scheffer, 2010)

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Appendix: Mentoring Contract

Clinical Science Scholars Program :

Mentoring Expectations

Mentoring is critical to career success in research. Each scholar will have two primary

mentors who will be accomplished independent investigators and committed to the career

development of their mentees. The scholar will have at minimum weekly contact and

meetings with their primary mentors (often more frequently) since the scholar will be working

in the laboratory of the primary mentors or work on a related project. In addition, each scholar

may have additional one or more co-mentors, preferably from different disciplines, forming a

multidisciplinary team. We will obtain written commitments from all of the mentors to have

continuous involvement with the scholars throughout the program. Because the program is

promoting team science through the conduct of multidisciplinary research and the use of team

mentoring for mentees, the entire mentoring team will meet with the mentee at least monthly

to design and plan the research projects, discuss progress, provide advice on project

management, and to help guide data collection, analysis, and manuscript preparation.

Expectations for Mentors

1. Team meetings with the mentee. There should be a minimum of one hourly meeting of the

primary mentors and the mentee per week, and one hourly meeting per month of the entire

mentoring team and the mentee.

2. Attending scholar’s presentations. The mentoring team is expected to attend meetings and

seminars in which the mentee is presenting.

3. Evaluation. The mentoring team will participate in biannual evaluations and assessments

of mentoring relationships.

4. Confidentiality. The content of all exchanges between the team mentors and the mentee

are subject to the expectations of professional confidentiality.

5. Customized Career Development Plan (CCDP). Review, approve, and monitor progress of

mentee’s CCDP.

Expectations for Mentees

1. Team meetings with mentors. There should be a minimum of one hourly meeting with the

primary mentors per week and at least one hourly meeting per month with the entire

mentoring team.

2. Training. The mentees participate in the one-day training to obtain skills in working in

with mentors in a team science environment.

3. Scholar’s presentations. The scholars present their work at research-in-progress meetings

and at seminars with the mentoring team in attendance.

4. Evaluation. The mentee will participate in biannual evaluations and assessments of the

mentoring relationships.

5. Confidentiality. The content of all exchanges between the team mentors and the mentee

are subject to the expectations of professional confidentiality.

6. Customized Career Development Plan (CCDP). Develop CCDP, review CCDP with

mentor and program director, and review progress.

We, acting as team mentors and mentee, agree to enter into a team mentoring relationship

based on the expectations described above.

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___________________________ (mentor’s signature) date____/____/____

___________________________ (mentor’s signature) date____/____/____

___________________________ (mentee’s signature) date____/____/____

___________________________ (Director's signature) date____/____/____

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Appendix: Site Specific Agenda and Objectives

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78

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