The Preceptor Imperative
By Janine White
“A preceptorship takes everything students learn and puts it into practice in an environment where there’s a lot of support, so it’s not so scary. They can make a mistake because their preceptor is still the one ultimately in charge of that patient. We teach students in the classroom to get them ready, but the preceptors give them access to patients,” says Alycia Bischof DNP CRNP PNP-BC Nu’90 GNu’95 GRN’21, Central Clinical Site Coordinator at Penn Nursing and chair of the School’s Preceptor Committee.
“There’s very careful selection about who goes to what clinical site, and it’s very purposeful, to make sure that our students get exactly what they need,” adds Sue Renz PhD DNP GNP-BC Nu’84 GNu’87, Penn Nursing Primary Care Program Director. Dr. Renz and Dr. Bischof both evaluate clinical sites for preceptorships.
From Classroom To Clinical Setting
Thanks to the school’s process, at the end of their preceptorships, many Penn Nursing alumni are thanking their preceptors for helping them to become more confident, more comfortable, and more prepared to deliver high-quality care to patients.
In Pennsylvania Hospital’s surgical intensive care unit (SICU), preceptor Baron Bryant RN says he starts a relationship with a new BSN preceptee by getting a baseline of their knowledge and then having them shadow him. From there, he sets them up with one patient for a head-to-toe assessment. Throughout, he’s always asking questions. “Do you know what this medication is for, why we’re giving it? If they are answering correctly, we are moving forward. If not, then I am teaching them,” he explains.
According to Tarikwa Leveille RN Nu’21, Bryant’s teaching style was an ideal fit with how she learns. “He’s very hands on, in the sense that he will let you do things, which for me was fantastic because I am more of a hands-on learner,” she recalls of her preceptorship with Bryant in the SICU. “He is very good at explaining concepts, simplifying them to make sense. A patient had left-sided congestive heart failure, and it was my first time seeing a jugular vein distention. He asked, ‘do you know what this is?’ and I said no. And he explained the physiology. That was awesome.”
She says that she not only gained medical knowledge during her time with Bryant, but he also made an impact on how she thought about dealing with patients.
“There was an older patient who was deteriorating very fast, and family members were unaccepting of what was happening,” Leveille says. “I would have said they were difficult to deal with, but [Bryant’s] interpersonal skills were so amazing. He went above and beyond trying to explain, trying to calm family members. I talked to him about that, and he explained that people are scared, and they don’t know what’s going on. I remember how respectful and kind he was toward the family members.”
For many nurses, the preceptor-preceptee relationship is a lifetime bond. They become friends, stay connected.
A lot end up as colleagues on the same floor. Leveille will start work in the NICU next door to Bryant this spring. And over at Penn Medicine Princeton Medical Center, Lauren Malinowski RN Nu’19 GNu’23 works with Tina Senoo RN, her onetime preceptor, as well as someone Malinowski herself precepted, Shaye Nozoe RN Nu’21—all in medical-neurology-oncology.
“As you’re precepting, you have that goal in mind to share your experience with that new person, knowing that you’re going to be teammates one day. I think that gets passed along down the line of preceptors. Mine passed it to me, and I try to pass that down to my preceptees now. Tina is an incredible role model, a phenomenal nurse, and I feel lucky to have been precepted by her,” says Malinowski, who was a Sands Scholar, as was her preceptee, Nozoe. (Sands Scholars are selected undergraduates who receive loan-forgiveness in exchange for a two-year work commitment at the Penn Medicine Princeton Medical Center.)
“[Nozoe] loved it so much, she came back and followed in my footsteps, which I have loved to see. If we ever have a shift together, there’s a very open communication, where she knows she can come to me and ask me questions. I’ll go check in on her and say, ‘How are your patients today? Is there anything that you have questions about or things that you’ve never had before?’” Malinowski says.
Senoo says she sees precepting as a way to foster a positive environment for her junior colleagues. She starts by telling- ing new preceptees: “I’m ready to listen to you and hear what you have to share with me, because there is always something new out there. I don’t know it all.”
Nurses often find their true calling through preceptorships—whether that’s because they do a rotation in an area they’re very drawn to, or one where they’re not a fit. Victoria Fisher MSN APN PMHNP GNu’21 changed her mind after being precepted by Kim Joffe MSN CRNP PMHNP GNu’19, a psychiatric men- tal health nurse practitioner at Penn Medicine’s Chester County Hospital. Fisher went into the rotation convinced she wanted to continue working with inpatients. “As much as I enjoyed working there, with Kim, it was actually very beneficial for me to see that’s not what I wanted.” Fisher recently started as a psychiatric nurse practitioner in an outpatient office.
Despite the career direction change, the time with Joffe still resonates with Fisher. She remembers on her first day, her preceptor opened with, “Do you need coffee?” They talked about work experiences and got to know each other. Their shared Penn Nursing affiliation made a difference. It meant, Joffe says, that she had a solid understanding of what education Fisher had coming into the rotation.
“Kim and I would literally take laps around the hospital outside and discuss key scenarios or labs,” Fisher recalls. “We were always talking about something that was beneficial to my practice or getting credentialed. It’s so helpful to talk through that with someone who has already done it.”
Penn Nursing students at the DNP level don’t do preceptorships, but they are assigned faculty mentors who shepherd them through a clinical project. They meet frequently, often weekly. “I would consider them preceptors, in a way, but we call them faculty leads,” ex- plains Dr. Renz, who serves as a DNP student mentor.
When Isabelle Joseph MSN AG- ACNP-BC FNP-BC DNP’22 was matched with Dr. Renz as a mentor, she was initially a little worried. “It was very intimidating to think, ‘oh, my gosh, the director of the program. She’s going to have these super high expectations.’ She does have high expectations, but she’s provided a lot of encouragement. The feedback that I’ve gotten from her as I’ve been developing my project has been so motivating.”
When Joseph had to overhaul her project based on stakeholder feedback, she says Dr. Renz helped her keep moving forward: “She gave me examples of some of the obstacles that she had to go through that were pretty similar when she was doing her DNP project, and how the alternative intervention ended up being better. And it was similar for my situation as well.”
Joseph, who says she loves precepting students, believes that nurses can learn from one another at every step in the profession.
“Nursing at an undergraduate level, a graduate level, and at a doctoral level, it’s a community, it’s a village, that’s going to help you really get through this,” she says. “Books are great for structure, but a mentor animates what you’re gain- ing from a lecture or from reading. The preceptor is really there to frame all of that together to make it applicable and practical.”
Penn Nursing’s Preceptorship Advantage
In many nursing programs around the country, students must figure out preceptorships on their own, and even pay a hefty sum for the experience. But at Penn Nursing, students benefit from a long-established system of the School vetting and securing clinical sites and finding preceptors—no fee involved. “That’s what sets us apart,” says Dr. Bischof, who adds that she’s heard about how some sites pack in students for preceptorships with little oversight to make money. Penn focuses on partnering with sites that prioritize a one-on-one connection between student and preceptor. “When the students are in the sites, we go out twice a semester and visit with the preceptors,” Dr. Bischof says. “I have precepted for other programs, and I’ve never seen anybody from their school. At Penn, we have a good relationship with our preceptors, and we stay in contact with them to make sure that things are going well.”
According to Sarah Shumsky CCNP GNu’18 GRN’24, who works at AtlantiCare in New Jersey, Penn’s approach is invaluable.
“You’re dealing with so many other stressors while you’re in school. If I had to write 100 emails begging someone to be my preceptor, it would just be another level of stress,” Shumsky says “It’s so great that Penn has such a strong network and is able to provide those clinical opportunities for you.”
Victoria Fisher has seen co-workers from other schools pay “$1,000, $2,000, $3,000 to have a one-semester preceptor,” she says. “Everyone who’s not at Penn is in a sheer state of chaos trying to find their preceptors.”
Beyond the built-in preceptorship structure that Penn Nursing provides, Tarikwa Leveille says she appreciated being matched with Baron Bryant on many levels.
“I think diversity within preceptors is really important, not only in terms of years of experience, but racial and social diversity of preceptors is very important, too,” Leveille says. “I was happy to have been paired with a male in a female-saturated industry, and a person of color. It made my experience a lot better to work with someone who kind of looks like me.”
A Call For More Preceptors
A preceptor shortage existed long before COVID-19, and the pandemic has exacerbated the problem. Preceptors who have been called on by Penn Nursing for years have retired, while some have moved on to other positions. With clinical hours being a graduation requirement, the scarcity is a crisis for students and nursing programs around the country. The authors of a January 2021 article titled “The Significance of the NP Preceptorship Shortage” in The Online Journal of Issues in Nursing, wrote that the problem is hindering career advancement. They called for more research into why people decide to precept and suggested exploring the potential of a universal matching system. They also acknowledged that while “paying an NP preceptor for clinical hours is not a new concept,” the practice is a “hotly debated one in academic circles.”
Penn Nursing doesn’t pay preceptors but, Dr. Bischof says, many “nurse practitioners feel dedicated to the future of health care. They realize that this is how we’re going to bring in the next generation.”
Precepting Penn Nursing students comes with some perks: a one-year clinical associate appointment at the University, and access to Penn Libraries and their resources, such as online clinical and education database UpToDate.
Dr. Bischof believes that preceptorships also benefit clinical sites, in terms of quality patient care: “Students come through with the latest knowledge, and they’ll filter the latest recommendations, the latest guidelines through to the patients. Also, a student is free to spend as much time as necessary, as long as the patient is OK with it, and get a really, really good history. Sometimes it’s that interaction that really makes a difference in the patient’s life.” Dr. Renz says the School is dedicated to making sure preceptors have what they need to be successful mentors.
“In addition to offering educational resources, we keep in very close contact with our preceptors. We all make our- selves available in case a preceptor has a question or concern about a student,” she says. The site visits that she and Dr. Bischof conduct are also a chance to ask preceptors if they have what they need. “Are there any other things that we can provide as a school to you to help you do your job better or support your role as preceptor?” she says.
According to Betty Craig DNP CRNP FACHE GNu’95, CNO at Pennsylvania Hospital, preceptors are the “first influencers in a clinical practice environment that really shape the way you actualize nursing.” Craig believes there are ways to encourage more nurses to precept.
She sees a big opportunity in a current effort she’s working on to meet one-on-one with her entire staff regularly. The goal is to “understand not only what they are doing in the practice but also their goals,” she says, “and where they think their strengths are. Many times, through these conversations, we can identify if people have an interest in education.”
According to Dr. Renz, precepting is a way for providers who want to teach to pursue that path:“I think that being a preceptor is really one of the best ways to do it. It’s how I started out, teaching in the clinical setting. Sometimes that translates into teaching in the classroom or even being a program director.”
Craig notes there’s also professional advancement to consider. Clinical Nurse IIs need to demonstrate their leadership as mentors to move up to CN III, and precepting can underpin that career progress.
“The more you teach, the more you acquire knowledge. I think I learn a lot from our mentees because they are brand-new from school. There are new evidence-based practices that are coming up, which they bring to the table.”
Many preceptors point to another big plus: continued learning.
“The more you teach, the more you acquire knowledge. I think I learn a lot from our mentees, the people we precept, because they are brand-new from school. There are new evidence based practices that are coming up, which they bring to the table,” says Tina Senoo. With one preceptor experience so far, Shumsky says she plans to do more. “I think that both at the bachelor’s level and at the master’s level, when you transition from being a competent practitioner to attempting to educate someone else, it pushes your level of knowledge so much further. I’d encourage more people to be open to taking on a student. It might take an extra 15 minutes or 20 minutes to do a procedure if you are teaching someone new how to do it, which can feel stressful sometimes, but at the same time it is so beneficial for the nursing profession and for your own personal development.”
Kim Joffe chalks up those 15-20 minutes to “the cost of knowledge,” and sees precepting as part of a solution to a major health care challenge. “We need more compassionate, confident providers, and Penn produces that caliber of provider,” says Joffe, who only precepts Penn Nursing students. “To contribute to solving the problem, one way is to precept. I think that is the biggest reason to do this.”
Preparing Nurse Practitioners for the ICU
A Penn Medicine fellowship aimed at nurse practitioners and physician assistants teaches independent clinical decision-making—and offers a post-graduate certificate from Penn Nursing.
Preceptorships for BSN and MSN students and mentoring of DNP students are just one way that Penn Nursing helps shepherd the best providers into the workforce. The School continually looks for opportunities to enhance the profession and partner with Penn Medicine to offer the best patient care. The highly competitive Penn Medicine Advanced Practice Provider Critical Care Fellowship is one example of that mission in action.
The paid, 12-month post-graduate program, designed for nurse practitioners and physician assistants, has a didactic and clinical curriculum. Fellows also collaborate on an evidence-based medicine project in partnership with the Penn Center for Evidence-based Medicine. NPs and PAs who complete the program—which includes monthly rotations through several intensive care units (ICUs)—are awarded a post-master’s certificate from Penn Nursing.
The fellowship, according to Program Director Mike Pisa ACNP-BC RN EMT-P Nu’05 GNu’07, “eases the transition from new-to-practice to a critical care advanced practice provider in a really complex clinical environment.” Pisa helps the fellows to synthesize the feedback they must regularly solicit through their various rotations from department physicians, nurse practitioners, and physician assistants.
As a Penn Nursing Program Lead for the fellowship, Heidi Elgart MSN ACNP-BC Nu’91 GNu’98 leads the didactic component in a classroom setting every Friday, where Elgart says, guest lecturers hold highly interactive sessions. In an introduction to ventilators, for example, a respiratory therapist plugs in a ventilator; fellows get a hands-on look at settings and guidance on interpreting the machine’s data. “It’s not your traditional sit-in-the-classroom lecture,” Elgart says.
Kristin Welch MSN CRNP GNu’18 GNu’19, who completed the fellowship in 2019, says she was a big fan of Fridays.
“Skilled lecturers who were content area experts would come in and break things down for us in terms that made it understandable. It’s a safer place to slow things down, to ask the questions that you’ve been building up,” Welch says of that didactic portion of the program. Welch also appreciated the program’s monthly check-ins with Pisa and the ICU managers. “I cannot tell you how much I valued the chance to have somebody like these people who were invested in me as a clinician and as a person, and I know have my back, to just sit down and tell me, ‘These are the things you’re doing well, these are the things you can improve on.’ It’s like the fast track to being better,” she says.
Both Pisa and Elgart say the partnership between Penn Medicine and Penn Nursing makes he fellowship stand out from the growing number of advanced practice fellowships.
“We have such a tight partnership with the university and the School of Nursing, which is pretty rare as far as these programs go,” Pisa says. “We are in a fairly unique position to offer this post-graduate credit to our fellows.”
Because the fellowship was launched in 2014, past participants are also part of the ongoing success. “We have multiple graduates from the fellowship who are now working in all the different critical care units,” Elgart says. “They often will see the new APP critical care fellows, and on an informal basis, mentor them and take them under their wing, and say, ‘I survived the fellowship and you will, too.’”