Nurse practitioner preceptors' perceived facilitators and barriers to precepting

ABSTRACT

Background:

Preceptors are an integral part of nurse practitioner (NP) education; they mentor students and facilitate experiential learning in the clinical setting. Understanding factors that motivate clinicians to serve as preceptors can inform recruitment and retention of preceptors.

Purpose:

To understand factors that motivate and challenge clinicians to choose to precept NP students.

Methodology:

A survey was emailed to preceptors of NP students asking them to rate the importance of factors on a scale from not at all important (1) to extremely important (5) in influencing their decision to precept. Factors were categorized into five domains: university process, finance/time/productivity, recognition, certification/education, and intrinsic/other. Descriptive statistics were calculated.

Results:

Seventy-three of 224 preceptors responded (33% response rate). Highly rated motivating factors included having the role of preceptor clearly defined (mean = 4.00, SD = 1.01), coworkers support (mean = 4.07, SD = 0.91), and enjoying precepting NP students (Mean = 4.32, SD = 0.72). Lowest rated motivating factors include faculty presence during site visit (Mean = 2.74, SD = 1.11), financial renumeration (M = 2.13, SD = 1.38), and receiving gifts (mean = 1.66, SD = 0.98).

Conclusion:

Our findings indicate having coworkers who are supportive of their role as a preceptor, and clearly defined roles are more important than financial renumeration and faculty site visits.

Implications for Practice:

Building relationships with staff, administrators, and preceptors could strengthen academic–clinical partnerships resulting in an environment supportive of precepting NP students. Faculty may be able to reduce travel to clinic sites by communicating more frequently through email or telephone.

Introduction

Nurse practitioner (NP) preceptors are vital to NP education. Clinical professions rely on the unique contributions preceptors bring in mentoring, coaching, and contributing to the experiential aspect of clinical education that serves as a foundation for health care professionals' training. Preceptors also play a critical role in the growth and sustainability of the future of the nursing workforce (National Task Force, 2022). There is a need for NPs to serve as primary care providers, especially in rural and urban underserved areas. Currently, 76 million Americans live in Health Provider Shortage Areas in the United States, and an estimated 13,272 primary care providers are needed to eliminate the shortage areas (Health Resources and Services Administration HRSA, 2024a). In response to the increased demand, programs educating primary care providers, including NPs, expanded (American Association of Colleges of Nursing [AACN], 2024). Doctor of Nursing Practice (DNP) Programs, which prepare nurses for the highest level of practice, have steadily grown over the past 20 years (AACN, 2024). In 2003, there were only 70 students enrolled in DNP programs, and this has grown exponentially to 41,831 students across 433 DNP programs throughout the United States as of 2023 (AACN, 2024).

Finding sufficient clinical placements for NP students has been a long-standing problem that has become especially notable in a post-COVID pandemic era. During the height of the COVID pandemic, there were disruptions to clinical placements due to nationwide fear of exposure, increased health risks, lack of personal protective equipment, and redeployment or even furlough of NPs, many who had served as preceptors (O'Keefe & Auffermann, 2022). Although the acute challenges faced during the COVID pandemic have subsided, in a post pandemic environment, new challenges in finding adequate clinical placement sites and qualified preceptors have emerged.

Many primary care providers are leaving the profession or working reduced hours (Health Resources & Services Administration, 2024b). Increasing levels of stress and burnout, which have been exacerbated by the COVID pandemic, as well as lower compensation compared with other specialties have been cited as potential reasons for this reduction in the primary care workforce (Health Resources & Services Administration, 2024b). Current data indicate that only 34% of NPs are choosing to practice in primary care following the COVID pandemic (Millbank Memorial Fund, 2024). Burnout among primary care physicians has increased from 42% in 2020 to 49% in 2023 (Health Resources & Services Administration, 2024b), resulting in a gap in the number of preceptors willing to take NP students. This reduction in the number of primary care NPs and physicians willing to serve as preceptors had a direct impact on the capacity to train enough future primary care health care providers to meet the growing demand. This shortage causes competition for clinical training sites (Kayingo et al., 2023).

A limited supply of primary care providers to precept is only part of the challenge. In one recent survey of 334 NPs, 60% of NPs surveyed reported that they are not currently precepting students, 37.6% said that they did not precept because no one asked them to be a preceptor, and 32.8% reported that their employer restricted them from precepting (Gigli & Gonzalez, 2022). In addition, 12.4% indicated that they were not currently precepting as it decreased their productivity (Gigli & Gonzalez, 2022). Although the researchers in this study did not include rationale for why employers restricted precepting, they discussed that schools of nursing may want to focus on educating employers on the preceptor role, benefits of student involvement in their organization, and strategies to balance preceptor productivity (Gigli & Gonzalez, 2022). These issues highlight the importance of developing strategies to recruit and retain primary care preceptors.

Over the past decade, many preceptor surveys have been conducted to identify facilitators and barriers for recruiting and retaining clinical preceptors. Financial renumeration in some form, whether in the form of a stipend, continuing medical education funds, adjustment in workload, or assistance with license or certification payments have been cited as incentives in recruiting and retaining preceptors (Boyce et al., 2022; Burt et al., 2022; Morgan et al., 2017; Renda et al., 2021; Roberts et al., 2017; Todd et al., 2019; Webb et al., 2015). Professional obligation and desire to teach the next generation of clinicians have also been cited as strong motivators to precept (Boyce et al., 2022; DeClerk et al., 2021; Morgan et al., 2017; Renda et al., 2021; Webb et al., 2015). Top barriers experienced by preceptors include lack of time, workload, and productivity demands (Boyce et al., 2022; DeClerk et al., 2021; Morgan et al., 2017; Renda et al., 2021; Roberts et al., 2017; Webb et al., 2015).

Since the COVID pandemic was declared over in 2023, 2 studies related to preceptor motivators and barriers have been conducted (DeClerk et al., 2024; McCann et al., 2024). A study by DeClerk et al. (2024) found that well prepared, motivated students, institutional support from their clinical organizations, and clear expectations and ongoing communication from educational institutions were important facilitators to precept. A study by McCann et al. (2024) found altruistic themes such as wanting to give back to the profession and mentoring future colleagues as motivating factors. Barriers to precept included time constraints, impact on productivity, limited support from their own clinical institution, and lack of adequate experience as a clinician (DeClerk et al., 2024; McCann et al., 2024). The paucity of surveys related to precepting NP students in the last year highlights the need for further research to determine if factors for precepting students have changed in a postpandemic environment.

The purpose of this study was to understand the current post-COVID barriers and motivators of preceptors for the DNP family NP (FNP), psychiatric mental health NP (PMHNP), and pediatric NP (PNP) programs. This study was undertaken as part of a HRSA Advanced Nursing Education and Workforce–funded project, Building a Diverse NP Workforce, and Advancing Health Equity in Underserved Communities in Oregon (Health Equity Oregon). A goal of the Health Equity Oregon project is to identify gaps in current strategies for recruiting and retaining NP preceptors and to inform planning for potential solutions.

Methods

Data collection

A link to a Qualtrics survey was sent through email to all FNP, PMHNP, and PNP preceptors who had precepted a DNP student during the 2023–2024 academic year (n = 224). We sent a reminder email after 2 weeks. The survey remained open for 1 month. The institutional review board reviewed the study and determined that the project was not engaging in human participants' research.

Measures

Demographic, professional, and preceptor information

Respondents were asked to provide demographic information, including age, gender, and race. They were asked about their professional background, such as their highest degree (e.g., MD, MN/MSN, DNP) and primary specialty (e.g., family medicine, internal medicine, pediatrics, psychiatry/mental health), their years of experience in their specialty, and their years of experience serving as a preceptor. They were also asked about their practice setting, such as whether they worked in primary care clinics/practices, mental health centers, or federally qualified health centers. In addition, they were asked about the academic programs they precept for (i.e., FNP, PMHNP, and PNP programs), the number of hours per term, number terms per year, the number of students per year that they precepted, and which campus they were associated with at our multicampus school.

Factors influencing the decision to precept

We adapted the 57-item questionnaire developed by Todd et al. (2019) to assess factors influencing the decision to precept. The items were categorized into five domains: university processes, finance/time commitment/productivity, recognition, certification/education, and intrinsic/other. Respondents rated the importance of factors in influencing their decision to serve as a preceptor on a five-point Likert-type scale from “not at all important” to “extremely important.” Factors in the university process domain included a preceptor handbook, electronic health record (EHR) access/log-on for students, and having access to student Curriculum Vitae/resume. In the finance/time commitment/productivity domain, factors included financial renumeration to you (personally) and to the practice. The recognition domain factors included receiving personal thank you letters from students, nomination for service award, and gifts of appreciation. In the certification/education domain, factors included opportunities for professional development, access to online clinical resources, and library privileges. The intrinsic/other domain, factors included enjoyment of precepting, the professional obligation to give back, patient's receptivity to NP students, and recruitment opportunities.

Analysis

The survey data were analyzed using R version 4.1.2. Descriptive statistics were calculated for demographic variables, and mean scores for individual items were computed across the five domains. Internal consistency for each domain was assessed using Cronbach alpha, and item-level analysis was performed to examine whether removing any question would improve the reliability of the domain. We identified the two highest and two lowest rated factors in each domain and the three highest and lowest rated factors overall. Chi-square was calculated to assess differences between preceptors serving the FNP, PMHNP, and PNP programs.

Results

A total of 73 respondents (33% response rate) participated in the survey, with an average age of 46 years. Most respondents were female and White. The largest group held an MN/MSN degree, and family (primary care) was the most frequent specialty. Sixty-four preceptors were from our main campus, and a range of 1–3 preceptors were from 1 of 4 regional campuses. Additional information can be found in Table 1.

Table 1.

Demographics

	Overall (N = 73)
Age, year
34 or younger	3 (4.1%)
35–44	31 (42.5%)
45–54	26 (35.6%)
55–64	8 (11.0%)
65 and older	3 (4.1%)
Missing	2 (2.7%)
Race
Asian or East Asian	4 (5.5%)
Black or African American	2 (2.7%)
White	61 (83.6%)
Missing	6 (8.2%)
Gender
Female	53 (72.6%)
Male	16 (21.9%)
Transgender	1 (1.4%)
Missing	3 (4.1%)
Highest degree
MD	11 (15.1%)
MN/MSN	34 (46.6%)
DNP	23 (31.5%)
MS/PA	1 (1.4%)
Other professional degree	4 (5.5%)
Preceptor specialty
Family (primary care)	28 (38.4%)
Internal medicine (adult, gero, HIV)	3 (4.1%)
Other specialties	9 (12.3%)
Pediatrics	16 (21.9%)
Psychiatry/mental health	15 (20.5%)
Urgent care/emergency	2 (2.7%)
Clinic setting
Primary care	29 (39.7%)
Mental health center	15 (20.5%)
Rural health center	3 (4.1%)
FQHC	15 (20.5%)
Indian health center/clinic	1 (1.4%)
Missing	10 (13.7%)
Years served as a preceptor
Less than 1 year	8 (11.0%)
1–2 years	10 (13.7%)
3–5 years	19 (26.0%)
6–9 years	13 (17.8%)
10 or more years	23 (31.5%)
Program primarily precepted for
FNP	41 (56.2%)
PMHNP	17 (23.3%)
PNP	15 (20.5%)

Note: DNP = Doctor of Nursing Practice; FNP = family NP; FQHC = federally qualified health center; PMHNP = psychiatric mental health NP; PNP = pediatric NP.

The top two motivating factors from each domain and overall top three motivators for precepting can be seen in Table 2. The least two motivating factors from each domain and the overall lowest three can be seen in Table 3. The least motivating factors overall were all from the recognition domain.

Table 2.

Top motivators

Domain	Mean (SD)
University process
EHR access/log-on for students	4.53 (0.88)
Role as preceptor is clearly defined	4.00 (1.01)
Finance/time/productivity
Coworkers in the clinic are supportive of the preceptor role	4.07 (0.91)
Protected teaching time	3.81 (1.07)
Recognition
Enhance your credentials as a clinical teacher	3.23 (0.98)
Personal thank you letter from a student	2.62 (1.15)
Certification/education
Enhance your knowledge from students who keep up to date about trends in medicine and newest clinical practice guidelines	3.97 (0.88)
Credit toward professional certification or recertification	3.62 (1.20)
Intrinsic/other
Enjoyment of precepting	4.32 (0.72)
Professional obligation/a chance to give back	4.15 (0.94)
Overall top 3
EHR access/log-on for students	4.53 (0.88)
Enjoyment of precepting	4.32 (0.72)
Professional obligation/a chance to give back	4.15 (0.94)

Note: EHR = electronic health record.

Table 3.

Least Motivators

Domain	Mean (SD)
University process
Faculty presence during the site visit	2.74 (1.11)
Access to a summary of NP students' final evaluation of the experience	3.10 (1.22)
Finance/time/productivity
Financial remuneration to the practice	2.13 (1.38)
Productivity (RVU) credit	2.46 (1.46)
Recognition
Acknowledgement at school commencement ceremony	1.64 (0.99)
Featured article of you in school and/or professional newsletters	1.66 (1.02)
Certification/education
Opportunity to serve as student evaluator for Objective Structured Clinical Examination (OSCE)	2.12 (1.15)
Consulting on student DNP project	2.12 (1.08)
Intrinsic/other
Allegiance to alma mater	1.97 (1.20)
Tech-savvy NP students to help research and download topics	2.59 (1.14)
Overall lowest 3
Acknowledgement at school commencement ceremony	1.64 (0.99)
Featured article of you in school and/or professional newsletters	1.66 (1.02)
Gifts of appreciation	1.66 (0.98)

Note: DNP = Doctor of Nursing Practice; NP = nurse practitioner.

Factors rated as important were the role of preceptor clearly defined, coworkers in clinic who are supportive of preceptor role, and protected teaching time. In addition, EHR access/log-in for students rated highest among all factors and had a mean of 4.53. Enjoyment of precepting was also rated high with a mean of 4.32. Results related to least motivating factors include acknowledgment at school commencement ceremonies, being featured in school or professional newsletters, and gifts of appreciation. Faculty presence during the site visit had a mean of 2.74 and was ranked as least important within the university process domain. In addition, financial remuneration to you personally (such as bonus) had a mean of 2.68 (SD = 1.45), and financial remuneration to practice had a mean of 2.13 (SD = 1.38).

Cronbach alpha for the domains ranged between 0.79 and 0.90 for each separate domain, demonstrating good internal consistency, and item-level analysis showed no significant improvement in alpha by removing any individual questions. The overall Cronbach alpha for the entire survey was 0.75, indicating good internal consistency across the domains, and item-level analysis confirmed that removing any domain summary score would not improve the reliability.

The chi-square analysis (Table 4) of difference by program identified several significant findings across different domains, highlighting variations in motivators based on the NP program that the respondent precepted for. In the intrinsic/other domain, FNP preceptors had the highest mean score of 2.64 (SD = 1.16) for the factor, tech-savvy NP students to help research and download topics. This demonstrated a significant difference between the programs (χ² = 16.99, p = .030). Recruitment opportunities also demonstrated a significant difference between the different specialty programs (χ² = 19.53, p = .012) with PMHNP preceptors having the highest mean score of 3.12 (SD = 1.45).

Table 4.

Significant differences in domains by preceptor program

	FNP (N = 41)	PMHNP (N = 17)	PNP (N = 15)	Chi-Square (p-Value)
Recognition
Acknowledgement at school commencement ceremony	1.90 (1.02)	1.12 (0.49)	1.53 (1.13)	.032
Participation on school committees or advisory boards	2.34 (1.09)	1.71 (1.26)	1.53 (0.83)	.020
Publication of your name in the school catalog	2.20 (1.10)	1.24 (0.56)	1.53 (1.06)	.038
Certification/education
Credit toward professional certification or recertification	3.83 (0.99)	3.53 (1.50)	3.13 (1.25)	.037
Opportunity to serve as student evaluator for Objective Structured Clinical Examination (OSCE)	2.61 (1.12)	1.47 (1.07)	1.53 (0.64)	.010
Information on how to be an effective preceptor	3.49 (0.95)	3.24 (1.60)	2.93 (0.96)	.001
Intrinsic/other
Previous NP students from OHSU	2.95 (1.30)	2.94 (1.48)	2.53 (0.92)	.030
Taking an NP student is a change of pace	3.10 (1.02)	2.41 (1.12)	2.47 (1.19)	.012
Recruitment opportunities	2.83 (1.11)	3.12 (1.45)	2.00 (1.00)	.049

Note: FNP = family NP; NP = nurse practitioner; PMHNP = psychiatric mental health NP; PNP = pediatric NP.

Discussion

The results of this survey were analyzed with a goal of identifying barriers and facilitators to precepting and to inform potential strategies to recruit and retain preceptors for FNP, PMHNP, and PNP students. The findings demonstrate that having coworkers who are supportive of the role of a preceptor and having the preceptor role clearly defined are more important than having financial renumeration for the practice or performing faculty site visits. Appreciation gifts and types of recognition were rated as least important. Expected findings include preceptors' enjoyment of precepting students, and professional obligation or a chance to give back.

Having coworkers supportive of their role as a preceptor was found to be important in this study. This aligns with pre- and post-COVID studies that also found the importance of the clinical sites being supportive of the preceptor–student relationship (Burt et al., 2022; DeClerk et al., 2021, 2024; Roberts et al., 2017). When all clinic staff, including office staff, registered nurses, providers and administration, are accepting of students in the setting, providers are more likely to precept (DeClerk et al., 2021, 2024; DeClerk et al., 2024). Earlier researchers have also shown that lack of support from the preceptor's employer, including lack of space and staff support, is a key barrier to precepting (Roberts et al., 2017). Researchers have also shown that clinical practices and communities benefit from developing academic–clinical partnerships, as it benefits NP programs to retain clinical placements, NP faculty to maintain practice hours, and improve community access to care (Morgan et al., 2017; Nicoteri, 2020). This suggests that schools could focus more on developing strategic academic–clinical partnerships, especially in rural and underserved areas in which students could gain the essential skills needed for practice, and preceptors could receive support of clinical faculty. Further research is needed to delineate what information clinic staff need to be more supportive of student–preceptor relationship.

The role of preceptor being clearly defined was equally important. Previous researchers have shown that preceptors appreciate and desire opportunities to increase their understanding of the preceptor role through online educational interventions, guidance for clinical expectations regarding student outcomes, and formal preceptor training (Perryman 2022; Renda et al., 2021; Roberts et al., 2017). By contrast, one post-COVID study indicated that preceptors surveyed reported a high level of confidence in their role as a preceptor and their ability to precept (McCann et al., 2024). However, another post-COVID study showed that NPs who had not yet precepted reported a lack of self confidence in their clinical role and indicated needing more time in their current role to feel comfortable taking on a student to precept (DeClerk et al., 2024). Both current preceptors and NPs surveyed who had not yet precepted indicated that clear expectations from schools of nursing and ongoing, open communication with clinical faculty about the students' goals, student role, and preceptor role were important facilitators to precepting (DeClerk et al., 2024). This suggests that programs can focus more attention on providing education related to the role of preceptor tailored to clinicians who are new to the role of precepting and provide all preceptors with clear expectations for student progression and clinical performance specific to each rotation.

This study's results suggest that paying preceptors is not as critical as previously thought. Studies post-COVID align with our findings. One study found that preceptors identified incentives such as financial reimbursements and tax credits as nice but not necessary incentives (DeClerk et al., 2024). In another study, the lowest reported motivators were tax credits (McCann et al., (2024). By contrast, the literature before COVID indicated that financial compensation was a significant incentive for preceptors (Roberts et al., 2017; Webb et al., 2015).

Preceptors in this study also indicated that it was not important to have faculty present during site visits. This contrasts with previous studies pre-COVID, which have reported that most preceptors prefer in-person site visits by faculty, citing that in-person visits improve communication, allow more time for clarification about student expected outcomes and improve the student experience (Aquila & Lie, 2015; Hudak et al., 2018). Studies conducted post-COVID did not address having in-person faculty site visits but did highlight the importance of having clear and open communication with clinical faculty (DeClerk et al., 2024; McCann et al., 2024). The results from this study suggest a change in importance of frequent site visits. This implies that the frequency of in-person site visits could potentially be decreased and other modes of communication with preceptors increased. Faculty could consider more formal emails to preceptors before a clinical rotation and then continued written follow-up from faculty throughout the term. Faculty may be able to complete student evaluations through virtual visits when appropriate, potentially reducing the need for travel to clinical sites.

Of interest, recognition ranked overall lowest as a motivator, however being able to enhance credentials as a clinical teacher and personal thank you letters from students were more important within this domain. Acknowledgement at school commencement ceremony, being featured in a school and/or professional newsletters, and gifts of appreciation were ranked overall lowest among all domains. Pre-COVID studies found similar results that gifts of appreciation and formal recognition are inconsequential as incentives to preceptors (Todd et al., 2019; Webb et al., 2015). A post-COVID study by McCann et al., (2024) also found personal recognition as the overall lowest motivator for precepting.

The factors “enjoyment of precepting” and “professional obligation/a chance to give back” are consistent with results from other studies both before and after COVID. The highest motivators reported by McCann et al., (2024) for precepting both pre and post COVID was personal enjoyment/fulfillment, prior association with a student, and professional obligation. Nurse practitioners consistently rank professional obligation, altruism, and respect toward their profession, as well as joy in precepting and devotion to students as compelling reasons to precept (McCann et al., 2024; Renda et al., 2021; Todd et al., 2019).

The chi-square results demonstrate that PMHNP preceptors rated recruitment opportunities as a higher motivator to precept than FNP and PNP preceptors. Family NP preceptors ranked having tech-savvy students to help with research projects as a higher motivator to precept than other specialties. Although two studies reviewed shared that potential recruitment of students to join their practice in the future was an incentive to precept, the literature did not differentiate results among advanced practice registered nurse specialties (Morgan et al., 2017; Renda et al., 2021). This suggests that these differences among specialties should be explored further.

There are a few limitations to this study. One limitation is that this study was conducted in Oregon and may not be generalizable to other states. Another limitation is that the survey was sent out in spring to preceptors who served in the previous year, which could lead to recall bias for those who had precepted in the summer or fall. In addition, we only surveyed preceptors from FNP, PMHNP, and PNP programs, and it may not be generalizable to preceptors serving other programs. A strength of this study is that we had an acceptable response rate of 33% (Keough & Tanabe, 2011).

Conclusion

This study's results contribute to the current body of knowledge related to motivators and barriers to precept DNP students. Our findings highlight the importance of having the role of preceptor defined, as well as having support of colleagues and administrators to precept students. As NPs education moves toward a more competency-based model, it will be even more critical for clinical faculty to partner closely with clinical preceptors to evaluate students’ clinical reasoning skills and demonstration of application of knowledge to clinical practice (National Task Force, 2022). The experiential learning that clinical preceptors provide is a cornerstone of NP programs. Academic–clinical partnerships are key to creating environments that are supportive of precepting NP students. Faculty presence at a site visit may be reduced by using other communication means with preceptors. The results of this survey will help inform further efforts to recruit and retain preceptors who have the vision and passion to work collaboratively with clinical faculty in training the next generation of NPs and deepens our understanding of the current post-COVID factors that influence a clinician's decision to serve as a preceptor.

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DOI: 10.1097/JXX.0000000000001205