Supporting nurse practitioner education: Preceptorship recruitment and retention

Abstract

Objectives

Clinical experience is an essential component of nurse practitioner (NP) education that relies heavily on preceptors. Recruitment and retention of preceptors is challenging due to many variables that can affect NP education and practice. We surveyed Canadian NP programs to understand their preceptorship structures, how they support preceptorship, and to identify gaps and challenges to recruitment and retention of preceptors.

Methods

An 18-item survey, developed by the NP Education Interest Group, was distributed to 24 universities across 10 Canadian provinces. Construct validity and reliability was assessed by experienced NPs and NP faculty. Data were analyzed using relative frequency statistics and thematic analysis. Participants consisted of administrative staff and/or faculty designated as responsible for recruitment and retention of NP preceptors.

Results

Seventeen returned surveys were analyzed and demonstrated more similarities than differences across Canada's NP programs, particularly related to barriers affecting recruitment and retention of preceptors. The findings identified NP programs have too many students for the number of available clinical sites/preceptors, resulting in overutilization, burnout, or refusal to take students. Competition with other health disciplines for clinical placements was identified as a challenge to placements. Respondents commented they lack time to recruit, provide follow-up, offer support, or seek preceptors' feedback due to competing work demands. They identified the need for standardized funding for preceptor remuneration and recognition across the country.

Conclusion

The findings suggest the need for exploring a wider intraprofessional collaboration among graduate NP programs/faculty, clinical placement sites, and NPs to facilitate the recruitment and retention of preceptors.

1. Introduction

The clinical experience for nurse practitioner (NP) students is an essential component of their education. In 2012, the Canadian Association of Schools of Nursing (CASN) published Nurse Practitioner Education in Canada: National Framework of Guiding Principles & Essential Components. From this initiative, the Nurse Practitioner (NP) Education Interest Group was formed in 2013, followed by a subgroup, the Preceptorship Working Group in 2014 to focus attention on issues related to NP preceptorship.

Like those in the United States (US), NP educational programs in Canada are at the graduate level and the number of programs has increased. This, in turn, has created an escalation in demand for competent and willing preceptors [1]. The increase in NP programs resulted, for example, in the number of NPs increasing by 25% in one year alone and has seen the supply of NPs more than doubling to over 4800 [2,3].

According to CASN [4] there are 27 universities and two college/university collaborations in Canada delivering one or more NP programs or streams in both English and/or French, for a total number of 29 universities. The largest number of programs is in the province of Ontario, which also has the largest provincial population. Programs in Canada fall into three categories, Family/All Ages, NP-Adult, and NP- Pediatrics, which also includes the neonatal NP (NNP) role. The number of students admitted into NP programs increased to 28% in 2014–2015 [4].

Unlike those in the US, Canadian NP programs are relatively small, graduating 532 NPs in 2015 compared to 449 in 2014 [5]. The number of students graduating from NP programs decreased by 5.8%–520 graduates in 2016. The majority of programs, 89%, are being delivered utilizing a blended online and on-campus format [5]. As well, there is a paucity of NP faculty, with only 124 full-time faculty having NP credentials [4].

The number of students entering NP programs decreased by 9.3% in 2015–2016 [4]. This is due, in part, to a decline in RNs across health care settings; a decline in RN and post-RN enrollment; an aging regulated nursing workforce; and economic constraints on educational funding [2,5,6]. Employment and practice barriers continue to challenge the integration of NPs in Canada due a lack of funding models; a lack of continuity of care between the community and hospital; and a general lack of understanding, by the public and the health care system, of the NP role [7].

To compound matters, over a five-year period, NPs working in primary health care settings decreased 10% and the number working in hospitals and long-term care (LTC) increased 10% [8]. In one Canadian province, Ontario, remuneration and benefits for NPs practicing in primary health care settings have not kept up with salaries in the tertiary care sector, thus more NPs are accepting positions where there is greater perceived job security, higher salary and a pension plan [9]. This is problematic because the majority of programs prepare students as Family/All Ages NPs who are prepared to practice in primary health care settings. With more NPs in tertiary care settings, there have been fewer NPs to precept NP students in the community.

The purpose of this study was to understand how NP preceptorship is structured across Canadian NP educational programs. The objectives of the study were to: 1) examine preceptorship models in the 28 NP programs across Canada; 2) identify gaps and challenges related to recruitment and retention of NP preceptors; and 3) explore ways to assist NP program or school of nursing administrative staff and/or faculty who are responsible for recruitment and retention of NP preceptors.

2. Review of the literature

A review of the literature was conducted using CINAHL, Medline, and ERIC databases to identify original and/or descriptive based articles. Search terms included precept, preceptor, nurse practitioner, experience, attitudes, resources, facilitators and barriers. All articles were considered for their content if they discussed preceptorship in NP education.

To date, most of the nursing literature related to preceptorship has focused primarily on baccalaureate nursing education. While there are similarities, there are also differences when precepting nursing students in undergraduate programs versus those in graduate NP programs. Firstly, they are both students, and therefore share common concerns based on the principles of adult learning. The major difference between the two types of students is that NP students are licensed and regulated registered nurses and bring with them nursing expertise in both knowledge and practice. NP students are in the process of acquiring advanced knowledge and skills to further develop their nursing practice beyond the legislated scope of practice for registered nurses.

Traditional models of preceptorship for undergraduate nursing students can provide information that is applicable to NP education. The Canadian Nurses Association (CNA) Guide for Preceptorship and Mentorship [10] can be relevant for APN education as it addresses the triad of student, faculty, and preceptor. However, modifications are required to meet the unique characteristics and expectations of the advanced practice nursing (APN) role and the document does not provide a ‘how to’ approach to recruitment and retention which was of interest in this study.

Three models of clinical supervision of students have been cited in the literature: direct supervision by faculty, a preceptorship model using clinical experts as preceptors, and collaborative teaching models [11]. Historically, Canadian NP programs utilize a preceptorship model that recruits clinical experts in health care, whether primary or tertiary, such as NPs and physicians. This model relies heavily on preceptors to support role socialization and prepare students for NP practice. Preceptors act as role models and provide clinical learning experiences that assist students in applying theory to real life situations, and the development of APN practice competencies [12]. In Canada, these include clinical practice, research, leadership and consultation/collaboration competencies [13].

The literature related to recruitment of NP preceptors varies widely, and frequently relates to preparing for and enacting the role of the preceptor; facilitators and barriers to precepting; teaching strategies during the preceptorship experience; and perceptions, usually using satisfaction as a measure, with the preceptor role. To date, little has been published on “how to” strategies to recruit and retain NP preceptors [1,[14], [15], [16]].

Furthermore, the literature related to the retention of NP preceptors addresses several facilitators and barriers to preceptorship. Facilitators include professional and personal growth, networking with faculty, and impacting NP education [17]. Barriers to recruitment and retention of NP preceptors include a number of variables such as: the lack of sufficient infrastructure to support them; clinical practice demands in community agencies; competition with other NP programs; increasing number of NP students and a relatively small number of practicing NPs to precept; lack of remuneration; and competition with schools of medicine and other health professions for their services [1,15,[17], [18], [19], [20], [21], [22], [23], [24]].

The two most identified barriers in studies of over 450 preceptors and potential preceptors were productivity and time issues [1,17]. There is consensus in the literature that students should not be identifying and securing their own preceptors and clinical placements, and that NP programs need to develop a sense of responsibility in students to be future preceptors who support future generations of NPs [[25], [26], [27], [28]].

In summary, the literature offers several broad observations and guidance related to NP preceptorship, primarily in programs in the US. Consequently, we undertook this survey to learn more about Canadian NP programs including who was responsible for recruitment and retention of preceptors; how preceptors are supported and recognized; how NP faculty and preceptors communicate; challenges in placing NP students in clinical settings; and perceptions of whether or not a pan-Canadian approach would be of benefit to those who are responsible for recruiting and retaining NP preceptors.

3. Methodology

3.1. Study design

To assess preceptorship across Canadian NP educational programs, members of the NP Education Interest Group developed an 18-item survey (Appendix A). Construct validity and reliability of the survey tool was assessed by the Preceptorship Working Group and the NP Education Interest Group who were experienced NPs, NP faculty, and had direct experience in recruiting and/or precepting students.

3.2. Ethical consideration

Representing baccalaureate and graduate nursing programs in Canada, CASN is the national voice for nursing education, research, and scholarship. In this capacity, CASN regularly involves university programs and faculty in undertaking activities, such as surveys, for quality assurance or improvement for operational purposes. As per Article 2.5 of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2), surveys fall “within normal educational requirements when used exclusively for assessment, management or improvement purposes, do not constitute research for the purposes of this policy, and do not fall within the scope of REB review” [28].

3.3. Data collection

A convenience sampling method was utilized by emailing the survey to NP program directors or leads identified through program websites and were known to members of the NP Education Interest Group. Email recipients were asked to distribute the survey to the person, whether it be NP program or school of nursing administrative staff and/or faculty, who had the responsibility for recruitment and retention of NP preceptors within their NP program(s) and return it via email to the CASN office. Completion of the survey was voluntary, and informed consent was demonstrated when a respondent completed and returned the survey. NP preceptors were not eligible to complete the survey as NP preceptors' experience was not a goal of the survey.

3.4. Data analysis

Surveys were emailed to 24 universities (83%) delivering one or more NP program(s), and 27 surveys were returned for analysis. The survey data were uploaded to an Excel spreadsheet assisted by CASN administrative staff and cleaned of errors, omissions, and any duplications. Seven of the returned surveys were incomplete, and three were completed twice for an n = 17 completed surveys. Provinces and programs represented included: British Columbia - 2; Alberta - 2; Saskatchewan - 1; Manitoba - 1; Ontario - 8; Quebec - 1; Nova Scotia - 1; and Newfoundland - 1. Data from closed ended questions were analyzed using relative frequencies of responses and thematic analysis for responses to open ended questions.

4. Results

4.1. Program characteristics

The majority (70%) of NP programs represented in the sample (n = 17) were Family/All Ages, which is supported widely in the Canadian literature as the largest, fastest growing NP role, and represents the largest group of NPs in Canada [29,30]. Adult NP programs were offered either full-time or part-time in 15% of the programs, followed by a small number of pediatric programs (5%) and neonatal NP programs (10%). Fourteen NP programs (82.35%) offered full-time and part-time study options, two offered full-time only (11.76%) and one only offered part-time only (5.88%). Additionally, there were two Neonatal NP (NNP) programs (one full-time and one part-time), and one full-time NP-Pediatrics program.

Respondents indicated that a variety of administrative NP program or school of nursing staff and/or faculty were responsible for recruitment and retention of NP preceptors including designated placement coordinators. Although the full-time equivalent (FTE) allocated for recruitment and retention of NP preceptors varied across programs, the majority (65%) allocated a part-time or less than part-time FTE and 35% (n-17) allocated one or more full-time positions.

All programs identified specific criteria for the recruitment and retention of NP preceptors. These included being an NP or an MD that worked with an NP faculty advisor; scope of practice of NP preceptor matched the NP program of study (generalist versus specialist); one to two years (minimum) experience as an NP; a graduate nursing degree; in good standing with the provincial regulatory body; adequate space that supported an NP student; and the support of their clinical site manager.

NP programs identified that they utilized a variety of tools and strategies to support preceptors including orientation materials, student evaluation tools, university policies such as accident reporting and confidentiality, and preceptor dinners that included educational presentations. Only 41% of respondents had a dedicated website for NP students and preceptors. The programs who offered a formal orientation for preceptors did so through short webinars and an online preceptor resource centre. Using online resources, programs were able to reach preceptors who were located across large geographic locations.

Formal NP preceptor recognition or acknowledgement varied across the country. Ways preceptors were recognized included providing them access to university's library and student educational materials, adjunct faculty appointments, preceptor appreciation events, recognition awards, and preceptor workshops. Remuneration of NP preceptors was provided by 47% of NP programs, and where both MD and NPs acted as preceptors, both were paid equally.

Systems utilized by most of respondents across the country to track the number of NP preceptor requests and/or placements per term included an online collaborative placement site such as HSPnet; Excel or other SON-based spreadsheets; manual tracking; and school of nursing specific forms.

Communication between NP faculty and preceptors varied; 82% used regular emails followed by 77% arranging telephone meetings and 47% engaged in face-to-face meetings. Approximately 48% of programs required NP faculty to visit students in their clinical placements, while in other programs it was not a requirement. While site visits were preferred, it may not be possible and/or necessary. Participants stated that communication between NP faculty and preceptors occurred through emails and/or telephone contact and was ongoing. One participant described the decision-making process NP faculty used to decide when or if to make a site visit as:

Typically NP faculty make one site visit per semester in the first year of the program (that would be 3 site visits). In the second year if the student is doing well we may not make a site visit, instead would communicate via email and over the phone with preceptors to determine student progress. If the preceptor has any concerns about the student's ability to meet course requirements faculty will make a site visit and work with the student and preceptor to develop a plan for going forward.

4.2. Gaps in student placements

In an open-ended question, participants were asked to describe any NP program needs or gaps related to student placements and recruitment and retention of preceptors. Common needs or gaps in student placements included; lack of space to accommodate a student, the mismatch between student learning needs, i.e. health assessment skills, and the preceptor's practice which is primarily with patients with complex care needs, or the preceptor's practice was specialized and the program prepared generalist NPs in Family/All Ages.

One participant described the gap as: difficulty matching clinical settings to life-stage of the course the student is taking. In other words, if a student was enrolled in a health assessment course and the preceptor had a specialized cardiac practice, this created a gap in the ability of the student to learn basic health assessment skills because the patients in the practice needed advanced cardiac assessments. Similarly, the preceptor might request students who were more advanced in the program, and who could function more independently than a student early in their program. Finally, another program participant described a gap in student placements because: student demographics are showing less maturity and the student initially expect the preceptor to teach rather than research the info for themselves. Health assessment skills are not taught as well in the undergraduate programs so students are not as ready as they should be. As a result of RNs entering NP programs without a strong background in health assessment and less RN experience, preceptors and faculty members must spend more time preparing them to enter a clinical practice setting.

4.3. Challenges in recruiting and retaining preceptors

A participant expressed frustration with recruiting and retaining NP preceptors by stating:

Finding suitable willing preceptors is one of the most time consuming tasks in the program. We have attempted (and continue to look for opportunities) for retention and non-monetary acknowledgement. However, lack of remuneration is an issue for many NPs and physicians and may play a role in willingness to act as preceptors (no hard data on this).

Participants listed lack of time to recruit NPs for preceptorship roles; competition for clinical sites with students from other NP programs or medical students; the inability to provide remuneration; preceptors in specialty practice; pressure from their employers to see more patients; and the continuous struggle to find enough NP preceptors to accommodate the number of students. As well, NPs appear to change positions often and need to take time out of precepting to establish a practice in the new setting or take parental leave. Some respondents indicated that preceptors get tired of the demands of precepting and want to take a break for a while. Participants stated that NPs may not perceive precepting as part of their professional responsibility, resulting in suggestions like:

If this can be seen more as part of one's professional role, and not an add on, that would be helpful. Or: adding content in the last semester of the NP programs related to precepting, and the professional obligation of paying it forward would be helpful.

These suggestions indicate a need for NP programs to socialize NP students into understanding the value, and perhaps a professional obligation to help those coming after them, giving students a hands-up to learning.

Finally, we asked respondents to indicate ways to address ongoing preceptor recruitment and retentions and if a national NP preceptorship website would be of interest to them. Overwhelmingly, respondents commented that standardized remuneration and recognition of preceptors across the country would improve preceptor recruitment and retention. There was limited interest in a national preceptorship website.

5. Discussion

Despite Canada's vast geography and the differences in size of Canadian NP educational programs and/or cities in which they are found, the survey demonstrated similarities related to the gaps and challenges encountered when recruiting and retaining NP preceptors across the country. Several needs and/or gaps were identified by respondents related to NP student placements, and the recruitment and retention of NP preceptors that are supported in the literature as barriers to preceptorship. Even though the number of NPs in Canada has more than doubled over the past five years, survey respondents identified that NP programs have too many students for the number of available clinical sites and preceptors resulting in overutilization of NP preceptors, burnout, or refusal to take students. Competition with other health disciplines for clinical placements was identified as another challenge to placements.

Respondents identified the need for more NPs in primary health care (PHC) clinical sites, to fill the widening gap created by NPs moving from community-based practice to tertiary practice due to health system barriers. Site managers may also affect the recruitment of NP preceptors by not permitting an employed NP to accept a student placement request or limiting the frequency the NP is able to precept students. Lack of facility space to accommodate NP students, and preceptor remuneration continue to be identified as a barrier. University system barriers include the inability to provide NP preceptors with adjunct faculty status or other incentives. Conversely, respondents reported that NP preceptors appear to change jobs frequently and therefore are not able to accept an NP student when they are in a new position.

All respondents commented that they do not have sufficient time to recruit, provide follow-up, offer support, or seek NP preceptors' feedback due to other competing work demands. In many areas, survey respondents identified a lack of consistency in processes to request clinical placements as each health authority or facility may have different requirements for requesting an NP student placement. Students seeking a clinical placement or NP preceptor prior to formally registering in a clinical course, was also identified as breaches of program and agency processes. As well, out of province placements were a challenge because a province's priorities are for NP students from their own university programs. Additionally, provinces were increasingly resistant to sign out of province affiliation agreement.

Matching NP students' learning needs with NP preceptors was also identified as a gap. Some students need two days per week of clinical time and that often was difficult for NP preceptors to manage within the demands of their role. As well, matching clinical setting placements to the life-stage of a course an NP student is taking may be difficult, making theory to practice learning somewhat disconnected. Lastly, there was a sense that the NP student population was less mature than in previous years. Contributing to this was the belief that health assessment skills were not being taught as well in undergraduate nursing programs. This resulted in NP students being underprepared for clinical site placements. Students' lack of experience contributed to NPs not wanting to precept until the student was further along in the NP program.

Barriers identified in our survey echo those from the literature including insufficient infrastructure; demands in community agencies; competition, the number of NP students outmatch the number of NP preceptors; and competition for placements with other NP programs, schools of medicine, and other health professions [1,15,[17], [18], [19], [20], [21], [22], [23], [24], [27],27].

To address ongoing NP preceptor recruitment, development, and retention, some respondents identified the need for formal preceptor training or a preceptorship website to support NP preceptors in how to assist in students' learning. Increasing resources and tools available for NP preceptors and funding for remuneration were described as a key need. Other perks included cross-appointments and funded preceptor workshops. Respondents felt that socializing students to value the preceptor role and expect to preceptor students in the future was a way of paying forward for the mentoring they received during their education program. We were interested in knowing if respondents would value a national NP website, however only 24% stated they were interested and 12% would be interested dependent upon the content, if it was applicable to their program, and was not duplicating other existing websites.

Although 24 of 29 universities having one or more NP program(s) were emailed surveys, not all NP programs or leads in them were known, nor could be obtained. Therefore, surveys may not have been distributed to all NP programs at a university who had more than one program, creating an under-sampling of available programs. Several of the surveys returned though were completed by one person on behalf of all NP programs identified at a university having more than one NP program. This may account for the incomplete or duplicated surveys received, particularly if more than one person at a university attempted but did not follow through on completing the survey for their program(s).

The survey did not request the educational level of the NP program or school of nursing administrative staff who may have been the designated person recruiting NP preceptors, but the data indicates that recruitment is a collaborative process and undoubtedly, involves faculty members. Furthermore, we did not seek preceptors' observations as the focus was the perspective of NP educational programs' experiences with recruitment and retention of NP preceptors. We acknowledge we may have obtained additional insight into NP preceptor issues and will consider preceptors' perceptions in a future survey.

The four Francophone universities in New Brunswick and Quebec, Canada were not surveyed due to a lack of financial resources for translation therefore, only Anglophone or bilingual universities were surveyed. Two of the provincial university NP programs surveyed did not complete or return the survey, although all were sent two reminders. The NP Education Interest Group discussed whether other measures to obtain data from the two programs were required, but given the similarities of the overall results, it was decided this was not necessary.

6. Conclusion

There is no doubt that NP preceptors are an essential clinical component for acquiring APN competencies and for role development. The findings of this survey suggest a complementary need for exploring a wider intraprofessional collaboration among graduate NP programs, clinical site administrators, NP faculty, and NPs to facilitate the recruitment and retention of preceptors.

Health care organizations rely on NP education programs to develop the next generation of NPs. Successful collaboration between NP programs and these stakeholders around benefits, rewards, and supports has the potential to make NP preceptorship more inviting and rewarding for future preceptors, and to strengthen their role commitment over time. However, instability and changes in the health care system are affecting practice opportunities for NPs and placing additional constraints on NP preceptors. This is of concern for NP programs in relation to recruitment and retention, reliability on health care organizations to take more NP students, and the capacity of NPs to be preceptors to meet the growing numbers of NP students across the country. Given the small number of NP programs in Canada, the findings of this survey point to a need for NP faculty and programs to continue to look for improved ways to recruit and retain NP preceptors and to establish consistency from province to province.

Appendix A. Supplementary data

The following is the supplementary data related to this article: