To become a women’s health nurse practitioner (WHNP), students must complete a minimum of 600 hours of supervised clinical practice, 500 of which must be providing direct patient care in the advanced practice nursing role.¹ Clinical experiences must be tailored to ensure the graduate will have the required WHNP competencies. Most clinical experiences should be with WHNP preceptors but may also include other clinicians with current, extensive women’s health experience.¹ 

Historically, health professionals, including nurse practitioners (NPs), have been educated in a 1:1 model of student to preceptor.² Challenges to finding NP student clinical placements to implement this model are not new, but these have increased during the last decade.

As advanced practice nursing programs proliferate and medical students and physician assistant students also seek clinical experiences, competition for preceptors at appropriate clinical sites has intensified. Additionally, the clinicians who do precept are often confronted with time, productivity, and practice constraints.² Recruiting, training, and maintaining qualified preceptors is an ongoing challenge for WHNP academic program leaders (APLs).

WHNP APLs across the country have established an organized group in collaboration with the National Association of Nurse Practitioners in Women’s Health (NPWH) to address relevant issues such as this. It is important work for WHNP APLs and NPWH to facilitate successful learning for current and future WHNP students. The purpose of this article is to identify the challenges and propose potential solutions to securing high-quality clinical experiences for WHNP students. 

Methods

A secondary analysis of data collected from the Women’s Health Nurse Practitioner 2018 Workforce Survey was used to identify trends and attitudes regarding the preceptor role.^A The original survey was conducted by NPWH and, through collaboration with the National Certification Corporation (NCC), was sent to 11,319 certified WHNPs. The survey had a response rate of 21%, with a total of 2,374 respondents. University Institutional Review Board approval was obtained for the original study. The survey was distributed via Survey Monkey and responses were anonymous. 

The workforce survey included six questions related to precepting (Box). The final question was directed to respondents who indicated they did not precept students. This question had multiple choice options and an option of “other” to write in reasons for not precepting. 

Data analysis

Descriptive statistics were analyzed using SPPS 25 to report frequencies and percentages. Open-ended response data were analyzed using traditional content analysis.³ All three authors reviewed the qualitative data from the write-in option of “other” for the reason for not precepting, identified similar threads, and winnowed the data to three major categories.

Results

Of the 2,374 WHNPs who responded to the survey, 1,951 answered the question of do you precept students. Of these respondents, more than half reported they currently precepted students (64%, n = 1,242), with the remainder (36%, n = 709) not precepting. For those who were precepting, the majority precepted NP students: WHNP 75%, family nurse practitioner (FNP) 74%, adult-gerontology nurse practitioner (AGNP) 14%, and midwifery students 18%. Fewer WHNPs reported precepting medical students and residents (24%), physician assistant students (21%), and other students (6%).

WHNPs who precepted were queried about monetary and nonmonetary compensation in the survey. Very few (1%) of the respondents reported being consistently paid by students’ schools for serving as a preceptor. The majority (86%) were never paid, while 13% indicated they have been compensated by some but not all schools for this work. One respondent indicated being paid an additional $5.00 per hour, and the remainder reported a onetime per semester payment with a wide range of compensation from $50 to $5,000. Some respondents reported that the practice made the financial compensation arrangement and all funds were paid directly to the practice while the preceptor was not directly compensated. Additionally, 29 respondents reported that a for-profit preceptor finder agency paid them (range $200–$3,000) to precept students. A few respondents reported receiving non-monetary compensation of free continuing education opportunities (6%) or library privileges (10%). Individual responses on other compensation included Up To Date subscriptions, gift cards to restaurants, money that could be used toward continuing education, tuition discounts, luncheons, and adjunct faculty status.

Respondents who indicated they were not precepting submitted a variety of reasons, which were sorted and grouped into three main categories. These categories include clinician-related issues, clinical practice-related issues, and academic partner issues. 

Discussion and implications

Securing quality preceptors and clinical experiences for NP students is important for students and their academic institutions. Challenges to finding preceptors have been documented by professional organizations and documented in published literature.^2,4,5 Although there are no simple resolutions to this complex issue, a variety of creative solutions can be used to address the varied reasons why experienced practicing NPs do not precept. Based on the categories derived from this study, we discuss issues related to the clinician, the clinical practice, and the academic partner.

Clinician-related issues

One of the main reasons WHNPs reported for not precepting students was a perceived lack of experience or confidence to work with a student. Of note, 8.5% of total survey respondents indicated they had 1 year or less of experience as a WHNP.^A National organizations have not specified minimum years of practice for NP preceptors, and therefore individual school requirements may vary. Follow-up with WHNPs after they have established their role as an independent clinician could provide a new pipeline of preceptors. All potential and new preceptors can be offered a structured orientation or tool kit using a variety of methods. Strategies that have been suggested include online modules, mentorships, and checklists to enhance the student–preceptor relationship.^6–8 NP conferences offer another venue for preceptor training during expanded pre- or post-event workshops. Preceptor mentoring databases maintained by schools or by national NP organizations can provide a resource to match experienced preceptors with preceptors who are new to the role. 

Respondents also reported concerns related to reduced productivity, being too busy, or having limited clinical hours. Some respondents reported only working per diem and did not have a set schedule, which interfered with consistency in precepting students. Other concerns were expressed regarding scheduling and needing to meet target
productivity goals for patient visits.

Clinicians who work limited days/shifts or per diem can still be valuable to students for a smaller portion of their overall clinical hours, especially if students have flexibility for clinical days and times. If a clinician works in a multi-provider practice, the student may be able to spend some time with other providers at the site. WHNP students can benefit from working with experienced physicians, certified nurse midwives, and physician assistants.

Several WHNPs who responded that they did not precept students indicated they worked in a specialty area and did not believe it would provide an appropriate experience for a student. Common specialty areas for WHNPs include, but are not limited to, breast and gynecologic oncology, urogynecology, reproductive endocrinology/infertility, urgent care for sexual and reproductive health, genetics, gender-based healthcare, postpartum/lactation services, and aesthetics. Students can benefit from experience with a preceptor in these specialty areas as a smaller portion of their overall clinical hours. Although the student may not choose to work in a specialty area, the focused experience provides concentrated learning that can be applied more generally after graduation. They also learn about the variety of specialty practice opportunities for WHNPs. 

Last, there were a portion of respondents who had previously been preceptors who reported they were experiencing burnout, with statements such as “I’ve done my duty” and “teaching is not my gift.” Preceptors who have had a long career as NPs are an invaluable resource to students and the next generation of WHNPs. Creative solutions to preventing burnout might include contracting with students for a limited number of hours, scheduling the student every other week, taking a semester off if needed, or limiting students to a half day in the clinical setting. Experienced preceptors who are feeling burned out might also appreciate the opportunity to shift roles and instead mentor less experienced preceptors.  

Clinical practice-related issues

Respondents reported multiple barriers to precepting students that were related to the practice setting. A major barrier reported was a lack of willingness by organizations to allow NP preceptorships. This could in part be related to lack of knowledge at the practice administrative level about advanced practice nursing, the role of NPs in clinical care, their educational preparation, and competencies. One component of the role of advanced practice registered nurses (APRNs) is to educate the public and other healthcare providers about NPs and how they are an integral part of the healthcare system and network of providers. It is imperative that we educate our healthcare colleagues including hospital and practice administrators and practice support staff. WHNPs who want to precept but face this barrier can use resources such as the NPWH white paper “The Essential Role of Women’s Health Nurse Practitioners”^B and the Women’s Health Nurse Practitioner: Guidelines for Practice and Education to inform administrators about the education, competencies, and roles of WHNPs on the healthcare team.¹ APLs can also provide these documents and/or offer to meet with practice administrators to discuss concerns as well as provide education about the benefits of precepting future healthcare providers. 

The extensive process to establish placement contracts that meet the requirements for both the academic institution and the clinical agency was identified by some respondents as a barrier to being able to precept students. Efforts on the part of the school and APLs to facilitate this process are essential. Strategies can include having a designated representative from the academic institution available to explain and review the terms of the placement contract with the preceptor and/or agency representative. Clearly defined expectations of the school, faculty, preceptor, student, and clinical agency promote confidence in responsibilities and collaboration. Documentation of completion of all school-instituted preclinical requirements of students prior to attending any clinical site and school-provided student liability insurance should be readily available. Fulfillment of any additional preclinical requirements that are site specific (eg, confidentiality agreements, electronic health record training) should be assured. A well-thought-out and consistent process that is fully regulation and safety compliant without being unduly complicated will reduce barriers.  

Many respondents cited the inability to precept students due to employment in a highly procedure-based practice. Although the respondents did not always name the type of procedures, some that are typical for women’s health include early pregnancy ultrasounds, hysterosalpingograms, endometrial biopsies, and colposcopies, which are all within the scope of practice for appropriately trained WHNPs. These are revenue generating for practices and therefore are valuable skills for WHNPs to acquire and should be encouraged as part of student learning. Even if students are not allowed to perform the procedures in these settings, they can participate in assessment and patient education and gain knowledge about procedure-related diagnosis and treatment. Communication between clinical faculty and the preceptor in these settings can clarify what students will be able to do and any preparation the preceptor recommends prior to the clinical experience such as reviewing intake processes, watching videos, or participating in procedure simulations in the school setting. 

Respondents also raised concerns about patients in their clinical practice not wanting students as part of their healthcare experience. Patients should always have the option to refuse having a student provide care. However, when the preceptor explains the education, credentials, and supervision of the student in a confident manner, patients may be more receptive. Medical and nursing education has always been grounded in precepted clinical practice. Although the public may have an awareness of medical student preparation, their awareness of NP student preparation may be limited. APLs can provide practices with consumer-oriented educational materials about NPs such as the NPWH “What is a WHNP?” flyer to share with patients.^C Healthcare agencies that endorse nursing and medical education as a part of their mission can post statements of this support and the rationale. 

Schools and APLs can emphasize to practices that education, patient support, and care management are the cornerstone of advanced nursing practice and that WHNP students can be a valuable resource. This may be especially true in the care of patients with chronic conditions or multiple comorbidities in which management can be time consuming and resource intensive. Students can spend the time necessary to obtain a comprehensive health history, look up resources, provide patient education, and work collaboratively with the team on developing the plan of care. Many WHNP students in doctorate of nursing practice programs are required to complete a scholarly quality improvement project in the clinical setting. Practices can be offered the opportunity to suggest issues in their clinical setting they see as potential topics for these projects. The practice benefits when the student implements a project to improve the care for patients with chronic and/or complex conditions such as gestational diabetes, endometriosis, infertility issues, and adolescent pregnancy.  

Academic program issues

Some respondents to the survey reported feeling disconnected from the requesting school or desiring more support from the faculty. Clinical faculty are the crucial liaisons to ensure the student–preceptor relationship is compatible with student learning and preceptor satisfaction. As such, faculty who are new to this role can benefit from an orientation and having an experienced clinical faculty mentor.   

The connection between preceptor and faculty begins prior to the student’s arrival at the clinical site. Clinical faculty are responsible for discussing the preceptor’s student preferences (including level of learning for the student and any required language skills), communicating the course objectives, syllabus, and student evaluation processes, and reviewing any specific expectations for type and number of patient experiences. Clinical faculty can also promote the preceptor–faculty connection by asking the preceptor what support they need, providing information on how to contact them, and informing them how often they will routinely be in communication. 

A few of the respondents indicated frustration because the students they have precepted were not prepared well for their clinical rotations. The clinical faculty–preceptor communication previously described may help to avert this situation. Selecting the correct level of student for the preceptor to work with is fundamental. Students, of course, are expected to be prepared for their clinical experience. When the student is completing course work concurrently with the clinical placement, the student can share the course topic schedule with the preceptor so they can plan clinical learning activities accordingly. As well, the student can ask the preceptor for a list of the most common health issues that are anticipated to be seen in the clinical setting so they can do additional preparation. Realistic expectations for both the student and preceptor should be addressed prior to the start of the semester, during the mid-semester check-in, and periodically as needed. 

Respondents also indicated that some students were not interested in their specific area of women’s health. It is unclear from the responses if this was related to specialty clinics or general women’s health. Ideally, the student should be involved in the selection of specialty clinical experiences that are of interest to them so they will be engaged in the learning process. They should also be encouraged to keep an open mind to a variety of clinical experiences they may not initially value.  

Most schools do not have the resources to provide preceptors with direct monetary compensation. Alternative demonstrations of appreciation for preceptors are important. Academic partners can consider library privileges, adjunct faculty status, or continuing education offerings. APLs can provide the documentation preceptors need to apply for continuing education credits for precepting from their certifying organizations (eg, NCC, ANCC [American Nurses Credentialing Center]). Collaboration with national NP organizations has potential to result in other ideas for showing appreciation for the important work of preceptors.

Many respondents indicated that they had not been contacted by prospective academic partners or advanced practice nursing students to be a preceptor. Reaching this untapped resource requires being able to identify WHNPs who are interested in precepting. NPWH and the WHNP APL group are collaborating to do this. When NPWH members join or renew their membership, there is a place to indicate if they are interested in becoming a preceptor. The list of NPWH members who are interested in precepting along with contact information will be available to WHNP academic programs. Another avenue for connecting NPWH members interested in precepting with schools in their area is the directory of WHNP programs on the NPWH website.^D 

Strengths and limitations 

These results must be viewed in terms of study limitations. As with all self-report measures, social desirability bias may exist. The cross-sectional nature of the study precludes determination of causality. Although consistent with other electronic survey data collection, the response rate of 21% was lower than desired. However, the results of this study provide important information for WHNP programs and students when formulating clinical practice experiences.

Conclusion

The education of the future generation of WHNPs is dependent on the availability of qualified preceptors and appropriate clinical sites. Students need extensive real-life patient care experiences with knowledgeable, dedicated preceptors to achieve competency for practice. The analysis of data on precepting trends and attitudes reveals multiple challenges. We have suggested strategies that may address some of these challenges. Creative solutions are needed to ensure that the clinician, the practice site, and the academic partner engage collaboratively in promoting high-quality student learning. WHNPs who are willing to precept students need support through training, mentoring from experienced preceptors, effective connections with faculty and the academic institution, and demonstrations of appreciation. Collaboration with national NP organizations can foster support for preceptors, students, and APLs.

Sandi Tenfelde is Associate Professor and Director of the Women’s Health Nurse Practitioner Program at Loyola University Chicago, Marcella Niehoff School of Nursing, in Chicago, Illinois. Heidi Collins Fantasia is Associate Professor and Department Chair for the Solomont School of Nursing, Zuckerberg College of Health Sciences, at the University of Massachusetts Lowell. Allyssa L. Harris is Department Chair and Associate Professor at the Connell School of Nursing, Boston College, in Chestnut Hill, Massachusetts. The authors state that they do not have any financial interest in or other relationship with any commercial product named in this article.

References

National Association of Nurse Practitioners in Women’s Health. Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 8th ed. Washington, DC: NPWH; 2020. 

Clark CA, Kent KA, Riesner SA. A new approach for solving an old problem in nurse practitioner clinical education. J Nurse Pract. 2018;14(4):e69-e75.

Sandelowski M. Qualitative analysis: what it is and how to begin. Res Nurs Health. 1995;18(4):371-375.

American Association of Colleges of Nursing. White paper: Current state of APRN clinical education. Washington, DC: AACN; 2015.

Amirehsani KA, Kennedy-Malone L, Alam MT. Supporting preceptors and strengthening academic-practice partnerships: preceptors’ perceptions.
J Nurse Pract. 2019;15(8):e151-e156.

Kuensting L, Beckerle C, Murphy N, et al. Web-based training modules for nurse practitioner preceptors.
J Nurse Pract. 2020;16(8):e113-e115.

Pitts C, Padden D, Knestrick J, Bigley MB. A checklist for faculty and preceptor to enhance the nurse practitioner student clinical experience. J Am Assoc Nurse Pract. 2019;31(10):591-597.

Wilkinson M, Turner BS, Ellis KK, et al. Online clinical education training for preceptors: a pilot QI project. J Nurse Pract. 2015;11(7):e43-e50.

Web resources

1. npwomenshealthcare.com/2018-npwh-womens-health-nurse-practitioner-workforce-demographics-and-compensation-survey-highlights-report/.   
2. npwh.org/lms/filebrowser/file?fileName=NPWH%20White%20Paper%20The%20Essential%20Role%20of%20WHNPs%20final%207.13.2020.pdf 
3. www.npwh.org/lms/filebrowser/file?fileName=NPWH%20What%20Is%20A%20WHNP%20v3.pdf
4. npwh.org/pages/whnp-graduate-programs.