Facilitators of and Barriers to Effective Preceptorships for Pre-licensure Nursing Students: What Nursing Faculty Need to Know

Abstract

Introduction

Preceptorships offer prelicensure nursing students the opportunity to meet their clinical objectives by working one-on-one with a registered nurse (RN). Although preceptorships can be provided for any clinical course, most prelicensure nursing programs offer them during the final semester. Preceptorships provide a bridge between academic study and the real world of nursing. By acting as a teacher, role model, evaluator, and person who can help a student to socialize with the profession, a preceptor can reduce the reality shock experienced by new nurses and provide them with realistic expectations about the nursing profession. The recent nursing shortage has inadvertently led to a preceptor shortage and forced the nursing leadership to become dependent on available RNs, including those without preceptor training or experience.

Purpose

This practice update paper aimed to address the facilitators and barriers associated with preceptorships for prelicensure nursing students and discuss the proposed solutions for effective clinical preceptorship based on evidence and the author's personal reflections.

Conclusion

The major facilitators were the discussion of nursing program expectations, the selection of teaching strategies with real-world examples, the creation of a structured weekly plan to promote learning, and the consideration of alternative teaching approaches. The major barriers were preceptors' dual responsibilities to students and patients, challenging students, and the lack of experienced preceptors. The proposed solutions included obtaining support from the nursing leadership team to ensure that the preceptor had a balanced workload, developing the emotional competence of the preceptor, addressing challenging students through a three-way conference with the student, the preceptor, and the clinical faculty and a written plan to ensure student progress, having the nursing leadership conduct periodic assessments of the preceptor pool, and ensuring that appropriate training was offered to candidates who were willing to become preceptors.

Keywords

nursing students clinical learning clinical nursing faculty facilitators for effective preceptorship barriers to preceptorship

Introduction

Nursing students are an integral part of the nursing workforce. The nurse employment rate grew by 6% from 2013 to 2021, and 203,000 registered nurse (RN) positions are expected to be created between 2021 and 2023 in the United States (US; U.S. Bureau of Labor Statistics, 2022). However, the nursing profession suffers from rapid staff turnover and critical shortages (Lockhart, 2020). Many new graduates experience a phenomenon called reality shock in which they identify a gap between their theory-based training and nursing practice (Duchscher & Windey, 2018; Wakefield, 2018) and struggle to adjust to the clinical practice environment. It has been estimated that approximately 18% of new nurses leave the profession within one year of employment in the US (American Nurses Association, n.d.; Kovner et al., 2014). According to a recent survey in the US, RN turnover can cost a hospital around $52,350; when nursing staff onboarding expenses are considered, this figure rises to $6.6–10.5 million per year (Nursing Solutions, 2023).

To address these issues, many nursing schools' designed their curricula to enable nursing students to apply the cognitive, psychomotor, and affective skills they learn in theory classes to the clinical environment with the help of a clinical preceptor (Otoo, 2016). Many nursing programs offer this clinical experience globally with a preceptor during the final semester of nursing students in countries such as Australia, Canada, China, Egypt, Ghana, Singapore, and Thailand (Anderson et al., 2020; Atakro & Gross, 2016; Helay, 2021; Sarnkhaowkhom & Suwathanpornkul, 2018; Subramanian & Kleib, 2023; Yeng et al., 2024; Zhou et al., 2024). Even though preceptors have been utilized to support other clinical experiences, this paper focuses on the senior semester preceptor experience for prelicensure nursing students.

Many countries have adopted the clinical preceptorship model to expose prelicensure nursing students to a real-world clinical environment before graduation and provide them with one-on-one instruction from a qualified and experienced nurse (Happel, 2009; Kamolo et al., 2017). The preceptor serves as a teacher, role model, and evaluator, helps students to socialize with the nursing profession for a specific period of time and pursues predetermined goals to facilitate experiential learning (Otoo, 2016). However, the recent nursing shortage and the retirement of experienced RNs due to the COVID-19 pandemic have led to a shortage of experienced preceptors (Bodine, 2022; Morris, 2023; Rashwan et al., 2023).

To meet the clinical preceptor needs of nursing school programs, the nursing leadership must utilize the available nursing staff. This approach may jeopardize student learning needs because the staff available to be preceptors may not have adequate training or experience in innovative learning strategies (Bodine, 2022; Otoo, 2016). Based on this context, the clinical faculty of a prelicensure program needs to support the available clinical preceptors with resources to help them build the qualities required for a preceptor, such as teaching, leadership, and mentoring skills to better equip them to acclimate to the preceptor role and the demands of the clinical supervision (National Advisory Council on Nurse Education and Practice, 2021). The purpose of this practice update paper is to discuss the barriers and facilitators associated with the prelicensure nursing preceptorship program as well as to discuss the proposed solutions for effective clinical preceptorship based on evidence and personal reflections of the author.

Brief Review/Discussion of the Topic

This practice update paper focuses on the discussion of the current status of the preceptorship programs within nursing education for prelicensure students. The author has organized the current status as facilitators and barriers to effective preceptorship.

Facilitators of Effective Preceptorship

Discussion of Nursing Program Expectations

To enable the success of clinical preceptorships, the clinical faculty of nursing programs needs to meet with preceptors in person or virtually before the clinicals begin to discuss expectations. Discussion topics include the number of hours allotted for the preceptorship based on their curricula as well as specific days that students are not allowed to work due to class schedule conflicts, sick day rules, and other considerations. The students' academic and clinical backgrounds, including the theory and clinical courses they completed in the previous semesters, are also discussed. This information helps preceptors become aware of the academic and clinical progress of the students and plan the best days to offer clinical preceptorships (Bodine, 2022; Nash & Flowers, 2017). Additionally, preceptors need to be notified of skills that the students are not allowed to perform because they are beyond the students' abilities or prohibited per hospital policy. Furthermore, preceptors are encouraged to establish a line of communication with their assigned students via email or phone before starting the clinicals as an icebreaker strategy (Lazarus, 2016).

Selection of Teaching Strategies

Many institutions offer preceptors formal training opportunities, such as structured programs that employ a live class approach or a blended approach consisting of a few hours of live training followed by online training (Bodine, 2022; Nash & Flowers, 2017). Such support is essential for sharpening the teaching skills of novice and experienced preceptors (Nash & Flowers, 2017).

The use of preceptors with appropriate qualifications and/or sufficient formal training is a nationwide problem (Bengtsson & Carlson, 2015). In such situations, clinical faculty members have the added responsibility of preparing preceptors to be effective teachers, role models, evaluators, and socializers for their students.

Studies have documented many teaching strategies are applicable to preceptors in a clinical environment, including observation, modeling, direct questioning, thinking aloud, directed readings, and coaching (Baker & Pittman, 2010; Loughran & Koharchik, 2019). Clinical faculty members need to take the initiative to explain the application of these teaching strategies in a clinical environment, such as through the case scenario approach captured in Table 1. The author has developed this case scenario based on their years of clinical teaching experience. In addition, clinical faculty members should encourage preceptors to identify their teaching styles using screening tools, such as the teaching perspectives inventory (TPI; Teaching Perspectives Inventory, 2020; Loughran & Koharchik, 2019). As a 45-item inventory, the TPI proposes five different perspectives of teaching reflecting the teaching style of a teacher. TPI further explains the commitment of a teacher via their actions, intentions, and beliefs (Teaching Perspectives Inventory, 2020). The clinical faculty also needs to encourage students to assess their learning styles via tests http://www.whatismylearningstyle.com/learning-style-test-1.html (What is My Learning Style, 2021; Loughran & Koharchik, 2019).

Table 1.

Practical Applications of Teaching Strategies in Clinical Preceptorships.

Case scenario The preceptor is taking care of a 78-year-old male patient admitted with exacerbating symptoms of congestive heart failure (CHF). The patient is a widower who lives alone and, according to his daughter, has been noncompliant with his regular medications for CHF management. Upon assessment, the patient had +3 bilateral extremity swelling, shortness of breath, and coarse crackles on lung auscultation. His vital signs revealed a blood pressure reading of 142/88 mmHg, a heart rate of 112/mt, a temperature of 98.6°F, and an O₂ saturation of 88%. The laboratory results were as follows: blood urea nitrogen: 20, creatinine: 1.2, sodium: 136 mEq/L, and potassium: 3.1 mEq/L. Medication orders Furosemide: 40 mg via IV twice a day Lisinopril: 40 mg by mouth twice a day Potassium chloride: 40 mEq via IV piggyback once a day O2: 2 L/min via nasal cannula
Teaching strategies	Objective	Example based on the case scenario
Modeling (Loughran & Koharchik, 2019)	To promote the development of affective skills	The preceptor tries to establish a rapport with the patient and then asks him why he has been noncompliant with his medications. Possible reasons include financial constraints and the adverse effects of the medications. For example, diuretics can cause an individual to void frequently. This method allows the student to witness the empathetic approach of the preceptor without being judgmental toward his noncomplaint behavior.
Observation (Loughran & Koharchik, 2019)	To begin the first day or initial phase of the preceptorship	The student observes the preceptor preparing furosemide for an IV push
Direct questioning (Loughran & Koharchik, 2019)	To teach content related to cognitive domains	The preceptor checks the mechanism of action and the monitoring required for each medication directly with the student for them to answer why, how, and what questions related to the medications. For example, the preceptor explores why furosemide was prescribed, why it is administered via an intravenous route, and how this needs to be prepared. What patient teaching and monitoring need to be done with furosemide administration?
Thinking aloud (Loughran & Koharchik, 2019)	To promote critical thinking and clinical judgment	The preceptor asks the student to apply the patient history with the pathophysiology to determine the reason why the patient experienced exacerbation of CHF (i.e., noncompliance with medications), which led to fluid retention in the body, which, in turn, led to edema, respiratory difficulty, coarse crackles, shortness of breath, and low O₂ saturation. The student is also asked to try to connect the symptoms to the medications. For example, the patient needs a diuretic (i.e., furosemide) to remove extra fluids, angiotensin to convert enzymes (and promote the pumping action of the heart), and a potassium replacement to reverse hypokalemia. The student is also asked to determine what types of monitoring are required (e.g., intake output, K levels, O₂ saturation, and weight).
Directed readings (Loughran & Koharchik, 2019)	To promote the development of cognitive skills or expand knowledge of a concept	The preceptor gives can pull out hospital policies and approved resources related to potassium infusion (e.g., slow infusion via piggyback and kidney function monitoring) and dietary and fluid restrictions related to CHF to extend the student's knowledge.
Coaching (Loughran & Koharchik, 2019)	To achieve mastery of a skill that requires multiple practice sessions	The preceptor coaches the student in setting up the IV piggyback for potassium chloride administration. The student will need multiple practice sessions to master the piggyback infusion technique.

These evaluations can help determine whether there is an alignment between preceptor teaching styles and student learning styles. Although it is difficult to create the best preceptor–student pairing in the clinical setting, the author's clinical teaching experience revealed that such assessments help to provide mutual insights to preceptors and students about the areas on which they need to work to improve their teaching or learning, respectively. For example, some students may have a preference for particular learning styles such as an auditory learning style which could be discussed as part of learning with the preceptor. The preceptor can then identify strategies to promote auditory learning such as explaining steps, talking out loud, as well as assigning video recordings of relevant concepts to enhance their learning (Morris, 2023).

Creation of a Structured Weekly Plan to Promote Learning

Senior semester nursing students are adult learners who want to actively participate in their own learning. However, a qualitative study found that preceptors wanted additional knowledge of adult learning principles to guide their preceptorships (Bengtsson & Carlson, 2015). A structured progressive approach to preceptorships that incorporates adult learning principles may be most beneficial for senior semester nursing students (Amaral & Figueiredo, 2023; Bodine, 2022). Table 2 provides an example of a structured, progressive patient assignment and tasks for a senior nursing student which has been used by the author to guide their preceptors. However, preceptors need to consider individual learning differences when developing a structured weekly plan because some students are fast learners, whereas others require additional time to grasp ideas (Lazarus, 2016; Nash & Flowers, 2017).

Table 2.

Clinical Preceptor Preparation: A Structured Approach for Weekly Expectations for the Students.

Week 1	Week 2	Week 3	Week 4 and beyond
Establish a rapport with the preceptor and discuss the preferred mode of communication (email vs. phone) Get acquainted with the policies and procedures specific to the unit Get familiar with the electronic documentation of patient care Create a report sheet with the help of the preceptor Make a timely documentation checklist Collaborate with the preceptor until half-day and observe nursing care activities Complete one-afternoon physical assessment Try to administer one medication in the afternoon in accordance with medication administration rights	The preceptor should : Assign a simple (uncomplicated) patient to the student Ensure that the student researches the patient's condition (review of pathophysiology, lab monitoring, interventions, medications, and other orders) Encourage the student to receive the shift report for their patient from the night/day nurse Help the student prioritize patient care and supervise that care Verify the student's documentation at the end of the shift Encourage the student to report off to the next shift at the end of the day	Assign a more complex patient to the student Ensure that the student researches the patient's condition The preceptor should supervise and guide the student as necessary in terms of physical assessments, medication administration, and other nursing skills. The preceptor should verify the student's documentation. The preceptor should help the student report off to the next shift and provide any missing information.	Based on the student's clinical progress and confidence, the preceptor can decide the number of patients to assign the student this week and in subsequent weeks. The student is expected to take care of the number of patients set by the syllabus by the end of the rotation. The preceptor should consider individual learning differences because some students will progress quickly each week, while others may need to work at a slower pace for a longer period of time.

Consideration of Alternative Teaching Approaches

Preceptors need to consider the opportunities for parallel teaching during clinical preceptorships. Preceptors need to develop strategies to educate their students by utilizing other team members' knowledge and skills. However, this approach requires support from the nursing leadership to ensure the cooperation of the team members. For example, a student can be paired with a charge nurse for a few hours to observe their duties and responsibilities or assigned to a coworker of the preceptor to assist them during emergency management of a patient. Even though an emergency setting is an unfavorable learning environment, students can learn about many key nursing activities through observation (Lazarus, 2016). Such alternative approaches offer many additional learning opportunities, including broad exposure to the entire unit and other collaborative and interprofessional efforts to provide patient care. This type of exposure could be considered a marketing opportunity for attracting nursing students to work in the observed unit after graduation (Jönsson et al., 2021). However, the clinical faculty as well as the clinical preceptor needs to consider the state regulatory standards of supervision while considering such alternative approaches in teaching.

Establishment of a Robust Plan for Evaluating Students

Students should be evaluated based on the clinical objectives of the nursing program, and clinical faculty members should discuss this requirement with the preceptors at the start of the clinical preceptorship program. The nature of the evaluations may vary depending on the program. Examples include weekly written evaluations, weekly or biweekly formal or informal meetings with clinical faculty members, and midterm and final evaluations. The evaluations should be done privately. In fact, many schools use anonymous online surveys for the preceptor to provide direct feedback to the clinical faculty. To promote student learning, the evaluations should focus on the actions of the students, not on their personalities (Barker & Pittman, 2010).

Barriers to Effective Preceptorship and Proposed Solutions

Preceptors' Dual Responsibilities to Students and Patients

The burdens of simultaneously serving as preceptors and managing patients have been documented in the literature (Jönsson et al., 2021; Novotny & Stark, 2020). Oftentimes, preceptors have to accept additional leadership roles, such as charge nurse or admission/discharge nurse roles, to meet the demands of the unit. Although these responsibilities can be challenging for any preceptor, they can be especially difficult for new preceptors because a preceptorship is a demanding and time-consuming endeavor that can negatively affect the productivity of a new nurse (Barker & Pittman, 2010). Preceptors need support from the nursing leadership team to ensure that they are free of additional leadership roles and that their workload is balanced compared to the standard nurse–patient ratio of the unit (Bodine, 2022; Kamolo et al., 2017). In this way, the nursing leadership can provide preceptors with an environment that is conducive to committing their time to teaching and supporting the learning needs of students (Bodine, 2022).

Dealing With Challenging Students

Many unprofessional behaviors exhibited by challenging students during preceptorships have been documented in the literature (French, 2018; Otoo, 2016). There may be cognitive barriers, such as the student's inability to translate classroom knowledge into clinicals, which can jeopardize clinical judgment and critical thinking related to patient care. Some students exhibit psychomotor barriers, including their lack of experience or dexterity with nursing skills. Other barriers can also be a concern, including professional violations, such as not following hospital or School of Nursing policies and procedures (Otoo, 2016). In addition, students may display poor communication skills when engaging with patients and the healthcare team. There may also be cultural differences between students and preceptors (Otoo, 2016) which could act as a barrier. Lack of adequate sleep and rest, and stress from school and life can be contributing factors to these unprofessional behaviors (Dyer & Latendresse, 2016).

Preceptors must have emotional skills that enable them to handle challenging students without negatively affecting the learning of those students (Amaral & Figueiredo, 2023). If a student exhibits unprofessional behaviors, does not meet weekly learning objectives, or creates other challenges, the preceptor must promptly notify the clinical faculty (Barker & Pittman, 2010). A three-way conference with the student, the preceptor, and the clinical faculty is warranted in such situations. Possible solutions, especially written instructions or a learning contract with goals, will be offered by the clinical faculty and signed by the student, the clinical faculty, and the nursing program coordinator. All students should be made aware of these measures at the beginning of the preceptorship to provide them with anticipatory guidance on the negative effects of an unprofessional behavior.

Lack of Experienced Preceptors

The reports from a nationwide study indicated that the lack of qualified preceptors in the US continues to be a challenge in offering preceptorships (Novotny & Stark, 2020). The findings from the survey results of the above study (n = 98 nursing programs), which did not use a preceptorship, reported lack of qualified preceptors as the major reason for not using preceptorship programs for the prelicensure nursing students (Novotny & Stark, 2020). This problem, which is a consequence of the aforementioned nursing shortage in the country, forces the nursing leadership to look to its “leftover pool” and resort to utilizing new nurses with insufficient nursing or preceptorship experience. Teaching and learning quality can be greatly compromised by depending on this “leftover pool” approach, which prompted many nursing programs to stop offering preceptorships (Novotny & Stark, 2020). The nursing leadership must frequently monitor their unit's RN turnover status and make sure that a sufficient number of RNs are trained as preceptors based on their interests and irrespective of their years of experience.

Limitations of the Paper

This practice update paper has some limitations. Firstly, its focus is on addressing the facilitators and barriers associated with preceptorships for prelicensure nursing students. However, it may not have covered many other factors related to preceptorship. Secondly, the regulatory boards and their functions in nursing programs vary across countries, which can inadvertently influence the preceptorship model offered to prelicensure nursing students. Thirdly, the majority of studies related to preceptorship development have been conducted within the US, with limited evidence on this subject from countries outside the US. Future studies are recommended to address these gaps and develop solutions to support preceptorship for prelicensure nursing students, regardless of the country.

Conclusion

While the nursing shortage is at its peak, it is important to provide prelicensure nursing students with superior clinical experience to enable them to face the real world of nursing. Preceptorships provide a unique introduction to the realities of clinical nursing. However, the inadequate number of available preceptors since the COVID-19 pandemic is a major concern. The major facilitators addressed in this practice update paper for effective preceptorships were the discussion of nursing program expectations, the selection of teaching strategies that match with the learning styles of the students, the creation of a structured weekly plan to promote learning, and the consideration of alternative teaching approaches. Additionally, the paper addressed the major barriers to preceptorship and recommended solutions to overcome such barriers, including having nursing leadership support to ensure a balanced workload for the preceptor, ensuring an adequate number of preceptors, developing the emotional competence of the preceptor, creating strategies to address challenging students, and offering preceptorship training to the candidates who were willing to become preceptors. The insights in this paper can help the clinical nursing faculty and nursing leadership understand and propose solutions to resolve the struggles of preceptors. Additionally, the clinical faculty can utilize the practical application of teaching strategies discussed in Table 1 and the structured approach for weekly expectations for the students discussed in Table 2 to guide their preceptors.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Suja P. Davis

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