AACN Issue Bulletin
December 1998

Volunteer preceptors who mentor students in the clinical setting continue a long and respected tradition in nursing education, facilitating some of the most critical and influential experiences of a student's training. But today's high-pressure practice environment has called into question the impact this responsibility has on clinical productivity.

Tending to the bottom line has driven some clinical sites to curtail educational activities, refusing to take as many students as in the past, or accepting only advanced students. Nursing schools report growing difficulty securing an adequate number of training sites and preceptors for their students; meanwhile the demand for advanced practice nurses (APNs) and for other nurses in key specialties is on the rise, and with it, the need for more clinical training opportunities.

A 1995 Lewin-VHI study cited the availability of clinical training sites for appropriate clinical education as one of the major problems facing education today for nurse practitioners, clinical nurse specialists, and other nurses with advanced practice skills. The data also show that this availability is the single most important factor in determining a school's ability to expand its APN training capacity.

Not surprisingly, expanding training needs, coupled with the added strain of managed care's mandates for provider productivity, have raised the question of whether preceptors and sites should be routinely compensated for their educational activities. Other entities who have the means to pay sites and preceptors, like medical many schools, have emerged as keen competitors for training slots, and some nursing schools report they have been squeezed out as a result.

"We have lost a few sites, particularly in rural areas, to the School of Medicine when they had money to pay preceptors," says Kathleen Potempa, dean of Oregon Health Sciences University School of Nursing. At the University of Texas Medical Branch in Galveston, School of Nursing dean Mary Fenton reports, "In some situations the medical school pays preceptors from a grant and that can create a problem when we are seeking preceptors in the same area."

As payment precedents are becoming established, training sites have begun requesting monetary reimbursement more often, in ways that range from subtle hints to outright demands. A small handful of nursing schools -- less than 5 percent of those responding to an informal survey by the American Association of Colleges of Nursing (AACN) -- have begun supplying monetary compensation, usually discreetly, and often with the help of grants. For example, a few years ago in North Carolina, nursing deans negotiated with the state's Area Health Education Center to fund payments to preceptors for all nurse practitioner students. "This has helped in placement of NP students, but it opens a Pandora's Box," says Sue Bishop, dean of the College of Nursing and Health Professions at University of North Carolina-Charlotte. "We could not afford to pay all preceptors for students in all of our programs."

Conversely, can training sites afford to train nursing students without some offsetting compensation? According to nursing deans surveyed by the AACN, preceptors and sites frequently cite productivity as a reason for not accepting students. Says UT-Galveston's Fenton, "The productivity issue comes up all the time: the fact that students slow the clinic and cut into the clinician's productivity. This is a common problem and it is reality-based. Students do slow clinic work."

Others hold that productivity isn't as great an issue as clinicians might believe. Although no comparable data exist for nursing preceptors, a recent study by the federal Bureau of Health Professions of medical residents training in ambulatory settings indicates that, "There was not a significant difference in the productivity of ambulatory site-based clinicians when teaching residents and when not teaching. . . ."

Nevertheless, in the era of managed care, decisions are driven, at least in part, by mandates to maximize time and resources. "Many agencies feel the need to have every minute of their nurses' time accounted for in terms of revenue-generating activities," says Anita Hufft, dean of Indiana University Southeast School of Nursing.

But some deans argue that these agencies and sites view their training responsibilities from the wrong perspective; that lost productivity is, in fact, a short-term effect of a long-term solution. "Back in the old diploma days, every hospital wanted a school of nursing because they provided cheap labor for taking care of patients. Now clinical facilities don't want to get involved in education because they think it is too costly," says Vickie Lambert, dean of the Medical College of Georgia School of Nursing. "One has to ask, what will clinical facilities do when there is a lack of qualified nurses as a result of the lack of [the facility’s] commitment to become involved in educating the next generation of nurses?"

Nursing schools must help clinicians understand the importance of their educational responsibilities, says Ruth Alteneder, professor and associate dean of the graduate nursing program at the Medical College of Ohio. "Assisting them to accept the fact that our students as APNs will assist them in achieving care goals for their patients seems to be our role as faculty."

Schools can also point out ways that nursing students can be productive resources on the job, effectively "selling" the benefits to prospective sites. For example, a student who speaks Spanish, or signs for the deaf, can be a valuable addition to any clinic, educators note. "Students may take time initially, but . . . if the match is good, the student frees time for the preceptor to do paperwork, follow up on clients, or take more time with individuals who require more time," says Kris Robinson, associate professor and coordinator of the family nurse practitioner program at Idaho State University. "In addition, the time a student spends with an individual client is often therapeutic in and of itself."

Melanie Dreher, dean of the University of Iowa College of Nursing, asserts, "Nursing students are an asset, not a liability. . . . An agency or hospital should be thrilled to get one of our outstanding students, as they are not that easy to get. . . [Our profession should not] feel guilty about engaging clinical colleagues in the education of future professionals."

A financial arrangement could also lock preceptors into impossible situations, some deans worry. "I would be concerned that paid preceptors would feel 'forced' to take students even when they are burned out, have limited time, or just need a break, says Idaho State's Robinson. And some reimbursement systems take unfair advantage of preceptors, says Linda Brady, associate dean of nursing at Drake University in Des Moines, Iowa. "One school reimburses preceptors because they also hire them as part-time clinical faculty, responsible for evaluating as well as for teaching. They have no full-time faculty. [Preceptors] are being reimbursed really poorly for faculty and quite well for precepting."

But for most nursing schools, paying preceptors is a moot point. "We could not absorb that kind of a hit," says Rita Carty, dean of George Mason University College of Nursing and Health Science in Fairfax, Va. "We would have to pass that cost directly on to the students." In addition, schools with numerous and diverse training sites would face administrative chaos. "The structure of payments, contracts, etc. would be a nightmare given the number of sites we use," says Oregon's Potempa.

But pressure from clinical sites is mounting, some nursing schools report. "Recently I had one clinical site for undergraduate students deny our use of the facility unless we reimburse them for the clinical time," says Virginia Adams, dean of the University of North Carolina-Wilmington School of Nursing. "We have not acquiesced."

Some nursing schools have had to fight precedent by forming coalitions with educational partners. Two years ago in Utah, an agency refused to take students unless it was paid. According to Imogene Rigdon, associate dean for academic affairs at the University of Utah College of Nursing, the state's nursing schools unanimously refused to place students there under those conditions. Their unified stance of not paying has since been formalized through a statewide clinical placement consortium, and through support of the state’s Leadership Forum of Deans, Directors of Schools of Nursing, and Agency Directors.

Jan Lee, director of undergraduate and non-traditional programs at the University of Michigan School of Nursing, reports that, less formally, programs in her area have agreed in general not to offer reimbursement. At The Ohio State University, says College of Nursing Dean Carole Anderson, the health science deans as a group -- including also Medicine, Pharmacy, Dentistry, Optometry, and Veterinary Medicine -- have agreed to not reimburse.

"If graduate nursing were to be eligible for Medicare 'pass-through' funds like medical schools do through graduate medical education funds, we could solve this problem immediately," says Patricia Starck, dean of the University of Texas Health Science Center-Houston School of Nursing. "Preceptors serve a vital role in the teaching of our students. It is too bad that in nursing we have to say we are not able to attach a monetary value to what they do."

If paying preceptors becomes unavoidable in the quest to secure training slots, it would be a tactical mistake for nursing schools themselves to act as the funding source, many deans believe. "Once we establish by our actions that the cost of educating health care professionals must be borne fully by the education side, we will lose the opportunity to pressure emerging health care agencies and organizations -- and insurers -- to pay their fair share to maintain a stream of well-prepared health care professionals," says Kathleen Long, dean of the University of Florida College of Nursing.

Indeed, a coalition that includes the AACN, the American College of Nurse Practitioners, the National Organization of Nurse Practitioner Faculties, and eight other nursing organizations is now advocating for "pass-through" funding from Medicare to support APN education and enable the profession to meet the workforce needs of the future. Medicare has long provided both direct and indirect graduate medical education (GME) funding to support the costs of training resident physicians -- up to $7 billion per year. But educational costs for most APN programs are not eligible for reimbursement now.

Last month, Rep. Benjamin Cardin (D-Md.) introduced H.R. 4739, a bill to provide $300 million in Medicare funds for the graduate education of nurses and for allied health professionals. It is the first legislative proposal to put AACN's Graduate Nurse Education concept into legislative language. Although it is too late for action in this Congress, AACN will be working on the proposal when Congress returns in January.

In September, nursing education was the focus of hearings by the National Bipartisan Commission on the Future of Medicare's GME Study Group. At that time, AACN submitted written testimony, urging redirection of Medicare funding from hospital diploma programs to advanced nurse practice training programs. The commission will report recommendations to Congress in March 1999. Another federal panel, the Medicare Payment Advisory Commission, will also make recommendations to Congress in August 1999.

In the meantime, many schools of nursing are looking to non-monetary motivations that will help recruit and retain preceptors and sites. Many schools make concerted efforts to show their appreciation to preceptors, hosting recognition events, granting certificates, and awarding gifts. Others, about 16 percent responding to the AACN survey, give preceptors affiliate faculty status, which unlocks the doors to school resources such as the library, the school's Internet access, leisure facilities, arts and sporting events, and parking. Offering workshops and lectures designed especially for practitioners is another way some schools inexpensively reward preceptors. More than 30 percent of respondents offer CE credits or free courses linked to training efforts, while other schools reimburse tuition costs. Says Carty at George Mason University, "We provide as many things as we can that they can list on their resumes as professional development."

Another way to encourage the participation of sites is to offer them nursing resources they currently lack. "In the past, we have met with preceptors and asked what their needs are,” says Starck at UT-Houston. "One such request was that our faculty provide nurse practitioner coverage [so that preceptors can] attend conferences."

Schools should also be sensitive to ways they can ease the pressures on sites that training can create. "We work on long-term relationships and recognizing needs of sites," says Madeline Wake, dean of Marquette University College of Nursing in Milwaukee, Wis. "For example, we tend to place an experienced student in a site that had a novice the previous semester, to address productivity concerns."

Nursing schools could also consider a more formalized approach, like the "Preceptor Perks" program operated by the Lienhard School of Nursing at Pace University in New York. The plan extends opportunities such as admission to the campus swimming pool, free online access at the computing centers, workshops on personal and professional development, library and research resources, and access to on-campus theater and art events, says dean Harriet Feldman. "We also established a 'point' system. Precepting earns points which are converted to one-day programs in continuing education."

As most nurses who have worked with students know, there are benefits of teaching that are less tangible than money or incentive programs, but can be as rewarding. The University of San Diego's Philip Y. Hahn School of Nursing distributes a marketing brochure to potential sites that, alongside the standard perks like the use of library resources and being considered for appointment as a faculty clinical associate, spells out some of the more impalpable benefits to both preceptors and clinics. Among them:

• Opportunity to do clinical teaching and improve instructional skills.
• Opportunity to learn about various nursing roles and what these providers contribute to the practice.
• Recognition by, and interaction with, the academic faculty.
• Potential to incorporate students into the practice, with a plan to hire upon graduation.
• Potential to generate increased revenue with the hiring of former students.
• Satisfaction of contributing to increased access to high-quality care delivered by new, clinically competent primary care providers.

Contributing Writer: Martha Frase-Blunt

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