RESOURCES for PRECEPTORS in TODAY’S HEALTH CARE

1. RESOURCES for PRECEPTORS in TODAY’S HEALTH CARE MNPA SPRING CONFERENCE APRIL 27, 2018 Nancy Fishwick, PhD, FNP Susan Doughty, WHNP-BC Margaret Macdonald, FNP Lyndsey Patton, FNP

2. THE ONE MINUTE PRECEPTOR5 microskills for teaching NPs • Get a commitment “What do you think is going on with this patient?” • Probe for Supporting Evidence “What findings led to your conclusion?” • Teaching General Rules “When this happens, do this…” • Tell them what they did right “You stayed open until the patient revealed her true agenda…” • Correct mistakes Allow learner to critique own contribution, then how to correct the error for future Gordon, et.al., July, 1995, Presentation. Primary Care Practitioner Conference, Keystone, Colorado

3. TECHNIQUES for PRECEPTORING • Case discussions • Matching patient and student for specific learning experience • Direct questioning • Think aloud sessions • Assignment of directed readings • Coaching and cheerleading • Direct observation Barker, E. and Pittman, O. (2010), Journal of the American Academy of Nurse Practitioners, 22, 144-149.

4. SCHEDULING STRATEGIES for PRECEPTORING • Focused Half days • Focused observation • Wave-scheduling 2 patients simultaneously with 10 minute break for discussion • Appointment modification Remove 1-2 patients am and/or pm for catch up discussion Barker, E. and Pittman, O. (2010), Journal of the American Academy of Nurse Practitioners, 22, 144-149

5. EVALUATION TIPS for PRECEPTORING • Base on performance, not personality • Understand student’s response to the feedback • Put the behavior in the context of the patient’s outcomes • Assure privacy for evaluations • Be honest and constructive in your intent • Communicate feedback to faculty in a timely manner • Mutually devise a strategy for improvement • Do not generalize to more than one student Barker, E. and Pittman, O. (2010), Journal of the American Academy of Nurse Practitioners, 22, 144-149

6. PRACTICAL STRATEGIES of a CLINICAL PRECEPTOR • Identify learning needs through reflective practice • Identify potential barriers that may impede the learning experience • Set goals and objectives for the clinical experience • Frame the clinical experience based on what is feasible • Incorporate “in the moment” as well as formal learning activities • Integrate EBP in the learning activities for clinical decision making • Evaluate the learning experience through reflection, outcome-based objectives, and formative and summative assessment Ferrara, L. (2012). The Nurse Practitioner, 37,(5): 49-53.

7. TIPS for TEACHING on BUSY DAYS • Pre-planning ~Let student know the pressures you face. ~Get to know student’s learning style and needs before the first day. ~Review the cases for the day, decide best learning opportunities. ~Have other strategies like observing other professionals, researching a question. ~Set priorities to accomplish and activities to complete by the day’s end.

8. BUSY DAYS 2. Student time with patient ~Work together with one patient: student sees your assessment and care; or student does history, you do exam, rotate for next patient. ~Help student learn what to include in focused history and exam for presenting concern. ~Assign to patients who appreciate extra time. ~Set a time limit to get as much history as can until you come in. ~Wave schedule: 2 patients slot 1, 1 slot 2, 0 slot 3. Slot 1 you and student different patients, slot 2 you see patient, student finishes and prepares to discuss with you, slot 3 complete student’s case, discuss, chart, prepare for next wave. • ~Go in with student, chart history and exam while data collected by student. Then reverse roles for next patient.

9. BUSY DAYS 3. Case presentation time ~Set a time limit: “H&P, differential, and plan in 5 minutes.” ~Ask the student to present while in the room with the patient if appropriate. ~Assign to well-known patients, give student background to help focus.

10. BUSY DAYS 4. Finding discussion time ~Have student write down questions for discussion later, follow up daily 15-20 minutes. ~Use lunch, travel, or break time to discuss cases. ~Set limits on time for discussion: “We have 5 minutes before our next patient.” ~Ask student to look up info on 3 cases you jointly saw, making clear you will ask for a report of only 1 of the 3 cases at discussion time. ~Jot down case pearls arising from different sources, share list with students. ~Honor your appointments with student keeping brief and focused. ~Expose student to complete day including conferences, meetings, and civic activities. Burns, C. et.al. (2006). J. Pediatric Care, 20, 172-183.

11. PRECEPTOR/STUDENT DOCUMENTATION From Tip of the Month email , Law office of Carolyn Buppert March, 2018."As I said in my email of March 1, the Centers for Medicare & Medicaid Services (CMS) has changed its requirements regarding preceptor documentation of students' work. I interpreted the change to be applicable to advanced practice clinicians (APCs). My reasoning was a) there are no CMS rules on preceptor documentation that specifically name APCs, b) that section of Medicare rules is titled "Physicians/Non-physician practitioners," and c) there is no logical or legal reason why the physician rules should be different from APC rules. But 2 people contacted me after they called their local Medicare Administrative Contractor's office and asked whether the rule change applies to APCs. Two were told no. One nurse practitioner called, and was told yes, the rule change applies to APCs. To recap the change: Up until now, CMS required a preceptor to verify (personally perform) and re-document a student's history of present illness, physical exam and medical decision-making. Now, the preceptor need only "verify" the student's documentation of the components of evaluation and management services. No need to re-document. Here is a link to the article CMS sent out on the change: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10412.pdfLocal contractors are allowed some leeway to interpret transmittals from CMS. Also, it may depend on whom one speaks with at the contractor office.So my best advice, as of today, for APC preceptors, is have someone at your organization contact your local Medicare Administrative Contractor and ask whether this rule change applies to APCs. If they say yes, make a note of the name of the staff person and the date, and follow their direction. If they say no, make a note of the name of the staff person and the date, and ask: "Where do we find the rules on documentation for APC preceptors?" Follow their direction. • For more information about the legal and business issues affecting nurse practitioners, visit www.buppert.com.

12. Online resources for NP preceptors • American Association of Nurse Practitioners PRECEPTOR TOOL KIT (Elizabeth Barker & Oralee Pittman) • https://www.aanp.org/images/documents/education/PreceptorToolkit.pdf • Preceptor Development Initiative: Supporting health preceptors in practice. 8 online modules with practical tips which take ~ 10 minutes each; hyperlinks are no longer active. Develop by an interprofessional collaborative group in Vancouver, including Univ. of British Columbia faculty (see ref list) http://www.practiceeducation.ca/ • Some schools of nursing have information for clinical preceptors on their websites. As one example: University of Minnesota School of Nursing • https://www.nursing.umn.edu/outreach/clinical-preceptors/general-preceptor-information

13. KEY BENEFITS Serving as a Preceptor • Stay current with latest evidence-based practice (EBP) By teaching we learn. • Learn about yourself as a provider and a teacher from what works and doesn’t work with your approach. • Improve styles of communication and developing relationships

14. BENEFITS 4. Experience the opportunity to give back to the profession, pass on the culture of who we are as providers. 5. Watch a student grow from novice to grounded in their skills, bringing energy to the practice. 6. Meet new friends and colleagues who will, in turn, carry the profession forward.

15. BENEFITS 7. Break through the monotony and pressures of daily practice. 8. Get CEUs for ongoing certification.

16. Brief bibliography for future reading • Barker, E., & Pittman, O. (2010). Becoming a super preceptor: A practical guide to preceptorship in today’s clinical climate. Journal of the American Academy of Nurse Practitioners, 22, 144-149. • Bartol, T. (2018). Perpetuating our profession: Nurturing NP students. The Nurse Practitioner, 43(1), 1-2. • Buppert, C. (Nov. 28, 2017). Should I agree to precept nurse practitioner students? Medscape • https://www.medscape.com/viewarticle/888918 • Burns, C., Beauchesne, M., Ryan-Krause, P., & Sawin, K. (2006). Mastering the preceptor role: Challenges of clinical teaching. Journal of Pediatric Health Care, 20(3), 172-183. • Ferrara, L. (2012). Strategies for success as a clinical preceptor. The Nurse Practitioner, 37(5), 49-53.

17. Forsberg, I., Swartwout, K., Murphy, M., Danko, K., & Delaney, K. (2015). Nurse practitioner education: Greater demand, reduced training opportunities. Journal of the American Association of Nurse Practitioners, 27, 66-71. • Kassam, R., McLeod, E., Kwong, M., Tidball, G., Collins, J., Neufeld, L., & Drynan, D. (2012). Research: An interprofessional web-based resource for health professions preceptors (eTips). American Journal of Pharmaceutical Education, 76(9), article 168. • Logan, B., Kovacs, K. & Barry, T. (2015). Precepting nurse practitioner students: One medical center’s efforts to improve the precepting process. Journal of the American Association of Nurse Practitioners, 27, 676-682. • Roberts, M.E., Wheller, K.J., Tyler, D., & Padden, D. (2017). Precepting nurse practitioner students: A new view – Results of two national surveys of nurse practitioner preceptors. Journal of the American Association of Nurse Practitioners, 29, 484-491.