Preceptorships Shifting but Essential During Pandemic

By Dorsey Griffith
Contributing Writer

When Holly Adamous, MSN, RN first began her nurse practitioner training, she wondered how she would discern an abnormal abdomen from a normal one simply by pressing down on someone’s belly. But last spring, when a patient casually mentioned feeling chronically full, the 27-year-old Los Angeles native got to work.

“I said, ‘why don’t you get on the exam table?'” she told the patient. “I palpated his mid-abdomen area. It didn’t feel normal. I detected something really large.”

She turned to her preceptor, Khoa “Joey” Dang, DNP, RN, FNP-C, and suggested he feel the patient’s abdomen, too. “We discovered a mass,” Adamous said. “And then he was urgently scheduled for imaging and surgery.”

Adamous would not have discovered the potentially life-threatening tumor if she’d communicated with the patient over the phone or via video conferencing as they have been doing for a majority of patients since the COVID-19 pandemic hit, said Dang, a family nurse practitioner practicing Internal Medicine in Chino and Montclair who directs the Family Nurse Practitioner program at College of Graduate Nursing (CGN), Western University of Health Sciences (WesternU) in Pomona.

Dang said missing out on in-person clinical experiences may put the next generation of nurse practitioners – and their patients, at risk. As nurse practitioner programs prepare for the academic year, they are scrambling to come up with alternative ways to ensure that students get the most out of their education so they can best care for patients when they launch their careers.

“Things are changing on a week-to-week basis, but the pandemic has hit us quite hard,” Dang said. “A lot of practices have either closed for a time period or shifted to telehealth, and some of those have not allowed students at all. It was already hard finding sites for rotations for students, but now that this has hit, we have had to resort to alternative experiences.”

In normal times, nurse practitioner students like Adamous would log over 500 hours in clinical settings seeing patients in person. In those hours, students are given the opportunity to interview and examine patients on their own before discussing the findings with their preceptors then returning to the patient with a diagnosis and treatment plan.

For Adamous, once she built trust with Dang, the flow of the experience worked beautifully. 

“Our clinic days were really smooth,” she said. “I would go in, see patients on my own, come outside and report to him what I saw. He would agree, then we would go back in to talk to the patient together. It was great.”

Ricky Norwood, DNP, MSN, MSBH, RN, FNP-BC, is an assistant clinical professor for the Master of Science-Nurse Practitioner degree program at the Betty Irene Moore School of Nursing at UC Davis. He spends 80 percent of his time seeing patients at Sacramento County Health Center, a primary care clinic serving some of the region’s most vulnerable adults. In his role as a preceptor, his students would normally see about a dozen patients face-to-face every day. 

One of his students was Laura Schaffer, MS, BSN, FNP-BC. She saw patients at the county clinic from 8 a.m. to 5 p.m. Dr. Norwood allowed her to independently evaluate patients and work up a diagnosis and treatment plan. 

“It was very valuable,” said Schaffer, who will begin a fellowship in palliative care at Mayo Clinic in Phoenix in September. “I felt like I was actually doing what a nurse practitioner would do. I felt more like a practitioner than a student, handling a patient load that a beginning nurse practitioner would take, which made me feel more confident that I would be ready when that came.”

Schaffer said the preceptorship differed from her previous nursing school experience, in which the preceptors were not always willing participants, the relationship was episodic and brief, unlike with her advanced nursing training.

Schaffer had two other rotations during her nurse practitioner training — one in a pain clinic and another working in geriatrics (skilled nursing and long-term care facilities and with a home health program), and three more preceptors. These experiences, she said, provided valuable additional experience, especially in the field of palliative care.  

The pandemic caused seismic shifts in clinical education. Some clinical rotations were canceled altogether.

At the Sacramento County clinic, a vast majority of patients are now having telephone visits, which has made preceptorships difficult, said Norwood, who is a past president of the Sacramento Chapter of CANP.

Now, the students see about two to three patients face to face a day, but the rest of the visits are done over the phone. The process is far more time consuming, in part because patients seem to want to talk about everything over the phone, including fears of contracting COVID-19, but also because the student interface is more complex. The need for Spanish interpreters during phone visits can multiply that effect, Norwood said.

The educational experience has suffered, too.

“They are learning to get a patient history and how to interview a patient, but they are missing out on the physical exam,” Norwood said. “The interaction they need to become proficient and efficient has been affected. They need that face-to-face encounter with the patient because that is how you build that experience – learning how to talk to a patient.”

Dang agrees. 

“In-person experiences are so important because the student can elicit a history from a patient and go through their complaints, their health including mental health, and health at home,” he said. “I am worried they will be missing the physical interaction with the patients, where they can touch the skin, palpate an abdomen, and perform that important physical assessment. If telehealth is all they can do to fill their clinical requirements, they will miss a large portion of our NP toolkit.”

Dang said FNP Program instructors at WesternU meet weekly to review the situation and brainstorm ways to advance the program and get students into rotations with preceptors.

“As nurse practitioners, we are all very problem-focused,” Dang said. “That drives us to create new, innovative ways to do clinical education and training.”

The school has developed a series of video workshops showing different patient scenarios. One video, for example, shows an obstetric nurse practitioner interacting with a simulated patient during different stages of pregnancy. Students have benefited from the simulations, particularly learning how various pregnancy-related complications should be managed.

WesternU College of Graduate Nursing students are also using virtual reality technologies, which allow them to interact with avatar patients in fields including mental health and gerontology. Time spent doing virtual training can be applied to the time required for clinical rotations, he said.

As Schaffer readies herself for the move to Phoenix, she looks forward to having additional preceptors to further prepare her for the next phase of her nursing career, the learning experiences she said have been most valuable.

“I’m anticipating that my rotations through school and my upcoming fellowship at Mayo Clinic will provide me with more real-life experience,” she said. “I believe that will lead me towards understanding the role of a nurse practitioner better than if I had only simulations, classroom experience, and different preceptors each week during my rotations.”