This story about nurse practitioners was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger higher education newsletter.
CHICAGO — Midway through her graduate nursing program, Yesenia Raithel Vargas made a desperate plea to a Facebook group for other moms in Chicago: Does anyone know a licensed therapist willing to let her sit in on sessions and work with their clients under their supervision? It was a strange ask in the therapy world, which is one reason Raithel Vargas had resorted to Facebook.
“I must have sent 50 emails, or made phone calls, just trying to figure this out,” recalled Raithel Vargas, a 45-year-old mother of four who is studying to become a nurse practitioner specializing in psychiatry. “I was so overwhelmed.”
In order to graduate, nurse practitioner students must spend at least 500 hours working with patients in a clinical setting with a supervisor, known as a preceptor. Raithel Vargas needed to find preceptors licensed in psychotherapy and medication management. Bridging classroom theory and real-world experience, preceptors train nursing students, provide feedback, and evaluate their performance, playing a major role in whether or not they pass.
But there are not nearly enough of these preceptors willing to take on students — and that threatens to choke off a supply of medical professionals the country urgently needs. Nurse practitioners are among the highest level of nurses, holding master’s degrees and performing many of the same duties as physicians. Amid a shortage of primary care providers, more states are allowing nurse practitioners to step in and open their own practices.
Yet finding qualified preceptors to supervise clinical hours is a giant obstacle, as Raithel Vargas learned. The two major accrediting agencies for these nursing programs require schools to provide clinical placements for students or help students find them. In reality, many students are left to find them on their own. That adds to students’ stress, and it can also be costly. Students often have to resort to paying preceptors out of their own pocket, sometimes spending tens of thousands of dollars — on top of tuition — and prompting ethical concerns.
Raithel Vargas’ Facebook post ultimately proved successful, and she found a therapist who agreed to supervise her for free. But because of the delays and challenges she faced in finding someone, she has had to delay her graduation from the University of Cincinnati, which she attends online, by a year.
With more autonomy and better pay and hours compared to registered nurses, the number of nurse practitioners is growing fast. Research from the Columbia University School of Nursing showed that the workforce grew by 10 percent every year between 2016 and 2023, compared to 1.1 percent for physicians. Finding preceptors is a long-standing issue, but it’s growing as more students enter these programs.
Schools that educate nurses with less advanced education, like registered nurses, often set up clinical placements for students. They have difficulty doing this, too, and as a result, many of them turn away qualified students despite the need. For nurse practitioners, the bottleneck comes later, after students are already enrolled and must find their own placements.
Many schools skate by the accrediting agency requirements that they find clinical placements for their students by instead offering them lists of doctors and nurses who’ve served as preceptors in the past. Some hire coordinators to help, but their methods are often outdated, according to Elaina McAdams, a health care executive with a doctorate in nursing who created an artificial intelligence-enabled platform called CAUHEC Connect to help schools match their students with clinical supervisors.
“Many schools have a spreadsheet and they call around, but they aren’t always successful,” McAdams said. “If they are successful, it may not be a high-quality connection. There are schools that’ll say, ‘Hey, we found someone. They’re 100 miles away, if you can make it.’ So technically, they find the preceptors, but is that reasonable for a student who’s paying tuition?”
In contrast, medical schools usually coordinate the entire clinical placement process for future doctors, largely because they have affiliations with teaching hospitals. Nursing schools usually don’t have those partnerships.
Another reason is funding. The U.S. spends roughly $20 billion per year to train medical residents, with the funding mostly coming from Medicare. Nursing receives just a fraction of that amount from the federal government — about $300 million in funding for workforce development programs in general, only a share of which goes to clinical training.
The main challenge for students is convincing a busy provider to give their time. Traditionally, nursing preceptors have not been paid for the extra work of teaching and evaluating students — they’re told they should do it for free because someone did it for them. But with burnout on the rise in health care, many clinicians are turning away students. And that has many students resorting to paying preceptors themselves.
Raithel Vargas was initially against that idea. In her earlier career as a midwife, she taught and supervised students for free, at most getting a gift card as a thank you. But as her stress grew, she finally gave in. In her most recent rotation, she directly paid a nurse practitioner in Chicago $10 an hour for 168 hours.
As paying preceptors becomes increasingly common, some nursing educators question whether they might be incentivized to pass the students who are paying them.
The worst-case scenario, McAdams said, is “what happens when a student pays cash out of pocket, and they’re not really safe to practice?”
Ideally, schools would pay preceptors, McAdams said, “but the schools say they just don’t have the budget to pay, so students have to figure it out.”
In the absence of solutions for desperate students, for-profit companies are opening to meet the demand — for a price.
Krish Chopra leads one of those companies, NPHub. When he launched the site in 2017, he tried to get nursing schools to partner with him and pay to use his app, which would match students and preceptors. If the school raised tuition to cover the charge, he figured, students could use financial aid to offset the cost.
But of 40 nurse practitioner programs he reached out to initially, only one expressed interest. Chopra said about 10 programs are now “infrastructure partners,” paying his company a fee to help students find placements, though most students still come to the site independently. KeyPath Education runs another matching service for nurse practitioner students that charges only the schools, not the students. This month, they were acquired by a larger education management company eager to expand into this field, signaling a growing realization among schools that the status quo isn’t working anymore.
“Finding and securing clinical sites is a sales job,” Chopra said. “It’s literally outreach and interviewing and onboarding. It’s a business motion. Universities don’t have the infrastructure to be able to do it.”
NPHub uses a formula to decide how much to charge a student, depending on what kind of rotation they need and their geographic location. Chopra says the average cost per rotation is $2,500, with 50% to 60% going to the preceptor and the rest to his company. Another similar business, Clinical Match Me, usually charges students a flat rate of $1,995, with $1,000 going to the preceptor.
For students, these services can be a godsend. But the costs add up. Kim Orta, who lives in rural Crescent City, Calif., had to take out a loan for $16,000 to afford to pay preceptors, as well as to cover her travel and hotel to complete her rotations several hours from her home. That’s almost as much as she’s paying in tuition at Purdue Global for her program in mental health and psychiatry. She’s considered dropping out, she says, but there is only one other mental health nurse practitioner in her county now, which motivates her to keep going.
“I see people who have depression, anxiety and bipolar,” Orta said of her current work as a family nurse practitioner. “I want to be able to help them better.”
Even using preceptor matching services, Orta ran into difficulties because of her school’s requirements. She could have done rotations in Oregon, which is 17 miles from her home, but Purdue Global doesn’t allow rotations to be completed in that state.
There is no national standard as to what makes a doctor or nurse qualified as a preceptor, so each school decides for itself. This can cause further complications for students.
Shani DeShield was a registered nurse in the Canadian province of Alberta when she traveled to Chicago to pursue a degree as a family nurse practitioner. She started at the health care-focused Oak Point University and lined up preceptors using the usual methods — sites like NPHub and Clinical Match Me, emails and calls to colleagues, even a call to her grown children’s former pediatrician. Then the university abruptly closed in 2024. She and her classmates were transferred to Lewis University, which had different preceptor requirements. DeShield said she had to start over.
“It was very stressful,” said DeShield, who is in her mid-50s. “Many times, I said, ‘That’s it. I’m going home. I’m leaving.’ I left my husband behind and my family and my grandkids — everything — to go to school.
“It was almost a full-time job trying to find a preceptor,” she added.
Tim Porter-O’Grady sees all sides of the preceptor dilemma. He is an advanced practice nurse in gerontology, a volunteer at a wound clinic, a clinical professor at Emory University’s school of nursing and a consultant for health systems. In his mind, nursing schools, hospitals, and clinics all need to be involved in finding a solution.
“Nursing is the single largest profession within health care, and it has paid little or no attention, as a discipline, to standardizing our transition to practice in a way that is effective, meaningful, evidence-based, and sustainable,” Porter-O’Grady said. “None of the other major professions — law, engineering, medicine, architecture — are like this.”
Porter-O’Grady advocates for nursing schools to build partnerships with health systems, the way many medical schools do, and take over the responsibility of securing clinical placements for students. He also thinks hospitals and clinics, for their part, should recognize the work of preceptors, protecting their time and offering compensation, which he sees as an investment in the future workforce.
In 2022, a group called the Society of Clinical Placement Professionals formed to facilitate preceptor matching by improving communication between health systems and nursing schools and by studying other professions’ placement methods. The group held its first virtual summit last year, expecting maybe a dozen people to show up. Instead, 150 people did.
“There’s a missed opportunity for collaboration,” said Abigail Smetana, a co-founder of the group. “And a lot of finger-pointing.”
Raithel Vargas was satisfied with her paid preceptor. The days were busy, but she was able to see a broad range of patients, including children and men, whom she doesn’t see in her current job at a women’s health clinic.
The preceptor originally agreed to stay on for Raithel Vargas’ final rotation in the fall but at the last minute said she could not. She referred Raithel Vargas to a colleague, who agreed to step in and supervise her for free. Raithel Vargas is holding her breath that this final rotation will go as planned, so that she can finally start working as a licensed psychiatric-mental health nurse practitioner by the end of the year.
“Every drop of blood, sweat, and tears is definitely worth it because I feel good about what I’m going to be able to do,” she said. “But when I was desperately trying to find a preceptor, I was so ready to give up.’”
This story about nurse practitioners was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger higher education newsletter.