What if the concept of a teaching hospital, well-established in the free world, were adapted to a prison setting? Wouldn’t it be great if medical and nursing students could receive training at a state prison system, building their skills and experience and at the same time strengthening prison health care delivery and staffing? For the past eight years, that vision has developed into reality at the Massachusetts Department of Corrections.

With the Massachusetts Correctional Institution at Concord
(MCI-C) leading the way, the DOC, the University of Massachusetts Worcester, UMass Correctional Health and other partners created a preceptor program that is bringing the concept of “teaching prison” to fruition. Since others may wish to reap the same benefits, this article will describe the logistics, challenges and rewards of our clinical rotation program.

Getting Started
We found that it is important to plan and prepare for student presence in your health service unit. Without buy-in from the HSU as a whole, it is difficult to provide a positive learning experience. Ideally, all staff support and can articulate the vision of the teaching prison. HSU leaders must be committed to successful student learning, and must encourage the staff to help provide an optimal environment for this to happen. This means HSU staff must be flexible, open to new opportunities and willing to take risks, recognizing the potential of each student placement.

A caution: The HSU must resist the temptation to use students to supplement staff, which would be unfair to both student and staff. It is prudent to orient staff to student roles and expectations. They should be encouraged to treat students as colleagues in learning.

Once everyone is on board, contact the health professions programs at educational institutions within a 30- to 60-minute drive. HSU leaders or an employee who is a graduate of the program can describe the rich learning opportunities available.

If the institutions agree to pursue the relationship, a contract is drawn up (most educational programs have a template for such agreements) and signed by senior administrators. For all parties to benefit, the relationship must be clearly defined. A release clause will enable either party to terminate the contract at any time or to remove a student should irreconcilable issues arise.

Assign one HSU representative as the point of contact (POC) with the educational institutions to streamline communication and scheduling of students. In our case, most schools are on the semester basis, so most students are at the prisons one or two days a week for 15 to 18 weeks. Most also take courses along with their clinical work.

At the outset, note the course length, number of clinical hours, days per week, number of students, other demands on students and the required student evaluation tools. It is vital to know the schools’ learning objectives and expected outcomes for the students so that you know what the student is expected to be able to do each week as well as cumulatively when the rotation ends.

The POC arranges for students’ DOC orientation and ensures appropriate credentialing of preceptors and students. The POC matches the student with the appropriate preceptor, ensures that there is “space” for the student near the preceptor, and arranges for sufficient on-site staff to enable the preceptor to devote time to the student and still fulfill regular responsibilities.

A major challenge at first was having students complete the DOC’s required 40-hour safety and security training before beginning rotations. However, word-of-mouth about the rotation was so positive that students soon were not only willing but even asking to complete the training during school breaks so they could start on schedule. Planning is now done weeks or months beforehand.

The Preceptor
A preceptor is one who takes on an intensive but short-term teaching and supervision role; who for a fixed period teaches, counsels, inspires, serves as a role model, supports the growth and development, and helps to socialize a novice into the new role. In terms of qualifications and attributes, preceptors must…
• Value student/staff contributions as a catalyst to high quality care
• Have adequate time to precept
• Exhibit good interpersonal skills
• Be comfortable with their clinical skills
• Reject the “eat your young” philosophy
• Be capable of supportive nurturing as well as directive behaviors
• Be willing to take a chance, assuming that a meaningful connection with the student will ensue
• Remember personal experiences as a student/new staff member
• Maintain flexibility
• Have a sense of humor

To fulfill their responsibilities, preceptors must be able to...
• Plan the experience to meet student learning needs and objectives
• Provide a thorough orientation to the site, as well as policies, procedures and paperwork
• Perform teaching and role modeling
• Demonstrate an evidence-based practice model
• Understand adult learning principles for students having significant life experiences and maturity
• Foster a relationship conducive to learning
• Assess and evaluate the student
• Provide positive feedback and encouragement at every opportunity
• Provide constructive suggestion in a timely, unthreatening manner
• Allow time for reflection, feedback and discussion regarding the student’s progress…or lack thereof
• Guide the student to be successful

Make no mistake—being a preceptor can be labor intensive and time consuming. Other staff must be sensitive to the demands preceptors face and understand that their work productivity and speed will decrease initially as they explain to the student the rationale for their actions and behaviors.

Careful selection of the preceptor is essential. HSU leaders should know their staff well enough to make a good match based on the information they have about a student. We also ask the student to visit the HSU before finalizing the placement to let the staff meet the student and to give the student a sense of whether this environment will be conducive to their learning.

Should two staff members ever share the preceptor role? Possibly. Advantages are that the student receives broader exposure to different styles of care management, and if one preceptor is away, the student can continue. It may disadvantage the student if the preceptors have very different directive styles and philosophies, or especially if their care management or documentation differ. One solution is to have one primary preceptor (e.g., responsible for managing the evaluation), or for the preceptors to take turns in the primary role.

To ensure that the match is effective and that both student and preceptor are learning from the experience, the program administrator seeks feedback from both parties throughout the placement. In addition, preceptors and the site are evaluated by the students and their institutional faculty member.

The Relationship
Preceptors will do well to foster a professional relationship with the student. Get to know him or her early, ask about past clinical experiences, learning needs and concerns about a clinical placement. Explain your expectations and the ground rules. Ask what types of patients and procedures cause the most anxiety, and be present and supportive until their competence and confidence increase. Familiarity with the student’s program of study and objectives for the clinical placement is essential.

Preceptors will differ in how they perform their role, but for one nurse practitioner at MCI-C, a tried-and-true approach is to have the student “shadow” her for a day or two, closely observing her interactions to gain a sense of the process, timing and special approaches to patients that are unique to a correctional health care setting.

She then observes the student perform six episodic encounters (sick call) and three comprehensive physical exams to assess skills, knowledge, comfort level, strengths and weaknesses, and the level of trust for allowing the student to work independently. She gives students space to see patients independently, and co-signs all documentation after discussion and review for each patient.

Different approaches toward oversight are worth noting. Directing provides specific instructions and closely supervises performance; it is useful when the student is hesitant or unable to complete a task. Coaching is useful when the student is unable but willing to try to complete the task. Supporting works best when the student can complete the task but lacks sufficient confidence. Delegating works when the student can and will perform the task relatively independently.

For example: A student struggling with basic patient care tasks should not work with a preceptor with a delegating style. This student would succeed better with a coaching or supportive preceptor. A student who demonstrates mastery of clinical skills or strong initiative in satisfying his or her learning needs might object to a directing/coaching person but would thrive in a delegating environment.

It is very important to reward student contributions with frequent praise and constructive feedback. If the preceptor has problems with a student or is not sure the student is progressing on schedule, the assigned faculty member should be contacted. No surprises should surface at the end of the rotation.

— About the authors:  Janet Fraser Hale PhD, APRN, BC, is a family nurse practitioner, professor and director of interdisciplinary and community partnerships in the Graduate School of Nursing (GSN), UMass (Worcester) and UMass Correctional Health. Lynne Foster Davidson, MSN, RN, FNP, is director of nursing at MCI-Concord and an instructor at UMass Worcester GSN. Rosalie Berry, MSN, APRN, BC, is an adult nurse practitioner at MCI-Concord and an instructor at UMass Worcester GSN.

[This article first appeared in the Summer 2004 issue of CorrectCare.]