Conversations about closing nursing skill gaps tend to start with the new nurse: more simulation hours, a longer orientation, a slower ramp-up to a full patient load. A three-year, $75 million grant administered by the Arizona State Board of Nursing started somewhere else entirely, with the preceptor.
The Arizona State Legislature approved the grant in 2022, allocating $25 million annually over three years to strengthen and expand nurse preceptor training programs across the state.
Three veteran nursing leaders and researchers oversaw the grant program: Kathy Malloch, PhD, RN, a nursing leadership consultant, author and former Arizona State Board of Nursing president; Kathy Scott, PhD, RN, a healthcare executive consultant and adjunct faculty member at Arizona State University’s College of Health Solutions; and Tim Porter-O’Grady, EdD, APRN, senior partner at TPOG Associates and clinical professor at Emory University’s School of Nursing.
Over three years, the trio worked with more than 60 healthcare organizations, from critical access hospitals to academic medical centers, on how they prepare new nurses for practice. The leaders first sought to understand how healthcare organizations were approaching this within their own walls, which led to a surprising discovery.
“When we asked them to describe their program for transition to practice, everybody immediately went to the new grad nurse,” Dr. Scott told Becker’s. “They never brought up the preceptor.”
Preceptors play a crucial role in training new graduate nurses and creating a psychologically safe culture for them to learn and grow, yet few hospitals or health systems had organized structures in place for preceptor training.
In addition, many healthcare organizations were caught in a cycle of onboarding new nurses just to backfill the ones who were leaving, without ever getting ahead of the churn. The pattern pointed the team to an increasingly common diagnosis among nursing executives and associations: the healthcare industry doesn’t have a nurse supply problem, but rather a retention problem.
Both threads traced back to the same undervalued position in healthcare organizations, according to Dr. Malloch.
“As an industry, we have made the nurse preceptor role invisible and unimportant,” she said. “The essence of what we tried to do is to elevate and formalize that role.”
Elevating the role meant treating it as a defined discipline with its own training and expectations, rather than an assignment handed to whichever nurse was free that shift.
These observations set the direction for the grant program, which aimed to help systems build a structured, intentional preceptorship model. Rather than write procedures for how to precept, the team built policy-level standards flexible enough to fit a 25-bed rural hospital and a quaternary academic medical center alike, organized around six domains of preceptor practice: technical and clinical skill, personal and professional growth, relational and interactional capacity, professional communication, peer integration and organizational culture. Grantees kept whatever transition-to-practice infrastructure they already had and layered the standardized principles on top of it.
Based on feedback from grantee organizations, the leaders identified several non-negotiables for the preceptor programs. For one, preceptors need training in communication and relational skills, not just clinical competency, since a new nurse’s confidence often hinges more on how a preceptor talks them through a hard moment than on technical instruction. Despite the availability of online modules, preceptors overwhelmingly preferred in-person, hands-on training. And training the preceptor wasn’t enough on its own: programs only held up in organizations where leadership backed the role with protected time and visible support, rather than treating precepting as an unpaid add-on to a nurse’s existing workload.
The grant asked organizations to give preceptors and new nurses 15 minutes of protected time each shift to talk through what had happened and what was coming.
“That’s time away from the bedside,” Dr. Scott said. “You can take a breath, you can sit down, you can think about what you just did. What kinds of questions do you have? What has made you really anxious? Let’s unpack that.”
It was, by the leaders’ account, one of the hardest asks to get organizations to follow through on consistently. It was also one of the clearest drivers of the results that followed. Preceptor retention across participating organizations swung from -11% before the grant to 35% after, according to program data, and 97% of preceptors surveyed said they intended to keep precepting a year later.
Twelve grantee organizations also volunteered to track return on investment with the help of an outside economist. Dr. Scott said 91% of them reported a positive ROI within the first year of running a structured transition-to-practice program. Most of that return came from a reduction in turnover, she said, with faster time to competency for new hires as the second-largest driver. In several cases, new nurses reached full competency in about half the time it previously took.
Another strategy to emerge from the grant program was the transition-to-practice specialist: a preceptor with no permanent nurse assignment who stays available to nurses after orientation ends, for the questions that come up once they’re on their own.
Culture is another crucial component to an effective preceptor program, according to Dr. Porter-O’Grady. A standardized curriculum and protected time can shape how a preceptor teaches, he said, but they don’t determine whether a new nurse feels like they belong. That sense of belonging is what ultimately decides whether the investment in training pays off in the long run.
“You’re inviting people into the nursing professional community of practice, not into a job,” he said. “Make sure it is a community and … the culture is one that values that community, because that’s what creates the conditions of sustainability.”
Dr. Malloch, Dr. Scott and Dr. Porter-O’Grady are turning these lessons into two publications: “Preparing Nurses Who Stay: The Apex Advantage,” a book featuring grantees’ own accounts of the work, coming out this fall, and a companion handbook with the practical tools organizations used to build their programs.
Ultimately, closing clinical skills gaps and retaining nurses long-term depend on a complex web of factors. No single fix will resolve all of it, but Dr. Malloch’s answer for where to start is direct.
“Pay attention to a more formalized, standardized preceptor role,” she said. “That’s got to be the number one message.”
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