31 May Psychiatric Mental Health Nurse Practitioner

College of Nursing

Office of Field Experience

Preceptor Commitment Form

NP- PMHNP

Preceptor Commitment Form

Psychiatric Mental Health Nurse Practitioner

A Walden University nursing student has nominated you as a preceptor for an upcoming practicum course. We appreciate your contribution to the training of student nurses by sharing your time, expertise, and knowledge. We are asking that you please read and sign this document, acknowledging your role as a preceptor for the student. Return this form back to the student to upload to their application.

College of Nursing at Walden University

· Accreditation: The Master’s Degree in Nursing (MSN) program at Walden University is accredited by the Commission on Collegiate Nursing Education ( http://www.ccneaccreditation.org).

· Mission: The College of Nursing, dedicated to excellence in nursing education, provides programs to transform diverse nursing professionals into champions of change who will improve health outcomes and advance health equity.

Purpose of Practicum:

A practicum is a distinctly defined supervised onsite experience, in which students develop applied skills and integrate professional knowledge in the provision of “hands-on” care. The didactic (classroom – NRNP) and practicum (clinical- PRAC) components of the courses are separated. The following courses are the practicum courses for the PMHNP specialization:

· Practicum Courses:

· PRAC/PRCM 6635 – Psychopathology and Diagnostic Reasoning

· PRAC/PRCM 6645 – Psychotherapy with Multiple Modalities

· Preceptors must conduct therapeutic psychotherapy.

· Psychiatric evaluation and medication management with supportive therapy do not qualify for this course.

· PRAC/PRCM 6665 – PMHNP Care Across the Lifespan I

· Preceptors must have prescriptive authority and practice medication management

· PRAC/PRCM 6675 – PMHNP Care Across the Lifespan II

· Preceptors must have prescriptive authority and practice medication management

· Practicum Hours: 160 hours per course for a total of 640 hours for the program.

· Patient Hours & Requirements: Review the Course Overview on our Preceptor Resources webpage

· Nurse Practitioner practicum courses require students to be involved in hands-on direct patient care.

· Students must complete practicum experiences onsite at the practicum site unless approved for telehealth practicum.

· Review course information online: http://academicguides.waldenu.edu/fieldexperience/son/PreceptorResources

Role of the Preceptor:

· Guides, directs, mentors, and supports the student, to facilitate the achievement of practicum learning objectives.

· Orients the student to the practicum site, facility, personnel, policies, and procedures.

· Provides opportunities for role analysis, as well as the application of skills and knowledge.

· Supervises the student, which encompasses instruction, monitoring, mentoring, evaluation, supervision, and feedback.

· Provides ongoing feedback about student performance and progress in meeting practicum goals and objectives.

· Collaborates with the faculty instructor to ensure the student is meeting practicum learning objectives.

· Completes video conference meetings with the faculty instructor to discuss the student’s practicum experience and performance.

· Signs off on practicum time logs in Meditrek to verify the completion of required practicum hours.

· Completes a midterm and final evaluation in Meditrek to assess and evaluate the student’s performance during practicum.

Role of Faculty:

· The faculty instructor is a Walden faculty member responsible for assuring that this student meets the course learning objectives.

· The faculty instructor teaches and leads the practicum course and manages the practicum experience.

· The faculty instructor communicates with the student and preceptor regarding student performance, progress and learning needs.

· The faculty instructor will make a site visit, either virtually and/or onsite, to review the student’s practicum experience.

· The faculty instructor is the point of contact for the preceptor and helps have resolve any problems if they arise.

· The faculty instructor must verify practicum hours with the preceptor and sign time logs in Meditrek.

· The faculty instructor evaluates the student’s practicum work, grades assignments, and assigns a final grade.

Compliance Requirements for Preceptors: Walden University abides by the appropriate compliance requirements and standards as determined by various state, national, accreditation bodies, and professional nursing agencies/associations. Therefore, we request preceptors agree to abide by the following standards and requirements:

1. Is currently licensed in the state where practicum will occur with an active and unencumbered license.

2. Has a minimum of one year of postgraduate experience and a current job role relevant to the specialization.

3. Is a permanent employee of the facility/site where the practicum will take place.

4. Is not the student’s supervisor, family member, friend, or any other relationship that would be a conflict of interest.

5. Will complete evaluations to assess the student’s work during practicum and verify practicum hours by signing time logs.

6. Will complete video conference meetings with Walden faculty to assess student’s performance during practicum.

7. Student must conduct direct patient care and have access to the electronic medical/health record system for practicum.

8. Agree to engage in a preceptor to student ratio of 1:1 for direct student supervision at any given time.

Meditrek:

Meditrek is the online clinical rotation management system we utilize to track, monitor, and manage the practicum experience.

· Preceptors will verify and sign time logs in Meditrek.

· Preceptors will complete a midterm and final evaluation in Meditrek.

· The link to Meditrek is https://edu.meditrek.com/

· Meditrek credentials will be emailed to preceptors Monday of the third week of the course.

· Contact [email protected] if you don’t receive an email with your Meditrek account information.

Additional Resources for Preceptors:

The following additional resources can be found online at http://academicguides.waldenu.edu/fieldexperience/son/PreceptorResources

· Practicum Manual & College of Nursing Handbook

· Academic & Course Information – Course Overviews: Course Objectives, Course Outcomes & Clinical Checklists

· Meditrek Information, Resources & Webinars

· Walden University and College of Nursing – Mission, Vision & Accreditation

Benefits for Preceptors: As a benefit to you and to show our appreciation, we provide benefits for serving as a preceptor. Review our Preceptor Resources webpage for additional information regarding preceptor benefits.

Next Steps:

· After completing and signing this Preceptor Commitment Form, please send it directly to the student. The student must upload this form as part of their practicum application in Meditrek by the application deadline.

· This Preceptor Commitment Form is student, course, term, site, and location specific, for compliance purposes. Thus, a form is required to be completed for each student for each course, term and for each site location where practicum will occur.

· The Field Experience staff at Walden will work directly with the administrator at your facility to establish an affiliation agreement, which is a legal agreement directly with the practicum site, which is different from this “Preceptor Commitment Form”.

· Upon final approval of the student’s practicum application, you will receive a confirmation email with a Preceptor Orientation.

Policy on Electronic Signatures:

Walden University manages the practicum application processes in a nearly paperless environment, which requires reliance on verifiable electronic signatures, as regulated by the Uniform Electronic Transactions Act. Legally, an “electronic signature” can be the person’s typed name, his or her e-mail address, or any other identifying marker. An electronic signature is just as valid as a written signature if both parties have agreed to conduct the transaction electronically. The Field Experience Coordinator for the College of Nursing will verify any electronic signatures that do not originate from a password protected source (i.e., an e-mail address officially on file with Walden University). The preceptor’s e-mail address provides authentication for electronic signature and thus must match the e-mail address contained in the student’s application for field experience.

How to Contact the Office of Field Experience

Email: [email protected]

Phone: 800-925-3368

Nurse Practitioner – Psychiatric Mental Health Nurse Practitioner Program (PMHNP)

This form must be completed by the preceptor. A separate form must be completed for each site location.

Students are not authorized to complete this form. After form is completed by preceptor, students upload this form to their practicum application in Meditrek.

Student’s Name:      

Practicum Course: |_| 6635 |_| 6645 (psychotherapy) |_| 6665 (Preceptor must have prescriptive authority) |_| 6675 (Preceptor must have prescriptive authority)

Term of Practicum: |_| Fall Quarter (Aug-Nov) |_| Winter Quarter (Nov-Feb) |_| Spring Quarter (Feb-May) |_| Summer Quarter (May-Aug)

Preceptor’s Name:      

Preceptor Phone Number:      

Email: Employer Issued E-mail:      

Practicum Site:

Name of Site Where Student Will Complete Practicum:      

Physical Address of Site Where Student Will Complete Practicum:      

Administrative Contact & Email for Legal Agreements:      

Employment:

Current Position:      

Current Employer:      

Length of Employment at Current Position:       Year(s)       Month(s)

Employment Status of Site: |_| Permanent Employee |_| Services provided under contract but not an employee.

I have approval for this preceptorship through my employer: |_| Yes |_| Not Required by Employer/Site

Education:

Highest Degree:      

Major/Concentration of Degree:      

College/University:      

Month & Year of Graduation:       (MM/YYYY)

Licensure: Highest Licensure Related to This Preceptorship:

Type of License: |_| PMHNP |_| Psychiatrist (Board-Certified) |_| Psychologist |_| Counselor |_| Social Worker |_| Other:      

License State:       License Number:      

License Exp. Date:       (MM/YYYY)

Length of Time Practicing at Current Level of Licensure:       Year(s)       Month(s)

Certifications or Specializations:      

Will this student have access to the electronic medical/health record system during practicum? |_| Yes |_| No

Do you provide direct patient care and will student be able to complete direct patient care during practicum? |_| Yes |_| No

Do you conduct assessment and diagnosis services for acute and chronic psychiatric disorders? |_| Yes |_| No

Do you provide therapeutic psychotherapy as part of your current role? |_| Yes |_| No

Do you have prescriptive authority AND does your current role include medication management? |_| Yes |_| No

Do you see enough patients for the student to complete the requirements of this course in 10 weeks? |_| Yes |_| No

Please select the age range(s) of patients you serve: |_| 0 – 17 |_| 18 – 54 |_| 55 – + |_| All Age Groups

Describe your practice setting: |_| Private Practice |_| Hospital/Inpatient |_| Counseling Center |_| Drug/Alcohol Rehab |_| Other:      

Describe the unit/department, the clinical services you provide, and the patient types you serve at this site:      

Initial:       I understand the 1:1 student to preceptor relationship listed on page 2 and I cannot precept more than three students a quarter.

Initial:       I understand that by signing this form, I have reviewed the practicum information and I am willing and able to meet all practicum

criteria, course requirements, preceptor role, and compliance requirements for preceptors as stated on pages 1 and 2 of this form.

Date:       (MM/DD/YYYY)

Preceptor Signature (Must be physically signed by preceptor if completing form manually):

Preceptor Electronic Signature (Email must be entered by preceptor for an electronic signature):      

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