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Teaching for Practice

Ensuring a Successful Preceptorship

Loughran, Mary Catherine DNP, MHA, RN; Koharchik, Linda DNP, MSN, RN

Author Information
AJN, American Journal of Nursing: May 2019 - Volume 119 - Issue 5 - p 61-65
doi: 10.1097/01.NAJ.0000557917.73516.00
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Abstract

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Figure:
Photo by H. Gans / The Image Works.

Nursing preceptors are critical to the successful transition of new nurses to the practice environment and nursing culture. It's been estimated that about 17% of newly qualified nurses leave their first job within 12 months.1 Even worse, if new nurses have a poor experience during this transition period, they may leave the profession. During a preceptorship, a new nurse is paired with a preceptor for a period of time, during which the latter supports, educates, and aids the preceptee during her or his clinical orientation to a specialized health care setting.2 Having the support of a preceptor can be important to the new nurse's job satisfaction, professional development, confidence, and socialization. In addition, preceptor programs can increase nurse retention rates: Pine and Tart describe how one program led to a 37% increase in the nurse retention rate.3

Yet, preceptorships aren't only for new nurses. Experienced nurses who are new employees, nurses returning from a hiatus, and undergraduate or graduate nursing students can also benefit from such a partnership. As health care systems continue to become more complex, placing greater demand on the nursing profession to maintain high-quality care, preceptorships are frequently being used to ensure continuous professional development and to facilitate learning in the clinical setting, with the goal of developing competent and independent nurses.4 Such partnerships provide professional support and allow preceptees to develop the knowledge and competencies needed to assume responsibility for their nursing practice.

Being responsible for preceptees can be both challenging and demanding, and nurses who become preceptors do so for a variety of reasons, including a love of teaching, a commitment to the nursing profession, and the personal satisfaction they gain from being preceptors.5 Typically, nurse managers and educators will survey their staff to find potential preceptors. Qualifications may include having a baccalaureate or more advanced degree, possessing good interpersonal skills, and being culturally sensitive. In a survey conducted by Mohide and colleagues, participants ranked 24 preceptor qualities and characteristics, rating the following as among the most important: clinical competency, enthusiasm for teaching, providing guidance for problem-solving and clinical judgment, offering positive and negative feedback in a constructive manner, demonstrating empathy toward learners, promoting autonomy, and being passionate about nursing.6

Many facilities offer a formal preceptorship program; smaller institutions may encourage and support such partnerships but may not have a structured program in place. Regardless, all preceptors need a supportive work environment in which there are clear expectations of their role and responsibilities. They also need training, which may include live ed­ucation sessions or independent learning opportunities. Often, a blended learning approach is most convenient for preceptors. This entails attending an introductory session, which may last a few hours, followed by the completion of online modules, as described by Nash and Flowers.7 These modules address topics such as communication, the culture of safety, clinical judgment and critical thinking, prioritization, and constructive feedback.

Learning about the resources and support available within one's organization is an important first step to becoming a preceptor. In this article, we offer tips to help preceptors prepare for and navigate the precepting experience.

CONSIDERATIONS FOR AN EFFECTIVE PRECEPTING EXPERIENCE

Preceptors can take the following steps to ensure a partnership benefits both the preceptee and preceptor.

Determine preferred methods of learning and teaching. At the beginning of the preceptorship process, it's helpful for preceptors to identify their preferred methods of learning and teaching.5 Preceptors taking part in a facility's formal preceptor training program may be assisted in their assessment of which teaching and learning methods they prefer. Preceptors can also independently identify their preferences using an online assessment resource, such as What Is My Learning Style? (www.whatismylearningstyle.com/learning-style-test-1.html) and Teaching Perspectives Inventory (www.teachingperspectives.com/tpi). In addition, they may want to reflect on their experiences as new nurses, identifying how their own preceptors made the experience a positive one, for instance.5

Meet the preceptee beforehand. If possible, preceptors should arrange to meet the nurses with whom they'll be working before the start of the preceptorship. They'll want to know about their experiences, perceived strengths and weaknesses, and preferred learning styles, as well as which nursing skills the preceptee hopes to develop and how the preceptor can best help the preceptee to accomplish her or his goals.8 Preceptors can also use this time to introduce themselves, share their work experiences, and welcome preceptees as new staff members on the unit and in the organization. This meeting is an ideal time for the preceptor to establish goals, responsibilities, and clear expectations and to provide the preceptee with information about unit routines, the patient population, and the facility's dress code, for instance.

Establish a relationship. Preceptors can help to establish relationships with preceptees by emphasizing the preceptor's role in providing support, answering questions, clarifying policies and procedures, and helping the preceptee to eventually provide patient care independently. By establishing a supportive environment, the preceptor ensures that the preceptee is always comfortable asking questions.8 The preceptor may need to evaluate the preceptee's knowledge, abilities, and prior experiences—a newly graduated nurse and an experienced nurse beginning a new job or returning after an absence may require different instructions. Nielsen and colleagues found that a “professional learning relationship,” in which the preceptor and preceptee felt “seen and heard” both professionally and personally, strengthened their relationship, although it was important to find the right balance between a professional and personal relationship.4 They note the importance of developing a trusting relationship that establishes a positive learning environment.4 Such a relationship can also enhance critical thinking and increase the preceptee's competencies.9

Contemplate teaching strategies. Such strategies include modeling, direct observation and questioning, think-aloud sessions, assigning directed readings, and coaching and cheerleading.10, 11 It's important to consider the level of experience of both the preceptor and the preceptee when selecting teaching methods. Burns and colleagues have identified the advantages of various teaching strategies11:

  • Modeling. Preceptors using this strategy demonstrate their clinical skills and reasoning to preceptees. Novice nurses learn by observing this process, and modeling helps all preceptees to see how classroom education is used during patient care. This method may be used whether the preceptee is a beginner or more advanced. More experienced preceptees will benefit by noticing the sometimes-subtle techniques used by preceptors when caring for patients during difficult situations, such as when the patient has a serious illness or has been physically abused.
  • Observation. With this strategy, the preceptor and the preceptee observe each other. Direct observation works well when the preceptee is new to a site or at the beginning of a preceptorship.
  • Direct questioning. This tactic fosters critical-thinking skills and provides insight into the preceptee's knowledge base and ability to problem-solve in clinical situations. It's important not to “grill” preceptees and to avoid situations that put them on the spot in front of patients or staff, create stress, and/or make it difficult for the preceptee to concentrate. Questions such as “What do you think?” and “Why do you think that?” stimulate thinking and the formation of generalizations, which can be subsequently tested.
  • Think-aloud method. This technique can be especially helpful to beginners, who are asked to provide responses to questions asked by the preceptor and a rationale for their decisions. The think-aloud method fosters critical-thinking and clinical-reasoning skills.
  • Directed readings. Assigning readings is helpful at the beginning of the preceptee experience. These readings are typically focused on clinical topics that arise in practice. The preceptor should ask the preceptee to provide a brief report on the reading the next clinical day. Directed readings support the development of conceptual frameworks.
  • Coaching. Using this strategy, preceptors provide verbal cues to preceptees during the performance of procedures. This provides preceptees with opportunities to build and master skills in the clinical setting.

Preceptees may bring nursing and other personal experiences to the clinical setting and, like most adult learners, are often experiential learners who prefer an active role in the learning process.11 For this reason, preceptors need to understand adult learning principles. Two of the most commonly described approaches are the sink-or-swim and manipulated-structure methods.11 With the former, preceptees conduct patient interactions without support. By contrast, a manipulated-structure approach takes into account the preceptee's skills and experience when matching the preceptee with the patient. Depending on the preceptee's skills and confidence level, the preceptor may vary the use of these approaches over the course of the preceptorship.11 For example, preceptors may begin with the manipulated-structure approach, using the sink-or-swim technique as the preceptee becomes more confident and is agreeable to using this approach. Although the preceptee is exposed to a variety of clinical situations and expected to handle them independently, the preceptor should always be available, if needed. The goal of the preceptorship is for the preceptee to achieve independence in providing safe, quality patient care. It's important to encourage this independence, but preceptors must be cautious not to allow this to happen before the preceptee is ready. Preceptors should always closely monitor preceptees, especially when they are providing direct patient care.

Durning has highlighted several points about learning that preceptors should keep in mind when working with preceptees12:

  • Everyone has a preferred learning style, whether the person is a visual learner or learns by reading and listening. It's important to remember that the preceptee's style of learning may differ from that of the preceptor.
  • Some people learn quicker than others. If the preceptee is slow to learn a concept, preceptors should be patient, reinforce the concept, and find another way to teach it, if necessary.
  • Learning effectively involves participation, repetition, and reinforcement. Until the preceptee actually does the procedure or takes care of a certain type of patient, she or he cannot claim to know how to do it. The preceptee needs hands-on experience.
  • Immediacy trumps “later.” It's important to remember that the sooner the preceptee can practice the skill, the better she or he will retain what was taught and apply it appropriately in the clinical setting.
  • Learners need variety. The preceptor should use a variety of learning and teaching methods to enhance the preceptee's retention of what was taught. The preceptee must be an active adult learner and take initiative in meeting the goals of the preceptorship.

‘Walk the talk.’ Preceptors should keep in mind that as role models for preceptees, they must “walk the talk.” If the preceptor does one thing but tells the preceptee to do another, the preceptee will remember what was done, not what was said. Professionalism includes respecting nurses, unit staff, other members of the health care team, and patients, and the way the preceptor communicates and works with these people teaches the preceptee how to act professionally.8 For example, if a preceptee tells her preceptor that she feels intimidated by a physician who reacted angrily to her questions about a patient order, the preceptor should suggest that she use the “CUS” communication approach to frame her concerns to the physician: “I am Concerned; I am Uncomfortable; it is a Safety issue.”13 This simple and easy-to-use tool can support the preceptee in communicating with physicians and other members of the health care team.

Offer timely feedback and evaluation. This is a key function of being a preceptor. Formative feedback should be provided on a frequent basis throughout the orientation period. If possible, feedback, evaluation, and a brief discussion should occur at the end of each clinical day. This provides preceptees with an opportunity to talk about the care they provided and goals they achieved; it also allows them to identify future goals. Learning is enhanced for adult learners if they believe they are making progress.11 The process does not have to take long—it can be completed within five minutes.5 Effective feedback is not judgmental and reinforces what has been done well and what needs to be improved. Such feedback can prompt preceptees to assess and discuss their performance. Preceptors also provide summative feedback, in which the preceptor evaluates the preceptee at preset times during the preceptorship, particularly at the end of the experience. This type of feedback focuses on reviewing the goals and objectives of the preceptorship. Evaluations should always be held privately and provided in a timely, professional, and empathetic manner.5

Various techniques can be used to provide feedback. Using the directive approach, preceptors share their observations about the preceptee's performance; this technique does not allow for the active involvement of the preceptee in the feedback process.5 By contrast, the preceptee is involved in the elaborative feedback approach, in which self-reflection and self-assessment are encouraged. According to Lazarus, this approach promotes more effective feedback and trust between preceptors and preceptees.5 Using this technique, the preceptor invites the preceptee to comment on what went well and what the preceptor could have done to improve the preceptee's experience.

Feedback can be both positive and negative. If a preceptee is struggling, it's important to let the nurse manager, unit educator, and/or academic faculty know as soon as possible and to request support, if necessary. Barker and Pittman have recommended that such a report include a description of the problem(s), approaches that have been used to ameliorate it, and any progress that has been made.10 Reasons why preceptees may be struggling include being unable to prioritize care or being unprepared, having gaps in their knowledge base, being unable to incorporate theory into practice, personal problems, and poor communication skills.5 New graduate nurses may also struggle with psychomotor skills. Such skills can be practiced outside of the patient care area to decrease anxiety when using new equipment.14

Providing constructive feedback can be stressful for preceptors. In her review of various approaches, Lazarus highlighted the feedback sandwich technique, in which the preceptor provides positive feedback, followed by constructive feedback and then positive feedback again.5 The preceptor should be honest and constructive, giving feedback that is based on performance—not personality—and both the preceptor and preceptee should work together to devise a strategy for improvement.10 An important point to remember is that evaluations should not contain any surprises for the preceptee if the preceptor has been providing formative feedback and addressing any concerns as they arose during the preceptorship.

Identify workplace support. Preceptors should be aware of the workplace support available to them during the preceptorship. The nurse leader, charge nurses, and unit nurse educators are available to assist preceptors in providing information that is suited to the goals and learning needs of preceptees. Furthermore, preceptors should take advantage of opportunities to attend educational programs to further develop their skills and shouldn't hesitate to ask their nurse colleagues for help, when needed. The support and commitment of nursing leadership to the preceptorship is the key to its success.

A SENSE OF ACCOMPLISHMENT

An effective preceptor can support the preceptee in identifying with the health care organization's mission and vision as well as successfully transitioning to a new clinical environment. Preceptors need to make the most of their time with preceptees, helping them to strive for excellence in their nursing practice. This can lead to greater job satisfaction among both preceptors and preceptees, improvements in recruitment and retention, and the provision of quality care.7 Moreover, preceptors often describe a strong sense of accomplishment when they see their preceptee functioning as a competent practitioner or commended for a job well done.

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