Building relationships: the key to preceptoring nursing students.
Preceptorship is a form of support offered to student nurses in the
clinical setting by a registered nurse (preceptor) who offers guidance
and acts as a role model to the student. Research suggests this can be a
rewarding role for preceptors, but there are challenges which may impact
on their ability to develop the role to its full potential. To better
understand the experiences of being a preceptor and the factors that
impact on the role, a qualitative descriptive study was undertaken in a
small provincial hospital in New Zealand. A purposeful sample of Ave
registered nurse preceptors completed semi-structured audio-taped
interviews. Data analysis was completed using a step-by-step process
informed by Burnard (1991).
The key finding of this research was the importance of the preceptor and student nurse establishing a professional working relationship. This then enables the preceptor to better assess, and assist promoting in the student's level of knowledge and understand. At that point the preceptor can determine whether it is safe to allow the student more practice opportunities, or whether constant supervision is still required. Rostering students with one preceptor for the entire placement would better enable both parties to develop a cohesive working relationship, and result in a more positive, effective placement for both the student and preceptor.
Key Words: Preceptorship experience, New Zealand, undergraduate nursing students, relationships.
|Subject:||Nursing students (Research)|
|Publication:||Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2011 Nursing Praxis in New Zealand ISSN: 0112-7438|
|Issue:||Date: April, 2011 Source Volume: 27 Source Issue: 1|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
As a result of government directives, in 1988 nursing education moved from hospital-based programmes into the tertiary setting (Ryan-Nicholls, 2004). Instead of student nurses learning primarily within hospital settings, they now acquire knowledge in both tertiary education and clinical settings. Nursing students are placed with experienced registered nurses (preceptors) who provide supervision and instruction within the clinical environment (McLeland & Williams, 2002). Despite the frequency with which preceptors work with student nurses in New Zealand, there has been limited research here on preceptorship in the nursing context, especially in relation to hospitals outside of the main centres. This research therefore sought to answer the research question 'What is the experience of being a preceptor in a small provincial hospital in New Zealand?'
A Broad Perspective.
There is a significant body of international literature related to preceptorship. The most positive aspects of being a preceptor have been identified as assisting the student to develop personally and achieve professional goals within the placement, and being able to share and increase their own knowledge (Hyrkas & Shoemaker, 2007). Many preceptors believe it to be their professional duty to nurture and support nursing students (Mannix, Wilkes, & Luck, 2009).
Gassner, Wotton, Claire, Hofmeyer, and Buckman (1999), describe the need for "industry and academia" to have a collegial relationship which includes "cooperation, shared planning and decision making, shared power and non-hierarchical relationships" (p. 21) to best assist student learning in clinical placements. Mannix et al., (2009) agree and suggest that educators and preceptors work together to provide optimum experiences for students. Generally preceptors valued the support they received from the educational facility, colleagues and/or hospital (Henderson et al., 2010; Ohrling & Hallberg, 2001). Unfortunately not all preceptors felt supported in the role, citing a lack of availability and accessibility of clinical lecturers and lack of support from colleagues (Henderson, Fox, & Malko-Nyhan, 2006). Instances of preceptors not having sufficient time to spend with the students are frequently noted. Carlson, Pilhammar, and Wann-Hansson (2009) describe heavy workloads as one of the major factors that impact on preceptors' time to teach. These authors suggest that protected time must be given to preceptors and students to facilitate learning.
The importance of orientating to the preceptorship role was highlighted (Hallin & Danielson, 2009; Zilembo & Monterosso, 2008). While some preceptors felt adequately prepared for the role (Hallin & Danielson), others did not and perceived preceptorship as being thrust upon them, resulting in failed relationships and negative learning experiences for the student nurse (Andrews & Wallis, 1999). A well-developed orientation enhances preceptor knowledge of important factors such as student evaluation (Burns, Beauchesne, Ryan Krause, & Sawin, 2006), and managing the emotional stress associated with the preceptorship role (Hrobsky & Kersbergen, 2002; Mamchur & Myrick, 2003).
New Zealand research regarding nursing preceptorship is limited. Kaviani and Stillwell (2000) evaluated the relationship between preceptor, preceptee and the manager within the clinical setting. Dyson (1998) focused on the experiences of the clinical nurse lecturer in the preceptor model. Three studies focused on the experiences of preceptors in large public hospitals (Macdiarmid, 2003; Orchard 1999; Rummel, 2001). To date there has been no research into the experiences of preceptors in New Zealand hospitals outside of the main centres. As preceptorship is such a significant component of clinical learning for student nurses, it is important to further understanding of the experiences of preceptors in smaller provincial hospitals.
A qualitative descriptive design appropriate to "examine a known phenomenon in a new population" (Wright, 1993, p. 117) was used to answer the research question. In order to generate new knowledge, qualitative descriptive designs seek to explore participants' "thoughts and feelings and/or attitudes towards an event" (Sandelowski, 2000, p. 337). The researcher then interprets the event in such a way that it is clear and meaningful to the participant.
Research/ethics approval was gained from the Otago Polytechnic Ethics Committee and the Director of Nursing, Maori Health Advisor and Clinical Governance Committee at the hospital where the study occurred. Participants in this research were all registered nurses drawn from two acute inpatient wards in a small, provincial New Zealand hospital which provides a wide range of secondary services. Their practice experience ranged from less than one year to over twenty years, and they were working full or part-time rostered rotating shifts or on the casual pool. All had preceptored undergraduate nursing students at least four times, but only one had completed a formal preceptorship course.
Posters describing the study were posted in the medical and surgical wards. Five staff members contacted the first author for further information on the study, and all subsequently consented in writing to participate in the research. All participants were interviewed individually by the first author at a location agreed by both parties. One participant was interviewed twice to clarify information given during the first interview. The interviews, lasting between 45-60 minutes, were initially guided by a brief interview schedule. Only the authors, a second research supervisor and a transcriber (who had signed a confidentiality agreement) had access to the raw data during the study. To help maintain the anonymity, privacy and confidentiality of participants, pseudonyms have been used in all publications and presentations arising from the research, including this article.
The first author knew all participants personally prior to the research commencing, as she was working as a clinical lecturer in the wards concerned. At the beginning of each interview the first author clarified her research role with the participants, and reinforced her interest in their experiences as preceptors. They were also assured of confidentiality and anonymity in relation to their participation in the research, and informed of the steps that would be taken by the researchers to ensure this.
A modified framework based on Burnard (1991) and informed by Glaser and Strauss (1967) was used as to guide data analysis. The process used in the research is outlined in Table 1. This was appropriate for qualitative research where data collection was obtained using face to face interviews which had been recorded and transcribed.
In order to maintain rigour throughout the research Lincoln and Guba's (1985) criteria to establish trustworthiness, and Tuckett's (2005) operational techniques were used. Credibility and triangulation were established and maintained by the first author through self reflection and journaling, honest and open disclosure to participants, and keeping a self reflective journal. A fieldwork journal, having audio-taped interviews which enhanced accuracy of the data, notes made on the transcripts used for reflection, a record log throughout the research process and regular meetings with supervisors all contributed towards dependability. Confirmability is the final criterion in establishing trustworthiness and this is achieved when research decisions and influences are described throughout the study and the research process is transparent (Koch, 2006; Lincoln & Guba). The process of this research and decisions made were clearly documented in the final research report (Haitana, 2007).
There were eight themes generated from the data. The core theme that emerged from the preceptors' narratives centred on the significance of their relationship with the student nurse. Within the context of the preceptors' responsibility for patient safety, getting to know the student, and developing a sense of trust, are essential pre-requisites for allowing the student some autonomy (letting go). The first step in building this fundamentally important professional relationship begins with the preceptor getting to know the student nurse.
Building a Relationship.
Getting to know the student is an inherent part of the preceptor-preceptee relationship (Gillespie, 2002). All the preceptors in this study stressed the importance of connecting with the student, and while it was potentially the most satisfying aspect of the role for them, it was seldom achieved because they were only intermittently rostered with the students. This was due to the students usually working Monday to Friday on either mornings or afternoons, and the preceptors being on rostered rotating shifts.
Part of the preceptoring is developing their trust and developing a relationship. You can't do that if you have only got the person for a day, you would actually spend half of that shift getting to know that person, reassessing them, what can they do what can't they do (Alex).
Spending so little time with the student reduced the preceptors' ability to develop trust, which then impacted on their ability to evaluate the effectiveness of their teaching. This was extremely frustrating for the preceptors who valued their teaching role highly:
... cause you get a continuous flow-on effect, its... you've already learnt the trust at the beginning, a therapeutic relationship, you've opened it up, you've settled it all at the beginning of the actual time-frame, you know what's going to happen and you can actually build on that (Stacey).
Preceptors also valued the feedback they received from the student, and working consistently with a student enhanced the development of this feedback:
You know what I mean, I think that's why having a single preceptor per placement and getting that really good feedback is really good, and also good for the preceptor 'cos they feel like they've been really useful (Bernie).
Spending limited time with a student, and/or working with them only intermittently, placed severe constraints on a preceptor's teaching and coaching role. Limited contact between preceptor and student nurse also makes it more difficult to establish a sense of trust.
Trust. Feeling that they were unable to trust the student resulted in role dissatisfaction for the preceptors. They could not then have the degree of confidence required to allow the student some degree of autonomy within the clinical setting. Working with a student over a longer period of time made it far easier to establish some sense of trust.
The last student I had was a student in her third year and she was really, really good. She was great and you could trust her. She knew what she was on about, she followed instructions well. You'd talk to her about what you wanted from her and what she wanted from me and she was honest. I could delegate and know that she would come back to me with her information (Kim).
These are things we need. I need for you to understand that I find it difficult to let a student go. It is about your professionalism, I think it is about you being able to, because you are responsible for those patients, it's about you knowing in your heart that you have to trust that student but in order to trust them you need to keep them on a leash for a period of time (Alex).
All the participants thought they needed to work with the student for a minimum of three to four days to complete their evaluation of the student, and assess whether or not it was safe to allow him/her increasing autonomy. Not only did working with the student consistently over a period of days help with building the relationship between the two parties, but it was likely to lead to the student being offered more opportunities within the clinical setting. A one-to-one relationship provided continuity and increasing satisfaction levels for both parties. It also enabled the preceptor to establish the confidence to let the student have more autonomy in practice, the process of "letting go".
Letting go. At some stage in the relationship, preceptors needed to decide when it was safe to manage the nursing student from a distance, to allow them greater autonomy. This engendered a huge sense of responsibility for the preceptors, which weighed heavily on each of them.
I ask you to do observations and there is a change, I want to know why; if you can compare it to others and what's happening, because I want to know, because I need to trust that you understand what's happening. Because I said at the time if I'm going to let you have a patient load I need to know that you are going to make sense otherwise I am not going to let you have any of my patients. And they sort of look at me and I say, no it's as black and white as that because at the end of the day it is my responsibility and if you want to take some of my patients and care for them then you have to prove to me that you can actually do it (Stacey).
This internal conflict about when to let the student manage the patient was clear during the interviews. Prior to letting the student go the preceptors had to determine whether the student was adequately prepared. It was difficult to make this judgement when so little time had been spent with the student.
You have to make a judgement on every student you see. You have to make a quick judgement about how capable you think they are, and how confident or how likely they are to come to you (Alex).
And then, I wondered what the hell she was doing, I went down there and she was on her third person and she hadn't bought me any obs. I discussed with her the parameters beforehand of what was normal, but I just wanted to go through with her again and have a look at them to see if she had done them and if they were normal for that person because sometimes it's different to what is considered. This girl was just standing there she didn't understand, I don't know, I felt like I was explaining it well, and she just didn't understand. She would just say yes and that was hard for me because she was so keen and so eager and she was like 'Oh I have a patient today' and I had to keep saying 'no' because we aren't doing so well (Kim).
They will have worked with a nurse for three or four days, built up so that the nurse was quite confident and then let them do a bit more advanced stuff and then they'd get a new nurse who doesn't know them and then makes them do nothing more than temperature. They get a bit of momentum, get a bit more confidence and then all of a sudden they're back to square one again (Bernie).
Bernie highlights the frustration that arises for both preceptor and student when they work together for only a short period of time. The student works with a preceptor for a few days, is given some autonomy, gains confidence, and then the preceptor changes so the student is then directed back to doing the basics such as taking vital signs. Preceptors valued their relationship with the patient and as a result felt the need to protect the patient and not allow the students autonomy until they were confident of their practice:
Not, yeah partly but the other thing I am thinking of is the relationship you develop with the patient and their families and our work ethic is extremely sometimes intimate in a sense, extremely intense and involved and this can happen in a very short time, you know you develop an intense relationship in a very short time. That is sometimes students, it takes some time to develop, some students you know they have just got it and some students just stand well back and I have to stand back and let them do it, I find that hard, I find that really hard (Alex).
I mean I always have as the bottom line whether I'm being the nurse or the preceptor 'would I want this person nursing me?' (Stacey).
Another key consideration for preceptors that made it difficult to allow the student more autonomy was the feeling that they were ultimately responsible for patient safety, and if anything did go wrong there could be repercussions, such as the loss of their nursing registration.
Two reasons, one is because I have seen what mistakes can happen and because the work environment is so regulated by legislation and consequences you feel very much under pressure every day, that you can't do, wouldn't want to do anything wrong (Alex).
I'm sitting there thinking, 'Oh my goodness! Can I trust this particular person, is this person capable?' You don't know what you're thinking, you don't know how they learn, and the whole rules changed and it was kinda like fear, and then all of a sudden I looked at responsibility, my responsibility and the key thing was my badge, and I thought, 'No, this is what I've done all my training for, now you have to prove to me exactly what you can do', and yeah, it changed the whole initial way I thought about it (Stacey).
All participants stated they would prefer to have the student for a longer period of time. Firstly, this would assist in the essential task of relationship building, and the development of a sense of trust that would lead to the student having greater autonomy. A one-to-one relationship would also provide continuity for both parties during the clinical experience, and result in a more satisfying experience for each.
This study sought to understand the experiences of preceptors working in a small hospital in a provincial city in New Zealand. The findings identified were not unique and have been previously discussed in the literature. Findings such as the contribution of the preceptor, workload and support issues associated with the preceptorship role and legal responsibilities of the preceptor mirror those from studies of preceptors working in larger, urban hospitals (Calman, Watson, Norman, Redfern, & Murrells, 2002; Carlson et al., 2009; Gassner et al., 1999; Henderson et al., 2010; Hrobsky & Kersbergen, 2002; Hyrkas & Shoemaker, 2007; Kaviani & Stillwell, 2000; Macdiarmid, 2003; Ohrling & Hallberg, 2001; Orchard, 1999; Rummel, 2001; Yonge, Krahn, Tojan, Reid, & Haase, 2002). It appears therefore that the location and size of the hospital is not a major factor in the experiences of preceptors. Nevertheless, the key contribution of this research is a confirmation of the importance of the relationship the preceptor has with the student, and how this relationship impacts not only on preceptor satisfaction, but also on student learning and development.
Hyrkas and Shoemaker (2007) suggest that one of the intrinsic rewards associated with preceptorship is the sense of achievement associated with the teaching component. This contributes to preceptor satisfaction and ongoing commitment to the role. One of the main factors to impact on the sense of achievement is the ability of the preceptor to spend an adequate amount of time with the student. Gillespie (2002) describes how being connected in the preceptor-preceptee relationship allows the student "to feel at ease, feeling valued and respected, and experiencing positive self regard" and experience "the connected student-teacher relationship as a safe environment that affirmed them as people, learners and nurses and supported their learning experience" (p. 569). Connection also provides the preceptor and preceptee with some understanding of each person's role in the relationship; the academic and clinical work that needs to be completed by the student; and the opportunity to negotiate how each party will fulfil their obligations during the clinical placement.
Research also supports the belief that it is beneficial to have one preceptor per placement for a variety of other reasons. These include; continuity of the preceptorship experience (Kaviani & Stillwell, 2000), teaching and socialisation of the preceptee (Myrick & Barrett, 1994), a better understanding of students' learning needs and expectations (Schroyen & Finlayson, 2004) and an ability to develop trust and mutual confidence, which is fundamental in establishing a successful partnership between the preceptor and the student (Ohrling & Hallberg, 2001). Furthermore, trust can only develop over a period of time (Hupcey, Penrod, Morse, & Mitcham, 2001); therefore it would be beneficial for students and preceptors to be rostered together.
The difficulty for preceptors allowing students more autonomy has also been identified (Ohrling & Hallberg, 2001; Rummel, 2001). Participants in this research were reluctant to allow the students more autonomy if they had not been working with them for a number of shifts. This was in part due to the Nursing Council of New Zealand statement that Registered Nurses are accountable for "directing, monitoring and evaluating care that is provided by nurse assistants, enrolled nurses and others" (2005, p. 3). The preceptors could not allow students to provide care if they were not confident the student's practice was safe.
This descriptive study focused on the experiences of five preceptors working in one small provincial hospital in New Zealand. One cannot assume that the experiences of these preceptors will be the same as for other preceptors working in the same hospital, or any other hospital. A further limitation was that due to the small sample size, the experiences of preceptors across all areas of the hospital were not explored.
Implications for Nursing Practice
The benefits arising from the preceptor and student working together in an ongoing one-on-one relationship were clearly evident in this study. While there may be some difficulty in regard to planning and implementation of a one-on-one partnership throughout the whole of the student's placement, this research indicates it would be a valuable strategy within the New Zealand context.
The aim of the research was to gain an understanding of the experience of being a preceptor in a small provincial hospital in New Zealand. The participants' stories capture the day-to-day realities of this important role and the valuable contribution they make to undergraduate nursing education. The most significant finding arising from this research relates to the need for student nurses to work with their preceptor on rostered rotating shifts. The complexities associated with such an arrangement mean that further research into its feasibility, benefits and disadvantages is indicated, especially in relation to other provincial hospitals in New Zealand.
The preceptor-student nurse relationship is one support system that must be nurtured if it is to achieve its full potential. Increasing support for preceptors must come from within the clinical agencies, and the respective Schools of Nursing. Only then can the preceptor and student nurse develop the partnership necessary to develop and maintain quality nursing care, now and in the future.
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Table 1. Process of Data Analysis Step l Own personal thoughts regarding the interview, body language of participants, main ideas raised were all written in a journal following each interview. All data was number coded as to identify each participant. Step 2 Following each interview data transcribed by first author and typist. Data from first author's journal was added to the transcribed data. Step 3 Transcripts and data were read and re-read by first author. Step 4 A line by line analysis on computer. Step 5 The data from the line by line analysis was photocopied, cut out and sorted into themes and sub-themes. Step 6 Supervisors were asked for feedback regarding the data themes. Step 7 Themes and sub-themes were reconfigured and a final list of themes and sub-themes were formed. Step 8 Final list of themes and sub-themes discussed with supervisors. Step 9 Writing up of data. Supervisors had further input with data interpretation and how themes were presented in research.
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