Entry to nursing practice preceptor education and support: could we do it better?
High quality preceptorship during their first year of practice is
seen as critical for new graduate nurses' development of competence
and confidence. Quality preceptorship is dependent upon skilled and
knowledgeable preceptors who are committed to this role. A recent
longitudinal evaluation of 21 Nursing Entry to Practice (NETP)
programmes in New Zealand identified that preceptorship selection,
education and support do not always receive the attention they warrant.
Failure to plan preceptor selection leads to ad hoc selection and
consequent allocations of many preceptors who may not have attended
appropriate education, or have a desire to undertake this role. Such a
situation is detrimental to the job satisfaction of both preceptors and
new graduate nurses. High workloads, rostering difficulties and
increased acuity in many clinical areas often prevent preceptors from
attending appropriate education and that, in turn, impacts negatively on
the preceptor's expectations and clarity with respect to the role.
To offset this effect the authors recommend development of a clearly
defined preceptor selection process, along with flexible preceptor
education programmes that provide a good foundation for support of new
graduates in their first year of practice; but do not increase preceptor
Key words: preceptorship, new graduates, evaluation, support and education
Nursing education (Methods)
|Publication:||Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2012 Nursing Praxis in New Zealand ISSN: 0112-7438|
|Issue:||Date: March, 2012 Source Volume: 28 Source Issue: 1|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
It is well documented that in order to develop their confidence and competence the newly registered nurse needs targeted support in their first year of practice. (McCloughen & O'Brien, 2005; McClure & Hinshaw, 2002; Oermann & Moffitt-Wolf, 1997; Reeves, 2004; Teasdale, Brocklehurst, & Thom, 2001). In 2006 the New Zealand Ministry of Health (MOH) commenced funding for Nursing Entry to Practice (NETP) programmes for newly graduated nurses in all 21 District Health Boards (DHBs) across secondary care areas. A three and a half year longitudinal evaluation was commenced at the same time to capture data on the effectiveness and appropriateness of the national NETP programmes. A key focus of this evaluation was how the preceptorship process within NETP programmes was supported. In particular, the identification of best practice in the preparation of, and support for, registered nurses undertaking preceptor roles (Haggerty, McEldowney, Wilson & Holloway, 2009) was studied. This component of the evaluation is the focus of this article. Current literature and the findings of the longitudinal evaluation provide the foundation for a discussion of preceptorship selection, education, and support as it relates to the preceptor role within NETP programmes.
The role of the preceptor is seen as pivotal in bridging the theory-practice gap, supporting new graduate socialisation, increasing new graduate levels of confidence in practice and promoting job satisfaction (Barker, 2006; Dracup & Bryan-Brown, 2004; Faron & Poeltler, 2007; Goodwin-Esola, Deely, & Pwell, 2009; Kilcullen, 2007; Reeves, 2004; Reinsvold, 2008; Zilembo & Monterosso, 2008). Skilled preceptorship plays a central role in the success of the new graduate's transition into practice (Anderson, 2008; Billay & Myrick, 2008; Golden, 2008; Henderson, Fox, & Malko-Nyhan, 2006). Planned preceptor selection, education, role preparation and adequate resources have all been found to positively affect development of confidence, competence and critical thinking ability. These factors also help to build a positive new graduate-preceptor learning relationship. It also led to positive changes in nursing and preceptorship practice (Chesnutt & Everhart, 2007; Messmer, Jones & Taylor, 2004; MOH, 2004; Newton & McKenna, 2007; Orsini, 2005; Proulx & Bourcier, 2008; Sorensen & Yankech, 2008).
The preceptor role takes time to develop, and requires both initial and ongoing education as well as professional support (Allen, 2002; Dibert & Goldenberg, 1995; Fox, Henderson, & Malko-Nyhan, 2006; MOH, 2004; New Zealand Nurse Educators Preceptorship Subgroup, 2006). Content identified as integral to the education of preceptors is knowledge of adult learning, the development of expertise through the concept of novice to expert, preceptoring phases, facilitation of critical thinking, evaluating performance, conflict resolution, communication skills, and giving feedback (Altmann, 2006; Anderson, 2008; Boyer, 2008; Smedley, 2008; Sorensen & Yankech, 2008). Ideal preceptor attributes include being positive, patient, and supportive, in addition to having the desire to motivate and inspire, and a passion for the role (Anderson, 2008; MOH, 2004; Smedley, 2008; Zilembo & Monterosso, 2008).
The literature argues that there are many benefits for registered nurses who take on preceptor roles. These benefits include increased autonomy (Cooney, 1992), increased peer respect, professional satisfaction, and improved collegial relationships (McClure & Hinshaw, 2002; Reeves, 2004), career advancement and professional development (MOH, 2004). However, the preceptor needs to feel satisfied and valued, as this role can be stressful and increase their workloads (Hautala, Saylor & O'Leary-Kelley 2007).
Effective preceptorship can be adversely affected by a lack of education, limited skills and motivation, hasty selection processes, unclear structures and processes, as well as a lack of support and recognition for the role (Chesnutt & Everhart, 2007; Haggerty, 2002; Johnstone, Kanitsaki & Currie, 2008; Kilcullen, 2007; MOH, 2004; Morris et al., 2007; Proulx & Bourcier, 2008; Smedley, 2008). Major challenges identified in the literature include the appointment of suitable preceptors and the implementation of adequate structures to meet preceptor needs (Henderson, Fox, & Malko-Nyhan, 2006). These key themes informed the evaluation designed to identify current practice in the preparation of, and support for, registered nurses in New Zealand undertaking preceptor roles.
Design and Method
The evaluation was aimed to gather information with respect to lessons learnt from NETP programmes across New Zealand, to identify new graduates and DHB success factors, and to share resources and support best practice development nationally. As previously mentioned, the focus of this article is the preceptor aspect of this evaluation. The evaluation was a longitudinal study which utilised fourth generation evaluation (FGE) (Guba & Lincoln, 1989). FGE utilises a constructive epistemology, is collaborative and pays attention to the claims and concerns of a wide range of stakeholders, the latter aspect being particularly relevant when considering the context of NETP programmes in New Zealand (Grbich, 1999; Guba & Lincoln, 1989). To ensure the reliability and validity of the evaluation process, mixed methods were used to gather data from a variety of sources (Denzin & Lincoln, 2003; Munhall, 2007; Sandelowski, 2002). At the commencement of the evaluation a rolling literature review, an environmental scan and documentation analysis was undertaken to gather baseline data relating to how NETP programmes were being enacted nationally and internationally. Following the baseline data collection, the main foci of the evaluation were yearly questionnaires and interviews with individual key stakeholders, along with in-depth case studies of eight DHBs offering NETP programmes during 2007 to 2009. Ethical approval was given by the Victoria University of Wellington Research and Ethics Committee at each stage of the study.
There were a large number of stakeholders identified as potential participants in the study. These included new graduates currently in a NETP programme, registered nurses six months after completing a NETP programme, NETP programme co-ordinators, preceptors, Directors of Nursing, nurse managers, nurse educators, other relevant DHB personnel, the Nursing Council of New Zealand (NCNZ), District Health Boards of New Zealand (DHBNZ) and the Ministry of Health.
DHBNZ provided a list of the 21 DHB NETP programme co-ordinators. Each of these was then invited to participate in the study. These coordinators were pivotal in the recruitment of participants within their DHB. They also circulated the questionnaires and worked with the research team to organise focus groups and individual interviews during the case study visits. Other key stakeholders were approached by the research team and individually invited to participate in a face to face or telephone interview.
The study could not be anonymous, as several key participants had the potential to be identified due to their role in either NETP programme coordination or national key stakeholder positions. Thus it was imperative that confidentiality of the data was maintained and the final report was careful not to identify any particular DHB or individual. Information sheets were provided to all participants prior to their involvement in each data collection stage. Consent was implied by voluntary participation in data collection, with the exception of focus group interviews and key stakeholder interviews, where written consent was obtained from participants.
All new graduate registered nurses (RNs) undertaking NETP programmes were surveyed six months into their programme. Questionnaires were sent to each cohort over the three years of the study. The responses for the successive years were grouped into three distinct cohorts (2007, 2008 and 2009). Questionnaires were also sent to RNs in 2008 and 2009 six months after completion of their NETP programme (post-NETP RNs). NETP programme coordinators and preceptors were also surveyed during 2007 and 2009. Response rates across the groups are presented in Table 1.
The questionnaires were developed by the Ministry of Health (MoH) and piloted in 2004 across three NETP sites. It was a requirement of our contract with the MoH that the same questionnaires be used in this longitudinal evaluation. Some modifications were made to the original questionnaires throughout the evaluation, with the consent of the MoH.
The generally low preceptor and coordinator return rates are thought likely to reflect multiple demands on their time and energy. Additionally poor return rates among post-NETP RNs, may reflect that NETP was no longer a priority for them. It is difficult to explain the 2009 low response rate from new graduates six months into their NETP programme. However the data obtained were consistent across both the returned questionnaires, as well as across the three years of data collection. Despite the low return rates, the findings of the questionnaires were mostly consistent with data from other sources, such as interviews and case studies. The exception was in the area related to the appropriateness of preceptor education which revealed some conflicting views.
Eight DHB NETP programmes from a variety of geographical settings were selected as case study sites. The programmes were a combination of North (5) and South (3) Islands, and rural (2), urban (3) and metropolitan (3), and also included DHBs with either unique characteristics and/or where postgraduate study was a component of the NETP programme. Six case study DHBs were visited each year for three years, with two DHBs visited during the second and third year of the evaluation. During these visits focus groups were conducted with new graduate nurses currently completing a NETP programme, second year registered nurses who had completed a NETP programme, preceptors, nurse educators and nurse managers. Individual interviews were also undertaken with NETP programme coordinators, Directors of Nursing, and other key personnel such as human resource managers where available.
The questionnaires were analysed using SPSS and Excel spreadsheets. This allowed for targeted analysis to be undertaken on the vast amount of data collected. The focus group and individual interviews were electronically recorded and as well, handwritten notes were taken. Where possible, two members of the research team facilitated each focus group meeting. A thematic analysis was used to identify themes within and across the case study DHBs and the data obtained from questionnaires.
The key evaluation findings related to preceptorship were the overall lack of clear selection processes for preceptors, inconsistent preceptor education related to inability to attend and oversubscription. Participants reported that the preceptor role lacked clarity and that preceptors' overwhelming workloads had the potential to lead to preceptor 'burnout'. These findings are discussed in more detail in the following sections.
During the case study visits preceptors, NETP programme co-ordinators and senior nurses identified a variety of reasons for registered nurses taking on a preceptor role--they wanted to teach and/or support others, were asked by senior nurses, or told to participate by their nurse manager. Most registered nurse job descriptions included supervision and/or education of others, which may or may not use the word preceptorship. From the data collected from preceptors and case study visits, there appeared to be no formalised preceptor selection processes, although some DHBs did have a preceptor nomination process. In focus groups, both preceptors and new graduates identified that some registered nurses should never be preceptors as they lacked interest and/or commitment, and therefore were deemed not suited to the role. These preceptors were seen to have a detrimental effect on new graduate development. It became clear that there was need for a rigorous preceptor selection process, and that prospective preceptors should indicate they have a desire to undertake the role.
During the focus groups preceptors reported that the education they received was a good introduction and appropriate for their needs. However, in contrast, preceptor questionnaires identified just under half (49%) agreed or strongly agreed when asked if the education (or training) that they received prepared them for the role of the preceptor (see Figure 1).
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Fewer than half of the preceptors agreed or strongly agreed that the information they received made them confident about their role as preceptor (see Figure 2).
Just under half of those surveyed (47% in 2007, and 48% in 2008/09) had additional support or education for their role of preceptor. Some attended N ETP update days, others consulted senior nurses, or found what they needed as part of their own postgraduate study. Preceptors consistently raised three issues during the case studies--the need for ongoing education and updates following the initial education, regular feedback on their effectiveness, and a concern that nurses were acting as preceptors without education for the role. Participants also reported that oversubscription to programmes and inadequate staffing interfered with their ability to attend preceptor education.
Preceptor role clarity
The preceptor questionnaires identified that clarity of role was a problem for around half of the responding preceptors. When asked to indicate agreement that the information provided about the role and expectations of a preceptor were sufficient--only 56% (2007) and 44% (2008/09) agreed or strongly agreed as outlined in Figure 3.
[FIGURE 3 OMITTED]
[FIGURE 4 OMITTED]
Fewer than half of the preceptors identified that before commencing their role as preceptors they had the opportunity to clearly understand what level of practice could reasonably be expected from new graduates (see Figure 4).
Throughout the study preceptors identified concerns about their workloads. Preceptor workloads were identified as something DHBs needed to address within the context of systems and processes. Even though most preceptors were positive about their role, all acknowledged that at times the role became overwhelming and fatigue was a real issue. Many preceptors reported that in addition to the high acuity levels across the health care sector, they were supporting not only new graduates, but also undergraduate students, new employees and overseas registered nurses for whom English was a second language. As a consequence, many commented on being tired and frustrated. The preceptor questionnaire responses also identified that many viewed the new graduate as "just another nurse to orientate; very difficult in winter when busy and short staffed and new graduates rotating". The frustration often left the preceptors feeling they were not able to fulfil the role as well as they would have liked to have done. Insufficient time to discuss practice issues with the new graduate, complete NETP documentation, or just take the time to spend with the new graduate to reflect on how things were going were all seen as barriers.
Overall, the evaluation reinforced the benefits of quality preceptorship on the development of new graduates confidence and competence during their first year of practice, as supported by the literature. Even so, three key issues were identified. These related to the selection process for preceptors, need for collaboratively developed national preceptor training standards, and for creative solutions to support preceptors to access appropriate training for the role.
For preceptorship to be effective, with preceptors able to fulfil the expectations of their role, NETP programme providers need to ensure that preceptors are appropriately selected, as well as adequately prepared, resourced and supported. The Nursing Council of New Zealand (NCNZ) Competencies for Registered Nurses (NCNZ, 2007) stated that the registered nurse "provides guidance and support to those entering as students, beginning practitioners and those who are transferring into a new clinical area" (p. 18). As this guidance and support is a required competency for all registered nurses, it is often assumed that any registered nurse can undertake the role of preceptor. It would appear from the NETP evaluation that this is not the case. The New Zealand Nurse Education Preceptor Subgroup (2010) developed a national framework for nursing preceptor programmes, which also identified the need for a clear selection process to ensure registered nurse suitability to be a preceptor.
National Standards and Working in Collaboration
A recommendation from the evaluation was establishment of national standards for preceptor selection, preparation and delivery. The National Framework for Nursing Preceptorship Programmes (2010) has subsequently set up guidelines, and recommended their adoption nationally. However while the guidelines provide a beginning framework for preceptor education, they do not require or recommend that preceptor education should be undertaken jointly between DHBs and undergraduate education providers. Undergraduate education providers could supply the clarity that preceptors are asking for in relation to what can reasonably be expected from a newly registered nurse. Additionally, education providers have the expertise to develop and deliver educationally sound programmes to prepare registered nurses for the preceptor role. It is our view that preceptor education undertaken in partnership, with the combined expertise of both the educational and clinical sectors, strengthens the programmes. The advantages of strong preceptor education are quality preceptorship and support for new graduates, clarity for preceptors, as well as increased likelihood of job satisfaction for both preceptors and new graduates.
Access to Training
The NETP evaluation highlighted that due to workload issues it is increasingly difficult for registered nurses to access preceptor education. One way this could be alleviated is through the use of educational technologies that allow for preceptor education to occur at a time and place that best suits the registered nurse and their employers. With education providers working alongside DHBs as key stakeholders in the planning and implementation of preceptor programmes, there would be greater opportunity to explore flexible delivery options that improve registered nurse access to initial preceptor education, as well as ongoing educational updates (Myrick, Caplan, Smitten & Rusk, 2010; Parsons, 2007).
However such options for delivering preceptor education need to be well planned and take into account what preceptors are already identifying as a heavy workload. Flexible delivery can be seen as something to be done outside normal working hours, which has the potential to increase the exhaustion that preceptors identified they already experience, and hence would not support preceptor job satisfaction. Preceptor workload was clearly identified by participants as something that needs to be addressed. Improving preceptor access to education and on going support, through a planned process that accounts for the additional workloads for preceptors, could bring about extensive long-term benefits to new graduates, preceptors, DHBs and the nursing profession generally.
The NETP programme has had a positive impact on recruitment and retention of new graduate nurses across New Zealand DHBs. This programme supports the development of new graduate nurses' confidence and competence, and as such provides for transferability of knowledge and skills across the nursing workforce. Preceptorship, although currently working, requires further development to better meet the needs of the new graduate nurse and the profession as a whole. DHBs and tertiary education providers need to establish strong relationships to ensure that NETP programmes develop new graduates past their undergraduate education within a supportive environment.
Some work has already been undertaken by the DHB sector to establish national guidelines for preceptor selection and education. However, these guidelines have not been developed in partnership with the tertiary education sector, as recommended by the NETP evaluation. Developing guidelines for preceptor education in partnership with tertiary education providers will better support the development of more flexible delivery options so increasing access to preceptor education, and ensuring greater clarity regarding expectations of new graduate capability at the commencement of NETP programmes.
Overall, the findings of the study echoed many of the themes from the large body of literature that exists around preceptorship. Best practice occurs where preceptors are selected appropriately, given adequate education and support to effectively undertake this important role in supporting the new graduate nurse. Nurses in New Zealand are expected to provide the Ministry of Health recommended ABC approach to smoking cessation interventions; but not all nurses receive adequate preparation.
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Carmel Haggerty, RN, MA (Applied) Nsg, M Ed, Associate Dean, Faculty of Health, Whitireia Community Polytechnic Kathryn Holloway, RN, PhD, DN, FCNA(NZ), Associate Dean, Faculty of Health, Whitireia Community Polytechnic Debra Wilson, RN, PhD, PGCertTT Senior Nursing Lecturer, Bachelor of Nursing, Whitireia Community Polytechnic
Table 1. Summary of the Stakeholder Questionaire Return Rates 2007 2008 2009 Stakeholders n % n % n % New graduates six months into NETP 389 54% 348 56% 104 15% Post NETP RNs -- -- 78 13% 104 20% Preceptors 110 20% -- -- 77 11% Coordinators 5 20% -- -- 11 39%
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