The increase in demand for registered nurses, which is in part because of difficulties in retaining nurses, is predicted to exceed supply by more than 25% by the year 2020 (Mills, Jenkins, & Waltz, 2000). Research has shown that there is a correlation between a well thought out orientation process and retention. Dedicated and competent nurse preceptors are vital to the success of healthcare organizations and to the retention of nurses in the profession. As role models, effective preceptors socialize, protect, educate, and evaluate the nurses who are making the transition into a new work environment (Alspach, 2000; Boyer, 2008). With the increased complexity of healthcare environments, it is imperative that preceptors are capable of assisting new nurses to make the transition to the work setting with more realistic expectations and maximal preparation.
The Nurse Preceptor Academy
The Nurse Preceptor Academy (NPA) was created to provide nurse preceptors with tools to empower new graduate nurses and/or newly hired experienced registered nurses (RNs) to become competent and valuable members of their healthcare team. The mission of the NPA, to take a proactive approach in the education and support of nurse preceptors in the Kansas City community, became the focus of the workshop. The NPA's vision was to foster a collaborative work environment based on nursing's core values of professionalism, diversity, compassion, and integrity.
The NPA was one of several healthcare initiatives funded by the Department of Labor through a Workforce Innovations in Regional Economic Development grant to increase the workforce in the Kansas City metropolitan area. These initiatives were a collaborative effort of the Kansas City Metropolitan Healthcare Council, the Kansas City Area Nurse Executives, and the Collegiate Nurse Educators of Greater Kansas City.
Collaboration between service and education entities was a primary goal and critical to the success of the program. Three project leaders were hired to develop and teach in the academies. Two were staff development educators at local hospitals, and one was a professor at a local private university. All three project leaders were experienced in working with nurse preceptors, new graduates, and experienced newly hired nurses in hospitals.
Because of the dynamic nature of the hospital environment, increased complexity of patients and the specialization of skills, nursing staff may be ill prepared to provide individual attention for preceptees to promote optimal clinical experiences (Alspach, 2008; Beeman, 2001). The preceptor model has been well documented in the nursing literature and has received widespread acceptance as a clinical teaching model (Alspach, 2000; Boyer, 2008; Byrd, Hood, & Youtsey, 1997; Kaviani & Stillwell, 2000; Nehls, Rather, & Guyette, 1997; Nordgren, Richardson, & Laurella, 1998; Rogan, 2009; Sandau & Halm, 2011; Wright, 2002). The current concept of preceptorship evolved out of the necessity of preparing new RNs to become functional as soon as possible to ease the adjustment of new nurses in their work environment, to promote patient safety, and to retain nurses in an effort to decrease the cost of nurse turnover (Kaviani & Stillwell, 2000; Murphy, 2008). The formal preparation and education of the preceptor to function effectively in this role has been identified as one of the most important components of a successful program.
Multiple studies have identified the importance of educating staff nurses to serve as preceptors (Byrd et al., 1997; Dibert & Goldenberg, 1995; Kaviani & Stillwell, 2000; Speers, Strzyzewski, & Ziolkowski, 2004). "Clinical teaching and supervision is a skill, and it cannot be assumed that, by virtue of their knowledge and expertise, practitioners can automatically function as preceptors. The need for preceptor preparation and ongoing support is evident" (Kaviani & Stillwell, 2000, p. 221). Preceptors require the nursing knowledge necessary to establish clinical objectives, execute evaluation and feedback techniques, identify role responsibilities, use positive communication skills, employ principles of adult education, and develop teaching/learning strategies (Beeman, 2001; Burns & Northcutt, 2009; Hautala, Saylor, & O'Leary-Kelley, 2007; Kaviani & Stillwell, 2000; Reid, Krahn, Trojan, Haase, & Yonge, 2002). Not only is it optimal for nursing staff to be formally trained as preceptors, it is widely supported in the literature that preceptors require the support of their coworkers, nurse educators, and the organization (Kaviani & Stillwell, 2000). And while preceptor expertise and knowledge are undoubtedly essential to a successful preceptorial relationship, other aspects such as the ability to self-reflect on performance, be honest, organized, objectively evaluate performance, and demonstrate a genuine concern for the preceptee have been identified as equally important (Boyer, 2008; Myrick & Barrett, 1994; Patton, 2010).
Expertise provided by nurse educators and preceptors is critical to the success of the new nurse's orientation experience (Beeman, 2001; Burns & Northcutt, 2009). Advantages of a strong preceptor orientation model are use of clinical expertise of the staff nurse, increased preceptee confidence, introduction of the preceptee to the reality of clinical nursing practice on a specific unit, increased skill acquisition of the preceptee, greater variety of patient care experiences, improved social integration of the preceptee to the unit, and the individual attention the preceptors are able to give the preceptees (Beeman, 2001; Byrd et al., 1997; Nehls et al., 1997; Nordgren et al., 1998; Sandau & Halm, 2011). Furthermore, the preceptor model introduces the preceptee, whether an experienced nurse or a new graduate, to the challenges of clinical nursing with a support person by his or her side.
The preceptor model is not without limitations. Not all nurses have the ability or the desire to be preceptors. Letizia and Jennrich (1998) used precise guidelines for the selection of preceptors based on four areas: personal characteristics, clinical expertise, teaching skills, and motivation. Preceptors must balance the caregiver and teaching roles simultaneously, which is a significant challenge (Alspach, 2000; Burns & Northcutt, 2009; Hautala et al., 2007). Additional barriers of the preceptor model such as time intensity of clinical supervision, the challenge of nurse educators and preceptors to maintain clinical competence (especially in a high-technology and dynamic environment), institutional politics, and the difficulty in keeping current with agency policies and equipment must be addressed. The limited amount of time that staff and nurse educators have to interact with the preceptors while maintaining the everyday responsibilities of their jobs is significant.
The learning environment is an important factor in the success of the preceptee's clinical orientation. Improving preceptor-preceptee relationships is a step toward the development of caring practitioner relationships (Birx & Baldwin, 2002). The foundation of Watson's theory of human caring is organized on a framework dedicated to the concept of caring in nursing. This framework contains 10 "carative factors"; two of these can be appropriately applied to the relationships between preceptors, preceptees, and nurse educators. These factors are "being sensitive to self and others and developing helping-trusting, caring relationships" (Watson & Leininger, 1990). Healing and creativity can result when caring communities are established (Birx & Baldwin, 2002). This philosophy lends itself to the development of a partnership between the preceptee, the preceptor, and the nurse educator (Nehls et al., 1997). If preceptees are expected to be able to practice caring, then they must be shown caring within their preceptee-preceptor-educator relationships (Grams, Kosowski, & Wilson, 1997). Preceptors have the opportunity to demonstrate to new staff how caring can make nursing practice more effective for the patient and the nurse.
The literature confirms that the preceptor approach to clinical orientation is an effective mechanism to ensure a successful orientation. Collaboration between nurse educators, managers, preceptees, and preceptors is imperative to facilitate a positive experience and a successful outcome of the new RN's clinical orientation. Without formal training, however, preceptors may find themselves lacking the knowledge and skills they need to facilitate an optimal orientation experience for the preceptee. The scarcity of resources and the daily challenges preceptors must face prompt the nursing profession to seek new ways to assist preceptors in providing new RNs with an orientation that is not only valuable but also exceptional.
NPA Program Development
During 1-day workshops, preceptors participated in activities to increase their understanding of the preceptor role and to enhance their ability to assess the learning needs of preceptees, communicate effectively, provide constructive feedback, and resolve conflict successfully. Preceptors completed the Meyers-Briggs Type Indicator assessment to increase their awareness of individual differences and the behaviors that may enhance the working relationship they develop with the preceptee. Watson's theory of human caring and the nursing process were integrated as the framework for forming caring partnerships between the preceptors and preceptees. Legal and ethical issues were discussed to provide the professional context of the partners' responsibilities to self and others.
A number of teaching strategies were used to keep the preceptors engaged in the learning process. For example, discussion was the dominant format that allowed participants to share their own stories and stressors about the precepting experience. A video on conflict resolution showed the behaviors that many employ to deal with conflict. In one of the last activities of the day, small groups were required to analyze a scenario in which a preceptee struggles with an issue. The group had to draw on many of the skills learned during the workshop to resolve the issue. Responses to the NPA were overwhelmingly positive. The mean overall rating for the NPA was 4.75 on the 5-point Likert scale evaluation tool that was completed by the participants at each session.
Purpose of Study
The purpose of this study was to determine (a) if the preceptors felt better prepared to precept after attending the NPA; (b) the content they believed to be most important to them; (c) the ideas or content discussed at the NPA they were using in the preceptor role; (d) the level of support provided by peers, managers, and educators; and (e) the factors that caused them the most stress when precepting. The research question guiding this investigation was, "Did the preceptors feel better prepared to precept after attending the Nurse Preceptor Academy?"
Descriptive statistics were used to describe the sample. An investigator-developed questionnaire was designed to elicit quantitative and qualitative data. Some questions used Likert-type scales to measure responses, but open-ended questions as well as comment sections were included to allow the preceptors to elaborate. The questionnaire did not elicit identifying information. Consent was implied from the participant by having returned the survey. Approval from the institutional review board of the researcher's academic institution was granted.
The 714 participants were RNs who attended the 8-hour NPA between November 2006 and April 2009. They had already precepted and/or were slated to precept new hires in a hospital setting. The RNs in each workshop came from 18 area hospitals. The number of attendees at each workshop ranged from 24 to 34. Ages of the attendees were categorized into four groups: almost 29% were between 20 and 29 years old, 26% were between 30 and 39 years, 24% were between 40 and 49 years, and 21% were 50 years and older. All 714 participants were mailed a survey 3-11 months after they had attended the NPA. A total of 171 returned the surveys for a response rate of 24%.
Approximately 25% of the respondents reported having between 1 and 5 years of nursing experience, 22% reported having between 6 and 10 years of experience, 22% reported having between 11 and 20 years of experience, and 32% reported having over 20 years of experience as nurses. As preceptors, 18% reported having less than 1 year of experience. Forty-five percent had precepted for 1-5 years, 15% had precepted for 6-10 years, and 23% had precepted for over 10 years.
Since attending the NPA, 106 preceptors reported precepting one to four new hires, and one preceptor reported precepting nine new hires.
RESULTS AND ANALYSIS
A Likert-scale format ranging from 1 (no), 2 (probably not), 3 (undecided), 4 (probably), to 5 (yes) was used to determine if the preceptor felt "better prepared to precept new nurses after having attended the NPA." The score of 4.56 clearly indicated that the purpose of the workshop had been achieved. One preceptor stated that, "We focus on the role of the preceptee so much that (the workshop) was a great way to focus and evaluate the preceptor's role and ways to improve our effectiveness. I think because we are experienced that this is sometimes overlooked." Preceptors reported the integration of knowledge learned at the workshop to increase their comfort level and, therefore, their effectiveness as preceptors.
Academy Content Being Used
Because the preceptors were from 18 hospitals, it was not possible to determine if they incorporated knowledge learned at the NPA into their practice through observation. Therefore, a list of content items from the NPA was included in the survey (see Table 1).
|TABLE 1 |
Participants were instructed to "Check which ideas and tools you have used since attending the preceptor academy."
Most (63%) of the respondents reported setting weekly goals with preceptees, and 48% were conducting weekly evaluations. Weekly evaluations give the partners an opportunity to communicate, share concerns, get better acquainted, discuss how learning is best facilitated, and create new goals for the next week. It was surprising at the workshops to learn that most preceptors did not have a mechanism to evaluate the performance of preceptees other than a skills checklist. The preceptors did not have a plan or a framework for orienting a new hire. Many did not participate in a formal evaluation of their proteges. Their efforts were focused on assessing performance on the skills as they arose. Preceptors were asked to bring their facility's checklists/evaluation forms to share among the group and broaden their awareness of what others were doing. The forms ranged from a few pages to over 30 pages. Participants had the opportunity to discuss the effectiveness of the evaluation process. One preceptor noted that it was beneficial to gain a better understanding of the "difference related to precepting students and new employees [and] seeing how different hospitals have evaluation tools."
When asked what was the most helpful thing that you learned at the workshop, the most common comment related to learning about personality types and how that affects communication and learning. Indeed, 49% indicated that they were employing knowledge learned by taking the Meyers-Briggs Type Indicator assessment and other self-awareness information presented. For example, one participant stated that "awareness of my own personality and how that impacts [sic] my teaching style/preceptee" was most helpful. And "it makes me more aware of how I interact and how I can be a better preceptor." Increased self-awareness seemed to be a common theme, "I really enjoyed the personality profile-it made me stop and think about how to better communicate and about how my personality may come across to others." And another wrote, "I tend to place more awareness on the way I communicate with my preceptee and put myself in their shoes once again." Others indicated that they learned about the importance of being a good preceptor. One gained "general insight into the role. Also to expand my thinking in order to better modify the orientation/precepting experience to the individual."
Several noted that understanding that everyone learns differently was important. One replied that "increased awareness of different learning styles of myself and others and incorporating that in methods of communication for learning" was most helpful. Many mentioned that understanding their own as well as the preceptees' learning styles helped them to have more patience as they were teaching new skills. One found it helpful to learn "how to help orientees think critically-it's very hard to learn and to teach."
Preceptors found that having resources readily available was important. They specifically noted that the "critical thinking questions" and handouts on generational differences enhanced their ability to learn about their preceptees. Only 15% indicated that they use concept mapping. This is not surprising because concept maps were introduced only in the last year of the NPA. Although many nursing schools in the geographic area are using concept maps in conjunction with nursing care plans, many preceptors were not familiar with these new models. Samples of concept maps were distributed and discussed in the NPA as a tool to evaluate critical thinking.
Benner's novice-to-expert model is typically introduced in the nursing curricula, but for many preceptors, it had been several years since they had reviewed it (if at all). Understanding how novice nurses typically think and act can help the preceptor plan learning activities and evaluate performance realistically. Twenty-five percent of the respondents were using Benner's model in some way. One preceptor incorporated Benner's model into determining weekly goals, "finding out where the nurse is, her experience and needs, and then setting goals, [and] giving structure."
Preceptors tend to have difficulty dealing with conflict in general but in particular with preceptees who are not doing as well as expected. Conflict management was noted numerous times as an important content area in which they gained skill. Several noted that they now use different communication techniques to redirect a new nurse. One respondent reported that, "I have been much more comfortable confronting their problem areas [with phrases such as] It worries/concerns me when you do this[horizontal ellipsis]." An obvious benefit to allowing discussion is that more than a few participants appreciated hearing the "situations other preceptors were in and how they handled it." One preceptor learned "how to give praise and how to give criticism." Another noted that understanding the "importance of documentation" of positive and negative behavior was most helpful.
Only 33% of the participants marked that they had a final meeting with the preceptee, manager, and/or educator. This is a missed opportunity of managers and educators to give feedback and/or praise to the preceptor and preceptee. It could be a time to identify successes as well as areas on which the preceptee needs to continue to work to meet future expectations. Managers and educators must take every opportunity to show support of those involved in orientation. Their support could be showcased at a graduation or other celebration at the end of orientation. Only 36% of the participants reported such activities.
Less than 50% of the respondents reported that they were evaluated by the preceptees. Managers and educators must demonstrate that they value the opinions of the preceptees by providing a meaningful evaluation procedure so they can assess the orientation process, which includes the effectiveness of the preceptors. Preceptors need to be aware of their own strengths and weaknesses so they can change their practice accordingly.
Preceptor Satisfaction and Support
Preceptors indicated perceived support from coworkers as 4.13 and from managers and educators as 4.20 (1 [definitely not] to 4 [most of the time] and 5 [all of time]). In contrast, a good number of the comments elicited from the preceptors regarding the most stressful responsibilities or tasks of precepting were related to the workload. They noted that, for the most part, preceptors had to "carry a full load of patients and be a preceptor," saying that "charge nurses and other staff members don't fully appreciate this added responsibility." They reported that they had "too many patients to be effective." There is the misconception that having a preceptee means that there are "two people to do the job now."
Another frequently cited stressor is the preceptor's desire to "ensure patient safety." It is evident that preceptors feel a tremendous sense of responsibility to patients and preceptees; they take their role seriously. Precepting is "Scary! Trying to teach people the correct way and to do no harm." Preceptors want to balance "good patient care with learning and practice opportunities for the preceptee." The responsibility to the preceptee can weigh heavily as being a preceptor "could set a pattern for life in another person." Consequently, some are reluctant to let preceptees "become autonomous" when they do not believe that the preceptees have had enough time to learn everything they need to know.
Although the list of stressors was long, preceptors indicated their level of satisfaction with the preceptor role as 4.17 (1 [very low], 4 [high], and 5 [very high]) and their level of being happy as a preceptor as 4.18 (1 [very unhappy], 4 [happy], and 5 [very happy]). Many said they really "enjoy helping new coworkers get started" and "It's rewarding to see someone move from a novice to a competent nurse." One stated that, "I enjoy teaching at the bedside[horizontal ellipsis]. It reenergizes my passion for nursing!" One preceptor who had been a nurse for just over two years stated that, "It is helping me realize how far I have come!"
Some surveys were sent more than 6 months after the preceptors had attended the NPA, and recall of content may have been compromised as a result. Only 25% response rate may also have been due to the time lapse between attendance at the NPA and receiving the survey. It is probable that beneficial information could have been gleaned from a larger sample. Testing the survey for validity and reliability would lend more credence to a future study. In addition, it is likely that the list of content items could be expanded to incorporate more specificity.
It is critical to understand the needs of the preceptors to better support them. Preceptors choose to employ content and skills that will help them develop a new nurse into a valuable team member on the unit. Healthcare institutions are responsible for orienting newly hired nurses to become competent healthcare professionals who meet the needs of patients through application of professional and institutional standards. Consequently, the institution must prepare preceptors to be effective facilitators of the orientation process. Because hospitals hire a number of new graduate nurses annually, it is beneficial for academic educators preparing new nurses to enter the profession and staff development educators preparing new nurses to work within the healthcare system to collaborate to create programs that will promote positive orientation experiences for the new nurses and preceptors (Wright, 2002).
Nursing faculty must understand the role of the preceptors who will be working with the new graduates so faculty can convey the expectations of the preceptor to students. New graduates need to understand the demands on a preceptor. Educators can explain the many roles of the preceptor as well as the stressors. Faculty can prepare the new graduates to be active learners and assist the preceptor in the orientation process. Orientation is an active process, and new graduates should be able to articulate their own learning needs to the preceptors. Faculty can meet with each student at the end of the senior year for a thorough assessment in which, together, they identify the student's learning needs as a new graduate. Graduates can share their learning needs with the preceptor so graduates and preceptors can incorporate these learning needs into the orientation plan.
Although the NPA was focused on preparing preceptors to orient newly hired nurses, there was much discussion about precepting students. Faculty must provide clear expectations to guide the preceptors when working with students. It is imperative that supervising instructors nurture supportive relationships with nurses who precept students in senior clinical practicum courses to ascertain strengths and weaknesses of the students (Murphy, 2008; Rogan, 2009). Faculty can use this information to change course objectives, evaluation methods, and possibly curricula to better prepare new graduates.
Staff Development Educators and Managers
Facilities must create or send preceptors to quality workshops. As adult learners, preceptors choose to learn and use content that is relevant to their responsibilities. It may be beneficial for nurse managers and educators to attend the workshops to gain a better understanding of the preceptors' needs and workload. RNs are now required to precept senior nursing students as well as new coworkers. Content areas for both groups of preceptees are similar and yet significantly different, and these differences must be addressed appropriately (Alspach, 2008; Rogan, 2009). Preceptors must be selected based on appropriate skills to orient each group and evaluated routinely by preceptees and managers.
Preceptors benefit from group classes where they can share their own experiences and learn from one another (Sandau & Halm, 2011). Other delivery methods, however, may be just as beneficial for some preceptors. Self-directed modules are available and cost-effective for independent learners (Riley-Doucet, 2008). Online discussion boards are another avenue for sharing experiences. Once they complete a preceptor workshop, preceptors need and want ongoing support. Staff development educators can support them with additional resources online and in person. Nurses who attended the NPA receive a monthly newsletter online. Educators may offer "lunch and learn" activities to reinforce and/or add necessary content as well as show support.
Evaluating preceptees can be stressful. Preceptors need the support of educators and managers, especially when working with a struggling novice (Yonge, Krahn, Trojan, Reid, & Haase, 2002). Preceptors and preceptees especially need feedback from managers (Fink, Krugman, Casey, & Goode, 2008) when educators are not available in their institutions. Educators and managers can mentor preceptors to teach and model how to use appropriate communication skills when providing effective feedback. A number of preceptors reported increased awareness of how they communicated to their preceptees and changed their communication style based on the preceptee's needs. Preceptors need meaningful assessment tools that will support their endeavors to effectively set goals and evaluate the progress of preceptees (Hickey, 2009).
Educators and managers must collaborate to provide a supportive work environment that will allow preceptors to meet the many demands of their roles as educators and evaluators. They need time to do their jobs effectively, including time to teach and time to evaluate the progress of their orientees. Preceptors identify a number of stressors, but most commonly cited is the requirement to take a normal clinical workload while precepting (Alspach, 2008; Henderson, Fox, Malko-Nyhan, 2006; Hautala et al., 2007). This practice is detrimental to the preceptor, the preceptee, and the budget. The more support the preceptor has to precept effectively, the sooner the preceptee will become an effective team member. At least for the first few weeks of the preceptorship, preceptors must be responsible for fewer patients. The inability to decrease the workload has typically been blamed on managers. Managers must put organizational structures in place to support preceptors; however, perhaps the staff of the entire patient care unit could come together to create strategies to support their colleagues when precepting.
The preceptors reported that they were more effective at precepting after attending the NPA. On the basis of the positive response to the NPA in Kansas City, the Missouri Hospital Association replicated the program and has educated over 2,000 additional preceptors.
The authors wish to thank Kathryn E. Nadlman, MBA, for critiquing the manuscript.