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This article presents research results applying Peplau's Theory of Interpersonal Relations to the preceptor-new graduate relationship and describes implications for successful transition. These results will help nursing professional development educators with more appropriate preparation and assignment of preceptors.
Of all the nurses employed in nursing in the United States, 62.2% work in hospitals (Health Resources and Services Administration, 2010). With the decreasing supply of experienced nurses, hospitals have concentrated on hiring new graduate nurses representing as much as 10% of the nursing staff (Berkow, Virkstis, Stewart, & Conway, 2009). As they enter the workforce, new nurses face a challenge experienced by every graduate nurse: successful transition from student to professional nurse. Studies show that preceptors have a great influence on that transition (Chesnutt & Everhart, 2007; Everhart & Slate, 2004; Oermann & Moffitt-Wolfe, 1997). Nursing professional development educators can be instrumental in evaluating this relationship and facilitating a successful transition for new graduates.
The preceptor-new graduate dyad will typically be together for the length of orientation. Preceptors may not be aware of the nature or importance of this relationship and may not always make the conscious effort to nurture it. Being prepared mentally, physically, and emotionally to be a preceptor is necessary to set the environment for new graduates. Nursing professional development educators are in the position to monitor these relationships to maximize their positive effect on new graduates.
The manner in which new graduates are socialized and oriented into the unit and facility is essential. This relationship with preceptors can have a positive or negative influence on how new graduates perform and therefore affect their turnover rates (Hyrkas & Shoemaker, 2007; Lavoie-Tremblay, Paquet, Marchionni, & Drevniok, 2011). Preceptors must be nuturing, socially supportive, and authentic leaders and caring role models. The qualifications and willingness of the preceptor to serve in this very important role of teacher, coach, evaluator, learning facilitator, and clinical and knowledge expert will have a major impact on new graduates' successful transition (Giallonardo, Wong, & Iwasiw, 2010; Phillips, 2006).
New graduates have said that they need guidance, acceptance, and support from preceptors; help with preparation for the responsibilities they will assume; and assistance with practical knowledge and confidence building (Godinez, Scheiger, Gruver, & Ryan, 1999). The dynamics of this relationship affect their socialization into the unit, their professional development, their self-concept, and their retention in the workplace and profession (Kelly & Courts, 2007; Lavoie-Tremblay et al., 2011).
Statements such as "What am I going to do with you," "I hate precepting," and "I don't know why they gave you to me" do not make transition easier, particularly when such statements are made to or in the hearing of new graduates. These sentiments show a lack of understanding of the need for relationship building (Romp & Kiehl, 2009) and illustrate one problem that may lead to an unsuccessful transition. The purpose of this study was to determine if the theory of interpersonal relations could be applied to the preceptor-new graduate relationship and to quantitatively measure the presence, strength, direction, and magnitude of that relationship.
The theory of interpersonal relations was originally intended to help nurses intervene more intelligently and sensitively in situations with patients (Penckofer, Byrn, Mumby, & Ferrans, 2011; Peplau, 1997). The theory of interpersonal relations includes a series of four overlapping phases: orientation, identification, exploitation, and resolution (Forchuk, 1993; Peplau, 1952/1991). Orientation can last from minutes to months and is the time in which the nurse and the patient come to know and trust each other. The patient begins to recognize and understand the need for help. In the identification phase, the patient identifies opportunities for improvement and responds to those who can provide help. In the exploitation phase, the patient uses the nurse as a resource and support to help with those improvements as well as recognize other available resources. The resolution phase occurs when former dependencies no longer exist, identified goals are achieved, and ongoing interpersonal relations continue for further developmental change (Forchuk, 1993; Peplau, 1952/1991).
The phases of Peplau's theory of interpersonal relations are applicable to the relationship between preceptors and new graduates (C. Forchuck, personal communication, September 9, 2007, and November 20, 2011). During the orientation phase, the preceptor and new graduate come to know each other and learn how to work together as the new graduate recognizes the need for help with the transition. The identification phase is the time to discover opportunities for learning and improvement for the new graduate and to recognize the preceptor as a resource. During the exploitation phase, the new graduate uses the preceptor as a resource and support to help meet identified learning needs. When resolution occurs with the achievement of goals, mentoring can continue as the new graduate becomes more and more competent and continues the transition to be a professional nurse.
There are many similarities between the nurse and patient relationship and that of the preceptor and new graduate. Both the nurse caring for the patient and the preceptor with the new graduate must be competent in their roles and be able to provide individualized structured plans of care or orientation programs (Peplau, 1997; Wright, 2002). The functions of the preceptor are comparable with those of the nurse including being a role model, teacher, and support person; having a desire to teach; and having good communication and interpersonal skills (Chesnutt & Everhart, 2007; Everhart & Slate, 2004; Forchuk, 1991; Peplau, 1997; Wright, 2002). Both the nurse and the preceptor have conferences to assess progress; manipulate the environment for the best outcomes; are part of an interactive, dynamic process; and can affect the relationship with their attitudes. The level of experience of the nurse or preceptor will also affect the relationship and the outcomes (Delaney, 2003; Godinez et al., 1999; Peplau, 1997; Wright, 2002).
New graduates depend on the preceptor to assist with learning during transition just as the patient depends on the nurse. Patterns of communication between the preceptor and new graduate are very important. By virtue of the teacher and learner relationship and the need for nurturing, this communication is often therapeutic. The well-being and growth of new graduates are the foci of this professional relationship. Because preceptors can have such a major impact on new graduates, Peplau's theory helps explain the nature of the preceptor and new graduate relationship.
Using questioning, careful analysis of the individual's words, and verbal exchanges, multiple research studies have shown that therapeutic relationships between nurses and individual patients or clients do exist. In these relationships, nurses can help the individuals address challenges and solve problems (Forchuk, 1994a; McNaughton, 2005; O'Toole & Welt, 1989). Interpersonal relationships with preceptors have been found to be associated with developing a sense of belonging and higher job satisfaction in new graduates (Shermont & Krepcio, 2006).
Research by McNaughton (2000, 2005) supported both the presence and importance of interpersonal relationships. In an integrated review of the literature and a qualitative study of data from audio recordings, one study showed that the relationship develops over time and that the longer a relationship exists, the stronger the relationship and the more work accomplished. It was determined that one-sided or difficult relationships are unproductive in solving problems. The key to mutual problem identification is building relationships and using appropriate behaviors to develop solutions to those problems.
Quantitative studies (Forchuk, 1994b; Poorman, Mastorovich, Malcan, & Webb, 2009) determined that each relationship is unique and that, if a working relationship is not established within 6 months, it is unlikely to develop. Forchuk (1994a) determined that preconceived notions influenced how long the orientation phase lasted and how long it took, if ever, for the relationship to reach the working phase as described by Peplau. It was noted that the impression formed at the beginning of the relationship, positive or negative, was the impression that lasted; there was no change over a 3-month period. Forchuk et al. (1998) determined that, if the nurse was unavailable or distant, progress was slowed, if not halted. If the relationship progressed to the working phase, it was considered powerful and successful.
The preceptor model is the most common method of facilitating the transition of new graduates. This model facilitates development of competence and confidence, acceptance, and retention in new graduates (Fox, Henderson, & Malko-Nyhan, 2006). Although there is no published research measuring the strength of this relationship, research does exist explaining the effects of the relationship and its effect on the new graduates' work environment, which may influence job satisfaction and turnover (Lavoie-Tremblay et al., 2011; Romp & Kiehl, 2009).
Roche, Lamoureux, and Teehan (2004) conducted research evaluating an orientation program in collaboration with a healthcare system. They reported strong negative correlations between satisfaction with orientation and working with more than four preceptors. Contrary to Delaney's (2003) findings, these new graduates indicated that one to three preceptors gave them opportunity to work with more than one practice pattern.
A phenomenological study investigating new graduates' transition experiences revealed that, when they had positive relationships with their preceptors, both their thoughts and progression in orientation were positively affected. Less experienced or inconsistent preceptors led to negative thoughts, slower progression, and confusion and frustration for the new graduates (Chesnutt & Everhart, 2007; Delaney, 2003; Peplau, 1997; Wright, 2002). Several studies indicated that preceptors helped with confidence building and ease of transition, provided emotional support, and helped with learning and advice on professional issues (Fox et al., 2006; Sorensen & Yankech, 2008).
Kramer (1974) and Farnell and Dawson (2005) concluded that new graduates needed to spend time with preceptors to feel supported and to take advantage of the preceptor's knowledge and skills. They, too, concluded that working with multiple preceptors decreased the ability to build a relationship, which does affect the ability to attain competency. The theory of interpersonal relations also states that time spent in a therapeutic relationship helps individuals develop the competencies needed for personal development and problem solving (Forchuk, 1993).
After receiving institutional review board approval, this study was conducted at the Level 1 trauma center flagship hospital of a 15-facility healthcare organization, located in the southeastern United States. The new graduates participating in the study were working in patient care areas in all facilities across the organization.
The organization implemented a revised graduate nurse orientation, which included a nurse residency program, to facilitate the transition from student to professional nurse. Therefore, experienced registered nurses new to the organization were not included in the residency program or this sample. The nurse residency program was 6 months in length and based on the University Healthcare and the American Association of Colleges of Nursing collaborative nurse residency model for new graduates.
Using nonprobability purposive sampling and a pretest-posttest design, the principal investigator approached the new graduates participating in the nurse residency program during the first session offering the opportunity to participate in this study, providing responses to questions and obtaining written consent. Those agreeing to participate completed the relationship form at the beginning and end of the 6-month program.
The relationship form measures the patient's perception of the phase of their relationship with the nurse. The four phases between orientation and resolution phase are measured on a 7-point Likert scale, with midpoints between each phase (Forchuk, 1994b; Forchuk & Brown, 1989).
The components of each phase of the nurse-patient relationship were identified directly from Peplau's theory, providing construct and content validity. Three mental health clinical nurse specialists with theory-based practices evaluated the relationship form for content validity. Interrater reliability for this form was found to be 91% (Forchuk & Brown, 1989).
The relationship form was adapted for use with preceptors and new graduates with the permission of C. Forchuk (personal communication, December 10, 2007, and November 20, 2011). The adaptation included changing "nurse" to "preceptor," "client" to "new graduate," "integrates illness" to "integrates new RN role," "initiate rehabilitation plan" to "initiate orientation plan," "help plan for total needs" to "help plan for total orientation needs," and "teach preventive measures and self-care" to "assists preceptee to be self-directed." "Uses work stimuli" was deleted for this context, as suggested by Forchuk. The adapted form was used to determine new graduates' perception of the phase of the relationship with preceptors at the beginning and end of the program (see Figure 1).
The new graduates were instructed to circle the behaviors that applied to themselves to determine their perception of their relationship with their preceptor in terms of the phases described by Peplau. They also circled those characteristics they perceived as pertaining to their preceptors. On the basis of the phase where most of the circles fell and using the Likert scale, a numerical score of 1 through 7 was assigned by the principal investigator to reflect the perceived phase of the relationship (C. Forchuk, personal communication, December 10, 2011; McNaughton, 2000). The points between the phases were used when the circles fell equally across two phases (Forchuk & Brown, 1989). In the event the new graduate was assigned more than one preceptor, the new graduate was asked to complete the form based on the primary preceptor or the one with whom they spent most of the time.
The quantitative data were coded, entered into the computer, and analyzed using the statistical package for social sciences (SPSS) GradPack version 17. This sample of new graduates (see Table 1) did not have statistically significant differences between preorientation and postorientation scores, suggesting that the relationship remained in the identification phase (see Table 2).
According to the scores on the relationship form, at the end of the 6-month residency program, this group of new graduates did not progress beyond the identification phase, where the preceptor and the new graduate identify learning needs. The participants were primarily young women who were professionally inexperienced. In addition, most were first degree students, so these factors could be influential in the inability to build a professional working relationship.
This study is limited by its small sample size and the inability to control the number of preceptors for each new graduate. There was no information available about the preceptor related to clinical experience or preparation and experience as a preceptor, all of which could have influenced how the preceptor related to the new graduate.
Limitations related to the form are related to its development to measure the nurse-pateint relationship and its adaptation for use with preceptors and new graduates. The form was not pilot tested.
There was no information about work schedules, particularly which shift the the new graduates worked most of the time. A combination of multiple preceptors along with working a less-desired shift may also have influenced the progression of the relationship.
These results objectively verified that a relationship is present between new graduates and preceptors, which could be useful to nursing professional development educators who are involved with new graduate transition programs. Educators could use the tool to periodically measure the relationship during the orientation process. If progressing, then the educator will have data to continue to support the dyad and the continued progress of the relationship to the resolution and the end of orientation. If not progressing, objective data will be useful in evaluating the viability of the relationship and searching for factors that are inhibiting its progress.
Depending on factors identified, the relationship form results would also be useful in determining if orientation needs to be extended to allow for the identification and resolution of more learning needs. The items on the form and the concepts of the theory may also be useful as content for preceptor development.
Further research should be conducted to determine the reliability and validity of this adapted tool used with preceptors and new graduates. A larger sample size, mechanisms to control or account for varying numbers of preceptors, would also be a worthy investigation. Finally, the preceptor's clinical and precepting experience and preceptor preparation should be investigated to determine the influence of any of these factors on the preceptor-new graduate relationship.
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