The reality of new nursing graduates' entry into clinical practice is often inconsistent with their expectations of their first nursing job. Preceptors play a key role in guiding and supporting these new nurses during this time. Despite their key role, little research has been conducted to gain an understanding of the experience of the preceptors. The purpose of this qualitative phenomenological study was to achieve a better understanding, from the perspective of the preceptor, about the experience of being the primary nurse preceptor for newly graduated nurses during their transition into clinical practice. For the purposes of this study, primary nurse preceptors were defined as registered nurses (RNs) assigned to provide one-to-one guidance to a newly graduated nurse during at least 75% of their total clinical orientation time.
BACKGROUND
Preceptorship in nursing evolved during the 1970s and 1980s when nursing schools were removed from hospital settings (Shamian & Inhaber, 1985). At this time, the need arose for a more comprehensive initial hospital orientation for new nurses entering clinical practice. Centralized orientation programs were developed to instruct new employees about hospital-wide policies and procedures and also to familiarize them with organizational culture. Upon completion of the centralized programs, new nurses were sent to their units to be informally acquainted with the practical aspects of their new roles. However, the lack of structure associated with many unit-based orientations led to reality shock and high turnover rates for new nurses, as well as burnout, and diminished satisfaction among all of the nursing staff (Shamian & Inhaber, 1985). As a result of the issues associated with transition of new nurses into clinical practice, the preceptor model emerged.
LITERATURE REVIEW
Nursing literature and research have primarily addressed the role of the preceptor in the transition experience of newly graduated nurses from the perspective of the preceptees. Although this perspective explains only one side of the transition process, it does help illustrate the significance of the role of the preceptor. Several studies have concluded that preceptors play a key role in the transition experience of newly graduated nurses during their entry into nursing practice (Billay & Yonge, 2004; Delaney, 2003; Schumacher, 2007). Preceptors are not only responsible for role modeling and educating newly graduated nurses but also for helping them socialize into their new roles (Baltimore, 2004; Casey, Fink, Krugman, & Propst, 2004; Hickey, 2009; Schumacher, 2007). The existing literature has also illuminated both benefits and challenges associated with the role of the preceptor.
Henderson, Fox, and Malko-Nyhan (2006) reported that two of the most important benefits to precepting were personal satisfaction and the opportunity to learn from others. Insufficient time and increased workload have been described in the nursing and health sciences literature as challenges associated with being a preceptor (Henderson et al., 2006; Kaviani & Stillwell, 2000; Marriott et al., 2006; Yonge, Krahn, Trojan, Reid, & Haase, 2002). In addition, the nursing literature has pointed to the often challenging need for preceptors to balance their responsibilities to both their patients and preceptees (Henderson et al., 2006; Ohrling & Hallberg, 2000).
METHODOLOGY
A phenomenological method of inquiry, guided by the work of van Manen (1990) and Munhall (2001, 2007), was used to discover what it is like to be the primary nurse preceptor for a newly graduated nurse during his or her transition into clinical practice in an acute hospital setting. The focus of phenomenology is on gaining a deeper understanding of the meaning of the experience of a particular phenomenon (Creswell, 1998). One of the potential strengths of this method is that, if it is carried out effectively, what is learned from the participants about their experiences as preceptors and the meanings they attach to those experiences may allow us to "derive directions, interventions, and education" (Munhall, 2001, p. 162).
SAMPLING AND STUDY PARTICIPANTS
Purposive sampling was used to recruit participants from a large, urban hospital in the Western United States. Inclusion criteria were RNs who (1) worked a minimum of 24 hours a week at the bedside at the study hospital and (2) were primary preceptors for at least one newly graduated nurse during the year prior to their participation in the study. Nurses who worked on the researcher's home unit were excluded from participating.
A total of six RNs participated in this study (five female and one male). The highest level of education reported by the five participants was a bachelor's degree; one participant had a master's degree. Their years of experience as RNs ranged from 1 to 26 years. The number of experiences they had as primary preceptors for newly graduated nurses ranged from 1 to 6. It is important to note that one participant had 26 years of nursing experience, and the range for the other five participants was from 2 to 3 years. It is also important to note that, despite having 26 years of experience as an RN, this participant only had five precepting experiences with newly graduated nurses. The number of preceptor-related education classes they each had taken ranged from 0 to more than 5.
DATA COLLECTION
Participants took part in two semistructured interviews lasting between 30 and 60 minutes each. The opening question for the initial interview was "Tell me about your experiences as the primary preceptor for newly graduated nurses during their transition into clinical practice." Subsequent questions were used to guide the interviews and depended on what was learned from the participant from the opening question. The primary purpose of the second interview with each participant was to return the verbatim transcriptions of individual responses in the initial interviews and the researcher's interpretations of the descriptions of these experiences for validation. In addition, participants were given an opportunity to add any additional information to the existing data from their first interviews.
DATA ANALYSIS
Each interview was transcribed and imported into NVivo8, a qualitative data analysis software package (QSR International, 2007). As outlined in Table 1, data were analyzed using Colaizzi's framework as described by Sanders (2003). In addition, during the data analysis phase an audit trail was reviewed by two expert qualitative researchers.
FINDINGS
The overall essence of being the primary preceptor for newly graduated nurses during their transition into clinical practice was understood as an altruistic responsibility to the greater good of the profession. The experiences of the primary preceptors who participated in this study are described in the context of three main themes and nine subthemes (see Figure 1).
MAIN THEME: PROFESSIONAL COMMITMENT
The first main theme, "professional commitment," involved the subthemes (a) internal motivation, (b) wearing multiple hats, (c) sharing ownership of the experience, and (d) beyond being a preceptor. The six primary preceptors who participated in this study shared stories that illuminated the selfless ways in which they embraced their roles, beginning with their own internal motivation to be preceptors.
Subtheme: Internal Motivation
This subtheme emerged when participants talked about what motivated them to be preceptors and how they were recognized and rewarded for their work. Collectively, the primary motivating factors for the six preceptors in this study were commitment to their individual nursing units, love of teaching, appreciation of the mutual learning opportunities provided by the preceptor role, and opportunity to make a difference in the development of a new nurse and for nursing as a whole.
Mostly for me I want to make a difference in the people who are coming up to be nurses. I want to try to get my two bits in there and see if I can make a difference[horizontal ellipsis]. It motivates me because it makes the unit I work on run better.
Some preceptors in this study were also motivated by their experiences as preceptees, learning both what they wanted to take away and also what they might change. Those preceptors who were only a year or two out of school brought a certain degree of empathy to their roles as evidenced by comments such as "I try to understand that this is their first job out of school" and "I've been in their shoes, I know what it feels like to kind of be let loose."
It was also apparent that their ambition to precept came more from their own internal motivation than anything external when the participants discussed the recognition and reward they receive for their work. Collectively, their primary source of recognition came from preceptees in the form of gratitude for the preceptors' contributions to their success. They had varying responses when asked whether it would be meaningful to receive some type of reward and recognition outside of their own units, but for the most part they agreed that, although it might be helpful, it was not what they were seeking.
The biggest reward for preceptors in this study came when they watched preceptees grow into competent, critically thinking nurses. Some described satisfaction and, in certain cases, relief when the orientation period was over, and they knew that their peers felt comfortable working alongside their former preceptees.
I feel that great nursing care is so beneficial for the patient because if you know how to orchestrate everything, all the team together[horizontal ellipsis]you are like a conductor for the patient. And I feel that my job is rewarding when I can look back and see that the nurse I precepted is able to do that.
Subtheme: Wearing Multiple Hats
This subtheme surfaced when preceptors discussed the challenges they face in their roles. At times, some preceptors were torn between their responsibilities to patients and preceptees, feeling as though they were not as available to preceptees as they should be. Wearing multiple hats was also understood in the more literal sense when preceptors had multiple roles within the course of the day, leaving them unable to focus on preceptees.
[horizontal ellipsis]we would still have to be the charge nurse, we would still be having to take a (patient) assignment, and we would still have to be precepting. So that was really hard. Going a few times (to the supervisor) to say, this is a lot of hats to wear in one day, and if you want our preceptees to get a good education out of this, and get something out of this, we need to take one of those hats away.
Subtheme: Shared Ownership
This subtheme transpired when preceptors talked about their feelings of accountability for the actions of the preceptees and the outcomes of the preceptorship and also when they discussed their roles in providing feedback about the progress of the preceptorship.
And then if they're not at a point where you're expecting them to be, then it kind of feels like you failed them because they're not where they're supposed to be in a certain timeframe or they're not as fast a learner as some of the other preceptees. It's kind of hard. I felt like, okay, what am I doing wrong.
Despite the level of accountability felt by preceptors and also expected by supervisors and managers, there were inconsistencies related to their roles in providing feedback related to the progress of the preceptorship. This variability was related to lack of a formal process for providing feedback, insufficient time for feedback, and, in some cases, providing feedback and feeling like it was not heard. As the individuals who work most closely with newly graduated nurses during their transition into clinical practice, preceptors have invaluable insight related to preceptees and want to be given an opportunity to share their feedback.
We should all sit down, me, the preceptee and them (the supervisor, manager, and nurse educator) and say okay, these are the things that I see you still need to work on[horizontal ellipsis]I think it would make the person being precepted a lot more comfortable, because they're just kind of scared, period. And they're wondering what the heck's going on.
Subtheme: Beyond Being a Preceptor
This subtheme surfaced as the participants discussed perceptions of their role in the transition experience of newly graduated nurses. The term mentor came up in the first interviews with participants when they were asked about their roles in the socialization of newly graduated nurses.
I feel like I'm that confidant-like we're friends and she feels comfortable to come to me, like I'm a safe person to come to and ask a question. She doesn't feel like she's asking me a dumb question. Not that I would think anybody else would think that's a dumb question, but definitely I feel like I'm her mentor.
The relationship between a preceptor and preceptee is generally assigned and lasts for a defined period of time, whereas that between a mentor and mentee is often sought out by one or both individuals and does not have a defined start or end point. The preceptors in this study acknowledged the differences between being a preceptor and being a mentor; however, there was a clear sense that most of the preceptors saw themselves as being both to preceptees.
MAIN THEME: RAISING OUR YOUNG
The second main theme involved the subthemes (a) need for support, (b) balancing autonomous nursing practice and safe patient care, and (c) recognizing the individual. During a follow-up interview with one participant, she reflected on her approach to precepting a newly graduated nurse where she was responsible for educating and being there for the preceptee. She made the analogy that being the primary preceptor for a newly graduated nurse was like being a parent.
[horizontal ellipsis]it's kind of like you're their parent, whereas there are all of these people in a child's life, you have grandparents, school teachers, you have all of these people who influence them but the parents are primary, I guess would be the best analogy.
Subtheme: Need for Support
This subtheme emerged when participants talked about how they were supported in their preceptor roles. Support from the supervisors and managers was shown by allowing preceptors to voice concerns, matching preceptors and preceptees based on learning styles, and assuming the charge nurse role for the preceptor when possible. Although thoughtfulness related to matching preceptors and preceptees was viewed as support from supervisors and managers, not matching preceptors and preceptees was perceived as a lack of support by two of the participants in this study.
[horizontal ellipsis]in the situations that I've been placed as a preceptor, there wasn't a lot of ground work done about whether you two would be a good fit personality wise, or whether you had sort of the same kind of style[horizontal ellipsis]sometimes two people are like oil and water, and if you don't know that from the beginning and you're all the way into it, three weeks into it, and it's like you're not getting what I'm saying, and I'm not liking what you're saying.
Subtheme: Balancing Autonomous Nursing Practice and Safe Patient Care
This subtheme transpired as some of the preceptors spoke about the fine line between pushing preceptees too hard and sheltering them too much and also about letting go of their responsibilities in order to nurture independence in preceptees.
Subtheme: Recognizing the Individual
This subtheme emerged as the preceptors talked about adapting to the learning styles of preceptees and constantly questioning the effectiveness of their teaching and what they could do differently. Some preceptors were prepared for their roles with unit-based education on learning styles and also by their previous roles in education. Others discussed adapting and individualizing the focus of teaching and learning to preceptees after assessing their learning styles.
MAIN THEME: BRIDGE BETWEEN THE BOOK AND THE BEDSIDE
The third main theme involved the subthemes (a) setting the stage for success and (b) connection to clinical practice. Preceptors in this study shared their perspectives about the characteristics and factors that contributed to positive and negative transition experiences for preceptees. They also acknowledged the importance of their role in linking what preceptees learned in nursing school with what they experienced at the bedside.
Subtheme: Setting the Stage for Success
This subtheme became apparent when preceptors talked about the importance of matching criteria in preceptor-preceptee pairing.
She's (supervisor) done those studies with learning styles, and she does this learning style inventory. We did that this go around with trying to match up preceptors with preceptees who have similar learning styles. It was actually really interesting[horizontal ellipsis]It worked in my case, that's how I got my preceptee who worked kind of like I do and learned like I do.
Setting the stage for success was also understood as recognition by the preceptors of preceptee characteristics that both contributed to and interfered with successful preceptorship experiences. The language used to describe positive preceptee characteristics included motivated, knowledgeable, being proactive about learning, takes criticism well and improves from it, direct, straightforward, quick at organizing, big picture thinking, very organized, and trusted. Preceptors identified characteristics that interfered with successful preceptorship experiences for both the preceptor and the preceptee. The words used to describe unconstructive preceptee characteristics included expect spoon-fed information, sitting down/sitting back, does not take advice very well, so far out there, not very insightful, and negative person.
Subtheme: Connection to Clinical Practice
This subtheme surfaced as preceptors acknowledged that the reality of a nurse's first job may be different from school, recognized that teaching and learning must evolve throughout the precpetorship from basic to more complex, and identified the importance of helping preceptees make the transition from textbook knowledge to practice and move away from the tasks toward the bigger picture.
I think as a preceptor you're spending so much time just teaching them how to be a nurse, and then teaching them like how to survive, and just how to do their job[horizontal ellipsis]they get so caught up in their tasks that they need to do[horizontal ellipsis]I think that's the biggest thing about survival, is getting over that first mindset of how am I going to do this?
STUDY LIMITATIONS
The researcher's personal and professional experience with preceptorship potentially may have biased the study, although every effort was made to limit this bias. Every effort was made to limit this bias through the use of bracketing before and during the interview process and at all stages of data analysis. Bracketing is a method used in phenomenology to set aside the researcher's own thoughts and assumptions about the phenomena being studied. In addition, because the sample was limited to a few participants, the findings may not be transferrable to other settings. The 3- to 6-month time period between the initial and follow-up interviews is another potential limitation.
DISCUSSION AND IMPLICATIONS FOR CLINICAL PRATICE
Some of the findings from this study corroborate findings in the preceptor-related literature. The findings from this study should prompt organizations to evaluate whether preceptors are being expected to fulfill other roles, such as charge nurse, while they are precepting newly graduated nurses. As evidenced by the vivid descriptions provided by preceptors in this study who "wore multiple hats," these circumstances have the potential to lead to frustration and even burnout for preceptors and may also bring about a perception that precepting is an extra burden. In addition, these situations lead to less than optimal learning experiences for preceptees.
Similarly important is the need for nursing leaders and nurses in staff development roles to involve preceptors in the entire orientation process and to use a systematic approach, based on learning styles, to match preceptors with preceptees. Preceptors have indispensable insight related to preceptees, and they want opportunities to provide feedback related to the progress of their orientation. More importantly, preceptors want their feedback, especially as it relates to preceptees' ability to function safely and independently, to be valued.
Nursing leaders and nurses in staff development roles can also learn from the preceptor's articulate descriptions of preceptee characteristics that both contribute to and interfere with optimal transition experiences. Positive preceptee characteristics could contribute to development of guidelines when interviewing prospective graduate nurses. Interview questions could be designed to elicit responses that demonstrate these characteristics in newly graduated nurses and those who appear to be motivated and receptive, have insight, and are generally positive could be identified before they are hired. In addition, recognition of the importance of these characteristics by nursing instructors in the academic setting could help them cultivate these characteristics from the time students enter their nursing programs.
Nurses in staff development roles should invest time in the professional development of preceptors and support them in their day-to-day preceptor practice. Learning how to foster the development of critical thinking and time management skills should be key components of preceptor orientations and educational programs. One strategy may be to involve preceptors in simulation experiences with preceptees as a means of helping them teach and evaluate critical thinking and prioritization skills. Preceptors could also benefit from education related to learning and personality styles and about how to work effectively with preceptees whose learning and personality styles may be different from their own. The same type of education might be beneficial in the beginning of and throughout undergraduate nursing programs in order to prepare nursing students to work effectively with different personalities. Finally, preceptors might benefit from their own preceptor or mentor, to assist and support them in the development of the preceptor role.
References