Joumal of Advanced Nursing, 1996,24,104-107

Preceptorship: a review of the literature Louise Bam RGN Staff Nurse, Ward NI, Neurosciences Directorate, Royal Hallamshire Hospital, Glossop Road, Sheffield, England

Accepted for publication 18 August 1995

BAIN L (1996) Journal of Advanced Nursing 24,104-107 Preceptorship: a review of the literature Preceptorship is an important part of the Umted Kingdom Central Council for Nursing's (UKCC) post-registration and practice recommendations Therefore, there is a great need for educationalists and clinical practitioners to explore the issues surrounding preceptorship and come to informed decisions on hov\r they intend to implement preceptor programmes There is a need to identify existing knowledge and its application to practice hased on the commonly occuring themes within the theoretical and empincal literature This paper reviews the current literature addressing these themes of role definition, preceptor selection, preceptorship programmes, the preceptorship experience and the limitations of preceptorship m clmical practice INTRODUCTION Diffieulbes eneounted m role transibon for newly qualified nurses were first identified by Kramer (1974) The eoneept of preeeptorship addresses the need for effecbve socializabon of these nurses mto the frequently changing hospital environment and attempts to narrow the pracbce-theory gap that exists within nursing (Alexander 1983) Preceptorship is an important element of the Umted Kingdom Central Council's post-regisbabon educabon and pracbce proposals (PREPP) (UKCC 1990) Therefore, there is a great need for educabonalists and climcal pracbboners to explore the issues surroundmg preceptorship and to come to informed decisions on how they intend to implement preceptor programmes An extensive literature addresses preceptorship preparabon and preceptor programmes, and is mostly supportive of the concept However, there is also empirical evidence contrary to this (Oleson et al 1984, Itano et al 1987) Whilst researchers descnbe much of the literature as subjecbve, descnpbve and anecdotal (Ouellet 1993) it IS also important to consider the reliability and validity of the empirical evidence Another considerabon is that much of the availahle literature comes from the United States and is therefore not totally applieahle to elinieal praebee m this eoimtry Most professioned journals have addressed preeeptorship but the majonty of empirieal data IS presented m the journals eoneemed with nurse edueabon This has relevance for a number of clinical 104

praetiboners who will not roubnely have aeeess to the edueational journals and are therefore denied the most relevant informabon as it is not readily available in the more widely read nursmg literature The aim of this review is to idenbfy the important aspeets of preeeptorship using the theorebeal and empmeal literature and idenbfy commonly occumng themes Themes that occur withm the literature are defining the role of preceptors, preceptor selection, preceptor programmes and the preceptorship expenence It is the mtenbon of the author to present a literature review addressmg these themes and discuss the limitabons of preceptorship m cluueal pracbce WHAT IS PRECEPTORSHIP Newly qualified nurses enter professional pracbce with knowledge and skills and have been eissessed as reaching at least the minimal acceptahle levels of competence for pracbce Beginning a new role with limited expenence and knowledge provokes much anxiety, desenbed by Kramer (1974) as the 'reeJity shoek' This may be equally applieable to the eompetent praebboner expeeted to eope vnth the new role as a student undertaking a seeond registerable qualifieabon m an unfamiliar area, or those undertakmg the higher award programmes of study This is reeognized by the UKCC, who reeommend a penod of support (of about 4 months) under the gmdanee of a preeeptor to help praebboners aehieve eonfidenee Preeeptorship ® 1996 BlackweU Science Ltd

Freceptorship a review of the literature offers a penod of support and attempts to ease transibon mto professional pracbce or sociahzabon mto a new role Lack of definibon and clanfy regarding the concept of preceptorship was evident m much of the literature reviewed This was identified as problemabc m some of the opimon-based articles that attempt to define preceptorship (Armit^e & Bumard 1991, Brennan & Wilhams 1993) A literature review by Burke (1994) effecbvely explores tbe concept of preceptorship and descnhes the role as havmg several mam funcbons, providing onentabon and support and the teachmg and shanng of climcal experbse bemg paramount This paper attempts to clearly define the roles and funcbons of preceptors and introduces new areas of thought m view of the related literature and empincal evidence It provides logical and coherant arguments supported by relevant and effecbve evidence For example. Burke addresses more contenbous issues of preceptorship, such as the nature and extent of the relabonship between novice and preceptor Morrow (1984) descnbes the preceptor as a person, generally a staff nurse, who teaches, counsels and inspires, serves as a role model and supports growth and development of an individual (the novice) for a fixed and limited amount of bme, with the specific purpose of socializing the novice mto a new role

professional sociahzabon for their students, but also acknowledges that generalizabilify of the study will be affected by the sample size and selecbon (a non-randomized convemence sample of 103 subjects) This issue may be a relevant vanable m the Umted Kingdom context m relabon to nurses who expenenced tradibonal nurse training and those who tramed using Project 2000 (UKCC 1986) Piemme et al (1986) associates success with personal charactensbcs and lists numerous virtues such as pabence, enthusiasm, knowledge and orgamzabonal abilibes, to name a few Kramer (1993) su^ests that the nurse manager IS the person who best understands the strengths and weaknesses of nurses and states that the responsibihfy for selecting preceptors belongs witb the manager It is an important observation that Kramer, who is in fact a nurse manager, presents an opimon-based paper advocating a very structured and top-down approach to the lmplementabon of preceptorship Selecbon cntena, including selecbng baccalaureate nurses and formal selecbon by managers, could possibly carry the nsk of encouraging formabon of elibst and generahst ranks withm nursing and should be applied with caubon Rigidify withm the selection critena will restrict selection to availabilify rather than abilify of preceptors PRECEPTOR PROGRAMMES

SELECTION OF PRECEPTORS The only formal specificabon for preceptor selection hy the UKCC IS that they will be first level nurses (mcludmg midwives and health visitors) who have had at least 12 months (or equivalent) expenence vnthin the same or associated clinical field as the pracbboner requinng support Parsons et al (1985) state that it is vital that selecbon cntena are establisbed and adhered to if programmes are to be effecbve One aim of this review was to ldenbfy skills required to be an effecbve preceptor None of tbe hterature reviewed explicitly addressed this issue However, there are theorebcal and empincal suggesbons of attnbutes required for preceptor selecbon Recommendabons for preceptor selecbon based on empmcal evidence are based on knowledge and clmical competence Studies by Langston (1990) and Ouellet (1993) suggest that bacculareate-prepared preceptors provide greater professional sociahzabon for novices, while diploma-prepared preceptors tend to adhere to a techmcal model for pracbce Ouellet's quasi-expenmental study exammes the effects of a preceptor expenence on nursmg students before and after a 4- and 7-week expenence Vanables such as length of expenence and educabonal preparabon of preceptors were mcluded There were significant differences m scores between students paired with baccalaureate-prepared nurses and those with diplomaprepared nurses Ouellet concludes 'with some confidence' that baccalaureate-prepared preceptors provided greater

The UKCC (1993) recognizes that preceptors will require specific preparabons and anbcipates that m addibon to existing skills the specific preparabon penod would not exceed 2 days What is required is a unified policy for the preparabon of preceptors (Burke 1994) One uubabve is to mcorporate preceptor preparabon mto the English Nabonal Board teaching and assessment course (998), as su^ested by Ashton & Richardson (1992) The mtroducbon of such mibabves will provide nabonally agreed contents and standards which have the benefit of consistency, avoidmg repebbon and retraming, and would therefore be cost-effecbve Empincal studies of preceptorship programmes can be cnticized as having inconsistent and contradictory findmgs McGrath & Pnnceton (1987) claim to produce both qualitabve and quanbtabve evidence to support preceptorship programmes and suggest that effecbve programmes have some influence on recruitment and retenbon of staff McGrath & Pnnceton descnbe their paper as a summary of a research project to evaluate a preceptor programme and Its effects on staff recruitment and retenbon They used an exploratory research design to ldenbfy preceptor programme phenomena There is no mclusion of the quantitabve study and methods of qualitabve data analysis are not addressed m this paper The reliabihfy and validify of McGrath & Pnnceton's paper is therefore quesbonable without further mformabon about tbe research A further considerabon is that the authors conclude that their findmgs can be utilized to support proposals for contmued

© 1996 BlackweU Science Ltd, Joumal of Advanced Nursmg, 24, 104-107

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L Bain funding of the programme Whilst bias is not lmphed, the authors must expect speculation when they do not include their research methods Oleson et al (1984) offer evidence contrary to this and claim there are no significant benefits of preceptor programmes Their experimental quantitative study is, however, limited by a small sample (49 subjects) from one university setting Evaluation of the study suggests tbat tbe changes occunng as a result of tbe programme were so small tbey bad no statistical significance and tbat tbe tools used did not reflect tbe cbanges Tbe autbors of this study conclude tbat since tbe programme is fcurly costly to the nursmg service agency and tbe scbool of nursmg, documentation of benefits sbould be done to support tbe need for sucb programmes In view of sucb contrasting evidence it could be suggested tbat tbere is a need to obteun additional substanbve evidence to demonstrate tbe effectiveness of preceptor programmes Part of tbe problem could be due to a problem of definition and it could be argued tbat we need more researcb to define tbe concept before we attempt to demonstrate effectiveness

PRECEPTORSHIP EXPERIENCE AND RELATIONSHIPS Witbin tbe available literature tbere is some controversy surrounding tbe nature of tbe preceptorsbip expenence Unfortunately, witbin tbe limits of tbis literature tbere were no empirical data regardmg tbe preceptorsbip expenence and relationships Tbe tbeoretical and opinion-based literature also lacked similanty in opmions, suggesting tbis to be a very mdividuahzed experience Influential factors m tbe preceptorsbip relationship are tbat tbe novice must be recogmzed as accountable eind tbat tbe preceptor role is sbort and functional Armitage & Bumard (1991) present an opimon-based article tbat descnbes tbe expenence as teacblng tbe novice tbe routmes of tbe ward and sbanng tbeir clinical exjjertise by a process of one-to-one teaching and role modelling Peuameetal (1986) feel tbat tbe preceptor's cbief functions are goal settmg, value clarification and evaluation In contrast to tbese suggestions. Parsons et al (1985) believe tbat tbe preceptorsbip expenence is mucb more of a peer relationsbip working on an equal basis Wbat clearly needs to be establisbed from tbe outset is tbe perceived needs and expectations of botb tbe preceptor and tbe novice Rasbid (1992) acknowledges tbat tbere is very little identification of tbe actual needs of tbe postregistration student Witbout recognition of needs tbe preceptor cannot begin to fulfil tbem On-going evaluation and peer review is a fundamental component of tbe preceptorsbip expenence and bas mutual benefit to botb tbe preceptor and novice Pendleton (1991) suggests self and peer assessment as a central way of developing standards of professional practice 106

Wbere a more structured approach is required, Kramer (1993) suggests a preceptorship policy as a tool for successful implementation of preceptorship This policy clearly defines the roles and responsibilities of tbe preceptor and novice and provides very structured guidehnes Kramer's ideas would provide interestmg debate, unfortunately tbis IS lacking, as is the empincal evidence to support some of tbe ideeis put forward LIMITATIONS OF PRECEPTORSHIP Nursing is currently expenencmg great cbange Advances m medical tecbnology, financial constraints and tbe restructurmg of bealth care m the United Kmgdom have resulted in greater responsibilities and pressures on tbose witbm tbe bealtb care arena Cbickerella & Lutz (1981) identified tbat tbe preceptorsbip experience needs extra time and adds to preceptor responsibilities This opinionbased work, presented over a decade ago, acknowledges tbe denmnds of preceptorsbip, tbe demands on nurses today are mucb greater Preceptorship's credibility as a workable option seems doubtful if tbe increasing demands on expenenced practitioners continue to be ignored (Brennan & Williams 1993) Preceptorsbip is said to enbance tbe performance of nurses, preceptors remam stimulated educationally and professionally by tbe expenence Novices display enbanced performance and successful preceptorsbip affects retention and recruitment of staff (Kramer 1974, McLure et al 1983), tberefore tbere are multiple benefits to be gained by successful programmes A number of autbors (Goldenburg 1987, Gnepp 1989, Kramer 1993) suggest rewards for preceptors, sucb as monetary compensation, recognition luncbes and name badges to identify position It could be suggested tbat sucb initiatives are idealistic and unnecessary, adequate acknowledgement and recogmtion can be given by managerial encouragement and support and tbe provision of time and resources for adequate training of preceptors and scbeduled tune for preceptor and novice interaction Tbere sbould be a collaborative interest m tbe success of preceptorsbip, incorporating educational estabhsbments, clnncal practitioners, managers and professional bodies Witbout tbis Burke's (1994) prediction, tbat tbe effort and entbusiasm of practitioners will end m confusion and disillusionment and tbe preceptor will become merely a cbeap and potentially meffective substitute for a clnncal teacber, may become reality CONCLUSIONS AND SUGGESTIONS FOR PRACTICE Tbe purpose of tbis review was to identify tbe important aspects of preceptorsbip and pick out tbe issues relevant to successful implementation Tbere is a lack of clanty of

© 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 104-107

Preceptorship tbe concept defimtion and failure of many of tbe empincal studies to identify strategies for successful implementation of preceptor programmes Tbe empincal data available on tbe selection of preceptors provide some suggestions for practice Tbe educational preparation of preceptors was an identified vanable Tbis is an area wbere tbere is a need for researcb to be conducted m tbis country m view of tbe many metbods of nurse traimng practismg nurses will bave imdertaken, for example Project 2000 trainmg and enrolled nurse conversion courses Wbere tbere is no formal selection process m operation it may be useful for potential preceptors to prepare profiles of tbeir clmical experience, and educational and personal attnbutes, and allow tbe novice to select a preceptor wbom they consider will best meet their individual needs Tbe empirical evidence addressing preceptorsbip programmes IS contradictory and mconsistent Unfortunately mucb of tbe literature lacks tbe essential elements of replication and compatibilify for scientific credibility However, one need only reflect upon personal expenence as a newly qualified practitioner to identify tbe need for a period of support Tbe UKCC (1993) acknowledges tbe need for clinical supervision and is currently, in collaboration witb tbe Department of Healtb for England, developing a model of clinical supervision for nursing and bealtb visiting practice Evidence pertaining to tbe preceptorsbip expenence and relationship is sadly lacking It could be suggested tbat tbe expenence sbould reflect tbe mdividual needs of tbe novice Wbilst some will flounsb m an informal peer evaluation relationsbip, otbers will lack tbe expenence and matunfy and need a more structured and supportive mecbamsm Preceptorsbip will add to tbe responsibilities and pressures on nurse practitioners Tbis sbould be acknowledged by managers and practitioners and given adequate consideration, time and financial resources for its development and implementation Witbout adequate knowledge and preparation preceptorsbip programmes are m danger of becoming condensed orientation programmes or crasb courses in survival witbm nursmg It is, tberefore, tbe responsibility of tbose withm nurse education and clmical practice to mcreeise tbeir awareness of tbe concept of preceptorsbip and take mformed decisions on bow it sbould be implemented witbm tbeir area of practice

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11, 225-229

arevtewoftheliteixituTe

Ashton P & Richardson G (1992) Preceptorsbip and PREPP BnUsh Journal of Nursing 1(3), 143-146 Brennan A & Williams D (1993) Preceptorship is it a workable concept' Nursing Standard 7(52), 34-36 Burke L M (1994) Preceptorship and post-registration nurse educabon Nurse Education Today 14, 60-66 Chickerella B G & Lutz W J (1981) Professional nurturance preceptorship for undergraduate nurses American Journal of Nursmg 81(1), 107-109 Goldenhuig D (1987) Preceptorship a one to one relationship with a triple P Preceptor, preceptee and patients Nursing Forum 23(1), 10-15 Greipp ME (1989) Nursing preceptors looking back looking ahead Journal of Nursing Staff Development 5, 183-186 Itano J K , Warren J J & Ishida D N (1987) A comparison of role conceptions and role depnvation of baccalaureate students in nursing, participating in a preceptorship or traditional clinical program Journal of Nursing Education 26(2), 69-73 Kramer M (1974) The Reality Shock, Why Nurses Leave Nursing Mosby, St Louis, Missouri Kramer N (1993) Preceptorship policy a tool for success The Journal of Continuing Education m Nursing 24(6), 274-276 Langston R A (1990) Comparative effects of haccalaui«ate and associate degree educational programmes on the professional socialisation of nursing students In The Nursing Profession, Turning Points Mosby, St Louis McGrath B J & Princeton R, (1987) Evaluation of a clmical preceptor program for new graduates — eight years later The Journal of Continuing Education m Nursing 18(4), 133-136 McLure M L , Poulm M A , Sovie M D & Wandelt M (1983) Margret Hospital Attraction and Retention of Professionals American Nurses' Association, Kansas City, Missouri Morrow K L (1984) Preceptorship m Nursing Staff Development Aspen, RockviUe, Maryland Oleson R K , Sens Gresley R & Stewart Heater B (1984) The effects of an undergraduate clinical internship on the selfconcept and professional role mastery of baccalaureate nursing students Journal of Nursing Education 23(1), 105-108 Ouellet L (1993) Relationship of a preceptor expenence to the views about nursing as a profession of baccalaureate nursing students Nurse Education Today 13, 16-23 Parsons R , Butcher P , McLean J & Sharman J (1985) The staff nurse as a peer educator preceptorship on the unit The Canadian Nurse 81(7), 19-20 Pendleton S (1991) Curriculum Planning m Nurse Education Hodder and Stoughton, Sevenoaks, Kent Piemme J A , Kramer W , Tack B B & Evans J (1986) Developing the nurse preceptor Journal of Continuing Education m Nursing 17(6), 186-189 Rashid C (1992) Patchy provision Nursing Times 88(14), 38-40 United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1986) Project 2000 UKCC, London United BCingdom Central Council for Nursing, Midwifery and Health VisiUng (1990) The Report of the Post-Registration Education and Practice Project UKCC, London Umted Kingdom Central Council for Nursing, Midwifery and Health Visitmg (1993) Registrar's Letter 1 11 993 UKCC, London

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