Preceptors are role models, teachers, and facilitators who share knowledge and experience with nurse-trainees and facilitate the acquisition of clinical and critical thinking skills (Madhanvanpraphakaran, Shukri, & Balachandran, 2014; Varley, MacNamara, & Mannix-MacNamara, 2012; Wiseman, 2013). Aside from being skillful and knowledgeable, preceptors must possess good communication skills and a higher level of training in nursing (Jahan, Sadaf, Kalia, Khan, & Hamza, 2008; McClure & Black, 2013; Varley et al., 2012). In many countries, staff nurses who act as preceptors have the critical role of supporting and facilitating nurse–trainees' learning in clinical settings.
In Kenya, staff nurses in academic hospitals take up the dual role of patient care and preceptorship by virtue of working in the hospital. The staff nurses are expected to precept diploma (a 3.5-year program in a middle-level nursing school) and baccalaureate trainees on clinical placement in their respective clinical areas. A clinical instructor from the nursing schools visits trainees on clinical placement, usually once or twice per week, to check whether the objectives of the placement are being met. Although the local regulatory body (Nursing Council of Kenya) recommends preceptor–trainee ratio of 1 to 7, the actual number can be as high as 15 trainees per preceptor.
Effective clinical preceptorship is critical for the achievement of instructional objectives for any nursing curriculum (McClure & Black, 2013) and, ultimately, the acquisition of knowledge, skill, and attitude necessary for nursing care (Varley et al., 2012). To effectively execute their mandate, preceptors must be knowledgeable, through training, about their role in preceptorship (Jahan et al., 2008) and must demonstrate willingness to help trainees acquire competences for quality nursing care (Duteau, 2012). Conversely, in the absence of training, preceptors are unlikely to create a stimulating learning environment (Dale, Leland, & Dale, 2013).
Some countries have formal training programs for preceptors. In Ireland, nurses complete an approved preceptorship program (Varley et al., 2012), whereas in Oman, preceptors undergo a training program offered by hospitals and nursing schools (Madhanvanpraphakaran et al., 2014). The overarching aim of these training programs is to equip preceptors with knowledge and innovative techniques to facilitate trainees' learning.
Preceptors' training programs are generally lacking in most African countries. For instance, preceptors in Ghana are inadequately prepared for their teaching roles (Asirifi, Mill, Myrick, & Richardson, 2013). In recognition of the critical role of preceptors in nurse training and professional competence, a need exists to evaluate the level of preparedness of preceptors in other African countries. Therefore, this study was undertaken to determine preceptor knowledge and sources of knowledge on preceptorship in an academic hospital in Kenya.
Materials and Method
A descriptive cross-sectional survey was conducted in an academic hospital in Western Kenya among a purposive sample of 254 preceptors who had worked in the hospital for at least 6 months. A questionnaire to assess knowledge was developed by a researcher after thorough review of related literature. Content review was conducted by five experts in nursing education who made revisions to the tool by deleting four redundant questions and adding one question on anticipatory reflection. The final questionnaire consisted of an 11-item, 3-point Likert scale (1 = disagree, 2 = neutral, 3 = agree) to assess level of knowledge and open-ended questions to determine the sources of knowledge on preceptorship. All except two of the Likert scale questions (9 and 11) were formulated such that an affirmative response (agree) would denote knowledge about the question item. The study tool was pilot tested in a regional training hospital on a sample of 25 nurses to assess its usability. The nurses found the questions easy to understand and, thus, no further modifications were made.
A trained research assistant (a Bachelor of Science in Nursing intern) distributed the questionnaire to preceptors during change-of-shift meetings with a request that they complete them in the course of the shift. The distribution continued until all the preceptors were captured—mostly during a 3-day period—in each clinical area. Respondents were required to place the completed questionnaires in a sealed envelope and drop them in a clearly labeled drop-box at the nurse station. The first author (E.M.N.) collected the box containing the completed questionnaires from each clinical area 48 hours after the last distribution in the respective clinical area.
Descriptive statistics were computed to demographic characteristics. Sum and mean (± SD) scale scores were computed for knowledge score; mean scale score of less than 1.5 was interpreted as lack of knowledge on preceptorship. Association between training on preceptorship and level of knowledge was explored using chi square because in presence of a large sample size, parametric tests are appropriate for Likert scale data even if a normality test is violated (Sullivan & Artino, 2013). Qualitative data were analyzed using simple content count. The study was approved by the research and ethics review board of College of Health Sciences, Moi University, Kenya.
Two hundred thirty preceptors returned the questionnaires, for a response rate of 91%. The majority of respondents were diploma nurses and had been precepting for more than 3 years. Table 1 summarizes the demographic characteristics of the respondents.
The total knowledge scale score was 392.15 for a mean score of 1.71 (SD ± 0.41). When individual question items were analyzed, the majority of respondents were knowledgeable on the importance of nurse– trainee orientation and use of positive feedback to correct, modify, and improve performance. However, respondents lacked knowledge on use of negative feedback and anticipatory reflection during preceptorship. Table 2 summarizes how preceptors responded to each question item.
Self-Reporting Agreement of Preceptor Knowledge About Preceptorships
Few respondents (8.5%, n = 17) had undergone training on preceptorship. Sources of knowledge on preceptorship ranged from experiential learning by working in the hospital (46.8%, n = 22), nursing schools during training (25.5%, n = 12), orientation programs in the hospital (14.9%, n = 7), and role modeling with clinical instructors (12.8%, n = 6; Table 3).
Preceptorship Training and Sources of Knowledge
The influence of professional qualification and preceptorship training on level of knowledge was explored. The overall level of knowledge on preceptorship did not differ between those who had undergone training and those who had not. Conversely, most of those who had undergone training (94.1%, n = 16) agreed that the role of preceptors and trainees should be clearly defined at the beginning of the clinical placement, χ2(1) = 15.54, p = .016.
Effective clinical learning integrates theory and practice in the development of skills and competence in nursing practice. In many low- and middle-income countries (LMICs), preceptorship is undertaken by staff nurses (preceptors), owing to shortage of faculties in nursing schools. Considering that preceptors are expected to teach, guide, and role model trainees, inadequate knowledge and skills on preceptorship is likely to compromise on the quality of training. The mere pairing of trainees with preceptors does not guarantee learning (Bengtsson & Carlson, 2015).
Only a negligible number (8.5%) of preceptors were trained on preceptorship. However, the training was informal and unstructured. This is in contrast to the situation in other countries (Madhanvanpraphakaran et al., 2014; Tsai et al., 2014; Varley et al., 2012), where preceptors are formally trained prior to taking their preceptorship roles. For instance, preceptors in Oman must undergo mandatory training at the hospital and participate in preceptorship workshops organized by nursing faculties (Madhanvanpraphakaran et al., 2014). Given that adequate knowledge and training is critical for effective preceptorship (McClure & Black, 2013; Varley et al., 2012), the lack of formal training for preceptors in Kenya raises the question of the quality of the training programs for nurses.
Preceptors who had been trained were more knowledgeable about their roles and responsibilities. The study results are consistent with the findings by Myrick, Caplan, Smitten, and Rusk (2011) in Canada, where preceptors who had undergone a structured online preceptorship program were more knowledgeable and skilled on preceptorship. Al-Hussami, Saleh, Darawad, and Alramly (2011), as well as Smedly, Morey, and Race (2010), also found that undergoing a preceptorship training program improved knowledge and skills on clinical teaching and self-efficacy among staff nurses. Considering that preceptor knowledge is the most critical ingredient for effective learning (Jahan et al., 2008), the need for a structured training program on preceptorship cannot be overemphasized.
Sources of knowledge on preceptorship were varied and inconsistent. Similar to previous studies (Tsai et al., 2014; Wiseman, 2013), role modeling with former clinical instructors played a significant role in shaping preceptors' knowledge. Tsai et al. (2014) found that many preceptors construct their teaching style by modifying their experiences with their preceptors during training. Experiential knowledge was also prevalent in the current study, as it is in other LMICs (Asirifi et al., 2013). Through experiential knowledge, preceptors are able to connect with trainees, role model, and demonstrate respectful professional practice that encompasses application of critical thinking skills in nursing care (Paton, 2010).
The significance of structured training programs in improving knowledge, skills, and self-efficacy of clinical preceptors is clearly discussed in literature (Haggerty & Holloway, 2012; Smedley et al., 2010). Although there is no consensus on the optimum duration of the training programs, some researchers have suggested that even 2-day programs could suffice as long as critical topics such as role and responsibility of preceptors, promotion of critical thinking, evaluation process, and teaching learning styles are addressed (Butler et al., 2011; Myrick, Luhanga, Billay, Foley, & Yonge, 2012). The training programs would be most successful when they are developed and implemented collaboratively by academic hospitals and nurse training institutions (Asirifi et al., 2013).
Although these findings provide a snapshot of the level of knowledge on preceptorship in a resource-limited setting, they are limited on several fronts. The survey was conducted in a single academic hospital, thus limiting the generalizability of the findings to hospitals in the country and other LMICs. In addition, the use of a self-report survey puts the findings at risk for social desirability bias. Nonetheless, the findings provide invaluable insight on the need for preceptor training in LMICs, particularly in Kenya.
Although preceptors had some knowledge about preceptorship and were actively involved in nurse training, few had been adequately prepared for the preceptorship role. Sources of knowledge on preceptorship included nursing institutions, role modeling, experiential learning, and orientation programs in the hospital. A standardized formal training of clinical preceptors is warranted.
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|Gender (n = 226)|
| Female||181 (80)|
| Male||45 (20)|
|Professional qualification (n = 229)|
| Certificate||14 (6.1)|
| Diploma||179 (78.2)|
| Degree||34 (14.9)|
| Master||2 (0.9)|
|Duration of working with nurse-trainee (n = 229)|
| < 3 years||81 (35.4)|
| ⩾ 3 years||148 (64.6)|
|Number of nurse-trainees working with preceptor (n = 230)|
| 0 to 3 nurse-trainees||150 (65.2)|
| 4 to 6 nurse-trainees||63 (27.4)|
| > 6 nurse trainees||17 (7.4)|
Self-Reporting Agreement of Preceptor Knowledge About Preceptorships
|Questiona||Disagree, n (%)||Neutral, n (%)||Agree, n (%)|
|1. Trainee orientation prior to clinical placement helps create a positive learning environment. (n = 230)||1 (0.4)||19 (4.3)||210 (95.2)|
|2. Preceptor–trainee relationship is important for clinical learning. (n = 228)||5 (2.2)||9 (3.9)||214 (93.9)|
|3. Positive feedback corrects, modifies, and improves nurse–trainee performance. (n = 224)||7 (3.1)||18 (8.1)||199 (88.8)|
|4. The role of preceptors and nurse–trainees should be defined at the beginning of clinical placement. (n = 226)||6 (2.7)||26 (11.5)||194 (85.8)|
|5. The style of conflict management to use with trainees depends on situation and circumstances. (n = 225)||16 (7.1)||51 (22.7)||158 (70.2)|
|6. Clinical teaching fosters critical thinking. (n = 218)||11 (5)||59 (27.1)||148 (67.9)|
|7. Preceptors incorporate reflection into professional practice and trainee–preceptor relationship. (n = 222)||9 (4.1)||68 (30.6)||145 (65.3)|
|8. Feedback is varied according to trainee's level of training. (n = 223)||36 (16.2)||67 (30)||120 (53.8)|
|9. Anticipatory reflection is critical for final-year trainees. (n = 223)||27 (12.1)||90 (40.4)||106 (47.5)|
|10. Negative feedback is used when trainee puts the patient at risk. (n = 215)||57 (26.5)||69 (32.1)||89 (41.4)|
|11. Clinical reasoning is common sense. (n = 210)||97 (46.2)||58 (27.6)||55 (26.2)|
Preceptorship Training and Sources of Knowledge
| No||183 (91.5)|
| Yes||17 (8.5)|
|Sources of knowledge on preceptorshipb|
| Experiential learning||17 (46.8)|
| Nursing institutions during training||12 (25.5)|
| Orientation program in a hospital||7 (14.9)|
| Role modeling with clinical instructors||6 (12.8)|