The Journal of Continuing Education in Nursing

Original Article 

Measuring Preceptor Selection in Long-Term Care

Susan C. Burt, DNP, RN, BC

Abstract

Orienting new nursing staff is costly for health care organizations. Identifying preceptor characteristics and structuring preceptor education to support those characteristics may improve the orientation process and decrease orientation cost. A descriptive, observational study identified preferred characteristics of potential preceptors (N = 39) in a long-term care/subacute facility. Results showed that mean ranks of three items on the preceptor instrument were significant, thus providing insight regarding content and desired outcome of preceptor education. [J Contin Educ Nurs. 2019;50(10):455–462.]

Abstract

Orienting new nursing staff is costly for health care organizations. Identifying preceptor characteristics and structuring preceptor education to support those characteristics may improve the orientation process and decrease orientation cost. A descriptive, observational study identified preferred characteristics of potential preceptors (N = 39) in a long-term care/subacute facility. Results showed that mean ranks of three items on the preceptor instrument were significant, thus providing insight regarding content and desired outcome of preceptor education. [J Contin Educ Nurs. 2019;50(10):455–462.]

Nursing orientation costs and staff turnover can be problematic for a health care organization, affecting both financial stability and patient safety (Birnbaum et al., 2017). Preceptors are key to the orientation process. They articulate and demonstrate standard patient care and organizational values and assist in evaluating whether preceptees can provide safe patient care (Kaddoura, 2013).

The term preceptor has been defined as an experienced nurse guiding new or inexperienced nurses into their new roles (Kaddoura, 2013). The preceptor role involves being a role model, socializer, teacher, and evaluator (Condrey, 2015). However, ensuring that a preceptor has the characteristics to be effective needs to be evaluated. The evaluation of preceptor characteristics using a valid and reliable instrument can guide educators in providing further professional development in these characteristics. Furthermore, nursing managers can have a consistent method by which to select effective preceptors. Consistent use of a preceptor selection instrument that is valid and reliable may enhance preceptees' orientation processes and guide educators as they develop preceptor education.

Acute care facilities have estimated the cost of replacing a nurse to be 200% of his or her salary (Sandau, Cheng, Pan, Gaillard, & Hammer, 2011). Birnbaum et al. (2017) noted that turnover costs can be as much as 5.8% of annual budget costs for a health care organization. Long term care/subacute facilities nursing staff retention have been noted to be 66.7% (Salmond, Cadmus, Black, Bohnarczyk, & Hassler, 2017). Measuring the financial implications of preceptor services has not been easy. Many variables can influence nursing retention and nurse-sensitive outcomes. Preceptor education and incentives have been emphasized, with little attention to identifying consistent characteristics of preceptors or the effects of preceptors on retention.

A quantitative, descriptive, comparative observational study identified preferred characteristics of potential RN-preceptors, certified nursing assistants (CNAs), and licensed practical nurses (LPNs) in a long-term care/subacute facility as judged by orientation committee members (two RNs and one LPN). The committee comprised two nursing leaders and a staff member representing different educational levels (Master's, Bachelor's, and LPN). Each staff member was evaluated once by a committee member who was knowledgeable of their precepting characteristics. The committee members represented real-time observation of the preceptor, as opposed to a self-evaluation tool or another method of appraisal. The question posed was: What are preceptor characteristics of RNs, LPNs, and CNAs employed by a long-term/subacute care facility, as measured by a valid reliable preceptor evaluation instrument? Additional questions were asked following preliminary data analysis: Is there a difference among the roles (RNs, LPNs, and CNAs) by total scores on overall preceptor characteristics? Is there a difference among the roles (RNs, LPNs, and CNAs) by individual item ranks on preceptor characteristics?

Literature Review

A focused, systematized review of the literature published from 2014 to 2018 on preceptor selection and retention supported the need for further research regarding this topic. Implications for preceptor selection call for the administration of a valid and reliable instrument for screening preceptor candidates (Cotter & Dienemann, 2016; Odelius, Traynor, Mehigan, Wasike, & Caldwell, 2017). Salmond et al. (2017) addressed a need for a consistent method in selecting preceptors in the long-term care setting that will support best practices, model organizational values, and support positive retention data.

Literature supported that long-term/subacute care settings are plagued with poor staffing, low nurse–resident ratios, limited financial reimbursement, low educational requirements for nursing staff, and high staff turnover (Aaron, 2011; Miller, 2012; Pattock, 2014; Salmond et al., 2017). The need for change and a combination of interventions to support preceptors' and preceptees' success in the workplace was clearly identified in the literature (Gueorguieva et al., 2016; Hsu, Hsieh, Chiu, & Chen, 2014).

Theoretical Framework

The transtheoretical change model served as a framework for the project. The model has been used in nursing practice to guide change and is particularly useful in this study, as mean ranks of three items on the preceptor instrument were significant (Srigley et al., 2015). Identifying the content of preceptor education may differ according to the preceptor's role in the organization. Using a change theory to guide the selection and, most importantly, the professional development of preceptors is vital, as the theory provides understanding as to how change occurs.

The transtheoretical model is composed of six stages: precontemplation, contemplation, preparation, action, maintenance, and relapse (Glanz, Burke, & Rimer, 2015). The organization's educator and staff awareness of these stages of change may affect their ability to embrace the use of a valid and reliable instrument that can guide the selection, education, and, most importantly, the ongoing professional development of preceptors (Figure 1).

The transtheoretical model is made up of six stages of change. The precontemplation stage occurs prior to a person thinking about making a change. The contemplation stage occurs when there is awareness that a change is needed. That may occur when an organization becomes aware of the cost of orientation and of the significant role preceptors play in the orientation process. The third stage is preparation, which involves a plan for change, such as using a preceptor selection instrument. The fourth stage, action, takes place when there is a commitment to change, such as consistently using a preceptor selection instrument to choose preceptors. Stages five and six, maintenance and relapse, are vital if change is to have a lasting impact. Planning for maintenance and relapse from the beginning of the change process allows organizations to implement measures during the change process to ensure sustainability (Neill & Neill, 2013).

Figure 1.

The transtheoretical model is made up of six stages of change. The precontemplation stage occurs prior to a person thinking about making a change. The contemplation stage occurs when there is awareness that a change is needed. That may occur when an organization becomes aware of the cost of orientation and of the significant role preceptors play in the orientation process. The third stage is preparation, which involves a plan for change, such as using a preceptor selection instrument. The fourth stage, action, takes place when there is a commitment to change, such as consistently using a preceptor selection instrument to choose preceptors. Stages five and six, maintenance and relapse, are vital if change is to have a lasting impact. Planning for maintenance and relapse from the beginning of the change process allows organizations to implement measures during the change process to ensure sustainability (Neill & Neill, 2013).

Method

Design

A quantitative, descriptive observational design explored characteristics of potential preceptors employed as nursing staff in a long-term/subacute care setting. The Cotter Preceptor Selection Instrument (CSPI; Cotter, Eckardt, & Moylan, 2018) is a valid and reliable instrument (internal consistency reliability Cronbach's alpha = .85.). Convergent validity was established between the CPSI and Annual Evaluation of Preceptor (r = .56, p = .032) (Cotter et al., 2018). The CPSI was used to describe preceptor attributes, as evaluated by a three-person (two RNs, one LPN) orientation committee.

Setting and Sample

Setting. Nursing staff in the 180-bed long-term/subacute care setting, located in a major northeastern U.S. city, employed approximately 154 nursing personnel (RNs, LPNs, CNAs). Approximately 15 to 20 staff routinely volunteered and served as preceptors, depending on the needs of the organization.

Preceptors and Orientation Committee Members. A quota nonprobability sampling approach was obtained, based on the proportion of the number of each nursing group (RN, LPN, CNA). Inclusion criteria consisted of RNs, LPNs, and CNAs of all genders who worked for the organization for at least 1 year and who were recommended by their unit manager or nurse leader. The orientation committee sample was made up of two nurse leaders and one staff nurse serving as preceptors within the organization. One bias that was self-identified by committee members involved their personal orientation process and preceptor experience.

Ethical Considerations

A university institutional review board reviewed and approved the study for human subjects' considerations. The administrator of the participating long-term care facility reviewed the study and granted approval for the study. The preceptors and the orientation committee participation were voluntary and consent forms were signed by all participants.

Instrumentation

The CPSI is a valid and reliable instrument (Cotter et al., 2018) and uses 10 domains, or conceptual qualities, founded on the domains of effective health care organizations by the American Nurses Credentialing Center, a subsidiary of the American Nurses Association (Cotter et al., 2018; Magnet Recognition Program, 2011). The 10 domains of the CPSI consist of 14 questions to evaluate preceptor characteristics.

The 10 domains of the CPSI include the following: Clinical Competence (one question); Nursing Process (two questions); Transformational Leadership (two questions); Collaboration/Communication Skills (two questions); Professional Development (two questions); Conflict Resolution (one question); Commitment (one question); Flexibility (one question); Empowerment (one question); and Values (one question). The items elicit responses based on the following scale: 1 = needs improvement, 2 = meets expectations, 3 = exceeds expectations. Scores are calculated as a sum of items responses. The highest score possible was 42.

The goal of the CPSI is for a preceptor to score a total of 35 or higher (Cotter et al., 2018). Achieving a score of 35 or higher may not be realistic for the nursing staff in the long-term/subacute care settings, due to staff and managers' unfamiliarity and lack of knowledge of Magnet®/Path of Excellence® standards, such as shared governance and funds for staff development. A middle score of 21 or higher was the benchmark score used for preceptors in the study. A middle score was set as a benchmark due to limited staff development education and poor retention of staff.

Procedures for Data Collection

Following institutional review board approval, a flyer announcing the study was located near the time clock for 2 weeks. The orientation committee met one time after a list of current or potential preceptors was identified by nursing leadership following signed consent. The orientation committee members used a paper CPSI to evaluate preceptors they had observed precepting and in clinical practice. Committee members received directions and explanation of the CPSI. Only one CPSI was completed and scored for each preceptor participant.

Results

Descriptive statistics on the study cohort's demographic attributes were calculated using SPSS® version 24 (Table 1). Forty participants signed consent forms for the study; a total of 39 participants were evaluated using the CPSI. One CNA withdrew from the study due to personal reasons. The mean age of the sample (Table 1), including RNs, LPNs, and CNAs, was 47.89 years (SD = 11.34). Preceptors who worked for the organization for more than 5 years constituted 71.8% of the sample. Table 1 provides a comparison of preceptor candidates' demographic characteristics by nursing staff position. Only one participant who was a CNA scored below 21 on the composite score of the CPSI. The CPSI instrument used a benchmark of 35 for all selected preceptors in the acute care setting (Cotter et al., 2018). The study found that if a benchmark of 35 were used (Cotter et al., 2018), only 33% of the sample would be asked to be preceptors. The Cronbach's alpha coefficient was .903 for this sample, which indicates that the CPSI reflects a fine discrimination in the levels of the construct (Burns & Grove, 2009).

Demographic Characteristics of Preceptor Candidates (N = 39)

Table 1:

Demographic Characteristics of Preceptor Candidates (N = 39)

Table 2 provides descriptive statistics on CPSI items. Mean item scores on CPSI items ranged from 2.07 to 2.51 on the 3-point scale for all characteristics except two. The lowest item mean was 1.82 for “Provides ‘learning moments’ to develop peers.” The second item mean was 1.89 for “Objectively identifies strengths and weaknesses of self and others. Provides constructive feedback in a manner that allows for progression and growth.” These low scores could identify an educational gap relating to peer evaluation and peer-to-peer education. Preceptors' highest item mean was 2.51 for “Provides nursing care according to established nursing standards.” The second highest items mean was 2.35 for “Projects positive attitudes as it relates to work environment.”

Descriptive Statistics on Cotter Preceptor Selection Instrument Items (N = 39)

Table 2:

Descriptive Statistics on Cotter Preceptor Selection Instrument Items (N = 39)

A Kruskal–Wallis, nonparametric ANOVA, inferential statistical test was calculated to test the hypothesis that CPSI total scores differed by nursing staff position (RN, LPN, and CNA). Results did not support the hypothesis (χ2 = 1.94, df = 2, p = .379). Nonetheless, the mean ranks across nursing positions showed that RNs ranked higher than LPNs and CNAs. LPNs' and CNAs' ranks were similar (Table 3). Table 4 includes the results of a Kruskal–Wallis test on CPSI items compared by nursing staff position. The results showed that there were statistically significant results by nursing staff role for three of the 14 CPSI items.

Mean Ranks on Total Cotter Preceptor Selection Instrument by Nursing Staff Position (N = 39)

Table 3:

Mean Ranks on Total Cotter Preceptor Selection Instrument by Nursing Staff Position (N = 39)

Kruskal–Wallis Test on Cotter Preceptor Selection Instrument Item Mean Ranks by Nursing Staff PositionKruskal–Wallis Test on Cotter Preceptor Selection Instrument Item Mean Ranks by Nursing Staff Position

Table 4:

Kruskal–Wallis Test on Cotter Preceptor Selection Instrument Item Mean Ranks by Nursing Staff Position

The Mann-Whitney U test (Table 5) was used as a post hoc test to compare the three statistically significant ranks by nursing staff position. The RNs' mean ranks were higher than CNAs' ranks (statistically significant) for three items (“Documentation is appropriate and complete,” “Set priorities and demonstrates time management skills,” and “Delegates appropriately and effectively to nursing support staff”). The LPNs' mean rank was higher than the CNAs' mean rank at a statistically significant difference for one item (“Documentation is appropriate and complete”). This may be related to professionalism and role responsibilities.

Post Hoc Mann-Whitney U Tests on Cotter Preceptor Selection Instrument Items Showing Statistically Significant Different Ranks

Table 5:

Post Hoc Mann-Whitney U Tests on Cotter Preceptor Selection Instrument Items Showing Statistically Significant Different Ranks

Conclusion

This study described preceptor characteristics in a sample of current and potential preceptors in a 180-bed long-term/subacute care setting. This study was the first in which a standardized instrument was used to identify characteristics of preceptors in the long-term care/subacute health care sector. The rationale was that selecting preceptors using a valid and reliable instrument would be useful in guiding preceptor education and developing preceptors in meeting the challenge of orienting new staff that may affect both retention and nurse-sensitive outcomes.

The results indicated that preceptors scored high in organizational processes and positive attitudes toward the organization, thus making them ideal preceptors for organizational processes and positive representatives of the organization. Clinical competency and attitudes are often the primary focus of nursing leaders when identifying preceptors but may not be the only factors that affect retention and nurse-sensitive outcomes. Preceptors scored low in self-awareness of strengths and weaknesses and in providing constructive feedback and learning moments for peers. Self-awareness and feedback are critical factors in creating a positive learning environment for new staff. Identifying the need preceptors have in these areas is critical to developing preceptor education that can support professional growth for preceptors.

CNAs were stronger than RNs in active involvement in learning activities, providing learning moments for peers, willingness to vary work assignments, and positive attitudes related to their work environment. Higher CNA scores in these areas may be related to CNAs needing 12 hours of education each year, tracked by the facility and which can be requested by regulatory bodies during a survey. Also, the need for teamwork in patient care with frequent staffing challenges may be a reason why CNAs scored higher in these items. Understanding CNAs' strengths can be helpful to educators as they address specific preceptor needs of CNAs.

Using a preceptor selection instrument in the long-term/subacute care setting is important for several reasons. According to the 2018 U.S. Census, by 2030 there will be more people over age 65 than people under age 18 (U.S. Census Bureau, 2018). Only 21% of the United States population has long-term care insurance (Miller, 2012). Staff orientation in the long term/subacute setting can be as short as 6 to 8 days, with minimal to no education for preceptors. In addition to the cost of orientation, turnover of staff is high and nurse patient ratios are low (Aaron, 2011; Miller, 2012; Pattock, 2014; Salmond et al., 2017).

Implications of this study include the need to use a valid and reliable instrument to guide health care leaders in selecting and developing preceptors and the consideration that carefully selected preceptors could affect orientation cost and nurse-sensitive outcomes. No longer can preceptor selection be based on a nurse's longevity with the organization or desire to be a preceptor, nor can it be determined by who is the best nurse working on a given day (Aaron, 2011; Salmond et al., 2017).

Hsu et al. (2014) supported the need for educating preceptors and the use of reliable instruments to evaluate the effectiveness of preceptor education and preceptee response. Consistent use of a preceptor selection instrument may be key to improving the long-term/subacute and other health care setting's nursing staff retention, orientation costs, and staff satisfaction. The transtheoretical theory provides a guide to health care leaders and educators regarding the stages of changes that will occur as stakeholders embrace the use of a valid and reliable instrument to guide preceptor selection, education, and sustainability of the process. When valid and reliable instruments are used, consistent outcomes and sustainability may occur (Cotter & Dienemann, 2016; Miller & Rollnick, 2013; Odelius et al., 2017).

The Institute of Healthcare Improvement encourages all health care organizations to decrease costs, improve population health, maximize quality care, and address staff satisfaction—the quadruple aim (Feeley, 2017). The use of a preceptor selection tool may be one step that health care organizations can incorporate as leaders seek to embrace the Institute of Healthcare Improvement quadruple aim. Further research needs to be completed using the CPSI to test the effect of a preceptor selection process on staff retention, preceptor education/development, and nurse-sensitive outcomes.

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Demographic Characteristics of Preceptor Candidates (N = 39)

VariableMean (SD)n (%)
Participant role
  RNs6
  LPNs11
  CNAs22
Age, years (combined)47.89 (11.34)
  RNs55.5 (10.36)
  LPNs50.81 (10.26)
  CNAs44.36 (11.09)
Sex
  Male3 (7.7)
  Female36 (92.3)
Total years working in your current role in the organization
  14 (10.3)
  22 (5.1)
  34 (10.3)
  41 (2.6)
  More than 5 years28 (71.8)
Years in health care
  RNs29.00 (13.81)
  LPNs17.09 (9.33)
  CNAs20.18 (11.31)
Total years in practice
  RNs11.00 (15.78)
  LPNs13.09 (8.63)
  CNAs15.95 (11.86)

Descriptive Statistics on Cotter Preceptor Selection Instrument Items (N = 39)

ItemMeanSD
Provides nursing care according to established nursing standards.2.510.60
Documentation is appropriate and complete.2.330.58
Sets priorities and demonstrates time management skills.2.280.68
Sets priorities and demonstrates critical thinking skills.2.150.78
Delegates appropriately and effectively to nursing support staff.2.070.70
Promotes effective/skilled communication through the use of tactful, direct, and sensitive interaction.2.150.67
Narrates patient care and explains the purpose behind his/her actions to others.2.150.67
Participates in learning activities, committees, and/or staff meetings.2.070.66
Provides “learning moments” to develop peers.1.820.64
Demonstrates problem-solving skills and minimizes escalation of situations to ensure safe patient care.2.200.66
Works to provide feedback to new employees and welcomes them.2.250.72
Demonstrates willingness to vary work assignment/schedules to meet the needs of the unit and new orientees.2.330.66
Objectively identifies strengths and weaknesses of self and others. Provides constructive feedback in a manner that allows for progression and growth.1.890.59
Projects positive attitudes as it relates to work environment.2.350.63

Mean Ranks on Total Cotter Preceptor Selection Instrument by Nursing Staff Position (N = 39)

PositionNMean Rank
RN625.92
LPN1119.27
CNA2218.75

Kruskal–Wallis Test on Cotter Preceptor Selection Instrument Item Mean Ranks by Nursing Staff Position

ItemNMean Rankχ2, df, p
1. Provides nursing care according to established nursing standards.0.433, 2, .805
  RN622.33
  LPN1120.09
  CNA2219.32
2. Documentation is appropriate and complete.6.995, 2, .030
  RN625.83
  PN1124.18
  CNA2216.32
3. Sets priorities and demonstrates time management skills.6.091, 2, .048
  RN628.67
  LPN1121.18
  CNA2217.05
4. Sets priorities and demonstrates critical thinking skills.0.468, 2, .792
  RN622.50
  LPN1120.27
  CNA2219.18
5. Delegates appropriately and effectively to nursing support staff.6.654, 2, .036
  RN628.83
  LPN1121.59
  CNA2216.80
6. Promotes effective/skilled communication through the use of tactful, direct, and sensitive interaction.1.852, 2, .396
  RN625.25
  LPN1119.05
  CNA2219.05
7. Narrates patient care and explains the purpose behind his/her actions to others.0.747, 2, .688
  RN623.00
  LPN1118.50
CNA2219.93
8. Participates in learning activities, committees, and/or staff meetings.1.212, 2, .546
  RN618.75
  LPN1117.59
  CNA2221.55
9. Provides “learning moments” to develop peers.0.333, 2, .846
  RN620.08
  LPN1118.55
  CNA2220.70
10. Demonstrates problem-solving skills and minimizes escalation of situations to ensure safe patient care.0.692, 2, .708
  RN621.67
  LPN1117.91
  CNA2220.59
11. Works to provide feedback to new employees and welcomes them.1.275, 2, .529
  RN624.08
  LPN1120.41
  CNA2218.68
12. Demonstrates willingness to vary work assignment/schedules to meet unit needs and needs of new orientees.1.642, 2, .440
  RN620.42
  LPN1116.88
  CNA2221.55
13. Objectively identifies strengths and weaknesses of self and others. Provides constructive feedback in a manner that allows for progression and growth.1.665, 2, .435
  RN619.17
  LPN1123.18
  CNA2218.24
14. Projects positive attitudes as it relates to the work environment.0.492, 2, .782
  RN619.00
  LPN1118.55
  CNA2221.00

Post Hoc Mann-Whitney U Tests on Cotter Preceptor Selection Instrument Items Showing Statistically Significant Different Ranks

ItemRoleU, p*
2. Documentation is appropriate and complete.RN compared with CNA33.00, .023
3. Set priorities and demonstrates time management skills.27.00, .017
5. Delegates appropriately and effectively to nursing support staff.25.00, .011
2. Documentation is appropriate and complete.LPN compared with CNA73.00, .033
Authors

Dr. Burt is Director of Education and Quality, KeystoneCare Home Care and Hospice, Wyndmoor, Pennsylvania, and Jonas Leadership Scholar.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Susan C. Burt, DNP, RN, BC, 8 Henfield Terrace, Cherry Hill, NJ 08003; e-mail: suecburt@hotmail.com.

Received: February 02, 2019
Accepted: April 30, 2019

10.3928/00220124-20190917-07

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