The key to a successful transition from student to professional depends on an effective and competent preceptor to assist the new graduate in this process. The preceptor serves as educator, guide, support, and resource person to the new graduate (Ulrich, 2012). In a study by Salmond et al. (2017), new nurses indicated that preceptors were crucial to their clinical practice. It is acknowledged that education is needed to provide the preceptor with the skills and competencies he or she needs to educate, guide, and direct the new nurse. The effectiveness of preceptor programs have been evaluated to the degree that they contribute to the preceptor's confidence and competence in their role (Chang et al., 2015; Salmond et al., 2017; Sandau et al., 2011; Tsai et al., 2014).
The preceptor role becomes more crucial in out-of-hospital settings. As more care delivery shifts out of the hospital, the need will increase for new nurses in these settings. Collaborative efforts in New Jersey Action Coalition, Healthcare Association of New Jersey, the New Jersey Hospital Association, and Rutgers University School of Nursing resulted in the design of a statewide preceptor training and education program that was offered to all long-term care facilities in New Jersey. The New Jersey Action Coalition (NJAC) preceptor education program was based on a research-driven, evidence-based curriculum (Cadmus et al., 2016). It contained topics that reflected the role of the preceptor including adult learning principles, feedback and communication, time management principles, strategies for facilitating new nurse transition to the professional role, and teaching strategies to stimulate critical thinking (Chang et al., 2015; Foy et al., 2013; Ulrich, 2012).
The effectiveness of a preceptor education program is measured by successful implementation of the preceptor concepts in the practice setting. Research findings evaluating the NJAC program indicated that nurse residents thought having a preceptor had a positive impact on their role development and clinical practice (Salmond et al., 2017). Although summative evaluations completed by preceptor participants indicated the NJAC preceptor education program was effective, postprogram site visits to participating nursing homes by program faculty yielded differences in the degree of preceptor role implementation. Although many new nurse residents were positive about their relationship with their preceptor and felt fully supported by them, some new nurse residents had a less positive experience. Many studies have addressed the selection criteria for preceptors (Bourgault et al., 2014; Clement-O'Brien et al., 2011). Smedley et al. (2010) also conducted ANOVA testing with demographic variables of their sample and found that no significant difference existed in preceptor education outcomes (changes in knowledge, skills, attitudes) based on age, nursing education level, or years of nursing experience. Other studies examined methods and process for assuring consistency in preceptor selection by the use of designated criteria (Barba et al., 2019; Cotter & Dienemann, 2016; Cotter et al., 2018). This criteria focused on the potential preceptor's clinical skills and competence (Barba et al., 2019; Ward & McComb, 2017); communication, conflict resolution, nursing process (Cotter et al., 2018); and personal attributes such as flexibility, commitment, values, and openness (Cotter et al., 2018; Quek & Shorey, 2018; Ward & McComb, 2017).
In reviewing the literature, we found it did not address selection of preceptors based on specific criteria or characteristics that would result in more consistent implementation of the preceptor role, nor did it address the unique learning or support needs for preceptors based on criteria or characteristics. One way to address preceptor selection is to use Rogers's diffusion of innovation framework. Rogers's framework classifies individuals into innovator categories based on their openness to adopt or implement an idea or concept in terms of their risk-taking tolerance and motivation (Rogers, 2003). The nurse taking on the preceptor role undergoes a role change. He or she shifts from independent clinician to educator, guide, and advocate for the new nurse. This role change requires education and training to accommodate new skills such as fostering critical thinking and providing the new graduate with constructive feedback. Innovation categories is one possible way to describe the diversity that preceptors bring to a training program and thus may lead to identifying if gaps in learning needs and application of concepts in the clinical work setting are more specific one group versus another.
Innovation is a new concept applied to the preceptor role. Key tenets of innovators include questioning, observing, networking, experimenting, getting people to take chances, and tolerance for ambiguity. The innovative preceptor's tolerance of ambiguity puts them in a unique position to use some of these strategies with new nurses to make the new nurse feel validated, empowered, and autonomous (Melnyk & Raderstorf, 2019). Helping new nurses to overcome challenges and become competent and confident in their new role is imperative to their future success.
Rogers defined five categories of innovators from highest to lowest: innovators (IN), early adopters (EA), early majority adopters (EM), late majority adopters (LM), and laggards (L). The incidence of each category falls along a normal distribution curve within the population. Although the literature describes the criteria of preceptors participating in each study, no one has used a framework to better characterize the most appropriate candidate for the preceptor role, which is the focus of the current study.
The current study sought to further examine the inconsistent implementation of the preceptor role identified in the NJAC preceptor program through the lens of Rogers's framework, by addressing the following questions:
Do identified benefits to implementing the preceptor role differ based on the preceptor's innovator category? (Do preceptors who are more innovative identify more benefits to implementing the preceptor role)?
Do identified challenges to implementing the preceptor role differ based on the preceptor's innovator category? (Do preceptors who are more innovative identify less challenges to implementing the preceptor role?)
This study used a mixed-methods research design to examine the implementation experiences of nurses who participated in the NJAC preceptor education program. The data for the study were collected in two phases:
- a quantitative online survey to identify demographic characteristics and degree of innovativeness of the participants
- purposive qualitative interviews for a subset of the same group of preceptors to identify benefits and challenges to implementing the program, or preceptor role, based on innovator category
Quantitative Evaluation Tools
The online survey collected demographic data (level of education, job title, years of experience in current job), as well as innovator category/willingness to innovate (Scale for the Measurement of Innovativeness; Hurt et al., 1977) for each participant.
The Measure of Innovativeness Tool is an instrument that predicts willingness to adopt innovations across populations (Hurt et al., 1977) and considered innovativeness as a personality characteristic of a person's willingness to change (Goldsmith, 2011; Hurt et al., 1977; Rogers, 2003). This 20-item Likert scale tool consisted of 12 positively worded statements and eight negatively worded statements that address the key tenets of Rogers's (2003) framework, including comfort with risk taking and level of social status and power as opinion leader in the work setting. Scoring items by a formula yielded the total innovativeness score, with a maximum potential score of 100. A range of scores identified each category of innovator can be found in Table 1.
Innovativeness Scores by Category
Interviews were conducted with a stratified random sample of preceptors from each innovator category. Participants were asked to identify program benefits and challenges to applying preceptor concepts in the clinical setting through three key questions:
In describing your experience as a participant in the NJAC preceptor education program, can you tell me about how you were able to implement the content (adult learning, critical thinking, transition to practice, and feedback) of the various sessions?
Were there specific aspects that were beneficial to your ability to implement in the work setting?
Were there specific aspects that were challenging to implement in the work setting?
An interview guide was used to promote dependability of results, and participants were given the opportunity to clarify any comments during the process. Interviews were audiotaped and electronic notes were taken to document key points, note observations (such as long pauses between discussions, and tone of discussion), and provide a summary at the end of the interview. All data were read and reread to gather significant statements. From these statements, themes and subthemes were identified. A colleague familiar with the study also read transcripts to determine a level of agreement on themes and subthemes. Trustworthiness was established through member checks with the participating preceptors. Statements and key ideas were summarized at the end of each interview, and each participant was asked to confirm the conversation, correct any inaccurate statements, or add clarifying remarks.
Prospective participants included the 55 nurses who took part in the NJAC preceptor education program. Thirty-two preceptors completed the survey for an actual response rate of 58%. Interview participants were a subset of the survey participants. To obtain a reasonable number of interview respondents in the innovator categories to analyze results, categories were combined (i.e., innovators/early adopters; early adopters/early majority) to obtain a sample size of five participants for each combined innovator category. The majority of participants had at least a bachelor's degree. Nurse educator was the most prevalent job held by the preceptors. In terms of longevity, the group was divided between being relatively new to the setting (1 to 3 years) and being among the most senior staff (> 10 years). Table 2 provides further demographic details.
Interview Participant Demographics
Findings and Results
Individual innovativeness survey scores for this study indicated that participants skewed to the higher end of the innovativeness scale, with IN (n = 4) comprising 12.5% of the sample, EA (n = 20) comprising 62% of the sample, and EM (n = 8) comprising 25% of the sample. No participants scored in the LM or L categories.
Qualitative: Interview Results
Participants were asked about the benefits the program provided to preceptors in implementing the role in the work setting, as well as the challenges to implementing this role. Data from preceptor interviews were arranged into two major themes: implementation benefits and implementation challenges. Subthemes were extracted from the major themes. Direct quotations are provided to include the preceptors' voice. A summary of these themes can be found in Table 3.
Summary of Qualitative Themes by Innovator Category
Theme 1: Benefits to Applying Preceptor Concepts. When queried about the program's benefits in implementing adult learning strategies, critical thinking, transition to practice, and feedback, two subthemes emerged: program material resources and introducing preceptor concepts to others in the work setting.
Subtheme: Program material resources. All innovator categories found the program material resources to be beneficial in applying the preceptor concepts in the workplace. Preceptors noted that having a guide they could use on a regular basis helped them in their role. Each innovator category used the booklet that contained guides for weekly and monthly meeting with preceptors to provide feedback and set goals. This material helped preceptors to plan and arrange for more effective meetings with new nurses. One preceptor remarked, “Using the little folder for weekly and monthly follow-up, I'm setting up goals and then meeting on a regular basis to make sure that I know there is a process.”
Subtheme: Introducing preceptor concepts to others. The other subtheme that emerged as a program benefit to implementation of preceptor education concepts was the idea of introducing preceptor concepts to others in the work setting. Participants emphasized the importance of making other staff nurses and nurse leaders in the facility aware of the needs of the new nurse. This would improve the effectiveness of the program on the unit even if the preceptor were not present. In this case, the least innovative category (EM) did not mention working with others beyond their preceptees. However, both the IN and EA category interviewees noted instances of bringing concepts into the workplace and applying their education to train others. In most cases, this was to guide other nursing staff on how to effectively give constructive feedback to new nurses. A more innovative preceptor noted, “I have mentored others on how to give feedback in a constructive way.” Another observed, “Managers needed my assistance on some of the techniques. I haven't kept it to myself. I spread it to the other staff so they have an understanding.”
Theme 2: Challenges to Applying Preceptor Concepts. When queried about the program's challenges or gaps in implementing adult learning strategies, critical thinking, transition to practice, and feedback, two subthemes emerged: role conflict, and lack of continued support. It is interesting to note that the themes related to challenges in implementing the preceptor role focused more on the work environment, rather than gaps in the education they received.
Subtheme: Role conflict. In the case of role conflict, only the EA and EM categories expressed the issue of not having enough time to do their primary job and find time to meet and work with the new nurse. The support received from facility leadership and colleagues was considered important to fully implement the role in an effective manner. When this support was not present, preceptors found it difficult to be effective in their role. They did not feel that their leaders understood the complexity of the role and did not allow for flexibility in assignments due to this expanded responsibility. A preceptor scoring in the EM category reflected, “I could have done a better job. You know we don't have just this job.” Another preceptor added, “Maybe more marketing of the program to administrators would be helpful to get buy-in.”
Subtheme: Lack of continued program support. The second subtheme to emerge when examining program challenges to applying the preceptor role was a lack of continued support from the program. Preceptors who attended training and were not immediately assigned to a new nurse felt unprepared if assigned as a preceptor to a new nurse weeks later. This challenge to applying preceptor concepts in the work setting was evidenced in all identified innovator categories. Those who worked for organizations where new nurses were hired less frequently also indicated that their skills and knowledge would have benefited from an educator refresher on implementing the preceptor role. Calling for continued support from the education program, one preceptor explained, “Sometimes we come back to the work setting and then we don't have the opportunity to use it (preceptor skills) for 6 months or more. If you don't have the opportunity to precept a new nurse in a few months, it becomes harder to remember.”
It is interesting to note that while all the groups discussed themes as listed in Table 3, the IN category mentioned benefits more frequently than the other two categories. IN category members also mentioned gaps less frequently than the EA or EM categories. Conversely, the EM group mentioned gaps or challenges more frequently than the IN or EA groups. Statements describing benefits of the program included 50% by the IN category; 28% by the EA category; and 23% by the EM category. Statements describing gaps or challenges included 43% by the EM category; 22% by the EA category; and 9% by the IN category.
These results are in keeping with the aims of the study: to identify whether preceptors who are more innovative (IN) identify more benefits to implementing the preceptor role. The more innovative preceptors also identified fewer challenges to implementing the role. Conversely, the less innovative preceptors identified fewer benefits to implementing the preceptor role. However, they identified encountering more challenges in their implementing the preceptor role in the work setting. These results are in keeping with Rogers's (2003) description of the more innovative category as more amenable to taking risks and implementing innovations. The EAs, as thought leaders and influencers in their environment, followed the IN in their description of benefits and ways that the program impacted their understanding and application of preceptor concepts in the work setting. Finally, the EM (described as pragmatists) were more cautious in their interviews. They discussed the challenges of understanding preceptor concepts and applying the role in the workplace due to the conflict this new role presented when adding it to their current job. Challenges resonated with EM individuals regardless of their level of education or job title.
Use of the diffusion of innovation framework accomplishes several objectives. It serves as a way to further differentiate from preceptors with similar education and experience. In the case of a heterogeneous group of preceptors, a better understanding of the needs and challenges of each can be addressed. The framework provides staff educators with the opportunity to develop tools and guides for the preceptors' increased self-confidence and self-efficacy. Nurse leaders are better able to support the preceptor in their role and reduce the conflict felt by those trying to perform different responsibilities simultaneously.
The tool provides a more objective method of classifying the preceptor than a self-report by the preceptor or a subjective observation by the nurse leader (Cotter & Dienemann, 2016; Cotter et al., 2018). Once the innovator category is established, the nurse leader or educator can be more aware of the potential challenges faced by the less innovative preceptor and support them when they are experiencing role conflict or lack of support. Nurses who indicate an interest in taking on the preceptor role can provide an added asset to the facility (Ward & McComb, 2017). This, in turn, will increase the effectiveness of the preceptor. Those preceptors identified as more innovative can be encouraged to serve as mentor or facilitator for other preceptors. Considering the innovator category of a preceptor does not have to eliminate the more traditional selection criteria already in place (e.g., seniority or clinical competence) (Cotter et al., 2018; Ward & McComb, 2017). Although preceptors are generally selected based on their willingness to take on the role, the Measure of Innovativeness Scale showed there was further delineation that needed to be considered. Although none of the participants scored in the two lowest innovator categories, the interview themes pointed to different benefits and challenges based on the individual innovator scores. On the basis of the findings, those in higher innovative categories were able to adapt and provide a better experience for the new nurse. Less innovative preceptors perceived encountering more challenges. A master's-prepared nurse educator with a higher innovativeness score addressed the increased responsibility of being a preceptor by working with other staff members to assist in the role. The lower scoring master's-prepared nurse educator noted that she could not be an effective preceptor due to the added responsibility to her daily duties. This serves as an example of the need to anticipate potential challenges that the less innovative preceptor may experience in implementing the role. Role conflict can be addressed and decreased by a nurse leader who actively works with the preceptor.
Meeting Diverse Learning Needs
In situations where it is not possible to select the potential preceptor from the highest innovator category, the diffusion of innovation framework can also be beneficial in anticipating the challenges encountered by individuals scoring in lower innovator categories. The use of additional tools, instructional materials, managerial support, and educational updates will lessen these challenges and provide for a more consistent implementation of the role (Cotter & Dienemann, 2016). This requires the support and oversight of nursing leaders in the facility. Providing education and information to leaders in the long-term care setting is important to guide them in selecting the most appropriate member of the team to take on the responsibilities of the preceptor role. On the basis of this study's findings, the leader needs to understand the nuances of the preceptor role to continue support for it. Education for the leader includes a review of preceptor concepts and actions applied in the work setting.
Interview data provided merit to the idea that the education level or job position of the preceptor were not sole criteria to consider when selecting nurses to serve as preceptors. Challenges and benefits were not experienced the same by all preceptors sharing a common level of education, job title, or longevity in the job. The EM category identified role conflict as challenges despite have master's-prepared nurses and educators as part of the interview group. The IN category did not identify role conflict as a challenge and added the benefits of introducing the preceptor role to others in their settings. Interviews indicated that not all innovator groups shared common benefits and challenges after distribution of master's-prepared and seasoned preceptors were equal. In this case, participant perceptions of program benefits and challenges were identified by the individual's innovator category rather than their level of education.
Nurse Educator Opportunities
The nurse educator can use the innovator category designation to develop learning strategies that meet the unique needs of each category (Cotter & Dienemann, 2016). This, in turn, will provide for more consistent implementation of the preceptor role in the work setting. Scaffolds, or educational materials such as checklists, scripts, and worksheets with simple instructions and case studies directly related to the work setting, can foster the application of preceptor concepts for the more pragmatic and risk-averse participant (Bengtsson & Carlson, 2015). The provision of supplemental materials with additional instruction to more innovative participants will better allow them to share information with others and sustain the preceptor role in their work setting. The challenge of continued postprogram support creates an opportunity to develop continuing education that provides support, information, and education to preceptors who are in need of a refresher when called on to mentor a new nurse (Tracey & McGowan, 2015). The use of classroom or online modules posteducation can serve to provide a refresher for previous preceptors, support of the preceptor as they continue in the role, or supplemental information for preceptors wishing to train and educate their colleagues.
Nurse Leader Opportunities
The unique needs of individual innovator categories should be considered by nurse leaders responsible for selecting nurses to be trained as preceptors, and the nurse educators charged with developing and delivering the preceptor education and training. Preceptor selection, usually predicated by level of education and job position, is a challenge in settings where the number of higher educated, long-tenured nurses is lacking. If the proposed preceptor is more risk averse, he or she may identify challenges in applying the concepts. A leader can set the tone in the facility that communicates the value of the preceptor role in transitioning the new nurse from student to professional. Support from the leadership in the facility can mitigate the role conflict experienced by the less innovative preceptor as they deal with the duties of their traditional job (Quek & Shorey, 2018; Ward & McComb, 2017). The nurse leader can work with the preceptor to temporarily delegate the preceptor's job responsibilities to other colleagues so that the preceptor effectively applies all program concepts. In this way, the role conflict experienced by a less innovative preceptor may be decreased. Leaders can also foster the more innovative preceptor to share knowledge and information to others in the facility as a trainer. By setting the expectation that all staff play a role in the support of the new nurse, the nurse leader supports the importance of all staff understanding preceptor concepts.
The population was limited to participants from the four cohorts of the NJAC preceptor education program. It is possible that participants may have differed from those preceptors who chose not to participate. Although three innovator categories (innovator, early adopter, and early majority) are represented in the sample, there are no late majority or laggard participants.
The effective implementation of the preceptor role is pivotal to the successful transition of the new nurse from student to professional. Part of the challenge is selecting the most effective person for the role. The focus of the study was to better characterize the most appropriate candidate for the preceptor role. Selection criteria based on the potential preceptor's level of education, job title, or years of experience are not a guarantee that the preceptor will be successful in his or her role. The degree to which an individual was willing to take risks and take on the role of innovator may be a better indicator or selection criteria when considering the most appropriate person to select as preceptor. Demographic criteria did not provide a clear indicator of the benefits and challenges presented to preceptors as they strive to apply the role in the work setting. This is a more objective method for selecting the most appropriate preceptor. It also identifies the challenges faced by preceptors who may be more risk averse and provides an opportunity for delivering the education and training that best meets the needs of a more diverse group of preceptors. In addition to identifying preceptors who are best-suited to the role via organization-defined criteria, having candidates take the 20-item Scale for Measurement of Innovativeness (Hurt et al., 1997) to determine their innovativeness level can also provide educators and leaders with challenges to address for optimum preceptor effectiveness. This initial work on preceptor selection and innovativeness addressed a relatively small sample. Future studies of preceptors and innovativeness will be conducted to expand on examining innovativeness in more diverse groups of new preceptors.
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Innovativeness Scores by Category
|< 46||Laggard (L)|
|46–56||Late majority (LM)|
|57–68||Early majority (EM)|
|69–80||Early adopter (EA)|
|> 80||Innovator (IN)|
Interview Participant Demographics
|Individual Innovator Score From Survey||Assigned Interview Group||Education||Job Title||No. of Years in Job||No. of Preceptees|
| 84 (IN)||IN||MSN||Regional director||1–3||1–2|
| 81 (IN)||IN||ASN||Charge nurse||1–3||1–2|
| 78 (EA)||IN||BSN||Director of nursing||>10||1–2|
| 77 (EA)||IN||MSN||Regional director||4–6||1–2|
| 77 (EA)||IN||ASN||Educator||1–3||>5|
|Early adopter (EA)|
| 76 (EA)||EA||MSN||Regional director||>10||1–2|
| 75 (EA)||EA||ASN||Director of nursing||6–10||>5|
| 73 (EA)||EA||BSN||Director of nursing||>10||0|
| 72 (EA)||EA||MSN||Educator||4–6||3–5|
| 71 (EA)||EA||ASN||Charge nurse||4–6||1–2|
|Early majority (EM)|
| 71 (EA)||EM||MSN||Director of nursing||>10||1–2|
| 71 (EA)||EM||BSN||Director of nursing||1–3||>5|
| 68 (EM)||EM||BSN||Director of nursing||1–3||>5|
| 66 (EM)||EM||ASN||Educator||>10||0|
| 59 (EM)||EM||MSN||Educator||>10||3–5|
Summary of Qualitative Themes by Innovator Category
|Introducing Preceptor Concepts to Others||Materials as Resources||Role Conflict||Lack of Postprogram Support|