Clinical excellence remains at the center of most educational programs. Yet educators are divided on how to configure clinical learning experiences for undergraduate nursing students (Itano, Warren, & Ishida, 1987; Myriek, 1988a, 1988b; Shamian & Inhaber, 1985). Failure to provide relevant clinical experiences has ramifications not only for the students, but for the program and the profession as well. For the student, a poor clinical experience can lead to disillusionment about nursing and failure to integrate and learn. If students are continually dissatisfied with the quality and scope of their clinical experiences then the program may suffer. Finally, failure to adequately introduce students to the reality of nursing has been blamed, in part, for the large numbers of nurses who leave the profession (Itano et al., 1987; Limon, Spencer, & Waters, 1981).
Background of Study
Traditionally, the role of faculty has included direct clinical supervision of undergraduate students. Within a university or college setting, faculty are expected to be expert clinicians, teachers, and productive researchers. Maintaining clinical skills in light of other professional responsibilities may be difficult at best (Donius, 1988; Mundinger, 1988). Such demands may prevent faculty from spending adequate time in the clinical setting to keep skill levels up-to-date.
Another problem within the traditional clinical supervision system is student-instructor ratios of up to 1:10. This means that very little actual teaching time can be spent with each student. WaBg7S and Blumberg's (1983) observational study noted type and times of student-instructor interactions. They found that a third of the interactions between students and instructors took 1 minute or less. These short periods of interaction may mean that few students receive in-depth clinical instructions.
To provide the in-depth supervision necessary for clinical excellence, the faculty of the Columbia University School of Nursing have adopted preceptorship as the method of choice for the first and the last clinical experiences in the undergraduate program. The preceptorial experience at Columbia for first-level students consists of the clinical portion of the last 7 weeks of the Foundations of Nursing course. The first 7 weeks are skills laboratory sessions where students learn such nursing skills as vital signs, hygiene, and mobility and immobility concepts. At the last level, students have a preceptor for their leadership clinical experience. The students* clinical occurs at a variety of hospitals within the metropolitan area.
Preceptors provide one-on-one supervision in clinical experiences. All preceptors are prepared at the baccalaureate level at least, and may apply for associated appointment at the university. All the preceptors receive an orientation to the program and a manual that explains their duties as preceptors.
The purpose of the study was to examine how undergraduate students perceive the preceptorial experience. The use of preceptorships for senior experiences are well-documented, but no literature was found on the students' perception of the experience. Also, as the use of preceptors in the first clinical is unique, the study examined the similarities and differences in perception between first- and second-level students.
The word preceptor has its origins in 15th century England where it meant a tutor or instructor. Preceptor first appeared as a classification term in the Nursing Indexes in 1975. Indicating its growing popularity, in 1988 alone, there were 17 references listed under precepting in Cumulative Index of Nursing. According to Shamian and Inhaber (1985, p. 79) most references within the nursing literature refer to preceptorship as the "one-on-one teaching of new employees or nursing students, in addition to her regular unit duties." Within an educational setting, preceptorship is generally defined as an intense, one-onone, reality-based clinical rotation for a student nurse whose learning experiences are coordinated and supervised by a staff nurse (Clayton, Broome, & ElHs, 1989; Donius, 1988; Itano et al., 1987; Myrick, 1988a, 1988b).
The first and most common reason why preceptorship programs are established is that they are thought to reduce "reality shock." Kramer's (1974) conceptualization of reality shock has provided the framework for many of the preceptor studies. Clayton et al. (1989) asked whether students in a preceptorship program during a senior practicum would report higher professional socialization behaviors than students who were not. They used a nonequivalent control group design. A total of 66 senior nursing students were assigned to a control or experimental group. Schwirian's Six-Dimension Scale of Nursing Performance was used to measure professional socialization. There were no differences in the groups when measured before study. Immediately after the experience, the preceptorial group scored higher on five of the six subscales. At 6 months after the study there were still significant differences in four of the six scales. Their study appears to indicate that preceptorial experience did provide a change in role conception for this sample.
Dobbs (1988) studied anticipatory socialization using Corwin's Nursing Role Conception Scale. She administered the questionnaire to 103 students before and after a preceptorial experience. She hypothesized that students would exhibit a significant decrease in perceived role deprivation after the preceptorial experience. Total role deprivation scores did decrease significantly (p<-001) after the experience. In addition, she found an increase in the number of students choosing a work-centered role model as opposed to a school-centered or no role model. Unfortunately, the lack of control group and the use of gain scores reduces the value of this study.
Itano et al. (1987) also examined role conception and role deprivation between preceptorial and nonpreceptorial students. It appears that the preceptorial experience was a senior one, although that is not clear from the description of the study. A total of 1 18 students were in the study. The researchers used Corwin's Role Conception Scale to measure the variables of role deprivation and role conception. The students were measured during the program, immediately after, and 4 months after graduation. The researchers found no significant differences between the groups at any time of measurement in contrast to Dobbs" study. Differences in the sample and in the study design make it difficult to discern the reason for the discrepancy.
Researchers have also examined whether preceptorial students show differences in learning. Shamian and Lemieux (1984) evaluated the preceptor model against a formal model of teaching nurses about the assessment and management of confused patients. They used Cooper's theory of dependent and independent learning as the basis for their study. The nurses on 14 hospital units were randomly assigned to receive preceptorial or formal teaching. The total number of nurses participating was 316. Each group completed two questionnaires, the first immediately after the teaching and the second 3 months later. While there was virtually no difference in knowledge at first questioning, at 3 months there was significant difference. The preceptorial group answered correctly 50% more often than the formal education group. The authors suggested that preceptorships helped with the reinforcement and internalization of knowledge.
Huber (1981) and Marchette (1984) both studied whether a preceptor model would improve clinical performance of new graduates. The preceptorial graduates were compared to those who received a traditional orientation. No difference was found between the groups in either study. Olson, Greasley, and Heater (1984) found the same results in undergraduate students who went through an 8-week preceptorial program when compared to a group who were traditionally taught. Myrick ( 1988b) also found no difference in performance between preceptorial and nonpreceptorial students at the end of a 3-week clinical period. In light of Shamian's and Lemieux's (1984) finding that differences were not apparent immediately, the time of measurement may have masked results in the aforementioned studies.
A study by Infante, Forbes, Houldin, and Naylor (1989) provided some evidence that the use of preceptors may aid performance, although they did not define preceptorship as involving teaching, but rather role modeling, mentoring, and as a resource. Their study contrasted the results of the traditional clinical teaching with the atypical method that used preceptors along with faculty and extensive use of clinical laboratories.
In the study by Infante et al. (1989), a total of 161 students were randomly assigned to either the traditional or nontraditional program at the beginning of their junior year. The students were measured on Grade Point Average (GPA), NCLEX scores, Mosby Assesstest scores, psychomotor skills, and responses to vignettes that measured critical thinking and creativity. The nontraditional students scored significantly higher in GPA (t =1.79, p<.05), Assesstest scores (t= 1.92, p<.05), and psychomotor skills test scores (t=2.35, p<.05). There were no significant differences between vignette responses for critical thinking or creativity, or NCLEX scores. While the responses show some benefits for the nontraditional program, it is significantly different from more typical preceptor programs and the results should be viewed cautiously.
Infante et al. (1989) use the term preceptor to mean a staff nurse who does not have teaching responsibilities but serves as a role model, mentor, or resource person to the student. While role modeling may serve to educate, it is haphazard in that observation at the correct time usually cannot be guaranteed. Mentoring is generally conceived as an optional or voluntary activity in which an experienced worker provides advice, supervision, and help to a less experienced worker in order to help their career growth. Preceptorship may or may not involve elements of role modeling and mentoring and so the terms should not be used interchangeably.
In yet another view of the preceptorial experience, Scheetz (1989) looked at non-school-sponsored summer preceptorship programs' effect on the development of clinical competence. Scheetz used a nonequivalent comparison group pretest/posttest design. A total of 72 baccalaureate students participated in the study; 36 students participated in a preceptorial summer experience, and 36 worked as hospital aides. The Clinical Competence Rating Scale (CCRS) was used to measure the variable of interest. Scheetz found a significant difference in CCRS scores, with those in the preceptorial experience scoring higher than those who were aides. The study lends some credence to the anecdotal findings that preceptor programs help students to practice skills, to apply theory, and to improve decisionmaking and priority setting.
Brown, Collins, and Duguid (1989) write that learning takes place best within the setting in which it is to be practiced. They call the process cognitive apprenticeship. They write that "cognitive apprenticeship methods try to enculturate students into authentic practices through activity and social interaction in a way similar to that evident - and evidently successful - in craft apprenticeship" (Brown et al., 1989, p. 37). Scheetz (1989) defines preceptorship as an experience outside of the formal curriculum, such as in the summer where a student is guided by the RN preceptor in caring for assigned patients. As defined by Scheetz, preceptorial experiences are more akin to apprenticeships where job training is provided without the benefit of a college- or university-based educational program.
It is apparent from the literature review that although preceptorship is popular, studies of its benefits have mixed results. Many of the studies are flawed and should be viewed with extreme caution. Also, the only information contained in most articles was that the student or new graduate worked one-on-one with staff There was no mention of the quality of clinical experiences provided or how the students viewed their clinical experience.
The fact remains that preceptor programs are popular with educators and in clinical settings. A traditional preceptor program allows for a more economical use of nursing faculty; one instructor can be assigned to more than 10 students because the direct clinical supervision is done by the staff member. Theoretically, the student may also receive a better clinical experience as she is guided by someone who knows the patient, the unit, and is up-todate on the care of that type of patient. In addition, the preceptorial clinical's base in reality may help decrease reality shock. It is also theorized that being a preceptor should lead to increased job satisfaction as a result of personal and professional growth.
The research questions that guided this study were:
* How do preceptorial students perceive their clinical experience?
* Are there differences between first- and second-level students in how they perceive the preceptorial clinical?
The target sample consisted of 29 first- and 15 secondlevel undergraduate students. The students in the program had an average age of 32 years, 60% had another degree, 20% were married, and all were female. The response rate was 50%.
The investigation was a qualitative descriptive study. To assure as much honesty as possible, data were collected by anonymous questionnaire rather than interview. The questionnaire asked no identifying information, such as hospital site, title of preceptor, or type of patient. All the students received a letter explaining the purpose of the study, their rights, the anonymity of the questionnaire, and how the information was to be used. To provide a means of follow-up without compromising anonymity, the students were asked to develop a self-selected three digit code and place it on the form.
The questionnaire consisted of a series of open-ended questions adapted from Windsor (1987). Windsor's study examined clinical in the traditional mode so the questions were changed to reflect the preceptorial experience. Figure 1 lists the questions that were asked of each respondent.
After the questionnaires were returned, content analysis was performed on the answers. The categories were established by the questions posed and the whole response to the question became the unit of analysis. Each answer from each question was examined for key terms by the researcher. The key terms were placed on file cards, rank ordered under each question, and were examined for themes.
Once the themes emerged, they were judged to be appropriate and exhaustive by another researcher. As a check of reliability, the themes were examined for internal and external plausibility. Internal plausibility was judged by internal consistency and relevance to the clinical experience. The themes also appeared externally plausible because they appeared to reflect the totality of the clinical experience. No answers were unassigned, so the themes were also judged to be inclusive. The themes provided evidence for their validity as the answers were consistent with the literature about student clinical experiences (Windsor, 1987; Infante, 1985).
To explore the differences between the experiences of first- and second-level students, the questionnaires were divided and examined within each level. The answers were placed in descending order, with the most frequent responses appearing first on the list.
Two overall themes emerged from the content analysis of all the returned questionnaires: what students desired from their clinical experience, and the factors that influenced that experience. Within the factors that influenced the experience, four subfactors emerged: the influence of the school, the hospital, the staff, and the student (Figure 2). In general, the first-year students concentrated on becoming comfortable as student nurses and learning the parameters of that role. The second-year students were much more concerned with their own performance and professionalism. If a second-year student did not accomplish her goals or those of her preceptor, she saw it as a reflection of herself as a nurse rather than a failure of the preceptor to provide direction, as would the first-level student.
Themes Pertinent to the Preceptorial Clinical Experience
Clinical Views of Preceptorial First- and Second-Level Students
Figure 3 lists the differences in perception of the preceptorial experience between first- and second-level students. It is interesting that while the second-level students would change nothing about their clinical experience, the first-level students indicated a need for more structure and guidance.
In general, the responses relating to what students want from clinical provided few surprises. Preceptorial students, like any other nursing students, want to learn within an environment which is conducive to that learning. The fact that the responses are consistent with students who are educated within the traditional clinical model provides some evidence that the students* education is not jeopardized by the preceptorial experience.
The factors that influence the students' clinical are clearly important to the student experience. Preceptorial students need as much, if not more, guidance than the instructed student. The difference is that the hospital, the preceptor, and the unit provide more ofthat direction to preceptorial students. Faculty need to ensure the preceptorial student experience by providing clear directives about learning experiences and the objectives of the clinical course, by providing faculty support to all clinical settings, and by following up on clinical experiences to assure that the appropriate lessons are learned. The one unexpected finding is that the staff nurses on the floor are very important to students. Students want staff nurses to be welcoming and to provide them with role models.
Windsor's (1987) study provided the format for the questions asked in this present study. However, Windsor studied students in a traditional program, and the present study examined only preceptorial students. While there are obvious methodological problems in comparing the two studies, it is apparent that many student concerns may be universal. For instance, students in both studies emphasized the importance of preparation and the value of caring for a variety of patients.
The students in Windsor's study were very concerned with the personal characteristics of the clinical instructor, such as whether she had a sense of humor, was warm to them, enthusiastic, and so forth. The students in the present study were more concerned with their preceptor's professional competence than personal style. Preceptors are chosen for their clinical expertise, and that is how the students appeared to judge them. Instructors were judged not only on clinical expertise but on a variety of other personality characteristics. The instructor's direct link to the educational system may be part of the reason for this difference.
The present study had no means of comparing the stages of development in preceptorial students with nonpreceptorial students, so the results were again compared to those of Windsor (1987). Windsor studied students in the last clinical course only and found that the students moved through three levels of development during that time. In the first stage, students were unsure and focused on skills; in the second stage, they were more sure of themselves but had no articulated focus for their clinical care; and in the third stage, the students became confident, more independent, and felt more like real nurses. In the present study, only the first-year students exhibited attributes of the first and second levels. The second-year students reported functioning on par with staff nurses, being comfortable in their clinical setting, and exhibited no dependence upon the preceptor or staff
Thus, it may be that preceptorship hastens the professional growth of students. By providing a more realistic view of nursing, it may indeed reduce reality shock. The low response rate may provide a biased view of the preceptorial experience by selectively highlighting either those that were very satisfied or those that were very unsatisfied. Future studies are planned that will examine job satisfaction, length of employment in first position, and other selected indicators of reality shock in graduated preceptorial students. In addition, the movement of preceptorial students through the stages of professional growth warrants further study.
The preceptorship of undergraduate student nurses is gaining in popularity, especially for second-year experiences. No studies were found that examine the students' view of the preceptorial experience, nor was there any mention of the use of preceptorials for first-year students. The present study sought to determine the positive and negative factors contributing to the preceptorial experience. The study revealed that the school, the hospital, and the student all contribute to the clinical experience. The study also sought to determine if students at the first and second level viewed the preceptorial clinical differently, and found both similarities and differences. It appears that the difference in viewpoint between the two levels probably reflects the difference in professional growth.
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Themes Pertinent to the Preceptorial Clinical Experience
Clinical Views of Preceptorial First- and Second-Level Students