Sometimes it seems that a lot of nursing interventions in rapidly changing situations are either reflex or intuition and difficult to teach. I try to teach new nurses by keeping them at my side, observing me, and explaining things as I can.
As Joan Osburn, an experienced preceptor and nurse of over 20 years, points out, precepting new employees or student nurses is a more complex process than is currently understood. Learning about precepting through stories of nurses' lived experiences provides nurses with a rich context for discovering skilled practices and shared meanings involved with precepting. An interpretive or hermeneutic method (Benner, 1984; Benner & Wrubel, 1989; Packer, 1985) can be used to understand how nurses precept.
The power in narratives and an interpretive approach to teaching is derived from the authoring process (Bruner, 1987; Diekelmann, 1991; Polkinghorne, 1988). "Authorship* involves more than a simple recounting of events. Authoring a story, then sharing the story publicly has been described by Tappan and Brown (1989) as a powerful process in developing moral sensibility. They argued that "a central aspect of the process of moral development is both expressed and enhanced through the use of stories" (Tappan & Brown, p. 190). The telling of a story gives authority and responsibility to the storyteller. Thus, authoring and telling a story changes the authoring person over time and is empowering to staff nurses as they appreciate the skilled practices involved with precepting.
This article has two purposes. First, it describes an interpretive approach using narratives in preceptor development programs, and proposes precepting as one path toward developing a sense of community in nursing practice. Second, narratives written by nurses are included to show how we can understand and learn about precepting through hermeneutic interpretations of nurses' narratives.
Preceptor Development Programs
The behavioristic conception of precepting includes extensive use of skills checklists emphasizing technical competencies with principles of adult learning used to guide the precepting process. The behavioral model is, however, inadequate to understand the complexity of precepting, which can only be understood within the context of the practice of precepting. Moreover, a behavioristic approach does not consider the importance of creating a community of care in nursing practice, which is important to sustain caring practices in precepting. The turn toward communities of care moves us away from the individualism inherent in behavioral education and provides alternatives to the isolation and competition of behavioral pedagogy. Using narratives in preceptor development programs provides a powerful way to assist in reconceptualizing precepting and in transforming preceptor education.
The preceptor development program at the Gainesville VA Medical Center in Gainesville, Florida, uses narratives as a central teaching-learning strategy to uncover skills and aspects of precepting that are often taken for granted or glossed over. The program, adapted from Diekelmann's clinical education course at the University of WisconsinMadison, consists of four 2-hour seminars. Nurses write two narratives during the program: (1) a student experience they will never forget because it taught them something about what it means to be a student in nursing, and (2) what it means to be a preceptor in nursing. During seminars, nurses read their stories and talk with other nurses and staff development instructors to discover and reveal the shared practices and meanings embedded in the stories.
Written stories are usually submitted prior to the seminar so the instructors have an opportunity to reflect on the meanings and skills included in the story and can guide the discussions. Stories are read by the preceptor during the seminar, shaping the discussions as participants share their understandings of the narratives. For the instructors, the emphasis shifts from giving of information and evaluating outcomes to joining with the nurse clinicians in discovering aspects of the lived experiences of nurses in the skilled practice of precepting.
Conversations about shared practices and ways of thinking can be transformative, providing the possibility for a sense of community to develop. Sharing stories creates the possibility for nurses to develop communities of memory that not only tie us to the past but also move us toward the future as communities of hope (Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985). Preceptors may be a critical link in promoting communities of care that are so badly needed in nursing and in the health care system.
Narratives of Student Experiences: Being a Student Nurse
Teaching is an important aspect of precepting. It is influenced in part by the early experiences nurses have in their educational programs. Stories about a significant event that occurred when preceptors were students can evoke memories of past experiences and the meanings they bring with them into teaching and learning situations (Diekelmann, 1990, 1991). When used in discussions with preceptors, these stories provide valuable knowledge and insight about teaching and learning in nursing.
Joyce Hauner, a skilled preceptor and nurse of 20 years, shares the following story:
It was my third day on a hospital unit as a student. The morning was progressing well when suddenly a physician appeared and told me that I would help him change a dressing. I, of course, being the obethent student as we were always taught, knew I was to do what the doctor said.
An older nurse also came to assist. Where was my instructor? I didn't know but still couldn't refuse to assist a doctor even if all I knew how to do was give a bath and make a bed!
When we arrived at the patient's room, we stopped at the foot of this very obese elderly lady's bed. No one addressed the patient. The doctor proceeded to don sterile gloves while the older nurse proceeded to remove the dressing from the left stump of the patient. I was instructed to elevate this very heavy stump and "hold it because I can't." Following orders, I picked up this very heavy thigh - so heavy I had to rest my elbows on the bed for support.
Just as I had a good grasp on the stump, the older nurse unwrapped the final portion of the dressing revealing a huge gaping wound with black edges, red raw flesh, and a bone protruding from it. Not wanting to appear squeamish in front of the doctor and nurse, I set my jaws and held on. The doctor wasn't just changing the dressing, he was poking and prodding this grotesque thing I was holding! It became heavier and heavier as I became sicker and sicker. After about five minutes I knew I was going to faint. I dropped the stump and ran to the nearest bathroom to compose myself After a couple of minutes, my instructor found me. Where was she before this took place? She came to see if I was OK. Of course, I was by then.
Had I been forewarned by the older nurse, if she had told me what was under the dressing, I might have survived through the entire procedure. This experience has been indelible in my memory. As a seasoned nurse, I rarely fail to inform a new RN or student nurse of the experience she may expect, especially those unpleasant portions in the day of a nurse's working life.
Joyce relates what she learned about teaching and learning from a traumatic experience as a student and connects this previous understanding about teaching and learning with how she precepts now. The student's turmoil was influenced by the fact that both she and the patient were treated as objects. In addition, her story helps us to understand the importance of preceptors providing backup and support for orientées and students in addition to anticipatory guidance. Her story speaks to the unintended domination and control experienced by new nurses, how it is passed from one generation of nurses to the next in our common struggle for equality in the practice environñTent. We see in this story the possibility for breaking the cycle of reproducing unintended domination and control through caring practices in precepting and in nursing practice with patients.
Nidia Back, an experienced nurse, extends this understanding as she relates a memorable story telling how she learned about the meaning of preserving personhood.
There is one day during my nursing school days I will never forget. It was my first experience in the hospital during my first year. It was a cancer hospital and my first patient had a tracheostomy. The patient was sitting in a chair and I was making the bed. After I finished making the bed, the teacher made me do it all over because the bottom sheet was wrong side out. I felt angry because she was watching me all the time and waited until I finished the whole bed before telling me the sheet was wrong.
Then, the patient was trying to tell me something, but with a trach, I couldn't understand what he was saying. He was losing patience with me and began talking faster and making wild gestures. I was very nervous and upset and about to cry. At that time I thought about quitting nursing altogether.
Nidia recalls years later the pain and anger she felt when a teacher watched her make a mistake in front of the patient and said nothing. She describes the helplessness and frustration she felt as a novice when the guidance and support needed to help her communicate with a trach patient was missing. From this painful experience, Nidia reflects on her lived experiences as a novice in nursing and sees the connection between what nurses teach each other and how we teach. She understands the damage that a depersonalizing and disrespectful approach can have in teaching and learning experiences.
Nidia seeks to create respectful, caring, and empowering relationships, not just for her patients but with her colleagues also. For her, providing the backup, supportive guidance, and learning experiences that are so important in novice nursing is a part of her nursing practice. To nurse is to precept. We are always providing, in one way or another, this backup, support, and learning that characterize precepting to both our patients and our colleagues. It is what nurses do for their patients, each other, and the other members on the health care team. Precepting becomes a form of nursing practice. It takes advantage of knowledge and skills of adult education. But precepting is principally shaped and informed by nursing practice.
Narratives About Precepting: Being a Preceptor
Precepting new employees or student nurses is an intricate process because nurses are faced with teaching a novice or new nurse while providing care to patients, supervising other employees, and monitoring other patients. Nurses know how to attend to these multiple demands as a part of their nursing practice.
Joan Osburn describes her experience as a preceptor.
It started off being a quiet Sunday afternoon. I was precepting a nurse in her fourth week of orientation, I was working with another RN who had just completed orientation, two LPNs, and an NA. I overheard the doctors discussing Mr. S., a patient on the other UN's team who had been having melena stools. His hematocrit had dropped and the medical student asked the LPN to do orthostatic vital signs. Since the nurse who had that team was off the floor, I decided to also check the patient.
It was decided to insert a salem sump and lavage the patients stomach. While myself and two LPNs were monitoring vital signs and assisting the doctors with the procedure, I asked the orientée to talk with Mr. S.'s wife and reassure her. The doctors were having some difficulty with the procedure so I gave them some helpful hints when we started getting some bright red blood return.
When the other RN returned from break and saw what we were doing, she stated she did not know why we were lavaging him and did not seem to know what to do. I knew I would need to help with this situation. The patient was continuing to have emesis even with the nasogastric tube and loose tarry stools. The patient became extremely anxious and I knew this was not the time or place to instruct the RN. The orientée was doing quite well taking my lead and assisting with the patient.
When the first unit of blood arrived, I went through the procedure with the two new nurses. Realizing that I would have to revise my own assignment, I asked the LPN to make rounds, complete intakes and outputs, and pass meda while the NA answered the phone and call lights because there were no ward clerks available. I then had my orientée complete her work so that she would be available to help me later.
As we worked on the patient, the doctors decided to transfer him to the ICU. I felt comfortable with the other RN giving the ICU nurse a report and arranging the transfer. We let the patient and his wife have a few moments together and then transferred him to the unit. After all of this was completed, I knew I would have to break down the afternoon occurrences and explain how the RN could have assisted more effectively. In addition, I would review the whole event with the orientée, outlining all of the responsibilities in this type of situation.
Joan's story helps us understand the range of skills required of preceptors - clinical expertise, management skills, and teaching ability. Her story shows us that when a patient's condition worsens, or when breakdown occurs, the preceptor becomes the newer nurse's backup while managing the ongoing needs on the ward and the orientee's learning needs. Providing backup to new nurses means developing the practical knowledge of when to take over and when to allow the new nurse to continue providing the care. Her story makes visible the nuances and intricacies of precepting while balancing multiple demands on a busy surgical unit. Precepting is "being in the thick of it* and includes meeting multiple demands in rapidly changing situations, the importance of backup during breakdown, and the importance of timing in teaching preceptees or students. Timing is a recurrent theme in preceptor stories. These themes become topics for discussion during the preceptor education course.
Jennifer Bauder-Heidt, a nurse on a cardiovascular surgical ward, also tells a story about the importance of timing in coaching a student nurse through a difficult procedure. Her story is important because it speaks to the skill of knowing when and how to push learners to complete difficult patient care activities.
One of my patients was having a hard time adjusting to life after his leg amputation. I knew him and his family very well because he had been my patient off and on for a couple of years. At 55, he had run 10 miles; by 59, he had had 5 major surgeries. No wonder he was having problems adjusting. He enjoyed having nursing students involved with his care and he often requested one, but had lost interest in this since his amputation.
I talked him into having a nursing student work with him on one particular day but I regretted it after I met the student. She had problems coping with anything out of the ordinary and she definitely had problems relating to people who belong to cultural groups different from her own. I overheard her tell one of her peers that she didn't want to do his dressing change because it was "just too gross." Exactly what he needed, I thought to myself - someone to reinforce his negative feelings about himself.
It was an uncomfortable day for everyone and the student's instructor spent a lot of time talking with her about her feelings about doing his care and his dressing - more time than I thought was necessary. My patient and his family also let me know that they weren't having a good experience with this student but they decided to give her a second chance. The afternoon came and it was time to do his dressing. I offered to go and watch the student do this, mostly, I thought, in order to protect the patient.
I arrived at the room as the student was setting up for the dressing and as soon as I got there, she wanted to argue with me. I don't remember now what it was about but I do remember that it made the patient visibly more upset. Needless to say, I didn't argue - I just listened to her, assuming she was anxious. Finally, she started to take off the old dressing and when the patient flinched slightly, she stopped abruptly and informed me that she simply couldn't handle doing this. Another blow to my patient's self-esteem had occurred. He was very perceptive and he realized she had problems looking at his stump. I stood there for a minute and I was getting aggravated in addition to understanding how bad this was for the patient. Finally, I said to the student in a low but rather firm voice, "Cut this stuff out and just do it." There could have been no doubt in her mind that I would tolerate no further discussions. Without another word, she did the dressing using excellent technique and in record time. I was amazed.
What I had learned was that there are so many times in nursing that situations make you want to be hysterical, uncomfortable, or anxious and that, often, all this analyzing of why you are uncomfortable only makes you more anxious. It also may make your patient more anxious or reinforce negative feelings he or she is having. Many times you have to tell yourself to "just do it" without any further hesitation. This is something I work on with my orientées now . . . the concept of doing something without hesitating. I have had quite a few tell me later that this was a technique they found very useful in anxiety-provoking situations which seem to be abundant for new nurses and students. I was off for a few days after that incident, and when I returned, my patient proudly informed me that he did his own dressings now and would be going home the next morning. I asked him what had made this big change in his attitude. He looked up at me with a wide grin and told me, "Oh, I decided it was time to cut out that stuffand just do it."
Jennifer attended to the needs of the patient and the student. This story shows us how the nurse achieved a delicate balance between the patient's needs and student's needs. She knew the patient well and felt that he could benefit from having an experience with the student. While coaching the student and perhaps even the patient she was able to achieve goals for both! She expresses some of the frustration that preceptors experience as they guide students through situations that have a potentially negative impact on patients. However, her story resonates with her joy in "getting it right" for both the student and the patient who also benefited from her advice to "cut out that stuff and just do it." Because precepting is demanding of nurses' time and energy and because precepting, like any other skilled practice, does not always go the way we would like, the need for a supportive and caring community is ever more important. Stories such as this one help preceptors recognize the need for a supportive community in which to practice.
Narratives from the preceptor's experiences of being a student can provide opportunities for preceptors to explore the background knowledge they bring into their practice of precepting. Narratives of precepting experiences provide a way for nurses to understand their work as preceptors and to uncover their skilled practices. Understanding precepting from the "inside out" through narratives is an exciting alternative approach to developing preceptors. An interpretive approach to precepting education promotes positive learning experiences for students and orientées and restores the narrative to the nursing practice of preceptors.
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