Nursing students need to successfully complete an exiting clinical course prior to being approved to write the Canadian Registered Nurse Examination. In this final clinical course, students are taught, supervised, and evaluated by a registered nurse, who is designated as the students’ preceptor. Throughout this final clinical practicum, the nurse preceptor is central to students’ education, skill development, and evaluation of students’ readiness for practice. Hence, preceptors are not only key to ensuring the best caring practices that characterize every day nursing in the clinical setting, they also ensure students are committed to the professional responsibility of life-long learning (Paton, Martin, McClunie-Trust, & Weir, 2004).
The preceptorship model’s effectiveness for guiding student learning during the final clinical practicum and preparing students to embody the role of a newly registered nurse has been well documented (Robinson, McInerney, Sherring, & Marlow, 1999; Trevitt, Grealish, & Reaby, 2001). However, the role of preceptoring students is less understood, rewarded, and acknowledged, and the process of recruiting and retaining preceptors is a concern (Paton et al., 2004; Yonge & Myrick, 2004). To date, the nurse preceptor role is not commonly viewed by nurses as one of career advancement; however, the vital role that these nurses have in educating and evaluating students in their final clinical practicum requires advanced level clinical expertise and knowledge.
Nursing research identifies a direct relationship between preceptor acknowledgement; support and development; and the ease in preceptor recruitment, retention, and commitment (Greene & Puetzer, 2002; Griffin, Hanley, & Saniuk, 2002; Myrick & Yonge, 2005; Usher, Nolan, Reser, Owens, & Tollefson, 1999). In preparing and evaluating students for the RN role, preceptors acquire practical skills and expertise in teaching; they pass on, role model, and assess professional competencies and standards of care; and they demonstrate and evaluate knowledge gained through patient care situations and experience (Myrick & Yonge, 2005; Paton & Binding, 2009; Paton, Robertson, McKiel, & Thirsk, 2006). Preceptors accrue practical, professional, and experiential teaching knowledge (Higgs, Titchen, & Neville, 2001; Paton, 2005), yet there is a dearth of literature and research describing how nurse preceptors integrate these three forms of knowledge in their everyday preceptorship practice.
In an endeavor to explicate the knowledge represented in the integration of practical, professional, and experiential knowledge of nurse preceptors, and to more fully acknowledge the professional practice of nurse preceptors, two funded research projects were conducted. The genuine knowledge nurses acquire during preceptoring was revealed through four unique domains of practice: artfully connecting, creating a culture of respect, acknowledging contextual realities, and preserving the ideals of respectful, ethical, and competent practice. These domains of preceptor practice will be described, following the presentation of the background and the research process of the conducted research projects.
Clinical practicums offer undergraduate nursing students the opportunity to integrate and apply the multilayered levels of knowledge provided theoretically, technologically, and practically in the classroom, the teaching laboratory, and more recently, through simulation (Gaberson & Oermann, 2007; Hauri & Gibson, 2000; Kaviani & Stillwell, 2000; Paton, 2005). Through experiencing the realities of practice, students learn “how” to ask questions and provide care to patients in a continually changing and often chaotic, complex clinical environment. In the clinical environment, the patient and family are foreground; theoretical and laboratory knowledge are background. The implication is that students are able to access the appropriate knowledge gained in one setting (academia) to respond ethically and competently to the complexity of patient care situations in another environment.
The process of translating knowledge from the classroom and laboratory context to the clinical environment is challenging and fraught with assumptions that overlook the contributions of precepting. For example, the conventional model of teaching and learning proposes that propositional knowledge gained through theory and classroom teaching and testing (Higgs et al., 2001; Ironside, 2003) is applied to practical situations with ease. Not only does this assumption overlook the unpredictability and complexity of patient care situations, but it also dismisses the contributions that experienced RNs make in the act of preceptoring students during the practicum experience.
Juxtaposed within the students’ well-intentioned purpose of learning in the clinical environment is the real-life experience that they are scared, feel incompetent, and need support (Paton et al., 2004). Preceptors then are called to answer to this next layer of complexity of relationship that involves assessment, human concern, and skilled communication (Cowin, 2002; Davies, Turner, & Osborne, 1999; Myrick & Yonge, 2005; Oermann, 1996). Herein lies the dilemma: many clinical preceptors are hired on the basis of availability and willingness, not necessarily teaching competence and experience (Myrick & Yonge, 2005; Paton et al., 2006). Yet the ones who remain over time seem to be the ones who intrinsically complete this reciprocity of relationship.
This research was situated around a profound curiosity as to the explanations RNs might offer for their own professional, practical, and experiential competencies, and ultimately, their practice knowledge within this role. Two research studies were conducted using combined quantitative and qualitative research methods. The first research project was implemented at a local level and the second at a provincial level. The first phase of both research projects was a descriptive survey sent to 770 preceptors throughout the southern area of the Canadian province. A response rate of 46% was achieved in this phase. The descriptive analysis of the surveys enabled a profile of nurse preceptors in this area to be created (Paton et al., 2006).
The second phase encompassed a qualitative interpretive phase that involved individual interviews and focus groups. The analysis of the second phase was informed by the primary work of Heidegger (1927/1962) and Gadamer (1989) and secondary nurse scholars’ interpretations offered by Benner (1984); Benner, Tanner, and Chesla (1996); Diekelmann (2001), and Moules (2002). Hermeneutic inquiry is described as the tradition, theory, and practice of interpretation and understanding in human contexts (Moules, 2002). This research approach enables a deep and rich understanding of the knowledge represented within the everyday work life of RN preceptors.
In the second phase, researchers conducted 5 individual interviews and 15 focus groups, which ranged in size from 3 to 5 participants. To ensure confidentiality, participants and focus groups were conducted in a venue unrelated to the workplace. All participants were asked to describe their experiences preceptoring undergraduate students; elaborate on any memorable, unique, or uncomfortable situations; and identify how they responded within these experiences. The interviews and focus groups lasted between 45 and 90 minutes. All interviews and focus groups were audiotaped, with participant permission, and transcribed to textual data.
The primary investigator and two coinvestigators, who had developed expertise in qualitative research informed by the writings of Heidegger (1927/1962) and Gadamer (1989), read and reread all of the transcripts individually, striving to reveal the knowing represented within the preceptors’ discussions and descriptions of their everyday work life. The primary investigator and coinvestigators met biweekly to further discuss their understandings and explicate the skill, expertise, and knowing represented within the preceptors’ descriptions.
Preceptors perceive themselves as teachers, offering students, nurses, and educators clarity on the unique professional practice knowledge that preceptors acquire as they teach students in the clinical environment. Nurse preceptors are clinically sound, and their clinical knowledge was described as a “given.” Being asked to fulfill the preceptor role was understood as an acknowledgment of their clinical expertise and their collegial approach to their peers, patients, and family members. The interpretive analysis highlighted the genuine knowledge preceptors acquire, constituted with four domains of preceptor practice:
- Artfully connecting.
- Creating a culture of respect.
- Acknowledging contextual realities.
- Preserving the ideals of ethical, competent, and respectful care.
The genuine knowledge that these preceptors described is not something that can be simply received from another, but rather, as described by Socrates, it is a “personal achievement, won only at the cost of constant intellectual struggle and self-critical reflection” (Tarnas, 1991, p. 35). Preceptors described their teaching practice as open, critically reflective, and enlightening in relation to the challenges of translating knowledge and assessing competence. One preceptor alluded to the openness and intentional nature of the role in how she “learned something new from each student…it makes you validate and challenge your own practice and the way you talk to the students…and get them to think about what is going on with the patient.”
Another preceptor described the critically reflective aspect of this role. The preceptor noted that, “An excellent preceptor is one who is willing to be introspective—introspective as to their practice, introspective as why I do it this way.” Preceptors described how they learned “from them [students] the fact that they do challenge what you’re doing; you learn to evaluate your own practice as to how you’re doing and what you’re doing.” The act of questioning, a predominant teaching strategy to get to the student’s thinking, was described as central to connecting, respecting, and preserving ethical and safe care. Best practice was learned through role-modeling care, “as if the care was being provided to their loved ones or themselves,” while also being cognizant of contextual challenges such as nursing shortages and the unpredictability of patient progression.
Artfully connecting was expressed in the preceptors’ manner of getting to know the student, while being mindful of the student’s sensitivity of “not knowing the routine,” and possibly not having the experiential knowledge that an experienced RN smoothly integrates into patient care. As described by one preceptor, this domain of practice “sets the scene for getting to the student’s thinking…assessing and evaluating the student’s level of competence.”
Another preceptor explained, “Each time there is a new student, there is another assessment and evaluation of what the student needs, and I adapt myself to each student, so they [the students] are not spoon-fed,” but rather have the chance to move ahead at “their own pace.”
Another preceptor offered how she wanted to encourage students to ask questions by “being approachable.” This preceptor tries to convey to students that “no question is silly…by asking questions, you demonstrate that you are thinking…I want you to think.”
Preceptors spent time and energy encouraging students to ask questions, challenging their clinical reasoning, and clarifying actions with knowledge and research. These discussions enhanced the trust between the preceptor and student, conveying an attitude described by one preceptor as, “We’re in it together.” Questioning was understood as a form of knowing, central to safe practice, rather than representative of incompetence on the student’s part.
Artfully connecting also was described as how preceptors included students in their experiences, sharing their knowledge, and reflecting on the unpredictability of patient progress. In sharing experiences, preceptors opened opportunities for students to describe their interpretations of a situation. One preceptor described:
Being a preceptor is about sharing experiences and knowledge…working with somebody that is able to learn, and focusing on their needs…by getting them to describe how they “see” the patient and family.
This is central to explicating how students comprehend and intervene in patient care situations and ensure safe and competent caring practice.
Artfully connecting is crucial in understanding students’ thinking, becoming familiar with students, and learning students’ personal commitments, previous clinical work, and current academic course work requirements. These insights offer preceptors direction by incorporating students’ needs, patient assignments, and learning opportunities (i.e., observing diagnostic tests, surgical procedures, and patient teaching). Artfully connecting is essential for talking with students in a trusting and extensive manner that enables accurate assessment, constructive feedback, and evaluation. Preceptors create opportunities for students to voice their thoughts; as described by one preceptor, “they create a platform for thinking to bridge understandings” between the student and the preceptor. This platform is a safe place for talking and coaching, and as one preceptor described, this platform allows her to speak plainly to her students:
Okay, think. Come on now, think. I don’t want you to give me all the fancy bookwork, scientific stuff. Just tell me basically what’s going on.
Artfully connecting is reflective of the preceptor’s wish to “be” with the student—to understand together what is and what could be happening by creating a platform for thinking and nurturing learning in an environment that is unpredictable and emotional.
Creating a Culture of Respect
Creating a culture of respect enables preceptors to accommodate students’ learning needs while being cognizant of the needs of patients and their families; the inter-professional element; and at times, institutional expectations. By role modeling engaged and intuitive communication, preceptors attune to anxieties and tensions that exist within the context and respond to these in an insightful and respectful manner. One preceptor described a discussion with a student en route to a patient visit:
One time…we were out somewhere and we got a call from the lodge informing us that we have a little old lady who has a big bruise around her eye. And her “eye is all bloodshot” and this sort of thing, you know. So we’re driving there and I say, “Okay, nurse, what are we going to be looking for?” The student never thought to ask whether she had a cold or whether she was coughing or sneezing, or had fallen…that is, to consider some of the other reasons for an increased intracranial pressure. And that’s exactly what it was! This woman had been unwell for a short period of time and had been coughing profusely.
The preceptor described how she had encouraged the student to consider the patient’s context: living on her own with little possibility for transport and minimal family involvement. She encouraged the student to think beyond the symptoms of conjunctivitis to symptoms that could increase the client’s intracranial pressure and to envision possible contextual complexities relevant to this woman’s life. This preceptor described how she challenged the student’s thinking by looking at the community and “the isolation that this woman is living in, as isolation is a big concern in community care” and to consider how this woman could be cared for in a way that would respect her needs.
In creating a culture of respect, preceptors enabled the students to think about the patient and family in the current situation as well as living within a particular context. They were mindful of the larger context of the nursing profession, the current shortages and demographics, and the need for new nurses to practice with values reflective of caring practice. As one preceptor described:
I want to bring up nurses the way I would like to be cared for, basically. And how my family wants to be cared for…And that’s why I’ve become a preceptor, because you know I think I portray the values and the beliefs and proper professional practice.
Acknowledging Contextual Realities
The third domain of practice—acknowledging contextual realities—was revealed by how preceptors integrated unit-specific knowledge with students’ knowledge, acquired theoretically and experientially. Unit-specific knowledge included, but was not confined to, policy and procedures; preceptors always referred to manuals to add clarity to unit-specific skills (e.g., central venous line dressing changes, intravenous insertion, pain medication protocols). Also included in this domain was preceptors’ perception of the skill mix of nurses currently “on duty,” the preceptors’ understanding of the complexity of and potential for patients’ health complications, and family responses.
One preceptor described:
[I] scanned the horizon…checking to see “Who’s practicing? Who do I really value the way they’re doing things? Who can I count on?, and that sort of thing.
Preceptors enabled an understanding of working within a community (Wenger, 1998) rather than in isolation (Paton et al., 2004) by asking students questions such as “Do you like the way they do things, the way they practice?” As one preceptor noted, her goal was to
teach [students] how to look at a nurse’s practice that they like and emulate that person and say, “I like the way you practice…can I learn from you?”
In acknowledging contextual realities, preceptors placed the care of patients and families as primary, yet in integrating caring and learning, preceptors described how they were attuned to how others work, the routine of the unit, and “getting the job done.” Although being aware of how others work and knowing the routine of the unit predominantly related to their nursing colleagues, preceptors also incorporated an understanding of the contributions of other professions. As one member of a focus group described:
A nurse is not just someone who puts in NGs [naso-gastric tubes] and does IVs [intravenous insertions]. We [nurses] work with the doctors, we work with dieticians, we work with pharmacists, right? We work with transition. Like there’s so many other health care professionals that we work with and trying to incorporate that whole picture.
Preceptors realized how they had taken their own clinical expertise and knowledge of the context in which they worked for granted, which revealed another layer of acknowledgment.
Preserving the Ideals of Ethical, Competent, and Respectful Practice
Preceptors identified this domain of practice as the crux of safe practice. It is characterized with a high degree of professional accountability, whereby preceptors become immersed in assessing and evaluating students’ knowledge and competence in practice, clarifying and documenting perceptions, and voicing concerns. At times, preceptors were “at the elbow” with students, and at other times, the preceptors remained more distant but were always watchful. The enormity of preserving the ideal of safe and competent practice cannot be overestimated. As many preceptors noted, “I think part of it [preceptoring] is realizing what our job…as a preceptor and as a nurse is…that’s a big responsibility.”
This responsibility is significant, often having negative consequences on preceptors’ self-esteem and desire to continue precepting.
Preceptors observe students, and through questioning, reflecting, and considering previous experiences, they determine whether appropriate care levels are upheld and whether safe practices are ensured. In preserving the ideals of practice, preceptors used clinical situations to probe, clarify, and question understandings, and get to the heart of students’ thinking. Understanding students’ thinking was considered essential for clarifying and evaluating whether students’ actions were informed by safe and well-reasoned intentions. Clarifying the potential for disparity between actions and intentions was necessary in sorting out the parameters of safe practice (Paton & Binding, 2009). When students demonstrated consistency between their actions and intentions, reflecting a “borderline” understanding or unsafe care, preceptors felt professionally and morally bound to confirm their perceptions with colleagues and ultimately the faculty advisor. Preceptors agonized throughout the process of determining a student not ready for practice. Furthermore, the reality for preceptors was that in many cases, the student was granted a pass from the faculty advisor, despite thorough assessment, documentation, and anecdotal support by colleagues within the context. The process of assessing student competence was described by a member of a focus group, in the following situation:
Charting was terrible, [the student] didn’t know, didn’t even know terminology, and I was teaching pretty much the basics of nursing, and I kept expressing this to the instructor, who kept trying to work through it and work through it. And it started getting close to the time where they were supposed to be done, and I was sharing this student with another very experienced nurse, and we both felt the same way about it. And the college…told us that they were going to recommend all this stuff to the student and they weren’t going to pass her, and then we found out that the student was placed on another floor and passed the practicum...that makes you never want to do it again; it makes your unit never want to take a preceptor again.
Preceptors need to be autonomous in student assessment, and their evaluation needs to be respected. By not respecting this knowledge, preceptors’ clinical and teaching expertise are marginalized. Preceptors felt devalued and experienced a loss of self-esteem in situations where students did not meet the expectations of academia or practice, as outlined by policy, procedure, institutional guidelines, and regulating bodies. Many preceptors would not continue the practicum with the student; others would not precept in the future.
Preserving the ideals of best practice involved role modeling holistic care and teaching students beyond the task to see the context. As one preceptor identified, “they come with family.” Preceptors described how they role modeled inclusive, respectful, knowledgeable, and caring practice, in busy times of nursing shortages. As one preceptor explained:
I certainly love to teach, but I think I primarily love to show by example. I’m not all about…tasks, though they are certainly important, but I wanted to convey that [for] the individuals that we are caring for and the individuals that we are helping to make well, we are making a difference. And probably my biggest attribute is I do it by example. And certainly when I was doing the preceptoring, we were extremely understaffed, so they would have to observe by, you know, just watching…and learning that fundamental part of nursing—the patient and the family.
In preserving the ideals of safe and competent practice, preceptors were attuned to students’ vulnerability, hesitation, and doubts, and acknowledged the challenge of “learning how to nurse.” Preceptors described the “need to be a protector, both physically and psychologically,” in accordance with their perception of where the student was “at” in relation to clinical reasoning, skill acquisition, and patient safety. This was particularly apparent at the beginning of precepting when students were apprehensive and preceptors needed to spend more time coaching and guiding. As one preceptor described, “Initially, you feel like a mother duck,” providing clear guidelines and almost “being at the student’s elbow” to ensure actions are performed and carried out in a safe manner. Generally with time, preceptors were able to “let go of the role of protector” and extend the students’ competence as they demonstrated confidence in explaining and performing actions.
Through preceptoring, nurses acquire knowledge specific to teaching within a particular practice area, while being aware of the requirements of the academic and health care contexts, and regulating bodies. The preceptorship triad—defined as an equilateral relationship among the student, faculty member and preceptor (Frank, 2008; Myrick & Yonge, 2005; Trevitt et al., 2001; Usher, et al., 1999)—identifies the lines of communication and to some degree, the responsibilities preceptors have between organizations. However, to effectively assess and guide student learning while meeting the needs of patients, families, institutions, and regulating bodies, preceptors move beyond this triad. That is, although preceptors are well versed on the preceptorship triad, the everyday professional teaching practice that preceptors are immersed in is genuine and characterized by preceptors artfully connecting with students and creating a culture of respect, while acknowledging contextual realities and preserving the ideals of safe, ethical, and competent practice.
Artfully connecting, a term not well documented in the context of preceptor and student learning, appeals to the intentional, intuitive, and experiential knowledges that preceptors acquire and integrate to purposely converse with students, and importantly sustain this connection through unpredictable patient change and emotionally charged student assessment. Through role modeling and practicing with students, preceptors demonstrate respectful caring practice that is inclusive, reflective, and collegial and expected to be included in the students’ professional competence repertoire. In acknowledging the contextual realities, preceptors make choices around patient assignment, student inclusion in diagnostic tests, and potential opportunities for debriefing, questioning, and extending learning. These opportunities enable preceptors to determine the relationship between students’ intentions and actions, which is central to evaluating competence. In preserving the ideals of safe and competent practice, preceptors are called to grade students’ readiness for practice and substantiate this grade with sound reasoning, knowing the grade may be swayed in the academic process of evaluation.
Nurse preceptors create a unique set of teaching skills and expertise that are mindful of, yet go beyond, clinical expertise and relational skills (Paton, Thompson-Isherwood, & Thirsk, 2009). Arguably, the professional practice knowledge of nurse preceptors is created in isolation, with minimal academic involvement, through a process of analysis characterized with “intellectual struggle and self-critical reflection” (Tarnas, 1991, p. 35). The genuine knowledge represented within the everyday practice of nurse preceptors is overlooked and not considered in the recruitment, retention, and acknowledgement of talent these nurses offer toward undergraduate nursing education and, preceptors would argue, the practice of future nurses. Yet it could be posed that these domains of practice could inform RNs thinking of taking on this role but unsure of the role’s expectations. The four domains of practice could be used as a framework by experienced nurse preceptors to reflect on teaching expertise, career advancement, and contribution to the nursing profession.
Recent research focusing on evidence-based practice for nurse educators (Gaberson & Oermann, 2007; Halstead, 2007; Valiga, 2007) identifies relevant core competencies of facilitating learning, enhancing socialization, using assessment and evaluation strategies, and functioning as a change agent and leader. The difficulty for nurse preceptors is that they teach students “on their own” in the clinical environment, an environment that is unpredictable at all levels—patient population, RN population, student population, and unit culture. As a consequence, teaching approaches reflect the dynamics of the relationship as perceived within a particular context and situation. Furthermore, nurse preceptors are not considered nor are they commonly qualified with postdegree status nurse educators but rather are recruited for their clinical expertise, lessening the relevance of the evidence-based core competencies identified for nurse educators or faculty. It does not, however, lessen the need for faculty and the profession of nursing to acknowledge the contributions of these nurses; the credibility of their student assessment; and the need for support, guidance, and acknowledgement of their contributions to undergraduate student learning and the retention of new nurses in the workforce. The domains of practice proposed through the rigorous process of this triangulated research offers only one understanding of the professional practice knowledge of nurse preceptors. The author anticipates and recommends further research and interpretations highlighting and acknowledging the everyday professional practice of nurses in this role.
The majority of nurses agree to precept students because of perceived internal rewards, such as opportunities for professional growth, sharing of nursing knowledge and expertise, and the feeling of satisfaction in watching students grow in the role (Neumann et al. 2004). Unknown to the RN who takes on the responsibilities of this role are the challenges and expertise related to artfully connecting with students, as crucial to enabling an accurate assessment of the students’ level of knowledge, competence, and confidence in the clinical area. In recruiting and retaining nurses in this role, it is important to consider the anxieties inherent to creating a critical relationship with an unknown individual, particularly when a power differential exists and continual assessment is a requirement of the role. Creating a culture of respect requires a high level of understanding in relation to acknowledging the contributions of others and the inter-professional context of caring and the complexities in patient care and family responses. The time it takes to preserve the ideals of safe and competent practice is not clearly articulated or acknowledged; in most cases, this entity is not accounted for in workload. Yet assessing student learning, planning for future opportunities, and analyzing competent practice are expectations, not only for accountable and responsible preceptor practice but also for nursing practice.
Preceptors are caught in challenging situations where they experience significant levels of inner turmoil and anxiety before calling for assistance or passing a judgment on students’ performances. To sustain nurses in this role, they require support, acknowledgment, and guidance in articulating their own unique professional teaching practice, which is distinct from their role as a clinically competent RN and beyond the realm of the preceptorship triad.
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