Over the past 100 years, the nursing profession has evolved in response to the dynamic changes of the health care environment, which include advances in technology and diagnostic testing that have resulted in improved patient outcomes. In addition, increases in public knowledge about health care as a result of the Internet and the financial impacts on care delivery models have created challenges for nursing. Subsequently, these changes have affected the clinical environment for nursing education. The clinical learning environment has been internationally identified as central to nursing education by providing undergraduate nursing students with the opportunity to combine cognitive knowledge with the development of psychomotor and affective nursing skill sets (Omansky, 2010).
Nursing faculty identify the clinical learning environment as a “holistic experience attending to intellectual, physical, and passion components with active involvement of students, faculty, patients, and clinical staff” (Ard, Rogers, & Vinten, 2008, p. 243). Undergraduate nursing students identify preceptors as a key component to their learning within the clinical setting (Bourbonnais & Kerr, 2007; Grealish & Ranse, 2009; Kilcullen, 2007; Wieland, Altmiller, Dorr, & Wolf, 2007), but preceptors feel unprepared to serve in this role (Burns & Northcutt, 2009; Kemper, 2007; Pollard, Ellis, Stringer, & Cockayne, 2007; Pulsford, Boit, & Owen, 2002; Wieland et al., 2007). For clinical nursing education to produce successful educational outcomes in undergraduate nursing student programs, nursing faculty must collaborate with preceptors to provide an optimal learning experience for undergraduate nursing students.
Considerable attention has been given to the role of the preceptor and the preceptorship experience in the research literature. The majority of these studies address the preparation of clinical preceptors to assist students in the clinical application of didactic theory. Integrative literature reviews have been published that examine the process of clinical education (Pollard et al., 2007), preceptor views of assessing nursing students (Cassidy et al., 2012), and staff nurses’ experiences as preceptors and mentors (Omansky, 2010). No literature review specifically examining the role of the clinical preceptor through the perspective of students, preceptors, and clinical faculty has been published to date. This integrative literature review intends to fill that gap.
Literature Review Strategy
A literature review was conducted by searching the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), ERIC™, PubMed®/Medline®, and ScienceDirect® (Elsevier Electronic Journals). The following search terms were used: preceptors, preceptorship, mentors, mentorship, clinical learning environment, pre-licensure nurses, undergraduate nurses, preceptors of student nurses, staff nurses as preceptors, clinical supervision, student nurses, and dedicated education units. Inclusion criteria for this literature review required that the article pertains to preceptorship of prelicensure nursing students, was written in English, and was published within the preceding 10 years, with the exception of seminal works. Articles that examined preceptors of newly graduated and experienced nurses or nurses in an advanced degree program were excluded from this review.
Challenges arise when examining this body of literature because the terms preceptor and mentor are often used interchangeably when discussing undergraduate nursing students (McCarthy & Murphy, 2010; Pollard et al., 2007). Omansky (2010) defined the preceptor role as one that guides nursing students to apply classroom knowledge in the clinical setting, function as a role model, teach clinical skills, and model critical thinking. Preceptors provide an effective means for bridging the theory–practice gap in nursing education, typically in a time-limited, one-to-one relationship with a nursing student in a clinical setting (Barker, 2010; Duteau, 2012; Mamchur & Myrick, 2003; Myrick & Yonge, 2004). However, the mentoring relationship is one that develops through stages over a period of time ranging from months to years. Differing from the time-limited and clinically focused preceptorship model, mentorship is a “humanistic model” (Wagner & Seymour, 2007, p. 201) that enriches clinical practice while focusing on the holistic development of the nurse being mentored. Articles obtained through the initial search process were examined and those that described a time-limited relationship with a nursing student in a clinical setting were retained for further analysis.
For the purposes of this article, the term preceptor is used to identify the RN assigned to provide guidance to the undergraduate nursing student during the clinical learning experience. The term nursing student is used to define students who have not yet completed a basic prelicensure program. The term nursing faculty is used to describe instructors, employed by undergraduate nursing educational institutions, who have direct interaction with students in the clinical setting. The article first provides a general overview of the preceptor role, giving consideration to the changing dynamic of undergraduate students. The preceptor role is then examined through the perspectives of the nursing student, the clinical faculty, and the staff nurses who act as clinical preceptors. Recommendations for enhancing the preceptorship experience for students, faculty, and preceptors will be offered.
The preceptorship model was initially established in the 1970s to assist in transitioning newly graduated nurses from school to work. This preceptor role was eventually expanded into undergraduate nursing education to assist in bridging the gap from theory to practice (Omansky, 2010). In the early 1980s, the nursing profession saw a significant increase in research examining nursing students’ clinical learning environment and the associated roles of staff nurses who precept undergraduate nursing students. These initial studies identify that rigid environments do not provide ideal learning environments for students. In addition, these early studies recognized the influence of the staff RN preceptor as key within the clinical environment to ensure optimal learning outcomes for students (Fretwell, 1980; Ogier, 1981; Pembrey, 1980; Pollard et al., 2007; Sellek, 1982; Smith, 1988). In the 1990s, nursing research further solidified the importance of the staff RN in the clinical learning environment (Anforth, 1992; Hsieh & Knowles, 1990). Although the role of the preceptor within the clinical setting continues to be examined, a lack of consistency remains regarding how undergraduate nursing programs ensure preceptors are adequately trained to facilitate their students’ learning needs.
Unlike the classroom setting, which has significant structure and defined ground rules, the clinical environment for nursing education is complex and can be difficult for undergraduate nursing students to successfully navigate. Undergraduate nursing students often find themselves in unplanned situations with both patients and preceptors, which are often anxiety provoking for students and may potentially lead to poor patient outcomes (Andrews et al., 2006; Haskvitz & Koop, 2004; Ip & Chan, 2005; Papp, Markkanen, & von Bonsdorff, 2003; Pearcey & Elliott, 2004; Seropian, Brown, Gavilanes, & Driggers, 2004). At the same time, preceptors for undergraduate nursing students must balance the student’s learning needs while ensuring optimal patient care is delivered (Hallin & Danielson, 2009; Luhanga, Dickieson, & Mossey, 2010). Nursing faculty must monitor the competing demands of the clinical environment, which consists of oversight of their students, preceptors, and patients (Omansky, 2010).
Nursing students identify the clinical environment as highly influential to their professional development by providing opportunities to practice nursing assessment and psychomotor skills, recognize role models, develop professional socialization, think critically, and self-reflect (Chan, 2002; James & Chapman, 2009; Mamchur & Myrick, 2003). Nursing students identify that affective and emotional roles of nursing faculty are of highest priority to the student (Yoder & Saylor, 2002). In addition, students identify the importance of the nursing faculty’s role in guidance and support while in their clinical environment (Kocaman, Dicle, & Ugur, 2009).
Nursing students recognize preceptors as being instrumental to their learning in the clinical setting (Kristofferzon, Martensson, Mamhidir, & Lofmark, 2012; Omansky, 2010; Walker, Dwyer, Moxham, Broadbent, & Sander, 2012). Positive preceptor experiences are essential to a successful clinical experience. Nursing students state that preceptors play a significant role in facilitating learning by helping them to become proficient in the clinical application of theoretical principles (James & Chapman, 2009; Kilcullen, 2007; Wieland et al., 2007). The development of an effective relationship with a clinical preceptor can be pivotal to a successful student experience.
Chan (2002) developed the Clinical Learning Environment Inventory (CLEI) to examine nursing students’ perceptions of their clinical learning environment. The CLEI uses individualization, innovation, satisfaction, involvement, personalization, and task orientation as constructs to examine the clinical learning environment (Chan, 2002). Of these constructs, nursing students identified personalization, which is associated with the individual student’s interaction with the preceptor and nursing faculty, as being the most important. On the other hand, innovation, which examines new experiences or learning techniques provided by the preceptor or nursing faculty, was identified by nursing students as the least important factor in a successful clinical learning experience (Ip & Chan, 2005).
Saarikoski, Leino-Kilpi, and Warne (2002) developed the Clinical Learning Environment and Supervision instrument (CLES) to examine nursing students’ perceptions of the clinical environment and their assigned preceptors. The CLES provides a robust understanding of factors that affect students’ clinical experiences, accounting for differences in clinical oversight across multiple contexts (Saarikoski & Leino-Kilpi, 2002). Nursing students who had one-to-one preceptor supervision were more satisfied with their learning experience than those who were supervised as part of a group. However, nursing students who had a negative experience with their preceptors were the least satisfied with their clinical environment (Saarikoski & Leino-Kilpi, 2002). Preceptor behaviors, such as friendliness, understanding the students’ needs, interest in student learning, and explaining nursing skills and technique, were described as helpful to nursing students. Students identified passive preceptor behavior as an indication that the students were not welcome in the clinical setting (Mamchur & Myrick, 2003).
Nursing students perceive a lack of consistency between preceptors during their clinical learning experiences (Bradbury-Jones, Irvine, & Sambrook, 2010; Kilcullen, 2007; Mamchur & Myrick, 2003). This inconsistency may account for the difficulty preceptors describe in identifying student competency in practice and could impede the development of students’ confidence in clinical practice. Nursing students also recognize the lack of training and external challenges faced by the preceptor when trying to facilitate student learning (Kilcullen, 2007; Mamchur & Myrick, 2003).
Nursing faculty believe that they, not the preceptor, are responsible for nursing students’ learning needs within the clinical learning environment (Wagner & Seymour, 2007). To effectively oversee student learning in the clinical learning environment, nursing faculty must maintain some degree of clinical expertise to provide appropriate instruction. However, current patient populations have complex health problems in which nursing faculty may lack the expertise to directly supervise patient care delivery (Alinier, Hunt, Gordon, & Harwood, 2006). In addition to clinical competency, nursing faculty must be organized and have effective feedback mechanisms when teaching in the clinical environment (Billings & Halstead, 2009). However, nursing programs often are challenged with faculty shortages that limit the breadth of expertise required to provide the clinical teaching and supervision that students need and preceptors want (Sedgwick & Harris, 2012).
Along with the current nursing shortage, there is also a shortage of nursing faculty. The numbers of master’s-prepared and doctorally prepared nursing faculty in the United States is steadily decreasing, negatively impacting efforts to expand nursing student enrollments to the degree necessary to arrest the growing U.S. nursing shortage (Clark & Allison-Jones, 2011
). According to the report by the American Association of Colleges of Nursing (AACN) on 2010–2011 Salaries of Instructional and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing
The average ages of doctorally-prepared nurse faculty holding the ranks of professor, associate professor, and assistant professor were 60.5, 57.1 and 51.5 years respectively. For master’s degree-prepared nurse faculty, the average ages for professors, associate professors and assistant professors were 57.5, 56.4 and 50.9 years respectively. (as cited in AACN, 2012, p. 2)
In 2011, U.S. undergraduate and graduate nursing programs turned away 75,587 qualified applicants related to lack of faculty, budget constraints, clinical and classroom space, and preceptors (AACN, 2012).
Current economic constraints may limit the ability of educational institutions to hire nursing faculty, which directly impacts the clinical environment for both preceptors and nursing students. The utilization of the preceptor to facilitate learning within the clinical environment for nursing students has significantly increased over the past 30 years in conjunction with the nursing faculty shortage and the lack of available clinical sites for student placement (AACN, 2005; Omansky, 2010). Nursing faculty rely on preceptors in the clinical environment to have the clinical knowledge and skills to teach and accurately evaluate nursing students, even though preceptors state they feel unprepared to serve in this role (Parker, Lazenby, & Brown, 2012). With the increasing workloads of nursing faculty, the dedicated time spent with preceptors must be a priority to ensure nursing student learning objectives are being met within the clinical environment (Bourbonnais & Kerr, 2007).
The preceptor role in undergraduate nursing education is complex and multifaceted. Preceptors facilitate the development of practical skills, professional socialization, report and documentation, prioritization, communication, and planning of daily activities (Parker et al., 2012). However, inconsistent selection and preparation of clinical preceptors may limit control over the quality and consistency of the student’s learning experience.
Current estimates show that 86% of U.S.-accredited prelicensure nursing programs use a preceptor model, although most existing knowledge related to the use of preceptors in undergraduate nursing education is either anecdotal or theoretical (Altmann, 2006). Preceptors in the clinical environment either volunteer to work with nursing students or are selected based on availability rather than on criteria such as the preceptor’s experience, education, attitude, communication skills, and ability to teach (Altmann, 2006; Andrews & Chilton, 2000; Bourbonnais & Kerr, 2007; Burns & Northcutt, 2009).
For preceptors to be effective in the clinical environment, they need to understand the learning goals and objectives outlined by nursing faculty. Preceptors also need to recognize the effectiveness of their own teaching methods used with nursing students (Parker et al., 2012). However, preceptors are often not prepared to function in this role and students miss out on vital learning opportunities when preceptors lack understanding of how to facilitate learning or how to communicate their knowledge to students (Burns & Northcutt, 2009; Field, 2004; Kemper, 2007; Pollard et al., 2007; Pulsford et al., 2002; Wieland et al., 2007).
Preceptors describe feeling a lack of support in their role, inadequate preparation with no formalized training, and lack of allocated time to precept (Aston & Molassiotis, 2003; Burns & Northcutt, 2009; Corbett & Bent, 2005; Hallin & Danielson, 2009; Kemper, 2007; McCarthy & Murphy, 2010; Pollard et al., 2007; Pulsford et al., 2002; Wieland et al., 2007). Pollard et al. (2007) described preceptors as having a lack of time to teach students, a lack of training, increased workloads due to staff shortages, role conflicts, and a lack of identified responsibility for students. Pulsford et al. (2002) found that preceptors spent a significant amount of time on nursing students’ paperwork without appropriate training. Preceptors also noted that they frequently did not understand the paperwork they were asked to complete related to the students they oversaw (Pulsford et al., 2002). Luhanga et al. (2010) identified similar findings when examining the preparation and support of preceptors. Preceptors identified the need for substantial support and preparation to perform as a preceptor to nursing students. They stated in-person workshops are potentially beneficial in this development.
Bourbonnais and Kerr (2007) conducted structured interviews with nurses who had been used as preceptors for nursing students. The preceptors recognized their role as assisting students to learn and grow as professional nurses, providing protection during difficult situations, assisting in good decision making, and setting priorities. Preceptors are able to identify nursing students who are inadequately prepared for the clinical setting. This lack of preparation by nursing students is reported by preceptors as being stressful and the least rewarding experience of precepting (Kemper, 2007; Luhanga et al., 2010; Mamchur & Myrick, 2003; McCarthy & Murphy, 2010). Additional challenges of being a preceptor were identified as a lack of recognition by their peers and by management and a lack of support from the nursing faculty member (Bourbonnais & Kerr, 2007).
Altmann (2006) conducted an exploratory, descriptive comparative survey of deans and directors of U.S. undergraduate baccalaureate nursing programs. That study found that 73% of programs provide a preceptor orientation program in which preceptors receive approximately 2.5 hours of orientation, which was acknowledged by nursing programs as insufficient. The literature identifies recommendations for improving preceptor orientation programs and focuses on nursing faculty providing ongoing feedback on preceptor performance (Altmann, 2006; Kemper, 2007; Luhanga et al., 2010).
Preceptors identified the support of nursing faculty as essential to their role and expressed a desire for more input regarding their process of how to precept nursing students (Bourbonnais & Kerr, 2007). Preceptors expect nursing faculty to intervene when the nursing student is not successful within the clinical setting, and they identify frequent visits by nursing faculty, understanding of role expectations, and feedback from both the nursing student and faculty as being supportive of the precepting role (Bourbonnais & Kerr, 2007; Carlson, Pilhammar, & Wann-Hansson, 2010; Kemper, 2007; Wieland et al., 2007). In addition, preceptors want support from their management team, including recognition, guidance on prioritization, and clearly delineated expectations for both the nursing students and the preceptors. Specific attention must be given to the needs of preceptors, as unsupportive precepting experiences may contribute to nurse burnout (Bourbonnais & Kerr, 2007; Burns & Northcutt, 2009; Kemper, 2007; Pollard et al., 2007).
Discussion and Recommendations
This integrative literature review reveals a significant disconnect between the perceptions of nursing students, nursing faculty, and staff nurse preceptors on the role of the clinical preceptor. Although nursing faculty believe they are responsible for meeting students’ learning needs, students identify preceptors as integral to their education. However, preceptors are consistently reported as feeling unprepared to act in this pivotal role. Bridging these gaps is essential to the optimal preparation of prelicensure students for clinical practice.
When examining the spheres of influence within the clinical environment, Bradbury-Jones et al. (2010) recognized that the importance of the relationship between the preceptor and the nursing student should not be undervalued by nursing faculty and health care institutions. Inconsistent use of preceptor orientation programs is one reason why preceptors identify a lack of preparation for precepting undergraduate nursing students. Preparation programs for preceptors typically consist of written material, in-person workshops and courses, self-directed packets, and online modules, although it is also common for preceptors to receive no preparation at all for the preceptor role (Luhanga et al., 2010). Preparation is essential for the preceptorship experience to be successful for both the student and the preceptor. Undergraduate nursing programs need to examine current practices and ensure that preceptor orientation programs meet the needs of the preceptor. Hallin and Danielson (2009) identified that with a well-defined preceptor model, preceptors felt more prepared and satisfied and better understood the expectations of the preceptor role. Schools of nursing should also consider providing preceptors with extrinsic incentives, such as continuing education units or discounted tuition, to recognize them for their educational efforts toward nursing students.
Orientation programs need to provide preceptors with methods on how to facilitate adult learning and teaching methods, communication, evaluation, and conflict resolution that are congruent with the specific goals and objectives of the nursing program (Altmann, 2006; Luhanga et al., 2010). Preceptor manuals allow for self-paced learning but are dependent on the preceptor’s ability to comprehend and use the material provided. However, manuals may not be user friendly and require ongoing revision to ensure that material is up to date and reflective of the requirements from the schools of nursing and the health care institution (Luhanga et al., 2010).
Use of online and other multimedia tools offer preceptors a mechanism to better prepare to work with undergraduate nursing students. The electronic format allows training materials to be easily updated as clinical agency policies and educational guidelines evolve. Parker et al. (2012) examined the use of a self-paced CD-ROM for preceptor preparation, which included information on student evaluation methods, tools, and examples of learning activities to facilitate critical thinking in nursing students. Preceptors identified the CD as being beneficial to their role. However, preceptors stated that a lack of time to review all content was a challenge to successfully completing self-paced learning opportunities. To enhance the success of the clinical preceptorship model, preceptors must be provided with the means to benefit from training that is made available. The majority of acute care nurses are scheduled for a 36-hour work week. Allowing these nurse preceptors to intermittently use the balance of a 40-hour work week to complete electronic preceptor training modules would increase preceptor preparation without the added expense of overtime pay.
Clinical teaching and supervision is a skill, and it cannot be assumed that by virtue of their knowledge and expertise, excellent staff nurses can automatically function as preceptors (Horton, DePaoli, Hertach, & Bower, 2012). Initial and ongoing support from nursing faculty and facility administration is crucial to preceptors. Preceptors must have an understanding of realistic expectations and standards of nursing student performance, including specific guidance on how to facilitate remediation of student actions and behaviors. Horton et al. (2012) described the implementation of a “Nurse Preceptor Academy” (p. E1) that paired nursing faculty with facility educators to empower preceptors to provide meaningful learning opportunities for students. Nursing management teams need to support preceptors to ensure they are not overwhelmed or overburdened, while attempting to balance patient care with the nursing students’ learning needs.
The use of the dedicated education unit (DEU) model may assist in supporting the roles and responsibilities of preceptors. The DEU model was originally developed in the late 1990s by Flinders University in Australia and was introduced in the United States in 2003 (Ranse & Grealish, 2007). DEUs are defined as “pre-existing clinical unit[s], such as a ward in a hospital or a community health programme, that [are] collaboratively developed to provide practical experience for students from one university” (Ranse & Grealish, 2007, p. 172). These units potentially create an ideal teaching and learning environment for nursing students through specific collaborative efforts of staff nurses, nursing management, and nursing faculty, with the ultimate goal of providing a positive clinical learning environment to maximize student learning through evidence-based teaching practices. DEUs create a community of nursing practice between preceptors and nursing students, engage students in meaningful practice, and develop partnerships between nursing faculty (Ranse & Grealish, 2007). Importantly, DEUs allow nursing students to develop confidence in their nursing practice when they are surrounded by familiar environments, people, and routines. These familiar environments allow nursing students to initiate new learning activities and provide nursing care independent of their assigned preceptor within the student’s scope of practice and state practice requirements (Grealish & Ranse, 2009; James & Chapman, 2009). DEUs assist students in both social and professional role socializations and support positive outcomes for both preceptors and nursing students, while providing an optimal learning environment of learning how to become a nurse (Grealish & Ranse, 2009).
The clinical environment has been in constant change recently due to reforms of health care systems and advancements in technology and treatment. Educational institutions must be able to adapt to these changing environments to facilitate appropriate educational opportunities for the future of nursing. The clinical environment will always be a vital component of nursing education because nursing is a practice profession. However, the degree to which and how this clinical environment is used continues to be a topic of debate. Nursing faculty must establish collaborative relationships and facilitate open communication with preceptors in the clinical environment to facilitate optimal learning experiences for nursing students. By providing specific learning objectives and evaluation criteria, adult learners are provided with an environment that assists their educational experiences and promotes self-directed learning (Billings & Halstead, 2009).
Nursing students place significant importance on being accepted by their defined work group, and they value the feedback given by preceptors. However, preceptors overwhelmingly identify that they are unprepared to provide quality feedback. Preceptors must be provided with the skills to provide specific feedback to students in a way that reflects an understanding of andragogical principles. If nursing education continues to utilize preceptors as adjuncts for clinical education, undergraduate nursing programs need to continue to advance research regarding the preceptor’s role within the clinical environment to ensure that optimal methods and models are being used.
When teaching nursing practice, practicing from a solid evidence base is emphasized. However, the same level of evidence is not always used when preparing nursing students for clinical practice. Current practices in preceptor preparation must continue to be examined to ensure that processes adequately meet the preceptors’ needs. Due to constant and dynamic changes in our current health care systems, faculty, preceptors, and students must engage in an interactive teaching and learning process to ensure that future generations of nurses are meeting the learning objectives needed to be successful.
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