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Preceptors' reflections on their educational role before and after a preceptor preparation course: A prospective qualitative study
Nurse Education in Practice 19 (2016) 1e6
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Clinical education
Preceptors' reflections on their educational role before and after a preceptor preparation course: A prospective qualitative study € fmark a, c, Anna-Greta Mamhidir a, b, Bernice Skytt a, b Gunilla Mårtensson a, b, *, Anna Lo €vle, Ga €vle, Sweden Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, University of Ga Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden c Stord/Haugesund University College, Department of Health Sciences, Haugesund, Norway a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 February 2015 Received in revised form 18 February 2016 Accepted 26 March 2016
During clinical practice, preceptors play an important educational role in helping nursing students become secure and effective practitioners. For this educational role they need adequate preparation. The aim of the present prospective study was to describe preceptors' experiences of their educational role before and after attending a university preceptor preparation course. This 7.5-credit, Master's level course is offered on a part-time basis and covers one semester. The theoretical approach was selfdirected and reflective learning. Twentyseven preceptors participated in group interviews before and after the course, and data were analyzed using qualitative content analysis. The findings revealed a shift in preceptors' perceptions. Their view of the educational role changed from being characterized by individual experiences and notions to being guided by personal and formal demands. Before the course, the lack of sufficient preconditions for preceptorship predominated, whereas after the course participants described ways of creating such preconditions. Before the course, the supervisory process was described as teaching, whereas after the course it was described as a learning process for students. Using reflective learning in a preceptor preparation course can develop and strengthen preceptors' view of their educational role and help them manage and create the preconditions for preceptorship. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Preceptor Educational role Preceptor preparation course
1. Introduction Clinical practice is essential in the process of developing nursing students' cognitive and affective nursing skills, thus in helping them to learn and to become secure and effective practitioners. Preceptors play a critical role in this process (Carlson et al., 2010). Preceptors, as described by Yonge et al. (2007), are registered nurses responsible for nursing students' learning in clinical practice, which includes reflection, feedback, assessment and evaluation. If preceptors are to maximize the learning opportunities required for professional clinical practice, they need specific teaching and supervision skills and it cannot be assumed that nurses will automatically function as preceptors by virtue of their clinical knowledge and expertise. Further, it is well known that nurses' educational role is demanding (e.g., Danielsson et al., 2009; Pellatt, 2006), stressful (e.g., Omansky, 2010), and associated with
€vle, Kungsba €cksv€ * Corresponding author. University of Ga agen 47, 801 76 G€ avle, Sweden. E-mail address: [email protected] (G. Mårtensson). http://dx.doi.org/10.1016/j.nepr.2016.03.011 1471-5953/© 2016 Elsevier Ltd. All rights reserved.
feelings of not being adequately prepared to undertake this role (e.g., McClure and Black, 2013). If nurses are to feel well prepared for this important educational role, they need to acquire an array of clinical, personal and academic qualities (McCarthy and Murphy, 2010). Precepting is, and should be seen as, an educational process (Carlson, 2013) and efficient precepting requires pedagogical €ggman-Laitila et al., 2007). Efforts e in competence and skills (Ha form of preparation courses and programs, workshops and group supervision have been made to support nurses in this role. However, despite the importance of this educational role, research on it and on the outcome of preceptor preparation courses has been limited (Veeramah, 2012). The focus of the present study is therefore on preceptors' experience of their educational role before and after participating in a university preceptor preparation course. 2. Background The topic of preceptors' important and complex role has received increasing attention during recent decades. A great deal of research has been done on the support needed by nurses acting as preceptors for nursing students. Henderson and Eaton (2013)
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recommended that managers, in addition to effectively planning work-loads and feedback mechanisms ensure that nurses are adequate prepared for the educational role. However, to date, there has been little structure regarding how preceptors are prepared for their educational role (Myrick et al., 2012). Requirements and national guidelines for compulsory preparation courses can be found, for example, in the United Kingdom (NMC, 2008), Australia and Ireland (Heffernan et al., 2009; Mallik and Aylott, 2005). In other countries, like Sweden and Norway, specific preceptor education is better characterized as an expectation or recommendation and preceptors' expected competence is stipulated in agreements between the individual universities and country councils concerning nursing students' clinical practice (e.g., Hallin and Danielson, 2009; Hall-Lord et al., 2013). Several studies have reported findings from preceptor preparation activities. Myrick et al. (2012) developed a two-day workshop with interactive sessions. In post-workshop interviews with preceptors, they found that preceptors described having changed their teaching approach as a result of the work-shop; thus they €s and Shoemaker described a transformed preceptorship. Hyrka (2007) concluded that preceptor workshops seemed to increase preceptors' confidence, but that broader preceptors' programs were preferable. In a Master's level course for preceptor preparation, Zannini et al. (2011) found, by analyzing a reflective exercise that participants had experienced professional and personal growth after the program. Mårtensson et al. (2013) found that a significant predictor of preceptors' overall view of their performance as preceptors was participation in a preceptor preparation course. Group supervision is another preceptor preparation activity showing positive influence on preceptors' educational role (Danielsson et al., 2009). Preceptor preparation activities have generally been shown effective in achieving learning goals and desired outcomes: providing support to nursing students (Heffernan et al., 2009; Lambert and Glacken, 2005) and increasing preceptors' satisfaction with their own performance (Mårtensson et al., 2013; O'Brien et al., 2014). In summary, there is evidence that different preceptor preparation activities are significant factors in providing support for nursing students, developing preceptors and increasing their confidence in the educational role. There are however, a limited number of studies evaluating preceptor preparation activities prospectively, with pre- and post-data collection. Therefore, we have less knowledge, other than from retrospective studies, about how a preceptor preparation program or a course could influence preceptors' development. The aim of the present study is to describe preceptors' experiences of their educational role before and after attending a preceptor preparation course.
university courses such as emergency medicine, adult psychology, neonatal care, diabetes care, nutrition care, nursing documentation, organization and leadership, and ten had taken other preceptor preparation courses. Twelve nurses held a Bachelor's degree in nursing and one a Master's degree in nursing. 3.3. The preceptor preparation course
3. Method
The course, offered at the Master's level, to a small numbers of students (about 30), is given on a part-time basis and covers one semester. The theoretical approach of the course is inspired by selfdirected learning (Knowles, 1975), according to which students, as adults, should demonstrate curiosity and be self-motivated to €n, 1983) implies grow and achieve. Further, reflective learning (Scho that understanding involves exploring experiences of complex, unpredictable and stressful everyday practices in connection with feelings that have emerged. This process of reflection-in-action and reflection-on-action may build new understandings that can explain actions, as they unfold, in clinical practice situations. The pedagogical idea implemented in the course is that preceptors, as learners should be encouraged to assume responsibility for their own learning. The learning outcomes of the course deal with communication methods in supervision, reflection as an educational strategy, and supervision methods. Pedagogical implementation of the content uses different methods for active student learning inspired by €n (1983), i.e., seminars, lectures, home Knowles (1975) and Scho assignments and group supervision. Preceptors actively participate in a peer-learning process between scheduled course days by sending documents to an assigned classmate. In these documents, they describe and reflect on what they have learned from seminars, lectures and home assignments. The classmate provides feedback based on defined criteria. Documents collected in a portfolio allow lecturers to assess the progression toward learning outcomes by using chronological work samples collected at different time points, thus enabling both formative and summative assessment. For group supervision, the model described by Lindgren et al. (2005) is used. This part of the course involves six sessions (lasting 1.5 h), and the preceptors are divided into smaller groups. During each session, one is chosen to be “in focus” and to share a situation from his/her experiences as a preceptor. The group members share their understanding of the situation in a dialogue with the person in focus (What happens in the situation? What are the cognitive and affective responses to the situation?). The group leaders are qualified group supervisors. A contract, comprising confidentiality and secrecy, between the group and the group leader is agreed upon.
3.1. Design
3.4. Data collection
A prospective design with a qualitative approach was used (Polit and Beck, 2012).
The preceptors were verbally informed about the study at the beginning of the first day of the course. They received written information and had opportunities to ask questions. They were given time during the day to consider their decision. The agreement was that those who volunteered to participate in the study would stay after completion of the course day for group interviews. The first interviews took place at the end of the first day of the course and the second interviews at the end of the last day of the course. At the time of the interviews, the interviewers, senior lecturers at the university, were not involved in the preceptor preparation course. The researchers had previous experience of performing group interviews, which probably minimized any possible interviewer effects. The group interviews, eight altogether, were carried out in a
3.2. Participants Convenience sampling was used. Preceptors who, in 2010 and 2012, had voluntarily applied to a university preceptor preparation course entitled Supervision in Clinical Nursing (7.5 credits) were invited to participate. In total, 27 out of 37 students agreed to participate. Twenty-six of the participants were female, median age 43 years (range 27e56). They had worked as registered nurses (RN) between 1 and 26 years and their length of experience as preceptors was between 0 and 24 years. Seventeen had taken
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private room at the university, lasted from 50 to 60 min, were taperecorded and transcribed verbatim. Due to a technical error, a 15min section of one of the group interviews was not audible. A semi-structured interview guide was developed (Polit and Beck, 2012) covering questions about preceptors' experiences of their educational role, commitment and performance as preceptors. The group interviews began with an open-ended question: Can you describe your experiences and thoughts regarding supervision of nursing students? Other examples from the interview guide are: Can you describe how you experience your ability to precept? Clarifying questions were asked (‘What do you mean? Can you describe or tell me more about this?’) to encourage them to share information and provide more extensive descriptions of their experiences. In addition, data on participants' age, gender, university courses and time working as a preceptor were collected. The interviews were audio recorded and transcribed verbatim. 3.5. Data analysis The transcribed interviews were analyzed using manifest and latent qualitative content analysis (Sandelowski, 1998). In order to understand and become familiar with the text, the transcriptions were read and re-read. In the text, three content areas e “a specific explicit area or content identified with little interpretation” (Graneheim and Lundman, 2004, p.106) e were identified. Based on the aim of the study, interviews from before and after the course were analyzed separately when meaning units (words, sentences or paragraphs) were identified. Meaning units were condensed into a descriptive text, abstracted and labelled with a code. Within each of the content areas the codes from before and after were analyzed separately and grouped into categories based on similarities and differences. Based on the pattern of the three content area categories, before and after the course, six themes were formulated. The analyses were initially carried out by the first author; categories and thematic patterns were discussed with the co-authors during the analysis process until agreement was reached. The analysis process was transparent for all authors during the study.
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experiences and understandings. The role was described as being based on the supervisors' own experiences; at the same time it was stated that the role should be based on the syllabus and students' clinical education goals. “… there's a danger here when the individual preceptor is so important, it's like a lottery, what should be done about it?” (Group 1). Being a preceptor was a positive experience; it was fun, stimulating and enabled learning. Constructive feedback from students was described as helpful. They were uncertain as to whether the knowledge acquired during their previous nursing education was sufficient. They perceived the educational role as demanding and associated it with insecurity. This resulted in a need to keep updated and a hope that the imminent course would be of help. After e Personal and formal demands guide role performance. The participants stated that the course had given them a new awareness of the demands and complexity that came with the educational role. Being a preceptor was described as playing an important role, including great responsibility and obligations in relation to students, their future colleagues. “ … it's become a university course and all, you can keep developing and that's meant that the demands placed on us have changed too, the demands are much greater” (Group 4). The university course had helped increase the status of the educational role. Providing the same information on nursing procedures and caring as the students had been taught at the university was important. After the course, being a preceptor was described as more interesting and enjoyable than before. The participants had found support in their role performance in the course literature, and the course had increased their self-esteem as well as their capacity as preceptors. It was important to improve feedback from students.
3.6. Ethical considerations
4.2. Preconditions for preceptorship
Permission to conduct the study was received from the head of the faculty. The participants received oral and written information about the study purpose and procedure as well as the voluntary nature of participation; they were assured confidentiality. Furthermore, the participants were informed that they could withdraw from the study at any time, without any explanations or consequences. National laws (SFS, 2003:460) and guidelines were followed. In accordance with Swedish requirements, ethical approval was not required because the study can be classified as an educational evaluation, where no patients were involved and where no registration of sensitive personal data was carried out.
Before e Inadequate and unclear preconditions lead to feelings of insufficiency. The agreement between the university and the healthcare system regarding clinical education was perceived as support, as it clarified the ambitions and basis of supervision of students, e.g., preceptors' level of competence and the guiding function of the syllabuses aims. The latter was described as important, as it could prevent individual preceptors from basing supervision on their own understandings and convictions. Preconditions for preceptorship were described as a managerial responsibility. Insufficiency, e.g. lack of time, was experienced as influencing the relation to the students and students' learning. The unit managers expressed expectations, support and encouragement as well as colleagues' support and understanding that supervision takes time were important. Particularly challenging were situations in which students had difficulties or when they were unable to provide safe care. Participants stated that individual students' different prerequisites, interests and previous knowledge were important to consider.
4. Results The results section is structured according to the three content areas: the educational role focusing the preceptor's individual experiences, preconditions focusing conditions of importance to fulfill the task and supervisory process focusing the interaction in supporting students' learning. In each of the three areas, two themes are described (one before and one after the course) (Table 1). Quotations illustrate the themes. 4.1. The educational role Before e The educational role is characterized by individual
“… more time, there's a lot of talk about special considerations for preceptors but that's not how it works, you never get that time” (Group 3). After e Dialogue and openness is a way to ensure sufficient
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Table 1 Content areas, themes and categories. Content areas The educational role
Preconditions for preceptorship
Supervisory process
Themes
Categories
before The role is characterized by individual experiences and understanding after Personal and formal demands guide the role performance
before Inadequate and unclear preconditions lead to feelings of insufficiency after Dialogue and openness is a way to ensure sufficient preconditions before Teaching students “how” requires planning and adjustment after Students' learning is enabled by flexibility and support -
preconditions. The agreement between the university and the healthcare system was described as clarifying what is required of preceptors. Having opportunities to frequently discuss and update what was required of preceptors was perceived as important. The participants called for dialogues about experiences concerning, e.g., which individuals should function as preceptors, what amount of time is needed, and organization to allow planning for supervision that suits both students and preceptors. The unit managers were reported to lack knowledge about the agreement, and this prevented any dialogue about the required preconditions for supervision. “… we have to work actively to get our bosses to understand that we need to schedule time for this, I think that's a problem for the future ”(Group 4). It was emphasized that students need to be considered important if supervision is to be allocated sufficient resources as part of everyday operations. The importance of supportive colleagues was described; colleagues must accept that students take time and invite students to participate in their work. It was stressed that everyone in the staff group must be aware that they all contribute to creating a work environment in which students feel welcome. A dialogue in the staff group regarding shared values, knowledge and good work environment was described as an important prerequisite for supervision. One way of creating such an environment was to encourage many preceptors from one unit to attend preceptor preparation courses. Having information about differences between students regarding knowledge and confidence is important, as that may be one basis for planning. Students' motivation was described as an important precondition.
4.3. Supervisory process Before e Teaching students “how” requires planning and adjustment. The participants talked about the importance of adapting supervision and being aware of students' different experiences and levels of knowledge. Because students are in a subordinate position, the participants described the importance of establishing a good relation with students to compensate for this imbalance. Giving two preceptors primary responsibility for one student was described as a way to establish continuity for teaching the students “how”. It is important that students assume responsibility for asking questions and taking a critical approach to what they experience during their clinical practice. Different aims for supervision were described, from awakening or increasing students'
Opinion on the role Positive experiences of being a preceptor Reflections on demands for knowledge and competence Need for feedback from students Colleagues assume responsibility Attitudes of management Support, guidelines and demands from the university Students' prerequisites Attitudes toward students' learning Goals of supervision Planning for the entire clinical placement and for different phases - Need for flexibility in implementation - Reflection
interest in nursing to teaching students various nursing procedures. “Well, you get used to teaching them the practical things, taking samples, observing the patient, feeling secure, they learn the rest in school” (Group 2). Supervision was planned with the students' experiences in mind, although daily planning could be better. A need for flexibility was stressed, as supervision had to be adapted to activities on the ward. Fulfilling the role of both RN and preceptor was also described as stressful, and finding time for reflection e especially after a “catastrophic day” e was stressed. After e Students' learning is enabled by flexibility and support. The participants stressed that it was important to meet students in their subordinate position, treat them with respect and help them feel confident. At the same time, students are viewed as future colleagues. Supervision was described as a responsible role, and adapting to students' different prerequisites was stressed. Participants felt it was important that students not feel pressure to know “everything” about what to do and how to do it. Participants described their notions of different models of and alternatives for supervision. This knowledge had given them a broader repertoire; the model for action-reflection was described as useful, as was the master-apprentice model, although the latter was said to be used infrequently. The aim of supervision was described as enriching students' clinical experience and helping them develop; it was important and challenging to help weak students feel that they had grown. “… that they should move on and dare to develop and everything and I really hadn't thought about that before ”(Group 3). Furthermore, the aim was to show students the content of caring rather than to teach them how to carry out various procedures. The participants emphasized the importance of planning and preparation before students arrived on the ward. The students should be allowed to choose among different tasks, to observe different activities at the ward or hospital and to see how different healthcare professions work. The preceptors should be supportive and answer questions, explain or discuss different issues. Supervision of a group of nursing students and supervision on a “student ward” were two examples of ways to organize supervision that the participants regarded as alternatives to test.
5. Discussion The main findings of the present study revealed a shift in
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preceptors' perceptions of their educational role, preconditions for preceptorship and the supervisory process. Their view of the educational role altered from being characterized by individual experiences and notions to being guided by personal and formal demands. Before the course, the lack of sufficient preconditions for preceptorship was described, whereas after the course the participants described ways of creating such preconditions. Before the course, the supervisory process was described as teaching, whereas after the course it was described as a learning process for students. Thus, the present findings add knowledge to the subject area and show how participants develop as a result of taking part in a preceptor preparation course. Before the course, the preceptors' statements were clearly in line with earlier findings (e.g., Carlson et al., 2010; Omansky, 2010). Their role ambiguity was evident, as characterized by lack of clear descriptions, unknown expectations and insecurity. It would seem reasonable to conclude that the course gave them a repertoire of new insights, not only access to information on what is expected of them. These new insights have probably shaped their understanding of the educational role and given them ideas about dealing with insufficient preconditions for preceptorship and about ways to act in the supervision situation. The pedagogical approach used in € n, 1983), involves the course, including reflective learning (Scho exploring experiences of complex and stressful everyday practice. Course participants have to reflect on their new knowledge and understanding, orally and in writing, during the course and affectively and cognitively reflect on their own performance as preceptors in the group supervision sessions. This approach of reflection-in-action and reflection-on-action as well as actively taking part in a peer-learning process (which was used in both portfolio and group supervision) may have helped the nurses form a new and shared understanding. The preceptors' perceptions of their preconditions shifted from identification of difficulties and inadequate conditions to awareness of how the preconditions could be managed. Before the course, their perceptions of inadequate conditions were in accordance with findings from many previous studies, e.g., lack of designated time (Carlson et al., 2010; McCarthy and Murphy, 2010) and lack of managers' support (McCarthy and Murphy, 2010; Omansky, 2010). Interestingly, after the course, they described how it was possible to improve preconditions for preceptorship through openness and dialogue. Perhaps the group supervision sessions could make nurses aware, and discussing problems with colleagues could be one way of forming a new understanding of preceptorship. Reflective groups, where thoughts and experiences from reality are shared, have been shown to create altered perspectives (Manning et al., 2009), and other studies have revealed that group supervision could have a positive effect on perceived demands (e.g., Danielsson et al., 2009). Preceptors' view of the supervisory process after the course and the shift in focus are in certain respects consistent with earlier findings (Myrick et al., 2012; Zannini et al., 2011). Before the course, individual ambitions and knowledge were important in order to “teach the students how.” After the course, their pedagogical ethos seems to have altered, and their description of the supervision process was student-driven, involving encouraging and challenging students to learn, develop and grow. The model of group supervision (Lindgren et al., 2005) is based on the idea that every individual is willing to learn and to be responsible for his/her own development as well as the idea that experience, understanding and knowledge-building are shaped in interactions between humans. Willingness to change (perceptions and assumptions) is seen as one of the most important prerequisites for personal growth. Earlier studies have shown that the group itself has a significant meaning (Andersson et al., 2013). One prerequisite for
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having the courage to share difficult experiences, in this case from their work as preceptors, is that group members have confidence and trust in each other (Lindgren et al., 2005), which the pedagogical approach and working process used in the present course seems to have enabled. 5.1. Methodological considerations In group interviews, interaction between the participants is essential and creates opportunities to debate, contradict and affirm opinions. On the other hand, participants may hesitate to express their opinions or not dare to express them (Patton, 2002). In the present study, the participants did not know each other at the start of the study. However, during the education period, they gradually got to know each other quite well, which made them feel free to share and discuss opinions with each other. The interviewers were careful to involve all participants in the discussion, which is an important aspect of this method (Polit and Beck, 2012). Choosing participants with a range of experiences increases the credibility of the results (Graneheim and Lundman, 2004). The sample is limited to a Swedish context and based on a sample from two classes that participated in training during a limited time period. The descriptive design, using a qualitative approach, was a first step in further understanding of the educational role before and after a preceptor course, as there is a lack of studies evaluating both the outcome of and preceptors' own development during such courses. One limitation of the present study is that different researchers conducted the interviews before and after the intervention. To deal with this, an interview guide was used to assure that the same questions were asked (Patton, 2002). 6. Conclusions and clinical implications After the preceptor preparation course, the preceptors' perception of the educational role and the supervisory process is characterized by confidence in their own abilities. Furthermore, they were certain that adequate preconditions for preceptorship could be ensured through dialogue and openness. It may be that the pedagogical idea of portfolios and group supervision had a positive effect on preceptors' perceptions. The participants shared the experience of being a preceptor. Their confidence and learning increased when they were actively involved in the course and were members of a community of practice. Lave and Wenger (1991) argue that communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly. Using reflective learning in a preceptor preparation course can develop and strengthen preceptors' view of their educational role and help them manage and create the preconditions for preceptorship. This, in its turn, gives nursing students opportunities to develop their professional competencies during clinical practice. Preceptor preparation courses, as in several other countries, need to be compulsory. Expectations and recommendations to attend courses is not enough, if, as Carlson (2015) argues, preceptors need to continuously reflect on their practices in order to develop professional pedagogical competence and skill. Conflicts of interest The authors declared no conflict of interest. Authors' contributions Study design (all authors), data collection (BS, AL, A-GM) data analysis (BS), interpretation of data (all authors), drafting the article
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(GM, AL, BS) revising critically (A-GM), approval of the version to be published (all authors). Acknowledgements €vle, Sweden. The study was supported by the University of Ga We are grateful to the preceptors who participated in the study. References Andersson, C.S., Danielsson, A., Hov, R., Athlin, E., 2013. Expectations and experiences of group supervision: Swedish and Norwegian preceptors' perspectives. J. Nurs. Manag. 21 (2), 263e272. Carlson, E., 2013. Time, trust and reflection: three aspects of precepting in clinical nursing education. Nurse Educ. Pract. 13 (4), 237e238. Carlson, E., 2015. Critical friends: a way to develop preceptor competence? Guest editorial. Nurse Educ. Pract. 15 (6), 470e471. Carlson, E., Pilhammar, E., Wann-Hansson, C., 2010. Time to precept: supportive and limiting conditions for precepting nurses. J. Adv. Nurs. 66 (2), 432e441. Danielsson, A., Sundin-Andersson, C., Hov, R., Athlin, E., 2009. Norwegian and Swedish preceptors' views of their role before and after taking part in a group supervision program. Nurs. Health Sci. 11 (2), 107e113. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24 (2), 105e112. €ggman-Laitila, A., Eriksson, E., Riita, M., Sillanpå, K., Rekola, L., 2007. Nursing Ha € r clinical supervision. students in clinical practice e developing a model fo Nurse Educ. Pract. 7 (6), 381e391. Hall-Lord, M.L., Theander, K., Athlin, E., 2013. A clinical supervision model in bachelor nursing education e purpose, content and evaluation. Nurse Educ. Pract. 13 (6), 506e511. Hallin, K., Danielson, E., 2009. Being a personal preceptor for nursing students. Registered nurses' experiences before and after introduction of a preceptor model. J. Adv. Nurs. 65 (1), 161e174. Heffernan, C., Heffernan, E., Brosnan, M., Brown, G., 2009. Evaluating a preceptorship programme in South West Ireland: perceptions of preceptors and undergraduate students. J. Nurs. Manag. 17 (5), 539e549. Henderson, A., Eaton, E., 2013. Assisting nurses to facilitate students and new graduate learning in practice setting: what ‘support’ do nurses at the bedside need? Nurse Educ. Pract. 13 (3), 197e201. €s, K., Shoemaker, M., 2007. Changes in the preceptor role: re-visiting preHyrka ceptors' perceptions of benefits, rewards, support and commitment to the role. J. Adv. Nurs. 60 (5), 513e524. Knowles, M., 1975. Self-Directed Learning: a Guide for Learners and Teachers. Folert, Chicago. Lambert, V., Glacken, M., 2005. Clinical education facilitators: a literature review. J. Clin. Nurs. 14 (6), 664e673. Lave, J., Wenger, E., 1991. Situated Learning. Legitimate Peripheral Participation. University of Cambridge Press, Cambridge.
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Clinical education
Preceptors' reflections on their educational role before and after a preceptor preparation course: A prospective qualitative study € fmark a, c, Anna-Greta Mamhidir a, b, Bernice Skytt a, b Gunilla Mårtensson a, b, *, Anna Lo €vle, Ga €vle, Sweden Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, University of Ga Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden c Stord/Haugesund University College, Department of Health Sciences, Haugesund, Norway a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 February 2015 Received in revised form 18 February 2016 Accepted 26 March 2016
During clinical practice, preceptors play an important educational role in helping nursing students become secure and effective practitioners. For this educational role they need adequate preparation. The aim of the present prospective study was to describe preceptors' experiences of their educational role before and after attending a university preceptor preparation course. This 7.5-credit, Master's level course is offered on a part-time basis and covers one semester. The theoretical approach was selfdirected and reflective learning. Twentyseven preceptors participated in group interviews before and after the course, and data were analyzed using qualitative content analysis. The findings revealed a shift in preceptors' perceptions. Their view of the educational role changed from being characterized by individual experiences and notions to being guided by personal and formal demands. Before the course, the lack of sufficient preconditions for preceptorship predominated, whereas after the course participants described ways of creating such preconditions. Before the course, the supervisory process was described as teaching, whereas after the course it was described as a learning process for students. Using reflective learning in a preceptor preparation course can develop and strengthen preceptors' view of their educational role and help them manage and create the preconditions for preceptorship. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Preceptor Educational role Preceptor preparation course
1. Introduction Clinical practice is essential in the process of developing nursing students' cognitive and affective nursing skills, thus in helping them to learn and to become secure and effective practitioners. Preceptors play a critical role in this process (Carlson et al., 2010). Preceptors, as described by Yonge et al. (2007), are registered nurses responsible for nursing students' learning in clinical practice, which includes reflection, feedback, assessment and evaluation. If preceptors are to maximize the learning opportunities required for professional clinical practice, they need specific teaching and supervision skills and it cannot be assumed that nurses will automatically function as preceptors by virtue of their clinical knowledge and expertise. Further, it is well known that nurses' educational role is demanding (e.g., Danielsson et al., 2009; Pellatt, 2006), stressful (e.g., Omansky, 2010), and associated with
€vle, Kungsba €cksv€ * Corresponding author. University of Ga agen 47, 801 76 G€ avle, Sweden. E-mail address: [email protected] (G. Mårtensson). http://dx.doi.org/10.1016/j.nepr.2016.03.011 1471-5953/© 2016 Elsevier Ltd. All rights reserved.
feelings of not being adequately prepared to undertake this role (e.g., McClure and Black, 2013). If nurses are to feel well prepared for this important educational role, they need to acquire an array of clinical, personal and academic qualities (McCarthy and Murphy, 2010). Precepting is, and should be seen as, an educational process (Carlson, 2013) and efficient precepting requires pedagogical €ggman-Laitila et al., 2007). Efforts e in competence and skills (Ha form of preparation courses and programs, workshops and group supervision have been made to support nurses in this role. However, despite the importance of this educational role, research on it and on the outcome of preceptor preparation courses has been limited (Veeramah, 2012). The focus of the present study is therefore on preceptors' experience of their educational role before and after participating in a university preceptor preparation course. 2. Background The topic of preceptors' important and complex role has received increasing attention during recent decades. A great deal of research has been done on the support needed by nurses acting as preceptors for nursing students. Henderson and Eaton (2013)
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recommended that managers, in addition to effectively planning work-loads and feedback mechanisms ensure that nurses are adequate prepared for the educational role. However, to date, there has been little structure regarding how preceptors are prepared for their educational role (Myrick et al., 2012). Requirements and national guidelines for compulsory preparation courses can be found, for example, in the United Kingdom (NMC, 2008), Australia and Ireland (Heffernan et al., 2009; Mallik and Aylott, 2005). In other countries, like Sweden and Norway, specific preceptor education is better characterized as an expectation or recommendation and preceptors' expected competence is stipulated in agreements between the individual universities and country councils concerning nursing students' clinical practice (e.g., Hallin and Danielson, 2009; Hall-Lord et al., 2013). Several studies have reported findings from preceptor preparation activities. Myrick et al. (2012) developed a two-day workshop with interactive sessions. In post-workshop interviews with preceptors, they found that preceptors described having changed their teaching approach as a result of the work-shop; thus they €s and Shoemaker described a transformed preceptorship. Hyrka (2007) concluded that preceptor workshops seemed to increase preceptors' confidence, but that broader preceptors' programs were preferable. In a Master's level course for preceptor preparation, Zannini et al. (2011) found, by analyzing a reflective exercise that participants had experienced professional and personal growth after the program. Mårtensson et al. (2013) found that a significant predictor of preceptors' overall view of their performance as preceptors was participation in a preceptor preparation course. Group supervision is another preceptor preparation activity showing positive influence on preceptors' educational role (Danielsson et al., 2009). Preceptor preparation activities have generally been shown effective in achieving learning goals and desired outcomes: providing support to nursing students (Heffernan et al., 2009; Lambert and Glacken, 2005) and increasing preceptors' satisfaction with their own performance (Mårtensson et al., 2013; O'Brien et al., 2014). In summary, there is evidence that different preceptor preparation activities are significant factors in providing support for nursing students, developing preceptors and increasing their confidence in the educational role. There are however, a limited number of studies evaluating preceptor preparation activities prospectively, with pre- and post-data collection. Therefore, we have less knowledge, other than from retrospective studies, about how a preceptor preparation program or a course could influence preceptors' development. The aim of the present study is to describe preceptors' experiences of their educational role before and after attending a preceptor preparation course.
university courses such as emergency medicine, adult psychology, neonatal care, diabetes care, nutrition care, nursing documentation, organization and leadership, and ten had taken other preceptor preparation courses. Twelve nurses held a Bachelor's degree in nursing and one a Master's degree in nursing. 3.3. The preceptor preparation course
3. Method
The course, offered at the Master's level, to a small numbers of students (about 30), is given on a part-time basis and covers one semester. The theoretical approach of the course is inspired by selfdirected learning (Knowles, 1975), according to which students, as adults, should demonstrate curiosity and be self-motivated to €n, 1983) implies grow and achieve. Further, reflective learning (Scho that understanding involves exploring experiences of complex, unpredictable and stressful everyday practices in connection with feelings that have emerged. This process of reflection-in-action and reflection-on-action may build new understandings that can explain actions, as they unfold, in clinical practice situations. The pedagogical idea implemented in the course is that preceptors, as learners should be encouraged to assume responsibility for their own learning. The learning outcomes of the course deal with communication methods in supervision, reflection as an educational strategy, and supervision methods. Pedagogical implementation of the content uses different methods for active student learning inspired by €n (1983), i.e., seminars, lectures, home Knowles (1975) and Scho assignments and group supervision. Preceptors actively participate in a peer-learning process between scheduled course days by sending documents to an assigned classmate. In these documents, they describe and reflect on what they have learned from seminars, lectures and home assignments. The classmate provides feedback based on defined criteria. Documents collected in a portfolio allow lecturers to assess the progression toward learning outcomes by using chronological work samples collected at different time points, thus enabling both formative and summative assessment. For group supervision, the model described by Lindgren et al. (2005) is used. This part of the course involves six sessions (lasting 1.5 h), and the preceptors are divided into smaller groups. During each session, one is chosen to be “in focus” and to share a situation from his/her experiences as a preceptor. The group members share their understanding of the situation in a dialogue with the person in focus (What happens in the situation? What are the cognitive and affective responses to the situation?). The group leaders are qualified group supervisors. A contract, comprising confidentiality and secrecy, between the group and the group leader is agreed upon.
3.1. Design
3.4. Data collection
A prospective design with a qualitative approach was used (Polit and Beck, 2012).
The preceptors were verbally informed about the study at the beginning of the first day of the course. They received written information and had opportunities to ask questions. They were given time during the day to consider their decision. The agreement was that those who volunteered to participate in the study would stay after completion of the course day for group interviews. The first interviews took place at the end of the first day of the course and the second interviews at the end of the last day of the course. At the time of the interviews, the interviewers, senior lecturers at the university, were not involved in the preceptor preparation course. The researchers had previous experience of performing group interviews, which probably minimized any possible interviewer effects. The group interviews, eight altogether, were carried out in a
3.2. Participants Convenience sampling was used. Preceptors who, in 2010 and 2012, had voluntarily applied to a university preceptor preparation course entitled Supervision in Clinical Nursing (7.5 credits) were invited to participate. In total, 27 out of 37 students agreed to participate. Twenty-six of the participants were female, median age 43 years (range 27e56). They had worked as registered nurses (RN) between 1 and 26 years and their length of experience as preceptors was between 0 and 24 years. Seventeen had taken
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private room at the university, lasted from 50 to 60 min, were taperecorded and transcribed verbatim. Due to a technical error, a 15min section of one of the group interviews was not audible. A semi-structured interview guide was developed (Polit and Beck, 2012) covering questions about preceptors' experiences of their educational role, commitment and performance as preceptors. The group interviews began with an open-ended question: Can you describe your experiences and thoughts regarding supervision of nursing students? Other examples from the interview guide are: Can you describe how you experience your ability to precept? Clarifying questions were asked (‘What do you mean? Can you describe or tell me more about this?’) to encourage them to share information and provide more extensive descriptions of their experiences. In addition, data on participants' age, gender, university courses and time working as a preceptor were collected. The interviews were audio recorded and transcribed verbatim. 3.5. Data analysis The transcribed interviews were analyzed using manifest and latent qualitative content analysis (Sandelowski, 1998). In order to understand and become familiar with the text, the transcriptions were read and re-read. In the text, three content areas e “a specific explicit area or content identified with little interpretation” (Graneheim and Lundman, 2004, p.106) e were identified. Based on the aim of the study, interviews from before and after the course were analyzed separately when meaning units (words, sentences or paragraphs) were identified. Meaning units were condensed into a descriptive text, abstracted and labelled with a code. Within each of the content areas the codes from before and after were analyzed separately and grouped into categories based on similarities and differences. Based on the pattern of the three content area categories, before and after the course, six themes were formulated. The analyses were initially carried out by the first author; categories and thematic patterns were discussed with the co-authors during the analysis process until agreement was reached. The analysis process was transparent for all authors during the study.
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experiences and understandings. The role was described as being based on the supervisors' own experiences; at the same time it was stated that the role should be based on the syllabus and students' clinical education goals. “… there's a danger here when the individual preceptor is so important, it's like a lottery, what should be done about it?” (Group 1). Being a preceptor was a positive experience; it was fun, stimulating and enabled learning. Constructive feedback from students was described as helpful. They were uncertain as to whether the knowledge acquired during their previous nursing education was sufficient. They perceived the educational role as demanding and associated it with insecurity. This resulted in a need to keep updated and a hope that the imminent course would be of help. After e Personal and formal demands guide role performance. The participants stated that the course had given them a new awareness of the demands and complexity that came with the educational role. Being a preceptor was described as playing an important role, including great responsibility and obligations in relation to students, their future colleagues. “ … it's become a university course and all, you can keep developing and that's meant that the demands placed on us have changed too, the demands are much greater” (Group 4). The university course had helped increase the status of the educational role. Providing the same information on nursing procedures and caring as the students had been taught at the university was important. After the course, being a preceptor was described as more interesting and enjoyable than before. The participants had found support in their role performance in the course literature, and the course had increased their self-esteem as well as their capacity as preceptors. It was important to improve feedback from students.
3.6. Ethical considerations
4.2. Preconditions for preceptorship
Permission to conduct the study was received from the head of the faculty. The participants received oral and written information about the study purpose and procedure as well as the voluntary nature of participation; they were assured confidentiality. Furthermore, the participants were informed that they could withdraw from the study at any time, without any explanations or consequences. National laws (SFS, 2003:460) and guidelines were followed. In accordance with Swedish requirements, ethical approval was not required because the study can be classified as an educational evaluation, where no patients were involved and where no registration of sensitive personal data was carried out.
Before e Inadequate and unclear preconditions lead to feelings of insufficiency. The agreement between the university and the healthcare system regarding clinical education was perceived as support, as it clarified the ambitions and basis of supervision of students, e.g., preceptors' level of competence and the guiding function of the syllabuses aims. The latter was described as important, as it could prevent individual preceptors from basing supervision on their own understandings and convictions. Preconditions for preceptorship were described as a managerial responsibility. Insufficiency, e.g. lack of time, was experienced as influencing the relation to the students and students' learning. The unit managers expressed expectations, support and encouragement as well as colleagues' support and understanding that supervision takes time were important. Particularly challenging were situations in which students had difficulties or when they were unable to provide safe care. Participants stated that individual students' different prerequisites, interests and previous knowledge were important to consider.
4. Results The results section is structured according to the three content areas: the educational role focusing the preceptor's individual experiences, preconditions focusing conditions of importance to fulfill the task and supervisory process focusing the interaction in supporting students' learning. In each of the three areas, two themes are described (one before and one after the course) (Table 1). Quotations illustrate the themes. 4.1. The educational role Before e The educational role is characterized by individual
“… more time, there's a lot of talk about special considerations for preceptors but that's not how it works, you never get that time” (Group 3). After e Dialogue and openness is a way to ensure sufficient
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Table 1 Content areas, themes and categories. Content areas The educational role
Preconditions for preceptorship
Supervisory process
Themes
Categories
before The role is characterized by individual experiences and understanding after Personal and formal demands guide the role performance
before Inadequate and unclear preconditions lead to feelings of insufficiency after Dialogue and openness is a way to ensure sufficient preconditions before Teaching students “how” requires planning and adjustment after Students' learning is enabled by flexibility and support -
preconditions. The agreement between the university and the healthcare system was described as clarifying what is required of preceptors. Having opportunities to frequently discuss and update what was required of preceptors was perceived as important. The participants called for dialogues about experiences concerning, e.g., which individuals should function as preceptors, what amount of time is needed, and organization to allow planning for supervision that suits both students and preceptors. The unit managers were reported to lack knowledge about the agreement, and this prevented any dialogue about the required preconditions for supervision. “… we have to work actively to get our bosses to understand that we need to schedule time for this, I think that's a problem for the future ”(Group 4). It was emphasized that students need to be considered important if supervision is to be allocated sufficient resources as part of everyday operations. The importance of supportive colleagues was described; colleagues must accept that students take time and invite students to participate in their work. It was stressed that everyone in the staff group must be aware that they all contribute to creating a work environment in which students feel welcome. A dialogue in the staff group regarding shared values, knowledge and good work environment was described as an important prerequisite for supervision. One way of creating such an environment was to encourage many preceptors from one unit to attend preceptor preparation courses. Having information about differences between students regarding knowledge and confidence is important, as that may be one basis for planning. Students' motivation was described as an important precondition.
4.3. Supervisory process Before e Teaching students “how” requires planning and adjustment. The participants talked about the importance of adapting supervision and being aware of students' different experiences and levels of knowledge. Because students are in a subordinate position, the participants described the importance of establishing a good relation with students to compensate for this imbalance. Giving two preceptors primary responsibility for one student was described as a way to establish continuity for teaching the students “how”. It is important that students assume responsibility for asking questions and taking a critical approach to what they experience during their clinical practice. Different aims for supervision were described, from awakening or increasing students'
Opinion on the role Positive experiences of being a preceptor Reflections on demands for knowledge and competence Need for feedback from students Colleagues assume responsibility Attitudes of management Support, guidelines and demands from the university Students' prerequisites Attitudes toward students' learning Goals of supervision Planning for the entire clinical placement and for different phases - Need for flexibility in implementation - Reflection
interest in nursing to teaching students various nursing procedures. “Well, you get used to teaching them the practical things, taking samples, observing the patient, feeling secure, they learn the rest in school” (Group 2). Supervision was planned with the students' experiences in mind, although daily planning could be better. A need for flexibility was stressed, as supervision had to be adapted to activities on the ward. Fulfilling the role of both RN and preceptor was also described as stressful, and finding time for reflection e especially after a “catastrophic day” e was stressed. After e Students' learning is enabled by flexibility and support. The participants stressed that it was important to meet students in their subordinate position, treat them with respect and help them feel confident. At the same time, students are viewed as future colleagues. Supervision was described as a responsible role, and adapting to students' different prerequisites was stressed. Participants felt it was important that students not feel pressure to know “everything” about what to do and how to do it. Participants described their notions of different models of and alternatives for supervision. This knowledge had given them a broader repertoire; the model for action-reflection was described as useful, as was the master-apprentice model, although the latter was said to be used infrequently. The aim of supervision was described as enriching students' clinical experience and helping them develop; it was important and challenging to help weak students feel that they had grown. “… that they should move on and dare to develop and everything and I really hadn't thought about that before ”(Group 3). Furthermore, the aim was to show students the content of caring rather than to teach them how to carry out various procedures. The participants emphasized the importance of planning and preparation before students arrived on the ward. The students should be allowed to choose among different tasks, to observe different activities at the ward or hospital and to see how different healthcare professions work. The preceptors should be supportive and answer questions, explain or discuss different issues. Supervision of a group of nursing students and supervision on a “student ward” were two examples of ways to organize supervision that the participants regarded as alternatives to test.
5. Discussion The main findings of the present study revealed a shift in
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preceptors' perceptions of their educational role, preconditions for preceptorship and the supervisory process. Their view of the educational role altered from being characterized by individual experiences and notions to being guided by personal and formal demands. Before the course, the lack of sufficient preconditions for preceptorship was described, whereas after the course the participants described ways of creating such preconditions. Before the course, the supervisory process was described as teaching, whereas after the course it was described as a learning process for students. Thus, the present findings add knowledge to the subject area and show how participants develop as a result of taking part in a preceptor preparation course. Before the course, the preceptors' statements were clearly in line with earlier findings (e.g., Carlson et al., 2010; Omansky, 2010). Their role ambiguity was evident, as characterized by lack of clear descriptions, unknown expectations and insecurity. It would seem reasonable to conclude that the course gave them a repertoire of new insights, not only access to information on what is expected of them. These new insights have probably shaped their understanding of the educational role and given them ideas about dealing with insufficient preconditions for preceptorship and about ways to act in the supervision situation. The pedagogical approach used in € n, 1983), involves the course, including reflective learning (Scho exploring experiences of complex and stressful everyday practice. Course participants have to reflect on their new knowledge and understanding, orally and in writing, during the course and affectively and cognitively reflect on their own performance as preceptors in the group supervision sessions. This approach of reflection-in-action and reflection-on-action as well as actively taking part in a peer-learning process (which was used in both portfolio and group supervision) may have helped the nurses form a new and shared understanding. The preceptors' perceptions of their preconditions shifted from identification of difficulties and inadequate conditions to awareness of how the preconditions could be managed. Before the course, their perceptions of inadequate conditions were in accordance with findings from many previous studies, e.g., lack of designated time (Carlson et al., 2010; McCarthy and Murphy, 2010) and lack of managers' support (McCarthy and Murphy, 2010; Omansky, 2010). Interestingly, after the course, they described how it was possible to improve preconditions for preceptorship through openness and dialogue. Perhaps the group supervision sessions could make nurses aware, and discussing problems with colleagues could be one way of forming a new understanding of preceptorship. Reflective groups, where thoughts and experiences from reality are shared, have been shown to create altered perspectives (Manning et al., 2009), and other studies have revealed that group supervision could have a positive effect on perceived demands (e.g., Danielsson et al., 2009). Preceptors' view of the supervisory process after the course and the shift in focus are in certain respects consistent with earlier findings (Myrick et al., 2012; Zannini et al., 2011). Before the course, individual ambitions and knowledge were important in order to “teach the students how.” After the course, their pedagogical ethos seems to have altered, and their description of the supervision process was student-driven, involving encouraging and challenging students to learn, develop and grow. The model of group supervision (Lindgren et al., 2005) is based on the idea that every individual is willing to learn and to be responsible for his/her own development as well as the idea that experience, understanding and knowledge-building are shaped in interactions between humans. Willingness to change (perceptions and assumptions) is seen as one of the most important prerequisites for personal growth. Earlier studies have shown that the group itself has a significant meaning (Andersson et al., 2013). One prerequisite for
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having the courage to share difficult experiences, in this case from their work as preceptors, is that group members have confidence and trust in each other (Lindgren et al., 2005), which the pedagogical approach and working process used in the present course seems to have enabled. 5.1. Methodological considerations In group interviews, interaction between the participants is essential and creates opportunities to debate, contradict and affirm opinions. On the other hand, participants may hesitate to express their opinions or not dare to express them (Patton, 2002). In the present study, the participants did not know each other at the start of the study. However, during the education period, they gradually got to know each other quite well, which made them feel free to share and discuss opinions with each other. The interviewers were careful to involve all participants in the discussion, which is an important aspect of this method (Polit and Beck, 2012). Choosing participants with a range of experiences increases the credibility of the results (Graneheim and Lundman, 2004). The sample is limited to a Swedish context and based on a sample from two classes that participated in training during a limited time period. The descriptive design, using a qualitative approach, was a first step in further understanding of the educational role before and after a preceptor course, as there is a lack of studies evaluating both the outcome of and preceptors' own development during such courses. One limitation of the present study is that different researchers conducted the interviews before and after the intervention. To deal with this, an interview guide was used to assure that the same questions were asked (Patton, 2002). 6. Conclusions and clinical implications After the preceptor preparation course, the preceptors' perception of the educational role and the supervisory process is characterized by confidence in their own abilities. Furthermore, they were certain that adequate preconditions for preceptorship could be ensured through dialogue and openness. It may be that the pedagogical idea of portfolios and group supervision had a positive effect on preceptors' perceptions. The participants shared the experience of being a preceptor. Their confidence and learning increased when they were actively involved in the course and were members of a community of practice. Lave and Wenger (1991) argue that communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly. Using reflective learning in a preceptor preparation course can develop and strengthen preceptors' view of their educational role and help them manage and create the preconditions for preceptorship. This, in its turn, gives nursing students opportunities to develop their professional competencies during clinical practice. Preceptor preparation courses, as in several other countries, need to be compulsory. Expectations and recommendations to attend courses is not enough, if, as Carlson (2015) argues, preceptors need to continuously reflect on their practices in order to develop professional pedagogical competence and skill. Conflicts of interest The authors declared no conflict of interest. Authors' contributions Study design (all authors), data collection (BS, AL, A-GM) data analysis (BS), interpretation of data (all authors), drafting the article
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