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The concept and practice of preceptorship in contemporary nursing: a review of pertinent literature
Inl. J. Nurs. Stud., Vol. 22. No. 2, pp. 79-88. 1985 Printed m Great Brnain
C020-7489185 13.00+0.00 ’ 1985 Pergamon Pres L.td.
The concept and practice of Preceptorship in con temporary nursing: a review of pertinent literature JUDITH
SHAMIAN,
R.N.,
M.P.H.
and ROSALIND
INHABER,
B.Sc.
The Sir Mortimer B. Davis Jewish General Hospital, 3755 Cote Ste-Catherine Road, Montreal, Quebec, Canada, H3T IE2.
authors review 21 articles on preceptor programs in schools of nursing and service settings. They provide comparative details of various aspects of preceptor programs but particularly emphasize, first, the ways in which preceptors are trained and secondly, the content of preceptor training programs. The purpose of the review is to help administrators set up preceptor programs in their own localities. Abstract-The
The term preceptorship has been used in the context of nursing for a relatively short period of time, having first appeared as a classification in the International Nursing Index of 1975. While the word ‘preceptor’ itself has enjoyed circulation in the English language since the mid-fifteenth century, having the general connotation of tutor or instructor, the nursing profession has adapted and modified the term to describe a unit-based nurse who carries out one-to-one teaching of new employees or nursing students, in addition to her regular unit duties. The assumption underlying the use of preceptors is that the one-to-one situation provides a most effective mechanism for learning. Allen Tough, in a relevant passage from his book (Tough, 1979), notes that “learning can proceed very effectively when guided by the appropriate person interacting with the learner in a one-to-one situation”, and further that “for certain subject matter . . . this is clearly the most efficient way to learn” (p. 129). In specific reference to preparation for certain occupations, Tough points out that the person who is already successful in an occupation knows exactly what knowledge and skills are necessary for the profession in question. That person can effectively provide one-to-one teaching because he or she can easily modify the teaching process according to the needs of the learner, provide immediate responses to questions and correct errors before they become habits. 19
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JUDITH
SHAMIAN
AND
ROSALIND
INHABER
The concept of preceptorship has been applied in a variety of health service settingsambulatory services, critical care units and general nursing units, to name but three-as well as in schools of nursing. The preceptor role has been utilized in a variety of ways involving differences of purpose? role definition, selection of preceptors and preparation of preceptors. The following article comprises a review of 21 papers that describe the USC of preceptors in teaching and in service settings, and as such should prove of value to managers and educators who at present utilize a preceptor model, as well as to those who are considering the use of such a model. Conceptual
framework
In recent years, with the removal of nursing schools from hospital facilities, the role of initial hospital orientation for new employees has become increasingly vital. In most hospitals there is a standard orientation provided by the inservice education department. During the centralized orientation sessions, which generally last from one to two weeks, new employees are instructed in hospital-wide policies and procedures and in institutional philosophy. Such a method assists newcomers in familiarizing themselves with the overall function of the institution, and following this centralized orientation, the new employee usually undergoes an additional, informal orientation to the nursing unit, during which she acquaints herself with the practical aspects of the job. Different nurses guide the orientee into the unit routine, and this orientation consists for the most part of on-the-job training in an unstructured form, some of the learning involved being gained by trial and error. In some institutions, nursing management came to realize that this second form of orientation was inadequate, especially in the case of new graduates signing up for their first job, The inefficiency of the informal, unit-based orientation was manifested in high turnover of staff, reality shock syndrome, early burnout and general lack of satisfaction among both new and senior nurses. The tension and high degree of anxiety among new and senior members of the nursing team grew destructive to the functioning of the units. Analysis of the symptoms by a variety of authors has revealed that the problem often begins as early as the orientation period (Everson et al., 1981; Friesen and Conahan, 1980; Moyer and Mann, 1979; Plasse and Lederer, 1981). Although the centralized orientation provides the orientee with an overall knowledge of the institution, it fails to furnish the structured learning of practical unit routine, and with nursing-unit orientation tending also to prove deficient in this regard, a knowledge gap inevitably comes into existence. The preceptor model was developed to bridge this gap to allow for an unstressful adjustment to the new work environment. Kramer and Schmalenberg (1977) based a book on research into the conflicts that arise when the school-bred ‘professional values’ of nurses must confront the apparently discrepant ‘bureaucratic values’ of the workplace, and attempted to bridge the gap between education and practice by promoting strategies designed to ensure that patientcentred professionalism will prevail over all obstacles. Schools of nursing were confronted with a similar problem (Crancer et al., 1975; McGrath and Koewing, 1978; Walters, 1981). Feeling inadequately prepared for the service settings, new graduates had difficulties functioning on the job. Internships were consequently established which consisted of future graduates being teamed with preceptors chosen from among hospital staff nurses. Such programs provided an experience through which the students were assisted in making the adjustment from theory to practice. The concept of decentralized teaching makes for a non-stressful environment where positive feedback and learning are supported and encouraged.
CONCEPT
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The implementation of the preceptor model seems then to respond to the needs identified by both hospitals and schools of nursing. Utilization of this model has led to many of the objectives of both types of institutions being met. Integration of the new employee into the unit is facilitated by someone who is close to the scene of activity, and there is good reason to believe that a peer relationship is better able to affect the required learning. As a bonus, the use of preceptors rather than clinicians for purposes of orientation would appear to be more cost-effective.
Nursing education
programs
Universities and junior colleges are aware of the difficulties new graduates encounter during their integration into the work setting. In order to avert these negative experiences, numerous schools have set up structured internships whereby senior-year nursing students work in a hospital with preceptors who act as guides over the internship period (Bushong and Simms, 1979; Chickerella and Lutz, 1981; Ferguson and Hauf, 1973; Friesen and Conahan, 1980; Helmuth and Guberski, 1980; Limon et al., 1982; Murphy and Hammerstad, 1981; Plasse and Lederer, 1981; Sherman, 1980; Taylor and Zabawski, 1982).
Orientation
of new employees
Eleven of the papers reviewed describe the use of preceptors for orientation purposes both to further the cause of biculturalism (efficient functioning, that is, in two subcultures of life, student practice and professional practice) and to ensure smooth adjustment to the service setting (Bushong and Simms, 1979; Dell and Griffith, 1977; Everson et al., 1981; Ferris, 1980; Knauss, 1980; May, 1980; McGrath and Koewing, 1978; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Patton et al. 1981; Plasse and Lederer, 1981). The preceptor model is used in a variety of service settings: cardiac care or critical care units (Ferris, 1980; Moyer and Mann, 1979), childrens’ hospitals (Everson et al., 1981; Patton et al., 1980), university teaching community hospitals (Bushong and Simms, 1979; May, 1980; Murphy and Hammerstad, 1981), ambulatory care settings (Sherman, 1980) and cardiac care teaching in rural communities (Ferris, 1980). The use of this method is endorsed unanimously in all reports cited, but to date the only published research data evidencing the superiority of the preceptor over the traditional teaching model is that of Shamian and Lemieux (1984). Responsibilities
of the preceptor
Preceptor responsibilities include planning, teaching, role modelling and evaluation. Whereas all preceptors function as teachers and role models, only a few are responsible for program planning and evaluation of students or new employees (Knauss, 1980). There are two primary responsibilities mentioned in most reports. Twelve studies indicate that the preceptor is responsible both for assisting the student nurse or orientee in acquiring basic knowledge of the unit’s policies and procedures and for teaching the technical skills that are required (Bushong and Simms, 1979; Chickerella and Lutz, 1981; Crancer et al, 1975; Everson et al., 1981; Friesen and Conahan, 1980; Knauss, 1980; May, 1980; McGrath and Koewing, 1978; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Patton et al., 1981; Walters, 1981). In nine out of twelve programs the preceptor is also expected to conduct some form of evaluation (Bushong and Simms, 1979; Chickerella and Lutz,
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JUDITH
SHAMIAN
AND
ROSALIND
INHABER
1981; Everson er al., 1981; Friesen and Conahan, 1980; McGrath and Koewing, 1978; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Patton er a/., 1981; Walters, 1981). The second most frequent responsibility of the preceptor is to assist the preceptee in the socialization process. Acting as a guide to the newcomer, the preceptor helps her identify the purpose and philosophy of the department. She also helps a newly hired nurse integrate into the unit; for example, she may indicate how schedules are made, who is responsible for education and other useful information. Elimination or reduction of reality shock is indicated in ten reports as either an essential role or natural outcome of the preceptor model (Crancer et al., 1975; Everson et al., 1981; Friesen and Conahan, 1980; Knauss, 1980; Limon et al., 1982; McGrath and Koewing, 1978; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Patton et al., 1981; Plasse and Lederer, 1981). The ways by which the preceptor is to accomplish the goals are varied. Some of the articles indicate that the preceptor has to set up objectives with the orientee-for example, define her specific educational needs and outline the strategies for learning (Chickerella and Lutz, 1981; Everson et al., 1981). Another recommends establishing an orientation manual with guidelines (Everson et al., 1981). We summarize. the responsibilities of the preceptor below: (1) Orientation of preceptees to the unit; (2) Socialization of preceptees within the unit; (3) Teaching, observation and evaluation of preceptees; (4) Assisting in the establishment of objectives and priorities during orientation or internship; (5) Communicating with superiors regarding progress of preceptees. The preceptor acts as a liaison between students and new orientees and the new practice environment. The role of the preceptor decreases as the new nurse takes on more and more responsibility. The responsibility is both complementary and changing; as the student or orientee becomes more comfortable in the unit’s function, the preceptor steps back and assumes the role of resource person. Other personnel in the organization also have a responsibility for the success of the program. The student or orientee, for example, must become a partner in designing the orientation to meet her specific needs. In certain programs, the orientee is expected to define her objectives and to keep a record of her experience. Some of the students are expected to do the same. Other members of the team who have well-defined duties are nursing administration personnel such as the head nurse, nurse educator or another representative of nursing management. This person meets the preceptor periodically to review the progress of the orientee and to evaluate the preceptor program, and also acts as a resource person to the preceptor. Occasionally, where the preceptor is used as a facilitator for nursing students, a faculty representative must review the progress of the student and the success of the program (Murphy and Hammerstad, 1981; Taylor and Zawbaski, 1982), and her responsibilities will vary from being a preceptor to supporting and providing a link between educational and service settings (Taylor and Zabawski, 1982). The preceptor, preceptee, nursing manager and educator all therefore have responsibilities at different phases of assessment, planning, implementation and evaluation. Selection of preceptors
The selection of preceptors is carried out by nursing management of the hospital, by educators from the teaching setting, or jointly. The individual doing the selecting may vary from the head nurse (Everson et al., 1981; May, 1980), to the director of nursing (Knauss,
CONCEPT
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1980; Walters, 1981), to other nursing administrators (Crancer ef al., 1975; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Taylor and Zabawski, 1982). In situations where preceptors are utilized to teach nursing school students, on some occasions a professor may have a joint appointment and function as both professor and preceptor (Everson et al., 1981; Patton et al., 1981) or the school may request that the hospital appoint preceptors (Ferris, 1980; Knauss, 1980), or the school and hospital may jointly make the decision (Crancer et al., 1975; Friesen and Conahan, 1980). Prerequisites for the selection of preceptors are as follows: (1) Years of experience (Ferguson and Hauf, 1974; Ferris, 1980; Knauss, 1980; Taylor and Zabawski, 1982), which vary from at least one year of experience (Taylor and Zabawski, 1982) to from 5 to 10 years; (2) Leadership skills (Friesen and Conahan, 1980; Moyer and Mann, 1979; Murphy and Hammerstad, 1981); (3) Communication skills (Friesen and Conahan, 1980; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Plasse and Lederer, 1981); (4) Decision-making ability (Friesen and Conahan, 1980; Moyer and Mann, 1979; Murphy and Hammerstad, 1981); (5) Interest in professional growth (Friesen and Conahan, 1980; Murphy and Hammerstad, 1981).
Preparation of preceptors
Although it is important to select a preceptor with strong clinical expertise, a good, conceptual base of nursing, and educational commitment, the subsequent preparation of preceptors is a serious task to which agencies devote careful attention. All nursing education programs (Crancer et al., 1975; Ferguson and Hauf, 1973; Friesen and Conahan, 1980; Limon et al., 1982; Taylor and Zabawski, 1982; Walters, 1981) that use the preceptor model for internship have faculty members to train the hospitalbased preceptor. The educational format assumes different length and content, ranging from a brief orientation of preceptors to the program and philosophy of the school by nursing management of the hospital (Chickerella and Lutz, 1981) to a brief introduction and weekly followup by a faculty member to assist the preceptor (Friesen and Conahan, 1980). Other programs involve self-teaching and one-day workshops (Limon et al., 1982). Table 1 demonstrates some of the different ways in which nursing education programs prepare preceptors, and Table 2 demonstrates who teaches preceptors in service settings and how they are taught. Content of preceptor training
According to the information provided in the publications, preparation for the role of preceptor at both educational and service settings varies from extensive to minimal. Table 3 summarizes the content of preceptor for educational settings; Table 4 does the same for service settings. Because the foci of the papers differ, and because similar aspects of the programs are not always equally well covered, it is difficult to draw an effective comparison regarding the structure of preceptor training. Nevertheless, the available data can be utilized at least as a guideline, if not as a blueprint for action.
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JUDITH
SHAMAN
Table 1. Preparation
AND
Bushong and Simms (1979) Chickerella and Lutz (1981) Crancer et al. 1975) Ferguson and Hauf (1973) Friesen and Conahan (1980)
Helmuth and Guberski (1980) Limon ef al. (1982) Sherman (1980) Taylor and Zabawski (1982) Walters (1981)
Dell and Griffith (1977) Everson et (1981)
al.
Ferris ( 1980) Knauss (1980) May ( 1980) McGrath and Koewing (1978) Moyer and Mann
(1979) Murphy and Hammerstad (1981) Patton et al. (1981) Plasse and Lederer (1981)
Training done by
Six schools in Northern Virginia Capital University, Columbus OH Arapanoe Community College, Littleton, CO Montana State University, Bozeman, MA University of California, San Francisco, CA
University of Maryland, Baltimore, MD Ohlone College, Fremont, CA University of Illinois, College of Nursing British Columbia Institute of Technology University of North Carolina, Chapel Hill, NC Table 2. Preparation
Author
INHABER
of preceptors in schools of nursing
Educational setting
Author
ROSALIND
Faculty Faculty
Orientation to preceptors, supervisors, head nurses Orientation one-to-one
Faculty
Three workshops over 8 months6 days in all
Faculty
Small groups orientation 1.5 hours daily to weekly discussions re preceptor’s progress and preceptor’s needs One-to-one
Faculty Faculty
One-day workshop self-directed learning of 6 hours
Faculty
Orientation
Faculty
Classes
of preceptors in service settings
Service setting
Training done by
Duke University Medical Center, Durham, NC Children’s Hospital Medical Center, Boston, MA
Inservice department
Rural hospitals of North Carolina 250-bed, general hospital, Charlottesville, VA Beth Israel Hospital, Boston, MA
Teaching format
Teaching format Two 4-hour sessions
Three workshops Senior staff from clinical areas; Members of dept. of staff development and research Two to three weeks Task force members Weekly meetings
Educational coordinators Preceptor development program Workshop Brief orientation Moore Memorial Planning Case presentation Hospital, Pinehurst, NC committee Harborview Medical Orientation coordinator Ad hoc meeting of preceptors and Center, Seattle, WA orientation coordinators Self-instruction format Task force Stanford University Hospital, Stanford, CA Children’s Hospital Medical Center, Boston, MA Workshop El Camino Hospital, Mt View, CA
CONCEPT Table
AND
3. Content
PRACTICE
of preceptor
training
in schools
of nursing Limon (1982)
Chickerella and Lutz (1981) ~ _ ~~ _~~~___ _~
Friesen (1980)
and Conahan
Purpose of the course Expectations about the preceptor role
Philosophy and goals of internship program Function and responsibility of preceptor
Review student practice policies Review school curriculum Handout-course syllabus -preceptor guidelines --clinical objective5
Evaluation
of teaching
tools
et al.
Ferguson (1973)
Theory
conflict
integration
Helmuth (1980)
and Guberski
Problem
solving
method
skills
Table 4. Content
of preceptor
May
et al.
Evaluation
Learning contract5 Reality shock (Kramer)
Concepts of empathy Value clarification Communication
Knauss (1980)
Moyer (1979) of preceptor
Organizational Introduction
priorities to each shift
Dell and Griffith (1977) Teaching methodology Learning theory (Knowle’s) Feedback concepts
Adult
training Murphy (1981)
(1980)
Adult teaching and learning theory (Knowle’s) I‘eedback and empathy concepts
(‘oncept
concept\
and Hauf
Role of preceptor Development of manual Teaching and counselling
Everson (1981)
Communication
Walters (1981)
Purpose and method of implementing program
et al.
Role description Evaluation concept5 Teaching and learning theories Feedback concepts
Evaluation of student performance Reality shock (Kramer)
Professional and bureaucratic Conflict resolution Crancer (1975)
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OF PRECEPTORSHIP
concepts
learning
Teaching
theory
and Mann
methodology
Policies and procedures Counselling skills
in service settings and Hammerstad
Plasse and Lederer (1981)
Role transformation
Use of orientation
Reality
Counselling skills Feedback concepts
Assessment of learning needs Written objectives Feedback concepts
Ferris (1980)
McGrath (1978)
Teaching and learning theories Clinical concepts
Concept person
shock
(Kramer)
tools
and Koewmg
of resource
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JUDITH
SHAMIAN
AND
ROSALIND
INHABER
Four major components that emerge most frequently as aspects of the training of preceptors and the number of times they are noted are shown in Table 5. Table 5. Aspects of the training of preceptors and the number of times they are noted _____ The preceptor’s role description and expectation Adult education concepts Constructive feedback Evaluation concept
No. of times noted 7 6 6 3
First, a description of the role of preceptor and shared expectations among preceptors, preceptees, schools of nursing and hospitals are noted by seven authors as a structured part of orientation (Chickerella and Lutz, 1981; Ferguson and Hauf, 1973; Friesen and Conahan, 1980; Knauss, 1980; Limon et al., 1982; McGrath and Koewing, 1978; Murphy and Hammerstad, 1981). Secondly, six facilities indicate that preceptors are introduced to adult teaching and learning theory (Dell and Griffith, 1977; Everson et al., 1981; Ferris, 1980; Limon et al., 1982; May, 1980; Moyer and Mann, 1979). It is interesting to note that only one educational institution (Limon et al., 1982) introduces teaching theories to preceptors, whereas four service settings deem it important. Thirdly, the art of giving and receiving feedback appears to be an important integrated aspect of six programs (Dell and Griffith, 1977; Limon et al., 1982; May, 1980; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Plasse and Lederer, 1981). Finally evaluation is noted by only three authors as a formal part of the preparation of a preceptor (Ferris, 1980; Limon et al., 1982; May, 1980). As becomes apparent, there are great variations among the programs that prepare preceptors. The first step in standardizing the concept of a preceptor model would be to agree on the elements that constitute this role and then to prepare preceptors according to those elements. Supervision
of preceptors
Preceptors who work for nursing schools are supervised by faculty members who coach and guide them during their preceptorships. Preceptors working in service settings are supervised by different individuals in the setting: an educational coordinator or nursing specialist (May, 1980; Murphy and Hammerstad, 1981; Plasse and Lederer, 198 I), an orientation coordinator (Moyer and Mann, 1979) and others. Benefits to preceptors
The overall impression gained from the literature review is that preceptors find the experience very valuable. The major perceived value is added job satisfaction (Chickerella and Lutz, 1981; Dell and Griffith, 1977; Friesen and Conahan, 1980; Limon et al., 1982; Murphy and Hammerstad, 1981), which seems to arise from the additional challenge and increased involvement with the institution. Another frequently noted benefit is the opportunity for professional growth (Chickerella and Lutz, 1981; Friesen and Conahan,
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1980; Knauss, 1980; Limon et al., 1982; Taylor and Zabawski, 1982), an especially effective motivation for senior nurses to renew their feelings of professionalism.
Recommendations
Based on the information provided in the articles it would seem that the following recommendations, if observed, would facilitate the preceptorship process: (I) The preceptor should be available for the preceptee at all times (in other words, they should work the same shifts) (Bushong and Simms, 1979; Chickerella and Lutz, 1981; Friesen and Conahan, 1980; Plasse and Lederer, 1981); (2) Manuals should be developed to describe roles and functions within the unit (Chickerella and Lutz, 1981; Limon et al., 1982; Taylor and Zabawski, 1982); (3) Workshops ought to be conducted prior to preceptorship (Chickerella and Lutz, 1981; Friesen and Conahan, 1980; Limon et al., 1982; Taylor and Zabawski, 1982); (4) Preceptors should have a role description (Everson et al., 1981; Limon et al., 1982; Taylor and Zabawski, 1982); (5) Some form of reward for preceptors ought to be built into the system (Ferguson and Hauf, 1973; Friesen and Conahan, 1980; Limon et al., 1982; McGrath and Koewing, 1978; Murphy and Hammerstad 1981; Taylor and Zabawski, 1982). Other recommendations deal with the selection of preceptors (Murphy and Hammerstad, 198 1; Plasse and Lederer, 198 l), the involvement of the preceptor in program development (McGrath and Koewing, 1978), and the research required to evaluate programs properly (Everson et al., 1981).
Discussion
Although it is difficult to draw solid conclusions from these descriptive data, it is apparent that the preceptor model in nursing is alive and well for both educational and orientation purposes. The authors are convinced that the use of a preceptor model provides a ‘winand-win’ situation where everybody stands to gain. The school of nursing gains because its graduates are better prepared for the work force. Moreover, the school boasts a better program without having to shoulder an additional financial burden. The hospital gains because the turnover rate decreases and job satisfaction increases, as does the overall quality of care. It is also more cost-effective to use preceptors than instructors. The preceptor wins because she is given an opportunity that allows her to grow in the profession; the orientee and student win because their adjustment to the new environment becomes smooth and exciting instead of frustrating and grim. And, above all, the clients win because the better prepared nursing staff have a clear understanding of their duties. The time has come to evaluate these assumptions in an impartial manner, to prove the value of preceptors and to select those methods for training preceptors that are most effective. We must pose research questions and evaluate the model. In the meantime, administrators and educators should continue to implement preceptor models, and make an attempt to evaluate the program. It is only in this way that substantive evidence regarding the utility of the system can be demonstrated.
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AND ROSALJND
JNHABER
References Bushong, N. V. and Simms, S. (1979). Externship: a way to bridge the gap. Sup. Nurse 10. 14-22. Chickerella, B. G. and Lutz, W. J. (1981). Professional nurturance: preceptorships for undergraduate nursing students. Am. J. Nurs. 81, 107-109. Crancer, J., Fournier, M. and Maury-Hess, S. (1975). Clinical practicum before graduation. Nuts. Outlook 23, 99-102. Dell, M. B. and Griffith, E. (1977). A preceptor program for nurses’ clinical orientation. J. Nuts. Admin. 7. 30-38 Everson, S., Panoc, K., Pratt, P. and King, A. M. (1981). Precepting as an entry method for newly hired staff. J. cont. Educ. Nurs. 12, 22-26. Ferguson, M. and Hauf, B. (1973). The preceptor role: implementing student experience in community nursing. J. cont. Educ. Nuts. 4, 12-16. Ferguson, M. and Hauf, B. (1974). The preceptor role; implementing student experience in community nursing, part 2. J. cont. Educ. Nurs. 5, 14-16. Ferris, L. (1980). Cardiac preceptor model: access to learning by nurses in rural communities. J. cont. Educ. Nurs. 11, 19-23. Friesen, L. and Conahan, B. .I. (1980). A clincial preceptor program: strategy for new graduate orientation. J. nurs. Admin. 10, 18-23. Helmuth, M. R. and Guberski, T. D. (1980). Preparation for preceptor role. Nurs. Outlook, 28, 36-39. Knauss, P. J. (1980). Staff nurse preceptorship: an experiment for graduate nurse orientation. J. conf. Educ. Nurs. 11, 44-46. Kramer and Schmalenberg (1977). Path to Biculturalism. Aspen Systems, Wakefield, MA. Limon, S., Bargagliotti, L. A. and Spencer, B. J. (1982). Providing preceptors for nursing students: what questions should you ask? J. nurs. Admin. 12, 16-19. May, L. (1980). Clinical preceptors for new nurses. Am. J. Nurs. 80, 24-26. McGrath, B. J. and Koewing, J. R. (1978). A clinical preceptorship for new graduate nurses. J. nurs. Admin. 8, 12-18. Moyer, M. G. and Mann, J. K. (1979). A preceptorship program of orientation within the critical care unit. Heart Lung 8, 530-534. Murphy, M. L. and Hammerstad, S. M. (1981). Preparing a staff nurse for precepting. NurseEducator6, 17-20. Patton, D., Grace, A. and Rocca, J. (1981). Implementation of the preceptor concepts: adaptation to high stress climate. J. cont. Educ. Nurs. 12, 27-31. Plasse, N. J. and Lederer, J. R. (1981). Preceptors-a resource for new nurses. J. nurs. Leadership and Management-supervisor Nurse 12, 35-41. Shamian, J. and Lemieux, S. (1984). An evaluation of the preceptor model versus the formal teaching model. J. cont. Educ. Nurse 15, 86-89. Sherman, J. E. (1980). Role modelling for fnp students. Nurs. Outlook 28, 40-42. Taylor, J. and Zabawski, P. (1982). Preceptorship is alive and well and working at bcit. Can. Nurse 21, 19-22. Tough, A. M. (1979). The Adult’s Learning Projects; a Fresh Approach to Theory and Practice in Adult Learning. Toronto: Ontario Institute for Studies in Education. Research in Education Series, No. 1. Walters, C. R. (1981). Using staff preceptors in a senior experience. Nurs. Outlook 29, 245-247. (Received 3 January 1984; accepted for publication 18 September 1984)
Judith Shamian, R.N., M.P.H., is a coordinator of Ambulatory Services and Research at The Sir Mortimer B. Davis Jewish General Hospital, Montreal, with a joint-appointment at McGill University. Mrs Shamian recently completed her Master’s degree in Public Health at New York University with specialization in International Health Education. She is currently a doctoral student at Case Western University, Cleveland, Ohio. Mrs Shamian is involved in a variety of research projects examining the learning process of both clients and professionals. Rosalind Inhaber, B.Sc., a former teacher who works with Mrs Shamian, is currently completing her M.A. studies at Concordia University, Montreal.
C020-7489185 13.00+0.00 ’ 1985 Pergamon Pres L.td.
The concept and practice of Preceptorship in con temporary nursing: a review of pertinent literature JUDITH
SHAMIAN,
R.N.,
M.P.H.
and ROSALIND
INHABER,
B.Sc.
The Sir Mortimer B. Davis Jewish General Hospital, 3755 Cote Ste-Catherine Road, Montreal, Quebec, Canada, H3T IE2.
authors review 21 articles on preceptor programs in schools of nursing and service settings. They provide comparative details of various aspects of preceptor programs but particularly emphasize, first, the ways in which preceptors are trained and secondly, the content of preceptor training programs. The purpose of the review is to help administrators set up preceptor programs in their own localities. Abstract-The
The term preceptorship has been used in the context of nursing for a relatively short period of time, having first appeared as a classification in the International Nursing Index of 1975. While the word ‘preceptor’ itself has enjoyed circulation in the English language since the mid-fifteenth century, having the general connotation of tutor or instructor, the nursing profession has adapted and modified the term to describe a unit-based nurse who carries out one-to-one teaching of new employees or nursing students, in addition to her regular unit duties. The assumption underlying the use of preceptors is that the one-to-one situation provides a most effective mechanism for learning. Allen Tough, in a relevant passage from his book (Tough, 1979), notes that “learning can proceed very effectively when guided by the appropriate person interacting with the learner in a one-to-one situation”, and further that “for certain subject matter . . . this is clearly the most efficient way to learn” (p. 129). In specific reference to preparation for certain occupations, Tough points out that the person who is already successful in an occupation knows exactly what knowledge and skills are necessary for the profession in question. That person can effectively provide one-to-one teaching because he or she can easily modify the teaching process according to the needs of the learner, provide immediate responses to questions and correct errors before they become habits. 19
80
JUDITH
SHAMIAN
AND
ROSALIND
INHABER
The concept of preceptorship has been applied in a variety of health service settingsambulatory services, critical care units and general nursing units, to name but three-as well as in schools of nursing. The preceptor role has been utilized in a variety of ways involving differences of purpose? role definition, selection of preceptors and preparation of preceptors. The following article comprises a review of 21 papers that describe the USC of preceptors in teaching and in service settings, and as such should prove of value to managers and educators who at present utilize a preceptor model, as well as to those who are considering the use of such a model. Conceptual
framework
In recent years, with the removal of nursing schools from hospital facilities, the role of initial hospital orientation for new employees has become increasingly vital. In most hospitals there is a standard orientation provided by the inservice education department. During the centralized orientation sessions, which generally last from one to two weeks, new employees are instructed in hospital-wide policies and procedures and in institutional philosophy. Such a method assists newcomers in familiarizing themselves with the overall function of the institution, and following this centralized orientation, the new employee usually undergoes an additional, informal orientation to the nursing unit, during which she acquaints herself with the practical aspects of the job. Different nurses guide the orientee into the unit routine, and this orientation consists for the most part of on-the-job training in an unstructured form, some of the learning involved being gained by trial and error. In some institutions, nursing management came to realize that this second form of orientation was inadequate, especially in the case of new graduates signing up for their first job, The inefficiency of the informal, unit-based orientation was manifested in high turnover of staff, reality shock syndrome, early burnout and general lack of satisfaction among both new and senior nurses. The tension and high degree of anxiety among new and senior members of the nursing team grew destructive to the functioning of the units. Analysis of the symptoms by a variety of authors has revealed that the problem often begins as early as the orientation period (Everson et al., 1981; Friesen and Conahan, 1980; Moyer and Mann, 1979; Plasse and Lederer, 1981). Although the centralized orientation provides the orientee with an overall knowledge of the institution, it fails to furnish the structured learning of practical unit routine, and with nursing-unit orientation tending also to prove deficient in this regard, a knowledge gap inevitably comes into existence. The preceptor model was developed to bridge this gap to allow for an unstressful adjustment to the new work environment. Kramer and Schmalenberg (1977) based a book on research into the conflicts that arise when the school-bred ‘professional values’ of nurses must confront the apparently discrepant ‘bureaucratic values’ of the workplace, and attempted to bridge the gap between education and practice by promoting strategies designed to ensure that patientcentred professionalism will prevail over all obstacles. Schools of nursing were confronted with a similar problem (Crancer et al., 1975; McGrath and Koewing, 1978; Walters, 1981). Feeling inadequately prepared for the service settings, new graduates had difficulties functioning on the job. Internships were consequently established which consisted of future graduates being teamed with preceptors chosen from among hospital staff nurses. Such programs provided an experience through which the students were assisted in making the adjustment from theory to practice. The concept of decentralized teaching makes for a non-stressful environment where positive feedback and learning are supported and encouraged.
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The implementation of the preceptor model seems then to respond to the needs identified by both hospitals and schools of nursing. Utilization of this model has led to many of the objectives of both types of institutions being met. Integration of the new employee into the unit is facilitated by someone who is close to the scene of activity, and there is good reason to believe that a peer relationship is better able to affect the required learning. As a bonus, the use of preceptors rather than clinicians for purposes of orientation would appear to be more cost-effective.
Nursing education
programs
Universities and junior colleges are aware of the difficulties new graduates encounter during their integration into the work setting. In order to avert these negative experiences, numerous schools have set up structured internships whereby senior-year nursing students work in a hospital with preceptors who act as guides over the internship period (Bushong and Simms, 1979; Chickerella and Lutz, 1981; Ferguson and Hauf, 1973; Friesen and Conahan, 1980; Helmuth and Guberski, 1980; Limon et al., 1982; Murphy and Hammerstad, 1981; Plasse and Lederer, 1981; Sherman, 1980; Taylor and Zabawski, 1982).
Orientation
of new employees
Eleven of the papers reviewed describe the use of preceptors for orientation purposes both to further the cause of biculturalism (efficient functioning, that is, in two subcultures of life, student practice and professional practice) and to ensure smooth adjustment to the service setting (Bushong and Simms, 1979; Dell and Griffith, 1977; Everson et al., 1981; Ferris, 1980; Knauss, 1980; May, 1980; McGrath and Koewing, 1978; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Patton et al. 1981; Plasse and Lederer, 1981). The preceptor model is used in a variety of service settings: cardiac care or critical care units (Ferris, 1980; Moyer and Mann, 1979), childrens’ hospitals (Everson et al., 1981; Patton et al., 1980), university teaching community hospitals (Bushong and Simms, 1979; May, 1980; Murphy and Hammerstad, 1981), ambulatory care settings (Sherman, 1980) and cardiac care teaching in rural communities (Ferris, 1980). The use of this method is endorsed unanimously in all reports cited, but to date the only published research data evidencing the superiority of the preceptor over the traditional teaching model is that of Shamian and Lemieux (1984). Responsibilities
of the preceptor
Preceptor responsibilities include planning, teaching, role modelling and evaluation. Whereas all preceptors function as teachers and role models, only a few are responsible for program planning and evaluation of students or new employees (Knauss, 1980). There are two primary responsibilities mentioned in most reports. Twelve studies indicate that the preceptor is responsible both for assisting the student nurse or orientee in acquiring basic knowledge of the unit’s policies and procedures and for teaching the technical skills that are required (Bushong and Simms, 1979; Chickerella and Lutz, 1981; Crancer et al, 1975; Everson et al., 1981; Friesen and Conahan, 1980; Knauss, 1980; May, 1980; McGrath and Koewing, 1978; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Patton et al., 1981; Walters, 1981). In nine out of twelve programs the preceptor is also expected to conduct some form of evaluation (Bushong and Simms, 1979; Chickerella and Lutz,
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1981; Everson er al., 1981; Friesen and Conahan, 1980; McGrath and Koewing, 1978; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Patton er a/., 1981; Walters, 1981). The second most frequent responsibility of the preceptor is to assist the preceptee in the socialization process. Acting as a guide to the newcomer, the preceptor helps her identify the purpose and philosophy of the department. She also helps a newly hired nurse integrate into the unit; for example, she may indicate how schedules are made, who is responsible for education and other useful information. Elimination or reduction of reality shock is indicated in ten reports as either an essential role or natural outcome of the preceptor model (Crancer et al., 1975; Everson et al., 1981; Friesen and Conahan, 1980; Knauss, 1980; Limon et al., 1982; McGrath and Koewing, 1978; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Patton et al., 1981; Plasse and Lederer, 1981). The ways by which the preceptor is to accomplish the goals are varied. Some of the articles indicate that the preceptor has to set up objectives with the orientee-for example, define her specific educational needs and outline the strategies for learning (Chickerella and Lutz, 1981; Everson et al., 1981). Another recommends establishing an orientation manual with guidelines (Everson et al., 1981). We summarize. the responsibilities of the preceptor below: (1) Orientation of preceptees to the unit; (2) Socialization of preceptees within the unit; (3) Teaching, observation and evaluation of preceptees; (4) Assisting in the establishment of objectives and priorities during orientation or internship; (5) Communicating with superiors regarding progress of preceptees. The preceptor acts as a liaison between students and new orientees and the new practice environment. The role of the preceptor decreases as the new nurse takes on more and more responsibility. The responsibility is both complementary and changing; as the student or orientee becomes more comfortable in the unit’s function, the preceptor steps back and assumes the role of resource person. Other personnel in the organization also have a responsibility for the success of the program. The student or orientee, for example, must become a partner in designing the orientation to meet her specific needs. In certain programs, the orientee is expected to define her objectives and to keep a record of her experience. Some of the students are expected to do the same. Other members of the team who have well-defined duties are nursing administration personnel such as the head nurse, nurse educator or another representative of nursing management. This person meets the preceptor periodically to review the progress of the orientee and to evaluate the preceptor program, and also acts as a resource person to the preceptor. Occasionally, where the preceptor is used as a facilitator for nursing students, a faculty representative must review the progress of the student and the success of the program (Murphy and Hammerstad, 1981; Taylor and Zawbaski, 1982), and her responsibilities will vary from being a preceptor to supporting and providing a link between educational and service settings (Taylor and Zabawski, 1982). The preceptor, preceptee, nursing manager and educator all therefore have responsibilities at different phases of assessment, planning, implementation and evaluation. Selection of preceptors
The selection of preceptors is carried out by nursing management of the hospital, by educators from the teaching setting, or jointly. The individual doing the selecting may vary from the head nurse (Everson et al., 1981; May, 1980), to the director of nursing (Knauss,
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1980; Walters, 1981), to other nursing administrators (Crancer ef al., 1975; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Taylor and Zabawski, 1982). In situations where preceptors are utilized to teach nursing school students, on some occasions a professor may have a joint appointment and function as both professor and preceptor (Everson et al., 1981; Patton et al., 1981) or the school may request that the hospital appoint preceptors (Ferris, 1980; Knauss, 1980), or the school and hospital may jointly make the decision (Crancer et al., 1975; Friesen and Conahan, 1980). Prerequisites for the selection of preceptors are as follows: (1) Years of experience (Ferguson and Hauf, 1974; Ferris, 1980; Knauss, 1980; Taylor and Zabawski, 1982), which vary from at least one year of experience (Taylor and Zabawski, 1982) to from 5 to 10 years; (2) Leadership skills (Friesen and Conahan, 1980; Moyer and Mann, 1979; Murphy and Hammerstad, 1981); (3) Communication skills (Friesen and Conahan, 1980; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Plasse and Lederer, 1981); (4) Decision-making ability (Friesen and Conahan, 1980; Moyer and Mann, 1979; Murphy and Hammerstad, 1981); (5) Interest in professional growth (Friesen and Conahan, 1980; Murphy and Hammerstad, 1981).
Preparation of preceptors
Although it is important to select a preceptor with strong clinical expertise, a good, conceptual base of nursing, and educational commitment, the subsequent preparation of preceptors is a serious task to which agencies devote careful attention. All nursing education programs (Crancer et al., 1975; Ferguson and Hauf, 1973; Friesen and Conahan, 1980; Limon et al., 1982; Taylor and Zabawski, 1982; Walters, 1981) that use the preceptor model for internship have faculty members to train the hospitalbased preceptor. The educational format assumes different length and content, ranging from a brief orientation of preceptors to the program and philosophy of the school by nursing management of the hospital (Chickerella and Lutz, 1981) to a brief introduction and weekly followup by a faculty member to assist the preceptor (Friesen and Conahan, 1980). Other programs involve self-teaching and one-day workshops (Limon et al., 1982). Table 1 demonstrates some of the different ways in which nursing education programs prepare preceptors, and Table 2 demonstrates who teaches preceptors in service settings and how they are taught. Content of preceptor training
According to the information provided in the publications, preparation for the role of preceptor at both educational and service settings varies from extensive to minimal. Table 3 summarizes the content of preceptor for educational settings; Table 4 does the same for service settings. Because the foci of the papers differ, and because similar aspects of the programs are not always equally well covered, it is difficult to draw an effective comparison regarding the structure of preceptor training. Nevertheless, the available data can be utilized at least as a guideline, if not as a blueprint for action.
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Table 1. Preparation
AND
Bushong and Simms (1979) Chickerella and Lutz (1981) Crancer et al. 1975) Ferguson and Hauf (1973) Friesen and Conahan (1980)
Helmuth and Guberski (1980) Limon ef al. (1982) Sherman (1980) Taylor and Zabawski (1982) Walters (1981)
Dell and Griffith (1977) Everson et (1981)
al.
Ferris ( 1980) Knauss (1980) May ( 1980) McGrath and Koewing (1978) Moyer and Mann
(1979) Murphy and Hammerstad (1981) Patton et al. (1981) Plasse and Lederer (1981)
Training done by
Six schools in Northern Virginia Capital University, Columbus OH Arapanoe Community College, Littleton, CO Montana State University, Bozeman, MA University of California, San Francisco, CA
University of Maryland, Baltimore, MD Ohlone College, Fremont, CA University of Illinois, College of Nursing British Columbia Institute of Technology University of North Carolina, Chapel Hill, NC Table 2. Preparation
Author
INHABER
of preceptors in schools of nursing
Educational setting
Author
ROSALIND
Faculty Faculty
Orientation to preceptors, supervisors, head nurses Orientation one-to-one
Faculty
Three workshops over 8 months6 days in all
Faculty
Small groups orientation 1.5 hours daily to weekly discussions re preceptor’s progress and preceptor’s needs One-to-one
Faculty Faculty
One-day workshop self-directed learning of 6 hours
Faculty
Orientation
Faculty
Classes
of preceptors in service settings
Service setting
Training done by
Duke University Medical Center, Durham, NC Children’s Hospital Medical Center, Boston, MA
Inservice department
Rural hospitals of North Carolina 250-bed, general hospital, Charlottesville, VA Beth Israel Hospital, Boston, MA
Teaching format
Teaching format Two 4-hour sessions
Three workshops Senior staff from clinical areas; Members of dept. of staff development and research Two to three weeks Task force members Weekly meetings
Educational coordinators Preceptor development program Workshop Brief orientation Moore Memorial Planning Case presentation Hospital, Pinehurst, NC committee Harborview Medical Orientation coordinator Ad hoc meeting of preceptors and Center, Seattle, WA orientation coordinators Self-instruction format Task force Stanford University Hospital, Stanford, CA Children’s Hospital Medical Center, Boston, MA Workshop El Camino Hospital, Mt View, CA
CONCEPT Table
AND
3. Content
PRACTICE
of preceptor
training
in schools
of nursing Limon (1982)
Chickerella and Lutz (1981) ~ _ ~~ _~~~___ _~
Friesen (1980)
and Conahan
Purpose of the course Expectations about the preceptor role
Philosophy and goals of internship program Function and responsibility of preceptor
Review student practice policies Review school curriculum Handout-course syllabus -preceptor guidelines --clinical objective5
Evaluation
of teaching
tools
et al.
Ferguson (1973)
Theory
conflict
integration
Helmuth (1980)
and Guberski
Problem
solving
method
skills
Table 4. Content
of preceptor
May
et al.
Evaluation
Learning contract5 Reality shock (Kramer)
Concepts of empathy Value clarification Communication
Knauss (1980)
Moyer (1979) of preceptor
Organizational Introduction
priorities to each shift
Dell and Griffith (1977) Teaching methodology Learning theory (Knowle’s) Feedback concepts
Adult
training Murphy (1981)
(1980)
Adult teaching and learning theory (Knowle’s) I‘eedback and empathy concepts
(‘oncept
concept\
and Hauf
Role of preceptor Development of manual Teaching and counselling
Everson (1981)
Communication
Walters (1981)
Purpose and method of implementing program
et al.
Role description Evaluation concept5 Teaching and learning theories Feedback concepts
Evaluation of student performance Reality shock (Kramer)
Professional and bureaucratic Conflict resolution Crancer (1975)
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OF PRECEPTORSHIP
concepts
learning
Teaching
theory
and Mann
methodology
Policies and procedures Counselling skills
in service settings and Hammerstad
Plasse and Lederer (1981)
Role transformation
Use of orientation
Reality
Counselling skills Feedback concepts
Assessment of learning needs Written objectives Feedback concepts
Ferris (1980)
McGrath (1978)
Teaching and learning theories Clinical concepts
Concept person
shock
(Kramer)
tools
and Koewmg
of resource
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Four major components that emerge most frequently as aspects of the training of preceptors and the number of times they are noted are shown in Table 5. Table 5. Aspects of the training of preceptors and the number of times they are noted _____ The preceptor’s role description and expectation Adult education concepts Constructive feedback Evaluation concept
No. of times noted 7 6 6 3
First, a description of the role of preceptor and shared expectations among preceptors, preceptees, schools of nursing and hospitals are noted by seven authors as a structured part of orientation (Chickerella and Lutz, 1981; Ferguson and Hauf, 1973; Friesen and Conahan, 1980; Knauss, 1980; Limon et al., 1982; McGrath and Koewing, 1978; Murphy and Hammerstad, 1981). Secondly, six facilities indicate that preceptors are introduced to adult teaching and learning theory (Dell and Griffith, 1977; Everson et al., 1981; Ferris, 1980; Limon et al., 1982; May, 1980; Moyer and Mann, 1979). It is interesting to note that only one educational institution (Limon et al., 1982) introduces teaching theories to preceptors, whereas four service settings deem it important. Thirdly, the art of giving and receiving feedback appears to be an important integrated aspect of six programs (Dell and Griffith, 1977; Limon et al., 1982; May, 1980; Moyer and Mann, 1979; Murphy and Hammerstad, 1981; Plasse and Lederer, 1981). Finally evaluation is noted by only three authors as a formal part of the preparation of a preceptor (Ferris, 1980; Limon et al., 1982; May, 1980). As becomes apparent, there are great variations among the programs that prepare preceptors. The first step in standardizing the concept of a preceptor model would be to agree on the elements that constitute this role and then to prepare preceptors according to those elements. Supervision
of preceptors
Preceptors who work for nursing schools are supervised by faculty members who coach and guide them during their preceptorships. Preceptors working in service settings are supervised by different individuals in the setting: an educational coordinator or nursing specialist (May, 1980; Murphy and Hammerstad, 1981; Plasse and Lederer, 198 I), an orientation coordinator (Moyer and Mann, 1979) and others. Benefits to preceptors
The overall impression gained from the literature review is that preceptors find the experience very valuable. The major perceived value is added job satisfaction (Chickerella and Lutz, 1981; Dell and Griffith, 1977; Friesen and Conahan, 1980; Limon et al., 1982; Murphy and Hammerstad, 1981), which seems to arise from the additional challenge and increased involvement with the institution. Another frequently noted benefit is the opportunity for professional growth (Chickerella and Lutz, 1981; Friesen and Conahan,
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1980; Knauss, 1980; Limon et al., 1982; Taylor and Zabawski, 1982), an especially effective motivation for senior nurses to renew their feelings of professionalism.
Recommendations
Based on the information provided in the articles it would seem that the following recommendations, if observed, would facilitate the preceptorship process: (I) The preceptor should be available for the preceptee at all times (in other words, they should work the same shifts) (Bushong and Simms, 1979; Chickerella and Lutz, 1981; Friesen and Conahan, 1980; Plasse and Lederer, 1981); (2) Manuals should be developed to describe roles and functions within the unit (Chickerella and Lutz, 1981; Limon et al., 1982; Taylor and Zabawski, 1982); (3) Workshops ought to be conducted prior to preceptorship (Chickerella and Lutz, 1981; Friesen and Conahan, 1980; Limon et al., 1982; Taylor and Zabawski, 1982); (4) Preceptors should have a role description (Everson et al., 1981; Limon et al., 1982; Taylor and Zabawski, 1982); (5) Some form of reward for preceptors ought to be built into the system (Ferguson and Hauf, 1973; Friesen and Conahan, 1980; Limon et al., 1982; McGrath and Koewing, 1978; Murphy and Hammerstad 1981; Taylor and Zabawski, 1982). Other recommendations deal with the selection of preceptors (Murphy and Hammerstad, 198 1; Plasse and Lederer, 198 l), the involvement of the preceptor in program development (McGrath and Koewing, 1978), and the research required to evaluate programs properly (Everson et al., 1981).
Discussion
Although it is difficult to draw solid conclusions from these descriptive data, it is apparent that the preceptor model in nursing is alive and well for both educational and orientation purposes. The authors are convinced that the use of a preceptor model provides a ‘winand-win’ situation where everybody stands to gain. The school of nursing gains because its graduates are better prepared for the work force. Moreover, the school boasts a better program without having to shoulder an additional financial burden. The hospital gains because the turnover rate decreases and job satisfaction increases, as does the overall quality of care. It is also more cost-effective to use preceptors than instructors. The preceptor wins because she is given an opportunity that allows her to grow in the profession; the orientee and student win because their adjustment to the new environment becomes smooth and exciting instead of frustrating and grim. And, above all, the clients win because the better prepared nursing staff have a clear understanding of their duties. The time has come to evaluate these assumptions in an impartial manner, to prove the value of preceptors and to select those methods for training preceptors that are most effective. We must pose research questions and evaluate the model. In the meantime, administrators and educators should continue to implement preceptor models, and make an attempt to evaluate the program. It is only in this way that substantive evidence regarding the utility of the system can be demonstrated.
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References Bushong, N. V. and Simms, S. (1979). Externship: a way to bridge the gap. Sup. Nurse 10. 14-22. Chickerella, B. G. and Lutz, W. J. (1981). Professional nurturance: preceptorships for undergraduate nursing students. Am. J. Nurs. 81, 107-109. Crancer, J., Fournier, M. and Maury-Hess, S. (1975). Clinical practicum before graduation. Nuts. Outlook 23, 99-102. Dell, M. B. and Griffith, E. (1977). A preceptor program for nurses’ clinical orientation. J. Nuts. Admin. 7. 30-38 Everson, S., Panoc, K., Pratt, P. and King, A. M. (1981). Precepting as an entry method for newly hired staff. J. cont. Educ. Nurs. 12, 22-26. Ferguson, M. and Hauf, B. (1973). The preceptor role: implementing student experience in community nursing. J. cont. Educ. Nuts. 4, 12-16. Ferguson, M. and Hauf, B. (1974). The preceptor role; implementing student experience in community nursing, part 2. J. cont. Educ. Nurs. 5, 14-16. Ferris, L. (1980). Cardiac preceptor model: access to learning by nurses in rural communities. J. cont. Educ. Nurs. 11, 19-23. Friesen, L. and Conahan, B. .I. (1980). A clincial preceptor program: strategy for new graduate orientation. J. nurs. Admin. 10, 18-23. Helmuth, M. R. and Guberski, T. D. (1980). Preparation for preceptor role. Nurs. Outlook, 28, 36-39. Knauss, P. J. (1980). Staff nurse preceptorship: an experiment for graduate nurse orientation. J. conf. Educ. Nurs. 11, 44-46. Kramer and Schmalenberg (1977). Path to Biculturalism. Aspen Systems, Wakefield, MA. Limon, S., Bargagliotti, L. A. and Spencer, B. J. (1982). Providing preceptors for nursing students: what questions should you ask? J. nurs. Admin. 12, 16-19. May, L. (1980). Clinical preceptors for new nurses. Am. J. Nurs. 80, 24-26. McGrath, B. J. and Koewing, J. R. (1978). A clinical preceptorship for new graduate nurses. J. nurs. Admin. 8, 12-18. Moyer, M. G. and Mann, J. K. (1979). A preceptorship program of orientation within the critical care unit. Heart Lung 8, 530-534. Murphy, M. L. and Hammerstad, S. M. (1981). Preparing a staff nurse for precepting. NurseEducator6, 17-20. Patton, D., Grace, A. and Rocca, J. (1981). Implementation of the preceptor concepts: adaptation to high stress climate. J. cont. Educ. Nurs. 12, 27-31. Plasse, N. J. and Lederer, J. R. (1981). Preceptors-a resource for new nurses. J. nurs. Leadership and Management-supervisor Nurse 12, 35-41. Shamian, J. and Lemieux, S. (1984). An evaluation of the preceptor model versus the formal teaching model. J. cont. Educ. Nurse 15, 86-89. Sherman, J. E. (1980). Role modelling for fnp students. Nurs. Outlook 28, 40-42. Taylor, J. and Zabawski, P. (1982). Preceptorship is alive and well and working at bcit. Can. Nurse 21, 19-22. Tough, A. M. (1979). The Adult’s Learning Projects; a Fresh Approach to Theory and Practice in Adult Learning. Toronto: Ontario Institute for Studies in Education. Research in Education Series, No. 1. Walters, C. R. (1981). Using staff preceptors in a senior experience. Nurs. Outlook 29, 245-247. (Received 3 January 1984; accepted for publication 18 September 1984)
Judith Shamian, R.N., M.P.H., is a coordinator of Ambulatory Services and Research at The Sir Mortimer B. Davis Jewish General Hospital, Montreal, with a joint-appointment at McGill University. Mrs Shamian recently completed her Master’s degree in Public Health at New York University with specialization in International Health Education. She is currently a doctoral student at Case Western University, Cleveland, Ohio. Mrs Shamian is involved in a variety of research projects examining the learning process of both clients and professionals. Rosalind Inhaber, B.Sc., a former teacher who works with Mrs Shamian, is currently completing her M.A. studies at Concordia University, Montreal.