Preception Essay, Research Paper

The transition from student status to qualified practitioner can be a daunting and traumatic time for the majority of individuals. Feelings of inadequacy and the inability to cope with this change can prove extremely stressful for the newly registered nurse and place new, ill-prepared for demands on them. Kramer (1974) describes this as ‘Reality Shock’. It could even result in a change of career for some people. Allanach and Jennings (1990) stated that ‘by easing the transition into the professional practice role, preceptorships may be useful in mitigating negative affective states which, in turn may effectively reduce the premature exit of new nurses from the profession’. There could also be a damaging effect on the standard of client care caused by lack of experience and skill incompetence. Lathlean and Corner (1991) conclude that ‘most newly qualified nurses require further knowledge and development of skills and the traditional initial training does not prepare the student adequately for their first staff nurse post’.

The word Preceptor dates back to fifteenth century England and means tutor or instructor. The concept of preceptorship has been recognised in the United States of America since the nineteen seventies. The United Kingdom Central Council state in the Post Registration Education Practice document that preceptors should be first level practitioners with at least twelve months clinical experience in their relevant field, (UKCC 1990).

So what is preceptorship? There are various definitions as to exactly what it is from ‘the one to one teaching of new employees or nursing students by clinical nurses’ (Shamian and Inhaber 1985), to Chickerella and Lutz (1981) defining it as ‘an individualised teaching / learning method, in which each student is assigned to a particular preceptor so they can experience day to day practice with a role model and resources immediately available within the clinical setting’. Because the preceptor is an identified member of the nursing team, the newly appointed staff nurse should feel confident enough to approach them with any difficulties they may experience or learning needs they have. It should also enhance security needs of the preceptee and ensure they do not feel incompetent by asking for support and assistance. The preceptor needs to possess certain personal qualities such as patience, confidence, a good knowledge base and enthusiasm, to name but a few. Preceptorship can often become confused with mentorship. May et al (1982) defines mentorship as ‘an intense relationship calling for a high degree of involvement between a novice in a discipline and a person who is knowledgeable and wise in that area’. Preceptorships tend to be more short lived and are on a more equal basis as both parties are registered professionals. The preceptor is more concerned with teaching and learning aspects of the relationship (Burnard 1990). If the preceptor / preceptee relationship continues for longer than is necessary, then there is a danger of it fusing with mentorship. Preceptorship programmes should run for approximately the first four months of registration, as recommended by the UKCC (UKCC 1990). My own experience as a novice practitioner has enabled me to realise that preceptorship programmes are essential to help make the role change as smooth and stress-free as possible. The unit where I currently work as a staff nurse is a specialised area, always locked and catering for people who exhibit challenging behaviours. This in itself is stressful enough even for the more experienced staff on the unit. To enable a preceptorship programme to take place the preceptor and the preceptee ( whom I shall refer to as the student ), must spend time working with each other, at least one shift per week. There must also be time put aside for one to one sessions to allow feedback and evaluation. Hsieh and Knowles (1990) suggest that the preceptor and student must work together for a specified period, gradually increasing the amount of responsibility and independent functioning on the part of student, to the stage where they eventually take over the duties of the staff nurse role. After the initial meeting between preceptor and student, orientation of the ward environment should take place and also introduction to other members of the ward team. This should make the student feel at ease, although it will take time and the preceptor must be careful not to bombard the novice with too much information. Progress should follow an agreed pace between the two professionals. Each preceptee is an individual in their own right and learning needs will differ greatly.

Jarvis (1983) defines learning as ‘the acquisition of knowledge, skills and attitudes by study, experience or teaching’, whereas Curzon (1985) has described learning as the ‘apparent modification of a person’s behaviour through his activities and experiences so that his knowledge , skills and attitudes, including modes of adjustment towards his environment are changed, more or less permanently’. There are various theories of learning which have been derived by psychologists. These include Behaviourism which is when learning occurs as a result of an individual’s response to a given stimulus. The Cognitive theory places emphasis on the way the brain processes information and how the cognitive structures gained from experience influence the organisation and acquisition of knowledge. The theory of Social learning concerns itself with learning by observation of role models. If the student has observed another person performing a task, then this will influence their approach and behaviour when completing the task themselves. The Humanistic theory emphasises human growth and individual fulfilment. Humanistic psychologists believe that individuals have an innate potential for growth and development and that teachers should be concerned with facilitating this natural process. Rogers (1983) states that ‘humanist education aims to enable learners to express their own needs and interests, building their self confidence, independence and creative energy’. I have covered these theories briefly just to give an idea of the different ways in which people believe we learn.

There are certain other aspects of learning to consider. The preceptor must be aware of the factors which may interfere with learning such as anxiety, environmental distractions and lack of motivation. These are just a few examples. There are also factors which may influence the students learning such as past experiences , prior knowledge and physical / mental state. These must all be taken into account before and during a preceptorship programme. The first few meetings between preceptor and student will enable learning needs and initial difficulties to be worked out before teaching strategies and approaches can be put into practice. However the student will most likely encounter numerous problems along the route of preceptorship.

There are many definitions as to what teaching is. Curzon (1985) suggests that ‘it should be considered as the deliberate and systematic creation and control of the condition in which learning does occur’. Moore (1984) believes that ‘education is deliberate, planned, organised and undertaken with the conscious intention of changing knowledge, skills or attitudes’. The principle of Pedagogy is based on the assumption that the individual is the product of the social system in which they are located. Knowles (1973) describes Pedagogy as ‘the art of science of teaching children’. It implies that the student is a passive recipient of the teaching, as in children. Androgogy was described by Knowles as the ‘art of science of helping adults to learn’ (Knowles 1973). This is an adult-centred approach and implies that a partnership is developed between student and teacher. Synagogy places emphasis on both the student and the teacher-centred approaches. It boasts active student involvement and a systematic approach, and has the combined qualities of pedagogical and androgogical teaching. Having discussed teaching principles and learning theories the preceptor and student must work together and decide which approaches are most suitable and appropriate to their preceptorship programme. The student must be encouraged to make decisions about their own learning needs.

As well as possessing qualities for the role of preceptor there are desirable qualities required for the role of the teacher. These include confidence, knowledge of subjects taught and patience. A teacher should also have a sense of humour and a pleasant manner, as well as respect for others. The preceptor must also ensure that the learning climate is appropriate as people learn best in a non-threatening environment. Some individuals may feel that the learning environment is so dissimilar to what they are used to that they could end up rejecting and resisting it. The roles of the qualified practitioner must be established. These range from clinician and key worker to administrator. The novice may have certain skills in each area but will probably lack the confidence and competence to carry out these duties to the best of their ability. The preceptorship programme should have aims and objectives and an audit tool to allow assessment and evaluation to take place.

Assessment is a measure of student competence and progress. ‘It is the procedure by which a student is judged to have achieved the standard required for qualification’ (English National Board 1987). The dictionary defines an assessor as an expert who advises. There are various methods of assessment that the preceptor could use. Direct observation of the preceptee when performing a task and the use of themselves as a role model. The preceptor and preceptee should have regular discussions to talk about progress made and any problems encountered. During these discussions the preceptor could assess the student by asking questions and gaining feedback from them. Written questions, projects and assignments could also be carried out, as well as ‘role-play’ situations. There are different types of assessment such as formative. This is on going throughout the learning process Summative assessment is the type of assessment used at the end of a period of instruction. This is more appropriate to student nurses rather than preceptorship programmes however. Critical Incident Analysis can be used as a method of developing reflection in nursing practice. Incidents can be chosen as discussion between preceptor and preceptee. Thoughts, feelings and behaviour can be analysed and new approaches to problems reflected on with the outcome of improving or changing learning and behaviour. This can be used as part of the assessment process and the preceptee could keep a reflective journal. As well as the chosen form of assessment the preceptor must be able to evaluate what, if any, progess is made.

‘Evaluation is the process by which educational experiences and the course overall is judged to be of value, and it’s purpose is to provide information that can be utilised to effect development and improvement of the educational experience or course’ (Bradshaw 1989). Formative evaluation is on going throughout the learning experience whilst summative evaluation is at the end of a learning experience. The reason for evaluation is to develop and improve learning experiences. Planned, systematic and focused evaluation serves to enhance the educational experiences and to promote the professional development of preceptees. It is essential to ensure that the preceptorship is working effectively. By evaluating learning experiences as they progress, it enables minor modifications to take place. Evaluation is an essential tool to learning, to plan new strategies and improve performance. Evaluation methods fall into two main categories. Quantitative is where information can be analysed. Qualitative is where experiences and processes can be captured. The quantitative approaches can be in the form of questionnaires or rating scales. Qualitative evaluation is probably more suitable for a preceptorship programme as it includes discussions, participant and non-participant observation, diaries, self reporting and critical incident techniques. It is important that evaluation is not seen as a ritualistic exercise with no substantive outcome. The preceptor will need time to review and reflect on the evaluation. A preceptorship programme may take the form of an action plan which could be written and take place between preceptor and preceptee. The preceptee should be encouraged to self evaluate on their strengths and weaknesses. ‘Student evaluation may in some circumstances reflect more accurately their own learning difficulties’ (Bradshaw 1989). Evaluation sessions can be on a formal basis each week in the form of a meeting between preceptor and preceptee as well as informally throughout the course of the preceptorship programme. The key characteristics of evaluation are that it should be planned, systematic, focused and utilised.

After reading this essay most people who are aware and involved with preceptorship will agree with the author that it is a valuable and much needed practice in today’s nursing. It does however have some downfalls. There are concerns that there may be personality clashes and conflicts between preceptors and preceptees. This could be caused by differing expectations or age and gender. The preceptee may have unrealistic expectations about themselves or their preceptors roles and abilities. Also preceptors may hold unreasonable expectations about the preceptees level of knowledge and performance ability. Therefore a good working relationship is required to ensure preceptorship programmes work. If this is not possible then a change of preceptor is advisable. Munton (1995) stresses the concern that if a situation occurs where a preceptee failed to perform at an agreed standard during the preceptorship period, then how would it be handled? We must remember that the preceptee is still qualified and accountable for there actions, therefore they would be exposed to the same managerial action as any other employee. Ashton and Richardson (1992) suggest that there are a number of issues to be addressed in a preceptorship programme such as the need to provide preceptors with ongoing feedback and support. Just like the novice practitioner, the novice preceptors will need a period of support if they are to become effective in their role. This could be achieved by study sessions which allow reflection or alternatively by peer support at regular meetings with other preceptors. When preceptors are selected it is essential to focus on the quality and quantity of the staff nurses’ expertise. The staff nurse must also be willing to take on the role of preceptor or this will not be beneficial to the preceptee. It should also be good practice to ensure consistency throughout a preceptorship programme as a change in preceptor will lead to unnecessary stress for the preceptee by having to adopt to different preceptors. Another problem which may occur is the contact time spent with the preceptees. Chickerella and Lutz (1981) point out that ‘preceptorship experience requires extra time and adds to the responsibility of the nurse preceptor’. Brennan and Williams (1993) suggest that ‘if this fails to be acknowledged then there is the danger of preceptorship becoming a paper exercise with only it’s statutory assessment functions being performed in the proper manner’. If all these negatives factors are taken into account and addressed prior to problems occurring then there is no reason why a preceptorship programme should not work. There may be problems from older, more experienced staff who don’t see the need for preceptorships as they never had them when they were newly qualified. This could cause the preceptee to feel unaccepted.

Looking on the positive side, preceptorship relationships can be of great benefit to the novice nurse. ‘Preceptors can share their personal resolutions of conflicts and act as sounding boards for the preceptees, to help them establish their own acceptable balance between work and college values’ (Brennan and Williams 1993). Another beneficial aspect is the creation of a free interchange environment between peers, where goals can be agreed and clinical skills promoted to allow self and peer assessment. Preceptorship can also be beneficial to the preceptor. It can bring more job satisfaction through challenge and being actively involved with staff. It can also promote the sharing of ideas within the clinical environment and lead to improved quality of care. Allanach and Jennings (1989) found that after evaluation of a preceptorship programme there remained important and necessary interventions to facilitate a successful transition from student nurse to staff nurse and without such programmes, integration and enactment of the professional nursing role could be compromised.

As well as mitigating the reality shock which often accompanies transition to a new role and responsibilities, preceptorship can be seen as a step along the continuum of personal and professional development. One of the aims of preceptorship is to assist the novice through the transition and also to promote socialisation into the professional role. ‘Professional socialisation is a specific portion of adult socialisation, a complex interactive process by which the content of the professional role (skills, knowledge, behaviour), is learned and the values, attitudes and goals integral to the profession and sense of identity which are characteristic of a member of that profession are internalised’ (Cohen 1981). A preceptorship programme can also be adapted for nurses changing to a new clinical area or for those returning to practice after a break. The implementation of preceptorship determines whether the goals of teaching and learning have been achieved. It is not the strategy of preceptorship itself which is questionable or flawed, but rather the manner in which is implemented. It is only through a process of ongoing monitoring, guidance, support and collaboration that this teaching strategy can hope to provide nurse education with a viable method for preparing the newly qualified staff nurse for professional nursing practice.

REFERENCES

Allanach B.C. and Jennings B.M., (1990): Evaluating the effects of a nurse Preceptorship programme. Journal of Advanced Nursing 15, 22-28

Ashton P. and Richardson G., (1992): Preceptorship and Prepp. British Journal of Nursing, 1, 3: 143-146

Brennan A. and Williams D., (1993): Preceptorship: is it a workable concept? Nursing Standard, 15, 7: 34-36

Burnard P., (1990): The Student Experience: Adult learning and mentorship revisited. Nurse Education Today, 10, 4: 349-354

Chickerella B.G. and Lutz W.J., (1981): Professional Nurturance: preceptorship for undergraduate nursing. British Journal of Nursing, 1, 3: 143-146

Cohen H.A., (1981): The Nurses Approach to a Professional Identity. California: Addison and Wesley

Curzon C.B., (1985): Teaching in Further Education. New York: Holt, Reinhart and Winston

English National Board, (1987): Course Approved Process: Rules, Regulations and Guidelines. London: ENB

Hsieh N.L. and Knowles D.W., (1992): Instructor facilitation of the Preceptorship relationship in nursing education. British Journal of Nursing, 1, 3: 143-146

Jarvis P., (1983): Teaching in Further Education. New York: Holt, Reinhart and Winston

Knowles M., (1973): The Adult Learner; A neglected species. Houston: Gulf Publishing

Lathlean J. and Corner J. (1991): Becoming a staff nurse: A guide to the role of the newly qualified nurse. Prentice Hall Int. (UK) Ltd.

May K.M. et al., (1982): Mentorship for scholarliness: Opportunities and Dilemmas. Nursing Outlook, 30, 22-26

Munton R., (1995): Preceptorship and Mental Health Nursing. Mental Health Nursing, 15, 4: 8-10

Moore N., (1984): Concept of Adult Education. Milton Keynes: OU Press

Rogers C., (1983): Freedom to Learn. New York: Merrill

Shamian J. and Inhaber R., (1985): The concept and practice of Preceptorship in contemporary nursing, a review of pertinent literature. The International Journal of Nursing Studies, 22, 79-88

United Kingdom Central Council, (1993): Registrars letter – the councils position concerning a period of support and Preceptorship. London: UKCC

79-8

United Kingdom Central Council, (1990): The report of the post-registration, education and practice project (PREPP). London: UKCC