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A model of preceptorship in nursing: reflecting the complex functions of the role.

ABSTRACT Preceptorship has been consistently acknowledged in the literature as a strategy to maximize the benefits of clinical nursing education in terms of knowledge and skill acquisition, confidence, and professional socialization. Further benefits have also been recognized for preceptors, and for the broader health care agency. Despite recognition of the importance of this role, there has been no clearly articulated model of preceptorship that reflects the broader factors impacting upon the relationship between registered nurse and nursing student. This article presents a model of preceptorship that is directly based upon the preceptor-preceptee relationship and reflects the factors and influences that might impact, both positively and negatively, the strength and effectiveness of the relationship and subsequent learning outcomes. This model will provide a useful resource for the planning and implementation of a preceptorship program that maximizes clinical learning to the satisfaction of all stakeholders.


FOLLOWING THE TRANSFER OF NURSING EDUCATION INTO THE HIGHER EDUCATION SYSTEM IN AUSTRALIA, clinical education and support were generally provided by clinical teachers specifically employed by the university for that role (Morton-Cooper & Palmer, 2000). This approach was found to have a number of limitations. A major shortcoming arose because clinical teachers were not necessarily familiar with the clinical environment, FURTHERMORE, the acceptable ratio of clinical teacher to student was generally set at one to eight, meaning that not all students were able to receive constant and consistent supervision (Charleston & Happell, 2004). * Preceptorship has been recognized a crucial strategy to enhance recruitment into the nursing profession (Bumgarner & Biggerstaff, 2000; Celia & Gordon, 2001; Clare, White, Edwards, & van Loon, 2002;

Hardyman & Hickey, 2001; Olson et al., 200I); assist in the acquisition of skills and knowledge (Lofmark & Wikblad, 200I; Ohrling & Hallberg, 2000; O'Malley, Cunliffe, Hunter, & Breeze, 2000); enhance confidence (Freiburger, 2002; Hardyman & Hickey; McCarty & Higgins, 2003); and socialize students into the expectations of the profession (Kaviani & Stillwell, 2000; Mullen & Murray, 2002; Myrick & Yonge, 2002; Ohrling & Hallberg). It also provides nursing students with access to clinicians who are familiar with the clinical environment (Charleston & Happell, 2004).

In the case of some nursing specialties, such as psychiatric nursing, preceptorship has been regarded as an important strategy in overcoming the negative attitudes of nursing students, and therefore increasing the likelihood that some will consider mental health as a potential career destination following graduation (Bell, Horsfall, & Goodin, 1998; Clinton & Hazelton, 2000; Curtis, 2007; Happell, 1998, 1999, 2000, 2001, 2008a, 2008b; Henderson, Happell, & Martin, 2007; Mullen & Murray, 2002; Stevens & Dulhunty, 1992, 1997; Wynaden, Orb, McGowan, & Downie, 2000). Because students may become particularly distressed by issues specific within the mental health environment (Charleston & Happell, 2004, 2005), such as involuntary treatment or disturbing comments told to them by patients (Suikkala & Leino-Kilpi, 2001), a preceptorship may be particularly important for this nursing specialty.

Preceptorship has been acknowledged in the literature as a potentially rewarding part of the work role of registered nurses (Greenberg, Colombraro, DeBlasio, Dolan, & Rich, 2001; Jackson, 2001; McCarty & Higgins, 2003; Ohrling & Hallberg, 2001; Wright, 2002). Engagement in a preceptorship relationship can provide the RN with enhanced professional development and self-esteem. Furthermore, by being engaged in the educative role as preceptors, RNs are expected to maintain high levels of skill and knowledge.

Despite recognition for the importance of the preceptorship and the extent to which it is used as an integral part of clinical nursing education, no clear model has been developed to clearly articulate preceptorship and distinguish it from other relationships (such as buddy, mentor, or clinical supervisor). However, the development of a preceptorship model is more than purely a semantic exercise. Rather, it provides a basis from which the complex relationships between individuals and organizations can be examined in order to maximize the value and effectiveness of the preceptorship experience for all stakeholders: students, RNs, universities, and health care organizations alike.

This article presents a detailed model of preceptorship that reflects the complex functions of the role. The model incorporates the views of both preceptors and preceptees as to what makes the relationship work most effectively, and what factors are essential to ensure that the optimum value is met.

Developing a Model for Preceptorship The term preceptorship refers to an educational relationship in which an experienced and skilled professional provides knowledge, skills, support, and encouragement to a nursing student in order to enhance the latter's understanding of, and level of comfort with, the nursing profession (Morton-Cooper & Palmer, 2000). The success of the preceptorship is determined by the strength of the relationship between the student (preceptee) and the professional (preceptor). This relationship forms the basis of the preceptorship model presented in the Figure. An overview of the attitudes of nursing students and registered nurses to the preceptorship relationship is provided by way of background to, and further explanation of, the preceptorship model.


NURSING STUDENTS (PRECEPTEES) The literature is consistent in demonstrating that nursing students value feeling welcomed into the clinical area as a part of the team. This feeling is generally best achieved by providing a thorough orientation and a plan outlining activities and expectations (Charleston & Happell, 2004, 2005; Morton-Cooper & Palmer, 2000; Mullen & Murray, 2002). In addition, students appreciate the opportunity to participate in nursing activities and learn from observing the practices of more experienced colleagues (Charleston & Happell, 2005; Kaviani & Stillwell, 2000; Mullen & Murray; Myrick & Yonge, 2002; Ohrling & Hallberg, 2000).

When asked to describe the specific characteristics of preceptors they find beneficial, nursing students include a consistent and professional approach to their work and to students; the ability to know and appreciate the level of knowledge and the limitations of students' theoretical preparation (a knowledge of the specific university curricula is particularly helpful); and support as a role model in helping students feel they are safe and valued. In addition, the willingness to provide constructive and regular feedback on performance is considered particularly valuable (Charleston & Happell, 2005; Mullen & Murray, 2002; Myrick & Yonge, 2002; Ohrling & Hallberg, 2000).

REGISTERED NURSES (PRECEPTORS) The experience of providing preceptorships is often likened by RNs to being caught in the middle; relationships must be negotiated and maintained with students, peers and colleagues, the broader health service, and the university (Charleston & Happell, 2005). In order to fulfill the preceptor role to the best of their ability, preceptors seek various attributes from each of the stakeholder groups. From students, preceptors seek genuine interest and a desire to learn; adequate preparation for the placement in terms of an appropriate level of theoretical knowledge; an ability to identify some of their own learning objectives; and some understanding of the practice culture within the specific health care environment (Charleston & Happell; Mullen & Murray, 2002).

There is a paucity of literature addressing the type of information and support preceptors seek from universities. However, the limited literature and anecdotal evidence suggest that preceptors seek an understanding of, and information about, the educational program the student is completing (Charleston & Happell, 2005). In many instances, preceptors may be working with nurses from six or more different universities, and marked differences may be evident among curricula.

To be best placed to meet student needs, preceptors require an overview of the student's theoretical component relating to the particular clinical placement; clear and realistic objectives for the placement; the opportunity for input into the clinical program (e.g., the type of learning objectives); and genuine input into students' progress. Preceptors express frustration when they have concerns about a student's competence and/or confidence and reflect this in their written assessment, only to find that the student has passed the placement, with no interventions implemented to encourage improved clinical learning (Charleston & Happell, 2005).

Significantly more literature is available in relation to what preceptors want from their employing health care organization. Broadly speaking, these factors can be summarized as valuing and acknowledging the preceptorship role, and training and support for the role.

The Role of the Health Care Organization VALUING THE PRECEPTORSHIP Registered nurses often view the preceptor role as one they are expected to take on in addition to a full workload, often with little in the way of formal or informal acknowledgment of their contribution and the importance it holds for the organizations involved (Greenberg et al., 2001; Jackson, 2001). Recognition does not necessarily involve additional money, but acknowledgments such as letters of recognition, certificates, badges, and increased access to professional development or formal award functions have been found to increase satisfaction and commitment to the role (Greenberg et al.; Jackson; Stone & Rowles, 2002).

TRAINING Education for the preceptorship role is regarded in the literature as essential for the success of this important strategy. However, education and training specific to this role are considered to be lacking (Charleston & Happell, 2004; Coates & Gormley, 1997; Usher, Nolan, Reser, Owens, & Tollefson, 1999). Charleston and Happell described the evaluation of a formal preceptorship education program that was implemented in recognition of significant problems in the recruitment of nurse graduates into the mental health field, for which the negative image of this specialty was considered at least partially responsible. The program focused strongly on the importance of preceptorship in promoting a positive image of the practice environment. In addition to formal theoretical instruction on such topics as approaches to facilitate teaching and learning and the preeeptor-preceptee relationship and learning outcomes, the importance of organizational and attitudinal change was emphasized. Participants were encouraged to consider the practice setting as it might be seen by students, and how they might contribute to creating an environment more conducive to learning.

A formal evaluation of the program was conducted (Charleston & Happell, 2004). One hundred fifty participants completed an evaluation form, comprising a combination of closed and open-ended questions. The participants expressed a high level of satisfaction with the program and considered how the knowledge and skills they had acquired through completing it would enhance their attitudes toward, and competency in, the preceptorship role (Charleston & Happell). In the absence of formal training, preceptors described feeling underprepared for the role, which impacted their ability to become effective teachers and role models for nursing students (Coates & Gormley, 1997; O'Malley et al., 2000).

SUPPORT FOR THE ROLE Success as a preceptor depends quite heavily on having sufficient time to spend with students in an educative role (Wright, 2002). The literature suggests that preceptors are frequently expected to take the preceptorship role on as an addition to their usual workload. Thus, providing care to patients or clients generally takes priority over student learning (Allen, 2002; Charleston & Happell, 2005; Yonge, Krahn, Trojan, Reid, & Haase, 2002), leading to a sense of dissatisfaction with the preceptor role.

In order to undertake the role effectively, preceptors seek the support of health services, including the nursing and hospital administration, to provide protected time with students (Allen, 2002; Wright, 2002; Yonge et al., 2002). Not only does this make the role more possible, it indicates that the health service recognizes the importance of the preceptorship and has allocated time to ensure that it has every chance of succeeding.

The Preceptorship Model The model presented in this article (see Figure) was developed in full consideration of the factors that influence clinical learning from the perspectives of nursing students and the clinicians who take on the role of teaching them. But the relationship between the nursing student and the RN that forms the basis of the preceptorship cannot be considered in isolation from the two other major stakeholders: the university and the health care agency.

Teaching and learning, the central tenet of the preceptorship relationship, extends far beyond the transmission of knowledge and skills. The preceptor is a role model, with the responsibility to inspire students to develop clinical skills and to appreciate the importance and inherent value of nursing practice. Rather than viewing the student's presence as an additional, even burdensome, task, the preceptor respects the student as a future member of the nursing workforce. The preceptor also recognizes that the student is inexperienced and is likely to lack confidence; therefore, as part of the role, the preceptor facilitates a supportive environment by creating clear and open communication channels.

It is important to note that the relationship is not one way. The preceptee may also provide inspiration to the preceptor.

This relationship constantly encourages RNs to ensure that their knowledge and skills are up to date and to reflect on their practice on a regular basis.

The model clearly portrays the importance of partnership and collaboration. The complexity of nursing education means that nursing education can no longer be conceived as a system where universities "teach" students how to do things, while health services provide the opportunity for them to "practice" things with real people. This involves recognition that the production of knowledgeable, skilled, and competent graduates is a shared responsibility. The preceptorship must be viewed as an essential component of high quality nursing education for which universities and health services provide the necessary resources.

To achieve this goal, universities need to provide preceptors with learning objectives and information, including an overview of the theoretical preparation students have had for the placement. This cannot be a one-way process. As partners, preceptors should have the opportunity, and indeed be encouraged, to contribute to the theoretical program and the development of learning objectives. By being better informed about the theoretical aspect of the education process, preceptors will more likely be adequately prepared to meet the need for, and encourage, learning opportunities for nursing students.

Health care organizations can contribute to this partnership by acknowledging the importance of the role and demonstrating their commitment to it. It is important that agencies recognize the value of preceptorships in securing adequate numbers of well-prepared nurses for future health care needs. This contribution can occur at a number of levels. Two important areas are training, which may involve collaboration with the university and include time release to attend, and incorporating some designated time within the preceptor's workload to be dedicated specifically to the conduct of this role.

The students at the receiving end of the relationship are frequently unaware of the complex environments of universities and health care services. However, they are very clear in their desire for a positive environment. They want to be welcomed, supported, and included. They seek preceptors who are consistent and professional; who understand the level students are at; and are able, and willing, to provide regular feedback regarding the student's performance.

Conclusion The preceptorship model presented in this article has been developed to reflect the complex influences on how preceptorships are enacted. It has been designed to be sufficiently flexible to be utilized in different clinical settings and specialty areas. It reflects a realistic image of interests and needs of stakeholder groups in order that they may be fully considered in planning for the implementation of quality and effective preceptorship experiences.

Key Words Nursing Education--Nursing Students--Preceptorship--Psychiatric/Mental Health Nursing


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Brenda Happell, PhD, RN, is professor of contemporary nursing and director of the Institute of Health and Social Science Research, Department of Health Innovation and Centre for Social Science, CQUniversity, Rockhampton, Queensland, Australia. Write to her at
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Author:Happell, Brenda
Publication:Nursing Education Perspectives
Article Type:Report
Geographic Code:8AUST
Date:Nov 1, 2009
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