Clinical transition of baccalaureate nursing students during preceptored, pregraduation practicums.
Key Words Pregraduation Preceptorship--Undergraduate Nursing Students--Transition to the Role of Registered Nurse
FOLLOWING GRADUATION, DURING THEIR INITIAL EMPLOYMENT, NEW NURSES OFTEN FEEL OVERWHELMED AND UNPREPARED FOR THE CHALLENGES OF THE WORKPLACE (1) PRECEPTORED, SENIOR-YEAR PRACTICUMS CAN EASE THE STRESS OF ADAPTATION AND SOCIALIZATION INTRINSIC TO INDEPENDENT NURSING PRACTICE AND SERVE AS A TRANSITION FOR NURSING STUDENTS TO THE ROLE OF REGISTERED NURSE (2-4). SUCCESSFUL PRECEPTOR PROGRAMS SUPPORT NURSES AND HELP ENSURE THEIR RETENTION IN NURSING.
* The literature describes experiences of new nurse graduates who are assigned preceptors in orientation programs (5-10). However there is a dearth of research literature on the transition of students to the graduate nurse role through preceptored experiences that take place during the final year of a baccalaureate nursing program. THIS ARTICLE reports on a triangulated, descriptive study designed to describe the clinical transition experience of seniors during a pregraduation, preceptored clinical experience. TWO RESEARCH QUESTIONS WERE POSED:
1. From the perspectives of students, liaison faculty, and clinical preceptors, what is the clinical transitional experience for BSN students who participate in an intensive preceptorship, three days per week for three weeks, during the senior year?
2. What patterns in the clinical transitional experience reveal issues for continuous improvement of the BSN program?
Consistent with VanGennep, the clinical transitional experience was defined as a social and physical passage in which students progress to the graduate nurse role during a preceptorship prior to graduation (11). Issues for continuous quality improvement were defined as matters for discussion by faculty to improve the preceptored experience, and the preceptorship program was defined as a pregraduation "intensive, reality-based clinical experience to facilitate transition into the real world of nursing" (12, p. 26). Review of the Literature The clinical transition from the nursing student role to the graduate nurse role can be viewed as a rite of passage that encompasses three major phases: separation, transition, and incorporation (11). As a transition, the preceptored practicum in the senior year might include the separation of students from dependence on faculty, their feelings of increasing competence, and their incorporation into the new role of professional nurse.
The clinical competence of baccalaureate nursing students participating in a summer preceptorship was compared to that of a similar group who worked as nursing assistants in a non-instructional clinical setting (13). Clinical competence was rated by head nurses. Students in the summer preceptor groups demonstrated greater gain in clinical competence, problem solving, application of theory to practice, and performance of psychomotor skills. Similarly, Yonge and Trojan (14) compared the nursing performance of nonpreceptored and preceptored students in their final clinical course of a BSN program. Non-preceptored students were assigned to a small clinical group with one clinical faculty member; preceptored students were assigned to individual preceptors. Students in the preceptored group had statistically significantly higher postclinical scores compared to the nonpreceptored group.
Following a 12-week preceptorship that took place during the last term of the BSN program, students rated their perceptions of the demands of nursing practice environments and their learning competencies (12). They rated themselves higher on all competencies and skill levels, including testing theories and experimenting with new ideas.
White (15) reported on how students enrolled in a management clinical rotation in their final semester described their clinical decision making. Students described their decisions and nursing actions as consistent with patients' immediate needs. A model of clinical decision making emerged that included gaining confidence in skills, building relationships with staff, connecting with patients, achieving comfort with self as a nurse, and understanding the clinical picture. The support and participation by staff nurses fostered the development of self-confidence in students.
An integrative clinical preceptor model was implemented as a collaborative partnership between a school of nursing and nurses in community health settings (16). Students underwent an intensive orientation period, adopting a service-learning approach. Faculty, who served as resources for students and preceptors, participated in students' projects, made site visits, and assessed the achievement of service-learning goals and objectives related to population-focused care. They also evaluated the outcomes of the experience and student performance. Preceptors attended a course on the characteristics of a good preceptor, role expectations and responsibilities, conflict resolution, and an overview of teaching/learning principles for effective clinical teaching. They developed relationships with faculty members, functioned as clinical teachers and role models, and participated in planning and implementing clinical experiences.
Rogers described the preceptor role as essential to a preceptorship program, whether it takes place before or after graduation (17). In helping neophytes transition to the role of professional nurse, preceptors serve as coaches, role models, socializers, and evaluators. They ease new nurses through the honeymoon, shock, and recovery phases into the resolution phase and help them identify with positive professional behaviors and develop a balanced perspective on health care settings. Preceptors validate interpersonal competencies, critical thinking, and decision-making skills; their evaluations are beneficial if they are timely and factual, include criticism and praise, promote professional growth, and affirm respect for new nurses.
Hrobsky and Kersbergen (18) reported on clinical preceptors' perceptions of associate degree nursing students whose clinical performance during a practicum was deemed unsatisfactory. Identified themes were: hallmarks of poor clinical performance, preceptors' feelings, and the role of liaison faculty. Poor performance consisted of unenthusiastic behavior toward nursing, not asking questions, and unsatisfactory skill performance. While concerned about patient safety, preceptors were fearful, anxious, and self-doubting, especially when they knew that students would fail based on their negative evaluations. Liaison faculty provided support for the preceptors, listening to them and following up at the end of the practicum.
Yonge, Ferguson, Myrick, and Haase examined preparation for the preceptorship experience (19). Faculty liaisons noted that the preparation of preceptors was inconsistent and the frequency of faculty visitation with students and preceptors varied. Liaisons saw their role as one of supporting students and preceptors, communicating curriculum trends, and fostering students' application of knowledge to clinical situations.
Method This triangulated, descriptive study used journal entries (20,21) to foster students' critical thinking and reflection (22) about their practice. A form titled "Daily Feedback Sheet on Transition to the Graduate Nurse Role" (DFSTGNR) was the chief data source. Triangulation was achieved by analysis of textual data from three sources: the DFSTGNR and liaison faculty and clinical preceptor journals. Two themes were identified using the narratives recorded by participants: the transitional experience and process improvement issues.
Thirty-two senior nursing students attending a full-time undergraduate nursing program and enrolled in an adult, acute care, senior-level course at the end of the program were invited to participate (23-25). Fourteen students completed journals. Three clinical or liaison faculty employed by the university and nine clinical preceptors employed by health care agencies also participated.
Students ranged in age from 21 to 42 years old. Two of the 14 students were male and two were married. Most, 11 students, were white: two were African American; and the ethnic background of one student was not identified. All but one student spoke English as their primary language.
The institutional review board of the university approved the study; participants' anonymity was maintained. Each participant signed a consent form and complied with Health Insurance Portability and Accountability Act (HIPAA) regulations regarding patient assignments.
Students recorded handwritten comments on the DFSTGNR. This journal, constructed to document the transition to the graduate nurse role during the preceptorship, asked students to record as follows: describe your patient assignment (comply with HIPAA guidelines and do not include identifying information); number of patients assigned; gender: diagnosis: comments on changes you are experiencing; your goals and additional comments.
A Preceptor Form was created for preceptors to comment on changes they saw in students. Similarly, clinical or liaison faculty completed a Nursing Faculty Form, which elicited comments on the performance of individual students as well as group changes. The forms were also used to provide individual feedback to students throughout the preceptorship, by both the preceptor assigned to the student and the faculty member responsible for the student.
Students worked at clinical sites tot a total of nine eight-hour shifts (each Tuesday, Wednesday, and Thursday for three weeks). This schedule was selected following a focus group with employers that took place at the university and centered on the logistics of when, and in which units, the preceptorships would be provided. Employers attending the focus group preferred that a nine-day experience be provided to allow for greater exposure to the nursing role. Faculty adopted their recommendation. Previously, the school had offered a six-day experience.
Students were given a packet of three DFSTGNRs that they completed on the third, sixth, and ninth days of the practicum. On the same days, faculty and clinical preceptors also recorded their responses. Often, preceptors were not paired with the same students from day to day, depending on the nurse preceptor's work schedule.
Data were analyzed using the constant-comparative methods of Glaser and Strauss as adapted by Lincoln and Guba (23-25). Checks were performed at the completion of data analysis; students, faculty, and preceptors confirmed the findings. Trustworthiness was established with peer review and an audit trail. Transferability was achieved by two current students and a liaison faculty member participant who read the study and confirmed that it described many aspects of pregraduation, preceptored practicums.
Results STUDENT OBSERVATIONS Students selected their own units of preference and were assigned to patients with many different diagnoses. Four students were in the medical-surgical unit; three selected oncology; and the others were in the emergency unit, maternity, the operating room, a cardiac catheterization laboratory, the intermediate neuro intensive care unit, the acute psychiatric unit, and a short procedure unit.
Among the patients cared for were a 68-year-old woman with breast cancer who had nausea, vomiting, and diarrhea; an 80-year-old woman with diverticulitis and pseudomonas colitis; a 69-year-old woman with anemia pancytopenia; a 98-year-old with dehydration, urinary tract infection, and dementia: and a 59-year-old with metastatic lung cancer with rule-out spinal cord compression. The number of patients assigned increased gradually over the nine-day period.
Students wrote of enjoying nursing care and relishing patients' appreciation of their care. "My patients were very receptive to my presence: I enjoyed their company." They were thankful that their knowledge was demonstrated: "I felt really good when I was able to answer their questions." One student, however, was exhausted by the preceptorship and the demands of her courses: "It was very difficult for me to come home and attempt to study or do homework." Financial stress was a concern as some students were employed on a part-time basis as patient care associates while attending the university and found they were unable to work during the three weeks of the preceptorship.
The preceptorship enabled students to expand their knowledge base and skill performance. Stimulated by the challenge, students became increasingly comfortable with, and proud of, their developing skills: "I feel very comfortable giving meds, assessments, trache care, suctioning, and using pumps." They appreciated seeing procedures, such as a paracentesis and a central line flush, learning about more medications and IVs, learning how to administer different medications, and gaining information regarding medical conditions as well as nursing care specific to abnormal laboratory values. One wrote, "I have gotten much better at reading fetal heart monitoring which was one of my goals." Students' capacity to access information from computers and understand staff assignment strategies increased, along with their assessment documentation and charting abilities.
The comfort of students corresponded to their increased independence and competence. One wrote, "I felt much more involved with patient care, talking to doctors and other care providers." Another wrote, "I now feel comfortable dealing with vented patients. Throughout the week (three days) the nursing staff on the unit has placed me with a vented patient.... I feel more comfortable now, when I graduate, to handle a patient in this condition. One patient had a PEG tube, so I did a lot of work with putting reeds down the tube, checking residual, and flushing."
During the second week, as nursing care progressed more smoothly, most students became increasingly independent and communicated more easily with staff when they needed assistance. Students were challenged by how much there was to learn about caring for patients, but their self-confidence increased: "I feel like I can do anything," and "I feel proud because I am competent and learning." Students were also proud that they managed an increased number of patients and felt part of the culture and functioning of units. One wrote, "I have come to know the staff members here very well and I feel like I am part of the team."
Students had specific as well as general goals. Some focused on such areas as knowing how to set up patient-controlled analgesia equipment, knowing when to call physicians, using better time management, teaching patients about medications, and learning more about the actions and side effects of medications: "[I want to] become comfortable using pumps and other hospital technology."
During the final week, students persisted in setting their agendas for learning. One shared her plan: "I hope to have a general understanding of psychiatric reeds, multidisciplinary approaches to psychiatric management, the role of the psychiatric nurse, and effective communication techniques for patient/nurse interaction." They began to see a broader scope of learning possibilities. One student was determined to become more knowledgeable in the area of ontology and to take care of an "entire nurse's assignment"; another was interested in understanding cardiac drugs and principles of triaging emergency unit patients. Students learned how to practice in specialized settings such as cardiac catheterization ("I am better able to identify what I see as the heart as viewed with dye and x-ray"), the operating room ("I am learning how to set up sterile fields for the procedure"), and to care for difficult patients ("I had a couple of noncompliant patients so I have had a firsthand account in the nursing position dealing with these patients").
While improvements in time management were noted over the nine days, more skill was desired. Students became aware of competing and sometimes unequal needs and priorities of patients: "I realize how difficult it is to care for four patients, especially when one of them requires more care than others."
Students were very comfortable with their preceptors, who answered their questions and positioned them to "see new things." Some thought that their preceptors trusted them: "My RN lets me take on the entire workload and helps me with problems such as PD (peritoneal dialysis) and urinary irrigations." Some regretted that they had more than one preceptor, but tried to make the best of the situation. A few had a more difficult time meeting the expectations of preceptors. "Everybody is possessive over what they feel we should be doing" and "It was difficult to assess what changes/ improvements l was making since I had a different preceptor every day."
Students gained confidence in interacting and working with the nursing staff. They felt free to ask questions and appreciated receiving "excellent" explanations. One felt privileged when working with the team of nurses and physicians: "I have come to know the staff members here very well and I feel like I am part of the team."
Students valued the preceptorship most of the time. Many realized immediately that they needed to reach out to the staff by asking questions and becoming accustomed to the independence associated with the preceptorship. "The nurses were very helpful, but in order to learn I had to ask questions or else they thought you knew what you were doing." Later they recognized the preceptorship as "integral in my development from nursing student to graduate nurse." Their adaptation to the units was facilitated by preceptors and enhanced by their commitment to learning.
For some students, who were concerned about their performance in class, the nine-day preceptorship was too long. One student wrote: "Although the preceptorship was a little too long for me in my setting, I am proud I have finished my clinical experience well. I feel the three days a week is a lot to handle, perhaps two days a week for an extended period would be more beneficial. I found by the third day [the preceptorship], along with studying, was very tiring."
A few students criticized the role of liaison faculty. They did not appreciate the brief time spent with them and the fact that faculty completed a clinical evaluation form on student performance. They noted also that the first phase of the preceptored experience was disorganized: "[We] were made to go to the units themselves, even if [we] were unsure of how to get there." In some cases, students were "hostile to the clinical (liaison) instructor" and hoped for better communication among the administrator, liaison faculty, students, and classroom teacher. They also were annoyed about competition among nursing programs for clinical sites and limited assignments due to low patient census. They appreciated the opportunity to select the clinical sites that most interested them.
LIAISON FACULTY OBSERVATIONS As the practicum began, liaison faculty saw students as apprehensive about the immersion experience and, at the same time, excited about its challenges. While some students seemed detached, it was understood that they might have been concentrating on the challenges ahead. Initially, students did not seem to trust faculty members and gave the impression that they were confused about their role as preceptee. Some complained that the preceptored experience was extended from six to nine days and that the goals of the immersion experience had not been discussed with them. They were frustrated since fewer patients were assigned during the preceptorship compared to the clinical experience during the previous semester when they were expected to care for up to four patients per day. In addition, a few patient units accommodated students from different nursing programs, which led to competition for patients.
On the whole, students settled in comfortably as they took care of patients with different diagnoses. They worked somewhat autonomously and seemed confident. One faculty member mentioned that they might have been too confident. While on some specialty units, students seemed to be helping nursing staff rather than caring for patients independently, they were involved with patient assignments and asked for increasing independence.
As the days went by, students tested the limits of their role as they tried to perform as much nursing care as allowable, and most seemed comfortable with greater responsibility. Some called physicians to follow up on patient problems. They modeled nursing staff behavior and acted more like staff, for example, giving a change-of-shift report. Some stood out as particularly confident, competent individuals. In general, students' documentation abilities improved and they progressed in organizational skills and time management.
By the last day of the preceptorship, students were more accountable for their actions and demanded challenges to improve their critical thinking. They followed through in discussions of patient problems with physicians and pharmacists, and some students were too busy to pay attention to the liaison faculty when they were observed on the last day. While a few students had "bad" attitudes about the experience, most were very positive about the preceptorship, interacted well with the nursing staff, and were respected by them. As they gained the trust of staff, they were assigned more patients and given greater independence.
PRECEPTOR OBSERVATIONS Preceptors were conscious that students looked to them as role models. As the days of the practicum progressed, preceptors were eager to hire some students as co-workers and singled certain students out for praise. In general, they saw students becoming more aware of patients' needs, taking initiative, organizing patient care, prioritizing the needs of patients, and understanding the workflow and needs of the unit. Students were alert to physicians' orders, progress notes, and patient regimens, and were also very willing to help the members of the team.
While some students needed to improve their skill base, organizational skills, and knowledge of patient chart information, most were motivated to learn and actively sought additional learning opportunities. They were efficient and organized, friendly and outgoing with nursing staff, and attentive to the subtleties of the role differences among the nurses working in different settings. Gradually, students gained independence and confidence, began to ask more questions, adjusted to unit environments, and managed time more efficiently as they administered medications. Several adjusted to having more than one preceptor, and all became more comfortable with the increased number of patients assigned.
Students handled stressful situations, asked questions, were eager to learn, and worked well with preceptors and nursing staff. They knew their limits and continued to sharpen documentation, organization, knowledge recall, and prioritization skills. They looked more competent and confident and completed assignments in a timely fashion.
Discussion Students made many gains during the preceptored experience. Their time management abilities and documentation skills increased, and they became comfortable with more assignments and expanded responsibilities. They emulated the practice of nursing staff and began to act like staff members. By the final day of the preceptorship, they requested challenges to improve their critical thinking, were more accountable with their actions, and collaborated more often with other health care providers. They were more efficient, organized, and performed clinical skills more competently, and they began to adjust to unit environments, handle stress, and manage medication administration proficiently. Most students felt supported by preceptors and clinical liaison faculty and believed that they had achieved goals identified at the beginning of the preceptorship.
Students' confidence in their performance, the relationships
they built with staff, their connections with patients, and their comfort as nurses were consistent with findings from White's (15) study. Planning and evaluation and interpersonal relationships and communication also corresponded with performance changes reported by Yonge and Trojan (14).
The investigation provided a voice for students, liaison faculty, and preceptors to contribute to continuous quality improvement of the preceptored experience. Issues for continuous improvement include facilitating connections between students and preceptors; having one preceptor, if possible, throughout the preceptorship; having clinical liaison faculty conduct clinical rounds at least twice daily; enhancing the orientation for preceptors and preceptees; clarifying guidelines concerning final student clinical evaluations; reviewing with students reality-based expectations of the preceptored experience; and maintaining consistency among liaison faculty by retaining those who had taught the students earlier that semester.
Other recommended strategies include liaison faculty escorting students to assigned units or settings; encouraging the development of positive student-preceptor relationships; contacting students at least twice during a shift and more often if assignments increase in complexity due to workload or unforeseen events; and developing an evaluation form specific to the preceptorship. It may also be beneficial to clear students' schedules of all other class demands and allow them to follow preceptors' schedules, regardless of the day of the shift. This might eliminate the stress that comes with having multiple preceptors with varying styles.
Future research on the perceptions of clinical liaison faculty about the preceptorship experience via a focus group might yield insights for continuous program improvement. Pretest/posttest design studies measuring differences in student competencies and skills before and after the preceptorship are also recommended. A possible tool would be Yonge and Trojan's Six Dimensional Scale of Nursing Performance (measuring leadership, critical care, Leaching/collaboration, planning/evaluation, professional development, communication, and interpersonal relationships) (14). Another area for study might involve comparing traditional and nontraditional students in a preceptorship in order to tailor preceptorships specifically to each group.
Finally, a national survey is recommended. Such a survey should ask how preceptorships are structured, where in the curriculum they are implemented, the length of time for preceptored experiences, and procedures used in the implementation of preceptorships. The results could provide guidance for evaluation, managing increased student enrollment, and obtaining clinical sites.
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Diane M. Wieland, PhD, RN, BC, is director of the undergraduate nursing program and associate professor, La Salle University School of Nursing, Philadelphia, Pennsylvania. Geralyn M. Altmiller, MSN, APRN, CCRN, is an assistant professor, and Zane Robinson Wolf, PhD, RN, FAAN, is dean and professor, La Salle University School of Nursing. For more information, contact Dr. Wolf at firstname.lastname@example.org.