the preceptor should promote critical thinking by performing which tasks

Mastering Precepting: Core precepting concepts

"The most important practical lesson that can be given to nurses is to teach them what to observe, how to observe, what symptoms indicate improvement, what the reverse, which are of importance, which are of none, which are evidence of neglect and of what kind of neglect.”    —Florence Nightingale OBJECTIVES

• Understand development of competence
• Understand critical thinking, clinical reasoning, and clinical judgment and how to help preceptees develop each skill
• Understand the development of preceptee confidence
• Understand core concepts of nursing practice

At the heart of any precepting experience is the development of competence; the development of ability and expertise to effectively utilize that competence; and the confidence to take action when needed. Combined with other core precepting concepts, these form the foundation of effective, safe nursing practice.

• Knowledge  encompasses thinking; understanding of science and humanities; professional standards of practice; and insights gained from context, practical experiences, personal capabilities, and leadership performance.
• Skills  include psychomotor, communication, interpersonal, and diagnostic skills.
• Ability  is the capacity to act effectively. It requires listening, integrity, knowledge of one’s strengths and weaknesses, positive self-regard, emotional intelligence, and openness to feedback.
• Judgment  includes critical thinking, problem-solving, ethical reasoning, and decision-making.

Requirements for competence and competency assessment have been established by national nursing and nursing specialty organizations, state boards of nursing credentialing boards, and statutory and regulatory agencies. The presence (or absence) of competency can also be a legal issue.

• Juggling complex patients and assignments efficiently
• Intervening for subtle shifts in patients’ conditions or families’ responses
• Having interpersonal skills of calm, compassion, generosity, and authority
• Seeing the big picture and knowing how to work the system
• Possessing an attitude of dedicated curiosity and commitment to lifelong learning

Participants described how competence developed and changed over time. Also of interest was how the development of competency affected their career plans and job satisfaction. Kearny and Kenward (2010) note:

Those who continued to feel insecure in their ability to efficiently identify and respond to important downturns in patients’ conditions in a high-acuity environment, who continually felt beaten down in their attempts to get resources and help for patients from fellow nurses, and/or who believed physicians did not listen to them or respect them appeared most likely to change jobs to less complex or less acute settings or to leave nursing. (p. 13)

This study clearly has implications for preceptors. Nurses’ career decisions and job satisfaction are both affected by how well they develop competence, especially for less experienced nurses.

Unconscious incompetence —The individual seeks to solve problems intuitively with little or no insight into the principles driving the solutions. This stage is especially dangerous with novices. When NGRNs first begin professional practice or experienced nurses move into a new role, they often don’t know what they don’t know. Preceptors have to be especially vigilant with a preceptee at this level.

Conscious incompetence —The individual seeks to solve problems logically, recognizing problems with their intuitive analysis, but not yet knowing how to fix them. This awareness— of knowing what you don’t know—can affect confidence. Preceptors can help preceptees in this level understand what they are expected to know at this point vs. what they will learn in the future.

Conscious competence —As skills are acquired, individuals become more confident but need to realize that the skills have not yet become automatic. They are not yet ready to spontaneously transfer the concepts of the skill to new situations. Preceptors need to help preceptees see how the concepts transfer from one situation to another.

Unconscious competence —At this level, skills become second nature and are performed without conscious effort. Skills can be adapted creatively and spontaneously to new situations. You know it so well, you don’t think about it. The challenge in this level is to not become complacent and be closed to new ways of doing things.

A fifth level of conscious competence learning—reflective competence—has been suggested (Attri, 2017). It involves an awareness that you’ve reached unconscious competence; analyzing and being able to articulate how you got there well enough to teach someone else to reach that level and opening yourself to the need for continuous self-observation and improvement.

This concept supports adult learning theory concerning learner readiness in the assertion that individuals develop competence only after they recognize the relevance of their own incompetence. It also blends easily with the levels in Benner’s Novice to Expert model.

• What are the essential competencies and outcomes for contemporary practice? Identify the required competencies and word them as practice-based competency outcomes.
• What are the indicators that define those competencies? Only identify the behaviors, actions, and responses mandatory for the practice of each competency.
• What are the most effective ways to learn those competencies?
• What are the most effective ways to document that learners and/or practitioners have achieved the required competencies? Develop a systematic and comprehensive plan for outcomes assessment.

Eight core practice competency categories define practice in the COPA model (Lenburg, 1999):

• Assessment and intervention skills
• Communication skills
• Critical thinking skills
• Human caring and relationship skills
• Management skills
• Leadership skills
• Teaching skills
• Knowledge integration skills

Wright Competency Model The Wright Competency Assessment Model is an outcome-focused, accountability-based approach that is used in many healthcare organizations. The following principles form the foundation of the model (Wright, 2015, p. 5):

• Select competencies that matter to both the people involved and to the organization.
• Competencies should reflect the current realities of practice, be connected to quality improvement data, be dynamic, and be collaboratively selected.
• Competency selection itself involves critical thinking.
• Select the right verification methods for each competency identified.
• Clarify the roles and accountability of the manager, educator, and employee in the competency process.
• Employee-centered competency verification creates a culture of engagement and commitment.
• In ownership, competencies are collaboratively identified and are reflective of the dynamic nature of the work.
• Empowerment is achieved through employee-centered verification in which verification method choices are identified and appropriately match the competency categories.
• In accountability, leaders create a culture of success with a dual focus—focus on the organizational mission and focus on supporting positive employee behavior.

Critical Thinking Critical thinking is an essential competency for nurses to provide safe and effective care (Berkow, Virkstis, Stewart, Aronson, & Donohue, 2011). Alfaro-LeFevre (2017) says that critical thinking is “deliberate, informed thought” (p. 2) and that the difference between thinking and critical thinking is control and purpose. “Thinking refers to any mental activity. It can be ‘mindless,’ like when you’re daydreaming or doing routine tasks like brushing your teeth. Critical thinking is controlled and purposeful, using well-reasoned strategies to get the results you need” (p. 5).

Jackson (2006, p. 4) notes that three themes are found within all definitions of critical thinking: “the importance of a good foundation of knowledge, including formal and informal logic; the willingness to ask questions; and the ability to recognize new answers, even when they are not the norm and not in agreement with pre-existing attitudes.” Chan (2013), in a systematic review of critical thinking in nursing education, found that despite there being varying definitions of clinical thinking, there were some consistent components: gathering and seeking information: questioning and investigating; analysis, evaluation, and inference; and problem-solving and the application of theory. The principles of skepticism and objectivity underlie critical thinking (Chatfield, 2018). Objectivity includes recognizing and dealing with both conscious and unconscious bias.

Critical Thinking—A Philosophical Perspective In 1990, the American Philosophical Association conducted a Delphi study of an expert panel to define critical thinking and to identify and describe the core skills and dispositions of critical thinking. The expert panel, led by Peter Facione (1990), defined critical thinking to be a pervasive and deliberate human phenomenon that is the “purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based” (p. 2). The core skills and sub-skills identified by the expert panel are shown in Table 4.1.

According to the American Philosophical Association Delphi Study, the affective dispositions of critical thinking (approaches to life and living) include (Facione, 2011):

• Inquisitiveness with regard to a wide range of issues
• Concern to become and remain generally well informed
• Alertness to opportunities to use critical thinking
• Trust in the processes of reasoned inquiry
• Self-confidence in one’s own ability to reason
• Open-mindedness regarding divergent world views
• Flexibility in considering alternatives and opinions
• Understanding of the opinions of other people
• Fair-mindedness in appraising reasoning
• Honesty in facing one’s own biases, prejudices, stereotypes, and egocentric or sociocentric tendencies
• Prudence in suspending, making, or altering judgments
• Willingness to reconsider and revise views where honest reflection suggests that change is warranted
• Clarity in stating the question or concern
• Orderliness in working with complexity
• Diligence in seeking relevant information
• Reasonableness in selecting and applying criteria
• Care in focusing attention on the concern at hand
• Persistence though difficulties are encountered
• Precision to the degree permitted by the subject and the circumstance

Critical Thinking in Nursing Facione and Facione (1996) suggest that to observe and evaluate critical thinking in nursing knowledge development or clinical decision-making, you need to have the thinking process externalized by being spoken, written, or demonstrated. For preceptors, this means having preceptees externalize their thinking processes. Preceptors must also be able to externalize their own critical thinking to role model critical thinking for preceptees. Paul, the founder of the Foundation for Critical Thinking, and Heaslip note, “Critical thinking presupposes a certain basic level of intellectual humility (i.e., the willingness to acknowledge the extent of one’s own ignorance) and a commitment to think clearly, precisely, and accurately and, in so far as is possible, to act on the basis of genuine knowledge. Genuine knowledge is attained through intellectual effort in figuring out and reasoning about problems one finds in practice” (Paul & Heaslip, 1995, p. 41). Expert nurses, say Paul and Heaslip, “can think through a situation to determine where intuition and ignorance interface with each other” (p. 43).

Building on the work of Facione and the American Philosophical Association Delphi study, Scheffer and Rubenfeld (2000) conducted a Delphi study of international nursing experts (from 27 U.S. states and eight countries) to develop a consensus statement of critical thinking in nursing. The result of the study was a consensus statement and identification of 10 affective components (habits of the mind) and seven cognitive components (skills) of critical thinking in nursing.

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge (Scheffer & Rubenfeld, 2000, p. 357).

Precepting Critical Thinking Berkow and colleagues (2011) note that identifying and providing feedback on specific strengths and weaknesses is the first step to help nurses meaningfully improve their critical thinking skills. They interviewed more than 100 nurse leaders from academia, service settings, and professional associations and developed a list of core critical-thinking competencies in five broad categories: problem recognition, clinical decision-making, prioritization, clinical implementation, and reflection. Each of the categories has detailed competencies. Alfaro-LeFevre (1999) developed a list of critical-thinking key questions that can be used by a preceptor to help preceptees learn how to think critically:

• What major outcomes (observable results) do I/we hope to achieve?
• What problems or issues must be addressed to achieve the major outcomes?
• What are the circumstances (what is the context)?
• What knowledge is required?
• How much room is there for error?
• How much time do I/we have?
• What resources can help?
• Whose perspectives must be considered?
• What’s influencing my thinking?
• Be clear about the desired outcome.
• Decide what exactly the person must learn to achieve the desired outcome and decide the best way for the person to learn it.
• Reduce anxiety by offering support.
• Minimize distractions and teach at appropriate times.
• Use pictures, diagrams, and illustrations.
• Create mental images by using analogies and metaphors.
• Encourage people to remember by whatever words best trigger their mind.
• Keep it simple.
• Tune into your learners’ responses; change the pace, techniques, or content if needed.
• Summarize key points.
• Analytic processes —Breaking a situation down into its elements; generating and systematically and rationally weighing alternatives against the data and potential outcomes.
• Intuition —Immediately apprehending a situation (often using pattern recognition) as a result of experience with similar situations.
• Narrative thinking —Thinking through telling and interpreting stories.
• Recognizing a pattern or an inconsistency in the expected pattern
• Providing explanations for why they had reasoned as they had
• Forming relationships between data
• Drawing conclusions
• Noticing —“A perceptual grasp of the situation at hand” (p. 208). Noticing, Tanner says, is “a function of nurses’ expectations of the situation, whether they are explicit or not” and further that “these expectations stem from nurses’ knowledge of the particular patient and his or her patterns of responses; their clinical or practical knowledge of similar patients, drawn from experience; and their textbook knowledge” (p. 208).
• Interpreting —“Developing a sufficient understanding of the situation to respond” (p. 208). Noticing triggers reasoning patterns that help nurses interpret the data and decide on a course of action.
• Responding —“Deciding on a course of action deemed appropriate for the situation, which may include ‘no immediate action’” (p. 208).
• Reflecting —“Attending to the patients’ responses to the nursing action while in the process of acting” (reflection in action) and “reviewing the outcomes of the action, focusing on the appropriateness of all of the preceding aspects (i.e., what was noticed, how it was interpreted, and how the nurse responded)” (p. 208; reflection on action).
• Noticing —Focused observation, recognizing deviations from expected patterns, information seeking
• Interpreting —Prioritizing data, making sense of data
• Responding —Calm, confident manner; clear communication; well-planned intervention/ flexibility; being skillful
• Reflecting —Evaluation/self-analysis, commitment to improvement
• Decisions made very quickly can be every bit as good as decisions made cautiously and deliberately.
• We have to learn when we should trust our instincts and when we should be wary of them.
• Our snap judgments and first impressions can be educated and controlled.

Decision makers recognize the situation as typical and familiar . . . and proceed to take action. They understand what types of goals make sense (so priorities make sense), which cues are important (so there is not an overload of information), what to expect next (so they can prepare themselves and notice surprises, and the typical way of responding in a given situation. By recognizing a situation as typical, they also recognize a course of action likely to succeed (Klein, 1998, p. 24).

• Patterns that novices do not notice
• Anomalies, events that did not happen, and other violations of expectancies
• The big picture (situation awareness)
• The way things work
• Opportunities and improvisations
• Events that either already happened (the past) or are going to happen (the future)
• Differences that are too small for novices to notice
• Their own limitations

• critical thinking
• Beth Ulrich
• RNL Feature

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It is possible to do the important work of precepting students and still get home in time for dinner.

FRANCES E. BIAGIOLI, MD, AND KATHRYN G. CHAPPELLE, MA

Fam Pract Manag. 2010;17(3):18-21

Dr. Biagioli is associate professor in the Department of Family Medicine at Oregon Health & Science University in Portland, Ore. Kathryn Chappelle is assistant professor there. Author disclosure: nothing to disclose.

“Students slow me down” and “Students take too much time” are common complaints of precepting physicians, and yet some physicians have endless energy for teaching and are able to maintain their clinical productivity. What do these doctors do differently?

We held five professional seminars in 2007 and 2008 to talk with experienced physicians from health education programs across the United States about their precepting experiences. We collected and analyzed the suggestions that emerged in search of common themes. Doing so made it clear that physicians should focus on six areas to be efficient and effective preceptors:

1. Establish a teaching environment

A positive teaching experience begins with an appropriate match between student and preceptor. Make sure the educational programs you work with know your personality and work-style preferences. The programs should also know the makeup of your practice, such as patient population, and the learning experiences you can offer students, such as different types of procedures.

Once the program has matched you with a student, you and your staff will need to address a number of logistical issues.

First, your scheduling template may need to be revised to maximize clinical efficiency and quality teaching. There are several ways you can do this:

Book urgent care visits and complex visits simultaneously. You can conduct one or more brief visits while the student sees a patient with more complex problems.

Block 15 minutes of your schedule in the morning and afternoon to allow time for student review and teaching.

Double-book your first appointment and block your last appointment. This allows you and your student to start seeing patients at the same time, and it provides catch-up time at the end of the day.

At the beginning of each day the student is in the office, review the schedule and consider which patients you would like to include in the student's schedule. Have the staff member rooming the patient ask whether it is OK if a student conducts the visit. Use positive phrasing like, “Your physician is teaching a student. Is it OK if the student sees you first?”

These selections should be based on patient and visit type and the student's educational needs. Some patients take forever even for experienced physicians, so they may not be appropriate for beginning students, but patients who need or desire more in-depth interactions may be ideal for students. Students can help set up appointments for these patients, arrange needed ancillary services and explain their test results.

When possible, plan any follow-up appointments with these patients for a day when the student is in the office. This continuity gives students the opportunity to discover whether treatment plans they helped develop are working. In addition, some patients may appreciate the extra attention and enjoy seeing the student's educational growth.

When selecting patients, also consider what the student is currently learning. Ask, “What are you studying now? We'll try to find a patient with that system issue.”

Ultimately it is important for both preceptor and student to be flexible. Occasionally you may need to ask the student to do other work while you see several patients in a row, because of the nature of the visits or because you need to catch up.

It is also important to provide students with a work-space that includes a desk and a place for personal items. Prior to the student's arrival, arrange for the student to have a computer workstation and access to patient records, including log-in information for electronic health records as needed.

Ask a staff member to orient the student on his or her first day. The student will need to know where to park and be introduced to the staff and the office space. Orientation should include time to attend to administrative details, such as computer training and obtaining a security badge.

2. Communicate with everyone involved

Communication is key to ensuring a successful teaching arrangement. It is essential that you express your expectations and goals to students, their educational program and your fellow clinicians and staff members. Prior to the student's arrival at your practice, the program should describe the student's skill level and explain what it expects the student to learn from the experience in your office.

Students and preceptors should communicate early and frequently regarding expectations, goals, and learning and teaching styles. This saves time and prevents frustration. Soon after the beginning of their rotations, start talking with students about their progress and the extent to which they are meeting their educational goals. Have students keep track of what types of patients they have seen and which procedures and clinical activities they have seen and done, such as taking a patient's history and providing patient education. Ask, “Is there any type of patient we need to have you work with today?” This helps students focus on their goals and helps you focus on meeting their needs. Ask questions that elicit reflection, such as, “What did you learn today?” These discussions could direct future sessions or independent research topics.

Feedback is necessary for evaluation, and it can prevent repetitive, time-wasting mistakes. Be sure to provide students with continuous feedback, and ask them about their experience with questions such as, “Is there a different way that I could teach to help your education?” If you have any concerns about a student's progress or ability, contact the student's educational program immediately.

Because students become part of the clinical team, it is essential that preceptors and students communicate with fellow clinicians and staff members. Preceptors should begin with the attitude that students add value to the practice. This approach will then likely spread to physician partners and clinic staff, and in such an environment, students will be more likely to make significant contributions. Ensuring buy-in from partners and clinic staff will save time for everyone by preventing misunderstandings and duplication of effort. Supportive colleagues can also enhance the student's educational experience. Be sure to let your colleagues know if the student needs experience with certain procedures or diseases. You could say something like, “The student needs more work with diabetic patients. Could you let us know if you see any opportunities for that today?”

3. Tailor your teaching to the student's needs

It is important to adapt your teaching to each student's educational needs, goals and learning style. Doing this boosts the quality of the student's education and helps you to remain efficient. You can assess the student's strengths and weaknesses early on by observing the student's interactions with patients, then adjust your approach as needed based on your findings.

Your teaching method may also be influenced by how much time and how many exam rooms you have. Here are some suggestions for ways the two of you might share patient visits and structure learning opportunities:

Observe the student for an entire patient visit. Create your note while the student takes the history, and ask additional questions or assist with the exam as necessary.

See the patient after the student presents the history to you but before the exam is completed. Assist the student with the exam or demonstrate. Medicare's billing and coding rules permit students to document the review of systems and past, family and social history. A student-documented history of the present illness must be “verified and redocumented” by the preceptor, according to the Centers for Medicare & Medicaid Services' Claims Processing Manual , Chapter 12, Section 100 (see “ Medicare's Rules for Student Documentation ”).

Take the history while the student listens, and have the student perform the exam while you observe. Then repeat the exam and redocument it as required by the Medicare guidelines.

Have the student observe an entire encounter between you and a patient. This is especially beneficial if you have the opportunity to demonstrate specific interviewing or exam techniques.

Use the classic teaching method if time allows. Have the student see the patient, leave the exam room and present to you, then return together to see the patient. Alternatively, you might have the student present to you in front of the patient. In either case, be sure to give the student time to process the patient's information before presenting. This method can be time-consuming, but it allows the student autonomy that other styles may not achieve. If there are enough exam rooms, you can see other patients while the student is conducting the visit and formulating a plan.

MEDICARE'S RULES FOR STUDENT DOCUMENTATION

Medicare's Claims Processing Manual has this to say about student documentation:

“Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing. Students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. The teaching physician may not refer to a student's documentation of physical exam findings or medical decision making in his or her personal note. If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.”

4. Share teaching responsibilities

Students don't need to spend every minute of the day with you to advance their education. Preceptors, partners, staff, patients and students themselves can all be part of the teaching team. For example, students can learn different exam techniques from your partners, or phlebotomy from ancillary staff. They can also “teach themselves” by building clinical knowledge through independent research. Opportunities like these can enrich the students' experience while enabling you the flexibility you may need to work independently. Here are some additional ways to get other members of the teaching team more involved:

Ask nurses and medical assistants to teach students to administer injections, perform lab tests, obtain ECGs, complete blood draws, etc.

Ask office staff to orient students to the business side of family medicine.

Ask other physicians for help. If they are receptive, you might even consider rotating preceptors daily, weekly or monthly.

Here are some ways to encourage the student to be more involved:

Have the student teach you more about a subject you'd like to study. You could say, “I don't know much about this disease. Would you read up on it and teach me before our next clinic? Be sure to include your resources.”

Know when to answer a student's question and when to have the student find the answer on his or her own. Encourage self-directed learning. Give students examples of what to do when they aren't with you, such as start the next visit, review a chart or look up a question.

Have students create or update patient information resources (e.g., standard one-pagers on common issues). Preceptors can share these student-made resources with patients and future students.

WEB-EXCLUSIVE CONTENT

Download six easy-to-use tables that summarize the tips and advice found in each section of this article.

5. Keep observation and teaching encounters brief

Dividing observation and teaching into short, focused time segments helps fit precepting into a busy schedule. Observing student history-taking or exam skills in two- or three-minute segments enables you to assess ability and progress without getting behind on patient care. Teaching can be broken into short, focused interactions as well. Not everything can or should be taught all at once; concepts are often best reinforced with repetition. Students are more likely to benefit from small amounts of information linked directly to patient problems rather than large amounts on general topics. Try these tips:

Don't lecture on every patient visit. In fact, you may not need to lecture on any of them. When you do teach concepts, emphasize key points and avoid lengthy discussions.

Give feedback on individual exam skills. For example, focus only on the student's ear, nose and throat exam for one week.

Teach portions of a procedure over time. For example, have students provide a patient's digital block/lidocaine injection one day and remove another patient's toenail on a different day.

Focus on one aspect of a patient encounter. For example, for a patient who complains of shortness of breath, ask the student to focus on the HPI; for a patient who has asthma, focus on patient education; for a patient with a new rash, focus on the physical exam.

6. Broaden student responsibilities

Expanding students' responsibilities maximizes their educational experience and fully utilizes their skills in patient care. When you think the student is ready to do more, try these ideas:

Have students document their reflections after seeing a patient and summarize learning points.

Ask students to look up answers to patient questions. For example, during a patient visit you might say, “Mrs. Smith, I don't know the answer, so our student will look that up, and we will get back to you this week.” After the student has found the answer and discussed it with you, have the student call the patient or send the answer via e-mail.

Review patient test results and treatment plans with the student, and then have the student call the patient to give test results and follow-up instructions. Chart or complete other paperwork next to the student during the call so that you can verify the accuracy of the message and give feedback as needed.

Have students facilitate ancillary services (make necessary phone calls to the lab, communicate with therapists, etc.).

Have students provide patient education and direct patients through the rest of the office visit while you move on to the next patient.

Have students help improve chart details. Students can sit with patients to review and update medication lists, preventive screening schedules, histories and problem lists. When you see the patient, you should quickly review the student's notes with the patient.

Give students clinical tasks such as administering questionnaires or helping with blood draws.

Have students assist with patient flow by rooming patients and taking vital signs.

As you expand the student's responsibilities, be sure not to repeat tasks you've entrusted him or her to do, unless billing and coding guidelines require it. In such cases, you can confirm and clarify: “Mrs. Smith, my student tells me that your headaches began about one week ago. Is this correct?”

Make sure students contribute to the top of their ability level. The more responsibility a student can take on, the more he or she can contribute to patient care. This makes the student more valuable to you and the clinic, and makes the experience more valuable to the student.

A final note

Some of these suggestions may not apply to every practice setting. Preceptors and practices should consider which strategies work best for them. We hope this article will supply physicians with a pearl or two that will boost their clinical productivity while doing the important work of training future family physicians.

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CHAPTER SEVEN – PRECEPTORS: ESSENTIAL TO LEARNER SUCCESS

“While we teach, we learn” —Seneca

Precepting is an organized, evidence-based, outcome-driven approach to assuring competent practice (Eley, 2015). Clinical heath education often employees a preceptor model for senior practicum courses and frequently as part of orienting new employees. Through clinical experiences and orientation activities, learners acquire knowledge and essential skills for professional practice. The preceptor plays a vital role in developing students as professionals and a critical role in successfully integrating new staff.

For student learners, a representative from the student’ institution is often part of the teaching–learning team along with the student and a preceptor who is an employee of the clinical agency. Each member of the trio usually has specific roles and responsibilities, with the faculty representative often supporting and advising the preceptor. While the preceptor has important roles in student evaluation, the faculty member usually makes critical decisions on final grades and on whether a learner passes or fails a practicum.

Being a preceptor for a student or new employee is an essential role but not one for which most preceptors are formally prepared. The short- and long-term success of the student or employee can be enhanced greatly by an excellent preceptor or affected negatively by a preceptor who is not well prepared for the role. The goal of this chapter is to provide readers with knowledge, skills and attitudes that are key to being an effective preceptor in the clinical setting. As with most careers, when you are well prepared and able to excel in a role, those you work with are positively affected. As you carry out your role well, your level of satisfaction with the role is also enhanced. This leads to a positive cycle with affirmative effects on all involved, including recipients of care.

This chapter discusses the difference between preceptoring and mentoring, examines the theoretical foundations of effective preceptoring, and presents strategies for becoming and being a successful preceptor. We conclude with a discussion of the preceptor–preceptee relationship. The strategies included provide a road map for practitioners who are new to precepting. The chapter is infused with practical creative ideas and founded on theory, making it both a stand-alone chapter for educators embarking on being a great preceptor and part of the greater understanding of becoming skilled as a clinical educator.

The Difference Between a Mentor and a Preceptor

The origin of the concept of mentorship is well documented. In Homer’s Odyssey a Mentor, a wise and trusted friend of Odysseus, takes on the rearing of Odysseus’ son in his absence (Roberts, 1999). The mentor is depicted as an older, wiser male who takes on the responsibility for a younger male’s learning and development, acting rather like a guardian. The term mentor is traditionally associated with professions such as medicine, law and business, but it began appearing in nursing literature in the 1990s (Andrews & Wallis, 1999).

Much of the current mentor literature focuses on defining the concept, yet a precise and complete definition that is universally embraced remains elusive (Dawson, 2014; Gopee, 2011; Mentoring Resources, n.d.). To confuse it further, terms such as preceptor, coach and facilitator are used interchangeably in some instances. In jurisdictions such as Great Britain, practicing nurses who are responsible for students in the clinical area are called mentors, while in most North American jurisdictions, these supervising nurses are called preceptors. Commonly the term mentor is reserved for a longer-term personal development relationship between a less experienced and a more experienced person, with the focus of the relationship being assistance, befriending, guiding and advising (Eby, Rhodes & Allen, 2007). More concisely the mentor is less focused on assessment and supervision and more focused on the mentee’s well-being and career advancement (Eby, Rhodes & Allen, 2007).

In contrast a preceptor–preceptee relationship is usually shorter term and the preceptor has responsibility for teaching and assessing clinical performance. In the base definition of preceptor, the focus of the preceptor’s work is to uphold a precept or law or tradition. Myrick & Yonge (2005, p. 4) define a nursing preceptor as a skilled practitioner who oversees students in a clinical setting to facilitate practical experience with patients.

The roles of mentor and preceptor do overlap. For example, a preceptor who has no concern for the well-being of the preceptee is not likely to provide the learner with a positive clinical experience. Likewise a mentor who does not assess student practice will not have the information needed to be an effective mentor. The assessment in which a mentor engages is more likely to be formative in nature and focused on providing the mentor with knowledge to fulfill the role of guide effectively.

Students in practice-based health care professions rely on others to support, teach and supervise them in practice settings. The underlying rationale for this approach to learning is the belief that working alongside practitioners aids students to become safe caregivers who are successfully socialized to the clinical world (Benner, 1984). In this chapter we focus on the role of the preceptor.

Theoretical Foundations of Effective Preceptoring

Effective preceptoring of students in health care clinical environments can be understood by briefly examining adult learning theory, transformational learning theory, and the novice to expert model. Here we outline each theory or model and discuss each in relation to the preceptoring literature.

Adult Learning Theory

As described in chapter 1, Malcolm Knowles (1984) is credited with naming the theory of andragogy, a theory specifically for adult learning. Andragogy emphasizes how adult learners differ from child learners in being self-directed and taking responsibility for their learning decisions. Further, according to Knowles, adults want to know why they are learning something, need to learn experientially (including having the opportunity to make mistakes), use problem-solving to learn, and learn most effectively if they can apply what they learn immediately. Knowles states that adults learn best if their teacher is primarily a facilitator or resource person. Smith (2002) further discusses Knowles’ andragogy theory, highlighting the ideas that a) learners move from being dependent to self-directed, b) learners accumulate a reservoir of experience and knowledge, and c) a learner’s motivation to learn is internal. Given these principles of adult learning, teaching strategies such as simulations, role-play and case studies are considered useful. Likewise, clinical practicum learning opportunities with the student working alongside a preceptor are compatible with the principles of andragogy. Practicum students are directed by a more knowledgeable person (the preceptor) until they can accumulate experience and knowledge to be independent practitioners.

Sandlin, Wright & Clark (2013) further our understanding of Knowles’ theory by additional focus on Knowles’ beliefs that adult learners are autonomous, rational and capable of action, and on the assumption that autonomy and rationality are desirable and attainable in adult learners. Their perspective on Knowles’ fundamental views provides an interesting contrast in considering the role of preceptor in the clinical environment. The tenets of Knowles’ adult learning theory offer no substantive role for the preceptors who hold responsibility for overseeing, guiding and evaluating the work of the preceptee, as learners are thought to be totally autonomous and capable of independence. In contrast, as Sandlin, Wright & Clark (2013) propose, adult learners may actually be at various levels of autonomy and rationality and thus a skilled preceptor does have a role in adult learning.

Transformational Learning Theory

As explained in chapter 1, Jack Mezirow (1995) is credited with making significant contributions to the theory of transformative learning. The essence of this theory is that learners must engage in critical reflection on their experiences in order to transform their beliefs, attitudes and perspectives, which Mezirow terms their meaning schemes. Others have critiqued some of Mezirow’s assumptions and views. Boyd & Myers (1988) note that learners must be open to changing their meaning schemes; to adopt new perspectives, they must realize that their old perspectives are no longer relevant. Dirkx, Mezirow & Cranton (2006) emphasize the self-actualization possibilities of transformative learning with the statement “learning is life – not a preparation for it” (p. 123). They note the importance of a relationship between the learner and others, which is required to make sense of one’s perspective and to become aware of (and transform to) new meanings.

To Mezirow, the essence of learning is change. To be truly transformational, learners must engage in inquiry, critical thinking and interaction with others. Brookfield (2000) adds that transformative learning must include a fundamental questioning of one’s thinking and actions. Reflection alone does not result in transformative learning unless this reflection includes an analysis of taken-for-granted assumptions.

Part of the entry-to-practice competencies for health professionals include elements of critical reflection, adoption of professional values, beliefs and attitudes, and ongoing questioning of taken-for-granted assumptions and values. If Mezirow is correct that acquiring a competency does require the involvement of others, this becomes part of the role of the skilled preceptor. Preceptors may be well placed to encourage honest self-review and critical reflection that ends in learner transformation. In this view, preceptors need to be aware of strategies to engage learners in reflection, causing learners to gaze deeply into long- and deeply-held values and biases that they may not even be aware they hold.

The ‘From Novice to Expert’ Model

Benner’s (1984) well-used and much respected From Novice to Expert model has implications for understanding the role of an effective preceptor for health care learners. While Benner focused on nursing students in the clinical setting, her theory likely applies to learners from other health care disciplines. This model holds that nurses develop skills over time from both education (including clinical experience) and personal experience. The model identifies five levels of nursing experience: novice, advanced beginner, competent, proficient and expert. Novices are beginners with no experience—they learn rule-governed tasks by being told and by following instructions. Advanced beginners have gained experience in actual nursing situations and recognize recurring elements that create principles they can use to guide actions. Competent nurses have more clinical experience and use it to become more efficient in providing care. Proficient nurses have an understanding of the bigger picture that improves decision making and allows for changes in plans as needed. Experts no longer need principles or rules to guide action—they use intuition to guide their flexible, highly proficient clinical approaches. As learners transition from novice to expert, they rely less on principles, they see a situation more holistically, and they engage in situations from the inside rather than being external to a situation.

Preceptors can play a vital role in this transition. Benner’s model requires clinical experience for the transition to occur and guidance in the clinical situation is essential for successful transition. Preceptors need to have awareness of the needs of learners at various stages of the continuum and be attuned to the stage(s) at which their students are functioning. For example, a novice student needs a preceptor who provides more direct guidance in learning the rules to guide their actions. A preceptor for an advanced beginner helps learners recognize recurring patterns and develop them into principles of effective care.

Benner also comments that expert clinicians may not be the most effective in preceptoring roles. Expert clinicians may have difficulty explaining their actions in a step-by-step manner because they are functioning by intuition and may not be consciously aware of the rules and principles that they use to make clinical judgments. Analogous to riding a bike, beginners are very aware of the steps needed to balance the bike, propel it forward, stop momentum and avoid obstacles. An expert at cycling is able to just ride without thinking about how to ride and thus may have a challenge teaching a new cyclist.

Strategies for Being and Becoming a Successful Preceptor

This section focuses on strategies for being (and becoming) a successful preceptor for students from various health care professions in clinical learning environments. We also address the challenges and rewards of being a preceptor and characteristics of effective preceptors. The goal is to provide both new and established preceptors with new knowledge that can be used as a road map to beginning and continuing this journey with learners.

Challenges of Precepting

You are invited by your manager to be a preceptor. You are both honoured and terrified. If this is your first time formally in this role, you have a lot to learn. To begin, recognize that becoming a really good preceptor takes experience, just as becoming a competent (even expert) care provider takes experience. Reading this chapter and other resources will help. You may be fortunate that the agency you work for provides preceptor education. The first step is to determine what is available in the form of lectures, workshops, preceptor manuals, etc. and to engage with these before your preceptee arrives. You cannot possibly be fully prepared on day one no matter how much homework you do, so begin with a positive attitude and a sense that you are going to learn every day through reflection, experience and ongoing formal learning. Know that your apprehension is normal—with preparation, this apprehension can be lessened. With a positive approach, being a preceptor can be a fulfilling experience for you and a gift to a learner.

From the Field

Learning together.

I was delighted to be asked to be a preceptor! This would be my first time. I thought “Wow they think I am good enough to teach a new person—that’s super!” My sense of excitement was soon drowned out by horror. What if I made a mistake? What if my student asked a question I couldn’t answer? What if…? I didn’t sleep a wink the night before our first shift together. I just did my best to have a positive attitude and kept reminding myself—my student and I will learn together.

Beth Perry Professor, Faculty of Health Disciplines, Athabasca University, Athabasca, AB.

Once you overcome the initial challenge of self-doubt about your ability to be a preceptor, you can become aware of some of the realities and challenges faced by preceptors. One important challenge is that preceptors must balance the needs of preceptees with the needs of patients they are caring for and the realities of the workplace. Patients may be seriously ill (or become seriously ill during a shift) and work environments may have high staff turnover and other challenges (Hallin & Danielson, 2009). As a preceptor you may feel torn between the needs of your patients and those of the preceptee. The reality is that patient safety always supersedes anything else. If you keep this in mind, you will know what to do. If you do have to make a choice and the preceptee’s needs are not addressed at that point, explain the situation later to the learner and use it as a learning moment to help understand setting priorities.

All students are not going to succeed (at least not at first). You may have a learner who lacks appropriate knowledge, skills and attitudes to perform safe, competent (for their level) and ethical care in the clinical environment. You may be the only line of defense for the patient and your responsibility to, and advocacy for, the patient and society may become your priority. As Luhanga, Yonge & Myrick (2008) write, preceptors must be able to recognize and manage unsafe practice in students—preceptors are the “gatekeepers for the profession” (p. 214). If you have a learner who is disruptive and exhibits other problematic or unsafe behaviours, Luhanga, Yonge & Myrick (2008) provide strategies gathered from preceptors with experience in such situations. Their first recommendation is to catch unsafe practices early or even prevent them if possible. A key first step is giving the learner a complete orientation to the learning environment and establishing clear expectations. Preceptors need to make their own expectations clear, ask learners about their expectations, and understand the program expectations before the learning experience begins. Clear expectations, understood by all involved, can prevent issues and problems. One preceptor in the Luhanga, Yonge & Myrick (2008) study describes how she presents her expectations (p. 216).

Actively involved preceptors often prevent problem behaviours and unsafe practices in learners by providing learners with demonstrations, chances to practice, cues, prompts and frequent feedback throughout the learning experience (Hendrickson & Kleffner, 2002). Such active involvement of the preceptor, including close observation especially in the early days of the relationship, may give learners the best chance for success. As learners gain confidence and competence, preceptors may deliberately step back and encourage more independence within agency guidelines. However, that initial investment of time and energy by the preceptor can be crucial as learners stretch towards practicing at their full scope.

Preventing unsafe and disruptive behaviours is not always possible. If a learner is doing something that is jeopardizing the safety of another (or themselves) the preceptor must stop the behaviour immediately. Further actions (Luhanga, Yonge & Myrick, 2008) include:

• communicating concerns directly to the learner, to determine whether the learner is aware of the problem
• working with the learner to set up a detailed plan for improving performance
• involving the faculty advisor, if the learner is a student.

Preparing preceptors for their role is important to the success of the preceptor–preceptee relationship. Ensuring preceptors are enthusiastic about being preceptors is essential. Careful preparation can fuel this enthusiasm and prepare the preceptor for positive outcomes from their preceptoring experience, encouraging them to continue in this role. Hallin & Danielson (2009) do note that in some clinical environments in which students are preceptored, turnover is high. Preceptors may be placed in the role before they have appropriate orientation, being appointed not because they are ready to be preceptors but because “now it is your turn.” If you are asked to be a preceptor and do not, after careful reflection and self-assessment, feel safe in this role, then do discuss your concerns with your manager before agreeing. Again, the principle of patient safety over-rides all else.

Characteristics of Effective Preceptors

Research has been carried out on the qualities of effective preceptors in various health care disciplines. Effective preceptors in pharmacy have professional expertise, actively engage learners, create a positive learning environment, are collegial, and discuss career-related topics and concerns (Huggett, Warrier & Malo, 2008). Pharmacy students value preceptors who they perceive as role models, who are interested in teaching, relate to learners as individuals, are available to provide direction and feedback, and spend time with learners (Young, Vos, Cantrell & Shaw, 2014). Medical students note that effective preceptor behaviours include openness to questions, constructive feedback, enthusiasm, review of differential diagnoses, and delegation of patient responsibilities (Elnicki, Kolarik & Bardella, 2003). Nursing learners value experienced, knowledgeable professionals who guide them to think critically and create a supportive and nurturing environment (Phillips, 2006).

While these studies note slightly different emphasis on the characteristics of effective preceptors, some commonalities are clear. First, excellent preceptors want to be preceptors, or at least are able to be perceived as wanting this role. Students are attentive to the level of enthusiasm and support that preceptors bring to the relationship. Second, effective preceptors have expertise to share and share it willingly with learners. Learners appreciate preceptors who share their knowledge by involving learners in the learning process—preceptors who make learning interactive and two-way, challenging learners to think critically. Finally, we can note a theme of openness, collegiality, support, respect and nurturing. Students report learning best in a positive learning environment infused with these attitudes.

Creative Strategies

How to be positive when you don’t feel very positive.

This could also be called the ‘fake it until you make it’ approach. You are human. You have days when you don’t feel like being at work, let alone having a student with you. You have more than enough to do to get through the day and you just don’t have one ounce of energy left over to answer another question!

When this happens, forgive yourself. Remember you do have limits. You can try for an attitude adjustment—give yourself a little lecture and start fresh. If that fails, just take one hour or even one moment at a time and try to be a positive preceptor for just a short period. Fake your enthusiasm until, perhaps after one or two positive exchanges, your real enthusiasm may start to return.

Perry (2008) concludes that nurses who do their job very well come to know they are making a difference for patients (and in your case learners). This realization starts a positive cycle of feeling good about their work, trying even harder to do well, and feeling even better about their success in their role.

So on those days that you just don’t want to be a preceptor, fake it until you can get this positive cycle started. The result may be a great day after all!

What Helps People be Better Preceptors?

You can use multiple strategies to become an outstanding preceptor. First, be sure you have the support you need to succeed. Being a preceptor can be stressful but you can be more effective if you receive support from faculty advisors, managers, colleagues and clinical educators on the unit (Yonge et al., 2002). Support can come in many forms, including formal education programs and workshops through your agency, opportunity to meet with faculty advisors to learn about their expectations of a preceptor, discussion with colleagues about how they enhance their success as a preceptor, or informal chats with clinical educators for teaching tips. You can identity the forms and sources of support most useful to your knowledge gaps. Do reflect on your needs and ask for the support you need to perform your role well.

A second important strategy is preparation. Less experienced preceptors may feel unprepared and unsure of their roles and responsibilities, which adds to the stress of the role. Hallin & Danielson (2009) recommend that, in addition to the preparation outlined earlier in this chapter, preceptors confirm that they have clear guidelines on expectations for their role and what students are allowed to do in clinical settings. In part to gain this knowledge and to learn the more subtle skills of being an effective preceptor, Hallin & Danielson (2009) suggest that inexperienced preceptors be preceptored by experienced preceptors. This requires team-preceptoring rather than initially being a single preceptor on your own and may be effective for some individuals. In particular, new preceptors must be specifically prepared for student evaluation, which can be idiosyncratic to each student’s agency, complex and demanding.

Consider Forming a Preceptor Support Group

You can organize a group of preceptors in your agency for regular gatherings to share experiences, debrief problems and engage in professional development on being an exemplary preceptor. You may meet in person or online through Skype or another real-time meeting software.

Do set some guidelines for your group on requirements for participation, frequency of meeting, nature of discussions, etc. Just as in the learning environment you are creating with students, the group should be a positive, supportive, nurturing and engaging gathering. Confidentially will be an important consideration. Give your group a catchy name, like the Preceptor Partners or the Pre Ceptors, to instil a sense of togetherness and build group morale. Adding an element of food sharing or exercise (meet while you walk) can augment the group purpose.

The Preceptor–Preceptee Relationship

Being a preceptor is being a teacher. To succeed as a preceptor you need to be skilled both as a clinician and as an educator. Previous chapters offer numerous clinical teaching strategies that you can apply as a preceptor. Here is a brief overview of some educational strategies you might be able to incorporate into your role.

As a preceptor, developing an effective relationship with the learner is an essential starting point and critical to learning. The preceptor–preceptee relationship has potential to be more effective with mutual respect and a demonstration that the preceptor cares for the learner as a unique individual. A warm welcome is the first step. The tone of the first interaction with the preceptee is important to the success of the relationship. A smile and pleasant tone set the stage for a mutually satisfying respectful relationship and for optimum learning. If the initial contact is by telephone or email, a pleasant welcoming tone is equally important. Something as simple as remembering (and using) the names of learners demonstrates respect.

Beyond a personal welcome, the preceptor must take steps to help the preceptee feel part of the team by introducing the learner to other team members (Hilli, Salmu & Jonsén, 2014). An effective preceptor makes time for the learner to ask questions and become familiar with routines and the culture of the environment. Preceptees also need orientation to practical things like washroom location, what to do if they need to call in sick, break times, daily schedules, and the idiosyncrasies of each workplace.

Trust is built over time. As a preceptor, your goal is to help the learner feel like a partner who evolves to function to the full extent of their skill and knowledge level over time. Preceptors can build trust by seeing preceptees as a valuable addition to the team, by being honest and saying “I don’t know” if they are not sure of the answer to a question, and by being open to new ideas introduced by the preceptee (Vancouver Coastal Health, 2006).

Kramer (1974) describes four stages of reality shock for new employee preceptees: honeymoon, shock, recovery and resolution. These stages are a normal part of learning. In the honeymoon phase preceptees are enthusiastic and full of energy that a good preceptor can harness and encourage. During the shock phase preceptees may become unmotivated and discouraged and struggle with self-doubt. The recovery and eventual resolution phases see a cautious optimism resolving into a positive outlook. Excellent preceptors are mindful that learners may be at any of these stages of reality shock during their time together. Being attentive to how learners are feeling and finding time to chat with them about what makes them anxious, excited or worried can help build a trusting relationship that poises the learner (and preceptor) for success.

Create a Worry Quilt

Sometimes people are reluctant or unable to share their worries with others, especially with a person in a position of perceived power such as a preceptor. Sensitive preceptors may notice a learner expressing anxiety in clinical situations. You can chat privately with the learner to encourage sharing of anxieties. One strategy that you could use prior to this chat is to have the learner create a worry quilt. You can ask the learner to create visual representations of things that worry them in the clinical situation. The learner places each worry on a quilt square and pieces them together into a quilt pattern. The quilt squares can be pieces of coloured paper or they can be virtual boxes. What the learner puts into the squares can be words or images. When the quilt is pieced together as a whole, you and the learner have a visual depiction of the learner’s major worries. Themes may become evident and lead to specific strategies for mitigating stressors. The constructed quilt may show that the learner is worrying about the same issue in different ways. Being able to address the worries expressed, or condense them into one issue that can be addressed, may help the learner move forward.

A Strengths-Based Approach

Clinical instructors may encounter difficulties in their relationships with students through personality or value differences, or seemingly limited skills or interest on the part of learners (Cederbaum & Klusaritz, 2009). A strength-based approach focuses on learners’ self-determination and strengths. This can be a useful strategy for preceptors encountering difficult relationships with learners (McCashen, 2005). In a strengths-based approach, the preceptor places emphasis on discovering, enhancing and promoting the interests, knowledge and goals of the learner. The preceptor facilitates self-discovery and clinical reflection, creating a learning environment with mutuality and respect and a focus on strengths over deficits. If a strengths-based approach is used effectively, learners feel empowered and affirmed. Some learners who are more familiar with a deficit model may feel uneasy at first if they expect a teacher-centred top-down teaching approach. The strengths perspective can provide an innovative framework for working with students, one that emphasizes student empowerment, collaborative learning and mutual growth (Cederbaum & Klusaritz, 2009).

How can preceptors enact a strengths-based approach? One strategy is to use a learning contract, as explained in chapter 6. This contract can be verbal or written, outlining by mutual agreement the roles and responsibilities of the preceptor and preceptee and emphasizing the mutuality of the learning experience. Another strategy is to express concerns positively and frame overcoming of problems as adding to existing strengths rather than overcoming deficiencies. Preceptors who embrace strengths-based approaches view the clinical situation from the perspective of the learner and try to create a positive learning space (Cederbaum & Klusaritz, 2009).

Catch Them Doing Something Right—And Tell Them

Being a preceptor is a challenge. Getting caught up in a spiral of finding weaknesses and trying to think of creative ways to address these is unfortunately too easy. If you focus on the positive, be sure to spend time and energy finding and praising the things that are done well. If you see something positive, tell the person right away and pause for a moment to relish the feelings of success.

Halfer (2007) calls debriefing a magnetic strategy for preceptoring learners. Preceptors can use debriefing as an intentional teaching strategy and an example of guided discovery learning. Usually debriefing is a short exchange that occurs between the preceptor and preceptee after a care experience. Ideally, debriefing occurs in a private and safe location away from others who are not involved in the experience (Wickers, 2010). Debriefing has four elements: reflection, rules, reinforcement and correction (Roberts, Williams, Kim & Dunnington, 2009). Initially a preceptee is invited to reflect on his or her performance, giving the preceptor an opportunity to gain insight into the learner’s perspective. This reflection requires learners to gather their thoughts and share them, which is often a learning experience in itself. Next, the preceptor teaches general rules about the procedure, reinforces them, and corrects errant thinking expressed or demonstrated by the learner. Wickers (2010) emphasizes that “structuring a seemingly unstructured learning event is paramount to the effectiveness of the debriefing session” (p. 83) and reminds us that positive support is part of the successful debriefing model.

Reflective Practice

Preceptors can use the instructional strategy of reflective time to enhance consolidation of theory and practice (Duffy, 2009), encouraging students to reflect on their practice through guided reflection. Schon (1983) suggests that the capacity to reflect on action as part of engaging in a process of continuous learning is one of the defining characteristics of professional practice. Schon differentiates the capacity to reflect in action (while doing something) and on action (after you have done it). To elicit real reflection, the preceptor must ask appropriate questions that move the reflection beyond self-justification or self-indulgence. The desired result is learning, and perhaps behaviour change or enhanced skills proficiency.

Instant Replay Without a Camera

Consider using a sports approach to encourage reflection on action. The instant replay allows athletes to review the effectiveness of their actions by watching a video of the action. In a health care interaction the preceptor will not have a video camera in hand to provide this tool, but after the interaction the preceptor can invite the learner to replay (role play) the scenario—creating their own instant replay. Through acting out the interaction, learners will have a chance to reflect on action. After the replay the preceptor and learner can discuss what happened, lessons learned, and changes the learner would make the next time.

Educational Process: Assessment, Planning, Implementation, Evaluation

The educational process parallels the health care process with four stages or steps: assessment, planning, implementation and evaluation. Preceptors need to spend time assessing the learning needs, goals, strengths and limitations of each learner to be able to coach and guide the student to maximum learning. No two learners are the same and thus skilful assessment helps personalize the learning experiences that are facilitated by the preceptor. While assessment is quite important at the outset of the relationship, assessment is also an ongoing activity for preceptors.

Excellent assessment sets the stage for planning instructional opportunities to meet the knowledge and skill gaps identified for each learner. After learning strategies are implemented, evaluation by the learner in consultation with the preceptor determines if the knowledge and skill gaps have been addressed. If not, further specific learning activities need to be sought to continue addressing learning needs and goals. Each evaluation feeds back into assessment and the cycle continues.

The key to success in skilfully implementing this cycle is effective communication through building of excellent rapport between the preceptor and learner. Positive interpersonal relationships are the starting point for rich learning experiences in the clinical environment. A successful preceptorship requires honest and respectful interaction. particularly when the preceptor provides feedback or evaluation to the learner.

Talk Out Loud

One strategy for communicating clearly with preceptees is to talk to yourself! Talk out loud as you ask yourself how you are assessing patients, planning care, or implementing and evaluating the success of your intervention. Students benefit from hearing the preceptor’s thought processes aloud (Smedley, Morey & Race, 2010). No extra time is needed to complete a task if you include the verbal commentary, yet hearing your thought processes provides learners with great learning—especially the auditory learners.

Rewards of Being a Preceptor

Although being a preceptor is challenging, and partly because it is challenging, many professionals experience the role as stimulating. The most desired and frequent rewards are often non-tangible. Rewards that preceptors rank highest are the ongoing learning a preceptor achieves, opportunities to share students’ enthusiasm for learning, and fostering professional skills, attitudes and confidence in learners (Campbell & Hawkins, 2009).

In some cases more tangible rewards are provided, depending on the agency involved. Campbell & Hawkins (2009) give examples of preceptors who receive continuing education vouchers; verification of hours towards recertification; reduced price or free admission to museums, lectures, or cultural and sports events; certificates of appreciation; and opportunities to be part of research publications and presentations. Other institutions provide preceptors with paid time off or salary adjustments. As the competition for clinical placements and preceptors becomes more intense, considering some of these more tangible reward systems may be advantageous to clinical practice programs. If administrators and educators plan to offer tangible rewards for participation as preceptors, preceptors must be consulted on what they consider appropriate and valued rewards. Most preceptors are motivated intrinsically and by their values of altruism. They engage in this role because they have a strong desire to pass on their knowledge and skills to the next generation of caregivers.

Ideas for Preceptor Rewards

If you are an administrator or educator seeking ideas for rewards that preceptors may find appealing, here are some creative ideas you can consider.

• A plaque with a new inscription for each year a person is a preceptor
• Apprecigrams: Hand-written notes of thanks
• Introduction of preceptors at convocation
• Parking privileges
• Adjunct professor status
• Ask preceptors what they would find rewarding!

Simply put, preceptors are vital. They are charged with the pivotal responsibility of helping learners gain competency to deliver safe, autonomous, professional care. Preceptors have tremendous power to guide the development of professional practice and ultimately the success of learners in the health care professions.

This chapter offered an overview of the roles, challenges and rewards of being a preceptor. Several strategies were discussed to help preceptors excel. The foundational element of all instruction as a preceptor is building a strong relationship with the learner. A caring relationship founded on mutual respect and reciprocity is a prerequisite for a health learning environment. In such an environment learners can thrive and preceptors will be rewarded for devoting time and sharing knowledge, skills and professional insights.

Health care professionals have a responsibility as licensed professional health care team members to help others rise up to meet their potential (Eley, 2015). Preceptors have a responsibility to guide learners, to act as role models, and to lead others into the profession by preparing them to succeed (Hilli, Salmu & Jonsén, 2014). Being an exemplary preceptor can be as rewarding for the teacher as it is for the learner. It is not a role that can be taken lightly. Preparation, reflection on and in action, and continuous learning are fundamental to becoming and excelling as a preceptor.

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1.7: PRECEPTORS- ESSENTIAL TO LEARNER SUCCESS

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“While we teach, we learn” —Seneca

Precepting is an organized, evidence-based, outcome-driven approach to assuring competent practice (Eley, 2015). Clinical heath education often employees a preceptor model for senior practicum courses and frequently as part of orienting new employees. Through clinical experiences and orientation activities, learners acquire knowledge and essential skills for professional practice. The preceptor plays a vital role in developing students as professionals and a critical role in successfully integrating new staff.

For student learners, a representative from the student’ institution is often part of the teaching–learning team along with the student and a preceptor who is an employee of the clinical agency. Each member of the trio usually has specific roles and responsibilities, with the faculty representative often supporting and advising the preceptor. While the preceptor has important roles in student evaluation, the faculty member usually makes critical decisions on final grades and on whether a learner passes or fails a practicum.

Being a preceptor for a student or new employee is an essential role but not one for which most preceptors are formally prepared. The short- and long-term success of the student or employee can be enhanced greatly by an excellent preceptor or affected negatively by a preceptor who is not well prepared for the role. The goal of this chapter is to provide readers with knowledge, skills and attitudes that are key to being an effective preceptor in the clinical setting. As with most careers, when you are well prepared and able to excel in a role, those you work with are positively affected. As you carry out your role well, your level of satisfaction with the role is also enhanced. This leads to a positive cycle with affirmative effects on all involved, including recipients of care.

This chapter discusses the difference between preceptoring and mentoring, examines the theoretical foundations of effective preceptoring, and presents strategies for becoming and being a successful preceptor. We conclude with a discussion of the preceptor–preceptee relationship. The strategies included provide a road map for practitioners who are new to precepting. The chapter is infused with practical creative ideas and founded on theory, making it both a stand-alone chapter for educators embarking on being a great preceptor and part of the greater understanding of becoming skilled as a clinical educator.

The Difference Between a Mentor and a Preceptor

The origin of the concept of mentorship is well documented. In Homer’s Odyssey a Mentor, a wise and trusted friend of Odysseus, takes on the rearing of Odysseus’ son in his absence (Roberts, 1999). The mentor is depicted as an older, wiser male who takes on the responsibility for a younger male’s learning and development, acting rather like a guardian. The term mentor is traditionally associated with professions such as medicine, law and business, but it began appearing in nursing literature in the 1990s (Andrews & Wallis, 1999).

Much of the current mentor literature focuses on defining the concept, yet a precise and complete definition that is universally embraced remains elusive (Dawson, 2014; Gopee, 2011; Mentoring Resources, n.d.). To confuse it further, terms such as preceptor, coach and facilitator are used interchangeably in some instances. In jurisdictions such as Great Britain, practicing nurses who are responsible for students in the clinical area are called mentors, while in most North American jurisdictions, these supervising nurses are called preceptors. Commonly the term mentor is reserved for a longer-term personal development relationship between a less experienced and a more experienced person, with the focus of the relationship being assistance, befriending, guiding and advising (Eby, Rhodes & Allen, 2007). More concisely the mentor is less focused on assessment and supervision and more focused on the mentee’s well-being and career advancement (Eby, Rhodes & Allen, 2007).

In contrast a preceptor–preceptee relationship is usually shorter term and the preceptor has responsibility for teaching and assessing clinical performance. In the base definition of preceptor, the focus of the preceptor’s work is to uphold a precept or law or tradition. Myrick & Yonge (2005, p. 4) define a nursing preceptor as a skilled practitioner who oversees students in a clinical setting to facilitate practical experience with patients.

The roles of mentor and preceptor do overlap. For example, a preceptor who has no concern for the well-being of the preceptee is not likely to provide the learner with a positive clinical experience. Likewise a mentor who does not assess student practice will not have the information needed to be an effective mentor. The assessment in which a mentor engages is more likely to be formative in nature and focused on providing the mentor with knowledge to fulfill the role of guide effectively.

Students in practice-based health care professions rely on others to support, teach and supervise them in practice settings. The underlying rationale for this approach to learning is the belief that working alongside practitioners aids students to become safe caregivers who are successfully socialized to the clinical world (Benner, 1984). In this chapter we focus on the role of the preceptor.

Theoretical Foundations of Effective Preceptoring

Effective preceptoring of students in health care clinical environments can be understood by briefly examining adult learning theory, transformational learning theory, and the novice to expert model. Here we outline each theory or model and discuss each in relation to the preceptoring literature.

Adult Learning Theory

As described in chapter 1, Malcolm Knowles (1984) is credited with naming the theory of andragogy, a theory specifically for adult learning. Andragogy emphasizes how adult learners differ from child learners in being self-directed and taking responsibility for their learning decisions. Further, according to Knowles, adults want to know why they are learning something, need to learn experientially (including having the opportunity to make mistakes), use problem-solving to learn, and learn most effectively if they can apply what they learn immediately. Knowles states that adults learn best if their teacher is primarily a facilitator or resource person. Smith (2002) further discusses Knowles’ andragogy theory, highlighting the ideas that a) learners move from being dependent to self-directed, b) learners accumulate a reservoir of experience and knowledge, and c) a learner’s motivation to learn is internal. Given these principles of adult learning, teaching strategies such as simulations, role-play and case studies are considered useful. Likewise, clinical practicum learning opportunities with the student working alongside a preceptor are compatible with the principles of andragogy. Practicum students are directed by a more knowledgeable person (the preceptor) until they can accumulate experience and knowledge to be independent practitioners.

Sandlin, Wright & Clark (2013) further our understanding of Knowles’ theory by additional focus on Knowles’ beliefs that adult learners are autonomous, rational and capable of action, and on the assumption that autonomy and rationality are desirable and attainable in adult learners. Their perspective on Knowles’ fundamental views provides an interesting contrast in considering the role of preceptor in the clinical environment. The tenets of Knowles’ adult learning theory offer no substantive role for the preceptors who hold responsibility for overseeing, guiding and evaluating the work of the preceptee, as learners are thought to be totally autonomous and capable of independence. In contrast, as Sandlin, Wright & Clark (2013) propose, adult learners may actually be at various levels of autonomy and rationality and thus a skilled preceptor does have a role in adult learning.

Transformational Learning Theory

As explained in chapter 1, Jack Mezirow (1995) is credited with making significant contributions to the theory of transformative learning. The essence of this theory is that learners must engage in critical reflection on their experiences in order to transform their beliefs, attitudes and perspectives, which Mezirow terms their meaning schemes. Others have critiqued some of Mezirow’s assumptions and views. Boyd & Myers (1988) note that learners must be open to changing their meaning schemes; to adopt new perspectives, they must realize that their old perspectives are no longer relevant. Dirkx, Mezirow & Cranton (2006) emphasize the self-actualization possibilities of transformative learning with the statement “learning is life – not a preparation for it” (p. 123). They note the importance of a relationship between the learner and others, which is required to make sense of one’s perspective and to become aware of (and transform to) new meanings.

To Mezirow, the essence of learning is change. To be truly transformational, learners must engage in inquiry, critical thinking and interaction with others. Brookfield (2000) adds that transformative learning must include a fundamental questioning of one’s thinking and actions. Reflection alone does not result in transformative learning unless this reflection includes an analysis of taken-for-granted assumptions.

Part of the entry-to-practice competencies for health professionals include elements of critical reflection, adoption of professional values, beliefs and attitudes, and ongoing questioning of taken-for-granted assumptions and values. If Mezirow is correct that acquiring a competency does require the involvement of others, this becomes part of the role of the skilled preceptor. Preceptors may be well placed to encourage honest self-review and critical reflection that ends in learner transformation. In this view, preceptors need to be aware of strategies to engage learners in reflection, causing learners to gaze deeply into long- and deeply-held values and biases that they may not even be aware they hold.

The ‘From Novice to Expert’ Model

Benner’s (1984) well-used and much respected From Novice to Expert model has implications for understanding the role of an effective preceptor for health care learners. While Benner focused on nursing students in the clinical setting, her theory likely applies to learners from other health care disciplines. This model holds that nurses develop skills over time from both education (including clinical experience) and personal experience. The model identifies five levels of nursing experience: novice, advanced beginner, competent, proficient and expert. Novices are beginners with no experience—they learn rule-governed tasks by being told and by following instructions. Advanced beginners have gained experience in actual nursing situations and recognize recurring elements that create principles they can use to guide actions. Competent nurses have more clinical experience and use it to become more efficient in providing care. Proficient nurses have an understanding of the bigger picture that improves decision making and allows for changes in plans as needed. Experts no longer need principles or rules to guide action—they use intuition to guide their flexible, highly proficient clinical approaches. As learners transition from novice to expert, they rely less on principles, they see a situation more holistically, and they engage in situations from the inside rather than being external to a situation.

Preceptors can play a vital role in this transition. Benner’s model requires clinical experience for the transition to occur and guidance in the clinical situation is essential for successful transition. Preceptors need to have awareness of the needs of learners at various stages of the continuum and be attuned to the stage(s) at which their students are functioning. For example, a novice student needs a preceptor who provides more direct guidance in learning the rules to guide their actions. A preceptor for an advanced beginner helps learners recognize recurring patterns and develop them into principles of effective care.

Benner also comments that expert clinicians may not be the most effective in preceptoring roles. Expert clinicians may have difficulty explaining their actions in a step-by-step manner because they are functioning by intuition and may not be consciously aware of the rules and principles that they use to make clinical judgments. Analogous to riding a bike, beginners are very aware of the steps needed to balance the bike, propel it forward, stop momentum and avoid obstacles. An expert at cycling is able to just ride without thinking about how to ride and thus may have a challenge teaching a new cyclist.

Strategies for Being and Becoming a Successful Preceptor

This section focuses on strategies for being (and becoming) a successful preceptor for students from various health care professions in clinical learning environments. We also address the challenges and rewards of being a preceptor and characteristics of effective preceptors. The goal is to provide both new and established preceptors with new knowledge that can be used as a road map to beginning and continuing this journey with learners.

Challenges of Precepting

You are invited by your manager to be a preceptor. You are both honoured and terrified. If this is your first time formally in this role, you have a lot to learn. To begin, recognize that becoming a really good preceptor takes experience, just as becoming a competent (even expert) care provider takes experience. Reading this chapter and other resources will help. You may be fortunate that the agency you work for provides preceptor education. The first step is to determine what is available in the form of lectures, workshops, preceptor manuals, etc. and to engage with these before your preceptee arrives. You cannot possibly be fully prepared on day one no matter how much homework you do, so begin with a positive attitude and a sense that you are going to learn every day through reflection, experience and ongoing formal learning. Know that your apprehension is normal—with preparation, this apprehension can be lessened. With a positive approach, being a preceptor can be a fulfilling experience for you and a gift to a learner.

From the Field

Learning together.

I was delighted to be asked to be a preceptor! This would be my first time. I thought “Wow they think I am good enough to teach a new person—that’s super!” My sense of excitement was soon drowned out by horror. What if I made a mistake? What if my student asked a question I couldn’t answer? What if…? I didn’t sleep a wink the night before our first shift together. I just did my best to have a positive attitude and kept reminding myself—my student and I will learn together.

Beth Perry Professor, Faculty of Health Disciplines, Athabasca University, Athabasca, AB.

Once you overcome the initial challenge of self-doubt about your ability to be a preceptor, you can become aware of some of the realities and challenges faced by preceptors. One important challenge is that preceptors must balance the needs of preceptees with the needs of patients they are caring for and the realities of the workplace. Patients may be seriously ill (or become seriously ill during a shift) and work environments may have high staff turnover and other challenges (Hallin & Danielson, 2009). As a preceptor you may feel torn between the needs of your patients and those of the preceptee. The reality is that patient safety always supersedes anything else. If you keep this in mind, you will know what to do. If you do have to make a choice and the preceptee’s needs are not addressed at that point, explain the situation later to the learner and use it as a learning moment to help understand setting priorities.

All students are not going to succeed (at least not at first). You may have a learner who lacks appropriate knowledge, skills and attitudes to perform safe, competent (for their level) and ethical care in the clinical environment. You may be the only line of defense for the patient and your responsibility to, and advocacy for, the patient and society may become your priority. As Luhanga, Yonge & Myrick (2008) write, preceptors must be able to recognize and manage unsafe practice in students—preceptors are the “gatekeepers for the profession” (p. 214). If you have a learner who is disruptive and exhibits other problematic or unsafe behaviours, Luhanga, Yonge & Myrick (2008) provide strategies gathered from preceptors with experience in such situations. Their first recommendation is to catch unsafe practices early or even prevent them if possible. A key first step is giving the learner a complete orientation to the learning environment and establishing clear expectations. Preceptors need to make their own expectations clear, ask learners about their expectations, and understand the program expectations before the learning experience begins. Clear expectations, understood by all involved, can prevent issues and problems. One preceptor in the Luhanga, Yonge & Myrick (2008) study describes how she presents her expectations (p. 216).

I try to nip it in the bud pretty quickly so as to prevent it. Upfront, I tell students what I expect. Like, I expect you to know every med you give. I expect if you don’t know something to ask me, we’ll look it up. I don’t expect you to know everything, so don’t feel pressured.

Actively involved preceptors often prevent problem behaviours and unsafe practices in learners by providing learners with demonstrations, chances to practice, cues, prompts and frequent feedback throughout the learning experience (Hendrickson & Kleffner, 2002). Such active involvement of the preceptor, including close observation especially in the early days of the relationship, may give learners the best chance for success. As learners gain confidence and competence, preceptors may deliberately step back and encourage more independence within agency guidelines. However, that initial investment of time and energy by the preceptor can be crucial as learners stretch towards practicing at their full scope.

Preventing unsafe and disruptive behaviours is not always possible. If a learner is doing something that is jeopardizing the safety of another (or themselves) the preceptor must stop the behaviour immediately. Further actions (Luhanga, Yonge & Myrick, 2008) include:

• communicating concerns directly to the learner, to determine whether the learner is aware of the problem
• working with the learner to set up a detailed plan for improving performance
• involving the faculty advisor, if the learner is a student.

Preparing preceptors for their role is important to the success of the preceptor–preceptee relationship. Ensuring preceptors are enthusiastic about being preceptors is essential. Careful preparation can fuel this enthusiasm and prepare the preceptor for positive outcomes from their preceptoring experience, encouraging them to continue in this role. Hallin & Danielson (2009) do note that in some clinical environments in which students are preceptored, turnover is high. Preceptors may be placed in the role before they have appropriate orientation, being appointed not because they are ready to be preceptors but because “now it is your turn.” If you are asked to be a preceptor and do not, after careful reflection and self-assessment, feel safe in this role, then do discuss your concerns with your manager before agreeing. Again, the principle of patient safety over-rides all else.

Characteristics of Effective Preceptors

Research has been carried out on the qualities of effective preceptors in various health care disciplines. Effective preceptors in pharmacy have professional expertise, actively engage learners, create a positive learning environment, are collegial, and discuss career-related topics and concerns (Huggett, Warrier & Malo, 2008). Pharmacy students value preceptors who they perceive as role models, who are interested in teaching, relate to learners as individuals, are available to provide direction and feedback, and spend time with learners (Young, Vos, Cantrell & Shaw, 2014). Medical students note that effective preceptor behaviours include openness to questions, constructive feedback, enthusiasm, review of differential diagnoses, and delegation of patient responsibilities (Elnicki, Kolarik & Bardella, 2003). Nursing learners value experienced, knowledgeable professionals who guide them to think critically and create a supportive and nurturing environment (Phillips, 2006).

While these studies note slightly different emphasis on the characteristics of effective preceptors, some commonalities are clear. First, excellent preceptors want to be preceptors, or at least are able to be perceived as wanting this role. Students are attentive to the level of enthusiasm and support that preceptors bring to the relationship. Second, effective preceptors have expertise to share and share it willingly with learners. Learners appreciate preceptors who share their knowledge by involving learners in the learning process—preceptors who make learning interactive and two-way, challenging learners to think critically. Finally, we can note a theme of openness, collegiality, support, respect and nurturing. Students report learning best in a positive learning environment infused with these attitudes.

Creative Strategies

How to be Positive When You Don’t Feel Very Positive

This could also be called the ‘fake it until you make it’ approach. You are human. You have days when you don’t feel like being at work, let alone having a student with you. You have more than enough to do to get through the day and you just don’t have one ounce of energy left over to answer another question!

When this happens, forgive yourself. Remember you do have limits. You can try for an attitude adjustment—give yourself a little lecture and start fresh. If that fails, just take one hour or even one moment at a time and try to be a positive preceptor for just a short period. Fake your enthusiasm until, perhaps after one or two positive exchanges, your real enthusiasm may start to return.

Perry (2008) concludes that nurses who do their job very well come to know they are making a difference for patients (and in your case learners). This realization starts a positive cycle of feeling good about their work, trying even harder to do well, and feeling even better about their success in their role.

So on those days that you just don’t want to be a preceptor, fake it until you can get this positive cycle started. The result may be a great day after all!

• Apr 27, 2017

Critical Thinking for Nurse Preceptors

Critical Thinking from Three Perspectives

Thinking ahead is the ability to be proactive. Help your preceptee to think ahead by asking, “What complications might arise for this patient? What are some of the difficulties we have to manage? What supplies will we need?”

Thinking in action is the ability to think on your feet. To prepare preceptees for this, give them hands-on, low-risk experiences to build their skills and confidence. For example, have them gather all the supplies that are needed for a procedure. Then, they also must observe and assist you when you are thinking in action. Tell them what you’re doing and why. Teach them.

Thinking back is the ability to recall and analyze the reasoning process to gain a better understanding. Facilitate reflective thinking by asking questions and allowing your preceptee to ask questions. Ask questions to help your preceptee understand relevance, significance and clarity. “How does that relate to the problem? What was the most important problem to consider? Which of the facts are the most important? Could you elaborate or give me an example of why?”

Critical Thinking: What Does It Look Like?

According to Alfaro-Lefevre (2008), critical thinking is the ability to focus your thinking to get the results you need. It is outcome-focused. It is purposeful. Critical thinking is always driven by the patient’s needs and the nurse’s desire to meet those needs. Critical thinkers are constantly re-evaluating, self-correcting and striving to improve. So, how do you know if your preceptees are thinking critically? You must ask them questions and observe their behavior.

Critical thinking indicators can help you assess your preceptees’ critical thinking skills. CTIs “are evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote CT in clinical practice.”

(www.AlfaroTeachSmart.com). CTIs are most effective when they are incorporated into your evaluation tools. The following are examples of CTI behavior questions, with examples of CTIs in italics. If you answer yes to these, you are observing critical thinking.

 Are your preceptees curious and inquisitive?  Do they ask you, physicians or others questions to learn more? Do they delve into the resources for answers?  Do your preceptees communicate effectively?  Are they open and fair-minded? Do they listen to other views?  Are they analytical and insightful?  Do they recognize cause and effects of interventions? Can they tell you the reasons for their interventions?  Can your preceptees identify any opportunities for improvement?  Do they verbalize an understanding of complex situations or pathophysiology and act accordingly?  Do they demonstrate their knowledge by distinguishing normal from abnormal symptomatology?  Do your preceptees question inconsistencies?  Do they consider multiple explanations and solutions?  Do they assess their patients systematically and comprehensively and demonstrate the use of the nursing process by assessing, planning and implementing care effectively?  Do your preceptees apply standards and ethics codes when caring for their patients?  Are they able to set priorities as they provide care?  Can they make decisions appropriately?

Share these CTI questions with your preceptees. Together, you can focus on improving their ability to think critically, and you will both gain from the experience. More important, your patients will benefit when both of you think critically while providing quality care.

Resources Alfaro Lefevre (2008). Critical Thinking Indicators: 2007-2008 Evidence-Based Version . www.alfaroteachsmart.com Elder and Paul (2008). Miniature Guide to Critical Thinking . www.criticalthinking.org

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• Research article
• Open access
• Published: 24 May 2020

Measuring and assessing the competencies of preceptors in health professions: a systematic scoping review

• Andrew D. Bartlett   ORCID: orcid.org/0000-0003-1887-7698 1 ,
• Irene S. Um   ORCID: orcid.org/0000-0002-5315-6469 1 ,
• Edward J. Luca   ORCID: orcid.org/0000-0001-6604-2463 2 ,
• Ines Krass   ORCID: orcid.org/0000-0002-0466-9807 1 &
• Carl R. Schneider   ORCID: orcid.org/0000-0002-2921-5609 1  

BMC Medical Education volume  20 , Article number:  165 ( 2020 ) Cite this article

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Metrics details

In healthcare, preceptors act as a role model and supervisor, thereby facilitating the socialisation and development of the preceptee into a professional fit to practice. To ensure a consistent approach to every preceptorship experience, preceptor competencies should be measured or assessed to ensure that the desired outcomes are achieved. Defining these would ensure quality management and could inform development of an preceptor competency framework.

This review aimed to evaluate the evidence for preceptor competencies and assessment in health professions.

This study followed the PRISMA ScR scoping review guidelines. A database search was conducted in Embase, Medline, CINAHL and IPA in 2019. Articles were included if they defined criteria for competency, measured or assessed competency, or described performance indicators of preceptors. A modified GRADE CERQual approach and CASP quality assessment were used to appraise identified competencies, performance indicators and confidence in evidence.

Forty one studies identified 17 evidence-based competencies, of which 11 had an associated performance indicator. The competency of preceptors was most commonly measured using a preceptee completed survey (moderate to high confidence as per CERQual), followed by preceptor self-assessment, and peer-assessment. Preceptee outcomes as a measure of preceptor performance had good but limited evidence.

Conclusions

Competencies with defined performance indicators allow for effective measurement and may be modifiable with training. To measure preceptor competency, the preceptor perspective, as well as peer and preceptee assessment is recommended. These findings can provide the basis for a common preceptor competency framework in health professions.

Peer Review reports

Preceptorship may be defined as the formal arrangement, situated within a clinically related setting, between a practicing health professional (the preceptor) and a graduate or student (the preceptee). The preceptor acts as a role model, supervises, provides guidance, learning experiences, and facilitates the socialisation and development of the preceptee into a competent professional, fit for practice during the taught curriculum and pre-registration [ 1 , 2 , 3 ]. In some countries, professional bodies mandate a period of supervised practice or an internship prior to full registration [ 4 ]. The nature of the preceptor’s role will differ depending on the scope of supervision, which can range from a short-term clinical placement within an undergraduate/postgraduate curriculum to a long-term pre-registration internship [ 5 ]. A good placement or internship experience lays a solid foundation for development of professionalism [ 6 ] throughout a practitioner’s career. Developing and supporting preceptors also leads to improvements in retention and satisfaction of new graduates [ 7 ].

Competencies comprise a combination of knowledge, skills, abilities or attributes[ 66 ] . Multiple preceptor competencies have been articulated in the literature such as effective communication skills and being a role model practitioner [ 8 , 9 , 10 , 11 ]. However, the evidence for identified competencies have yet to be evaluated. To ensure a consistent approach to every preceptorship experience, it then follows that competencies are measured or assessed to ensure that delivery is of a standard that achieves the desired outcomes. Assessment allows for setting a benchmark for comparison as well as for measuring the effect of change over time, eg the effect of an educational intervention such as a training program. Defining the standards that preceptors should strive to attain, as well as methods of assessment, could inform development of a preceptor competency framework and a standard by which preceptors may be measured.

The aim of this review was to evaluate the evidence for preceptor competencies and assessment in health professions. The objectives of this review were to:

Evaluate evidence for competencies or performance indicators of preceptors in health professions;

Describe implemented methods of measurement and assessment of competency;

Research question

What is the evidence for preceptor competencies in health professions and to how are they assessed?

Operational definitions

Preceptorship: Preceptorship is the formal arrangement between a practicing health professional (the preceptor) and a graduate or student (the preceptee). Within a clinically-related setting, the preceptor supervises, provides guidance and facilitates the socialisation and development of the preceptee into a competent professional fit for practice [ 1 , 2 , 3 ].

Assess: To consider (give careful thought to) someone or something and make a judgement about them or it [ 12 ].

Measure: to determine magnitude or quantity based on a standard [ 13 ].

Rating: a classification based on assessment of quality, standard or performance [ 14 ].

The literature was comprehensively searched using the following databases: Embase, Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and International Pharmaceutical Abstracts (IPA). A search strategy was developed via consensus with all authors and then applied to each database by the primary author (AB) on 19th June 2019 with no date limitation applied. The following PCC (population, concept, and context) strategy was developed a priori. The study population included medicine, nursing, pharmacy or other allied health practitioners. The concept of preceptor was captured using the terms clinical teacher, clinical educator, clinical supervision, preceptor, preceptorship, tutor or clerkship. The context of professional competence incorporated evaluation, guideline, framework, education, skill or quality. Each term was grouped with the boolean operator “OR”, and each concept with the operator “AND”. The search was restricted to peer-reviewed journal articles and those published in English. The search strategy used for Medline is presented in Additional file  1 .

Selection criteria

The inclusion and exclusion criteria were developed in an iterative fashion as described by Arksey and O’Malley [ 15 ] as more familiarity with the literature was gained (Table  1 ). A systematic approach was taken based on the PRISMA-ScR (Preferred Reporting Items for Systematic Scoping Reviews) guidelines [ 16 ]. Search results were collated in the reference management program EndNote, then de-duplicated. All titles, abstracts, and full-text articles were screened by the primary author (AB). A random sample of 10% of citations were assessed for eligibility by two additional authors (IU and CS), with consensus agreement being reached. Reference lists were hand searched to identify any additional articles that may fit the eligibility criteria.

Data extraction

Data were extracted and analysed by the primary author (AB), using a standardised data extraction form containing a predefined set of items. Items included study characteristics (e.g. author; year; setting; health discipline; type of study/study design; sample size); mode of measurement, measurement tool and scale; competency criteria; results; reliability/validity. The form was pilot tested with three articles, and discrepant items were clarified and resolved by discussion.

Risk of bias appraisal

As the included articles in this review had mixed study designs, two critical appraisal tools were used, the Critical Appraisal Skills Program (CASP) Cohort checklist [ 17 ] and the Qualitative checklist [ 18 ]. The primary author (AB) allocated each article to either checklist, depending on the study design, and evaluated all included articles. A random article from each checklist was independently evaluated by two authors (IU and CS). Any discrepancies identified were resolved by discussion and consensus agreement. A traffic light system was devised to visually describe the articles in terms of each of the CASP criteria; that is, addressed (green), not addressed (red), or unclear (orange).

Assessment of confidence

To assess the level of confidence in the findings, an approach based on the GRADE CERQual (CERQual) framework was followed [ 19 ]. CERQual is an approach that is usually applied to synthesize qualitative findings and to assess confidence in the evidence. While studies in the review were a mix of qualitative and quantitative evidence, the narrative nature of the findings warranted the use of CERQual. A conservative evidence synthesis approach was adopted with synthesis performed by AB and a random 10% selection independently reviewed by CS and IU. CERQual has four criteria (methodological limitations, coherence concerns, adequacy concerns and relevance concerns) against which the included articles were assessed leading to an overall assessment of confidence, described below.

Methodological limitations were assessed by looking at aspects of each contributing study that may reduce the confidence in the finding [ 20 ].

Coherence refers to the extent to which contributing studies fit with the finding in a convincing way. Studies that contain contradictory results to the other contributors would be seen to reduce the confidence in the finding [ 21 ].

Assessing adequacy involves making a judgement on the quantity of data along with the quality or richness of the information gained [ 22 ].

The confidence in the relevance of the papers contributing to the finding was a matter of examining the setting, context, perspective and phenomenon of interest [ 23 ].

After these assessments were made, they were considered as a whole to determine confidence in the evidence for the finding. These were then graded on a scale from low to high confidence. All findings were synthesised narratively.

Study selection

The literature search retrieved a total of 1642 citations after removing duplicates. Screening for eligibility based on titles excluded 1463 papers, leaving 179 papers for review of abstracts. A further 69 papers were excluded after reviewing abstracts, with 110 papers carried forward for full text review. Careful screening provided 36 papers fitting the selection criteria. Hand searching found an additional 5 references, resulting in a total of 41 [ 8 , 9 , 10 , 11 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ] articles to be included for review (Fig.  1 ).

PRISMA flow diagram of process to identify eligible articles 63

Study characteristics

Of the 41 included articles, 26 were conducted in the United States [ 9 , 10 , 25 , 26 , 28 , 29 , 30 , 31 , 33 , 34 , 35 , 36 , 38 , 39 , 40 , 44 , 45 , 46 , 47 , 48 , 50 , 51 , 52 , 56 , 59 ], three in Canada [ 8 , 11 , 54 ], two in Taiwan [ 42 , 43 ], two in Iran [ 27 ], and one each in Thailand [ 57 ], Ethiopia [ 53 ],Saudi [ 24 ], Brazil [ 37 ], Australia [ 49 ], Sweden [ 58 ], Belgium [ 55 ] and the United Kingdom [ 32 ]. Seventeen were based on preceptorship/education in medicine [ 10 , 31 , 32 , 35 , 44 , 46 , 50 , 51 , 52 , 54 , 55 , 56 , 58 , 59 , 60 ], twelve in pharmacy [ 9 , 11 , 24 , 25 , 26 , 30 , 33 , 34 , 36 , 38 , 53 , 57 ], and eleven in nursing [ 8 , 27 , 28 , 37 , 40 , 41 , 42 , 43 , 47 , 48 , 49 ] and one in dentistry [ 45 ]. There were twelve quantitative studies [ 25 , 26 , 30 , 33 , 35 , 39 , 46 , 47 , 49 , 53 , 57 ], ten qualitative studies [ 29 , 34 , 37 , 41 , 42 , 44 , 45 , 48 , 58 , 59 ], three mixed methods [ 43 , 50 , 51 ], four descriptive papers that did not report results [ 36 , 38 , 40 , 56 ], five papers concerned with validity testing [ 28 , 31 , 52 , 54 , 55 ] and seven papers describing consensus building, three with Delphi approaches [ 10 , 29 , 32 ] and four with expert opinion based on literature review and qualitative synthesis [ 8 , 9 , 11 , 60 ]. Data were extracted and are presented in Additional file  2 .

Competencies and methods of assessment of preceptors

Seventeen competencies with associated methods of assessment were identified, as outlined in Table  2 . The methods used to identify competencies of preceptors included expert opinion based on literature reviews and qualitative synthesis [ 8 , 9 , 11 , 60 , 61 ], Delphi approaches [ 10 , 29 , 32 ], and qualitative studies examining the qualities of preceptors that preceptees value most [ 27 , 37 , 42 , 44 , 45 , 51 ]. Fifteen studies identified competencies, but assessment had not been implemented or reported [ 8 , 9 , 10 , 11 , 27 , 29 , 32 , 37 , 38 , 41 , 45 , 48 , 56 , 58 , 60 ], with only four studies detailing performance indicators for the competencies described [ 8 , 9 , 10 , 11 ].

The competency of preceptors was measured in four ways. Most commonly, and with moderate to high confidence as per CERQual, preceptees used a survey instrument to assess the competency of their preceptor [ 26 , 30 , 46 , 53 , 57 ]. Preceptee assessment was also combined with a preceptor self-assessment instrument which allowed for comparison between preceptors’ and preceptees’ perceptions of their experience working together [ 36 , 53 , 57 ]. Preceptors were shown to overestimate their abilities when self-evaluating, compared to preceptee evaluations (CERQual assessment: low confidence). Another method used was an assessment of preceptors by peers or faculty using a survey instrument [ 30 ] or by direct observation of interactions with preceptees [ 31 , 33 , 59 ]. While this approach provided greater specificity and detail [ 50 ], it was reported as more difficult to implement on a large scale, due to time and cost constraints, as well as lower preceptor acceptance [ 30 ]. The fourth approach was associating preceptees’ examination performance with the ‘quality’ of teaching as rated by preceptees via subjective measurement [ 39 ]. While the strongest evidence exists for preceptee evaluation of preceptors; there is moderate confidence in evidence for self-assessment and peer evaluation, the confidence is lowered by the limited amount of evidence. Although there was good correlation between preceptee evaluations of preceptors and preceptors’ self-assessment; preceptors overestimated their effectiveness as communicators [ 53 ] and their ability to provide feedback [ 53 , 57 ]. Measurement of preceptee outcomes had good but limited evidence (low confidence) [ 39 ]. Only one study linked the quality of the preceptor with a preceptee outcome; preceptees with a perceived higher preceptor quality performed better in their exams [ 39 ]. Table 2 describes the methods of assessment, and confidence in evidence. The full CERQual evaluation is presented inpresented in Additional file  3 .

Quality appraisal

The CASP Cohort checklist was used for the quantitative and validity testing papers, and the CASP Qualitative checklist was used for qualitative studies, descriptive studies and consensus building based on literature review and qualitative synthesis. The results of the CASP assessments tabled with a traffic light legend can be found in Additional file  4 . Very few studies received green ratings across all categories. In the CASP Qualitative assessment, only two papers were green in all catagories [ 42 , 44 ]. Most commonly, articles did not contain enough information to make an assessment on the relationship between participants and researchers, ethical considerations, and data analysis. For the CASP Cohort assessment, there were no randomised controlled trials, and no studies received green ratings on all categories. Most commonly, articles did not have enough information regarding follow up of participants, or the length of follow-up of participants. Many articles did not have enough information to ascertain whether confounding factors were considered in the study design.

This systematic scoping review of the literature and evaluation of the quality of evidence using GRADE CERQual, informed the development of a 17-item evidence-based set of preceptor competencies and corresponding methods of assessment that is applicable to a diverse range of health professions. This review did not find evidence for significant differences for requisite preceptor competencies across health professions. The identification of the minimum level of performance at which a health practitioner may be deemed a ‘competent’ preceptor requires calibration. These competencies and methods of assessment may form the basis for a competency framework and be applied to recognise preceptors working at an advanced level of practice, thereby enabling a system of quality management and oversight.

In assessing the confidence in evidence for these findings using CERQual, it was apparent that 11 of the identified competencies have defined performance indicators that may allow for effective measurement of competence, while six could be described as attributes. Attributes such as being ethical, enthusiastic, or empathetic, were not associated with performance indicators and would therefore to be less conducive to measurement and standardisation. Without adequate measurement, discerning the effect of any potential intervention, such as training is problematic. Interestingly, the competencies or attributes without performance indicators, such as empathy, could be considered as intrinsic to the individual preceptor. Intrinsic traits have been identified as being difficult to modify through training but may develop with personal reflection and maturity [ 60 ]. Sutkin and colleagues conclude that affective or non-cognitive characteristics are of greater importance than the skill based cognitive abilities in making a “truly great” preceptor. A way forward is proposed by Davis (1989) who recommends that preceptors model empathy as an extrinsic behaviour in order to facilitate preceptee development via professional socialisation [ 62 ]. By modelling intrinsic affective traits as behaviours, measurement is thereby possible.

A disconnect between the competencies and the mode of measurement of some competencies was identified. For instance, adapting to the learning needs of preceptees had evidence for assessment by peer observation in both simulation and practice environments. This would seem to be a competency that lends itself to evaluation from the perspective of the preceptee, however, in the literature there was no evidence for this mode of measurement. Likewise, demonstrating reflective practice had evidence for assessment via a preceptee survey, whereas self-reflection as a mode of measurement would seem logical, but again, evidence was not apparent. A recommendation is to consider alignment of the mode of measurement with the competency being assessed in a consistent manner across all competencies in the framework.

There was a lack of evidence to demonstrate a relationship between competencies or attributes of preceptors and preceptee outcomes. According to Bigg’s framework of constructive alignment, learning outcomes should be clearly outlined at the beginning, then learning activities and assessment aligned, so that the level to which those outcomes have been achieved can be measured [ 63 ]. In the context of preceptorship, this framework could be applied. Preceptor competencies would be the outcome to be measured (and potentially also the preceptees’ exam performance) against a defined standard, and preceptor development constitutes the learning activities. The competencies being measured and the mode of measurement also needs to be aligned. Gill (2004) notes that the ultimate goal would be to link preceptor performance and preceptee learning [ 61 ]. Whilst Griffith (2000) linked preceptee performance in an exam with perceived preceptor quality, the competencies that led to those preceptors being rated highly were not detailed [ 39 ].

An additional consideration in constructive alignment would be to align assessment with assessors who are well placed to provide the assessment. Brookfield describes four lenses through which teachers can view their practice from different perspectives as a tool for critical reflection and ultimately to perform more confidently and at a higher level [ 64 ]. A tripartite preceptorship model with preceptor, preceptee and faculty being in partnership with assessment from all perspectives, along with some theoretical training, would fit this model. At a minimum, all preceptors should undertake preceptor development training and evaluation by their preceptees. A portfolio of evidence could then comprise of assessment from all partners. Registration bodies who conduct examinations on behalf of professional boards could provide feedback to preceptors on preceptee performance, preceptees could provide evaluations of the preceptor at various timepoints, and preceptors could include a reflective self-evaluation of their performance. Peer assessment would be more expensive to deploy on a large scale and may be less acceptable and convenient, however, judicious use of peer assessment would provide a high degree of detail and specificity (CERQual assessment: high confidence. Finally, the validity and reliability of the assessment method also needs to be considered. If this framework were to be applied to credential preceptors at an advanced level of practice, peer observation and evaluation should also be included as part of a portfolio of evidence built over time. Finally, the validity and reliability of the assessment method also needs to be considered. If this framework were to be applied to credential preceptors at an advanced level of practice, peer observation and evaluation should also be included as part of a portfolio of evidence built over time.

The strengths of this scoping review are that a rigorous, standardised approach of CERQual was used to assess the confidence in the evidence. This provides credibility to the competencies and methods of assessment identified from the literature search. The nature of the scoping review process allowed for the inclusion of papers of various study design such as validity testing and qualitative studies. A conservative synthesis approach was adopted to facilitate inclusivity of the language used to describe competencies across the literature. Further rationalisation of the identified competencies may be possible. The review followed the PRISMA ScR guidelines and an iterative process was maintained between authors. Limitations of the review are that title and abstract screening, data extraction and evidence assessment were primarily carried out by the primary author, although a random selection of results for all stages were assessed by two additional authors, with points of difference discussed to achieve consensus. An additional limitation was the preponderance of studies from a single country (USA), resulting in a potential risk to generalisability of findings.

Implications for future

This review has synthesised a common set of preceptor competencies across health professions. Additional unique preceptor competencies for individual health professions may need to be considered. The relationship between measuring the performance of preceptors and effective outcomes of preceptees has yet to be determined and requires further investigation. It would be worthwhile to examine which of the competencies identified are most relevant to the outcomes for graduates. Retention in the workforce, professional satisfaction, and career progression are all outcomes that may indicate that the model of preceptorship is successful, but this requires evaluation. In addition, the minimum level of preceptor competence has not been determined. A consensus approach, such as the Delphi method [ 65 ], could be used to improve confidence in the identified competencies and determine the minimum standard against which preceptors should be assessed. Future primary studies with the aim to identify variation in preceptor competencies between professions are required.

A standardised, evidence-based set of preceptor competencies and accompanying methods of assessment has been identified across health professions. Most competencies have an associated performance indicator which allow for effective measurement, while others are more intrinsic to the individual resulting in measurement difficulty. Further research is required to identify the minimum standard of performance that is necessary, as well as to identify the factors that have the greatest influence on the outcomes for preceptees.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Abbreviations

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

Grading of Recommendations Assessment, Development, and Evaluation.

Confidence in the Evidence from Reviews of Qualitative research.

Critical Appraisal Skills Programme

Andrew Bartlett

Carl Schneider

Edward Luca

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Additional file 1..

Appendix 1 – Example search strategy using Medline.

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Appendix 2 – Data extraction table.

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 Appendix 3 – GRADE CERQual evaluation table.

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Appendix 4 Risk of Bias appraisal.

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Bartlett, A.D., Um, I.S., Luca, E.J. et al. Measuring and assessing the competencies of preceptors in health professions: a systematic scoping review. BMC Med Educ 20 , 165 (2020). https://doi.org/10.1186/s12909-020-02082-9

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• Chithra Maria Joseph   ORCID: orcid.org/0009-0006-9248-7187 2 ,
• Adnan Anwar Ahmad Al-Akkam   ORCID: orcid.org/0009-0006-0029-9243 3 ,
• Albara Mohammad Ali Alomari   ORCID: orcid.org/0000-0001-7693-4617 4 &
• Esmat Swallmeh   ORCID: orcid.org/0000-0001-8717-0587 5  

BMC Nursing volume  22 , Article number:  456 ( 2023 ) Cite this article

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The role of preceptors is vital in the successful integration of new graduate nurses in hospital settings. This study aimed to explore the experiences of nurse preceptors in training newly joined nurses in Qatar.

Qualitative study was conducted between May 2022 and May 2023. Online semi-structured interviews were conducted through MS Teams with 13 nurse preceptors who had completed preceptorship training and trained at least one newly joined nurse. Participants were recruited until data saturation was obtained and data were analyzed using qualitative thematic analysis.

The results of the study revealed several main themes: teaching strategies and progressive skill development in preceptorship, challenges faced by the preceptor and preceptor better supported in training new nurses. The preceptors utilized different techniques to support new nurses including demonstration, discussion, use of technology, application of real-life clinical scenarios, simulations, and a gradual decrease in supervision to promote independence. However, a significant challenge was also reported including preceptors experienced high levels of exhaustion from the dual responsibilities of training new staff while also performing their regular care duties.

Conclusions

The study underscores the fundamental role preceptors play in the training and development of newly joined nurses. While the challenges are considerable, particularly related to managing workload, the sense of achievement following the successful completion of training a new nurse suggests a strong commitment to this role. Despite the challenges, preceptors demonstrated innovative strategies to ensure the successful development of their preceptees, highlighting the importance of preceptorship in nursing education and practice.

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Preceptors are multifaceted professionals, serving as educators, evaluators, protectors, and role models. They play an instrumental role in cultivating professional values, instilling confidence, honing goal-setting skills, and guiding clinical decision-making processes among their trainees [ 1 , 2 ]. Nurse preceptors serve as crucial pillars in the hospital environment, particularly in terms of assimilating newly recruited nurses and fostering their job satisfaction [ 3 ]. They also have a crucial part in integration and retention of newly recruited nurses [ 4 ]. With their vast experience and specialized knowledge in their respective fields, preceptors are effectively “educators” who offer on-the-job training to novice nurses and nursing students [ 5 ]. Leveraging their extensive experience and domain-specific knowledge, preceptors act as hands-on educators, facilitating the induction and training of novice nurses and nursing students [ 1 ]. Their primary role is to guide these new nurses in adjusting to the clinical environment and provide them with the specialized knowledge required for their job roles. Their pivotal role lies in assisting these new entrants in acclimatizing to the clinical environment and transferring specialized knowledge required for their professional roles [ 6 ].

The existing body of literature has documented the significant impact of preceptors on newly graduated nurses who are still in their early stages of professional development. [ 7 ]. Empirical evidence shows that regular interaction with preceptors significantly reduces stress among novice nurses [ 8 , 9 ]. A study further highlighted this point by demonstrating that structured preceptorship programs aid in reducing novice nurses’ anxiety levels [ 10 ]. Moreover, a recent study conducted also underscores the effectiveness of preceptor-based training programs in enhancing the satisfaction and retention rates of newly recruited nurses [ 10 ]. Additionally, previous studies illustrated a positive correlation between the quality of care provided by preceptors and the job satisfaction and competence of new nurses [ 6 , 11 ]. Such findings emphasize the importance of fostering healthy relationships between preceptors and novice nurses, ultimately leading to a more favorable perception of nursing work [ 1 ].

However, there is a significant problem we aim to address: there is limited research that explores the experience of preceptors in the workplace, creating a substantial gap in our understanding of their role and its impact on nursing education and patient care. This knowledge deficit hampers our ability to identify areas for improvement and provide better support for the crucial role that preceptors play in clinical education [ 12 ].

This study aims to bridge this gap by delving into the experiences of nurse preceptors in training newly joined nurses within the medical and Neuroscience units of a tertiary level hospital in Qatar. By doing so, it seeks to address the pressing issue of how to best prepare and support preceptors in their vital role, ultimately contributing to the objectives set forth in Qatar’s National Health Strategy 2018–2022. This strategy places a strong emphasis on the development of a skilled national workforce and the nurturing of a world-class healthcare system [ 13 ].

For the purpose of this study, “New nurses” encompasses a diverse range of individuals freshly entering the nursing job in the specific setting of Qatar’s healthcare system. This includes newly recruited nurses from overseas who, although they may have previous experience in their home countries, are novel to the dynamics of Qatar’s health system. It also comprises recent graduates from Qatari universities who have just commenced their practical careers after their educational journey [ 13 ]. Furthermore, it encompasses final practicum students from universities within Qatar who are transitioning from academia to full-time practical roles.

This study utilizes a qualitative research method with a methodological orientation of phenomenology. Qualitative design allows for a comprehensive understanding of the lived experiences and perceptions of the participants [ 14 ]. The phenomenological approach underpins the study, enabling an in-depth exploration of the nurse preceptors’ experiences in training newly joined nurses. To ensure methodological rigor and transparency, this study follows the consolidated criteria for reporting qualitative research (COREQ) 32-item checklist [ 15 ].

The study was conducted in medical and neuroscience units of a tertiary level hospital in Qatar.

Sampling method and recruitment

The study focused on the target population, which included a total of 109 nurse preceptors - experienced healthcare professionals who had successfully completed preceptorship training and were actively involved in training newly joined nurses. These nurse preceptors were identified and approached through email to participate in the study.

To ensure that the selected participants had the relevant experience and expertise, specific inclusion criteria were applied. Participants were required to meet two key criteria: (1) completion of preceptorship training, and (2) an experience of training at least one newly joined nurse. Nurse preceptors who did not meet both of these criteria were excluded from the study. This careful selection process ensured that the participants possessed first-hand experience and knowledge in the role of training newly recruited nurses within the context of inpatient neuroscience and medical units.

In line with the study’s objectives, a purposive sampling method was employed to select nurse preceptors with the necessary expertise and experience in the specific context of inpatient neuroscience and medical units [ 16 ]. This approach allowed for the deliberate and systematic selection of participants who could provide valuable insights into the experiences of nurse preceptors in this particular healthcare setting.

Sample size

Out of the 109 nurse preceptors, a sample of 20 inpatient nurse preceptors were initially selected for the online interviews. However, during the course of the study, data saturation was reached after conducting interviews with 13 participants. Data saturation in qualitative research signifies the point at which new information or themes cease to emerge from the data [ 17 ]. Therefore, the sample size of 13 participants was deemed adequate for achieving the study’s research objectives.

Data collection

Semi-structured, one-on-one online interviews were conducted through an online platform, MS Teams. The interviews were led by the study principal investigator, a male nurse/midwife educator with extensive nursing experience and a bachelor’s degree. The interview guide was specifically developed for this research to explore nurse preceptors’ experiences, challenges in the precepting process, and strategies for better support and fulfilment in the nurse preceptor role.

The online interviews were thoughtfully scheduled during nurses’ days off, allowing participants to engage in a calm and uninterrupted environment conducive to meaningful discussions, offering valuable insights, suggestions, and feedback. Before the interviews, participants voluntarily signed a research consent form, and the entire audio was meticulously recorded using MS Teams “Start Recording” feature. Verbatim transcripts were generated through the “Transcription” option in MS Teams.

Efforts were made to establish rapport and trust before the interviews. Participants were informed about the researcher’s professional background and motivations for conducting the research, ensuring transparency. The research team strictly adhered to confidentiality and secure data storage protocols. The interviewer maintained an unbiased, open stance toward diverse perspectives throughout the interviews.

Notably, there were no refusals to participate or dropouts, and only the participants and researchers were present during the interviews. The interviews continued until data saturation was reached, with audio-recorded interviews varying in duration from 29 to 43 min.

The interview guide underwent a pilot test before the main study to ensure the effectiveness and appropriateness of the interview questions and data collection process. The pilot test involved conducting trial interviews with a small sample of participants to identify any issues, refine the interview protocol, and make necessary adjustments to improve overall data collection quality. This pilot test was essential in adapting the interview guide to the unique context of qualitative research, where questions are often shaped by participant responses.

Field notes were taken during and after the interviews by the principal investigator. These notes captured important observations, reflections, and contextual details about interactions with the participants. Participants did not review or provide comments or corrections to the transcripts.

Data analysis

The thematic analysis framework described by Braun and Clarke (2006) was employed to explore the lived experiences and perceptions of preceptors in training new staff and the challenges they encountered, as well as the value they placed on their role in training new nurses [ 18 ].

In this study, the verbatim data collected from in-depth interviews were transcribed using the “Transcription” option in MS Teams. The transcripts were then anonymized by assigning pseudonyms to the participants, and they were not returned to them for comments. No software was used for coding in this study. Thematic analysis involved six distinct steps. Initially, two authors (BV and CJ) engaged in the process of familiarizing themselves with the data by reading the transcripts multiple times. During this phase, quotes were classified and clustered into themes.

Throughout the analysis, two researchers (BV and CJ) independently reviewed and coded the interview transcripts, identifying initial themes and subthemes. To enhance reliability and agreement, a third researcher (AA) was involved in developing credibility around the themes and addressing any discrepancies between the initial coders. Following the reconciliation process, the final codebook was revised, and clusters of linked codes were organized into categories, emergent themes, and supported by verbatim quotes. Participant quotations were effectively utilized to illustrate the themes and findings, and each quotation was attributed to the corresponding participant number. The themes were iteratively refined and revised to ensure credibility and trustworthiness among the researchers.

Trustworthiness of qualitative data

All elements of trustworthiness, including credibility, dependability, and transferability, were carefully considered in this study [ 19 ]. Credibility was attained through the sustained engagement of participants and the application of the researcher’s professional expertise. To enhance dependability, comprehensive records of the research process were maintained, facilitating the potential replication of similar research endeavors. In terms of transferability and confirmability, detailed journal notes were diligently kept, and a comprehensive audit trail of all research processes was meticulously maintained.

Preceptor characteristics

A total of 20 inpatient nurse preceptors were initially selected for the study from a pool of 109 nurse preceptors, but data saturation was reached after interviewing 13 participants during the course of this research. The average age of the preceptors was found to be 38.6 years, whereby more than half of them, (54%), were observed to be within the age range of 30–40 years. All the preceptors were female. More than half of participants have a Bachelor of Science in Nursing (BSN) degree (54%) and 46% have a diploma.

The mean number of years of experience was 14.9 years. In terms of their experience as preceptors, the mean number of years of preceptorship experience was 7.4 years. The characteristics of the preceptors participating in the study are summarized in Table  1 .

Three main themes emerged from the qualitative analysis: (1) Teaching Strategies and Progressive Skill Development in Preceptorship (2) Challenges faced by the preceptor, and (3) Preceptor better supported. Table  2 , provide a summary of the themes. Preceptors are marked from P1 to P13.

Teaching strategies and progressive skill development in preceptorship

The theme of “Teaching Strategies and Progressive Skill Development in Preceptorship” emerged from the narratives of nurse preceptors who shared their experiences in training newly joined nurses in medical and neuroscience units of a tertiary hospital in Qatar. Within this theme, preceptors detailed their innovative teaching strategies, emphasizing personalized approaches that catered to the unique needs of their preceptees. Their wealth of experience and domain-specific knowledge allowed them to implement diverse learning methods, fostering a dynamic learning environment. This theme highlights the critical role preceptors play in shaping the skill development of novice nurses through hands-on guidance and mentorship.

Preceptor teaching strategies

Preceptors highlighted a range of teaching strategies they employ in their role, focusing on hands-on instruction, demonstration and re-demonstration, and a step-by-step progression of learning objectives.

Many preceptors approach the teaching process with a gradual progression of skills. They start with basic tasks and as the preceptees gain confidence and competence, they move on to more complex responsibilities. This not only helps preceptees gradually acclimate to their new roles, but also gives them the opportunity to build a solid foundation before moving on to more complex tasks. This is encapsulated in the P1 quote:

“ First week, I won’t teach anything, only vital signs checking, NGT feeding and personal care. After that medication exam. First my preceptee will watch while I am demonstrating and will re-demonstrate. Once I will feel my preceptee confident, they can do themselves”.

The teaching method of demonstration followed by re-demonstration is frequently utilized by the preceptors. They believe it allows for a hands-on approach where preceptees can observe a task being done correctly before they have to perform it themselves. This method reinforces learning, ensures competency, and builds confidence. As P2 explains “ I used observation, direct instruction, discussion, lecture, sharing clinical personal experience, active listening and embedded strategy as my way of teaching ”.

Practical opportunities and hands-on experience

Developing skills through practical opportunities and hands-on experience was highlighted by the preceptors. They strive to provide their preceptees with real patient scenarios, case presentations, and simulations to bridge the gap between theoretical knowledge and clinical practice.

Preceptors place a high value on ensuring that preceptees get exposure to real clinical situations. P3 believes that nurses “ will learn if there is only real situation. I am directing my preceptee to my colleagues for any new procedure ”. Such experiences also help preceptees in developing problem-solving skills and thinking critically in high-pressure situations. Preceptors frequently use simulations and case presentations in their teaching strategies. These methods allow preceptees to apply theoretical knowledge in a simulated clinical scenario, facilitating their understanding of how different pieces of knowledge fit together in-patient care. P4 says: “We will use case presentation and simulation which will help my preceptee to correlate their theoretical knowledge with practical”.

Preceptors recognize the significance of fostering self-sufficiency and instilling confidence in their preceptees while simultaneously cultivating a supportive and nurturing learning environment that promotes questioning, evaluation, and learning from mistakes. To achieve this goal, they gradually stops supervision, allowing preceptees to progressively assume more autonomy. The preceptors gradually reduce their level of supervision to inspire self-sufficiency and self-assurance in their preceptees. As preceptees become more skilled and knowledgeable, they are given more responsibility, which helps them to become self-sufficient and self-reliant practitioners as P1 explains: “After two weeks I will step back little by little to see how much they can manage independently”.

Preceptors strive to create a supportive learning environment where they are “ always open for any questions and doubts nurses have and will discuss with them to make their concept clear ” according to P5. Preceptors believe that such an environment helps preceptees to learn effectively, build confidence, and develop their problem-solving skills.

Feedback is seen as a crucial element in the learning process by the preceptors. Preceptors attempts to continually give timely, non-judgmental feedback, highlighting both strengths and areas needing improvement. P6 believes that “Timely and constructive feedback, delivered without judgment, and accompanied by clear explanations of both strengths and areas for improvement, can motivate preceptees to evaluate and discuss their performance. This approach enhances educational strategies that promote critical thinking and a commitment to excellence”.

Preceptors use observation as a primary method to assess the learning progress of their preceptees. Watching preceptees perform tasks allows them to evaluate the understanding and application of theoretical knowledge in a practical setting. They also encourage preceptees to reflect on their daily activities and experiences, fostering a continuous learning environment. P7 explains this as: “I ensure that my orientees are learning from me by direct questioning, discussion and reflection from the daily activities”.

Challenges faced by the preceptor

The theme of “Challenges Faced by the Preceptor” originates from the candid reflections of nurse preceptors as they navigated the complexities of their role. These challenges encompassed the dual responsibilities of training new staff while maintaining their regular patient care duties. The origin of this theme lies in the recognition of the significant burden and exhaustion experienced by preceptors due to the demanding nature of their role. This theme underscores the need to address these challenges to ensure the well-being and effectiveness of nurse preceptors.

Overload of roles and responsibilities

While preceptors are committed to providing high-quality patient care, they are also tasked with the role of a preceptor, responsible for guiding and mentoring new nurses. The administrative duties that come along with these roles often pile up, creating a sense of being overwhelmed. The challenge is thus to efficiently manage time and tasks, ensuring that neither patient care nor mentoring duties are compromised, all while dealing with the bureaucratic aspects of their roles.

Preceptors face the challenging task of balancing their responsibilities for patient care and mentorship, which can put a strain on their abilities. Attempting to devote equal time and effort to both roles can result in feelings of frustration and burnout. This challenge is made even more difficult by the unpredictable nature of healthcare settings, where unforeseen circumstances and emergencies can add complexity. P8 says “I remember a particularly intense situation when a patient’s condition suddenly deteriorated, and I had to guide the new nurse on how to respond quickly and effectively. It was like a test of our training and readiness. That experience taught me the importance of being prepared for the unexpected in healthcare”.

In addition to caring for patients and mentoring, preceptors must also handle significant administrative tasks. This includes “Paperwork is overload”. The bureaucratic aspect of their role often demands time and effort that could otherwise be spent on patient care or mentoring. The difficulty is not only the amount of paperwork, but also the fact that these tasks frequently must be completed “ After regular duty hours ”, cutting into personal time as per P9.

Language and cultural barriers

The theme encompasses the issues that arise when preceptors must interact with trainees from diverse cultural and linguistic backgrounds. Preceptors stated that communication forms the backbone of effective preceptorship. However, P10 recalls “Some staffs, they have a language problem and training commonly difficult because of new non-English speaking staffs”. They reported that this led to misunderstandings and slow down the learning process, causing frustration on both ends .

P9 says “ when trainees come from various countries and backgrounds, they have their own learned practice and experience that they are continuously using in the corporation, they have different perceptions and not open for changes in skills and practice ”. This diversity may create clashes at times with existing procedures and guidelines. The preceptor, therefore, has the additional task of reconciling these differences and molding the preceptees according to the current practices. P9 says “ most of the experienced nurses from different region ”.

Lack of support and appreciation

The preceptors expressed a sense of disappointment regarding the inadequate support and recognition they receive in their role. It is common for preceptors to take on additional responsibilities, and when these efforts go unnoticed and unrewarded, it can lead to feelings of dissatisfaction and demotivation. The preceptors requested collegial support to establish a precepting-friendly environment and according to P10 “ When colleagues and superiors are empathetic and encouraging, it can significantly ease the burden of our job ”. However, the absence of such support can exacerbate the challenges associated with fulfilling the precepting role and contribute to stress. “I feel like the absence of support makes everything so much harder. The demands of precepting can be overwhelming, and when you don’t have the support you need, it just adds to the stress and makes it really difficult to do our job effectively as per P11.“

There is a feeling among preceptors that their efforts are not adequately acknowledged or rewarded. This can significantly impact their morale and willingness to take on extra responsibilities, potentially affecting the overall quality of preceptorship.

P13 says “I feel pressurized by additional job without any incentives and appreciation”.

Preceptor better supported

The theme of “Preceptor Better Supported” emanates from the narratives of nurse preceptors who highlighted the importance of continued support and resources in their role. Their experiences underscored the critical need for ongoing professional development, mentorship programs, and recognition for their contributions. The origin of this theme lies in the collective voice of preceptors advocating for improved support systems to enhance their effectiveness in training newly joined nurses. This theme emphasizes the importance of investing in preceptorship programs to facilitate the successful integration and retention of novice nurses, ultimately benefiting patient outcomes and the overall healthcare environment.

Recognition and appreciation

Many of the participants express a feeling of contentment when their work as mentors is acknowledged, whether verbally or formally. The mentors note that recognition, especially in the form of appreciation from those in higher positions, boosts their motivation and satisfaction. Official recognition would not only validate their hard work but could also be added to their professional portfolios, which could help advance their careers. P3 explains “ If I received a certificate of appreciation, that would be great - I could keep it in my portfolio ”. The mentors acknowledge how even a simple act of verbal recognition affects their morale as one preceptor explained, “ When preceptee is happily telling that they learned something new…. it will make my day ”.

Personal and professional growth

The preceptors perceive the role as an opportunity to improve their professional skills and update their knowledge. They believe that teaching others helps them revise and consolidate their own understanding of nursing science. P9 says “ Being a preceptor is more than just a responsibility; it’s a chance to increase my nursing knowledge and improve my own skills. Being a preceptor contributes to the development of my competencies ”. They also highlight how they benefit from being continually updated on the policies and practices of their healthcare setting. P8 affirms, “ I am updating the knowledge from the HMC policies and procedures while training new staff ”.

P8 stated that being a preceptor increases “ confidence after each training, as I gain more knowledge ”. The role requires guiding and mentoring trainees, leading to an enhancement of these traits over time.

Trust in the role of preceptor

Preceptors viewed the frequent assignment of new trainees as an expression of trust in their abilities. This strengthens their sense of being valued and trusted in their role as P12 explained “ Yes, I feel trusted in the role as a preceptor. I have completed the tasks assigned to me, so the HN is giving me preceptee again and again”.

Experienced preceptors who have served for several years and mentored multiple trainees perceive their extensive tenure as evidence of the trust vested in them. They believe that their ability to successfully guide numerous trainees over time reflects the confidence their superiors have in their precepting abilities. As P13 expressed, “Yes, that’s why I had 5–6 preceptees”.

The aim of this study was to explore the experiences of nurse preceptors in training newly joined nurses in the medical and neuroscience departments. The findings from the interviews conducted with the preceptors shed some light on the role and strategies used by the preceptors to perform their jobs. However, the results revealed that preceptors have many challenges and in order to face these challenges, preceptors identify few strategies to continue supporting the new nurses.

Clinical preceptors in the present study employ diverse techniques to facilitate the learning and development of newly joined nurses who come from different backgrounds and possess distinct learning requirements. Nursing is a profession that attracts individuals from diverse backgrounds, each with their own unique learning preferences [ 20 ]. Given the diverse backgrounds of these nurses, preceptors in this study employ a variety of teaching strategies that may enable them to cater to the various learning styles and preferences of the nurses [ 21 ]. By employing multiple teaching strategies, preceptors can assist new nurses in refining their critical thinking skills, enhancing their ability to prioritize patient care, and improving their decision-making skills in challenging situations. By providing ongoing guidance, preceptors can identify areas for improvement and offer constructive criticism to help new nurses improve their skills [ 22 ].

The findings of this study are in line with prior research, underscoring the crucial role of nurse preceptors in the education and training of newly joined nurses. The preceptors expressed a sense of fulfillment in their mentoring role and highlighted the significance of sharing their knowledge to foster the professional growth of novice nurses. These consistent results reinforce the existing evidence supporting the value of preceptorship programs in healthcare settings, underscoring the importance of providing adequate support and recognition to facilitate the successful integration and retention of newly recruited nurses [ 6 , 22 ].

The satisfaction reported by the preceptors in this study is likely a result of feeling valued and recognized for their significant contribution to the training of new nurses. They expressed a sense of accomplishment from witnessing the growth and progress of their preceptees, which positively influenced their job satisfaction. These findings are consistent with existing literature, which highlights the importance of appreciation and recognition in the workplace. When preceptors feel acknowledged and valued for their efforts, it fosters a positive work environment, enhances their sense of purpose, and ultimately contributes to the successful integration and retention of newly recruited nurses [ 23 ]. Recognition and appreciation are essential elements in motivating and retaining experienced preceptors, ensuring their continued commitment to nurturing and guiding novice nurses. A strong and meaningful relationship between preceptors and nurses can influence the perception of nursing work and overall job satisfaction [ 1 , 24 ].

However, despite the feeling of appreciation and being valued, preceptors are facing many challenges. The preceptors in this study reported experiencing significant exhaustion due to the added responsibilities of training newly recruited nurses in addition to their routine patient care duties. This finding is in line with previous research which also emphasized the demanding nature of the preceptor role [ 25 ]. The study indicated that preceptors often face the challenge of balancing their own workload while simultaneously providing guidance and support to novice nurses.

Moreover, the preceptors mentioned that the lack of adequate support and resources from the healthcare organization contributed to their feelings of exhaustion. They emphasized the need for additional support, such as workload management assistance and dedicated training time, to effectively fulfill their preceptor roles. The absence of such support could potentially hinder the preceptors’ ability to provide optimal guidance and training to the newly recruited nurses [ 23 ]. Our findings resonate with the research which also highlighted the challenging nature of the preceptor role [ 26 ]. The demands of precepting can impact not only the preceptors’ job satisfaction and well-being but also the quality of training provided to the novice nurses [ 26 ]. Therefore, addressing the challenges faced by preceptors and providing them with the necessary support and resources is crucial to enhancing their effectiveness in training new nurses and ultimately improving patient care outcomes. To overcome these challenges, healthcare organizations should prioritize the implementation of comprehensive preceptorship programs, provide workload management support, foster a culture of appreciation and recognition, establish open communication channels, and invest in the professional development of preceptors [ 27 ]. By doing so, organizations can create a supportive environment that enhances preceptor effectiveness and contributes to a positive and sustainable healthcare workforce.

Limitations

The study has several limitations. Firstly, it was conducted within a single department, which may limit the generalizability of the findings to other healthcare settings. Additionally, the lack of participation by male preceptors could introduce gender bias in the study’s insights. Furthermore, the subjective nature of qualitative data may be influenced by individual perspectives and biases, potentially affecting the objectivity of the study’s conclusions. It is crucial to acknowledge these limitations when interpreting the findings and considering their application in broader healthcare contexts.

This study delves into the multifaceted experiences of nurse preceptors, highlighting their pivotal role in training newly joined nurses. The findings emphasize the necessity of ongoing support and resources for these professionals.

In summary, this investigation uncovers the invaluable contributions of nurse preceptors in facilitating the integration and retention of novice nurses, with potential benefits for patient outcomes and work environments. Challenges underscore the need for comprehensive support systems.

To conclude, recognizing and nurturing the role of nurse preceptors is vital. This research advocates for sustaining and enhancing existing preceptorship programs, fostering the development of support mechanisms, and empowering these professionals. Further research in this area is warranted to explore strategies for addressing the challenges faced by preceptors and enhancing the effectiveness of preceptorship programs.

Availability of data and materials

The availability of data and materials may be subject to certain access restrictions, such as ethical, legal or commercial sensitivities. The Corresponding author Bejoy Varghese at [email protected] should be contacted if someone wants to request the data from this study.

Abbreviations

Coronavirus disease 2019

Hamad Medical Corporation

Institutional Review Board

Medical Research Center

Hamad General Hospital

Ministry of Public Health

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Acknowledgements

The study team would like to acknowledge the nurses who participated in the study, and Hamad Medical Corporation for enabling the study to be undertaken.

The study was not supported by any funding sources.

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Neuroscience & Medical Department, In-patient services, Hamad General Hospital, Doha, Qatar

Bejoy Varghese & Rida Moh’d Odeh A.M. AL-Balawi

Neuroscience Department, In-patient services, Hamad General Hospital, Doha, Qatar

Chithra Maria Joseph

Neurosurgery, In-patient services, Hamad General Hospital, Doha, Qatar

Adnan Anwar Ahmad Al-Akkam

Department of Nursing and Midwifery, College of Health Sciences, Doha, Qatar

Albara Mohammad Ali Alomari

Neuroscience, Medical & Outpatient Department, Hamad General Hospital, Doha, Qatar

Esmat Swallmeh

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Contributions

“BV contributed to the study design, implementation of the protocol, and significant inputs for data analysis. BV and CJ conducted the qualitative interview. BV and AM did the data analysis and study supervision. BV and RB coordinated the study. BV, CJ, and AA wrote the manuscript and RB, ES, and AM reviewed the manuscript. BV and AM did all critical revisions for intellectual content. All authors read and approved the final manuscript.“

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Correspondence to Bejoy Varghese .

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Ethics approval and consent to participate.

The study received ethical approval from Institutional Review Board (IRB), Hamad Medical Corporation (HMC). The study was carried out in adherence to the guidelines and principles set out in the “Declaration of Helsinki”, Good Clinical Practice (GCP), and in compliance with the laws and regulations governing research conducted by the Ministry of Public Health (MoPH) in Qatar. The study number is MRC-01-22-211. Informed consent was obtained from subjects who participated in the research interview. The data used in this study was anonymized prior to its utilization.

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The authors declare no competing interests.

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Supplementary Information

Additional file 1: supplementary file 1..

The Interview Guide.

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Varghese, B., AL-Balawi, R.O., Joseph, C.M. et al. The lived experiences of nurse preceptors in training new nurses in Qatar: qualitative study. BMC Nurs 22 , 456 (2023). https://doi.org/10.1186/s12912-023-01619-9

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Received : 18 August 2023

Accepted : 22 November 2023

Published : 04 December 2023

DOI : https://doi.org/10.1186/s12912-023-01619-9

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