Preceptors perceptions of the leadership skills of newly qualified healthcare practitioners

Transcription

1 Preceptors perceptions of the leadership skills of newly qualified healthcare practitioners Dr Mary Morley- Director of Therapies, South West London and St George's Mental Health NHS Trust Dr Lisa Marie Bayliss-Pratt- Assistant Director of Nursing NHS Midlands and East Strategic Health Authority Miss Elizabeth Bagley- Cancer Service Improvement Manager 3 Counties Cancer Network Correspondence: Dr Mary Morley Abstract This article focuses on the findings of a study that evaluated the leadership competencies required by newly qualified staff from the perspective of their preceptors and also their perceptions of how confident the preceptees are in using these skills. The findings may be of interest to those planning pre-registration and continuing development activities, as well as managers of services. Key Messages: Preceptorship occurs through a variety of mechanisms with regular meeting between preceptors and preceptees being the most popular Preceptors consider that NQPs showed respect, promoted equality and diversity, worked with others and was able to gain and maintain trust and support. Most importantly, NQP were view to be safe from a patient safety perspective NQPs continue to require a transition period to enable them to function effectively in leadership areas that include, delegating and supporting staff to take on more responsibilities and being confident to challenge current ideas and practice Key words: Preceptorship Leadership, Newly Qualified Registered Practitioners Submitted for Publication- September

2 INTRODUCTION In 2010, the NHS in England launched a preceptorship framework for nurses, midwives and allied health professionals (DH, 2010) to provide guidance and standards for NHS organisations in the implementation of preceptorship. The framework was developed by the Department of Health in conjunction with a wide range of stakeholders from across the NHS and other organisations and presented a valuable tool to ease the successful transition of new staff into practice (Bayliss-Pratt et al, 2012). The emerging research on preceptorship in nursing suggested that where it was happening there were benefits to the newly qualified nurse and also the service in terms of retention and improved patient care (Leigh et al, 2005, Bradley, 1999, Clark et al, 1996). Preceptorship is defined in the framework as a transition phase for newly registered practitioners when continuing their professional development, building their confidence and further developing competence to practice (DH 2010). Preceptorship can alleviate the transitional stress of new practitioners but its ability to do this depends on a clear definition of preceptorship followed by commitment from managers to build infrastructures and support for its implementation (Harbottle, 2006, Morley, 2009); this includes training, supervisory support and resources. Successful preceptorship requires normative as well as formative feedback (Miller and Blackman, 2003), regular supervision or mentoring as well as regular access to the preceptor (Morley 2009, Morton-Cooper and Palmer, 1993, O Malley, 2000). The role of the preceptor is key to successful implementation (Morley 2006, Procter et al 2011). The qualities of a good preceptor include sound clinical skills, an ability to motivate and communicate (Morton-Cooper and Palmer, 1993, O Malley, 2000, Harbottle, 2006) as well as providing constructive feedback (Miller and Blackman, 2003, Morton-Cooper, 2000). Preceptorship has the potential to promote clinical practice and knowledge and to improve patient care (Bain, 1996, Brasler, 1993) and to bridge the theory-practice gap (Clark 1996 et al, , Maben et al, 2006). Ashurst (2008) suggests that support during an effective preceptorship period may assist staff to understand how to use theoretical knowledge in the reality of practice providing higher rates of engagement and satisfaction (Giallonardo et al, 2010). This support may help the retention of staff which will subsequently improve confidence in clinical care within the healthcare setting and reduce the costs of high staff turnover (Pickens and Fargostein, 2006, Leigh et al, 2005) and promote safe and effective care (Whitehead and Holmes, 2011, Bayliss-Pratt et al, 2012). As the NHS in England undergoes a period of unprecedented change and financial constraint (DH, 2011), the challenges facing newly qualified practitioners may be greater than ever. Healthcare professionals at all levels need to not only develop clinical expertise but also be equipped with management and leadership skills. The NHS Leadership Competency Framework (DH, 2011) describes the leadership and management competences clinicians need to become involved in the planning, delivery and transformation of services. There has been no reported evaluation of the leadership competences required by newly qualified practitioners although some studies highlight strengths and weaknesses in skills, knowledge and behaviours that may be considered aspects of leadership. This evaluation considers the leadership competencies required by newly qualified staff from the perspective of their preceptors and also their perceptions of how confident the preceptees are in using these skills. The findings may be of interest to those planning pre-registrations and continuing professional development activities as well as managers of services. BACKGROUND Healthcare practitioners successful transition to practice is made more difficult when the working environment is undergoing rapid extensive change as currently being experienced in the UK (Miller and Blackman, 2003, Morley, 2009b, Barnitt and Salmond, 2000). Despite education reforms such as Project 2000 (UKCC, 1986) designed to equip

3 nurses to work within rapidly changing health environments and to take greater responsibility earlier in their career (Macleod Clark et al, 1997, Gerrish, 2000), challenges still persist for newly qualified nurses and midwives (Hughes and Fraser, 2011). Competences linked to leadership aspects of practitioner roles may be particularly hard, for example, prioritising workloads and delegating to other staff (Miller and Blackman, 2003) and organisational skills and decision making (Hickey, 2009). Allied Health Professionals describe a similar experience in occupational therapy (Morley, 2009), speech and language therapy (McCartney et al, 1993, Bebbington, 1996), physiotherapy (Tryssenar and Perkins, 2001) and podiatry (Mandy and Tinley, 2004). Several authors highlight management skills (Gerrish 2000, Baillie, 1999, Maben and Macleod, 1998) as an area that newly qualified nurses report as highly stressful. There is evidence that the demands placed on new practitioners are increasing with growing workloads and early expectations of autonomy within an interprofessional context (Barnitt & Salmond, 2000, Morley, 2009, Mooney, 2007) and so it is likely that the reality shock on moving into practice may also be increasing. Hickey (2009) argues that facilitating the transition into practice is as important as preparing students at under-graduate or pre registration level. To do this requires an understanding of current expectations of leadership as well as clinical skills. This evaluation goes some way to presenting a summary of leadership skills and confidence of newly qualified staff from the perspective of preceptors in one NHS strategic health authority. METHODS The purpose of this evaluation, conducted across all NHS Trusts in the West Midlands, was to establish how confident preceptors were of their newly qualified practitioners (NQP) ability to undertake the leadership competencies required in their posts. The evaluation also considered environmental factors such as preceptorship and learning activities to see what support was provided in the first year of practice to preceptors. 3 The survey was approved by the Nurse Director of the Strategic Health Authority. Participants were invited to complete the survey via their preceptorship lead from within their organisation. The data was collected by a survey tool developed by the first author. A small project group of Band 5 staff and their preceptors in a mental health trust developed a shortened list of relevant competencies from the early career section of the NHS leadership framework (DH, 2011). These relate to effective leadership in the context of one s own practice or within the immediate team. Staff at this first stage of the NHS Leadership Competency Framework (2011) need to be competent in a range of leadership behaviours across each of the five core leadership domains: demonstrating personal qualities, working with others, managing services, improving services and setting direction. Each domain is divided into four elements and each of these elements is further divided into four descriptive statements which describe the behaviours all staff should be able to demonstrate. The project group selected two of these statements felt to be most relevant to Band 5 roles and included them in the survey. The survey utilised an electronic survey, Lime Survey (licensed to NHS West Midlands), as a web based survey takes less time to complete. It can also be ed directly to the potential recipients rather than being posted, it reduces respondent burden and may increase the response rate. In addition, this data collection method allows the evaluators to survey participants without the expense associated with mailing costs. The survey was disseminated to the Preceptorship Lead for each Trust within the West Midlands who in turn distributed the electronic link to all preceptors. The survey was available for access for a total of four weeks in December 2011 and participants were advised that a separate survey should be completed for each newly qualified professional they supervised and all information would be confidential.

4 RESULTS Invitation to take part in the evaluation was extended to 47 West Midlands NHS Trusts. The organisations who responded ranged from acute trusts (n=30), mental health trusts (n=6), primary care (n=11) and other (n=1). Of the 48 evaluations returned by participants, 33 were completed by nurses, 13 by allied health professionals and two by those categorising themselves as other. The employment status of the participant s NQPs consisted of 43 individuals working full time and the remaining five were employed less than full time (under 37 ½ hours per week). The majority of participants supervised only one NQP (n=43) and the number of designated NQPs ranged from zero to four+. Participants met with their respective NQP on average weekly however this ranged from daily (n=5), weekly (n=18), fortnightly (n=5), monthly (n=14) and other (n=6).thirty four of the participant s NQPs were in a nonrotational placement. Of the 14 participants who s NQPs were in a rotational placement, 11 believed that rotations did not hinder the supervisory relationship however three participants did consider the relationship hampered. The most useful learning tool available to participants to prepare them for their preceptorship duties were utilising resource handbooks with 31% of participants classing this tool as very useful. There were only three learning tools available to more than half of all participants these were one day (or less) of training, management support and preceptorship resources (e.g. handbooks) The most popular strategy to support NQPs was felt by participants to be regular meetings between the preceptor and NQP with 60% of participants stating this was beneficial; 15% of participants reported that this strategy was not available to them. Another beneficial strategy available to NQPs was the ability to attend an in-house preceptorship course with 52% of participants believing this useful for their NQP. For the NQPs who had the ability to attend either a University or Flying Start England course, the main benefits were thought to be enhancing professional knowledge, having a structured learning experience and putting 4 theory in practice with results for all three showing that 73% of participants stated this was very useful for their NQP s learning experience. CONFIDENCE Participants were asked to indicate the extent to which they felt confident in their NQP to undertake the leadership competencies. They rated on a scale from not at all confident, somewhat confident, confident and very confident. The results for each of leadership domains from the NHS leadership framework are set out in the tables below. The first domain relates to confidence relating to demonstrating personal qualities. Across these competencies, at least half of participants felt confident or very confident in their NQPs ability in the listed competencies. The competency with the most confidence was showing respect for the needs of others and promoting equality and diversity which received a confident/very confident rating of 87%. The two competences receiving the least confidence from participants were planning and managing own time effectively and remaining calm and focused under pressure having a not at all confident/somewhat confident rating of 34% and 45%. Even higher confidence levels were exhibited in the leadership domain working with others with over 71% of participants confident/very confident in all the listed competencies. The competency receiving the highest confidence was gaining and maintaining trust and support with a confident/very confident rating of 79%. The fourth table summarises the responses relating to managing services. The confidence levels were lower than those reported for demonstrating personal qualities and for the domain working with others. More than half of participants reported that they were not at all confident/somewhat confident in their NQPs ability in contributing to service plans. In the competency supporting team members to develop more roles and responsibilities 19% of participants were not at all confident in their NQPs ability.

5 The fifth domain relates to improving services. The competencies that participants felt least confident in their NQPs ability were questioning established practices which do not add value and also expressing the need for change to processes and systems. The competencies in relation to patient safety, putting the safety of patients and service users at the heart of thinking and taking action to report or rectify shortfalls in patient safety, received high ratings of confidence from participants with confident/very confident results at 86% and 77%. The final domain setting direction encompasses the competencies that present the most challenges to NQPs according to the participants. With the exception of consulting with others which rated confidence quite highly, all other competencies received low rates of confidence with the areas using evidence to suggest changes that will improve services in the future and making recommendations for future improvements receiving less than 50% of participants rating confident/very confident in their NQPs ability. DISCUSSION The responding organisations all had taken steps to implement the preceptorship framework. There is evidence of a strong infrastructure with allocated preceptor leads and preceptors. This is in line with the recommendations in the framework (DH, 2010) and may indicate that the preceptorship process will promote the successful adaptation of new practitioners into practice (Morley, 2009, Harbottle, 2006). Almost all had had some training on preceptorship of at least one day s duration. This is significantly higher than that reported in other studies (O Malley, 2000, Harbottle, 2006) and may be due to the preceptorship framework that ring-fenced monies for the preceptorship programme. Despite almost universal provision of preceptorship training, only half reported that management support was available. There was evidence of handbooks and other resources but four fifths were not aware of availability of the free on-line web-based tool Flying Start 5 England that made available to all NHS organisations across England from March 2010, hosted by NHS West Midlands Strategic Health Authority. This suggests organisations may need to ensure more robust communication strategies to facilitate support and guidance for preceptors. Less than a fifth of preceptors had allocated time to undertake their preceptor s duties. This may be an indication of the busy clinical environments and workloads of the preceptors. However, this may place unacceptable demands on preceptors and may lead to frustration about undertaking the role as reported elsewhere (Morley, 2009, O Malley, 2000). Again, this may be an issue that senior managers and preceptorship leads consider as preceptorship is to be embedded successfully into practice. Most preceptors had only one preceptee and this may facilitate the frequency of meetings with the preceptees. This study does not give information on the length of time that new practitioners have been working in their first post. However, the preceptors appear to be offering flexible levels of support, ranging from one day to weekly. The relationship between the timing for supervision and the length of time the preceptee has been working may be an issue to explore in future evaluations. The second part of the survey considered the extent to which the preceptors felt confident in their NQP to undertake leadership competencies selected from the NHS Leadership Competency Framework (2011). The results will be discussed in relation to the five leadership domains. The first domain relates to demonstrating personal qualities. Across this domain as whole, the preceptees appear relatively confident. The preceptors reported that over three quarters were confident or very confident in showing respect for others, upholding values and putting learning into practice. As with other studies such as Miller and Blackman (2003) and Barnitt and Salmond (2000), remaining calm under pressure and managing time effectively were areas in which the preceptees were perceived to be less confident.

6 Two thirds of the preceptees were reported by the preceptors as appearing confident or very confident to work across leadership competencies related to working with others. This includes skills and behaviours relating to communicating with and listening to others, recognising different perspectives and understanding the contribution of others. These are areas that have been reported as challenging for some new practitioners especially in situations where practitioners are working as the sole practitioner of their profession in a team (Tryessanaar and Perkins, 2001, Morley, 2009). Preceptors may need to ensure that the needs of less confident practitioners are overlooked in the business of the work environment. The leadership domain relating to managing services is perceived to be an area that the preceptees are less confident in that the previous two domains. The preceptees display less confidence in the task of delegating and supporting staff to take on more responsibilities, consistent with other earlier evidence (Miller and Blackman, 2003). The confidence displayed in the personal qualities such as reflection may explain the relatively high confidence seen as the preceptees are able to respond to feedback from patients and from colleagues and to learn from their mistakes. The capacity to do this has been seen to be key to developing self-awareness (Morton-Cooper and Palmer, 1993) and developing resilience to adapt from the student role to that of fully fledged practitioner (Tryssenaar and Perkins, 2000). Without these attributes, new practitioners struggle to develop both professional identity and clinical skills (Morley, 2009). These competencies may therefore be indicators that many of the preceptees described in this study have some important attributes that will assist them to develop leadership competencies needed in their roles. However, these intrapersonal skills are not sufficient to enable them to take on responsibilities related to service improvement. This domain requires practitioners to question practices that do not add value and to suggest changes to systems and processes. New practitioners bring a wealth of knowledge of recent practice developments and an ability to 6 use the evidence base (Barnitt and Salmond, 2000). However, the preceptors saw that half of the preceptees in this survey were not confident to challenge current ideas and practice. This echoes findings by Maben and Clark (1996) and Procter et al (2011). This lack of confidence has been attributed to power differentials in the workplace (Morton-Cooper and Palmer, 1993). It may be necessary for the preparation of new practitioners at student level and in early practice to consider how to build skills in assertion and resilience. CONCLUSION This small study has identified that learning resources to support preceptorship continues to occur in a variety of guises, the most popular being regular meetings between the preceptor and NQP Despite this, a small number of participants reported that this strategy was not available to them. It is also of interest that whilst it is a well know fact that NQPs can feel overwhelmed with their new role as a registrant, formal preceptorship programmes were considered to enhance professional knowledge, having structured learning and putting theory into practice highlighting a possible thirst for continuing professional development, which can only be a positive thing for both the professions and the patients they serve. With regards to NQP confidence, it was pleasing to find that these preceptors viewed on the whole that their NQPs were competent in relation to showing respect, promoting equality and diversity, working with others and gaining and maintaining trust and support. Of most importance, the majority of these preceptors also considered that NQPs were confident at putting and acting on patient safety issues. These findings suggest that these qualities, skills and abilities have been embedded throughout relevant aspects of pre-registration curricula. However, the fact that the competencies receiving the least confidence included; planning and managing own time effectively, remaining calm and focused under pressure, contributing to service plan, supporting team members to develop more roles and responsibilities and setting direction reiterates the need for a meaningful preceptorship period, to enable the newly qualified practitioner to

7 make an effective transition from student to competent/confident practitioner. Alternatively, these findings may suggest that these elements of pre-registration curricula are absent and require including. Whether this will enable all NQPs of the future to be fit for practice at the point of registration to work in an ever changing NHS, is perhaps another debate and worthy of further consideration. REFERENCES Ashurst, A., (2008) Career Development; the preceptorship process; Nursing and Residential Care, Vol 10, No 6 Bain, L. (1996) Preceptorship: A Review of the Literature, Journal of Advanced Nursing, Vol 24, No 1 Barnitt, R. & Salmond, R. (2000), Fitness for purpose of occupational therapy graduates: two different perspectives, British Journal of Occupational Therapy, 63 (9), pp Bayliss-Pratt L, Morley M, Serrant-Green L (2012) The journey to implementing a multi professional preceptorship practices? Journal of Health and Social Care Improvement, VOL 1, Accessed at Bebbington, D. (1996) Recruitment, retention and returners: a study of the career paths of people with a speech and language therapy qualification London, College of Speech and Language Therapists. Brasler, M. E. (1993) Predictors of Clinical Performance of new graduate nurses participating in preceptor orientation programmes. The Journal of Continuing Education in Nursing, 24, pp Department of Health (2010) Preceptorship Framework for newly registered nurses, midwives and allied health professionals Department of Health (2011) The Operating Framework for the NHS 2012/3 HMSO London Gerrish, K. (2000), Still fumbling along? A comparative study of the newly qualified nurse's perception of the transition from student to qualified nurse, Journal of Advanced Nursing, 32(2), pp Giollonardo, L. M., Wong, C. A., and Iwasiw, C. L., (2010) Authentic Leadership of Preceptors: predictor of new graduate nurses work engagement and job satisfaction, Journal of Nursing Management, 18, Harbottle, M. (2006) An Investigation into the perceived usefulness of preceptorship: an exploratory study between two radiotherapy centres, Journal of Radiotherapy in Practice, Oxford Hughes, A. J. & Fraser, D. M. (2011) Sink or Swim: the experience of newly qualified midwives in England, Journal of Midwifery, vol 27 (3), p Kramer, M. (1974) Reality Shock; why nurses leave nursing, St. Louis: Mosby Leigh, J. A., Douglas, C. H., Lee, K., & Douglas, M. R. (2005), A case study of a preceptorship programme in an acute NHS Trust -- using the European Foundation for Quality Management tool to support clinical practice development, Journal of Nursing Management, 13(6), pp Maben, J. and Clark, J. M. (1996) Preceptorship and Support for Staff: the good and the bad, Nightingale Institute, London Macleod Clark, J. and Maben, J. (1998) Health promotion: perceptions of Project 2000 educated nurses. Health Education Research, 13, Mandy, A. and Tinley, P. (2004), Burnout and occupational stress: comparison between United Kingdom and Australian podiatrists, Journal of the American Podiatric Medical Association, 94 (3), pp McCartney, E., Kerr, J., Cannon, L., and Martin, P. J. (1993), Supporting New Graduates in the Health Service: The Experiences of Entrants to the Speech and Language Therapy Profession, Journal of Management in Medicine, 7,(6), pp Miller, C. and Blackman, C. (2003) Learning during the first three years of post registration/postgraduate employment The LiNEA Project, Interim report for nursing, Funded by the economic and social council, TLRP Programme

8 Morley, M. (2006), Moving from Student to New Practitioner: The Transitional Experience, British Journal of Occupational Therapy, 69(8), pp Morley M (2009a) An evaluation of a preceptorship programme for newly qualified occupational therapists. British Journal of Occupational Therapy. 72(9), Morley, M. (2009b) Contextual factor that have an impact on the transitional experience of newly qualified occupational therapists. British Journal of Occupational therapy. 72(11), Morton-Cooper, A. and Palmer, A. (1993) Mentoring, Preceptorship and Clinical Supervision: A Guide to Professional Roles in Clinical Practice 2 nd edition, Oxford, Blackwell Science NHS Institute for Improvement and Innovation, (2011), NHS Leadership Framework O Malley, C. (2000) Preceptorship in Practice, Nursing Standard, Vol 14 (28) Pickens, J. M. and Fargostein, B., (2006) Preceptorship: A Shared Journey between Practice and Education, Journal of Psychosocial Nursing, vol 42, 2 United Kingdom Central Council, (1986) Project 2000; A new preparation for practice Tryssenaar, J. and Perkins, J., (2001) From student to therapist: exploiting the first year of practice, American Journal of Occupational Therapy, 55(1) pp Whitehead, B. and Holmes, D., (2011) Are newly qualified nurses prepared for practice?,nursing Times, vol./is. 107/19-20(20-23) 8

9 Appendix 1 Table 1: Learning tools available to develop preceptor abilities Not Useful Sometimes Useful Mostly Useful Very Useful Not Available 1 Day (or less) of training 15% 4% 17% 15% 49% A preceptor course (2 + Days in continuation) 10% 2% 13% 25% 50% Higher Education Course 10% 0% 10% 15% 65% Preceptor network 10% 2% 13% 8% 67% Management support 8% % 46% Flying Start England website 10% 4% 2% 4% 80% Other E-Learning 10% 2% 8% 2% 78% Protected time to meet preceptees 13% 2% 2% 19% 64% Preceptorship resources (e.g. handbook) 8% 13% 10% 31% 38% 9

10 Table 2: Demonstrating Personal Qualities Not At All Somewhat Very Reflecting on how factors such as own values, prejudices and emotions influence judgement, behaviour and self belief Using feedback from appraisals and other sources to consider personal impact and to change behaviour 4% 17% 58% 21% 4% 23% 50% 23% Planning and managing own time effectively 13% 21% 40% 26% Remaining calm and focused under pressure 10% 35% 40% 15% Seeking out new opportunities 6% 29% 48% 17% Putting learning into practice 4% 19% 54% 23% Upholding personal and organisational ethics and values 0% 17% 54% 29% Showing respect for the needs of others and promoting equality and diversity 0% 13% 43% 44% 10

11 Table 3: Working with others Not At All Somewhat Very Identifying where working and cooperating with others can result in better service 6% 19% 48% 27% Working collaboratively 8% 19% 38% 35% Communicating and listening to others and recognising different perspectives 4% 17% 48% 31% Gaining and maintaining trust and support 10% 13% 52% 25% Seeking and acknowledging the views and inputs of others 10% 19% 50% 21% Showing respect for the contributions and challenges of others Understanding the roles, responsibilities and purpose within the team Adopting a collaborative approach and respecting team decisions 4% 25% 50% 21% 2% 23% 40% 35% 4% 19% 48% 29% 11

12 Table 4: Managing Service Not At All Somewhat Very Contributing to service plans 15% 38% 40% 7% Receiving and incorporating feedback from others including patients, service users and colleagues 6% 25% 48% 21% Understanding what resources are available 6% 21% 66% 7% Organising the appropriate type and level of resources required to deliver a safe and efficient service Supporting others in delivering high quality and excellence in healthcare Using information and data about performance to identify improvements 4% 33% 46% 17% 7% 25% 44% 24% 6% 38% 46% 10% Developing and learning from experience and future plans 2% 21% 58% 19% 12

13 Table 5: Improving Services Not At All Somewhat Very Putting the safety of patients an service users at the heart of thinking 1% 13% 44% 42% Taking action to report or rectify shortfalls in patient safety 6% 17% 50% 27% Gathering feedback from patients, carers and service users 10% 23% 46% 21% Using feedback to contribute to healthcare improvements 6% 33% 46% 15% Questioning established practices which do not add value 13% 31% 54% 2% Putting forward creative suggestions to improve the quality of service provided 15% 24% 46% 15% Expressing the need for change to processes and systems 21% 38% 31% 10% Acknowledging the impact on people and services 13

14 Table 6: Setting Direction Not At All Somewhat Very Understanding the range of factors which determine why changes are made Understanding and interpreting recent legislation and accountability frameworks Gathering data and information about aspects of the service and analysing evidence Using evidence to suggest changes that will improve services in the future 10% 33% 50% 7% 10% 38% 42% 10% 17% 33% 46% 4% 10% 44% 31% 15% Consulting with others 7% 13% 54% 26% Contributing to decisions about the future direction/vision of the service Assessing the effects of change on service delivery and patient outcomes 19% 31% 37% 13% 7% 42% 42% 10% Making recommendations for future improvements 10% 42% 31% 17% 14