Preceptorship and pre-registration nurse education L Currie and C Watts, 2012 Key findings This rapid review analysed studies from nursing literature from 2008-2012 to answer the question: What are the benefits of, and approaches to, supporting new graduate nurses in post-registration role transition through preceptorship programmes in the UK? There is no evidence on the clinical or cost-effectiveness of preceptorship provision in the UK. Existing studies are generally descriptive and based on self-report. Terminology used around preceptorship is variable internationally. In the UK, preceptorship programmes are run at organisational level post-qualification. In the US and Canada, preceptorship forms part of pre-registration education and is more closely associated with UK pre-registration mentoring activities. While preceptor attributes and programme approaches have been documented, preparatory training for the preceptor role in the UK is less widespread than in other international contexts. Although mutual benefits of preceptorship programmes for new qualified nurses, preceptors and organisations are well documented, there is little evaluation of programmes demonstrating effectiveness in terms of quality of care or making recommendations concerning best practice. A lack of the understanding of the value of preceptorship programmes together with no regulatory and professional consensus as to best practice may impact prioritisation of preceptorship programmes at organisational level. A range of organisational systems that need to be in place in order to provide formalised preceptorship programmes, including training and ongoing support for those nurses carrying out the role. Introduction This report presents the findings of a rapid review giving an overview of the evidence addressing preceptorship programmes following pre-registration nurse education. The review question was: What are the benefits of and approaches to supporting new graduate nurses in post-registration role transition through preceptorship programmes in the UK? The rapid review took place over a three-week period, and an appropriate scope was determined for this timeline, with literature searched from nursing literature from the past five years. A literature search of material from 2008-2012 was undertaken using British Nursing Index, CINAHL and Medline databases. Thirty-two papers were identified from the search and 29 were retrieved for review. Since few papers were UK-based international articles were also considered for the purpose of this review. Only English language studies were considered.
This review focuses on preceptorship provision across the UK National Health Service (NHS). Overview of the evidence The evidence base on preceptorship in the UK is limited and of variable quality. There is some debate around the benefits of preceptorship. Descriptive research exploring the benefits of preceptorship comes from outside the U K and is based on self reports (Hickey, 2009; Wilson et al, 2009; DeWolfe et al, 2010; Giallonardo et al., 2010). No research evidence was found on the clinical or cost-effectiveness of preceptorship provision in the UK. No systematic reviews were found, although a scoping review of preceptorship was identified (NNRU, 2009). Two literature reviews were identified one from Australia (Procter et al., 2011) and one from the USA (Billay & Myrick, 2010). The majority of the research articles retrieved explored proctorship in the USA (Hickey 2009; Wilson et al., 2009) Canada (DeWolfe et al., 2008; Billay & Myrick, 2010; Giallonardo et al., 2010) and Australia (Cubit & Ryan, 2010; Procter et al, 2011). Of the four articles reviewed from the UK, one was an opinion piece on preceptorship for newly qualified midwives (Davies & Mason, 2009); one described the implementation of preceptorship across an acute trust (Morgan & Medows, 2012); and one described the implementation of preceptorship for four health visitors working in the community (Morton et al, 2011). The remaining article reported a qualitative study exploring the challenges facing newly qualified nurses in the community (Maxwell et al, 2011). The limited nature of the evidence base on preceptorship provision in the UK makes any generalisation of findings problematic. Given this, this review does not contain a what works section. Further research may be needed in order to generate more robust evidence about the benefits of and barriers to preceptorship in the UK. Terminology: preceptorship inside and outside of the UK Preceptorship delivered in the UK is identified as important in preparing newly registered nurses for the transition from nursing student to professional practitioner. In other countries preceptorship is provided for student nurses in their final year of pre-registration education. Most preceptorship provision in the UK is voluntary rather than mandatory. There is a requirement for standardised programmes of preceptorship that is provided within a period of between 6-12 months and includes formal training, preparation and continuing support for preceptors. Failure to provide such support results in challenges in the recruitment and retention of preceptors. Given the current economic climate and the present Government s commitment to decentralisation it would appear that any future rollout of formalised preceptorship programmes may prove challenging. In some countries outside the UK, including the US and Canada, preceptorship programmes are a model of support forming part of pre-registration nurse education (Billay & Myrick, 2008; Medley & Penney, 2009; NNRU, 2009; Cubit & Riley, 2011). Preceptorship is also offered to newly graduate nurses under the banner of Orientation Programmes (Steffan & Goodwin, 2010; Willemsen-McBride (2011); Graduate Nurse Programs (Cubit & Ryan (2011) and Transition to Practice Programs (Proctor et al, 2011). A recent development in the USA is the team preceptorship model which teams an experienced/expert nurse with a novice nurse to oversee their orientation, but who also facilitates the career development of a new preceptor (Beecroft et al, 2008: 145).
Structure of the report Findings from the review are divided into three sections below: What does good look like? Discussion of what is meant by preceptorship, its definition, standards and implementation. What s promising? Learning from the literature indicating potential good benefits of preceptorship. What are the challenges and barriers? Impediments to providing preceptorship programmes. What does good look like? Definition The definition of preceptorship used in this report is... a model of enhancement, which acknowledges new graduates/registrants as safe, competent but novice practitioners who will continue to develop their competence as part of their career development / continuing professional development, not as individuals who need to address a deficit in terms of education and training (Council of Deans, 2009, cited in DH, 2010: p10). Standards for preceptorship Guidance on nurse preceptorship in England has been identified by the Department of Health (England) (DH, 2010) and suggests the need for a mandatory period of preceptorship which is supported by the Nursing and Midwifery Council (NMC 2010). The DH framework for preceptorship builds on earlier work undertaken in Scotland through the implementation of the Flying Start NHS programme. It describes the key elements of good preceptorship and suggests outcome measures to ensure preceptorship meets the need of newly registered nurses, demonstrates value for money and underpins the delivery of high quality, safe patient care. There is a need to ensure that organisations implement systems to identify all new registered nurses requiring preceptorship, to identify preceptors and train and support them, to monitor and track completion rates, to ensure preceptorship arrangements meet the requirement of regulatory bodies and the KSF, to evaluate preceptorship in demonstrating effectiveness and value for money, to ensure evidence produced during preceptorship is available for audit and verification by the NMC and Health Professions Council (HPC), and that preceptorship operates within a governance framework (DH, 2010). Preparation and attributes of preceptors Whilst the DH framework (DH, 2010) lists a number of preceptor attributes the National Nurses Research Unit (NNRU, 2009) describes the profile and preparation of preceptors. Preceptors in the UK are less likely to have been trained for the role than their colleagues in the USA (NNRU, 2009). Research in the USA identifies a range of preceptor characteristics including: charisma; empathy; a supporting, nurturing attitude; trustworthiness; enthusiasm; commitment; competence; compassion; and integrity (Wilson et al., 2009). The range of preceptor
behaviours were identified as both facilitating and hindering the development of critical thinking in the newly qualified nurses. Facilitating behaviours are identified as flexibility; respect and scepticism; whilst hindering behaviours are described as role consciousness, lack of questioning attitude, constraint, and lack of safety (Wilson et al., 2009). Implementing preceptorship In terms of an organisationally delivered model of preceptorship a number of leaning methods have been identified. These include learning sets; self-directed learning; clinical practice focus days; reflective practice; shadowing; and one-to-one support. Alternative delivery mechanisms are identified as partnerships with higher education establishments and accredited academic programmes; work-based portfolio building programmes; webbased/blended learning models like Flying Start NHS in Scotland; or through attitudinal and behavioural-based role-modelling (DH, 2010). The length of time of the preceptorship period has been identified by the DH (2010) as the first 6-12 months following registration and should be planned in the context of individual responsibilities and the needs of the employer organisation. Researchers at the NNRU (2009) suggest the evidence reveals considerable diversity in the length of time newly registered nurses wanted preceptorship and the length of time it was provided. Newly registered nurses identified the optimum period of preceptorship to be six months (NNRU, 2009). Record keeping for preceptorship needs to meet the requirements of the KSF appraisal process, continuining professional development requirements and any potential future revalidation required by the NMC and HPC (DH, 2010, p.19). The model of preceptorship described by Maxwell (2010) can be seen to be based on the model outlined in the DH framework for preceptorship, and this model has been accredited by the University of Northumbria. What is promising? Benefits for newly registered nurses A range of benefits have been identified for newly registered nurses, preceptors and employing organisations (NNRU, 2009; DH, 2010). Preceptorship has been identified by newly registered nurses as something they want and that most of them received. There is variability in the ways newly qualified nurses were allocated a preceptor and received preceptorship. While many newly registered nurses reported being satisfied with their relationship with their preceptor they also reported the relationship could be compromised as a result of personal circumstances and employment moves. This often resulted in shortened periods of time spent with preceptors (NNRU, 2009). Self reports by newly registered nurses identified the key function of preceptors as supporting the development and consolidation of their clinical skills (NNRU, 2009; p.11). In some cases newly registered nurses reported benefits associated with being allocated two preceptors although some difficulties were reported when preceptors disagreed on the preceptees progress. According to the DH (2009) benefits to newly registered nurses receiving preceptorship include: the development of confidence; professional socialisation into the working environment; increased job satisfaction leading to improvement in delivery quality patient
care; feeling valued and respected; feeling invested in future career development; feelings of pride and commitment to their employer s strategy and objectives; development of greater understanding of the commitment to working within nursing and the regulatory requirements; and taking personal responsibility for maintaining up-to-date knowledge. The NNRU (2009) however reports that there is no evidence to support the contention that preceptorship had any effect on the newly registered nurse s choice of career direction. Research from Canada (Giallonardo et al, 2010) reports that newly graduated nurses paired with preceptors who demonstrated high levels of authentic leadership felt more engaged and more satisfied with the preceptee-preceptor relationship and identified this as positively affecting their job satisfaction. Similar findings on the benefits of preceptorship have been reported in relation to community nursing (Morton et al, 2011; Maxwell et al, 2011), and acute nursing in the NHS (Morgan & Medows, 2012). Benefits for preceptors Self reports from preceptors have identified the benefits of the role as satisfaction in helping new registrants during the transition to professional practice, greater opportunities to further their own knowledge and improve their teaching competencies (DeWoolfe et al., 2008; NNRU, 2009: Wilson et al., 2009; Schaubhut & Gentry, 2008), and further opportunities for networking (Wilson et al., 2009). The DH (2010) identifies the range of benefits for preceptors as the development of appraisal, supervision, mentorship and supportive skills. Furthermore it suggests that preceptorship enhances the ability to progress through AfC gateways; that preceptors feel valued by the organisation, newly qualified nurses and patients; preceptors are committed to nursing and its regulatory requirements; and how undertaking a preceptorship role it supports their own lifelong learning; and enhances their future career aspirations. The NNRU (2009) however suggests that whilst there is some evidence to suggest benefits to preceptors these need to be tangible if experienced nurses are to commit to the role. In addition, preceptors appeared to receive little preparation for their role. Employer organisations need to ensure that preceptors are formally trained and provided with the support and the time to fulfil their role as preceptors. Furthermore the preceptor role should be formally acknowledged as part of an experienced nurse s job description rather than being seen as an ad hoc arrangement (NNRU, 2009; Sherrod et al., 2008; Davies & Mason, 2009; Wilson et al., 2009; Schaubhut & Gentry, 2010). Benefits to employer organisations The DH (2010) framework identifies a wide range of benefits for employer organisations. These include enhanced quality of care; enhanced recruitment and retention; reduced sickness and absence; enhanced staff satisfaction; opportunity to identify staff who require additional support or who require a change in role; reduced risk of complaints; opportunities to talent spot to meet the leadership agenda; and registered practitioners who understand the regulatory impact of the care they deliver and develop an outcome/evidence-based approach. There is some evidence to support the idea that preceptorship increased newly registered nurses levels of competence although there is little evidence to support any contention that nurses in receipt of preceptorship had any effect on the quality of care (NNRU, 2009). It may not be possible to compare the quality of care delivered by those nurses who had received preceptorship against those that had not and it is challenging to isolate the preceptorship
variable from all the other sources of support newly registered nurses receive in the development of their clinical skills (NNRU, 2009: p.12). Whilst the DH (2010) contend that preceptorship improves retention in nursing the research undertaken by the NNRU reports finding little evidence to support this. (NNRU, 2009, p.12). However research from the USA suggests preceptorship can have a positive impact on the recruitment and retention of new graduate nurses and nurse preceptors (DeWoolfe et al, 2008; Sherrod et al, 2008; Aaron, 2011). What are the challenges and barriers? Organisation commitment Maintaining the positive aspects of preceptorship requires organisational commitment including workload planning, dedicated time for preceptorship, and the training, preparation and ongoing support needed for those experiences nurses who carry out the role of preceptor (NNRU, 2009). In addition there have been calls for formal preparation courses for preceptors, as well as the need for professional standards and guidance in such preparation, and greater collaboration between academic centres and healthcare provider organisations (Hickey, 2009: Smedley & Penney, 2009; Wilson et al, 2009). Contextual variables Contextual variables are also important in seeking to embed a framework of preceptorship across the NHS. Although it has been a decade since the NMC published its guidance on preceptorship there has been little systemic growth in the provision of preceptorship programmes. This is the result of a lack of robust, formalised systems for the development, implementation and audit of preceptorship programmes which has resulted in the failure of management and practitioners to prioritize preceptorship. Such failures are reported as being exacerbated through a lack of consensus between regulatory and professional bodies which in turn makes success less likely because it makes it difficult to convince those who hold education and training budgets of the value of preceptorship and the requirement to fund its ongoing provision and evaluation (Davies & Mason, 2009).
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