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Being a preceptor—A Nordic qualitative study

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DOI: 10.1016/j.nedt.2014.04.013 · Source: PubMed

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Nurse Education Today 34 (2014) 1420–1424

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Nurse Education Today


journal homepage: www.elsevier.com/nedt

Being a preceptor—A Nordic qualitative study


Yvonne Hilli a,b,⁎, Hanna-Leena Melender c, Marita Salmu c, Elisabeth Jonsén d
a
Novia University of Applied Sciences, Vaasa, Finland
b
Oslo and Akershus University College of Applied Sciences, Norway
c
VAMK, University of Applied Sciences, Vaasa, Finland
d
Umeå University, Umeå, Sweden

a r t i c l e i n f o s u m m a r y

Article history: Background: Positive preceptor experiences enhance learning and even affect the decisions of students to remain
Accepted 1 April 2014 in nursing. In light of this, nurse managers have a responsibility, besides maintaining staff competence, to assess
whether preceptors live up to their professional obligations.
Keywords: Aim: The aim of this Nordic qualitative study was to gain a deeper understanding of the perceived experiences of
Preceptorship
preceptorship used to support undergraduate student nurses during their clinical education.
Clinical education
Method: Data was collected through narrative interviews with 31 preceptors in Finland and Sweden before being
Learning
Student nurse
analysed using a hermeneutical approach.
Interview Findings: Preceptorship is all about teaching in a supportive environment with ethical dimensions uniting theory
Hermeneutics and praxis. A caring relationship is essential and the basis for student learning and development.
Conclusion: The preceptors emphasise a caring relationship as the foundation for student learning. Moreover, pre-
ceptorship is an ethical issue, a responsibility that should be recognised by all stakeholders. The findings suggest
that preceptorship should be examined from a new perspective. The ethical dimension must be recognised and
linked to the further education of preceptors. Nurse managers are in a key position to lead for change.
© 2014 Elsevier Ltd. All rights reserved.

Introduction However, the quality of supervision is not linked to the quantity of su-
pervision (Walker et al. (2012). Significant factors determining the
Preceptorship as a means of clinical teaching is widely in use within effectiveness of perception were seen as the preceptor's own advanta-
nursing as well as in other disciplines. The preceptor is a role model, geous attitude, capabilities and competence, supportive cooperation
with a responsibility to inspire students to develop clinical skills and ap- with colleagues and lecturers, enthusiasm and active participation
preciate the value of nursing practice. Preceptorship has been consis- with students (Jokelainen et al., 2013).
tently recognised in literature as a strategy to maximise the benefits of In many cases, preceptorship is a highly positive experience. Precep-
clinical education in terms of assisting in the acquisition of skills and tors are often willing and committed to teaching students and want to
knowledge, enhancing confidence and professional socialisation be actively involved in their clinical education (Raines, 2012). Besides
(Happel, 2009). the satisfaction of teaching, preceptors appreciate the feelings of being
In a study by Mårtensson et al. (2013), nurses reported that the respected, seeing students develop, imparting the legacy of their profes-
structural conditions needed for them to work as preceptors must in- sion, strengthening nursing knowledge and increasing their own
clude the ability to receive feedback on their function as a preceptor knowledge base (Danielsson et al., 2009; Carlson et al., 2010; Foley
as well as the ability to plan and prepare the clinical education period, et al., 2012). However, some preceptors seem to lack the pedagogical
receive support from unit managers, and have specific preception edu- competence as well as support, feedback, and acknowledgement from
cation. However, structural conditions and professional experiences do the faculty and organisation (Hyrkäs and Shoemaker, 2007; Foley
not explain the preceptors' use of reflection and critical thinking when et al., 2012). Furthermore, preceptorship is sometimes experienced as
acting as preceptors. In earlier studies, preceptors have felt that there an extra burden, without enough time allocated for it. As the main
has not always been sufficient time to precept (Hilli et al., 2011). duty of nurses is considered to be nursing patients, supervision is some-
thing that is only done whenever there is time for it (Barker and
Pittman, 2010; Carlson et al., 2010; Hilli et al., 2011). Likewise, adequate
training in preceptorship does not seem to guarantee the desired learn-
⁎ Corresponding author at: Seriegatan 2, 65320 Vaasa, Finland. Tel.:+47 67236245 ing outcomes in students. According to several studies, student learning
E-mail addresses: yvonne.hilli@novia.fi, yvonne.hilli@hioa.no (Y. Hilli). and development is based on the relationship between the student and

http://dx.doi.org/10.1016/j.nedt.2014.04.013
0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Y. Hilli et al. / Nurse Education Today 34 (2014) 1420–1424 1421

the preceptor, and in particular, the preceptors' respect, support and nurses they considered to be good representatives of preceptors and
compassion for the student (Danielsson et al., 2009; Koontz et al., role models within nursing. The informants were working as qualified
2010; Jokelainen et al., 2011). nurses in hospitals and primary care and acting as preceptors for under-
Since a faculty has few contacts with students during their clinical graduate student nurses during their clinical education.
education, preceptors see the responsibility of interpreting the academ- Based on the above, 27 female and four male preceptors were cho-
ic theoretical knowledge into real situations within health care as sen to participate in this study; 15 from Sweden (Swe) and 16 from
challenging (Barker and Pittman, 2010; Foley et al., 2012; Raines, 2012). Finland (Fin) (n = 31). Their ages spanned from 27 to 59 years. These
The findings in the review of Jokelainen et al. (2011) shows that precep- preceptors were working in different contexts, such as medical, surgery,
torship integrates individual and organisational aspects. This integration oncology, psychiatric, emergency units and primary care. Their work
of theory and practice, i.e. development on a professional and personal experience varied between 1.5 and 37 years and the experience of pre-
level, bridges the gap between theory and practice. When combined, all ceptorship varied from 1 to 31 years. Seven of the preceptors (22%) had
these aspects have a unified importance in student preception. undergone pedagogical further education in preceptorship.
Success as a preceptor requires a good knowledge of the curricula
and more detailed information about the theoretical background the
students possess before the clinical period begins. Although it seems Interviews
obvious that the students' learning objectives should be crucial in per-
ception, that is not always the case. This is because many preceptors Thematic narrative interviews were conducted in spring 2011,
are unfamiliar with the learning objectives of the nursing curriculum during which the informants spoke on preceptorship, learning out-
(Hilli et al., 2011). comes, reflection, feedback and the theory–praxis relationship. A
According to the Bologna process in Europe, clinical education is theme guide was constructed for the researchers in order to guide the
incorporated into all courses in Bachelor of Nursing programmes and conversation with the informants. The opening question was, “Could
constitutes 50% of the programme (European Union EU Parliament you please tell me what preceptorship is according to you?” The charac-
and Council, 2005). In line with this, clinical education is to be organised ter of the interview was a conversation where the preceptors' narratives
in health care organisations outside the faculty and performed by staff and the pre-understanding of the interviewer guided the conversation
nurses. Although there is an abundance of literature regarding what af- towards deeper understanding. The interviews, lasting between 45
fects student-learning outcomes during clinical education (Walker and 120 min, were tape recorded and transcribed verbatim with nota-
et al., 2012), what is not known very well concerns what is significant tions of non-verbal expressions such as silence and laughter. The infor-
for good preceptorship. In this study we investigated clinical pre- mants were positive and welcoming in their attitudes towards being
ceptors' perspectives on preceptorship, learning outcomes, feed- interviewed.
back, reflection and the connection between theory and praxis
in relation to the student nurses' learning process. Our aim with
this study is to increase the body of knowledge on the topic of Ethical considerations
preceptorship.
Ethical issues were considered carefully, and the study conformed to
Aim the principles outlined in the ethical recommendations of the
Guidelines of the Finnish Advisory Board on Research Integrity (2012)
The aim of this study was to gain a deeper understanding of the and the ethical guidelines for nursing research in the Nordic countries
perceived experiences of preceptorship, which is used to support the (2003). Approval was obtained from the management within health
process of learning and development among student nurses during care. The nurse managers then contacted the nurses and asked if they
their clinical education. were interested in participating in this study. In Finland and Sweden
there is no requirement of approval from an ethical committee when
Method interviewing staff. All the nurses agreed to participate and the partici-
pants were given written and oral information before the interview, in-
Design, sampling, and informants cluding information on the study design, assurance of confidentiality,
and the option to withdraw their participation from the study if
A hermeneutic approach (Gadamer, 1999) was used in this study wished. In addition, the informants were informed about the inter-
since we wanted to gain a deeper understanding and explore the mean- view themes, the estimated duration of the interviews and that
ing of preceptorship according to those under investigation. With this in the interviews would be tape-recorded. A theme guide was sent to
mind, thematic interviews were used to discover the message as it was the informants in advance. Each interview was allowed to take
delivered in the language of those under investigation. In hermeneutics, place during working hours.
the point of emanation is the will to understand, an understanding based
on historically evident pre-understanding. Gadamer (1999) emphasises
a certain way to withhold pre-understanding in order to acquire an open Data analysis
attitude, i.e. a suspension of our own prejudices. Pre-understanding em-
anates from a tradition or context, our horizon, and it may facilitate as The data were analysed using a hermeneutical approach (Gadamer,
well as constrain understanding. Hence, interpretation emanates from 1999) in order to grasp what the research group narrated about the
a certain horizon within which we conduct our thinking. Having an themes. This meant that each interview was initially read through
open attitude when confronted with new experiences enables us to many times to obtain a picture of the whole. In the second phase, the
see “the otherness” of the phenomenon which does not already authors gathered to reflect and discuss the meaning units that emerged.
exist in our pre-understanding. Understanding is thus a dialectic The meaning units, each comprising several words, are sentences or
process, an interaction of the things encountered as well as the self paragraphs related to each other through their content and context.
that encounters the things. In this respect, pre-understanding is The first author was responsible for the overall analysis and synthesis
not merely a memory that one has access to when needed; it also of the findings. The themes that emerged from the meaning units
provides direction. were then presented and discussed among the authors once more in
This study is part of a longitudinal study in Finland and Sweden. The order to confirm that the findings were in congruence with the original
nurse managers within health care were asked to name experienced material.
1422 Y. Hilli et al. / Nurse Education Today 34 (2014) 1420–1424

Findings care”(Fin). They saw the student as a future colleague and wanted to
educate and guide the student towards becoming a good workmate,
The findings are presented as three themes in order to present the one of the corps. “In my opinion…preceptorship is important because we
perceived experiences of preceptorship in supporting the process of are, in some manner, we are shaping new nurses” (Swe).
learning and development among student nurses. The three themes The preceptors' thinking went beyond their own context. They
are as follows: 1) the basis for learning is a caring student–preceptor re- seemed to want to transfer the spirit of nursing from one generation
lationship; 2) teaching in a safe and supportive learning environment; to another by introducing the students into an esprit de corps.
and 3) theory and praxis — two sides of the same coin. The meaning
units form a pattern in a web and there is no hierarchy between the
themes. Teaching in a safe and supportive learning environment

The preceptors explained how they walked “side by side” with the
The basis for learning is a caring student–preceptor relationship
student. At first, when the student came to the practice placement, the
preceptor was more supportive, staying in the background. “They don't
Developing a supportive relationship with the student nurse was
have the responsibility…you just don't go by yourself; instead we walk
considered to be the starting point and essential to the process of learn-
side by side” (Fin). This means that the preceptor was receptive to the
ing and development. This relationship was characterised by the fact
needs of the student and tried to respond to those needs. “You are a
that the preceptor bears the final responsibility for the nursing care of
support and a coach at the same time as they carry out activities…standing
the patients. Otherwise reciprocity was emphasised, a process whereby
there beside and you are there…as a support…for questions and answers”
both the student and the preceptor are learners enriching each other. In
(Fin). When the student's knowledge base grew and he or she was
this regard, the most important consideration was considered to be the
ready for more responsibility, it was given by the preceptor, step by
mutual will and interest to learn.
step. “Teaching and…supporting the student to…independent work…
The encounter between the student and the preceptor…the student supporting and precepting throughout the whole clinical education period”
seeks knowledge from the preceptor and the preceptor shares (Swe). The student was supported, allowing him or her to develop at his
knowledge…the activity and interest of the student spur the precep- or her own pace from an observer to an actor.
tor into being more motivated…you can actually benefit from each The preceptors explained how they tried to strengthen the students
other (Fin). “weak” points and to minimise the fears of the students. “We are not
supposed to take away from them the things they are doing well, but we
The preceptors emphasised the importance of welcoming the should strengthen the things that are not done well” (Swe). This was
student into a safe and permissive atmosphere. “If the situation is too done by giving the student responsibility under preception. “I think I
stressful and the student senses a tense atmosphere…the atmosphere and brought some peace by being able to play down everything. I saw that
the situation may affect learning in a negative way” (Fin). she could do things but didn't really dare to…we got this relationship and
In a permissive learning environment, each student is allowed to be she trusted me” (Swe). When the students felt safe in the relationship
the person he or she is and have space to be a student. This could also be with the preceptors, they dared to ask questions and reflected upon
referred to as a supportive environment, where each student feels different matters. The students also knew that they didn't have to
welcome and is treated as being part of a team and not left alone. In know everything, and they felt they had space and the right to be a
such an atmosphere, students feel safe and the conditions favour learner in their own pace.
student learning. “I suppose it's a mutual confidence, I would say. I trust The learning outcomes set the tone of the aims and were often
the student and the student trusts me” (Swe). supporting the learning process.
The preceptors considered themselves to be role models, both as
If I don't have any aims I cannot say to 100% how to instruct the
guides and teachers. In this respect, it is important that the preceptor
student. If I get the aims I know a little about what she is thinking
acts in the same manner as he or she guides the student. That is to
and what she wants to get out of this practice period (Fin).
say, the student learns nursing care by following the preceptor's
conduct. The preceptor teaches how to think and act like a nurse and
The preceptors considered it to be of the utmost importance to find
teaches different ways of conduct. The preceptor guides the student
out the level of the student. This meant for example that the student
into working life while instructing in the nursing process. As such,
articulated the learning outcomes or that the preceptor “checked” the
good preceptorship is considered to be the basis for student learning.
aims in order to be able to make a fair evaluation.
I think that it's basically about being interested in supervising, to be
Feedback is about that…the students get a feeling of…yes I move
interested in teaching someone else…or helping the other ‘along the
forward or that new steps are taken on the journey. I think that is
road’. I also think that you need to have knowledge as a nurse in
very very important in order to be able to develop and be brave
order for the student to grasp the connection (Swe).
enough to take part (Swe).
In the interviews, the preceptors emphasised the importance of a
Although feedback was considered to be very important, it was not a
sound knowledge base, both theoretical and practical. The relation
planned pedagogic activity. Nevertheless, students were given feedback
between theory and praxis is like a dialectic movement, you cannot do
during the working shift and during different activities.
one without the other.
A good preceptor must…have a strong theoretical knowledge base
and practical experience…not just teach what is in the paper but Theory and praxis — two sides of the same coin
should also try to work and live in the same manner I think (Fin).
The preceptors explained how theory and praxis complemented
According to the preceptors, preceptorship is both an education and each other to give a more holistic picture of nursing care. However, as
introduction into working life. The preceptors described how they intro- theory and praxis are two sides of the same coin, so to speak, it was
duced the student into working life in different ways as well as to the very difficult for the preceptors to actually separate one from the
context where they work. “I like to think that I teach what is required other. Therefore, each concept was considered to be the same in an
from a nurse in this particular work…what you must know in home ongoing dialectic movement.
Y. Hilli et al. / Nurse Education Today 34 (2014) 1420–1424 1423

The students often know something about diabetes…about insulin that the preceptor bears the final responsibility for the nursing care
and what one should eat and about physical activity, but then when of the patient. Both parties are responsible for learning and sharing
in reality the patient's glucose is not in balance and we must decide knowledge with each other. In the encounter with the student, the
what to do in order to get a better balance, we open the computer preceptor is receptive to the needs of the student and willing to re-
and search…theory is absolutely vital in order to know about these spond to those needs. The preceptors went on to explain how they
matters (Fin). walk side by side with the students, giving them more responsibility
when they are ready for it. This responsibility can be perceived as an
The preceptors expressed in a number of ways how they helped the inner responsibility (caring ethics) or as an outer responsibility, i.e. a
students to understand how theory and praxis are connected and how duty (nursing ethics) guided by law and directives. In this study the
they are united. One common way of supporting the students was by preceptors seemed to be guided by a strong inner responsibility in
thinking aloud and explaining to them the nursing care that was being terms of introducing the students into working life and an esprit de
given. corps.
Although some of the preceptors emphasised the importance of the
As one example, I used to explain that if a liquid is saturated with
learning outcomes to guide the student-learning process, it is obvious
glucose or salt it will suck in another liquid in the same way as when
that it is often the practical work, in fact, that guides what the students
we put salt on a fish. We buy salmon and we put a lot of salt on it in
learn. The focus is often on technical skills and the students may lose the
order to suck the liquid out of the fish. This is one way of explaining
opportunity to learn personal skills in clinical judgement and ethical
how dialysis is possible using a liquid (Fin).
aspects of nursing (Epstein and Carlin, 2012). However, the preceptors
pointed out that sometimes the learning outcomes are unrealistic or
Another method was by demonstrating technical skills. “I do it myself
impossible to achieve. Therefore, more attention should be paid to the
first…the student is beside me and watches how I do it while I explain and
learning outcomes at the faculty and to preparing the students for the
discuss with her (the student)” (Fin). Challenging the knowledge of the
clinical education.
students by asking questions was another commonly used method.
Although the preceptors consider it to be of the utmost importance
“The following time you then ask her (the student) how was it now…you
to unite theory and praxis, there is no time planned for reflection and
don't give the answer…you can help if she doesn't quite remember”
critical thinking. Reflection is dependent on the student's own activity.
(Fin). Critical reflection together with the students was also an often-
Nevertheless, although evidence-based praxis is neither emphasised
used method.
nor implemented, some preceptors do encourage the students to search
Ethical issues…They are thinking a lot about things and why, what is for evidence.
the reason and what are the consequences, why is this happening? According to the preceptors, theory and praxis are two sides of the
…why did the patient say like that to me and now I understand that same coin. However, this study revealed that they do not have enough
the patient started to show symptoms already earlier…. (Fin) pedagogical tools to consider this together with the students. The teach-
ing methods used, at present, are more preceptor-centred than student-
Ethical issues seemed to be common issues that students wanted to centred. In this study, only 22% of the informants had received a further
reflect upon together with the preceptors. The reflection sessions were education in pedagogics. As in earlier studies (Hyrkäs and Shoemaker,
considered important by many preceptors in relation to the student's 2007; Foley et al., 2012), this study revealed that some preceptors
learning process, but they were not planned activities. “The fact that seem to lack the pedagogical competence, support and acknowledge-
the students may come up with the answers themselves…that the student ment from their faculty and organisation. Furthermore, the students'
may try, test and even think by themselves how they function as a nurse” encounters with the preceptors do have an ethical dimension. This
(Swe). In this regard, the students could be taught ethical skills by ethical dimension must be heard and linked to the nursing ethics taught
following the preceptor's manner of conduct and by reflecting on at the faculty and linked to the preceptors' further education. Nurse
these ethical issues together with the preceptor. managers are in a key position to lead for change by ensuring the
competence of the preceptors through strategic planning. Focusing on
Discussion preceptorship will ensure the supply of professional nurses in the
future.
In this study we set out to discover the perspectives of preceptorship
experienced by the preceptors. We interviewed 31 experienced precep-
tors in western Finland and northern Sweden, 22% of whom had Trustworthiness of the study
received further education in preceptorship. All the preceptors were
recommended by nurse managers within the health care sector. The In this study 31 clinical preceptors were interviewed representing
preceptors willingly talked about preceptorship, thus providing us different contexts. The preceptors were recommended by the nurse
with a rich source of material. The main findings show that a supportive managers as good preceptors. The informants seemed happy to be
and caring relationship is the basis for student learning and develop- able to talk on preceptorship, which gave us a rich source of material.
ment (Danielsson et al., 2009; Koontz et al., 2010). However, the caring However, it is worth noting that there is always a small risk that the
relationship between the student and the preceptor is not merely a informants only say what they think the interviewer wants to hear. Nev-
cooperative relationship, since there is also an ethical dimension ertheless, the interviews, conducted in Western Finland and Northern
(Jokelainen et al., 2011). Moreover, a supportive environment for both Sweden, are undivided, which increases the trustworthiness of the
the students and preceptors is paramount, since positive preceptor ex- study. In qualitative interviews, valid knowledge is created through
periences enhance learning and even affect the decisions of students conversation, whereby use of language is most important (Gadamer,
to remain in the nursing profession. Epstein and Carlin (2012) reported 1999). The interviews in this study had the character of a conversation
that students felt alone, excluded and not respected in a non-supported about preceptorship in relation to student learning for nurses. As such,
clinical environment. Furthermore, they felt that they missed out on the pre-understanding of the interviewers guided the conversations to
educational opportunities. To counteract this problem, the ethical di- a deeper level. In order to ensure trustworthiness, an effort was made
mension implies welcoming each student into a caring relationship, to describe the context, the analysis of the data and the findings as clearly
thus confirming the student's dignity (Jokelainen et al., 2011). As such, as possible. To further strengthen the credibility of the themes, a variety
the student is allowed to be a student and to develop at his or her of quotes from the original data are presented so that the reader can eval-
own pace. In this light, the relationship is asymmetrical in the sense uate the transferability of the findings.
1424 Y. Hilli et al. / Nurse Education Today 34 (2014) 1420–1424

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ences and Umeå University for funding this project. Special thanks to
all the nurses who participated in the study and thus made it possible.
We also thank Paul Wilkinson for reviewing the language.

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