Praise for the Second Edition of
Mastering Precepting: A Nurse’s Handbook for Success
“Mastering Precepting is a must-have handbook for teaching and learning clinical science and a practical
overview of how and when that science is relevant. Preceptors are central knowledge workers in today’s
complex, fast-paced healthcare systems. ‘On the spot’ precepting calls attention to critical changes in
patients across time, while also teaching a vast amount of local knowledge about how a community of
practice learns, collaborates, and communicates. This book is an invaluable guide—a must-read for all
preceptors and nurse managers.”
–Patricia Benner, PhD, RN, FAAN
Executive Director, EducatingNurses.com
Professor Emerita, School of Nursing, Department of Social and Behavioral Sciences,
University of California, San Francisco
“Since the concept of reality shock was identified in the early 1970s, we have known that how nurses are
socialized into the profession influences the success of their practice and their entire careers. Subsequent
research has found that preceptors and a precepted experience are instrumental in helping new graduate
registered nurses make the transition to professional nurses. In Mastering Precepting, Beth Ulrich and
colleagues provide an excellent resource for nurses who are learning to become preceptors and for educators
who are responsible for preceptor development.”
–Marlene Kramer, PhD, RN, FAAN
President, Health Science Research Associates
“This book is the most significant contribution to the literature in the last two decades on the art and
science of preceptorship in the nursing profession. Beth Ulrich and her fellow authors provide theories,
practical applications, and ultimately the path forward for transforming organizations and individuals
in a complex, modern world that requires disruptive thinking and intentional action to create a better
tomorrow for our patients, our colleagues, and our profession.”
–Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN
Robert Wood Johnson Foundation Executive Nurse Fellow Alumna 2012-2015 Cohort
Chief Nursing Officer, Texas Health Dallas
NLN Foundation Chair
“This book is a brilliant and comprehensive resource for all nurses who participate in the critically
important preceptor role. Beth Ulrich and her team have created an exceptionally practical and wellevidenced tool for preceptors and managers that is a must-read for all involved in this process! This book
elevates the preceptor role firmly into a formal position that recognizes the essential responsibility preceptors
hold.”
–Judith G. Berg, MS, RN, FACHE
President and CEO, HealthImpact
“Preceptors are the linchpins in the smooth transition of nurses and students into new roles. Mastering
Precepting: A Nurse’s Handbook for Success is a terrific guide to how to be successful in the preceptor
role.”
–Rose O. Sherman, EdD, RN, NEA-BC, FAAN
Editor in Chief, Nurse Leader
Professor and Program Director, Nursing Administration and Financial Leadership,
Florida Atlantic University
“I have had the privilege of being mentored by Beth Ulrich. I say ‘privilege’ because she takes mentorship
to heart and, as such, would never take on a mentee if she was unable to give the person her all. This is but
one of the essential qualities of mentorship I learned from her. I have met no one who is more skilled at
helping mentees navigate difficult situations or reminding them to celebrate their successes. I celebrate you,
Beth. Thank you for sharing your wisdom with me and the nursing community.”
–Kenneth W. Dion, PhD, MSN, MBA, RN
Assistant Dean for Business Development and Strategic Relationships
Johns Hopkins School of Nursing
“The second edition of Mastering Precepting: A Nurse’s Handbook for Success improves on the already
excellent, evidence-based original. The new chapter on precepting advanced practice nurses adds essential
content, and the final chapter, ‘Preceptor Development,’ gives the reader a template for applying every
chapter in the book to a preceptor development program. This is a must-read for anyone developing or
improving a preceptor program for new graduates transitioning from academic education to practice, for
experienced nurses changing specialties or roles, or for nurses changing practice settings. In addition to
facilitating the transition of nurses by ensuring adequate knowledge and competency, preceptors transmit
the culture of quality and safety. This book keeps its promise—it truly is a handbook for creating successful
transitions.”
–Patsy Maloney, EdD, MSN, MA, RN-BC, NEA-BC, CEN
Senior Lecturer, Nursing and Healthcare Leadership
University of Washington Tacoma
“Beth Ulrich has produced a wonderful book full of thoughtful resources to assist nurses in mastering the
art of precepting new leaders. The contributions are masterful and useful for educators, clinicians, and
nurse executives!”
–Linda Burnes Bolton, DrPH, RN, FAAN
Senior Vice President and Chief Nursing Executive
Cedars-Sinai Medical Center
“The role of preceptor is indispensable in the complex, dynamic environments in which nurses at all levels
practice today. This second edition of Mastering Precepting provides a compendium of resources for anyone
interested in becoming a preceptor, becoming a better preceptor, or improving an organization’s preceptor
program. This edition contains practical tips and tools that can be tailored to unique situations and
implemented immediately. It is also a ready reference for all nurses on coaching, communicating, selecting
preceptors, and providing feedback.”
–David Marshall, JD, DNP, RN, CENP, NEA-BC, FAAN
System Chief Nursing and Patient Care Services Executive
The University of Texas Medical Branch
“Learning facilitators are known by many names, and one of those is ‘preceptor.’ Preceptors abound
because nursing relies on them to develop talent in specific situations. With the first edition of Mastering
Precepting, Dr. Ulrich and her colleagues gave all who precept a ready reference to understand the role
and specific skills to be successful. This second edition doesn’t disappoint. Being a preceptor is a complex
challenge, a combination of expert practitioner and clinical educator. Because these roles are typically
more focused on practitioner than educator, the book’s resources—tables that summarize key information,
forms that invite readers to respond to questions—are especially useful. This second edition concludes
with a chapter that supports the preceptor by offering a suggested outline of chapter-by-chapter learning.
Mastering Precepting is a one-stop place to learn about what it means to precept, what preceptors do, and
what a curriculum focused toward development of preceptors would include. With the emergence of the
Certified Nurse Educator–Clinical credential from the National League for Nursing, this book becomes an
even more valuable resource.”
–Patricia S. Yoder-Wise, EdD, RN, NEA-BC, ANEF, FAAN
Professor and Dean Emerita, Texas Tech University Health Sciences Center
President, The Wise Group
“Nurses are expected to lead and serve others toward a better health. Dr. Ulrich said it best: ‘Preceptors
are leaders and influencers.’ This book is a must-have for all preceptors to ensure a successful professional
journey. I was amazed to see the depth of knowledge found in this book. Furthermore, the content offers
an opportunity for the reader to develop a professional plan. This is an excellent resource for all preceptors
seeking and pursuing a lifelong journey of professional development.”
–Sylvain “Syl” Trepanier, DNP, RN, CENP, FAAN
Chief Clinical Executive Officer, Providence St. Joseph Health
Southern California Region, Irvine, California
“Mastering Precepting: A Nurse’s Handbook for Success, Second Edition, provides strategies for use by
nurses at all levels of practice. The role of precepting has increased importance and newfound trials in
today’s complex healthcare environment. Dr. Ulrich explores opportunities, challenges, and best practices
in this book. Her contemporary view of precepting examines generational differences, specific learner
populations, instructional technologies, and self-care strategies. This important book fills gaps in knowledge
that nurses may not have known existed.”
–Tamara Kear, PhD, RN, CNS, CNN
Associate Professor of Nursing
M. Louise Fitzpatrick College of Nursing, Villanova University
Nursing Research Consultant, Main Line Health
Mastering Precepting
A Nurse’s Handbook for Success
Second Edition
Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
Copyright © 2019 by Sigma Theta Tau International Honor Society of Nursing
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ISBN:
EPUB ISBN:
PDF ISBN:
MOBI ISBN:
9781945157868
9781945157875
9781945157882
9781945157899
________________________________________________________________________
Library of Congress Cataloging-in-Publication data
Names: Ulrich, Beth Tamplet, editor. | Sigma Theta Tau International issuing
body.
Title: Mastering precepting / [edited] by Beth Tamplet Ulrich.
Description: Second edition. | Indianapolis, IN : Sigma Theta Tau
International Honor Society of Nursing, [2019] | Includes bibliographical
references.
Identifiers: LCCN 2018041175| ISBN 9781945157868 (pbk.) | ISBN 9781945157882
(PDF) | ISBN 9781945157899 (MOBI) | ISBN 9781945157875 (ePUB)
Subjects: | MESH: Preceptorship | Education, Nursing--methods
Classification: LCC RT74.7 | NLM WY 18.5 | DDC 610.73--dc23 LC record available at https://lccn.loc.gov/2018041175
________________________________________________________________________
First Printing, 2018
Publisher: Dustin Sullivan
Acquisitions Editor: Emily Hatch
Development Editor: Kevin Kent
Cover Designer: Michael Tanamachi
Interior Design/Page Layout: Rebecca Batchelor
Managing Editor: Carla Hall
Project Editor: Kevin Kent
Copy Editor: Erin Geile
Proofreader: Gill Editorial Services
Indexer: Joy Dean Lee
Dedication
To my husband, Walter, who is my biggest fan and supporter; my daughter, Blythe, who makes me so proud
to be her mom; my son-in-law, Michael; and my grandson Henry, who brings me such joy and shows me
new ways to see the world.
To my colleagues who have precepted me throughout my career. I have been fortunate in every role I’ve ever
had to have had someone who was willing to precept me—someone to help me transition to the new role
and develop the competence and confidence to succeed. This book is dedicated to each of them with my
utmost gratitude and appreciation.
To every nurse who has ever been a preceptor and every nurse who will become a preceptor. There is no
greater contribution to nursing and to patient care than to ensure the competence of the next generation
of nurses. Your commitment to the nursing profession and to our patients makes me proud to be your
colleague.
Acknowledgments
It truly takes a village to create a book.
Thank you first and foremost to a dedicated group of contributors. I appreciate their willingness to share
their knowledge and expertise.
Thanks to everyone who read and used the first edition of Mastering Precepting and made suggestions on
ways to improve the second edition.
Thanks to the wonderful Sigma team who take care of every aspect of making a book come to life.
About the Author
Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
Beth Ulrich is a nationally recognized thought leader who is known for her research studying nursing work
environments and the experiences of new graduate nurses as they transition from nursing school into the
workforce and for her leadership in developing the roles of nephrology nurses and improving the care of
nephrology patients. Ulrich has extensive experience as a healthcare executive, educator, and researcher.
She is currently a professor at the Cizik School of Nursing at The University of Texas Health Science Center
at Houston, teaching in the DNP Program, and editor of the Nephrology Nursing Journal, the professional
journal of the American Nephrology Nurses Association. Ulrich has been a co-investigator on a series of
national nursing workforce and work environment studies and four studies of critical-care nurse work
environments conducted with the American Association of Critical-Care Nurses.
Ulrich received her bachelor’s degree from the Medical University of South Carolina, her master’s degree
from The University of Texas Health Science Center at Houston, and her doctorate from the University
of Houston in a collaborative program with Baylor College of Medicine. She is a past president of the
American Nephrology Nurses Association, a fellow in the American College of Healthcare Executives, and
a fellow in the American Academy of Nursing. She was recognized as the Outstanding Nursing Alumnus
of the Medical University of South Carolina in 1989, as a distinguished alumnus of The University of Texas
Health Science Center at Houston School of Nursing in 2002, received the Outstanding Contribution to
the American Nephrology Nurses Association award in 2008, and received the Marguerite Rodgers Kinney
Award for a Distinguished Career from the American Association of Critical-Care Nurses in 2018. Ulrich
has numerous publications and presentations to her credit on topics including nephrology nursing, nurses’
work environments, and how new graduate nurses transition into professional nurses.
Follow her and engage with other preceptors on Twitter at @RNPreceptor. For tools and other
resources, go to www.RNPreceptor.com.
Contributing Authors
Larissa Africa, MBA, BSN, RN
Larissa Africa is President of Versant Holdings, LLC. Her experience began as a new graduate nurse at
Children’s Hospital Los Angeles in their first RN Internship Program in 1999. Africa was a key stakeholder
in transitioning a department-based internship program capability to what is now known as the Versant, an
organization that provides an outcomes-based transition to practice residencies and fellowships at healthcare
organizations nationwide. Africa has published articles related to the economic benefit of transition to
practice programs and the benefits of using a competency-based system for nursing students’ capstone
program. Africa has also served as the executive leader in the development and implementation of Versant’s
Transition Nurse Fellowship and Versant’s Home Health Residency and Fellowship.
Cherilyn Ashlock, DNP, RN, NE-BC
Cherilyn Ashlock is the Director of Professional Practice at Johns Hopkins All Children’s Hospital in St.
Petersburg, Florida. Prior to coming to this role, Ashlock worked with Versant RN Residencies to support
implementation of a clinical transition to practice program for new graduate registered nurses. In her
current role as director for professional practice, Ashlock oversees clinical and unit-based onboarding,
development and education, nursing research, and nursing quality outcomes. Under her leadership, Johns
Hopkins All Children’s continues to develop their transition to practice programs, as well as build upon
the preceptor role for nursing and patient care services. Ashlock completed her doctor of nursing practice
(DNP) degree in executive leadership at Old Dominion University in 2017 and focused her capstone work
on interventions to prevent missed nursing care in the pediatric acute care environment.
Cindy Bianchini, MSN, RN, CNOR
Cindy Bianchini is the Director of the RN Residency program at Legacy Health in Portland, Oregon. She
received her master’s degree in nursing in 2016 with a focus on executive administration and leadership
from the University of South Alabama in Mobile. Bianchini’s background is in operating room nursing,
and she spent 5 years as a system-wide surgical services educator helping to onboard new employees
as well as facilitate ongoing professional development. Bianchini developed the current RN Residency
program in 2015 when Legacy Health decided to bring the program internal. Bianchini led the building and
development of Legacy’s current residency program including specialty competencies, the mentor program,
the curriculum, selecting and guiding subject matter experts, and preceptor development and support, with
a focus on continuous quality improvement.
Carol A. Bradley, MSN, RN, CENP
Carol Bradley is the Senior Vice President and System Chief Nursing Officer for the Legacy Health
System, an eight-hospital integrated healthcare delivery system serving Portland, Oregon, and southwest
Washington. Prior to joining Legacy, Bradley served in a variety of senior nursing executive
positions in large health systems, including the not-for-profit, for-profit, and public hospital sectors and was
also the Regional Vice President and Editor for the California edition of NurseWeek.
Contributing Authors
xi
Within her nursing career, she has worked as a staff nurse, clinical specialist, clinical director, and
senior nurse executive. Bradley holds associate and bachelor’s degrees in nursing from the University
of Nebraska and a master of science in nursing degree from the University of Arizona. She is a 1991
Wharton Fellow and is certified in Executive Nursing Practice (CENP) by the American Organization of
Nurse Executives. She is a nationally known speaker and consultant on nursing/patient care, workforce
issues, and work environment improvement, and is a frequent contributor to journals, media, and
professional publications on topics important to nursing and patient care. She has contributed to several
books and serves on the editorial board of Nursing Administrative Quarterly.
Cathleen M. Deckers, EdD, RN, CHSE
Cathleen Deckers has over 36 years of nursing education and training experience in both the service
and the academic arenas. Her academic areas of expertise include utilization of high fidelity simulation
for education training and competency assurance, management and supervision of clinical rotation
experience, and data collection and research in clinical workforce development. Deckers’s research
interests include high fidelity simulation, learning theory, and gaming. She is an active participant on
the Accreditation Committee for the Society for Simulation in Healthcare to improve standardization of
simulation practices internationally. Deckers currently works for California State University, Long Beach
as an assistant professor in the School of Nursing. She also provides consultation and education services
for CAE Healthcare.
Amy K. Doepken, MSN, RN
Amy Doepken is a registered nurse who manages the Medical Specialties Unit at Legacy Salmon Creek
Medical Center in Vancouver, Washington. Amy has partnered with the University of Portland to adopt
their Dedicated Education Unit Model for her medical unit. Doepken is the former program director
for the RN Residency and Academic Relationships for Legacy Health in Portland, Oregon. Doepken has
a passion for promoting a positive preceptor experience and was involved in the early development of
Legacy’s preceptor program. She has developed and supported debriefing and mentoring in her roles.
Doepken graduated with her bachelor of nursing science from the University of Portland in 2002
and a master’s degree in health system leadership from Gonzaga University in 2014. She has a strong
background in critical care nursing. Doepken is an active member of NWONE and AONE. She
completed the AONE Nurse Manager Fellowship in 2016 and was the AACN 2010 Circle of Excellence
Award Winner.
Virginia Downie, MSN, RN-BC, NPDS
Virginia Downie is a Nursing Education and Practice Specialist for Legacy Health in Portland, Oregon.
She provides program support for the Legacy RN Residency Program in the areas of
curriculum, mentorship, and preceptorship. Downie spearheaded the development and implementation
of the Legacy Preceptorship Program, which provides ongoing recruitment, training, and support for
RN and non-RN preceptors throughout the organization.
xii
Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Downie received her master’s degree in nursing education from Nebraska Methodist College in 2014,
and is board certified as a Nursing Professional Development Specialist. These accomplishments and her
30 years of direct care nursing experience enrich the commitment she has for creating and sustaining
robust RN residency programs and preceptorships.
Denise D. Fall, DNP, RN, CENP
Denise Fall is the Vice President and Chief Nursing Officer for Legacy Good Samaritan Medical
Center. Fall completed her doctoral work at the University of San Francisco. She was the hospital nurse
executive for Legacy Salmon Creek for 3 years before returning to Good Samaritan where she started
her nursing career. Fall is known for building strong collaborative teams who drive quality and patient
outcomes. Fall continues to support the clinical and academic progression of all nurses through her
work as a preceptor for doctoral and master’s students, as well as by advocating for new nurse graduates
to be welcomed into all clinical settings.
Mary S. Haras, PhD, MBA, APN, NP-C, CNN
Mary Haras is currently Associate Professor and Chair, Department of Advanced Nursing Practice at
Georgetown University in Washington, DC. Prior to that, she was Associate Dean for graduate nursing
programs at Saint Xavier University in Chicago. Haras is certified as an adult nurse practitioner by
the American Academy of Nurse Practitioners, and is a certified nephrology nurse by the Nephrology
Nursing Certification Commission. Haras has extensive experience in curriculum and preceptor
development and has authored several book chapters and numerous manuscripts. She received her
PhD in nursing from Illinois State University. Her research interests include advance care planning for
persons with chronic kidney disease.
Cindy Lefton, PhD, RN, CPXP
Cindy Lefton is Manager and Researcher, Patient Experience, Emergency Services at Barnes-Jewish
Hospital and Vice President, Organizational Consulting at Psychological Associates, Inc. She has
combined her knowledge of organizations with her extensive experience as a registered nurse,
paramedic, and clinical research nurse to develop a variety of effective interventions for academic
medical centers and hospitals. These projects encompass a broad scope of services, including coaching,
team building, survey development, and organizational collaboration training. Her research interests
include healthy work environments, with an emphasis on meaningful recognition, demonstrating
respect in the workplace, and team collaboration. Currently, she is leading The DAISY Award Impact
Research team. Lefton has published articles on meaningful recognition, collaboration, respect, and
culture change.
Lefton obtained her PhD in psychology from St. Louis University. She earned a master of science
in research from St. Louis University and a master of arts in human resource management from
Contributing Authors
xiii
Washington University, a bachelor of science in industrial psychology and organizational psychology from
Washington University, and a nursing diploma from Jewish Hospital School of Nursing.
Robert E. Lefton, PhD
Robert Lefton, Cofounder and Current Chairman and CEO of Psychological Associates, Inc., has 60 years
of experience as a consultant in leadership, organization and cultural change, and succession planning.
Since earning his PhD at Washington University in St. Louis, Missouri, he has worked as a consultant with
many of Fortune’s top 500 companies, has served on the faculty of Washington University, the Motorola
Executive Institute, the ALCOA Executive Institute, and CEO International, Inc. As one of the original
developers of Dimensional Training, he has conducted seminars for and consulted with several hundred
leading hospitals and corporations in the United States and Europe. Lefton is coauthor of five books:
Leadership Through People Skills, Dimensional Selling, Effective Motivation Through Performance Appraisal,
Making Common Sense Common Practice, and Why Can’t We Get Anything Done Around Here? Lefton
currently serves on the board of directors for Barnes-Jewish Hospital of St. Louis and numerous privately
held and family-owned businesses. He is honored to be an executive in residence at the John M. Olin
School of Business at Washington University in St. Louis.
Kim A. Richards, RN, NC-BC
As an author, inspiring professional speaker, and ANCC Board Certified Nurse Coach, Kim Richards is
passionate about supporting busy caregivers in their quest for practical self-care integration. As a nurse
and an executive recruiter, Richards became increasingly aware of the “revolving door” of nurses in acute
care facilities. After interviewing hundreds of nurses, she noticed a common theme was emerging. Nurses
were expressing signs and symptoms of compassion fatigue and burnout. By combining her passion for
nursing, fitness, and coaching as well as her extensive research on the science of self-care, Richards created
the components of Self-Care Academy, LLC, a comprehensive program that reduces turnover, improves
engagement, and creates a culture of caring.
Karen C. Robbins, MS, RN, CNN
Karen Robbins has spent the majority of her nursing career in nephrology nursing. She has been a staff
nurse in hemodialysis, a nurse clinician in transplantation, a nurse educator in a dialysis and transplant
program, and the independent living donor advocate for live kidney donors. Robbins has been a mentor
and educator for many nurses, especially in nephrology nursing, and an advocate for patients. She
is a published author, editor, recognized speaker, and legal nurse consultant. Robbins is a Certified
Nephrology Nurse by the Nephrology Nursing Certification Commission. The associate editor of the
Nephrology Nursing Journal, she is a past president of the American Nephrology Nurses Association.
xiv
Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Laura Lynn Rooney, DNP, RN, FNP-BC, BC-ADM, FAANP
Laura Rooney has over 20 years of nursing and advanced nursing practice experience, and more than
10 years in nursing education, focusing on the advanced practice role. Rooney has been a family nurse
practitioner in primary care, pain management, occupational health, and rural medicine. As Director of
a nurse-managed clinic, Rooney was successful in implementing the first certified Diabetes Education
Management Program in the system, followed by Level 3 recognition from the National Center for
Quality Assurance (NCQA) as a Patient Centered Medical Home—the first nurse-managed clinic with
this distinction in the health system. As the Director and Head Administrator for the clinic, Rooney was
instrumental in establishing protocols and procedures, recruiting and retaining staff, and facilitating
teamwork while demonstrating leadership.
Currently Rooney is an assistant professor at Cizik School of Nursing, with primary responsibilities in
the doctor of nursing practice (DNP) program. She continues to practice in family medicine, with a
focus on an underserved population, in a large multispecialty practice.
Laurie Shiparski, MS, BSN, RN
Laurie Shiparski has over 30 years’ experience in nursing and healthcare leadership positions. She has
worked in various roles including critical-care RN, clinical hospital leadership, healthcare consulting
business owner, and corporate executive in a healthcare technology and clinical practice company. She
is currently a principal at Edgework Institute. As a consultant, Shiparski works in partnership with
hospital leadership on leadership development and coaching, communication, physician-driven practice
improvement, strategy, and operations improvement.
Shiparski has sought to uncover her gifts and bring her authentic self to work and life, which has
inspired her to offer programs that focus on taking care of self, navigating change, finding passion and
purpose, and creating new possibilities. She is also an international speaker and an author of numerous
articles and five books.
Kelly C. Walker, DNP, CNM
Kelly Walker is an Assistant Professor and Core Program Director in the Department of Advanced
Nursing Practice at Georgetown University’s School of Nursing and Health Studies. Prior to that, she
was an Assistant Professor and Program Director for the Nurse Midwifery Program at Stony Brook
University School of Nursing. She was a member of the Regional Perinatal Center at Upstate Medical
University as a Certified Nurse Midwife and faculty member for 11 years. Her clinical experience also
included 7 years in nursing at New York University. Her current practice includes midwifery care in
a community outpatient setting. She holds a bachelor’s degree in English from Russell Sage College, a
bachelor’s and master’s degree in nursing from New York University, and a doctorate in nursing practice
from Stony Brook University. Walker also completed a post-doctorate fellowship in leadership and
education at Stony Brook University.
Contributing Authors
Walker’s clinical scholarship includes improving maternal fetal outcomes and access to healthcare
for vulnerable populations. Specific areas of interest include improving access to care for the LGBT
community, identifying women at risk for postpartum depression, and decreasing elective induction
of labor rates. Her scholarship in education includes promoting technology in distance education and
outcome evaluation in midwifery and graduate education.
Walker holds an appointment on the Board of Midwifery for New York State. She is also a member
of American College of Nurse Midwives, New York State Association of Licensed Midwives, and the
Accreditation Commission for Midwifery Education.
Wendy Jo Wilkinson, MSN, ARNP
Wendy Jo Wilkinson has over 40 years’ experience in the healthcare industry, serving in various roles
within the acute hospital setting, home healthcare operations, and education. In these roles, she has
gained expertise in leadership, multi-site management, start-up operations, strategic and financial
planning, establishing clinical standards and competencies, development of specialized clinical
programs, quality management and improvement, customer relations, and sales and marketing
initiatives. Wilkinson now serves as Chief Nursing Officer and Manager for the Domestic Academy
for CAE Healthcare, managing a team that consults and assists customers with applying, developing,
implementing, and facilitating high fidelity patient simulation into their academic and hospital-based
programs. She is ultimately responsible for the oversight of all CAE’s educational products to ensure
they are clinically and pedagogically sound.
xv
Table of Contents
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Contributing Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Foreword by Kathleen Sanford. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
Foreword by Gwen Sherwood. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxix
1
The Preceptor Role. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
The Context of Precepting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Nursing Context. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Healthcare System Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Preceptor Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Teacher/Coach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Leader/Influencer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Facilitator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Evaluator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Socialization Agent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Protector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Role Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2
Learning: The Foundation of Precepting. . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
Adult Learning Theory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Social Learning Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hierarchy of Needs Theory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Experiential Learning Theory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transformative Learning Theory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Novice to Expert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Learning Stages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Learning Styles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Curry’s Learning Style Classification System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cognitive Styles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gregorc’s Learning Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Myers-Briggs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Field Dependence/Independence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Kolb’s Learning Cycle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Instructional Preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sensory Learning Preferences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
24
24
26
28
29
31
32
33
34
34
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36
36
37
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3
Precepting Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Precepting Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Single Preceptor Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Married State Preceptor Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Team Preceptor Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preceptee Cohorts or One at a Time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sharing Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Creating Positive Learning Environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enhancing Experiential Learning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Brain Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interprofessional Clinical Learning Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A Safe Learning Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
It Takes a Village. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Establishing the Preceptor-Preceptee Relationship. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preceptee Learner Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Managing Transitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical Teaching Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Strengths-Based Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Microskills Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Debriefing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reflective Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mindfulness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resilience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ending the Preceptor-Preceptee Relationship. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
45
46
47
47
48
48
49
50
51
51
52
53
56
56
57
58
58
58
60
62
65
66
68
70
71
79
Core Precepting Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
Competence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Competence Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Conscious Competence Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Competency Outcomes and Performance Assessment (COPA) Model. . . . . . . . . . . . . . 87
Wright Competency Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Critical Thinking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Critical Thinking—A Philosophical Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Critical Thinking in Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Precepting Critical Thinking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Clinical Reasoning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Clinical Judgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Developing Situational Awareness, Expert Reasoning, and Intuition. . . . . . . . . . . . . . 96
Confidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Table of Contents
5 Having a Plan: Developing and Using Goals, Objectives,
and Outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Kelly C. Walker, DNP, CNM; Karen C. Robbins, MS, RN, CNN;
Mary S. Haras, PhD, MBA, APN, NP-C, CNN
Expectations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
The Relationship Among Goals, Objectives, and Outcomes . . . . . . . . . . . . . . . . . . . . . 107
Objectives vs. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Learning Taxonomies and Learning Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Bloom’s Taxonomy: Objectives and Domains of Learning. . . . . . . . . . . . . . . . . . . . . . . . 109
Fink’s Taxonomy of Significant Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Kolb’s Theory: Experiential Learning Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Behavioral Objectives—Are They a Magic Potion?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Creating Outcome Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Distinguishing Outcomes From Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Developing Measurable Objectives and Outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Useful Frameworks for Preceptors and Preceptees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
One-Minute Preceptor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
SNAPPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Pitfalls of Developing Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
6
Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Laurie Shiparski, MS, BSN, RN
The Five Skills of Effective Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Intent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Listening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Inquiry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Silence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Managing Different Methods of Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Patient Safety and Handoffs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Considerations for Participating in Team Communications. . . . . . . . . . . . . . . . . . . . . . 148
Managing Difficult Conversations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Communication Strategies for Education and Meetings . . . . . . . . . . . . . . . . . . . . . . . . 150
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
7
Coaching. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Laurie Shiparski, MS, BSN, RN
What Is the Role of the Preceptor as Coach?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Setting Up a Coaching Agreement With a Preceptee . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Utilizing a Coaching Interaction Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
A Case Study to Exemplify 4 Gateways Coaching. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
The Issue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
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Strategies to Inspire Learning and Move Through Challenges. . . . . . . . . . . . . . . . . . . 164
The Preceptor’s Role in Working With Resistance and Edges. . . . . . . . . . . . . . . . . . . . 165
An Edge Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Ending a Coaching Relationship With a Preceptee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
8
Effectively Using Instructional Technologies. . . . . . . . . . . . . . . . . . . . . . 171
Cathleen M. Deckers, EdD, RN, CHSE; Wendy Jo Wilkinson, MSN, ARNP
Why Technology Is Imperative for Today’s Healthcare Environment. . . . . . . . . . . . . . 171
Technology Across Generations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Web-Based Technologies for Presenting Didactic Material . . . . . . . . . . . . . . . . . . . . . . 173
Web-Based Collaboration Tools for Maximizing Informal Learning. . . . . . . . . . . . . . . 176
Effectiveness of Web-Based Collaboration Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Simulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
The Pursuit of Fidelity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
High-Fidelity Patient Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Developing Clinical Competence and Confidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Facilitating Clinical Judgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Using HFPS to Develop Situation Awareness and Clinical Reasoning . . . . . . . . . . . . . 182
Design of High-Fidelity Patient Simulation Experiences . . . . . . . . . . . . . . . . . . . . . . . . . 184
Implications of Using High-Fidelity Patient Simulation for Preceptors,
Educators, and Managers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Quality Improvement in Precepting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Future of Instructional Technology/Future Implications of Instructional
Technology Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
9
Precepting Specific Learner Populations. . . . . . . . . . . . . . . . . . . . . . . . . . 197
Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
Prelicensure Student Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Creating a Positive Clinical Learning Environment for Prelicensure Students. . . . . . 202
A Recruitment Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
New Graduate Registered Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
The Practice-Education Gap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Bridging the Gap—Transition to Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Precepting NGRNs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Managing the Normal Chaos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Scope of Practice and Autonomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
New Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Being a Nurse—Developing Professional Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Leadership and Interprofessional Teamwork. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Other Considerations with NGRNs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Post-Baccalaureate Graduate Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Experienced Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Table of Contents
Internationally Educated Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Nurses From Different Generations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Learning Styles and Preferences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Precepting and Working With Each Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
10
Precepting Advanced Practice Registered Nurses. . . . . . . . . . . . . . . . . 227
Laura Lynn Rooney, DNP, RN, FNP-BC, BC-ADM, FAANP
Understanding the Role of the APRN Preceptor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Know Your Preceptee, Know Yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Precepting the APRN Student . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Making the Most of the Clinical Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Understanding Yourself as the Preceptor—Incentives and Barriers . . . . . . . . . . . . . . 233
Precepting Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
11
Assessing and Addressing Preceptee Behavior and Motivation. . . . 245
Cindy Lefton, PhD, RN, CPXP; Robert E. Lefton, PhD
Just Culture: A Problem-Solving Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
Three Types of Errors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Applying Just Culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Providing Feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
The Dimensional Model of Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Quadrant 1 Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Quadrant 2 Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Quadrant 3 Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Quadrant 4 Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Understanding Preceptee Motivations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Interacting With Influence—The Five-Step Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Step One: Start the Conversation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Step Two: Get the Preceptee’s Views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Step Three: Give Your Views (of the Preceptee’s Views) . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Step Four: Resolve Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Step Five: Develop an Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Five-Step Format Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
12
Pragmatics of Precepting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Larissa Africa, MBA, BSN, RN; Cherilyn Ashlock, DNP, RN, NE-BC
Organization and Time Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Preparing for the Shift and Patient Assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Shift Reports and Patient Handoffs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
xxi
xxii
Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
The Clinical Shift. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Establishing a Routine and Facilitating Prioritization. . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Delegation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Performance Discrepancies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Problem-Solving Preceptor-Preceptee Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
When Competency Performance Becomes a Challenge. . . . . . . . . . . . . . . . . . . . . . . . . . 278
Challenging Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Preceptor-Preceptee Mismatch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
13
Self-Care for Preceptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Kim A. Richards, RN, NC-BC
Self-Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Compassion Fatigue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Self-Care Pathways. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Physical Pathway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Mental Pathway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
Emotional Pathway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
Spiritual Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Relationships Pathway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Choices Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Your Accountability Buddy and Self-Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
14 For Managers: Selecting, Supporting, and
Sustaining Preceptors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Carol A. Bradley, MSN, RN, CENP; Amy K. Doepken, MSN, RN;
Denise D. Fall, DNP, RN, CENP; Virginia Downie, MSN, RN-BC, NPDS;
Cindy Bianchini, MSN, RN, CNOR
Establishing Performance Standards and Preceptor Competencies. . . . . . . . . . . . . . 300
Preceptor Selection Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Setting the Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Creating a Culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Defining Needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Matching Preceptors With Preceptees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Setting Expectations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Preceptor Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Evaluating Preceptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Supporting and Sustaining Preceptors and Preceptorships . . . . . . . . . . . . . . . . . . . . . 314
Providing Adequate Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Table of Contents
Preceptor Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Meaningful Recognition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Getting Creative to Overcome Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
315
316
317
318
322
Preceptor Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Assess the Practice Gap and Identify the Educational Needs . . . . . . . . . . . . . . . . . . . . . 324
Preceptor Program Delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Face-to-Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Online . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
Blended Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
Learner Engagement Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Program Length. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Evidence-Based Decisions and Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Content—Using the Mastering Precepting Book for Preceptor Education . . . . . . . . 329
Chapter/Module 1: The Preceptor Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Chapter/Module 2: Learning: The Foundation of Precepting . . . . . . . . . . . . . . . . . . . . . 330
Chapter/Module 3: Precepting Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Chapter/Module 4: Core Precepting Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Chapter/Module 5: Having a Plan: Developing and Using Goals, Objectives,
and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Chapter/Module 6: Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Chapter/Module 7: Coaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Chapter/Module 8: Effectively Using Instructional Technologies . . . . . . . . . . . . . . . . . 336
Chapter/Module 9: Precepting Specific Learner Populations . . . . . . . . . . . . . . . . . . . . . 337
Chapter/Module 10: Precepting Advanced Practice Registered Nurses. . . . . . . . . . . . 338
Chapter/Module 11: Assessing and Addressing Preceptee Behavior and
Motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Chapter/Module 12: Pragmatics of Precepting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Chapter/Module 13: Self-Care for Preceptors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Chapter/Module 14: For Managers: Selecting, Supporting, and Sustaining
Preceptors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Precepting the Preceptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Program Evaluation and Continuous Improvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
A
Additional Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
American Nurses Association (ANA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
The Association for Nursing Professional Development (ANPD) . . . . . . . . . . . . . . . . . 347
Campaign for Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
xxiii
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Institute for Healthcare Improvement (IHI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Interprofessional Education Collaborative (IPEC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Missouri Preceptor Academy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
National Academy of Medicine Clinician Well-Being Knowledge Hub. . . . . . . . . . . . 349
National League for Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
QSEN Institute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Faculty Learning Modules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
QSEN Competencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
QSEN Teaching Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
Foreword
by Kathleen Sanford
I wish this wonderful book had been available when I graduated with my newly minted BSN. If it had
been, perhaps my “preceptor,” a very competent nurse, wouldn’t have considered me ready to take on a
full patient load after only a week of orientation. This book would have been very handy when, after a
few months of practice, I was assigned to precept another novice. Having been through recent trial-anderror learnings myself, I thought I had improved on the process by adding patient care experiences to
the two weeks my “preceptee” spent with me. I made sure she knew how to insert a Foley catheter, put
in an IV, place an NG tube, and change a tracheostomy dressing. These were all procedures I had been
sadly inept at doing at the time my preceptor said I was ready to take my place on the RN schedule.
Precepting was a fairly new concept in those years. It was just being defined in the literature, and nurses
used the term loosely, as my early experiences illustrate. The cursory introductions many of us received
to new roles and new jobs could scarcely be described as true initiations to the work and workplace,
much less preceptorships. Some of us confused precepting with processes as different as orienting and
mentoring for decades. Now, we have a more sophisticated understanding of these terms, and today’s
preceptors are much better prepared, largely thanks to the first edition of this book, which received two
American Journal of Nursing Book of the Year Awards in 2012.
In this second edition, Beth Ulrich and her contributing colleagues have compiled a comprehensive
compendium about the science and art of precepting. They cover the various roles of a preceptor in
depth while also addressing the needs of preceptees, managers, and organizations. They address crucial
topics such as resilience, compassion fatigue, mindfulness, just culture, and critical thinking. The new
edition includes information on using new instructional technologies and a chapter about precepting
advanced practice registered nurses. I can’t think of anything they’ve left out about how to help nurses
bridge the gap between theoretical knowledge and the realities of
practice.
The success of these changes is vitally important. The year I started my nursing career, Marlene Kramer’s
book Reality Shock: Why Nurses Leave Nursing was published. Among other things, she spelled out the
merit of preceptorships to mitigate the reality shock that new nurses experience. Forty-four years later,
preceptorships are needed more than ever. Working with hospital patients is becoming more complex
at a time when an unprecedented number of expert nurses are retiring. As a result, we have a less
experienced healthcare workforce, including a greater percentage of novice nurses, with a critical need
for precepting.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
That’s why I’m grateful for this book. Nurses need help to successfully navigate change, whether they
are moving from a student to a nurse role or from a nurse to a new specialty position. Patients need
competent, caring, and confident nurses. To meet these needs, preceptors must be proficient in a variety
of teaching, coaching, role-modeling, and leadership skills. This complete guide ensures that they will
be.
–Kathleen Sanford, DBA, RN, FACHE, FAAN
Chief Nursing Officer, Catholic Health Initiatives
Editor-In-Chief, Nursing Administration Quarterly
Foreword
by Gwen Sherwood
The work of nursing is physically and emotionally intense, made more challenging during periods
of transition. We all have times when we benefit from an experienced preceptor—whether as a
new graduate entering practice, an experienced staff nurse changing clinical areas, or a clinician
transitioning to academia. Transitions involve a careful balance of role models, relationships, and
reflection—three R’s that are at the core of this signature second edition of Mastering Precepting: A
Nurse’s Handbook for Success.
Preceptors have a major role in nursing education. The special skills required have often been
overlooked; not all great clinicians are effective preceptors. Teaching involves craft, and effective
precepting involves both art and science. Like good teaching or good nursing care, good precepting
is a carefully developed expertise that develops over time. This updated, expanded second edition is a
comprehensive guide to the apprenticeship learning model that can apply to nurse educators, managers,
and staff nurses.
A preceptor can ease transitions anytime roles and performance expectations change. Adjusting to a
new role or clinical area presents challenges in demonstrating new competencies, learning the social
milieu, and finding one’s place in the new group. Having an experienced role model, the first key of an
effective preceptor, helps smooth the adaptation process. Preceptors support the pillars of education
by guiding the preceptee in learning to do, know, be, and work/live as a productive team member. This
critical book recognizes the art and science of excellent precepting to help learners bridge the worlds of
nursing education and practice.
The preceptor role is similar to that of a mentor; however, selection of preceptors is based on their
accomplishment of competencies. Often overlooked is the imperative to provide preceptors for novice
faculty transitioning from clinical areas to academia. The demands of understanding the politics of
the academic environment, comprehending academic promotion and tenure, and establishing an area
of scholarship—while demonstrating excellence in teaching—contribute to high turnover and faculty
shortages. One strength of this book is its broad spectrum in applying the art of precepting. It provides
a double model for schools of nursing by both helping faculty adapt and developing preceptors for their
students.
The relationship between preceptor and learner (preceptee) is the second key to an effective precepting
experience. Learning by “doing,” or experiential learning, is a valued pedagogy for service professions.
Learning by doing is a systematic, supervised process based on evidence-based standards of excellence
in which learners demonstrate their applicable knowledge, skills, and attitudes. To learn by doing
involves careful coaching, facilitation, mentoring, guidance, and supervision from a skilled practitioner;
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
thus, it is relationship-dependent. Preceptors must master the art of observation, assessment, and
feedback while building a relationship of support and encouragement. Communication of the learner’s
development must be clearly delineated in the initial learning contract—whether it is with the nurse
manager for a new employee or graduate or with a faculty member for student learners.
Good preceptors not only guide skill acquisition based on the science of nursing—they also practice
the art of nursing by helping learners reflect on their experiences. Reflection, the third key to effective
precepting, is the process of examining the meaning and objectively looking at varying perspectives
to make sense of an event within the context of empirical knowledge. Reflecting to learn from one’s
experience is the basis of Patricia Benner’s book From Novice to Expert (1984) that is used in many
professional practice models. Preceptors are frontline guides who observe learners’ developing
competencies and thus have a key role in evaluation and assessment. Reflecting on their experiences
helps preceptees identify areas of improvement and establishes the practice of lifelong learning.
Reflection also contributes to satisfaction through self-recognition of progress. Developing relationships
and learning new roles amid the demands of caregiving is challenging; through systematic reflection,
preceptees learn to balance ideal responses with reality and continually improve their work. An expert
preceptor engages the learner in critical dialogue to explore outcomes and serves as coach, guide, and
mentor in recognizing alternative perspectives and ways of performing.
These three R’s—role models, relationships, and reflection—illustrate the competencies for mastering
precepting. Authored by an experienced educator, scholar, and clinician who has lived the model for
effective precepting, this book describes preceptor orientation, qualifications, and skills and details the
assessment and evaluation process. Mastering Precepting will benefit all nursing education programs—
transition to practice, new employee orientation in clinical settings, academic programs for learners in
capstone courses, and advanced practice clinical experiences.
–Gwen Sherwood, PhD, RN, FAAN, ANEF
Professor Emeritus
University of North Carolina at Chapel Hill School of Nursing
Reference
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley
Publishing.
Introduction
“Live as if you were going to die tomorrow.
Learn as if you were going to live forever.”
–Mahatma Gandhi
Preceptors live at the intersections of education and practice and of the present and the future. They
practice at the point where theoretical learning meets reality and where the gap between current and needed
knowledge and expertise gets filled. Preceptors are the essential link between what nurses are taught and
what they do, and between what nurses know and what they need to know. Having competent preceptors
is critical to educating nursing students, transitioning new graduate nurses to the professional nursing role,
and transitioning experienced nurses to new roles and specialties.
Preceptors teach at the point of practice. They create experiences in which the preceptee can engage
and learn. Benner, Sutphen, Leonard, and Day (2010, p. 42) note that “only experiential learning can
yield the complex, open-ended, skilled knowledge required for learning to recognize the nature of the
particular resources and constraints in equally open-ended and undetermined clinical situations,” and
that “experiential learning depends on an environment where feedback in performance is rich and the
opportunities for articulating and reflecting on the experiences are deliberately planned” (p. 43). Teaching/
precepting is a two-way street—it requires a constant back-and-forth communication between the preceptor
and the preceptee. Precepting uses listening and observation skills as much or more than talking and doing
skills.
Myths
Several myths about preceptors and precepting need to be dispelled. The first is that because you are a
good clinical nurse, you will be a good preceptor. While preceptors do indeed need to be competent in
the area of nursing they will be precepting, becoming a preceptor is like learning a new clinical specialty.
Although some previously learned knowledge and skills are useful, there are many more to be learned
before you become a competent preceptor. The next myth is that you have to be an expert clinician to be a
preceptor. In many cases, being much more expert than the person you are precepting can be a hindrance
and is frustrating to the preceptor and the preceptee. Yet another myth is that precepting must work around
whatever patient assignment is made and whatever is happening on the unit. Such activity is not precepting.
It is ineffective at its best and, at its worst, disheartening and anxiety-provoking for the preceptor and the
preceptee. Every nurse deserves a competent preceptor and a safe, structured environment in which to learn.
That is not to say that every precepting activity will go as planned. It will not. There is much unpredictability
in the nursing work environment, but precepting activities must start with a plan based on the needs of the
preceptee and the outcomes that must be obtained. Part of the competence of preceptors is making the plan,
adjusting when the need arises, and recognizing and using teachable moments.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
The Second Edition
When we wrote the first edition of Mastering Precepting, there was not a lot of information available on
precepting, and most of the information that was available was largely focused on precepting nursing
students in the clinical setting. The good news is that since the first edition, there has been an increased
awareness of the importance of the use of preceptors and the need to educate and support RNs who
transition into the preceptor role.
In preparation for developing the second edition, we asked for input and suggestions for improvement
from people who had used the first edition of the book—preceptors and those who developed and
implemented preceptor programs. In this second edition, all of the chapters have been updated with the
most recent evidence. In addition, a chapter has been added on precepting advanced practice registered
nurse (APRN) students and APRN new graduates (Chapter 10), and another chapter provides strategies
and information on developing preceptors and on developing, implementing, and evaluating preceptor
programs (Chapter 15).
Who Should Read This Book
This book is a handbook for individual preceptors and a resource for those who are developing or
improving preceptor programs. The book is both evidence-based and pragmatic. It provides information
on the why and the how and is written in a style that can be easily read by busy registered nurses who
are moving into the preceptor role and by current preceptors who want to improve their practice.
Book Content
The chapters in the book build on each other and are designed to be read in order.
• Chapter 1 is an introduction to precepting and discusses all the aspects of the
preceptor role.
• Chapter 2 provides an overview of learning theories, learning stages, learning styles, and
learning preferences.
• Chapter 3 offers an overview of precepting strategies, beginning with the preceptor and
manager setting role expectations and responsibilities.
• Chapter 4 is on core precepting concepts, including developing competence and confidence;
critical thinking, clinical reasoning, and clinical judgment skills; and situational awareness,
expert reasoning, and intuition.
• Chapter 5 is about planning experiences for preceptees and developing and using goals,
objectives, and outcomes.
• Chapter 6 discusses communication skills, preceptee handoffs, and managing difficult
communication.
Introduction
xxxi
• Chapter 7 provides information on establishing, conducting, and ending a coaching
relationship.
• Chapter 8 presents an overview of instructional technologies—from web-based strategies to
human patient simulation—and details on when and how to use the technologies effectively.
• Chapter 9 offers information and strategies on specific learner populations—
prelicensure nursing students, NGRNs, post-baccalaureate graduate students,
experienced nurses learning new specialties or roles, internationally educated nurses,
and nurses from different generations.
• Chapter 10, a brand-new chapter, has details on precepting advanced practice registered
nurses in student and graduate roles.
• Chapter 11 discusses assessing, addressing, and influencing preceptee behaviors and
motivation and providing preceptees with action-oriented feedback as well as using just
culture as a problem-solving framework.
• Chapter 12 offers pragmatic information on the day-to-day performance of the precepting
role including organization and time management, delegation, problem-solving preceptorpreceptee relationships, and addressing challenging behaviors.
• Chapter 13 discusses the need for preceptors to practice self-care behaviors and provides
suggestions to prevent burnout and create optimal healing environments.
• Chapter 14 is designed for managers and discusses how to select, support, and sustain
preceptors.
• Chapter 15, another new chapter, includes information on developing preceptors and on
developing, implementing, and evaluating preceptor programs.
• The appendix contains resources on precepting.
The first 13 chapters end with a Preceptor Development Plan, a manager plan concludes Chapter 14,
and a plan to do an initial assessment in preparation for developing a preceptor program wraps up
Chapter 15. The Preceptor Development Plans are templates for preceptors to use to create their own
development plans. The templates are available from www.SigmaNursing.org/MasteringPrecepting2 as
modifiable Microsoft Word documents and can be used by individuals or by organizations. By putting
your own plan in writing, you will be making a commitment to implement the plan. For organizations,
the plans can be used to set goals and measure progress for participants in preceptor programs.
More Information Online
Follow our @RNPreceptor Twitter handle to engage with us and other preceptors. For tools and other
resources, go to www.RNPreceptor.com.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Final Thoughts
Precepting is a complex endeavor that requires competence and commitment. By becoming a preceptor,
you have accepted the professional responsibility of sharing your knowledge and expertise with others.
There is no greater contribution to nursing and to patient care than to ensure the competence of the
next generation of nurses.
–Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
BethTUlrich@gmail.com
Twitter: @RNPreceptor
References
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco,
CA: Jossey-Bass.
1
“No one was ever able to teach who was not able
to learn.”
–Florence Nightingale
1
The Preceptor Role
Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
Precepting is an organized, evidence-based, outcome-driven approach to ensuring
competent practice. Precepting is used for students who are rotating into clinical
areas, for new graduate registered nurse (NGRN) onboarding, for new hire
onboarding, when experienced staff members learn a new specialty or new skills,
and when individuals move into new roles (e.g., educator, manager, or preceptor).
A preceptor is an individual with demonstrated competence in a specific area who
serves as a teacher/coach, leader/influencer, facilitator, evaluator, socialization
agent, protector, and role model to develop and validate the competencies of
another individual. This chapter presents an overview of precepting and the
preceptor role.
Precepting takes place in the context of the healthcare system and involves
many role functions. A precepting model that illustrates the roles and context of
precepting is shown in Figure 1.1.
OBJECTIVES
•
Understand precepting
in the context of nursing
and the healthcare
system
•
Understand the role of a
preceptor
•
Know the competencies
required to practice as a
preceptor
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Teacher/
Coach
Protector
Role Model
Precepting
Safety
Quality
Leader/
Influencer
Evaluator
Socialization
Agent
Facilitator
Evidence
Roles and Context of Precepting
FIGURE 1.1
Ulrich Precepting Model
The Context of Precepting
Precepting takes place in the context of nursing and the broader healthcare system. To be effective, the
preceptor must be grounded in and knowledgeable about both.
Nursing Context
Professional nursing practice is complex and multifaceted. At its most basic, nursing is defined as
“the protection, promotion, and optimization of health and abilities, prevention of illness and injury,
facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response
and advocacy in the care of individuals, families, groups, communities, and populations” (American
Nurses Association [ANA], 2015c, p. 1). Nursing has evolved into a profession that has a distinct body
of knowledge, a defined scope, standards of professional nursing practice, a code of ethics, tenets of
contemporary nursing practice, a nursing process, and a social contract with the public.
Standards of Practice. The Nursing Standards of Practice are “authoritative statements of the duties
that all registered nurses, regardless of their role, population, or specialty, are expected to perform
competently” (ANA, 2015c, p. 3, see Table 1.1). Each standard has a list of competencies for the RN,
with additional competencies for graduate-level prepared specialty nurses and advanced practice
registered nurses (APRNs). The Nursing Standards of Professional Performance “describe a competent
3
1 The Preceptor Role
level of behavior in the professional role” (ANA, 2015c, p. 5; see Table 1.1). Specialty practice
nursing standards, based on the overall standards, are established by professional specialty nursing
organizations.
The ANA Code of Ethics for Nurses provides a succinct statement of the ethical obligations and duties of
every RN. This code is the profession’s nonnegotiable ethical standard and is an expression of nursing’s
own understanding of its commitment to society (ANA, 2015a; see Table 1.2).
Table 1.1
Standards of Nursing Practice
Standards of Practice
Standard 1. Assessment. The registered nurse collects pertinent data and information relative to the
healthcare consumer’s health or the situation.
Standard 2. Diagnosis. The registered nurse analyzes the assessment data to determine actual or
potential diagnoses, problems, and issues.
Standard 3. Outcomes Identification. The registered nurse identifies expected outcomes for a plan
individualized to the healthcare consumer or the situation.
Standard 4. Planning. The registered nurse develops a plan that prescribes strategies to attain expected,
measurable outcomes.
Standard 5. Implementation. The registered nurse implements the identified plan.
Standard 5A. Coordination of Care. The registered nurse coordinates care delivery.
Standard 5B. Health Teaching and Health Promotion. The registered nurse employs strategies
to promote health and a safe environment.
Standard 6. Evaluation. The registered nurse evaluates progress toward attainment of goals and
outcomes.
Standards of Professional Performance
Standard 7. Ethics. The registered nurse practices ethically.
Standard 8. Culturally Congruent Practice. The registered nurse practices in a manner that is congruent
with cultural diversity and inclusion principles.
Standard 9. Communication. The registered nurse communicates effectively in all areas of practice.
Standard 10. Collaboration. The registered nurse collaborates with the healthcare consumer and other
key stakeholders in the conduct of nursing practice.
Standard 11. Leadership. The registered nurse leads within the professional practice setting and the
profession.
Standard 12. Education. The registered nurse seeks knowledge and competence that reflects current
nursing practice and promotes futuristic thinking.
Standard 13. Evidence-Based Practice and Research. The registered nurse integrates evidence and
research findings into practice.
Standard 14. Quality of Practice. The registered nurse contributes to quality nursing practice.
Standard 15. Professional Practice Evaluation. The registered nurse evaluates one’s own and others’
nursing practice.
continues
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Table 1.1
Standards of Nursing Practice (cont.)
Standard 16. Resource Utilization. The registered nurse utilizes appropriate resources to plan, provide, and
sustain evidence-based nursing services that are safe, effective, and fiscally responsible.
Standard 17. Environmental Health. The registered nurse practices in an environmentally safe and healthy
manner.
Source: ANA, 2015c, pp. 4–6
Table 1.2
ANA Code of Ethics
Respect for Others
Commitment to the Patient
Advocacy for the Patient
Accountability and Responsibility for Practice
Duty to Self and Duty to Others
Contribution to Healthcare Environments
Advancement of the Nursing Profession
Promotion of Community and World Health
Promotion of the Nursing Profession
Source: ANA, 2015a
Tenets of Nursing Practice. ANA notes that five tenets characterize nursing practice (2015c, pp. 7–9):
• Caring and healthcare are central to the practice of the registered nurse.
• Nursing practice is individualized.
• Registered nurses use the nursing process to plan and provide individualized care for healthcare
consumers.
• Nurses coordinate care by establishing partnerships.
• A strong link exists between the professional work environment and the registered nurse’s
ability to provide quality healthcare and achieve optimal outcomes.
Nursing Process. Nursing achieves its work through the use of the nursing process—a structured scientific
process that includes assessment, diagnosis, outcomes identification, planning, implementation, and
evaluation. All components of the process are intricately connected and movement is often multidirectional. The process is similar to the problem-solving process and the scientific reasoning process.
Originally designed as a process for nurses to use when providing patient care, the process is now used in
other areas such as quality improvement, management, and general problem-solving.
Social Contract. Nursing has a social contract with society; the contract is reciprocal with society’s
expectations of nursing as a profession and nursing’s expectations of society (ANA, 2015b; see Table 1.3).
1 The Preceptor Role
5
The results from the annual Gallup poll on honesty and ethical standards in professions are an example
of the evidence of nursing meeting society’s expectations and having people’s trust. For 15 years in a
row, nurses have been ranked highest of all professions. In the December 2017 poll, 82% of the poll
participants described the honesty and ethical standards of nurses as very high or high (Brenan, 2017).
Table 1.3
Elements of the Social Contract Between Nursing and Society
Society’s Expectations of Nursing
Caring service
Primacy of the patient
Knowledge, skill, and competence
Hazardous service
Responsibility and accountability
Progress and development
Ethical practice
Collaboration
Promotion of the health of the public
Nursing’s Expectations of Society
Autonomy of practice
Self-governance
Title and practice protection
Respect and just remuneration
Freedom to practice
Workforce sustainability
Protection in hazardous service
Source: ANA, 2015b
Healthcare System Context
Preceptors also need to understand nursing in the context of the entire healthcare system. Over the past
2 decades, a number of studies and reports have been completed that are relevant to nursing practice in
the context of the healthcare system. The two prevalent themes of these studies have been quality and
safety.
The Institute of Medicine (IOM), now called the National Academy of Medicine (NAM), is a nonpartisan, multidisciplinary group of experts who provide unbiased, evidence-based information on
topics in health and medicine. In its 2000 report, To Err Is Human: Building a Safer Health System, the
IOM discussed the issue of errors in hospitals, estimating that as many as 98,000 hospitalized Americans
die each year not as a result of their illness or disease, but as a result of errors in their care. That report
was followed closely in 2001 by an IOM report entitled Crossing the Quality Chasm: A New Health
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
System for the 21st Century, which identified healthcare quality issues, called for a radical redesign of the
U.S. healthcare system, and proposed six quality outcomes: safety, effectiveness, patient-centeredness,
timeliness, efficiency, and equity. This report also emphasized that safety and quality issues are more
often the result of systems issues rather than individual performance. In 2003, Health Professions
Education: A Bridge to Quality focused on integrating a core set of competencies into the education of all
health professionals. The five core competencies for all clinicians are (IOM, 2003):
• Provide patient-centered care
• Work in interdisciplinary teams
• Employ evidence-based practice
• Apply quality improvement
• Utilize informatics
The Agency for Healthcare Research and Quality (AHRQ) then asked the IOM to conduct a study to
identify key aspects of the work environment for nurses that likely have an impact on patient safety
and potential improvements in healthcare working conditions that would likely increase patient safety.
As a result, in their 2004 report Keeping Patients Safe: Transforming the Work Environment of Nurses,
the IOM specifically addressed the critical role nurses play in ensuring patient safety, observing that
“how well we are cared for by nurses affects our health, and sometimes can be a matter of life or death”
(p. 2). Further, they identified that the typical work environment of nurses was characterized by many
serious threats to patient safety in all four of the basic components of all organizations—organizational
management practices, workforce deployment practices, work design, and organizational culture. Since
that time, the evidence has mounted that the health of the work environment impacts both nurse and
patient outcomes.
In early 2007, the Robert Wood Johnson Foundation (RWJF) funded an initiative called Quality
and Safety Education for Nurses (QSEN) “to address the challenge of preparing nurses with the
competencies necessary to continuously improve the quality and safety of the healthcare systems in
which they work” (Cronenwett et al., 2007, p. 122). The QSEN team adapted the competencies from
the IOM (2003) Health Professions Education report for nursing (see Table 1.4) and delineated the
knowledge, skills, and attitudes for each competency. The QSEN competencies were first designed to be
used in schools of nursing and later moved into the practice setting.
Quality and safety are two major parts of the context in which nurses practice and, as such, are critical
to precepting. In looking at the QSEN competencies, you can easily see how they could also be applied
to precepting—for example, recognizing the preceptee as a partner and ensuring the safety of the
preceptee and of the patient. However, not all schools of nursing implemented the QSEN competencies
at the same rate or to the same degree. In a recent national study of nursing school faculty, 86% of the
respondents indicated that they were using the QSEN competencies in some manner in their teaching,
but only a third reported including QSEN competencies in at least 80% of their courses (Altmiller &
1 The Preceptor Role
7
Armstrong, 2017). The two QSEN competencies that were the least integrated into the curriculum were
quality improvement and informatics, two competencies that are critical for nurses in the practice setting.
This indicates a need for preceptors to assess the knowledge of preceptees on the QSEN competencies.
Table 1.4
Quality and Safety Education for Nurses
Patient-Centered Care
Recognize the patient or designee as the source of control and full partner in providing compassionate and
coordinated care based on respect for patient’s preferences, values, and needs.
Teamwork and Collaboration
Function effectively within nursing and interprofessional teams, fostering open communication, mutual
respect, and shared decision-making to achieve quality patient care.
Evidence-Based Practice
Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery
of optimal healthcare.
Quality Improvement
Use data to monitor the outcomes of care processes and use improvement methods to design and test
changes to continuously improve the quality and safety of healthcare systems.
Safety
Minimize risk of harm to patients and providers through both system effectiveness and individual
performance.
Informatics
Use information and technology to communicate, manage knowledge, mitigate error, and support decisionmaking.
Source: Cronenwett et al., 2007
In 2010, with the goal of improving how healthcare is delivered to better meet the needs of all patients,
the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) partnered on a
landmark initiative on the future of nursing to ensure that nurses are well positioned to lead change and
advance health (IOM, 2011). Four key messages structure the discussion and recommendations presented
in their report (IOM, 2011, p. 29):
• Nurses should practice to the full extent of their education and training.
• Nurses should achieve higher levels of education and training through an improved education
system that promotes seamless academic progression.
• Nurses should be full partners, with physicians and other health professionals, in redesigning
healthcare in the United States.
• Effective workforce planning and policy making require better data collection and an improved
information structure.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
The specific recommendations from the IOM/RWJF initiative on the future of nursing are shown in Table
1.5. Many of the recommendations have direct implications for preceptors.
Table 1.5
Recommendations from the Future of Nursing Initiative
• Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to
the full extent of their education and training (p. 278).
• Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Private
and public funders, healthcare organizations, nursing education programs, and nursing associations
should expand opportunities for nurses to lead and manage collaborative efforts with physicians and
other members of the healthcare team to conduct research and to redesign and improve practice
environments and health systems. These entities should also provide opportunities for nurses to diffuse
successful practices (p. 279).
• Implement nurse residency programs. State boards of nursing, accrediting bodies, the federal
government, and healthcare organizations should take actions to support nurses’ completion of a
transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced
practice degree program or when they are transitioning into new clinical practice areas (p. 280).
• Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. Academic nurse
leaders across all schools of nursing should work together to increase the proportion of nurses with
a baccalaureate degree from 50% to 80% by 2020. These leaders should partner with education
accrediting bodies, private and public funders, and employers to ensure funding, monitor progress,
and increase the diversity of students to create a workforce prepared to meet the demands of diverse
populations across the lifespan (p. 281).
• Double the number of nurses with a doctorate by 2020. Schools of nursing, with support from
private and public funders, academic administrators, university trustees, and accrediting bodies,
should double the number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty and
researchers, with attention to increasing diversity (p. 281).
• Ensure that nurses engage in lifelong learning. Accrediting bodies, schools of nursing, healthcare
organizations, and continuing competency educators from multiple health professions should
collaborate to ensure that nurses and nursing students and faculty continue their education and
engage in lifelong learning to gain the competencies needed to provide care for diverse populations
across the lifespan (p. 282).
• Prepare and enable nurses to lead change to advance health. Nurses, nursing education programs,
and nursing associations should prepare the nursing workforce to assume leadership positions across
all levels, while public, private, and governmental healthcare decision-makers should ensure that
leadership positions are available to and filled by nurses (pp. 282–283).
• Build an infrastructure for the collection and analysis of interprofessional healthcare workforce
data. The National Health Care Workforce Commission, with oversight from the Government
Accountability Office and the Health Resources and Services Administration, should lead a
collaborative effort to improve research and the collection and analysis of data on healthcare workforce
requirements. The Workforce Commission and the Health Resources and Services Administration should
collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in
this effort to ensure that the data are timely and publicly accessible (p. 283).
Source: IOM, 2011
1 The Preceptor Role
9
Following publication of the report, the RWJF, the AARP, and the AARP Foundation created The Future
of Nursing: Campaign for Action to improve America’s health through nursing. The campaign has seven
major areas of concentration that are based on IOM recommendations (Campaign for Action, 2018):
• Improving access to care
• Fostering interprofessional collaboration
• Promoting nursing leadership
• Transforming nursing education
• Increasing diversity in nursing
• Collecting workforce data
• Building healthier communities
The campaign has action coalitions in all 50 states and the District of Columbia and is coordinated
nationally. Ongoing information on state and national activities of the campaign as well as resources can
be found at https://campaignforaction.org/
Most recently, recognizing that burnout has become pervasive in healthcare clinicians, the NAM launched
the Action Collaborative on Clinician Well-Being and Resilience, an initial network of more than 50
organizations committed to reversing trends in clinician burnout. The Collaborative has three goals:
“improve baseline understanding of challenges to clinician well-being; raise the visibility of clinician
stress and burnout; and elevate evidence-based, multidisciplinary solutions that will improve patient
care by caring for the caregiver” (NAM, 2018a, p. 1). In early 2018, the Action Collaborative created the
Clinician Well-Being Knowledge Hub (https://nam.edu/clinicianwellbeing/) to provide information on
clinician burnout and on clinician well-being and resilience (NAM, 2018b). As of August 2018, over 175
healthcare organizations had joined the NAM in formally committing to promote clinician well-being
and combat burnout (NAM, 2018b).
Preceptor Roles
Preceptors have many roles: teacher/coach, leader/influencer, facilitator, evaluator, socialization agent,
protector, and role model (refer to Figure 1.1 earlier in the chapter).
Teacher/Coach
The teacher/coach role is the one most people think of when they think of precepting. Regardless
of whether preceptees are NGRNs or experienced nurses going into a new specialty or new role, the
preceptee comes to the preceptor to learn something the preceptor knows and to enhance or expand the
preceptee’s knowledge and expertise. Preceptors need to understand not only the science of teaching
(learning theories, etc.) but also the art of teaching (how to apply the science in a way that is effective).
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Ohrling and Hallberg (2000) found four themes critical to preceptees’ learning:
• Creating a space for learning
• Providing concrete illustrations
• Providing control over the opportunities and pace of learning
• Allowing time for reflection
The coaching role takes teaching one step further. It’s not just about learning the skill; it’s about how
and when to use the skill and how to use it most effectively. That’s where the coaching comes in. It also
comes in when preceptees have a difficult time grasping what is being taught or, on the other end of the
spectrum, show the potential to move to a higher level of performance. Coaching is a collaborative, timelimited, goal-directed relationship. It demands competence in the implementation of theoretically based
approaches (Dyess, Sherman, Opalinski, & Eggenberger, 2017). To coach effectively, preceptors must
be knowledgeable about and competent in coaching methods. See Chapter 7 for more information on
coaching.
Leader/Influencer
Preceptors are leaders and influencers. Leadership is expected of all registered nurses—“The registered
nurse leads within in the professional practice setting and the profession” (ANA, 2015c, p. 75). Preceptors
especially need to understand their leadership role.
Often, people incorrectly believe that leadership and influence only come with authority. Generally,
preceptors do not have line authority over the preceptees or others who are needed to assist in the
preceptors’ work with the preceptees. Cohen and Bradford (2005) developed an Influence Without
Authority model using reciprocity and exchange that can be helpful to preceptors. The key aspects of the
model are:
• Assume that everyone is a potential ally.
• Clarify your goals and priorities—know what you want.
• Diagnose the world of other people—their goals, concerns, and needs.
• Identify relevant currencies—what do you each value?
• Deal with relationships—both the nature of your current relationship and how the person
wants to be related to.
• Influence through give and take.
Grenny, Patterson, Maxfield, McMillan, and Switzler (2013) have identified three keys for influencers:
focus and measure (identify what you really want; create measures); find vital behaviors (put your energy
where it will do the most good); and engage all six sources of influence:
1 The Preceptor Role
11
• Personal motivation—Do they enjoy it? If not, help them love what they hate. Allow for
choice. Create direct experiences. Tell meaningful, influential stories.
• Personal ability—Can they do it? If not, help them do what they can’t. Demand full attention
for brief intervals. Provide immediate feedback against a clear standard. Break mastery into
mini-goals. Prepare for setbacks. Build in resilience.
• Social motivation—Do others encourage them to enact the wrong behavior? Provide
encouragement for the right behavior. Lead the way. Engage formal and informal opinion
leaders. Create new norms. Create a culture of 200% accountability in which everyone holds
everyone accountable.
• Social ability—Do others help individuals to take action? What help do they need to face
risky or challenging new behaviors? Build social capital by providing support and concrete
assistance, especially during crucial moments.
• Structural motivation—Do rewards and sanctions encourage them? Change their economy.
Use incentives wisely. Less can be more. Reward vital behaviors, not just results: Reward right
results and right behaviors. Watch for perverse incentives.
• Structural ability—Does their environment (e.g., physical space and the things and behaviors
in it) help them? Learn to notice the environment. Provide meaningful, accurate data. Change
space and equipment/technology to make it easier for the desired behaviors to occur.
Preceptors can use their influence in many situations to obtain what is needed in their roles as
preceptors and nurses.
Another way that preceptors lead and influence is through their values. The American Association of
Colleges of Nursing (AACN, 2008) has identified five values that epitomize the caring, professional
nurse:
• Altruism (a concern for the welfare and well-being of others)
• Autonomy (right to self-determination)
• Human dignity (respect for the inherent worth and uniqueness of individuals and
populations)
• Integrity (acting in accordance with a code of ethics and standards of practice)
• Social justice (fair treatment)
Some values are more specific, for example, timeliness, job security, peer support, and recognition. It is
important to understand what you value and what others value. You can influence the values of another
individual without any intention to do so, so preceptors must understand the values they convey by their
words and by their actions.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Preceptors also need to identify when values conflicts occur. This can sometimes be especially difficult
for NGRNs to deal with, for example, in situations in which what the patient or family wants or values
conflicts with what the NGRN wants or values. A significant correlation has been found between value
congruence and quality care, and between value congruence and nurse job satisfaction (Kramer &
Hafner, 1989), making the need to resolve values differences important for both patient care outcomes
and nurse retention.
Values
What do you value?
What does your manager value?
What does your organization value?
What does your preceptee value?
Facilitator
Preceptors are constantly facilitating, whether it’s finding assignments that meet the needs of preceptees
or making connections between preceptees and other departments. At the beginning of the preceptorpreceptee relationship, preceptors facilitate more. As preceptees progress, they can assume more of the
facilitation responsibility.
A key goal of the facilitating role is creating a positive and rich learning environment for the preceptee.
John Dewey (1925), an American educational reformer who emphasized pragmatism, the teacher’s role
as a facilitator and guide, and the need for experiential learning, said, “No one with an honest respect for
scientific conclusions can deny that experience is something that occurs only under highly specialized
conditions, such as are found in a highly organized creature which in turn requires a specialized
environment. There is no evidence that experience occurs everywhere and everywhen” (p. 3a). For
nursing, that specialized environment needs to include other healthcare professionals. Interprofessional
clinical learning environments can be valuable for patients, healthcare organizations, and learners
(Hawkins et al., 2018). Experiential learning requires an environment in which the experiences, and the
learning that occurs from those experiences, are intentionally planned.
Evaluator
Evaluation is often a new skill for preceptors. It is not an easy thing to evaluate the performance of
another, especially when the person’s job rests on your evaluation. Evaluation is made easier for the
evaluator and the evaluatee by the presence of criteria-based competencies. In other words, you both
know the outcomes and standards that need to be met before you begin the process. Preceptors need to
separate teaching and coaching activities from evaluation activities so that the learner is free to learn
during the time designated for teaching and coaching.
1 The Preceptor Role
13
A major aspect of evaluating is providing feedback and constructive criticism to reinforce good
performance, correct poor performance, and understand how improvements can be made. Cantillon
and Sargeant (2008) provide general principles for effective feedback.
• Feedback should be viewed as a normal, everyday component of the teacher-learner
relationship so that both sides can expect it and manage its effects.
• Learners are much more likely to appreciate feedback if teachers indicate from the start that
they expect and welcome feedback from the students.
• Learners should be clear about the criteria against which their performance will be assessed.
• Feedback should be given on specific behaviors rather than on general performance.
• Feedback should be based on what is directly observed.
• Feedback should be phrased in nonjudgmental language.
• Timeliness of feedback is important. Feedback should be given at the time of the event or as
soon as possible after the event.
• Corrective feedback should be given in private.
• Feedback should be limited to one or two items at a time.
• Feedback from the teacher should be balanced by deliberately seeking the learners’
perceptions of their performance and their ideas about how to improve it.
• Feedback should include a discussion about how the learner plans to move from the actual to
the desired performance.
• Feedback should lead to changes in the learner’s thinking, behavior, and performance.
Socialization Agent
Hinshaw (1977) defined socialization as “the process of learning new roles and the adaptation to them,
and, as such, continual processes by which individuals become members of a social group” (p. 2).
Preceptors facilitate the socialization of preceptees into the organization, into the unit, and even into the
nursing shift within a unit by teaching preceptees the norms, the “sacred cows,” the formal and informal
expectations, and the unwritten rules of the game. For NGRNs, preceptors also facilitate socialization
into the profession. In addition, preceptors can influence others to be accepting of and encouraging to
preceptees.
Socialization is particularly important with NGRNs. As Kramer (1974) noted in Reality Shock, the
seminal work on NGRN transition, “It seems that the socialization that takes place in medical and
nursing schools prepares students to be medical and nursing students, but not physicians and nurses”
(p. 42). It is the job of the preceptor to socialize the NGRN into the professional nursing role.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Protector
Preceptors are protectors of both patients and preceptees. The number one concern in precepting is
ensuring a safe environment for patients. Preceptors have to find or create situations in which preceptees
can learn while at the same time protecting the safety of patients. There should never be any doubt that
patient safety is job one.
Preceptors are also responsible for creating a safe learning environment for preceptees. Creating a safe
learning environment begins with making sure that preceptees feel safe asking questions. The message
that “there are no dumb questions” is important. Learners must be able to freely express their lack of
understanding, their doubts about their competence, etc., so that these issues can be addressed in a
professional and timely manner.
Creating a safe learning environment also includes protecting preceptees from disruptive behavior
and lateral/horizontal (nurse-on-nurse) violence. A recent national study of critical-care nurse work
environments found that over 80% of the RNs experienced verbal abuse at least once while working as
a nurse in the past year; 47% physical abuse; 46% discrimination; and 40% sexual harassment (Ulrich,
Barden, & Cassidy, 2018). National studies have repeatedly found that 17%–19% of the verbal abuse
experienced by RNs comes from other RNs (Ulrich, Lavandero, Woods, & Early, 2014). Preceptors
must protect preceptees and, at the same time, teach them how to mitigate and deal with these types
of behaviors. Modic and Schoessler (2008) suggest the following strategies for minimizing horizontal
violence:
• Be alert to behaviors indicating that horizontal violence or bullying is going on.
• Be aware that the preceptee, especially if an NGRN, is in a vulnerable position.
• Be aware of your own behavior. Model professional behaviors.
• If you see bullying or incivility, point out the behavior to the individual in a respectful
manner.
• Help preceptees learn how to speak up.
• Talk to the manager or others in authority about your concerns.
• Talk with your colleagues about how to create a healthier work environment.
1 The Preceptor Role
15
Role Model
Preceptors role model competencies and professional practice. Preceptors must have demonstrated
competence in the roles they are precepting. Preceptees will quickly notice if there is dissonance
between what their preceptor tells them to do and what they see the preceptor doing. Though there
might be more than one way to accomplish a task that results in the same outcome, preceptees do not
have the experience to know that. They will be confused if you tell them one thing and do another, or if
they see other nurses doing a task differently from how they have been taught. Preceptors need to make
other staff aware that they, too, are role models for the preceptees. As with evaluations, role modeling is
easier if everyone adheres to the same standards of practice and professional performance. As this is not
always what occurs, preceptors need to be prepared to explain the conflicts to preceptees.
Conclusion
Precepting occurs in the context of quality and safety in nursing and healthcare. Through many roles,
preceptors work with preceptees to move them from novices to experts and to ensure that they are
competent to care for patients and perform their roles. Being a preceptor involves understanding the
context in which nurses practice and learning the aspects of all the preceptor roles. Details on fulfilling
all these roles are discussed throughout this book.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Preceptor Development Plan: Preceptor Roles
Think about each of the roles of a preceptor. What are your strengths in each role? In which areas do you
need to increase your knowledge and expertise? What is your plan for expanding your knowledge and
expertise? What resources are available? Who can help you?
Name:
Date:
Role: Teacher/Coach
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Role: Leader/Influencer
Strengths
Role: Facilitator
Strengths
1 The Preceptor Role
Role: Evaluator
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Role: Socialization Agent
Strengths
Role: Protector
Strengths
Role: Role Model
Strengths
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
17
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
References
Altmiller, G., & Armstrong, G. (2017). 2017 national quality and safety education for nurses faculty survey results. Nurse
Educator, 42(55), 53–57.
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing
practice. Washington, DC: Author.
American Nurses Association. (2015a). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.
American Nurses Association. (2015b). Guide to nursing’s social policy statement: Understanding the profession from social
contract to social covenant. Silver Spring, MD: Author.
American Nurses Association. (2015c). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.
Brenan, M. (2017, December 26). Nurses keep healthy lead as most honest, ethical profession. Gallup. Washington, DC:
Gallup, Inc. Retrieved from https://news.gallup.com/poll/224639/nurses-keep-healthy-lead-honest-ethical-profession.
aspx
Campaign for Action. (2018). About us. Retrieved from https://campaignforaction.org/about/
Cantillon, P., & Sargeant, J. (2008). Giving feedback in clinical settings. British Medical Journal, 337, 1292–1294.
Cohen, A. R., & Bradford, D. L. (2005). Influence without authority. Hoboken, NJ: John Wiley & Sons.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P.,…Warren, J. (2007). Quality and safety
education for nurses. Nursing Outlook, 55(3), 122–131.
Dewey, J. (1925). Experience and nature. London, UK: Open Court Publishing Company.
Dyess, S. M., Sherman, R., Opalinski, A., & Eggenberger, T. (2017). Structured coaching programs to develop staff. The
Journal of Continuing Education in Nursing, 48(8), 373–378. doi: 10.3928/00220124-20170712-10
Grenny, J., Patterson, K., Maxfield, D., McMillan, R., & Switzler, A. (2013). Influencer: The science of leading change (2nd
ed.). New York, NY: McGraw-Hill.
Hawkins, R., Silvester, J. A., Passiment, M., Riordon, L., & Weiss, K. B. for the National Collaborative for Improving the
Clinical Learning Environment. (2018). Envisioning the optimal interprofessional clinical learning environment: Initial
findings from an October 2017 NCICLE symposium. Retrieved from http://www.ncicle.org/resources
Hinshaw, A. S. (1977). Socialization and resocialization of nurses for professional nursing practice. In L. Netzer (Ed.),
Education, administration, and change (pp. 1–15). New York, NY: National League for Nursing.
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
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aspx
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC:
National Academies Press. Retrieved from http://nationalacademies.org/hmd/reports/2001/crossing-the-qualitychasm-a-new-health-system-for-the-21st-century.aspx
Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.
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Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC:
National Academies Press. Retrieved from http://nationalacademies.org/hmd/reports/2003/keeping-patients-safetransforming-the-work-environment-of-nurses.aspx
Institute of Medicine. (2011). The future of nursing: Leading change, advocating health. Washington, DC: National
Academies Press. Retrieved from http://nationalacademies.org/hmd/reports/2010/the-future-of-nursing-leadingchange-advancing-health.aspx
Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: C.V. Mosby Company.
Kramer, M., & Hafner, L. P. (1989). Shared values: Impact on staff nurse job satisfaction and perceived productivity.
Nursing Research, 38(3), 172–177.
Modic, M. B., & Schoessler, M. (2008). Preceptorship: The role of the preceptor in minimizing horizontal violence. Journal
for Nurses in Staff Development, 24(4), 189–190.
National Academy of Medicine. (2018a). Action collaborative on clinician well-being and resilience. Retrieved from https://
nam.edu/initiatives/clinician-resilience-and-well-being
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National Academy of Medicine. (2018b). Clinician well-being knowledge hub. Retrieved from https://nam.edu/
clinicianwellbeing/
Ohrling, K., & Hallberg, I. R. (2000). Student nurses’ lived experience of preceptorship. Part 2: The preceptor-preceptee
relationship. International Journal of Nursing Students, 37(1), 25–36.
Ulrich, B., Barden, C., & Cassidy, L. (2018, May 21). Critical care nurse workplace: Preliminary results of the 2018 AACN
healthy work environment study. Presentation at the AACN 2018 National Teaching Institute, Boston, MA.
Ulrich, B. T., Lavandero, R., Woods, D., & Early, S. (2014). Critical care nurse work environments: A status report. Critical
Care Nurse, 34(4), 54–79. doi: 10.4037/ccn2014731. Retrieved from http://ccn.aacnjournals.org/content/34/4/64
21
“Knowledge is power, and professional practice
means a lifetime commitment to learning.”
–Luther Christman
2
Learning: The
Foundation of
Precepting
–Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
OBJECTIVES
Learning is a component of precepting that might sound simple, but it requires
a great deal of attention from preceptors. To successfully work with preceptees,
preceptors need to understand learning theories, models, and styles. The
information in this chapter provides an overview of adult learning theory,
transformative learning theory, social learning theory, Maslow’s hierarchy of needs,
Benner’s Novice to Expert model, learning stages, learning styles, and learning
preferences. Understanding how learning occurs and is facilitated is the foundation
of precepting.
•
Understand assumptions
about adult learners
•
Understand the
concepts of observing
and modeling and how
they apply to preceptor
behavior and preceptee
learning
•
Apply the Novice to
Expert framework to
both preceptor and
preceptee learning
•
Understand learning
styles
Adult Learning Theory
Malcolm Knowles is generally recognized as the father of adult learning. Knowles
believed that adults learn differently than children and that adult learners possess
unique characteristics. To differentiate adult learning from pedagogy (the art and
science of teaching children), he used the term andragogy (from the Greek words
aner meaning “man” and agogus meaning “the leader of ”; Knowles, 1973). Knowles’
work also shifted the focus of learning from the teacher to the learner. In adult
learning, the learner’s experience counts as much as the teacher’s knowledge. In
some adult learning situations, it even becomes difficult to determine whether the
teacher or the student is learning more (Knowles, Holton, & Swanson, 2005).
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Learning Theories/Models
•
•
•
•
•
•
Adult Learning Theory—Knowles
Social Learning Theory—Bandura
Hierarchy of Needs—Maslow
Experiential Learning Theory—Kolb
Transformative Learning Theory—Mezirow
Novice to Expert—Benner
Knowles (1973) began with four assumptions about the adult learner and later added two more
(Knowles, 1984, 1987; see Table 2.1). The assumptions are:
• Need to know—Adults need to know why they need to learn something.
• Self-concept—As individuals mature, they have increasing self-directedness.
• The role of experience—As individuals mature, they accumulate experiences that cause them
to be an increasingly rich resource for learning and also provide them with a broadening base
on which to relate new learning.
• Readiness to learn—As individuals mature, their readiness to learn becomes a product of
their perceived need to learn.
• Orientation to learning—Adults have a problem-centered approach to learning. They want
to learn a particular competency or acquire knowledge that they can apply immediately to an
identified problem.
• Motivation—Adult learners are internally motivated.
Table 2.1
Core Adult Learning Principles
• Learner’s need to know: why, what, how
• Self-concept of learner: autonomous, self-directed
• Prior experience of learner: resource, mental models
• Readiness to learn: life-related, developmental task
• Orientation to learning: problem-centered, contextual
• Motivation to learn: intrinsic value, personal payoff
Source: Knowles, Holton, & Swanson, 1998
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Learning: The Foundation of Precepting
23
It should be noted, however, that Knowles did not believe that all of his assumptions about adult
learning must be utilized in all situations. Rather, he believed that an essential feature of the model was
its flexibility, and he encouraged adaptation based on the purpose of the learning event.
Holton, Swanson, and Naquin (2001) reviewed Knowles’ adult learning theory and subsequent research
on adult learning. They concluded that the biggest advancement in the understanding of adult learning
since the work of Knowles was the research on how individual differences of learners affect adult
learning, and they expressed their belief that understanding individual differences makes Knowles’ adult
learning theory more effective. Individual differences have been described in three main areas (Jonassen
& Grabowski, 1993):
• Cognitive—General mental abilities, primary mental abilities, cognitive controls, cognitive
styles in information gathering and information organizing, and learning styles
• Personality—Attentional and engagement styles, and expectancy and incentive styles
• Prior knowledge
Knowledge of the individual differences can be used to individualize adult learning experiences in a
variety of ways.
Knowles, Holton, and Swanson (1998) created what they termed the Andragogy in Practice model,
which incorporated Knowles’ adult learning assumptions with individual and situational differences and
the goals and purposes for learning. Holton et al. (2001) then suggested an approach for adult learners
using the Andragogy in Practice model:
1. Use Knowles’ assumptions to form the foundation for planning adult learning experiences.
2. Conduct analyses to understand “a) the particular adult learners and their individual
characteristics, b) the characteristics of the subject matter, and c) the characteristics of the
particular situation in which adult learning is being used” (p. 136) and anticipate adjustments to
the assumptions.
3. Use the goals and purposes for which the learning is conducted to provide a frame that shapes
the learning experience.
Preceptors can use the Andragogy in Practice model to apply adult learning theory, assess the learner’s
readiness to learn and prior experience, and create meaningful learning experiences that encourage
learner engagement. Nursing students at both undergraduate and graduate levels (and practicing
nurses) have had experience with at least some hands-on learning. However, given the limited clinical
time in nursing education, the experience might not have been long enough or in enough depth to allow
nursing students to apply their theoretical knowledge.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Knowledge of adult learning theory can help preceptors understand their preceptees and create more
meaningful learning experiences for them. Preceptors can create situations in which learners can use
what they learn immediately—a scenario that is attractive to adult learners. Such immediate use is
advantageous, because if adult learners begin to acquire a new skill but then do not have the opportunity
to practice it, the skill competency fades quickly (Zemke & Zemke, 1995).
Social Learning Theory
Social learning theory emphasizes learning through observing and modeling (Bandura, 1969, 1977).
Of special interest to nursing is Bandura’s (1969) finding that modeling is “an indispensible means of
transmitting and modifying behavior in situations where errors are likely to produce costly or fatal
consequences” (p. 213).
Several conditions must be met for the observing and modeling to occur (Bandura, 1977):
• Attention—In order to learn, an individual must be attentive to the behavior being modeled.
• Retention—Retention involves the ability to retain information about the behavior that was
observed.
• Reproduction—Reproduction of the behavior relies on having observed all components of
the behavior as well as having the ability to perform the behavior.
• Motivation—The learner has to have a good reason to do the observed behavior. Individuals
are more likely to adopt a behavior if they value the outcome of performing the behavior.
Preceptors should note that the observation and modeling of behaviors are not limited to those
behaviors that the learner should model. Being a preceptor is akin to having a video recording of
everything you do implanted in the learner’s brain. It becomes the responsibility of preceptors to
critically reflect on their own behaviors and to ensure that what the learner observes is what should be
modeled.
Hierarchy of Needs Theory
Maslow’s hierarchy of needs theory has applicability in both precepting and patient care. Maslow’s
original hierarchy of needs (the one most people are familiar with) contained five levels of basic needs
that Maslow believed every individual attempts to attain (Maslow, 1954):
• Biological and physiological needs—Hunger, thirst
• Safety needs—Safety, security
• Belongingness and love needs—Affiliating with others, being accepted
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Learning: The Foundation of Precepting
25
• Esteem needs—Achievement, competence, recognition
• Self-actualization—Fulfillment, reaching one’s potential
These needs were based on the premise that an individual would be ready to act on higher-level growth
needs only if the basic needs were met.
In Maslow’s subsequent work, he expanded the hierarchy of needs to include eight levels (see Figure 2.1;
Maslow, 1971; Maslow & Lowery, 1998). He added two levels below self-actualization—the cognitive
need to know, understand, and explore and the aesthetic need for order, symmetry, and beauty. Above
self-actualization, he added self-transcendence—the need to connect with something beyond one’s ego
and to help others find self-fulfillment and realize their potential. Maslow also noted that while striving
for higher levels of need, individuals can enjoy experiences along the way: “Achieving basic-need
gratifications gives us many peak experiences, each of which are absolute delights, perfect in themselves,
and needing no more than themselves to validate life” (Maslow & Lowery, 1998, pp. 169–170).
SelfTranscendence
Self-Actualization
Aesthetic Needs
Cognitive Needs
Esteem Needs
Belongingness & Love Needs
Safety Needs
Biological & Physiological Needs
FIGURE 2.1 Maslow’s Hierarchy of Needs
Adapted from Maslow & Lowery, 1998.
At the most basic level of Maslow’s hierarchy of needs, preceptors need to ensure that learners feel safe
in their practice environment. After that is attended to, the preceptor can then help the learner move up
the hierarchy. Preceptors themselves can find self-actualization and even self-transcendence in the act of
precepting others.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Experiential Learning Theory
Kolb’s experiential learning theory (ELT) is based on the work of a number of scholars whose theories of
human learning and development emphasized experience (Kolb, 1984). Kolb (2015) notes that the theories
of Dewey, Lewin, and Piaget share six propositions (pp. 37–48).
• Learning is best conceived as a process, not in terms of outcomes.
• All learning is re-learning.
• Learning requires the resolution of conflicts between dialectically opposed modes of adaptation
to the world.
• Learning is a holistic process of adaptation.
• Learning results from synergetic transactions between the person and the environment.
• Learning is the process of creating knowledge.
ELT defines learning as “the process whereby knowledge is created through the transformation of
experience” and notes that “knowledge results from the combination of grasping experience and
transforming it” (Kolb, 1984, p. 41). Kolb’s experiential learning cycle describes grasping experiences
through concreate experience (experiencing) and abstract conceptualization (thinking) and transforming
experiences through reflective observation (reflecting) and active experimentation (acting) (see Figure 2.2).
Concrete Experience
(Experiencing/Feeling)
Transform
Grasp
Experience
Experience
Active Experimentation
(Acting/Doing)
Reflective Observation
(Reflecting)
Abstract Conceptualization
(Thinking)
Adapted from Kolb, 1984
FIGURE 2.2 Kolb’s Experiential Learning Cycle
Adapted from Kolb, 1984
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Learning: The Foundation of Precepting
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The learner uses all of these in a process that is responsive to the learning situation and to what is
being learned. Kolb (2015) notes that this cycle provides for the examination and strengthening of the
critical linkages between education, work, and personal development. The parts of the learning cycle are
mutually supportive and feed into the next. Learners can enter the cyclical learning process at any point.
Kolb believes that they learn a task best if they practice all four modes, moving and balancing between
concrete experience and abstract conceptualization and between reflective observation and active
experimentation.
Experiential learning is critical to nurses. Benner, Sutphen, Leonard, and Day (2010) observe that
“only experiential learning can yield the complex, open-ended, skilled knowledge required for
learning to recognize the nature of the particular resources and constraints in equally open-ended and
undetermined clinical situations,” (p. 42) and that “experiential learning depends on an environment
where feedback in performance is rich and the opportunities for articulating and reflecting on the
experiences are deliberately planned” (p. 43). Preceptors need to understand experiential learning
theory and its application and need to create learning spaces and environments for preceptees that
contribute to growth in their knowledge and skills. Suggestions for the preceptor’s responsibilities in
providing experiential learning are shown in Table 2.2.
Table 2.2
Preceptor Responsibilities for Experiential Learning
• Preparation
• Find/create experiential learning opportunities
• Give clear instructions
• Discuss any potential risks or complications
• Determine preceptee’s understanding of the experience
• Answer any questions
• During the experience
• Provide a safe environment for the preceptee and the patient
• Observe the preceptee
• After the experience
• Provide time for the preceptee to reflect on the experience
• Debrief the experience with the preceptee—first getting the preceptee’s view of the experience
• Provide feedback—be positive and constructive
• Guide preceptee in reflecting on how to apply the knowledge gained in the experience to
future experiences
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Transformative Learning Theory
Transformative learning theory complements and supports adult learning theory. Transformative
learning, according to Mezirow (1997, p. 5), is “the process of effecting change in a frame of reference.”
It is based on the premise that all individuals have perspectives and meaning derived from their
experiences, thoughts, values, and insights (Mezirow, 1991). Transformations occur when default, longstanding beliefs, assumptions, and perspectives are challenged.
Transformative learning has three aspects: experience, critical reflection, and development (Merriam
& Caffarella, 1999). A learner’s experience, which is also one of Knowles’ adult learning assumptions,
forms the basis for future learning. Critical reflection, part of Knowles’ self-directedness assumption, is
an integral part of transformative learning because the learner needs time and often encouragement to
contemplate and reflect on how the new learning fits with past experience (Lieb, 1991). Development is
a necessary ongoing process in transformational learning.
Transformational learning is concerned with stimulating shifts in thinking; it changes learners’
fundamental assumptions about themselves and changes frames of reference. Mezirow (1997) describes
frames of reference as “structures of assumptions through which we understand our experiences. They
selectively shape and delimit expectations, perceptions, cognition, and feelings” (p. 5). Once a frame of
reference is set, individuals have a tendency to reject any idea or information that doesn’t fit into the
established frame.
Mezirow (1990) described seven phases of transformation:
• Self-examination—exploration of feelings
• Critical assessment of assumptions
• Recognizing that discontent and the process of transformation are shared
• Exploring options
• Planning a course of action
• Re-integrating
• Critical reflection
To facilitate transformational learning, the preceptor must help the learner become aware and critical
of the assumptions and experiences of themselves and others. Learners must be encouraged to view
problems and new information from different perspectives. For this to occur, the preceptor needs to
create positive learning environments in which the learner feels safe in trying out new thoughts and
critical reflections. The preceptor should encourage and support discourse.
2
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Learning: The Foundation of Precepting
Novice to Expert
Patricia Benner’s (1984) landmark work on the Novice to Expert model of how nurses acquire skills
and knowledge forms the foundation of many nursing school curricula and of many hospital-based
preceptorship programs. Benner applied the Dreyfus model of skill acquisition to nursing. The Dreyfus
model, developed by Stuart and Hubert Dreyfus (1980) after studying airline pilots, chess players,
and individuals who were learning languages, is composed of a five-level proficiency hierarchy of skill
acquisition and development. Benner (1984) notes that the levels reflect changes in three aspects of skilled
performance:
• Movement from reliance on abstract principles to the use of past concrete experience as
paradigms
• Change in learner’s perception of the demand situation from equally relevant bits to a whole
with only some relevant parts
• Passage from detached observer to involved performer
The levels are novice, advanced beginner, competent, proficient, and expert (see Table 2.3). Experiential
learning is essential to progress from the novice to expert level. The preceptor can tailor the learning
experiences by recognizing the level of the learner and understanding the progression needed to attain the
skills and knowledge to move toward expert practice. This process is discussed in detail in future chapters.
Table 2.3
Novice to Expert
Novice
Advanced
Beginner
Experience
None
Recollection
Competent
Proficient
Expert
Minimal
Moderate,
specific
Moderate,
broad
Extensive
Non-situational
Situational
Situational
Situational
Situational
Recognition
Decomposed
Decomposed
Holistic
Holistic
Holistic
Decision
Analytical
Analytical
Analytical
Intuitive
Intuitive
Awareness
Monitoring
Monitoring
Monitoring
Monitoring
Absorbed
Information
Little
understanding
of contextual
meaning
Beginning to
see contextual
meaning
Sees patterns
and begins to
discriminate
relevance
Prioritizes
information
Deep understanding of
total situation
Behavior
Rule-governed,
inflexible
Uses more
sophisticated
rules; begins
to identify
conditional
rules
Begins to
devise new
rules and
reasoning
procedures
Involved,
intuitive
response
Sees what
needs to be
done and
does it; trusts
intuition
continues
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Table 2.3
Novice to Expert (cont.)
Responsibility
for Outcomes
Novice
Advanced
Beginner
Low
responsibility
Low
responsibility
Competent
Proficient
Expert
Responsible
for own
decisions and
practice
Sense of
responsibility
increases
Responsible
and seeks
to improve;
extends
responsibility
to others and
organization
Adapted from Benner, 1984; Benner, Tanner, & Chesla, 2009; Dreyfus & Dreyfus, 1980, 2009
The Novice to Expert model is situational. A nurse can be at the expert level in one area of nursing
and at the novice level in another. For example, a nurse who is learning to become a preceptor might
be a novice or advanced beginner in precepting yet be an expert in a clinical specialty. Likewise, an
experienced nurse entering a new clinical specialty has certain skills, knowledge, and experience on
which to build expertise in the new specialty, but both the experienced nurse and the preceptor must
assess what is known and applicable and what is yet to be learned.
Learning Is Facilitated . . .
•
•
In an atmosphere that encourages the learner to be an active participant in the process.
•
When the learner feels that his or her ideas, feelings, and perspectives have value and
significance.
•
In an atmosphere in which different ideas can be accepted (but not necessarily agreed
with). Situations that emphasize the “the one right answer” or a “magical solution” limit
exploration and inhibit discovery.
•
•
•
In an atmosphere where the learner’s right to make mistakes is recognized.
•
In an atmosphere that permits free and open communication and confrontation.
In an atmosphere that provides opportunities for the learner to discover the personal
meaning of ideas.
In an atmosphere that encourages openness of self rather than concealment of self.
When learners are encouraged to trust themselves as originators of ideas and to share their
ideas with others.
Source: Lore, 1981
2
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Learning: The Foundation of Precepting
Learning Stages
Taylor and Hamdy (2013) propose a multi-theories model that describes five stages in the learning
experience: dissonance, refinement, organization, feedback, and consolidation. The basis for the model is
that all learning starts with the learner’s existing knowledge (Taylor & Handy, 2013):
• The dissonance stage occurs “when the learner’s existing knowledge is challenged and found
to be incomplete” (p. e1566). The challenge can come from the learner’s own realization of the
deficit or from the teacher.
• In the refinement stage, the learner seeks out possible explanations or solutions and refines the
new information into concepts that are new for the learner.
• In the organization stage, the learner incorporates the new information, tests and re-tests
hypotheses, and organizes the information into schema that make sense to the learner.
• The feedback stage is the stage in which the learner tests out the schema with peers and
teachers, which results in either reinforcing the schema or having to reconsider it.
• In the consolidation stage, the learner reflects on what has been learned and on the learning
process itself.
In each stage, the learner and the teacher (preceptor) have specific responsibilities (see Table 2.4).
Table 2.4
Learning
Stage
Learning Stages
Learner’s/Preceptee’s Role
Teacher’s/Preceptor’s Role
Dissonance
Identify/acknowledge knowledge
gap; recognize learning needs;
participate in planning objectives
and experiences.
Identify knowledge gap; provide context;
extrinsic and intrinsic motivation; explore and
help preceptee explore the preceptee’s prior
knowledge and experience; help preceptee identify
needs; provide advance organizers by having
clear learning outcomes and strategies; consider
learning styles and their implications, the stage
of development of the preceptee, the preceptee’s
motivation, the resources, and the task.
Refinement
Elaborate; brainstorm possible
explanations or solutions; don’t
assume the obvious answer is
the right answer; determine the
most likely resources to use to
refine the possibilities; research,
reflect, discuss, refine; actively
engage and participate; refine the
information into a hypothesis.
Ensure relevant learning experiences are available;
support preceptee in processes.
continues
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Table 2.4
Learning Stages (cont.)
Learning
Stage
Learner’s/Preceptee’s Role
Teacher’s/Preceptor’s Role
Organization
Test and re-test hypothesis against
what the preceptee already
knows; look at the problem
from all angles; organize the
information into a “story” that
makes sense to the preceptee.
Support the preceptee; provide scaffolding or a
skeleton to support the preceptee’s ideas and give
the preceptee coherence and structure; make sure
the scaffolding/skeleton provides a framework
but also leaves room for the preceptee to have
freedom and responsibility to learn; encourage
critical reflection and critical thinking; provide
opportunities for the preceptee to use reflective
skills.
Feedback
Articulate what has been learned;
provide feedback; accept and—as
indicated—act upon feedback
from others.
Point out strengths and weaknesses of hypothesis;
ask questions; facilitate and encourage; use formal
and informal communication opportunities; accept
and—as indicated—act upon feedback from
preceptee.
Consolidation
Reflect on what has been learned
in light of what was known
before and whether what has
been learned is consistent and
logical; consider how the new
knowledge fits with the bigger
picture and whether it increases
understanding; reflect on own
strengths and weaknesses, level
of confidence, and personal
responsibility for the success
or breakdown of the learning
process.
Provide opportunities for the preceptee to practice
and apply new knowledge; encourage reflection
on action; make explicit the possibilities for future
development; lead the preceptee toward a deeper
understanding.
Adapted from Taylor & Hamdy, 2013
Learning Styles
Individuals are different in many ways, including how they learn. Not everyone learns or learns best
in the same way, or learns best in the same way in all situations. In the quest to continually improve
learning, and concomitantly teaching, researchers have developed many approaches to determining
learning styles. It is not necessary to choose or prefer one style over the others. Multiple style concepts
can occur simultaneously or sequentially.
As with any tools such as these that categorize behavior or preferences, users are cautioned against
developing stereotypes based on the styles. There are no hard and fast lines between the styles, but
rather the styles raise awareness and stimulate the preceptor to consider options for how the preceptee
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Learning: The Foundation of Precepting
33
may learn the easiest and the best. Preceptors can use the awareness gained from an overview of
learning style concepts to better understand the needs and preferences of individual preceptees and to
better provide information and experiences to the preceptees in ways that have the best chance of being
effective and efficient. Opinions are mixed on whether it is beneficial to encourage preceptees to move
out of the comfort of their preferred styles to learn new styles, thereby expanding their future options.
Like many other things, the best approach might be a progression—starting with using the preferred
style for novices and adding new styles to their repertoire as novices acquire skills and knowledge.
The ways individuals learn are sometimes referred to as learning theories (although some are not
theories), learning styles (although some are not styles), learning preferences, and learning models and
constructs, among other names. Regardless of the name, the main interest in how people learn emanates
from wanting to know how individuals receive and process information, how they store information
in the brain, and how they retrieve and use it. Though many learning style concepts exist, each of the
concepts has in common an acknowledgement of the diversity among learners.
Characteristics of Styles
Styles …
Are preferences, not abilities
Are not good or bad
Can vary across tasks and situations
Are socialized
Can vary across the life span
Are measurable
Are modifiable
Source: Sternberg, 1997
Curry’s Learning Style Classification System
Curry (1983, 1987) developed a classification system for learning styles, describing the system as being
like layers of an onion. The innermost core layer is cognitive personality style, a relatively permanent
personality dimension that addresses an individual’s approach to adopting and assimilating information.
The next layer is information processing style, followed by the layer of social interaction. The outermost
layer is instructional preference—how the learner interacts with the learning environment and with
instructional practices, and the learner’s preference of the environment in which to learn. Instructional
preferences are seen as the least stable and the most easily influenced layer.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Cognitive Styles
Cognitive styles describe an individual’s approach to acquiring, adapting, assimilating, and processing
information. Merriam and Caffarella (1999) have described cognitive styles as “consistencies in
information processing that develop with underlying personality traits” (p. 11). Cognitive styles are seen
as an underlying and relatively permanent personality dimension that affects more than learning.
Gregorc’s Learning Styles
Gregorc (1979) studied how learners perceive and order new information. He believed that “the human
mind has channels through which it receives and expresses information most efficiently and effectively”
(Gregorc, 1982, p. 5). He found that information is acquired through either abstract or concrete
processes, or a combination of both, and that arranging, prioritizing, and using that information occur
by random or sequential ordering patterns. Gregorc believed that these tendencies—abstract, concrete,
random, and sequential—reflect inborn predispositions, but he also felt that individuals need to be able
to function in ways other than their natural style.
Gregorc (1979, 1984) identified four learning styles: concrete sequential, concrete random, abstract
sequential, and abstract random.
• Concrete sequential learners prefer learning that is direct, orderly (step-by-step instructions),
and hands-on—for example, workbooks and computer instruction.
• Concrete random learners prefer trial and error, flexibility, and problem-solving—for
example, simulation and independent study.
• Abstract sequential learners prefer analytic, logical approaches—for example, group
discussion.
• Abstract random learners prefer holistic, unstructured learning—for example, lectures and
reading.
Myers-Briggs
The Myers-Briggs Type Indicator (MBTI), developed in 1962, is one of the oldest and longest-standing
assessment instruments to describe personality traits. It is based on the theory of personality types
developed by Carl Jung (Myers & McCaulley, 1985). The MBTI identifies four dichotomous dimensions/
preferences (Myers & McCaulley, 1985):
• Extroversion (outward turning)—Introversion (inward turning)
• Sensing (looks for facts)—Intuitive (looks for meaning)
• Thinking (uses objective data)—Feeling (uses subjective data)
• Judgment (ordered)—Perception (flexible and open)
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Learning: The Foundation of Precepting
35
Sixteen different combinations of the dimensions/preferences are possible, but because most preceptees
will not have taken the MBTI, preceptors can best use the four dimensions/preferences of the MBTI to
raise their awareness of ways in which the preceptees might learn better.
Field Dependence/Independence
Witkin, Oltman, Raskin, and Karp (1971) studied individual differences in perception and spatial
awareness. Their major finding related to field dependence/independence, the degree to which an
individual “uses context in order to understand and make sense of new information” (Smith, 2002, p.
65). In other words, does the individual need the context to better identify new information? Can the
individual see new information as separate from the field surrounding it, or must the information be
immersed in the surrounding field to be seen? Some nurses are known among their peers as being able
to spot key observations about patients regardless of the setting and the distractions that are around the
patient; such nurses would be described as field independent. In sports, a quarterback who always seems
to spot the open receiver would also be said to be field independent. The quarterback sees the receiver
regardless of what’s around him or the receiver.
Learners process information differently based on their field independence/dependence. Learners who
are field independent tend to be more analytical and logical; are less influenced by authority, social
attachments, and external standards; and tend to be intrinsically motivated and guided by their own
values. Field-dependent learners tend to have a less defined sense of autonomy and independence and
are extrinsically motivated, relying on an external frame of reference for information and guidance
(Jonassen & Grabowski, 1993). Field independence and field dependence can be measured using an
embedded figures test but can also be observed by an astute preceptor. Given the chaos and number of
people who can sometimes surround a patient and the interruptions that frequently occur in a hospital
while trying to deliver patient care, it is important for the preceptor to help the preceptee develop field
independence.
Kolb’s Learning Cycle
Information processing styles reflect an individual’s preferred approach to assimilating information.
Kolb (1984) identified two continuums of learning: the processing continuum (doing/watching: the
learner’s approach to a task) and the perception continuum (feeling/thinking: the learner’s emotional
response). Using these two continuums, Kolb developed a learning cycle with four stages (discussed
previously) and identified four learning styles that are based on the stages:
• Diverging—Feeling and watching. Good at idea generation and looking at situations from
different perspectives; gather information and use imagination; usually prefer to work in
groups and receive personal feedback
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
• Assimilating—Thinking and watching. Use a concise, logical approach; ideas more important
than people; more attracted to logic and theory than practical value; want time to think things
through
• Converging—Thinking and doing. Find practical solutions; solve problems; prefer technical
tasks and problems to social/interpersonal issues; like to experiment with new ideas
• Accommodating—Feeling and doing. Hands-on approach; relies on intuition rather than
logic; take a practical, experiential approach; attracted to new challenges and experiences;
prefer to work in teams
Kolb believes that learning styles are not fixed personality traits, but rather are stable patterns of
behavior based on the learner’s background and experience. Kolb’s Learning Style Inventory (Kolb,
1999) is a widely used information processing assessment tool.
Instructional Preferences
Dunn and Dunn (1978) studied how individuals prefer to learn and developed a learning style concept
that includes environmental, sociological, emotional, psychological, and physical preferences:
• Environmental—Sound, temperature, lighting, formality of setting, etc.
• Sociological—Whether the learner prefers to learn alone or in groups, with authority figures
present or not, or through routine or variety
• Emotional—The learner’s motivation, persistence, and need for structure
• Psychological—How learners process information: analytical/global, right brain/left brain,
impulsive/reflective
• Physical—Perceptual strengths—verbal, visual, tactile, kinesthetic, time of day, need for
mobility
By understanding how learners prefer to learn, the preceptor can tailor to their preferences when
possible.
Sensory Learning Preferences
Individuals often have preferences on how they process information. Sensory learning preferences
include visual, auditory, and kinesthetic. Visual learners prefer reading written materials and seeing
pictures. Auditory learners prefer processing information by listening. Kinesthetic learners want to
immerse themselves and put hands on. “Just show me how to do it.”
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Learning: The Foundation of Precepting
37
Part of sensory preferences may be how the individuals first learned new information. The postmillennial generation, for example, has grown up with flashcards on iPads, smart phones, and
computers that integrate all the senses—touch the screen, see the picture, and hear the sound—
compared to individuals in previous generations whose flashcards were made of cardboard. Recent
nursing graduates are more likely to have learned clinical skills on human patient simulators before
they care for real patients, rather than only having the options of reading the information or hearing an
instructor describe a procedure.
Preceptors need to be attuned to how their preceptees learn best. People often give you cues in
conversation to their preferred sensory style: “I see what you mean.” “I hear what you say.” “I feel your
pain.” Sensory preferences are not “locked in” forever and may be different for different content.
Sensory styles apply to more than learning. It’s good to know, for example, how your boss likes to receive
information. Does he or she want to meet and talk about it? Does your boss prefer to read the details?
Or is a picture really worth a thousand words?
Conclusion
Preceptors can use the information in this chapter in two ways. As a learner, you should critically
reflect on your own learning and your own experience. What do you need to learn to be a competent,
proficient, and then an expert preceptor? What experience do you have that will be applicable? What is
your frame of reference? Are you ready to learn?
As a teacher, this chapter’s information can form the foundation of how you approach learners and the
learning experiences that you develop for them. Who will you be precepting? Undergraduate nursing
students? New graduate nurses? Experienced nurses entering a new specialty? Each will have different
needs. How will you model for them what they need to learn?
To be a successful preceptor, you must begin by understanding learning. Also, when you are learning
a new role, such as precepting, you will find it helpful to understand how you yourself learn best. The
theories and models presented in this chapter form the foundation on which preceptor competence is
built.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Preceptor Development Plan: Learning
Think about the learning theories and styles described in this chapter. How are the theories and
styles applicable in your precepting role? Also, think about how you learn best.
Name:
Date:
Learning Theories
Learning Theory
Adult Learning Theory
Social Learning Theory
Hierarchy of Needs Theory
Experiential Learning Theory
Transformative Learning Theory
How is the theory applicable in your precepting
role? What are the key points you need to
remember?
2
Learning: The Foundation of Precepting
Novice to Expert Theory
Learning Stages
Learning Stage
Dissonance
Refinement
Organization
Feedback
Consolidation
How is the stage applicable in your precepting
role? What are the key points you need to
remember?
39
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Learning Styles
Learning Style
How is the style applicable in your precepting
role? What are the key points you need to
remember?
Gregorc Learning Styles
Myers-Briggs
Field Dependence/Independence
Kolb’s Learning Styles
Learning Preferences
Preferences
Instructional Preferences
Sensory Preferences
How are the preferences applicable in your
precepting role? What are the key points you
need to remember?
2
Learning: The Foundation of Precepting
How do you learn best?
It’s helpful to think about how you learn best. Think about the instructional and sensory
learning preferences discussed in the chapter. How do you learn best?
How do you learn best?
Environment
Sociological
Emotional
Psychological
Physical
Sensory
41
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
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“Education is the kindling of the flame, not the
filling of the vessel.”
–Socrates
3
Precepting Strategies
–Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
As you begin your precepting role, you need to understand the basic strategies used
in precepting. Clarifying the preceptor role is a first step, followed by understanding
precepting models, sharing information, engaging others, conducting a preceptee
learner assessment, helping the preceptee manage transitions, using clinical
teaching strategies, and finally, ending the preceptor-preceptee relationship. This
chapter provides an overview of these strategies to get you started in your new role.
OBJECTIVES
•
Understand basic
precepting strategies
•
Create a positive
learning environment
•
Know how to begin
and end a preceptorpreceptee relationship
•
Use teaching strategies
in the preceptor role
Getting Started
At the outset (or, better yet, before you decide to accept the preceptor role), you
need to have a detailed conversation with your manager about your role as a
preceptor. At a minimum, you should discuss:
• The outcomes your manager expects from you as a preceptor
• The preceptor role requirements
• The support available for you and your preceptees
• The amount of time that will be dedicated to the preceptor and preceptee
roles
• The priority of your precepting role with your other duties
Examples of statements that should make you see warning signs of potential future
role conflicts include: “Just teach her what you know.” “You’re very efficient. You
can just work it in with your patient care, can’t you?” “You’re an experienced nurse.
You’ll figure it out.” It is much easier and much less frustrating to address these
issues before you start precepting. Some sample detailed questions are shown in
Table 3.1. In organizations with structured preceptorships, many of the topics will
have already been addressed and decisions made.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Table 3.1
Role Clarification
Expected Outcomes
At what level of practice do you expect the preceptee to be at the end of the preceptorship?
What specific competencies do you expect the preceptee to have at the end of the preceptorship?
Preceptor Role Requirements
What are your expectations of me in the preceptor role?
Are there classes I need to take?
Are there continuing education requirements?
Will I need to liaison with anyone (e.g., nursing school faculty for student nurses)? If yes, with whom?
Support Available for the Preceptor and Preceptee
What initial preparation will I get for the preceptor role?
Will additional education be available in the future? If so, what?
Who is available for me as resources? Will I have an experienced preceptor to precept me in my preceptor
role?
What information resources are available to me and my preceptee?
If the preceptee is a new graduate RN (NGRN), do we have a structured RN residency or transition to
practice program in place? Will there be training for me on that program?
Time Dedicated to the Preceptor and Preceptee Roles
How much of my time will be dedicated to the preceptor role for each type of preceptee (e.g., NGRN, new
hire experienced nurse, experienced nurse new to our specialty)?
How much preceptee time will be dedicated to the preceptee role for each type of preceptee (e.g., NGRN,
new hire experienced nurse, experienced nurse new to our specialty)?
What part of my hours and my preceptee’s hours will be counted in staffing?
Priority of the Precepting Role With Other Duties
Except for emergencies, will I be pulled to staff other shifts or units when I am in my preceptor role? If yes,
will someone take my place with my preceptee?
Precepting Models
In the initial use of precepting in nursing, a preceptor was assigned to a preceptee, but too often, the
preceptor and the preceptee were not always on the same shifts or the preceptor got pulled away during
the shift. In the best cases, another preceptor was assigned to the preceptee, but often preceptees were
left on their own until their next shift with their preceptor. Such unplanned changes in preceptors
often resulted in “lost shifts” and/or confusion for the preceptee and frustration for the preceptors.
Preceptor inconsistency appeared to be a particular problem for NGRN preceptees, who did not yet
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47
have a foundation of clinical experience on which to rely. As NGRN residencies were developed, those
developing the residencies began to address the preceptor issues.
Single Preceptor Model
In the single preceptor model, the preceptee is assigned one preceptor. The advantage of the single
preceptor model is that, in theory, it provides for continuity, especially if there is a commitment to
schedule the preceptor and preceptee on the same shifts. The problem is maintaining that continuity
in the real world of hospital staffing. Because of the potential lack of matching preceptor and preceptee
shifts, the single preceptor model might well be the best model for use with preceptees who are
experienced nurses new to the organization or in new specialties or roles, but it can be less advantageous
for novice nurses who do not yet have a foundation of experience.
Married State Preceptor Model
In the married state preceptor model (MSPM), NGRNs and preceptors work together—the preceptee
and preceptor together take on a full patient load from the beginning, with the two viewed as one nurse
(Figueroa, Bulos, Forges, & Judkins-Cohn (2013). Tasks, rather than patient load, increase over time.
The model is composed of three phases—side by side, shadowing, frontline—each lasting 6 weeks.
• In Phase 1 (side by side), the preceptee and the preceptor work side by side, with the
preceptee having specific goals.
• In Phase 2 (shadowing), the paradigm starts to switch as the preceptor steps back and the
preceptee assumes the leading role.
• In Phase 3 (frontline), the preceptee assumes the patient load and the preceptor is at the
nurses’ station/on standby for the preceptee. The preceptor provides continued support.
Outcomes and perceptions of the MSPM were studied in NGRN residencies in a seven-hospital system
(Figueroa et al., 2013). The NGRNs overwhelming thought the MSPM was beneficial for NGRNs,
promoted safety, and created less anxiety. Preceptor responses were in alignment with the responses
of the NGRNs and indicated that the use of the MSPN increased the confidence of the NGRNs. A
statistically significant decrease in turnover was found in the MSPM compared to the traditional model.
In focus groups held with the NGRNs to discuss the MSPM, four themes were identified—partnership,
critical thinking, learning, and transition. A subsequent study found similar results (Figueroa, Gardner,
Irizarry, & Cohn, 2016). NGRNs found the MSPM to be beneficial, promote safety, lessen anxiety,
and prepare NGRNs to take a full patient load. Preceptors perceived that the MSPM promoted safety,
boosted confidence, and enhanced the competency and safe practice of NGRNs. In addition, in focus
groups with the NGRNs, the same themes were identified. MSPM partnerships were perceived to
decrease negative relationships between generations of nurses; learning occurred in an apprenticeshiptype of setting; critical thinking progressed as responsibilities increased; and transitions were smoother
(Figueroa et al., 2016).
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Team Preceptor Model
There are many variations of the team preceptor model. The team preceptor model has been used most
often with NGRNs. Versant, an early leader in the development of structured RN residencies, created
a team preceptor model in response to identified problems using traditional preceptor approaches
with NGRNs. Versant began its RN residency program in 1999, assigning a preceptor and an alternate
preceptor for each preceptee (Beecroft, Hernandez, & Reid, 2008). All of the preceptors were expert
nurses. After several cohorts of residents, it became apparent that, despite the attempts to provide more
consistency with preceptors, improvements in the preceptor program were needed. Too often, if the
primary and alternate preceptors were unavailable, any available nurse was substituted. In addition,
it was clear that the same nurses were being called on over and over to precept, and the potential for
burnout was high (Beecroft et al., 2008). In addition, using only expert nurses as preceptors of NGRNs
was frustrating for everyone. The expert nurses, who were at an intuitive level of practice, found it
hard to break down their practice to the 1-2-3, A-B-C steps that NGRNs needed to learn at the novice
or advanced beginner level. In turn, the NGRNs were not progressing as fast as they could or as they
wanted to when they got caught in preceptor musical chairs. Versant moved to a team precepting model
(Ulrich et al., 2010).
In one version of the team preceptor model, preceptors at various levels of competence work together,
but in sequence, to precept the NGRN. The NGRN’s first preceptor is a newly competent nurse who has
an experience level closer to that of the NGRN. The newly competent nurse as preceptor remembers
well what it was like to be an NGRN and understands how to work with the NGRN. The use of newly
competent nurses as preceptors also provides an opportunity for them to engage in the work of the
organization in a new way and recognizes their professional development and potential. As the NGRN
gains knowledge and expertise, a preceptor with more clinical experience takes over the preceptor
responsibility, and finally, in the last part of the immersion period of the residency, an expert nurse
preceptor works with the NGRN.
Another approach to team precepting is to integrate the MSPM and the team preceptor model.
Preceptees work side-by-side with their preceptor (MSPM) in each phase, but the clinical expertise of
the preceptor increases with each phase of the immersion portion of the residency.
Critical components of a team preceptor model are transparency and accountability as well as a
communication and documentation system that allows easy access by all involved to preceptee-related
information (e.g., competency validation, notes on strengths, and areas for improvement).
Preceptee Cohorts or One at a Time?
Preceptees can be singles or grouped in cohorts. Cohorts have been used successfully for NGRNs and
specialty nurse education. The single preceptee versus cohort approach has implications for preceptors.
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When a preceptee is a single, all of the responsibility falls to the preceptor. This might not be a problem
if the preceptee is an experienced nurse in a new job or a new role. Precepting in these situations
generally requires less structure and less direct observation by the preceptor. Precepting a single NGRN
or a single nurse in a new specialty can be labor-intensive and emotionally intensive for the preceptor.
Cohorts often have more committed resources and structure. For example, in a cohort of nurses
learning critical care as a new specialty, classes or learning with human patient simulators can occur as a
group and with objectives established for what each preceptee is to accomplish prior to the next session.
Cohorts also provide the opportunity for group meetings, such as debriefing sessions with NGRNs. And
for preceptors, cohorts provide the potential of preceptors for the cohort supporting each other, sharing
ideas and strategies, and problem-solving as a group.
Sharing Information
Regardless of the preceptorship model, key components to the success of precepting are communication,
transparency, and accountability among all those involved: the preceptee, preceptor(s), manager, charge
nurse, etc. These components mimic those required for successful patient handoffs.
Riesenberg, Leitzsch, and Cunningham (2010) identified strategies for effective patient handoffs. These
strategies can also be applied to preceptee handoffs:
• Communication skills—General communication; preparation, transfer of responsibility;
language
• Standardization strategies—Standardize the process; use interactive questioning during faceto-face communication; check equipment, check for missing information or ask questions,
and include the patient and family in discussion of plans and goals in walking rounds or
bedside report; monitor, evaluate, or audit the process
• Technological solutions—Use an electronic handoff system, an audio- or videotaped report,
or a telephone-based voice technology system
• Environmental strategies—Limit interruptions and distractions; maintain privacy; allow
sufficient time
• Training and education—Provide adequate refresher training or education; use role-playing;
teach assertiveness and listening skills
• Staff involvement—Involve staff in development of handoff guidelines, tools, procedures,
training
• Leadership—Have consistent expectations for compliance; facilitate dialogue; allow time to
plan the process
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Riesenberg et al. (2010) also found eight major categories of barriers to effective patient handoffs:
• Communication barriers, the most frequent—General communication problems, social and
hierarchical problems, cultural issues
• Problems associated with standardization—Lack of standardization; problems with
standardized tools; staff resistance
• Equipment issues—Limitations associated with the communication medium
• Environmental issues—Interruptions; distractions; multitasking during handoff; chaotic
environment; noise; lack of privacy
• A lack of or misuse of time—Time constraints; process used takes too much time
• Difficulties related to complexity of cases or a high caseload—Too many patients; more
complex handoffs; increasing volume of patient information; complex care environment
• A lack of training or education—Inadequate or no training
• Human factors—Too few nurses, sensory and information overload; stressful or overlong
shifts; human limitations
All of these barriers can also apply to preceptee handoffs. Just as inadequate patient handoffs can
increase costs, misuse resources, and result in poorer patient outcomes, so too can inadequate preceptee
handoffs increase costs, misuse resources, and result in poorer preceptee outcomes.
Preceptors need access to a system of documentation and communication with everyone involved with
the preceptee. Characteristics of such a system include easy access, easy use, and confidentiality as
indicated. For example, preceptors need to see at a glance which competencies have been validated and
which have not. If charge nurses also have access to this information, they can take it into consideration
when making assignments or when opportunities come up to do certain procedures. If the manager can
see the information on the preceptee, the manager will know the preceptee’s progress or lack of progress
and can support the preceptor’s efforts.
Creating Positive Learning Environments
One of the key responsibilities of a preceptor and the organization is to create a positive learning
environment for the preceptee. In addition to improving learning, positive clinical learning
environments can influence practice patterns throughout the learner’s career (Wagner, Weiss, Passimet,
& Nasca, 2016).
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51
Enhancing Experiential Learning
Experiential learning can be enhanced by creating learning spaces or environments that promote
growth-producing experiences for learners and offer educational principles that can contribute to
growth (Kolb & Kolb, 2005). Principles of creating these positive learning spaces include (Kolb & Kolb,
2005):
• Respect learners and their experience.
• Begin learning with the learner’s experience of the subject matter. Learners build on what they
already know but may not realize that they already have a foundation for what they need to
learn.
• Create and maintain a hospitable space for learning. Provide support as well as challenges.
• Make space for conversational learning. Not all learning must be formal and planned.
• Make space for development of expertise, space for acting and reflecting, and space for feeling
and thinking.
• Make space for inside-out learning. Link educational experiences to the learner’s interests to
spark intrinsic motivation.
• Make space for learners to take charge of their own learning.
Brain Rules
Part of creating the best environment for the preceptee to learn and for you to precept involves
understanding what makes both of your brains work better. Molecular biologist John Medina (2014),
in Brain Rules, reviews the evidence on how the brain works. Some of his takeaways that can be
particularly useful in precepting include:
• Exercise boosts brain power. Do you get enough exercise? Does your preceptee?
• Sleep well, think well. What are you and your preceptee—Early birds? Night owls? One of
each? Compare notes and gain an understanding of when you each are at your best learning
and teaching times.
• Stressed brains don’t learn the same way. Not all stress is the same, but all stress has similar
components. How does the preceptee respond to stress? How do you? How do you mitigate
the preceptee’s stress?
• Every brain is wired differently. Try to understand how your preceptee’s brain is wired.
• We don’t pay attention to boring things. And we only pay attention to almost anything for a
maximum of 10 minutes before our attention shifts. Break classes and clinical teaching into
smaller chunks.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
• Better attention equals better learning. The things that get your attention are connected
to memory, interest, and awareness. How can you help your preceptee learn what to pay
attention to?
• Medina dispels the myth of multitasking, noting that one can truly only attend to one thing at
a time. Moving attention from one task or thing to another requires sequential steps to shift
from attending to the first task/thing to attending to the next. Practicing mindfulness can be
helpful to both you and your preceptee.
• Repeat to remember. Medina’s recommendation is to incorporate new information gradually
and repeat it at timed intervals.
• Stimulate more of the senses. Learning occurs better when we stimulate several senses at
once. Vision is the most dominant of the senses, but what our brain tells us we see may not be
accurate.
• We are powerful and natural explorers. How can you help your preceptee explore new worlds,
new ideas, and new ways of doing things?
Interprofessional Clinical Learning Environments
The National Collaborative for Improving the Clinical Learning Environment is a diverse, interprofessional forum for healthcare organizations that is committed to improving the educational
experience and patient care outcomes within clinical learning environments (CLEs). CLEs are defined
as “the settings in which healthcare professionals are enculturated to provide high-quality, safe, and
efficient patient care” (Disch et al., 2017, p. 6). In a review of the literature, NCICLE found that training
in patient safety was inconsistent within and across professions and produced a guidance document on
creating CLEs that rapidly engage new clinicians in patient safety activities. Four key concepts informed
their work (Disch et al., 2017, p. 5):
• “Engagement in patient safety is an essential part of care for any clinician, and lack of
clinician engagement is an important ‘patient safety gap.’
• To close this gap, new clinicians need to fully engage in patient safety activities during their
first year of clinical practice in a new clinical environment…
• Leaders of the CLE need to ensure that, throughout their first year, new clinicians work with
other members of their patients’ clinical care team to actively engage in and promote the CLE
patient safety system…
• The CLE’s leadership should ensure that each of its new clinicians is engaged in evidencebased patient safety.”
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At the end of their first year in practice, the goal is for new clinicians to be able to: “(1) understand
the CLE ‘culture of safety,’ (2) recognize and report patient safety issues, (3) participate in the analysis
of patient safety events, and (4) recognize how CLE translates patient safety event reports into
improvements…” in order to have “safer new clinicians, a stronger patient safety culture, and safer
patient care” (Disch et al., 2017, p. 9). The foundational elements of an optimal CLE were identified as
leadership; culture (a just culture and a culture of safety); infrastructure (to report, track, and trend
patient safety events; perform event analysis; develop and implement action plans; and evaluate the
efforts); and methods and measurement. To achieve such a CLE, preceptors need to be knowledgeable
about other healthcare professions, develop collaborative relationships with preceptors from other
healthcare professions, and work with the preceptors from other healthcare professions to develop
opportunities for experiential learning for all members of the clinical team.
An NCICLE interprofessional symposium held in October 2017 identified key characteristics of an
optimal interprofessional CLE (IP-CLE) (Hawkins et al., 2018):
• Patient centeredness, which includes the patient, family, and community as integral parts of
the healthcare team
• Continuum of learning, with everyone in the clinical environment considered a learner
• Reliable communications, which allow teams to effectively and actively communicate
• Team-based care, with interprofessionalism instilled into all aspects of patient care
• Shared accountability, which includes experiential learning with measureable outcomes and
clear competencies
• Evidence-based patient care based on interprofessional experience
A Safe Learning Environment
For learning to occur, the environment must be safe for the preceptee. Being safe includes both physical
and psychological safety. Maslow’s (1954, 1971) Hierarchy of Needs provides a good foundation for
considering the preceptee’s basic needs. If preceptees do not feel safe from harm, it is difficult for them
to perform basic functions, much less learn new ones or perform higher-order functions such as critical
thinking. The Lucien Leape Institute (2013) describes workplace safety as “a workplace free from the
risks of both physical and psychological harm” and further notes that “workplace safety is inextricably
linked to patient safety. Unless caregivers are given the protection, respect, and support they need, they
are more likely to make errors, fail to follow safe practices, and not work well in teams” (p. 1).
Physical Safety. The Occupational Safety and Health Administration (OSHA) identifies healthcare
as one of the most hazardous industries in which to work (Bureau of Labor Statistics [BLS], 2017).
Creating a safe physical environment begins with teaching the preceptee how to prevent or mitigate
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
the effects of workplace injuries (e.g., musculoskeletal injuries, needlesticks), exposure to hazardous
materials, and physical abuse. Resources such as the American Nurses Association (ANA, 2013)
publication on safe patient handling and mobility can provide valuable information. Physical abuse is
a real danger for nurses. Learning de-escalation strategies will help the preceptee be more prepared if
threatened with physical abuse.
Psychological Safety. Edmundson and Lei (2014) note that psychological safety involves the
“perceptions of consequences of taking interpersonal risks in a particular context such as a workplace”
(p. 24). They describe the vital role of psychological safety in addressing the “human need to feel safe at
work in order to grow, learn, contribute, and perform effectively in a rapidly changing world” (p. 41).
In a review of the psychological safety literature, Edmundson and Lei (2014) found three consistent
relationships across the studies: psychological safety plays a role in enabling performance; psychological
safety is very relevant to organizational learning; and individuals who feel psychologically safe are more
likely to speak up.
The preceptee must feel safe in asking any question. Especially early on in the preceptorship, set up
frequent times when you and the preceptee can be alone so that the preceptee will not hesitate to
ask questions that he/she may hesitate to ask in front of others. Discuss with the preceptee when it is
appropriate (and not) to ask questions in front of patients, families, etc.
Unfortunately, incivility, verbal abuse, and bullying are still far too prevalent for nurses. In a national
study of critical-care nurse work environments with over 8,400 respondents, Ulrich, Lavandero, Woods,
and Early (2014) found that, in the previous year in their work as a nurse, 39% of the respondents had
experienced verbal abuse from patients; 33% from patients’ families and significant others; 27% from
physicians; and 20% from other RNs. In a follow-up study in 2018, the incidence of verbal abuse was
even higher, and the incidence of discrimination and sexual harassment had increased (Ulrich, Barden,
& Cassidy, 2018). NGRN preceptees will likely be relatively inexperienced in dealing with incivility,
verbal abuse, and bullying as their interactions are limited while in the student role. Preceptors must
protect the preceptees and teach them strategies to deal with these disruptive behaviors.
Other psychological safety issues include moral distress and compassion fatigue. Jameton (1984) defined
moral distress as a phenomenon in which one knows the right action to take but is constrained from
taking it. The issues in moral distress generally fall into three categories: moral uncertainty, moral
dilemma, and moral conflict. Moral uncertainty occurs when a nurse (or other healthcare provider) is
unsure whether an ethical conflict or dilemma is present or is unclear what principles apply to resolve
an ethical conflict or dilemma (Jameton, 1984). An example would be when a nurse is unclear about
who should make the decisions about a patient’s treatment (Rushton & Kurtz, 2015). A moral dilemma
occurs when two or more ethical values or principles conflict, making it difficult to choose among the
various options (Jameton, 1984). All options could be morally supportable, but only one can be chosen.
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An example would be when a nurse struggles to reconcile her primary commitment to the patient and
contradictory requests by the patient’s surrogate that appear to be in opposition to the patient’s stated
goals and preferences (Rushton & Kurtz, 2015). Moral conflicts arise when two or more stakeholders
hold different opinions about how a moral dilemma should be resolved (Rushton & Kurtz, 2015).
Preceptors can help prevent moral distress by making sure that preceptees are aware of the ethical
implications of all their practice. In general, nurses and nursing students are aware of the ethical
implications of obvious, well-discussed ethical issues, but they “commonly do not recognize the ethical
elements underlying everyday clinical encounters” (Truog et al., 2015). By increasing and fostering what
has been termed “ethical awareness,” nurses are better prepared to make early identification of potential
ethical issues and act as moral agents in providing care to patients (Milliken, 2018). By being prepared,
they are more likely to develop and implement strategies to prevent and mitigate ethical issues, making
them less likely to experience moral distress. Preceptors can role-play ethical issues—big and small,
obvious and mundane—with preceptees to prepare them for when the real issues occur.
The American Association of Critical-Care Nurses (AACN) developed a framework for recognizing and
addressing moral distress—the 4 A’s to Rise Above Moral Distress (AACN, 2004):
1. The first step is ask—to become aware of moral distress you are experiencing and determine if it
is work-related.
2. The next step is affirm—to validate your feelings with others and to accept your personal
responsibility to act.
3. The third step is to assess—to analyze the risks and benefits and make a plan.
4. The final step is to act—to implement strategies to make and maintain the changes you desire
while preserving your integrity and authenticity.
Compassion fatigue is a form of secondary traumatic stress, which Figley (1995) defines as “the
natural and consequent behaviors and emotions resulting from knowing about a traumatizing event
experienced by a significant other—the stress resulting from helping or wanting to help a traumatized or
suffering person” (p. 7). Compassion fatigue in nurses can manifest as physical and emotional symptoms
including burnout, fatigue, distancing, and hopelessness (Nolte, Downing, Temane, & Hastings-Tolsma,
2017). Nurses who are younger and less experienced are at a greater risk for compassion fatigue (Kelly,
Runge, & Spencer, 2015).
Role of the Preceptor. The first role of the preceptor is to create and maintain a physically and
psychologically safe environment for the preceptee. However, some of the people and things that make
these environments hazardous are not under the preceptor’s control, so the preceptor needs to teach
the preceptee how to identify potential hazards and how to deal with them when they occur. Preceptors
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must be knowledgeable and alert about the signs and symptoms of moral distress and compassion
fatigue to identify these issues early on in preceptees. Precepting strategies such as the strengthsbased approach, debriefing, reflection, and mindfulness can be helpful to preceptees in preventing and
mitigating physical and psychological safety issues.
It Takes a Village
Bringing someone new into a position or role truly does take a village. Though the preceptor takes
the lead and is the “go-to” person for the preceptee, the preceptor needs the support of others to be
successful. Engaging others can help you as the preceptor and can give the preceptee opportunities to
form new relationships. Colleagues can be alert to practice opportunities that will help develop the
preceptee’s competence. Physicians, pharmacists, social workers, and other health professionals can
assist in teaching the preceptee. All can be supportive of the preceptee’s need to learn and be socialized
into the organization and the unit.
Establishing the Preceptor-Preceptee Relationship
It is relatively rare for any matching to be done between preceptors and preceptees, so establishing a
relationship with the preceptee is pretty much starting from scratch. If possible, spend some one-on-one
time with the preceptee as soon as possible. Go on a break or have lunch together. Spend a little time
just getting to know each other.
Role clarification comes next. Discuss your role and the preceptee’s role. What are you each responsible
for? If the preceptee will be participating in a structured program such as an NGRN residency or
specialty nursing education, discuss how the preceptorship fits into the program.
Begin to build trust. Bracey (2002) has developed a five-step trust-building model:
1. Be transparent—Open, easily readable, and vulnerable
2. Be responsive—Give honest feedback respectfully, spontaneously, and non-judgmentally
3. Use caring—Whatever is said or done comes from the heart; behavior is compassionate, affirming,
and understanding
4. Be sincere—Congruent, integral, accountable; actions are consistent with words
5. Be trustworthy—Honest, honor your word, manage by agreements
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Remember that trust is a two-way street. As the preceptor, you hold the power in the relationship
(whether you like to think of it that way or not, it is reality), and you must be especially vigilant where
trust is concerned.
You also need to discuss ground rules and relationship agreements at the beginning. One example is
establishing a way to communicate in critical or unsafe situations. For example, you and the preceptee
are in a patient’s room, and you see the preceptee doing something incorrectly. You don’t want to call
her out on it in a way that might alarm the patient, but you need to step in. One suggestion is to agree
on a word or phrase that you can say in those situations so the preceptee knows that you need to take
over (Modic & Schoessler, 2008). Another example would be to discuss that there might be times in
emergency situations when you must act and cannot take the time to teach, and when you need the
preceptee to act quickly and not expect explanations until later. Again, you and the preceptee can agree
on a code word or phrase that, in essence, means do what I say and do it now—we’ll talk about it later.
The agreement should include a commitment to debrief after the emergency is over.
Another example of a ground rule would be that the preceptee commits to let you know when she is
unsure of what you mean or doesn’t understand something. One of my colleagues, Dr. Sean Early, taught
me a technique to use while teaching classes. He stacks three cups in front of each attendee—a green
cup, a yellow cup, and a red cup. He then tells the attendees that the top cup is their signal to him and
the rest of the group of where they are in understanding what is being discussed. The green cup means,
“I’m with you. Keep going.” The yellow cup means, “I need clarification,” or, “I may be getting lost.” It is
a signal for the presenter to stop and offer assistance, clarification, etc., and to keep doing that until the
green cup is put back on top. The red cup means, “Stop right now; you’ve lost me,” and is the indicator
that the presenter needs to stop immediately and help the attendee. The interesting things about this
process are how quickly you, as the presenter, can have an almost Pavlovian response to the cup colors
and how even the shyest attendees, who might have never spoken up, will use the cups to communicate
their needs. You can’t use cups in clinical teaching, but you can develop an equivalent way for preceptees
to communicate their needs.
Preceptee Learner Assessment
You need to have a starting point for the precepting experience. You cannot assume that the preceptee
has knowledge or expertise based on his or her educational degree or past experience. Learner
assessment starts with conversations. Case studies, simulation scenarios, and online testing can be used
to assess competencies. Prompts such as, “Tell me how you would handle xyz” can be enlightening.
If preceptees balk at the need for you to do a preliminary assessment or for them to demonstrate
knowledge and/or competency, explain that your obligation is first and foremost to make sure that the
patients receive safe, quality care and that the only way you can let the preceptees care for the patient is
if you know their level of competence.
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Managing Transitions
Preceptees are transitioning into a new world, and that new world might mean transitioning from
student to professional nurse, into a new role or specialty, or into a new organization. William Bridges
(1991) says, “It’s not the changes that do you in, it’s the transitions. Change is not the same as transition.
Change is situational: the new site, the new boss, the new team roles, the new policy. Transition is the
psychological process people go through to come to terms with the new situation. Change is external,
transition is internal” (p. 3). Or as Marilyn Ferguson, a futurist, describes it, “It’s not so much that we’re
afraid of change or so in love with the old ways, but it’s that place in between that we fear . . . It’s like
being between trapezes. It’s Linus when his blanket is in the dryer. There’s nothing to hold onto” (as cited
in Bridges, 1991, p. 34).
As the preceptor, you must be attuned to the effect that being in a state of transition can have on
preceptees. This is especially true with NGRNs who are going through personal and professional
transition. They’re paying rent. They no longer have every weekend off. There’s no summer vacation.
They have to work 12-hour days. They’re learning to balance life and work. If you’re precepting new
managers, the transition might be particularly hard if they’ve been promoted from within and they now
supervise people who were their peers last week. Sometimes a simple “How’s it going?” is enough to
show that you have an understanding of how hard transitions can be and that you are available to help if
needed. Another strategy is to verbally paint preceptees a mental picture of what it will look like in their
new world when the transition is done. Bridges (1991) suggests reinforcing the new beginning by being
consistent, ensuring quick successes, symbolizing the new identity, and celebrating success.
Clinical Teaching Strategies
Preceptors can use a number of teaching strategies. Four of the most common are the strengths-based
approach, the five-step microskills model of clinical teaching, debriefing, and reflective practice.
Strengths-Based Approach
The strengths-based approach, according to Saleebey (2002), emphasizes discovering, affirming,
and enhancing the capabilities, interests, knowledge, resources, and goals of individuals. For many
preceptees, the preceptor will have to begin the strengths-based approach by explaining it to the
preceptees. Preceptees whose past experiences have been predominantly with deficit-based approaches
and one-way, teacher-directed communication have to adjust to not hearing mainly what they’ve done
wrong and generally “waiting for the other shoe to drop” in communications. Using the strengths-based
approach, the preceptor facilitates discovery and clinical reflection and creates a learning environment
that is based on mutuality and building on strengths. Cederbaum and Klusaritz (2009) identify several
tenets of the strengths-based approach: self-determination, empowerment, mutuality, collaboration,
reflection on change, community membership, and regeneration.
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Cederbaum and Klusaritz (2009) also offer some practical suggestions on using the strengths-based
approach with students that can be adapted for use in all precepting endeavors:
• Use a learning contract—The learning contract emphasizes the mutual process between
preceptors and preceptees and delineates roles and responsibilities of both participants. The
contract can be a verbal or a written agreement.
• Express concerns in a positive manner—The strengths-based approach, in contrast to the
often used deficit-based approach, emphasizes identifying and building on existing strengths.
It does not mean that deficits and problems are not addressed but, rather, that they and the
actions needed are framed in a positive manner.
• See the learning process through preceptees’ eyes—Preceptors can use the strengths-based
approach to help them understand how preceptees view the clinical situation and the learning
environment. Preceptors can work with preceptees to create a plan to address any concerns.
• Create a safe practice environment—The preceptor is responsible for ensuring that
preceptees have a safe environment in which to learn, including physical and mental safety.
• Practice tolerance—Being a preceptor isn’t easy. Preceptees will sometimes not share your
beliefs, skills, views, etc. They often (hopefully) have a lot of questions, and their pace of both
thought and action is generally not as fast as the preceptor’s pace. Being a preceptor includes
accepting that your way is not the only way, and preceptors can often learn from their
preceptees.
• Examine your teaching style—Reflecting on your own teaching style and being open to new
ideas and strategies enhance your effectiveness as a preceptor.
Gallup has conducted multiple research studies that demonstrate a connection between strengths and
employee engagement in the workplace (Sorenson, 2014). They have also found that building people’s
strengths is a more effective approach to improving performance than merely trying to improve
weaknesses. In order to help people use their strengths, Gallup recommends not assuming that people
know their strengths; finding ways to apply strengths in a team setting to achieve common goals; and
incorporating strengths into performance conversations. Ken Blanchard and Spencer Johnson (1981),
in their long-acclaimed book, The One Minute Manager, put it very simply: “Help people reach their
full potential. Catch them doing something right” (p. 39). Details on their suggestions for one-minute
praising are found in Table 3.2.
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Table 3.2
One-Minute Praising
• Tell people upfront that you are going to let them know how they are doing.
• Praise people immediately.
• Tell people what they did right—be specific.
• Tell people how good you feel about what they did right and how it helps the organization and the
other people who work there.
• Stop for a moment of silence to let them “feel” how good you feel.
• Encourage them to do more of the same.
• Make it clear that you support their success in the organization.
Source: Blanchard & Johnson, 1981, p. 44
One other suggestion is what Michael LeBoeuf (1985) calls the greatest management principle in the
world—“The things that get rewarded get done.” He goes on to say, “The greatest single obstacle to the
success of today’s organizations is the giant mismatch between the behavior we need and the behavior
we reward” (p. 9). Rewards come in many forms, and you have to be careful not to unintentionally
reward behavior that you don’t want. For example, if you pay a lot of attention and express concern
when your preceptee is whiny and not so much attention and concern when the preceptee is acting more
professional, and if the preceptee likes to receive your attention and concern, the whiny behavior is the
behavior that will likely recur. With a strengths-based approach, you need to make sure that strengths,
and building on strengths, are what gets rewarded.
Microskills Model
Neher, Gordon, Meyer, and Stevens (1992) created the five-step microskills model of clinical teaching to
provide efficient and effective teaching in the clinical setting for family practice students and residents.
The model is learner-centered. More recently, this model has been referred to as the One-Minute
Preceptor (Iyer, Nanditha, & Raman, 2017; Neher & Stevens, 2003; Swartz, 2016), although in practice
the model generally takes more than one minute. The five microskills of the model are (Neher & Stevens,
2003):
1. Get a commitment to a diagnosis and/or course of action by engaging the student in an
interactive learning experience. Ask: “What do you think is going on?” “What do you want to
do?”
2. Probe for supporting evidence; find out how the decision was made. Ask: “What factors did
you consider in making that decisions?” “Were there other options you considered and decided
against?”
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3. Teach general rules; discuss how what was learned in this experience can be applied more
generally.
4. Reinforce what was done right; be specific.
5. Correct mistakes and/or discuss common mistakes to avoid.
This sequence is important because it fosters learner ownership of the problem. It also allows the
preceptor and preceptee to identify gaps in the preceptee’s knowledge and provides direction to the
preceptor on what to focus on to meet the perceptee’s needs. Iyer et al. (2017) found that the OneMinute Preceptor model was more effective for teaching interns and more preferred by the interns as
compared to the traditional teaching method.
The One-Minute Preceptor model has also been used in nursing with positive results. Bott, Mohide, and
Lawlor (2011), after reviewing the model and doing a literature review, modified the model to better fit
nursing and renamed it the Five Minute Preceptor, to better reflect the actual time for using the model.
The steps of the Five Minute Preceptor model are as follows (Bott et al., 2011):
1. Get the student to take a stand—This statement allows for the broader options and situations
that the nurse might be experiencing beyond diagnoses and courses of action in the first step
of the One-Minute Preceptor model. In this step, the preceptor would use general questions or
comments to help students/preceptees work through their thought process.
2. Probe for supporting evidence—In this second step, the preceptor “asks clearly framed, higher
order questions to elicit evidence or rationale” (Bott et al., 2011, p. 38) and to determine
how preceptees decided on the decision in step one. This action provides the preceptor the
opportunity to identify preceptee learning needs and knowledge gaps.
3. Teach general rules—Having done the previous two steps, the preceptor has the opportunity to
extend the preceptee’s knowledge and learning in the current specific situation to more general
situations.
4. Reinforce the positives—In this step, the preceptor “provides positive feedback with rationale or
explanations that reinforce the student’s strengths and competencies (knowledge, skills, and/or
attitudes) so that positives can be applied reliably in future situations” (Bott et al., 2011, p. 39).
Feedback should be very specific.
5. Correct errors or misinterpretations—The preceptor provides constructive feedback and
additional relevant information and discusses with the preceptee how to apply this information
in the future.
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Bott and colleagues note that in their analysis of the Five Minute Preceptor model, they recognized a
strong parallel between the model and the experiential learning process described by Kolb (1984).
Parrott, Dobbie, Chumley, and Tysinger (2006), after reviewing the research on the One-Minute
Preceptor model, summarized the factors that had been found to contribute to the success of the model:
• The clinical teacher’s ability to correctly diagnose the patient’s problem
• The clinical teacher’s confidence in evaluating the learner
• The clinical teacher’s ability to encourage the learner to do independent learning and outside
reading
• The quality of feedback that clinical teachers give to learners (high-order feedback is better)
• The frequency with which clinical teachers give feedback to learners (more is better)
Debriefing
To achieve maximum learning, you need to have time to debrief after clinical experiences to review the
experience in a systematic and purposeful way. Warrick, Hunsaker, Cook, and Altman (1979) note that
debriefing is designed to synergize, strengthen, and transfer learning, but also that it is often the most
overlooked part of the experiential learning process. They found that for meaningful and transferable
learning to occur, there should be an opportunity for learners to reflect on their experience, receive
specific behavioral feedback, integrate observation and feedback within conceptual frameworks, and
create mechanisms for transferring learning to other situations. This coincides with the learning cycle
described by Kolb (1984): concrete experience, reflective observation, abstract conceptualization, and
active experimentation (see Chapter 2 for additional information).
The objectives for debriefing include:
• Identify and discuss what occurred from the perspectives of preceptees and preceptor (clinical
and behavioral aspects).
• Transfer of knowledge—Link the experience to evidence, theory, practice guidelines, and
skill-building specific to this experience. Reinforce teaching points.
• Answer preceptees’ questions.
• Identify potential resources.
• Enhance critical thinking, clinical reasoning, and clinical judgment skills.
• Summarize the key points of the experience and what was learned.
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Debriefing is best done as close in time to the event as possible to better capture recall of events,
thinking, and feelings. In the clinical setting, this might mean taking time during the shift to do a short
debriefing for critical events and a longer debriefing at the end of the shift that covers the experiences of
the day. This is especially the case for NGRNs who are experiencing major events for the first time, such
as the death of a patient, an ethics issue, or a code. All debriefings—short or long—need to occur in an
environment in which the preceptee feels safe.
The preceptor’s ability to communicate is a critical factor in the success of debriefing. Listening
attentively to what preceptees say and being able to articulate and summarize succinctly what occurred
and what is to be learned are both important elements. Detailed information on communication can be
found in Chapter 6.
Rudolph, Simon, Dufresne, and Raemer (2006) discuss what they call “debriefing with good judgment.”
They contrast the two extremes of debriefing, judgmental and nonjudgmental, and find both lacking.
The judgmental approach “places truth solely in the possession of the instructor, error in the hands of
the trainee, and presumes that there is an essential failure in the thinking or actions of the trainee” (p.
51). They further note that “a judgmental approach to debriefing, especially one that includes harsh
criticism, can have serious costs: humiliation, dampened motivation, reluctance to raise questions about
later areas of confusion, or exit of talented trainees from the specialty or clinical practice altogether” (p.
51). On the other hand, preceptors using the nonjudgmental approach might employ protective social
strategies (e.g., sugarcoating, surrounding the negative with more positives) and not address critical
issues, thereby inadvertently implying that what is not discussed is unimportant or that mistakes should
not be talked about.
Rudolph et al. (2006) propose another option—debriefing with good judgment. This approach “values
the expert opinion of the instructors, while at the same time valuing the unique perspective of the
trainees. The idea is to learn what participant frames drive their behaviors so that both their ‘failures’
and successes can be understood as an ingenious, inevitable and logical solution to the problem as
perceived within their frames” (p. 52). The debriefing-with-good-judgment approach focuses on
creating a context for adult learners to learn important lessons that can help them move toward key
objectives and includes the learner’s meaning-making systems and the sharing of insights by the
instructor to initiate dialogue. Errors are openly discussed so they can be a source of learning.
Rudolph and colleagues (2006) suggest using an advocacy-inquiry approach, with advocacy being an
assertion, observation, or statement, and inquiry being a question. After noticing a result and observing
what actions led to the result, the instructor uses advocacy-inquiry to discover the frames or context
that guided the learner’s actions. This approach helps preceptees articulate their thinking and reasoning
and gives preceptors the opportunity to help preceptees identify gaps or errors and learn from the
experience.
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Debriefing is not limited to the one-on-one debriefing between the preceptor and the preceptee.
Preceptees need to become competent in debriefing with others—both as a debriefing leader and a
debriefing participant. Interprofessional debriefing is an important component of collaborative practice.
Zinns, Mullan, O’Connell, Ryan, and Wratney (2017) developed a cognitive aid (named REFLECT) for
structured post-resuscitation debriefings conducted in the clinical area shortly after the event. The use of
the REFLECT aid was found to result in richer debriefing discussions that exhibited more team member
engagement; more feedback; more emphasis on communication and team-based care; and more focus
on improving performance. Their REFLECT mnemonic stands for:
• Review the event—preferably in one sentence
• Encourage team participation—elicit feedback on what went well and what could have been
improved
• Focused feedback—target feedback to the team
• Listen to each other—foster a safe learning environment
• Emphasize key points—highlight take-home messages
• Communicate effectively—use common language
• Transform the future—discuss how to improve in the future
Debriefing is a key component of an NGRN residency. For NGRNs, debriefing should occur daily
(both during the work shift and at the end of the work shift) and as planned debriefing sessions with
the entire cohort of NGRNs in the residency. Debriefing is most effective if done as soon after the
experience as possible, so taking the time to debrief after both positive and negative experiences is
important. In a summary debriefing at the end of the shift, the preceptor and the preceptee can review
what has been learned, identify performance gaps, and discuss areas for improvement and new learning.
Debriefings will be needed on transition experiences and when traumatic events happen for the first
time. For example, Shinners, Africa, and Hawkes (2016) identified the top-ranked debriefing topics in
one NGRN residency program as response to stress, self-care techniques, reality shock—transitioning
to the workforce, and reality shock—from novice to expert. Traumatic events such as an NGRN’s first
experience with a patient death, first code, first major negative encounter with verbal abuse or other
disruptive behavior, and first major ethical issue require one-on-one debriefing as soon after the event
as possible, but also present an opportunity to discuss and debrief the event with the entire cohort
of NGRN residents. In these events, NGRNs often need to reconcile their theoretical knowledge and
expectation of what would happen with the reality of the event and need to discuss and understand their
feelings and reactions—both in the moment and after. NGRN residents appreciate and benefit from
debriefing with other NGRN residents—learning from each other’s experiences and understanding that
other NGRN residents were having the same issues.
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Reflective Practice
Part of experiential learning is discussing and reflecting in the experience to understand and grasp
abstract concepts and emotional aspects. For you as a preceptor, it is a valuable tool both for your
own growth and as a skill to teach preceptees to improve their understanding of situations and their
responses.
Dewey (1933, p. 3) defined reflection as “the turning over of a subject in the mind and giving it serious
and consecutive consideration.” Reflective practice is a term coined by Schoen (1983) to describe
examining the knowledge base, values, and assumptions that drive your professional practice. Schoen
discusses two types of reflection—reflection in practice or reflection in action, which occurs during an
action or practice, and reflection on practice or reflection on action, which occurs after.
Sherwood and Horton-Deutsch (2015) describe reflection as a “systematic way of thinking about actions
and responses using knowledge; it is learning from experience by considering what one knows, believes,
and values within the context of current situations and then reframing to develop future responses or
actions. This process applies theory from all ways of knowing so that learning is applied and integrated
into future decision-making; thus an extension of evidence-based practices and research” (p. 10).
Johns (2017) created a model of structured reflection. It includes a description of the reflection
experience (e.g., What was I trying to achieve? Why did I act as I did? What were the consequences?
How did I feel? How did others feel? How do I know how others felt?); influencing factors (internal and
external); and learning (What were other options? What would be the consequences of those options?
How has the experience changed my way of knowing?). These cues can be used to help people reflect.
Reflective learning is important for both preceptors and preceptees. Scanlan and Chernomas (1997) say
that “to teach reflectively, we must be reflective ourselves” (p. 1141). They describe being a reflective
teacher as thinking about your teaching, modeling reflective thinking strategies, and using teaching
strategies that encourage the learner to be reflective. Not everyone is skilled in self-reflection or
comfortable engaging in it. Part of the work of preceptors is to learn to be reflective in our own practice
and to encourage and support self-reflection by preceptees.
Pappas’ Taxonomy of Reflection, modeled on Bloom’s approach, illustrates developing higher-order
thinking skills and can be used as a simple tool for formative assessment and learning (see Figure 3.1). A
version of the taxonomy with reflective questions for preceptors is shown in Figure 3.2.
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Taxonomy
Reflective Questions
Creating
What should I do next? What’s my plan?
Evaluating
How well did I do?
What worked? What do I need to improve?
Analyzing
Do I see any patterns or relationships in what I did?
Applying
Where could I use this again?
Understanding
What was important about it? Did I meet my goals?
Remembering
What did I do?
Adapted from Pappas, 2010
FIGURE 3.1 Taxonomy of Reflection
Adapted from Pappas, 2010
Taxonomy
Reflective Questions
Preceptor Reflective Questions
Creating
What should I do next?
What’s my plan?
How would I incorporate the best aspects of this experience in the future?
What changes would I make? How can I best use my strengths to improve?
Is there training or networking that would help me? What can I suggest/do
to improve the learning environment?
Evaluating
How well did I do?
What worked?
What do I need
to improve?
What was learned and is it important? Were my assumptions correct? Were
any elements of the lesson more effective than others? Were the preceptee’s
needs met? What level of mastery did the preceptee reach? What have I
learned about my stengths and areas in which I can improve? How am I
progressing as a preceptor?
Analyzing
Do I see any patterns
or relationships in
what I did?
What knowledge and experience did I assume the preceptee was bringing to
the experience? Were the teaching strategies the right ones for this? Do I see
patterns in how I approached the experience or in my teaching style? Were
they effective or could I have eliminated or re-organized steps?
Applying
Where could I
use this again?
Did I build on previous learning? How does this learning experience scaffold
learning for the next experience? Can this be modified for different learners?
Understanding
What was important
about it?
Did I meet my goals?
Can I explain the major components? Do I understand how they connect to
the previous and next learning experience? What teaching strategies did I
use? Was the content evidence-based?
Remembering
What did I do?
What was the learning experience? Did it address the necessary content?
How did the preceptee do?
Adapted from Pappas, 2010
FIGURE 3.2 Taxonomy of Reflection for Preceptors
Adapted from Pappas, 2010
Mindfulness
Have you ever been palpating for an intravenous (IV) needle insertion site that was particularly hard to
find and realized that you had closed your eyes? You were turning off your visual sense to heighten your
attention to your sense of touch. In today’s crazy, loud, ever-changing healthcare environments, with all
the simultaneous demands on our attention, it is hard sometimes to concentrate on what you are doing
and to focus on the present. But that is exactly what we need to do, and mindfulness is how we can do it
and how we can teach preceptees to do it.
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Jon Kabat-Zinn (2003), a professor of medicine emeritus at the University of Massachusetts
Medical Center who is largely credited with introducing mindfulness into healthcare, describes
mindfulness as “the awareness that emerges through paying attention, on purpose, in the present
moment, and nonjudgmentally to the unfolding of experience moment by moment” (p. 145).
Shapiro, Carlson, Astin, and Freedman (2006) note that there are three fundamental components
of mindfulness: intention (on purpose), attention (paying attention), and attitude (in a particular
way). The formal practice of mindfulness occurs when you plan the time to be mindful. An
example would be meditation. Informal mindfulness is embedding mindfulness into your daily life.
Mindfulness practices help nurses and patients, but how do you find time for mindfulness when
you don’t have time to do all you need to do now? The evidence says that time spent in mindfulness
practice will have many positive benefits that will ultimately save you time. Halm (2017), in a
clinical evidence review, studied the role of mindfulness in enhancing self-care for nurses and
found that mindfulness practices, even over a short term, resulted in improvement in physiological
and psychological well-being; increased attention awareness, self-compassion, and a sense of
coherence; a buffer from burnout; greater work satisfaction and life satisfaction; an increased
likelihood of using patient-centered patterns of communication; higher patient satisfaction in
patient-provider communications; and improved patient safety.
In studying the results of a mindfulness-based intervention (meditation, mild yoga movement,
and music) for 1 hour a week for 8 weeks, Steinberg, Klatt, and Duchemin (2017) found that
participants’ work satisfaction increased significantly and burnout symptoms decreased compared
to the control group. All participants in the mindfulness intervention group rated recognizing their
stress responses as the number one benefit, followed by 85% rating learning mindfulness as a way
to deal with stress as number two. All participants were still practicing mindfulness 8 months later.
There are other personal benefits to mindfulness. Kozak, Foreman, Streeter, Maruti, and Pipe
(2017), in a review of the benefits of mindfulness of providers for the Institute for Healthcare
Improvement (IHI), found the benefits to include decreased stress anxiety, depression, and pain;
increased sense of control and personal energy; strengthened job performance; and greater
acceptance of what is beyond one’s control.
Practicing mindfulness can even change the function and structure of our brains; Hölzel et al.
(2011) found that after even short-term mindfulness programs, the amygdala (the fight-or-flight
part of the brain) becomes smaller while the portions of the brain that are associated with working
memory, attention, and emotional integration (cerebral cortex) become thicker.
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Even taking 5 minutes a day to refocus and quiet your mind can be helpful (Gauthier, Meyer, Grefe, &
Gold, 2015). In fact, less than a minute of mindfulness can be beneficial. A purposeful pause/mindful
moment takes only 10–60 seconds—stopping to think about where your attention is, being aware of
the distractions, and focusing (Streeter, 2017). You can even work a purposeful pause into times like
washing your hands, waiting for the elevator, or just before entering a patient’s room. We all like to
think that we can multitask—to focus on many things at once—but the evidence says we can’t, that the
brain has to switch off the attention on one thing before it can truly attend to the other (Medina, 2014).
Practicing mindfulness helps bring our attention to the thing we need to focus on right now.
The use of mindfulness in precepting can be helpful to the preceptee and the preceptor. Integrating
either formal or informal mindfulness practices can be beneficial. Being a preceptee, regardless of what
the new role or position is, can be very stressful. To learn something new, you have to accept being a
novice, and that often includes feeling vulnerable. Mindfulness practices can help relieve the stress and
can help focus your attention on what you are trying to learn. As the preceptor, you need to understand
mindfulness in order to help your preceptee learn mindfulness practices and use them. Also, KabatZinn (2003) does not believe that you can teach mindfulness without doing it, so you need firsthand
experience. And being a preceptor is stressful. You are responsible for transitioning a person into a new
role or position and for making sure the preceptee and the patients are safe. Using mindfulness practices
can help you, too.
Resilience
Resilience has many definitions, but all share two common themes—adversity (the antecedent of
resilience) and positive adaptation (the positive consequence) (Fletcher & Sarkar, 2013). Some of the
definitions of resilience include:
• A “positive adaptation despite significant adversity or trauma” (Luthar & Cicchetti, 2000,
p. 857),
• “The capacity of individuals to successfully maintain or regain their mental health in the face
of significant adversity or risk” (Stewart & Yuen, 2011, p. 199), and
• “The capacity of an individual to respond and even prosper from negative or positive stressful
circumstances” (Luthans, Vogelgesang, & Lester, 2006, p. 30).
Organizations and individuals can be resilient. Hopkin (2014) studied resilient organizations and found
that five criteria were necessary to achieve resilience:
• Ability to anticipate problems
• Diversification of resources
• Strong relationships and networks
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• Ability to launch a rapid response in times of crisis to normalize operations
• Ability to learn from experience and make improvements accordingly
Many of these criteria are also related to individual resilience. A review of the literature on individual
resilience found several essential characteristics: self-efficacy, hope, coping, rebounding, determination,
social support, endurance, adaptability, recuperability, hardiness, internal locus of control and selfesteem, and purpose in life (Shaw, 2016). Fletcher and Sarkar (2012) studied individual resilience
by studying the relationship between psychological resilience and optimal sports performance in
Olympic gold medalists. They found that psychological resilience was an overarching concept that
included “stressors, cognitive appraisal and meta-cognitions, psychological factors (positive personality,
motivation, confidence, focus, perceived social support), and facilitative responses” (p. 672). They also
found that most of the participants in their study thought that they would not have won their gold
medals if they had not been exposed to the stressors they overcame. The ways in which the Olympians
developed resilience are shown in Table 3.3.
Table 3.3
Nine Ways Olympians Develop Resilience
• Develop a positive personality—Be open to new experiences, optimistic, competitive and
conscientious, as well as proactive.
• View decisions as active choices, not sacrifices—This helps maintain a sense of control over the
situation. This will also keep intrinsic motivation high.
• Use support available from other people—Seek out people who can help you.
• Identify your motivation for succeeding—Identify what’s important to you.
• Focus on personal development—Don’t spend too much time comparing yourself to others.
• View setbacks as opportunities for growth—Ask yourself what you have learned and what you
would do differently next time.
• Strengthen your confidence from a range of sources—Drawing on a range of sources can make
your confidence more robust.
• Take responsibility for your thoughts, feelings, and behaviors—Avoid the temptation of playing
the blame game.
• Concentrate on what you can control—Focus on what you can control, not on what you can’t
change or can only influence. This means focusing on the process, not the outcome.
Source: Fletcher & Sarkar, 2012
In a nurse-specific study, Gillespie, Chabover, Wallis, and Grimbeck (2007) investigated resilience in
operating room (OR) nurses and found that five variables explained 60% of the variance in resilience:
hope, self-efficacy, coping, control, and competence, with the highest statistical association between
hope and resilience. Though noting that hope is an intrinsic factor, they postulated that it was likely that
hope would be enhanced in supportive work environments.
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Rushton (2016) discusses resilience in relation to moral distress in nurses and defines moral resilience
as the capacity of individuals “to sustain or restore their integrity in response to moral complexity,
confusion, distress, or setbacks” (p. 112). Rushton (2017) notes that moral resilience “represents
the cultivation of skills and practices that support clinicians in deepening their connection and
commitment to their primary intentions, recognizing their sense of moral responsibility, and effectively
navigating ethically complex, ambiguous, or conflicting situations” (p. S13). Ways to develop moral
resilience include: cultivating mindfulness; developing self-awareness and insight; providing ethics
education; and providing organizational support (Rushton, 2017).
Certainly nurses face stress and adversity in their work, and developing psychological and moral
resilience has the potential to be of benefit to them personally and to their patients. Preceptors can role
model resilience and help preceptees develop the knowledge, skills, confidence, and other practices that
support the development of resilience.
Ending the Preceptor-Preceptee Relationship
Just as important as how you begin the preceptor-preceptee relationship is how you end it. A final
meeting with just you and the preceptee and another meeting with you, the preceptee, and the manager
are important for closure and to ensure that the preceptee’s growth and learning will continue. Closure
allows affirmation and action planning, ties things together, and allows and encourages celebration.
In the meeting with you and the preceptee, at a minimum:
• Review the preceptorship, covering the highlights.
• Acknowledge any loose ends or unfinished work, and discuss a plan for completion.
• Recognize the preceptee’s growth.
• Acknowledge what you have learned.
• Ask for feedback for the preceptorship as a whole and for you as a preceptor.
• Ask about the preceptee’s future plans, and offer to be of help.
At the meeting with the preceptee and the manager:
• Discuss the preceptorship as a whole.
• Recognize the preceptee’s growth.
• Discuss any additional work that the preceptee needs to complete and help develop a plan for
completion.
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Last, but not least, celebrate, preferably with the unit as a whole, to acknowledge completion of
the preceptorship. Some organizations literally have a “cut the cord” ceremony symbolizing the
advancement of the preceptees. Find whatever works in your culture for celebrations to acknowledge the
completion of this transition.
Conclusion
As you move into the preceptor role and begin preceptor-preceptee relationships, consider the general
precepting strategies discussed in this chapter. By clarifying your manager’s expectations of the
preceptor role at the beginning, you will better understand the work you are to do and the conditions
under which you are to do it. Understanding the prevalent preceptorship models will help you know the
advantages and disadvantages of each model. Using the strategies for starting, maintaining, and ending a
relationship as well as teaching strategies will let you plan the overall preceptorship and ensure that both
you and your preceptee are successful.
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Preceptor Role Clarification
Use the questions in this form to guide a conversation with your manager to clarify expectations
of you in the preceptor role.
Name:
Manager:
Date:
Expected Outcomes
At what level of practice do you expect the
preceptee to be at the end of the preceptorship?
What specific competencies do you expect
the preceptee to have at the end of the
preceptorship?
Preceptor Role Requirements
What are your expectations of me in the
preceptor role?
Are there classes I need to take?
Are there continuing education requirements?
Will I need to liaison with anyone (e.g., nursing
school faculty for student nurses)? If yes, with
whom?
3
Support Available for the Preceptor and the Preceptee
What initial preparation will I get for the
preceptor role?
Will additional education be available in the
future? If so, what?
Who is available to me as resources?
Will I have an experienced preceptor to precept
me in my preceptor role?
What information resources are available to me
and my preceptee?
If the preceptee is an NGRN, do we have a
structured RN residency or transition to practice
program in place? Will there be training for me
on that program?
Time Dedicated to the Preceptor and Preceptee Roles
How much of my time will be dedicated to the
preceptor role for each type of preceptee (e.g.,
NGRN, new hire experienced nurse, experienced
nurse new to our specialty)?
Precepting Strategies
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
How much preceptee time will be dedicated to
the preceptee role for each type of preceptee
(e.g., NGRN, new hire experienced nurse,
experienced nurse new to our specialty)?
What part of my hours and my preceptee’s hours
will be counted in staffing?
Priority of Precepting Role With Other Duties
Except for emergencies, will I be pulled to staff
other shifts or units when I am in my preceptor
role? If yes, will someone take my place with my
preceptee?
Other Items/Issues Discussed
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
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Preceptor Development Plan: Precepting Strategies
Review the precepting strategies described in this chapter. What are your strengths? In which
areas do you need to increase your knowledge and experience? What is your plan for expanding
your knowledge and expertise? What resources are available? Who can help you?
Name:
Date:
Sharing Information
Strengths
Needs
Plan
Resources
Creating Positive Learning Environments: Enhancing Experiential Learning
Strengths
Needs
Plan
Resources
Creating Positive Learning Environments: Brain Rules
Strengths
Needs
Plan
Resources
Creating Positive Learning Environments: Interprofessional Learning Environments
Strengths
Needs
Plan
Resources
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Creating Positive Learning Environments: A Safe Learning Environment
Strengths
Needs
Plan
Resources
Establishing the Preceptor-Preceptee Relationship
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Preceptee Learner Assessment
Strengths
Managing Transitions
Strengths
Clinical Teaching Strategies: Strengths-Based Approach
Strengths
Needs
Plan
Resources
3
Precepting Strategies
Clinical Teaching Strategies: Microskills Model
Strengths
Needs
Plan
Resources
Plan
Resources
Plan
Resources
Plan
Resources
Plan
Resources
Clinical Teaching Strategies: Debriefing
Strengths
Needs
Clinical Teaching Strategies: Reflective Practice
Strengths
Needs
Clinical Teaching Strategies: Mindfulness
Strengths
Needs
Clinical Teaching Strategies: Resilience
Strengths
Needs
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Ending the Preceptee-Preceptee Relationship
Strengths
Needs
Plan
Resources
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
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PEC.0000000000001111
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“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.”
4
–Florence Nightingale
Core Precepting
Concepts
–Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
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.
Competence
Professional competence is required of all registered nurses (RNs). Although we
mostly talk about clinical competence for nurses, all nursing roles and positions
require competence. The purposes of ensuring the competence of nurses are to
protect the public (the primary purpose), advance the profession, and ensure the
integrity of the profession.
Competence is included in Nursing: Scope and Standards of Practice: “The
registered nurse seeks knowledge and competence that reflects current nursing
practice and promotes futuristic thinking” (American Nurses Association [ANA],
2015b, p. 5) and in the Code of Ethics: “The nurse owes the same duties to self
as to others, including the responsibility to promote health and safety, preserve
wholeness of character and integrity, maintain competence, and continue personal
and professional growth” (ANA, 2015a, p. 73). In addition, the ANA Position
Statement on Professional Role Competence (ANA, 2014) defines competence and
competency and identifies principles for addressing competence in the nursing
profession (see sidebar).
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
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ANA Position Statement on Professional Role Competence
The public has a right to expect registered nurses to demonstrate professional competence
throughout their careers. ANA believes the registered nurse is individually responsible and
accountable for maintaining professional competence. The ANA further believes that it is
the nursing profession’s responsibility to shape and guide any process for assuring nurse
competence. Regulatory agencies define minimal standards for regulation of practice to
protect the public. The employer is responsible and accountable to provide an environment
conducive to competent practice. Assurance of competence is the shared responsibility of
the profession, individual nurses, professional organizations, credentialing and certification
entities, regulatory agencies, employers, and other stakeholders.
Source: ANA, 2014, p. 1
The ANA (2014) defines a competency as “an expected level of performance that integrates knowledge,
skills, abilities, and judgment” (p. 3). Knowledge, skills, ability, and judgment are defined as follows
(ANA, 2014, p. 4):
• 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.
The ANA Position Statement on Professional Role Competence states, “Competence in nursing practice
must be evaluated by the individual nurse (self-assessment), nurse peers, and nurses in the roles of
supervisor, coach, mentor, or preceptor. In addition, other aspects of nursing performance may be
evaluated by professional colleagues and patients/clients” (ANA, 2014, p. 5). Competence is not about
checking items off a list. In fact, the frequent use of terms such as “competency checklist” and “checking
off preceptees” devalues the work required to develop and maintain competence and makes the process
of validating competence sound as if it requires little thought—that it is merely an inconsequential
nuisance and a documentation chore to be completed as quickly as possible. Nothing could be further
from the truth. The validation of competence is one of the most critical elements to ensure safe, highquality patient care and competent role performance.
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ANA Principles for Competence in the Nursing Profession
•
Registered nurses are individually responsible and accountable for maintaining
competence.
•
The public has a right to expect nurses to demonstrate competence throughout their
careers.
•
•
•
•
Competence is definable, measurable, and can be evaluated.
•
The competencies contained in ANA’s various scope and standards of practice documents
are the competence statements for each standard of nursing practice and of professional
performance.
•
•
Regulatory bodies define minimal standards for regulation of practice to protect the public.
•
Assurance of competence is the shared responsibility of the profession, individual nurses,
regulatory bodies, employers, and other key stakeholders.
Context determines what competencies are necessary.
Competence is dynamic, and both an outcome and an ongoing process.
The nursing profession and professional organizations must shape and guide any process
assuring nurse competence.
Employers are responsible and accountable to provide an environment conducive to
competent practice.
Source: ANA, 2014, pp. 6–7
Competence Development
Seeking to better understand the development of competency, the National Council of State Boards of
Nursing (NCSBN) completed a qualitative longitudinal (5-year) study of a national sample of nurses
from 2002–2008 (Kearney & Kenward, 2010). By the end of the fifth year, nurses had identified and
demonstrated five characteristics of competence:
1. Juggling complex patients and assignments efficiently
2. Intervening for subtle shifts in patients’ conditions or families’ responses
3. Having interpersonal skills of calm, compassion, generosity, and authority
4. Seeing the big picture and knowing how to work the system
5. Possessing an attitude of dedicated curiosity and commitment to lifelong learning
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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.
Conscious Competence Learning
The concept of conscious competence learning is a description of how individuals learn new
competencies. The concept serves to remind us that learning a competence happens in stages. The stages
of the conscious competence as described by Howell (1982) and expanded on by Cannon, Feinstein, and
Friesen (2010) include unconscious competence, conscious incompetence, conscious competence, and
unconscious competence.
• 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.
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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.
Competency Outcomes and Performance Assessment (COPA) Model
Lenburg (1999) developed the Competency Outcomes and Performance Assessment (COPA) model.
She describes it as “a holistic but focused model that requires the integration of practice-based
outcomes, interactive learning methods, and performance assessment of competencies” (Lenburg, 1999,
para. 2).
The basic framework of the model consists of four guiding questions (Lenburg, 1999):
1. What are the essential competencies and outcomes for contemporary practice? Identify the
required competencies and word them as practice-based competency outcomes.
2. What are the indicators that define those competencies? Only identify the behaviors, actions, and
responses mandatory for the practice of each competency.
3. What are the most effective ways to learn those competencies?
4. 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):
1. Assessment and intervention skills
2. Communication skills
3. Critical thinking skills
4. Human caring and relationship skills
5. Management skills
6. Leadership skills
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7. Teaching skills
8. Knowledge integration skills
In the COPA model, learner performance is assessed against a predetermined standard after the learning
and practice have occurred. Lenburg (1999) notes how important it is to separate these activities—
assessing versus learning/practicing—to keep the focus of each clear. The learner is then better able to
concentrate on learning, and the preceptor can concentrate on teaching and coaching during the learning
and practice periods, rather than both trying to split their attention and their purposes between learning
and assessing and, perhaps, one not always knowing the focus of the other.
Lenburg (1999) has found that assessments are most effective when they are designed and implemented
based on 10 basic concepts: examination, dimensions of practice, critical elements, objectivity, sampling,
acceptability, comparability, consistency, flexibility, and systematized conditions.
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.
The model is grounded in three concepts—ownership, empowerment, and accountability (Wright, 2005):
• 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.
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• 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.
Table 4.1
Core Critical Thinking Skills and Sub-Skills
INTERPRETATION: To comprehend and express the meaning or significance of a wide variety of
experiences, situations, data, events, judgments, conventions, beliefs, rules, procedures, or criteria
Sub-skills: Categorization, decoding significance, clarifying meaning
ANALYSIS: To identify the intended and actual inferential relationships among statements, questions,
concepts, descriptions, or other forms of representation intended to express beliefs, judgments,
experiences, reasons, information, or opinions
Sub-skills: Examining ideas, detecting arguments, analyzing arguments
continues
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Table 4.1
Core Critical Thinking Skills and Sub-Skills (cont.)
EVALUATION: To assess the credibility of statements or other representations that are accounts or
descriptions of a person’s perception, experience, situation, judgment, belief, or opinion; and to assess
the logical strength of the actual or intended inferential relationships among statements, descriptions,
questions, or other forms of representation
Sub-skills: Assessing claims, assessing arguments
INFERENCE: To identify and secure elements needed to draw reasonable conclusions; to form conjectures
and hypotheses; to consider relevant information and to educe the consequences flowing from data,
statements, principles, evidence, judgments, beliefs, opinions, concepts, descriptions, questions, or other
forms of representation
Sub-skills: Querying evidence, conjecturing alternatives, drawing conclusions
EXPLANATION: To state the results of one’s reasoning; to justify that reasoning in terms of the evidential,
conceptual, methodological, criteriological, and contextual considerations upon which one’s results were
based; and to present one’s reasoning in the form of cogent arguments
Sub-skills: Stating results, justifying procedures, presenting arguments
SELF-REGULATION: Self-consciously to monitor one’s cognitive activities, the elements used in those
activities, and the results educed, particularly by applying skills in analysis and evaluation to one’s own
inferential judgments with a view toward questioning, confirming, validating, or correcting either one’s
reasoning or one’s results
Sub-skills: Self-examination, self-correction
Source: American Philosophical Association, 1990
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
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• 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
The dispositions to specific issues, questions, or problems include (Facione, 2011):
• 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
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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?
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In addition, Alfaro-LeFevre (1999) offers suggestions on thinking critically about how to teach others:
• 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.
Preceptors can also use role-playing, case studies, reflection, and high-fidelity patient simulation to
teach clinical thinking.
Clinical Reasoning
Tanner (2006) defines clinical reasoning as “the processes by which nurses and other clinicians make
their judgments, and includes both the deliberate process of generating alternatives, weighing them
against the evidence, and choosing the most appropriate, and those patterns that might be characterized
as engaged, practical reasoning (e.g., recognition of a pattern, an intuitive clinical grasp, a response
without evident forethought)” (pp. 204—205).
Tanner (2006), in reviewing research on nurses and reasoning, found three interrelated patterns of
reasoning that experienced nurses use in decision-making:
• 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.
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Facione and Facione (2008) discuss research in human reasoning that has found evidence of the
function of two interconnected “systems” of reasoning. System 1 is “reactive, instinctive, quick, and
holistic” and often “relies on highly expeditious heuristic maneuvers which can yield useful response
to perceived problems without recourse to reflection” (Facione & Facione, 2008, p. 4). System 2, on the
other hand, is described as “more deliberative, reflective, analytical, and procedural” and is “generally
associated with reflective problem-solving and critical thinking” (p. 4). They note that the two systems
never function completely independently and that, in some cases, the two systems actually offer
somewhat of a corrective effect on each other. In fact, they say, “Effectively mixing System 1 and System
2 cognitive maneuvers to identify and resolve clinical problems is the normal form of mental processes
involved in sound, expert critical thinking” (p. 5).
Simmons, Lanuza, Fonteyn, Hicks, and Holm (2003) investigated clinical reasoning of experienced
(2–10 years) medical-surgical nurses. They found that the nurses used a number of thinking strategies
(heuristics) that consolidated patient information and their knowledge and experience to speed their
reasoning process. The most frequently used heuristics were (Simmons et al., 2003):
• Recognizing a pattern or an inconsistency in the expected pattern
• Judging the value of the information about which they were reasoning
• Providing explanations for why they had reasoned as they had
• Forming relationships between data
• Drawing conclusions
Clinical Judgment
Critical thinking, clinical reasoning, and clinical judgment are interrelated concepts (Victor-Chmil,
2013). Critical thinking and clinical reasoning are processes that lead to the outcome of clinical
judgment (Alfaro-LeFevre, 2017). Facione and Facione (2008) describe the relationship in this way:
“critical thinking is the process we use to make a judgment about what to believe and what to do about
the symptoms our patient is presenting for diagnosis and treatment” (p. 2).
Tanner (2006) defines clinical judgment to mean “an interpretation or conclusion about a patient’s
needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard
approaches, or improvise new ones as deemed appropriate by the patient’s response” (p. 204). Clinical
judgment relies on knowing the patient in two ways—knowing the patient as a person and knowing the
patient’s pattern of responses (Tanner, Benner, Chesla, & Gordon, 1993).
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Tanner (2006) has proposed a model of clinical judgment, based on a synthesis of the clinical judgment
literature, that can be used in complex, rapidly changing patient situations. The model includes:
• 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).
The use of this model can be helpful to preceptors as a structure for debriefing. It is a model of expert
practice—what the new graduate aims for and what the experienced nurse needs to perfect. Based on
Tanner’s model, Lasater (2007) developed a detailed rubric (Lasater Clinical Judgment Rubric [LCJR])
that could be used in simulation with dimensions for each of the phases of the model:
• 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
While the LCJR has been primarily used in academic settings, Miraglia and Asselin (2015) suggest that
it can be used as a framework to enhance clinical judgment skills of novice and experienced nurses.
New graduate registered nurses (NGRNs) have been shown to need major improvements in their
clinical judgment skills. In reviewing 10 years of data using the Performance Based Development System
(PBDS) for assessment, del Bueno (2005) found that only 35% of NGRNs met the entry requirements
(safe level) for clinical judgment, regardless of their prelicensure educational preparation. They were
unable to translate theory into practice. Accordingly, del Bueno posits that clinical practice with
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preceptors who ask questions (as opposed to giving answers) is the most critical intervention needed to
improve the clinical judgment skills of new graduates.
Developing Situational Awareness, Expert Reasoning, and
Intuition
Situational awareness, expert reasoning, and intuition are critical attributes to move from novice to
expert nurse. If you’ve ever walked into a patient room and instantly become alert because you knew
that something wasn’t right—even if you didn’t know what was wrong—you’ve used your situational
awareness, expert reasoning, and intuition.
Situational awareness is the foundation of decision-making and performance. Put simply, situational
awareness is being aware of what is happening around you, understanding what that information
means now, and anticipating what it will mean in the future (Endsley & Jones, 2012). Begun in the
aviation industry, the formal definition of situational awareness is “the perception of the elements in the
environment in a volume of time and space, the comprehension of their meaning, and the projection of
their status in the near future” (Endsley, 1995, p. 36). Endsley’s model of situational awareness has three
incremental levels: perception of the elements in the environment (gathering data); comprehension
of the current situation (interpreting information); and projection of what can happen in the future
(anticipation of future states) (Endsley, 1995; Orique & Despins, 2018; Stubbings, Chaboyer, &
McMurray, 2012).
The first level includes becoming aware of overt and subtle important cues that can be perceived
through any or all of the senses. A nurse’s abilities, training, experience, and information-processing, as
well as level of stress, workload, noise, and complexity, can all positively or negatively affect whether and
how well the cues are perceived.
The next level is interpreting the significance of and discerning the relationships between the cues and
synthesizing what may appear to less-skilled nurses as disjointed cues into the whole of the situation.
The last level in the model is predicting and anticipating what will happen next. Endsley and Jones
(2012) note the importance of time in situational awareness—that is, anticipating how much time is
available in which to act. Nurses with expert situational awareness can quickly identify that something
is wrong, distill the important cues, put the pieces of information together, anticipate what will happen
next and how quickly it will happen, and know what to do to intervene.
Malcolm Gladwell, in his book Blink (2005), discusses the adaptive unconscious of the mind, which he
describes as “a kind of giant computer that quickly and quietly processes a lot of the data we need in
order to keep functioning as human beings” (p. 11) and a “decision-making apparatus that’s capable of
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making very quick judgments based on very little information” (p. 12). The key themes of the research
described in Blink are:
• 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.
Gladwell describes what he calls thin-slicing, “the ability of our unconscious to find patterns in situations
and behavior based on very narrow slices of experience” (p. 23). In this case, the term “experience” is not
being used, for example, to mean the long-term experience of caring for many patients of the same type,
but rather “very narrow slices of experience” would refer to when you first walk into a patient’s room
and within seconds know that something does not fit the pattern you expect to see.
Gary Klein (1998) has studied nurses and other people who make decisions under time pressure when
the stakes are high (e.g., firefighters, Navy SEALS, battlefield platoon leaders). Based on his research,
he has found that what is generally termed “intuition” comes from experience, that we recognize
things without knowing how we do the recognizing, and that what actually occurs is that we are drawn
to certain cues because of situational awareness. He also notes, however, that because we often don’t
understand that we actually have experience behind “intuition,” intuition gets discounted as hunches
or guesses. His research, indeed, shows just the opposite. His findings indicate that the part of intuition
that involves pattern matching and recognition of familiar and typical cases can be trained by expanding
people’s experience base.
Klein (1998) describes what he has termed the recognition-primed decision model, a model that brings
together two processes: “the way decision makers size up the situation to recognize which course of
action makes sense, and the way they evaluate the course of action by imagining it” (p. 24).
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).
This is compared to a rational choice strategy, a step-by-step process of considering and eliminating
alternatives, which is similar to what we do in the nursing process. Though a rational choice strategy
is often needed as a first step for novices or for initially working in teams to determine how everyone
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views the options, it is less useful with experts, who usually look for the first workable option (based on
their knowledge and experience) in the current situation, and for high-risk situations that require rapid
response.
Klein (1998) notes many things that experts can see that are invisible to others (pp. 148–149):
• 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
In describing expert nursing, Dreyfus and Dreyfus (2009) note that experts use deliberative rationality—
that is, when time permits, they think before they act, but normally, “they do not think about their rules
for choosing goals or their reasons for choosing possible actions” (p. 16). Deliberative rationality (the
kind of detached, meditative reflection exhibited by the expert when time permits thought), they say,
“stands at the intersection of theory and practice. It is detached, reasoned observation of one’s intuitive,
practice-based behavior with an eye to challenging, and perhaps improving, intuition without replacing
it by the purely theory-based action of the novice, advanced beginner, or competent performer” (pp.
17–18).
Debriefing after an incident in which situational awareness, expert reason, and intuition are used is
important to learning. The preceptor needs to walk through the whole process step-by-step with the
preceptee—discussing observations, rationale for actions, etc., and answering whatever questions the
preceptee has. This may take some practice and reflection for the preceptor in order to be able to break
down what was done intuitively so the preceptee can understand the steps and the logic.
Confidence
Self-efficacy (confidence) is the belief of individuals in their capability to exercise some measure of
control over their own functioning and over environmental events (Bandura, 1997). According to
Bandura, “A capability is only as good as its execution. The self-assurance with which people approach
and manage difficult tasks determines whether they make good or poor use of their capabilities.
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Insidious self-doubts can easily overrule the best of skills” (1997, p. 35) and “unless people believe they
can produce desired results and forestall detrimental ones by their actions, they have little incentive
to act or to persevere in the face of difficulties. Whatever other factors may operate as guides and
motivators, they are rooted in the core belief that one has the power to produce effects by one’s actions”
(Bandura, 2009, p. 179).
Kanter (2006) notes that confidence consists of positive expectations for favorable outcomes and
influences an individual’s willingness to invest. “Confidence,” she says, “is a sweet spot between
arrogance and despair. Arrogance involves the failure to see any flaws or weaknesses, despair the failure
to acknowledge any strengths” (p. 8).
Manojlovich (2005), in a study of predictors of professional nursing practice behaviors in hospital
settings, found a significant relationship between self-efficacy and professional behaviors. Ulrich et al.
(2010) found that self-confidence improved in NGRNs across and beyond an 18-week immersion RN
residency that used one-to-one preceptors.
Helping preceptees develop confidence in themselves requires the use of many of the preceptor roles
described in Chapter 1 and requires the creation of a positive, enriching, and supportive learning
environment. Competence and confidence are interrelated—each builds on, reinforces, and promotes
the other.
Conclusion
Competence, critical thinking, clinical reasoning, clinical judgment, and confidence are all necessary
components of any preceptorship. Role competence can be attained only by the connection of theory
and practice. Critical thinking, clinical reasoning, and clinical judgment are the keys to making that
happen. Competence without confidence is opportunity wasted. Preceptors are charged with helping
preceptees master critical thinking, clinical reasoning, and clinical judgment skills so preceptees can
move from novice to expert competency.
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Preceptor Development Plan: Core Precepting Concepts
Review the information on the core precepting concepts described in this chapter. What are your
strengths? In which areas do you need to increase your knowledge and expertise? What is your
plan for expanding your knowledge and expertise? What resources are available? Who can help
you?
Name:
Date:
Competence Assessment
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Competence Development
Strengths
Critical Thinking
Strengths
4
Core Precepting Concepts
Clinical Reasoning
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Clinical Judgment
Strengths
Situational Awareness, Expert Reasoning, and Intuition
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Confidence
Strengths
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
101
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Preceptor Development Plan: Preceptee Role Competencies
Review the competencies that are required for your preceptee. If written descriptions of these
competencies are not available, work with other stakeholders to develop them. Assess your own
knowledge and expertise on each of the competencies. What are your strengths? In which areas
do you need to increase your knowledge and expertise? What is your plan for expanding your
knowledge and expertise? What resources are available? Who can help you?
Preceptee Role:
Competency
Preceptor
Strengths
Preceptor
Needs
Plan
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
Resources
4
Core Precepting Concepts
103
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Jackson, M. (2006). Defining the concept of critical thinking. In M. Jackson, D. D. Ignatavicius, & B. Case (Eds.),
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“If you don’t know where you are going, any road
will get you there.”
5
–Lewis Carroll, Alice’s Adventures in Wonderland
Having a Plan:
Developing and Using
Goals, Objectives, and
Outcomes
–Kelly C. Walker, DNP, CNM
Karen C. Robbins, MS, RN, CNN
Mary S. Haras, PhD, MBA, APN, NP-C, CNN
A nurse entering a new position—either as a new graduate registered nurse
(NGRN), a nurse with experience moving into another practice area, or a nurse
pursuing a graduate degree—will need to become familiar with and competent
in the new practice area and/or new role. Preceptors are the key to ensuring that
this occurs. Goals, objectives, and outcomes form the road map for the work of
the preceptor and the preceptee. They can be written and/or verbal and should be
agreed upon by the preceptor and preceptee. As a preceptor, you need to know the
goals of the institution, as well as those of the preceptee. Buy-in and acceptance will
facilitate the best preceptor-preceptee relationship.
This chapter focuses on the development of measurable goals, objectives, and
outcomes; how the preceptor and preceptee can interact to achieve them; and the
tools you can use to measure these accomplishments. The preceptor and preceptee
both need to understand these principles so that the precepting experience is
focused and can be measured. Said another way, you will not know when you have
achieved the aim of the precepting experience if the target is not defined.
OBJECTIVES
•
Distinguish the
differences among
goals, objectives, and
outcomes
•
Discuss learning
taxonomies
•
Apply the learning
taxonomies and theories
to the preceptorship
process
•
Create goals, objectives,
and outcomes
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Expectations
The transfer of knowledge learned and applying that knowledge to clinical practice to provide quality
patient care is the ultimate goal of nurse educators (Su & Osiek, 2011). Preceptors play a critical
role in preparing nurses for new and expanded roles. Understanding the intricacies and overlapping
roles of a preceptor will inform the design of the precepting experience. The precepting relationship
involves role modeling, teaching, coaching, and evaluating in a safe environment (Buck, Wilkinson, &
Phillips, 2014; Omer, Suliman, & Moola, 2016; Smith, Hecker-Fernandes, Zorn, & Duffy, 2012; Ulrich,
2011). Preceptors are expected to provide the needed experiences with accompanying oversight so the
preceptee can become competent. In keeping with adult learning principles, learning should progress
from simple to complex. Four questions must be answered to meet these needs (Buck et al., 2014):
• What are the preceptee’s goals and objectives?
• What learning activities will support these goals and objectives?
• What approaches will be used to promote learning?
• How will success be measured and evaluated?
Worral (2019) identifies that “outcomes (summative) evaluation measures the changes that result
from teaching and learning” (p. 605). Glennon (2006) distinguishes between outcomes and objectives:
“Outcomes relate directly to professional practice; objectives relate to instruction” (p 55). The American
Association of Colleges of Nursing (AACN) baccalaureate essentials document defines outcome as a
“broad performance indicator, related to the knowledge, skills, and attitudes needed by a baccalaureate
graduate” (AACN, 2008, p. 38). From the time that an individual enters a nursing program, the process
of preceptorship begins, with the ultimate goal of providing the graduate nurse the ability to care for
complex, diverse, and changing patient populations and/or developing skills in specialties such as
education and management. The American Nurses Association (ANA) and the National Nursing Staff
Development Organization (NNSDO) state that the development of desired outcomes should involve
the learners and the key stakeholders (ANA & NNSDO, 2010). At the master’s level, the learning
objectives of the program frame the precepting experience (AACN, 2011). At the doctoral level,
“practice experiences should be designed to help students achieve specific learning objectives related
to the DNP Essentials and specialty competencies” (AACN, 2006, p. 19). Hence, learner objectives and
outcomes should be discussed between the preceptor and preceptee from the outset and throughout the
preceptorship experience so that expectations are clear and are consistent with the overall goals of the
program.
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
107
In an ideal world, all preceptorships would have pre-planned learning activities that reinforce learning
objectives and performance outcomes (Buck et al., 2014), but this is not always the case. In addition,
precepting occurs in a variety of dynamic inpatient and outpatient settings that may include hospitals,
clinics, or other communities of interest, where precepting plans often go awry because of the needs of
the patients. At times you have to abandon the objectives agreed upon for a given time frame because
of the circumstances of the day, the assignment, or the responsibilities. Preceptors sometimes need to
adjust the intended activities “on the fly” as situations arise. For example, a preceptor might be planning
to work with a manager preceptee on the process of performance reviews when a clinical emergency
arises and demands the involvement of the preceptor and preceptee. This provides valuable experience
for the manager’s role in the situation even though it deviates from the agreed-upon activity. To have
this flexibility, preceptors must understand the concepts behind the development, use, and evaluation of
goals, objectives, and outcomes.
The Relationship Among Goals, Objectives, and Outcomes
Goals serve as the overarching purpose of the activity—the aim, or the endpoint. The goal is the
final, global outcome of the teaching-learning process, sometimes referred to as learning outcomes
(Bastable & Quigley, 2019). Goals drive the actions of the nurse, the unit/department, the hospital/
organization, and the educational institution. Goals are forward-thinking and must be clearly stated so
that the objectives and outcomes that follow can be articulated in such a way as to achieve the ultimate
goal. The interrelationship among goals, objectives, and outcomes is shown in Figure 5.1. The term
goal is sometimes used synonymously, although incorrectly, with the term objective. Goals are multidimensional, accomplished over weeks or months, and incorporate a number of specific objectives and
outcomes that are met during that time (Bastable & Quigley, 2019). For the preceptee, the goal might
be to become a competent nurse, a competent advanced practice provider, or a competent educator.
For the preceptor, the goal might be to serve as a role model for newer nurses or new advanced practice
providers. For the unit/department, the goal of the preceptorship program might be to improve staff
morale and decrease turnover. For the healthcare institution, the goal might be improved quality of
patient care. For the educational institution, the patient care goal might be to develop the advanced
practice nursing student’s ability to function independently (Buck et al., 2014). Regardless of the goal, it
must be clearly stated, be important to the involved parties, and be realistic.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
GOALS
OBJECTIVES
OUTCOMES
FIGURE 5.1 Interrelationship Among Goals, Objectives, and Outcomes
Objectives vs. Outcomes
Objectives have guided education since the 1950s, when Benjamin Bloom released his taxonomy
of educational objectives. Objectives are one dimensional, concrete, teaching-focused and contentfocused, short-term, and action-oriented. There may be sub-objectives that are specific and short
term that contribute to achieving the primary objective (Bastable & Quigley, 2019). Outcomes are
learning-focused and student-focused, more long-term, and behaviorally or competency oriented.
Both are important in a preceptor-preceptee relationship, and you cannot have one without the other.
Outcome statements require the blending of several domains of knowledge to achieve a higher level of
functioning, as is necessary in the complexity of nursing care today (Glennon, 2006).
The paradigm in nursing education is shifting from content/skills-based to competency-based, with
the focus shifting from teaching-centeredness to learning-centeredness (Schumacher & Risco, 2017).
Understanding the relationship between goals, objectives, and outcomes is critical in order to construct
optimal learning activities and evaluation strategies. Objectives and outcomes survive the test of time,
however, as they “capture the complexity of the teaching/learning process” and “have the simplicity and
practicality needed for mapping out and evaluating understanding of what is to be learned” (WittmannPrice & Fasolka, 2010, p. 233).
Objectives and outcomes both use behavioral terms, but outcomes are broader and reflect the evolution
from learning to performing. Outcome format/verbiage describes what the learner will be able to do as a
result/outcome of the learning session (e.g., at the end of this session, the preceptee will be able to…) as
compared to objectives, which simply state what the learner will be able to do (e.g., the preceptee will…)
(Wittmann-Price & Fasolka, 2010). The learner, the behavior, and the content are common elements
of both. Ultimately, clinical judgment and skills development must support the ability of nurses to
practice safely, and there must be a formal means to measure or observe the nurses’ achievement of their
stated outcomes. Goals and objectives remain the common verbiage in the various taxonomies when
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
109
discussing the interaction between a preceptor and a preceptee. Knowing where the preceptee is in the
learning cycle will guide the preceptor in designing appropriate learning activities (Witt, Colbert, &
Kelly, 2013). Specificity is needed in this process to clearly articulate the expectations of the experience.
Daily goals provide a vehicle to assess progress toward meeting clinical competencies and in areas
needing additional attention (Schumacher & Risco, 2017).
Buy-in from the preceptor, preceptee, and manager from the outset is a critical element for a successful
preceptorship. The goals and objectives must be realistic. Failure to establish realistic goals will set all
parties up for failure. These goals and objectives are focused upon what the preceptee is expected to be
able to do, not upon what the preceptor is expected to teach. The objectives provide the map to reach
the destination: the goal. Applying the primary learning taxonomies to the preceptor-preceptee learning
process is an integral part of this.
Learning Taxonomies and Learning Theories
Simply stated, a taxonomy is a classification for information or a mechanism that categorizes how things
relate to each other. A learning taxonomy reflects the level of knowledge to be learned, the types of
behaviors that are relevant for the preceptee, and the sequence of experiences, from simple to complex
(Bastable & Quigley, 2019). “Learners have different preferred ways of taking in information, such as
verbally or visually, and for processing that information, like manipulating something or thinking about
details before acting” (Ullrich & Hafer, 2009, p. 89). Because adult learners do not all learn the same
way, it is sometimes necessary to alter the teaching approach to be effective. Preceptors have a number
of learning taxonomies and theories available to guide development of the teaching-learning interaction.
Each approaches the process differently. These are discussed in Chapters 2 and 3.
Bloom’s Taxonomy: Objectives and Domains of Learning
Bloom’s (1956) taxonomy classifies cognitive learning objectives that are widely used in education.
Bloom’s three domains of learning are cognitive, affective, and psychomotor (Bloom, 1956). Each of the
domains in this taxonomy has multiple levels and is illustrated in Figure 5.2 (Churches, 2009).
The first of these, the cognitive domain, is known as the thinking domain and is further divided into
six hierarchical levels: knowledge, comprehension, application, analysis, synthesis, and evaluation
(Bastable & Quigley, 2019; Koepke & Cerbin, 2009). This is predicated on the hierarchy being described
as a stairway. It encourages the preceptee to climb to the higher or the next level of thought, so that
someone functioning at the analytical level has mastered those levels preceding it (i.e., knowledge,
comprehension, and application) from lower order to higher order thinking skills (Churches, 2009).
The affective domain addresses attitudes, feelings, beliefs, and emotions (Neumann & Forsyth, 2008)
and is sometimes referred to as the feeling domain (Bastable & Quigley, 2019). The affective domain
consists of five levels and considers the depth of a person’s emotional responses to tasks, in contrast to
the cognitive domain, which looks at the complexity of behaviors (Bastable & Quigley, 2019). Objectives
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
are more difficult to write in the affective domain because these behaviors tend to be less tangible and,
therefore, not as easily measured. This is a more difficult domain for the preceptor because it does not
rely upon facts or principles (the cognitive domain) or motor skills (the psychomotor domain) that
are measured more easily; hence, easily measureable affective domain objectives are more difficult to
develop (Bastable & Quigley, 2019; Neumann & Forsyth, 2008). Learning in this domain is a long-term
process and might be more difficult to learn for nurses who are less aware of their own value system
(Neumann & Forsyth, 2008). This might, however, present an opportunity for preceptees to become
more aware of their own values and attitudes.
Bloom’s Research
Psychomotor: manual or physical skills (Skills)
Category
Preception
Domains of Learning
Guided response
Complex overt response
Set
Adaptation
Origination
Mechanism
Affective: growth in feelings or emotional areas (Attitude)
Category
Organisation
Valuing
Receiving phenomena
Internalising values
Responding to phenomena
Cognitive: mental skills (Knowledge)
Category
Evaluation
Knowledge
Synthesis
Comprehension
Analysis
Application
FIGURE 5.2 Bloom’s Original Taxonomy identifies the domains of learning and represents a
hierarchy. It begins with the cognitive domain (lower left) and progresses through the affective and
psychomotor domains. Not only are the domains in a hierarchy, but there is also a progression of skills
within each domain, as shown here.
Used with permission. Churches, 2009
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
111
Preceptors play a key role in helping preceptees identify their values and attitudes by asking probing
questions and using role-play, case studies, and critical reflection. The personal value system of an
individual, however, must be consistent with the values of the profession. The ANA Code of Ethics for
Nurses with Interpretive Statements is an example of a source for professional values (ANA, 2015). These
tenets affirm the ethical obligations and duties for anyone entering the nursing profession, reflect the
understanding of nursing’s commitment to society, and are non-negotiable (ANA, 2015). The mission,
vision, and model of care reflect the culture and values of an organization and fall in the affective domain
of learning (Neumann & Forsyth, 2008).
Skills are addressed in the six levels of the psychomotor domain (Churches, 2009). Fine and gross motor
abilities that require increasingly complex actions fall under this domain. The goals and objectives in this
domain focus more upon the skill itself rather than acquiring new knowledge, and require drawing upon
that knowledge acquired in the cognitive and affective domains (Bastable & Quigley, 2019). A preceptor,
for example, should not ask questions from the cognitive domain when working with a psychomotor skill
because that might shift the preceptee’s focus away from the skill. Instead, the preceptee should have the
opportunity to practice the skill and then demonstrate successful mastery of that skill. This is the “hands
on” component of the preceptor-preceptee relationship and is critical to the integration of knowledge and
skill for the preceptee. As preceptees gain the knowledge, skills, and attributes to become proficient, they
move along the continuum from objective to outcome to goal achievement.
The Revised Bloom’s Taxonomy, sometimes referred to as the Anderson/Bloom Taxonomy, was released
in 2001 (Anderson et al., 2001; O’Neil & Murphy, 2010; Wilson, 2018). The greatest changes can be seen
in the areas of terminology, structure, and emphasis (see Figures 5.3 and 5.4). The original taxonomy
focused on the development of tests to assess student performance, while the revised taxonomy focuses
on student learning (Anderson et al., 2001; Su & Osiek, 2011). The change in wording—changing nouns
to action verbs—reflects this change in focus and is applicable for a much broader audience (Churches,
2009). The original lowest level, knowledge, was changed to remembering based upon the notion that if
you cannot remember something, you cannot apply knowledge or concepts to understand it (Churches,
2008, 2009). The two highest levels were changed from synthesis and evaluation to evaluating and
creating. You must be able to evaluate (that is, judge or test) something before being able to devise or
invent (that is, to create). You must be able to analyze and evaluate the efficacy for specific nursing
interventions before being able to devise a new plan of care. Note that these two functions (evaluate
and devise) are hierarchical and are dependent upon the ability to complete the lower levels before
progressing to these higher-level functions.
However, Churches (2009) states that the learning can begin at any point when the lower levels of the
taxonomy are included in a scaffolded learning task, a metaphor for the preceptor’s guidance to support
the preceptee as the preceptee progresses in skills accomplishment. Skills can and should be broken down
into individual steps, especially if the procedure is lengthy, so the preceptee understands each step, or
scaffold, of the skill being developed and avoids the acquisition of bad habits (Fitzgerald & Keyes, 2019).
As the preceptee advances, the preceptor slowly withdraws direction and support, enabling the preceptee
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
to become independent in the newly acquired skill or knowledge. As Churches (2009) explains,
scaffolding can enhance the progression of lower order thinking skills (LOTS) to higher order thinking
skills (HOTS). The changes in the hierarchy of LOTS to HOTS, not only in verbiage, but in reversing the
order of the top two levels in the revised iteration, are shown in Figures 5.3 and 5.4.
Higher Order Thinking Skills
Evaluation
Synthesis
Analysis
Application
Comprehension
Knowledge
Lower Order Thinking Skills
FIGURE 5.3 Bloom’s Original Taxonomy illustrates the progression in the taxonomy of lower order
thinking skills to higher order thinking skills, as compared to the Revised Bloom’s Taxonomy.
Used with permission. Churches, 2009
Higher Order Thinking Skills
Creating
Knowledge Creation
Evaluating
Analysing
Applying
Knowledge Deepening
Understanding
Knowledge Acquisition
Remembering
Lower Order Thinking Skills
FIGURE 5.4 The Revised Bloom’s Taxonomy reflects the change in verbiage from nouns to verbs and
a change in the order of lower order thinking skills to higher order thinking skills. The progression of
knowledge depicted on the right represents the ascension of higher order thinking skills necessary to
advance beyond remembering and understanding—that is, the ability to critically think.
Used with permission. Churches, 2009
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
113
The Revised Bloom’s Taxonomy adds a second dimension of knowledge to each of the three domains,
whereas the unidimensional original taxonomy considered only the domains of learning and did
not consider the factual, conceptual, procedural, and metacognitive forms of knowledge. These two
dimensions of the knowledge to be learned by the preceptees and the cognitive processes to help
preceptors in their interactions, along with sample verbs in each category, are shown in Table 5.1.
Examples of the verbs in ascension of the affective domain are found in Table 5.2.
Table 5.1
Knowledge
Dimension
Revised Bloom’s Taxonomy: Knowledge and Cognitive Processes
Cognitive Process Dimension
Remember
Understand
Apply
Analyze
Evaluate
Create
Factual
Define, list,
recall
Calculate,
identify,
report
Classify,
solve, use
Test,
compare,
infer
Judge,
appraise,
verify
Change,
design,
predict
Conceptual
Describe
Interpret
Experiment
Explain
Assess
Plan
Procedural
Tabulate
Predict
Calculate
Differentiate
Conclude
Compose
MetaCognitive
Appropriate
use
Execute
Construct
Achieve
Action
Actualize
Sources: O’Neill & Murphy, 2010; Oregon State University, 2011
Table 5.2
Revised Bloom’s Taxonomy: Affective Domain
Level
Examples of Verbs
Receiving
Ask, reply, accept
Valuing
Justify, propose, relinquish
Organization and Conceptualization
Arrange, balance, theorize
Characterization by Value
Discriminate, question, change
Source: O’Neill and Murphy, 2010
Bloom did not fully develop the psychomotor domain when the taxonomy was released in 1956, and
others have adapted and expanded upon it (Churches, 2009; Davis, Chen, & Campbell, 2010; O’Neill &
Murphy, 2010). One example is the work of Elizabeth Simpson, who adapted and further developed this
domain in 1972 (Bastable & Quigley, 2019; O’Neill & Murphy, 2010; Simpson, 1966).
Four orderly steps are common to the various iterations of the psychomotor domain: observing,
imitating, practicing, and adapting (Bastable & Quigley, 2019). Simpson’s (1966) taxonomy is recognized
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as one of the most relevant for patient, staff, and student teaching (Bastable & Quigley, 2019). Simpson’s
taxonomy contains seven progressive levels: perception, set, guided response, mechanism, complex
overt response, adaptation, and origination (Simpson, 1966).
• The first level is perception. As the name implies, a sensory awareness prompts the preceptee
about a task to be performed. This could include observing a procedure being performed
or perhaps reading the steps in a procedure (e.g., inserting an intravenous (IV) line). If the
preceptor is demonstrating a skill, the technique should be flawless and per the facility’s
established procedure. If an error occurs, it can be used as an opportunity to demonstrate to
the preceptee how to problem-solve the situation; it may even enhance the rapport between
the preceptor and preceptee (Fitzgerald & Keyes, 2019).
• The set level indicates the ability of the preceptee to follow directions and a readiness to learn.
• Imitation of a skill with return demonstration with coaching or direction from the preceptor
is guided response; that is, the preceptee performs the task with the preceptor’s oversight
(Fitzgerald & Keyes, 2019).
• In the example of inserting an IV line, the mechanism level would indicate that some type of
preparation had been performed, such as viewing a recording of the steps and/or reviewing
them with the preceptor, or performing this with the preceptor. With this step, the preceptee
begins to demonstrate some ability to perform the skill with little conscious effort.
• When the preceptee is able to perform the IV line insertion confidently, efficiently, and
seemingly automatically, this is the complex overt response, the fifth of the seven levels.
• When less than ideal circumstances are present, the preceptee achieves the level of adaptation
when the IV line is inserted despite obstacles to which the preceptee must adapt, such as
determining how to place the IV line in a patient with limited sites.
• Origination, the highest level of the psychomotor domain, might be the development of a skill
(e.g., placing an IV with the non-dominant hand because of possible barriers, such as a hand
injury to the dominant hand).
A list of sample verbs that are present in the psychomotor domain is shown in Table 5.3. Remember that
the preceding levels are prerequisite behaviors to progress through the hierarchy.
Table 5.3
Psychomotor Domain: Examples of Levels and Verbs
Level
Examples of Verbs
Perception (respond to a stimulus)
Chooses, describes, differentiates, identifies, relates,
recognizes, selects, separates
Set (prepare to act)
Arranges, begins, displays, prepares, reacts, recognizes,
responds, shows, starts
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
Level
115
Examples of Verbs
Guided response (assistance with
response)
Assembles, builds, calibrates, dismantles, follows, lifts,
manipulates, measures, mixes, pours, responds, simulates,
transfers
Mechanism (habitual response)
Assembles, constructs, grasps, manipulates, measures,
mixes, organizes, performs
Complex overt response (use a
coordinating series of actions for the
response)
Assembles, builds, calibrates, coordinates, demonstrates,
makes, mixes, organizes
Adaptation (respond to a new situation
with a changed response)
Adapts, adjusts, alters, conforms, converts, integrates,
rearranges, reconciles, regulates, revises, standardizes,
substitutes
Origination (create new actions)
Arranges, combines, creates, designs, reformulates,
trouble-shoots
Source: Simpson, 1966-67
Churches (2009) has identified action verbs for the Revised Bloom’s Taxonomy, as shown in Table 5.4,
with a progression of LOTS to HOTS. The higher levels are needed for the creation of new knowledge,
not merely remembering information, as happens at the LOTS level.
Table 5.4 Lower Order Thinking Skills (LOTS) to Higher Order Thinking
Skills (HOTS)—Sample Verbs
Lower Order Thinking Skills (LOTS)
• Remembering—Recognizing, listing, describing, identifying, retrieving, naming, locating, finding
• Understanding—Interpreting, summarizing, inferring, paraphrasing, classifying, comparing,
explaining, exemplifying
• Applying—Implementing, carrying out, using, executing
• Analyzing—Comparing, organizing, deconstructing, attributing, outlining, finding, structuring,
integrating
• Evaluating—Checking, hypothesizing, critiquing, experimenting, judging, testing, detecting,
monitoring
• Creating—Designing, constructing, planning, producing, inventing, devising, making
Higher Order Thinking Skills (HOTS)
Source: Churches, 2009 (Used with permission)
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Churches (2009) considered these verbs in the context of classroom activities and suggests these do
not adequately reflect the emergence of multiple forms of communication technology. Accordingly,
he proposed Bloom’s Digital Taxonomy (see Figure 5.5). The column on the right of the image, titled
“Communication Spectrum,” is indicative of the significant role that communication has in learning.
Collaborating is one of the skills under the Communication Spectrum, and Churches has proposed that
communication is essential for collaboration. An expanded discussion of the digital taxonomy can be
found on Churches’s website (Churches, 2009). Figure 5.6 depicts each iteration of the Bloom Taxonomy
and the evolution of the changes, including the digital taxonomy and relevant verbs (Major, n.d.).
Bloom’s Digital Taxonomy
HOTS
Higher Order Thinking Skills
Key Terms
Creating
Evaluating
Analysing
Applying
Understanding
Remembering
Verbs
Verbs
Verbs
Verbs
Verbs
Verbs
designing constructing, planning,
producing, inventing, devising, making,
programming, filming, animating, blogging
video blogging, mixing, re-mixing, wiki-ing
publishing, videocasting, podcasting,
directing, broadcasting
checking, hypothesising, critiquing,
experimenting, judging, testing, detecting,
monitoring, blog commenting,
reviewing, posting, moderating, collaborating,
networking, refactoring, testing
comparing, organising, deconstructing,
attributing, outlining, finding, structuring,
integrating, mashing, linking, validating,
reverse engineering, cracking, media clipping
Communication
Spectrum
Collaborating
Moderating
Negotiating
Debating
Commenting
Net meeting
Skyping
Video conferencing
Reviewing
implementing, carrying out, using,
executing, running, loading, playing,
operating, hacking, uploading, sharing, editing
Questioning
interpreting, summarising, inferring,
paraphrasing, classifying, comparing,
explaining, exemplifying, advanced searches,
Boolean searches, blog journaling, twittering,
categorising, tagging, commenting, annotating,
subscribing
Posting & Blogging
recognising, listing, describing,
identifiying, retrieving, naming,
locating, finding, bullet pointing, highlighting,
bookmarking, social networking, social
bookmarking, favouriting/local bookmarking,
searching, googling
Replying
Networking
Contributing
Chatting
e-mailing
Twittering/Microblogging
Instant messaging
Texting
LOTS
Lower Order Thinking Skills
FIGURE 5.5
Bloom’s Digital Taxonomy
Used with permission. Churches, 2009
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
Bloom’s Taxonomy
Bloom
1956
Evaluation
appraise, argue, assess, attach,
choose, compare, defend,
estimate, judge, predict, rate,
select, support, value
Synthesis
arrange, assemble, collect,
compose, construct, create,
design, develop, formulate,
manage, organize, plan, prepare,
propose, set up, write
Analysis
analyze, appraise, calculate,
categorize, compare, contrast,
criticize, differentiate, discriminate,
distinguish, examine, experiment,
question, test
Application
apply, choose, demonstrate,
dramatize, employ, illustrate,
interpret, operate, practice,
schedule, sketch, solve, use, write
Comprehension
classify, describe, discuss, explain,
express, identify, indicate, locate,
recognize, report, restate, review,
select, translate
Knowledge
arrange, define, duplicate, label,
list, memorize, name, order,
recognize, recall, relate, repeat,
reproduce, state
Bloom’s Revised Taxonomy
Anderson & Krathwohl
2001
Creating
designing, constructing, planning,
producing, inventing,
devising, making
Evaluating
checking, hypothesizing, critiquing,
experimenting, judging, testing,
detecting, monitoring
Bloom’s Digital Taxonomy
Churches
2008
Creating
programming, filming, animating,
blogging, video blogging, mixing,
remixing, wikis, publishing,
videoconferencing, podcasting
Evaluating
blog/vlog commenting, reviewing,
posting, moderating, collaborating,
networking, refactoring,
alpha/beta testing
Analyzing
comparing, organizing,
deconstructing, attributing,
outlining, finding,
structuring, integrating
Applying
implementing, carrying out,
using, executing
Understanding
implementing, summarizing,
inferring, paraphrasing,
classifying, comparing,
explaining, exemplifying
Remembering
recognizing, listing, describing,
identifying, retrieving, naming,
locating, finding
117
Analyzing
mashing, linking, validating,
reverse-engineering, cracking
Applying
running, loading, playing,
operating, hacking, uploading,
sharing, editing
Collaboration
Moderating
Debating
Commenting
Net meeting
Skyping
Videoconferencing
Reviewing
Questioning
Commenting
Posting
Networking
Contributing
Chatting
Emailing
Tweeting
Texting
Instant messaging
Understanding
advanced searches, boolean
searches, blog journaling,
categorizing, tagging, commenting,
annotating, subscribing
Remembering
bookmaking, social networking,
social bookmaking, favoriting,
searching, googling
FIGURE 5.6 The Evolution of Bloom’s Taxonomy
Used with permission. Major, n.d.
Fink’s Taxonomy of Significant Learning
Most nurses and nurse educators are comfortable and familiar with the taxonomies of Bloom and
Anderson, but they might be unfamiliar with Fink’s taxonomy of significant learning, first presented
in 2003 and updated in 2013. Fink’s taxonomy emerged from his recognition of important kinds of
learning beyond the cognitive domain, based on his definition of learning as a change in the learner. It
has long been recognized that one of the major roles of the preceptor is to help socialize nurses to their
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new roles in the organization (Buck et al., 2014; Burns & Northcutt, 2009; Omer et al., 2016; Schaubhut
& Gentry, 2010; Smedley, Morey, & Race, 2010), which is congruent with Fink’s belief that “significant
learning requires that there be some kind of lasting change that is important in terms of the learner’s
life” (Fink, 2013, p. 31).
Fink describes six major categories of significant learning (foundational knowledge, application,
integration, human dimension, caring, and learning how to learn) that are meaningful to all levels of
learners and provides a framework for the preceptor-preceptee relationship (see Figure 5.7).
Learning How to Learn
• Becoming a
better student
• Inquiring about
a subject
• Self-directing
learners
Caring
Developing new:
• Feelings
• Interests
• Values
Foundational
Knowledge
Understanding
and remembering:
• Information
• Ideas
Application
• Skills
• Thinking
Critical, creative
and practical thinking
• Managing projects
Human Dimension
Learning about:
• Oneself
• Others
Integration
Connecting
• Ideas
• People
• Realms of life
FIGURE 5.7 Fink’s Taxonomy of Learning Styles
Used with permission. Fink, 2003
Fink’s taxonomy is not hierarchical, but it is relational and interactive and is well suited to graduate
nursing education (Marrocco, 2014). When one type of learning occurs, it becomes easier for the learner
to see the significance of other components of the learning process and their application to themselves
or others (see Figure 5.8). Objectives and the learning strategies written using Fink’s taxonomy sharply
reflect what the student is expected to remember long-term, are student-centered, and adhere to
principles of adult learning (Marrocco, 2014).
NG RN
NI
AR EA
LE TO L
W
HO
SIGNIFICANT
LEARNING
APPLICATION
N
IO
AT
GR
TE
IN
H
DIM UM
EN AN
SIO
N
CARING
119
FO
U
KN NDA
OW TIO
L E NA
DG L
E
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
FIGURE 5.8 Fink’s Taxonomy of Significant Learning
Used with permission. Fink, 2003
Fink’s category of foundational knowledge ensures that preceptees have a basic understanding of the
relevant ideas and information in their new area of practice. Through formal learning activities,
repetition, and performance review, preceptees will strengthen their understanding and recall of the
specific information necessary to safely practice. It is the preceptor’s task to construct and plan the
formal learning activities necessary for foundational knowledge, building upon the identified objectives
and intended outcomes. In a competency-based curriculum, preceptors identify a variety of settings and
experiences to meet course outcomes, rather than being limited to matching experiences with specific
content outcomes (Schumacher & Risco, 2017). This foundational knowledge is key to developing
other types of learning; for example, when engaging in activities such as role-playing and simulated
experiences, the learner gains additional knowledge from classmates and from faculty feedback during
debriefing (Blanchard & Buchs, 2015).
Application includes socialization to the unit and organization, as well as prioritization of patient
assignments; critical, creative, and practical thinking; and skill utilization. It “allows other kinds of
learning to become useful” (Fink, 2013, p. 36). Besides fostering socialization, preceptors encourage
their preceptees to be self-directed to develop necessary critical thinking skills (Bazzell & Dains, 2017).
The value of application learning is in the development of communication skills and learning how
to manage complex patient situations. Helping the preceptee develop skills in creative presentation,
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communication, focus, and critical thinking enhances learning in the human dimension (Blanchard &
Buchs, 2015). Some examples of questions that the preceptor can ask of the preceptee to stimulate the
three kinds of thinking—critical thinking, creative thinking, and practical thinking—are shown in
Table 5.5.
Table 5.5 Sample Preceptor Questions to Stimulate Three Types of
Thinking for Preceptees
Critical Thinking
Creative Thinking
Practical Thinking
In what ways are Type 1 and
Type 2 diabetes similar?
Conversely, how do Type 1
and Type 2 differ?
What are the complications
associated with the
pathophysiological changes
associated with diabetes?
What are some of the lifestyle
changes a person with diabetes
might need to make?
In what ways are patients on
hemodialysis and peritoneal
dialysis similar?
How might you encourage a
patient to accept dialysis?
Why do patients choose a
particular treatment modality?
How can clinical practice
guidelines be implemented
for patients with diabetes?
What are some strategies that
would promote adherence to
a management plan?
What are some challenges to
developing a plan for a patient
with multiple comorbidities?
Integration learning enables the preceptee to make necessary connections, such as between ideas,
concepts, procedures, people, or realms of life (work and home, work and school, etc.). By making
new connections, the nurse gains intellectual power and self-confidence. One major kind of
connection is that of connecting academic work with actual nursing practice. This involves the
preceptor helping the preceptee build the connection with the theory learned in class or school and
real-life patient situations. For example, a preceptee reviews clinical guidelines for hypertension
during the didactic portion of their curriculum. In the clinical setting, the management plan will
reflect the preceptee’s understanding of the guidelines.
Learning in the human dimension enables nurses to learn new things about themselves and others.
Fink (2013) states, “When students learn something important about themselves or about others, it
enables them to function and interact more effectively” (p. 36). The preceptor is key in this process by
asking the preceptee important questions; providing relevant, meaningful feedback about the preceptee
performance; and serving as a role model. The preceptee is then better able to understand why and how
a patient/family acts and how to more effectively interact with others.
Caring as a result of a learning experience increases the depth or manner in which preceptees care about
something, increasing their ability to learn more and integrate it into their daily life. They might have
new feelings or values as a result of their learned experiences. Preceptors can facilitate this process by
asking preceptees, “What is the most important thing you would like to get out of this experience?”
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
121
Preceptors can ask themselves, “What do I want my preceptee to get excited about?” By paying attention
to responses and looking for key terms such as enjoy, like, amazed by, and fascinated by, the preceptor
can see that the preceptee has developed feelings for a subject and that values have emerged that might
not have been there before.
Finally, through the course of the preceptorship experience, the preceptee is learning how to learn. The
preceptee learns how to be a better student and learns how to add knowledge specific to nursing. This
commits the preceptee to lifelong learning and the ability to learn more effectively. The preceptee might
learn how to report using handoff procedures or learn ways to become more self-directed in identifying
learning needs.
Because Fink’s taxonomy is relational and interactive, the preceptor also works through the six
categories of learning. Both the preceptee and the preceptor learn from each other, and significant
learning occurs. Fink’s taxonomy has two major implications for preceptors: First, the learning goals
must incorporate yet exceed content mastery; second, the preceptor must use a combination of goals to
create interaction effects to enhance the preceptee’s learning (Fink, 2013).
Kolb’s Theory: Experiential Learning Cycle
The preceptor should consider learning theories to help the preceptee achieve their objectives,
outcomes, and goals. When reviewing Kolb’s (1984) experiential learning cycle, as discussed in Chapter
2, the concepts are helpful for preceptors to frame the objectives and outcomes for clinical student
experiences. Specific concepts in the experiential learning cycle include four steps and “progresses the
learner from the concrete to observation and reflection, then to formation of abstract concepts to testing
new situations” (Witt et al., 2013, p. 174). For example, identifying that a student is in the observation
phase of the cycle will help form the clinical experience for that day. The goal is to facilitate the
preceptee to move from observation to performance.
When learners move through the experiential learning cycle, they will be able to form new ideas. In
turn, the learners will apply these new ideas to their future clinical experiences (Miller & Maellaro,
2016). A family nurse practitioner preceptee, for example, is instructed to perform an annual health
exam on a client with a diagnosis of asthma. During the concrete experience of the cycle, the preceptee
completes the task or physical assessment. While conducting the annual health exam, the preceptee
forgets to review the client’s asthma medication. The preceptee presents the case and reviews the
findings with the preceptor.
After preceptors complete their own assessments, they are able to reinforce what the preceptee has
done correctly, identify mistakes, and provide feedback. In this example, the preceptor reinforces the
performance of the annual health exam and instructs the preceptee to review medication management
with the client. The preceptee is then able to reflect on this clinical experience, which occurs during
reflective observation in Kolb’s experiential learning cycle. During abstract conceptualization, the
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preceptee thinks about what they have learned and through active experimentation incorporates new
knowledge for future clinical practice (Kitchie, 2019; Witt et al., 2013). The preceptor is also able to
reflect on the experience and create objectives and outcomes for the next clinical experience that will
focus on the management plan for the client.
Kolb’s learning cycle stages are fluid, and the learner moves from one stage to another. The learner may
begin at one stage of the cycle and move to the next. For example, the preceptee begins at concrete
experience and follows with reflective observation. Preceptees may also begin at another point in the
cycle. A preceptee may start at abstract conceptualization and follow with active experimentation (Witt
et al., 2013). When the preceptor provides a clinical learning opportunity, the preceptee will approach
the scenario based on the stage they are in the learning cycle. The preceptor can evaluate where the
preceptee is in the experiential learning cycle and provide appropriate instruction and feedback in order
to meet objectives, outcomes, and goals.
Behavioral Objectives—Are They a Magic Potion?
Bastable and Quigley (2019) have described the pros and cons of using behavioral objectives. Though
behavioral objectives are not a magic potion, they do provide a vehicle to address the issues of
planning, implementing, and evaluating the teaching-learning experience. Some of the advantages and
disadvantages of behavioral objectives are described in Table 5.6. When reviewing the pros and cons,
it seems clear that behavioral objectives might not be applicable in all situations, but their advantages
underscore their benefits more than their disadvantages detract from them.
Table 5.6
Advantages and Disadvantages of Behavioral Objectives
Advantages
• They help to keep the preceptor and preceptee focused.
• Colleagues will know what is planned for the learning experience.
• They clarify the expectations for the preceptee.
• They enhance organization of the teaching material to stay on track.
• They foster analysis of the content so that the preceptor scrutinizes the material being covered.
• They individualize the approaches for the preceptee’s unique needs.
• They focus upon the outcome of the teaching-learning experience, not the process.
• They identify behaviors to be accomplished that will demonstrate success (or failure) to achieve the
particular objective.
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
123
Disadvantages
• They might be superfluous for a person whose expertise at assessing the preceptee’s needs does not
require their use.
• The “big picture” might be lost when the activity is diminished into smaller parts.
• The time required to construct them does not justify the benefit in writing them.
• They are an exercise in pedagogy, focusing upon the preceptor’s expectations rather than the
preceptee’s ability to be self-directed.
• Their use can suffocate creativity, forcing the preceptor to focus upon specific activities.
• Nursing is multifaceted, and their use cannot comprehensively address all aspects of care.
• Complex cognitive skills cannot be easily observed or measured and, hence, not adequately captured
by behavioral objectives.
Source: Bastable & Quigley, 2019
Creating Outcome Statements
Competency outcome statements can guide the clinical experience and establish a foundation upon
which the actions of the preceptee can be assessed (Glennon, 2006). “Process evaluation helps the nurse
anticipate and prevent problems before they occur or identify problems as they arise” (Worral, 2019, p.
602). Worral (2019) has provided some specific questions that should be considered about the learning
experience. Worral’s (2019) questions are adapted here, and we provide the answers.
Q:
Does the learner have time to ask questions?
A: There must be adequate time for the preceptee to process
information provided and ask questions. Likewise, the
preceptor must allow sufficient time for a thorough answer.
Q: Is the preceptor’s information in synchrony with the teaching
materials that are provided to the preceptee?
A: It is important for the preceptor’s demonstrations and the
preceptee’s expectations to be consistent. For example, if the
preceptor is demonstrating a procedure, it should follow the
organization’s established procedure. The preceptor should
not use “shortcuts” or a personal adaptation to the established
procedure.
Q: Is the preceptee taking an active role?
A: Engagement by the preceptee is necessary for active learning.
Depending upon the complexity of a task, you may have to
repeat it to ensure learning has occurred.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Q:
Is the environment conducive to learning?
A: If in a classroom-type setting, the temperature, lighting, and
other environmental factors should be controlled to facilitate
learning. Some degree of distraction may be unavoidable in a
clinical setting, and if distractions are significant, the preceptor
should allow ample time for questions, de-briefing, and
clarification afterward.
Q: Are there adequate opportunities for return demonstration(s) and
feedback/teach-back?
A: If simulation is available for initial learning or remediation, this
may be a viable alternative to the patient care area, especially for
complex tasks.
Here are additional questions to consider and, again, we provide the answers.
Q: What will be done with the assessments of the learning
experiences?
A: This provides a means to measure the preceptee’s progress
throughout the teaching-learning process. This will help
determine when and if the preceptee can safely and effectively
meet the expectations of the role.
Q:
What decisions will be based upon the findings?
A: This monitors the measurable progress for the preceptee’s
teaching-learning process and if the preceptee is competent to
effectively and safely perform role-specific functions. This may
also be used as the basis to determine if the preceptor’s learning
experience should be completed, extended, or terminated.
Distinguishing Outcomes From Objectives
A practice-centered learning experience enhances the preceptee’s ownership of the teaching-learning
experience (Glennon, 2006). Distinctions between outcomes and objectives are shown in Table 5.7.
Table 5.7
Dimension
Distinctions Between Outcomes and Objectives
Outcomes
Conceptual Descriptors Whole
Complex
Objectives
Situation at a point in time
Tasks
Interrelationships
Skills
Unite several themes
Discrete points of knowing
Join knowledge domains
Linear, sequential
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
Dimension
Outcomes
Orientation
Results-focused
Process-focused
Student-oriented
Teacher-oriented
Learning-focused
Content-focused
Related to professional practice
Related to academic achievement
125
Objectives
Adapted from Glennon, 2006.
Developing Measurable Objectives and Outcomes
Preceptees need well-developed behavioral objectives that are clear, concise, articulate, measurable
outcomes that are demonstrated as a result of the teaching-learning experience (Bastable & Quigley,
2019). Robert Mager originally published performance-based objectives in 1962 and is regarded as an
expert in this field. In his seminal book, Mager (1997) identifies three characteristics that are important
to accomplish this—performance, condition, and criterion:
1. Performance—Visible actions the preceptee is expected to perform that demonstrate the
accomplishment of the objectives.
a. The preceptee inserts an IV without assistance.
b. The preceptee completes a history and physical exam.
c. The preceptee demonstrates use of evidence-based practice.
2. Condition—Depicts the situation, resources, or constraints under which the preceptee will
demonstrate the behavior.
a. The preceptee gathers appropriate equipment needed to take to the patient to start
an IV.
b. The preceptee gathers appropriate equipment needed to complete a health
assessment.
c. The preceptee gathers appropriate evidence and/or guidelines.
3. Criterion—Expresses the time frame, accuracy, or how well the behavior will be demonstrated to
ensure sufficient mastery of the competency being measured (i.e., what is the level of competence
that is expected).
a. The preceptee will successfully initiate an IV in four of five patients by the end of
the third week of orientation.
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b. The preceptee will successfully demonstrate a complete history and physical of
eight patients by the end of the fourth week of orientation.
c. The preceptee will cite appropriate evidence to support the six interventions
by the end of the fourth week of orientation.
Waller (2001) has identified four common elements that the actual structure of an objective contains:
action verb, conditions, standard, and intended audience—in this case, the preceptee. The most
important component is the action verb. One must always use an action verb because it declares what
the preceptee will be able to do as a result of the learning experience. An easy way of remembering these
four elements of a behavioral objective is the “ABCD rule:” audience, behavior, condition, and degree
(Bastable & Quigley, 2019). An example of a behavioral objective using this “rule” is as follows: The
preceptee (A-audience) will successfully place a Foley catheter (B-behavior) using appropriate aseptic
technique (D-degree) in the simulation lab (C-condition).
ABCD Rule for Developing Objectives
A—Audience (for whom is the statement written)
B—Behavior (what is the expected action)
C—Condition (what are the circumstances in which this is to occur)
D—Degree (how much and to what extent)
Source: Bastable & Quigley, 2019
Another model that is useful for both objectives and outcomes is the SMART rule because it lends itself
to a variety of audiences and settings (Bastable & Quigley, 2019). Several interpretations of the acronym
exist, as shown in the following list (Bastable & Quigley, 2019; University of Central Florida, 2008).
Specific—Specifies what is to be accomplished in clear and definite terms;
describes abilities, knowledge, values, attitudes, and performance; uses strong
action verbs.
Measurable—Can be assessed in more than one way; quantify or qualify
objectives (e.g., percentage amounts, cost, numeric).
Achievable, Attainable—Is it realistic? The outcome might move the system
forward.
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
127
Realistic, Results-Oriented—Describe the standards that are expected; can the
objectives be achieved with available resources?
Timely, Time-bound—Specify the time period in which this is to be achieved.
The following example demonstrates the application of these very similar concepts in an objective stated
earlier: The preceptee (intended audience or audience) will successfully initiate an IV line (action verb,
behavior, specific) in four of five patients (standard, degree, or measurable) by the end of the third week
of the NGRN residency (condition, timely).
The acronym of MATURE (University of Central Florida, 2008) has also been used to describe the
process of assessing student learning outcomes. This could easily be adapted to successfully assess
learning objectives.
Matches—Directly related to the outcome it is measuring
Appropriate methods—Uses appropriate direct and indirect measures
Targets—Indicates desired level of performance
Useful—Measures help identify what to improve
Reliable—Based on tested, known methods
Effective and Efficient—Concisely characterizes the outcome
Useful Frameworks for Preceptors and Preceptees
Assessing the preceptee’s clinical knowledge allows the preceptor to engage and evaluate the nurse or
advanced practice provider in the clinical setting (Pascoe, Nixon, & Lang, 2015). Resources such as the
One-Minute Preceptor Model and the SNAPPS model can be used to assess preceptee performance and
accomplish the developed objectives and outcomes.
One-Minute Preceptor
The One-Minute Preceptor model (Neher, Gordon, Meyer, & Stevens., 1992), discussed in Chapter 3,
may be most familiar to preceptors and preceptees at each level of education. “It has been used across
specialties and settings, provides a built-in mechanism for feedback, and allows educators to assess
trainees’ reasoning while extracting the clinical information needed to work efficiently” (Pascoe et al.,
2015, p. 126). This model of precepting is directed by the preceptor (Bott, Mohide, & Lawlor, 2011).
It may be a useful tool in assessing the preceptee and developing objectives, outcomes, and goals. An
example of this model: A community health nurse preceptee at the baccalaureate level, while providing
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pediatric wound care, suspects a wound infection. The preceptor will require the preceptee to produce
supporting evidence, give appropriate reinforcement, and correct mistakes. This feedback is used to assist
the preceptee in achieving their objectives and goals (Bazzell & Dains, 2017).
The AACN Essentials of Baccalaureate Education for Professional Nursing Practice (2008) require that the
“baccalaureate graduate understands and respects the variations of care, the increased complexity, and the
increased use of healthcare resources inherent in caring for patients” (p. 4). The preceptor can support this
goal by providing clinical experiences that include complex care. The One-Minute Preceptor Model is a
tool that can assist, for example, in the achievement of this essential.
SNAPPS
The SNAPPS model by Wolpaw, Wolpaw, and Papp (2003) includes six steps that the preceptee completes:
Summarize briefly the history and findings
Narrow the differential to two or three possibilities
Analyze the differential by comparing/contrasting the possibilities
Probe the preceptor by asking questions
Plan management for the patient’s medical issues
Select a case-related issue for self-directed learning
The SNAPPS model may be used with both registered nurse and advanced practice provider preceptees
for outpatient or inpatient clinical experiences (Bazzell & Dains, 2017). This model can be used by the
preceptor to support the preceptee in meeting objectives, outcomes, and goals.
The 2011 AACN Essentials of Master’s Education in Nursing describes the use of evidence-based practice.
The advanced practice provider preceptee at the master’s degree level must complete a history and physical
assessment, provide differential diagnoses, and develop a management plan supported with evidence-based
rationales to the preceptor. The final step of this model allows the preceptee to choose cases based on their
objectives and goals. The advantage of the use of this model is that the learning is directed by the preceptee
and supported by the preceptor (Bazzell & Dains, 2017; Pascoe et al., 2015). The model is discussed in
detail in Chapter 10.
Pitfalls of Developing Objectives
Saying that objectives should be clear and concise means that they should be open to few interpretations.
When the action is a clear performance verb (e.g., classify, demonstrate, explain, or recall), it leaves little
room for misinterpretation. The prescribed action is apparent. Verbs that reflect more abstract actions
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
129
(for example, understand and appreciate) are not as easily observed but are inferred from related
actions. Verbs that connote thinking, feeling, and believing should be avoided because they are difficult
to objectively observe (Bastable & Quigley, 2019). Examples of verbs that have few interpretations
(desirable in that they leave little room for interpretation) and verbs that are vague and not easily
measurable (and, therefore, not desirable) are shown in Table 5.8.
Table 5.8
Examples of Verbs With Few or Too Many Interpretations
Verbs With Few Interpretations
(Advised)
Verbs With Too Many Interpretations
(Not Advised)
ClassifyEnjoy
Compare Feel
Contrast Know
DefineLearn
Demonstrate
Understand
Differentiate Value
Explain
Predict
Recall
Select
Verbalize
Write
Source: Bastable & Quigley, 2019
Other possible errors in writing objectives that preceptors should be aware of include (adapted from
Bastable & Quigley 2019):
• Including more than one expected behavior in one objective. “The nurse will identify signs
of possible kidney transplant rejection and the appropriate interventions.” This objective calls
for both the identifiable signs of rejection and the actions, two distinctly separate behaviors
that should not be combined.
• Expecting a higher level of performance than the preceptee is capable of attaining. “The
NGRN will recognize indications for a possible biopsy based upon signs of kidney transplant
rejection.” This is an expectation of a nurse beyond the novice level of performance, might
exceed scope of practice, and is inappropriate. This may be appropriate for an advanced
practice RN (APRN), depending upon where that nurse is in the learning process of the
practice specialty.
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• Including unnecessary or unrelated information in an objective. “Identify possible signs of
kidney transplant rejection and the nurse’s knowledge of immunosuppressive medications.”
Though an understanding of immunosuppression is important in the treatment of rejection,
it is unrelated to the nurse’s recognition of possible signs of rejection. This objective also
combines two separate concepts into a single objective; this is not measurable and defies
the concepts of writing solid objectives. The nurse’s knowledge of immunosuppressive
medications and perhaps those to prescribe may be appropriate for the APRN, but different
expectations should not be contained in the same objective.
• Developing an objective that is vague, for which the behavior is not clear. “The nurse is
interested in the signs of rejection for a transplanted kidney.” Does “interested in” the topic
reflect comprehension or a need for relevant action/inaction? No.
• Failure to include all components of an objective. “List the signs of kidney transplant
rejection.” This objective fails to identify all of the necessary components of an objective.
Correctly stated: “Following participation in the Transplant Core Course, the nurse will be
able to identify the signs of kidney transplant rejection.”
• The focus is upon the preceptor rather than the preceptee. “The preceptor will demonstrate
proper central vein catheter care technique.” It is the preceptee who is the focus of the
objective and the one who needs to demonstrate proper catheter care technique, not the
preceptor. It may be important for the preceptor to demonstrate proper catheter care, but it is
the preceptee who should be the focus of the objective.
• Vague statements that do not capture the essence of the objective. “The patient will be
prepared for discharge.” This might be an appropriate outcome because it is global in nature,
but it does not identify the specificity needed for an objective. This fails to identify what
the patient needs to know with respect to her or his medical condition, medications, what
problems warrant contacting a medical professional for troubleshooting, etc., as would be
identified in an objective. This also exemplifies the misuse and confusion about appropriate
use of the terms outcome and objective.
Conclusion
The preceptor-preceptee relationship is critical to the success of the teaching-learning experience. The
very core of this experience is the thoughtful, careful articulation of objectives, goals, and outcomes that
are agreed upon by all involved. Using taxonomies such as those presented in this chapter to construct a
framework to guide the precepting experience will enhance the opportunities for success!
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
131
Preceptor Development Plan
Having a Plan: Developing and Using Goals, Objectives, and Outcomes
Review the information on developing and using goals, objectives, and outcomes described in
this chapter. What are your strengths? In which areas do you need to increase your knowledge
and expertise? What is your plan for expanding your knowledge and expertise? What resources
are available? Who can help you?
Name:
Date:
Relationship Among Goals, Objectives, and Outcomes
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Taxonomies of Learning
Strengths
Developing Goals
Strengths
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Developing Outcomes
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Developing Objectives
Strengths
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
Preceptor Development Plan
Having a Plan: Developing and Using Objectives, Goals, and Outcomes
Review the overall objectives, goals, and outcomes that are required for your preceptee
throughout their onboarding experience. If written descriptions of the objectives, goals, and
outcomes are not available, work with other stakeholders to develop them. Based on these
objectives, goals, and outcomes, create a plan for your preceptee.
Preceptee Role:
Goal:
Outcome:
Objective
Plan of Action
Time Frame
Plan
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Goal:
Outcome:
Objective
Plan of Action
Time Frame
Plan
Goal:
Outcome:
Objective
Plan of Action
Time Frame
Plan
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
5 Having a Plan: Developing and Using Goals, Objectives, and Outcomes
135
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Communication works for those who work at it.”
–John Powell
6
Communication
–Laurie Shiparski, MS, BSN, RN
Communication is something that people have to work on their entire lives. In
healthcare, it has wide-ranging impacts on patient safety and satisfaction, staff
satisfaction, interdisciplinary team effectiveness, and creating healthy work
cultures. Because of this impact, all healthcare team members must be involved in
ongoing, intentional work to improve communication. It is a critical competency
for preceptors and preceptees to master. This chapter focuses directly on the
practical application of five key dialogue skills that form the foundation for
effective communication. In addition, this chapter emphasizes preceptor-preceptee
communication, the enhancement of team communications, patient safety and
handoffs, and strategies for preceptor training/meetings.
The Five Skills of Effective Communication
Preceptors and preceptees can work on improving communication in many ways.
Dialogue is one way to focus on communication; it is about creating ways to
interact, work, and be together. William Isaacs (1999), who founded the Dialogue
Project at MIT’s Sloan School of Management, defines dialogue as the discipline
of collective learning and inquiry—a process for transforming the quality of
conversation.
The role of the preceptor is to become an excellent communicator and role model
of dialogue. This does not mean that the preceptor is a perfect communicator.
Preceptors have times when miscommunication occurs or times when an
interaction could have been handled better. The important thing is to see effective
communication and dialogue as ongoing learning processes. Each interaction
should be treated as an opportunity to practice the skills and grow.
OBJECTIVES
•
Describe the five
core skills of effective
communication
for preceptees and
preceptors
•
Articulate the behaviors
for self-improvement of
dialogue skills
•
Distinguish effective
ways of managing
different methods of
communication
•
Name key considerations
for participating in team
communications
•
State ways to manage
difficult conversations
between preceptors and
preceptees
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Dialogue beliefs that set us up for success include (Wesorick & Shiparski, 1997):
• There are many different ways to think about something.
• Each person has innate wisdom.
• As each person sees something different, we all have an opportunity to see it more clearly.
• Opposites are connected to the same truths.
• See and welcome the wisdom in the resistance.
There are five key dialogue skills to use in communicating: intent, listening, advocacy, inquiry, and
silence. The preceptor can practice these skills to create effective communication with preceptees,
colleagues, and patients. Dialogue is especially useful in situations when you (Wesorick & Shiparski,
1997):
• Explore an issue.
• Accomplish transformative work.
• Evoke wisdom from individuals and groups.
• Generate new knowledge.
• Create mutual opportunities for healing the workplace, care providers, patients, and families.
• Accelerate breakthrough experiences with issues and challenges.
Over the past few decades, these skills have been useful in moving conversations to effective levels in
healthcare and other industries. As a preceptor, leader, and mentor, you will find the skills of intent,
listening, advocacy, inquiry, and silence invaluable to being successful in your role.
Intent
The first skill is intent, and it sets the stage for people to connect in healthy ways. Intent involves creating
a safe place that invites participation and authenticity. It also refers to the capacity for individuals and
teams to connect in mission and purpose and move forward with action. In the preceptor-preceptee
relationship, preceptors have the responsibility to state their own intent and then invite preceptees to
share their intent. At the onset of the relationship, preceptors can share their answers to the following
intent questions and then invite preceptees to do the same.
• Without being humble, what do you value most about yourself, your work, your organization?
• What are the most important things you would like to get out of this experience?
After answering the two questions, take a moment to offer two to three concrete actions that each of you
can take to ensure the preceptor-preceptee relationship will support the intents shared.
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Listening
Listening is the second dialogue skill and is one of the most important of all. When you listen to another
person, you pay them the highest respect and honor possible. In the fast-paced day of a preceptor, this
skill is at risk of being lost. You need to pause and remind yourself to really listen to those around you.
Be fully present. To practice this skill, consider that listening can occur on four levels: listening to self, to
others, to the collective, and between the lines (Wesorick & Shiparski, 1997).
Listening to yourself means noticing the voice in your head and your intuition or gut feeling. When
you are in a situation, be aware of the wisdom that your body, mind, and spirit are offering you. This is
especially helpful with patient situations and preceptee interactions. If you hear a criticizing voice, then
be aware, but don’t let it hold you back. If you hear intuition, reveal and act on it if it seems right. Teach
the preceptee to do the same. In listening to others, listen with your heart and head. Be present in the
moment.
Listening to the collective refers to listening to the bigger picture of a group conversation. This kind of
listening can be applied in talking with a family or group of preceptees or other staff. The preceptor must
watch for themes and patterns and then name them for the group. The pattern might require an action
to follow up. An example would be if a group of preceptees discussed its experiences on a particular
unit and each story led to uncovering a pattern that this unit was highly supportive of preceptees. Key
behaviors of the unit staff might be enhancing the success of the preceptee experience. The preceptor
could then follow up by sharing the positive feedback with the unit named and other units.
Finally, listening between the lines refers to working with a group and noticing that its words and actions
don’t match. Or, you get a sense that something else is going on in the group that is not being spoken.
For example, a preceptor and preceptee were talking about the poor prognosis of a critically ill patient
to her children and husband. As they discussed options, the family was very engaged and helpful, but
an overriding resistance and anger seemed to be present. The preceptor noticed the pattern and asked
the family what the underlying issue of their emotion and concern was. After a moment of silence, the
patient’s youngest daughter spoke up to reveal that no one in the family felt they could take care of their
mother in this state, and they all felt very guilty about even feeling that way. As a result of the preceptor
listening between the lines, the family revealed important information.
Advancing listening skills takes effort and practice. Improving listening skills must be an ongoing
intentional action. However, the effort is worth it because you are showing respect and dignity to other
human beings.
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Advocacy
What comes to your mind when you hear the word advocacy? As a preceptor, you might think of
advocating for the needs of patients or advocating for a good learning assignment for your preceptee.
This definition usually means you are trying to convince others to support you in your efforts. Dialogue
has a different definition for advocacy. It is the willingness to share personal thinking and what is behind
the thinking with the intention of exposing, not defending it (Wesorick & Shiparski, 1997). Advocacy
requires the courage to speak your truth and check assumptions to avoid making judgments. It is not
about convincing others at all.
One of the most useful tools in understanding how this occurs in our communication efforts is the
“ladder of inference,” which comes from Peter Senge’s work (Senge, 1990; see Figure 6.1). Your thoughts
can quickly jump up the ladder as you observe the words and actions of others. The rungs of the ladder
represent the following sequence of events: First, you see the actions of another. Second, you add your
own meaning. Third, you jump to your own conclusions. Finally, you take actions based on it. You are at
risk of acting on your assumptions even if they are wrong. Have you ever jumped up your ladder only to
find you were wrong?
Take action
Draw conclusions
Make assumptions
Affix meaning
(cultural and personal)
INQUIRY
ADVOCACY
Adopt beliefs
Select data and experience
Observe data and experience
FIGURE 6.1 The Ladder of Inference
Source: Senge, 1990
For example, a group of preceptees was in an onboarding class, and the topic was severe wound care.
As the instructor went into more graphic description and showed illustrations of severe wounds, one
of the preceptees abruptly got up and ran out of the room (rung #1, the action). The instructor noticed
the action and wondered if the information had been too much for the preceptee (rung #2, she added
her meaning). The instructor drew a conclusion—maybe this preceptee is not strong enough to handle
sicker patients (rung #3). Based on her conclusion and belief, the instructor took action and notified
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the preceptor of the incident (rung #4). But the instructor jumped to conclusions. She should have used
questions to ask the preceptee what had happened. Later the preceptor did ask and found out that the
preceptee had not been feeling well that morning and came to work ill. It had nothing to do with her
ability to handle the topic.
You can use the ladder of inference in three ways:
1. Becoming more aware of your own thinking and reasoning
2. Making your thinking and reasoning more visible to others
3. Inquiring into the thinking and reasoning of others
Inquiry
For preceptors, the skill and art of asking questions are invaluable. In dialogue, this is called the skill
of inquiry. It is the willingness to ask genuine questions of curiosity to learn from self and others
(Wesorick & Shiparski, 1997). On occasion, the preceptor will need to ask questions to see what the
preceptee knows and understands. This is part of the learning process. In addition, some questions help
preceptees dig deeper to uncover the wisdom that is inside them. Self-realization and discovery make
for a powerful learning experience, so rather than just giving the answers to questions, the preceptor
can advance questions to evoke deeper learning. The following are examples of different kinds of
coaching questions that preceptors can use when trying to understand and deepen learning (Wesorick &
Shiparski, 1997).
• What leads you to think that? Give data.
• Could you give me an example?
• Could you say more about that?
• What do you mean by . . . ?
• How do you feel about that?
• I’m asking because . . .
Questions that can be used when trying to broaden thinking include:
• What values might others have that would help us understand this situation or think
differently about it?
• What might I/we be missing by looking at the issue from my/our view?
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Another type of deeper questioning is called appreciative inquiry. It is a methodology developed
by David Cooperrider, a professor of organizational behavior at Case Western Reserve University
(Cooperrider & Whitney, 2005). It is the skill of using a positive, appreciative approach to questioning,
and it differs from the traditional approach (Hammond, 1998; see Figure 6.2).
Traditional Process
Appreciative Inquiry
Define the problem
Search for solutions
Fix what is broken
Amplify what is working
Focus on decay
Focus on life-giving processes
FIGURE 6.2 Traditional Process vs. Appreciative Inquiry
In healthcare, we tend to focus on fixing the problems and often do not tap this appreciative approach
to grow our knowledge of what is working. It is necessary to recognize the problems and to balance that
recognition with noticing what works. Preceptors who want to inspire others and teach in energizing
ways use this type of questioning. Cooperrider and Whitney (2005) offer the following underlying
assumptions of appreciative inquiry:
• In every society, organization, or group, something works.
• What we focus on becomes our reality.
• The act of asking questions of an individual, group, or organization influences them in some
way.
• What we want already exists in ourselves, our firms, our organizations, and our communities.
When preceptors communicate with an appreciative approach, they can spark imagination, innovation,
and creativity and evoke essential values and learning. Good appreciative questions are stated in the
affirmative and are always presented as an invitation to answer them. The following are examples of
appreciative inquiry questions that can be used with preceptees.
• What do you like about your experience so far?
• What’s working well? What should we keep doing that is working?
• Think back through your career/experience. Locate a moment that was a high point when you
felt most effective and engaged. Describe how you felt and what made the situation possible.
• How can we be more supportive of you?
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Silence
Silence is the willingness to experience and learn by reflecting and discovering the lessons from personal
awareness, words unspoken, or the quiet of the soul (Wesorick & Shiparski, 1997). Good preceptors
understand the power of this skill. It might happen with patients as you sit quietly at their bedside and
support them with your presence, with no words needing to be spoken. Silence can arise when you are
sitting with a preceptee who is conveying a heart-moving story about a patient experience.
The skill comes in how you handle silence when it occurs. You have to ask yourself if silence makes you
uncomfortable. Those with experience in silence have built a comfort level to be in it calmly and fully
when it arises. It represents a profound moment, and you have the potential for many moments in your
caring as long as you recognize and welcome it.
In some ways, you can use silence to help in situations. Preceptors can ask a preceptee to leave an
intense patient situation for a few minutes to be in silence and regain calm perspective. If in a tense
patient-family situation where emotions are running high, the preceptee can call for a few moments of
silence for all to regroup. This can de-escalate a situation immediately. In another application of silence,
the preceptor can ask the preceptee to be in silence to reflect on what they are learning.
Also, at times, preceptors might find a few minutes of silence necessary to regroup or reenergize. A
quote from Jiddu Krishnamurti summarizes the power of silence, “Real communication can only take
place where there is silence” (Krishnamurti, 1967, para 4).
Checklist: Dialogue Behaviors for Self-Improvement
❑
Intent
❑
Clarify personal intent and act on it.
❑
Show vulnerability.
❑
Show up authentically.
❑
Respect the wisdom of self and others.
❑ Listening
❑
L isten on all levels: self and others, as well as the collective (internal and external)
and between the lines.
❑
ear your internal voice, but know how to move beyond negative self-talk, fear, and
H
worry.
❑
Listen with your heart.
❑
Honor yourself and each other.
continues
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Checklist: Dialogue Behaviors for Self-Improvement (cont.)
❑
❑
❑
Advocacy
❑
Speak your truth (be courageous).
❑
Manage candor and diplomacy as an ongoing dynamic.
❑
Share your thoughts and feelings to reveal a perspective, not convince others.
❑
Check out your assumptions.
❑
Avoid judgments of self and others.
Inquiry
❑
Ask genuine questions of curiosity to learn from self and others.
❑
se questions as a personal reflection tool to uncover new perspectives and
U
wisdom.
❑
tilize questions that help you remember what worked before, questions that grow
U
what is working well, and build on your strengths (appreciative inquiry).
Silence
❑
Create space to think and reflect.
❑
Be present in the moment.
❑
Call for silence to de-escalate a situation.
Managing Different Methods of Communication
The skills reviewed thus far are applicable to all forms of verbal, email, texting, and other written
communications. Though face-to-face communication is always the best mode, in this age of technology,
our interactions often take place via email, texting, or phone. The critical factor to consider when
communicating by these latter methods is that the risk of misunderstanding is higher. The possibility of
jumping to conclusions is much higher because you cannot tell the intent or tone of the communication.
The following tips for the preceptor can improve the effectiveness of email communication:
• If it is a sensitive or confidential topic, consider calling or meeting in person instead of writing
an email. Do not send confidential patient information unless approved by the organization.
• Never write anything in an email that you wouldn’t share with anyone.
• Keep messages short. Detail can be shared in person if necessary.
• Check your spelling.
• Use both uppercase and lowercase letters. It is considered rude to write in all caps.
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• If you’re responding to a message, be aware of the “reply all” option, and do not send the
response to all if it is not necessary.
• If you’re sending an important message, test it by sending it to yourself first.
• Answer your email quickly; not responding can convey a lack of respect.
• If you receive an email that conveys anger or upsets you in any way, follow up and check with
the sender in person to clarify intent and message.
In addition, be very cautious of sharing any patient or work-related information on social networking
sites unless they are internally protected sites within the healthcare organization.
Patient Safety and Handoffs
Communication is one of the key strategies for ensuring patient safety. Preceptors have a responsibility
to discuss the importance of this with preceptees and to offer strategies to help them communicate
appropriately. The Institute of Medicine (IOM) has identified that 44,000–98,000 annual deaths occur
as a result of errors (IOM, 2000). The Joint Commission (2011) review of sentinel event data found that
communication (or lack of communication) was the number-one cause of sentinel events for many
years. Many of these errors and sentinel events can be eliminated with effective communication.
Handoffs are a major area in which communication can prevent errors and improve patient outcomes.
Huang et al. (2010) estimated that 80% of serious medical errors involve miscommunication during the
handoff/handover between healthcare providers. A successful handoff has been defined as “a transfer
and acceptance of responsibility for patient care that is achieved through effective communication. It
is a real-time process of passing patient-specific information from one caregiver or team to another to
ensure the continuity and safety of that patient’s care” (The Joint Commission Center for Transforming
Healthcare, 2014, p. 2). The IOM (2000) recommends that handoff communication occur in a verbal
mode, where questions and explanations can be exchanged. Currently, many guidelines suggest that a
standard communication approach increases the effectiveness of patient handoffs.
One frequently used communication tool is the ISBAR format, which offers key points for
communicating during patient handoffs:
I—Introduction
S—Situation (the current issue)
B—Background (brief, related to the point)
A—Assessment (what you found/think)
R—Recommendation/request (what you want next)
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The preceptor needs to review what happens in situations in which the preceptee feels a patient need
is not being addressed. Preceptees must be encouraged to speak up and not hold back because of fear
of repercussions from physicians or others. Preceptors can find it helpful, for example, to role-play a
situation in which a patient is in trouble and it is difficult to get the attention of the physician. Ensure
that the preceptee utilizes the dialogue skills and seeks backup help from supervisors and staff mentors.
Preceptees should not go it alone in tough clinical situations in which they are not being heard.
The Association of periOperative Registered Nurses (AORN, 2007) developed a communication
checklist for handoffs:
❑
Get the person’s attention.
❑
Make eye contact; face the person.
❑
Use the person’s name.
❑
Express concern.
❑
Utilize a handoff format such as ISBAR.
❑
Re-assert as necessary.
❑
Decision reached.
❑
Escalate if necessary.
There are challenges and barriers to effective handoffs that have to be minimized. A few of these include
limited opportunities to ask questions and verify content, sharing too little information, unfamiliarity
with documentation systems, lack of a structured handoff process, and interruptions and noise (Kear,
2016; Welsh, Flanagan, & Ebright, 2010).
Handoffs are also important when a preceptee is being handed off to another preceptor. Just as with
patient handoffs, good communication during a preceptee handoff can help ensure a smooth, efficient
transition and maximize outcomes.
Considerations for Participating in Team Communications
Thus far in this chapter, the focus has been on communication skills between preceptor and preceptee
and with patients and their families. It is the role of the preceptor to emphasize and discuss ways to
interact with the interdisciplinary team as well. Whether in staff meetings, during interdisciplinary
rounds, or in care conferences, preceptees have to master the art of team communication to be
successful in their role. Tips on participating in team conversations include:
• Be aware that your goal is to contribute in respectful, thoughtful ways.
• Utilize the dialogue skills.
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• Be present and attentive—be an observer of the process and what is being said.
• Have the courage to speak your truth and think before you speak it. Present your ideas and
comments in calm, diplomatic ways so others can hear them.
• Ask questions to clarify what others are saying and to understand their perspectives without
evoking defensiveness. Check your assumptions. One approach could be to say, “That is an
interesting perspective. I’d like to understand more about that.”
• Encourage others to participate, and state your appreciation for the contribution of others.
• Basically, give to others what you would like for them to give to the conversation.
It is also helpful to recognize some of the barriers to effective team communication so they can be
prevented or mitigated (see the next sidebar). Preceptors need to become adept at recognizing behaviors
that can cause these barriers in a preceptee and at teaching the preceptee to modify the behaviors. This
is the first step in managing difficult conversations or conflict in team interactions.
Barriers to Effective Team Communication
Lack of time
Defensiveness
Conventional thinking
Complacency
Varying communication styles
Conflict
Distractions
Fatigue
Workload
Misinterpretation of cues
Lack of role clarity
Source: Agency for Healthcare Research and Quality (AHRQ), 2015
Managing Difficult Conversations
One of the most useful skills to have is the ability to manage difficult conversations. The basis for
effective communication in these situations is use of the dialogue skills, but you have a few more
strategies. All of us at some time or another bump up against a tough conversation. Many times, we
find ourselves avoiding them, and in many cases, this perpetuates strained relationships and
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de-energizes workplaces. Preceptors should spend time discussing the importance of having these
difficult conversations with others in the workplace to address patient issues and interpersonal issues.
Deepak Chopra (1997, para. 17) offers some insight into why these situations arise: “When you struggle
with your partner, you are struggling with yourself. Every fault you see in them touches a denied
weakness in yourself.” The important thing is that we make these conversations happen. A good resource
is Crucial Conversations: Tools for Talking When Stakes Are High (Patterson, Grenny, McMillian, &
Switzler, 2002). Patterson and colleagues describe a process for managing these difficult conversations:
1. Start with your heart. Identify what you really want for yourself, others, and the relationship.
How would I behave if I really did want this?
2. Learn to look. Identify when a conversation is crucial, and identify the risk. Is there stress
involved?
3. Make it safe. Apologize, fix misunderstandings, and maintain mutual respect.
4. State your path.
5. Explore others’ paths.
6. Agree and move on to actions.
It is always helpful to seek to understand the other person’s perspective before sharing your own views
and to look for the points of agreement to bridge the gap of the disagreement.
Communication Strategies for Education and Meetings
Also, some communication strategies can enhance effective communication in meetings and
educational gatherings. The intent or goal of these situations is to create a place where communication
is open, honest, and direct. You will find it helpful to state this as an intent to the group to invite them
to participate in this way. One strategy is to take time to develop a list of behaviors that the group
can commit to practicing and using. This can be a short process of about 15 minutes and comes from
suggestions in the group. Some examples of these group behaviors include:
• Keep confidentiality.
• Respect all views.
• Check assumptions.
• Speak your truth.
• Bring up “undiscussables.”
• Assume a positive intent from others.
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An agreement to behaviors such as these can lay the foundation to invite everyone to participate safely.
Readings (poems, stories, etc.) can be used to set the stage for effective communication (Shiparski, 2002).
Full and Empty
Our meetings are full
of schedules,
timed talk
and quick decisions.
They are full
of words that swirl
at the surface
of deeper issues.
They are full
of giving information,
fixing problems,
and staying on track.
They are full
of ego building,
defending, blaming,
and judgment of others.
They are full
of quieting the voices,
that bring questions and
unwanted truths.
Our meetings are full
and I am left empty.
Our meetings are full
and I am left empty.
Give me one clear
moment of silence
and the courage
to show my vulnerable self.
Let me be an invitation
for us to be together
in a meaningful,
genuine way.
–Laurie Shiparski, 2002
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Another strategy is utilizing a “check-in” process at the beginning or end of a meeting. This process
is used when you want to invite participation, practice dialogue skills, and create an environment of
learning and connection. Check-in is when all in attendance get a chance to speak without interruption.
It works best when the participants are seated in a circle. The facilitator or leader extends a welcome
and introduces the process. Doing a reading or calling for a moment of silence at the beginning of the
meeting to get everyone’s attention and presence is helpful. Then the facilitator offers a question that
each person answers. Examples of check-in questions include:
• What is something about yourself we don’t know?
• What’s up for you today?
• What did you have to leave behind to be present here?
• What energizes you at work?
• What is most important to you about the topic we are discussing today? (Name the topic.)
After a question is presented, each person takes a turn around the table to briefly speak their answer.
This process allows the group to know something more about each individual, and it invites further
participation.
Sometimes groups pass an object around the table to slow the process down and indicate when they are
done speaking (Shiparski, 2002). Another variation of this strategy is to do a round robin to hear from
each person at the end of a meeting with a one- or two-word description of how each person is feeling.
Conclusion
These practical techniques can help create cultures of effective communication and connection for
preceptors, preceptees, and the patients and staff with whom they work. The ongoing, intentional
effort invested in learning and practicing these skills can have a significantly positive effect on patient
outcomes, interdisciplinary teamwork, and effective teaching and learning experiences. In addition, as
you learn to manage your communication and interactions in healthy ways, your stress can be reduced
and your effectiveness increased.
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Preceptor Development Plan: Communication
Review the information on communication described in this chapter. What are your strengths?
In which areas do you need to increase your knowledge and expertise? What is your plan for
expanding your knowledge and expertise? What resources are available? Who can help you?
Name:
Date:
Effective Communication—Intent
Strengths
Needs
Plan
Resources
Plan
Resources
Plan
Resources
Effective Communication—Listening
Strengths
Needs
Effective Communication—Advocacy
Strengths
Needs
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Effective Communication—Inquiry
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Effective Communication—Silence
Strengths
Handoffs
Strengths
Team Communications
Strengths
6
Communication
Difficult Conversations
Strengths
Needs
Plan
Resources
Communication Strategies for Education and Meetings
Strengths
Needs
Plan
Resources
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
155
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References
Agency for Healthcare Research and Quality. (2015). TeamSTEPPS 2.0. Rockville, MD: Author. Retrieved from https://
www.ahrq.gov/teamstepps/instructor/fundamentals/index.html
Association of periOperative Registered Nurses. (2007). Handoff standardizing. Retrieved from www.aorn.org/
PracticeResources/ToolKits/PatientHandoffToolKit/
Chopra, D. (1997). An excerpt from The path to love. Retrieved from http://deepakchopra.wwwhubs.com/chopra6.htm
Cooperrider, D., & Whitney, D. (2005). Appreciative inquiry: A positive revolution in change. San Francisco, CA: BerrettKoehler.
Hammond, S. A. (1998). The thin book of appreciative inquiry. Bend, OR: TB Publishing.
Huang, D. T., Clermont, G., Kong, L., Weissfeld, L. A., Sexton, J. B., Rowan, K. M., & Angus, D. C. (2010). Intensive care
unit safety culture and outcomes: A US multicenter study. International Journal for Quality in Health Care, 22(3),
151–161. doi: 10.1093/intqhc/mzq017
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
Retrieved from http://nationalacademies.org/HMD/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.
aspx
Isaacs, W. (1999). Dialogue and the art of thinking together. New York, NY: Doubleday.
The Joint Commission. (2011). Collation of sentinel event-related data reported to The Joint Commission (1995–2010).
Retrieved from http://www.jointcommission.org/SentinelEvents/Statistics/
The Joint Commission Center for Transforming Healthcare. (2014). Improving transitions of care: Handoff communication.
Chicago, IL: Author. Retrieved from http://www.centerfortransforminghealthcare.org/assets/4/6/handoff_comm_
storyboard.pdf
Kear, T. M. (2016). Patient handoffs: What they are and how they contribute to patient safety. Nephrology Nursing Journal,
43(4), 339–342.
Krishnamurti, J. (1967, July 9). Talk and dialogues: Saanen 1967 1st public talk. Retrieved from http://jiddu-krishnamurti.
net/en/1967/1967-07-09-jiddu-krishnamurti-1st-public-talk
Patterson, K., Grenny, J., McMillian, R., & Switzler, A. (2002). Crucial conversations: Tools for talking when stakes are high.
New York, NY: McGraw-Hill.
Senge, P. (1990). The fifth discipline: The art & practice of the learning organization. New York, NY: Doubleday.
Shiparski, L. (2002). Turning points: A dialogue tool for realizing personal and group wisdom. Grand Rapids, MI: Practice
Field Publishing.
Welsh, C., Flanagan, M., & Ebright, P. (2010). Barriers and facilitators to nursing handoff: Recommendations for redesign.
Nursing Outlook, 58, 148–154.
Wesorick, B., & Shiparski, L. (1997). Can the human being thrive in the work place? Dialogue as a strategy of hope. Grand
Rapids, MI: Practice Field Publishing.
157
“You cannot teach a man anything; you can only
help him find it within himself.”
–Galileo
7
Coaching
–Laurie Shiparski, MS, BSN, RN
Coaching is about helping others find the answers within themselves, gain
understanding from their circumstances, and take action to move through their
challenges. The most effective preceptors are those who incorporate a coaching
approach. This chapter offers information on a coaching approach, ways to develop
a coaching relationship, and coaching techniques that inspire others to tap their
own wisdom, passion, perseverance, and strength.
OBJECTIVES
•
What Is the Role of the Preceptor as Coach?
Describe the role of the
preceptor as coach
•
The preceptor’s role is to be a clinical expert and teacher who helps others grow into
a new role, whereas a coach focuses on helping others grow in self-awareness, build
life skills, and take actions to change. A preceptor who incorporates a coaching
approach holds the preceptee accountable to safe clinical practice while also
understanding how experiences affect the preceptor’s personal growth.
Identify ways to set up
a coaching agreement
and utilize a coaching
interaction format with
preceptees
•
Articulate strategies
to inspire learning
and move through
challenges
•
Identify the preceptor’s
role in working with
resistance and edges
•
Describe how a
preceptor ends a
coaching relationship
with a preceptee
To be an effective coach, the preceptor must possess the following foundational
beliefs:
• Each preceptee has wisdom and the capacity for learning.
• All experiences and parts of ourselves are necessary and make us who we
are today.
• We are all unique and on our own journey of learning and self-awareness.
The preceptor has to meet the preceptee where the preceptee is in his/her
developmental journey.
• What goes on inside each of us is as important as what is happening
outside of us.
• Coaching addresses the health of body, mind, and spirit in both our
work and our personal lives. We are whole people, and all our aspects are
connected.
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• What we resist persists. If we focus only on learners’ deficits, they will not grow.
• Conflict is normal and essential to growth. Preceptors need to expect it and find the wisdom
in the resistance.
• All problems and challenges are our teachers; they offer an opportunity for growth.
• Focusing on the preceptee’s strengths and new possibilities is far more motivating than
identifying everything that is going wrong.
• The goal is not to give all the answers, but to use questions and observations to evoke the
preceptee’s own awareness and wisdom.
With these beliefs and behaviors in mind, the preceptor can make meaning of situations that arise as the
relationship and learning unfold. No matter what level of frustration or emotion arises in the preceptee,
the role of the preceptor is to be calm and use every situation as a learning opportunity.
Setting Up a Coaching Agreement With a Preceptee
Preceptors should establish a coaching agreement and boundaries at the onset of the relationship.
It is important to reveal the intent to incorporate a coaching approach with the clinical focus of the
preceptor role. The agreement can be written or verbal and should clarify the expectations for both
parties. The preceptor starts by saying what he or she brings to the relationship and what is needed from
the preceptee for optimal learning and support. In turn, the preceptee then gets a chance to express what
he or she needs from the preceptor and what she is willing to give to make the relationship effective. The
following represents a few examples of these mutual agreements.
We will:
• Have open, direct communication
• Respect each other’s opinions and viewpoints
• Keep confidences as part of building our trust
• Listen intently to each other
• Check our assumptions; avoid judgment and jumping to conclusions
• Honor each other by beginning and ending our meeting times as planned or discussed
• Seek to understand each other and assume positive intent in all actions
• Forgive and move on as challenges arise
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Preceptors can achieve greater levels of engagement if they enter into coaching relationships by staying
as impartial as possible. This means they have to own and be upfront about their own judgments and
biases. Preceptors have to be open to diverse views and let the preceptees be responsible for fueling their
own process, making choices, and mutually determining outcomes.
Utilizing a Coaching Interaction Process
A preceptor can use coaching strategies to enhance learning and clinical judgment. Some of these
include reflection, building on past learning, and using questions to deepen learning and goal
identification (Nielsen, Lasater, & Stock, 2016). To guide these actions, it is helpful to have a format to
guide the process.
One way is called 4 Gateways Coaching (Daly, 2007; see Table 7.1). This four-step process ensures a clear
understanding of an issue and sparks possible actions to move through it. You need to take notes during
the session; the format provides a sample worksheet to guide the interaction and document next steps.
This four-step process can be done in 45 to 60 minutes for complicated issues, or preceptors can use the
4 Gateways Coaching questions in an abbreviated way.
Table 7.1
Four-Step Coaching Process
1. Clarify the issue and desired outcome.
2. Ask questions from four perspectives: thinking, feeling, doing, knowing.
3. Integrate the learning.
4. Identify actions and support.
The first step of 4 Gateways Coaching is to identify the issue at hand. Sometimes the issue is clear, or
it could be unknown and the preceptor has to ask questions and help identify it. The preceptor can ask
questions such as:
• How has your day gone?
• What issues are you struggling with now?
• If you had to say what the real issue is, what would it be?
• Do you feel stuck and unable to see a way to move forward?
• Is there a situation you are trying to understand better?
Once the issue is identified, ask the preceptee what outcome they expect from your coaching discussion.
For example, the issue might be that the preceptee is feeling overwhelmed and out of control and the
desired outcome could be just gaining more insight to why she is feeling that way.
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Second, begin asking questions that help the preceptee gain insights and clarity on the issue. The 4
Gateways Coaching questions are designed to evoke self-awareness. Even though the questions do
provide a format, they are not meant to impede additional questions that the preceptor identifies as
the process unfolds. As a coach, the preceptor should always be aware of his or her own intuition and
insights to be added to the process. The suggested questions for this phase include:
• What are your perceptions and judgments about the situation? Do you see a pattern with this
kind of situation?
• How has this pattern or situation served you? What hard truths need to be spoken? What
boundaries need to be set?
• How do you feel when you look at yourself in this situation?
• What kind of appreciation or support do you need in this situation? How could this be a
learning experience? What purpose might it have in your life right now?
Third, the integration of learning from the session should take approximately one-fourth of the total
coaching time. This is the time in which the preceptor assesses how, when, and where to bring the
insights of the session into daily life. This is also when the preceptor helps the preceptee integrate his or
her internal thinking and external experience. The key questions here are:
• What are your takeaways from this process?
• How would support look?
• Are you willing to take a risk?
• Who would like to see you succeed?
The final phase is identifying action steps and support. The preceptor can ask the preceptee: What are
the logical steps to take for resolution? It is completely acceptable for the preceptor to suggest actions to
be taken, but it is critical that the preceptor check to see if the preceptee feels the actions would work for
him or her. The preceptee is the one who commits to the action. The preceptor also assures the preceptee
that he or she will offer support and check in to see what progress is being made with the action steps.
Identifying a time frame for the action steps is very helpful; this creates accountability to the action as
well.
The preceptor can use the Coaching Worksheet as a guide and place for taking notes. The preceptor
might want to give the notes to the preceptee for further reflection and thinking on the situation. A
sample Coaching Worksheet is shown in Table 7.2.
7
Table 7.2
Coaching
161
Sample Coaching Worksheet
Step 1 Clarify the issue and desired outcome
Step 2 Ask Questions
What are your perceptions and judgments about the situation? Do you see a pattern with this kind
of situation?
How has this pattern or situation served you? What hard truths need to be spoken? What
boundaries need to be set?
How do you feel when you look at yourself in this situation?
What kind of appreciation or support do you need in this situation? How could this be a learning
experience? What purpose might it have in your life right now?
Step 3 Integrate the learning
What are your takeaways from this process?
What options are there to consider?
Are you willing to take a risk? Who would like to see you succeed?
Step 4 Identify actions and support
What action is worth taking? Identify next steps and time frames. Make sure at least one of the
steps can be taken within a couple days.
Identify who else can support the preceptee and how the preceptor can support them. The
preceptor should schedule a time to check in with the preceptee on progress made and barriers
that might be holding him or her back.
Adapted from Daly, 2007.
A Case Study to Exemplify 4 Gateways Coaching
The following case study shows how one preceptor and preceptee utilized this process to move through
an issue. Deb was a new graduate RN (NGRN) working on a cardiac step-down unit. Her preceptor was
Jim, an experienced nurse who had been mentoring others for 7 years.
The Issue
Concern surfaced regarding the way that Deb was interacting with physicians about the needs of her
patients. Some physicians on the unit complained because they were not getting notified of patient
condition changes in a timely manner. Also, Jim noticed that critical lab results were not being called to
physicians in a timely manner. Jim wanted to really get to the bottom of this situation with Deb through
a coaching interaction, so they scheduled 45 minutes in a private conference room to talk about it. Jim
began the session by sharing the physician feedback and his observations. He then invited Deb to walk
through this coaching process, so they both could understand the situation better and identify next
steps to move through the challenge. Here are the notes and information from the session:
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1. Clarify the issue and desired outcome.
Deb identified that she was having difficulty finding the courage to call physicians with patient
issues. The outcome she hoped for was to feel confident in knowing what to call physicians about
and when.
2. Ask questions from four perspectives.
a. Thinking
What are your perceptions and judgments about the situation? Do you see a pattern with
this kind of situation?
Deb offered that she sometimes saw physicians express anger at other nurses when they
called in patient information. She offered that she has noticed a pattern in the past where
she had a difficult time bringing information to authority figures, such as parents, bosses,
and teachers. Her judgment of herself is that she is a bad nurse for not being able to do this
part of her job.
b. Doing
How has this pattern or situation served you? What hard truths need to be spoken? What
boundaries need to be set?
She offered a hard truth in that she sees the risk to patient care if she does not find a way
to convey the information to physicians. She also sees that her credibility is taking a hit by
not acting on this. Deb shared that, in the past, avoiding confrontation with authority has
served her in that she has not had to experience criticism from them. Another hard truth
was that she realized this information was different, and she had to contact physicians
to address patient conditions.Avoidance was not going to work in this situation. The
boundaries discussed were about healthy communication with those in authority. Jim
reassured her that, in speaking with physicians, she would be supported and would not
have to endure inappropriate behavior.
c. Feeling
How do you feel when you look at yourself in this situation?
Deb: “I feel afraid and unsure of myself—afraid my patients’ needs aren’t being met and
afraid to bother the physicians with things that don’t matter. My reputation is on the line.”
Deb began to cry at this point; her emotions were very high around this issue. Jim gave her
support and time to really feel her fear and sadness. Jim also affirmed that this was a tough
situation, but that he believed she could get through it. He also affirmed the deep caring
and commitment to her and patients that he saw in her. The reason she was so emotional
was because this was so important, and she really wanted to do the right thing.
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d. Knowing
What kind of appreciation or support do you need in this situation? How could this be a
learning experience? What purpose might it have in your life right now?
Deb: “I think I am being called to step into my own power as an advocate for patients. I
feel this situation is asking me to be courageous, and as I move through this hurdle, I will
gain more self-confidence.” She also realized she is learning to have healthy relationships
and communication, and this physician interaction will give her practice. Jim pointed out
to Deb that she needs to appreciate her own struggle with this situation, and that many
staff members have also dealt with it. She has many peers who will support her.
3. Integrate the learning.
• What are your takeaways from this process?
Deb shared that she realized she had been carrying the stress of not facing this situation,
ignoring it in the hope that it would go away. It was clear to her that she had to take the next
step and tap the support around her. She knew she could do it now that it was out in the open.
• What options are there to consider?
Deb articulated that she would work with Jim to identify the information to communicate to
the physicians and would like to role-play with him how she would communicate it.
• Are you willing to take a risk? Who would like to see you succeed?
Deb responded that she was willing to take a risk with the support she had. She knew her
patients, peers, and even the physicians would want to see her be successful.
4. Identify actions and support. What action is worth taking? Identify next steps and time
frames.
• Jim and Deb decided they would review her four patients today and discuss appropriate
information to be called to physicians.
• Deb will role-play with Jim about how to share the information today.
• Jim also noted three other staff RNs—Cindy, Kyle, and Pete—who are well respected by
physicians and are very experienced nurses. Jim was going to ask them today if Deb can seek
out help from them on physician communication.
• Jim offered tips on how to invite healthy communication and relationships with physicians.
He also encouraged Deb to ask the other identified staff for tips.
• Deb agreed to set up times this week to ask the identified staff members for tips.
• Jim offered to focus on supporting her to move through this challenge during the remaining
time of her orientation.
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• Jim also suggested that, in the future, Deb can always seek out his support and the support of
the department director if an inappropriate physician interaction occurs.
Strategies to Inspire Learning and Move Through Challenges
In addition to the 4 Gateways Coaching process, preceptors can use other strategies in coaching
preceptees and their peers. Often, preceptors are sought out by other staff for support and advice. When
working with a preceptee or peer, the following guidelines are effective for peer coaching. This process
can be done in as little as 20 minutes:
1. Listen intently to others with your heart and head; give them a chance to explain their situation
before offering advice.
2. Clarify what you are hearing by saying, “I heard you say______. Is that right?”
3. Break down the parts of what they are grappling with into manageable issues help them
prioritize and address them one at a time. Brainstorm options with them.
4. Offer support and empathy; let them know they are not alone in dealing with the issues and that
you believe they can make it through the situation.
5. Help them identify three to four steps they can take to begin to move through them. For
example, if a preceptee or peer is feeling overwhelmed in a situation, you might hear, “I am
having a really bad day. There are so many things going wrong. I don’t know where to start.” You
can then offer to listen to what is happening, but tell the individual that you are only going to
spend 5–10 minutes on what is happening, so you can move on to brainstorming what can be
done about it.
Another strategy is to use a strengths-based and appreciative approach when offering support to others.
A strengths-based approach includes noticing and revealing the strengths you see in others that can help
them move through their challenges. Often, we are so focused on what we don’t have that we forget to
recognize what we do have as strengths. For example, if someone is struggling with an overwhelming
day, the preceptor might reveal a strength he or she has noticed in that person that can be helpful. The
preceptor could say, “Jane, I have noticed you are a very organized person and have a gift for prioritizing
what needs to be done. Let’s tap that strength of yours to help you get through this day.”
Appreciative inquiry is another way to help a person identify next steps. It is a technique that many
coaches use to highlight what is working. This methodology was developed by David Cooperrider,
a professor of organizational behavior at Case Western Reserve University. In healthcare, we are
conditioned to focus on fixing problems; this is useful, but not enough. Sue Hammond (1998) notes that
appreciative inquiry involves searching for solutions, amplifying what is working, and focusing on lifegiving processes.
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To use appreciative inquiry, preceptors can employ some version of the following questions in any
situation (Whitney, Cooperrider, Trosten-Bloom, & Kaplan, 2001):
1. What do you like about what’s going on? What’s working? Tell me about a time…
2. What would you like to have more of? What would you like to do differently? What made that
experience so exciting/meaningful/satisfying…?
3.How can I help? What do you need from me? How can I support you? What training, resources,
etc., can I provide to help you succeed?
The Preceptor’s Role in Working With Resistance and Edges
In almost every coaching process, some resistance shows up. Preceptees and peers eventually come
to a point at which they have difficulty moving into unfamiliar territory that tests the limits of their
experience, and they will not proceed without assessment of the risks. This unfamiliar territory is called
their “edge” (Daly, 2007). Often, a preceptee cannot move through an edge without assistance, and the
preceptor can be the catalyst to help. The preceptor must be comfortable with conflict and see resistance
as an ally that can be helpful in reaching an effective solution. Resistance is not a problem to solve, but
rather a dynamic to manage. If a preceptor is not comfortable with resistance and tries to fight or ignore
it, it will grow stronger and potentially sabotage the coaching process.
Resistance has always been in our lives, and it is a natural, normal, useful part of us. Each one of us
has a risk manager inside of us whose job is to resist change. This internal risk manager has been our
protector when change threatens our status quo. When you are working with resistance and edges, the
key is to get the preceptee to name the edge, honor it, and work with it. An edge is simply a challenge or
dilemma that represents unknown territory for a person to move through. This kind of work is often a
deep, insightful process. If the preceptor can help the preceptee name the edge without judgment, that
is a great beginning. As a coach, it is imperative to curb your instinct to fix the situation and instead rely
on the preceptee deciding to move through it.
An Edge Story
An example of such an edge came from a coaching interaction between Phil, a preceptor, and Mary, a
preceptee. Phil had selected a patient assignment for Mary that was very challenging. He knew it would
be a difficult, but excellent, learning experience for her. The patient was a young trauma victim who
had a head injury and a poor prognosis for recovery. Mary immediately reacted to the assignment with
negativity. She said, “I feel it is unfair that I have this patient. I am not ready for this level of patient. I
can’t do it, and I am angry that I am put in this situation.” She was angry with Phil. Edges often manifest
as emotions toward the preceptor. This is a sure sign of an edge. The important thing here is for the
preceptor to remain calm and not engage in the emotion. So Phil began to try to understand where
Mary’s emotion was coming from and help her name her edge. Initially, the resistance seemed to come
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from her doubting her abilities, but as Phil questioned her, the real reason became clear. Mary had
lost her 17-year-old brother in a motorcycle accident 5 years earlier. In this case, Phil had used four
questions to get at the edge (Shiparski, 2002).
1. What leads me to think and act as I do?
2. What is at risk here?
3. Have you ever felt this way before?
4. If this had a purpose, what would it be?
Mary finally realized that this patient triggered her emotions of that event when Phil asked the third
question, “Have you ever felt this way before?” She began to cry and release all of her anger and
sadness. Phil respectfully sat with Mary and, when his intuition told him the time was right, he offered
compassion and understanding. He then asked her what options she saw to be more effective in moving
through this edge. He also asked what support she would need to move forward. Mary did decide she
could take care of this patient with Phil’s help.
Ending a Coaching Relationship With a Preceptee
At the conclusion of an assignment, the preceptor needs to end the relationship as it has been set up
and launch the preceptee into the next phase of their journey. This is a time to celebrate successes,
offer appreciation and encouragement, and let go. The preceptor should plan a concluding celebration
meeting with the preceptee. This is a time to:
• Welcome the preceptee to the celebration meeting.
• Review the progress, accomplishments, and strengths of the preceptee. This could include
letters of recognition and encouragement from peers and leaders of the department.
• Make this time a checkpoint for both the preceptor and the preceptee to reveal their key
learning from the relationship. Each exchanges what he or she most appreciated about the
other.
• The preceptor as coach reviews supports that are available to the preceptee from here forward.
The power of appreciation fuels the motivation of the preceptee and the preceptor to continue on with
confidence and energy. The coaching relationship should always have mutual learning and benefit for
both parties. It is crucial that this concluding meeting offers time for each to express gratitude, learning,
and well wishes for each other.
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Preceptors need to take time at the end of a coaching relationship to reflect on the experience
themselves. As a post-relationship checklist, preceptors as coaches should ask themselves these four
questions (Daly, 2007):
1. Was I really of service to my preceptee or peer?
2. Did I keep an open mind?
3. How did I feel about myself, my preceptee, and the experience as a whole?
4. Did I trust my own knowing and respect myself and the preceptee?
Conclusion
In conclusion, though approaches and tools are available, the most important things for the preceptor
to remember in creating an effective coaching relationship are to be present and aware, listen to your
intuition for guidance, and see the learning in all situations. The goal for preceptors using coaching
techniques is to create effective teaching-learning experiences, grow self-awareness, and build capacity
to handle situations. Preceptors who use coaching techniques have a distinct advantage in supporting
others and expanding their own self-awareness.
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Preceptor Development Plan: Coaching
Review the information on coaching described in this chapter. What are your strengths? In which
areas do you need to increase your knowledge and expertise? What is your plan for expanding
your knowledge and expertise? What resources are available? Who can help you?
Name:
Date:
Being a Coach
Strengths
Needs
Plan
Resources
Plan
Resources
Plan
Resources
Setting Up a Coaching Agreement
Strengths
Needs
Utilizing a Coaching Interaction Process
Strengths
Needs
Inspiring Learning and Moving Through Challenges
Strengths
Needs
Plan
Resources
7
Coaching
Working With Resistance and Edges
Strengths
Needs
Plan
Resources
Plan
Resources
Ending a Coaching Relationship
Strengths
Needs
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
169
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References
Daly, T. (2007). 4 Gateways Coaching: Evoking soul wisdom. Boulder, CO: Living Arts Publishing.
Hammond, S. (1998). The thin book of appreciative inquiry. Bend, OR: TB Publishing.
Nielsen, A., Lasater, K., & Stock, M. (2016). A framework to support preceptors’ evaluation and development of new
nurses’ clinical judgment. Nurse Education in Practice, 19, 84–90. doi: 10.1016/j.nepr.2016.03.012
Shiparski, L. (2002). Turning points: A dialogue tool for realizing personal and group wisdom. Grand Rapids, MI: Practice
Field Publishing.
Whitney, D., Cooperrider, D. L., Trosten-Bloom, A., & Kaplan, B. S. (2001). Encyclopedia of positive questions volume 1:
Using appreciative inquiry to bring out the best in your organization. Brunswick, OH: Crown Custom Publishing.
171
“The only source of knowledge is experience.”
–Albert Einstein
8
Effectively Using
Instructional
Technologies
–Cathleen M. Deckers, EdD, RN, CHSE
Wendy Jo Wilkinson, MSN, ARNP
OBJECTIVES
Today’s burgeoning technological capacity, coupled with a new generation
of learners who have a high level of digital literacy, mandates that preceptors
understand the function and use of instructional technologies; the role these
technologies can play as resources for preceptors and preceptees; and how to
integrate these technologies into current practice to improve the efficiency,
effectiveness, and safety of competency development and validation. This chapter
explores why embracing technology is important in today’s healthcare practice
and reviews some of the newer technological tools and their capabilities for use
in onboarding, competency development, and validation. This will highlight the
importance of matching the technology to meet the learning objectives.
Why Technology Is Imperative for Today’s
Healthcare Environment
The healthcare industry is employing technology more frequently in the care and
treatment of patients and in educating healthcare providers. Telemedicine, which
allows providers to perform many assessments using videoconferencing technology,
and diagnostic imaging applications such as Mobile MIM, which is used to view
high-resolution diagnostic X-ray and ultrasound images on a portable smartphone
device, are but two examples of how technology has revolutionized the care of
patients worldwide.
Technology is also increasingly expanding into the health-promotion domain.
Healthcare-focused technology puts medical advice, data collection, and education
at the fingertips of individuals with the goal of promoting health-seeking behaviors.
•
Identify various forms of
instructional technology
and appropriate use to
augment achievement of
learning goals
•
Develop a better
understanding
of the benefits of
using high-fidelity
patient simulation to
facilitate learning and
understanding during
new-hire and newspecialty orientation
•
Identify trends
and future uses of
instructional technology
methodologies
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Applications for self-regulation and monitoring are more frequently deployed in the management of
patients who suffer chronic illness, and prevention monitoring for healthy daily living is only an app
away with the use of smartphones. Healthcare workers must be familiar with this technology and savvy
enough to engage with it in order to remain competitive in the healthcare environment of today.
Similarly, technology has become a pertinent and prevalent part of the preceptor’s tool kit for
onboarding new nurses. The Commission on Collegiate Nursing Education (CCNE) Essentials of
Baccalaureate Education for Professional Nursing Practice mandate training to incorporate healthcare
technology and information management as one of the core standards in baccalaureate nursing
education (American Association of Colleges of Nursing [AACN], 2008). An important part of
preceptor workforce planning includes conducting a technology assessment of preceptors. Additional
training for preceptors might be required depending upon the amount and type of technology that will
be incorporated as part of the preceptor/preceptee relationship.
Technology Across Generations
Generational differences between preceptors and preceptees have the potential to create additional
stress in the workplace if you do not recognize and acknowledge them early on in the relationship.
Understanding how differences between the familiarity with technology and work styles contribute
to discord between a preceptor and preceptee can help keep this stress to a minimum. Working with
individuals from different generations is discussed in Chapter 9. How technology utilization may differ
by generation and specifically impact preceptor/preceptee relationships is discussed below.
The millennial/net generation has grown up within a world that is rich with technology. They are
connected 24/7, to each other and globally, through devices that make communication instantaneous
and engaging. Information technology has always been a part of their lives in a way that removes the
barriers of time and space and creates opportunities for endless learning. Yet, because technology has
become so seamless to their daily existence, they see it as “normal.” Preceptors may find this attribute
beneficial when teaching a millennial/net generation preceptee how to program a smart intravenous
(IV) pump, set alarm limits on monitoring devices, or complete documentation in the electronic health
record. But it can sometimes be challenging for preceptors from older generations who are not digital
natives and may not be as comfortable with newer technologies.
The need for the millennial/net generation to be constantly connected through their phones is also
a potential area for discord between the preceptor and the preceptee. Frequent discussions and role
modeling may need to occur in order to set professional boundaries for cellphone utilization.
Tapscott (2009) describes millennial/net generation members as innovative, inclusive, and open.
They value the autonomy of an active learning process that allows for innovation and creativity when
learning. Working in groups where knowledge can be shared, explored, and re-created while valuing
the diversity of multiple viewpoints is a preferred style. Millennial/net generation learners use tools
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that promote openness, allow for free expression, and provide immediate results in their search for
knowledge. The digital literacy of this group allows for widespread access to devices that help them
navigate their learning. They are often observed moving seamlessly from the virtual world to the real
world while multi-tasking from one activity to another or, better yet, performing them simultaneously
(Skiba & Barton, 2006). The preceptor is responsible for teaching the preceptee how to prioritize patient
care as a key skill outcome. The multi-tasking approach of younger preceptees may need to be discussed
frequently to help them prioritize and focus attention to details that have clinical significance.
Jenkins (2006) defines these characteristics as being part of a participatory culture:
a culture with relatively low barriers to artistic expression and civic engagement,
strong support for creating and sharing one’s creations, and some type of
informal mentorship whereby what is known by the most experienced is passed
along to novices. A participatory culture is one in which members believe
their contributions matter, and feel some degree of social connection with one
another (p. 3)
Clearly, the needs of these new learners mandate a different approach to assimilation into healthcare
culture than has been taken in the past. Preceptors will need to be aware that the traditional 1:1
approach for precepting may need to include additional opportunities for information searching, group
sharing of information, and brainstorming for problem-solving in order to meet the preceptee’s needs
for participation and creativity.
Nursing education within academic and healthcare settings has been using new technologies such as
web-based and mobile technologies, social networking tools, and simulation to enhance the traditional
apprenticeship model of learning, both to improve onboarding and competency development in
general and in response to the needs of millennial/net learners. This new combination of educational
techniques not only transforms the professional practice of novice nurses, but also has an effect on
experienced nurses as they travel together through onboarding and competency development. Creating
opportunities to demonstrate how mobile technologies can be utilized, when allowed by the institution,
will enhance the preceptor/preceptee relationship. An example would be the use of Lexicomp or
Epocrates on smartphones to check information about drug interactions.
Web-Based Technologies for Presenting Didactic Material
Clark and Mayer (2012) define E-learning as “instruction delivered on a computer by way of CD-ROM,
Internet, or intranet with the following features:
• Includes content relevant to the learning objective;
• Uses instructional methods such as examples and practice to help learning;
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• Uses media elements such as words and pictures to deliver the content and methods;
• May be instructor-led (synchronous E-learning) or designed for self-paced individual study
(asynchronous E-learning);
• Builds new knowledge and skills linked to individual learning goals or to improved
organizational performance” (p. 8).
E-learning experiences, most frequently managed today through web-based applications rather than
purchased software, offer healthcare educators and preceptors a vehicle to maximize adult learning
by delivering knowledge of standards and culture within an easily accessed format. Web-based tools
provide a platform for training that maximizes the ability for the pace of learning to be individualized
for each participant, which is an attractive feature for the adult learner. The E-learning experience needs
to be interactive and participatory to provide learners/preceptees with relevant knowledge that can be
used for practical purposes. The experience should provide practice with feedback, tailored instruction,
and application of knowledge rather than be a re-creation of the traditional talk-and-test model of
teaching.
Web-based learning can take place in synchronous or asynchronous modes. Synchronous learning refers
to learning that takes place at the same time, usually denoting that the student and instructor are present
together in a face-to-face environment or through videoconferencing technology. Examples of free
videoconferencing tools that allow for synchronous learning to take place include FaceTime, Google
Plus Hangouts, Skype, Zoom, and Talky. Many learning management systems have videoconferencing
applications built into them, such as Collaborate. Last but not least, in order to do business in today’s
global world, most institutions have access to conference calling capabilities such as GoToMeeting,
WebEx Meeting Center, and GoToWebinar.
Choosing a platform for synchronous learning requires that you consider how the platform enhances
the likelihood that the learning objectives can be met. Ease of use for the instructor is generally an
important factor to consider because fostering social presence as done within a classroom setting
is paramount for deep and meaningful learning to take place. The art of creating this type of space
also requires an analysis of the pedagogy to be used—a PowerPoint slide deck for a “talking heads”
lecture presentation will be even more painful in this environment than it is in the classroom. Other
considerations to think about when choosing to teach synchronously using videoconferencing tools are
group size and time zones. Making sure that the tool can accommodate a wide variety of configurations
of these two elements will ensure longevity of use.
Asynchronous learning is not limited by time or location. Asynchronous learning tools are abundant
and generally relate to what type of learning activity is being expected. These tools allow the learner to
proceed at their own pace without having to conform to a specific schedule. When considering the use
of asynchronous learning tools, you must clearly communicate learning objectives and time frames for
completion in order to keep the cohort on track with learning outcomes. It is also important that the
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instructor remains engaged in the process through frequent updates and feedback (both to the general
group and to the individual) to establish social presence and keep engagement high (Mayne & Wu,
2011). Under the framework of precepting, some asynchronous activities might include lecture, expert
demonstrations, and knowledge-based quizzes/exams. Some suggested software solutions for these
outcomes are indicated in Table 8.1.
Table 8.1
Free or Minimal Cost Web-Based Learning Tools
Name of Tool
Application
Synchronous
Asynchronous
FaceTime, Google Plus
Hangouts, Skype, Zoom,
Talky
Lecture, communication,
group discussion
X
X
YouTube, Camtasia, Filmora
Scrn
Lecture, expert practice
demonstration
X
WordPress, Blogger
Promotion of reflective
practice
X
bbPress, Discourse Forum,
FluxBB
Collaboration,
discussion, knowledge
creation, debate
X
Tiki Wiki, MediaWiki,
DokuWiki
Collaboration,
knowledge creation,
shared mental modelnegotiation
X
Quizworks, ClassMarker,
Google Forms + Flubaroo,
Adobe Captivate
Assessment
X
X
Decisions related to which of these modes to employ should be made in conjunction with the
learning objectives and time constraints of the onboarding program. Often, didactic materials (lecture
PowerPoint, videos, and policies/procedures) can be reviewed in advance of a learning event in order
to maximize the “hands on” practice time of skill acquisition and clinical application. This is commonly
called “flipped” learning and is in keeping with the active learning style preferred by millennials. The
role of the instructor or subject matter expert becomes one of facilitator, curator of knowledge, and
negotiator of meaning when using blended learning platforms (Verhaart, 2012).
Several professional organizations have translated specialty orientation and training materials for
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
precepting into an online learning format. Two examples of this are the American Association of
Critical-Care Nurses (AACN) and the American Heart Association (AHA). Generally, an organization
can purchase access, either through an institutional license or cost/per user basis, for access to the
training materials for a period of time.
AACN created the Essentials of Critical Care Orientation (ECCO), which is designed to deliver contextbased didactic material that is relevant to the practice setting (AACN, 2017). The design of the modules
is learner-centered and problem-based, providing core concepts and case studies to develop knowledge.
These modules are set within a community of practice of expert critical-care practitioners to provide
nuanced supplemental feedback important for learning new knowledge within a profession. The goal
in developing the modules was to provide an opportunity to build knowledge that created behavioral
change in the clinical setting. The program is designed to apply newly formed decision-making skills
and improve confidence. These modules are now commonly used to drive onboarding to the criticalcare specialty.
The American Heart Association (AHA) has translated its didactic preparation for Basic Life Support/
Advanced Cardiac Life Support (BLS/ACLS) training into a game-based simulation to provide efficiency
in recertification of these essential clinical skills (AHA, 2017). These E-learning courses provide
clinical scenarios in which learners must administer the correct life support interventions to match the
situation. Feedback loops are customized based on learner responses to provide continuing educational
support when and where the individual learner needs it. Upon completion of the online module, the
learner is deemed to have attained a baseline level of resuscitation skills and can then schedule a “live”
demonstration. The result is an increased level of proficiency in skill demonstration and an efficient use
of time for both the learner and the instructor.
Though web-based learning provides an important adjunct to training, it does not take the place of
clinical learning. If constructed well, E-learning provides a venue for safe practice and acquisition of
baseline skills that translate into core performance behaviors in the clinical setting. Online learning
provides a venue for safe practice and acquisition of core knowledge that can then be developed through
experiential practice with the preceptor in the clinical setting or the simulation lab.
Web-Based Collaboration Tools for Maximizing Informal
Learning
Interaction and learning are not confined to the classroom space. Informal learning through peer-topeer interaction, synthesis, and reflection can comprise a greater share of learners’ time than learning in
formal settings (Oblinger & Oblinger, 2005). Creating spaces and activities to engage in opportunities
for learning is a new concept for healthcare educators and preceptors to consider. The software tools
of wikis, blogs/vlogs, discussion forums, and podcasts provide new systems to deliver, evaluate, and
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create information. The ease of use and wide availability through open-source venues has increased
their use. These tools offer a way to enhance and deepen a clinician’s learning experiences by providing
information sharing, collaboration, and reflection features.
• Wiki—A wiki is a collaborative website where content can be created and edited. It is used
as a source for obtaining and/or creating knowledge through asynchronous participation of
multiple users. It features easy editing, evidence-based referencing, and a venue to construct
knowledge collaboratively. It is used as an asynchronous tool that allows groups to gather for
cognitive reflection and construction of meaning through a self-defined database (Boulos,
Maramba, & Wheeler, 2006). Wikipedia is perhaps the most commonly known wiki site
(www.wikipedia.com).
• Blog/Vlog—A blog functions as an online journal containing information in reverse
chronological order about a particular topic. A blog is usually written by one person sharing a
perspective about an identified topic, but its creation can be shared among a group. Standard
features of blogging software minimally include the ability to post information and pictures
and to provide links to articles/videos. Blogs create a dialogue among dispersed individuals
by inviting commentary and debate over the knowledge and reflections that are shared within
the site. Search features for archived posts and RSS (really simple syndication) feeds are
available to keep the user intimately connected with the author’s views and updates. Vlogs are
mutations of blogs that are created using video modalities.
• Discussion Forum—A discussion forum is a digital “bulletin board” where you can leave
messages and others can reply to your comments. It is also a space where others can review
new ideas and discussions without participating. These forums are frequently utilized as a
type of group collaboration space. There is generally a designated moderator who facilitates
discussion through commentary or Socratic questioning. Additionally, there are rules of
engagement that outline how respectful communication will take place. Forums are generally
utilized in an asynchronous mode but can also inspire commentary in real time.
• Podcast—A podcast is an audio file that can be downloaded to a computer, tablet, or
smartphone to take information “on the go.” The feature of mobility is increasingly attractive
for learning as busy professionals increase their attempts to multi-task to meet the needs of
their hectic and full schedules. Healthcare school curricula readily use this technology to
provide recordings of lectures, audiotapes of sample physical assessment sounds, and patient
education scripts. iTunes University (iTunes U) is an example of this type of interface.
Effectiveness of Web-Based Collaboration Tools
The effectiveness of using web-based collaboration tools as learning venues is dependent upon their
planned and systematic deployment. Social networking tools are best suited for environments in which
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dynamic and collaborative learning takes place. Users must be comfortable with negotiating meaning
within a larger community of practice. Adaptation, flexibility, and consensus—rather than perfection—
are the skills that are practiced within communities of learners using these tools. Learning becomes an
evolutionary experience changed and negotiated by the community of practice of experts and novices.
These tools allow learners to test their understanding of new knowledge from the periphery, starting
out by watching and absorbing the information and transitioning to full participation within the
community. Preceptors provide the expert knowledge within these communities of practice, handing
down their sage advice and experience to shape the ideas and knowledge base of preceptees. Preceptees,
on the other hand, provide new perspectives that in turn can improve the expert practitioner’s practice
(Lave & Wenger, 1991). These are the transitions of practice that can be maximized through the use of
collaborative tools to capture, highlight, and augment learning in the clinical space.
Simulation
Teaching clinical salience requires that preceptors use teaching techniques that provide context so that
preceptees can gain a sense of application to practice that is individualized for patients. Simulation is
a teaching strategy that can be utilized to assist the preceptor with this goal. Simulation can safely recreate the real world—with or without sophisticated technology—to educate, train, assess performance,
probe systems, or conduct research. Participation in simulated learning experiences helps preceptees
apply their knowledge, skills, and attitudes within realistic situations while allowing the preceptor to
assess the development of the preceptee’s ability to analyze and prioritize patient care. The simulated
learning experience is a controlled environment that doesn’t negatively impact patient safety and allows
“visualization” of preceptee thought processes and decision-making gaps that cannot always be allowed
in the patient care setting.
While simulation has been used in healthcare, the military, and aviation for many years, modernday simulation has morphed into a structured pedagogy of teaching with specific parameters and
techniques attributed to the practice. The NLN-Jeffries Simulation Theory provides the foundation for
simulation education practice, outlining the key “must haves” influencing simulation practice (Jeffries,
2016). The International Nursing Association for Clinical Simulation and Learning (INACSL) has
created Standards of Best Practice: Simulation, which define the core processes necessary to advance the
science of simulation practice. These include, but are not limited to, simulation design, outcomes and
objectives, facilitation, debriefing, participant evaluation, and professional integrity (INACSL, 2016).
The Society for Simulation in Healthcare (SSH) has developed criteria for Simulation Educator and Sim
Ops Certification, Simulation Center Accreditation, and a Healthcare Simulation Dictionary (Lopreiato
et al., 2016) to standardize and promote best practices in simulation education. Simulation education
today has a robust evidence-based practice that has been documented to refine critical thinking,
improve situation awareness, promote collaborative practice, and improve clinical skills.
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The Pursuit of Fidelity
Fidelity of simulation can refer to the degree to which the simulation replicates the real event or the
ability to reproduce the reactions, interactions, and responses of the real-world counterpart (Lopreiato
et al., 2016). Fidelity of simulation is measured in two general categories: environmental/physical, and,
psychological (see Table 8.2):
• In healthcare education and training, environmental fidelity refers to how closely the setting,
equipment, sounds, smells, and environmental props where simulation takes place mimic the
real clinical care setting, be it a home environment, clinic, hospital emergency department,
operating room, or intensive care unit (ICU). This includes the type of equipment that is
utilized.
• Psychological fidelity refers to the ability of the scenario and setting to create a sense of
realism that allows learners to engage with their emotions and values during a simulation
(Dieckmann, Gaba, & Rall, 2007).
Table 8.2
Comparing Simulation Fidelity
Type of Simulation
Environmental
Fidelity
Psychological Fidelity
Case studies/role-plays
Low
Low to medium
Partial-task trainers
Low to medium
Medium to high
Manikin-based integrated simulators
utilizing scenario-based learning
Medium to high
High
Immersive/alternative reality
Medium to high
High
Doyle, 2011. Used with permission.
The various forms of simulation can be viewed as a continuum with regard to fidelity, with partial and
complex task trainers as the lowest and integrated simulators the highest (Nehring, 2010):
• Role-play
• Partial task trainers
• Games
• Standardized patients
• Virtual reality and haptic-based systems
• Integrated simulators: low- through high-fidelity simulators that are instructor-driven, and/or
model-driven
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Role-play—Role-play has been used in nursing education for many years, especially for developing
therapeutic communication skills. Learners are traditionally grouped in dyads or triads to practice and
observe case-based scenarios where difficulty in communication might occur. Creating the opportunity
to “say” what is inside one’s head does not always result in the interaction proceeding as one might
imagine. Role-play demonstrations provide participants and observers with “practice” time under
minimal pressure because they are usually done without the context of performing clinical duties.
Constructive feedback from peers and expert practitioners is provided in a timely and specific manner
to facilitate learning.
Partial task trainers—Partial task trainers are models that simulate a subset of physiologic function and
might incorporate both normal and abnormal anatomy. Examples of partial task trainers include such
current-day simulators as IV arms or urinary catheterization models. Oftentimes these task trainers are
incorporated into immersive simulation education events in a hybrid fashion to provide a more realistic
experience and allow teaching of technical skills in a more integrated fashion.
Games—Games might range from something as simple as a crossword puzzle of medical terms to
virtual worlds that simulate a highly sophisticated care environment, such as an emergency department.
Gaming-type simulation has been seen to improve the psychomotor skills of surgeons, as well as
improve the function of patients during rehabilitation (Bonnechere, Jansen, Omelina, & Van Sint Jan,
2016; Lynch, Aughwane, & Hammond, 2010).
Standardized patients—Standardized patients (SPs) involve the use of individuals “who have been
carefully coached to portray a patient with specific condition in a realistic, standardized, and repeatable
way and where portrayal/presentation varies based only on learner performance” (Lopreiato et al.,
2016, p. 36). Standardized patients are often used for teaching assessment, physical examination, history
taking, and other clinical skills. The value of this simulation modality is that standardized patients are
often utilized to provide feedback and evaluate learner performance (Lewis et al., 2017).
Virtual reality and haptic-based systems—Virtual reality simulation uses computers to replicate actual
procedures, such as surgery or insertion of an IV. In today’s healthcare environment, these virtual reality
systems are often constructed as task trainers for specific procedures such as surgical, ultrasound, or
obstetrical training. These immersive learning systems promote the acquisition of technical skills by
providing equipment and psychological fidelity along with evaluative feedback.
Integrated simulators—Integrated simulators are low- through high-fidelity simulators, instructordriven, and model-driven (Nehring, 2010). Integrated simulators can also include emerging
technologies (such as handheld devices) into simulations (Jeffries, Bauman, & Schaefer, 2014).
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High-Fidelity Patient Simulation
High-fidelity patient simulation (HFPS; see Figure 8.1) has been used in the last 10–20 years in schools
of medicine, schools of nursing, emergency medical technician training, and training for military
healthcare personnel. HFPS is increasingly being used in hospitals to assess, develop, and ensure
competence and confidence; for quality improvement activities; and to test system and policy issues.
FIGURE 8.1 Example of a High-Fidelity Patient Simulator
Developing Clinical Competence and Confidence
Numerous reasons for adopting HFPS exist, many a direct result of a fast-paced, ever-changing
healthcare delivery system. A primary driver for using HFPS to train caregivers, however, is the
modality’s effectiveness in providing an environment centered around learners that enables learners
to learn and practice the skills and clinical reasoning necessary for safe and effective patient care.
Deliberate practice within HFPS is key to developing clinical competence by having the opportunity to
make, detect, and correct patient care errors in a safe, controlled environment without harming patients
(McGaghie, Issenberg, Petrusa, & Scalese, 2006).
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The ability to augment learning that cannot take place in the “real” clinical environment allows
educators to standardize the learning trajectory of all learners. Preceptors can observe pertinent practice
skills such as assessment, hand-washing, and patient safety checks during simulation that perhaps they
were unable to devote attention to because of the competing demands of the clinical environment.
HFPS creates the ability to build expertise over time in a deliberate way by engaging with routine types
of patient care that allow all learners to demonstrate mastery. In the same vein, low-volume, high-risk
patient care policies can be re-enacted within the simulation setting to solidify the core competencies
needed to complete the dreaded skills checklist for onboarding. HFPS creates opportunities for the
learner, freed from the inhibiting fear of harming a patient, to practice decision-making along with skill
acquisition through repetitive practice. Additional information on competence and confidence can be
found in Chapter 4.
Facilitating Clinical Judgment
Tanner (2006) defines clinical judgment as “the interpretation or conclusion about a patient’s needs,
concerns, or health problems, and/or the decision to take action (or not), use or modify standard
approaches, or improvise new ones as deemed appropriate by the patient’s response” (p. 204). HFPS
provides an enriched setting where decision-making is required within a complex and ambiguous
system. The ability to understand the salient aspects of the situation and respond appropriately in an
individualized manner is a skill that is honed through practice and experience. Expertise is developed
by having multiple exposures to diverse cases. This experiential knowledge that nurses carry with them
influences their current ability to make decisions (Tanner, 2006). HFPS provides an opportunity to
standardize the experiential exposure for all participants in an effort to build their knowledge base. It
creates an environment where nurses can conduct deliberate practice on low-volume, problem-prone
patient cases to improve decision-making in areas that would normally take years to attain. Additional
information on clinical judgment is available in Chapter 4.
Using HFPS to Develop Situation Awareness and Clinical Reasoning
The ever-changing dynamics of the practice setting mandate that healthcare practitioners develop a
new skill set of flexibility to adapt to the risk, uncertainty, and pace of patient care. Deficiencies in the
ability to make effective or efficient use of information for clinical decision-making can negatively
impact nurses’ ability to maintain safe patient care. The ongoing surveillance of care is perhaps the
most important role that the nurse plays in maintaining patient safety. Preparing nurses to excel in this
assessment ability is the essence of situation awareness.
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Endsley (1997) defines situation awareness as “being aware of what is happening around you and
understanding what that information means to you now and in the future” (p. 13). Situation awareness
is heavily influenced by goals and is context-specific: changing as the environment changes. Assessment
data are collected and continuously prioritized based on the nurse’s understanding of the current goals.
This prioritization can be negatively impacted by factors such as stress, workload, complexity, and
automation. Assessment data and analysis of those data form the basis for a clinician’s ability to make
decisions.
Clinical reasoning is a term that refers to the nurse’s ability to capture patient trends as a situation
changes and take into account the specific patient needs and concerns when formulating a response or
action plan for intervention (Benner, Sutphen, Leonard, & Day, 2010). Reasoning is usually developed
over years of experience, cultivated by unique patient care experiences rather than didactic learning.
HFPS can create specific patient care experiences that learners might never be able to experience,
such as blood transfusion reaction, and allow for development of reasoning based on a patient care
experience.
HFPS allows case-based learning under “real-life” pressures of time, consequence, and prioritization.
This type of learning supports the improvement of a practitioner’s ability to perceive and comprehend
data with the fidelity of time and high-stakes consequences. HFPS creates opportunities to understand
what augments decision-making and what interferes with the ability to make decisions. It is this
understanding that allows learners to create patterns of “knowing” or mental models of patient care that
will improve the speed of decision-making in the future.
The hierarchy of learning pyramid developed by CAE Healthcare captures the richness of the simulation
learning experience that a new practitioner undergoes throughout the precepted experience (see Figure
8.2). Simulation in particular gives learners the ability to practice knowledge application within the
context of collaboration and teamwork of patient care. The briefing and debriefing events of a simulated
clinical experience add the richness of expert mentoring to assist with time management, prioritization,
and problem-solving skills. Patient care safety is enhanced throughout the learners’ experiences as they
fluidly transition between the levels to reinforce their knowledge or sharpen clinical skills. Additional
information on situational awareness and clinical reasoning is available in Chapter 4.
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Competent
Practice
Solo with required
competencies
Live Coaching/Mentoring
Assistance with time management
prioritization and critical thinking skills
Simulated Clinical Experiences
Application of knowledge, collaboration and teamwork.
Blended Learning: Didactic Content/e-learning
Establishes foundation of patient care knowledge
Hierarchy of Learning=Safe Patient Care Delivery
May return to lower levels, as needed, to reinforce knowledge foundation or to sharpen skills
FIGURE 8.2 Hierarchy of Learning Pyramid
Source: CAE Healthcare, copyright 2010
Design of High-Fidelity Patient Simulation Experiences
Creating an optimal HFPS learning experience involves goal-oriented learning supported by strong
pedagogical principles (Jeffries, 2016). In other words, preceptors and instructors need to know how
they are going to conduct the simulation, i.e., what techniques they will use to assist the learning and
what they expect to attain as an outcome of their teaching. The Jeffries model supports that the HFPS
experience should pay particular attention to the maintenance of fidelity while scaffolding learning
opportunities through a multi-phased approach that minimally includes debriefing (Jeffries, 2016).
The design of the HFPS creates an overlapping richness to the experience, allowing learners to develop
their own individual understanding, formulate team goals, and end with reflection on action to create
improvements for future patient care. INACSL (2016) further specifies that simulation design should
include a contextual clinical case to ground the learning objectives, a facilitative approach by a subject
matter expert that is participant-centered. Conduct a pilot test prior to implementing with learners to
ensure that the simulation event meets the identified learning outcomes (INACSL, 2016).
An HFPS learning event has three key components: foundational knowledge assurance/briefing, HFPS
practice, and debriefing/reflection/feedback session (INACSL, 2016). Each phase provides the learner
with unique experiences for knowledge construction, skill practice, and reflection on action.
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Foundational Knowledge Assurance/Briefing
Nursing learning is not a linear application of theory to practice. It is a complex process that requires
individualization and modification of knowledge to meet specific clinical situations and to respond to
the specific context (Benner, 1984, 1991; Kim, 1999). Individualized care must be balanced with routine
tasks in a delicately prioritized manner to maintain patient safety. With HFPS, educators can duplicate
this environment for the purpose of creating learning opportunities that enrich the decision-making
capacity of the participants.
The briefing stage of simulation practice allows participants to actively create a plan for the
individualized care of the patient. Minimally, the environment, roles, goals, and social interactions
necessary for a successful nurse-patient interaction should be reviewed and defined during this phase.
Prebriefing has been used extensively in aviation practice to mediate the potential for deterioration
of situation awareness in situations involving high cognitive demands, ambiguity, and time pressure
(Orasanu & Fischer, 1997). The facilitator guides the process, providing expertise in the form of rich
description of theory and experience to highlight the pertinent aspects of clinical practice related to
standards and culture. The amount and duration of this guidance are dependent upon the practice
level of the participant (i.e., novice, advanced beginner, expert). It can involve the introduction and/
or reinforcement of standards of practice, policies, and procedures that are augmented by the HFPS
scenario.
Briefing provides learners an opportunity to defend and explain their understanding of care priorities as
part of a larger group and helps them move beyond memorized facts toward an evolving understanding
of care that is inclusive and collaborative. Briefing provides the team with the opportunity to formulate
specific, consensus-driven goals. The collaborative understanding or shared mental model that is
developed during this stage provides the basis for competent action during the HFPS practice.
Briefing is also an opportunity for the facilitator to set the “safe container” and create an environment
where learners can be vulnerable and open to new ideas for practice (Rudolph, Raemer, & Simon,
2014). The facilitator sets the stage through his/her language and deeds. Establishing a learning contract
that clarifies expectations during the simulation is paramount to a safe practice that maintains the
psychological safety of the participants. The learner must be able to engage without fear during the
simulation in order to promote deep reflection for learning or exploration of mistakes.
HFPS Simulation Practice
Jeffries & Rizzolo (2006) found that learning using HFPS promotes a heightened sense of reality,
provides opportunity for problem-solving, and allows for active and diverse ways of learning. The results
of their study also showed that the outcomes of learner satisfaction and self-confidence are rated higher
when HFPS is used to conduct clinical training.
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Simulation provides learners with an opportunity to apply a collaborative plan along with their
individual knowledge in a dynamically changing environment. The simulator’s responses are subject
to the learner’s interventions, and the interventions are dependent upon the patient’s response within
the environment. It is this reciprocal relationship and evolving awareness that creates the opportunity
to practice clinical reasoning during the HFPS practice. This type of learning not only develops
individuals, but can also help develop corporate culture and team culture.
Debriefing/Reflective Practice
Nursing as a profession requires practitioners to continually use their experiences to improve their
skills. Reflective practice is one of the tools used by the nursing profession to promote a continual focus
on lifelong learning (Kim, 1999; Ruth-Sahd, 2003). Rudolph and colleagues suggest that debriefing
should promote participant self-assessment along with critical thinking and analysis (Rudolph, Simon,
Raemer, & Eppich, 2008). The debriefing process should focus on relating simulation performance to
gaps in standards of care by understanding the frames and emotions that contributed to those gaps
rather than deeming an individual participant’s performance as right or wrong (Rudolph et al., 2008).
These studies support the importance of a debriefing process post simulation performance.
The design of the debriefing process is essential to the development of important situation awareness
and reflection-on-action skills. Reflection includes three key steps: (1) self-awareness; (2) critical
analysis of action, knowledge, and feelings; and (3) development of a new perspective resulting in a
behavior change (Atkins & Murphy, 1993; Ruth-Sahd, 2003). Kim (1999) describes the reflection process
as critical reflective inquiry and notes three ultimate goals: (1) to understand practice in the context of a
practitioner, (2) to correct and improve practice, and (3) to generate models of “good” practice.
Debriefing should highlight the specific cues, patterns, inferences, and information that were required
to make clinical decisions during the HFPS practice. Understanding how to deconstruct complex
tasks into basic elements is difficult for both novices and experts, but for different reasons. Novices
have difficulty because their experiential base is limited and might not allow them to understand the
subtlety of the evolving clinical situation (Benner, 1984). Experts, on the other hand, have difficulty
with deconstruction because their intuition-based practice has embedded the fine details deeply within
their long-term memory, creating an instantaneous pattern recognition that evokes action without
thinking. Debriefing that includes reviewing the simulation performance for gaps provides for a richer
opportunity to highlight decision-making in terms of cues, patterns, and inferences that are part of
developing situation awareness. The focus should be on understanding the rationale for action rather
than focusing on “right or wrong” actions. The debriefing phase also provides deliberate practice of
reflection-on-action skills and team communication skills. Both are essential to the delivery of safe
patient care within a complex, team-oriented system.
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Implications of Using High-Fidelity Patient Simulation for Preceptors, Educators,
and Managers
Using high-fidelity patient simulation has many implications for preceptors, educators, and managers.
Preceptors
Traditional nursing learning utilizes an apprenticeship model characterized by a novice becoming
acculturated to the community of practice with the guidance of an experienced expert (Benner, 1984;
Lave & Wenger, 1991). This results in a progressive engagement with the clinical practice that allows
the novice to move from “lurking and observing” around the periphery to becoming an active member
of the community (Lave & Wenger, 1991). During this transition, learners transform their identities
through the practice of nursing and gain knowledge and expertise by having experiences with the
context, tools, and social practices they have encountered (Benner, 1984; Lave & Wenger, 1991). The
learning is part of the richness of practice and is developed and changed by the interaction itself.
Expertise traditionally takes place over years as learners gain experience based on naturally occurring
interactions with patients, disease processes, and situations within the hospital environment. HFPS
provides standardized learning opportunities that can shorten the learning curve and standardize the
learning outcomes of healthcare workers.
Ethics—Because learning in nursing is a socially embedded and shaped practice, it follows that the
knowledge, skills, and tools used are vetted by the professional culture and specialty-specific subcultures
within the practice (Benner, 2000; Benner, Tanner, & Chesla, 1997; Kim, 1999). The preceptor plays a
key role in the socialization of preceptees with respect to ethics and knowledge development as they
transition from a new graduate RN (NGRN) role into professional practice or into specialty practice as
an experienced nurse. “Common meanings” of what is “good” and “right” come from this social culture
and become part of the nurse’s guiding value system that influences clinical decision-making (Benner,
2000; Benner et al., 1997; Kim, 1999).
Caring and clinical knowledge are embedded in the pooled expertise and power of multiple perspectives
modeled by preceptors. The active modeling process contributes to the shared vision of excellence and
strengthens the relationships to establish trust and a sense of possibility between the learner and his/her
preceptor (Benner, 2000). Preceptors create inclusion through their transformational stories of excellent
patient care and thus promote the cultural norms and values during these interactions.
HFPS creates an opportunity in which ethical decision-making can be practiced and explored within
a safe environment. The choice of simulated learning experiences can augment moral development
by providing realistic portrayals of end-of-life conflicts, pain management dilemmas, and crisis
management instances. The preceptor needs to match the clinical learning experiences with those that
are taking place during HFPS to create a realism that helps transition the learning out of the simulation
and to the bedside. Exemplars and storytelling are common ways that preceptors help their preceptees
make the connections between classroom learning and clinical practice. These stories not only solidify
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that the simulated learning experiences could “really happen,” but they also pass along the cultural and
ethical norms of the preceptor’s practice and that of the nursing unit.
Creating and maintaining a culture of patient safety require diligence for continual improvement. HFPS
used during onboarding and competency development can often identify system deficits that require
attention. To improve clinical practice, preceptors need to create dialogue around the gaps that are
discovered. Preceptees have the opportunity to reshape cultural practice and should be encouraged
to discuss their observations regarding gaps among policy, procedure, and clinical practice. This type
of inquiry can be challenging to the preceptor but should be viewed as an opportunity to improve
practice. Preceptors should take these opportunities to coach to enhance understanding for situations
that might necessitate deviation from the norms. By taking time to point out a patient’s unique history
or by highlighting the ambiguity within a specific patient care situation, preceptors can augment the
development of situation awareness outside of the simulation lab.
Knowledge development—Novice practitioners have deficiencies in their ability to make effective or
efficient use of available information, to estimate risk and uncertainty, and to select a course of action
(del Bueno, 2005). As they gain expertise, nurses change the way they think and apply skills in three
distinctive ways: (1) reliance on concrete, experience-based paradigms instead of abstract principles; (2)
ability to view the event holistically, instead of as distinct, concrete parts; and (3) movement into care as
an active practitioner instead of a detached observer (Benner, 1984). Experts spend the majority of their
decision-making time in the assessment and classification of a situation rather than performing lengthy
analysis of potential courses of action (Endsley, Bolte, & Jones, 2003). Working off their “gut reaction” or
“intuition,” experts can adapt quickly to the environment and/or a patient-specific situation.
A common frustration of preceptees is that the preceptor doesn’t explain his or her decision-making
process. The debriefing phase of HFPS focuses on teaching learners how to deconstruct their clinical
performance to understand the cues, patterns, and decisions that were used to take action. Making
connections between assessment data and the rationale for decision-making is an important step toward
formulating the mental models of experts. Preceptors need to continue this practice of deconstruction in
the clinical setting. Verbalization protocols, or “talk out loud” procedures, can help learners understand
the subtle cues, patterns, and priorities that the preceptor is attending to prior to making decisions. This
level of knowledge detail is essential to the development of clinical expertise over time.
Educators
The influence of facilitators/educators on the simulation learning experience is paramount. As expert
practitioners, they facilitate learning during the briefing and debriefing phases to encourage active
participation by all members, using their expertise to gently guide the learning process. It is important
that there is a process to gather evaluative feedback from the learners about the learning event AND the
facilitator. Evaluation feedback is an important part of the quality improvement process and should be
reviewed individually for educator improvement and in the aggregate for overall program improvement
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(INACSL, 2016). An informal evaluative process is for educators to meet weekly to discuss the outcome
of the simulation events. This is particularly helpful if simulations are being conducted by more than
one facilitator. Creating time for educators to collaborate about their own practice improves the overall
learning experience for all.
Educators and preceptors may need to have major discussions about key learning outcomes for
preceptees based on simulation performance evaluations. Preceptor collaboration with educators to
improve and individualize the preceptee’s developmental plan is an important outcome of simulation
learning activities. This developmental growth may begin in the simulation lab with the educator but is
continued in the clinical bedside apprenticeship with the preceptor, or vice versa.
Fidelity—The importance of fidelity has been discussed in detail as an essential component of HFPS
learning. The fidelity must represent believable and recognizable occurrences so that participants can be
expected to react as they would in the real environment (INACSL, 2016). Environmental and equipment
fidelity are usually easily identified and accomplished. After each simulation, educators need to reflect
on what could be done to make the experience more realistic. The equipment and supplies used at the
bedside must be continually updated in the simulation setting to maintain the realism necessary to allow
for clinical immersion for the participants. Psychological fidelity develops over time as the educator
develops expertise with the tool of HFPS. Educators’ personal clinical experiences come into play here
by providing subtle nuances to the responses of the patient or creating family dynamics that are not in
the original scripting of the scenario. These embellishments usually do not occur until educators are
comfortable in the role of facilitator and with the mechanics of running or working with the simulator.
Time and practice using HFPS create comfort and expertise; the important piece is starting somewhere
and having a continuous improvement focus.
Facilitation—If one of the goals of HFPS is to create learners who can “think on their feet” and make
decisions under time pressure, then the role of the facilitator is to create an environment that promotes
construction of knowledge and a propensity toward action. Facilitation requires a focus on providing
timely and specific feedback, encouraging reflective practice, and using a Socratic process to allow for
learner construction of knowledge. This is very different from creating a lecture that highlights all the
pertinent information that learners need to know about the care of a specific type of patient. Educators
need to have a clear understanding of the global goals of the HFPS practice and keep the focus of the
learning experience on attainment of those goals.
Facilitation takes place in all three stages of the HFPS practice. The key is to remember to be learnercentered. This means that educators create opportunities for learners to explore and construct their
knowledge. During the briefing and debriefing phases, these efforts are focused on drawing out the
individual knowledge of each learner while facilitating the distributed knowledge and consensus
building of the group toward shared goals and/or shared understandings. During the simulation
performance phase, it means letting the team care for the patient with minimal intervention from the
expert teacher. This observation piece is often the hardest for educators to do. HFPS is not about doing
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things perfectly, and it is more than just performing tasks according to procedure. HFPS learning is
messy and often goes in a direction that is not expected or intended because it is based on the learners’
choices—perhaps what educators fear most. Educators need to understand that their role as observers
is to guide the learning toward the global goals while being able to capture some of the unique learning
experiences from each group.
Lastly, facilitation is about maintaining the safety of the learning event. If HFPS is going to work as a
medium for learning, then failure has to be allowed and accepted as an opportunity for growth. The
facilitator creates the environment that supports risk taking and exploration for improvement. This
should minimally involve contracting for confidentiality prior to engaging in HFPS teaching.
Adaptation—Too often in healthcare, the end goal of training is seen as a static set of core
competencies. The tool of HFPS suggests that there should be a re-evaluation of that thought process
to look at the ability to maintain a flexible and adaptive approach to learning as the end objective of
teaching. Minimally, healthcare settings should begin to add adaptation as a desired core competency.
This would require that preceptors, facilitators, and educators adopt the same practice of adaptation
within teaching practice to support and role model these important behaviors. HFPS provides
participants with an ability to see how multiple interventions (based on sound theoretical knowledge)
can result in the same outcome. It is this expertise that is so necessary for today’s practice environment.
Managers
Creating and maintaining a process for educating preceptees is a core responsibility of managers.
Onboarding and competency training with HFPS is a resource-intense process. It depends upon having
structured time to conduct simulation activities that are valued in the same way that clinical experience
time is. It also requires a commitment to stable preceptor resources. Using preceptors who understand
what core competencies are being highlighted within the HFPS experiences helps create a transfer of
learning between the simulation setting and into the clinical setting. Managers who understand the
importance of creating schedules that maintain the integrity of the preceptor assignment create better
learning experiences for preceptees.
Quality Improvement in Precepting
Every hospital has a process for evaluation of preceptees. Minimally, it is conducted through informal
discussions among educators, preceptors, and managers. Decisions are made about length of onboarding
and competency development and readiness to perform job duties based on the answers obtained from
these conversations. Retrospective reviews are often conducted after training has occurred with the goal
of process improvement for the operational structure of orientation.
Using HFPS as a core methodology for onboarding and ongoing competency validation allows for a
more formalized approach to the performance evaluation of the preceptee. Collection of concurrent
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data about readiness to perform, self-confidence levels, and actual clinical performance provides a more
objective assessment of the preceptee’s performance. This approach involves a 360-degree review of the
preceptee from the educator, preceptor, manager, and learner viewpoints.
This type of evaluation data allows the preceptor, manager, and/or educator to intervene in an ongoing
manner to create individualized developmental planning for preceptees who aren’t meeting standards.
Concurrent data can also be used to customize the length of time required based on concrete data
rather than anecdotal discussions. HFPS provides learning experiences throughout the onboarding
and competency development training to place preceptees under time and high-stakes pressure that
might not happen on the unit. This type of experience demonstrates the decision-making capacity
of preceptees and creates a richer evaluation of their adaptation and readiness to perform the role of
bedside nurse.
Future of Instructional Technology/Future Implications of
Instructional Technology Use
Technology promises to play an even larger part in the ongoing education of nurses in the future than
it does today. The “participatory” nature of our profession’s newest participants, coupled with the
expansion of social networking technology, promises to present numerous challenges as we engage in
the practice of using the technology. It will be important as a profession for nursing to provide ethical
mentorship of the process. Knowledge building and knowledge sharing are two arenas that will be
affected most by technology in the near future.
Knowledge sharing for future healthcare workers becomes an ongoing and just-in-time process. Using
technology to create learning management systems needs to become the norm. Policies and procedures
will become living documents in these learning management systems in a way that healthcare providers
have always imagined but never had the tools to create. These learning management system platforms
will become spaces where cross-professional groups can come together (in formal and informal teams)
to complete tasks and refine processes. Our new generation of healthcare workers will guide us through
this transformation and begin to create a responsive healthcare system that can proactively meet the
needs of our patients. Evidence-based practice that is evolving can be posted, discussed, and piloted in
real time using these tools. Many global businesses of today have already begun this transition. It makes
sense that healthcare will follow. Preceptors will be on the forefront of this transformation.
Another avenue of knowledge sharing that is worth noting is the ability to access knowledge seamlessly.
The advent of “smartphones” as the main mobile technology platform creates an opportunity for
healthcare personnel to have the latest evidence-based practice tools at their fingertips. Applications or
“apps” enable users to create a personalized palette of tools to enhance care of the patient (e.g., Spanish
translation tools and medication calculators). Healthcare workplaces and personnel will grapple with
access and privacy issues as this seamless knowledge becomes more mainstream in the future.
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Because creative expression, circulation of information, and social affiliation are such prominent parts
of the net generation’s daily lives, preceptors need to provide these new professionals with ethical
mentorship regarding use of patient care information. Tweets, texts, blogs, and Facebook postings
of daily activities are normal for the net generation and present a potential danger for patient and
hospital privacy. Preceptors play a strong role in shaping the practice in this area. Preceptors need to
understand and help define these emerging practices in terms of the ethical implications that evolve.
Posting information, as benign as it might seem, creates an area that needs to be monitored, discussed,
and reified within the profession. To guide behavior in these affiliation spaces, preceptors and preceptees
must have an ongoing conversation that identifies and solidifies patient advocacy and patient privacy.
Conclusion
Clearly, technology is here to stay. The tools discussed in this chapter highlight only a portion of those
that are available in today’s world. Preceptors, educators, managers, and learners need to continue to
have dialogue regarding how to use technology to facilitate the exchange of information and knowledge
between preceptors and preceptees, as well as between diverse communities of learners. The challenge
will be to understand and maximize the use of new tools that fit within the culture of healthcare for
the benefit of our patients. Preceptors are and will increasingly be at the cutting edge of technology,
learning, and patient care.
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Preceptor Development Plan: Effectively Using Instructional Technologies
Review the information on effectively using instructional technologies described in this chapter.
What are your strengths? In which areas do you need to increase your knowledge and expertise?
What is your plan for expanding your knowledge and expertise? What resources are available?
Who can help you?
Name:
Date:
Technology Across Generations
Strengths
Needs
Plan
Resources
Web-Based Technologies for Presenting Didactic Materials
Strengths
Needs
Plan
Resources
Plan
Resources
Web-Based Collaboration Tools
Strengths
Needs
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Simulation—General
Strengths
Needs
Plan
Resources
Plan
Resources
Simulation—High-Fidelity Patient Simulation
Strengths
Needs
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
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195
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“Teaching is the highest form of understanding.”
–Aristotle
9
Precepting Specific
Learner Populations
–Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
Preceptors work with a number of specific learner populations, each of which
has different experiences, knowledge, and needs. This chapter discusses those
populations: prelicensure student nurses on their clinical rotations; new graduate
registered nurses (NGRNs); post-baccalaureate graduate students; experienced
nurses (changing specialties, returning to practice, learning new roles);
internationally educated nurses; and nurses from different generations.
Prelicensure Student Nurses
Schools can only teach so much information in didactic classes, skills laboratories,
and simulation centers. At some point, the student nurse must experience caring
for live patients in healthcare organizations. To accomplish that, schools of
nursing enter into agreements with hospitals and other healthcare agencies to
provide clinical rotations for their students. In most cases, the student rotations
are coordinated by a designated person in the nursing department to ensure that
the number of students and student rotations do not exceed the capacity of the
healthcare organization.
It takes a lot of patience and time to precept student nurses (especially prelicensure
students early in their education), and the role should not be accepted without a lot
of thought. I once moderated a panel of nursing faculty, hospital educators and staff,
and student representatives in a discussion about clinical rotations. One student
was very quiet through most of the discussion, and I asked her what her thoughts
were. She said, “My friends and I just don’t understand why we can’t be assigned to
nurses who like to work with students.” The room went dead silent—such a simple
request with such big implications. The student went on to describe a recent clinical
experience during which, after she got a report on the patient she was to care for,
the nurse she was assigned to did not speak to her the rest of the time she was
OBJECTIVES
•
Understand the needs
of specific learner
populations
•
Individualize precepting
based on the needs
of specific learner
populations
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there—certainly not the way we want to bring young nurses into our profession. The student was right—
the first criteria for precepting students should be that the preceptor enjoys that role.
The school of nursing, the healthcare organization, the faculty member, the preceptor, and the student
all have responsibilities in a student clinical rotation that should be delineated in written format and
shared with all stakeholders. An example of these responsibilities is provided in Table 9.1.
The school should also provide a preceptor orientation, details of the specific clinical experience (when,
what is to be accomplished, etc.), details of the students to be precepted, applicable school policies and
procedures, contact information for the faculty, and evaluation forms for the preceptor to evaluate the
student and vice versa, as well as for the evaluation of the preceptorship experience in general. The
healthcare agency (hospital, etc.) should have written policies and procedures about nursing student
clinical rotations that include any requirements for doing a preceptorship/clinical rotation at the agency
(e.g., background check, immunizations) and any limitations on what students can do during their
rotations. For example, in a national study on elements of nursing education, the National Council
of State Boards of Nursing (NCSBN) found that in 44% of the rotations, students were not allowed to
call physicians and in 15%, students did not have the opportunity to supervise the provision of care by
others (NCSBN, 2006).
Both the school and the agency must ensure that they meet the standards set by professional and
accrediting bodies such as the NCSBN (2012) and the Commission on Collegiate Nursing Education
(CCNE, 2013). It is also important to be knowledgeable about any state Board of Nursing (BON) rules
and regulations for the state in which you practice. A review of BON rules and regulations on the
use of staff nurses as preceptors found variation and inconsistency across the 50 states, the District of
Columbia, and the U.S. territories (L’Ecuyer, von der Lancken, Malloy, Meyer, & Hyde, 2018). As an
example, in Texas, the BON rules say that
After a student has received clinical and didactic instruction in basic areas of
nursing or instruction specific to a particular course, clinical preceptors may be
used in a one-on-one relationship with a staff nurse to enhance clinical learning
experiences…The preceptor may supervise student clinical learning experiences
without the physical presence of the faculty member in the affiliating agency or
in the clinical practice setting. However, nursing faculty shall be readily available
to students and clinical preceptors during the clinical learning experiences.
(Texas BON, 2013, para 5)
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Table 9.1 Sample Guidelines for Preceptor Experience for Prelicensure Nursing
Students—Cizik School of Nursing at The University of Texas Health
Science Center at Houston
UNDERGRADUTE FACULTY RESPONSIBILITIES
Prior to the initiation of clinical preceptorship, the faculty will:
• ENSURE that a current contract/affiliation agreement exists between the clinical agency and the
School of Nursing.
• REQUEST clinical placements for students prior to established deadlines.
• WORK with agency coordinator to ensure that sufficient qualified preceptors are available for
students.
• INFORM clinical agency of names of the students and supervising instructors, including instructor’s
contact information.
• POST the course syllabi and learning objectives.
• ORIENT the students to electronic submission of the clinical preceptor/student schedule.
• ENSURE student compliance with standards on immunization, screening, OSHA, HIPPA, CPR, and
current liability insurance.
• ORIENT the preceptor to the program (to include clinical objectives, student expectations, and
methods of student and preceptor evaluation for research purposes).
During the clinical preceptorship, the faculty will:
• PROVIDE regular on-site clinical visits (at least 1 visit per month per preceptor).
• BE AVAILABLE via telephone, pager, or email for consultation as requested by the student, preceptor,
or clinical agency.
• CONDUCT regular post conferences with students.
• WORK COOPERATIVELY with the preceptor and the agency to determine student learning needs and
appropriate assignments.
• EVALUATE the student’s performance in the clinical setting with feedback from the preceptor
regarding student performance, using appropriate agency and project forms.
Upon completion of clinical preceptorship, the faculty will:
• PROVIDE RECOGNITION to individual preceptors who provided clinical experiences for the student(s)
that semester.
• PROVIDE GENERAL FEEDBACK to the agency regarding student progression issues.
continues
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Table 9.1 Sample Guidelines for Preceptor Experience for Prelicensure Nursing
Students (cont.)
AGENCY RESPONSIBILITIES
The clinical agency (hospital or clinic) administrative/educational/personnel responsibility is to:
• RECRUIT and recommend preceptors.
• PROVIDE policies, procedures, and/or practice protocols specific to the setting and role.
• ENSURE adequate resources for educational instruction, online access, and equipment security.
• ALLOW student nurses to perform the activities appropriate to their clinical roles, under the
supervision of their assigned preceptor.
PRECEPTOR ROLES AND RESPONSIBILITIES
Preceptors serve as clinical instructors for students. RNs volunteering to serve as clinical preceptors are
expected to possess certain qualifications. These are as follows:
Preceptor Qualifications
• Current RN licensure
• A minimum of 1 year’s RN practice
• BLS certification or successful completion on hospital’s validation/competency testing
• A supervisor recommendation
Preceptor General Responsibilities
To be a preceptor, RNs agree to the following:
• SUPERVISE one student at a time per clinical rotation, and up to two students per semester.
• ASSIST student with time management and patient care.
• CONTRIBUTE to the evaluation of the student’s clinical skills.
• COMMUNICATE difficulties and student issues with school’s instructor.
• DEMONSTRATE a philosophy of healthcare congruent with that of participating school.
• ROLE MODEL humanistic, holistic nursing care practice; critical-thinking behaviors; and use of
evidence-based nursing practice.
Preceptor Responsibilities to Student
To prepare students for their clinical experience, the preceptor is to:
• COMMUNICATE specific guidelines to be used in preceptor/student interactions.
• REVIEW policies, procedures, and practice management protocols specific to the setting.
• REVIEW expectations for documentation.
• REVIEW student’s previous learning experiences and current clinical objectives.
• DISCUSS overall plan for progression of current clinical objectives.
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Precepting Specific Learner Populations
• INVOLVE student in assessment, validation, and decision-making about learning strategies to be
employed.
• REVIEW clinical agency’s educational and licensure documentation, parking, dress code, and other
pertinent policies.
• NEGOTIATE a clinical schedule with the student.
Clinical Supervision
Preceptor responsibilities during clinical supervision are:
• DIRECTLY SUPERVISE the student in the performance of patient care.
• ENSURE patient care provided by the student is consistent with standards set forth in agency policies,
procedures, and practice protocols.
• DIRECT the progression of student’s assignment based on readiness evaluation of knowledge and skill
competencies.
• REVIEW the student’s documentation and give constructive feedback for improvement.
• SCHEDULE regular student meetings to discuss specific learning objectives and experiences.
• INFORM school’s faculty immediately of concerns related to unsafe clinical practice or of student
difficulties in meeting requirements of the clinical experience.
GENERAL STUDENT OBJECTIVES
Upon completion of each clinical, the students will be able to:
• DEVELOP effective application of basic nursing concepts through care of patients.
• PERFORM nursing interventions under the direct supervision of an assigned preceptor.
• PRACTICE effective therapeutic communication techniques.
• CARE for patients using critical thinking in applying nursing interventions and monitoring outcomes.
UNDERGRADUATE BSN STUDENT RESPONSIBILITIES
The student is responsible for being self-directed in identifying initial and ongoing learning needs,
for seeking learning opportunities to meet identified needs, and for being accountable for her/his
performance in the selected role. Student responsibilities include:
• BE CHECKED OFF on knowledge prerequisites prior to the actual clinical experience.
• DISCUSS specific clinical objectives and negotiate a clinical schedule with the preceptor.
• PROVIDE the clinical agency with the necessary information/documentation as requested.
• PERFORM within the educational preparation standards set forth by the Nursing Program and the
Board of Nurse Examiners for the State regarding the practice of nursing.
• DEMONSTRATE professional behavior.
• MAINTAIN open communications with the preceptor and faculty.
• BE ACCOUNTABLE for her/his own actions while in the clinical setting.
continues
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Table 9.1 Sample Guidelines for Preceptor Experience for Prelicensure Nursing
Students (cont.)
• RESPECT the confidential nature of all information obtained during clinical experience preceptorship.
• ARRANGE for preceptors or designee’s supervision when performing advanced procedures.
• CONTACT faculty by telephone, pager, or email if assistance is needed.
• MAINTAIN a log of clinical skills, activities, clients, teaching-learning activities, and educational
experiences attended throughout the duration of the preceptorship.
• DEMONSTRATE progressive independence and competency in the specified role as dictated by
current placement within the nursing program curriculum and preceptorship clinical experiences.
• ACTIVELY SEEK input into the evaluation process; participate in self-evaluation of strengths and
identify areas for professional growth with faculty member and preceptor(s).
• COMPLETE clinical preceptor evaluations.
Used with permission from Cizik School of Nursing at The University of Texas Health Science Center at Houston (n.d.)
Creating a Positive Clinical Learning Environment for Prelicensure Students
After performing an extensive literature review of learning environments in general, Chan (2002,
2003) developed and tested a clinical learning environments inventory. Newton, Jolly, Ockerby, and
Cross (2010) performed a factor analysis on the inventory and identified six factors accounting for the
dimensions of clinical learning environments that are salient to students.
1. Student-centeredness—The attributes of the clinical teacher in taking time to engage with
students individually, to listen, and to offer support to help them achieve their goals.
2. Affordances and engagement—Opportunities afforded to students to actively engage in unit
activities and work.
3. Individualization—Students having some control over their clinical experiences and facilitating
the achievement of their individual learning needs.
4. Fostering workplace learning—A workplace that fosters learning, with clear, well-planned, and
interesting student assignments.
5. Valuing nurses’ work—Students recognizing the value of nursing work, making an effort to get
their work done and to be regarded favorably.
6. Innovative and adaptive culture—A person-centered approach and a workplace that promotes
creative, flexible, and adaptive work practices.
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203
Hartigan-Rogers Cobbett, Amirault, and Muise-Davis (2007) studied nursing graduates’ perceptions of
the effectiveness of their undergraduate clinical placements and found four themes around the relevancy
of the experiences to their future practice:
• Developing nursing skills and knowledge—They placed a high value on attaining nursing
skills and knowledge, so they wanted clinical placements that provided frequent opportunities
to practice all types of skills, including psychomotor, communication, time management, and
organizational skills.
• Experiencing the realities of work life—They wanted realistic patient care situations and
workloads.
• Preparing for future work—They wanted to do the work, not just observe others doing it.
• Experiencing supportive relationships—They preferred having preceptors and supportive
relationships.
A Recruitment Strategy
Precepting nursing students can be a direct investment in the future. Clinical rotations are an excellent
way to ascertain who you want to recruit and to recruit nursing students for part-time work during
school and full-time work after they graduate. NGRNs are more likely to seek employment in healthcare
organizations in which they had positive clinical learning experiences. Ulrich (2003), in a longitudinal
study of NGRNs, found that bonding students to the organization while they were students resulted in
the students rarely looking elsewhere for jobs.
New Graduate Registered Nurses
Think back to when you graduated from nursing school. How did you feel? The two words that NGRNs
entering their first job most frequently use are excited and scared (Ulrich, 2003). NGRNs come into the
workplace exhilarated at having accomplished their goals of completing their degrees and passing the
NCLEX exam, but they are anxious about being responsible for patient care.
NGRNs who are young in age are also dealing with a number of major life changes—moving away from
parents, having to work 40 hours a week or more, balancing work and life. It is helpful to appreciate and
remember that becoming an RN is only one of the transitions they are experiencing.
Reality shock for NGRNs is as real and prevalent today as it was when it was first described by Kramer
in 1974. Based on her 8 years of research with NGRNs, Kramer (1974) described the specific process
of socialization into the RN role and the need to provide NGRNs with socialization into the role of
RN. As Kramer noted, “It seems that the socialization that takes place in medical and nursing schools
prepares students to be medical and nursing students, but not physicians and nurses” (Kramer, 1974,
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p. 42). Kramer (1974) coined the term “reality shock” to describe what RNs experience as they move
from the expectations created in school to the reality of being an RN. As Duchscher (2008, p. 442)
says, the first year of work experience “encompasses a complex but relatively predictable array of
emotional, intellectual, physical, sociocultural, and developmental issues that in turn feed a progressive
and sequential pattern of personal and professional evolution.” Duchscher (2008) describes the first 12
months of transition as a process of becoming that occurs in three phases (although it is not always a
linear process):
• Doing—Learning, performing, concealing, adjusting, accommodating
• Being—Searching, examining, doubting, questioning, revealing
• Knowing—Separating, recovering, exploring, critiquing, accepting
Guay, Bishop, and Espin (2016) describe the transition experiences during the first 12 months as
“discovering professional self ” (p. 37). They found that in the early part of the transition, the NGRNs
experienced what they termed “surviving without a safety net,” which included “experiencing fear,
figuring it out, and learning on the job” and in the latter part, they experienced “turning the table,”
which included “being trusted, gaining confidence, and feeling comfortable in their professional role”
(p. 32). They also observed that the NGRNs experienced progressive change but experienced transitory
setbacks. Preceptors have to expect these experiences, prepare the preceptee, and offer support and
guidance as needed.
The Practice-Education Gap
A major finding in a study on educating nurses by Benner, Sutphen, Leonard, and Day (2010) was that
“a significant gap exists between today’s nursing practice and the education for that practice, despite
some considerable strengths in nursing education” (p. 4). They concluded that, “Even if nursing and
nursing education were to receive an immediate influx of appropriately designated resources to address
the shortages, along with appropriate policy changes, it would take many years to yield results” (p. 7).
This same gap has been identified in a number of other studies from a variety of viewpoints. Using
the Performance Based Development System (PBDS), del Bueno (2005) reviewed 10 years of data for
new nurses and found that 65% to 76% of inexperienced RNs did not meet the expectations for entrylevel clinical judgment. Further, the majority had difficulty translating knowledge and theory into
practice. A national survey of NGRNs conducted in 2004 to 2005 also supported the existence of a gap
in NGRNs’ readiness to practice (Kovner et al., 2007; Pellico, Brewer, & Kovner, 2009). Similarly, the
gap was identified at the beginning of the Quality and Safety Education for Nurses (QSEN) program
(Smith, Cronenwett, & Sherwood, 2007). What students were taught in school about quality and safety
was insufficient to prepare them for what they needed to know in the practice environment. Further,
in a study for the Advisory Board Company, Berkow, Virkstis, Stewart, and Conway (2008) surveyed
nursing school leaders and hospital nurse executives. When asked for their degree of agreement with
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the statement “Overall, new graduate nurses are fully prepared to provide safe and effective care in the
hospital setting,” 89.9% of the nursing school leaders agreed versus only 10.4% of the hospital nurse
executives (Berkow et al., 2008).
The practice-education gap continues. Hickerson, Taylor, and Terhaar (2016), in an integrative review
of the literature, found evidence to support the continued existence of the gap, the costliness of the gap
(turnover of NGRNs, patient safety issues, etc.), and the fact that eliminating and mitigating the gap—
much as Benner et al. noted in 2010—will require changes in education and changes in transitioning
NGRNs into practice. Edward, Ousey, Playle, and Giandinoto (2017), in a systematic review, found that
the readiness of the NGRN to practice was related to the preparation of the preceptor for precepting
prelicensure students.
Bridging the Gap—Transition to Practice
The evidence continues to mount that all NGRNs need a formal transition to practice program to move
from the student role to the role of a professional nurse (Goode, Ponte, & Havens, 2016). The NCSBN
has developed a Transition to Practice model that incorporates specialty content, communication, safety,
clinical reasoning, prioritizing/organizing, utilization of research, role socialization, and delegating/
supervising as well as the QSEN competencies and their accompanying knowledge, skills, and attitudes
(NCSBN, 2008) and funded a major multi-state study that demonstrated the efficacy of residencies
(Spector et al., 2015). Both the American Nurses Credentialing Center (ANCC, 2016) and the CCNE
(2008) have established residency accreditation programs.
Benner and colleagues (2010) recommend a 1-year residency program focused on one clinical area of
specialization and recommend that the residency include mentoring. Dyess and Sherman (2009) also
found that support was needed throughout the first year. Their study was based on data collected from
evaluations and focus groups of NGRNs who participated in the Novice Nurse Leadership Institute, a
community-wide program designed to strengthen the competencies of, provide ongoing support for,
and develop a leadership mindset among NGRNs.
Formal residency programs already in existence substantiate the need for such residencies and
demonstrate the positive outcomes that can be achieved for individual nurses and their organizations
(Beyea, Slattery, & von Reyn, 2010; Cline, La Frentz, Fellman, Summers, & Brassil, 2017; Fink,
Krugman, Casey, & Goode, 2008; Goode et al., 2016; Ulrich et al., 2010). Outcomes include a dramatic
decrease in first-year turnover, accelerated competence and confidence, and increased engagement
of NGRNs. Keys to the success of these programs are structure, the use of Benner’s Novice to Expert
model, an evidence-based curriculum, preceptor-guided clinical experiences, mentoring, recognition, a
dedicated residency coordinator/manager, and measurement of outcomes. It should also be noted that
these residency programs occur after the healthcare organization’s orientation program. Orientation
is the process of new employee assimilation and socialization into the organization, introducing new
employees to the hospital, gathering information, etc.
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Kramer et al. (2012) studied the organizational transformative power of nurse residency programs,
interviewing over 900 NGRNs, experienced RNs, preceptors, and managers from 20 hospitals around
the country that exhibited very healthy work environments and had organized, structured NGRN
residencies for at least 5 years. As a part of that study, they identified the challenges experienced by the
NGRNs. These included delegation; prioritization; managing patient care delivery; clinical autonomy;
making the right decisions; doing no harm; failure to rescue; nurse-physician collaboration; constructive
conflict resolution; and feedback to restore self-confidence (see Table 9.2).
Kramer et al. (2012) also found that NGRN residency programs that included transition plus integration
stages were more effective in developing NGRN competence in the management of professional role
responsibilities than programs that only included a transition phase. Preceptors can use this information
to raise their awareness of the major challenges that NGRNs experience and to plan and implement
strategies to prevent or mitigate the challenges.
Table 9.2
NGRN Challenges—Management of Professional Role Responsibilities
Delegation: Most frequently cited challenge. NGRNs confused. Reported little or no knowledge and
experience in delegation during school. Unclear about responsibility and accountability.
Prioritization: Difficulty prioritizing patients and prioritizing care. Unclear about unit priority system—
what the priority is on different types of units. Peaked when NGRNs started to work on their own.
Managing patient care delivery: Challenges getting work done, coping with high information intake and
output. Fear of harming patients due to workload. Issue of highest concern to NGRNs.
Clinical autonomy, making the right decisions, doing no harm, failure to rescue: Not prepared to
make decisions. Don’t know what they know.
Nurse-physician collaboration: NGRNs lack competence and self-confidence. Lack of structure and
opportunities for collaboration.
Constructive conflict resolution: Not prepared to handle conflicts. NGRNs major conflict issue is
delegation.
Restoration of self-confidence: Expectation-vs.-reality generated stress. Unclear goals and role
performance.
Source: Kramer et al., 2012
Kramer et al. (2012) investigated the time required for NGRNs to achieve competency in the
management of professional role responsibilities, as estimated by the NGRNs, preceptors, nurse
managers, and educators. In many of the areas, estimates by NGRNs were significantly less than those
of preceptors and nurse managers. Preceptors need to be aware of this discrepancy and set NGRN
expectations accordingly.
In addition to basic NGRN residencies, residencies are increasingly being developed and implemented
for specialty areas. Some of the specialty residencies include critical care (Adams et al., 2015; Bortolotto,
2015); long-term care (Cadmus, Salmond, Hassler, Black, & Bohnarczyk, 2016); and burn centers,
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emergency departments, and maternal-child health (Boyer, Valdez-Delgado, Huss, Barker, & MannSalinas, 2017).
If your organization does not have a formal residency or transition to practice program for NGRNs, the
components described previously should be incorporated as much as possible when NGRNs are hired.
You can find information and resources throughout this book and at www.RNPreceptor.com that can
help you prepare to precept NGRNs.
Precepting NGRNs
Schumacher (2007) studied how NGRNs perceive the caring behaviors of preceptors by analyzing
NGRNs’ daily reflective journal entries and follow-up interviews. Six themes were identified:
• Advocating—Made sure assignments facilitated good learning experiences; asked questions
to understand how the preceptee best learned.
Result: The preceptees thought the preceptors were on their side and helped them progress
and be successful.
• Welcoming—Warmly greeted the preceptee; demonstrated open, approachable, and friendly
attitudes; encouraged questions and discussions.
Result: The preceptees were less anxious and asked questions.
• Including—Introduced preceptee to other staff; included them in unit activities.
Result: Work was a more comfortable and less threatening place.
• Appropriate preceptor presence—Took the time to gauge preceptees’ capabilities and gave
them autonomy that was challenging yet appropriate.
Result: Preceptees learned and thrived.
• Making human-to-human connections—Went above and beyond; made deeper human-tohuman connections; shared some of the unspoken rules of the nursing culture.
Result: Longer term relationships.
• Genuine feedback—Provided continuous, constructive, nonpunitive, concise, and specifically
focused feedback.
Result: Preceptees understood the safest and best way to perform patient care.
Managing the Normal Chaos
Preceptors need to pay particular attention to helping NGRNs manage the normal chaos of a typical
patient care unit, coupled with the complexity of care needed and the need to deliver care to multiple
patients simultaneously. Kramer et al. (2013) emphasize the need to see the chaos of professional
practice as complexity, having found that managing patient care delivery (getting the work done) is the
issue of highest concern to NGRNs. NGRNs not only have to learn how to take a full patient load, but
they also need to learn how to work quickly, how to deal with interruptions, and how to move easily
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from one task or thought to another. Cornell and colleagues (2010), in a study of nurses on a medicalsurgical unit, found that the duration of 40% of the nurses’ activities was less than 10 seconds, and for
about another 25%, the duration was less than 20 seconds. Only 5% of the events lasted longer than 2
minutes. This is a far different pattern than most nursing students experience in school.
Scope of Practice and Autonomy
One of the most basic things for NGRNs to understand is their scope of practice—what they are
permitted and expected to do within the scope of their licensure as a registered nurse, what they cannot
do, and under what conditions. NGRNs also need to know the scope of practice for individuals who
work in other professions and roles (e.g., physician, nurse practitioner, pharmacist, respiratory therapist,
certified nursing assistant, licensed vocational/practical nurse). These scopes of practice vary from
state to state, so preceptors need to be knowledgeable of the scopes of practice in the state in which the
practice is occurring.
NGRNs must be precepted with the goal for them to eventually practice to the full scope of their RN
license. One aspect of that practice that is often not clear to NGRNs is clinical autonomy. Throughout
their education, they have always been under the direct or indirect supervision of an instructor or
clinical preceptor. The transition to practicing autonomously in many areas is new to them, and they
need guidance and support in this transition.
Kramer, Maguire, and Schmalenberg (2006) analyzed the concept of clinical autonomy and studied
nurses’ perceptions of autonomy. After an extensive literature review and interviews with nurses, they
created the following definition of clinical autonomy:
Autonomy is the freedom to act on what you know in the best interests of the patient—to make
independent clinical decisions in the nursing sphere of practice and interdependent decisions
in those spheres where nursing overlaps with other disciplines. Autonomy is facilitated through
evidence-based practice, being held accountable in a positive, constructive manner, nurse
manager support, and it often exceeds standard practice (Kramer et al., 2006, p. 480).
They further state, “The sine qua non of safe autonomous practice is knowledge and competence” (p.
488). When nurses in the study were asked to identify situations in their unit that commonly required
autonomous decision-making by staff nurses, six domains were found:
1. Emergency domain—Saving lives
2. Need to rescue domain—Patient safety and prevention of harm
3. Patient advocacy domain—Advocating for the patient’s physical and mental well-being
4. Triage domain—Effective and efficient care
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5. End-of-life domain—Maintaining quality of life and promoting a peaceful death
6. Coordinating/integrating domain—Providing holistic care
These domains can be used by preceptors when teaching NGRNs when, where, and how they should
practice autonomously. In the Kramer et al. (2006) study, it is also relevant to note that levels of expected
autonomous practice varied by type of hospital (community or university teaching hospital) and by type
of specialty unit (e.g., oncology, medical-surgical, intensive care, outpatient). Preceptors, therefore, must
be knowledgeable on the norms and expectations of the hospitals and units in which they practice.
New Experiences
Because NGRNs have limited clinical experience in school and are limited in the responsibilities
they can assume in the student role, there are some predictable new experiences that will require
education and the support of their preceptor. Caring for patients at the end of life is an example of such
an experience. Croxon, Deravin, and Anderson (2018) found that NGRNs did not feel prepared for
providing palliative care or dealing with death and dying. Herron (2017) identified a lack of readiness
to recognize and prevent failure to rescue due, in part, to their inexperience with emergent situations.
Other examples include handling disruptive behavior from patients, families, or other healthcare
professionals; experiencing ethical dilemmas; and making (or almost making) a medication error.
Preceptors and NGRN residencies can educate NGRNs and lay the foundation for new experiences, but
it is one thing to read about these experiences or role-play them and quite another when they actually
happen. Some NGRN residencies have pre-planned debriefing sessions that are designed to occur when
the event happens (with the NGRN involved and other NGRNs in the residency cohort).
Being a Nurse—Developing Professional Identity
Competencies, tasks, and procedures are relatively straightforward to teach. Helping NGRNs develop
their professional identity is more complex. While identity formation is a dynamic process that begins
in undergraduate education and continues throughout an RN’s entire career (Crigger & Godfrey, 2014),
NGRNs are at a particularly crucial stage when they transition from student to RN.
Godfrey and Crigger (2017) define professional identity in nursing as “a sense of oneself that is
influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual
thinking, acting, and feeling like a nurse” (p. 379). They note that professional identity is composed of
five attributes: doing (skills), being (adopting attitudes and behaviors that reflect the values of how a
professional thinks, feels, and acts), acting ethically (doing the right thing), flourishing (doing and being
with a sense of positive and transformational growth, having excellence as a core value), and changing
identities (recognizing that one is changing identities).
Day and colleagues (2017) recommend a Discovery Model that incorporates self-discovery and affective
domain learning to help nurses rediscover and reinforce the values that brought them into nursing.
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They describe the use of a Power of Nursing course, similar to a Healer’s Art course that has been used
with medical students, to achieve this goal. The course includes sessions on remembering authenticity
and wholeness; disappointment, loss, and grief—experiencing your healing presence; discovering your
healing lineage and personal healing qualities; the courage to make your power and perspective visible;
and calling and commitment—finding your voice, living your values (Remen, 2016).
Godfrey and Crigger (2017) recommend interventions for building a professional identity (see Table
9.3). Preceptors can encourage and facilitate these interventions for preceptees and can use these
interventions to develop their own professional identity as preceptors.
Table 9.3
Interventions to Help Build Professional Identity
• Hear expectations clearly.
• Value debriefing and feedback from role models.
• Engage in reflections.
• Actively adopt a professional identity.
• Understand your own responsibilities for learning and be accountable for them.
• Build relationships with those around you.
• Develop personal self-care habits.
• Embrace any opportunity for experiences with patients.
Source: Godfrey & Crigger, 2017
Leadership and Interprofessional Teamwork
NGRNs need to be leaders and to work in interprofessional teams. Often nursing students learn in
isolation. In a few schools, nursing students and other healthcare students attend some classes together,
but this is still not the norm. Even in clinical rotations, they generally do not interact with other
members of the healthcare team, except incidentally, to plan patient care or discuss changes in the
patient’s condition. Thus, when the students become RNs, they have little to no experience in leadership
or working in interprofessional teams.
Leadership is a standard of professional performance for all RNs (American Nurses Association [ANA],
2010). Often, NGRNs (and even some experienced RNs) do not see themselves as leaders. Teaching
NGRNs to be leaders involves setting expectations, role modeling, and teaching leadership behaviors.
Leadership includes supervising the care given by others such as unlicensed personnel; demonstrating
a commitment to lifelong learning; mentoring colleagues; treating others with respect; developing
communication and conflict resolution skills; participating in professional organizations; seeking ways
to advance nursing autonomy and accountability; and participating in efforts to influence health policy.
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Many NGRN residencies include planned exposure to and interactions with other healthcare
professionals as a way for NGRNs to learn the roles of others and to become competent in working as
part of an interprofessional team. One issue the preceptor needs to be mindful of is that NGRNs may
overestimate their abilities to work in interprofessional teams. Hopkins and Bromley (2016), in a study
of NGRNs’ abilities to work as part of an interprofessional team, found that the NGRNs rated their
team-related abilities (such as communication with physicians, communication with the team, working
as part of the team, conflict resolution) higher than experienced nurses rated the NGRNs’ abilities.
This is consistent with the pattern observed by Ulrich et al. (2010) in a report of 10 years of an NGRN
residency: Early on, the NGRNs believed their competence to be higher than did their preceptors. Later
in the residency, at the point when the NGRNs began to practice more independently, they rated their
competencies lower than did the preceptors. By the end of the residency, the NGRNs and preceptors
were generally in agreement on their ratings.
Being an active and engaged member of an interprofessional team can be a big challenge for NGRNs.
Pfaff, Baxter, Jack, and Ploeg (2014) performed an integrative review of the factors that influence
NGRN engagement in interprofessional collaboration and found individual, team, and organizationlevel factors. Self-confidence is a major factor. They reported NGRNs having a lack of confidence
when interacting with physicians and with patients and their families. With physicians, there is a fear
component; with patients and families, NGRNs lack self-confidence largely due to worry about not
having answers to the questions that may be asked. Lack of knowledge and experience is a barrier to
collaborating with physicians, delegating to ancillary staff, and leading the healthcare team. NGRNs
also do not have sufficient knowledge and experience to know what information should be discussed in
interdisciplinary rounds; they are unclear whom to consult, when to consult them, and how to contact
them. Communication skills, especially conflict resolution, are also a barrier. Team factors include
perceived lack of support from other team members, particularly ancillary staff; and lack of respect,
specifically from physicians and ancillary staff. Lack of formal support from leaders was identified as an
organizational barrier.
The preceptor’s role is to accurately assess the NGRN’s abilities, provide coaching and feedback when
needed, and role model behaviors. With interprofessional teamwork, the preceptor can also role-play
scenarios with the NGRN to build confidence. The Interprofessional Education Collaborative (IPEC,
2016) is a good source of information and competencies for working in interprofessional teams.
Domains and core competencies of interprofessional teamwork are shown in Table 9.4.
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Table 9.4 IPEC Competencies: Core Competencies for Interprofessional
Collaborative Practice
Domain
General Competency Statement
Values/Ethics for
Interprofessional
Practice
Work with individuals of other professions to maintain a climate of mutual
respect and shared values.
Roles/Responsibilities
Use the knowledge of one’s own role and those of other professions to
appropriately assess and address the healthcare needs of patients and to
promote and advance the health of populations.
Interprofessional
Communication
Communicate with patients, families, communities, and professionals
in health and other fields in a responsive and responsible manner that
supports a team approach to the promotion and maintenance of health
and the prevention and treatment of disease.
Teams and Teamwork
Apply relationship-building values and the principles of team dynamics
to perform effectively in different team roles to plan, deliver, and evaluate
patient/population centered care and population health programs and
policies that are safe, timely, efficient, effective, and equitable.
Source: IPEC, 2016
Other Considerations with NGRNs
Other things to consider with NGRNs include their prelicensure education, prior work experience in
healthcare, and whether nursing is their first career. Prelicensure education can be through a diploma
program, an associate degree, a bachelor’s degree, or an accelerated degree program. The curriculum
is different in each. Students also have the opportunity in some schools to do independent study their
last year, which, depending on the topic, can provide them with more reality-based experience prior to
graduation.
Accelerated or second-degree students tend to be very motivated and to be high achievers in school
(American Association of Colleges of Nursing [AACN], 2010), and they may also have a more realistic
view of what they don’t know. Nursing is a very stable and flexible career that pays well compared to
many jobs, so it has become attractive as a second career to people who previously chose less stable
professions. Though second-career nurses might come to you with more “street smarts” than the
young NGRN, remember that they are no less intimidated by their lack of knowledge and expertise.
Imagine, as an experienced nurse, if you started a job tomorrow as an elementary school teacher or an
accountant. How would you feel about being a total novice again? And when you’re a total novice in
a hospital, you understand that mistakes can have dire consequences. Prior paid work experience in
healthcare can also be a factor in what preceptees need to learn (or, in some cases, unlearn). Brandt,
Boellaard, and Wilberding (2017) interviewed accelerated second-degree NGRNs about their transition
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to professional nursing practice. While much of their transition experience was similar to other NGRNs,
these NGRNs appeared to have higher personal expectations and desire to succeed.
Preceptors need to spend sufficient time with these preceptees at the beginning of the relationship to
understand the experience and knowledge of the preceptees so that their learning needs can be better
identified.
Post-Baccalaureate Graduate Students
There are many options for RNs to obtain graduate degrees after completing their baccalaureate degree.
There are master’s degree programs as well as programs leading to a doctor of philosophy (PhD), doctor
of education (EdD), doctor of nursing practice (DNP), and other doctorates. Increasingly, there are BSN
to DNP options. Many of these programs have clinical experiences using preceptors, some in direct care,
and others in specialty areas such as administration and education.
When precepting graduate students, it is important for the preceptor to know the goals of the program
overall and the goals of the specific class the student is being precepted for. Some students will be in a
preceptorship to obtain direct care clinical experience, while others will be expected to learn a role and
may be required to do project work with the preceptor.
It is also important to know what experience the student has had since obtaining the BSN degree. For
students in BSN to DNP programs, preceptors need to be aware that this is the first graduate school
experience for these students and that these students typically have less experience as an RN than other
students in doctoral programs. Initially, they may act more like new master’s students than like doctoral
students. These programs are relatively new, and schools are learning what strategies work best and
where change is needed to ensure the success of this student population.
The number of RNs being educated to be advanced practice RNs (APRNs) has been steadily increasing,
especially as state laws continue to expand the scope of practice for APRNs. Detailed information in
precepting APRNs both as students and as new graduate APRNs can be found in Chapter 10.
Experienced Nurses
When experienced nurses change specialties or roles, they are no longer proficient or expert nurses in
their new positions. This includes nurses who want to learn a new specialty or sub-specialty; nurses who
move into new roles such as charge nurses, managers, educators, preceptors, and researchers; nurses
who become advanced practice nurses; nurses who complete an RN to BSN program; and re-entry
nurses. Preceptors are needed for all of these transitions.
Healthcare organizations increasingly have structured programs for learning new specialties or
roles (Windley, 2016). In some cases, professional nursing organizations have curricula and valuable
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resources that can be used (e.g., Association of periOperative Registered Nurses [AORN] and National
Nursing Staff Development Organization [NNSDO]). Some healthcare organizations have developed
residencies in clinical areas. For example, Massachusetts General Hospital reported the development of
an evidence-based nurse residency program in geropalliative care (Lee, Coakley, Dahlin, & Carleton,
2009). Bell, Bossier-Bearden, Henry, and Kirksey (2015) described a successful nursing fellowship to
transition experienced nurses into obstetrics that resulted in an increase in obstetrics nurses, improved
retention, and increased nurse satisfaction.
The increased demand for RNs to be BSN-prepared has resulted in many experienced nurses returning
to school for their bachelor’s degree. This transition must also be recognized as one that can benefit from
education and precepting for the new role. RNs with a BSN are prepared for leadership roles, expected
to be knowledgeable of and use evidence-based practice, understand the broader needs of community
and population health, and use critical thinking and clinical reasoning. Phillips and Evans (2017)
describe the RN-to-BSN transition as “a time of personal and professional growth” (p. 81). Recognizing
this growth and supporting these nurses in their transition can have positive results for the RN and the
organization.
Re-entry nurses have been out of the workforce for a while. How long they’ve been out and how long
they practiced before they left are good indicators for what they will need to learn. If they worked for
some time before taking time away, they are probably quite anxious because they know they are “rusty”
and that practices and technologies have changed since they worked. The good news is that they came
back because they wanted to, and they generally have a realistic view of what they don’t know.
Some states require that nurses who have been out of practice for a certain number of years complete a
refresher course prior to re-entry and that these courses include the use of an RN preceptor (Borgfeld,
2014; Weeks et al., 2012). The refresher course is not just for clinical competence. Imagine if you had
not been working in nursing for the past 5–10 years. Nursing and hospitals today are far different than
they were 10 years ago in the way we provide care, the technology we use, the emphasis on patient safety
and quality improvement, and even in the language we use. While we used to talk about nosocomial
infection rates, we now talk about hospital-acquired infections and have units that have not had a
central line infection in months or years. We emphasize evidence-based practice and stress the need to
be high reliability organizations.
When experienced nurses change specialties or roles, they can feel vulnerable in their new roles until
they acquire the new knowledge and expertise to advance to the proficient and expert stage. Often,
the new role can build on prior knowledge, but not always. As with NGRNs, the preceptor needs to
understand what outcomes are expected from the preceptorship and to assess the preceptee’s prior
knowledge and expertise.
Experienced nurses who are new hires to the organization generally have experience in the area they
are hired into. Patient safety requires that the hiring organization be sure that nurses are competent
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in clinical practice regardless of their years of experience. As the preceptor for these nurses, you will
often be the person to make that assessment and to ensure that any deficits are corrected. All hospitals
and other healthcare organizations have their own culture, policies and procedures, physician practice
patterns, model of care delivery, protocols, etc. The newly hired experienced nurse will need the
preceptor’s help to learn these things in the new organization.
Lucile Packard Children’s Hospital at Stanford developed an innovative concept to fill the gap between
general nursing orientation and unit orientation (Hargreaves, Nichols, Shanks, & Halamak, 2010).
Authors of the report identified that preceptors, despite being responsible for documentation of the
knowledge and skills of newly hired nurses and their education when needed, were rarely given specific
information about the nurses’ prior performance in general orientation, which includes didactic
information reinforced with simulation and debriefing. Applying the same concepts used with patient
handoffs, they created a handoff report card. It includes information from new hire nurses on their
prior jobs and self-assessments of their level of expertise, an instructor assessment, and documentation
of competency validation. The report card, which is used to document strengths and areas needing
improvement, is discussed with each orientee on the last day of orientation and distributed to the
orientee’s manager and preceptor. In this way, the unit orientation can be customized to build on the
findings during general orientation to result in more rapid skill and knowledge acquisition. This is an
excellent example of giving preceptors the information they need to ensure an effective and efficient
preceptorship. It is also a practice that can be used when preceptors hand off their preceptees to
managers at the end of the preceptorship.
Internationally Educated Nurses
The number of internationally educated nurses practicing in the United States has grown. In 2015, 8,641
internationally educated nurses took the NCLEX exam; this number grew to 14,113 in 2017 (NCSBN,
2018).
Practice gaps have been identified between internationally educated nurses and nurses educated in
the United States in areas such as performance of assessments, pain management, administration of
medications, and use of technology (Edwards & Davis, 2006; Ryan, 2003). Gerrish and Griffith (2004)
also note that the adjustment to differences in professional practice might be an issue. Sherman and
Eggenberger (2008) report that nurse leaders identified the impact of cultural differences (e.g., in
nurse autonomy and accountability) as an area of concern, and internationally educated nurses note
that collaboration between nurses and physicians is different in different cultures. Adeniran et al.
(2008) found that the transition of internationally educated nurses is not difficult because of a lack of
knowledge or clinical skills, but because of sociocultural differences, language subtleties, and unfamiliar
surroundings. Rosenkoetter, Nardi, & Bowcutt (2017) propose the use of a life patterns model to
examine and mitigate the issues that internationally educated nurses face when transitioning to practice
in the United States. They reviewed evidence that describes the changes that these nurses face in their
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roles, relationships, self-esteem, use of time, life structure, support, and new healthcare system designs.
As a result, internationally educated nurses might require an extended or more intense preceptorship so
that preceptors can address these issues in addition to the standard preceptorship content.
Nurses From Different Generations
It’s far different to precept a 20-year-old than it is a 40-year-old. They were brought up in very different
times and can have very different outlooks on the world in general, and nursing and healthcare in
particular. Though we never want to generalize or stereotype, it is informative to understand the trends
within each generation. By understanding that different generations have different life experiences, it is
easier to understand why people from different generations have different values and priorities and act
and react as they do.
According to Hicks and Hicks (1999), values are the key defining variable of each generation. They note,
“The values we develop in our youth are the foundation for what we believe as adults” (p. 4). This values
development applies not only to children, but also to joining a profession (Ulrich, 2001). Massey (1979)
defined three stages of value development: imprinting (observation), modeling (finding heroes—good
or bad), and socialization (by peers or significant others). As a preceptor, you might contribute to the
modeling stage of values development for student nurses, who will model themselves on nurses they
observe, and to the socialization stage for NGRNs and experienced nurses moving into new specialties
or roles. Zemke, Raines, and Filipczak (2000) also note that the work environment when individuals of a
generation look for their first job contributes to the long-term values and character of their generation.
Generations are usually grouped into time periods (Dimock, 2018):
• Baby boomers were born from about 1946–1964
• Generation X from 1963–1980
• Generation Y/millennials/net generation from 1981–1996
• Post-millennial/Generation Z beginning in 1997
The factors influencing a generation include things that simultaneously impact the population, such as
events, circumstances, life experiences, broad social forces, defining events, and life-shaping behaviors.
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217
Baby boomers were born into nuclear families in a healthy, growing economy with high employment.
They were doted on by their parents and encouraged to think independently and express themselves.
Defining events in their generation included the Vietnam War, the 1960s drug culture, and the civil
rights movement. They were a very large generation in sheer numbers and have heavily influenced all
aspects of the culture since their birth.
Generation X, on the other hand, grew up in a time of employment uncertainty, were often “latchkey”
kids, and lived in a time when the divorce rate skyrocketed. They learned self-sufficiency and flexibility
early in life. They grew up using television as a window on the world and learning from Sesame Street
and The Learning Channel. Defining events for Generation X included the birth of MTV in 1981, the
AIDS epidemic, and the Challenger accident. Birth control, divorce, and the economy together resulted
in Generation X being a much smaller generation in number than the baby boomers.
Like baby boomers, members of the millennial generation were born into a good economy but were
more likely than previous generations to be born to single mothers. They are much more racially
and ethnically diverse than previous generations, and they are very techno-literate. They came of age
during the internet explosion. As a result, members of the millennial generation expect to be constantly
learning, and indications are that they process information in more of a mosaic (multi-tasking) pattern.
They grew up with lots of attention, praise, and high expectations. They entered the workforce at the
height of an economic recession. Millennials favor work-life balance—working to live, not living to
work. Defining events of the millennial generation include Columbine, the Gulf Wars, and September
11, 2001. By 2019, millennials will outnumber baby boomers as the largest generation (Fry, 2017).
The first members of the post-millennial generation are just entering adulthood. Their world has always
included the Internet, Wi-Fi, constant connectivity, and on-demand entertainment, and for many of
them those connections have always been mobile and often handheld. The post-millennial generation
is even more diverse than the millennial generation. The Great Recession, school shootings, and the
invention of the iPhone and iPad are some of the defining events of this generation. A 2014 study by
Northeastern University found post-millennials to be very self-directed; highly interconnected by
social media yet most prefer to interact with their friends in person; believe college is important to
having the careers they want but very concerned about the cost of education; and more likely to be
politically active. Patel (2017) notes that, when compared to millennials, post-millennials are more
pragmatic, more competitive, prefer to work own their own, more seamlessly integrate technology, more
entrepreneurial, and more likely to want to communicate face-to-face. As this generation enters the
workforce in more numbers, we will learn more about their values and the strengths they can bring to
organizations. Some values and workplace strengths of each generation are shown in Table 9.5.
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Table 9.5 Generational Values, Workplace Strengths, and Learning Styles and
Preferences
Baby Boomer Generation
• Values—Optimism, personal growth, personal gratification, team play
• Workplace Strengths—Driven, team players, service-oriented, relationship-oriented
• Learning Styles and Preferences—Enjoy contact with the teacher, used to learning in a didactic
format, learn best when their experience can be connected to the subject matter, want to learn in a
caring environment, like positive feedback
Generation X
• Values—Diversity, balance, techno-literacy, self-reliance
• Workplace Strengths—Good with change, multi-taskers, techno-literate, not intimidated by
authority, self-reliant, creative
• Learning Styles and Preferences—Learn quickly and efficiently, want to learn things that benefit
them and their careers, like to learn on their terms, value flexibility, like to see a connection between
what they need to learn and how they will use it in their careers
Millennial Generation
• Values—Diversity, optimism, civic duty, achievement
• Workplace Strengths—Optimistic, want to help others, multi-taskers, techno-literate, outcomedriven, like to learn
• Learning Styles and Preferences—Like working in groups, like using technology whenever possible,
enjoy experiential activities, have little to no tolerance for delays and wasted time, like immediate
feedback
Post Millennial Generation
• Values—Self-direction, security, face-to-face communication, pragmatic
• Workplace Strengths—True digital natives, multitaskers, understand the need for constant skill
development to stay relevant, adept at finding information and data
• Learning Styles and Preferences—True digital natives, like to work alone, expect to multitask,
expect to be constantly connected, like face-to-face interactions, see the teacher as a coach, not the
source of all knowledge
Sources: Jenkins, 2017; Johnson & Romanello, 2005; Northeastern University, 2014; Patel, 2017; Zemke et al., 2000
9
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219
Learning Styles and Preferences
After you put all of the generational experiences and characteristics together, it is easy to understand
that people from different generations often have different learning styles and preferences (refer to
Table 9.5). For example, millennials grew up learning through video games and virtual environments
in which both strategy and experimenting with solutions were important. Most nursing students from
the latter part of the millennial generation used simulation as a learning tool. In fact, simulation became
so prevalent that, from 2011–2014, the NCSBN conducted a national study evaluating the acquisition
of clinical competency, clinical knowledge, and other outcomes with different amounts of simulation
being substituted in clinical courses and ultimately developed guidelines for the use of simulation in
prelicensure nursing programs (Alexander et al., 2015). Preceptors should be increasingly prepared for
preceptees who have extensive experience with learning with various levels of simulation. Additional
information on the use of these technological learning tools can be found in Chapter 8. By considering
these styles and preferences, preceptors can enhance the learning of members of each generation.
Precepting and Working With Each Generation
Members of each generation bring strengths and preferences to learning situations and to work.
Knowing the origin of these strengths and preferences helps us better understand the members of
each generation. As a preceptor, this knowledge can help you individualize learners’ experiences. As a
colleague, this knowledge can help you value what each person can contribute to the team and create an
awareness of what you can learn from people in each generation.
Conclusion
Preceptors are called upon to work with many different individuals in many different situations. By
having knowledge of specific learner populations, preceptors can be better prepared to meet the needs of
all learners.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Preceptor Development Plan:
Working With Specific Learner Populations
Review the information on working with specific learner populations described in this chapter.
What are your strengths? In which areas do you need to increase your knowledge and expertise?
What is your plan for expanding your knowledge and expertise? What resources are available?
Who can help you?
Name:
Date:
Prelicensure Student Nurses
Strengths
Needs
Plan
Resources
Plan
Resources
Plan
Resources
New Graduate Registered Nurses
Strengths
Needs
Post-Baccalaureate Graduate Students
Strengths
Needs
9
Precepting Specific Learner Populations
Experienced Nurses
Strengths
Needs
Plan
Resources
Plan
Resources
Plan
Resources
Internationally Educated Nurses
Strengths
Needs
Nurses From Different Generations
Strengths
Needs
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
221
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“We all carry seeds of greatness within us, but we
need an image as a point of focus in order that they
may sprout.”
–Epictetus
Precepting Advanced
Practice Registered
Nurses
–Laura Lynn Rooney, DNP, RN, FNP-BC, BC-ADM, FAANP
Clinical experiences are foundational components for training the advanced
practice registered nurse (APRN). But increasing numbers of APRN programs,
decreasing numbers of doctorally prepared faculty teaching in APRN programs,
and robust distance education programs have led to an increase in the demand for
clinical preceptors (American Association of Colleges of Nursing [AACN], 2015).
Today, over 86% of master’s programs incorporate some form of distance education
(Roberts, Wheeler, Tyler, & Padden, 2017). More distance education results in
less time students have direct contact with faculty (whether face-to-face or verbal
contact), who often serve as professional role models. Thus, preceptors are directly
involved in the transition from nurse to APRN (Moran & Nairn, 2017). Combine
these changes with a progressively complex patient population, and the challenges
facing preceptors are clear. In order to provide the student with a successful
experience, preceptors will need to have an organized approach to the role of
preceptor.
This chapter will provide you with an overview of the role of the preceptor in APRN
education, identify and provide suggestions for overcoming barriers, and cover how
to create a plan for successful clinical experiences.
Understanding the Role of the APRN Preceptor
APRNs are licensed professionals who have graduated from an accredited program
and passed a certifying examination in order to enter into practice. The APRN
10
OBJECTIVES
•
Understand the role of
the preceptor in clinical
training of advanced
practice registered
nurses
•
Identify incentives and
barriers that may impact
decisions to precept
•
Identify personal
characteristics and
teaching tools to
improve learning
outcomes
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Consensus Regulatory Model identifies four roles of APRNs (APRN Consensus Work Group & the
National Council of State Boards of Nursing APRN Advisory Committee, 2008):
• Certified registered nurse anesthetist (CRNA)
• Certified nurse midwife (CNM)
• Clinical nurse specialist (CNS)
• Certified nurse practitioner (CNP)
Each role has unique challenges and requirements for clinical practice. Individual students, as well,
come to programs with varied experiences; although accredited schools of nursing must ensure basic
curricula for successful completion, there is variability among APRN programs. Finally, each state
independently regulates practice for APRNs; therefore, the scope of practice for an APRN differs from
state to state. You can see then that precepting such a diverse group presents challenges, yet there are
some commonalities.
For example, APRNs all begin as RNs. This means they begin with a foundation in health sciences and
have some experience providing care at the bedside, while acting as part of the healthcare team. APRNs
take three core courses: Advanced Pharmacology, Advanced Pathophysiology, and Advanced Physical
Examination and Differential Diagnosis. These courses help to expand and strengthen knowledge that
will provide a foundation for practice. Beyond the core courses, each role provides additional specialized
education to support the student’s selected area of focus: CRNA, CNS, CNM, or CNP.
For the preceptor, working with a student APRN may be different from working with a graduate
APRN. Student APRNs focus on knowledge acquisition and assembly of a learning platform. Dramatic
advances in clinical judgment may be seen from one semester to the next. The role of the preceptor is to
facilitate learning and strengthen skills. Graduate APRNs, however, are assimilating into the role via role
modeling and focus on becoming part of the healthcare team. Therefore, the role of the preceptor is to
develop a strong provider and to polish skills while supporting growth.
Historically, clinical training has occurred in one-to-one preceptor-student models, which has been
successful (AACN, 2015). However, with increasing numbers and changes in care-delivery models, the
traditional model of clinical education may no longer be sustainable. Although new models of clinical
education are in various stages of exploration, the traditional one-to-one preceptor-student method still
provides most APRNs with the experience and training necessary to effectively carry out the role of the
APRN.
In order to graduate from an accredited APRN program, students must successfully complete course
content along with a minimum number of supervised clinical hours to be eligible for examination and
licensure. The number of hours has varied over the years, but the current requirement is 500 supervised
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Precepting Advanced Practice Registered Nurses
229
hours for master’s students, and 1,000 supervised hours for doctoral students (APRN Consensus Work
Group & the National Council of State Boards of Nursing APRN Advisory Committee, 2008). The hours
themselves have inherent variability due to the variety of clinical sites within which students train.
Interestingly, some practice disciplines have transitioned from nonspecific hours to competency-based
clinical trainings (National Organization of Nurse Practitioner Faculties [NONPF], 2017; Schumacher
& Risco, 2017). With competency-based training, focus shifts from teaching to learning, and while the
discussion is ongoing in the field of nursing, preceptors may encounter changes in clinical objectives in
the coming years (Schumacher & Risco, 2017).
According to the APRN Consensus Regulatory Model, students are licensed at either the role or the
population location (see Figure 10.1). Roles include nurse-anesthetist, nurse-midwife, clinical nurse
specialist, and nurse practitioner. Populations include family/individual across the lifespan; adultgerontology; neonatal; pediatrics; women’s health/gender-related; and psychiatric-mental health.
APRN Specialties
Licensure occurs at Levels of
Role & Population Foci
Focus of practice beyond
role and
population focus linked to healthcare needs
APRN
Specialties
Examples include but are not limited to:
Focus of practice beyond
role andOlder
population
linked to Nephrology,
healthcare needs.
Examples
Oncology,
Adults,focus
Orthopedics,
Palliative
Care include but are
not limited to: Oncology, Older Adults,Orthopedics, Nephrology, Palliative Care
Family/
Individual
Across
Lifespan
AdultGerontology*
Neonatal
Pediatrics
Women’s
Health/
GenderRelated
PsychiatricMental
Health**
POPULATION FOCI
Nurse
Anesthetist
Nurse-Midwife
Clinical Nurse
Specialist**
Nurse
Practitioner*
APRN ROLES
FIGURE 10.1 APRN Consensus Regulatory Model
Source: APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee, 2008
230
Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Therefore, clinical experiences will need to provide training specific to role and/or population. As a
preceptor, you should be aware of how the clinical training at your facility fits into the overall plan for the
preceptee as they progress. Although a variety of experiences may offer the most comprehensive training,
some preceptees are with you for the specialized training necessary to a particular role. Therefore, knowing
your practice and what it offers will help to ensure preceptees get the most out of the experience.
Clinical experience, whether while a student is in school, or while the APRN is transitioning to practice,
is key to developing a high-quality and safe practice. Historically, academic faculty have provided didactic
education to students and relied upon clinical experts to provide real-world experiences to the APRN
student. In this sense, the preceptor acts as the link between education and practice while the student is
engaged in training. Preceptors are, then, experienced professionals who teach, support, counsel, coach,
and evaluate students, while aiding in the professional socialization (Knisely, Fulton, & Friesth, 2015). But
as nursing education trends toward distance education, the role of the preceptor as professional role model
becomes ever more important. The role of the preceptor differs from the role of the mentor. Scott-Herring
and Singh (2017) note that a preceptorship has “a shorter time frame and has an external set of objectives,”
while a mentor is “both a professional and a role model who not only advises, but also provides feedback
to a junior colleague” (p. 464).
As you begin, or continue, your journey as a preceptor, keep in mind the overall objectives for each
student. Try to stay flexible as healthcare responds to changing complexities, leading to new and exciting
opportunities for teaching and learning.
Finally, strive to keep your sense of humor. Learning, and teaching, is hard work, and stressful on
everyone. Learn to laugh with your students, and you will find your job as a preceptor much more
rewarding. Remember your own personal experiences as a preceptee, and share some stories with your
preceptees to let them know we all have opportunities to learn each and every day.
Know Your Preceptee, Know Yourself
Nurses decide to seek the role of the APRN for a variety of reasons, and therefore come from a variety
of backgrounds and levels of experience. You will find that precepting students in their first semester of
clinical practice will vary greatly from precepting students in their second or final semesters, and vary
still from precepting the graduate APRN. Each preceptee is truly unique. When accepting a student or
graduate APRN, experts agree that allowing time to fully assess the student or graduate is time well spent
(Easton, O’Donnell, Morrison & Lutz, 2017; Lazarus, 2016; Sloand, Feroli, Bearss, & Beecher, 1998).
Precepting the APRN Student
Accepting a student into your clinical setting implies a degree of commitment and partnership. In order
to provide a successful rotation for the student, you should understand the unique backgrounds, needs,
and learning styles of your students and graduate APRNs to strengthen the partnership between clinical
educator and student.
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A successful rotation begins with open and honest communication. In order to learn about your
student and give the student an opportunity to learn about you and your practice, consider providing
an orientation before the first clinical day. Orientations are generally held before the first clinical
day and allow time for you to discuss expectations, objectives, preferred learning styles, preferred
communication styles, and pearls of wisdom for success (Barker & Pittman, 2010). Provide enough time
for the student to have all questions answered, which will help to alleviate anxiety on the first clinical
day. Using a checklist (see Table 10.1) will help to ensure a systematic approach to the orientation so
you do not miss any important topics, particularly if you have more than one student at a time (Lazarus,
2016; Sloand et al., 1998). During the orientation, engage the student as an active participant, and
encourage questions to demonstrate a safe environment.
Table 10.1
Student Orientation Checklist
Before meeting with the student
Confirm necessary contractual and onboarding requirements are completed.
Set up a meeting
This sets the tone for working together and provides a chance to introduce student to the site.
Learn about the student
Ask about prior experience, skills, and knowledge. Explore student’s self-perceived strengths, weaknesses,
and areas of expertise.
Share your history/style
Share your teaching style. Ask the student how they prefer to learn.
Learning Strategies
Discuss which strategies are effective in the clinical setting. Talk about the use of a manipulated structure
approach, versus “sink or swim,” and when these models work best.
Understand the program and courses
Ask the student for course and individual learning goals. These will help you understand where to focus
teaching and provide guidelines for measuring progress.
Introduce the clinical setting
Tour the clinical setting and introduce the student to key personnel.
Orient the student to the practice and providers
Introduce the student to staff and other providers. Explain the clinical services offered at the site, the
population served, and the roles of staff and providers.
Orient the student to policies and protocols
Locate policies and procedures for the student, and identify those of importance. Include items such as
dress code, breaks, access to medical records and documentation, and how to notify the clinic of schedule
changes. Consider additional orientation days specifically for orienting to technology.
continues
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Table 10.1
Student Orientation Checklist (cont.)
Site specifics
Identify where to park, how to best access the clinic, hours of operation, and where to store belongings.
Student introductions
Decide how to make patients aware of the student and who will ask, and how they will ask, about student
involvement in care.
Source: Adapted from Lazarus, 2016
Once you have completed the orientation checklist, you will have a sense as to whether the preceptee
is a beginning, intermediate, or advanced learner. Your assessment will have some impact on how to
structure your day and learning opportunities. For a beginner, expect a large amount of observation
initially, with progressive responsibility for the preceptees over time. You should focus on building
skills and clinical reasoning, increasing student independence only when you are comfortable that
the preceptee is ready (Lazarus, 2016). Intermediate students should be capable of gathering histories
and establishing priorities. Your goals for these students include role modeling patient advocacy
while working on interprofessional and intraprofessional communication (Chen, Rivera, Rotter,
Green & Kools, 2016). Case presentations should be improving along with efficiency of visits, but a
focus on quality remains. Advanced students, while still under supervision, should be able to care for
an increasingly complex patient while carrying out most of the duties of the APRN with increasing
independence.
As you become more experienced at precepting, you will begin to develop a comfort level in assessing
your students, quickly identifying areas of strength and weakness. Keep in mind, your role is not to
enhance areas of strength, but rather to offer a safe environment in which the student can strengthen
weaknesses, evolving into a stronger healthcare provider.
Making the Most of the Clinical Setting
Each clinical setting is unique in the types of learning opportunities it offers. A clinical rotation in a
busy urban center will provide a much different experience than a clinical rotation in a rural primary
care practice; however, both are equally important in the learning continuum. Use the orientation as an
opportunity to talk with the student about what to expect from your setting. Understanding your own
practice and what it offers is just as important as understanding student needs. Consider the population
and types of patients seen, disease processes the student is likely to encounter, and which procedures are
frequently performed in your setting. Communicate your assessment to the preceptee.
Give thoughtful consideration to scheduling on days when students will be in the clinic. If you have the
ability to reduce the schedule initially, you may want to consider this in the beginning, as it is time well
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spent. However, because many practices focus on productivity, this may not be an option. In this case,
you will want to have a plan, share the plan, and follow the plan. Along with thoughtful scheduling is
thoughtful patient selection. Less experienced preceptees should begin with simple, straightforward
patients and/or complaints and evaluations, progressing to more complicated patients when you are
comfortable with the preceptee’s knowledge and competence. Finally, provide temporal expectations to
students: how long should a visit take? Give clear goals. Thoughtful consideration to scheduling, patient
selection, and time constraints will help keep your clinic running smoothly when students are present.
Understanding Yourself as the Preceptor—Incentives and
Barriers
Preceptors are as unique as the students they precept. Different teaching styles will work with different
students; therefore, as a preceptor you should be familiar with a variety of teaching styles, while
understanding the characteristics that enhance your own natural teaching style, adding to the overall
success of the clinical experience. Clinical teaching incorporates a variety of techniques, and some may
be used more than others. Commonly reported techniques include the use of modeling, observation,
case presentations, direct questioning, think aloud, and coaching to influence clinical learning (Lazarus,
2016). More information is available on these topics in Chapters 3 and 7.
In addition to clinical teaching, students report a number of behaviors that help them learn. Although
no one preceptor will incorporate all of these techniques in every clinical encounter with a preceptee,
reflecting upon the list and identifying areas where the technique could logically fit may help to improve
your personal teaching style. Table 10.2 identifies the top 22 preceptor characteristics of effective clinical
teachers, as rated by program directors, clinical instructors, and students.
Table 10.2
Effective Clinical Teaching Characteristics of Preceptor
Clinical competence/judgment
Calm during times of stress
Ego strength/self-assurance
Flexibility
Appropriately encourages independence
Engenders confidence
Motivates students
Empathy/respect
Evaluation/counseling
Enjoys teaching
continues
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Table 10.2
Effective Clinical Teaching Characteristics of Preceptor (cont.)
Stimulates student involvement
Positive role model
Open-minded
Sensitivity
Scholarly teaching/knowledge
Accessibility
Communication skills
Individualizes teaching
Timely feedback
Actively teaches
Stimulates effective discussions
Use of student care plans
Source: Adapted from Hartland & Londoner, 1997
As you consider your own personal style and characteristics, you undoubtedly will begin to identify the
reasons you like to precept. However, while incentives help you to say “yes” to the preceptee inquiry,
often there are a number of barriers that may cause you to hesitate. A healthy inventory of both topics
will ensure you provide the best opportunity to the next APRN requesting you as a preceptor. Taking
time to consider the barriers that are most likely to impact you and your practice will allow you to be
proactive and to avoid common frustrations and pitfalls.
Incentives encourage you to engage in activities that may require additional time, energy, or talent.
Because precepting is by and large a voluntary activity, recognizing the reasons why you say “yes” adds
insight and depth into your own characteristics as a teacher. In a study on precepting NP students by
Webb, Lopez, & Guarino (2015), 40 items were identified as incentives to precepting and centered
around recertification, program information, remuneration, access to resources, professional affiliation,
recognition, and gifts and rewards, the last of which was least incentivizing. One of the primary
motivations for APRNs to precept is the sense that one has a duty to “give back” to the profession (Webb
et al., 2015). In a large national survey of nurse practitioners, Roberts et al. (2017) identified a list of
incentives ranked in order of importance by preceptors nationally. Although financial compensation is
at the top of the list as far as importance, the practice of remuneration is not widely used, although it has
been increasing in recent years. See Table 10.3 for a complete list of incentives.
10
Table 10.3
Precepting Advanced Practice Registered Nurses
235
Incentives to Be an APRN Preceptor
Incentives ranked most to least important by preceptors
• Financial compensation
• Include as part of performance review
• Learn about current clinical guidelines
• Learn about new medications
• Access to continuing education programs
• Develop a relationship with NP faculty
• Access to online clinical materials
• Opportunity to take a course
• Preceptor training
• Adjunct faculty status
• Opportunity to guest lecture
Source: Adapted from Roberts et al., 2017
If you are incentivized by access to continuing education programs or receiving training to be a
preceptor, ask your faculty member about that. Schools will provide different incentives for preceptors,
and you may be entitled to something that is of value to you, removing one of the primary barriers:
feeling as though you are doing something for nothing.
Just as important as knowing what motivates you is understanding and planning for any potential
barriers and the frustrations they bring to both you and your preceptee. Planning for barriers and
expecting challenges is key to success. Productivity expectations, internal organizational challenges,
feelings of inadequacy, and time constraints are common barriers many preceptors report (Bazzell
& Dains, 2017; Roberts et al., 2017). Roberts et al. (2017) constructed the following list as common
suggested barriers to precepting:
• Time constraints
• Lack of space
• Issues related to electronic medical recording
• Lack of employer support
• Inadequate provider staffing
• Lack of NP experience/new graduate
• Inappropriate practice setting for student
• Not interested in being a preceptor
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
• Patient acuity is not appropriate for student
• Lack of faculty supervision
• Distance learning issues
Each site has its own unique set of barriers. Create a comprehensive list of barriers you are most likely
to encounter in your practice, and then develop a plan for success. For example, identifying time
constraints and negotiating scheduling before the clinical day starts will help to alleviate stress. If your
employer is not supportive of precepting, discuss the potential of training advanced APRNs that may
be considering employment in the near future. Precepting these students will provide a way to identify
potential candidates for employment. If your practice is a busy, high-acuity practice, it may not be the
right place for all students. Know your practice’s limitations, and know that you cannot be all things to
all people. The time you spend knowing your student, your site, and yourself will be time well spent.
Preceptors should feel empowered to reach out to clinical faculty for support and to discuss concerns, as
well as to request resources for support. Although financial remuneration may not be possible, a number
of incentives may provide just what you need.
Precepting Strategies
Orienting your student, knowing your site, and communicating expectations are only part of the
process. The more important part of the process is the activity that goes on with each and every clinical
encounter. Successful preceptorships start with solid planning: before, during, and after the clinical day.
We have focused thus far on what needs to occur before the preceptee arrives for the first day. Now we
turn our focus to the clinical workday and how teaching occurs throughout the clinical visit. While
some preceptors simply do what comes naturally to them, research has shown that structured teaching
techniques help to build solid clinical skills (Bott, Mohide, & Lawlor, 2011; Lazarus, 2016; Sloand et al.,
1998), and Bazzell and Dains (2017), in a review of the literature, found that clinical reasoning improves
when structured preceptor models are incorporated into clinical practice.
Two tools commonly used by APRN preceptors are The Five Minute Preceptor and SNAPPS:
Summarize, Narrow differential, Analyze, Probe, Plan, Select (Bazzell & Dains, 2017; Lazarus, 2016).
These tools not only provide structure and organization while helping to develop clinical reasoning, but
generally take very little time to learn.
While preceptors help to develop clinical acumen, they are crucial to the development of professional
and effective communication. Recall that the Institute of Medicine (IOM) reported in 1999 that
medication errors caused 44,000 to 98,000 preventable deaths each year, and you can see why there
continues to be a focus on effective communication (IOM, 2000). The Five Minute Preceptor tool has
been suggested as a supportive teaching tool to aid in clinical integration (Bott et al., 2011; Lazarus,
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Precepting Advanced Practice Registered Nurses
2016). The Five Minute Preceptor is a method of reporting on clinical concerns identified by the
preceptee; it provides the preceptor with a structure around which to organize a clinical dialogue to aid
in clinical integration.
Steps involved in the Five Minute Preceptor tool include the following: background; ask for a
commitment; probe for supporting evidence; provide management guidelines; reinforce what was done
correctly; and correct mistakes (Lazarus, 2016). In this structured exchange, the student presents a
case and commits to a concern or diagnosis. The preceptor will probe for more information and guide
the student, if necessary, to other possibilities. Once these steps have occurred, the preceptor discusses
management guidelines and offers an overall assessment of performance, reinforcing what was done
well. Following this step, if any corrections are needed, they are discussed before moving on to another
topic. The overall exchange is designed to take place within 5 minutes, depending upon complexity of
the exchange. Structure allows the student to feel at ease, understand expectations, and begin to develop
the skill of creating a differential diagnosis list (see Table 10.4).
Table 10.4
Five Minute Preceptor Strategy—Teaching Example
Step
Preceptor
Preceptee
Tips
Background
Provide full attention to the
student.
“RR is a 15-year-old
female with a sore
throat and a fever of
102.3o for 2 days.”
Ask for additional HPI,
but avoid leading
questions.
Ask for a
commitment
“What is your assessment?”
“I would like to order a
rapid strep test.”
Ask if there is
anything else the
student should
consider.
Probe for
supporting
evidence
“What makes you think it is a
bacterial pharyngitis?”
“The patient has fever,
sore throat, and tender
cervical lymph nodes
and is complaining of a
headache.”
Encourage the
preceptee to display
knowledge and
thought process.
Provide
management
guidelines
“The patient is in a high-risk
age group for strep pharyngitis
due to adolescent behaviors.
The symptoms are consistent
with a strep pharyngitis.”
Listens
Teach a maximum of
three points.
continues
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Table 10.4
Five Minute Preceptor Strategy—Teaching Example (cont.)
Step
Preceptor
Preceptee
Tips
Reinforce what
was done
correctly
“You identified physical exam
findings consistent with
bacterial infection and asked
for testing before prescribing,
according to the guidelines.”
Listens
Comment on
strengths.
Correct
mistakes
“When providing your report,
be sure to list all pertinent
information. For this case,
include sick contacts,
gastrointestinal or respiratory
issues, and pertinent surgical
history.”
Positive response from
preceptee
Provide constructive
feedback with
specifics.
Source: Adapted from Lazarus, 2016
Another structured tool is SNAPPS: summarize the history and physical findings, narrow the
differential to two or three relevant possibilities, analyze the differential by comparing and contrasting,
probe the preceptee by asking questions, plan the management of the patient, select issues related to the
case (Bazzell & Dains, 2017) (see Table 10.5). This tool is designed to encourage thinking and reasoning.
Either of the tools can be effective at providing structure to clinical reports.
Table 10.5
SNAPPS Strategy—Teaching Example
Step
Student
Preceptor
Tips
Summarize
“RR is a 15-year-old female
with a sore throat and a fever
of 102.3 o for 2 days.”
Provide full attention to
the preceptee.
Preceptee provides
case presentation.
Narrow the
differential
“It could be strep pharyngitis.”
“What else could it be?”
Consider the full
range of differential
diagnoses.
Analyze the
differential
“It could be an upper
respiratory infection,
mononucleosis, or influenza.”
“You did a great job of
thinking of many of the
possibilities for fever
and sore throat.”
Have the preceptee
identify critical
factors in the
diagnostic process.
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Precepting Advanced Practice Registered Nurses
239
Step
Student
Preceptor
Tips
Probe the
preceptor
“Are there any other findings
that might help to narrow
down the differential?”
“In this case, a rapid
strep test may help to
identify the cause of the
sore throat. However,
if it is negative, we will
rely upon the history
and physical exam, so it
is important to obtain a
complete HPI.”
This is the place to
point out things
that may have been
missed.
Plan
management
“For the next step I will
order the rapid strep test.
Following that, I will consider
management options if the
test is positive.”
“This is definitely the
next step.”
Encourage full
explanation of
management
pending all results.
Select a case
for self-directed
learning
“What would be different if the
patient had mononucleosis?”
“When providing report,
be sure to include
not only the chief
complaint, but also the
physical exam findings
to help narrow down
the list of differentials.
Let’s talk about a
mononucleosis case.”
Provide time for
the preceptee to
report on findings
consistent with
mononucleosis at
the start of the next
clinical day.
Source: Adapted from Lazarus, 2016
Evaluation
Evaluation is an important component of learning. Preceptees need to know if they are making progress
and meeting expectations, or if they need to improve. Throughout the rotation, preceptors should
provide feedback and evaluate performance on an ongoing basis in order to adjust behaviors in a timely
and meaningful fashion. Waiting to provide feedback until the end of the rotation will provide lessthan-optimal outcomes. In fact, evaluation can, and should, occur throughout the day, with more formal
evaluation at prescribed intervals.
Address deficiencies head on. Although you strive for success in each and every preceptee, not every
preceptee will be successful, and feedback helps to make sure you have taken advantage of every
opportunity for success (Berte, 2017). Provide feedback in a neutral area and in private for best
outcomes. Avoid providing feedback, especially negative feedback, in front of patients. Try to keep
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
comments positive, and confirm understanding. As well, you should request an evaluation of your
precepting from preceptees. Doing so will help you continue to improve as well. Additional information
can be found in Chapter 3.
Conclusion
The role of the preceptor has taken on new meaning as the climate of education changes. Once viewed
as an apprenticeship, the education of today’s APRNs occurs via preceptors serving not only as
clinical resources, but also as coaches, role models, counselors, and ultimately colleagues. To maintain
consistency in the delivery of clinical education, the literature supports the use of structured tools to
assist with development of clinical reasoning and to improve communication.
In this chapter, you have been provided with an overview of the many roles preceptors take on, along
with strategies for organizing and delivering a successful clinical preceptorship. Although schools of
nursing may ultimately migrate from clinical hours to competency-based education or incorporate the
use of new models for training, the need for preceptors will remain (Logan, Kovacs, & Barry, 2015). In
the world of clinical education, nothing serves to educate better than real work experience.
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241
Preceptor Development Plan: Precepting APRNs
Review the information on precepting APRNs discussed in this chapter. What are your strengths?
In which areas do you need to increase your knowledge and expertise? What is your plan for
expanding your knowledge and expertise? What resources are available? Who can help you?
Name:
Date:
The Role of the APRN Preceptor
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Plan
Resources
Knowing Your Preceptee
Strengths
Knowing Yourself
Strengths
Precepting the APRN Student
Strengths
Needs
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Making the Most of the Clinical Setting
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Precepting Strategies for APRNs
Strengths
Evaluation
Strengths
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
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243
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Qualitative evidence synthesis. Journal of Advanced Nursing, 74(2), 251–262. doi: 10.1111/jan.13446
National Organization of Nurse Practitioner Faculties. (2017). Nurse practitioner core competencies content. Retrieved from
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/2017_NPCoreComps_with_Curric.pdf
Roberts, M. E., Wheeler, K. J., Tyler, D. O., & Padden, D. L. (2017). Precepting nurse practitioner students: A new
view—Results of two national surveys of nurse practitioner preceptors. Journal of the American Association of Nurse
Practitioners, 29(8), 484–491. doi: 10.1002/2327-6924.12482
Schumacher, G., & Risco, K. (2017). Competency-based nurse practitioner education: An overview for the preceptor. The
Journal for Nurse Practitioners, 13(9), 596–602.
Scott-Herring, M., & Singh, S. (2017). Development, implementation, and evaluation of a certified registered nurse
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Sloand, E. D., Feroli, K., Bearss, N., & Beecher, J. (1998). Preparing the next generation: Precepting nurse practitioner
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Webb, J., Lopez, R. P., & Guarino, A. J. (2015). Incentives and barriers to precepting nurse practitioner students. The
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“It’s better to light the candle than to curse the
darkness.”
–Eleanor Roosevelt
Assessing and
Addressing Preceptee
Behavior and Motivation
–Cindy Lefton, PhD, RN, CPXP
Robert E. Lefton, PhD
11
OBJECTIVES
On the drive home, you start analyzing your shift and rehashing the events one
by one. Although you can’t put your finger on why, a feeling in your gut tells you
that your preceptee is struggling. You are not quite sure if this struggle is related to
clinical competency issues, connecting with patients, or challenges collaborating
with other team members. Regardless of the source, the signs and symptoms of
a needed attitude or behavioral adjustment can vary. The key here is to “light the
candle” by acknowledging your gut feeling and devising a strategy that objectively
and constructively addresses the preceptee’s issues in a manner that influences
behavior change.
Focusing on observable change, this chapter provides you with tools aimed at
helping preceptees gain insight regarding how their behavior impacts care delivery,
the patient experience, and teamwork. Strategies preceptors can use to influence
preceptee behaviors are also presented.
Every day, you are surrounded and bombarded by attempts to change your attitudes
and behaviors. Billboards, commercials, and advertisement pop-ups on Facebook
are attempts to influence your attitude and shift your behaviors. Even your unit’s
patient satisfaction scores and clinical indicator data posted in the breakroom are
subtle attempts to impact behaviors of the team. Regardless of the media format,
researchers from the field of psychology study how you receive this information and
your behavioral responses to these messages.
•
Increase the
effectiveness of
preceptee problemsolving strategies
•
Assess preceptee
behavioral pattern
strengths and
developmental
opportunities
•
Implement evidencebased practices to
influence preceptee
behaviors
•
Utilize the Five-Step
Format as a framework
to provide preceptees
with action-oriented
feedback regarding
how their behavior
impacts care delivery,
patient interactions, and
teammates
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In essence, psychology is the science devoted to understanding human behavior or, simply, the study
of why people do what they do. Since the days of Plato and Aristotle (and probably before), men and
women have been trying to unravel the causes of human behavior. Many theories describe the hows and
whys of human behavior. Regardless of your theoretical beliefs, the various disciplines of psychology
agree that human behavior is both complex and fascinating.
In the hospital setting, where the patient continuum ranges from experiencing life to death, nurses
encounter a variety of circumstances in which human behavior (what we do and how we do it) saves
lives and/or leads to worsening of a condition or possibly a patient death. Over the past few decades,
a wealth of research has been devoted to exploring the link between patient outcomes and human
behaviors (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; American Association of Critical-Care Nurses
[AACN], 2016; Hall, Johnson, Watt, Tsipa, & O’Connor, 2016; Institute of Medicine [IOM], 2000; Salyers
et al., 2017). The consensus is clear that both actions and behaviors impact patient survival as well as the
health of our work environments.
Now that data support the impact of behavior on patient safety, outcomes, and work environments, it is
even more critical to address early on those preceptees whose attitudes or behaviors need improvement.
Attitudes and behaviors are different. Attitudes are what you think. Behaviors are what you do. Although
you can’t always see someone’s attitude, behaviors are 100% observable. Because behavior is observable,
behavioral change is easier to measure. Therefore, most of the tools and strategies in this chapter focus
on behavioral change; however, a by-product of behavior change can be an impact on one’s attitude
(Avey, Luthans, & Youssef, 2010; Petrocelli, Clarkson, Tormala, & Hendrix, 2010).
Similar to how you would begin patient care, attitudinal/behavioral improvements should begin with
an assessment of the situation. The purpose underlying both patient care and behavioral assessment
processes is to identify symptoms and search for causality. For example, when you notice that a patient’s
urine output is decreased, you assess for hypovolemia, and you might look to see if an issue with
kidney function exists, etc. When you encounter a person with a negative attitude and non-productive
behaviors, your assessment often involves attributing these occurrences to the person’s internal qualities
(Gilbert & Malone, 1995; Harvey, Madison, Martinko, Crook, & Crook, 2014; Heider, 1958). There
is often a human tendency to assign negative intentions to people when you encounter problematic
situations. This well-documented phenomenon, known as the fundamental attribution error (Gilbert
& Malone, 1995; Heider, 1958), can be avoided by increasing your awareness of how you approach
problems and by using a framework that promotes a more objective assessment of the situation at hand.
Just Culture: A Problem-Solving Framework
The Just Culture framework can help preceptors objectively assess preceptee performance and guide
preceptors away from making fundamental attribution errors. Operating on the premise that the
majority of errors occur because of system failures as opposed to individual failures, a Just Culture
11 Assessing and Addressing Preceptee Behavior and Motivation
247
promotes the philosophy that human beings make mistakes and, instead of jumping immediately
to assigning blame, we should encourage exploration of the factors related to the error; make
improvements based on these findings; strive to create an environment where candor is valued;
and reward people for speaking up to identify events, processes, and behaviors that create safety
vulnerabilities (GAIN Working Group E, 2004; Marx, 2012). In other words, a Just Culture emphasizes
solving the problem, not attributing negativity or blame.
Though a Just Culture might appear “soft” to some, this type of philosophy does not serve as an excuse
for error. Instead, a Just Culture helps avoid attributions and blame by redirecting focus to incorporate
both the individual and the system contributions to the errors. Organizations supporting a Just Culture
still hold employees accountable and responsible for their actions, and they still make a clear distinction
between acceptable and unacceptable behaviors (GAIN Working Group E, 2004).
Three Types of Errors
A Just Culture perspective recognizes three different types of errors: human error, at-risk behavior, and
reckless behavior.
Human Error. The first type, human error, involves those situations in which a person was
“inadvertently doing something other than what they should have been doing” (Marx, 2012, p. 29) and
a slip or a lapse occurs. Human error behaviors might occur, for example, when a preceptee who has
been taking care of a patient all day is in a hurry. The preceptee grabs the blood specimen label from the
printer, checks the name against the patient’s identification (ID) band, but misses that the birth date is
different (unbeknownst to the preceptee, a new patient with the same name was admitted to the unit),
and then sends the improperly labeled specimen to the lab. The preceptee should have been paying
attention to all the identifiers on the label but was not concentrating on the task at hand and made a slip.
At-Risk Behavior. The second type of error, at-risk behavior, encompasses choosing actions that
increase the risk of a mistake, “and the risk is not recognized, or it is mistakenly believed to be justified”
(Marx, 2012, p. 35). An example of at-risk behavior would be a preceptee who identifies that the patient
is crashing and attempts to treat the patient without seeking guidance from the preceptor. The preceptee
does not seek preceptor guidance because she/he thinks the preceptor is busy (and doesn’t want to
bother the preceptor) and views this event as an opportunity to demonstrate competency in handling
a high-acuity situation. The mistake in this scenario is that the preceptee convinces himself/herself
that demonstrating competency in handling the situation and not “bothering” the preceptor was the
correct action to take. The preceptee thought he/she was doing the “right thing” but failed to make the
connection between getting the preceptor involved and ensuring patient safety.
Reckless Behavior. The third type of error, reckless behavior, involves making a conscious effort to
disregard a practice, policy, or norm. This type of error also involves taking a considerable unjustified
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risk (Marx, 2012). An example of reckless behavior would be a preceptee who does not check the
drawn-up dosage of insulin with another nurse. Everyone on the unit is busy, and the preceptee is
confident he/she knows how to properly administer medication. He/she administers the insulin, and it’s
the wrong dose. In this scenario, the preceptee made the choice to be reckless by consciously ignoring
and disregarding the double-check, which is a patient-safety best practice.
Applying Just Culture
Applying the Just Culture philosophy as a preceptor allows you to examine preceptee disconnects by
dissecting behaviors while avoiding attribution errors. For example, ask yourself if the problems with
the preceptee seem to be more related to human error versus at-risk behavior or reckless actions. In the
example of the mislabeled specimen, does the preceptee acknowledge that when this error occurred
he or she was thinking about tasks that needed to be done for other patients? Not focusing on the task
at hand, multi-tasking, and/or interruptions can lay the groundwork for focus to drift, slip, or lapse,
which leads to missing, ignoring, or brushing over an important detail (Getnet & Bifftu, 2017; Monteiro,
Avelar, & Pedreira, 2015; Potter et al., 2005). Coaching the preceptee on the importance of focusing on
the patient, and providing some multi-tasking strategies, might help the preceptee avoid a potential
human error. In this scenario, using the Just Culture framework enables the preceptor to focus on the
preceptee’s behavior (lack of focus) instead of assigning blame or using energy to “attribute” causality
(that is, the preceptee doesn’t care, is spacey, doesn’t like to care for patients with this diagnosis, etc.).
If you identify that the preceptee is engaging in actions associated with at-risk behavior, this is a red flag
that the preceptee needs help in “connecting the dots.” In other words, the preceptee needs your help
in learning and understanding how certain behaviors can negatively impact a situation. As you help
the preceptee connect the dots, you might also identify developmental opportunities around critical
reasoning. At-risk behavior can, at times, be mistaken as a symptom of disengagement and carelessness
when, in reality, it is a by-product of learning new skills and adapting to a new environment. In the
scenario in which the preceptee tried to handle the crashing patient alone, identifying at-risk behavior
redirects the focus from attributing actions as being “renegade” to devising coaching strategies that
convey the message that, in high-acuity situations, delivering nursing excellence often involves a team
effort. Preceptees demonstrating at-risk behavior might benefit from closer observation and additional
coaching. Depending on the severity of the situation and/or the individual preceptee’s behavioral trends,
at-risk actions might warrant corrective action.
Using the Just Culture framework can also help preceptors identify those situations in which reckless
behavior is occurring. Because reckless behavior involves a choice that leads to a blatant disregard
for practices, this action is often associated with some form of corrective action. If a preceptee has
demonstrated reckless actions, avoiding the attribution error is critical. In these situations, the
preceptor’s role is to focus on the behaviors linked to the mistake or near miss; involving the unit
manager is a must. People exhibiting reckless behavior can turn it around, but the manager needs to
be involved with monitoring preceptee behavior and providing the preceptee with ongoing feedback.
11 Assessing and Addressing Preceptee Behavior and Motivation
249
Reckless behavior errors are associated with an unjustified risk or action; therefore, statements from
the preceptee such as “I meant to do X” or “I was trying to accomplish Y” are not part of this equation.
Instead, these types of justifications are associated with at-risk behavior.
The goal of integrating the concept of Just Culture into the preceptor toolbox is to help preceptors
avoid placing blame and making attribution errors. In addition to helping preceptors avoid attribution
errors, problem-solving from the Just Culture perspective emphasizes examining external factors
(e.g., equipment malfunction, lack of policy, and/or a new physician) as potential sources that could
have “set the stage” for non-productive behaviors to occur (e.g., a new physician was covering the unit
and did not communicate the order correctly, etc.). Utilizing the Just Culture framework provides
preceptors with a more “global view” of the problem at hand. This global perspective can help preceptors
identify developmental opportunities for preceptees and might even lead to making some significant
improvements that positively impact patient care processes throughout the hospital.
Providing Feedback
Though the Just Culture framework is helpful for guiding preceptors toward solutions that focus on
identifying individual behavioral lapses and system and process vulnerabilities, it does not provide
any information about delivering the message or providing feedback. As a preceptor, part of your role
involves creating an environment that promotes learning and allows the preceptee to thrive and become
a contributing member of the team. The preceptee is responsible for taking these opportunities to hone
his or her skills, grow as a nurse, and become a productive member of the team. You can use feedback
as a tool to synchronize preceptor and preceptee responsibilities (Lefton & Buzzotta, 2004; Lefton,
Buzzotta, & Sherberg, 1980).
Although feedback serves as a powerful tool, the reality is that you cannot change another person’s
behavior. However, you can influence others to change their behaviors (Aryee, Walumbwa, Seidu,
& Otaye, 2013; Cialdini, 2006). Your ability to influence others through feedback is one of the most
powerful tools you have as a preceptor. Increasing the chances that your feedback actually leads to
behavior change is, in part, related to your behavioral assessment skills. In other words, you want to
ensure that you are influencing the right behavioral patterns and addressing those actions that can lead
to errors, poor patient experiences, and ineffective teamwork.
The Dimensional Model of Behavior
The Dimensional Model of Behavior is a systematic process to identify preceptee behavioral pattern
strengths and developmental opportunities. Preceptors can use that information as a tool to influence
behaviors. The information preceptors can glean from using the Dimensional Model of Behavior enables
them to provide preceptees with actionable data based on observations of behavioral patterns, and
thereby influence behavior change.
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The premise underlying the Dimensional Model of Behavior is that observed workplace behaviors can
be broken down into two dimensions—accomplishing tasks and relating to others (Lefton & Buzzotta,
2004; Lefton et al., 1980). The task dimension (see Figure 11.1) helps the preceptor assess how the
preceptee goes about accomplishing the work associated with his or her job. The type of task does not
matter; it can be inserting a Foley catheter or calling the rapid response team. The emphasis is not on the
specific job, but rather on how the preceptee accomplishes the work. In other words, does the preceptee
approach the work by demonstrating proactive, take-charge, and “make things happen” behaviors?
For example, when the preceptee senses an angry family member, does the preceptee proactively try
to understand and problem-solve before the situation escalates? Or, does the preceptee deal with the
angry family by taking a more reactive, “let things happen,” passive (submissive) approach? In this latter
situation, a preceptee might sense the family’s frustration but avoid dealing with the family’s anger until
it explodes.
The Task Dimension
Measures how I get things done
INITIATES
(Dominant)
AVOIDS
(Submissive)
FIGURE 11.1 The Task Dimension
Copyright © Psychological Associates® 2018
The people dimension (see Figure 11.2) assesses how a person conveys warmth and regard toward
others. When you assess the people dimension, the focus is on those behaviors you observe as the
preceptee interacts with patients and with other members of the healthcare team. In other words,
how does the preceptee convey warmth and regard for others? Is the preceptee warm, approachable,
responsive, and sensitive to the needs of others? Does the preceptee give others eye contact? Does the
11 Assessing and Addressing Preceptee Behavior and Motivation
251
preceptee sit down at the bedside and touch the patient and engage in conversations with other staff
members? Or, does the preceptee send off a vibe that projects defensiveness, disengagement, disinterest,
or a non-caring attitude? Does the preceptee avoid eye contact with patients and peers, respond only to
questions that are asked and come across as mechanical, or seem to be uncomfortable communicating
with other team members?
The People Dimension
Measures how I approach others
LOW REGARD
(Hostility)
HIGH REGARD
(Warmth)
FIGURE 11.2 The People Dimension
Copyright © Psychological Associates® 2018
Combining the task and people dimensions of the Dimensional Model of Behavior yields four types
(quadrants) of behavioral patterns that can describe preceptee behaviors (see Figure 11.3). Individuals
tend to exhibit behaviors that reside in one quadrant more than the other three. These are primary
behaviors, and individuals rely on these actions more than they do the other behavioral styles. However,
depending on the situation, behavior can change, and most everyone from time to time demonstrates
actions associated with all four quadrants. For example, when the chief nurse executive calls you into
his or her office, you might exhibit different behaviors than you demonstrate when a peer asks to speak
with you. You might observe your preceptee interacting with other preceptees differently than he or
she interacts with you. The key point to remember is that everyone is capable of changing behavior,
and these changes are influenced by the people you interact with and the situations you encounter. As
with any tool such as this, people rarely fit neatly into a box and should always be viewed as individuals;
but the Dimensional Model of Behavior provides the preceptor with a way to systematically look at
preceptee behavioral pattern strengths and identify developmental opportunities.
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INITIATES
(Dominant)
Q1
•
•
•
•
•
LOW REGARD
(Hostility)
Interrupts
Overwhelms
Overcontrols
Bulldozes
Argumentative
Q4
•
•
•
•
•
Q2
•
•
•
•
•
Listless
Vague
Uncertain
Talks little
Guarded
Listens
Inquires
Explains
Involves others
Assertive
Q3
•
•
•
•
•
HIGH REGARD
(Warmth)
Meanders
Overly agreeable
Too friendly
Talkative
Smoothes over
AVOIDS
(Submissive)
FIGURE
11.3© Psychological
Dimensional
Model ®of2018
Behavior
Copyright
Associates
Copyright © Psychological Associates® 2018
Quadrant 1 Behaviors
Preceptees who exhibit dominant, proactive behaviors and low regard for others (quadrant 1or Q1)
demonstrate actions that are task-oriented, but these actions rarely convey sensitivity toward others.
Preceptees with primarily proactive and low-regard behaviors (Q1) get things done, but they leave
a trail of frustrated and often angry people. This occurs because the emphasis on completing tasks
overshadows concern and regard for others, and they run over people as they try to get work done.
Examples of Q1 behaviors include interrupting people, arguing, becoming defensive, not being open to
the feedback or opinions of others, and a “my way or the highway” attitude. Preceptees exhibiting these
behaviors like to “tell and do” and are so focused on getting things done that they often don’t realize
others perceive their behaviors as insensitive, defensive, or bullying.
Quadrant 2 Behaviors
Similar to dominant, proactive, and low-regard (Q1) behaviors, preceptees exhibiting primarily
avoidant, passive, and low-regard for others behaviors (quadrant 2 or Q2) also come across as
insensitive and defensive. However, these actions are buffered by their submissive and reactive approach
to getting things done. Therefore, these behaviors are often perceived as passive aggressive. Preceptees
with primarily Q2 behaviors are likely to display actions that convey a sense of aloofness; they appear
unengaged and come across as guarded, distant, cool, and noncommittal. Conversing with preceptees
who possess significant amounts of these behaviors might feel like “pulling teeth” as you try to get
information and input from them. Though their behaviors might convey a sense of disengagement,
preceptees with Q2 behaviors are more comfortable keeping themselves and their emotions close to the
vest. They prefer not to “rock the boat,” so they tend to follow the rules and stay out of the limelight.
11 Assessing and Addressing Preceptee Behavior and Motivation
253
Quadrant 3 Behaviors
Overdoses of warmth, sensitivity, and high regard, combined with avoidant and reactive actions, are
characteristics of preceptees who demonstrate predominantly quadrant 3 (Q3) behaviors. These overly
sensitive behaviors, coupled with a submissive, passive approach toward accomplishing the task, yield
actions that can be described as too friendly, focusing only on the positive (optimism on steroids),
and avoiding the negative by glossing over conflict and “sticky issues.” Preceptees with primarily Q3
behaviors will eagerly take your feedback and thank you over and over again for the information.
However, if they perceive that changing their behaviors may lead to conflict, they might not follow
through.
Quadrant 4 Behaviors
With an emphasis on both accomplishing the task and valuing others, preceptees with behaviors that
demonstrate initiative and convey high regard for others (quadrant 4 or Q4) are some of the strongest
team members. Preceptees who exhibit these behaviors focus on accomplishing the task but equally
value the contributions of others. Q4 behaviors are not “soft or fluffy” but, instead, balance the need to
accomplish a task with being responsive to teammates. Preceptees with these behaviors will question
the preceptor but do so in a respectful manner that encourages both of you to grow and develop. Some
examples of the actions demonstrated by preceptees with primarily Q4 behaviors include conveying
caring and respect to patients, peers, and family members; engaging in teamwork; providing timely
follow-up; and keeping you in the loop so you know what is happening with their patients. Preceptees
with Q4 behaviors are assertive but not aggressive. They are not afraid to take on a hard assignment and
do not hesitate to ask for help. In the event that they get into a situation that is over their heads, they
willingly listen to feedback and integrate the preceptor’s suggestions into their care delivery.
Summary
In summary, the Dimensional Model of Behavior serves the purpose of helping preceptors identify
patterns of both effective and ineffective behaviors. Similar to a Just Culture, this model shifts the
emphasis away from attribution to observing real-time clinical savvy and interactions among the
preceptee, patients, and team members. This kind of observation serves the purpose of providing
objective, behavior-based feedback that can enrich the preceptee’s experience and give them specific
examples of how their actions positively impact the patient experience, safety, and teamwork, as well
as help them identify developmental opportunities. Nurse competencies encompass both clinical
expertise and people skills. Identifying the behavioral patterns of your preceptee is the first step in
providing meaningful feedback that influences behavioral change. When assessing a preceptee, focus
on behaviors you are actually observing. Identify that task orientation first, and then assess the people
dimension. When you are assessing your own behavioral patterns, ask yourself, “What are the behaviors
I am demonstrating?” This question can help you focus on your actions, not intentions. Finally, always
remember the powerful impact your behavior has on the preceptee. Tips for using the Dimensional
Model of Behavior are found in Table 11.1.
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Table 11.1 Tips for Using the Dimensional Model of Behavior
1.Remember that you are categorizing behavior, not people. This is an important concept because
behavior can change, and the model allows you to assess these changes.
2.When using the model to assess behavioral patterns, begin by assessing how the preceptee goes
about accomplishing the task. Do the preceptee’s behaviors appear dominant, proactive, and take
a “make things happen” approach? Or does the preceptee exhibit actions that are more reactive,
passive, and take a “let things happen” approach?
3.After you have assessed the preceptee’s task behavior, evaluate behavior in the people
dimension—how the preceptee’s behaviors convey warmth and high regard for others.
4.As a preceptor, you are viewed by preceptees (and likely other team members) as an expert and
a leader. This is an important relationship dynamic to understand because your expertise and
leadership can influence preceptee behavior changes.
5.Increasing your awareness regarding how your behaviors impact others is a powerful way to
influence preceptee actions.
6.When assessing your own behaviors, don’t focus on your intentions (what you want to do) or how
you would like to act. Instead, focus on what you are doing and on the actual behaviors you are
demonstrating.
7.If you are exhibiting Q1 behaviors, your preceptee (and other coworkers, and even patients) might
slip into a Q2 or Q3 mode to avoid a confrontation with you.
8.Remember, behavior breeds behavior, and your actions are one of the strongest influencers in your
toolbox. As a leader, you owe it to yourself, your preceptee, patients, and teammates to role model
the behaviors you expect and desire from others.
9.Proactive and responsive actions (Q4) are generally the most effective behaviors, as they balance
accomplishing the task with regard for others. Preceptors should find ways of encouraging these
actions.
Understanding Preceptee Motivations
Understanding some basic concepts about motivation (why people do what they do) helps you translate
influence into behavior change. In essence, people change behavior based upon their reasons, not
necessarily yours (Hall, Lindzey, & Campbell, 1997). Therefore, gaining insight into their reasons or
tapping into their motivation can help you influence behavior change and obtain their commitment to a
course of action (Kurtessis et al., 2015; Perlini & Ward, 2000). Using the model to identify a preceptee’s
behavioral trends provides you with a window into the preceptee’s motivation. In other words, through
your behavior you broadcast the reasons for why you do what you do or, rather, why you demonstrate
certain behavioral patterns, such as those described in the Behavioral Pyramid (see Figure 11.4).
11 Assessing and Addressing Preceptee Behavior and Motivation
Q4 Behavior
Q1 Behavior
255
Selfrealization
needs
Independence
needs
Esteem needs
Q3 Behavior
Social needs
Q2 Behavior
Security needs
Biological needs
®
Copyright
Psychological
FIGURE
11.4 ©The
BehavioralAssociates
Pyramid 2018
Copyright © Psychological Associates® 2018
Several decades ago, psychologist Abraham Maslow devised a theory to explain how our intangible
needs motivate behavior (Maslow, 1967). Maslow’s theory stated that for individuals to move up the
hierarchy of needs, they must satisfy the lower level needs (at the bottom of the pyramid) before they
can advance to the next level. Similar to Maslow’s model, the Behavioral Pyramid focuses on needs
associated with the workplace (Lefton & Buzzotta, 2004; Lefton et al., 1980). For example, workers
must satisfy their biological needs (food, water, etc.) before they can become productive contributors.
After these needs have been met, a person can advance to the next level in the hierarchy: security
needs (e.g., safety, an income, role stability, clarity, and predictability). Once security needs have been
met, individuals are ready to advance to social needs, which center on the desire to be connected with
coworkers and create meaningful relationships at work. Upon meeting social needs, individuals can
advance to the esteem needs (e.g., achievement, recognition for their contributions, and respect from
colleagues). After these needs have been met, the individual can progress upward and focus on meeting
independence needs, which involve the desire for autonomy and control. Though independence needs
are not a part of Maslow’s hierarchy, these needs are associated with factors that motivate workplace
behaviors (Lefton & Buzzotta, 2004; Lefton et al., 1980). The next level, self-realization, is rarely attained
because everyone is always growing. Needs at the self-realization level are associated with obtaining
goals that are related to the greater good of the organization and mankind.
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Applying the Dimensional Model of Behavior to the Behavioral Pyramid, you can link behaviors to
satisfying various needs. Focusing on Q2 behaviors, a link exists between these actions and the need
to establish and maintain security. Preceptees with predominantly Q2 behaviors are motivated by
intangible needs that:
• Ensure security and stability
• Are predictable
• Value policies and procedures because they add a level of predictability and security to the job
How can you influence Q4 behaviors with a preceptee demonstrating Q2 actions? Link the desired
behavioral outcomes to creating stability and maintaining security.
Learning Moment
You notice that your preceptee is exhibiting some Q2 behaviors. The preceptee often eats
alone and does not get involved with staff conversations. Approaching the preceptee, you can
link the desired behavior change (engage with coworkers) by explaining that communicating
with staff helps keep things under control (stability) and allows all teammates to be apprised
of what is going on with all the patients in your area (predictability).
Preceptees exhibiting predominantly Q3 behaviors are motivated by intangible needs related to:
• Social needs and feeling connected with colleagues
• Creating team spirit
• Keeping everyone happy and avoiding conflict
How can you influence Q4 behaviors with a preceptee demonstrating Q3 actions? Link the desired
behavioral outcomes to connectedness and maintaining harmony among the team.
Learning Moment
Your preceptee comes across as disorganized, which creates the appearance that the
preceptee is “running in circles.” The preceptee wants to fit in, so often offers to help others,
even when running behind. Recognizing the need to help your preceptee be successful,
your conversation focuses on linking the desired behavior change (staying focused on
accomplishing their work first) and explaining how taking extraordinary care of patients
(connectedness) helps the team and puts the preceptee in a better position to offer assistance
to others (teamwork and harmony).
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If you encounter a preceptee who demonstrates primarily Q1 behaviors, these actions are motivated by
intangible needs related to:
• Esteem needs reinforced by accolades from others
• Accomplishing tasks and getting things done
• Valuing responsibility, independence, control, and the ability to shape one’s destiny
How can you influence Q4 behaviors with a preceptee demonstrating Q1 actions? Link the desired
behavioral outcomes to accomplishing goals and recognition of their contributions.
Learning Moment
A colleague shares with you that she witnessed your preceptee interrupting one of the
unit secretaries who was trying to pass along information regarding a patient request.
When debriefing the day with your preceptee, you can link the desired behavior change
(demonstrating respect through true collaboration with all team members) to describing how
interrupting others can lead to missing key information, hampering one’s ability to stay on top
of things (control and independence), and shaping perceptions that you are difficult to work
with (esteem).
Preceptees demonstrating mostly Q4 behaviors are motivated by intangible needs related to:
• Opportunities to demonstrate responsibility and independence
• Self-realization involving the development of the individual’s potential to benefit the team,
patients and their families, and the organization
How can you reinforce Q4 behaviors? Link the desired behavioral outcomes to personal growth and
positively impacting others.
Learning Moment
Your preceptee is a rock star in both the art and the science of nursing. The preceptee’s
clinical savvy and patient experience skills have raised the bar for the entire unit. You recently
observed an interaction with an angry physician wherein the preceptee struggled with
maintaining Q4 behaviors, even though his/her actions were following appropriate treatment
guidelines. Link the desired behavior change (maintaining your Q4 behaviors) to growth by
explaining how demonstrating Q4 actions can positively influence the behaviors of others
(self-realization).
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In summary, motivation provides the reasons underlying human behavior. Because individuals’ actions
broadcast their needs, using the Dimensional Model of Behavior to identify behavioral patterns can help
you identify the best strategy to influence change. Preceptees exhibiting Q1 behaviors are motivated
by the intangible needs of esteem and independence. People exhibiting actions associated with Q2
behaviors are driven by security needs. Preceptees demonstrating Q3 behaviors are motivated by
intangible needs associated with group harmony and positive connections with others. People exhibiting
Q4 actions are driven by intangible needs linked to independence and growth experiences that benefit
the team, patients, and family members.
Interacting With Influence—The Five-Step Format
The Just Culture framework provides a way to shift the focus from blame to gaining insight on the
factors associated with making an error. The Dimensional Model of Behavior is a tool to identify
behavioral patterns of preceptees. After a behavioral pattern is identified, this information can be used
to gain insight regarding how the preceptee is motivated to continue using those behaviors deemed
effective and change those actions in need of an adjustment.
All of these tools can be integrated into an influence strategy that increases the odds of eliciting
sustained behavior changes. The Five-Step Format is a strategy that enables you to structure a
conversation that influences behavior change by promoting a two-way dialogue and getting both parties
involved in the discussion (Lefton & Buzzotta, 2004). This format encourages a Q4 exchange of ideas
and includes formulating an agreed-upon action plan. The five steps are:
1. Start the conversation
2. Get the preceptee’s views
3. Give your views (of the preceptee’s views)
4. Resolve differences
5. Develop an action plan
Step One: Start the Conversation
Starting the conversation is one of the most important parts of the interaction because your behaviors
set the tone of the conversation. As the preceptor, you possess the power, so remember that this dynamic
can shut down the preceptee, especially if his or her predominant behavioral style is Q2. Starting the
conversation involves appropriate sociability (which is basically a greeting) and identifying both the
purpose and the reason for your conversation.
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259
Determining appropriate sociability depends upon the preceptee’s primary behavior. Preceptees who
primarily exhibit Q1 behaviors will likely want to cut to the chase and get to the crux of the interaction.
Asking preceptees of this type how their day is going is appropriate, but remember that they like to
quickly get to the task at hand. For preceptees who demonstrate mostly a Q2 behavioral style, too much
sociability might increase their anxiety, but jumping right into the “meat of the issue” might also be a bit
overwhelming. Remember, these conversations require a slow pace, and the preceptee’s behavioral cues
will help you sense when to increase and decrease sociability.
Preceptees with predominantly Q3 behaviors require part of the interaction to be devoted to “social
niceties,” so step one is a good place for that part of the conversation to occur. Preceptees demonstrating
mostly Q4 behaviors will engage with the social niceties and will also be prepared for an engaging
discussion of the situation.
After appropriate sociability has occurred, explain the reason and purpose for the conversation. The
reason encompasses the past behaviors that led to a discussion. The purpose is future-focused and allows
the preceptor to articulate the behavior change expectations that need to occur as the preceptee moves
forward. Describe the reason first, followed by the purpose. This reason-purpose “bundle” increases
the odds that the preceptee will actively participate in the conversation and take ownership of their
behaviors that created the need for this conversation.
Navigating a successful step one involves the ability to adapt your approach to the behaviors your
preceptee is exhibiting. Below are Q4 strategies you can use to keep the conversation blame-free and
future-focused.
• Preceptee behavior guides the appropriate level of sociability.
• A reason focuses on past behaviors.
• A purpose shifts the focus to future actions.
• The purpose shifts the content away from the past (an event the preceptee can no longer
change) to future behaviors they can control.
• The reason-purpose bundle, combined with Q4 preceptee behaviors, can help you avoid
placing blame.
An example of integrating Just Culture into a blameless reason and a purpose strategy is: “I am aware
that a lab error occurred last week. Let’s discuss what happened and then talk about what kind of
practice changes you believe need to occur so that, moving forward, these types of errors can be
avoided.”
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In summary, step one, starting with the conversation, is an opportunity to provide the preceptee with a
mentoring experience and utilize your Q4 behaviors to positively influence the preceptee’s actions. The
preceptee’s predominant behavioral style will guide the appropriate level of sociability needed to start
the conversation. Utilize the reason-purpose bundle as a strategy to identify, without blame, the specific
actions that led to the conversation (reason) followed by future focus (purpose), emphasizing behavior
change.
Step Two: Get the Preceptee’s Views
Why should you get the preceptee’s view of a situation before sharing your observations? Remember
that as the preceptor, the power is with you. If you put your views “on the table” first and the preceptee
does not share your opinion, the preceptee is automatically put in a defensive position because he/she
disagrees with you. The goal of step two is to gather information and seek clarity. The most effective way
to begin and manage this step is by asking open-ended questions. Asking open-ended questions invites
the preceptee to elaborate on key issues the preceptee feels are important, which encourages engagement
in the conversation. These types of probing questions begin with a “how,” a “what,” or a “why” and lay
the foundation for two-way communication. To increase the odds of a successful step two, refrain from
sharing your opinion during this part of the conversation (you’ll get an opportunity to provide your
views in step three). Sizing up the behaviors of your preceptee will also guide your open-ended strategy
during this step.
When interacting with preceptees who demonstrate predominantly:
• Q1 behaviors—Preceptees will actively share their views but may try to get you to express
your views, so be mindful to stay on track and get their full perspective before you respond.
• Q2 behaviors—Preceptees may struggle to share their opinions, so pausing after asking openended questions is important, as it gives them time to share their opinions.
• Q3 behaviors—Preceptees will actively participate in sharing their views but can wander off
topic. If this happens, closed-ended questions (questions that can be answered with a yes or
no or specific amount) can be used to rein them back to the topic at hand (Lefton & Buzzotta,
2004; Lefton et al., 1980). An example of a closed-ended question is, “Based on what you
explained, am I correct in understanding that you did not check the patient’s armband with
the label?”
• Q4 behaviors—Preceptees will actively participate in the discussion and be responsive to your
questions. People with Q4 behaviors will expect you to fully engage in a two-way dialogue.
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Navigating a successful step two: Active listening involves demonstrating Q4 behaviors to gain a better
understanding of the preceptee’s perspective, which will help you understand how to guide the preceptee
toward effective outcomes. Below are Q4 strategies to help enhance your active listening skills:
• Open-ended questions allow both the preceptee and the preceptor to seek clarity.
• After you ask an open-ended question, pause and give the preceptee time to answer.
• Probe the situation with open-ended questions, but withhold your views.
• Avoid closed-ended questions during this step unless you are addressing Q3 behaviors.
• Similar to teach-back, use summary statements to paraphrase what you have heard during
this discussion.
The power behind step two lies in the preceptor’s ability to understand the perspective of the preceptee.
This important data-collection process rests solely on the preceptor’s skill using open-ended questions to
obtain the critical details associated with the event in question and to surface any underlying preceptee
perceptions regarding how they go about accomplishing their work. Preceptors who have mastered step
two avoid “stacking” multiple questions on top of one another and instead ask one question at a time.
They exhibit active listening by pausing after a question is posed, giving the preceptee time to answer,
limiting the usage of closed-ended questions, and summarizing the key points of what they have heard
at the end of this step.
Step Three: Give Your Views (of the Preceptee’s Views)
The focus of step three is responding to what you just heard. This is an opportunity for you to provide
feedback, your views of the preceptee’s views. The key here is to focus on what the preceptee has just
shared and avoid bringing up behaviors from the past (you will have time to integrate additional
information in step four).
Keys for navigating a successful step three involve utilizing your Q4 behaviors to promote candid
discussions and keeping your emotions in check. Below are Q4 strategies that convey your perspective
of the situation:
• Give your views of the preceptee’s views by responding to what you heard.
• Allow your preceptee to clarify any points, but avoid agreement or resolving differences until
you have completed presenting what you heard.
• Close this step by asking the preceptee to provide a summary statement of what they heard.
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An effective step three involves sharing your views of what you heard and think and your perspective of
the topic under discussion. Present what you heard, and seek clarity to ensure both of you are focused
on discussing the same topic. This step is about summarizing the issues under discussion, not problem
resolution. Problem-solving occurs in step four, so end step three by summarizing what you have heard,
ensuring you and the preceptee clearly understand the issues at hand.
Preceptor—Mastering Difficult Conversations
•
•
•
•
•
•
•
•
•
Demonstrates by openness and candor
•
•
Sparks enthusiasm
Has the ability to present information in a way understood by the preceptee
Solicits the ideas of others
Treats people with respect
Approachable
Focuses on accomplishing the work and engaging the preceptee
Demonstrates sensitivity to the preceptee’s needs
Promotes an effective give-and-take relationship
Gives constructive, actionable feedback about successes as well as developmental
opportunities
Challenges and involves the preceptee to see the importance of the preceptee’s work and
growth
Step Four: Resolve Differences
Step four can, at times, unleash emotions, especially if disagreement occurs. Begin step four by focusing
on the areas of agreement, as this sets up the ability to have a win-win situation and helps both parties
ease into addressing the disagreements. This is also the time to bring up pertinent actions from the past
if they are relevant to effectively resolving a disagreement. Utilizing a Just Culture framework will help
you present this information in a non-blaming way and keep the conversation focused on attacking
the issue, not the preceptee. As the conversation progresses and disagreements surface, you may sense
frustration (yours or the preceptee’s). Frustration is a response that occurs when a person perceives
that the pursuit of a goal has been blocked (Lefton et al., 1980). People express their frustration to these
blocked goals by shifting their behaviors. If you see behavioral shifts and/or emotions, comments such
as, “You seem angry” or, “You seem frustrated” can help the preceptee express frustration and get touchy
issues out in the open.
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When interacting with a preceptee who demonstrates predominantly:
• Q1 behaviors—Expect that the preceptee will share disagreements openly; increase your selfawareness so you don’t get ruffled or caught up in emotional turmoil.
• Q2 behaviors—Establish trust by conveying that you are genuinely interested in the
preceptee’s success and ensure your feedback is not punitive.
• Q3 behaviors—Recognize that a lack of disagreement does not signal agreement, and easy
yeses can be a sign of a person’s discomfort with disagreement and conflict.
• Q4 behaviors—Expect to be challenged in a Q4 way, and be prepared to respond with data
and facts.
Keys for navigating a successful step four include increasing self-awareness of behavioral shifts—yours
and theirs. Below are some Q4 strategies you can use to keep a blame-free focus on resolution and
agreement:
• If your preceptee changes behaviors, adapt your strategy and actions.
• If you sense the preceptee has some anger, encourage venting those emotions in the moment;
getting it out in the open prevents that anger from reaching a patient.
• Increase your self-awareness of those situations where you shift your behaviors.
• If the preceptee observes your behavior shifting, he or she should be comfortable enough to
call out your behaviors, too.
An example of addressing a behavioral shift: You have assessed the behaviors of your current preceptee
as predominantly Q1. The preceptee is very task-focused, gets things done on time, is not afraid to speak
up and, at times, can come across as pushy and aggressive. Yesterday, a colleague heard the preceptee
tell a patient that the patient needed to stop pressing the call light unless he really needed something.
You and the preceptee discuss this at your daily debrief and steps one through three go well. As you
transition to step four, resolving differences, you start to observe the preceptee looking at the floor,
answering questions with yes or no answers, appearing disengaged, and providing little information.
Recognizing that a Q2 behavioral shift has occurred, you call out your observations, ask for the
preceptee’s help resolving the differences, and remind the preceptee that the goal is growth: “I am
sensing that something is going on here that you are not comfortable with. You have a lot of talent, and
I want to work with you and ensure that you have every opportunity to shine. At the same time, we need
to figure out how to help you increase your self-awareness of when you come across as aggressive toward
your patients. How can we move forward?”
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Step four allows for those differences to emerge. Although it is important to get differences and
emotions out on the table, this is also the time when frustration occurs. Behavioral shifts, where we go
when we perceive goal attainment has been blocked, are signals that frustration is present. Call out these
observations in a blame-free manner, restate the purpose of the conversation to redirect the focus of the
conversation to the future, and ask for help to resolve any differences and alleviate any frustration.
Step Five: Develop an Action Plan
Step five plays a critical role in influencing behaviors and gaining commitment for behavioral change.
An effective action plan does not have to be a long document or even something in writing. A plan
can be a verbal agreement to touch base at the end of the shift or next time you work together. When
formulating a plan, be sure to include a What’s in it for me? (WIIFM) statement so the preceptee clearly
recognizes what can be gained from a successful plan implementation. Recognizing the intangible
needs that motivate your preceptee’s behaviors will help you link the WIIFM statement to the desired
behaviors and increase the odds that your preceptee will follow through.
Key for navigating a successful step five: Behavior change is a measurable outcome. Below are some
behavioral strategies to help you craft a Q4 action plan:
• The key to a successful action plan is creating one and following through.
• A successful action plan includes a WIIFM statement so the preceptee recognizes the personal
impact from following through.
• Use summary statements so the preceptee clearly understands the role and the behavioral
expectations required for a successful plan implementation.
• Lack of a plan makes it easy to slip back into old behaviors.
Five-Step Format Summary
The Five-Step Format is a tool that helps you organize a Q4 conversation that engages preceptees by
involving them in a dialogue that promotes two-way communication. Utilizing open-ended questions
as a blame-free data-gathering strategy sends the message that you value the preceptee’s opinion and
promotes a Just Culture. Summary statements reflect that the preceptee has been heard. Allowing people
to have their say sends the message that you value their input. Feeling valued and heard are key pieces of
involvement, and when people are involved, they are more likely to commit to behavior changes (Avey
et al., 2010; Lucian Leape Institute at the National Patient Safety Foundation, 2013).
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Even when you use these tools and put your best Q4 foot forward, sometimes a preceptee may not respond
to your feedback. When these types of situations arise, assessing the fit between the preceptee and the
preceptor, and between the preceptee and the job, may be appropriate. If you have…
walked the Q4 talk,
sized up the preceptee’s behaviors,
used Just Culture to avoid attribution errors,
tapped into what motivates the preceptee’s actions,
utilized the Five-Step Format to obtain their perspective,
provided candid feedback, and
followed through on your action plans,
…then the reality might be that preceptee is not a good fit for you and/or your unit. If you find yourself in
this situation, then it is time to get management involved. Although these are difficult decisions to make,
your candor and Q4 actions might save the preceptee from encountering a career-ending situation and a
patient from a potential life-threatening situation.
Conclusion
Just Culture provides a framework to categorize errors and omissions, whereas the Dimensional Model
of Behavior helps identify specific behavioral patterns that are associated with errors. Combining a
behavioral pattern assessment with the appropriate motivational links can help preceptors devise strategies
to influence sustained behavior change. Taking the preceptee’s intangible needs into account, the Five-Step
Format utilizes behaviorally based, candid feedback to promote commitment and engagement.
Similar to starting an IV, delivering feedback is an acquired skill. Just as you assess the patient’s veins
before you insert the IV, a preceptor needs to assess the preceptee’s behavior before delivering feedback or
attempting to influence behavior change. When solving problems related to behavior or attitude challenges,
attribution-free feedback based on observations sets the stage to encourage preceptees to change their
behaviors. Candid, blame-free feedback tailored to the individual’s needs is one of the most powerful
influence tools you have.
Becoming proficient at using the Dimensional Model of Behavior, the Just Culture framework, the
Behavioral Pyramid, and the Five-Step Format takes practice. Combining your clinical mastery with
people skills and incorporating the patient experience into your preceptor toolbox enables you to impact
patient care through others. Using Q4 strategies promotes growth for both you and the people you
precept. This growth involves role modeling the behaviors you expect from others and providing blamefree, objective, observation-based feedback that motivates preceptees to strive for clinical excellence and
provide extraordinary patient experiences.
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Preceptor Development Plan:
Assessing and Addressing Preceptee Behavior and Motivation
Review the information on assessing and addressing preceptee behavior and motivation
described in this chapter. What are your strengths? In which areas do you need to increase your
knowledge and expertise? What is your plan for expanding your knowledge and expertise? What
resources are available? Who can help you?
Name:
Date:
Just Culture
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Plan
Resources
Providing Feedback
Strengths
Behavior
Strengths
Understanding Preceptee Motivation
Strengths
Needs
11 Assessing and Addressing Preceptee Behavior and Motivation
267
Interacting With Influence
Strengths
Needs
Plan
Resources
Dealing With Errors and Behaviors in Your Organization
What is the predominant way of dealing with behavior and errors in your organization? If it is not
a Just Culture, what can you do to influence the use of Just Culture with your preceptee?
Your Own Behavior and Motivation
Think about your own behavior and motivation. What is your predominant behavior? What
motivates you?
What is your predominant behavior?
What motivates you?
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
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“I hope the fruits of my labor are ripe for many
generations to come.”
–Donovan Nichols
Pragmatics of
Precepting
– Larissa Africa, MBA, BSN, RN
Cherilyn Ashlock, DNP, RN, NE-BC
Preceptors have the enormous responsibility of ensuring that their preceptees
are not only clinically competent, but also exude the values of the profession and
the organization. Preceptors are responsible for orienting the preceptee to the
healthcare environment, orienting the preceptee to the clinical unit/department,
creating a safe learning environment, and at all times demonstrating competency
in the role of a preceptor, including clinical leadership (Shinners & Franqueiro,
2017). Preceptees look to preceptors as role models in providing safe, competent
care; as facilitators for socialization into a new environment; and as their primary
example of nursing professional practice. This chapter discusses the pragmatics
of precepting, including key preceptor competencies, strategies, and techniques
that preceptors can use to assist preceptees with organization, time management,
and delegation; strategies on how to manage challenges with preceptees’ clinical
skill development; and strategies on how to manage negative and unproductive
behaviors.
Organization and Time Management
How do preceptors organize the duties of the precepting role while at the same
time providing patient care with preceptees, knowing that—as preceptors—
their behavior is constantly being observed by preceptees who see them as role
models? How do preceptees learn to organize and manage their own time? Timemanagement and organization skills are critical for efficient, productive nursing
practice, but they are often the most difficult to teach. Strategies and techniques
for organization and time-management should be embedded into all areas of
precepting, including preparation for the shift and patient assignment, the shift
report, the clinical shift, and the overall orientation experience for the nurse.
While a preceptor is precepting, the goal is establishing an effective routine for care
delivery within the practice setting.
12
OBJECTIVES
•
Develop strategies and
techniques to assist
in the preceptee’s
organization, time
management, and
delegation skill
development
•
Apply strategies on how
to manage challenges
with the preceptee’s
clinical skill development
•
Manage negative and
unproductive preceptee
behaviors
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Preparing for the Shift and Patient Assignment
The role of the preceptor in preparation for the daily shift includes ensuring appropriate patient
assignments, advocating for the preceptee’s learning experience, and aligning patient care opportunities
in preparation for competency validation at the point of care.
Preceptors need to arrive early for the shift to allow time to meet with the charge nurse or individuals
making patient care assignments and request an appropriate assignment that meets the established goals
of the preceptor-preceptee team. If the preceptee needs to work on a specific competency, diagnosis,
or procedure, seek out those types of patients and request that assignment. Often a preceptor is forced
into a circumstance in which the shift assignment is “overloaded” or with a larger than normal patientto-nurse ratio because of the perception that the preceptor and preceptee are two nurses and can carry
a heavier patient load; this can pose challenges to the learning experience for both the preceptor and
the preceptee and should be avoided. The preceptor must evaluate the potential assignment, asking
questions such as:
• “Is the patient assignment unrealistic?”
• “Will the patient assignment allow time for learning opportunities?”
• “Does the patient assignment resemble a typical nursing care assignment for one nurse?”
Just as a nurse advocates for patients, the preceptor should also serve as an advocate for the preceptee.
The preceptor and the preceptee must work together as one, not only to enable an optimal learning
environment, but also to ensure they are providing safe and quality care for the patient (Figueroa, Bulos,
Forges, & Judkins-Cohn, 2013).
Shift Reports and Patient Handoffs
Competence in giving and receiving shift reports and patient handoffs is crucial to the preceptee’s
development. For both the preceptor and the preceptee, shift reports should be the foundation for
organizing the oncoming shift. Shift reports can be a foreign concept to new graduate registered nurses
(NGRNs) and even experienced nurses who have learned a different method from past experiences. The
process of participating in a shift report can be intimidating to a new nurse on the unit, and it is helpful
to ease the preceptee into the process. During the first days of precepting, allow the preceptee to observe
shift report. As the preceptee’s clinical experience progresses, challenge the preceptee to write out the
report in preparation for delivery to oncoming staff. It might alleviate the preceptee’s anxiety to practice
or role-play delivering a shift report. Provide feedback to the preceptee regarding the content and
delivery of the shift report as soon as possible. As the preceptee gains more experience, he or she should
take the responsibility of receiving the shift report and giving the shift report.
Handoffs can be difficult, even for experienced nurses. The preceptor should maintain notes of the
report and compare to what the preceptee has identified as key information received from the outgoing
shift. Prior to giving a shift report or participating in a patient handoff, the preceptor and preceptee
12 Pragmatics of Precepting
273
should discuss the preceptee’s plan and clarify additional information as needed. Although constructive
feedback is essential, positive reinforcement will also contribute to the continuous growth of the
preceptee.
The Clinical Shift
Styles of precepting that foster clinical decision-making and assist in the transition of the preceptee to
independent practice can vary. The traditional method of precepting encourages a preceptee to follow
the style, delivery of care, and organization of the preceptor. The preceptee follows and takes direction
from the preceptor as the delivery of care for the patient assignment is provided. The preceptee observes
the nurse-patient relationship that occurs during the shift. If the preceptee is struggling with a concept
or skill, the preceptor can consider creating a half or full shift of focused care delivery. For example,
if the preceptee needs to hone skills surrounding physical assessment and documentation, consider
having the preceptee spend the first few hours of the shift performing a head-to-toe assessment and
documenting observations on the organization’s documentation system or chart. The strategy of focused
skill practice will require the preceptor to consider assignments of his or her fellow nurses to broaden
the preceptee’s learning opportunities and eventually be able to demonstrate ability to perform the
competency required.
Establishing a Routine and Facilitating Prioritization
To effectively precept, you need to establish a routine and assist the preceptee in prioritizing patient
care. At the beginning of each shift, clearly define what needs to be accomplished together. The
preceptor should help the preceptee prioritize a plan of care for the day based on the needs of the patient
assignment. One system of prioritization encourages the nurse to rank tasks based on the CURE scale
(Nelson et al., 2006):
C—Critical: potentially life threatening
U—Urgent: safety needs, pain control, anything that could potentially cause
harm or discomfort for the patient
R—Routine: scheduled shift activities
E—Extra: comfort requests of the patient
The CURE strategy assists with task mastery and supports clinical decision-making. As soon as task
mastery is no longer an obstacle, the preceptee can see the bigger picture. After a prioritized plan
has been established, the preceptor and preceptee should continue to communicate, reevaluate, and
reprioritize throughout the shift and as needs arise. The preceptee might find that breaking the shift into
small increments of time and setting overall goals are useful strategies in organizing the day. A daily
organization sheet (see Table 12.1 for an example) is often useful in helping the preceptee establish a
routine. At some point during the shift, set aside time for reflection, feedback, and documentation of
competency skill acquisition and future goal setting.
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Table 12.1 Sample Daily Organization Sheet
(Adapt as needed for different shifts or time frames.)
Primary Patient Goals:
Primary Preceptee Goals:
• Establish a goal for independent
completion of at least one ADL
• Anticipate patient needs and organize care as
needs change
• Ambulate independently to the bathroom
• Prepare to independently provide end of
shift report and practice with preceptor for
feedback
Plan for the Day
0700–0800
• Shift report
• Prepare/organize plan of care for day;
complete cheat sheet
0800–0900
• Check vital signs on all patients and
delegate tasks to assistive personnel
1300–1400
• Care plan and education documentation for all
patients
• Prepare patient in room 317 for cath lab
1400–1500
• Anticipated surgery admission, room 315
• Cath lab procedure scheduled—317
• Physical assessment and
documentation—312, 313, 314, 317
0900–1000
1500–1600
• Medications—312, 313, 317
• Admission assessment—315
• Check a.m. labs on all patients
• Check admission orders and prepare
paperwork/chart for continued care of
admission
• Break
1000–1100
1600–1700
• Medications—314
• Family care conference—314
• Check for new orders on all patients
• Break
1100–1200
• Pt reassessment and documentation
1700–1800
• Ensure documentation on all patients is up to
date
• Reflection and feedback with preceptor
• Documentation of competencies with
preceptor
1200–1300
1800–1900
• Medications—314, 315
• Prepare for shift report
• Lunch
• Room clean-up and prep for next shift
12 Pragmatics of Precepting
275
Delegation
Following the development of a prioritized plan for the day/shift, the next step is delegation. Delegation,
according to the American Nurses Association (ANA) Scope and Standards for Nursing Practice (2010),
is defined as “the transfer of responsibility for the performance of a task from one individual to another
while retaining accountability for the outcome” (p. 64). In 2016, the National Council of State Boards
of Nursing (NCSBN) published the National Guidelines for Nursing Delegation, in which they discussed
the difference between delegation and assignment. Delegation is described as “…allowing a delegatee to
perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and
not routinely performed,” while assignment is “the routine care, activities, and procedures that are within
the authorized scope of the RN or LPN/VN or part of the routine functions of the UAP [unlicensed
assistive personnel] (NCSBN, 2016, p. 6). The NCSBN delegation guidelines note that licensed nurses
“cannot delegate nursing judgment or any activity that will involve nursing judgment or critical decision
making” (2016, p. 6).
Delegation is one of the most complex skills to teach an NGRN preceptee. Delegation is particularly
challenging because it requires the setting of expectations, trust, and follow-up. As the complexity of
care increases in both the acute and the ambulatory setting, delegation is an essential skill of a registered
nurse and is a common challenge for NGRNs. The five “rights” of delegation, however, remain the same
today as they were when they were developed in 1995: right task; right circumstance; right person; right
directions and communication; and right supervision and evaluation (NCSBN, 1995, 2016).
The NCSBN (2016) National Guidelines for Nursing Delegation state that the licensed nurse must:
• “determine when and what to delegate based on the practice setting, the patients’ needs and
condition, the state/jurisdiction’s provisions for delegation, and the employer policies and
procedures regarding delegating a specific responsibility
• communicate with the delegatee who will be assisting in providing patient care
• be available to the delegatee for guidance and questions, including assisting with the delegated
responsibility, if necessary, or performing it him/herself if the patient’s condition or other
circumstances warrant doing so
• follow up with the delegatee and the patient after the delegated responsibility has been
completed
• provide feedback information about the delegation process and any issues regarding delegate
competence level to the nurse leader” (pp. 10–11).
Preceptors need to help new graduate registered nurse (NGRN) preceptees understand that they cannot
do everything themselves and that they need to delegate tasks when possible to have time to perform
the patient care that only RNs are qualified to do. The ANA and the NCSBN, in a joint statement
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on delegation, note that “the effective use of delegation requires a nurse to have a body of practice
experience and the authority to implement delegation” (2006, p. 3).
Ensuring competence in delegation is important for all preceptees, but especially for NGRNs who may
not have had the opportunity to delegate during their student experience. The preceptor must first assess
the competence of the preceptee to delegate, ensuring that the preceptee can perform all the functions of
the delegation process. Gaps in preceptee competence must then be filled by developing the preceptee’s
knowledge and skills as needed. When the preceptee is competent, the preceptor can begin to work with
the preceptee on a daily basis to determine what tasks can be delegated that day and to whom, and to
effectively use all components of the delegation process. Delegation skills are developed and refined over
time and are dependent on the confidence and competence of the registered nurse, the availability of
resources, and the relationships built in the clinical setting between members of the care delivery team.
Performance Discrepancies
A performance discrepancy occurs when there is a difference between what is and what should be—a
difference between actual performance and expected performance (Mager & Pipe, 1997). Effectively
resolving a performance discrepancy requires the use of a systematic process that begins with
identifying the discrepancy. Although it is often tempting to think you know the problem when you first
identify the discrepancy, experience teaches that things are not always what they seem.
Mager and Pipe (1997) have described the components of analyzing and resolving performance
discrepancies:
• Describe the problem. Make sure you fully and accurately understand the problem.
• What is the performance discrepancy? What is the actual performance at issue? What is
the desired performance?
• Is it worth pursuing? For example, the preceptee does a patient assessment in a different
order than you’ve demonstrated. It’s different, but does the order really matter? What
would happen if you left it alone? Are your expectations reasonable? What are the
consequences caused by the discrepancy?
• Explore fast fixes (obvious solutions).
• Can you apply fast fixes? Does the preceptee know what is expected? Can the preceptee
describe the desired performance and the expected accomplishments? Are there
obvious obstacles to the desired performance? Does the preceptee get regular feedback
on performance?
12 Pragmatics of Precepting
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• Check the consequences.
• Is the desired performance punishing? What are the consequences of performing as
desired? Is it actually punishing or perceived as punishing?
• Is the undesired performance rewarding in any way? For example, does the preceptee
get more attention from you when doing the undesired performance? What rewards,
prestige, status, or comfort support the present way of doing things? Does misbehaving
get more attention than doing it right?
• Are there any consequences at all? Does the desired performance lead to consequences
that the preceptee sees as favorable?
• Enhance competence.
• Is it a skill deficiency? Could the preceptee do it if he or she really had to?
• Could the preceptee do it in the past? If yes, what changed?
• Is the skill used often? How often is the performance displayed? How often is the skill
applied?
• Is there regular feedback on how things are going?
• Can the task be simplified? Are all the requirements necessary? Can you provide the
preceptee with performance aids? Can you redesign the workplace or provide physical
help?
• Are there any obstacles remaining? Does something get in the way of doing it right?
Does the preceptee know what is expected? Are there conflicting demands or restrictive
policies?
• Does the preceptee have what it takes to do the job? Is it likely that the preceptee can
learn to do the task? Does the preceptee lack the physical or mental potential to perform
as desired?
• Develop solutions.
• Which solution is best? Have all potential solutions been identified? Does each
solution identified address one or more parts of the problem? What are the tangible
and intangible costs of each potential solution? Which solutions are the most practical,
feasible, and economical? Which yield the most value, solving the largest part of the
problem(s) for the least effort?
• Implement solutions and reassess.
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It is important for the preceptor to identify and address preceptee performance discrepancies as soon
as possible. Using this process, the preceptor can determine the real problem(s) and can work with the
preceptee to create one or more solutions that resolve the discrepancy.
Problem-Solving Preceptor-Preceptee Relationships
The preceptor is key to the success of a preceptee’s clinical immersion. But what happens when the
preceptee has difficulty performing the required competency or is displaying behavior not conducive to
learning? What if the preceptor-preceptee match is just not working?
When Competency Performance Becomes a Challenge
The preceptor is the role model for safe, competent patient care and demonstrates the realities of
practice for the preceptee (Barker & Pittman, 2010). When competency performance becomes a
challenge, a preceptor might consider the following:
• Clarify the overall goals and goals for each clinical shift.
• Solicit the assistance of others in the department, such as the charge nurse, educator, or nurse
leader to ensure that the preceptee can get the experience.
• Provide constructive, real-time feedback.
Clarifying Clinical Goals
Communicating the clinical goals is not only essential in organizing the plan of care for the day, but also
assists in clarifying what needs to be achieved overall and during each shift. Goals should be realistic
and concise and have an identified time frame. The goals should be written, discussed, evaluated, and
revised with the preceptee. The preceptee should be given a copy of the documented goals. Whether the
competency being evaluated is technical, interpersonal, behavioral, or critical thinking, the key is giving
“clear guidelines regarding competency expectations” (Swihart, 2007, p. 17).
Soliciting Assistance to Ensure Appropriate Patient Care Assignments
Validating clinical competencies can be a challenge if the patient care assignment is not appropriate
or does not match the competency that needs to be validated. Soliciting assistance from other nurses
on the unit and the charge nurse can help ensure that the preceptee receives the clinical experience he
or she needs. For example, if the preceptee is having difficulty with central venous catheter care after
repeated instructions and demonstration, the charge nurse might be able to identify other patients
in the department who need central venous catheter care. Barker and Pittman (2010) suggest that
matching patients and learners for a specific learning experience is one of the most effective techniques
of precepting.
12 Pragmatics of Precepting
279
The preceptor should also help the preceptee become competent in low-frequency, high-risk skills. If
a patient on the unit is utilizing a piece of equipment or experiencing a procedure, advocate for the
preceptee to be exposed to this experience, even if it is not part of the preceptee-preceptor assignment.
Most importantly, the preceptor should focus the majority of the onboarding time on preparing the new
nurse for a realistic independent assignment. For example, if the nurses on the unit typically start the
shift with five patients, discharge one, and take two admissions, most of the clinical onboarding shifts
should look similar to this scenario. If most of the patients on the unit have a certain diagnosis or group
of diagnoses, most of the preceptee and preceptor assignments should prepare the nurse to care for
that patient population. Initial orientation is not the most ideal time to care for a unique or rare patient
assignment.
Providing Feedback
Providing specific, constructive feedback is essential for the preceptee’s learning. Providing feedback
does not have to begin at the end of the skill that the preceptee is asked to demonstrate. Providing
feedback can begin the moment the preceptor asks the preceptee to demonstrate the task. Beginning
the feedback process early encourages independent thinking and allows the connection between prior
knowledge and practice knowledge, thus empowering the preceptee to critically think (Sorensen &
Yankech, 2008). Some strategies for providing feedback are shown in Table 12.2.
Table 12.2
Strategies for Providing Feedback
• Provide a specific description of what you observed. Statements such as, “You did an excellent job
of…” are helpful.
• Focus on sharing information rather than giving advice. Statements such as, “Many times when…”
teach general rules.
• Provide feedback in a timely manner, and avoid providing feedback where everyone can hear
the conversation. Questions such as, “What do you think is going on?” or, “What led you to that
conclusion?” can assist in formulating the feedback to the preceptee.
• Give enough time for feedback to be accepted prior to making a plan for future validation.
• Avoid giving the impression that you and other staff members are “ganging up” on your preceptee.
Challenging Behaviors
“Success is the result of the positive work habits we form and observe on a daily basis” (Joseph &
Lakshmi, 2011, p. 43). The negative impact of unacceptable behaviors can affect productivity and
decision-making processes (Appelbaum & Shapiro, 2006; Brinkert, 2010). It is essential to clearly
identify the specifics before the behavior that hinders the learning process can be managed. Similar to
the importance of focusing on behaviors when providing feedback on skill development, identify and
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document the behaviors considered unacceptable. Behaviors also include nonverbal cues such as eye
rolling and crossing of arms across the chest. Documenting how frequently the behaviors are displayed
can help summarize the information for the discussion.
The goal is to be prepared to explain to the preceptee the cause of concern and the reason an immediate
change in behavior is necessary (Grote, 2005). Reasons an immediate change is necessary might include
the impact of the inappropriate behavior toward coworkers, patients, and families; values and standards
of the organization; and a negative impact on the learning process. Just as feedback on the preceptee’s
clinical competencies is best given in a safe environment, addressing negative behaviors is also best in a
safe, private environment. Provide information on the specific performance in behavioral terms instead
of focusing on the attitude (Management Education Group, Inc., n.d.). For example, discuss how the
preceptee is “arriving for shift 30 minutes late” instead of “preceptee is lazy,” or discuss “completing all
documentation on time without errors” instead of “preceptee does not pay attention to detail” behaviors
observed. Discuss the rationale for why the behaviors are of concern, and ask for help in solving the
problem. Denial might be the initial response from the preceptee. The goal is to communicate the
problem and ensure that a plan to address the issue is in place if it cannot be solved at that moment.
The preceptor should consider the following when dealing with challenging behavior:
• Do not react in anger; instead, express your concerns to the preceptee in a clear and nonthreatening way.
• Be specific when describing the challenging behavior by simply stating what you observed; for
example, “When I asked you a direct question, you turned your back and did not respond.”
• Explain the way the situation made you feel or how you were affected by the situation or
behavior.
• Consider their perspective and ask what their intention and feelings were about the situation.
Give the preceptee the opportunity to explain their point of view.
• Work together to create a solution.
Preceptor-Preceptee Mismatch
A successful preceptor-preceptee relationship relies on several factors. Sometimes, preceptors are told
they are going to be preceptors instead of being asked if they want to be preceptors. According to Barker
and Pittman (2010), the nurse must agree to be a preceptor and should have some knowledge and
understanding of the roles and responsibilities of precepting. Matching teaching styles with learning
styles has also been cited as an important factor when matching preceptors with preceptees (Vaughn &
Baker, 2008). Unfortunately, even if these factors are taken into consideration, the preceptor-preceptee
12 Pragmatics of Precepting
281
relationship might not be successful. Forcing the preceptor-preceptee relationship even after attempts
to address the challenges of skill development and negative behaviors can negatively impact the
preceptor’s experience and the success of the preceptee. At this point, the educator or manager should
be involved in the discussions. The preceptor-preceptee-leader discussion should occur in an attempt
to resolve the situation. If either the preceptor or the preceptee is not finding benefit to the relationship,
the leader should reassign the preceptee with another preceptor. The mismatch might be a result of
simple differences in personalities. The preceptee might struggle with one preceptor but thrive with
another. This is not a reflection of the preceptor or preceptee’s performance, but just a mismatch of the
relationship.
Conclusion
Preceptors face many challenges in their role. This chapter is designed to provide useful tools
and words of anticipation to help preceptors prepare for common mishaps. A key to successfully
transitioning an NGRN from onboarding to independent practice requires an assessment of the
preceptee’s organizational and time-management skills, use of the tools to bridge the gap, goal setting,
and providing timely feedback to achieve clinical competence. Finally, the preceptor needs to confront
challenging behaviors and correct preceptor-preceptee mismatches to ensure the success of both the
preceptor and the preceptee.
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Preceptor Development Plan: Pragmatics of Precepting
Review the information on pragmatics of precepting described in this chapter. What are your
strengths? In which areas do you need to increase your knowledge and expertise? What is your
plan for expanding your knowledge and expertise? What resources are available? Who can help
you?
Name:
Date:
Organization and Time Management
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Plan
Resources
Delegation
Strengths
Performance Discrepancies
Strengths
Needs
12 Pragmatics of Precepting
Problem-Solving Preceptor-Preceptee Relationships
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Plan
Resources
Challenging Behaviors
Strengths
Preceptor-Preceptee Mismatch
Strengths
Needs
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
283
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References
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
American Nurses Association and National Council of State Boards of Nursing. (2006). Joint statement on delegation.
Retrieved from https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf
Appelbaum, S. H., & Shapiro, B. T. (2006). Diagnosis and remedies for deviant workplace behaviors. Journal of American
Academy of Business, Cambridge, 9(2), 14–20.
Barker, E. R., & Pittman, O. (2010). Becoming a super preceptor: A practical guide to preceptorship in today’s clinical
climate. Journal of the American Academy of Nurse Practitioners, 22(3), 144–149. doi: 10.1111/j.1745-7599.2009.00487.x
Brinkert, R. (2010). A literature review of conflict communication causes, costs, benefits, and interventions in nursing.
Journal of Nursing Management, 18(2), 145–156. doi: 10.1111/j.1365-2834.2010.01061.x
Figueroa, S., Bulos, M., Forges, E., & Judkins-Cohn, T. (2013). Stabilizing and retaining a quality nursing work force
through the use of the married state preceptorship model. The Journal of Continuing Education in Nursing, 44(8),
365–373. doi: 10.3928/00220124-20130603-08
Grote, D. (2005, July). Attitude adjustments: To deal with an employee’s bad attitude, focus on his or her specific behaviors.
HR Magazine, 50(7), 105–107.
Joseph, C., & Lakshmi, S. S. (2011). Developing positive habits in the workplace. The IUP Journal of Soft Skills, V(1), 37–44.
Mager, R. F., & Pipe, P. (1997). Analyzing performance problems: Or, you really gotta wanna. How to figure out why people
aren’t doing what they should be, and what to do about it. Atlanta, GA: The Center for Effective Performance, Inc.
Management Education Group, Inc. (n.d.). Focus on employee behaviors to get results. Retrieved from http://
managementeducationgroup.com/2014/06/focus-on-employee-behaviors-to-get-results/#
National Council of State Boards of Nursing. (1995). Concepts and decision-making process. [NCSBN position paper.]
Chicago, IL: Author.
National Council of State Boards of Nursing. (2016). National guidelines for nursing delegation. The Journal of Nursing
Regulation, 7(1), 5–14. Retrieved from https://ncsbn.org/NCSBN_Delegation_Guidelines.pdf
Nelson, J. L., Kummeth, P. J., Crane, L. J., Mueller, C. L., Olson, C. J., Schatz, T. F., & Wilson, D. M. (2006). Teaching
prioritization skills: A preceptor forum. Journal for Nurses in Staff Development, 22, 172–178.
Shinners, J., & Franqueiro, T. (2017). The nursing professional development practitioner and preceptor role development.
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Sorensen, H. A., & Yankech, L. R. (2008). Precepting in the fast lane: Improving critical thinking in new graduate nurses.
The Journal of Continuing Education in Nursing, 39(5), 208–216.
Swihart, D. (2007). The effective nurse preceptor handbook: Your guide to success (2nd ed.). Marblehead, MA: HCPro, Inc.
Vaughn, L. M., & Baker, R. (2008). Do different pairings of teaching styles and learning styles make a difference? Preceptor
and resident perceptions. Teaching and Learning in Medicine, 20(3), 239–247. doi: 10.1080/10401330802199559
285
“Self-care is not selfish. You cannot give from an
empty vessel.”
–Eleanor Brown
Self-Care for
Preceptors
–Kim A. Richards, RN, NC-BC
The calling to the nursing profession is a powerful pull, full of heartfelt compassion,
deep care for others, and a strong desire to make a difference in the lives of others.
The need to consistently “give” requires courage, resilience, and mandatory refilling
of personal reservoirs. Nurses cannot continue to give from an empty basket. Soulnurturing, life-affirming activities that renew energy, compassion, and engagement
in the profession are as important to learn and practice as any other requirement
of a professional nurse’s life. Preceptors, who are assuming the responsibility for
teaching others in addition to maintaining their own knowledge and expertise,
need to pay particular attention to self-care. They also have the opportunity, as part
of precepting, to teach others to make self-care a priority as they emulate a healthy
lifestyle. This is especially important with young new graduate registered nurses
(NGRNs) who are also experiencing life transitions.
This chapter discusses self-care, compassion fatigue, and their relationship;
pathways to promote self-care practices; the benefits of making self-care a priority
in one’s own life, debunking the myth that self-care is “self-ish”; and practical
suggestions applicable for a nurse’s busy lifestyle. Sustainable self-care practices do
not always require large amounts of time; they can be moments of mindful activities
strung together throughout the day, creating respite from stressors, from feeling
overwhelmed, and from ending up mentally, physically, and emotionally exhausted.
Self-Care
What is self-care? Cheryl Richardson (2009), long considered the guru of self-care,
states simply, “Self-care is extraordinary mothering of self in mind, body and spirit”
(p. 12). A study by Hozak and Brennan (2011) of 20 care units found that self-care
had a significant relationship with teamwork for nurses (r = .519, p < .019). Another
13
OBJECTIVES
•
Understand the
importance of self-care
as a professional nurse
•
Develop an
individualized plan of
self-care practices for
yourself
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
study of staff nurses (N = 65) by Johnson (2011) revealed that self-care has a negative relationship with both
compassion fatigue (r = –.61, p < .001) and burnout (r = –.61, p < .001).
Compassion Fatigue
Compassion fatigue is a physical and emotional exhaustion that causes a decline in a person’s ability to
feel compassion when taking care of others. It is the cumulative result of internalizing the emotions of
patients, coworkers, family, and friends. Compassion fatigue takes a toll on nurses personally, can result in
a diminished capacity to provide care for patients, and costs the healthcare industry millions of dollars each
year in stress, burnout, and employee turnover. Compassion fatigue is a result of caregivers being focused
on providing care to others and not providing care to themselves. Providing care cannot be a one-way
street, especially for healthcare professionals. Too often, healthcare professionals give most of themselves to
others over a long period of time and don’t stop to recharge their own batteries (Richards, 2011). In a metaanalysis of compassion fatigue in nurses, Nolte, Downing, Temane, and Hastings-Tolsma (2017) identified
effective compassion fatigue prevention strategies including setting professional boundaries, reflecting,
exercising, spirituality, support at work and at home, professional development opportunities, debriefing,
and mentoring.
Self-Care Pathways
Dr. Barbara Dossey, founder of the Theory of Integral Nursing, has identified six key elements, or pathways,
of self-care (Dossey & Keegan, 2008; see Figure 13.1). These interconnected pathways are physical, mental,
emotional, spiritual, relationships, and choices. You might notice some of the same suggestions repeated in
several pathways. That is because some action steps have a global effect on self-care.
Physical
Pathway
Mental
Pathway
Choices
Pathway
Emotional
Pathway
Relationship
Pathway
Spiritual
Pathway
Dossey & Keegan,Self-Care
2011
FIGURE 13.1 Source:
Interconnected
Pathways
Source: Dossey & Keegan, 2011
13 Self-Care for Preceptors
287
Physical Pathway
Your physical health is your responsibility and yours alone. To practice self-care and healthy living,
education and knowledge are essential to determining what is best for you. Your body is the only vehicle
carrying you from birth to death, so routine maintenance is a no-brainer! Listen to your body, take
charge, and tune in to changes and sensations. Be keenly aware of the undeniable connection between
your mind and your body, as the dynamic is constant. As you strengthen your body, you will experience
a mirrored effect in all areas of your life.
Sleep is an important component of physical self-care and one that can often be difficult for nurses,
especially those working 12-hour or rotating shifts. Rogers (2008), in a meta-analysis of the effects of
fatigue and sleepiness on nurse performance and patient safety, found that insufficient sleep is associated
with reduced job performance; increased safety risks; cognitive problems; medication errors; mood
alterations; negative physiological changes; and increased stress, depression, and irritability.
Suggestions for physical pathway practices are shown in Table 13.1.
Table 13.1
Physical Pathway Practices
• Get an exercise buddy.
• Drinks lots of water (at least eight glasses per day), and take a multivitamin.
• Take deep, slow breaths often throughout the day.
• Plan ahead for quick, healthy meals.
• Take a walk outside.
• Intentionally touch one person a day.
• Meditate or set aside alone time for 10 minutes a day.
• Schedule all preventive health appointments.
• Schedule a massage/facial/manicure/pedicure on a routine basis.
• Pet my dog or cat.
• De-clutter my bedroom to create a restful, calm environment for sleep.
• Go to bed an hour early once a week and read.
• Avoid TV before bed or in bed.
• Soak in a warm bath.
• Forgive myself or others. Release emotional baggage.
• Take a laugh break! Daily comics, funny people, humorous situations…just laugh!
• Exercise at least three times per week.
• Always eat breakfast.
• When planning meetings with food, order healthy choices.
• Keep a notepad by my bed to write down and release worries for later. Take time to rest.
continues
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Table 13.1
Physical Pathway Practices (cont.)
• Keep healthy snacks nearby, and restock often.
• Put a cloth over my computer when done to signify “work done.”
• Take a 15-minute nap.
• Know my BMI, and keep it 25 or lower.
• Create a sanctuary at work and at home.
• Schedule a play date or game night.
Mental Pathway
Flexibility, open-mindedness, and constant learning are the pillars of a healthy mental environment.
Our brains possess unlimited, mostly untapped potential; but similar to our muscles, some “heavy
lifting” is required for them to grow and blossom. As you practice self-care strategies, you might find
that your brain seems to relax, focus, and retain more than ever. This concept gives new meaning to the
adage “food for thought.” You might find yourself becoming more mindful of how your environment
feeds your brain.
Those entering the world of professional nursing can easily find themselves feeling overwhelmed,
exhausted, and stressed out. Self-reflection, stress-reduction practices, and knowing what fuels your
fire are absolutely mandatory to create a thriving career for many years. Disconnecting from devices,
nurturing positive relationships, and scheduling time just for YOU is key to proactively preventing
burnout and improving resiliency. Waiting for challenges to arise and expecting to quickly rebound is
ineffective and eventually futile. The best way to maintain and grow your resiliency muscle is to work it
every day by practicing integrative techniques you can implement into your busy schedule.
Mindfulness is a mental self-care strategy that has been shown to ease mental stress. Davis and Hayes
(2011) have described mindfulness as a “moment-to-moment awareness of one’s experience without
judgment” (p. 198). Mindfulness practices focus on training one’s attention and bringing one’s mental
processes under greater control. They can improve mental well-being as well as calmness, clarity, and
concentration (Walsh & Shapiro, 2006). Richards, Sheen, and Mazzer (2014), in a review of evidence on
mindfulness, found the benefits of mindfulness to include enhanced self-insight, morality, intuition, and
fear modulation; increased immune functioning; reduced rumination; reduced stress; improved working
memory and focus; less emotional reactivity; more cognitive flexibility and more adaptive responses to
stressful or negative situations; and improved relationship satisfaction.
Practicing mindfulness for as short a period as 2 weeks has been shown to create changes in the brain
(Hanson, 2009), and these new patterns of thought can change the physiology of our brains, training
us to become more alert to good information. How do you practice mindfulness? When you notice a
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13 Self-Care for Preceptors
positive detail in yourself, someone else, or in your environment, savor the detail for at least 10 seconds.
Most of these observations will be simple, like “the sky is so blue” or “the sun is warm on my face,” but
if you do this a few times each day, you’ll feel an emotional shift. Using mindfulness techniques and
routinely practicing stress reduction can help you keep up with the demands of your professional and
personal life. Mindfulness helps increase awareness. Noise pollution in the forms of violent television,
drama- laden newscasts, and constant chatter are absorbed into our brains on a daily basis if we aren’t
vigilant about applying limits or trauma filters (Richards et al., 2014).
Suggestions for mental pathway practices are found in Table 13.2.
Table 13.2
Mental Pathway Practices
• Ask for help before I feel overwhelmed. Make a “how you can support me” list.
• Create a sanctuary at work and at home.
• Stop watching mindless TV or negative news media, especially before bed.
• Take deep, slow breaths and close my eyes periodically throughout the day.
• Create a “vision board” of how I want my life to be.
• Start the day with a positive affirmation, and then expect a good day.
• Create a wall or collage of mementos that trigger appreciation, gratitude, and joy.
• Take a walk and connect with nature by spending time outside.
• Meditate or set aside alone time for 10 minutes a day.
• Eliminate any appointments that are not necessary.
• Weed my garden of friends. Keep only those where friendship is a two-way street.
• Create a success team to reach my goals.
• Pet my dog or cat.
• Have a “safe” friend or colleague to talk with or vent to.
• Forgive myself and others. Release emotional baggage.
• Listen to inspirational music on the way to work, during breaks at work, and on the way home.
• Take a laugh break! Daily comics, funny people, humorous situations…just laugh!
• Exercise at least three times per week.
• Light a candle and set the tone for relaxation and positive moods.
• Consider hiring a crew for cleaning or outdoor chores once a month. My time is valuable. How much
am I worth?
• Read a book and discuss with others.
• Take public transportation to ease the stress of traffic.
• Refuse to listen to a rumor or nasty gossip. Speak up.
• Keep a notepad by my bed to write down and release worries for later. Take time to rest.
• Say “no” without feeling guilty once a day.
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Table 13.2
Mental Pathway Practices (cont.)
• Put a cloth over my computer when done to signify “work done.”
• When walking out of work, physically “throw away” worries in the trash can. Reverse the action on the
way into work by “throwing away” worries from home.
• De-clutter my closet and bedroom. Donate unused items and clothes. Create my bedroom for
calmness and sleeping, not working.
• Never allow computers or cellphones in bed.
• Know that by taking action first, the feeling will follow.
• Create a support network.
• Distance myself from too many people leaning heavily on me at once.
• Take a 15-minute nap.
• Talk kindly to my reflection in the mirror. Pump it up!
• Buy a bunch of flowers.
• Reward myself for milestones or accomplishments.
Emotional Pathway
Emotions are a dominant part of the human condition. We engage in constant dialogue within
ourselves; how we feel, perceive, and respond is regulated by our emotional state. Past joys, hurts, and
traumatic experiences all contribute to our emotional health, yet we also can choose to release toxic
feelings that cause us to be repeatedly victimized. Identifying where unresolved emotion is eroding your
self-care is freeing for both you and those around you. Suggestions for emotional pathway practices are
found in Table 13.3.
Table 13.3
Emotional Pathway Practices
• Find a photo that reminds me of a happy childhood memory.
• Stop watching mindless TV or negative news media, especially before bed.
• Collect items or pictures that reignite and reflect my spirit.
• Journal daily about how I feel.
• Start the day with a positive affirmation, and expect a good day.
• Create a wall or collage of mementos that trigger appreciation, gratitude, and joy.
• Take a walk.
• Connect with nature by spending time outside.
• Weed my garden of friends. Keep only those where friendship is a two-way street.
13 Self-Care for Preceptors
291
• Take 10 minutes of alone time per day.
• Pet my dog or cat.
• Have a “safe” friend or colleague to talk with or vent to.
• Forgive myself and others. Release emotional baggage.
• Listen to inspirational music on the way to work, during breaks at work, and on the way home.
• Take a laugh break! Daily comics, funny people, humorous situations…just laugh!
• Exercise at least three times per week.
• Light a candle and set the tone for relaxation and positive moods.
• Consider hiring a crew for cleaning or outdoor chores once a month. My time is valuable. How much
am I worth?
• Read books and discuss with others.
• Take time to talk with children or grandchildren.
• Take public transportation to ease the stress of traffic.
• Refuse to listen to a rumor or nasty gossip. Speak up.
• Say “no” without feeling guilty once a day.
• Put a cloth over my computer when done to signify “work done.”
• When walking out of work, physically “throw away” worries in the trash can. Reverse the action on the
way into work by “throwing away” worries from home.
• De-clutter my closet and bedroom. Donate unused items and clothes.
• Create my bedroom for calmness and sleeping, not working.
• Never allow computers or cellphones in bed.
• Know that by taking action first, the feeling will follow.
• Create a support network.
• Distance myself from too many people leaning heavily on me at once.
• Encourage others in their self-care practices.
• Talk kindly to my reflection in the mirror. Pump it up!
• Buy myself flowers.
• Reward myself for milestones or accomplishments.
• Keep a notepad by my bed to write down and release worries for later. Take time to rest.
• Create a sanctuary at work and at home.
• Find an old friend and reconnect.
• Say “I love you” three times per day.
• Support or donate to a cause of my choice.
• Mentor someone. Pass on my blessings.
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Spiritual Pathway
Spiritual self-care is a reflection of your belief, in a very personal way, in a higher power than yourself
that connects you with the universe. Your beliefs might or might not be deeply rooted in organized
religious practices, rituals, or celebrations, but the spirit that you reflect is unique to you. Your beliefs
shape your perceptions of your world; therefore, they serve to nurture your soul or deplete your spirit.
Suggestions for spiritual pathway practices are found in Table 13.4.
Table 13.4
Spiritual Pathway Practices
• Express my servant leadership purpose by being an example of “flow.”
• Collect items or pictures that reignite or reflect my spirit.
• Connect with nature by spending time outside.
• Journal about comments, situations, or people who reconnect me to my “calling.” Tell others.
• Allow myself to receive compassion before giving it away.
• Meditate for 10 minutes a day.
• Light a candle and ask for guidance.
• Create a vision board of my legacy.
• Create a support network. Join a like-minded study group.
• Encourage others in their self-care practices.
• Create a sanctuary at work and at home.
• Volunteer my time and talent to a cause important to me.
• Attend spiritual services or celebrations.
• Spend 5 minutes stargazing.
• Reconnect with my spiritual beliefs.
• Support or donate to a cause of my choice.
• Find a photo that reminds me of a happy childhood memory.
• Ask a colleague to compliment me on three attributes that contribute to my life purpose.
• Take 10 minutes of alone time per day.
Relationships Pathway
Your life is dynamic. The quality of relationships in which you participate is a direct reflection of how
you see yourself. Increasing awareness of the impact of relationships that either add to or subtract
from your life can be a lifelong process. Toxic relationships can quickly leave you feeling depleted
and exhausted. This element of self-care can be illusive and requires identification of cohesiveness or
disharmony. Your relationship with yourself is the foundation from which all others flow. Suggestions
for relationship pathway practices are shown in Table 13.5.
13 Self-Care for Preceptors
Table 13.5
293
Relationships Pathway Practices
• Write a note to someone I care for.
• Collect items or pictures that reignite and reflect your spirit.
• Create a wall or collage of mementos that triggers appreciation, gratitude, and joy.
• Intentionally touch one person each day.
• Weed my garden of friends. Keep only those where friendship is a two-way street.
• Create a success team to reach my goals.
• Pet my dog or cat.
• Have a “safe” friend or colleague to talk with or vent to.
• Forgive myself and others. Release emotional baggage.
• Read a book and discuss with others.
• Take time to talk with children or grandchildren.
• Refuse to listen to a rumor or nasty gossip. Speak up.
• When walking out of work, physically “throw away” worries in the trash can. Reverse the action on the
way into work by “throwing away” worries from home.
• Create my bedroom for calmness and sleeping, not working.
• Never allow computers or cellphones in bed.
• Create a support network. Encourage others in their self-care practices.
• Find an old friend and reconnect.
• Say “I love you” at least three times per day.
• Compliment two coworkers today.
• Volunteer my time and talent to an important cause.
• Mentor a child.
• Schedule a play date or game night.
• Support or donate to a cause of my choice.
• Ask a colleague to compliment me on three attributes.
Choices Pathway
Your life is precisely where it is currently because of the choices you have made, both those labeled
“good” and those “not so good.” When you make choices from a place of self-compassion and the
choices are in line with your core values, neither self-sacrifice nor self-flagellation has a place. Your
journey to improved self-care and harmony within can be naturally enhanced by your heightened
awareness of your values, your desires, and what makes your heart sing. When you choose to fully
participate in your own life, listening to your authentic spirit and giving yourself permission to take
action, you begin to fly! Suggestions for choices pathway practices are found in Table 13.6.
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Table 13.6
Choices Pathway Practices
• Plan ahead for quick, healthy meals.
• Take a walk.
• Intentionally touch one person each day.
• Meditate for 10 minutes a day.
• Eliminate any appointments that are not necessary.
• Weed my garden of friends. Keep only those where friendship is a two-way street.
• Create a success team to reach my goals.
• Schedule all preventive health appointments.
• Take 10 minutes of alone time per day.
• Have a “safe” friend or colleague to talk with or vent to.
• Forgive myself and others. Release emotional baggage.
• Listen to inspirational music on the way to work, during breaks at work, and on the way home.
• Take a laugh break! Daily comics, funny people, humorous situations…just laugh!
• Exercise at least three times per week.
• Consider hiring a crew for cleaning or outdoor chores once a month. Your time is valuable. How much
am I worth?
• Read a book and discuss with others.
• Take time to talk with children or grandchildren.
• Take public transportation to ease the stress of traffic.
• Always eat breakfast. When planning meetings with food, order healthy choices.
• Refuse to listen to a rumor or nasty gossip. Speak up.
• Keep healthy snacks nearby and restock often.
• Say “no” without feeling guilty once a day.
• When walking out of work, physically “throw away” worries in trash can. Reverse the action on the way
into work by “throwing away” worries from home.
• Distance myself from too many people leaning heavily on me at once.
• Create a support network.
• Take a 15-minute nap.
• Know that by taking action first, the feeling will follow.
• Reward myself for milestones or accomplishments.
Your Accountability Buddy and Self-Care
Support from other people can influence your success. An accountability buddy is someone “who
supports you in making sure you meet your self-care commitments, who helps you stay motivated, and
13 Self-Care for Preceptors
295
who wants to see you succeed—all of which will dramatically increase your chances of successfully
meeting your goals” (Richards et al., 2014, p. 15). While most self-evident with physical self-care, the
accountability buddy concept works for all the self-care pathways.
To choose an accountability buddy (or buddies), think of a person who can support you, motivate
you, hold you accountable, and share in your journey. The relationship may be a mutually beneficial
relationship, especially if you are both on a similar journey.
Tips for Working With an Accountability Buddy
Share your goals in writing.
Meet regularly with set time limits for meetings.
Respect confidentiality.
Start with a 3-month commitment.
Start with the end in mind.
Offer recognition and praise for the achievement of small steps.
If the relationship isn’t working, find another buddy.
Source: Weider, 2011
Conclusion
Connecting with your strengths and the values they represent is what energizes you! Your strengths make
you feel more alive and reflect your life passions. The pathways to self-care have no hierarchy; each affects
the other. They are interconnected and often work in tandem to create self-compassion, self-awareness,
and life harmony. When you identify and incorporate them more fully into your life, your overall life
satisfaction improves. Using your strengths to cultivate areas you choose to enhance can allow you to
develop a more balanced self-care journey and overall capacity for resilience. Developing each pathway
more fully might require self-compassion and identification of a void. Adding self-care practices that
support these new insights requires a balance of skill and challenge. The most critical action is to keep
moving forward, “trying on” what resonates with you and what seems to fit with your lifestyle. After some
practice and commitment, you will find the steps you are taking becoming less uncomfortable and more
routine; eventually the steps will be effortlessly habitual. Start small but start now.
Developing self-nurturing habits and healthy coping skills and proactively practicing self-care daily
are the first steps in creating a firm foundation for growth, productivity, and sustained engagement. Be
mindful of triggers that can cause disharmony. Feeling confident in your self-affirming routines allows
you to rise above the immediate stressors and expand your capacity for resilience.
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Preceptor Development Plan: Self-Care
Things I Commit to Including in My Life This Month
Review the information on the practices of self-care to prevent burnout and create an optimal
healing environment described in this chapter. Create a plan of self-care. To get started, pick two
of the practices in each pathway and develop a plan on how to include those practices in your
life in the next month.
Name:
Date:
Physical pathway practices I commit to including in my life this month
Practice
Plan
Mental pathway practices I commit to including in my life this month
Practice
Plan
Emotional pathway practices I commit to including in my life this month
Practice
Plan
13 Self-Care for Preceptors
Spiritual pathway practices I commit to including in my life this month
Practice
Plan
Relationships pathway practices I commit to including in my life this month
Practice
Plan
Choices pathway practices I commit to including in my life this month
Practice
Plan
Accountability buddy
Consider finding an accountability buddy. Who are the people who could be your buddy?
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
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References
Davis, D., & Hayes, J. (2011). What are the benefits of mindfulness? A practice review of psychotherapy-related research.
Psychotherapy, 48(2), 198–208. doi: 10.1037/a0022062
Dossey, B., & Keegan, L. (2008). Holistic nursing: A handbook for practice. Sudbury, MA: Jones and Bartlett.
Hanson, R. (2009). Buddha’s brain: The practical neuroscience of happiness, love and wisdom. Oakland, CA: New Harbinger
Publications.
Hozak, M., & Brennan, M. (2011). Caring at the core: Maximizing the likelihood that a caring moment will occur.
In J. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing
intervention (pp. 195–224). New York, NY: Springer.
Johnson, S. (2011). A U.S. study of nurses’ self-care and compassion fatigue using Watson’s concepts of caritas. In J. Nelson
& J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention (pp.
413–420). New York, NY: Springer.
Nolte, A., Downing, C., Temane, A., & Hastings-Tolsma, M. (2017). Compassion fatigue in nurses: A metasynthesis.
Journal of Clinical Nursing, 26, 4364–4378. doi: 10.1111/jocn.13766
Richards, K. A. (2011, April 28). Self-care academy: My self-care journey [Workshop].
Richards, K. A., Sheen, E., and Mazzer, M. C. (2014). Self-Care and YOU. Silver Spring, MD: American Nurses Association.
Richardson, C. (2009). The art of extreme self-care. Carlsbad, CA: Hay House.
Rogers, A. E. (2008). The effects of fatigue and sleepiness on nurse performance and patient safety. In R. G. Hughes (Ed.),
Patient safety and quality: An evidence-based handbook for nurses (Chapter 40). Rockville, MD: Agency for Healthcare
Research and Quality.
Walsh, R., & Shapiro, S. L. (2006). The meeting of meditative disciplines and western psychology: A mutually enriching
dialogue. American Psychologist, 61(3), 227–239. doi:10.1037/0003-066X.61.3.227
Weider, S. (2011). Tips for working with an accountability buddy. British Columbia, Canada: Youngblood Coaching.
299
“Leadership and learning are indispensable to
each other.”
–John Fitzgerald Kennedy
For Managers:
Selecting, Supporting,
and Sustaining
Preceptors
–Carol A. Bradley, MSN, RN, CENP
Amy K. Doepken, MSN, RN
Denise D. Fall, DNP, RN, CENP
Virginia Downie, MSN, RN-BC, NPDS
Cindy Bianchini, MSN, RN, CNOR
Selecting, supporting, and sustaining a skilled workforce begins with a strong
preceptorship program. In addition, a team approach is essential to the successful
development of nurses and their integration into the organization and their
unit/department. The nurse manager has the unique opportunity to create an
environment that supports the growth and development of newly hired nurses,
new nurse graduates, and current staff seeking to expand clinical and leadership
skills. Studies have shown that organized preceptorships with trained and engaged
preceptors provide a milieu in which growth and development occur with positive
results (Friedman, Cooper, Click, & Fitzpatrick, 2011; Friedman, Delaney,
Schmidt, Quinn, & Macyk, 2013). Developing preceptor competencies, establishing
recruitment and evaluation criteria, supporting education, successfully matching
preceptors and preceptees, providing meaningful recognition, and utilizing
creative strategies to overcome challenges are key components to incorporate in a
comprehensive preceptorship program.
14
OBJECTIVES
•
Compose preceptor
competencies utilizing
standard performance
concepts
•
Develop standardized,
objective tools for
preceptor recruitment
and evaluation
•
Identify creative
strategies for supporting
and sustaining an
effective pool of
preceptors
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Establishing Performance Standards and Preceptor
Competencies
Performance standards created by national and specialty agencies provide the fundamental structure
by which nursing practice is defined. These standards can be broad in scope, applying to all nurses,
or narrowed to a specific clinical practice; professional organizations establish nursing performance
standards. The American Nurses Association (ANA) provides a nursing code of ethics (ANA, 2015)
and standards of practice (ANA, 2010), and organizations should use this code as a starting point
for developing their individual performance standards (see Chapter 1). Specialty areas should rely
on established professional standards of commitment to patients, advocacy, and accountability for
nursing practice; examples include the American Association of Critical-Care Nurses (AACN), the
Association of periOperative Registered Nurses (AORN), the Emergency Nurses Association (ENA),
and the Oncology Nursing Society (ONS). Professional behaviors based on performance standards
are the cornerstone for establishing objective evaluation criteria for all employees’ performance.
These standards should promote effective patient care including patient rights and safety, patient- and
family-centered care, patient education, clinical judgement, interpersonal communication, information
management, and professional development. Integrating individual healthcare organizational values
with national and professional bodies is essential in guiding the development of preceptor performance
standards.
Defining successful outcomes for preceptorships is the next step in creating a strong preceptorship
program. A successful program promotes the independent, competent practice of a nurse, and nursing
units need to establish formal criteria for the completion of their orientation programs. Establishing
performance goals clearly communicates expectations to all stakeholders in the process. The Legacy
Health Nurse Competency Model (see Figure 14.1) is the framework utilized to ensure all nurses
practicing in the system are competent upon release to independent practice and remain competent in
the ever-changing world of healthcare.
Demonstration of competency defines successful completion of onboarding; checklists or passive
education modalities cannot measure competency. Competencies for clinical ability, problem-solving
ability, and communication skills must be established. Timelines for successful completion should be
flexible and depend upon the preceptor and the preceptee’s skill level. A standardized initial competency
assessment, as well as a self-evaluation of strengths and learning needs, should take place before the
preceptorship begins. This information will inform the planning and goal-setting for the preceptorship.
The preceptor, preceptee, and manager or educator should collaborate on this process. A preceptorship
that is individualized to meet the unique needs of each preceptee and his or her preceptor will promote
the successful completion of the preceptorship.
14 For Managers: Selecting, Supporting, and Sustaining Preceptors
Legacy Nurse Competency Model
Periodic
Competency
Verification
Performance Criteria
Standards of Performance
Standards
of Performance
Performance
Criteria
The
“Essence of Nursing”
basic competency
expectations of all
Legacy nurses
Competencies that
nurses must possess
to safely practice
in a specialty area
and/or unit
•
•
•
•
•
•
•
•
•
Care of Patients
Patient Rights
Patient Education
Interpersonal
Communication
Professional
Development
Patient Safety
Family-Centered Care
Critical Thinking
Information
Management
Validate during
preceptorship of all
new to Legacy hires
Periodic
Competency Verification
Per regulatory bodies,
and if care standards,
technology, or new
evidence create significant
changes in practice
• Patient population
specific
• Consistent across all
like-care areas
• Patient population
assessment skills
• Ability to plan and
perform care
• Specific interventions
and technical skills
• Ability to intervene
• Care of specific
disease processes
•
•
•
•
POC testing
Restraints
Blood administration
Other competencies
as designated by unit
leadership
Validate during
preceptorship of all new
to Legacy hires and all
transfers from other
units or Legacy facilities
Annually
And as needed
Used with permission. Legacy Health.
FIGURE 14.1 Legacy Health Nurse Competency Model
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Preceptor Selection Criteria
The process for selecting preceptors can vary immensely and be characterized by an inconsistent
application of selection criteria. Basing preceptor selection on unit seniority or clinical expertise was
widely used in the past but can be problematic. Clinical expertise does not guarantee the ability to
effectively teach or the attitude to support and welcome new hires. Legacy Health has successfully
utilized nurses at the competent level on Patricia Benner’s Novice to Expert continuum (Benner, 1984)
as first preceptors for new nurses in its RN Residency Program. These preceptors are often previous RN
residents who are motivated by their own positive preceptorship experiences and are better able to relate
to the unique needs of the new nurse.
Legacy Health uses its Values in Action as the minimum expectation of organizational performance
standards for all employees (see Figure 14.2). To this foundation, additional performance standards
important to the preceptor role were added to complete the RN Preceptor Recruitment and Evaluation
Tools (see Figure 14.3). When the nurse manager observes that a nurse demonstrates qualities of a good
preceptor, or a nurse approaches the manager with interest in becoming a preceptor, the RN Preceptor
Recruitment Tool helps the manager and nurse determine readiness for the role.
Legacy Health also developed a nursing preceptor rubric that enables the nurse manager and potential
preceptor to classify precepting capability utilizing a rubric format and Patricia Benner’s Novice to
Expert theory (Benner, 1984) (see Figure 14.4). Completion of this rubric is a requirement for entry into
the RN Preceptor Training Workshop, which is a mandatory, 8-hour class for all nursing preceptors.
The rubric also serves as a learning tool to familiarize the preceptor with Benner’s Novice to Expert
continuum (Benner, 1984) as it pertains to precepting; it promotes self-evaluation and reflection along
with providing guidance for professional development in the precepting role.
Integrating performance standards, recruitment and evaluation criteria, and professional development
resources into standardized tools provides the nurse manager with a framework for a simple and
repeatable preceptor selection process. Additionally, such tools promote consistent feedback, provide
opportunities for coaching, and encourage transparent communication between the nurse manager and
the preceptor.
14 For Managers: Selecting, Supporting, and Sustaining Preceptors
Legacy’s Values in Action
I commit to:
Legacy commits to:
Treating our people, patients, and
community with respect,
affirmation, compassion, and
inclusion.
Keeping our people informed,
soliciting feedback, and creating
opportunities to participate
in significant decisions about
their work.
RESPECT
We treat all people with respect
and compassion.
Engaging and collaborating in
ways that keep the well-being of
our patients, their families, our
people, and our community at the
center of all I do.
SERVICE
We putSERVICE
the needs of our patients
A service-driven culture by making
the patient experience a priority,
and by demonstrating respect and
sensitivity for each other and the
diverse people we serve.
Owning the quality of my work by
reporting and reducing errors,
eliminating waste, improving
quality, and ensuring staff and
patient safety.
QUALITY
QUALITY
We deliver outstanding clinical
services within healing environments.
A culture of safety and quality,
where employees are encouraged
to make suggestions, report errors,
and where we seek to learn from
our mistakes.
Modeling ethical behaviors and
actions that achieve the highest
possible standards and results.
EXCELLENCE
EXCELLENCE
We set high standards and
A positive, ethical and productive
work environment in which
employees work collaboratively to
achieve high quality outcomes.
Holding myself and others
accountable for operating with
integrity, care, and stewardship of
our resources.
Being curious and seeking
opportunities to improve and
embrace change in a positive,
productive manner.
Being accountable for modeling
and upholding these values in all
my actions.
11/2017
and their families first.
achieve them.
RESPONSIBILITY
We are good stewards of our resources,
RESPONSIBILITY
ensuring access to care for all.
A mission driven work
environment where we manage
resources in a balanced and
responsible way, to maintain open
access for patients, contribute to
the community, and remain
financially viable.
Innovation by embracing diverse
perspectives and new ways of
doing things, being open to
change, pressing for innovation,
and staying on the forefront of
emerging trends in the larger
healthcare environment.
INNOVATION
We are
progressive
. in our thinking
INNOVATION
and actions.
LEADERSHIP
LEADERSHIP
We serve as a role model of good
health and good citizenship.
Exceptional leadership by inspiring
our employees to deliver
great results for our patients, and
ensuring our actions reflect
our values.
LEGACY HEALTH | Legacy Values in Action
FIGURE 14.2 Legacy’s Values in Action
Source: Legacy Health. Copyrighted. Used with permission.
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Legacy Health
RN Preceptor Recruitment Tool
Preceptor_____________________________________________________ Date ___________
Minimum Qualifications
Demonstrates commitment to all Legacy Values in Action.
If NI, please explain:
Is clinically competent, as assessed by Charge Nurse, Assistant Nurse Manager, or Manager.
If NI, please explain:
Demonstrates effective communication skills with coworkers, inter-professional and
interdisciplinary team members.
If NI, please explain:
Consistently demonstrates strong organizational skills, an ability to prioritize
responsibilities, and equitable delegation skills.
If NI, please explain:
Works collaboratively with team members, students and faculty, new graduates, new
employees, the education department, and service-specific managers/supervisors.
If NI, please explain:
Demonstrates respect when interacting with others with diverse viewpoints, ethnicity,
gender orientation and educational backgrounds.
If NI, please explain:
Demonstrates commitment to developing in Preceptor Competencies of Professional
Development, Assessment, Planning, Implementation, Evaluation, Role Modeling, and
Advocacy.
If NI, please explain:
Ensures the timely completion of required orientation documentation.
If NI, please explain:
Y
*NI
Precepting Professional Development Plan
Employee meets all minimum requirements to function as a preceptor
Manager/Educator_____________________________________________ Date____________
•
NI = Needs Improvement. Marking the NI box in any of the evaluation categories does not
automatically disqualify the nurse from serving in the preceptor role. It is at the discretion of the
manager or designee if coaching is sufficient. This should be documented in the Precepting
Professional Development Plan box.
Used with permission. Legacy Health.
FIGURE 14.3 Legacy Health RN Preceptor Recruitment Tool
Source: Legacy Health. Copyrighted. Used with permission.
14 For Managers: Selecting, Supporting, and Sustaining Preceptors

305

Nursing Preceptor Rubric
Name ____________________________________________________ Date _____________ Medical Center/Unit ___________________________
 Check box if Preceptor Candidate will be Precepting in the Nurse Residency Program
All Legacy nurses must meet all of the preferred Employee Profile Criteria to be eligible to be a preceptor.
Patricia Benner, RN, PhD is a nursing theorist who patented her Novice-to-Expert Theory to explain a nurse's development process. There are five
levels of nursing experience: Novice, Advanced Beginner, Competent, Proficient, and Expert. The spectrum shows the progression from brand new
nurse who thinks everything through in steps, to a nurse who is able to practice intuitively. Benner's Novice to Expert theory is now the basis for
precepting at Legacy. A sequential progression of nurses from the Competent, Proficient and then Expert level will be utilized during the orientation
process. We need to clearly identify what category each of our preceptor is in. All criteria must be met in each box to receive that designation.
Criteria
Demonstrate
Accountability

Competent level
Column #1

Proficient level
Column #2

Some experience on which to build nursing
judgments.
Has developed baseline advocacy skills for
the patient and family.
Demonstrates basic skills & knowledge.
Explains basic rationale for interventions,
processes, and plans.
Performs conscious, deliberate planning
which results in efficiency and organization.
Possesses the basic ability to prioritize
appropriately.
Has his/her own style of nursing practice
based on evidence-based practice.
Is knowledgeable about and willingly to
utilizes resources
Adheres to organization & department
policies.
Can see the whole picture, but may need
support to achieve all the desired patient
outcomes.
May need assistance individualizing patients
Competent level
care plan
Has substantial experience in patient care
and exhibits sound clinical judgment.
Advanced advocacy skills for the patient and
family
Demonstrates skills in the recognition of
situational changes requiring unplanned and
unanticipated interventions.
More in-depth understanding of rational for
interventions, processes, and plans.
Succinctly plans, advocates and initiates
individualized plan of care for patients.
Able to effectively prioritize.
Exemplifies evidence-based nursing practice.
Readily accesses and uses resources.
Can reference policies in daily practice and
during emergencies
Independently able to achieve the desired
patient outcomes.
Independently able to individualized each
patient's care plan.
Manage for
Excellence



Emphasize
Teamwork



Communicate
Effectively



Recognize &
Develop Others


Criteria
Proficient level
Column #2
Column #1

Needs lots of support to develop plan for
their preceptee
May need assistance with coaching
preceptee.
Is willing to serve as a preceptor.
Able to contribute to the team effort by
assisting peers and members of the
healthcare team at times.
May need mentor for providing care
Is willing to share knowledge with new staff.
Exhibits basic clinical judgment in nursing
practice.
Utilizes effective communication skills with
peers and members of healthcare team.
Needs prompting or direction on what to
communication to Manger and care team to
provide for safe learning environment.
Demonstrates profession behavior, but may
need assistance with conflict resolution.
May need assistance with offering
constructive feedback.
Demonstrates clinical judgment by explaining
the “why” of decisions
Excitement for learning and maintains
intellectual curiosity
Is able to work with varying styles of learning,
incorporates learning curves, and learning
timeframes into the precepteeʼs experiences
with some guidance.
Limited to no precepting experience.
Needs minimal support to develop plan for
preceptee.
Developing ability to coach preceptee.
Is willing to serve as a preceptor.
Consistently contributes to the team effort by
assisting peers and members of the
healthcare team
May mentor others in providing care.
Some experience with sharing knowledge
with staff.
Possesses increased clinical judgment and
can apply knowledge into practice.
Models empathetic and effective
communication with peers and members of
healthcare team.
Needs minimal assistance in communication
with Manager are care team to provide for
safe learning environment.
Demonstrates professional behavior and is
able to seek appropriate resolution in difficult
and/or conflicting circumstances.
May need minimal assistance with offering
constructive feedback
Demonstrates solid clinical judgment with
explanations of decisions.
Maintains excitement for learning and
passion for teaching.
Embraces varying styles of learning,
incorporates learning curves, and learning
timeframes independently into the
precepteeʼs experiences
Some experience with precepting.
Expert level
Column #3
An experienced nurse who functions as
a role model in their unit.
Exceptional advocacy skills for the
patient and family
Possesses comprehensive knowledge
& skills.
Exceptional understanding of rational
for interventions, processes, and plans.
Easily manages the most complex
situations and can disseminate that
knowledge to others.
Models evidence- base practice,
leadership skills and high-level conflict
resolution abilities.
Readily evaluates practice against
organization & department policies.
He/she instrumental as a change agent
for evidence based practice.
Excellent skill in developing care plan to
support desired outcomes.
Expert with individualizing patient's care
Expert
level
plan to meet their
needs.
Column #3
Able to independently establish learning
plan and discern preceptee's ability.
Can successfully coach preceptee.
Is willing to serve as a preceptor.
Always contributes to the team effort by
assisting peers and members of the
healthcare team
Acts as a mentor and resource for other
nurses.
Acts as a clinical resource for staff.
Excellent clinical judgment and
anticipation of needs in practice.
Models exceptional communication
abilities in routine practice and in critical
events.
Independent in communication to
manager and team to provide for a safe
learning environment
Presents professional behavior in daily
practice and is skilled at conflict
resolution.
He/she is a motivator and demonstrates
team leadership through the appropriate
offering of constructive feedback.

continues
Exceptional clinical judgment
with
decisions
Maintains a significant passion for
Nursing and teaching.
Role models the acceptance of varying
styles of learning, learning curves, and
learning timeframes into the precepteeʼs
experiences.
Skilled preceptor
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FIGURE 14.4 Legacy Health Nursing Preceptor Rubric
Source: Legacy Health. Copyrighted. Used with permission.
Setting the Stage
Setting the stage is a key component of a successful preceptorship program. This requires creating and
sustaining a culture that supports the preceptorship program in general and that specifically supports
preceptors and preceptees; defining the needs of the unit, the preceptees, and the preceptors; matching
preceptors with preceptees; and setting expectations.
Creating a Culture
The manager is charged with creating and sustaining a unit culture that supports successful
preceptorships in which all colleagues understand the importance of high-quality precepting, the time
and energy involved, and the unique skills and abilities required to be a successful preceptor.
The manager must understand the current needs of the organization and the specific unit/department.
Bringing a new employee into a unit/department needs a thoughtful and intentional plan. Nurses
must work together as a team to accomplish the many goals and tasks assigned to them daily; likewise,
14 For Managers: Selecting, Supporting, and Sustaining Preceptors
307
onboarding new team members must be a decision that the majority of staff values and supports. The
entire staff will play a role in the success of a new team member.
Defining Needs
Determining the specific needs of the unit/department and what resources are available is a necessary
step when deciding to hire new nurses. Are the resources in place to allow a new nurse to develop? Is
the unit better able to transition an experienced nurse into a specialty environment, or should a new
graduate registered nurse (NGRN) be hired? Does the unit/department lack clinical experience or
staff who have specific knowledge and clinical skills needed? Is it time to advance the skills of one of
the current nurses? After the manager has determined the type of new hire that is most appropriate,
the process of matching the preceptor to the preceptee, or new hire, should begin. As part of the
decision to make an offer to potential candidates or to give advanced clinical opportunities to existing
staff members, nurse managers must consider the best preceptor match for individuals. This ensures
the preceptor resources are available to support the preceptor and preceptee; nurse managers should
approach this match in a proactive manner using the department’s preceptor profile to make your
choice.
Matching Preceptors With Preceptees
The manager should have a working knowledge of the qualities of each nurse in their pool of preceptors.
Maintaining a departmental preceptor profile is helpful in the matching process as well as in ensuring
that there are an adequate number of nurses who can precept when the need arises. It is important to
update this document periodically because there will be turnover, nurses on leave, and those who opt to
take a break from precepting duties. Nurse managers understand how time-consuming the onboarding
process is. A nurse manager needs to communicate the time commitment and expectations of the
preceptorship phase to all involved. Individual motivation is essential to successful integration into a
new team, and this commitment should be assessed during the preceptor selection process.
Promoting a good fit between preceptor and preceptee begins with maintaining a pool of trained and
motivated preceptors to choose from. Knowing which preceptor works most effectively with which kind
of preceptee is helpful, but it is difficult to coordinate this type of match for all preceptorships. Nurse
preceptors are professionals who need to be adept at adapting to a variety of personalities, learning
styles, communication styles, experience levels, and other inevitable differences in preceptees. An open
discussion on onboarding day between the preceptor and preceptee about these potential issues will
help mitigate challenges and make them easier to remedy when they occur. Figure 14.5 suggests topics
of discussion as “Guidelines for an Effective Preceptorship.” Additionally, the preceptor and preceptee
should discuss their roles and expectations for the preceptorship. A Preceptor/Preceptee Agreement
(see Figure 14.6) can serve as a guideline for managing expectations or as a contract between the two.
Legacy’s Preceptor/Preceptee Agreement has lines for multiple preceptors so that all who interact with
the preceptee acknowledge the expectations of the relationship.
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FIGURE 14.5 Legacy Health Guidelines for an Effective Preceptorship
Source: Legacy Health. Copyrighted. Used with permission.
14 For Managers: Selecting, Supporting, and Sustaining Preceptors
RN Preceptor / Preceptee Agreement
The Preceptor will:
•
•
•
•
•
•
•
•
•
•
The Preceptee will:
Collaboratively assess Preceptee learning
needs.
Plan for and provide learning opportunities to
meet competency validation goals.
Use the Legacy approach of precepting.
Observe Preceptee performance.
Evaluate learning needs based on progress.
Redefine goals and revise the plan as needed
with the Preceptee.
Provide timely and meaningful feedback.
Communicate plan and goals when alternate
preceptor is working with the Preceptee.
Communicate with manager/educator as to
progress and/or problem areas throughout
the Preceptee’s learning process.
Use the key phrase “LET ME HELP YOU WITH
THAT” (or other agreed upon phrase) when
needing to step in and take over care.
Complete required orientation
documentation in a timely manner.
Preceptor Name
Preceptor Signature
•
•
•
•
•
•
•
•
Collaboratively assess personal goals for
orientation based on past experiences,
education, and findings in evaluation.
Plan for learning opportunities in advance,
accessing available resources.
Use the Legacy approach of precepting.
Anticipate that the Preceptor will be
observing performance.
Collaborate with Preceptor to review
progress, goals and learning plan.
Actively engage in the feedback process: be
receptive to feedback from Preceptor, reflect
on own performance, and provide Preceptor
with meaningful feedback.
Use the key phrase “CAN YOU HELP ME WITH
THIS?” (Or other agreed upon phrase) when
needing the preceptor to immediately help
or take over care.
Complete the Preceptor evaluation.
Preceptee Name
Preceptee Signature
Preceptor Name
Preceptor signature
Preceptor Name
Preceptor Signature
Preceptor Name
Preceptor Signature
FIGURE 14.6 RN Preceptor/Preceptee Agreement
Source: Legacy Health. Copyrighted. Used with permission.
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Setting Expectations
The manager should share with potential new hires, or preceptees, the requirements needed to
successfully complete the onboarding process or advancement of their clinical/leadership skills and
provide a brief overview of what the unit can offer as far as orientation, onboarding, preceptorship,
mentorship, and educational opportunities. The new hires (preceptees) are expected to be active
participants in the process and to communicate. They need to know that the organization, the unit, and
its staff are committed to their success.
Even the most thoughtful pairing might not work. If the mismatch stems from behavioral issues,
the manager and preceptor need to institute an action plan for the preceptee. It is much easier for
the preceptee and the entire team to address concerns early on. The preceptee must be coached on
expectations and consequences, and the manager must follow through on continued concerns to ensure
that solutions are in place before the new hire becomes a permanent member of the team. If the divide
between a preceptor and preceptee is too wide, a manager might need to change the preceptor. If the
preceptee or preceptor identifies a mismatch, the person who brought the information forward should be
praised for honestly sharing his or her discomfort or unmet needs. If this is a true mismatch, talking with
each party individually and assigning a new preceptor whose personality and teaching style are a better
fit usually puts things back on track.
For assistance, managers can look to educational resources within their organization. Is there a specialty,
facility, or organizationally based Nursing Education Department? Are there Clinical Nurses Specialists,
Nursing Professional Development Specialists, or others trained in nursing education who assist with
preceptorship challenges?
Preceptor Education
The preceptor is the nurse who forms the profession of nursing, one nurse at a time. The manager must
recognize the value in initial and ongoing formal preceptor education. A strong clinician is not always a
solid preceptor. Workshops specifically tailored to the preceptor role should be formally established and
regularly offered. Concepts offered in preceptor workshops should include the roles and responsibilities
of the preceptor in your organization, adult learning theory, communication, effective feedback,
socialization, and clinical judgment—all of which need to be part of a continual learning process for all
preceptors. The sustained future of nursing depends upon the aptitude of preceptors, and this requires
initial and ongoing education to promote preceptor proficiency. The preceptor must demonstrate
commitment to ongoing professional development in the role of preceptor just as they must demonstrate
commitment to ongoing professional development in their nursing specialty.
14 For Managers: Selecting, Supporting, and Sustaining Preceptors
311
Communication
Maintaining open and honest communication for a safe environment begins with leaders listening
to those closest to the issues. A manager’s active participation and consistent facilitation of regular
communication among preceptor, manager, and preceptee promotes successful employees. To ensure
adequate support for new employees, nurse managers should set formal meetings, implement impromptu
check-ins, establish open office hours, and frequently review documentation. A framework for
establishing formal meetings with preceptors and preceptees with suggested time frames, areas of focus,
and follow-up is provided in Table 14.1.
Table 14.1
Suggested Guidelines for Formal Preceptorship Meetings
Time Frame
Onboarding
Day
Meeting
Participants
Manager,
preceptee,
preceptor
Focus
• Establish preceptor/preceptee
relationship
• Discuss “Guidelines for an Effective
Preceptorship” (see Figure 14.4)
Next Steps
Set timeline
for next
meeting
• Review Initial Competency Assessment
(ICA) and Self-Assessment of Strengths
and Learning Needs
• Set goals for first few shifts together
• Preceptor/Preceptee Agreement
Time Frame
One-third
of the way
through initial
preceptorship
timeline
Meeting
Participants
Manager,
preceptee,
preceptor
(Outgoing
and incoming
preceptor if
switching)
Focus
• Recognize accomplishments
• Review and revise goals
• Discuss transition of preceptors
• Plan for competency progression
• Review ongoing self-assessment
• Review set orientation documentation
• Provide opportunities for feedback,
including preceptee feedback for
preceptor and manager
Next Steps
Set timeline
for next
meeting
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Two-thirds
through
planned
preceptorship
timeline
Manager,
preceptee,
preceptor
• Discuss how far new employee
progressed and where next focus is
• Discuss transition of preceptors
Set timeline
for next
meeting
• Provide opportunities for feedback,
including preceptee feedback for
preceptor and manager
• Review set orientation documentation
Last few shifts
Manager,
preceptee,
preceptor
• Discuss transition from preceptor/
preceptee pair to independence
• Discuss what still needs to be
accomplished for successful orientation
Set timeline
for preceptorship completion
• Review set onboarding/orientation
documentation
• Provide opportunities for feedback
Additional:
Scheduled
as needed to
proactively
address any
challenges
Follow up
on any plan
to address
challenges
Source: Legacy Health. Copyrighted. Used with permission.
Evaluating Preceptors
Managers play a key role in the evaluation process for their preceptors. Evaluating preceptors based
on the organizational core performance standards is important for improving the preceptor process.
Seeking out all relevant sources of feedback and filtering them into the final evaluation are the first
responsibilities of the manager in the evaluation process. Coordination of evaluations from preceptees,
educators, charge nurses, peers, and other stakeholders should be part of a preceptor evaluation.
Incorporating peer feedback is crucial for preceptor growth because that feedback is often the most
relevant in content and honest in context. Focusing peer feedback on the competencies of the preceptor
established by the organization enables a standardized, consistent evaluation of the preceptor’s practice.
A sample preceptor evaluation is shown in Figure 14.7.
14 For Managers: Selecting, Supporting, and Sustaining Preceptors
Suggested Guidelines for Formal Preceptorship Meetings
Time frame
Meeting
participants
Focus
Onboarding Day
Manager,
preceptee,
preceptor
•
•
•
•
•
One third of the way
through initial
preceptorship timeline
Two thirds through
planned preceptorship
timeline
Manager,
preceptee,
preceptor
(Outgoing and
incoming
preceptor if
switching)
•
•
Manager,
preceptee,
preceptor
•
•
•
•
•
•
•
•
Last Few shifts
Manager,
preceptee,
preceptor
•
•
•
•
Next Steps
Establish preceptor/preceptee
relationship
Discuss “Guidelines for an Effective
Preceptorship” (See Figure 14.4)
Review Initial Competency Assessment
(ICA) and Self-Assessment of Strengths
and Learning Needs
Set goals for first few shifts together
Preceptor/Preceptee Agreement
Set timeline for
next meeting
Recognize accomplishments
Review and revise goals Discuss
transition of preceptors
Plan for competency progression
Review ongoing self-assessment
Review set orientation documentation
Provide opportunities for feedback,
including preceptee feedback for
preceptor and manager
Set timeline for
next meeting
Discuss how far new employee
progressed and where next focus is
Discuss transition of preceptors
Provide opportunities for feedback,
including preceptee feedback for
preceptor and manager
Review set orientation documentation
Set timeline for
next meeting
Discuss transition from
preceptor/preceptee pair to
independence
Discuss what still needs to be
accomplished for successful orientation
Review set onboarding/orientation
documentation
Provide opportunities for feedback
Set timeline for
preceptorship
completion
Additional: Scheduled as needed to proactively address any challenges
Follow up on
any plan to
address
challenges
FIGURE 14.7 Legacy Health RN Preceptor Evaluation by Preceptee
Source: Legacy Health. Copyrighted. Used with permission.
Managers should schedule meeting time with their preceptors to discuss the evaluation. Preceptor
feedback has the greatest impact during or immediately after the precepting process. Yearly staff
evaluations and end-of-orientation evaluations for the new hire are existing processes that can also
address preceptor performance. Managers must make preceptor evaluations a priority to grow and
support their nurse preceptors.
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The manager’s primary role with preceptor evaluation is to provide coaching, and having formalized
organizational core performance standards assists managers in this process; it is essential that individual
preceptor performance mirrors these set standards. Evaluation should be supportive and aimed at
growth, and managers should plan with their preceptors how this growth can occur. This collaborative
effort can help ensure necessary support for your preceptors and new hires.
Eliciting preceptor and preceptee feedback regarding their perceptions of the entire orientation program
can drive process improvement. Meeting expectations, praising positive outcomes, and planning for
how to deal with unexpected situations are topics for discussion. In practice, this feedback often surfaces
during a crisis. Being proactive in discussing any problems before they arise provides the most support
for your preceptors and preceptees.
A transparent and consistent approach is essential for preceptors to understand and be accountable
for their role performance. Such an approach enables preceptors to alter their practice to meet the set
standard. Managers can then hold preceptors accountable for the selection criteria or use the standards
to set performance goals; for this, follow-through is essential.
After the selection criteria are in place, manager support for the process is essential for preceptor
program success. As Studer (2009) states, “Remember, what we permit, we promote. What we allow, we
encourage…. It’s better not to have a standard in place than to have it and not hold people accountable
for it; it looks insincere and makes employees think other standards can be ignored, too” (p. 135).
Manager accountability to the process is essential for the rest of the team to follow.
Supporting and Sustaining Preceptors and Preceptorships
Preceptors play a crucial role in the success and development of staff. Their guidance and support of
new employees or current nurses who are advancing their skills are fundamental in nursing and to
the provision of high-quality, safe patient care. Preceptors are responsible not only for ensuring that
preceptees are competent, but also for continually role modeling professional behavior. To support
and sustain this important work, the manager must value, train, and support preceptors. Providing
meaningful recognition will show they are valued; providing opportunities for professional development
will give them the skills they need; and providing sufficient resources will help ensure their success.
Providing Adequate Resources
It is the manager’s role to ensure adequate resources are available for the preceptor and preceptee pairing
to be successful. The nurse manager is responsible for allocating time to the preceptor and preceptee
to address goals and evaluate that clinical assignments are appropriate based on the needs and skill
level of the preceptee. Each preceptor and preceptee comes to the table with varied strengths and skill
levels, and it is the nurse manager’s responsibility to develop those strengths and skills to their highest
potential. This fosters an engaged and sustainable workforce.
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315
Establishing a preceptorship that is conducive to teachable moments is crucial; therefore, the manager
should be focused on providing an environment of learning, including appropriate assignments,
exposure to learning opportunities, time for review of standards, evaluation of goals, and time for
debriefing. Assignments should be made in regard to the preceptee’s learning needs, and the preceptor
and preceptee should not “divide and conquer” to complete the tasks of the assignment in a timely
manner. The preceptor/preceptee couplet needs to work side-by-side to ensure that the preceptor
is there when teachable moments arise; in the clinical setting, teachable moments are missed if the
preceptor and preceptee are in different patient rooms when providing care.
Finding time for preceptors and preceptees to evaluate their shift, discuss new concepts, or elaborate
on teachable moments can be a challenge, so we show some potential strategies for the preceptor in the
next sidebar. The unit charge nurses can play an important role in helping to provide time away from
the bedside for the preceptor and preceptee to debrief, because the unit charge nurses are tuned into the
flow of the unit. Charge nurses can identify periods where other staff members might have time to cover
the preceptor and preceptee’s assignments to give them some time to meet.
Time Management for Preceptors
•
Work with your charge nurse to find uninterrupted time to review standards with your
preceptee.
•
•
•
•
•
Alter workflow to allow time to debrief with the preceptee during the shift.
Advocate for a patient assignment that promotes time for teaching.
Choose assignments that focus on the preceptee’s specific learning needs.
Communicate your needs.
Collaborate with your manager to complete orientation and competency requirements.
Managers can coach staff on time management strategies to assist with preceptor feedback and
communication. Often, if feedback is left until the end of the shift, it might not occur without accruing
overtime pay. Individuals might be able to alter their workflow to provide most of the feedback during
their clinical shift so that the end-of-the-day debriefing can be quick.
Preceptor Support
Managers can use organizational opportunities to support their preceptors. Newsletters are an excellent
form of communication; a newsletter can provide a venue for supporting and recognizing that the
institution values the preceptor role. Dissemination of information can be a means of supporting
preceptor education. Preceptor committees are another excellent format to get feedback and input into
the ongoing development and modification of the preceptor program. Insights into the preceptors’ work
are invaluable in creating an environment that supports networking, creative problem-solving, and unity
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
of purpose. Barriers to a successful clinical preceptor program are often best resolved by the nurses
providing direct patient care, preceptors, and preceptees.
Meaningful Recognition
Meaningful recognition comes in many forms. It is personal, and it can often be difficult for those
receiving recognition to articulate what truly makes them feel recognized. Recognition is not always a
grand, sweeping gesture, and what makes preceptors feel recognized may vary immensely from nurse to
nurse.
Asking a nurse to consider becoming a preceptor can be a morale boost in and of itself. Benner’s
(1984) Novice to Expert model has been used to create a new model for precepting. In the past, expert
nurses were relied on to precept new employees and new nurse graduates. When newer, “competent”
nurses were utilized successfully by Legacy as preceptors, mirroring Benner’s theory, those nurses felt
recognized and valued. These new preceptors demonstrated a sense of confidence and pride in their new
role. Legacy Health continues to successfully utilize competent-level nurses as first preceptors for RN
residents. These preceptors are often motivated by their own experiences as RN residents and can still
remember what it was like to be a new nurse.
After the manager and unit staff acknowledge a colleague as a preceptor, they have many ways
available to provide meaningful recognition. Some examples are shown in Table 14.2. The preceptor’s
effort, energy, and guidance toward the professional development of fellow staff can be recognized
via professional, financial, or personal means. Clinical ladders can be a means to advance nursing
practice, and recognition could come in the form of higher pay or professional advancement; in
addition, preceptor pay differentials provide financial incentives and recognition. Organizations without
embedded financial incentives for preceptors can still provide meaningful recognition by eliminating
the preceptors from forced cancellation rotations while they are precepting, or they can be given
preference when applying to attend conferences or special educational opportunities.
Table 14.2
Examples of Preceptor Recognition
• Clinical ladder advancement
• Preceptor differential
• No forced cancellation rotations
• Paid conference or educational day
• Authoring newsletter articles for preceptors
• Preceptor of the Year award
• Highlight and post individual preceptor biographies
• Special thank-you at staff meetings
• Preceptor pin or pen
• Preceptor Appreciation Week
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Meaningful recognition for preceptors can come in the form of official praise by nominating them for
awards within the organization, unit, or with local and national professional organizations. Managers
can continue to foster preceptors’ leadership and development by requesting their assistance on
system-wide committees and projects. At the unit level, managers can have preceptees nominate their
preceptors for recognition and then announce the winners during staff meetings or in unit newsletters.
Still, the most meaningful recognition might come in the form of a simple “thank you”—acknowledging
the important role preceptors play in the cohesiveness and success of the organization and unit.
Recognizing their efforts and including them as part of the reason the preceptees are successful can fill
preceptors with a sense of pride and accomplishment.
Getting Creative to Overcome Challenges
The manager is not an island; managers need to remember that they work with a team of highly skilled
clinicians and leaders. Successful managers use members of their teams to help ensure creative solutions
for tackling limited orientation and onboarding hours, heavy assignments, budgetary constraints,
and overall lack of time. Unit-based roles such as chairs of preceptor or mentorship councils, charge
nurses, supervisors, and unit educators can assist the manager in establishing and implementing
the onboarding/orientation process. These unit-based leaders are instrumental in the success of any
precepting program. By utilizing a shared governance model, managers can reach out to members of
their teams to support both the preceptor and the preceptee. The more team members who are involved
in the functioning of the unit, the more likely they are to be engaged and vested in the success of all
team members.
A mentorship program can help extend the support offered to a new employee. For example, a unitbased mentorship council that pairs a new employee with a mentor for a period (3–6 months post
orientation) can provide extended clinical and socialization support. The mentor should not be one of
the new employee’s original preceptors. Utilizing other staff to help in the mentorship process expands
the new employee’s network of support. The chair of the mentorship council and the unit manager can
monitor the mentorship program by establishing frequent meetings and using formalized feedback
tools to help identify learning opportunities and areas for further development or to assist in support by
recognizing accomplishments. A mentorship program might enable a team to extend clinical support
to the new employee without extending the onboarding/orientation budget. This clinical mentorship
model can also be successful in helping existing staff who are struggling with clinical issues or who need
support with skill advancement.
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Conclusion
Investing in the development of a unit by fostering staff to become preceptors and by successfully
growing new staff is one of the greatest legacies a manager can offer to the profession of nursing and
an organization. By creating a strong and successful unit that supports, recognizes, and embraces new
nurses, a manager can advance the profession of nursing by ensuring high-quality outcomes for the
patients and families who entrust their care to your organization.
14 For Managers: Selecting, Supporting, and Sustaining Preceptors
319
Manager Plan: Selecting, Supporting, and Sustaining Preceptors
Review the information on selecting, supporting, and sustaining preceptors described in this
chapter. What are your strengths? In which areas do you need to increase your knowledge and
expertise? What is your plan for expanding your knowledge and expertise? What resources are
available? Who can help you?
In addition, review your organization’s preceptor performance standards, selection criteria,
education program (initial and continuing), evaluation forms, and recognition plans. If any
of these are not yet available in your organization, work with stakeholders to develop and
implement them.
Name:
Date:
Establishing Performance Standards and Preceptor Competencies
Strengths
Needs
Plan
Resources
Plan
Resources
Plan
Resources
Setting the Stage: Creating a Culture
Strengths
Needs
Setting the Stage: Defining Needs
Strengths
Needs
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Setting the Stage: Matching Preceptors with Preceptees
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Setting the Stage: Setting Expectations
Strengths
Preceptor Education
Strengths
Communication
Strengths
Evaluating Preceptors
Strengths
14 For Managers: Selecting, Supporting, and Sustaining Preceptors
Supporting and Sustaining Preceptors and Preceptorships
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Providing Adequate Resources
Strengths
Meaningful Recognition
Strengths
Overcoming Challenges
Strengths
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
321
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References
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley
Publishing Company.
Friedman, M. I., Cooper, A. H., Click, E., & Fitzpatrick, J. J. (2011). Specialized new graduate RN critical care orientation:
Retention and financial impact. Nursing Economic$, 29(1), 7–14.
Friedman, M. I., Delaney, M. M., Schmidt, K., Quinn, C., & Macyk, I. (2013). Specialized new graduate RN pediatric
orientation: A strategy for nursing retention and its financial impact. Nursing Economic$, 31(4), 162–170. Retrieved
from https://www.nursingeconomics.net/ce/2015/article3104162170.pdf
Studer, Q. (2009). Straight A leadership: Alignment, action, accountability. Gulf Breeze, FL: Fire Starter Publishing.
323
“Let us never consider ourselves finished nurses…
we must be learning all of our lives.”
– Florence Nightingale
Preceptor Development
–Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN
The literature increasingly supports the significance of the preceptor role as well as
the need to educate registered nurses (RNs) in the knowledge and skills required to
be a preceptor. Clipper and Cherry (2015) found that new graduate RNs (NGRNs)
whose preceptors had received education in how to be a preceptor moved to a
higher level of professional practice faster than those whose preceptors had not
received education in the role. The NGRNs also rated their own competence,
development of critical thinking skills, and development of collegial working
relationships and promoting a positive work environment as higher at the end of
the preceptorship. Preceptor development programs have been shown to improve
preceptor competence, performance, and retention (Baumgardner & Williams,
2014; Sandau, Cheng, Pan, Gaillard, & Hammer, 2011; Scholtz, King, & Kolb, 2014).
Getting Started
Creating preceptor development programs requires considerable planning.
There are at least three components of a complete preceptor development
program: preceptor basics, advanced preceptor concepts, and ongoing preceptor
development. If you have RNs already practicing as preceptors who have not been
fully educated to function in that role, an additional component will be needed to
ensure that they have the knowledge and skills to function in the role. In addition,
if this is a new program or an expansion of an existing program, it is recommended
that you enlist the expertise of someone experienced in project planning.
Standards
The standards delineated in Nursing Professional Development: Scope and Standards
of Practice (Harper & Maloney, 2016) published by the Association for Nursing
Professional Development (ANPD), and the American Nurses Credentialing Center
(ANCC) Primary Accreditation Provider Application Manual (ANCC, 2015) provide
excellent roadmaps and details for developing preceptor programs.
15
OBJECTIVES
•
Identify strategies
for developing and
educating preceptors
•
Understand the
components of
preceptor training
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Both the Commission on Collegiate Nursing Education (CCNE, 2015) and the ANCC (2018) accredit
transition programs. The CCNE provides standards for accreditation of entry-to-practice nurse
residency programs. The ANCC Practice Transition Accreditation Program (PTAP) provides standards
for residency and fellowship programs that transition NGRNs, experienced RNs, and advanced practice
RNs (APRNs) into new practice settings. Individuals planning preceptor development programs should
review the standards and requirements of these programs.
The 2019 Magnet standards include a requirement for a nationally accredited transition program
(ANCC, 2017). If your organization has Magnet designation, is on the journey to become designated, or
is considering seeking designation in the future, consider the Magnet requirements. In February 2019,
new criteria are in effect. Specifically, Structural Empowerment (SE) 9 will require the organization to
“provide evidence of a nationally accredited transition to practice program (TTP)” (ANCC, 2017, p. 45)
that is in place in the organization or to choose three of five areas in which transition occurs: NGRNs,
newly hired experienced nurses, nurses moving into a new practice environment, APRNs who are
moving into new roles, and new managers (ANCC, 2017). There are six elements to transition programs
that must be addressed: program leadership, organizational enculturation, development and design,
practice-based learning, nursing professional development support, and quality outcomes.
Assess the Practice Gap and Identify the Educational Needs
The first step is to assess the practice gap, described by Dickerson and Graebe (2018) as “the distance
between where things are now and where they should be” (p. 4). In the case of preceptor development,
there may already be a program that needs improvement, or this may be a new endeavor for the
organization. Another important consideration is how to meet the needs of brand new preceptors;
ensure that the needs of existing preceptors are met so that all preceptors are practicing based on the
same information and expectations; and provide continuing education to all preceptors on a routine and
as-needed basis.
For example, in preparation for developing a certified registered nurse anesthetist (CRNA) preceptor
workshop for two large academic medical centers, Scott-Herring and Singh (2017) found that 94% of
the existing CRNA preceptors had never attended a CRNA preceptor education course, and 82% had
never participated in any type of preceptor education or preparation. After attending the preceptor
workshop, participants had significantly increased satisfaction in preceptor preparation, confidence, and
comfort in precepting. Several articles report the use of two levels of preceptor education—one on basic
essentials and the other more ongoing and advanced (Foy, Carlson, & White, 2013; Gueorguieva et al.,
2016; Shinners & Franqueiro, 2015).
Information gathering should include:
• Determining where things are now
• Information on preceptors (e.g., number, experience, knowledge, skills)
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• Current methods of preparing preceptors for the role
• Content of the current preparation
• Resources (e.g., human resources, equipment such as technology and simulators)
• Expectations
• Demand for preceptors (programs and number of preceptees—NGRNs? NGRN Residency?
APRNs? experienced nurses moving into new roles or specialties? etc.)
• Anything else that is pertinent to describing the current state
Obtaining this information will require accessing data as well as identifying and talking with
stakeholders (e.g., educators, nurse managers, current preceptors, the chief nursing officer). Stakeholders
include anyone who can influence or be impacted by the program, including those who know they can
be impacted as well as those who may not know. They are excellent sources of information, and engaging
them can have benefits as you move forward on design, implementation, and evaluation of the program.
Next, determine where things could or should be. What should preceptor development for your
organization consist of? Who should have preceptors? What should the preceptor role be? What are the
required preceptor competencies? One example in which certain populations of preceptors might need
different content or different depth of content was found in a study by Chang, Douglas, Breen-Reid,
Gueorguieva, and Fleming-Carroll (2016), in which less-experienced preceptors needed more guidance
and more-experienced preceptors wanted knowledge of advanced teaching concepts. Here again,
consulting with and engaging stakeholders is important. The more others are engaged in the program,
the more they will be invested and feel ownership of the results.
The next step is to conduct a needs assessment to identify the educational needs—knowledge, skills,
practice. Moyer and Graebe (2018) note that “the identification of the underlying educational need
focuses on what is required to fill the distance between what is occurring and what should be occurring
related to practice and patient outcomes” (p. 52).
Preceptor Program Delivery
Program delivery is determined by many things, such as content, available preceptor time, access to
physical facility, availability of technology, costs, etc. The program can be delivered in face-to-face
sessions, online, or in a blended program. Based on their study results, Foy et al. (2013) suggest asking
current and potential preceptors how they prefer to learn and not assuming that you know.
Face-to-Face
The face-to-face method is the traditional method. Face-to-face sessions encourage learner engagement
and active discussions. However, getting all the participants in a room at the same time is often difficult
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in healthcare organizations and is especially challenging if the education is for participants who are
geographically dispersed.
Online
Online technology can be used in many different ways—to provide webinars, provide access to
information and materials, communicate with and among participants, conduct assessments, track
experiences and evaluations, and more. Online programs depend on the self-discipline of the
participants. A systematic review of online learning programs for nurse preceptors found that online
learning provides accessibility, convenience, and flexibility (Wu, Chan, Tan, & Wang, 2018). Several of
the online programs reviewed used avatars and virtual worlds. The outcomes of the online programs
included increased knowledge and skills, confidence, leadership practices, and effectiveness of the
precepting program. Easton, O’Donnell, Morrison, and Lutz (2017) have described the development and
implementation of an online, evidence-based certified registered nurse anesthetist (CRNA) preceptor
training tutorial. This program offers online modules supported by introductions, references, suggested
practice activities, and relevant policies.
It is very important to understand that the use of online technology requires having or developing
expertise in that teaching strategy, or obtaining the services of experts, in order for online teaching
to be successful. It is also necessary to assess the experience and comfort of participants with online
learning and to provide sufficient information and support for them to be competent users. A common
mistake that educators new to online teaching make is to assume that what works in a face-to-face class
will work online. Keeping the attention of learners online is a major challenge. One strategy is to break
online learning into smaller chunks. Providing detailed instructions, ongoing feedback, discussion areas
for participants to communicate with each other and with the instructors, and links to online resources
can be effective in meeting the needs of online learners for more interaction with the instructor
(eLearning Miami, 2018).
Blended Approach
Increasingly, a blended approach is being used, combining the use of online learning with face-toface classes/workshops. If you use a blended approach, consider what can best be taught and learned
online vs. face-to-face. Participants can prepare for the face-to-face class with background information,
readings, prerecorded lectures, podcasts, etc. Interactive discussion, role-playing, application of content,
etc. are then done in the face-to-face class. The advantage of this blended approach is a better use of
time because the participants are prepared in the same way for the work that is to be done in the faceto-face class, resulting in richer and more meaningful discussions.
Senyk and Staffileno (2017) report converting their basic preceptor education class to an online
program, but offered advance workshops in a face-to-face format with positive results. They also created
a web page on the organization’s intranet to facilitate communication between preceptors and clinical
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educators and provide access to resources (Senyk & Staffileno, 2017). Condrey (2015) describes a
blended approach that includes both online and face-to-face components. Participants were required to
complete the online component before attending the face-to-face class.
Learner Engagement Strategies
Regardless of whether your program will be face-to-face, online, or a blended approach, learner
engagement is a priority. Both the ANCC (2015) and the Nursing Professional Development standards
(Harper & Maloney, 2016) are clear about the need to engage learners. Examples of learner engagement
strategies as suggested by Pilcher and Graebe (2018) are shown in Table 15.1.
Table 15.1
Learner Engagement Strategies
• Questions and answers
• Games and gaming
• Reflective activities
• Concept maps
• Problem-solving
• Hands-on activities
• Creation activities
• Flipped classroom model
• Virtual scavenger hunts
• Online field trips
• Virtual simulations
• Online journal analysis
• Virtual assessment activities
• Discussion forums
• Wikis
• Virtual rounds
Source: Pilcher & Graebe, 2018
Program Length
There are many options regarding the length of preceptor programs. Programs may include basic
information, planned interactions, advanced/continuing education, and more. A consideration
when deciding the length is what part of the program should be time-based and what part should
be competency-based. In 2017, the Josiah Macy Foundation conducted a conference on achieving
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competency-based, time-variable health professions education, with participants including invited
educators from nursing, medicine, pharmacy, and higher education with a mix of theoretical, clinical,
measurement, and regulatory backgrounds (Lucey, 2018). Competency-based, time-variable (CBTV)
education “posits that the amount of responsibility and level of supervision assigned to each learner
in the clinical environment must be determined by measuring competency, not by tabulating the
number of weeks, months, or years spent in the program” (Lucey, 2018, p. 12). In other words, CBTV
moves education from a fixed time–variable outcomes model to a fixed outcomes–variable time model.
Required competencies must include the knowledge, skills, behaviors, and attitudes expected. Consider
if parts of your program can be CBTV rather than everyone having to spend the same amount of time,
but also consider what amount of time is required for all the development that needs to occur, such as
the development of role or professional identity and confidence.
Evidence-Based Decisions and Content
Decisions about the program and the program’s content should be evidence-based. The use of evidence
improves the odds of success and role models the use of evidence to preceptors. Mallory, Franqueiro,
and Graebe (2018) note that content should be “developed based on the best available evidence to foster
achievement of desired outcomes” (p. 149).
Innovative Preceptor Programs—A Case Study
Billie Madler, DNP, APRN, FNP-C, FAANP, and Melanie Schlittenhardt, DNP, APRN, FNP-BC
As a recipient of a grant from the Health Resources and Services Administration (HRSA), the
University of Mary (Bismarck, North Dakota, USA) partnered with Catholic Health Initiatives
(CHI). The primary aim of the grant was to develop and advance the preparedness of healthcare providers in their role as preceptors to nurse practitioner students. Several methods to
deliver preceptor development content were considered, including workshops and seminars.
However, a needs assessment revealed that preceptor attendance would be difficult due to
clinician schedules and geographical barriers. As a result, University of Mary faculty considered
alternative methods for delivery of an evidence-based professional development program
for preceptors. Consequently, the grant partners developed a creative means to support
preceptor development in a flexible and accommodating manner. Using the university’s
existing online education platform, the partners established a three-credit graduate course,
Preceptor Development: Teaching in the Clinical Environment.
The course curriculum was framed by the text Mastering Precepting: A Nurse’s Handbook for
Success. The course concentrated on developing preceptor skills in clinical education, teaching
strategies, communication, feedback, and evaluation. The course emphasized strategies to
foster a positive relationship between the preceptor, student, and faculty while promoting a
meaningful experience and successful incorporation into a busy clinical environment.
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To incentivize preceptor participation, the university’s governance channels agreed to offer
the 15-week graduate course free of charge. CHI partners collaborated in the recruitment of
participants by extending communications to the providers across their national enterprise.
The course outcomes included examination of the purpose and value of serving as a
preceptor; exploration of adult learning principles in relationship to curriculum development
and clinical education; utilization of clinical teaching strategies, communication skills, and
feedback methods to cultivate preceptee competencies; consideration for effective preceptor
evaluation of the students’ clinical performance and the value this role has with determination
of clinical progression; and developing competence as a preceptor serving in the domain of
professional generativity. The course utilized a variety of teaching strategies and incorporated
evidence-based literature, online discussions, reflection, webinars, recorded lectures, expert
guest lectures, audio podcasts, video vignettes, and major assignments.
Feedback from participants was positive, especially regarding tangible takeaways. The
course attracted a variety of providers including nurse practitioners, physician assistants, and
physicians. Among the three cohorts that enrolled, a range of specialties from 12 different
states were represented. Course evaluations identified participant satisfaction with the
course textbook, supplemental materials, assignments, and delivery method. Although the
commitment required to complete a graduate online course did not appeal to all potential
preceptors, it proved to be a viable strategy to promote preceptor development. After
completing multiple course offerings, the University of Mary remains committed to sustaining
the course as an option for developing preceptor competencies for all who work with nurse
practitioner students in practice settings.
Content—Using the Mastering Precepting Book for Preceptor
Education
The Mastering Precepting book can be combined with other resources to form the basis of a preceptor
development program. The following are the objectives and the suggestions for the use of each chapter/
module.
Chapter/Module 1: The Preceptor Role
Objectives:
• Understand precepting in the context of nursing and the healthcare system.
• Understand the role of a preceptor.
• Know the competencies required to practice as a preceptor.
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Suggested Content/Strategies
• Introduction: Have all participants introduce themselves. This can be done in person or by
posting introduction videos online. Provide an overview of the program.
• Review and discuss the ANA Standards of Practice and Professional Performance and the
Code of Ethics. Ensure that everyone is familiar with the content. Have participants review
the standards from their specialty organizations.
• Discuss quality and safety as parts of the context of precepting. Use the QSEN competencies,
modules, and teaching strategies for information and examples.
• Discuss each preceptor role in general.
• If the organization has its values articulated, review and discuss the values and how they can
be integrated into precepting. Do the same for the nursing division. If the organization and/
or the nursing division do not have their values articulated, divide the participants into small
groups. Ask each group to come up with what they think the organization/division values are,
what they should be, and how these values can be integrated into precepting. Have each group
present to the entire class and discuss the results.
• Divide the participants into groups and ask them to create a list of sacred cows and unwritten
rules of the game in the organization, the nursing division, and their units. Have each group
present to the entire class and discuss the results.
• Discuss creating a safe learning environment. Review the organization’s policies on verbal
and physical abuse. Ask for examples from the group, and discuss strategies for preceptors to
protect preceptees from such abuse.
• Have the participants complete their individual Preceptor Development Plans on Preceptor
Roles.
Chapter/Module 2: Learning: The Foundation of Precepting
Objectives
• Understand assumptions about adult learners.
• Understand the concepts of observing and modeling and how they apply to preceptor
behavior and preceptee learning.
• Apply the Novice to Expert framework to both preceptor and preceptee learning.
• Understand learning styles.
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Suggested Content/Strategies
• Review and discuss learning theories.
• Discuss role modeling. Ask the participants for recent examples of good and not good role
modeling that they have observed. Challenge them to compare what they do with their values.
For example, if they value collaboration, ask for examples of how they collaborate with others.
• Discuss Maslow’s hierarchy of needs and how preceptors can help preceptees move up the
hierarchy.
• Ask participants to remember when they were novices and describe how that felt. Discuss
Benner’s Novice to Expert model and how the model can be used in precepting. As a group,
discuss strategies to support novices as they move toward expert practice.
• Discuss learning styles and engage participants in describing how they learn best.
• Ask participants to reflect on their own learning and experience. Ask questions such as,
“What do you need to learn to be a competent, proficient, and then an expert preceptor?
What experience do you have that will be applicable? What is your frame of reference? Are
you ready to learn?”
• Discuss who the participants will be precepting. Ask participants questions such as, “Who will
you be precepting? Undergraduate nursing students? NGRNs? Experienced nurses entering a
new role or specialty? APRNs? How will you model for them what they need to learn?”
• Have the participants complete their individual Preceptor Development Plans on Learning.
Chapter/Module 3: Precepting Strategies
Objectives
• Understand basic precepting strategies.
• Create a positive learning environment.
• Know how to begin and end a preceptor-preceptee relationship.
• Use teaching strategies in the preceptor role.
Suggested Content/Strategies
• Discuss the expectations of preceptors in your organization. Use the questions in Table 3.1 to
guide your preparation for this discussion.
• Discuss the model of precepting to be used in your organization (e.g., single preceptee,
cohorts). If more than one model is used, discuss all the models used and when each is used.
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• If your organization has structured onboarding programs such as an NGRN residency or
specialty preparation, discuss these programs and the preceptor role in these programs.
Provide specific examples of how preceptors integrate in the programs and how
communication about preceptees occurs between the programs and the preceptors.
• Discuss methods of communication between preceptors and other stakeholders (e.g., the
preceptee’s manager, charge nurses). Ask the group to discuss facilitators and barriers to
communication and strategies to promote facilitation and overcome barriers.
• Break into small groups and ask each group to come up with ground rules for preceptorpreceptee relationships. Discuss the results of the group work as a whole class.
• Discuss the transitions that preceptees go through and any support your organization has
for such transitions (e.g., career coach, employee assistance program). If the organization
does not have support mechanisms in place, discuss what preceptors can do to support—and
engage others to support—preceptee transitions.
• Discuss the preceptor’s role in creating positive learning environments, interprofessional
learning environments, and safe learning environments. Have participants brainstorm ways
they can create these environments. Discuss facilitators and barriers.
• Discuss establishing the preceptor-preceptee relationship and conducting the preceptee
learner assessment.
• Discuss the strengths-based approach to clinical teaching.
• Break the group into pairs. Have one member of the pair be the preceptor and the other the
preceptee. Have the preceptor do a one-minute praising. Reverse roles and repeat. Bring the
group back together and discuss the process.
• Review the microskills model. Use a case study to discuss the steps in the microskills model.
• Discuss debriefing. Ask the group for suggestions on how debriefing can be integrated into
the busy day.
• Discuss reflective practice, and ask for examples of how reflective practice can be used with
preceptees. Also discuss the preceptor’s use of reflective practice on their work as a preceptor.
• Discuss mindfulness for preceptors and preceptees. Practice the purposeful pause/
mindfulness moment for 60 seconds.
• Use the information in Table 3.3 to discuss resilience. Engage the participants in discussing
how they can help preceptees develop resilience.
• Discuss ending the preceptor-preceptee relationship. If your organization has a specific
handoff procedure from the preceptor to the manager or an end-of-preceptorship summary
form or status report, discuss how it is used. If these do not exist, talk as a group about how to
best hand off the preceptee.
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• Discuss any celebrations that your organization has to commemorate the preceptee
completing the onboarding process. For example, many organizations with NGRN residencies
have “graduation” or completion ceremonies to which hospital staff and the preceptees’
families are invited.
• Have participants complete the Preceptor Role Clarification with their manager and complete
their Preceptor Development Plan on Precepting Strategies.
Chapter/Module 4: Core Precepting Concepts
Objectives
• Understand development of preceptee 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.
Suggested Content/Strategies
• Discuss what competence is.
• Review role competencies that your organization has adopted and how they are measured and
validated. Review competency documentation systems.
• Discuss the Competency Outcomes and Performance Assessment model and the Wright
Competency model and their use in precepting. If your organization has adopted a
competency model, discuss that model.
• Discuss the core critical thinking skills and sub-skills (Table 4.1).
• Using Alfaro-LeFevre’s key questions and a case study, have the group work through helping a
preceptee learn how to think critically.
• Discuss clinical reasoning and the patterns of clinical reasoning that experienced nurses use.
Use a case study in which clinical reasoning occurs, and ask the participants how to break
down the reasoning steps for a novice nurse.
• Using Tanner’s model of clinical judgment and a case study, ask participants to discuss how
they would help a novice use clinical judgment.
• Ask participants to describe situations in which they used their intuition to act on a patient
problem. Then ask them to identify the pattern—or absence of a pattern—that was their cue
to act.
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• Discuss ways to promote confidence in preceptees.
• Have participants complete their individual Preceptor Development Plans on Core Concepts.
Chapter/Module 5: Having a Plan: Developing and Using Goals, Objectives, and
Outcomes
Objectives
• Distinguish the differences among goals, objectives, and outcomes.
• Discuss learning taxonomies.
• Apply the learning taxonomies and theories to the preceptorship process.
• Create goals, objectives, and outcomes.
Suggested Content/Strategies
• Discuss the concept of having a plan and the continuum of plans from a fully detailed written
plan to taking a few minutes at the start of a shift to decide and discuss what the plan is for
the patient and/or the day.
• Discuss what a goal is. Share the organization’s and nursing division’s goals as examples.
Additional goals can also be shared, such as the goals of the NGRN residency.
• Compare objectives and outcomes.
• Have the participants create an example of a goal, outcome, and objective.
• Review the taxonomies. Divide the participants into small groups, and have participants
create sample objectives in each knowledge dimension, domain, and level. Have some
groups create examples of written objectives, some create examples of beginning of the shift
objectives for working with one patient, and some create examples for the whole shift. Have
some create examples for NGRNs, experienced nurses in a new specialty or role, and for
APRNs.
• Have participants complete their individual Preceptor Development Plans on Developing and
Using Goals, Outcomes, and Objectives.
Chapter/Module 6: Communication
Objectives
• Describe the five core skills of effective communication for preceptees and preceptors.
• Articulate the behaviors for self-improvement of dialogue skills.
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• Distinguish effective ways of managing different methods of communication.
• Name key considerations for participating in team communications.
• State ways to manage difficult conversations between preceptors and preceptees.
Suggested Content/Strategies
• Discuss the five skills of effective communication—intent, listening, advocacy, inquiry, and
silence—and examples of each skill.
• Practice using the questions for setting intent for the preceptor-preceptee relationship.
• Review patient handoffs and how the same concepts can be applied to preceptee handoffs.
If your organization uses a specific handoff tool (such as ISBAR), discuss using that tool for
preceptee handoffs.
• Discuss team communications, with specific examples from your organization.
• Role-play examples of difficult conversations.
• Role-play a difficult patient safety situation or handoff utilizing effective communication.
• Have the participants complete their individual Preceptor Development Plan on
Communication.
Chapter/Module 7: Coaching
Objectives
• Describe the role of the preceptor as coach.
• Identify ways to set up a coaching agreement and utilize a coaching interaction format with
preceptees.
• Articulate strategies to inspire learning and move through challenges.
• Identify the preceptor’s role in working with resistance and edges.
• Describe how a preceptor ends a coaching relationship with a preceptee.
Suggested Content/Strategies
• Discuss coaching behaviors and beliefs.
• Discuss how to set up a coaching agreement. Engage participants in developing potential
mutual agreements.
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• Review the four-step coaching process.
• Use one or more case studies, and have the participants role-play coaching preceptees.
• Discuss resistance and edges. Use examples and/or case studies to have participants practice
working with preceptee edges. Have participants use the four edge questions (see Chapter 7)
to role-play moving a preceptee or colleague through an edge or challenge.
• Discuss ending a preceptor-preceptee coaching relationship.
• Have the participants complete their individual Preceptor Development Plan on Coaching.
Chapter/Module 8: Effectively Using Instructional Technologies
Objectives
• Identify various forms of instructional technology and appropriate use to augment
achievement of learning goals.
• Develop a better understanding of the benefits of using high-fidelity patient simulation to
facilitate learning and understanding during new-hire and new-specialty orientation.
• Identify trends and future uses of instructional technology methodologies.
Suggested Content/Strategies
• Review the concept of E-learning and discuss examples of it. If E-learning is used in your
organization, allow preceptors to become familiar with any programs that their preceptees
might use.
• Review web-based collaboration tools. Demonstrate wikis, blogs/vlogs, discussion forums,
and podcasts.
• Discuss the concepts of simulation and simulation fidelity.
• Discuss the use of role-playing, games, standardized patients, and virtual reality.
• Discuss the use of high-fidelity patient simulation and how it can be used to teach skills
competency, critical thinking, clinical reasoning, and judgment.
• If your organization has simulators, demonstrate them to the participants and inform
participants how the simulators will be used with their preceptees. Allow participants to
experience simulation scenarios themselves.
• Role-play a simulated clinical experience with preceptors so they can put into practice and
demonstrate the knowledge they have gained regarding how to be an effective preceptor, with
the faculty acting as the preceptee.
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• Have preceptors complete a self-efficacy tool prior to simulation and again after simulation to
assess their competence, confidence, and readiness to perform in the role of preceptor.
• Have participants complete their individual Preceptor Development Plans on Effectively
Using Instructional Technology.
Chapter/Module 9: Precepting Specific Learner Populations
Objectives
• Understand the needs of specific learner populations.
• Individualize precepting based on the needs of specific learner populations.
Suggested Content/Strategies
• Discuss precepting prelicensure nursing students. Review agreements and forms from schools
of nursing who have clinical rotations in your organization. Review role responsibilities and
any limitations to student practice in your organization.
• Discuss the need for transition to practice programs for NGRNs. If your organization has an
organized transition to practice program, review all aspects of the program with participants.
Discuss the role of preceptors in the program. If there is no program or only a minimally
organized program, discuss transition to practice in more detail.
• Ask participants to remember when they were NGRNs, and discuss what helped them
through that transition and what hindered them.
• Review scopes of practice for nursing and other healthcare professionals in your state. Perhaps
bring in some other healthcare professionals to discuss the scope of their practice.
• Discuss clinical autonomy. Have participants break into small groups and discuss expected
levels of autonomous practice in your organization and in various units. Be specific about
what nurses can do autonomously and what they cannot.
• Discuss the concept of developing professional identity in NGRNs. Have participants describe
what a professional RN identity looks like in your organization.
• Discuss developing leadership and interprofessional skills in NGRNs. Provide examples of
how NGRNs can be leaders in your organization.
• Discuss precepting post-baccalaureate nurses, experienced nurses, newly hired experienced
nurses, experienced nurses moving into a new specialty or role, and re-entry nurses. Review
available resources.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
• Review considerations for precepting internationally educated nurses and the practice gaps
that result from education and culture.
• Discuss the generations of nurses in the workplace. Have participants talk about the
music, television shows, and movies they grew up with and how these reflect examples of
generational differences.
• Discuss the values and strengths that each generation brings to the workplace and their
differences in learning styles.
• Have participants complete their individual Preceptor Development Plan on Precepting
Specific Learner Populations.
Chapter/Module 10: Precepting Advanced Practice Registered Nurses
Objectives
• Understand the role of the preceptor in clinical training of advanced practice registered
nurses.
• Identify incentives and barriers that may impact decisions to precept.
• Identify personal characteristics and teaching tools to improve learning outcomes.
Suggested Content/Strategies
• Discuss the role of APRNs in your organization.
• Discuss the transition from the RN to the APRN role and how the preceptor can facilitate and
support that transition.
• Discuss the use of the Five Minute Preceptor strategy and the SNAPPS strategy in precepting
the APRN student or new graduate APRN.
Chapter/Module 11: Assessing and Addressing Preceptee Behavior and Motivation
Objectives
• Increase the effectiveness of preceptee problem-solving strategies.
• Assess preceptee behavioral pattern strengths and developmental opportunities.
• Implement evidence-based practices to influence preceptee behaviors.
• Utilize the Five-Step Format as a framework to provide preceptees with action-oriented
feedback regarding how their behavior impacts care delivery, patient interactions, and
teammates.
15 Preceptor Development
339
Suggested Content/Strategies
• Discuss Just Culture as a problem-solving framework. Give participants examples of preceptee
errors, and have them discuss how they would apply Just Culture to working with preceptees
on those errors.
• Review the Dimensional Model of Behavior as a tool to influence behavior change. Have
participants discuss behavior examples and how they would deal with them.
• Discuss motivation in the workplace. Ask the participants what motivates them.
• Discuss using influence and the Five-Step Format. Have the participants role-play examples of
influencing behavior change using the Five-Step Format.
• Have the participants complete their individual Preceptor Development Plans on Assessing
and Addressing Preceptee Behavior and Motivation.
Chapter/Module 12: Pragmatics of Precepting
Objectives
• Develop strategies and techniques to assist in the preceptee’s organization, time management,
and delegation skill development.
• Apply strategies on how to manage challenges with the clinical skill development of
preceptees.
• Manage negative and unproductive preceptee behaviors.
Suggested Content/Strategies
• Discuss organization and time management: how to organize the shift for the preceptee,
helping the preceptee organize and prioritize the work that needs to be done, and how to give
a shift report.
• Discuss strategies for ensuring appropriate patient care assignments.
• Break the class into small groups, and ask the group to share how each of them currently
organize their shifts. A representative from each group can share a summary of how a shift
can be organized.
• Discuss delegation and its specific regulations in your state.
• Develop scenarios describing situations in which a preceptee displays unacceptable behaviors.
The scenario should have a preceptor, preceptee, and observer role. Ask the group to role-play
the scenario. Ask the preceptor, preceptee, and observer for feedback.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
• Ask the group to share experiences when a preceptor-preceptee relationship did not work and
how it was managed. Be prepared with scenarios if the participants do not have examples.
• Discuss the potential of a preceptor-preceptee mismatch and how it should be handled.
• Have the participants complete their individual Preceptor Development Plans on Pragmatics
of Precepting.
Chapter/Module 13: Self-Care for Preceptors
Objectives
• Understand the importance of self-care as a professional nurse.
• Develop an individualized plan of self-care practices for yourself.
Suggested Content/Strategies
• Discuss compassion fatigue and its effects on nurses.
• Discuss the concept of self-care. Break into small groups. Have the participants review the
pathway suggestions, select the ones that each of them wants to do, and discuss how they can
support each other.
• Have the participants complete their individual Preceptor Development Plans on Self-Care.
Chapter/Module 14: For Managers: Selecting, Supporting, and Sustaining
Preceptors
Though this chapter is written for managers, the information can also be used in preceptor education.
Objectives
• Compose preceptor competencies utilizing standard performance concepts.
• Develop standardized, objective tools for preceptor recruitment and evaluation.
• Identify creative strategies for supporting and sustaining an effective pool of preceptors.
Suggested Content/Strategies
• Review performance standards and competencies for preceptors if not done earlier in the
course.
• Discuss with the group what successful outcomes would be with various preceptees (e.g., new
hires, NGRNs, clinical advancement for experienced nurses, etc.).
15 Preceptor Development
341
• Discuss how managers and preceptors can work together to ensure that the preceptee is
successful and safe.
• Discuss how and by whom preceptors are evaluated in your organization.
• Discuss the resources and support available to preceptors in your organization.
• Discuss what would be meaningful recognition for the participants in their role as preceptor.
Precepting the Preceptors
In becoming a preceptor, an RN takes on a new role and a new specialty that requires acquiring
new knowledge and developing new competencies. Supporting these transitions includes providing
experienced preceptors for the novice preceptors who help operationalize what is taught in the
preceptor program, provide support, and assess the new preceptor’s progress.
Program Evaluation and Continuous Improvement
Program outcomes must be established from the start of a new program (or when modifying an existing
program). There may need to be different outcomes for different stakeholders. Examples of outcomes
can include measureable growth in competence, knowledge, confidence, and expertise; performance
of preceptors including evaluations from preceptees and managers; post-preceptorship performance of
preceptees; and turnover rates of the preceptor’s preceptees. It is also important to request information
and suggestions for improvement when the course ends and 6–12 months later after the new preceptors
have experience in their new role.
Plan-Do-Study-Act (PDSA) cycles can be used for testing changes. You plan the test or observation; try
out the test on a small scale; analyze the data and study the results; and refine the change based on what
was learned from the test (Deming, 2000). Learning from testing a change on a small scale and refining
the change through several PDSA cycles may lead to implementing the change on a larger scale. With an
ongoing program (such as a preceptor program), there will be many PDSA cycles.
Conclusion
There is increasing evidence to support the positive effect that preceptor education has on the
individuals they precept. This is especially evident in precepting NGRNs. To be successful, preceptors
need education and support. By using the information in this chapter and this book, an organization
can develop and implement an effective preceptor program that will benefit preceptors, preceptees, the
organization, and patient care.
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Preceptor Development: Planning and Implementing a Preceptor Program
Creating preceptor development programs requires considerable planning. Review the
information on preceptor development described in this chapter. What are your/your team’s
strengths? In which areas do you/your team need to increase your knowledge and expertise?
What is your plan for expanding your/your team’s knowledge and expertise? What resources are
available? Who can help you?
Name:
Team Composition—Do you have the competencies you need on your team?
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Plan
Resources
Plan
Resources
Standards
Strengths
Assess the Practice Gap
Strengths
Needs
Identify Educational Needs
Strengths
Needs
15 Preceptor Development
Program Delivery
Strengths
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Needs
Plan
Resources
Learner Engagement Strategies
Strengths
Program Length
Strengths
Content
Strengths
Program Evaluation and Continuous Improvement
Strengths
Needs
Plan
Resources
Note: Available as a modifiable Microsoft Word document at www.SigmaNursing.org/MasteringPrecepting2
343
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MD: Author.
American Nurses Credentialing Center. (2017). 2019 Magnet application manual. Silver Spring, MD: Author.
American Nurses Credentialing Center. (2018). ANCC Practice Transition Accreditation Program. Silver Spring, MD:
Author. Retrieved from https://www.nursingworld.org/organizational-programs/accreditation/ptap/
Baumgartner, R., & Williams, T. (2014). Advanced practice provider mentoring pilot project: Program development and
evaluation. The Tennessee Nurse, 77(2), 10–11.
Chang, A., Douglas, M., Breen-Reid, K., Gueorguieva, V., & Fleming-Carroll, B. (2013). Preceptors’ perceptions of their
role in pediatric acute care setting. The Journal of Continuing Education in Nursing, 44, 211–217.
Clipper, B., & Cherry, B. (2015). From transition shock to competent practice: Developing preceptors to support new nurse
transition. The Journal of Continuing Education in Nursing, 46(10), 448–454. doi: 10.3928/00220124-20150918-02
Commission on Collegiate Nursing Education. (2015). Standards for accreditation of entry-to-practice nurse residency
programs. Washington, DC: Author.
Condrey, T. (2015). Implementation of a preceptor training program. The Journal of Continuing Education in Nursing,
46(10), 462–469. doi: 10.3928/00220124-20150918-04
Deming, W. E. (2000). The new economics for industry, government, and education. Cambridge, MA: The MIT Press.
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training tutorial (CPiTT): A quality improvement project. AANA Journal, 85(5), 331–339.
eLearning Miami. (2018). Key differences between online and face-to-face teaching. Oxford, OH: Miami University.
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Gueorguieva, V., Chang, A., Fleming-Carroll, B., Breen-Reid, K., Douglas, M., & Parekh, S. (2016). Working toward a
competency-based preceptor development model. The Journal of Continuing Education in Nursing, 47(9), 427–432. doi:
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347
Appendix: Additional
Resources
The following resources are recommended for preceptors and preceptor
development programs.
American Nurses Association (ANA)
www.nursingworld.org
The American Nurses Association provides information and resources on nursing
practice and professional standards, ethics, and issues relevant to nurses such as safe
patient handling and preventing verbal abuse and violence in the work place.
The Association for Nursing Professional
Development (ANPD)
www.anpd.org
The Association for Nursing Professional Development provides tools and resources
for professional development, including how to develop and plan courses and how
to help nurses in transition to practice.
Campaign for Action
https://campaignforaction.org
Following publication of the IOM’s Future of Nursing report, the RWJF, the AARP,
and the AARP Foundation created The Future of Nursing: Campaign for Action to
improve America’s health through nursing. The campaign has seven major areas
of concentration that are based on IOM recommendations: improving access to
care; fostering interprofessional collaboration; promoting nursing leadership;
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transforming nursing education; increasing diversity in nursing; collecting workforce data; and building
healthier communities. The campaign has action coalitions in all 50 states and the District of Columbia.
Resources for the campaign’s areas of concentration as well as ongoing information on state and national
activities of the campaign can be found on the campaign’s website.
Institute for Healthcare Improvement (IHI)
http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
The IHI uses a model for improvement to guide and accelerate improvement work. IHI provides
modules on the following fundamentals of the model.
• Introduction
• Forming the team
• Setting aims
• Establishing measures
• Selecting changes
• Testing changes
• Implementing changes
• Spreading changes
Interprofessional Education Collaborative (IPEC)
https://collaborate.uw.edu/ipec-core-competencies-updated-2016/
The Interprofessional Education Collaborative (IPEC) has extensive resources for teaching and
facilitating interprofessional collaboration. This site lists the domains, general competency statements,
and specific domain competency statements for the core competencies for interprofessional
collaborative practice.
Missouri Preceptor Academy
https://web.mhanet.com/preceptor-academies.aspx
The Missouri Preceptor Academy produces Preceptor News, a monthly newsletter with tips for
preceptors. Click on the Preceptor News link at this website to find the newsletter.
Additional Resources
National Academy of Medicine Clinician Well-Being
Knowledge Hub
https://nam.edu/clinicianwellbeing
The National Academy of Medicine Clinician Well-Being Knowledge Hub provides information and
resources to help prevent and mitigate clinician burnout and to promote resilience.
National League for Nursing
http://www.nln.org/professional-development-programs/certification-for-nurse-educators
NLN offers certification and certification preparation information for clinical nurse educators.
QSEN Institute
The QSEN Institute provides learning modules, competencies, and teaching strategies.
Faculty Learning Modules
http://qsen.org/faculty-resources/courses/learning-modules/
The QSEN learning modules were designed for new and experienced faculty but contain valuable
information that can be used in preceptor development courses.
MODULES
• Module One—Appreciating the Complexity of Nursing Work: Implications for Nursing
Education
• Module Two—Managing the Complexity of Nursing Work: Cognitive Stacking
• Module Three—Mindfulness: Implications for Safety, Self-Care and Empathy in Nursing
Education
• Module Four—Informatics
• Module Five—Embedding QSEN Competencies in Beginning Clinical Courses
• Module Six—Teaching Patient-Centered Care Using Narrative and Reflective Pedagogies
• Module Seven—Nursing, Nursing Information Management, and Nursing Informatics
• Module Eight—Strategies for Making Assessment of QSEN Competencies Efficient and
Conducive to Learning
• Module Nine—Managing Curricular Change for QSEN Integration
• Module Ten—Interprofessional Education (IPE): Learning for Practice
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
• Module Eleven—Integrating QSEN into the Intermediate Nursing Curriculum: Working with
Courses that Focus on Specialty Populations
• Module Twelve—Integrating QSEN into the Advanced Nursing Curriculum
• Module Thirteen—Cultivating a Culture of Justice in Nursing Education and Healthcare
• Module Fourteen—Strategies for Incorporating Rubrics in Assessment of QSEN
Competencies
• Module Fifteen—Using Simulation in Leadership Courses: Providing a Means for Application
of Core Concepts
• Module Sixteen—Preparing Students to Think Through the Complexities of Practice in PostClinical Conferences
• Module Seventeen—Patient Safety: Our Intent Is to Do No Harm—So Why Do Errors
Happen?
• Module Eighteen—Embedding QSEN Competencies in Prelicensure Curricula: Fostering
Continuous Improvement
QSEN Competencies
http://qsen.org/competencies/pre-licensure-ksas/
The QSEN competencies—knowledge, skills, and attitudes—can be used for basic quality and safety
information, as well as helping preceptors understand preceptee competencies in these terms.
QSEN Teaching Strategies
http://qsen.org/teaching-strategies/
The QSEN teaching strategies include almost a hundred peer-reviewed lessons on the QSEN
competencies.
351
Index
A
AARP/AARP Foundation, The Future
of Nursing: Campaign for Action, 9,
347–348
ABCD rule, 126
ability, ANA competency, 84
abstract random and sequential learning
styles, 34
accommodating learning stage, 36
accountability, Wright Competency
Assessment Model, 88–89
accountability buddy, 294–295
Action Collaborative on Clinician WellBeing and Resilience, 9
adaptive unconscious of mind, 96
Adobe Captivate, 175
adult learning. See also learning theories/
models
andragogy, 21
assumptions about, 22
core principles, 22
learner differences, 23
learning cycles, 35–36
Advanced Pathophysiology, 228
Advanced Pharmacology, 228
Advanced Physical Examination and
Differential Diagnosis, 228
advanced practice registered nurses. See
APRNs
Advisory Board Company, 204
advocacy communication skills, 142–143
aesthetic needs, 25
affective domain, Bloom’s taxonomy,
109–113
AHA (American Heart Association), 176
AHRQ (Agency for Healthcare Research
and
Quality), 6
American Association of Colleges of
Nursing
DNP (Doctor of Nursing Practice)
Essentials, 106
Essentials of Baccalaureate Education
for Professional Nursing Practice,
128
Essentials of Master’s Education in
Nursing, 128
outcomes, definition of, 106
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Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
American Association of
Critical-Care Nurses
ECCO (Essentials of Critical
Care Orientation), 176
4 A’s to Rise Above Moral
Distress, 55
online orientation/training
materials, 175–176
standards, 300
American Nurses Association.
See ANA
American Nurses Credentialing
Center (ANCC)
Primary Accreditation Provider Application Manual,
323
PTAP (Practice Transition
Accreditation Program),
324, 327
TTP (transition to practice)
programs, 324
American Philosophical Association, critical thinking, 89–91
ANA (American Nurses Association)
Code of Ethics for Nurses,
3–4, 83, 300
Code of Ethics for Nurses
with Interpretive
Statements, 111
Nursing: Scope and Standards
of Practice, 2–4, 83, 300
outcomes, learners/stakeholders, 106
Position Statement on
Professional Role Competence, 83–84
Principles for Competence
in the Nursing Profession, 85
resources, 347
analysis, critical thinking skill, 89
ANCC (American Nurses Credentialing Center)
Primary Accreditation Provider Application Manual,
323
PTAP (Practice Transition
Accreditation Program),
324, 327
TTP (transition to practice)
programs, 324
Anderson/Bloom Taxonomy,
111–113, 115, 117
andragogy, 21
Andragogy in Practice model, 23
ANPD (Association for Nursing
Professional Development)
Nursing Professional Development: Scope and
Standards of Practice, 323,
327
resources, 347
AORN (Association of periOperative Registered Nurses)
learning new specialties, 214
patient handoff checklist,
148
standards, 300
appreciative inquiry approach,
144, 164–165
APRN Consensus Regulatory
Model, 228–230
APRNs (advanced practice registered nurses)
core course requirements,
229
Nursing Standards of Professional Performance, 2
preceptors of APRNs
barriers, 235–236
characteristics, 233–234
clinical rotation, use of,
232–233
evaluations, 239–240
incentives, 234–235
strategies, 236–237
strategies, Five Minute Preceptor tool, 236–238
strategies, SNAPPS, 238–239
roles of APRNs, 228–230
transition programs,
324–325
assessment/intervention skills,
COPA model, 87
assimilating, learning stage, 36
Association for Nursing
Professional Development
(ANPD)
Nursing Professional
Development: Scope and
Standards of Practice, 323,
327
resources, 347
Association of periOperative
Registered Nurses (AORN)
learning new specialties, 214
patient handoff checklist,
148
standards, 300
at-risk behavior errors, 247
attitudes versus behaviors, 246
auditory learners, 36
B
Bandura’s social learning theory,
22, 24
Basic Life Support/Advanced
Cardiac Life Support (BLS/
ACLS) training, 176
bbPress tool, 175
behaviors
versus attitudes, 246
Behavioral Pyramid,
254–258
Dimensional Model of
Behavior
applying to Behavioral
Pyramid, 256–258
description of, 249–250
guidelines for use of, 254
people dimension,
250–251
quadrants of behavior,
251–253
task dimension, 250
Five-Step Format, changes
with, 258
developing action plans,
264
Index
getting preceptee’s views,
260–261
giving preceptor’s views,
261–262
resolving differences,
262–264
starting conversations,
258–260
summary of, 264–265
Just Culture framework,
246–247
applying, 248–249
error types, 247–248
feedback, 249
motivations
Behavioral Pyramid,
254–258
leaders/influencers,
10–11
objectives, development of,
122–123
goals and outcomes,
relationship between,
107–108
measurable, 125–127
pitfalls, 128–130
for self-improvement,
checklist, 145–146
belongingness/love needs, 24
Benner, Patricia, 29
Benner’s Novice to Expert
learning theory, 22, 29–30
biological needs, 24
Blanchard, Ken, 59
Blink, 96–97
Blogger tool, 175
blogs/vlogs, 177
Bloom’s Digital Taxonomy,
116–117
Bloom’s Original Taxonomy,
108–112, 117
BLS/ACLS (Basic Life Support/
Advanced Cardiac Life
Support) training, 176
BON (Board of Nursing), state
regulations, 198
Brain Rules guidelines, learning
environments, 51–52
Bridges, William, 58
briefing stage, simulation, 185
burnout, combating
Action Collaborative on
Clinician Well-Being and
Resilience, 9
compassion fatigue, 54–55,
286
4 A’s to Rise Above Moral
Distress, 55
self-care pathways, 286–295
C
CAE Healthcare’s hierarchy of
learning pyramid, 183–184
Campaign for Action, 9, 347–348
Camtasia tool, 175
Case Western Reserve University,
144, 164
CBTV (competency-based, timevariable), 328
CCNE (Commission on Collegiate Nursing Education)
accredited transition programs, 324
Essentials of Baccalaureate
Education for Professional
Nursing Practice, 172
student rotations, standards,
198
certified nurse midwife (CNM),
228
certified nurse practitioner
(CNP), 228
certified nurse specialist (CNS),
228
certified registered nurse anesthetist (CRNA)
educational courses, 324
roles, APRN Consensus
Regulatory Model, 228
choices, self-care pathway,
293–294
353
Chopra, Deepak, 150
Churches’ LOTS to HOTS, 112,
115–116
Cizik School of Nursing, The
University of Texas Health
Science Center, Houston, 199
ClassMarker tool, 175
CLEs (clinical learning environments), 52–53
clinical judgment, 94–96
clinical reasoning, 93–94,
182–183
clinical teaching strategies
debriefing, 62–64, 186
microskills model, 60–62
mindfulness, 66–68
reflective practice, 65–66,
186
resilience, 68–70
strengths-based, 58–60
Clinician Well-Being Knowledge
Hub, 9
CNM (certified nurse midwife),
228
CNP (certified nurse practitioner), 228
CNS (certified nurse specialist),
228
coaches/coaching, 9–10
appreciative inquiry approach, 164–165
case study, 161–164
Coaching Worksheet,
160–161
foundational beliefs,
157–158
4 Gateways Coaching process, 159–160
preceptees
agreements with, 158–159
ending relationships,
166–167
peer coaching, 164
resistance/edges, 165–166
strengths-based approach,
164
354
Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Code of Ethics for Nurses, 3–4,
83
Code of Ethics for Nurses with
Interpretive Statements, 111
cognitive domain, Bloom’s
taxonomy, 109–113
cognitive needs, 25
cognitive styles
field dependence/
independence, 35
Gregorc’s learning styles, 34
learning factors, 23
MBTI (Myers-Briggs Type
Indicator), 34–35
cohort preceptee models, 48–49
Collaborate tool, 174–175
collaboration tools, 176–178
Commission on Collegiate
Nursing Education (CCNE)
accredited transition
programs, 324
Essentials of Baccalaureate
Education for Professional
Nursing Practice, 172
student rotations, standards,
198
communication skills. See also
teams/teamwork
advocacy, 142–143
behaviors for selfimprovement, checklist,
145–146
COPA model, 87
dialogue, 139–140
difficult conversations,
149–150, 262
email, 146–147
Five Minute Preceptor tool,
236–238
generation gaps
learning styles, 216–219
technology, 172–173
inquiry, 143–144
intent, 140
ladder of inference, 142–143
listening, 141
during meetings/educational
gatherings, 150–151
during patient handoffs
AORN checklist, 148
ISBAR format, 147
silence, 145
SNAPPS, 128, 236, 238–239
for teams, 148–149
compassion fatigue, 54–55, 286
competencies
clinical competence, 181
Code of Ethics for Nurses,
83
conscious competence
learning, 86–87
conscious competence/
incompetence learning,
86–87
COPA (Competency
Outcomes and
Performance Assessment)
model, 87–88
definition of, 83–84
development of, 85–86
Future of Nursing initiative,
8
Health Professions Education:
A Bridge to Quality, 6
IPEC (Interprofessional
Education Collaborative),
348
Nursing: Scope and Standards
of Practice, 83
Position Statement on
Professional Role
Competence, 83–84
Principles for Competence
in the Nursing Profession,
85
QSEN (Quality and Safety
Education for Nurses),
6–7
requirements, 84–85
Wright Competency
Assessment Model, 88–89
competency-based, time-variable
(CBTV), 328
concrete random learning style,
34
concrete sequential learning
style, 34
confidence (self-efficacy), 98–99
conscious competence/
incompetence learning, 86–87
Consensus Regulatory Model,
APRN, 228–230
converging learning stage, 36
Cooperrider, David, 144, 164
COPA (Competency Outcomes
and Performance Assessment)
model, 87–88
critical thinking, 89
American Philosophical
Association, affective
dispositions of, 90–91
American Philosophical
Association, skills of,
89–90
COPA model skills, 87
definition of, 89
key questions, 92–93
in nursing, 91–92
CRNA (certified registered nurse
anesthetist)
educational courses, 324
roles, APRN Consensus
Regulatory Model, 228
Crossing the Quality Chasm: A
New Health System for the 21st
Century, 5–6
Crucial Conversations: Tools for
Talking When Stakes Are High,
150
CURE scale, task prioritization,
273
Curry’s learning style
classification system, 33
Index
355
D
E
F
debriefing
clinical teaching strategies,
62–64
LCJR (Lasater Clinical
Judgment Rubric), 95
reflective practice, 186
situational awareness, 98
decision-making processes
clinical reasoning, 93
recognition-primed decision
model, 97
situational awareness, 96
deliberative rationality, 98
Dewey, John, 12
dialogue, communication skills,
139–140
Dialogue Project, 139
Dimensional Model of Behavior
applying to Behavioral
Pyramid, 256–258
description of, 249–250
dimensions
people, 250–251
task, 250
guidelines for use of, 254
quadrants of behavior,
251–253
Discourse Forum tool, 175
Discovery Model, 209
discussion forums, 177
dissonance learning stage, 31
diverging learning stage, 35
DNP (Doctor of Nursing Practice)
Essentials, 106
DokuWiki tool, 175
Dossey, Dr. Barbara, 286
Dreyfus model of skill
acquisition, 29
ECCO (Essentials of Critical Care
Orientation), 176
E-learning, 173–174. See also
technology; web-based learning
ELT (experiential learning
theory), 22, 26–27
email communication, 146–147
emotional, self-care pathway,
290–291
emotional learning style, 36
empowerment, Wright Competency Assessment Model,
88–89
ENA (Emergency Nurses Association) standards, 300
environmental learning style, 36
error types, Just Culture framework, 247–248
Essentials of Baccalaureate Education for Professional Nursing
Practice, 172
Essentials of Critical Care Orientation (ECCO), 176
Essentials of Master’s Education in
Nursing, 128
esteem needs, 25
evaluation, critical thinking skill,
90
experiential learning theory
(ELT), 22, 26–27
experimental learning environment, 51
expert reasoning, 96
explanation, critical thinking
skill, 90
extroversion/introversion personality type, 34
FaceTime, 174–175
Facione, Peter, 89
feedback
effectiveness of, 13
learning stage, 31–32
problem-solving relationships, 279
feeling domain. See affective
domain, Bloom’s taxonomy
Ferguson, Marilyn, 58
fidelity in simulation, forms and
measurements, 179–180. See
also HFPS
Filmora Scrn tool, 175
Fink’s taxonomy of significant
learning, 117–121
Five Minute Preceptor model,
61–62, 236–238
Five-Step Format, behavioral
changes, 258
developing action plans, 264
preceptors/preceptees,
giving/getting views,
261–262
resolving differences,
262–264
starting conversations,
258–260
summary of, 264–265
FluxBB tool, 175
Foundation for Critical Thinking, 91
4 A’s to Rise Above Moral Distress,
55
4 Gateways Coaching process,
159–160
fundamental attribution error,
246
The Future of Nursing: Campaign for Action, 9, 347–348
Future of Nursing initiative,
recommendations, 7–8
356
Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
G
game simulators, 180
generation gaps
learning styles, 216–219
technology, 172–173
Gladwell, Malcolm, 96–97
goals, relationship with objectives
and outcomes, 107–108
Google Forms + Flubaroo, 175
GooglePlus Hangouts, 174–175
GoToMeeting tool, 174–175
GoToWebinar tool, 174–175
Gregorc’s learning styles, 34
H
Hammond, Sue, 164
haptic-based simulation, 180
Health Professions Education: A
Bridge to Quality, 6
Healthcare Simulation Dictionary, 178
HFPS (high-fidelity patient simulation). See also simulation
clinical judgment, facilitation of, 182
design of experiences,
184–186
development
of clinical competence,
181–182
of clinical reasoning,
182–184
of situational awareness,
182–184
implications of use of,
187–190
quality improvement in
precepting, 190–191
hierarchy of learning pyramid,
CAE Healthcare, 183–184
hierarchy of needs theory, 22,
24–25
high-fidelity patient simulation.
See HFPS
Holton, Swanson, and Naquin’s
adult learning theory, 23
human caring/relationship skills,
COPA model, 87
human errors, 247
I
IHI (Institute for Healthcare
Improvement), 348
INACSL (International Nursing
Association for Clinical Simulation and Learning), 178
inference, critical thinking skill,
90
inquiry communication skills,
143–144
Institute of Medicine (IOM). See
NAM
instructional preferences, 36
integrated simulators, 180
intent communication skills, 140
International Nursing Association for Clinical Simulation
and Learning (INACSL), 178
interpretation, critical thinking
skill, 89
interpreting, clinical judgment,
95
intervention/assessment skills,
COPA model, 87
IOM (Institute of Medicine). See
NAM
IPEC (Interprofessional Education Collaborative)
competencies, 211–212
resources, 348
Isaacs, William, 139
ISBAR format, patient handoffs,
147
J
Jeffries Simulation TheoryNLN (National League for
Nursing), 178
Johnson, Spencer, 59
Johns’ model of structured reflection, 65
The Joint Commission, 147
Josiah Macy Foundation,
327–328
judgment, ANA competency, 84
judgment/perception personality
type, 34
Just Culture framework, 246–247
application of, 248–249
error types, 247–248
feedback, 249
K
Kabat-Zinn, Jon, 67
Keeping Patients Safe: Transforming the Work Environment of
Nurses, 6
kinesthetic learners, 36
Klein, Gary, 97
knowledge, ANA competency, 84
knowledge integration skills,
COPA model, 88
Knowles, Holton, and Swanson’s
Andragogy in Practice model,
23
Knowles, Malcolm, 21–23
Knowles’s adult learning theories,
22–23
Kolb, David A.
experiential learning theory,
22, 121–122
Learning Style Inventory,
35–36
Krishnamurti, Jiddu, 145
Index
L
ladder of inference, 142–143
LCJR (Lasater Clinical Judgment
Rubric), 95
leadership skills, COPA model,
87
learner engagement, 327
learning, synchronous or asynchronous, 174–175
learning cycles, Kolb, 35–36
learning environments, 50
Brain Rules guidelines,
51–52
CLEs (clinical learning environments), 52–53
experimental learning, 51
safety, physical and psychological, 53–56
learning stages, 31–32
Learning Style Inventory, Kolb,
36
learning styles, 32–33, 219
learning theories/models, 22. See
also adult learning
Anderson/Bloom Taxonomy,
111–113, 115, 117
Bandura’s social learning
theory, 22, 24
Benner’s Novice to Expert,
22, 29–30
Bloom’s Digital Taxonomy,
116–117
Bloom’s Original Taxonomy,
108–112, 117
CAE Healthcare’s hierarchy
of learning pyramid,
183–184
Churches’ LOTS to HOTS,
112, 115–116
Fink’s taxonomy of significant learning, 117–121
Holton, Swanson, and
Naquin’s adult learning
theory, 23
Knowles, Holton, and
Swanson’s Andragogy in
Practice model, 23
Knowles’s adult learning
theories, 22–23
Kolb, David A.
experiential learning
theory, 22, 121–122
Learning Style Inventory,
35–36
Maslow’s hierarchy of needs,
22, 24–25, 255
Mezirow’s transformative
theory, 22, 28
Revised Bloom’s Taxonomy,
111–113, 115, 117
Simpson’s taxonomy,
113–115
LeBoeuf, Michael, 60
Legacy Health
Guidelines for an Effective
Preceptorship, 308
Guidelines for Formal
Preceptorship Meetings,
311–312
Nurse Competency Model,
300–301
Nursing Preceptor Rubric,
305–306
RN Preceptor Evaluation by
Preceptee, 313
RN Preceptor Recruitment
Tool, 304
RN Preceptor/Preceptee
Agreement, 307, 309
Values in Action, 302–303
Lenburg’s COPA (Competency
Outcomes and Performance
Assessment) model, 87–88
listening communication skills,
141
LOTS to HOTS theory, 112,
115–116
love/belongingness needs, 24
Lucile Packard Children’s Hospital, Stanford, 215
357
M
Madler, Billie, 328
managers of preceptors
education needs, 310
evaluating, 312–314
HFPS use, 190
Legacy Health
Guidelines for an Effective Preceptorship, 308
Guidelines for Formal
Preceptorship Meetings, 311–312
Nurse Competency
Model, 300–301
Nursing Preceptor Rubric, 305–306
RN Preceptor Evaluation
by Preceptee, 313
RN Preceptor Recruitment Tool, 304
RN Preceptor/Preceptee
Agreement, 307, 309
Values in Action,
302–303
mentorship programs, 317
preceptorships
meeting guidelines,
311–312
program guidelines,
306–310
supporting, 314–315
providing
recognition, 316–317
resources, 314–315
selecting, 302
shared governance model,
317
skills, COPA model, 87
standards/competencies, 300
supporting, 314–316
time management, 315
married state preceptor model
(MSPM), 47–48
Maslow, Abraham, 255
358
Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
Maslow’s hierarchy of needs
theory, 22, 24–25, 255
Massachusetts General Hospital,
214
MATURE process, 127
MBTI (Myers-Briggs Type Indicator), 34–35
MediaWiki tool, 175
Medina, John, 51–52
mental, self-care pathway,
288–290
Mezirow’s transformative learning theory, 22, 28
microskills model, clinical teaching strategies, 60–62
mindfulness
clinical teaching strategies,
66–68
self-care strategies, 288–289
Missouri Preceptor Academy,
348
MIT’s Sloan School of Management, 139
Mobile MIM app, 171
moral issues, 54–55
motivations/abilities. See also
behaviors
Behavioral Pyramid,
254–258
leaders/influencers, 10–11
MSPM (married state preceptor
model), 47–48
Myers-Briggs Type Indicator
(MBTI), 34–35
N
NAM (National Academy of
Medicine)
Action Collaborative on
Clinician Well-Being and
Resilience, 9
Campaign for Action, 9,
347–348
Clinician Well-Being Knowledge Hub, 9
communication errors, 147
Crossing the Quality Chasm:
A New Health System for
the 21st Century, 5–6
Future of Nursing initiative,
recommendations, 7–8
Health Professions Education:
A Bridge to Quality, 6
Keeping Patients Safe:
Transforming the Work
Environment of Nurses, 6
To Err Is Human: Building a
Safer Health System, 5
National Academy of Medicine.
See NAM
National Academy of Medicine
Clinician Well-Being Knowledge Hub, 349
National Collaborative for Improving the Clinical Learning Environment (NCICLE),
52–53
National Guidelines for Nursing
Delegation, 275
National League for Nursing
(NLN)
Jeffries Simulation Theory,
178
resources, 349
National Nursing Staff Development Organization (NNSDO)
learning new specialties, 214
outcomes, learners/stakeholders, 106
NCICLE (National Collaborative
for Improving the Clinical Learning Environment),
52–53
NCSBN (National Council of
State Boards of Nursing)
competence, characteristics
of, 85
National Guidelines for Nursing Delegation, 275
student rotations, responsibilities, 198
Transition to Practice model,
205
new graduate registered nurses.
See NGRNs
NGRNs (new graduate registered
nurses)
challenges
new experiences, 209
normal chaos management, 207–208
nurses, from different
generations, 216–219
nurses, internationally
trained, 215–216
practice scope/autonomy
level, 208–209
practice/education gap,
204–205
reality shock, 203–204
residency, 206–207
transition period,
204–206
development
of interprofessional teamwork, 210–212
of leadership skills,
210–212
of professional identities,
209–210
preceptors of RNs
moving to graduate level,
213
moving to new specialties, 213–215
transition programs,
324–325
NLN (National League for Nursing)
Jeffries Simulation Theory,
178
resources, 349
NNSDO (National Nursing Staff
Development Organization)
learning new specialties, 214
outcomes, learners/stakeholders, 106
noticing, clinical judgment, 95
Index
Novice to Expert learning theory,
22, 29–30
Nursing Professional Development: Scope and Standards of
Practice, 323, 327
Nursing: Scope and Standards of
Practice, 2–3, 83, 275
O
Occupational Safety and Health
Administration (OSHA), 53
The One Minute Manager, 59–60
one-minute praising, 60
One-Minute Preceptor model,
60–62, 127–128
ONS (Oncology Nursing Society), standards, 300
organization learning stage,
31–32
organization/time management
delegating tasks, 275–276
establishing routines,
273–274
for managers of preceptors,
315
patient handoffs, 147–148,
272–273
prioritizing tasks with CURE
scale, 273
problem-solving relationships
performance discrepancies, 276–280
preceptor-preceptee mismatches, 280–281
providing feedback, 279
sample daily organization
sheet, 274
shifts
assignments, 272
clinical, 273
reports, 272
orientation/training materials,
175–176
OSHA (Occupational Safety and
Health Administration), 53
outcomes
COPA (Competency Outcomes and Performance
Assessment) model,
87–88
definition of, 106
goals and objectives,
relationship between,
107–108
learners’/stakeholders’ roles,
106
measurable outcomes, development of, 125–127
versus objectives, 124–125
statements, 123–124
ownership, Wright Competency
Assessment Model, 88–89
P
Pappas’ Taxonomy of Reflection,
65–66
partial task trainers, 180
patient handoffs
AORN checklist, 148
ISBAR format, using, 147
time/organization management, 272–273
PBDS (Performance Based Development System), 95, 204
PDSA (Plan-Do-Study-Act)
cycles, 341
pedagogy versus andragogy, 21
peer coaching, 164
people dimension, Dimensional
Model of Behavior, 250–251
Performance Based Development
System (PBDS), 95, 204
personality factors in learning, 23
physical, self-care pathway,
287–288
physical learning style, 36
physical safety, 53–56
359
physiological needs, 24
Plan-Do-Study-Act (PDSA)
cycles, 341
podcasts, 177
Position Statement on Professional Role Competence,
83–84
Practice Transition Accreditation
Program (PTAP), 324, 327
preceptees. See also preceptors/
precepting
assessment of, 57
and coaches
agreements with, 158–159
ending relationships,
166–167
peer coaching, 164
cohort or single models,
48–49
competencies, 211–212
Five-Step Format, 127–128
One-Minute Preceptor
model, 127–128
and preceptors
agreements between, 307,
309
evaluations of, 313
giving/getting views,
261–262
mismatches, 280–281
relationship with, 56–57,
70–71
role transitions, 58
SNAPPS model, 128
technology and generation
gaps, 172–173
Preceptor Development: Teaching
in the Clinical Environment
course, 328–329
preceptors/precepting. See also
preceptees
behavioral changes with
Five-Step Format,
258–264
characteristics of, 207
360
Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
competencies
Code of Ethics for
Nurses, 83
conscious competence
learning, 86–87
COPA (Competency
Outcomes and Performance Assessment)
model, 87–88
definition of, 83–84
development of, 85–86
Future of Nursing initiative, 8
Health Professions Education: A Bridge to Quality, 6
IPEC (Interprofessional
Education Collaborative), 348
Nursing: Scope and Standards of Practice, 83
Position Statement on
Professional Role
Competence, 83–84
Principles for Competence in the Nursing
Profession, 85
QSEN (Quality and
Safety Education for
Nurses), 6–7, 349–350
requirements, 84–85
Wright Competency
Assessment Model,
88–89
definition of, 1
healthcare system context
AHRQ (Agency for
Healthcare Research
and Quality), 6
Crossing the Quality
Chasm: A New Health
System for the 21st
Century, 5–6
The Future of Nursing:
Campaign for Action,
9, 347–348
Future of Nursing initiative, recommendations, 7–8
QSEN (Quality and
Safety Education for
Nurses), 6–7
managers of preceptors
evaluating, 312–314
mentorship programs,
317
preceptor/preceptee
agreements, 307, 309
providing recognition,
316–317
providing resources,
314–315
recruitment, 304
selecting, 302
shared governance
model, 317
standards/competencies,
300–306, 308
time management, 315
nursing context
Code of Ethics, 4
within healthcare system
context, 5–6
nursing process, 4
online orientation/training materials, 175–176
social contract, 4–5
Standards of Nursing
Practice, 2–4
preceptorships
meeting guidelines,
311–312
program guidelines,
306–310
supporting, 314–316
quality improvement,
190–191
roles of, 2
clarification, 46
evaluator, 12–13
experiential learning, 27
facilitator, 12
leader/influencer, 10–12
protector, 14
role model, 15
safety, physical and psychological, 55–56
self-care, 285–286
accountability buddy,
294–295
compassion fatigue, 286
self-care pathways
choices, 293–294
emotional, 290–291
mental, 288–290
physical, 287–288
relationships, 292–293
spiritual, 292
Primary Accreditation Provider
Application Manual, 323
Principles for Competence in the
Nursing Profession, 85
prior knowledge factors in learning, 23
psychological learning style, 36
psychological safety, 53–56
psychology, 246
psychomotor domain, Bloom’s
taxonomy, 110–114
PTAP (Practice Transition Accreditation Program), 324, 327
Q
QSEN (Quality and Safety
Education for Nurses)
Health Professions Education report, competencies
based on, 6–7
QSEN Institute
Faculty learning modules,
349–350
QSEN competencies, 350
QSEN teaching strategies,
350
Quizworks tool, 175
Index
R
Reality Shock, 13
reckless behavior errors, 247–248
recognition-primed decision
model, 97
refinement learning stage, 31
REFLECT mnemonic, 64
reflecting, clinical judgment, 95
reflective competence learning,
87
reflective practice
clinical teaching strategies,
65–66
simulation, 186
registered nurses. See RNs
(registered nurses)
relationships, self-care pathway,
292–293
resilience, 68–70
responding, clinical judgment, 95
Revised Bloom’s Taxonomy,
111–113, 115, 117
Richardson, Cheryl, 285
RJWF (Robert Wood Johnson
Foundation)
The Future of Nursing:
Campaign for Action, 9,
347–348
Future of Nursing initiative,
recommendations, 7–8
QSEN (Quality and Safety
Education for Nurses), 6
RNs (registered nurses)
Nursing Standards of Professional Performance, 2
preceptors of
moving to graduate level,
213
moving to new specialties, 213–215
RN Preceptor Evaluation
by Preceptee, 313
RN Preceptor Recruitment Tool, 304
RN Preceptor/Preceptee
Agreement, 307, 309
transition programs,
324–325
role-playing simulation, 180
S
safety/safety needs
hierarchy of needs theory, 24
Keeping Patients Safe:
Transforming the Work
Environment of Nurses, 6
physical and psychological,
52–56
QSEN (Quality and Safety
Education for Nurses)
Health Professions Education report, competencies based on, 6–7
QSEN Institute, 349–350
Ulrich Precepting Model, 2
workplace safety, 53–54
Schlittenhardt, Melanie, 328
SE 9 (Structural Empowerment),
ANCC, 324
secondary traumatic stress, 55
self-actualization needs, 25
self-care for preceptors, 285–286
accountability buddy,
294–295
compassion fatigue, 286
pathways
choices, 293–294
emotional, 290–291
mental, 288–290
physical, 287–288
relationships, 292–293
spiritual, 292
self-regulation, critical thinking
skill, 90
self-transcendence needs, 25
sensing/intuitive personality
type, 34
sensory learning preferences,
36–37
silence communication skills, 145
361
Sim Ops Certification, 178
Simpson, Elizabeth, 113
Simpson’s taxonomy, 113–115
simulation, 178. See also HFPS
CAE Healthcare’s hierarchy
of learning pyramid,
183–184
fidelity
environmental and psychological, 179–180
forms of, 179–180
measurements of,
179–180
Healthcare Simulation Dictionary, 178
NLN-Jeffries Simulation
Theory, 178
SSH (Society for Simulation
in Healthcare), 178
Standards of Best Practice:
Simulation, INACSL, 178
Simulation Center Accreditation,
178
Simulation Educator, 178
single preceptee model, 48–49
single preceptor model, 47
situational awareness, 96–98,
182–184
skill acquisition model, Dreyfus,
29
skills, ANA competency, 84
Skype, 174–175
SMART rule, 126–127
SNAPPS model, 128, 236,
238–239
social learning theory, 22, 24
Society for Simulation in Healthcare (SSH), 178
sociological learning style, 36
specialty nurses
Nursing Standards of Professional Performance, 2
professional standards,
300–301
transition programs,
213–215
362
Mastering Precepting: A Nurse’s Handbook for Success, Second Edition
spiritual, self-care pathway, 292
SPs (standardized patients)
simulators, 180
SSH (Society for Simulation in
Healthcare), 178
standards
AACN (American
Association of CriticalCare Nurses), 300
ANA (American Nurses
Association), 2–4, 83, 300
ANPD (Association for
Nursing Professional
Development), 323, 327
AORN (Association of
periOperative Registered
Nurses), 300
CCNE (Commission on
Collegiate Nursing
Education), 198
ENA (Emergency Nurses
Association), 300
INACSL (International
Nursing Association for
Clinical Simulation and
Learning), 178
Nursing Professional
Development: Scope and
Standards of Practice, 323,
327
Nursing: Scope and Standards
of Practice, 2–4, 83, 275
ONS (Oncology Nursing
Society), 300
preceptors
competence, 83–89
development programs,
323–324
managers of, 300
transition programs, 323,
327
prelicensure nursing
students, 198
Primary Accreditation
Provider Application
Manual, 323, 327
Standards of Best Practice:
Simulation, 178
Standards of Best Practice:
Simulation, 178
Standards of Nursing Practice,
2–4
strengths-based clinical teaching
strategies, 58–60, 164
Structural Empowerment (SE 9),
ANCC, 324
T
Talky tool, 174–175
task dimension, Dimensional
Model of Behavior, 250
Taxonomy of Reflection, 65–66
teaching skills, COPA model, 88
teams/teamwork. See also
communication skills
communication skills,
148–149
interprofessional teamwork,
NGRNs, 210–212
preceptor model, 48
technology. See also web-based
learning
collaboration tools, 176–178
free or minimal cost tools,
175
future of, 191–192
generation gaps, 172–173
HFPS (high-fidelity patient
simulation)
clinical judgment,
facilitation of, 182
design of experiences,
184–186
development of clinical
competence, 181–182
development of clinical
reasoning, 182–184
development of
situational awareness,
182–184
implications of use of,
187–190
quality improvement
with, 190–191
importance of, 171–172
learning, synchronous or
asynchronous, 174–175
orientation/training materials, 175–176
simulation, 178–180
fidelity, forms of, 179–180
fidelity measurements,
179–180
transition programs for
preceptors, 326–327
videoconferencing tools, 174
Theory of Integral Nursing, Dossey, 286
thinking/feeling personality type,
34
thin-slicing, 97
Tiki Wiki tool, 175
time/organization management
delegating tasks, 275–276
establishing routines,
273–274
for managers of preceptors,
315
patient handoffs, 147–148,
272–273
prioritizing tasks with CURE
scale, 273
problem-solving relationships
performance discrepancies, 276–280
preceptor-preceptee mismatches, 280–281
providing feedback, 279
sample daily organization
sheet, 274
shifts
assignments, 272
clinical, 273
reports, 272
Index
To Err Is Human: Building a Safer
Health System, 5
transformative learning theory,
22, 28
transition programs for
preceptors
accreditation
CCNE, 324
Magnet, 324
NCSBN, 205
PTAP (Practice
Transition
Accreditation
Program), ANCC, 324
case study, 328–329
content
evidence-based, 328
modules using Mastering
Precepting book,
329–341
delivery methods
blended, 326–327
face-to-face, 325–326
online, 326
educational needs,
identifying, 324–325
evaluation of, 341
learner engagement, 327
length of, 327–328
managing preceptors, 341
practice gaps, accessing,
324–325
standards
Nursing Professional
Development: Scope
and Standards of
Practice, ANPD, 323,
327
Primary Accreditation
Provider Application
Manual, ANCC, 323,
327
U
Ulrich precepting model, 2
unconscious competence
learning, 86–87
unconscious incompetence
learning, 86
University of Texas Health
Science Center, Houston, 199
V
videoconferencing tools, 174
virtual reality simulation, 180
visual learners, 36
vlogs/blogs, 177
W
web-based learning. See also
technology
collaboration tools, 176–178
free or minimal cost tools,
175
orientation/training
materials, 175–176
simulation, 178
fidelity, forms of, 179–180
fidelity measurements,
179–180
synchronous or asynchronous, 174–175
videoconferencing tools, 174
WebEx Meeting Center, 174–175
wikis, 177
WordPress, 175
worksheets
Manager Plan, Establishing
Performance Standards
and Preceptor Competencies, 319–321
Preceptor Development
Plans
Assessing and Addressing Preceptee Behavior and Motivation,
266–267
363
Coaching, 168–169
Communication,
153–155
Core Preceptee
Competencies, 102
Core Precepting
Concepts, 100–101
Effectively Using
Instructional
Technologies, 193–194
Having a Plan:
Developing and Using
Goals, Objectives, and
Outcomes, 131–134
Learning, 38–41
Planning and
Implementing a
Preceptor Program,
342–343
Pragmatics of Precepting,
282–283
Precepting APRNs,
241–242
Precepting Strategies,
75–78
Preceptor Roles, 16–17
Self-Care Things I
Commit to Including
in My Life This
Month, 296–297
Working With Specific
Learner Populations,
220–221
Preceptor Role Clarification,
72–74
Wright Competency Assessment
Model, 88–89
Y–Z
YouTube, 175
Zoom tool, 174–175
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