Developing a Quality Nursing Preceptorship Program

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Two trends that affect staffing today are new graduates lacking clinical skills due to social distancing requirements as well as retired nurses returning to the workforce. Both trends point to the need for a quality nursing preceptorship program that will assist in the success of new hires. 

Introduction   

I started my first job in nursing in the early 1970s. One of my responsibilities was to provide 24/7 staffing to all nursing units in a medium–sized community hospital. This was a new position with no predecessor to “show me the ropes.“ My second position was as a Director of Nursing at a small community hospital. Again, no predecessor. Have you had similar experiences? Is there a better way to ensure that every nursing position has an evidence-based pathway to success? 

This article will provide an outline to build a quality nursing preceptorship program based on the nursing process. The nursing process is a fundamental concept of Assessing, Diagnosing, Planning, Implementing, and Evaluating (ADPIE) patients, and it will follow us throughout our careers (1). 

To break this concept down, we will use ADPIE as an outline for this course.  

Assessment 

In this case, the assessment phase will be used to determine the present state of a new nurse hire process, its orientation, or preceptorship. Tools to be used include results from exit interviews, turnover rate statistics, infection control reports, patient satisfaction data, lists of new hire orientation forms, and hospital organizational value statements. 

• Results from exit interviews should elicit answers to questions such as, “Are you leaving because you felt unsupported?” or “Is there a clash in morals or values creating your motive to leave?” 
• When we design our preceptorship program, we must include methods to determine the “pulse“ of the organization. 
• Infection control reports can relate nosocomial infection rates for adherence to standards of practice.  
• Patient satisfaction reports can guide the committee toward areas of staff-patient interaction issues. 
• Turnover rate statistics from Human Resources can narrow down unit by unit where problems may exist. Focusing our attention on the ER, where the rate is 22% vs. OB, where the rate is 4%, will be time well spent. 
• New hire orientation forms should include attendance at mandatory education, skills checklists, new equipment orientation, copies of all licenses, certificates, and degrees. An audit of employee files should provide data about compliance. 

Every healthcare institution should have a corporate values statement. This statement must be written in a way that every employee can understand and incorporate into daily interactions with clients and coworkers. We will discuss this more in our implementation phase.

Diagnosis 

Once you have completed the assessment of the current state of your new hire orientation process, you must decide how to improve it to meet future needs.  

Why are staff leaving? What are the unit turnover rates? What did the audit of records reveal? Are patient satisfaction scores good? What issues are raised by the infection control report? 

This in-depth process should be done by a committee. The leader of that committee should select members who will listen, learn, collaborate, and innovate to create a preceptor process that will result in organizational change. 

What barriers exist that may not allow for a successful program? 

• Are managers / supervisors on board? 
• Are there time restraints that affect skills observation? 
• Can preceptors from all units meet regularly? 
• Are there skills checklists for clinical and managerial skills? 

The diagnosis is what is currently “wrong.“ It should also include barriers, as mentioned. The committee must decide what fixes and developmental process changes take priority, as well as having awareness of the “pulse“ of the organization and identifying if it is irregular, weak, or strong. 

What is the motivation to change? Is it due to outside the agency requirements, such as JCHAO or Magnet status? Or is it due to internal pressures to stop the trend of people leaving? 

It is just as important to understand the underlying motivation as it is to be motivated to change. Organizational change will not occur unless there is a motivated change agent. This could be an administrative champion or a change–motivated committee. 

Plan

The plan of action-oriented change should have both short-term and long-term goals. An example of a short-term goal could be, “Required Skills Checklists will be identified for each nursing position within three months.“ Following, a concurrent long-term goal would read, “Skills checklists will be 100% completed for all new hires within one year.“  

Skills checklists should include clinical skills, interpersonal skills, and managerial skills. The latest checklists in the clinical area should include PPE application and virus control. Management skills checklists may include operational issues such as managing via Zoom meetings.

Inter-rater reliability is when two or more observers can rate a new hire doing a skill with the same conclusion. This term plays an important role in writing skills checklists and are usually based on standards, patient safety, and efficiency. 

The plan should identify all components of a successful preceptorship program. 

• Preceptor selection criteria 
• Preceptor job description 
• Preceptor education program 
• Skills checklists identified for each nursing position
  
• Lists of certifications required for each nursing position
  
• Lists of degrees required for each nursing position
• Job descriptions for each nursing position 

Preceptor Education Program

Let’s take a closer look at the preceptor education program. Once the preceptors are identified and provided with a job description, it is time to educate them in this role. All education programs should have goals and objectives. A goal of a preceptor program could be, “Preceptors will be able to identify behaviors that do or do not reflect corporate values.“ An objective of this goal would follow, “After a role-play scenario, preceptor correctly identifies a client greeting according to the corporate script.“ 

This is an example of teaching in the affective domain. Affective relates to how staff expresses themselves in words, body language, and actions. If our corporate values encompass “treating all visitors and clients with respect and dignity,“ then how can we model excellent behavior? 

The great preceptor not only models good behaviors but can also coach new hires to achieve these same behaviors. Any client/visitor interactions should be documented to provide “proof“ of meeting that standard. 

Skills checklist education should reflect how to achieve inter-rater reliability. Conduct practice sessions with one person demonstrating a skill and preceptors checking off, comparing checklists, and discussing the results. 

Sample Preceptor Education Program

• Review of the role and job description of the preceptor 
• How to review the new hire job description 
• Selection of skills checklists (by job description) 
• Achieving inter-rater reliability for skills (role play) 
• Adult learning principles – creating a learning need assessment
• Development of critical thinking skills thru scenarios 
• Modeling behaviors – affective domain skits 
• Being a wingman – real–life scenarios 

Understanding Learner Types

In order to facilitate this program effectively, it should not be “death by PowerPoint.“ Learning activities should be planned to model adult education – this is one of the most important aspects of preceptor education. 

How adults learn best is based on everyone having a preferential learning style. The list below has seven learner types: 

• Visual (spatial)  
• Aural (auditory)  
• Verbal (linguistic) 
• Physical (kinesthetic)  
• Logical (mathematical)  
• Social (interpersonal) 
•  Solitary (intrapersonal)  

It is necessary for the preceptor be aware of the learning style(s) of their new hire to ensure good quality education is delivered and retained. There are many online resources that can be used to determine a preferential learner style (5). 

The Preceptor as a Wingman

Let’s explore more about the role of the preceptor as a wingman. This role will evolve with each new hire. The needs of the new graduate are different than an experienced nurse – but what about the nurse who is experienced, although not in this type of nursing? A wingman role is a collaborative function that will nourish (in this context, meaning that the preceptor will make introductions, give out practical tips, provide non-judgmental feedback and counseling) the new hire. 

Building on the concepts presented by Walden University (2), here are some additional attributes that may need development in both the preceptor and the new hire.  

Development

Assist the new hire to develop their professional identity. 

Clinical Mentor

Demonstrate how to access clinical resources: MD, pharmacist, chain of command.

Acceptance

Everyone must be comfortable with and accepting of diversity. Recognizing that a diversity of backgrounds and opinions can help the new hire to develop new ideas. Thus, providing the new hire with a safe place to learn. 

Self-Awareness

How do you get the new hire to know their own strengths and weaknesses? When they understand what they are good at and where they struggle, the preceptor can maximize their usefulness.

Generosity

For a collaboration to work, the preceptor has to accept that the new hire will make mistakes and that conflicts will arise. The right way to handle a mistake is to help correct the error and help make sure similar errors do not occur in the future.  

Patience

Having the preceptor get annoyed can create unhelpful conflicts and may cause the new hire to withhold their ideas, which might cause them to miss a potential diagnosis, cause an error, miss a treatment option or solution to the issue at hand. 

Flexibility

In a productive collaboration, great ideas and realization can occur anytime. Saying “it has always been done that way“ may not show openness to new ideas. (3) 

It is important to note that this list in not all-encompassing. However, it should give the committee some guidance when going through the preceptor selection process. 

Implementation 

This stage in the process of building a quality nursing preceptorship program will need a phased approach. 

1. Selection of new preceptors: 

– Excellent clinical skills 

– Minimum 3 years in current role 

– Excellent performance appraisals in past the years 

– Motivated to learn 

– Wonderful interpersonal attributes 

2. Education for preceptors initial and refresher:

– Consider at least 3 sessions per year 

– Choose a facilitator with good adult education experience 

– Consider creating a Preceptor Handbook 

3. Pairing preceptors and new hires:

– Scheduling together 

– Personality profiles 

4. Program evaluation:

– New hires 

– Preceptors 

– Nurse Managers 

There are about 16 different personality types, and some are more compatible than others. However, the reality is that you cannot predict whether a preceptor and new hire will have a successful outcome. In some cases, it may serve to be beneficial if the preceptor and new hire take a personality test to outline how they will interact, what potential conflicts may arise, and simply develop a better understanding of each other (4).  

When preceptors and new hires understand the differences in their teaching and learning styles, communication, and learning is enhanced. 

New hires whose preferences are different from those of a preceptor’s may find it difficult to adjust to the working atmosphere and delivered teaching methods. Preceptors who vary their teaching styles after learning about their own personality type as well as others’ often find that they can motivate and teach a higher volume of new hires because they are developing diverse approaches that better meet everyone’s needs (4). 

Evaluation 

Evaluating a Preceptorship Program should be a committee process that follows implantation within six months to a year. There should be written outcome measures that attest to the effectiveness of the program. These measures can include: 

• Improved retention statistics 
• Increased confidence of newly hired nurses 
• Improved satisfaction scores of preceptors 
• Improved patient satisfaction scores 
• Better Infection control statistics 

It is essential to create a quality nursing preceptorship program. In our current healthcare environment of Ebola, SARS, and COVID-19, clinical education has had to adapt, and new graduates are potentially lacking in skills and patient care exposure. A great nursing preceptorship program may prevent early departures, increase learning, and create a culture of clinical support. 

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