1.7: PRECEPTORS- ESSENTIAL TO LEARNER SUCCESS

“While we teach, we learn” —Seneca

Precepting is an organized, evidence-based, outcome-driven approach to assuring competent practice (Eley, 2015). Clinical heath education often employees a preceptor model for senior practicum courses and frequently as part of orienting new employees. Through clinical experiences and orientation activities, learners acquire knowledge and essential skills for professional practice. The preceptor plays a vital role in developing students as professionals and a critical role in successfully integrating new staff.

For student learners, a representative from the student’ institution is often part of the teaching–learning team along with the student and a preceptor who is an employee of the clinical agency. Each member of the trio usually has specific roles and responsibilities, with the faculty representative often supporting and advising the preceptor. While the preceptor has important roles in student evaluation, the faculty member usually makes critical decisions on final grades and on whether a learner passes or fails a practicum.

Being a preceptor for a student or new employee is an essential role but not one for which most preceptors are formally prepared. The short- and long-term success of the student or employee can be enhanced greatly by an excellent preceptor or affected negatively by a preceptor who is not well prepared for the role. The goal of this chapter is to provide readers with knowledge, skills and attitudes that are key to being an effective preceptor in the clinical setting. As with most careers, when you are well prepared and able to excel in a role, those you work with are positively affected. As you carry out your role well, your level of satisfaction with the role is also enhanced. This leads to a positive cycle with affirmative effects on all involved, including recipients of care.

This chapter discusses the difference between preceptoring and mentoring, examines the theoretical foundations of effective preceptoring, and presents strategies for becoming and being a successful preceptor. We conclude with a discussion of the preceptor–preceptee relationship. The strategies included provide a road map for practitioners who are new to precepting. The chapter is infused with practical creative ideas and founded on theory, making it both a stand-alone chapter for educators embarking on being a great preceptor and part of the greater understanding of becoming skilled as a clinical educator.

The Difference Between a Mentor and a Preceptor

The origin of the concept of mentorship is well documented. In Homer’s Odyssey a Mentor, a wise and trusted friend of Odysseus, takes on the rearing of Odysseus’ son in his absence (Roberts, 1999). The mentor is depicted as an older, wiser male who takes on the responsibility for a younger male’s learning and development, acting rather like a guardian. The term mentor is traditionally associated with professions such as medicine, law and business, but it began appearing in nursing literature in the 1990s (Andrews & Wallis, 1999).

Much of the current mentor literature focuses on defining the concept, yet a precise and complete definition that is universally embraced remains elusive (Dawson, 2014; Gopee, 2011; Mentoring Resources, n.d.). To confuse it further, terms such as preceptor, coach and facilitator are used interchangeably in some instances. In jurisdictions such as Great Britain, practicing nurses who are responsible for students in the clinical area are called mentors, while in most North American jurisdictions, these supervising nurses are called preceptors. Commonly the term mentor is reserved for a longer-term personal development relationship between a less experienced and a more experienced person, with the focus of the relationship being assistance, befriending, guiding and advising (Eby, Rhodes & Allen, 2007). More concisely the mentor is less focused on assessment and supervision and more focused on the mentee’s well-being and career advancement (Eby, Rhodes & Allen, 2007).

In contrast a preceptor–preceptee relationship is usually shorter term and the preceptor has responsibility for teaching and assessing clinical performance. In the base definition of preceptor, the focus of the preceptor’s work is to uphold a precept or law or tradition. Myrick & Yonge (2005, p. 4) define a nursing preceptor as a skilled practitioner who oversees students in a clinical setting to facilitate practical experience with patients.

The roles of mentor and preceptor do overlap. For example, a preceptor who has no concern for the well-being of the preceptee is not likely to provide the learner with a positive clinical experience. Likewise a mentor who does not assess student practice will not have the information needed to be an effective mentor. The assessment in which a mentor engages is more likely to be formative in nature and focused on providing the mentor with knowledge to fulfill the role of guide effectively.

Students in practice-based health care professions rely on others to support, teach and supervise them in practice settings. The underlying rationale for this approach to learning is the belief that working alongside practitioners aids students to become safe caregivers who are successfully socialized to the clinical world (Benner, 1984). In this chapter we focus on the role of the preceptor.

Theoretical Foundations of Effective Preceptoring

Effective preceptoring of students in health care clinical environments can be understood by briefly examining adult learning theory, transformational learning theory, and the novice to expert model. Here we outline each theory or model and discuss each in relation to the preceptoring literature.

Adult Learning Theory

As described in chapter 1, Malcolm Knowles (1984) is credited with naming the theory of andragogy, a theory specifically for adult learning. Andragogy emphasizes how adult learners differ from child learners in being self-directed and taking responsibility for their learning decisions. Further, according to Knowles, adults want to know why they are learning something, need to learn experientially (including having the opportunity to make mistakes), use problem-solving to learn, and learn most effectively if they can apply what they learn immediately. Knowles states that adults learn best if their teacher is primarily a facilitator or resource person. Smith (2002) further discusses Knowles’ andragogy theory, highlighting the ideas that a) learners move from being dependent to self-directed, b) learners accumulate a reservoir of experience and knowledge, and c) a learner’s motivation to learn is internal. Given these principles of adult learning, teaching strategies such as simulations, role-play and case studies are considered useful. Likewise, clinical practicum learning opportunities with the student working alongside a preceptor are compatible with the principles of andragogy. Practicum students are directed by a more knowledgeable person (the preceptor) until they can accumulate experience and knowledge to be independent practitioners.

Sandlin, Wright & Clark (2013) further our understanding of Knowles’ theory by additional focus on Knowles’ beliefs that adult learners are autonomous, rational and capable of action, and on the assumption that autonomy and rationality are desirable and attainable in adult learners. Their perspective on Knowles’ fundamental views provides an interesting contrast in considering the role of preceptor in the clinical environment. The tenets of Knowles’ adult learning theory offer no substantive role for the preceptors who hold responsibility for overseeing, guiding and evaluating the work of the preceptee, as learners are thought to be totally autonomous and capable of independence. In contrast, as Sandlin, Wright & Clark (2013) propose, adult learners may actually be at various levels of autonomy and rationality and thus a skilled preceptor does have a role in adult learning.

Transformational Learning Theory

As explained in chapter 1, Jack Mezirow (1995) is credited with making significant contributions to the theory of transformative learning. The essence of this theory is that learners must engage in critical reflection on their experiences in order to transform their beliefs, attitudes and perspectives, which Mezirow terms their meaning schemes. Others have critiqued some of Mezirow’s assumptions and views. Boyd & Myers (1988) note that learners must be open to changing their meaning schemes; to adopt new perspectives, they must realize that their old perspectives are no longer relevant. Dirkx, Mezirow & Cranton (2006) emphasize the self-actualization possibilities of transformative learning with the statement “learning is life – not a preparation for it” (p. 123). They note the importance of a relationship between the learner and others, which is required to make sense of one’s perspective and to become aware of (and transform to) new meanings.

To Mezirow, the essence of learning is change. To be truly transformational, learners must engage in inquiry, critical thinking and interaction with others. Brookfield (2000) adds that transformative learning must include a fundamental questioning of one’s thinking and actions. Reflection alone does not result in transformative learning unless this reflection includes an analysis of taken-for-granted assumptions.

Part of the entry-to-practice competencies for health professionals include elements of critical reflection, adoption of professional values, beliefs and attitudes, and ongoing questioning of taken-for-granted assumptions and values. If Mezirow is correct that acquiring a competency does require the involvement of others, this becomes part of the role of the skilled preceptor. Preceptors may be well placed to encourage honest self-review and critical reflection that ends in learner transformation. In this view, preceptors need to be aware of strategies to engage learners in reflection, causing learners to gaze deeply into long- and deeply-held values and biases that they may not even be aware they hold.

The ‘From Novice to Expert’ Model

Benner’s (1984) well-used and much respected From Novice to Expert model has implications for understanding the role of an effective preceptor for health care learners. While Benner focused on nursing students in the clinical setting, her theory likely applies to learners from other health care disciplines. This model holds that nurses develop skills over time from both education (including clinical experience) and personal experience. The model identifies five levels of nursing experience: novice, advanced beginner, competent, proficient and expert. Novices are beginners with no experience—they learn rule-governed tasks by being told and by following instructions. Advanced beginners have gained experience in actual nursing situations and recognize recurring elements that create principles they can use to guide actions. Competent nurses have more clinical experience and use it to become more efficient in providing care. Proficient nurses have an understanding of the bigger picture that improves decision making and allows for changes in plans as needed. Experts no longer need principles or rules to guide action—they use intuition to guide their flexible, highly proficient clinical approaches. As learners transition from novice to expert, they rely less on principles, they see a situation more holistically, and they engage in situations from the inside rather than being external to a situation.

Preceptors can play a vital role in this transition. Benner’s model requires clinical experience for the transition to occur and guidance in the clinical situation is essential for successful transition. Preceptors need to have awareness of the needs of learners at various stages of the continuum and be attuned to the stage(s) at which their students are functioning. For example, a novice student needs a preceptor who provides more direct guidance in learning the rules to guide their actions. A preceptor for an advanced beginner helps learners recognize recurring patterns and develop them into principles of effective care.

Benner also comments that expert clinicians may not be the most effective in preceptoring roles. Expert clinicians may have difficulty explaining their actions in a step-by-step manner because they are functioning by intuition and may not be consciously aware of the rules and principles that they use to make clinical judgments. Analogous to riding a bike, beginners are very aware of the steps needed to balance the bike, propel it forward, stop momentum and avoid obstacles. An expert at cycling is able to just ride without thinking about how to ride and thus may have a challenge teaching a new cyclist.

Strategies for Being and Becoming a Successful Preceptor

This section focuses on strategies for being (and becoming) a successful preceptor for students from various health care professions in clinical learning environments. We also address the challenges and rewards of being a preceptor and characteristics of effective preceptors. The goal is to provide both new and established preceptors with new knowledge that can be used as a road map to beginning and continuing this journey with learners.

Challenges of Precepting

You are invited by your manager to be a preceptor. You are both honoured and terrified. If this is your first time formally in this role, you have a lot to learn. To begin, recognize that becoming a really good preceptor takes experience, just as becoming a competent (even expert) care provider takes experience. Reading this chapter and other resources will help. You may be fortunate that the agency you work for provides preceptor education. The first step is to determine what is available in the form of lectures, workshops, preceptor manuals, etc. and to engage with these before your preceptee arrives. You cannot possibly be fully prepared on day one no matter how much homework you do, so begin with a positive attitude and a sense that you are going to learn every day through reflection, experience and ongoing formal learning. Know that your apprehension is normal—with preparation, this apprehension can be lessened. With a positive approach, being a preceptor can be a fulfilling experience for you and a gift to a learner.

From the Field

Learning Together

I was delighted to be asked to be a preceptor! This would be my first time. I thought “Wow they think I am good enough to teach a new person—that’s super!” My sense of excitement was soon drowned out by horror. What if I made a mistake? What if my student asked a question I couldn’t answer? What if…? I didn’t sleep a wink the night before our first shift together. I just did my best to have a positive attitude and kept reminding myself—my student and I will learn together.

Beth Perry Professor, Faculty of Health Disciplines, Athabasca University, Athabasca, AB.

Once you overcome the initial challenge of self-doubt about your ability to be a preceptor, you can become aware of some of the realities and challenges faced by preceptors. One important challenge is that preceptors must balance the needs of preceptees with the needs of patients they are caring for and the realities of the workplace. Patients may be seriously ill (or become seriously ill during a shift) and work environments may have high staff turnover and other challenges (Hallin & Danielson, 2009). As a preceptor you may feel torn between the needs of your patients and those of the preceptee. The reality is that patient safety always supersedes anything else. If you keep this in mind, you will know what to do. If you do have to make a choice and the preceptee’s needs are not addressed at that point, explain the situation later to the learner and use it as a learning moment to help understand setting priorities.

All students are not going to succeed (at least not at first). You may have a learner who lacks appropriate knowledge, skills and attitudes to perform safe, competent (for their level) and ethical care in the clinical environment. You may be the only line of defense for the patient and your responsibility to, and advocacy for, the patient and society may become your priority. As Luhanga, Yonge & Myrick (2008) write, preceptors must be able to recognize and manage unsafe practice in students—preceptors are the “gatekeepers for the profession” (p. 214). If you have a learner who is disruptive and exhibits other problematic or unsafe behaviours, Luhanga, Yonge & Myrick (2008) provide strategies gathered from preceptors with experience in such situations. Their first recommendation is to catch unsafe practices early or even prevent them if possible. A key first step is giving the learner a complete orientation to the learning environment and establishing clear expectations. Preceptors need to make their own expectations clear, ask learners about their expectations, and understand the program expectations before the learning experience begins. Clear expectations, understood by all involved, can prevent issues and problems. One preceptor in the Luhanga, Yonge & Myrick (2008) study describes how she presents her expectations (p. 216).

I try to nip it in the bud pretty quickly so as to prevent it. Upfront, I tell students what I expect. Like, I expect you to know every med you give. I expect if you don’t know something to ask me, we’ll look it up. I don’t expect you to know everything, so don’t feel pressured.

Actively involved preceptors often prevent problem behaviours and unsafe practices in learners by providing learners with demonstrations, chances to practice, cues, prompts and frequent feedback throughout the learning experience (Hendrickson & Kleffner, 2002). Such active involvement of the preceptor, including close observation especially in the early days of the relationship, may give learners the best chance for success. As learners gain confidence and competence, preceptors may deliberately step back and encourage more independence within agency guidelines. However, that initial investment of time and energy by the preceptor can be crucial as learners stretch towards practicing at their full scope.

Preventing unsafe and disruptive behaviours is not always possible. If a learner is doing something that is jeopardizing the safety of another (or themselves) the preceptor must stop the behaviour immediately. Further actions (Luhanga, Yonge & Myrick, 2008) include:

1. communicating concerns directly to the learner, to determine whether the learner is aware of the problem
2. working with the learner to set up a detailed plan for improving performance
3. involving the faculty advisor, if the learner is a student.

Preparing preceptors for their role is important to the success of the preceptor–preceptee relationship. Ensuring preceptors are enthusiastic about being preceptors is essential. Careful preparation can fuel this enthusiasm and prepare the preceptor for positive outcomes from their preceptoring experience, encouraging them to continue in this role. Hallin & Danielson (2009) do note that in some clinical environments in which students are preceptored, turnover is high. Preceptors may be placed in the role before they have appropriate orientation, being appointed not because they are ready to be preceptors but because “now it is your turn.” If you are asked to be a preceptor and do not, after careful reflection and self-assessment, feel safe in this role, then do discuss your concerns with your manager before agreeing. Again, the principle of patient safety over-rides all else.

Characteristics of Effective Preceptors

Research has been carried out on the qualities of effective preceptors in various health care disciplines. Effective preceptors in pharmacy have professional expertise, actively engage learners, create a positive learning environment, are collegial, and discuss career-related topics and concerns (Huggett, Warrier & Malo, 2008). Pharmacy students value preceptors who they perceive as role models, who are interested in teaching, relate to learners as individuals, are available to provide direction and feedback, and spend time with learners (Young, Vos, Cantrell & Shaw, 2014). Medical students note that effective preceptor behaviours include openness to questions, constructive feedback, enthusiasm, review of differential diagnoses, and delegation of patient responsibilities (Elnicki, Kolarik & Bardella, 2003). Nursing learners value experienced, knowledgeable professionals who guide them to think critically and create a supportive and nurturing environment (Phillips, 2006).

While these studies note slightly different emphasis on the characteristics of effective preceptors, some commonalities are clear. First, excellent preceptors want to be preceptors, or at least are able to be perceived as wanting this role. Students are attentive to the level of enthusiasm and support that preceptors bring to the relationship. Second, effective preceptors have expertise to share and share it willingly with learners. Learners appreciate preceptors who share their knowledge by involving learners in the learning process—preceptors who make learning interactive and two-way, challenging learners to think critically. Finally, we can note a theme of openness, collegiality, support, respect and nurturing. Students report learning best in a positive learning environment infused with these attitudes.

Creative Strategies

How to be Positive When You Don’t Feel Very Positive

This could also be called the ‘fake it until you make it’ approach. You are human. You have days when you don’t feel like being at work, let alone having a student with you. You have more than enough to do to get through the day and you just don’t have one ounce of energy left over to answer another question!

When this happens, forgive yourself. Remember you do have limits. You can try for an attitude adjustment—give yourself a little lecture and start fresh. If that fails, just take one hour or even one moment at a time and try to be a positive preceptor for just a short period. Fake your enthusiasm until, perhaps after one or two positive exchanges, your real enthusiasm may start to return.

Perry (2008) concludes that nurses who do their job very well come to know they are making a difference for patients (and in your case learners). This realization starts a positive cycle of feeling good about their work, trying even harder to do well, and feeling even better about their success in their role.

So on those days that you just don’t want to be a preceptor, fake it until you can get this positive cycle started. The result may be a great day after all!