EMPIRICAL STUDIES
doi: 10.1111/scs.12216
Developing preceptorship through action research: part 2 Yvonne Hilli PhD, RNT (Project Manager, Associate Professor)1 and Hanna-Leena Melender PhD, RMT (Principal Lecturer)2 1
Oslo and Akershus University College of Applied Sciences, Oslo, Norway and 2VAMK, University of Applied Sciences, Vaasa, Finland
Scand J Caring Sci; 2015; 29; 478–485 Developing preceptorship through action research: part 2 Clinical preception in practice plays a significant role in the education of both Registered Nurses and practical nurses. This study presents the evaluation of an interprofessional research and development project (2009–2103) on clinical preceptorship between two universities of applied sciences, two vocational institutes and four healthcare organisations in western Finland. The research question was as follows: How did the participants evaluate the process and outcomes of developing preceptorship through an action-research approach? The primary target group consisted of professionals within the healthcare sector and nursing teachers at the universities of applied sciences and the vocational institutes. The five units represented in the healthcare organisations functioned as clinical practice placements for both nursing and practical nursing students, with Registered Nurses and practical nurses acting as their preceptors. Each unit developed a unique preceptorship model to answer their specific needs. The models were implemented and tested during
Introduction Clinical preception in practice plays a significant role in the education of both Registered Nurses and practical nurses. Since the nursing programmes integrate both theoretical and clinical studies, the nursing teachers are responsible for the theoretical and clinical teaching (1). In Finland, at present, there exist no general recommendations concerning the work experience a nurse has to have before starting to precept nursing students. In a study by Carlson, only a few preceptors had ever completed a preceptorship training programme (2). This paper presents the evaluation of an interprofessional research and development project (2009–2103) on clinical preceptorship between two universities of applied Correspondence to: Yvonne Hilli, Oslo and Akershus University College of Applied Sciences, Norway. Postboks 4 St. Olavsplass, 00130 Oslo. E-mail: [email protected]
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one academic year followed by a quantitative (a 4-point scale) and qualitative evaluation of the process. The models are presented in another article, and the evaluation results are presented in this article. The evaluation showed that preceptorship has become an important and accepted part of work, including the practice of starting any preception at a unit with a thorough introduction. The project’s emphasis on critical thinking, reflection and focus on ethics were valued by the staff. Pedagogical further education should be arranged on a regular basis to strengthen the knowledge base of the preceptors. Furthermore, enough time for preceptorship should be allocated, as it is a pedagogical duty. The implication of this project is that more cooperation between different stake holders is needed, in order to narrow the gap between theory and praxis. Keywords: preceptorship, clinical education, Registered Nurse, practical nurse, health care, evaluation, action research. Submitted 31 October 2014, Accepted 18 December 2014
sciences, two vocational institutes and four healthcare organisations in western Finland. The primary target group consisted of professionals within the healthcare sector and nursing teachers at the universities of applied sciences and the vocational institutes. The five units represented in the healthcare organisations were as follows: a long-term care ward in the community, a ward for people with dementia, a geriatric ward, a medical ward and a surgical ward representing specialised care. These wards functioned as clinical practice placements for both nursing and practical nursing students, with Registered Nurses and practical nurses acting as their preceptors. In this article, the term ‘nurse’ is used interchangeably for both Registered Nurses and practical nurses. At the start of this project, each unit was expected to develop a unique preceptorship model to answer their specific needs. At each unit, three to five nurses were appointed to a core group being responsible for the development of the preceptorship model. The inspiration for the model was action research (AR), founded on a © 2015 Nordic College of Caring Science
Developing preceptorship through action research partnership between the researchers and participants, which is educative, advances knowledge and explores the application of theory. Moreover, AR is a cyclic process of different phases: problem identification, action planning, use of action to change practice and evaluation (3). This phase has been reported in an earlier article (4). The results of the whole action-research study project are presented as a two-part article. The first part focused on the development of preception models and a cultural analysis (4). Specifically, the findings from the cultural analysis unfolded the experiences, beliefs and attitudes of nurses in five units and served as a tool for reflection among practising nurses. Furthermore, documents used before, during and after clinical education were developed on the basis of best evidence available. Moreover, the findings from the cultural analysis gave a bottom-up perspective and were a starting point for developing preceptorship at the different units. During the action phase, it was decided that regular meetings should be held with the members of the core groups, the staff at the units and the project group. In this respect, several workshops for the core groups and seminars for the staff were arranged in order to give the nurses the possibility to come together and explore issues related to preceptorship. Not surprisingly, these events often elicited high levels of energy and interaction, and the postsession evaluations indicated an analogous level of participant satisfaction. Four units tested their developed preceptorship models during the academic year 2010–2011. However, one unit had some difficulties due to sick leave and staff turnover at the beginning and only started to develop their model later. This unit tested the developed model during the academic year 2011–2012. Once the units had tested their models for one year, the process was evaluated at the five units. In autumn 2012, the project was also evaluated among the members of the project group by a SWOT analysis (5). A SWOT analysis is a planned and structured method used to evaluate the strengths, weaknesses, opportunities and threats involved in a project. The evaluation of the project will be presented in this Part 2 article. The research question was the following: How did the participants evaluate the process and outcomes of developing preceptorship through an actionresearch approach?
Methods Data collection and analysis After the units had tested their developed preceptorship models for approximately one academic year, the process was evaluated. In this project, the study design was descriptive and all the preceptors involved were invited to participate. It is important that AR is evaluated and validated in order to be considered as evidence for © 2015 Nordic College of Caring Science
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practice. In this respect, the researchers should be able to demonstrate that new meaning and new understanding have been developed and that the tacit knowledge of the participants has become explicit as a result of working collaboratively. This type of evaluation can be used to serve the needs of funders as well as practitioners seeking to change practice. Furthermore, it might be argued that since members of staff have a duty to improve services, because of the benefits such improvements have for patients, families and nursing students, this, in itself, should be evaluated (6). The key issues to consider when evaluating AR are as follows: Was new knowledge generated and was there any change? Were ethical issues made explicit and discussed? Did the project demonstrate rigorous methods of enquiry and are the results transferable (7)? For the data collection, a self-administered structured three-part questionnaire was developed especially for the purpose. The content of this questionnaire was based on the actions implemented and the expected outcomes of the project. The first section contained three questions concerning the background details of the respondents. These were the working unit, educational background and whether the respondents had worked at the unit during the whole time period of the project. The second section comprised 23 statements, relating to how the process had influenced the clinical preception at the units, covering the following areas: the development process at the units; the development in the preceptors and need of further education; and the preceptors’ current practices. This section included a Likert-type 4-point scale (1 = totally other view, 2 = somewhat other view, 3 = somewhat same view and 4 = totally same view). The third section consisted of open-ended questions with the following themes: ‘What was the best thing about the project?’, ‘Ideas for further development?’, and ‘What new practices will be permanently implemented after the project ends?’ Since this project was unique, it was not possible to pretest the questionnaire beforehand. Moreover, any preceptors invited to pretest it would not have been able to participate in the actual data collection. However, the content of the questionnaire was discussed in the project group panel very carefully, in order to ensure content validity. The data were collected over a 4-week period in November and December 2012. During this time, invitations and questionnaires were placed in the coffee rooms of the respective units. The completed forms were then returned in a sealed box, in order to ensure confidentiality. Statistical analyses were then performed using SPSS for Windows, Release 17.0. As the study design was descriptive, all statistical analyses were descriptive, including frequency and percentile distributions of the background details of the respondents, and the means and standard deviations of the responses for the statements in the second section (8). The open-ended
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questions were analysed through content analysis. It is worth noting that qualitative content analysis is an interpretive process, focusing on subject and context, which specifically deals with differences and similarities between, and within, parts of the text. In this study, the answers to the questionnaires were read through several times by the first author to obtain a sense of the whole. Passages related to the participants’ experiences were then extracted and brought together into a single text. From this, meaning units, each comprising several words, sentences or paragraphs related to each other through their content and context, were condensed and labelled with codes. The codes and meaning units were subsequently interpreted and summarised to build threads of meaning (9). In reporting the results of this qualitative evaluation, citations of the original data have been presented and marked with Italics. A SWOT analysis was then conducted among the members of the project group in the following manner. Firstly, all the members of the project group individually evaluated and wrote down the strengths, weaknesses, opportunities and threats they had experienced. Secondly, the project group came together and all the members presented their different views on the project. Through reflection and discussion, the project group agreed on the final evaluation.
Ethical considerations All the healthcare professionals and student nurses in clinical practice were informed about the project and its aims by the management at the units. Moreover, both oral and written information about the project were given to the staff in the five units by the researchers. The participants were informed that their confidentiality was assured, that participation was voluntary and that they could withdraw from the project at any time without giving any reason. According to Finnish regulations, no ethical application was needed. Approval for conducting the evaluation, however, was granted in written form from the management in the organisations. In this regard, we have followed the guidelines of the National Advisory Board on Research Ethics (10).
Results Background details of the respondents The evaluation was conducted at all five units and a total of 68 members of staff completed the questionnaire. Of the respondents, 50% (f = 34) were Registered Nurses, 29.4% (f = 20) were Practical Nurses and 20.6% (f = 14) had another education. Out of all the respondents, 80% (f = 52) had been working at the units during the whole time that the project lasted, while 20% (f = 13) answered that they had not.
Findings from the quantitative part of the evaluation The quantitative part of the questionnaire comprised 23 statements. Out of these, the first six statements concerned the development process at the units. The highest means were related to the respondents’ intention to use the preceptorship model (3.55), the development of preceptorship at the unit (3.12), and the discussion around questions related to preceptorship (3.10). The means of the responses to other statements were between 2.85 and 2.23, the lowest score being associated with the relationship between the preceptors and the nursing teachers (Table 1). The following 10 statements concerned the preceptors’ apprehensions of their own development and need for further education. The highest means were related to the respondents’ experience that preceptorship was an important and accepted part of their work (3.17) and that by developing the preceptorship model, they had developed as preceptors (3.00). The means of the responses to other statements were between 2.95 and 2.72, the lowest score being associated with whether the respondents’ way of precepting had changed during the project (Table 2). The following seven statements concerned the preceptors’ current practices. The highest means were related to whether the respondents started the preception at the unit with a thorough introduction (3.42), and whether they encouraged the students to seek information independently more than earlier (3.08). The means of the responses to other statements were between 2.98 and 2.79, the lowest score being associated with whether the respondents encouraged students to seek evidence from scientific databases (Table 3).
Findings from the qualitative part of the evaluation What was the best thing about the project?. The first open question, concerning what was the best thing about the project, was answered by 40 participants at the units (U). According to the answers, the most valued aspect was a developed common praxis, which was the result of the preceptorship model developed at the units and the documents supporting preceptorship. This development occurred both on the unit level and on the individual level. ‘We now have a preceptorship model at the unit that is simple and easy to understand. One has developed as a preceptor’ (U1). The respondents believed that preceptorship had developed and deepened at the units, resulting in better preception for the students. Due to the project, preceptorship had now come into focus and was being discussed. ‘. . . the discussions and the engagement that it has caused at the unit’ (U3). On an individual level, preception had developed by gaining new
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Table 1 Staff evaluation on the development process at their own units*
Statement
N
Mean (M)
Standard deviation (SD)
We will continue to use the preceptorship model even after the project ends The preceptorship has developed at our unit during the process The result of the process is that we have started to discuss questions related to preceptorship A better cooperation between the preceptors has developed during the process The whole unit has been engaged in the project The relationship between the preceptors and the teachers has developed during the project
63 66 68 66 66 66
3.55 3.12 3.10 2.85 2.51 2.23
0.667 0.713 0.736 0.728 0.898 0.719
*Scales 1-4. 1 = Totally other view, 2 = somewhat other view, 3 = somewhat same view, 4 = totally same view.
Table 2 The preceptors’ apprehensions of their own development and need for further*
Statement
n
Mean (M)
Standard deviation (SD)
I experience that preceptorship is an important and accepted part of my work By developing the preceptorship model, I have developed as a preceptor I need further knowledge about critical thinking in relation to preceptorship The development has been important for my work I need further knowledge about evidence-based practice in relation to preceptorship The project has increased my self-evaluation of preceptorship My view of what preceptorship means has changed Due to the process, I have noticed that I need more further education in preceptorship I now think more about ethical questions regarding preceptorship My way of precepting has changed during the project
63 63 66 64 63 65 65 64 64 67
3.17 3.00 2.95 2.95 2.92 2.86 2.75 2.75 2.73 2.72
0.814 0.762 0.753 0.765 0.867 0.768 0.830 0.836 0.913 0.775
*Scales 1-4. 1 = Totally other view, 2 = somewhat other view, 3 = somewhat same view, 4 = totally same view.
Table 3 The preceptors’ current practices* Statement
n
Mean (M)
Standard deviation (SD)
I start the preception at the unit with a thorough introduction I encourage the students to seek information independently more than earlier I encourage the students to use critical thinking and reflection by discussion and writing a log I have started to plan the preception according to the student0 s learning outcomes I use planned reflection sessions in the preception of students Due to the process, I use critical thinking during preception I encourage students to seek evidence from scientific databases
66 62 64 63 60 63 61
3.42 3.08 2.98 2.90 2.88 2.82 2.79
0.583 0.753 0.745 0.734 0.761 0.708 0.878
*Scales 1-4. 1 = Totally other view, 2 = somewhat other view, 3 = somewhat same view, 4 = totally same view.
knowledge about preceptorship, including what it meant and how it could be implemented. ‘You have learnt that you needn’t be omniscient as a preceptor. You may also ask the student to check up different things independently’ (U2). The nurses felt that one of the best things with the project was that they had developed as nurses during the process. Future development for preceptorship at the units. The second open question, concerning the future development of preceptorship at the units, was answered by 31 preceptors. According to them, preceptorship could be developed at the units by improving the conditions needed for © 2015 Nordic College of Caring Science
preceptorship to take place. Furthermore, the staff felt that there were no incentives in place when it came to working as preceptors. A lack of time and resources were also deemed as being obstacles preventing good preceptorship. ‘There is no ‘carrot’ for the nurse in precepting a student. . . It’s difficult to develop, there is no time, our work is very heavy and it has become more demanding’ (U1). Another area of development was to get the whole staff committed to the preceptorship models developed. This was seen as a challenge since not all the members of staff were so actively involved during the project. ‘It has been difficult to involve all the preceptors in the project
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in our unit, the preceptor model should be an aid of assistance to everyone’ (U4). One way of doing this is to arrange further education in preceptorship for all the staff. ‘More discussion among the staff. Further education for everyone, even to those not directly working as preceptors’ (U5). The cooperation between the healthcare units and the faculty was seen as an important area needing to be developed. ‘It’s important to develop the communication between the faculty, the nursing teachers and the preceptors at the units’ (U2). What is the most important legacy of the project? The third open question, asking about what they felt was the most important legacy of the project, was answered by 28 preceptors. Their answers reflected both material and immaterial project benefits. The nurses particularly emphasised the preceptorship model they had developed during the project and the documents supporting preceptorship. These were seen as the most important and they would continue to use the documents in the future. ‘I will always use the preceptorship model in the future when I precept students, as it guarantees the same quality of preception to everyone’ (U4). They believed that their way of thinking had been transformed during the project; a way of thinking that strengthened their professionalism, which was something they wanted to preserve even after the project ended. ‘The way of thinking about preceptorship has changed somehow. The education has given us a lot of new tip-offs’ (U1). The emphasis on critical thinking, reflection and focus on ethics were valued by the staff, and were areas that they wanted to continue to develop. ‘At least reflection has proved to be important, . . . the student needs to think more carefully about what and why they are doing things’ (U2). The staff saw the students as future colleagues and preception as a possibility to facilitate mutual learning. ‘The students will be our future workforce/colleagues. It’s important that they will get all the knowledge we can bring’ (U5). These insights they wanted to cherish even when the project was over. ‘You start to think more about things from an ethical point of view and try to precept the student to encounter the client by being present in a caring mode’ (U4). Both theoretical and practical knowledge gained through further education during the project were seen as important.
Findings from the SWOT analysis Strengths of the project. A major strength of this project was that it responded to the expressed needs of both the educational organisations and working life/healthcare organisations. As such, a closer cooperation between the educational organisations and the healthcare units was developed during the project. The project brought together many organisations from different parts of the region, representing different languages (Swedish,
Finnish and English), resulting in the uniting of different areas of competence. Having external funding for this project was an important factor in terms of making it possible for the project to succeed as strongly as it did. In other words, the project had budgeted funds for all actors involved, including the members of the core groups at the units. Another important factor, seen as a strength, was the fact that many of the participants in the project group and in the organisations were known to each other from before. As such, all the members of the project group were very committed to the project and cooperation functioned well. A lot of material supporting preceptorship was developed during the project, and the active participation of the members of the core groups, with support from the nursing teachers, has enhanced critical reflective thinking among nurses. Moreover, the definition of the concepts of preceptorship and ethics has expanded and the nurses have started to discuss preceptorship as a pedagogical duty. The weaknesses of the project. One major weakness concerned some problems that arose when establishing the activities of the project with the activities of the organisations. It became evident that there was a risk that two parallel processes would subsequently exist, without there being any connections between them. The project tried to prevent this by working in close participation with the head nurses at the units and by arranging meetings to inform and engage the staff. Furthermore, the members of staff were invited to participate in further education, seminars and different meetings in order to promote the development work. Another weakness of the project was due to staff changes in the core groups as a result of new assignments or changes of workplaces during the process. Introducing new participants to the activities of the project was a time-consuming process. Moreover, a high staff turnover at the units might have been a factor that weakened commitment to the project. The opportunities of the project. One of the major opportunities was the genuine interest, held by the majority of those involved, to participate in the development of preceptorship. Furthermore, as a result of the pedagogical further education arranged for the staff, there is now clear evidence of an enhanced level of clinical competence being in place when precepting the students in the region. This project created a pedagogical arena for nurses to develop preceptorship and a space to discuss and reflect on preceptorship. In this regard, the project has formed the basis for further cooperation and new networks within the region. Moreover, the workshops that were arranged for the core groups at the units have enabled them to come together and discuss issues concerning preceptorship and ethics. Through good preceptorship, the students learn good nursing care, which © 2015 Nordic College of Caring Science
Developing preceptorship through action research enables the development of nursing care to benefit both the patients and their families. Threats to the project. One threat to the project was the lack of a genuine interest towards the project by certain units and some of the actors and leaders. As such, the prerequisites of implementation varied between the different units and actors. Another major threat was the result of rigid structures within the organisations. These had a restraining affect on the progress of the project which might have hindered development in the worst scenario. Finally, the high staff turnover at the units was also deemed as a threat.
Discussion In the following chapter, the results of the evaluation, both quantitative and qualitative, are discussed. The results showed that of the participants (n = 68), 50% were Registered Nurses, 29.4% were Practical Nurses and 20.6% had another education. The majority of the respondents (80%) had been working at the units for the entire time the project lasted. However, the remaining 20% shows the high staff turnover in the healthcare sector, which has been a challenge to the project. The participants reported that they had decided to continue to use the preceptorship model even after the project ended. This was due to the fact that the developed common praxis, as a result of the preceptorship model, was most valued as it responded to a direct need. Although it is not possible to claim that the preceptorship models have become established procedures at the units, because of the short period of time, this does, nevertheless show just how important it is to engage the nurses, i.e. the actors, in the development process. This shows the benefit of AR where participants are reflecting and acting close together. Furthermore, it was important to gain a bottom-up perspective in order to know what the members of staff considered to be the most important areas of development. The starting point was to conduct a cultural analysis at the units in order to unfold the attitudes, experiences and beliefs of nurses. The evaluation showed that a change had occurred at the units. The nurses felt that preceptorship had developed and deepened at the units during the project and that a development had occurred on an individual level as well as on the unit level. Preceptorship had now come into focus and was something that the staff discussed in a different manner. New knowledge was generated about preceptorship and the nurses thought they had developed both professionally and personally. They also experienced that their thinking had been transformed during the project which implied a change. Earlier studies have shown that reflection and critical thinking are important for the students in order to develop, both professionally and © 2015 Nordic College of Caring Science
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personally (11, 12). In this study, the emphasis on critical reflective thinking was valued among the staff and was something they wanted to preserve and continue with. In this respect, ethical issues were brought into focus, meaning that values supporting the wellbeing of patients were evident in the practice environment (e.g. 13). A closer cooperation between the preceptors had developed during the project, which may have been a result of the fact that the staff discussed more about preceptorship. It was now considered to be something important and therefore valued. However, one challenge had been to engage the whole unit in the project. This might have been because of a high staff turnover and nonregular working hours. According to EU directives (14), it is the duty of the staff nurses to act as preceptors for the students. As such, the nursing teachers usually build a liaison between the students and the preceptors at the units. The role of the nursing teachers should then be to communicate the expected learning outcomes to students and staff and provide support (15, 16). The preceptors expressed the need to have the opportunity to discuss and obtain feedback from the nursing teachers on a regular basis as shown in earlier studies (17, 18). The nurses experienced preceptorship as an important and accepted part of their work. This can be seen in their responses to the open questions, where they expressed an opinion that preceptorship should be developed at the units by improving the conditions for preceptorship. As in earlier studies, the obstacles they experienced were a lack of time and resources (19). They also felt that there were no incentives for preceptors. Hence, they felt that by developing the preceptorship model, they had developed as preceptors. Furthermore, the preceptors expressed that they needed further education in preceptorship, more knowledge about critical thinking and evidence-based practice in relation to preceptorship and that the development had been important for their work. Regarding the first point, the nurses suggested that further education be arranged on a regular basis to all members of staff. Regarding the other points, the preceptors experienced an increased selfevaluation of preceptorship and a change in the view of what preceptorship meant. Ethical issues, for example, began to be more explicitly defined and discussed as the preceptors became more aware of the importance of them. The answers mirrored a positive attitude towards development and further education. This project showed the benefits of AR and brought forth the tacit knowledge of the nurses. Their willingness and strong commitment to participate in close collaboration for the sake of developing preceptorship can also be seen as a moral obligation. Preception is an ethical issue and should be recognised as such by all stakeholders. An earlier study showed the importance of the receptiveness of nursing staff and whether they were welcoming and friendly, particularly on the first day of a
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placement. Being made to feel welcome was highly motivating according to the students and enhanced the conditions for learning (20). The preceptors in this project started the preception with a thorough introduction using the material they had developed during the project. The preceptors had now started to focus on the students’ learning outcomes, and a student-oriented approach was emphasised. According to earlier studies, this promotes a narrowing of the theory–practice gap which, in turn, promotes self-direction and lifelong learning (21, 22). This suggests that the preceptors had become more aware of the students’ learning needs and tried to respond to them (18). Some of the preceptors had started to plan reflection sessions with the students, and the students were encouraged towards critical thinking and reflection. The preceptors also encouraged students to search for evidence from scientific databases.
Trustworthiness and validity of the evaluation study A questionnaire was constructed to evaluate the quality of this AR process (7), and a SWOT analysis was conducted among the researchers. The content of the questionnaire was outlined according to the central elements of the project. For the face validity, the whole project group commented on the questions as a panel. A limitation of this study is the fact that the questionnaire was new and had not been pretested. When analysing the qualitative data, we followed the ideas of content-analysis procedures and how to achieve trustworthiness (9). In reporting the results from the qualitative data, citations have been used, in order to give the readers some examples of the original data. A similar project could be undertaken elsewhere. The findings from this project may be transferred to other contexts and may be of interest both nationally and internationally.
the units when they are given the possibility to participate in an action-research process like this. During the process, it was noted that the cooperation among the units and the faculties increased. New educational strategies and alternative possibilities for organising clinical education are required in order to prepare nurses for high-quality preceptorship. Moreover, preceptorship should be recognised by all stakeholders and efforts should be made to plan the nurses’ clinical work so that there is enough time allocated for preception. Future research should focus on interventions aimed towards developing preceptorship in close cooperation between faculties and healthcare units.
Acknowledgements We wish to thank Annika Wentj€arvi, R&D Manager, Novia, who carried out the statistical analyses. And finally, we want to thank the staff on the five development units, the researchers and the students who participated in this project.
Author contributions Yvonne Hilli was responsible for the design and for drafting the manuscript. The article was written in close collaboration with Hanna-Leena Melender. Both authors are in agreement with the content of the manuscript.
Ethical approval According to Finnish regulations, no ethical application was needed. Approval for conducting the evaluation was granted from the management of the healthcare organisations.
Funding Conclusion This project showed the importance of having a bottomup perspective when starting the development of preceptorship. The cultural analysis at the five units unfolded five different cultures with different needs. The project has shown the great potential there is among nurses at
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doi: 10.1111/scs.12216
Developing preceptorship through action research: part 2 Yvonne Hilli PhD, RNT (Project Manager, Associate Professor)1 and Hanna-Leena Melender PhD, RMT (Principal Lecturer)2 1
Oslo and Akershus University College of Applied Sciences, Oslo, Norway and 2VAMK, University of Applied Sciences, Vaasa, Finland
Scand J Caring Sci; 2015; 29; 478–485 Developing preceptorship through action research: part 2 Clinical preception in practice plays a significant role in the education of both Registered Nurses and practical nurses. This study presents the evaluation of an interprofessional research and development project (2009–2103) on clinical preceptorship between two universities of applied sciences, two vocational institutes and four healthcare organisations in western Finland. The research question was as follows: How did the participants evaluate the process and outcomes of developing preceptorship through an action-research approach? The primary target group consisted of professionals within the healthcare sector and nursing teachers at the universities of applied sciences and the vocational institutes. The five units represented in the healthcare organisations functioned as clinical practice placements for both nursing and practical nursing students, with Registered Nurses and practical nurses acting as their preceptors. Each unit developed a unique preceptorship model to answer their specific needs. The models were implemented and tested during
Introduction Clinical preception in practice plays a significant role in the education of both Registered Nurses and practical nurses. Since the nursing programmes integrate both theoretical and clinical studies, the nursing teachers are responsible for the theoretical and clinical teaching (1). In Finland, at present, there exist no general recommendations concerning the work experience a nurse has to have before starting to precept nursing students. In a study by Carlson, only a few preceptors had ever completed a preceptorship training programme (2). This paper presents the evaluation of an interprofessional research and development project (2009–2103) on clinical preceptorship between two universities of applied Correspondence to: Yvonne Hilli, Oslo and Akershus University College of Applied Sciences, Norway. Postboks 4 St. Olavsplass, 00130 Oslo. E-mail: [email protected]
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one academic year followed by a quantitative (a 4-point scale) and qualitative evaluation of the process. The models are presented in another article, and the evaluation results are presented in this article. The evaluation showed that preceptorship has become an important and accepted part of work, including the practice of starting any preception at a unit with a thorough introduction. The project’s emphasis on critical thinking, reflection and focus on ethics were valued by the staff. Pedagogical further education should be arranged on a regular basis to strengthen the knowledge base of the preceptors. Furthermore, enough time for preceptorship should be allocated, as it is a pedagogical duty. The implication of this project is that more cooperation between different stake holders is needed, in order to narrow the gap between theory and praxis. Keywords: preceptorship, clinical education, Registered Nurse, practical nurse, health care, evaluation, action research. Submitted 31 October 2014, Accepted 18 December 2014
sciences, two vocational institutes and four healthcare organisations in western Finland. The primary target group consisted of professionals within the healthcare sector and nursing teachers at the universities of applied sciences and the vocational institutes. The five units represented in the healthcare organisations were as follows: a long-term care ward in the community, a ward for people with dementia, a geriatric ward, a medical ward and a surgical ward representing specialised care. These wards functioned as clinical practice placements for both nursing and practical nursing students, with Registered Nurses and practical nurses acting as their preceptors. In this article, the term ‘nurse’ is used interchangeably for both Registered Nurses and practical nurses. At the start of this project, each unit was expected to develop a unique preceptorship model to answer their specific needs. At each unit, three to five nurses were appointed to a core group being responsible for the development of the preceptorship model. The inspiration for the model was action research (AR), founded on a © 2015 Nordic College of Caring Science
Developing preceptorship through action research partnership between the researchers and participants, which is educative, advances knowledge and explores the application of theory. Moreover, AR is a cyclic process of different phases: problem identification, action planning, use of action to change practice and evaluation (3). This phase has been reported in an earlier article (4). The results of the whole action-research study project are presented as a two-part article. The first part focused on the development of preception models and a cultural analysis (4). Specifically, the findings from the cultural analysis unfolded the experiences, beliefs and attitudes of nurses in five units and served as a tool for reflection among practising nurses. Furthermore, documents used before, during and after clinical education were developed on the basis of best evidence available. Moreover, the findings from the cultural analysis gave a bottom-up perspective and were a starting point for developing preceptorship at the different units. During the action phase, it was decided that regular meetings should be held with the members of the core groups, the staff at the units and the project group. In this respect, several workshops for the core groups and seminars for the staff were arranged in order to give the nurses the possibility to come together and explore issues related to preceptorship. Not surprisingly, these events often elicited high levels of energy and interaction, and the postsession evaluations indicated an analogous level of participant satisfaction. Four units tested their developed preceptorship models during the academic year 2010–2011. However, one unit had some difficulties due to sick leave and staff turnover at the beginning and only started to develop their model later. This unit tested the developed model during the academic year 2011–2012. Once the units had tested their models for one year, the process was evaluated at the five units. In autumn 2012, the project was also evaluated among the members of the project group by a SWOT analysis (5). A SWOT analysis is a planned and structured method used to evaluate the strengths, weaknesses, opportunities and threats involved in a project. The evaluation of the project will be presented in this Part 2 article. The research question was the following: How did the participants evaluate the process and outcomes of developing preceptorship through an actionresearch approach?
Methods Data collection and analysis After the units had tested their developed preceptorship models for approximately one academic year, the process was evaluated. In this project, the study design was descriptive and all the preceptors involved were invited to participate. It is important that AR is evaluated and validated in order to be considered as evidence for © 2015 Nordic College of Caring Science
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practice. In this respect, the researchers should be able to demonstrate that new meaning and new understanding have been developed and that the tacit knowledge of the participants has become explicit as a result of working collaboratively. This type of evaluation can be used to serve the needs of funders as well as practitioners seeking to change practice. Furthermore, it might be argued that since members of staff have a duty to improve services, because of the benefits such improvements have for patients, families and nursing students, this, in itself, should be evaluated (6). The key issues to consider when evaluating AR are as follows: Was new knowledge generated and was there any change? Were ethical issues made explicit and discussed? Did the project demonstrate rigorous methods of enquiry and are the results transferable (7)? For the data collection, a self-administered structured three-part questionnaire was developed especially for the purpose. The content of this questionnaire was based on the actions implemented and the expected outcomes of the project. The first section contained three questions concerning the background details of the respondents. These were the working unit, educational background and whether the respondents had worked at the unit during the whole time period of the project. The second section comprised 23 statements, relating to how the process had influenced the clinical preception at the units, covering the following areas: the development process at the units; the development in the preceptors and need of further education; and the preceptors’ current practices. This section included a Likert-type 4-point scale (1 = totally other view, 2 = somewhat other view, 3 = somewhat same view and 4 = totally same view). The third section consisted of open-ended questions with the following themes: ‘What was the best thing about the project?’, ‘Ideas for further development?’, and ‘What new practices will be permanently implemented after the project ends?’ Since this project was unique, it was not possible to pretest the questionnaire beforehand. Moreover, any preceptors invited to pretest it would not have been able to participate in the actual data collection. However, the content of the questionnaire was discussed in the project group panel very carefully, in order to ensure content validity. The data were collected over a 4-week period in November and December 2012. During this time, invitations and questionnaires were placed in the coffee rooms of the respective units. The completed forms were then returned in a sealed box, in order to ensure confidentiality. Statistical analyses were then performed using SPSS for Windows, Release 17.0. As the study design was descriptive, all statistical analyses were descriptive, including frequency and percentile distributions of the background details of the respondents, and the means and standard deviations of the responses for the statements in the second section (8). The open-ended
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questions were analysed through content analysis. It is worth noting that qualitative content analysis is an interpretive process, focusing on subject and context, which specifically deals with differences and similarities between, and within, parts of the text. In this study, the answers to the questionnaires were read through several times by the first author to obtain a sense of the whole. Passages related to the participants’ experiences were then extracted and brought together into a single text. From this, meaning units, each comprising several words, sentences or paragraphs related to each other through their content and context, were condensed and labelled with codes. The codes and meaning units were subsequently interpreted and summarised to build threads of meaning (9). In reporting the results of this qualitative evaluation, citations of the original data have been presented and marked with Italics. A SWOT analysis was then conducted among the members of the project group in the following manner. Firstly, all the members of the project group individually evaluated and wrote down the strengths, weaknesses, opportunities and threats they had experienced. Secondly, the project group came together and all the members presented their different views on the project. Through reflection and discussion, the project group agreed on the final evaluation.
Ethical considerations All the healthcare professionals and student nurses in clinical practice were informed about the project and its aims by the management at the units. Moreover, both oral and written information about the project were given to the staff in the five units by the researchers. The participants were informed that their confidentiality was assured, that participation was voluntary and that they could withdraw from the project at any time without giving any reason. According to Finnish regulations, no ethical application was needed. Approval for conducting the evaluation, however, was granted in written form from the management in the organisations. In this regard, we have followed the guidelines of the National Advisory Board on Research Ethics (10).
Results Background details of the respondents The evaluation was conducted at all five units and a total of 68 members of staff completed the questionnaire. Of the respondents, 50% (f = 34) were Registered Nurses, 29.4% (f = 20) were Practical Nurses and 20.6% (f = 14) had another education. Out of all the respondents, 80% (f = 52) had been working at the units during the whole time that the project lasted, while 20% (f = 13) answered that they had not.
Findings from the quantitative part of the evaluation The quantitative part of the questionnaire comprised 23 statements. Out of these, the first six statements concerned the development process at the units. The highest means were related to the respondents’ intention to use the preceptorship model (3.55), the development of preceptorship at the unit (3.12), and the discussion around questions related to preceptorship (3.10). The means of the responses to other statements were between 2.85 and 2.23, the lowest score being associated with the relationship between the preceptors and the nursing teachers (Table 1). The following 10 statements concerned the preceptors’ apprehensions of their own development and need for further education. The highest means were related to the respondents’ experience that preceptorship was an important and accepted part of their work (3.17) and that by developing the preceptorship model, they had developed as preceptors (3.00). The means of the responses to other statements were between 2.95 and 2.72, the lowest score being associated with whether the respondents’ way of precepting had changed during the project (Table 2). The following seven statements concerned the preceptors’ current practices. The highest means were related to whether the respondents started the preception at the unit with a thorough introduction (3.42), and whether they encouraged the students to seek information independently more than earlier (3.08). The means of the responses to other statements were between 2.98 and 2.79, the lowest score being associated with whether the respondents encouraged students to seek evidence from scientific databases (Table 3).
Findings from the qualitative part of the evaluation What was the best thing about the project?. The first open question, concerning what was the best thing about the project, was answered by 40 participants at the units (U). According to the answers, the most valued aspect was a developed common praxis, which was the result of the preceptorship model developed at the units and the documents supporting preceptorship. This development occurred both on the unit level and on the individual level. ‘We now have a preceptorship model at the unit that is simple and easy to understand. One has developed as a preceptor’ (U1). The respondents believed that preceptorship had developed and deepened at the units, resulting in better preception for the students. Due to the project, preceptorship had now come into focus and was being discussed. ‘. . . the discussions and the engagement that it has caused at the unit’ (U3). On an individual level, preception had developed by gaining new
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Table 1 Staff evaluation on the development process at their own units*
Statement
N
Mean (M)
Standard deviation (SD)
We will continue to use the preceptorship model even after the project ends The preceptorship has developed at our unit during the process The result of the process is that we have started to discuss questions related to preceptorship A better cooperation between the preceptors has developed during the process The whole unit has been engaged in the project The relationship between the preceptors and the teachers has developed during the project
63 66 68 66 66 66
3.55 3.12 3.10 2.85 2.51 2.23
0.667 0.713 0.736 0.728 0.898 0.719
*Scales 1-4. 1 = Totally other view, 2 = somewhat other view, 3 = somewhat same view, 4 = totally same view.
Table 2 The preceptors’ apprehensions of their own development and need for further*
Statement
n
Mean (M)
Standard deviation (SD)
I experience that preceptorship is an important and accepted part of my work By developing the preceptorship model, I have developed as a preceptor I need further knowledge about critical thinking in relation to preceptorship The development has been important for my work I need further knowledge about evidence-based practice in relation to preceptorship The project has increased my self-evaluation of preceptorship My view of what preceptorship means has changed Due to the process, I have noticed that I need more further education in preceptorship I now think more about ethical questions regarding preceptorship My way of precepting has changed during the project
63 63 66 64 63 65 65 64 64 67
3.17 3.00 2.95 2.95 2.92 2.86 2.75 2.75 2.73 2.72
0.814 0.762 0.753 0.765 0.867 0.768 0.830 0.836 0.913 0.775
*Scales 1-4. 1 = Totally other view, 2 = somewhat other view, 3 = somewhat same view, 4 = totally same view.
Table 3 The preceptors’ current practices* Statement
n
Mean (M)
Standard deviation (SD)
I start the preception at the unit with a thorough introduction I encourage the students to seek information independently more than earlier I encourage the students to use critical thinking and reflection by discussion and writing a log I have started to plan the preception according to the student0 s learning outcomes I use planned reflection sessions in the preception of students Due to the process, I use critical thinking during preception I encourage students to seek evidence from scientific databases
66 62 64 63 60 63 61
3.42 3.08 2.98 2.90 2.88 2.82 2.79
0.583 0.753 0.745 0.734 0.761 0.708 0.878
*Scales 1-4. 1 = Totally other view, 2 = somewhat other view, 3 = somewhat same view, 4 = totally same view.
knowledge about preceptorship, including what it meant and how it could be implemented. ‘You have learnt that you needn’t be omniscient as a preceptor. You may also ask the student to check up different things independently’ (U2). The nurses felt that one of the best things with the project was that they had developed as nurses during the process. Future development for preceptorship at the units. The second open question, concerning the future development of preceptorship at the units, was answered by 31 preceptors. According to them, preceptorship could be developed at the units by improving the conditions needed for © 2015 Nordic College of Caring Science
preceptorship to take place. Furthermore, the staff felt that there were no incentives in place when it came to working as preceptors. A lack of time and resources were also deemed as being obstacles preventing good preceptorship. ‘There is no ‘carrot’ for the nurse in precepting a student. . . It’s difficult to develop, there is no time, our work is very heavy and it has become more demanding’ (U1). Another area of development was to get the whole staff committed to the preceptorship models developed. This was seen as a challenge since not all the members of staff were so actively involved during the project. ‘It has been difficult to involve all the preceptors in the project
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in our unit, the preceptor model should be an aid of assistance to everyone’ (U4). One way of doing this is to arrange further education in preceptorship for all the staff. ‘More discussion among the staff. Further education for everyone, even to those not directly working as preceptors’ (U5). The cooperation between the healthcare units and the faculty was seen as an important area needing to be developed. ‘It’s important to develop the communication between the faculty, the nursing teachers and the preceptors at the units’ (U2). What is the most important legacy of the project? The third open question, asking about what they felt was the most important legacy of the project, was answered by 28 preceptors. Their answers reflected both material and immaterial project benefits. The nurses particularly emphasised the preceptorship model they had developed during the project and the documents supporting preceptorship. These were seen as the most important and they would continue to use the documents in the future. ‘I will always use the preceptorship model in the future when I precept students, as it guarantees the same quality of preception to everyone’ (U4). They believed that their way of thinking had been transformed during the project; a way of thinking that strengthened their professionalism, which was something they wanted to preserve even after the project ended. ‘The way of thinking about preceptorship has changed somehow. The education has given us a lot of new tip-offs’ (U1). The emphasis on critical thinking, reflection and focus on ethics were valued by the staff, and were areas that they wanted to continue to develop. ‘At least reflection has proved to be important, . . . the student needs to think more carefully about what and why they are doing things’ (U2). The staff saw the students as future colleagues and preception as a possibility to facilitate mutual learning. ‘The students will be our future workforce/colleagues. It’s important that they will get all the knowledge we can bring’ (U5). These insights they wanted to cherish even when the project was over. ‘You start to think more about things from an ethical point of view and try to precept the student to encounter the client by being present in a caring mode’ (U4). Both theoretical and practical knowledge gained through further education during the project were seen as important.
Findings from the SWOT analysis Strengths of the project. A major strength of this project was that it responded to the expressed needs of both the educational organisations and working life/healthcare organisations. As such, a closer cooperation between the educational organisations and the healthcare units was developed during the project. The project brought together many organisations from different parts of the region, representing different languages (Swedish,
Finnish and English), resulting in the uniting of different areas of competence. Having external funding for this project was an important factor in terms of making it possible for the project to succeed as strongly as it did. In other words, the project had budgeted funds for all actors involved, including the members of the core groups at the units. Another important factor, seen as a strength, was the fact that many of the participants in the project group and in the organisations were known to each other from before. As such, all the members of the project group were very committed to the project and cooperation functioned well. A lot of material supporting preceptorship was developed during the project, and the active participation of the members of the core groups, with support from the nursing teachers, has enhanced critical reflective thinking among nurses. Moreover, the definition of the concepts of preceptorship and ethics has expanded and the nurses have started to discuss preceptorship as a pedagogical duty. The weaknesses of the project. One major weakness concerned some problems that arose when establishing the activities of the project with the activities of the organisations. It became evident that there was a risk that two parallel processes would subsequently exist, without there being any connections between them. The project tried to prevent this by working in close participation with the head nurses at the units and by arranging meetings to inform and engage the staff. Furthermore, the members of staff were invited to participate in further education, seminars and different meetings in order to promote the development work. Another weakness of the project was due to staff changes in the core groups as a result of new assignments or changes of workplaces during the process. Introducing new participants to the activities of the project was a time-consuming process. Moreover, a high staff turnover at the units might have been a factor that weakened commitment to the project. The opportunities of the project. One of the major opportunities was the genuine interest, held by the majority of those involved, to participate in the development of preceptorship. Furthermore, as a result of the pedagogical further education arranged for the staff, there is now clear evidence of an enhanced level of clinical competence being in place when precepting the students in the region. This project created a pedagogical arena for nurses to develop preceptorship and a space to discuss and reflect on preceptorship. In this regard, the project has formed the basis for further cooperation and new networks within the region. Moreover, the workshops that were arranged for the core groups at the units have enabled them to come together and discuss issues concerning preceptorship and ethics. Through good preceptorship, the students learn good nursing care, which © 2015 Nordic College of Caring Science
Developing preceptorship through action research enables the development of nursing care to benefit both the patients and their families. Threats to the project. One threat to the project was the lack of a genuine interest towards the project by certain units and some of the actors and leaders. As such, the prerequisites of implementation varied between the different units and actors. Another major threat was the result of rigid structures within the organisations. These had a restraining affect on the progress of the project which might have hindered development in the worst scenario. Finally, the high staff turnover at the units was also deemed as a threat.
Discussion In the following chapter, the results of the evaluation, both quantitative and qualitative, are discussed. The results showed that of the participants (n = 68), 50% were Registered Nurses, 29.4% were Practical Nurses and 20.6% had another education. The majority of the respondents (80%) had been working at the units for the entire time the project lasted. However, the remaining 20% shows the high staff turnover in the healthcare sector, which has been a challenge to the project. The participants reported that they had decided to continue to use the preceptorship model even after the project ended. This was due to the fact that the developed common praxis, as a result of the preceptorship model, was most valued as it responded to a direct need. Although it is not possible to claim that the preceptorship models have become established procedures at the units, because of the short period of time, this does, nevertheless show just how important it is to engage the nurses, i.e. the actors, in the development process. This shows the benefit of AR where participants are reflecting and acting close together. Furthermore, it was important to gain a bottom-up perspective in order to know what the members of staff considered to be the most important areas of development. The starting point was to conduct a cultural analysis at the units in order to unfold the attitudes, experiences and beliefs of nurses. The evaluation showed that a change had occurred at the units. The nurses felt that preceptorship had developed and deepened at the units during the project and that a development had occurred on an individual level as well as on the unit level. Preceptorship had now come into focus and was something that the staff discussed in a different manner. New knowledge was generated about preceptorship and the nurses thought they had developed both professionally and personally. They also experienced that their thinking had been transformed during the project which implied a change. Earlier studies have shown that reflection and critical thinking are important for the students in order to develop, both professionally and © 2015 Nordic College of Caring Science
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personally (11, 12). In this study, the emphasis on critical reflective thinking was valued among the staff and was something they wanted to preserve and continue with. In this respect, ethical issues were brought into focus, meaning that values supporting the wellbeing of patients were evident in the practice environment (e.g. 13). A closer cooperation between the preceptors had developed during the project, which may have been a result of the fact that the staff discussed more about preceptorship. It was now considered to be something important and therefore valued. However, one challenge had been to engage the whole unit in the project. This might have been because of a high staff turnover and nonregular working hours. According to EU directives (14), it is the duty of the staff nurses to act as preceptors for the students. As such, the nursing teachers usually build a liaison between the students and the preceptors at the units. The role of the nursing teachers should then be to communicate the expected learning outcomes to students and staff and provide support (15, 16). The preceptors expressed the need to have the opportunity to discuss and obtain feedback from the nursing teachers on a regular basis as shown in earlier studies (17, 18). The nurses experienced preceptorship as an important and accepted part of their work. This can be seen in their responses to the open questions, where they expressed an opinion that preceptorship should be developed at the units by improving the conditions for preceptorship. As in earlier studies, the obstacles they experienced were a lack of time and resources (19). They also felt that there were no incentives for preceptors. Hence, they felt that by developing the preceptorship model, they had developed as preceptors. Furthermore, the preceptors expressed that they needed further education in preceptorship, more knowledge about critical thinking and evidence-based practice in relation to preceptorship and that the development had been important for their work. Regarding the first point, the nurses suggested that further education be arranged on a regular basis to all members of staff. Regarding the other points, the preceptors experienced an increased selfevaluation of preceptorship and a change in the view of what preceptorship meant. Ethical issues, for example, began to be more explicitly defined and discussed as the preceptors became more aware of the importance of them. The answers mirrored a positive attitude towards development and further education. This project showed the benefits of AR and brought forth the tacit knowledge of the nurses. Their willingness and strong commitment to participate in close collaboration for the sake of developing preceptorship can also be seen as a moral obligation. Preception is an ethical issue and should be recognised as such by all stakeholders. An earlier study showed the importance of the receptiveness of nursing staff and whether they were welcoming and friendly, particularly on the first day of a
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placement. Being made to feel welcome was highly motivating according to the students and enhanced the conditions for learning (20). The preceptors in this project started the preception with a thorough introduction using the material they had developed during the project. The preceptors had now started to focus on the students’ learning outcomes, and a student-oriented approach was emphasised. According to earlier studies, this promotes a narrowing of the theory–practice gap which, in turn, promotes self-direction and lifelong learning (21, 22). This suggests that the preceptors had become more aware of the students’ learning needs and tried to respond to them (18). Some of the preceptors had started to plan reflection sessions with the students, and the students were encouraged towards critical thinking and reflection. The preceptors also encouraged students to search for evidence from scientific databases.
Trustworthiness and validity of the evaluation study A questionnaire was constructed to evaluate the quality of this AR process (7), and a SWOT analysis was conducted among the researchers. The content of the questionnaire was outlined according to the central elements of the project. For the face validity, the whole project group commented on the questions as a panel. A limitation of this study is the fact that the questionnaire was new and had not been pretested. When analysing the qualitative data, we followed the ideas of content-analysis procedures and how to achieve trustworthiness (9). In reporting the results from the qualitative data, citations have been used, in order to give the readers some examples of the original data. A similar project could be undertaken elsewhere. The findings from this project may be transferred to other contexts and may be of interest both nationally and internationally.
the units when they are given the possibility to participate in an action-research process like this. During the process, it was noted that the cooperation among the units and the faculties increased. New educational strategies and alternative possibilities for organising clinical education are required in order to prepare nurses for high-quality preceptorship. Moreover, preceptorship should be recognised by all stakeholders and efforts should be made to plan the nurses’ clinical work so that there is enough time allocated for preception. Future research should focus on interventions aimed towards developing preceptorship in close cooperation between faculties and healthcare units.
Acknowledgements We wish to thank Annika Wentj€arvi, R&D Manager, Novia, who carried out the statistical analyses. And finally, we want to thank the staff on the five development units, the researchers and the students who participated in this project.
Author contributions Yvonne Hilli was responsible for the design and for drafting the manuscript. The article was written in close collaboration with Hanna-Leena Melender. Both authors are in agreement with the content of the manuscript.
Ethical approval According to Finnish regulations, no ethical application was needed. Approval for conducting the evaluation was granted from the management of the healthcare organisations.
Funding Conclusion This project showed the importance of having a bottomup perspective when starting the development of preceptorship. The cultural analysis at the five units unfolded five different cultures with different needs. The project has shown the great potential there is among nurses at
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