JNPD
Journal for Nurses in Professional Development & Volume 31, Number 1, E7YE14 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
Systematic Review Building a Preceptor Support System Carol R. Goss, DNP, RN-BC This systematic review identifies the significance of the preceptor role in affecting new graduate nurse retention. Findings from 20 research studies provide support that nurse preceptors receiving continuing education and perceiving reward and recognition from the preceptor position positively affect new graduate nurse retention. Hospital administration, nurse managers, nurse educators, preceptors, and new graduate nurses each play a role in the successful implementation of a preceptor support system.
INTRODUCTION The purpose of this article is to review the literature related to the significance of the preceptor role in affecting retention and end-of-1-year turnover rates for newly hired registered nurses (RNs). Baggot, Hensinger, Parry, Valdes, and Zaim (2005) found that implementing a preceptor support system with focus on education and reward and recognition of preceptors resulted in decreased turnover and increased RN retention. The role of the preceptor is not a new concept. According to King and Cohen (1997), the preceptor model, originating in the United States in the late 1960s, was the internationally accepted method to progress new graduate nurses from theory to practice, thus retaining those nurses. Miller and Brosovich (1991) stated that preceptor programs could be part of the answer to increase staff satisfaction and reduce turnover. The focus of this article is to review literature related to developing the preceptor and identifying the preceptor characteristics that will ultimately result in RN retention. The desired outcome is to impact preceptor satisfaction and commitment to the role, increase retention of overall nursing staff, and decrease end-of-1-year turnover rates by building a nurse preceptor support system, providing continuing education, creating an effective means of communication among preceptors, and developing a preceptor reward and recognition system. Armitage and Burnard (1991) defined the preceptor and mentor roles in an effort to determine which one would be
Carol R. Goss, DNP, RN-BC, is System Educator, Norton Healthcare Institute for Nursing, Norton Healthcare, Louisville, Kentucky. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. ADDRESS FOR CORRESPONDENCE: Carol R. Goss, DNP, RN-BC, Norton Healthcare Institute for Nursing, Norton Healthcare, Louisville, KY (e-mail: [email protected]). DOI: 10.1097/NND.0000000000000117
the most supportive in bridging the gap between theory and practice. The distinction between the two roles defines the preceptor role as more supportive in the clinical area, with the mentor role more nurturing. Bumgarner and Biggerstaff (2000) defined the preceptor as ‘‘one who guides the new nurse in gaining knowledge and skills needed in performing patient care and teaches the roles and responsibilities of the staff nurse in the clinical setting’’ (p. 251). University of Michigan Health Care Systems reported losing over 25% of their new RN graduate staff in the first year. This turnover equated to a loss of $5,500,000 for the organization (Baggot et al., 2005). Kovner et al.’s (2007) survey of 3,266 newly licensed nurses found that nurses who are dissatisfied with the work environment are more likely to leave within the first year of practice. The Advisory Board Company (2010) is a global consulting, research and technology firm serving over 350,000 healthcare organizations; the Board estimates the cost of replacing an RN to be between $62,100 and $67,100.
REVIEW OF THE CURRENT LITERATURE A review of the literature was conducted by using EBSCO host Cumulative Index to Nursing and Allied Health Literature database. The database was searched using the Cumulative Index to Nursing and Allied Health Literature indexing term ‘‘preceptorship’’ with the key terms ‘‘job satisfaction,’’ ‘‘personnel retention,’’ and ‘‘personnel turnover.’’ The indexing term ‘‘preceptorship’’ was also used to search the database with the keywords ‘‘satisfaction,’’ ‘‘satisfied,’’ ‘‘retain,’’ ‘‘retention,’’ and ‘‘turnover.’’ The literature review produced over 200 articles related to the identifying terms. All nonresearch articles, all research articles before 2006, all articles whose tools did not describe reliability and validity, and articles with mentor or residency in the title were excluded. The final review consisted of 20 research articles (ranging from 2006 to 2012) relating to the outcomes of preceptor satisfaction and commitment to the preceptor role, increase in retention of overall nursing staff, and decrease in end-of1-year turnover rates. Each research article was graded for the quality of evidence using Polit and Beck (2008) levels for grading of the evidence and then placed in an evidence table (Titler, 2008) for evaluation (see Table 1). Five of the studies included in this systematic review were conducted outside the United States: Canada, Taiwan, New Zealand, Ireland, and Sweden. Internal review board approval was stated in all studies with the exception of Yonge et al. Validity and reliability methods were briefly described in five
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studies: Carlson et al., Haggerty et al., Hallen and Danielson (2008), Hautala et al., and McCarthy and Murphy. Carlson et al. and Hallen and Danielson gave a separate subtopic
to validity and reliability for their studies. Three studies were excluded because there were no validity or reliability methods described in the use of their tools.
TABLE 1 Quantitative and Qualitative Research Findings
Source Quantitative Research Hallin and Danielson (2008)
Purpose/Variable
Design Type/Instrument
Compare experiences Correlation between 2000 and quantitative 2006 questionnaire
Sample Size and Statistical Methods 2000 (N = 113 RNs) and 2006 (N = 109 RNs); data analyzed
& & & &
Evidence Level, Quantitative Research Level 1: Experimental Level 2: Quasiexperimental Level 3: Correlational Level 4: Descriptive Key Findings
Evidence level 3 Statistically significant improvements: & Felt prepared for role & Support from teachers, colleagues Least improvement: & Workload & Constructive feedback
Henderson, Fox, and Malko-Nyhan (2006)
Nurse preceptors’ perceptions of a 2-day workshop, organization support
Descriptive quantitative workshop, focus group interviews
N = 36 RNs, data analyzed
Evidence level 4 Potential changes in their perceptions: & Support & Education opportunities over monetary rewards
Hykas and Shoemaker (2007)
Explore relationship preceptors’ perceptions of benefits, rewards, support, commitment
Descriptive correlation, quantitative
Two subgroups, N = 82 RNs
Evidence level 4 More benefits and support perceived: & More committed to role of preceptor No significance between & Years of experience to perceptions of benefits, reward, support, and commitment
Lee, Tzeng, Lin, and Yeh (2009)
Design a preceptor program: evaluate the turnover, cost, quality of care, and professional development
Quantitative quasiexperimental research
N = 24 RNs; t test to Evidence level 2 retest satisfaction related to nursing care High turnover rate impacts: & Hospital turnover cost, patient safety, and quality of patient care Rotating staff among preceptors: & May decrease stress related to the preceptor role Continued
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TABLE 1 Quantitative and Qualitative Research Findings, Continued
Source Quantitative Research
Purpose/Variable
McCarthy and Murphy Explore preceptors’ (2010) perception of precepting nursing students
Design Type/Instrument Descriptive quantitative questionnaire
Sample Size and Statistical Methods
Evidence Level, Quantitative Research Level 1: Experimental Level 2: Quasiexperimental Level 3: Correlational Level 4: Descriptive Key Findings
& & & &
N = 970 distributed, Evidence level 4 N = 470 return; Preceptor and student issues: content analysis and descriptive & Time, contact, failing students Role issues: & Preparation, stress, limited support, recognition
Tremblay, Paquet, Marchionni, and Drevniok (2011)
Investigate which domains of nursing proactive work environment influence the intent to leave a job among Generation Y of new nurses
Correlational and descriptive quantitative practice environment scale of the nursing work index
N = 145 RNs, univariate analysis of variances
Evidence levels 3 and 4 No difference found: & Generations of nurses relating to intent to quit Orientation and preceptorship programs: & That extend beyond a few weeks, key to retaining nurses
Source Qualitative Research Bourbonnais and Kerr (2007)
Carlson, Pilhammar, and Wann-Hansson (2009)
Design Type/ Instrument
Purpose/Variable
Sample Size and Statistical Methods
Personal reflections on being a preceptor; support/challenges to preceptor role
Qualitative one-on-one tape-recorded interviews
N = 8 interviewed, thematic analysis
Describe conditions for precepting in a Swedish clinical from the perspective of the nurse
Ethnographic qualitative participant observation and focus groups
N = 13 teaching wards
Evidence Level, Qualitative Research & Level 1: Ethnographies & Level 2: Phenomenology & Level 3: Grounded Theory Key Findings Evidence level 2 Role challenges: & Lack of recognition, support highlights: support, recognition Evidence level 1 Supportive conditions: & Organization, collaboration, personal perspective Limiting conditions: & Allocated time to precept Continued
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TABLE 1 Quantitative and Qualitative Research Findings, Continued
Source Qualitative Research Danielson, Sundin-Anderson, Hor, and Athlin (2009)
Purpose/Variable Determine how group supervision influences preceptors’ view of their role and their valued participation
Design Type/Instrument Qualitative self-reported open-ended questionnaire
Sample Size and Statistical Methods N = 48 RNs
Evidence Level, Qualitative Research & Level 1: Ethnographies & Level 2: Phenomenology & Level 3: Grounded Theory Key Findings Evidence level 2 Role satisfaction: & Continuous development, being acknowledged, confirmed Demands of preceptorship: & Difficult students, lack of time, smaller groups, role perception, and group supervision
Haggerty, Holloway, and Evaluate nurse entry to Wilson (2012) practice, key focus preceptorship supported
Ethnographic qualitative questionnaires, key stakeholders, and case studies
N = 21, longitudinal Evidence level 1 evaluation of entry National guidelines for practice programs preceptor selection and education: & Recommended for national adoption through council of New Zealand
Hautala, Saylor, and O’Leary-Kelly (2007)
Describe staff nurses’ perception of stress and support
Descriptive exploratory questionnaire, qualitative
N = 65 RNs, coding Evidence level 3 and grouped into Acknowledged precepting themes stressful: & Related to workload, time
Liu, Lei, Mingxia, and Haobin (2010)
Explore clinical preceptors’ experience and meaning of their lives in clinical teaching
Phenomenology, qualitative audio-taped individual reviews
N = 20 RNs, clinical Evidence level 2 preceptors Positive aspects: & Personal satisfaction, knowledge, skill improvement, respect from others Negatives: & Lack of formal recognition, excessive workload
Luhanga, Dickerson, and Explore and describe Massey (2010) preceptor support and development
Phenomenology, qualitative individual/group interviews
Evaluation, preceptor, Evidence level 2 resource manual Identified the need for: & Effective communication, clearer role expectation, reduced workloads, and time Continued
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TABLE 1 Quantitative and Qualitative Research Findings, Continued
Source Qualitative Research
Purpose/Variable
Design Type/Instrument
Sample Size and Statistical Methods
Evidence Level, Qualitative Research & Level 1: Experimental & Level 2: Quasiexperimental & Level 3: Correlational Key Findings
Omansky (2010)
Describe the staff nurses’ experience of preceptoring/ mentoring nursing students
Integrative review, qualitative
N = 20 research and Evidence level 1 10 nonresearch Recommendation for managers: articles from 1981 to 2009 & Decrease patient assignments, allocate teaching time, ongoing education, recognize, support
Schumacher (2007)
Explore caring interactions and, if caring is perceived, what does that mean
Phenomenological qualitative reflective journals and in-depth interview
N = 10 new graduate Evidence level 2 RNs, Colaizzi To retain nurses: method of analysis & Positive interaction, positive relationships Caring behaviors decrease: & Anxiety, fear, and stress and increase retention
Warren and Denham (2010)
Zinsmeister and Schafer (2009)
Discover evidence preceptor orientation, impacts student outcomes
Qualitative literature review
Explore the lived experiences of graduate nurses during the first 6Y12 months of employment: insight into transition phase
Phenomenology, qualitative interview
N = 13 research articles from 1990 to 2007
Evidence level 1 Most impact: & Preceptor preparation, orientation, and support
N = 9 new graduate Evidence level 2 RNs interviewed, Supportive work area: four levels of coding used & Positive preceptor experience, comprehensive orientation, sense of professionalism Clarity of role expectation & Preceptors assisted to develop the skills to work with new graduates Organization shows commitment & Providing opportunities and support to retain staff
Source Quantitative and Qualitative Research Park and Jones (2010)
Purpose/Variable Orientation program
Design Type/ Instrument Integrative review, quantitative and qualitative
Sample Size and Statistical Methods N = 17 published reports
Evidence Level Key Findings Evidence level 1 Competency of new graduate nurses: & Increased with one-on-one preceptor Continued
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TABLE 1 Quantitative and Qualitative Research Findings, Continued Source Quantitative and Qualitative Research Yonge, Hagler, Cox, and Drefs (2008)
Purpose/Variable Focus on identifying needs/expectations of preceptor preparation, role, stress, and support needed
Design Type/Instrument Quantitative and qualitative mailed survey
Sample Size and Statistical Methods N = 86 RNs; quantitative data analyzed using SPSS, qualitative data analysis using a coding scheme
Evidence Level Key Findings Evidence level 2 Influence to continue: & Recognition, benefit, negative experience with orientee Influences success need for: & Adjusted workload, preparation for the role, benefits, rewards
Of the 20 studies reviewed, 12 studies relating to the outcomes of preceptor satisfaction and commitment focused on the preceptor’s need for support and recognition in relation to commitment and satisfaction. Only one study measured actual commitment to the preceptor role. Two studies measured overall satisfaction with precepting. Review of the literature related to increase in overall nursing staff retention and decrease in end-of-1-year turnover rate resulted in three decreased turnover and increased retention-related studies; three retention-related studies; and one recruitment, support, and retention-related studies.
Satisfaction and Commitment The theme throughout the literature review, in reference to satisfaction and commitment, focused on support and recognition of the preceptors to sustain satisfaction in the preceptor role. Hykas and Shoemaker (2007) found a significant correlation (r = .42, p = .01, N = 82) between perception of support to the preceptor role and increased commitment when benefits were available. A study conducted by Liu et al. (2010) identified four themes to describe the experience of the clinical preceptor: ‘‘teaching is learning; being unable to do what one would like to do; experiencing bittersweet moments; and being a role model and acting as a mother’’ (p. 806). Clinical preceptors view personal satisfaction, respect from colleagues, and continued education as positive aspects of precepting. However, lack of recognition, insufficient time to role model, and stress related to workload were viewed as negative aspects of precepting (Hallen & Danielson, 2008; Hautala et al., 2007). Eight of the 13 studies concluded that preceptors perceive benefits and rewards as supportive to the preceptor role (Bourbonnais & Kerr, 2007; Carlson et al., 2009; Danielson et al., 2009; Hykas & Shoemaker, 2007; McCarthy & Murphy, 2010; Omansky, 2010; Warren & Denham, 2010; Yonge et al., 2008). Henderson et al. (2006); Wilson, Bodin, Hoffman, E12
and Vincent (2009); and Luhanga et al. (2010) further concluded that communication and educational opportunities are supportive to the preceptor role. All but three studies identified increased workloads and lack of time to precept as a barrier: Henderson et al., Wilson et al., and Liu et al. (2010).
Decreased Turnover The theme throughout the literature review, in relation to decreased turnover and increased retention, focused on the need for preceptor programs and the impact preceptors have on the overall nursing staff retention rate and decreased turnover. A study by Lee et al., using a quasiexperimental research design, evaluated the outcome of a preceptorship program and the program’s effect on turnover rate, cost, professional development, and quality of patient care. Twentyfour nurse preceptors and 34 new nurses participated in the study. After program completion, study results showed a decrease in turnover rate of 46.5% at a cost savings of $186,102 when compared with the previous year. Study results showed a 50% decrease in medication errors made by new nurses, a decrease in falls at the time of the study (from 52 falls the previous year to 43 falls), and a decrease in incidents with adverse effects (from 65 incidents the previous year to 52 incidents). Overall satisfaction of patient care, in comparison with the previous year, was not statically significant (t = 0.382, p Q .05). When compared with the previous year, however, the results of the descriptors ‘‘attitude of the nursing staff (t = 2.772, p G .01), privacy of the patient (t = 2.550, p G .05), maintaining tranquility of the wards (t = 2.741, p G .01), and instantaneous feedback of questions and needs to the medical doctor (t = j2.305, p G .05)’’ (p. 1221) were significantly improved. The 34 new nurses measured their satisfaction with the preceptor by completing a 20-item questionnaire based on a 4-point Likert scale to evaluate the performance of their preceptor. Satisfaction scores ranged from 3.15 to 3.44. Preceptors measured their satisfaction with professional development
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by completing a modified scale from Dilbert and Goldenberg’s (1995) 20-item preceptor perception questionnaire, also based on a 4-point Likert scale. Preceptor satisfaction scores ranged from 2.85 to 3.32. Preceptors experience job dissatisfaction, express feelings of being overwhelmed, and describe ultimate burnout (Lee et al., 2009). Park and Jones’ (2010) integrative review of 17 research studies evaluated the outcome of new graduate nurses who attended a structured orientation, residency, or internship programs with one-on-one preceptors. The data supported the concept that those receiving this in-depth orientation were more confident, more competent, and less likely to leave the profession. Qualified educated preceptors were identified as key to a successful preceptorship experience. The outcome of this systematic review resulted in the development of selection criteria for preceptors and a preceptor education program. The top selection criteria included leadership and communication skills, clinical competency, and professional development. The outcome of the preceptor program focused on ‘‘confidence, competency and retention’’ (p. 148). Tremblay-Lavoie et al. (2011) studied 150 new graduating nurses using an online survey to identify what influenced new graduate nurses to leave in the first year of practice. Study results showed that 49% (n = 71) of the respondents intended to leave their current position and 9.7% (n = 71) of the respondents intended to leave the nursing profession altogether. Reasons identified as statistically significant in influencing new graduate nurses to leave in the first year were ‘‘nurse participation in hospital affairs,’’ p e .05, ‘‘nursing foundations for quality care,’’ p e .01, and ‘‘collegial nurseY physician relations’’ p e .01 (p. 42). Study findings stressed the need for orientation and preceptor programs as essential elements in providing new graduates with supervision to develop their roles in providing quality patient care and decreasing turnover.
Retention In a qualitative study using journals and interviews, Schumacher (2007) examined the caring behaviors between new graduate nurses and preceptors during the course of orientation and the perceptions of the new graduate nurses in relation to the caring behaviors. New graduate nurses journaled daily; their instructions were to describe why they felt cared for by their preceptors and why they did not feel cared for by their preceptors. Additional data were collected from individual interviews with the new graduate nurses. Caring behaviors perceived were being welcomed as part of the staff and preceptors being physically present and open to questions. Noncaring behaviors perceived were preceptors not being present, preceptors not being open to questions, and not allowing new graduate nurses to function on their own. Results of the study (which identified both caring and noncaring behaviors) were evident during the course of orientation. Implications from this study were used
to design preceptor programs that teach caring behaviors to preceptors working with new graduate nurses. Preceptors educated in the caring behaviors, and who modeled the caring behaviors in practice, assisted the new graduate nurses in implementing caring behavior into patient care. Displaying caring behaviors has been shown to build trusting relationships, helping to decrease the anxiety levels of the new graduate nurse and improving staff retention. Studies by two research groups (Salt et al., 2008; Zinsmeister & Schafer, 2009) concluded that preceptor programs impact retention of new graduate nurses. Salt et al. found that the highest retention rates of new graduate nurses were directly linked to programs that had a 3- to 6-month preceptor program in place. The study categorized four retention strategies: externship pregraduation, new graduate nurse preceptor program, needs-based orientation, and preceptor programs with focus on supporting the preceptors in their role. Study results strongly suggested that merging the preceptor program model for new graduate nurses with the preceptor program for preceptors was the best strategy for new graduate nurse retention. Zinsmeister and Schafer (2009) explored the experience of new nurses’ transition in their first year of practice to identify aspects that would be most helpful in their transition and increased retention. Study findings from interviews with nine new graduate nurses were coded into five themes that reflect success in the preceptor program: ‘‘supportive work area, positive preceptor experience, comprehensive orientation process, sense of professionalism, and clarity of role expectation’’ (p. 30). Study results reflected the important role preceptors have in the positive transition and retention of new graduate nurses. Haggerty et al. (2012) conducted a 3.5-year evaluation of New Zealand’s nursing practice programs. A key focus of the evaluation was directed to preceptor support. Results of the surveys found inconsistencies in preceptor selection and education. Preceptors reported a lack of clarity regarding their roles and responsibilities and voiced their concerns of an increased workload while precepting. Study findings concluded that the best practice occurred when preceptors were selected, educated, and supported in their role. The study resulted in a recommendation from the New Zealand Board of Health to establish national standards for preceptor selection and education.
DISCUSSION AND CONCLUSION Study findings from this systematic review provided information that preceptors need continuing education to enhance their teaching, knowledge, and procedural techniques and that these refined skills play an integral role in new graduate nurse retention. Support of administration is vital to assist the preceptor by providing continuing education resources and displaying appreciation or recognition through tangible or intangible rewards.
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Findings from this systematic review support the need for formal preceptor programs with selection criteria, education requirements, roles and responsibilities defined, and preceptor reward and recognition. Improvement in preceptor satisfaction and commitment to the preceptor role and increased retention of overall nursing staff are supported by the findings of this systematic review; when the preceptor programs are 3Y6 months in length, preceptors are paid to attend preceptor education programs, and new graduate nurses define their preceptor needs. The impact of insufficient time and preceptor workload on the preceptor role identified in this systematic review needs further study to determine the outcome on preceptor satisfaction and retention of nursing staff. However, findings from this systematic review do indicate a significant association between the preceptor commitment to the preceptor role and the preceptor perception of rewards and benefits. Findings reported from this systematic review to the administrative staff of five multihospital system increased awareness for the need of preceptor programs and the importance of reward and recognition. The design and implementation of a standard preceptor model for a five multihospital system are in process. In addition, a preceptor Web site was developed with a preceptor blog, information to preceptor continuing education programs, a preceptor research library, quarterly newsletter, preceptor toolkit, and reward and recognition information.
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of stress and support in the preceptor role. Journal for Nurses in Staff Development, 23(2), 64Y70. Henderson, A., Fox, R., & Malko-Nyhan, K. (2006). An evaluation of preceptors’ perceptions of educational preparation and organizational support for their role. The Journal of Continuing Education in Nursing, 37(3), 130Y132. Hykas, K., & Shoemaker, M. (2007). Changes in the preceptor role: Re-visiting preceptors’ perceptions of benefits, rewards, support and commitment to the role. Journal of Advanced Nursing, 60(5), 513Y524. King, S., & Cohen, J. (1997). Facing ‘‘reality shock.’’ Nursing AYZ, 3(5), 16Y17. Kovner, C. T., Brewer, C. S., Fairchild, S., Poornima, S., Hongsoo, K., & Djukic, M. (2007). Newly licensed RNs’ characteristics, work attitudes and interventions to work. American Journal of Nursing, 107(9), 58Y70. Lee, T., Tzeng, W., Lin, C., & Yeh, M. (2009). Effects of a preceptorship program on turnover rate, cost, quality and professional development. Journal of Clinical Nursing, 18(8), 1217Y1225. Liu, M., Lei, Y., Mingxia, Z., & Haobin, Y. (2010). Lived experiences of clinical preceptors: A phenomenological study. Nurse Education Today, 30(8), 804Y808. Luhanga, F., Dickerson, P., & Massey, S. (2010). Preceptor preparation: An investment in the future generation of nurses. International Journal of Nursing Education Scholarship, 7(1), 1Y18. McCarthy, B., & Murphy, S. (2010). Preceptors’ experience of clinically educating and assessing undergraduate nursing students: An Irish context. Journal of Nursing Management, 18(2), 234Y244. Miller, D. M., & Brosovich, D. L. (1991). Maintaining an effective preceptor program. Focus on Critical Care, 18(1), 81Y83. Omansky, G. (2010). Staff nurses’ experiences as preceptors and mentors: An integrative review. Journal of Nursing Management, 18(6), 697Y703. Park, M., & Jones, C. (2010). A retention strategy for newly graduated nurses. Journal for Nurses in Staff Development, 26(4), 142Y149. Polit, D., & Beck, C. (2008). Nursing research: Generating and assessing evidence for nursing practice. New York, NY: Lippincott, Williams and Wilkins. Salt, J., Cummings, G. G., & Profetto-McGrath, J. (2008). Increasing retention of new graduate nurses. A systematic review of interventions by healthcare organizations. The Journal of Nursing Administration, 38(6), 287Y296. Schumacher, D. L. (2007). Caring behaviors of preceptors as perceived by new nursing graduate orientees. Journal for Nurses in Staff Development, 23(4), 186Y192. The Advisory Board Company. (2010). HR Investment Center 2010. Retrieved from http://[email protected] Titler, M. G. (2008). The evidence for evidence-based practice implementation. In Hughes R. G. (Ed.). Patient safety and quality: An evidence-based handbook for nurses (chapter 7). Rockville, MD: Agency for Healthcare Research & Quality. Tremblay, M., Paquet, M., Marchionni, C., & Drevniok, U. (2011). Turnover intention among new nurses. Journal for Nurses in Staff Development, 27(1), 39Y45. Warren, A. L., & Denham, S. A. (2010). Relationships between formalized preceptor orientation and student outcomes. Teaching and Learning in Nursing, 5, 4Y11. Wilson, L., Bodin, M., Hoffman, J., & Vincent, J. (2009). Supporting and retaining preceptors for NNP programs results from a survey of NNP preceptors and program directors. Journal of Perinatal and Neonatal Nursing, 23(3), 284Y292. Yonge, O., Hagler, P., Cox, C., & Drefs, S. (2008). Listening to preceptors: Part B. Journal for Nurses in Staff Development, 24(1), 21Y26. Zinsmeister, L. B., & Schafer, D. (2009). The exploration of the lived experience of the graduate nurse making the transition to registered nurse during the first year of practice. Journal for Nurses in Staff Development, 25(1), 28Y34.
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Journal for Nurses in Professional Development & Volume 31, Number 1, E7YE14 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
Systematic Review Building a Preceptor Support System Carol R. Goss, DNP, RN-BC This systematic review identifies the significance of the preceptor role in affecting new graduate nurse retention. Findings from 20 research studies provide support that nurse preceptors receiving continuing education and perceiving reward and recognition from the preceptor position positively affect new graduate nurse retention. Hospital administration, nurse managers, nurse educators, preceptors, and new graduate nurses each play a role in the successful implementation of a preceptor support system.
INTRODUCTION The purpose of this article is to review the literature related to the significance of the preceptor role in affecting retention and end-of-1-year turnover rates for newly hired registered nurses (RNs). Baggot, Hensinger, Parry, Valdes, and Zaim (2005) found that implementing a preceptor support system with focus on education and reward and recognition of preceptors resulted in decreased turnover and increased RN retention. The role of the preceptor is not a new concept. According to King and Cohen (1997), the preceptor model, originating in the United States in the late 1960s, was the internationally accepted method to progress new graduate nurses from theory to practice, thus retaining those nurses. Miller and Brosovich (1991) stated that preceptor programs could be part of the answer to increase staff satisfaction and reduce turnover. The focus of this article is to review literature related to developing the preceptor and identifying the preceptor characteristics that will ultimately result in RN retention. The desired outcome is to impact preceptor satisfaction and commitment to the role, increase retention of overall nursing staff, and decrease end-of-1-year turnover rates by building a nurse preceptor support system, providing continuing education, creating an effective means of communication among preceptors, and developing a preceptor reward and recognition system. Armitage and Burnard (1991) defined the preceptor and mentor roles in an effort to determine which one would be
Carol R. Goss, DNP, RN-BC, is System Educator, Norton Healthcare Institute for Nursing, Norton Healthcare, Louisville, Kentucky. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. ADDRESS FOR CORRESPONDENCE: Carol R. Goss, DNP, RN-BC, Norton Healthcare Institute for Nursing, Norton Healthcare, Louisville, KY (e-mail: [email protected]). DOI: 10.1097/NND.0000000000000117
the most supportive in bridging the gap between theory and practice. The distinction between the two roles defines the preceptor role as more supportive in the clinical area, with the mentor role more nurturing. Bumgarner and Biggerstaff (2000) defined the preceptor as ‘‘one who guides the new nurse in gaining knowledge and skills needed in performing patient care and teaches the roles and responsibilities of the staff nurse in the clinical setting’’ (p. 251). University of Michigan Health Care Systems reported losing over 25% of their new RN graduate staff in the first year. This turnover equated to a loss of $5,500,000 for the organization (Baggot et al., 2005). Kovner et al.’s (2007) survey of 3,266 newly licensed nurses found that nurses who are dissatisfied with the work environment are more likely to leave within the first year of practice. The Advisory Board Company (2010) is a global consulting, research and technology firm serving over 350,000 healthcare organizations; the Board estimates the cost of replacing an RN to be between $62,100 and $67,100.
REVIEW OF THE CURRENT LITERATURE A review of the literature was conducted by using EBSCO host Cumulative Index to Nursing and Allied Health Literature database. The database was searched using the Cumulative Index to Nursing and Allied Health Literature indexing term ‘‘preceptorship’’ with the key terms ‘‘job satisfaction,’’ ‘‘personnel retention,’’ and ‘‘personnel turnover.’’ The indexing term ‘‘preceptorship’’ was also used to search the database with the keywords ‘‘satisfaction,’’ ‘‘satisfied,’’ ‘‘retain,’’ ‘‘retention,’’ and ‘‘turnover.’’ The literature review produced over 200 articles related to the identifying terms. All nonresearch articles, all research articles before 2006, all articles whose tools did not describe reliability and validity, and articles with mentor or residency in the title were excluded. The final review consisted of 20 research articles (ranging from 2006 to 2012) relating to the outcomes of preceptor satisfaction and commitment to the preceptor role, increase in retention of overall nursing staff, and decrease in end-of1-year turnover rates. Each research article was graded for the quality of evidence using Polit and Beck (2008) levels for grading of the evidence and then placed in an evidence table (Titler, 2008) for evaluation (see Table 1). Five of the studies included in this systematic review were conducted outside the United States: Canada, Taiwan, New Zealand, Ireland, and Sweden. Internal review board approval was stated in all studies with the exception of Yonge et al. Validity and reliability methods were briefly described in five
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studies: Carlson et al., Haggerty et al., Hallen and Danielson (2008), Hautala et al., and McCarthy and Murphy. Carlson et al. and Hallen and Danielson gave a separate subtopic
to validity and reliability for their studies. Three studies were excluded because there were no validity or reliability methods described in the use of their tools.
TABLE 1 Quantitative and Qualitative Research Findings
Source Quantitative Research Hallin and Danielson (2008)
Purpose/Variable
Design Type/Instrument
Compare experiences Correlation between 2000 and quantitative 2006 questionnaire
Sample Size and Statistical Methods 2000 (N = 113 RNs) and 2006 (N = 109 RNs); data analyzed
& & & &
Evidence Level, Quantitative Research Level 1: Experimental Level 2: Quasiexperimental Level 3: Correlational Level 4: Descriptive Key Findings
Evidence level 3 Statistically significant improvements: & Felt prepared for role & Support from teachers, colleagues Least improvement: & Workload & Constructive feedback
Henderson, Fox, and Malko-Nyhan (2006)
Nurse preceptors’ perceptions of a 2-day workshop, organization support
Descriptive quantitative workshop, focus group interviews
N = 36 RNs, data analyzed
Evidence level 4 Potential changes in their perceptions: & Support & Education opportunities over monetary rewards
Hykas and Shoemaker (2007)
Explore relationship preceptors’ perceptions of benefits, rewards, support, commitment
Descriptive correlation, quantitative
Two subgroups, N = 82 RNs
Evidence level 4 More benefits and support perceived: & More committed to role of preceptor No significance between & Years of experience to perceptions of benefits, reward, support, and commitment
Lee, Tzeng, Lin, and Yeh (2009)
Design a preceptor program: evaluate the turnover, cost, quality of care, and professional development
Quantitative quasiexperimental research
N = 24 RNs; t test to Evidence level 2 retest satisfaction related to nursing care High turnover rate impacts: & Hospital turnover cost, patient safety, and quality of patient care Rotating staff among preceptors: & May decrease stress related to the preceptor role Continued
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TABLE 1 Quantitative and Qualitative Research Findings, Continued
Source Quantitative Research
Purpose/Variable
McCarthy and Murphy Explore preceptors’ (2010) perception of precepting nursing students
Design Type/Instrument Descriptive quantitative questionnaire
Sample Size and Statistical Methods
Evidence Level, Quantitative Research Level 1: Experimental Level 2: Quasiexperimental Level 3: Correlational Level 4: Descriptive Key Findings
& & & &
N = 970 distributed, Evidence level 4 N = 470 return; Preceptor and student issues: content analysis and descriptive & Time, contact, failing students Role issues: & Preparation, stress, limited support, recognition
Tremblay, Paquet, Marchionni, and Drevniok (2011)
Investigate which domains of nursing proactive work environment influence the intent to leave a job among Generation Y of new nurses
Correlational and descriptive quantitative practice environment scale of the nursing work index
N = 145 RNs, univariate analysis of variances
Evidence levels 3 and 4 No difference found: & Generations of nurses relating to intent to quit Orientation and preceptorship programs: & That extend beyond a few weeks, key to retaining nurses
Source Qualitative Research Bourbonnais and Kerr (2007)
Carlson, Pilhammar, and Wann-Hansson (2009)
Design Type/ Instrument
Purpose/Variable
Sample Size and Statistical Methods
Personal reflections on being a preceptor; support/challenges to preceptor role
Qualitative one-on-one tape-recorded interviews
N = 8 interviewed, thematic analysis
Describe conditions for precepting in a Swedish clinical from the perspective of the nurse
Ethnographic qualitative participant observation and focus groups
N = 13 teaching wards
Evidence Level, Qualitative Research & Level 1: Ethnographies & Level 2: Phenomenology & Level 3: Grounded Theory Key Findings Evidence level 2 Role challenges: & Lack of recognition, support highlights: support, recognition Evidence level 1 Supportive conditions: & Organization, collaboration, personal perspective Limiting conditions: & Allocated time to precept Continued
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TABLE 1 Quantitative and Qualitative Research Findings, Continued
Source Qualitative Research Danielson, Sundin-Anderson, Hor, and Athlin (2009)
Purpose/Variable Determine how group supervision influences preceptors’ view of their role and their valued participation
Design Type/Instrument Qualitative self-reported open-ended questionnaire
Sample Size and Statistical Methods N = 48 RNs
Evidence Level, Qualitative Research & Level 1: Ethnographies & Level 2: Phenomenology & Level 3: Grounded Theory Key Findings Evidence level 2 Role satisfaction: & Continuous development, being acknowledged, confirmed Demands of preceptorship: & Difficult students, lack of time, smaller groups, role perception, and group supervision
Haggerty, Holloway, and Evaluate nurse entry to Wilson (2012) practice, key focus preceptorship supported
Ethnographic qualitative questionnaires, key stakeholders, and case studies
N = 21, longitudinal Evidence level 1 evaluation of entry National guidelines for practice programs preceptor selection and education: & Recommended for national adoption through council of New Zealand
Hautala, Saylor, and O’Leary-Kelly (2007)
Describe staff nurses’ perception of stress and support
Descriptive exploratory questionnaire, qualitative
N = 65 RNs, coding Evidence level 3 and grouped into Acknowledged precepting themes stressful: & Related to workload, time
Liu, Lei, Mingxia, and Haobin (2010)
Explore clinical preceptors’ experience and meaning of their lives in clinical teaching
Phenomenology, qualitative audio-taped individual reviews
N = 20 RNs, clinical Evidence level 2 preceptors Positive aspects: & Personal satisfaction, knowledge, skill improvement, respect from others Negatives: & Lack of formal recognition, excessive workload
Luhanga, Dickerson, and Explore and describe Massey (2010) preceptor support and development
Phenomenology, qualitative individual/group interviews
Evaluation, preceptor, Evidence level 2 resource manual Identified the need for: & Effective communication, clearer role expectation, reduced workloads, and time Continued
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TABLE 1 Quantitative and Qualitative Research Findings, Continued
Source Qualitative Research
Purpose/Variable
Design Type/Instrument
Sample Size and Statistical Methods
Evidence Level, Qualitative Research & Level 1: Experimental & Level 2: Quasiexperimental & Level 3: Correlational Key Findings
Omansky (2010)
Describe the staff nurses’ experience of preceptoring/ mentoring nursing students
Integrative review, qualitative
N = 20 research and Evidence level 1 10 nonresearch Recommendation for managers: articles from 1981 to 2009 & Decrease patient assignments, allocate teaching time, ongoing education, recognize, support
Schumacher (2007)
Explore caring interactions and, if caring is perceived, what does that mean
Phenomenological qualitative reflective journals and in-depth interview
N = 10 new graduate Evidence level 2 RNs, Colaizzi To retain nurses: method of analysis & Positive interaction, positive relationships Caring behaviors decrease: & Anxiety, fear, and stress and increase retention
Warren and Denham (2010)
Zinsmeister and Schafer (2009)
Discover evidence preceptor orientation, impacts student outcomes
Qualitative literature review
Explore the lived experiences of graduate nurses during the first 6Y12 months of employment: insight into transition phase
Phenomenology, qualitative interview
N = 13 research articles from 1990 to 2007
Evidence level 1 Most impact: & Preceptor preparation, orientation, and support
N = 9 new graduate Evidence level 2 RNs interviewed, Supportive work area: four levels of coding used & Positive preceptor experience, comprehensive orientation, sense of professionalism Clarity of role expectation & Preceptors assisted to develop the skills to work with new graduates Organization shows commitment & Providing opportunities and support to retain staff
Source Quantitative and Qualitative Research Park and Jones (2010)
Purpose/Variable Orientation program
Design Type/ Instrument Integrative review, quantitative and qualitative
Sample Size and Statistical Methods N = 17 published reports
Evidence Level Key Findings Evidence level 1 Competency of new graduate nurses: & Increased with one-on-one preceptor Continued
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TABLE 1 Quantitative and Qualitative Research Findings, Continued Source Quantitative and Qualitative Research Yonge, Hagler, Cox, and Drefs (2008)
Purpose/Variable Focus on identifying needs/expectations of preceptor preparation, role, stress, and support needed
Design Type/Instrument Quantitative and qualitative mailed survey
Sample Size and Statistical Methods N = 86 RNs; quantitative data analyzed using SPSS, qualitative data analysis using a coding scheme
Evidence Level Key Findings Evidence level 2 Influence to continue: & Recognition, benefit, negative experience with orientee Influences success need for: & Adjusted workload, preparation for the role, benefits, rewards
Of the 20 studies reviewed, 12 studies relating to the outcomes of preceptor satisfaction and commitment focused on the preceptor’s need for support and recognition in relation to commitment and satisfaction. Only one study measured actual commitment to the preceptor role. Two studies measured overall satisfaction with precepting. Review of the literature related to increase in overall nursing staff retention and decrease in end-of-1-year turnover rate resulted in three decreased turnover and increased retention-related studies; three retention-related studies; and one recruitment, support, and retention-related studies.
Satisfaction and Commitment The theme throughout the literature review, in reference to satisfaction and commitment, focused on support and recognition of the preceptors to sustain satisfaction in the preceptor role. Hykas and Shoemaker (2007) found a significant correlation (r = .42, p = .01, N = 82) between perception of support to the preceptor role and increased commitment when benefits were available. A study conducted by Liu et al. (2010) identified four themes to describe the experience of the clinical preceptor: ‘‘teaching is learning; being unable to do what one would like to do; experiencing bittersweet moments; and being a role model and acting as a mother’’ (p. 806). Clinical preceptors view personal satisfaction, respect from colleagues, and continued education as positive aspects of precepting. However, lack of recognition, insufficient time to role model, and stress related to workload were viewed as negative aspects of precepting (Hallen & Danielson, 2008; Hautala et al., 2007). Eight of the 13 studies concluded that preceptors perceive benefits and rewards as supportive to the preceptor role (Bourbonnais & Kerr, 2007; Carlson et al., 2009; Danielson et al., 2009; Hykas & Shoemaker, 2007; McCarthy & Murphy, 2010; Omansky, 2010; Warren & Denham, 2010; Yonge et al., 2008). Henderson et al. (2006); Wilson, Bodin, Hoffman, E12
and Vincent (2009); and Luhanga et al. (2010) further concluded that communication and educational opportunities are supportive to the preceptor role. All but three studies identified increased workloads and lack of time to precept as a barrier: Henderson et al., Wilson et al., and Liu et al. (2010).
Decreased Turnover The theme throughout the literature review, in relation to decreased turnover and increased retention, focused on the need for preceptor programs and the impact preceptors have on the overall nursing staff retention rate and decreased turnover. A study by Lee et al., using a quasiexperimental research design, evaluated the outcome of a preceptorship program and the program’s effect on turnover rate, cost, professional development, and quality of patient care. Twentyfour nurse preceptors and 34 new nurses participated in the study. After program completion, study results showed a decrease in turnover rate of 46.5% at a cost savings of $186,102 when compared with the previous year. Study results showed a 50% decrease in medication errors made by new nurses, a decrease in falls at the time of the study (from 52 falls the previous year to 43 falls), and a decrease in incidents with adverse effects (from 65 incidents the previous year to 52 incidents). Overall satisfaction of patient care, in comparison with the previous year, was not statically significant (t = 0.382, p Q .05). When compared with the previous year, however, the results of the descriptors ‘‘attitude of the nursing staff (t = 2.772, p G .01), privacy of the patient (t = 2.550, p G .05), maintaining tranquility of the wards (t = 2.741, p G .01), and instantaneous feedback of questions and needs to the medical doctor (t = j2.305, p G .05)’’ (p. 1221) were significantly improved. The 34 new nurses measured their satisfaction with the preceptor by completing a 20-item questionnaire based on a 4-point Likert scale to evaluate the performance of their preceptor. Satisfaction scores ranged from 3.15 to 3.44. Preceptors measured their satisfaction with professional development
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by completing a modified scale from Dilbert and Goldenberg’s (1995) 20-item preceptor perception questionnaire, also based on a 4-point Likert scale. Preceptor satisfaction scores ranged from 2.85 to 3.32. Preceptors experience job dissatisfaction, express feelings of being overwhelmed, and describe ultimate burnout (Lee et al., 2009). Park and Jones’ (2010) integrative review of 17 research studies evaluated the outcome of new graduate nurses who attended a structured orientation, residency, or internship programs with one-on-one preceptors. The data supported the concept that those receiving this in-depth orientation were more confident, more competent, and less likely to leave the profession. Qualified educated preceptors were identified as key to a successful preceptorship experience. The outcome of this systematic review resulted in the development of selection criteria for preceptors and a preceptor education program. The top selection criteria included leadership and communication skills, clinical competency, and professional development. The outcome of the preceptor program focused on ‘‘confidence, competency and retention’’ (p. 148). Tremblay-Lavoie et al. (2011) studied 150 new graduating nurses using an online survey to identify what influenced new graduate nurses to leave in the first year of practice. Study results showed that 49% (n = 71) of the respondents intended to leave their current position and 9.7% (n = 71) of the respondents intended to leave the nursing profession altogether. Reasons identified as statistically significant in influencing new graduate nurses to leave in the first year were ‘‘nurse participation in hospital affairs,’’ p e .05, ‘‘nursing foundations for quality care,’’ p e .01, and ‘‘collegial nurseY physician relations’’ p e .01 (p. 42). Study findings stressed the need for orientation and preceptor programs as essential elements in providing new graduates with supervision to develop their roles in providing quality patient care and decreasing turnover.
Retention In a qualitative study using journals and interviews, Schumacher (2007) examined the caring behaviors between new graduate nurses and preceptors during the course of orientation and the perceptions of the new graduate nurses in relation to the caring behaviors. New graduate nurses journaled daily; their instructions were to describe why they felt cared for by their preceptors and why they did not feel cared for by their preceptors. Additional data were collected from individual interviews with the new graduate nurses. Caring behaviors perceived were being welcomed as part of the staff and preceptors being physically present and open to questions. Noncaring behaviors perceived were preceptors not being present, preceptors not being open to questions, and not allowing new graduate nurses to function on their own. Results of the study (which identified both caring and noncaring behaviors) were evident during the course of orientation. Implications from this study were used
to design preceptor programs that teach caring behaviors to preceptors working with new graduate nurses. Preceptors educated in the caring behaviors, and who modeled the caring behaviors in practice, assisted the new graduate nurses in implementing caring behavior into patient care. Displaying caring behaviors has been shown to build trusting relationships, helping to decrease the anxiety levels of the new graduate nurse and improving staff retention. Studies by two research groups (Salt et al., 2008; Zinsmeister & Schafer, 2009) concluded that preceptor programs impact retention of new graduate nurses. Salt et al. found that the highest retention rates of new graduate nurses were directly linked to programs that had a 3- to 6-month preceptor program in place. The study categorized four retention strategies: externship pregraduation, new graduate nurse preceptor program, needs-based orientation, and preceptor programs with focus on supporting the preceptors in their role. Study results strongly suggested that merging the preceptor program model for new graduate nurses with the preceptor program for preceptors was the best strategy for new graduate nurse retention. Zinsmeister and Schafer (2009) explored the experience of new nurses’ transition in their first year of practice to identify aspects that would be most helpful in their transition and increased retention. Study findings from interviews with nine new graduate nurses were coded into five themes that reflect success in the preceptor program: ‘‘supportive work area, positive preceptor experience, comprehensive orientation process, sense of professionalism, and clarity of role expectation’’ (p. 30). Study results reflected the important role preceptors have in the positive transition and retention of new graduate nurses. Haggerty et al. (2012) conducted a 3.5-year evaluation of New Zealand’s nursing practice programs. A key focus of the evaluation was directed to preceptor support. Results of the surveys found inconsistencies in preceptor selection and education. Preceptors reported a lack of clarity regarding their roles and responsibilities and voiced their concerns of an increased workload while precepting. Study findings concluded that the best practice occurred when preceptors were selected, educated, and supported in their role. The study resulted in a recommendation from the New Zealand Board of Health to establish national standards for preceptor selection and education.
DISCUSSION AND CONCLUSION Study findings from this systematic review provided information that preceptors need continuing education to enhance their teaching, knowledge, and procedural techniques and that these refined skills play an integral role in new graduate nurse retention. Support of administration is vital to assist the preceptor by providing continuing education resources and displaying appreciation or recognition through tangible or intangible rewards.
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Findings from this systematic review support the need for formal preceptor programs with selection criteria, education requirements, roles and responsibilities defined, and preceptor reward and recognition. Improvement in preceptor satisfaction and commitment to the preceptor role and increased retention of overall nursing staff are supported by the findings of this systematic review; when the preceptor programs are 3Y6 months in length, preceptors are paid to attend preceptor education programs, and new graduate nurses define their preceptor needs. The impact of insufficient time and preceptor workload on the preceptor role identified in this systematic review needs further study to determine the outcome on preceptor satisfaction and retention of nursing staff. However, findings from this systematic review do indicate a significant association between the preceptor commitment to the preceptor role and the preceptor perception of rewards and benefits. Findings reported from this systematic review to the administrative staff of five multihospital system increased awareness for the need of preceptor programs and the importance of reward and recognition. The design and implementation of a standard preceptor model for a five multihospital system are in process. In addition, a preceptor Web site was developed with a preceptor blog, information to preceptor continuing education programs, a preceptor research library, quarterly newsletter, preceptor toolkit, and reward and recognition information.
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