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• To appreciate that effective preceptorship may play an important role in nurse retention
• To understand the factors that can influence the effectiveness of preceptorship programmes
• To enhance your awareness of the characteristics of effective preceptors
The ageing population and the rising prevalence of long-term conditions have placed higher demands on primary care services, with practice nurses managing increasingly complex patient needs. As a result, there is a need to focus on improving the retention of primary care staff, including practice nurses, and to consider how effective preceptorship could assist in addressing some of the issues that cause newly registered nurses to leave the profession. This article discusses various factors that can influence the effectiveness of preceptorship programmes, including transition shock, emotional strain, the education-practice gap, the characteristics of preceptors and feedback.
Primary Health Care. doi: 10.7748/phc.2022.e1782
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Butler S (2022) Exploring how preceptorship could improve the experiences of newly registered nurses transitioning into primary care. Primary Health Care. doi: 10.7748/phc.2022.e1782
Published online: 26 October 2022
• Newly registered nurses (NRNs) may be more susceptible to the emotional strain associated with their role than experienced colleagues
• NRNs can experience transition shock while adapting to the change from student to registered nurse
• Preceptorship programmes for NRNs can support the transition from nursing student to registered nurse
• Effective preceptorship includes enabling the NRN to feel part of the team and bridging the gap between nurse education and clinical practice
• Preceptors should be informed about what is expected of them so that they can support NRNs effectively
Nursing and Midwifery Council (NMC) (2021) guidance states that all newly registered nurses (NRNs) should have a preceptorship, defined as a period of support for people who have joined the register to aid their transition from student to registered nurse. However, despite this guidance, preceptorship in primary care settings is an under-researched area in the UK, with much of the available research from international studies (Halpin 2015). There are differences in the programmes offered to NRNs worldwide. For example, those in the US are offered a nurse residency programme to assist with transition, which focuses on leadership, patient outcomes and professional development (Collard et al 2020), while those in Australia are offered GradConnect, which aims to assist NRNs to transition into a supportive work environment, enabling consolidation of theory and the development of clinical skills and judgement (Government of Western Australia Department of Health 2022).
Due to the ageing population and the rising prevalence of long-term conditions, demand on primary care services has increased, and practice nurses are frequently managing increasingly complex patient needs (Carrier and Newbury 2016). A major issue in the nursing workforce across primary and secondary care settings is staff shortages. It has been established that many NRNs leave the profession or leave their first post within less than 12 months (Edwards et al 2015). In London, the Capital Nurse scheme highlighted that 20% of NRNs leave within their first year (House of Commons Health Committee 2018), while across the UK this figure could be as high as 30-60% (Lydall 2021). Between March 2020 and September 2020, a total of 11,615 nurses, midwives and nursing associates left the NMC register (NMC 2020a). A survey conducted by the NMC (2020b) before the coronavirus disease 2019 (COVID-19) pandemic found that, after retirement, the second most cited reason for leaving the register was too much pressure, leading to stress and/or suboptimal mental health. Contributory factors included high expectations, the pressure of responsibility and the high volume of work (NMC 2020b). Effective preceptorship may have an important role in retaining NRNs.
The NMC (2020c) established five main principles for preceptorship, which can assist healthcare organisations to develop effective programmes for NRNs:
• Organisational culture and preceptorship – preceptorship programmes should immerse preceptees into their role and into the ways of working and the culture of their new workplace.
• Quality and oversight of preceptorship – preceptorship programmes should be viewed as important in the organisation and there should be evidence of management of the process, as well as evaluations of their efficacy and outcomes.
• Preceptee empowerment – preceptorship programmes should be tailored to the preceptee’s new role and the healthcare setting. They should also recognise and support the needs of preceptees to develop confidence in their role.
• Preparing preceptors for their supporting role – preceptors should receive appropriate preparation to understand and undertake their role.
• The preceptorship programme – preceptorship programmes should take account of the setting in which the preceptee is working and providing care.
In addition to following these principles, healthcare organisations and professionals should consider factors that can influence the effectiveness of preceptorship programmes. This article discusses some of the main factors, including transition shock, emotional strain, the education-practice gap, the characteristics of preceptors, and feedback.
Many NRNs experience a phenomenon known as ‘transition shock’ during their progression from nursing student to registered nurse (Clipper and Cherry 2015, Wakefield 2018). Transition shock is believed to occur when an NRN learns what is expected of them as a registered nurse and encounters the increased responsibility, accountability and pressure associated with their new role.
It is believed that the first 12 months after registration are associated with the most clinical errors (Martin and Wilson 2011). Even for experienced nurses, making a clinical error will often adversely affect confidence. For NRNs already experiencing transition shock, errors they make could profoundly affect confidence and their desire to continue as a nurse (Ortiz 2016). Preceptorship programmes need to acknowledge the risk of transition shock and enable preceptors to offer support and assistance in developing NRNs’ confidence and competence within the clinical area (Innes and Calleja 2018).
Undertaking any new role can be challenging – particularly in nursing, which has been described as a strenuous job with complex requirements, often resulting in little authority and too much responsibility (Sarafis et al 2016). There is a possibility that the issue of nurses having little authority and too much responsibility is more common in primary care settings and in the role of practice nurse than in secondary care settings and roles (Roberts 2016). The author suggests that this may be because the level of autonomy required in many primary care roles is often higher, indicating differing levels of responsibility and authority.
Practice nurses require a variety of skills, including adaptability, case management and autonomous working. Due to the nature of primary care, a detailed induction and a preceptorship programme are recommended for those new to the setting – whether that be NRNs or experienced nurses working in a new area for the first time – with the aim of mitigating transition shock and subsequently improving retention (NMC 2020c).
It is important to recognise that the process of transitioning from nursing student to registered nurse can lead to a range of emotions, with many NRNs reporting feelings of stress, cynicism and anxiety directly related to their change in role (Duchscher 2009). These emotions, accompanied by the stark reality of being held professionally accountable, can result in significant emotional strain (Barrett 2020).
For NRNs who leave their role or the profession within 12 months of registering, job dissatisfaction and stress have been identified as contributing factors (Edwards et al 2015). While the NHS is one of the world’s largest employers, it faces a potential workforce crisis due to the high number of vacancies and staff turnover (Worsley 2019), so there needs to be a focus on retaining staff. It is not always possible to protect all nurses against the emotional strain associated with being a nurse (Kinman and Leggetter 2016). However, support should be available to help all nurses cope with these emotions, particularly for those who are newly registered. It is not only NRNs who will require emotional support – experienced nurses will need this too but additional support may be necessary when nurses start their career. Therefore, when a nurse starts a new role or employment period, support in managing emotions and stressful situations should be a crucial component of their induction and preceptorship programme to help them adapt.
Nursing is often highly stressful, and this can be harmful to the development of an NRN if they do not receive the appropriate level of emotional support (Lipley 1998, Royal College of Nursing 2015). While nursing is known as a caring profession, and nurses frequently demonstrate care and compassion to patients, it has only been in recent years that has there been an increased focus on providing emotional support to nurses themselves (Schoenly 2016, Katugampola 2021). In March 2021, during the COVID-19 pandemic, NHS England (2022) launched the Professional Nurse Advocate programme to provide nurses with skills to facilitate restorative supervision to their colleagues and teams. This is the first programme of its kind for nursing, although midwives have been using a version of it for some time and have reported positive outcomes (NHS England 2022). Incorporating this role into a structured preceptorship programme could promote a nursing culture in which colleagues are emotionally supported.
Effective preceptorship programmes are important to protect NRNs against emotional strain during the first 12 months of their registration, and have been shown to have positive long-term effects on their confidence, readiness and retention (Woodruff 2017). This must be a goal of healthcare organisations and the NHS, given the current climate and high number of nurses leaving the register.
There is a debate about whether nurse education programmes are adequately preparing nursing students for the role of registered nurse or whether students are overly protected from the realities of the profession (Clipper and Cherry 2015, Salifu et al 2019).
The practice nurse role involves working autonomously, seeing patients ranging in age from infants to older people, and with complex conditions such as respiratory diseases and diabetes mellitus. At present, university nurse education programmes often focus on secondary care, with most clinical placements based in hospital settings (Lewis et al 2019) because of the limited availability of primary care placements. Consequently, NRNs who choose to work as practice nurses have limited exposure to the role, and so may lack understanding of how general practice works (Lewis et al 2019). Therefore, it is essential that they receive structured training and support throughout their induction and preceptorship, and undertake continuing professional development throughout their careers, so that they can develop the fundamental skills required of a practice nurse.
Nursing is a constantly evolving and evidence-based profession, with nurses encouraged to continuously develop and learn throughout their careers. In the UK, the importance of continuing professional development and lifelong learning has been emphasised by the NMC (2021) revalidation requirements and the introduction of nursing as an all-degree profession in 2009 (Shepherd 2009). This ensures that all nursing students are educated within universities, which provides them with evidence-based theory as a basis for their practice, preparing them to deliver high-quality patient care and to lead and influence healthcare services, delivery and policymaking.
Nursing students commonly encounter various challenges during their clinical placements, such as ineffective communication and inadequate readiness (Jamshidi et al 2016), which can prevent them from understanding and experiencing all the necessary elements of the role of a nurse. As a result, nursing students will not fully understand and experience the role of a nurse until they join the NMC register. Therefore, it is essential to narrow the gap between education and practice to reduce the difference between the role of nursing students and practice nurses, and to facilitate a smooth transition from student to registered nurse (Quek and Shorey 2018, Salifu et al 2019).
The transition from nursing student to registered nurse can be facilitated by an involved and willing preceptor who provides a strong basis for an effective preceptorship programme (Phuma-Ngaiyaye et al 2017). Preceptorship is intended to facilitate learning, set achievable goals and encourage development, and it is essential that all preceptors have the characteristics required to do so.
According to Underdown (2018), a preceptor should be a nurse who has had at least 12 months’ experience of practising in the clinical area. However, it is worth considering whether this is sufficient time for nurses to consolidate their learning and experience in a specific area before supporting NRNs. Preceptors require an appropriate level of knowledge and expertise to provide effective preceptorship to NRNs (Baldwin et al 2020), and 12 months may be insufficient time for a nurse to achieve this.
Box 1 shows Benner’s (1982) five stages from novice to expert. In this model, the ‘novice’ stage is aligned with nursing students while they are undertaking their undergraduate education programmes. A novice is someone with no professional experience, so many nurses start their careers as a ‘beginner’ and can develop through the subsequent stages, although not all nurses will pass through all five stages. Working in a particular clinical area can, over time, enable a nurse to develop competence in that area, but not necessarily expert status (Benner 1982). This suggests that 12 months is insufficient time for nurses to move from the beginner to expert stage, so while they could be proficient and competent in working as a preceptor, they may lack expertise in some areas.
• Novice – nursing students
• Advanced beginner – newly registered nurses in their first roles
• Competent – nurses who can recognise patterns and the nature of clinical situations more quickly and accurately than advanced beginners
• Proficient – nurses who can see the whole situation and learn from experience
• Expert – nurses who have an intuitive understanding of the situation based on deep knowledge and experience
(Adapted from Benner 1982)
It could be suggested that nurses who have been registered for less time may be more supportive than those who have been registered for longer, because they can more easily recall how it felt when they first joined the register. However, since there is no formal framework for nurses to follow regarding preceptorship, there is also no quality assurance that these nurses receive adequate training and are competent to act as preceptors.
Preceptors should be working in the same specialty as their preceptee, but this may not always be possible. For example, larger GP surgeries are likely to have access to a range of staff with the necessary skills to act as preceptors, whereas in single-handed GP surgeries that have only one principal doctor may be limited staff available who can take on this role.
The main duty of the preceptor is to ensure patient safety while the NRN develops their clinical knowledge and experience (Powers et al 2019). Preceptorship should be a time for NRNs to safely develop their existing skills and acquire specific skills for their role, with confidence that they have an expert from whom they can seek assistance where necessary. It is widely understood that NRNs are not expected to know everything and that nurses continue to learn throughout their careers. It is crucial to recognise this as most NRNs do not possess the skill set needed to work as a competent practice nurse immediately after registering. Therefore, they need to observe and shadow a competent and experienced nurse to learn the necessary skills, which can be included as part of their preceptorship.
Preceptors should be adequately informed about what is expected of the role so that they can support NRNs effectively (Skelley 2018). Nurses need to be prepared for the role of preceptor (Casey et al 2004, Bowles and Candela 2005, Leigh et al 2005, NMC 2020c); however, there is little information available about what this preparation should entail.
Enthusiasm and the requisite skills for the role are crucial to the delivery of effective preceptorship (Forneris and Peden-McAlpine 2009, Bengtsson and Carlson 2015). Therefore, nurses should be encouraged rather than mandated to take on the preceptor role. Insisting that all nurses become preceptors could lead to inconsistencies in their leadership, as well as discontent and pessimism among those who do not wish to take on this role (Jönsson et al 2021). Nurses who are not interested in becoming preceptors but are made to do so can negatively affect the development of NRNs (Washington 2013). Therefore, it is preferable for NRNs to work with nurses who are motivated to act as preceptors to support their transition.
While there is no clear consensus on how long the preceptor’s role should be for (Skelley 2018), Underdown (2018) has suggested it typically lasts for 4-12 months. This means that preceptors usually spend a period of several months with an NRN before acting as a preceptor for another NRN. This can cause issues for both the preceptor and the preceptee in terms of support. Some preceptors may feel like there is a ‘revolving’ process, as they work with an NRN to familiarise them with the clinical area, then have to start the process again when another NRN joins, often without a break in between. Doing so can add unnecessary stress to the preceptor, particularly if they do not want the role. Furthermore, since there is no specific training required to act as a preceptor, the role is sometimes not fully understood or appreciated (Nottingham 2015).
Preceptors should be knowledgeable and supportive since this is essential to retaining nurses in their roles for longer (Barrett 2020). NRNs need to feel a sense of belonging and working with a supportive preceptor can engender this and make NRNs feel part of the team (NMC 2020c).
Many NRNs have described conflicts with their preceptors due to personality differences, or spending insufficient time with their preceptor because of rota issues and staffing shortages (Wain 2017). Personality and age differences between preceptors and preceptees can lead to unsuccessful preceptorships. As NRNs are typically younger in age, it is likely that they will be working with nurses older than themselves when they enter the profession. This age disparity could lead to unsuccessful preceptorships due to differing ideas about nursing. Experienced nurses may hold certain values and traditions that are deep rooted in their role, whereas younger nurses entering the workforce may bring with them different perspectives, values and expectations, potentially leading to conflict between generations (Minnis 2004).
It is also possible that NRNs’ nursing colleagues may not hold a degree in nursing because it did not become an all-degree profession until 2009 (Shepherd 2009). This could cause concern that those who do not hold a degree or do not believe that a degree is warranted for nursing could view those nurses with such a qualification unfavourably and place higher expectations on them, which could lead to nurses opting to leave their role or even the profession.
NRNs need to receive regular feedback to support their professional development and to enhance their practice (Richards and Bowles 2012). When nurses receive support and adequate feedback, their confidence and job satisfaction increase and patient outcomes improve (Hardavella et al 2017). In contrast, a lack of feedback could lead to errors during the transition from NRN to competent nurse (Ende 1983, Gardiner and Sheen 2017). If NRNs do not receive feedback, they may assume that what they are doing is correct, even if it is not, and will continue to practise in the same way (Hardavella et al 2017). This can negatively affect NRNs because they may develop a false perception of their skills, so subsequently make mistakes and undertake tasks that are beyond the limits of their competence.
Providing effective feedback, particularly constructive feedback, can be challenging and is a skill that is not possessed by everyone (Duffy 2012). If delivered inappropriately, constructive feedback may be perceived as negative because it is usually focused on promoting a change in behaviour. Preceptors or other colleagues may also miss opportunities to give positive feedback or do not provide it in a timely manner, leaving NRNs unsure about whether they have met expectations and potentially leading to them becoming demoralised. Therefore, the ability to provide effective feedback is an essential skill that preceptors need to develop.
The documents in the further resources section provide information about the actions nurses can take to implement and support effective preceptorship in their practice.
All nurses are subject to multiple stresses due to the demands of the profession (Sarafis et al 2016), but those who are newly registered may be more susceptible to the emotional strain associated with their role. NRNs, including those who work as practice nurses, can experience transition shock while adapting to the change from student to registered nurse.
Preceptorship programmes are recommended to ease this transition (NMC 2021). For preceptorship to be effective, it is necessary for the preceptor to enable the NRN to feel part of the team and to bridge the gap between nurse education and clinical practice (Quek and Shorey 2018). Preceptors should also understand the emotions that NRNs are likely to experience during the first 12 months of their registration and how to support them in developing the skills required to be an effective practice nurse.
Royal College of Nursing – NMC: preceptorship
www.rcn.org.uk/Get-Help/RCN-advice/nmc-preceptorship
Capital Nurse – Preceptorship framework
www.hee.nhs.uk/sites/default/files/documents/CapitalNurse%20Preceptorship%20Framework.pdf
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