CPD
Page 57
Preceptorship multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
Page 60
Read Anita Skinner’s practice profile on atrial fibrillation
Page 61
Guidelines on how to write a practice profile
Successful preceptorship of newly qualified nurses NS722 Price B (2013) Successful preceptorship of newly qualified nurses. Nursing Standard. 28, 14, 51-56. Date of submission: May 31 2013; date of acceptance: August 20 2013.
Abstract There is widespread recognition that many newly qualified nurses find it difficult to make the transition from completing their university course to taking up their first registered nurse post. Preceptorship programmes during the first year of registered nurse practice have been recommended by the Department of Health. Preceptors have an important role in ensuring successful transition of the newly qualified nurse; however they also require practical guidance on how best to support the nurse. This article identifies aspects that need to be considered when guiding a registered nurse colleague rather than a student. Preceptorship concerns four main areas: orientation to patients and services provided locally, real-time clinical reasoning, skill review and refinement, and socialisation within the healthcare team. The article will explore each of these areas.
Author Bob Price Director, postgraduate qualifications in advancing healthcare practice, Faculty of Health and Social Care, The Open University, Milton Keynes. Correspondence to: [email protected]
Aims and intended learning outcomes The aim of this article is to assist preceptors to support newly registered nurses to adjust to role transition from student to qualified nurse. After reading this article and completing the time out activities you should be able to: Review the current strategy for working as a preceptor with newly qualified nurses in your place of work. Inform newly qualified nurses of local patient requirements, and important service processes and challenges. Support newly registered nurses to practise real-time clinical reasoning. Assist newly qualified nurses to reflect on their practice skills, identifying those skills that cause anxiety. Provide supportive consultation opportunities that assist the newly qualified nurse to feel part of the interdisciplinary team.
Keywords Clinical reasoning, education, guidance, preceptors, preceptorship, registered general nurses, role transition, skill development
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
© NURSING STANDARD / RCN PUBLISHING
Introduction While efforts continue to ensure that pre-registration nurse education equips students to become confident practitioners (Dreifuerst 2012), there is evidence that newly qualified nurses report difficulty in making the transition from student to qualified nurse in clinical practice (Hole 2009, Bjerkes and Bjørk 2012, Allnurses.com 2013). The Department of Health (DH) (2010) also recognises that this transition can be challenging. Nurses often struggle with the pace of reasoning that they have to engage in, and the level of engagement with patients and services that is required of them. december 4 :: vol 28 no 14 :: 2013 51
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD professional issues
1 What do you think preceptorship entails? Discuss with colleagues the type of learning that is most appropriate for newly qualified nurses and how you can provide such learning opportunities. 2 Refer to Box 1 and identify ways in which the preceptor supports, guides and reassures the newly qualified nurse. Review what other preceptorship support is available within your healthcare trust, for example study days, workshops, videos and audio case studies for discussion, and whether this meets the needs of nurses.
Duchscher (2009) referred to the ‘transition shock’ that nurses experience as they realise that they are professionally accountable for their actions and need to rapidly become acquainted with care responsibilities locally. Harrison-White and Simons (2013) observed that difficulty in transition is exacerbated in the current climate of economic recession, where there may be fewer nurses to guide newly qualified nurses and staff have additional responsibilities. Myrick et al (2011) described the transition to registered nurse practice as one that requires additional practical wisdom about the best ways to operate. Much of this is not readily learned at university, and cannot be attained solely through theory and principles. The nurse needs to acquaint him or herself with local practice requirements and preferred ways of working. In many instances, nurses are not only making a transition from student to registered nurse, but from a familiar care environment to a less familiar one (Ellis and Chater 2012). While all nursing students are required to be active learners, Chandler (2012) emphasised the particular need for nurses to be inquisitive and well organised in their first year of practice following registration, referring to this as ‘appreciative inquiry’. Yonge et al (2013) explained that the transition is then sometimes one of acclimatisation – becoming familiar with the care context and local expectations. In 2010, the DH published the Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals. This document identifies the importance of preceptorship in maintaining quality care standards and the retention of nurses post qualification. The document defines the preceptor as a: ‘registered practitioner who has been given formal responsibility to support a newly registered practitioner through preceptorship’ (DH 2010). However, healthcare trusts have been asked to develop their own preceptorship programmes, working with national knowledge and skill requirements (NHS Employers 2010). Preceptors may be uncertain about how they might best perform their role and how preceptorship differs from mentoring a student, especially with limited time available. Preceptorship does not involve the same assessment activity as that involved in mentoring nursing students. It is a ‘lighter touch’ in that it starts from a premise of what students have already achieved in their pre-registration course, it does not include
52 december 4 :: vol 28 no 14 :: 2013
formal assessments as other courses might and it is more facilitative, involving working with the newly qualified nurse’s perceived deficits and needs. It also requires an understanding of what it is like to begin work as a qualified nurse. Preceptorship requires a coherent structure (Harrison-White and Simons 2013), and focuses on the socialisation of newly qualified nurses into the interdisciplinary team. Complete time out activity 1
Preceptorship The DH (2010) states that preceptorship should not replace mandatory training programmes, for example on infection control; that it is not a form of performance management; that it is not formal coaching, although coaching skills are employed; and that it is not a grace period during which the preceptor takes responsibility for the nurse’s actions. The registered nurse is professionally accountable for his or her own actions. Preceptorship is not mentorship or clinical supervision, nor does it replace induction programmes arranged for new staff. Preceptorship is subtly different and arguably akin to the work of a research consultant. Like the research consultant, the preceptor provides support for the ongoing learning of others who are conducting their own enquiries, in this instance into what local care requirements and practices are and how well the nurse’s skills match these. The preceptor is not an instructor and he or she assists and facilitates, rather than dictates, learning (Box 1). Advice given by the preceptor focuses on the nurse’s own reflections and developing insights, and any needs that might arise. It also links to wider preceptorship programmes provided in the form of workshops, study days, seminars or guided forms of study arranged within the healthcare trust. Complete time out activity 2 The DH (2010) explains that preceptors are expected to: Help nurses fulfil their potential. Demonstrate an appropriate attitude towards continuing learning. Discuss practice with the newly qualified nurse, sharing knowledge and experience. Work empathetically with the newly qualified nurse. Act as an exemplary role model. Work with corporate initiatives to develop knowledge and skills as detailed within the
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
BOX 1 Role of the preceptor The nurse is helped to prepare a plan of action, which helps him or her to enquire about his or her new practice. Planning typically centres on care requirements, perceived skills already mastered and any deficits remaining. It attends to local protocols, policies and organisational systems that assist the delivery of care. The preceptor links what he or she does with the newly qualified nurse to other support provision within the preceptorship programme and the wider care team, avoiding duplication of support and wasted resources. The preceptor agrees a series of meetings with the newly qualified nurse to identify enquiries and address issues that have arisen. The meetings are appropriately spaced, leaving the nurse personal enquiry responsibilities in between – weekly meetings are recommended in the first month and monthly meetings for the remainder of the year. The preceptor explores which skills the newly qualified nurse is anxious about. The nurse may be invited to shadow the preceptor in some practice or the nurse may demonstrate the skill and receive immediate constructive feedback from the preceptor. The nurse can seek support from the preceptor during a crisis of confidence episode, and can rehearse what he or she did.
BOX 2 Example of a care requirement profile and skill requirements Care requirement profile: The majority of our work is with patients who experience burns and have completed the stabilisation period within the burns unit. Patients are transferred to the unit in a stable condition, in terms of homeostatic balances, but with residual physical and psychological care to be undertaken. We think of this as a residual trauma period during which dressing of patients’ wounds continues, when reconstructive surgery commences, when pain management remains an issue and when the psychological effect of the burn is potentially at its greatest. There is an intense rehabilitation effort to protect the function of limbs, to minimise the risk of immobility and to promote patient morale. Skill requirements: What are the typical care needs here? What skills are required to meet these needs? Are my skills well developed in these areas? What measures are necessary to improve skills that seem, at this time, underdeveloped?
© NURSING STANDARD / RCN PUBLISHING
Knowledge and Skills Framework (NHS Employers 2010). This list of requirements can seem all encompassing, but by focusing on the work indicated in Box 1 a strategic approach can be developed. This may include helping the nurse to formulate a plan of action and develop confidence rather than superintending all work or monitoring discrete procedures performed by the nurse.
Journal Club #NursingJC Join a discussion on Twitter about this article on Friday December 6 12.30-1.30 Using #NursingJC
Orientation to patients and services provided locally
One of the most daunting challenges that the newly qualified nurse faces is the need to become acquainted quickly with the patients cared for locally and their needs. There is also a requirement to understand the services and protocols or policies used. Nurses need to foresee the care work ahead and identify where their skills will be tested, otherwise learning is always reactive and may prove stressful (Deasy et al 2011). While introductory information about the healthcare trust, its work, policies and systems is usually included within staff induction sessions, the details of patients and protocols operating at ward or team level might not be covered. The basis of successful practice relies on the provision of timely and carefully attuned services being delivered to patients whose circumstances and needs are well understood. The more confidently the nurse feels that he or she is meeting real and appropriate needs, the more quickly he or she will develop an appropriate care approach. Briefing individual nurses on the profile of patients cared for by the local team, and the protocols and techniques that are used, is not a cost-effective way to proceed. It is more appropriate to prepare a series of care requirement profiles for the groups of patients, including their main concerns, to be used when planning care (Box 2). The nurse is asked to study the information provided, and this then forms the basis for discussion about patients’ care needs. While care is individualised, it is beneficial at this stage to identify the most commonly recurring patient needs involved in the particular clinical area. This helps the newly qualified nurse to focus his or her attention to anticipate what else he or she must learn or revise. Complete time out activity 3 The newly qualified nurse’s plan of action could focus on many things. However, attention to care needs and required skills provides a coherent focus to the enquiry.
3 What are the main groups of patients that you care for and what are their main concerns and frequently recurring physical, psychological and social needs? Look at Box 2 and consider whether there is any advantage in preparing more comprehensive versions of care requirement profiles and skill requirements?
december 4 :: vol 28 no 14 :: 2013 53
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD professional issues A skilful preceptor relates his or her experience of identifying and understanding needs and refers to the incremental way in which skills develop. While the newly qualified nurse will be accountable for his or her actions, it is accepted that skills will become more refined over the next few months.
Real-time clinical reasoning
4 Think back to your first day at work as a newly qualified nurse. Do you remember feeling anxious or fearful that you would not be able to think or work as fast or as precisely as others? How might you use this experience to support a newly qualified nurse to adjust to his or her new role? What experiences might you share that demonstrate empathy with the nurse’s situation?
5 Write a paragraph about a situation where you have used nursing ‘nous’ and which you can use in a discussion with a newly qualified nurse to explain the main points about forming first impressions. Accompany the nurse as he or she assesses a care situation and invite the individual to relate his or her own first impressions of the situation, for example what might confirm his or her suspicions regarding the condition of a patient, what decisions are important and how he or she could later evaluate what was done. The activity needs to be brief, perhaps five minutes, reflecting the time typically available to nurses on a busy ward.
Students have been protected to some degree from the requirements of real-time clinical reasoning in that they have been allowed additional review time – they may have been able to spend more time in the assessment stage of the nursing process before deciding what to do. Relatively little associated with learning in a classroom or even a skills laboratory prepares the student for the rapid appraisal of challenges associated with being a registered nurse. As a newly qualified professional, the nurse must demonstrate real-time clinical reasoning and this can be daunting. Real-time clinical reasoning means making quick but accurate assessments of situations and often under conditions where there may be competing demands (Simmons 2010). It involves working with evidence-based principles and essential facts to deliver prompt care. Complete time out activity 4 Real-time clinical reasoning can be discussed in terms of the following: Impressions – what is happening; what seems dangerous, problematic or needful. Enquiry – what will either confirm or challenge initial impressions of that required. Decisions – choosing how to proceed, using that which on balance is least likely to cause harm and most likely to address need. Implement and monitor – act and attend to the immediate reactions of others. Bott et al (2011) discussed similar reasoning when they described the ‘five minute preceptor conversation’. The nurse is invited to take a stance on what he or she thinks is happening and is needed. Next the nurse is asked to support his or her stance by referring to evidence that supports the interpretation. Evidence here is understood in broad terms and includes other observations made about the situation; it does not necessarily refer to published evidence. Bott et al (2011) suggested that the preceptor should discuss the general rules associated with such an assessment. The discussion then ends with the preceptor reinforcing positives – that were done well – and correcting any errors noted.
54 december 4 :: vol 28 no 14 :: 2013
This process of quickly assessing care requirements using first impressions of what is happening, is described as staff ‘nous’ (Menzies Centre for Health Policy/Nous Group 2012, Price 2013) (Box 3). It attends closely to what is safe, needed and sensitive to patients’ expectations and quickly conveys empathy towards patients. Nous is increasingly important as patients and their relatives become more discerning about care expectations and the quality of nursing and medical care is increasingly being understood in terms of the patient experience. Complete time out activity 5
Skill review and refinement
What happens as the nurse uses nous is that he or she exercises several skills in combination, for example listening, observing, questioning, reassuring and reviewing. The process seems so fluent and so quick that care appears polished and effortless. Newly qualified nurses may, however, sense that such sophisticated care relies at least in part on one or more skills that they have yet to develop fully. The fact
BOX 3 An example of ‘nurse nous’ Stella nearly fell out of bed this morning. The night staff said it was around 5am. Reports from the previous night state that the patient seemed more confused early in the morning as the ward became light. We are all groggy when we wake, but Stella has been in a lot of pain, and her last pain relief was given at around 10pm. Since her stroke she has not been able to talk so well – perhaps pain, a full bladder and her search for help is increasing her risk of having an accident (the impression). I am going to use one of our pain charts to assess her pain management (the enquiry). I have suggested that we move Stella’s bed nearer to the nurses’ station, we need to protect her from a fall, but I am going to have a word with the doctor as her reported pain suggests that we have not got the medication regimen right. I am going to speak to the night staff too about checking her pain levels before she goes to sleep and offering assistance to go to the toilet when she wakes (the decisions). Following my discussion with the doctor, Stella’s medication regimen was changed. However, this course of action was only agreed after I talked about my knowledge of older people, confusion, discomfort and profiling. Talking about that which is commonly observed helped to initiate a change in Stella’s treatment regimen (implement and monitor).
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
that the nurse has qualified, does not mean that every skill is highly developed. Some skills may be exemplary while others may be underdeveloped. At the point of qualification, each nurse has an individual profile of skill development, that which is already advanced and that which, to them at least, still seems uncertain or requires further development. Typically, students may have developed skills that are aligned closely with their preferred aptitudes – what they feel most engaged by and capable of (Price and Harrington 2013), for example in interpersonal communication or the interpretation of technical data. It is not surprising then that the nurse may approach the preceptor with queries about a particular skill. When invited to discuss a skill of concern, it is important that the preceptor does not dismiss or belittle it. No skill remains constant in practice, each may develop or deteriorate over time, so attention to skills and their fit with practice requirements remains a professional concern for all. Two activities can be used to help the nurse improve his or her chosen skill. The first, and often the most intuitive, is to invite the nurse to shadow the preceptor as he or she practises the skill in question (Price and Price 2009). Shadowing is more than a demonstration, it is an invitation to participate in the reasoning underpinning the skill – the thoughts, reflections and debates that are worked through as the skill is deployed. Because care is live, and conducted before an audience of patients, relatives and peers, the discussion of what the nurse is doing and why needs to be handled with considerable tact. Explanations to the nurse have sometimes to be rehearsed away from the bedside, rather than as an instruction that could undermine the confidence of the nurse in front of the patient. So the preceptor might, for example, reason: ‘I have been thinking again about patient confidence levels after a myocardial infarction and reconsidering how we encourage them to take planned exercise. We need to acknowledge their fears more, so let’s see if this approach works – tell me what you think afterwards.’ Because this is presented as a consultation, it is superior to the instruction: ‘now I want you to observe how I reassure this patient about taking exercise after their myocardial infarction’. Complete time out activity 6 The second activity associated with skill review is to invite the nurse to practise the
© NURSING STANDARD / RCN PUBLISHING
skill and then to conduct a supportive and constructive review of what the preceptor heard and observed. There are some risks associated with this approach if the preceptor perceives the activity as a review of performance, either good, bad, indifferent or reasonable. The review is better understood as a shared enquiry and to convey this successfully the preceptor needs to understand more about what the nurse thought he or she was doing, why it was being done in a particular way and what the care agenda or goal was in this instance. Review of the demonstrated skill needs to be conducted in private. At least 30 minutes discussion is needed to evaluate a skill in use. The preceptor should work with a series of questions: ‘Okay, I have heard and I have observed, but put this in context for me, what were you trying to achieve as you used the skill?’ ‘What did you feel or think as you proceeded? Did the skill seem to be going well or did you have concerns?’ ‘I noticed that you asked a lot of questions concerning how the patient experienced their wound care. What was the purpose of those? What did you think about that element of the skill in use?’ ‘Looking back at the skill now, how would you rate it out of ten and say why?’ Questions such as these are used to elicit the nurse’s own insights and feelings, which is then used to share constructive criticism or to celebrate something that was done well. Complete time out activity 7
Socialisation within the healthcare team
It is easy to assume that the newly qualified nurse comes to know his or her new colleagues incrementally and without much effort. The nurse learns about others through care encounters and decision making, how colleagues typically think, respond and behave. In practice, this can be a difficult process and before rapport is achieved, conflicts with other staff members may have arisen. It is important to help the nurse to identify how consultation happens within the team, and how colleagues typically respond to one another and put forward their case in relation to a particular care decision. It is important to review how care decisions are made, how team members influence one another, and most importantly, how they help each other. Each of the following can help the nurse to gain an understanding of the care process and
6 Identify any skills that you feel expert at and would welcome the opportunity to share with a newly qualified colleague. How might you engage this colleague in a critical discussion of the skill? What care episode experiences might you share to show that reasoning underpins the skill in use? 7 Make a list of the care consultation norms (dos and don’ts) where you work. How might this information be used to help newly qualified nurses?
december 4 :: vol 28 no 14 :: 2013 55
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD professional issues
8 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
decision making, as well as where support may be sought: Review of care consultations, case conferences, shift handovers and planning meetings for significant events such as hospital discharge. Review of critical incidents – these should include episodes of effective care as well as those where a problem was identified. There is a natural tendency for some nurses to evaluate their care in terms of what they got wrong. Profiling staff expertise and professional interest in one or two short paragraphs for the main individuals with particular expertise within the team. Identifying which members of staff are especially interested in an area of care can be helpful because they are more likely to share their knowledge and experience. If the nurse has to find this out by chance, learning may seem more difficult and stressful.
Conclusion Because preceptorship may seem a nebulous concept, one difficult to differentiate from others such as mentorship or induction training, a framework is necessary to help the preceptor proceed in a purposeful way. Newly qualified nurses need the empathetic support of a preceptor and in turn preceptors need a framework for their work to help them feel that it is coherent. Understanding patients and their particular needs, and the skills required to meet these needs, forms a good basis for the nurse’s plan of action. When the preceptor shows that he or she understands how daunting real-time clinical reasoning might seem, he or she is able to form a supportive relationship with the nurse, and help him or her to think and work more effectively in a busy care environment NS Complete time out activity 8
References Allnurses.com (2013) Newly Qualified… Are My Feelings Normal?! allnurses.com/nursingunited-kingdom/newly-qualifiedmy-824480.html (Last accessed: November 20 2013.) Bjerkes MS, Bjørk IT (2012) Entry into nursing: an ethnographic study of newly qualified nurses taking on the nursing role in a hospital setting. Nursing Research and Practice. Doi: 10.1155/2012/690348 Bott G, Mohide AE, Lawlor Y (2011) A clinical teaching technique for nurse preceptors: the five minute preceptor. Journal of Professional Nursing. 27, 1, 35-42. Chandler GE (2012) Succeeding in the first year of practice: heed the wisdom of novice nurses. Journal for Nurses in Staff Development. 28, 3, 103-107. Deasy C, Doody O, Tuohy D (2011) An exploratory study of
role transition from student to registered nurse (general, mental health and intellectual disability) in Ireland. Nurse Education in Practice. 11, 2, 109-113.
Harrison-White K, Simons J (2013) Preceptorship: ensuring the best possible start for new nurses. Nursing Children and Young People. 25, 1, 24-27.
Department of Health (2010) Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals. The Stationery Office, London.
Hole J (2009) The Newly Qualified Nurses’ Survival Guide. Second edition. Radcliffe Press, Oxford.
Dreifuerst KT (2012) Using debriefing for meaningful learning to foster development of clinical reasoning in simulation. Journal of Nursing Education. 51, 6, 326-333. Duchscher JE (2009) Transition shock: the initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing. 65, 5, 1103-1113. Ellis I, Chater K (2012) Practice protocol: transition to community nursing practice revisited. Contemporary Nurse. 42, 1, 90-96.
56 december 4 :: vol 28 no 14 :: 2013
Menzies Centre for Health Policy/Nous Group (2012) The Menzies-Nous Australian Health Survey 2012. tiny.cc/Menzies_nous (Last accessed: November 20 2013.)
(Last accessed: November 20 2013.) Price B (2013) Understanding nursing ‘nous’ in the context of service improvement. Nursing Management. 20, 4, 28-35. Price B, Harrington A (2013) Critical Thinking and Writing for Nursing Students. Second edition. Learning Matters, Exeter. Price A, Price B (2009) Role modelling practice with students on clinical placements. Nursing Standard. 24, 11, 51-56.
Myrick F, Yonge O, Billay DB, Luhanga FL (2011) Preceptorship: shaping the art of nursing through practical wisdom. Journal of Nursing Education. 50, 3, 134-139.
Simmons B (2010) Clinical reasoning: concept analysis. Journal of Advanced Nursing. 66, 5, 1151-1158.
NHS Employers (2010) Briefing 77: Supporting Appraisals: A Simpler KSF. www.nhsemployers.org/ Aboutus/Publications/Documents/ Supporting%20appraisals%20 a%20simpler%20KSF.pdf
Yonge OJ, Myrick F, Ferguson LM, Grundy Q (2013) Nursing preceptorship experiences in rural settings: ‘I would work here for free’. Nurse Education in Practice. 13, 2, 125-131.
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Page 57
Preceptorship multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
Page 60
Read Anita Skinner’s practice profile on atrial fibrillation
Page 61
Guidelines on how to write a practice profile
Successful preceptorship of newly qualified nurses NS722 Price B (2013) Successful preceptorship of newly qualified nurses. Nursing Standard. 28, 14, 51-56. Date of submission: May 31 2013; date of acceptance: August 20 2013.
Abstract There is widespread recognition that many newly qualified nurses find it difficult to make the transition from completing their university course to taking up their first registered nurse post. Preceptorship programmes during the first year of registered nurse practice have been recommended by the Department of Health. Preceptors have an important role in ensuring successful transition of the newly qualified nurse; however they also require practical guidance on how best to support the nurse. This article identifies aspects that need to be considered when guiding a registered nurse colleague rather than a student. Preceptorship concerns four main areas: orientation to patients and services provided locally, real-time clinical reasoning, skill review and refinement, and socialisation within the healthcare team. The article will explore each of these areas.
Author Bob Price Director, postgraduate qualifications in advancing healthcare practice, Faculty of Health and Social Care, The Open University, Milton Keynes. Correspondence to: [email protected]
Aims and intended learning outcomes The aim of this article is to assist preceptors to support newly registered nurses to adjust to role transition from student to qualified nurse. After reading this article and completing the time out activities you should be able to: Review the current strategy for working as a preceptor with newly qualified nurses in your place of work. Inform newly qualified nurses of local patient requirements, and important service processes and challenges. Support newly registered nurses to practise real-time clinical reasoning. Assist newly qualified nurses to reflect on their practice skills, identifying those skills that cause anxiety. Provide supportive consultation opportunities that assist the newly qualified nurse to feel part of the interdisciplinary team.
Keywords Clinical reasoning, education, guidance, preceptors, preceptorship, registered general nurses, role transition, skill development
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
© NURSING STANDARD / RCN PUBLISHING
Introduction While efforts continue to ensure that pre-registration nurse education equips students to become confident practitioners (Dreifuerst 2012), there is evidence that newly qualified nurses report difficulty in making the transition from student to qualified nurse in clinical practice (Hole 2009, Bjerkes and Bjørk 2012, Allnurses.com 2013). The Department of Health (DH) (2010) also recognises that this transition can be challenging. Nurses often struggle with the pace of reasoning that they have to engage in, and the level of engagement with patients and services that is required of them. december 4 :: vol 28 no 14 :: 2013 51
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD professional issues
1 What do you think preceptorship entails? Discuss with colleagues the type of learning that is most appropriate for newly qualified nurses and how you can provide such learning opportunities. 2 Refer to Box 1 and identify ways in which the preceptor supports, guides and reassures the newly qualified nurse. Review what other preceptorship support is available within your healthcare trust, for example study days, workshops, videos and audio case studies for discussion, and whether this meets the needs of nurses.
Duchscher (2009) referred to the ‘transition shock’ that nurses experience as they realise that they are professionally accountable for their actions and need to rapidly become acquainted with care responsibilities locally. Harrison-White and Simons (2013) observed that difficulty in transition is exacerbated in the current climate of economic recession, where there may be fewer nurses to guide newly qualified nurses and staff have additional responsibilities. Myrick et al (2011) described the transition to registered nurse practice as one that requires additional practical wisdom about the best ways to operate. Much of this is not readily learned at university, and cannot be attained solely through theory and principles. The nurse needs to acquaint him or herself with local practice requirements and preferred ways of working. In many instances, nurses are not only making a transition from student to registered nurse, but from a familiar care environment to a less familiar one (Ellis and Chater 2012). While all nursing students are required to be active learners, Chandler (2012) emphasised the particular need for nurses to be inquisitive and well organised in their first year of practice following registration, referring to this as ‘appreciative inquiry’. Yonge et al (2013) explained that the transition is then sometimes one of acclimatisation – becoming familiar with the care context and local expectations. In 2010, the DH published the Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals. This document identifies the importance of preceptorship in maintaining quality care standards and the retention of nurses post qualification. The document defines the preceptor as a: ‘registered practitioner who has been given formal responsibility to support a newly registered practitioner through preceptorship’ (DH 2010). However, healthcare trusts have been asked to develop their own preceptorship programmes, working with national knowledge and skill requirements (NHS Employers 2010). Preceptors may be uncertain about how they might best perform their role and how preceptorship differs from mentoring a student, especially with limited time available. Preceptorship does not involve the same assessment activity as that involved in mentoring nursing students. It is a ‘lighter touch’ in that it starts from a premise of what students have already achieved in their pre-registration course, it does not include
52 december 4 :: vol 28 no 14 :: 2013
formal assessments as other courses might and it is more facilitative, involving working with the newly qualified nurse’s perceived deficits and needs. It also requires an understanding of what it is like to begin work as a qualified nurse. Preceptorship requires a coherent structure (Harrison-White and Simons 2013), and focuses on the socialisation of newly qualified nurses into the interdisciplinary team. Complete time out activity 1
Preceptorship The DH (2010) states that preceptorship should not replace mandatory training programmes, for example on infection control; that it is not a form of performance management; that it is not formal coaching, although coaching skills are employed; and that it is not a grace period during which the preceptor takes responsibility for the nurse’s actions. The registered nurse is professionally accountable for his or her own actions. Preceptorship is not mentorship or clinical supervision, nor does it replace induction programmes arranged for new staff. Preceptorship is subtly different and arguably akin to the work of a research consultant. Like the research consultant, the preceptor provides support for the ongoing learning of others who are conducting their own enquiries, in this instance into what local care requirements and practices are and how well the nurse’s skills match these. The preceptor is not an instructor and he or she assists and facilitates, rather than dictates, learning (Box 1). Advice given by the preceptor focuses on the nurse’s own reflections and developing insights, and any needs that might arise. It also links to wider preceptorship programmes provided in the form of workshops, study days, seminars or guided forms of study arranged within the healthcare trust. Complete time out activity 2 The DH (2010) explains that preceptors are expected to: Help nurses fulfil their potential. Demonstrate an appropriate attitude towards continuing learning. Discuss practice with the newly qualified nurse, sharing knowledge and experience. Work empathetically with the newly qualified nurse. Act as an exemplary role model. Work with corporate initiatives to develop knowledge and skills as detailed within the
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
BOX 1 Role of the preceptor The nurse is helped to prepare a plan of action, which helps him or her to enquire about his or her new practice. Planning typically centres on care requirements, perceived skills already mastered and any deficits remaining. It attends to local protocols, policies and organisational systems that assist the delivery of care. The preceptor links what he or she does with the newly qualified nurse to other support provision within the preceptorship programme and the wider care team, avoiding duplication of support and wasted resources. The preceptor agrees a series of meetings with the newly qualified nurse to identify enquiries and address issues that have arisen. The meetings are appropriately spaced, leaving the nurse personal enquiry responsibilities in between – weekly meetings are recommended in the first month and monthly meetings for the remainder of the year. The preceptor explores which skills the newly qualified nurse is anxious about. The nurse may be invited to shadow the preceptor in some practice or the nurse may demonstrate the skill and receive immediate constructive feedback from the preceptor. The nurse can seek support from the preceptor during a crisis of confidence episode, and can rehearse what he or she did.
BOX 2 Example of a care requirement profile and skill requirements Care requirement profile: The majority of our work is with patients who experience burns and have completed the stabilisation period within the burns unit. Patients are transferred to the unit in a stable condition, in terms of homeostatic balances, but with residual physical and psychological care to be undertaken. We think of this as a residual trauma period during which dressing of patients’ wounds continues, when reconstructive surgery commences, when pain management remains an issue and when the psychological effect of the burn is potentially at its greatest. There is an intense rehabilitation effort to protect the function of limbs, to minimise the risk of immobility and to promote patient morale. Skill requirements: What are the typical care needs here? What skills are required to meet these needs? Are my skills well developed in these areas? What measures are necessary to improve skills that seem, at this time, underdeveloped?
© NURSING STANDARD / RCN PUBLISHING
Knowledge and Skills Framework (NHS Employers 2010). This list of requirements can seem all encompassing, but by focusing on the work indicated in Box 1 a strategic approach can be developed. This may include helping the nurse to formulate a plan of action and develop confidence rather than superintending all work or monitoring discrete procedures performed by the nurse.
Journal Club #NursingJC Join a discussion on Twitter about this article on Friday December 6 12.30-1.30 Using #NursingJC
Orientation to patients and services provided locally
One of the most daunting challenges that the newly qualified nurse faces is the need to become acquainted quickly with the patients cared for locally and their needs. There is also a requirement to understand the services and protocols or policies used. Nurses need to foresee the care work ahead and identify where their skills will be tested, otherwise learning is always reactive and may prove stressful (Deasy et al 2011). While introductory information about the healthcare trust, its work, policies and systems is usually included within staff induction sessions, the details of patients and protocols operating at ward or team level might not be covered. The basis of successful practice relies on the provision of timely and carefully attuned services being delivered to patients whose circumstances and needs are well understood. The more confidently the nurse feels that he or she is meeting real and appropriate needs, the more quickly he or she will develop an appropriate care approach. Briefing individual nurses on the profile of patients cared for by the local team, and the protocols and techniques that are used, is not a cost-effective way to proceed. It is more appropriate to prepare a series of care requirement profiles for the groups of patients, including their main concerns, to be used when planning care (Box 2). The nurse is asked to study the information provided, and this then forms the basis for discussion about patients’ care needs. While care is individualised, it is beneficial at this stage to identify the most commonly recurring patient needs involved in the particular clinical area. This helps the newly qualified nurse to focus his or her attention to anticipate what else he or she must learn or revise. Complete time out activity 3 The newly qualified nurse’s plan of action could focus on many things. However, attention to care needs and required skills provides a coherent focus to the enquiry.
3 What are the main groups of patients that you care for and what are their main concerns and frequently recurring physical, psychological and social needs? Look at Box 2 and consider whether there is any advantage in preparing more comprehensive versions of care requirement profiles and skill requirements?
december 4 :: vol 28 no 14 :: 2013 53
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD professional issues A skilful preceptor relates his or her experience of identifying and understanding needs and refers to the incremental way in which skills develop. While the newly qualified nurse will be accountable for his or her actions, it is accepted that skills will become more refined over the next few months.
Real-time clinical reasoning
4 Think back to your first day at work as a newly qualified nurse. Do you remember feeling anxious or fearful that you would not be able to think or work as fast or as precisely as others? How might you use this experience to support a newly qualified nurse to adjust to his or her new role? What experiences might you share that demonstrate empathy with the nurse’s situation?
5 Write a paragraph about a situation where you have used nursing ‘nous’ and which you can use in a discussion with a newly qualified nurse to explain the main points about forming first impressions. Accompany the nurse as he or she assesses a care situation and invite the individual to relate his or her own first impressions of the situation, for example what might confirm his or her suspicions regarding the condition of a patient, what decisions are important and how he or she could later evaluate what was done. The activity needs to be brief, perhaps five minutes, reflecting the time typically available to nurses on a busy ward.
Students have been protected to some degree from the requirements of real-time clinical reasoning in that they have been allowed additional review time – they may have been able to spend more time in the assessment stage of the nursing process before deciding what to do. Relatively little associated with learning in a classroom or even a skills laboratory prepares the student for the rapid appraisal of challenges associated with being a registered nurse. As a newly qualified professional, the nurse must demonstrate real-time clinical reasoning and this can be daunting. Real-time clinical reasoning means making quick but accurate assessments of situations and often under conditions where there may be competing demands (Simmons 2010). It involves working with evidence-based principles and essential facts to deliver prompt care. Complete time out activity 4 Real-time clinical reasoning can be discussed in terms of the following: Impressions – what is happening; what seems dangerous, problematic or needful. Enquiry – what will either confirm or challenge initial impressions of that required. Decisions – choosing how to proceed, using that which on balance is least likely to cause harm and most likely to address need. Implement and monitor – act and attend to the immediate reactions of others. Bott et al (2011) discussed similar reasoning when they described the ‘five minute preceptor conversation’. The nurse is invited to take a stance on what he or she thinks is happening and is needed. Next the nurse is asked to support his or her stance by referring to evidence that supports the interpretation. Evidence here is understood in broad terms and includes other observations made about the situation; it does not necessarily refer to published evidence. Bott et al (2011) suggested that the preceptor should discuss the general rules associated with such an assessment. The discussion then ends with the preceptor reinforcing positives – that were done well – and correcting any errors noted.
54 december 4 :: vol 28 no 14 :: 2013
This process of quickly assessing care requirements using first impressions of what is happening, is described as staff ‘nous’ (Menzies Centre for Health Policy/Nous Group 2012, Price 2013) (Box 3). It attends closely to what is safe, needed and sensitive to patients’ expectations and quickly conveys empathy towards patients. Nous is increasingly important as patients and their relatives become more discerning about care expectations and the quality of nursing and medical care is increasingly being understood in terms of the patient experience. Complete time out activity 5
Skill review and refinement
What happens as the nurse uses nous is that he or she exercises several skills in combination, for example listening, observing, questioning, reassuring and reviewing. The process seems so fluent and so quick that care appears polished and effortless. Newly qualified nurses may, however, sense that such sophisticated care relies at least in part on one or more skills that they have yet to develop fully. The fact
BOX 3 An example of ‘nurse nous’ Stella nearly fell out of bed this morning. The night staff said it was around 5am. Reports from the previous night state that the patient seemed more confused early in the morning as the ward became light. We are all groggy when we wake, but Stella has been in a lot of pain, and her last pain relief was given at around 10pm. Since her stroke she has not been able to talk so well – perhaps pain, a full bladder and her search for help is increasing her risk of having an accident (the impression). I am going to use one of our pain charts to assess her pain management (the enquiry). I have suggested that we move Stella’s bed nearer to the nurses’ station, we need to protect her from a fall, but I am going to have a word with the doctor as her reported pain suggests that we have not got the medication regimen right. I am going to speak to the night staff too about checking her pain levels before she goes to sleep and offering assistance to go to the toilet when she wakes (the decisions). Following my discussion with the doctor, Stella’s medication regimen was changed. However, this course of action was only agreed after I talked about my knowledge of older people, confusion, discomfort and profiling. Talking about that which is commonly observed helped to initiate a change in Stella’s treatment regimen (implement and monitor).
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
that the nurse has qualified, does not mean that every skill is highly developed. Some skills may be exemplary while others may be underdeveloped. At the point of qualification, each nurse has an individual profile of skill development, that which is already advanced and that which, to them at least, still seems uncertain or requires further development. Typically, students may have developed skills that are aligned closely with their preferred aptitudes – what they feel most engaged by and capable of (Price and Harrington 2013), for example in interpersonal communication or the interpretation of technical data. It is not surprising then that the nurse may approach the preceptor with queries about a particular skill. When invited to discuss a skill of concern, it is important that the preceptor does not dismiss or belittle it. No skill remains constant in practice, each may develop or deteriorate over time, so attention to skills and their fit with practice requirements remains a professional concern for all. Two activities can be used to help the nurse improve his or her chosen skill. The first, and often the most intuitive, is to invite the nurse to shadow the preceptor as he or she practises the skill in question (Price and Price 2009). Shadowing is more than a demonstration, it is an invitation to participate in the reasoning underpinning the skill – the thoughts, reflections and debates that are worked through as the skill is deployed. Because care is live, and conducted before an audience of patients, relatives and peers, the discussion of what the nurse is doing and why needs to be handled with considerable tact. Explanations to the nurse have sometimes to be rehearsed away from the bedside, rather than as an instruction that could undermine the confidence of the nurse in front of the patient. So the preceptor might, for example, reason: ‘I have been thinking again about patient confidence levels after a myocardial infarction and reconsidering how we encourage them to take planned exercise. We need to acknowledge their fears more, so let’s see if this approach works – tell me what you think afterwards.’ Because this is presented as a consultation, it is superior to the instruction: ‘now I want you to observe how I reassure this patient about taking exercise after their myocardial infarction’. Complete time out activity 6 The second activity associated with skill review is to invite the nurse to practise the
© NURSING STANDARD / RCN PUBLISHING
skill and then to conduct a supportive and constructive review of what the preceptor heard and observed. There are some risks associated with this approach if the preceptor perceives the activity as a review of performance, either good, bad, indifferent or reasonable. The review is better understood as a shared enquiry and to convey this successfully the preceptor needs to understand more about what the nurse thought he or she was doing, why it was being done in a particular way and what the care agenda or goal was in this instance. Review of the demonstrated skill needs to be conducted in private. At least 30 minutes discussion is needed to evaluate a skill in use. The preceptor should work with a series of questions: ‘Okay, I have heard and I have observed, but put this in context for me, what were you trying to achieve as you used the skill?’ ‘What did you feel or think as you proceeded? Did the skill seem to be going well or did you have concerns?’ ‘I noticed that you asked a lot of questions concerning how the patient experienced their wound care. What was the purpose of those? What did you think about that element of the skill in use?’ ‘Looking back at the skill now, how would you rate it out of ten and say why?’ Questions such as these are used to elicit the nurse’s own insights and feelings, which is then used to share constructive criticism or to celebrate something that was done well. Complete time out activity 7
Socialisation within the healthcare team
It is easy to assume that the newly qualified nurse comes to know his or her new colleagues incrementally and without much effort. The nurse learns about others through care encounters and decision making, how colleagues typically think, respond and behave. In practice, this can be a difficult process and before rapport is achieved, conflicts with other staff members may have arisen. It is important to help the nurse to identify how consultation happens within the team, and how colleagues typically respond to one another and put forward their case in relation to a particular care decision. It is important to review how care decisions are made, how team members influence one another, and most importantly, how they help each other. Each of the following can help the nurse to gain an understanding of the care process and
6 Identify any skills that you feel expert at and would welcome the opportunity to share with a newly qualified colleague. How might you engage this colleague in a critical discussion of the skill? What care episode experiences might you share to show that reasoning underpins the skill in use? 7 Make a list of the care consultation norms (dos and don’ts) where you work. How might this information be used to help newly qualified nurses?
december 4 :: vol 28 no 14 :: 2013 55
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD professional issues
8 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
decision making, as well as where support may be sought: Review of care consultations, case conferences, shift handovers and planning meetings for significant events such as hospital discharge. Review of critical incidents – these should include episodes of effective care as well as those where a problem was identified. There is a natural tendency for some nurses to evaluate their care in terms of what they got wrong. Profiling staff expertise and professional interest in one or two short paragraphs for the main individuals with particular expertise within the team. Identifying which members of staff are especially interested in an area of care can be helpful because they are more likely to share their knowledge and experience. If the nurse has to find this out by chance, learning may seem more difficult and stressful.
Conclusion Because preceptorship may seem a nebulous concept, one difficult to differentiate from others such as mentorship or induction training, a framework is necessary to help the preceptor proceed in a purposeful way. Newly qualified nurses need the empathetic support of a preceptor and in turn preceptors need a framework for their work to help them feel that it is coherent. Understanding patients and their particular needs, and the skills required to meet these needs, forms a good basis for the nurse’s plan of action. When the preceptor shows that he or she understands how daunting real-time clinical reasoning might seem, he or she is able to form a supportive relationship with the nurse, and help him or her to think and work more effectively in a busy care environment NS Complete time out activity 8
References Allnurses.com (2013) Newly Qualified… Are My Feelings Normal?! allnurses.com/nursingunited-kingdom/newly-qualifiedmy-824480.html (Last accessed: November 20 2013.) Bjerkes MS, Bjørk IT (2012) Entry into nursing: an ethnographic study of newly qualified nurses taking on the nursing role in a hospital setting. Nursing Research and Practice. Doi: 10.1155/2012/690348 Bott G, Mohide AE, Lawlor Y (2011) A clinical teaching technique for nurse preceptors: the five minute preceptor. Journal of Professional Nursing. 27, 1, 35-42. Chandler GE (2012) Succeeding in the first year of practice: heed the wisdom of novice nurses. Journal for Nurses in Staff Development. 28, 3, 103-107. Deasy C, Doody O, Tuohy D (2011) An exploratory study of
role transition from student to registered nurse (general, mental health and intellectual disability) in Ireland. Nurse Education in Practice. 11, 2, 109-113.
Harrison-White K, Simons J (2013) Preceptorship: ensuring the best possible start for new nurses. Nursing Children and Young People. 25, 1, 24-27.
Department of Health (2010) Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals. The Stationery Office, London.
Hole J (2009) The Newly Qualified Nurses’ Survival Guide. Second edition. Radcliffe Press, Oxford.
Dreifuerst KT (2012) Using debriefing for meaningful learning to foster development of clinical reasoning in simulation. Journal of Nursing Education. 51, 6, 326-333. Duchscher JE (2009) Transition shock: the initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing. 65, 5, 1103-1113. Ellis I, Chater K (2012) Practice protocol: transition to community nursing practice revisited. Contemporary Nurse. 42, 1, 90-96.
56 december 4 :: vol 28 no 14 :: 2013
Menzies Centre for Health Policy/Nous Group (2012) The Menzies-Nous Australian Health Survey 2012. tiny.cc/Menzies_nous (Last accessed: November 20 2013.)
(Last accessed: November 20 2013.) Price B (2013) Understanding nursing ‘nous’ in the context of service improvement. Nursing Management. 20, 4, 28-35. Price B, Harrington A (2013) Critical Thinking and Writing for Nursing Students. Second edition. Learning Matters, Exeter. Price A, Price B (2009) Role modelling practice with students on clinical placements. Nursing Standard. 24, 11, 51-56.
Myrick F, Yonge O, Billay DB, Luhanga FL (2011) Preceptorship: shaping the art of nursing through practical wisdom. Journal of Nursing Education. 50, 3, 134-139.
Simmons B (2010) Clinical reasoning: concept analysis. Journal of Advanced Nursing. 66, 5, 1151-1158.
NHS Employers (2010) Briefing 77: Supporting Appraisals: A Simpler KSF. www.nhsemployers.org/ Aboutus/Publications/Documents/ Supporting%20appraisals%20 a%20simpler%20KSF.pdf
Yonge OJ, Myrick F, Ferguson LM, Grundy Q (2013) Nursing preceptorship experiences in rural settings: ‘I would work here for free’. Nurse Education in Practice. 13, 2, 125-131.
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
