YNEDT-02716; No of Pages 5 Nurse Education Today xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
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The commitment of Israeli nursing preceptors to the role of preceptor Merav Ben Natan a,b,⁎, Hanan Qeadan a,1, Walaa Egbaria a a b
Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Centre, P.O.B. 169, Hadera 38100 Israel Department of Nursing, School of Health Professions, Tel Aviv University, Israel
a r t i c l e
i n f o
Article history: Accepted 1 April 2014 Available online xxxx Keywords: Israel Nursing Preceptor Support Benefits
s u m m a r y Background: Despite the professional importance of the preceptorship role and the rise in participation of nurses in training courses for the position, a significant number of nurses are not committed to this role. The reasons for this trend globally, and in Israel in particular, are not clear. Objectives: The aim of this study is to explore the connections between characteristics of preceptorship, supports, benefits and rewards, and commitment to the preceptor role in Israel. Methods: The present study is a quantitative correlational study. A questionnaire survey was given to a convenience sample of 200 Israeli registered nurses working as preceptors in hospitals and community settings in the northern part of Israel. Results: Respondents showed a moderate commitment to the role of preceptor. Support within nurses' employment framework, intrinsic benefits and rewards, and to a lesser degree, extrinsic benefits and rewards, were found to be related to nurses' level of commitment to the role of preceptor. No correlation was found between support received from outside the workplace and commitment to the role of preceptor. Additionally, no correlation was found between the characteristics of preceptorship (the number of preceptees during the last six months or the average number of preceptees per session), and commitment to the role of preceptor. The most important factor contributing to commitment was support within the nurses' employment framework Conclusions: The present study highlights the importance of support from within the nurses' employment framework, and also the role of intrinsic benefits and rewards, in relation to the level of commitment of Israeli preceptors to their role. © 2014 Elsevier Ltd. All rights reserved.
Introduction Nursing is a practice-based discipline and clinical practice is considered an integral part of nurses' education. The preceptorship model is extensively used in nursing education programs throughout the world (Hyrkas and Shoemaker, 2007). A preceptor is defined in the literature as an experienced nurse, a resource person, and a role model for preceptees. The preceptor facilitates and evaluates learning, fosters independence, development of skills, competencies and confidence, and socializes students or newly hired nurses into the nursing role through direct involvement in the teaching–learning process in clinical settings (Hyrkas and Shoemaker, 2007; Nursing Administration Circular, 2007). In the literature, preceptor and mentor are terms that are often used synonymously and interchangeably (Yonge et al., 2007). For the study reported in this paper, the term preceptor was chosen.
⁎ Corresponding author at: Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Centre, P.O.B. 169, Hadera 38100 Israel. Tel.: +972 4 6304367/9; fax: +972 4 6304730. E-mail address: [email protected] (M.B. Natan). 1 Tel.: +972 4 6304367/9; fax: +972 4 6304730.
Despite the rise in participation of nurses in preceptorship courses, there is evidence that a significant percentage of nurses are not committed to maintaining the preceptor role (Hyrkas and Shoemaker, 2007). Findings of previous studies show that several factors have an impact on the commitment of preceptors to their role. One of them is characteristic of preceptorship. The preceptor role is multi-faceted and complex (Hyrkas and Shoemaker, 2007), having both positive and negative aspects (Omansky, 2010). The preceptor role is a demanding one, and there are responsibilities and stressors associated with teaching students (Omansky, 2010). The increased stress that comes with these responsibilities takes a toll on staff nurse preceptors, and can be a factor affecting nurse retention and burnout (Kemper, 2007). Nurse preceptors experience role ambiguity, role conflict, and role overload; these factors can be overwhelming and lead to exhaustion (Omansky, 2010). Role ambiguity is a lack of definition of the preceptor role, creating a large discrepancy between the envisioned role of the preceptor and the reality of the role (Omansky, 2010). Role conflict is characterized by the requirement to balance demands made by patients and preceptees, resulting in loss of time with patients (Speers et al., 2004) or in an inability to fully attend to the needs of students (Hallin and Danielson, 2009; Carlson et al., 2009). Additionally, as they are
http://dx.doi.org/10.1016/j.nedt.2014.04.011 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
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M.B. Natan et al. / Nurse Education Today xxx (2014) xxx–xxx
responsible for errors made by students, preceptors are often torn between wishing to assist students in acquiring clinical experience and needing to protect their nursing license from lawsuits or allegations of malpractice (Hautala et al., 2007). Role overload and a lack of time are additional major issues identified by preceptors in other studies. These factors appear to be the result of misconceptions by managers and coworkers who wrongly interpret what the preceptor role entails and view the nurse preceptor as receiving additional assistance, when in fact the preceptor has additional responsibilities (Omansky, 2010). In this study the characteristics of preceptorship will be represented by two variables: number of preceptees during the last six months and the average number of preceptees per session. Another factor is support. Preceptors report a need for feedback and for recognition of the role of preceptor (McCarthy and Murphy, 2010). Structural conditions such as feedback and support seem to strengthen nurses' general view of their performance as preceptors (Mårtensson et al., 2013). Preceptors need ongoing support from educators, managers and administrators, and the forms and means of support required from each of these actors are different (Speers et al., 2004). Without support, preceptors tend to lose commitment (Hyrkas and Shoemaker, 2007). A supportive work milieu where co-workers acknowledge each other as preceptors has been found to strengthen the preceptor experience (Bourbonnais and Kerr, 2007). Landmark et al. (2003) suggest that the success of clinical supervision is dependent upon a workplace's ability to create supportive frameworks within the workplace, ensuring necessary time for supervising students. Studies exploring preceptors' perceptions of support have shown that the origin of support varies. It is unclear what the significant origins of support for the preceptor are, whether the origin of support is within the nurses' employment framework, e.g., the management or co-workers within the nurses' employment framework, or factors outside the workplace, e.g., school of nursing or the preceptorship training course (Hyrkas and Shoemaker, 2007). Another factor that seems to have an impact on the commitment of preceptors to their role is benefits and rewards. Intrinsic benefits and rewards reported by many nurses are personal growth, a sense of expanding professional abilities (Henderson et al., 2006; Murphy, 2008), facilitating the development of nursing students (Murphy, 2008; Hallin and Danielson, 2009), and the acquisition of educational techniques (Smedley, 2008). Examples of extrinsic benefits of operating as a preceptor which appear in the literature are pay differentials, educational advantages, and opportunities to attend conferences (Hyrkas and Shoemaker, 2007). Several studies show that preceptors value the preceptor role more in intrinsic rather than in extrinsic, i.e., material terms (Carlson et al., 2009; Hyrkas and Shoemaker, 2007; Lillibridge, 2007), in contrast to other studies that have emphasized the importance of extrinsic factors (Henderson et al., 2006; Murphy, 2008). There is ambiguity about the factors related to commitment to maintaining the preceptor role, and the relative impact and contribution of each of these factors. Therefore, the aim of the present study was to explore the connections between characteristics of preceptorship, supports, benefits and rewards, and commitment to the preceptor role in Israel. Methods Design The present study is a quantitative correlational study.
of the Pat Matthews Academic School of Nursing provided the names of 240 preceptors working in the northern part of Israel. The preceptors were contacted by phone and asked to participate in the study. Most of them agreed. Pat Matthews nursing students distributed a questionnaire at various clinical placements. The questionnaires were returned by mail to the primary investigator. The data were collected during January–March of 2013. During this period, the preceptors were twice given reminders by phone to complete the questionnaire. Twohundred preceptors completed the questionnaires, for a response rate of 83%. Instrument A five-part questionnaire was used to collect the data: Preceptor's Perception of Benefits and Rewards (PPBR) Scale, Preceptor's Perception of Support (PPS) Scale, Commitment to the Preceptor Role (CPR) Scale, experiences as preceptor and socio-demographic information section. This questionnaire was developed by Dibert and Goldenberg (1995). The PPBR is composed of 14 items rated on a 6-point Likert scale (1 ‘strongly disagree’ to 6 ‘strongly agree’) exploring the benefits and rewards of the preceptor role. A distinction was made between intrinsic and extrinsic benefits. An example of a typical item for intrinsic factors is: “Being a preceptor improves my self-esteem.” An example of a typical item for extrinsic factors is: “Being a preceptor raises my wage.” As the variable was divided into intrinsic and extrinsic factors, reliability analysis was performed, and the alpha coefficients were: 0.85 and 0.87, respectively. The PPS Scale is composed of 8 items that are also rated on a 6-point scale to measure preceptors' perceptions of support for the preceptor role. A distinction was made between support received within the nurses' employment framework and support received from the school of nursing supervising the preceptorship. An example of a typical item for support within the nurses' employment framework: “I feel that the head nurse of the department supports my work as a preceptor.” An example of a typical item for support received from the school of nursing supervising the preceptorship: “Nursing educators at the nursing school support me”. As the variable was divided into two variables, reliability analysis was performed, and the alpha coefficients were: 0.89 and 0.85, respectively. The CPR Scale is composed of 7 items rated on a 6-point scale to measure commitment to the role of preceptor, i.e., a combination of attitudes that reflect dedication to the role of preceptor. An example of a typical item is: “It is very important for me to continue in my role as a preceptor.” The final 7 questions of the questionnaire were about the preceptorship experience. The questionnaire was translated into Hebrew using a modified Brislin (1970) forward and backward translation approach. Questionnaires were independently translated from the original English into Hebrew by two native Hebrew speakers. The two Hebrew translations were then compared with one another and a common Hebrew translation was developed based on consensus between the translators and the investigators. The new Hebrew translation was then back-translated into English by two native English speakers working independently from each other. These two English back translations were then compared with the original questionnaire by the investigators. Whenever there was a discrepancy between the back-translated questionnaires and the original questionnaire, the translators were consulted and a consensus was reached related to the final Hebrew translation. Reliability analyses of the scales (PPBR, PPS & CPR) were reported by Dibert and Goldenberg (1995) as having alpha coefficients of 0.91, 0.86 and 0.87, respectively.
Sample and Procedure Data Analysis Inclusion criteria were being a registered nurse, completion of the preceptorship course, and currently operating as a nursing preceptor in hospitals and community settings. The clinical placement coordinator
Data analysis was performed with the Statistical Package for Social Sciences (SPSS-PC, version 14, SPSS Inc., Chicago, IL, USA). Descriptive
Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
M.B. Natan et al. / Nurse Education Today xxx (2014) xxx–xxx
statistics were used to depict sociodemographic and professional characteristics, and perceptions of the sample. Pearson correlations were performed to determine the connections between study variables. Additionally, linear regression analysis was performed to predict which factors had the highest level of impact. Reliability analyses of the scales (PPBR, PPS & CPR) in our research were alpha coefficients of 0.94, 0.86 and 0.70, respectively. Ethical Considerations This study was approved by the Tel-Aviv University ethics committee. The participants were asked on two occasions for their agreement to participate: first, by phone, and again at the time of administering the questionnaire. The purpose of the research and that participation was voluntary was explained to the participants. Each of the participants was assured confidentiality and promised that research findings would only be used for purposes of the present study. Written consent was obtained from each participant. Results Respondents' Characteristics The respondents' sociodemographic and professional characteristics are presented in Table 1. The mean age of respondents was 36.7 (SD = 9.2, range 22–60); most were women, native-born and Jewish. All of them had a baccalaureate degree, some had a Master's degree; most had taken at least one advanced course in nursing. Respondents had a mean nursing experience of 13.1 years (SD = 9.6, range 1–43). Most of them were employed full time. They had been working as preceptors for a mean of 4.7 years (SD = 5.6, range 1–34). Most of them worked with nursing students and new nurses. The respondents had worked with 8.3 preceptees on average (SD = 10.8, range 1–80) during the past six months, with 3.5 preceptees on average in each clinical rotation (SD = 2.4, range 1–4). Commitment to the preceptor role The research findings show that respondents had a moderate commitment to their role as preceptors (M = 4.2, SD = 0.7) (Table 2). About 70% of the respondents completely agreed that it is important for them to continue operating as preceptors, and agreed that their decision to work as preceptors was correct. Sixty three percent of
Table 1 The respondents' socio demographic and professional characteristics. Characteristic
Category
%
Female Male
73% 27%
Israel Other
63% 37%
Jewish Arab
69% 31%
BA MA
71% 29%
Yes No
60% 40%
Full time Partial time
74% 26%
Students New nurses
74% 71%
Gender
Country of birth
Nationality
3
respondents completely agreed that they feel proud to be preceptors; however, 24% doubted that they will continue to work as preceptors. Supports The research findings show that the respondents ranked the overall support they received for their role as preceptors as moderate (M = 4.2, SD = 0.9) (Table 2). Two sources of support within the nurses' employment framework which received the highest ranking were support by the head nurse of the department (72%) and by the employer's clinical coordinator (63%). As to sources of support outside the workplace, only 58% of the respondents agreed that teachers at the supervising nursing school supported them by helping solve problems they encounter as preceptors. Additionally, only 64% agreed that the preceptorship training course prepared them adequately for the job. Benefits and rewards The respondents ranked the benefits and rewards of preceptorship fairly high (M = 4.9, SD = 0.7), with intrinsic benefits (M = 5.1, SD = 0.7) ranked higher than extrinsic benefits (M = 4.5, SD = 0.8) (Table 2). The intrinsic benefits ranked highest were contribution to the nursing profession (91%). Correlations A positive correlation of moderate intensity was found between intrinsic benefits and rewards and commitment to the preceptor role (r = 0.30, p b 0.01). A weaker correlation was found between extrinsic benefits and rewards and commitment to the preceptor role (r = 0.16, p b 0.05). A positive correlation of moderate intensity was found between support received within the nurses' employment framework and commitment to the preceptor role (r = 0.22, p b 0.01), but no correlation was found between support from outside the workplace and commitment to the preceptor role (p N 0.05) (Table 3). No correlation was found between the number of preceptees during the last six months or the average number of preceptees per session and commitment to the preceptor role (p N 0.05). To determine the predictors of commitment to preceptor role, a linear regression was performed (Table 4). As the characteristics of preceptorship and support from outside the workplace were not found related to commitment to preceptor role, they were not entered into the regression. The findings show that the most important factor contributing to commitment to the preceptor role was support within the nurses' employment framework. The model predictability was found to be 43.2%. Discussion and Conclusions The respondents' commitment to the preceptor role was moderate, and this finding is consistent with previous international research (Omansky, 2010). Factors found to be related to commitment to the role of preceptor were similar to those reported by previous studies
Professional education Table 2 Means and standard deviations of respondents' perceptions.
Advanced course in nursing
Employment
Type of preceptees
CPR PPBR Intrinsic Extrinsic PPS Within nurses' employment framework Outside the workplace
M
SD
4.2 4.9 5.1 4.5 4.2 4.5 4.1
0.7 0.7 0.7 0.8 0.9 1.1 0.9
Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
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M.B. Natan et al. / Nurse Education Today xxx (2014) xxx–xxx
Table 3 Pearson correlations between research variables and commitment to the preceptor role.
Commitment to the preceptor role
Intrinsic benefits and rewards
Extrinsic benefits and rewards
Support within nurses' employment
Support from outside the workplace
Number of preceptees
Number of preceptees per session
0.30**
0.16*
0.22**
0.13
0.12
0.08
p b 0.05, **p b 0.01*
(Hyrkas and Shoemaker, 2007; McCarthy and Murphy, 2010; Speers et al., 2004). These include support within the nurses' employment framework, intrinsic benefits and rewards, and to a lesser degree, extrinsic benefits and rewards. The research findings validate the literature that describes support as important for preceptors (Omansky, 2010). Nonetheless, respondents attributed greater significance to support received within the nurses' employment framework, and particularly by the head nurse, than to support from outside the workplace. Moreover, support from the workplace was also found to be related to readiness to commit to the role, while support outside the workplace was not. This finding may be explained by the fact that preceptors usually combine their work as preceptors and as staff nurses. The workload required by the combined role and the ability to find time for their work as preceptors largely depends on the collaboration of preceptors' management and co-workers to distribute the workload (Omansky, 2010). In comparison to UK and other countries, the workload of preceptors in Israel is high: in UK, a maximum of two students per mentor is allowed (Royal College of Nursing, 2005), whereas in Israel, the number of preceptees per preceptor may reach six students. This includes tasks such as allocation of shiftwork and responsibility for patients (Omansky, 2010). In contrast, the support from factors outside the workplace, such as the supervising nursing school, although important, is limited to solving pedagogical problems involved in the perceptorship (Carlson et al., 2009; Hallin and Danielson, 2009). Furthermore, contact with the supervising nursing school is very limited compared to daily contact with managers, clinical coordinators and co-workers within the nurses' employment framework. The research findings indicate that the work of clinical preceptors in Israel involves a heavy workload, and that nursing managers do not always give preceptors enough time for their work as such. Additionally, the findings show that co-workers do not always cooperate and help alleviate the workload of preceptors. Work overload may be the result of managers and co-workers not realizing that the preceptor role entails additional responsibilities, rather than additional assistance from preceptees (Omansky, 2010). Another reason for the frequent inability of preceptors to find time for this role is the realistic constraint resulting from the shortage of nurses in Israel, leading to the need to combine staff nurse and preceptor roles (Ben Natan and Becker, 2010). In light of the finding that support from inside nurses' employment framework was found to be the most important factor contributing to the
prediction of commitment to the preceptor role, the insufficient support that Israeli preceptors receive may lead to lesser commitment. In the present study, preceptorship training courses did not arise as a significant contributing factor of support from outside the workplace to the respondents' commitment to the preceptor role. Sixty-four percent of the respondents felt that the preceptorship training course did not prepare them sufficiently for the job. This finding is consistent with those of the review conducted by Omansky (2010), whose findings reflect the ambiguity of the preceptor's role and indicate the discrepancy between the envisioned role of the preceptor and the reality of the role. Preceptors in Israel may not receive appropriate tools for coping with certain difficulties that arise on the job, but this subject requires further research. The current research findings support the research literature showing that benefits are important for preceptors (Hyrkas and Shoemaker, 2007). Previous studies show that preceptors value nonmaterial rewards and benefits, such as personal satisfaction, personal growth and competence development, more than material benefits (Carlson et al., 2009; Hales et al., 2004; Hyrkas and Shoemaker, 2007; Lillibridge, 2007). In the current study, intrinsic rewards were also found to be more significant than extrinsic rewards for nurses' readiness to commit to precepting. Significant rewards mentioned by the respondents were their contribution to the nursing profession, updated clinical and scientific nursing knowledge, improved teaching capabilities, and job satisfaction. Nonetheless, the lower ranking of extrinsic rewards by respondents might indicate that policy designers are less appreciative of the role filled by preceptors, as manifested in insignificant salary increments and improbability of advancing in the workplace. Contrary to concerns expressed in the literature about burnout associated with the busy preceptorship schedule (Kemper, 2007), the findings in the present study show that preceptors were committed to their role regardless of the number of preceptees per session, or the total number of preceptees during the last 6 months. A similar finding was reported by Hyrkas and Shoemaker (2007) which found that preceptors who reported positive perceptions of support were committed to their role independently of the number of preceptorships. The present study's findings, as well as Hyrkas and Shoemaker (2007), suggest that support is probably the mediator between commitment to the preceptor role and the workload, be it the number of preceptees per session, or the number of preceptorships. However, this relationship was not investigated in the present study.
Table 4 Summary of linear regression analysis for variables predicting commitment to the preceptor role. Coefficientsa Model
Constant Extrinsic Benefits and rewards Intrinsic Benefits and rewards Support within nurses' employment
Unstandardized coefficients
Standardized coefficients
B
Std. error
Beta
t
Sig.
2.575 −.148 .412 .985
.416 .114 .127 .218
−.138 .344
6.183 −1.304 3.252
.000 .194 .001
1.100
4.516
.000
R2 = 43.2% a Dependent variable: commitment to the preceptor role.
Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
M.B. Natan et al. / Nurse Education Today xxx (2014) xxx–xxx
In conclusion, the present study highlights that commitment of Israeli preceptors to their role derives from both support from within the nurses' employment framework, and also the intrinsic benefits and rewards of the position. Research limitations This research employed a convenience sampling, thus possibly hampering the ability to generalize the findings to the population of Israeli preceptors. Additionally, the research tool is a self-report questionnaire, a fact that may limit the validity of the findings. Respondents might have presented their perceptions in a more positive light than actually prevalent. Moreover, those who completed the questionnaires were probably the most active and enthusiastic of the preceptors. Recommendations The present study suggests several recommendations. It is necessary to raise awareness within the Israeli nursing community and among the ranks of nursing leadership and management as to the importance of workplace support for preceptors' commitment to their role. Such awareness is needed to promote changes in everyday practice. Professionals who offer preceptorship training courses should provide preceptors with appropriate tools to cope with the difficulties of their role. It is necessary to investigate why a considerable proportion of the preceptors feel inadequately prepared for their role. In order to attract nurses to commit to the role of preceptor, policy designers must emphasize and promote the intrinsic rewards of preceptorship. These include, first and foremost granting preceptors personal and professional recognition for their role in advancing and promoting the nursing profession in Israel. Other intrinsic rewards include updated clinical and scientific nursing knowledge, improved teaching capabilities, and job satisfaction. Policy designers must also promote the extrinsic rewards of preceptorship, such as the possibility of advancing in their career, in order to raise nurses' motivation to undertake this role. In light of the study limitations, it is recommended to conduct randomized prospective research on preceptors' commitment to their role to confirm the present study findings.
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Bourbonnais, F.F., Kerr, E., 2007. Preceptoring a student in the final clinical placement: reflections from nurses in a Canadian hospital. J. Clin. Nurs. 16 (8), 1543–1549. Brislin, R.W., 1970. Back-translation for cross-cultural research. J. Cross-Cult. Psychol. 1 (3), 187–216. Carlson, E., Pilhammar, E., Wann-Hansson, C., 2009. Time to precept: supportive and limiting conditions for precepting nurses. J. Adv. Nurs. 66 (2), 432–441. Dibert, C., Goldenberg, D., 1995. Preceptors' perceptions of benefits, rewards, supports and commitment to the preceptor role. J. Adv. Nurs. 21 (6), 1144–1151. Hales, A., Karshmer, J., Williams, J., Mann, A., Robbins, L., 2004. Preparing for prescriptive privileges: a standard for psychiatric-mental health preceptorship. Perspect. Psychiatr. Care 40, 93–101. Hallin, K., Danielson, E., 2009. Being a personal preceptor for nursing students: registered nurses' experiences before and after introduction of a preceptor model. J. Adv. Nurs. 65 (1), 161–174. Hautala, K.T., Saylor, C.R., O'Leary-Kelley, C., 2007. Nurses' perceptions of stress and support in the preceptor role. J. Nurses Staff Dev. 23 (2), 64–70. Henderson, A., Fox, R., Malko-Nyhan, K., 2006. An evaluation of preceptors' perceptions of educational preparation and organisational support for their role. J. Contin. Educ. Nurs. 37 (3), 130–136. Hyrkas, K., Shoemaker, M., 2007. Changes in the preceptor role: re-visiting preceptors' perceptions of benefits, rewards, support and commitment to the role. J. Adv. Nurs. 60 (5), 513–522. Kemper, N., 2007. Win–win strategies help relieve preceptor burden. Nurs. Manag. 38 (2), 10–12. Landmark, B.T.H., Hansen Storm, G., Bjones, I., Bohler, A., 2003. Clinical supervision— factors defined by nurses as influential upon the development of competence and skills in supervision. J. Clin. Nurs. 12 (6), 834–841. Lillibridge, J., 2007. Using clinical nurses as preceptors to teach leadership and management to senior nursing students; a qualitative descriptive study. Nurse Educ. Pract. 7 (1), 44–52. Mårtensson, G., Engström, M., Mamhidir, A.G., Kristofferzon, M.L., 2013. What are the structural conditions of importance to preceptors' performance? Nurse Educ. Today 33 (5), 444–449. McCarthy, B., Murphy, S., 2010. Preceptors' experiences of clinically educating and assessing undergraduate nursing students: an Irish context. J. Nurs. Manag. 18 (2), 234–244. Murphy, B.E., 2008. Positive precepting: preparation can reduce the stress. Medsurg Nurs. 17 (3), 183–188. Nursing Administration Circular, 2007. Registered clinical instructor - updated (in Hebrew). Available at: http://www.health.gov.il/hozer/ND68_07.pdf. Omansky, G.L., 2010. Staff nurses' experiences as preceptors and mentors: an integrative review. J. Nurs. Manag. 18, 697–703. Royal College of Nursing, 2005. Guidance for Mentors of Student Nurses and Midwives. Author, London. Smedley, A.M., 2008. Becoming and being a preceptor: a phenomenological study. J. Contin. Educ. Nurs. 39 (4), 185–191. Speers, A., Strzyzewski, N., Ziolkowski, L., 2004. Preceptor preparation: an investment in the future. J. Nurses Staff Dev. 20, 127–133. Yonge, O., Billay, D., Myrick, F., Luhanga, F., 2007. Preceptorship and mentorship: not merely a matter of semantics. Int. J. Nurs. Educ. Scholarsh. 4 (1). http://dx.doi.org/ 10.2202/1548-923X.1384.
References Ben Natan, M., Becker, F., 2010. Israelis' perceived motivation for choosing a nursing career. Nurse Educ. Today 30 (4), 308–313.
Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
The commitment of Israeli nursing preceptors to the role of preceptor Merav Ben Natan a,b,⁎, Hanan Qeadan a,1, Walaa Egbaria a a b
Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Centre, P.O.B. 169, Hadera 38100 Israel Department of Nursing, School of Health Professions, Tel Aviv University, Israel
a r t i c l e
i n f o
Article history: Accepted 1 April 2014 Available online xxxx Keywords: Israel Nursing Preceptor Support Benefits
s u m m a r y Background: Despite the professional importance of the preceptorship role and the rise in participation of nurses in training courses for the position, a significant number of nurses are not committed to this role. The reasons for this trend globally, and in Israel in particular, are not clear. Objectives: The aim of this study is to explore the connections between characteristics of preceptorship, supports, benefits and rewards, and commitment to the preceptor role in Israel. Methods: The present study is a quantitative correlational study. A questionnaire survey was given to a convenience sample of 200 Israeli registered nurses working as preceptors in hospitals and community settings in the northern part of Israel. Results: Respondents showed a moderate commitment to the role of preceptor. Support within nurses' employment framework, intrinsic benefits and rewards, and to a lesser degree, extrinsic benefits and rewards, were found to be related to nurses' level of commitment to the role of preceptor. No correlation was found between support received from outside the workplace and commitment to the role of preceptor. Additionally, no correlation was found between the characteristics of preceptorship (the number of preceptees during the last six months or the average number of preceptees per session), and commitment to the role of preceptor. The most important factor contributing to commitment was support within the nurses' employment framework Conclusions: The present study highlights the importance of support from within the nurses' employment framework, and also the role of intrinsic benefits and rewards, in relation to the level of commitment of Israeli preceptors to their role. © 2014 Elsevier Ltd. All rights reserved.
Introduction Nursing is a practice-based discipline and clinical practice is considered an integral part of nurses' education. The preceptorship model is extensively used in nursing education programs throughout the world (Hyrkas and Shoemaker, 2007). A preceptor is defined in the literature as an experienced nurse, a resource person, and a role model for preceptees. The preceptor facilitates and evaluates learning, fosters independence, development of skills, competencies and confidence, and socializes students or newly hired nurses into the nursing role through direct involvement in the teaching–learning process in clinical settings (Hyrkas and Shoemaker, 2007; Nursing Administration Circular, 2007). In the literature, preceptor and mentor are terms that are often used synonymously and interchangeably (Yonge et al., 2007). For the study reported in this paper, the term preceptor was chosen.
⁎ Corresponding author at: Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Centre, P.O.B. 169, Hadera 38100 Israel. Tel.: +972 4 6304367/9; fax: +972 4 6304730. E-mail address: [email protected] (M.B. Natan). 1 Tel.: +972 4 6304367/9; fax: +972 4 6304730.
Despite the rise in participation of nurses in preceptorship courses, there is evidence that a significant percentage of nurses are not committed to maintaining the preceptor role (Hyrkas and Shoemaker, 2007). Findings of previous studies show that several factors have an impact on the commitment of preceptors to their role. One of them is characteristic of preceptorship. The preceptor role is multi-faceted and complex (Hyrkas and Shoemaker, 2007), having both positive and negative aspects (Omansky, 2010). The preceptor role is a demanding one, and there are responsibilities and stressors associated with teaching students (Omansky, 2010). The increased stress that comes with these responsibilities takes a toll on staff nurse preceptors, and can be a factor affecting nurse retention and burnout (Kemper, 2007). Nurse preceptors experience role ambiguity, role conflict, and role overload; these factors can be overwhelming and lead to exhaustion (Omansky, 2010). Role ambiguity is a lack of definition of the preceptor role, creating a large discrepancy between the envisioned role of the preceptor and the reality of the role (Omansky, 2010). Role conflict is characterized by the requirement to balance demands made by patients and preceptees, resulting in loss of time with patients (Speers et al., 2004) or in an inability to fully attend to the needs of students (Hallin and Danielson, 2009; Carlson et al., 2009). Additionally, as they are
http://dx.doi.org/10.1016/j.nedt.2014.04.011 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
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responsible for errors made by students, preceptors are often torn between wishing to assist students in acquiring clinical experience and needing to protect their nursing license from lawsuits or allegations of malpractice (Hautala et al., 2007). Role overload and a lack of time are additional major issues identified by preceptors in other studies. These factors appear to be the result of misconceptions by managers and coworkers who wrongly interpret what the preceptor role entails and view the nurse preceptor as receiving additional assistance, when in fact the preceptor has additional responsibilities (Omansky, 2010). In this study the characteristics of preceptorship will be represented by two variables: number of preceptees during the last six months and the average number of preceptees per session. Another factor is support. Preceptors report a need for feedback and for recognition of the role of preceptor (McCarthy and Murphy, 2010). Structural conditions such as feedback and support seem to strengthen nurses' general view of their performance as preceptors (Mårtensson et al., 2013). Preceptors need ongoing support from educators, managers and administrators, and the forms and means of support required from each of these actors are different (Speers et al., 2004). Without support, preceptors tend to lose commitment (Hyrkas and Shoemaker, 2007). A supportive work milieu where co-workers acknowledge each other as preceptors has been found to strengthen the preceptor experience (Bourbonnais and Kerr, 2007). Landmark et al. (2003) suggest that the success of clinical supervision is dependent upon a workplace's ability to create supportive frameworks within the workplace, ensuring necessary time for supervising students. Studies exploring preceptors' perceptions of support have shown that the origin of support varies. It is unclear what the significant origins of support for the preceptor are, whether the origin of support is within the nurses' employment framework, e.g., the management or co-workers within the nurses' employment framework, or factors outside the workplace, e.g., school of nursing or the preceptorship training course (Hyrkas and Shoemaker, 2007). Another factor that seems to have an impact on the commitment of preceptors to their role is benefits and rewards. Intrinsic benefits and rewards reported by many nurses are personal growth, a sense of expanding professional abilities (Henderson et al., 2006; Murphy, 2008), facilitating the development of nursing students (Murphy, 2008; Hallin and Danielson, 2009), and the acquisition of educational techniques (Smedley, 2008). Examples of extrinsic benefits of operating as a preceptor which appear in the literature are pay differentials, educational advantages, and opportunities to attend conferences (Hyrkas and Shoemaker, 2007). Several studies show that preceptors value the preceptor role more in intrinsic rather than in extrinsic, i.e., material terms (Carlson et al., 2009; Hyrkas and Shoemaker, 2007; Lillibridge, 2007), in contrast to other studies that have emphasized the importance of extrinsic factors (Henderson et al., 2006; Murphy, 2008). There is ambiguity about the factors related to commitment to maintaining the preceptor role, and the relative impact and contribution of each of these factors. Therefore, the aim of the present study was to explore the connections between characteristics of preceptorship, supports, benefits and rewards, and commitment to the preceptor role in Israel. Methods Design The present study is a quantitative correlational study.
of the Pat Matthews Academic School of Nursing provided the names of 240 preceptors working in the northern part of Israel. The preceptors were contacted by phone and asked to participate in the study. Most of them agreed. Pat Matthews nursing students distributed a questionnaire at various clinical placements. The questionnaires were returned by mail to the primary investigator. The data were collected during January–March of 2013. During this period, the preceptors were twice given reminders by phone to complete the questionnaire. Twohundred preceptors completed the questionnaires, for a response rate of 83%. Instrument A five-part questionnaire was used to collect the data: Preceptor's Perception of Benefits and Rewards (PPBR) Scale, Preceptor's Perception of Support (PPS) Scale, Commitment to the Preceptor Role (CPR) Scale, experiences as preceptor and socio-demographic information section. This questionnaire was developed by Dibert and Goldenberg (1995). The PPBR is composed of 14 items rated on a 6-point Likert scale (1 ‘strongly disagree’ to 6 ‘strongly agree’) exploring the benefits and rewards of the preceptor role. A distinction was made between intrinsic and extrinsic benefits. An example of a typical item for intrinsic factors is: “Being a preceptor improves my self-esteem.” An example of a typical item for extrinsic factors is: “Being a preceptor raises my wage.” As the variable was divided into intrinsic and extrinsic factors, reliability analysis was performed, and the alpha coefficients were: 0.85 and 0.87, respectively. The PPS Scale is composed of 8 items that are also rated on a 6-point scale to measure preceptors' perceptions of support for the preceptor role. A distinction was made between support received within the nurses' employment framework and support received from the school of nursing supervising the preceptorship. An example of a typical item for support within the nurses' employment framework: “I feel that the head nurse of the department supports my work as a preceptor.” An example of a typical item for support received from the school of nursing supervising the preceptorship: “Nursing educators at the nursing school support me”. As the variable was divided into two variables, reliability analysis was performed, and the alpha coefficients were: 0.89 and 0.85, respectively. The CPR Scale is composed of 7 items rated on a 6-point scale to measure commitment to the role of preceptor, i.e., a combination of attitudes that reflect dedication to the role of preceptor. An example of a typical item is: “It is very important for me to continue in my role as a preceptor.” The final 7 questions of the questionnaire were about the preceptorship experience. The questionnaire was translated into Hebrew using a modified Brislin (1970) forward and backward translation approach. Questionnaires were independently translated from the original English into Hebrew by two native Hebrew speakers. The two Hebrew translations were then compared with one another and a common Hebrew translation was developed based on consensus between the translators and the investigators. The new Hebrew translation was then back-translated into English by two native English speakers working independently from each other. These two English back translations were then compared with the original questionnaire by the investigators. Whenever there was a discrepancy between the back-translated questionnaires and the original questionnaire, the translators were consulted and a consensus was reached related to the final Hebrew translation. Reliability analyses of the scales (PPBR, PPS & CPR) were reported by Dibert and Goldenberg (1995) as having alpha coefficients of 0.91, 0.86 and 0.87, respectively.
Sample and Procedure Data Analysis Inclusion criteria were being a registered nurse, completion of the preceptorship course, and currently operating as a nursing preceptor in hospitals and community settings. The clinical placement coordinator
Data analysis was performed with the Statistical Package for Social Sciences (SPSS-PC, version 14, SPSS Inc., Chicago, IL, USA). Descriptive
Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
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statistics were used to depict sociodemographic and professional characteristics, and perceptions of the sample. Pearson correlations were performed to determine the connections between study variables. Additionally, linear regression analysis was performed to predict which factors had the highest level of impact. Reliability analyses of the scales (PPBR, PPS & CPR) in our research were alpha coefficients of 0.94, 0.86 and 0.70, respectively. Ethical Considerations This study was approved by the Tel-Aviv University ethics committee. The participants were asked on two occasions for their agreement to participate: first, by phone, and again at the time of administering the questionnaire. The purpose of the research and that participation was voluntary was explained to the participants. Each of the participants was assured confidentiality and promised that research findings would only be used for purposes of the present study. Written consent was obtained from each participant. Results Respondents' Characteristics The respondents' sociodemographic and professional characteristics are presented in Table 1. The mean age of respondents was 36.7 (SD = 9.2, range 22–60); most were women, native-born and Jewish. All of them had a baccalaureate degree, some had a Master's degree; most had taken at least one advanced course in nursing. Respondents had a mean nursing experience of 13.1 years (SD = 9.6, range 1–43). Most of them were employed full time. They had been working as preceptors for a mean of 4.7 years (SD = 5.6, range 1–34). Most of them worked with nursing students and new nurses. The respondents had worked with 8.3 preceptees on average (SD = 10.8, range 1–80) during the past six months, with 3.5 preceptees on average in each clinical rotation (SD = 2.4, range 1–4). Commitment to the preceptor role The research findings show that respondents had a moderate commitment to their role as preceptors (M = 4.2, SD = 0.7) (Table 2). About 70% of the respondents completely agreed that it is important for them to continue operating as preceptors, and agreed that their decision to work as preceptors was correct. Sixty three percent of
Table 1 The respondents' socio demographic and professional characteristics. Characteristic
Category
%
Female Male
73% 27%
Israel Other
63% 37%
Jewish Arab
69% 31%
BA MA
71% 29%
Yes No
60% 40%
Full time Partial time
74% 26%
Students New nurses
74% 71%
Gender
Country of birth
Nationality
3
respondents completely agreed that they feel proud to be preceptors; however, 24% doubted that they will continue to work as preceptors. Supports The research findings show that the respondents ranked the overall support they received for their role as preceptors as moderate (M = 4.2, SD = 0.9) (Table 2). Two sources of support within the nurses' employment framework which received the highest ranking were support by the head nurse of the department (72%) and by the employer's clinical coordinator (63%). As to sources of support outside the workplace, only 58% of the respondents agreed that teachers at the supervising nursing school supported them by helping solve problems they encounter as preceptors. Additionally, only 64% agreed that the preceptorship training course prepared them adequately for the job. Benefits and rewards The respondents ranked the benefits and rewards of preceptorship fairly high (M = 4.9, SD = 0.7), with intrinsic benefits (M = 5.1, SD = 0.7) ranked higher than extrinsic benefits (M = 4.5, SD = 0.8) (Table 2). The intrinsic benefits ranked highest were contribution to the nursing profession (91%). Correlations A positive correlation of moderate intensity was found between intrinsic benefits and rewards and commitment to the preceptor role (r = 0.30, p b 0.01). A weaker correlation was found between extrinsic benefits and rewards and commitment to the preceptor role (r = 0.16, p b 0.05). A positive correlation of moderate intensity was found between support received within the nurses' employment framework and commitment to the preceptor role (r = 0.22, p b 0.01), but no correlation was found between support from outside the workplace and commitment to the preceptor role (p N 0.05) (Table 3). No correlation was found between the number of preceptees during the last six months or the average number of preceptees per session and commitment to the preceptor role (p N 0.05). To determine the predictors of commitment to preceptor role, a linear regression was performed (Table 4). As the characteristics of preceptorship and support from outside the workplace were not found related to commitment to preceptor role, they were not entered into the regression. The findings show that the most important factor contributing to commitment to the preceptor role was support within the nurses' employment framework. The model predictability was found to be 43.2%. Discussion and Conclusions The respondents' commitment to the preceptor role was moderate, and this finding is consistent with previous international research (Omansky, 2010). Factors found to be related to commitment to the role of preceptor were similar to those reported by previous studies
Professional education Table 2 Means and standard deviations of respondents' perceptions.
Advanced course in nursing
Employment
Type of preceptees
CPR PPBR Intrinsic Extrinsic PPS Within nurses' employment framework Outside the workplace
M
SD
4.2 4.9 5.1 4.5 4.2 4.5 4.1
0.7 0.7 0.7 0.8 0.9 1.1 0.9
Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
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Table 3 Pearson correlations between research variables and commitment to the preceptor role.
Commitment to the preceptor role
Intrinsic benefits and rewards
Extrinsic benefits and rewards
Support within nurses' employment
Support from outside the workplace
Number of preceptees
Number of preceptees per session
0.30**
0.16*
0.22**
0.13
0.12
0.08
p b 0.05, **p b 0.01*
(Hyrkas and Shoemaker, 2007; McCarthy and Murphy, 2010; Speers et al., 2004). These include support within the nurses' employment framework, intrinsic benefits and rewards, and to a lesser degree, extrinsic benefits and rewards. The research findings validate the literature that describes support as important for preceptors (Omansky, 2010). Nonetheless, respondents attributed greater significance to support received within the nurses' employment framework, and particularly by the head nurse, than to support from outside the workplace. Moreover, support from the workplace was also found to be related to readiness to commit to the role, while support outside the workplace was not. This finding may be explained by the fact that preceptors usually combine their work as preceptors and as staff nurses. The workload required by the combined role and the ability to find time for their work as preceptors largely depends on the collaboration of preceptors' management and co-workers to distribute the workload (Omansky, 2010). In comparison to UK and other countries, the workload of preceptors in Israel is high: in UK, a maximum of two students per mentor is allowed (Royal College of Nursing, 2005), whereas in Israel, the number of preceptees per preceptor may reach six students. This includes tasks such as allocation of shiftwork and responsibility for patients (Omansky, 2010). In contrast, the support from factors outside the workplace, such as the supervising nursing school, although important, is limited to solving pedagogical problems involved in the perceptorship (Carlson et al., 2009; Hallin and Danielson, 2009). Furthermore, contact with the supervising nursing school is very limited compared to daily contact with managers, clinical coordinators and co-workers within the nurses' employment framework. The research findings indicate that the work of clinical preceptors in Israel involves a heavy workload, and that nursing managers do not always give preceptors enough time for their work as such. Additionally, the findings show that co-workers do not always cooperate and help alleviate the workload of preceptors. Work overload may be the result of managers and co-workers not realizing that the preceptor role entails additional responsibilities, rather than additional assistance from preceptees (Omansky, 2010). Another reason for the frequent inability of preceptors to find time for this role is the realistic constraint resulting from the shortage of nurses in Israel, leading to the need to combine staff nurse and preceptor roles (Ben Natan and Becker, 2010). In light of the finding that support from inside nurses' employment framework was found to be the most important factor contributing to the
prediction of commitment to the preceptor role, the insufficient support that Israeli preceptors receive may lead to lesser commitment. In the present study, preceptorship training courses did not arise as a significant contributing factor of support from outside the workplace to the respondents' commitment to the preceptor role. Sixty-four percent of the respondents felt that the preceptorship training course did not prepare them sufficiently for the job. This finding is consistent with those of the review conducted by Omansky (2010), whose findings reflect the ambiguity of the preceptor's role and indicate the discrepancy between the envisioned role of the preceptor and the reality of the role. Preceptors in Israel may not receive appropriate tools for coping with certain difficulties that arise on the job, but this subject requires further research. The current research findings support the research literature showing that benefits are important for preceptors (Hyrkas and Shoemaker, 2007). Previous studies show that preceptors value nonmaterial rewards and benefits, such as personal satisfaction, personal growth and competence development, more than material benefits (Carlson et al., 2009; Hales et al., 2004; Hyrkas and Shoemaker, 2007; Lillibridge, 2007). In the current study, intrinsic rewards were also found to be more significant than extrinsic rewards for nurses' readiness to commit to precepting. Significant rewards mentioned by the respondents were their contribution to the nursing profession, updated clinical and scientific nursing knowledge, improved teaching capabilities, and job satisfaction. Nonetheless, the lower ranking of extrinsic rewards by respondents might indicate that policy designers are less appreciative of the role filled by preceptors, as manifested in insignificant salary increments and improbability of advancing in the workplace. Contrary to concerns expressed in the literature about burnout associated with the busy preceptorship schedule (Kemper, 2007), the findings in the present study show that preceptors were committed to their role regardless of the number of preceptees per session, or the total number of preceptees during the last 6 months. A similar finding was reported by Hyrkas and Shoemaker (2007) which found that preceptors who reported positive perceptions of support were committed to their role independently of the number of preceptorships. The present study's findings, as well as Hyrkas and Shoemaker (2007), suggest that support is probably the mediator between commitment to the preceptor role and the workload, be it the number of preceptees per session, or the number of preceptorships. However, this relationship was not investigated in the present study.
Table 4 Summary of linear regression analysis for variables predicting commitment to the preceptor role. Coefficientsa Model
Constant Extrinsic Benefits and rewards Intrinsic Benefits and rewards Support within nurses' employment
Unstandardized coefficients
Standardized coefficients
B
Std. error
Beta
t
Sig.
2.575 −.148 .412 .985
.416 .114 .127 .218
−.138 .344
6.183 −1.304 3.252
.000 .194 .001
1.100
4.516
.000
R2 = 43.2% a Dependent variable: commitment to the preceptor role.
Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
M.B. Natan et al. / Nurse Education Today xxx (2014) xxx–xxx
In conclusion, the present study highlights that commitment of Israeli preceptors to their role derives from both support from within the nurses' employment framework, and also the intrinsic benefits and rewards of the position. Research limitations This research employed a convenience sampling, thus possibly hampering the ability to generalize the findings to the population of Israeli preceptors. Additionally, the research tool is a self-report questionnaire, a fact that may limit the validity of the findings. Respondents might have presented their perceptions in a more positive light than actually prevalent. Moreover, those who completed the questionnaires were probably the most active and enthusiastic of the preceptors. Recommendations The present study suggests several recommendations. It is necessary to raise awareness within the Israeli nursing community and among the ranks of nursing leadership and management as to the importance of workplace support for preceptors' commitment to their role. Such awareness is needed to promote changes in everyday practice. Professionals who offer preceptorship training courses should provide preceptors with appropriate tools to cope with the difficulties of their role. It is necessary to investigate why a considerable proportion of the preceptors feel inadequately prepared for their role. In order to attract nurses to commit to the role of preceptor, policy designers must emphasize and promote the intrinsic rewards of preceptorship. These include, first and foremost granting preceptors personal and professional recognition for their role in advancing and promoting the nursing profession in Israel. Other intrinsic rewards include updated clinical and scientific nursing knowledge, improved teaching capabilities, and job satisfaction. Policy designers must also promote the extrinsic rewards of preceptorship, such as the possibility of advancing in their career, in order to raise nurses' motivation to undertake this role. In light of the study limitations, it is recommended to conduct randomized prospective research on preceptors' commitment to their role to confirm the present study findings.
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Please cite this article as: Natan, M.B., et al., The commitment of Israeli nursing preceptors to the role of preceptor, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.011
