Rural Boundaries- Student Perspective 5 PRECEPTORSHIP RURAL BOUNDARIES: STUDENT PERSPECTIVE Olive Yonge RN PhD1 1Professor & Vice-Provost Academics, Faculty of Nursing, University of Alberta, olive.yonge@ualberta.ca Key Words: Nursing Education, Nursing Students, Boundaries and Education, Preceptorship ABSTRACT This is one part of a grounded theory study that explored the perceptions of both students and preceptors regarding the student-preceptor relationship in a rural setting and the boundaries that must be developed to ensure it is successful. The success of preceptorship lies largely with the preceptor-student relationship and thus, the importance of developing and maintaining professional boundaries is paramount. This is particularly key in rural settings where boundary issues are explicit and challenging and the physical presence of a faculty instructor is often an impossibility. This article will focus on the perceptions of seven nursing students and is the first grounded theory study exploring nursing students' perceptions of learning and boundaries in a rural setting. The resulting core variable was learning and the psychosocial processes were the relationship they formed with their preceptors and members of the health care team. Students were highly professional and respected boundaries in their relationship with team members. INTRODUCTION If there’s anything blocking that relationship, or the relationship has crossed a boundary where you’re friends and you’re not within a professional boundary, then some things can get missed, and maybe I might not be evaluated as strictly as maybe I should be or something. The establishment of a professional relationship between student and preceptor is integral to the preceptorship experience as well as the transition from student nurse to practitioner. Implicit in the development of a professional relationship is the formation and maintenance of professional boundaries. The importance of these boundaries is heightened in a rural setting where practitioners work within a small community where visibility is high and confidentiality difficult to maintain. The lack of professional resources makes this challenge that much greater. Additionally, faculty support is limited by distance constraints and thus students and preceptors in rural areas who have greater awareness of boundary issues are left without this important source of support. Thus, this research aims to understand how professional boundaries are understood in the rural setting and how they are developed and maintained within the student-preceptor relationship. Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 http://www.uofaweb.ualberta.ca/nursing/ mailto:olive.yonge@ualberta.ca 6 SIGNIFICANCE OF THE RESEARCH Nursing shortages have had devastating effects on rural areas and thus it is imperative that education institutions take responsibility for developing recruitment strategies to these areas. For recruitment to be successful, positive work experience in a rural area is cited as a strong factor in influencing graduates to choose rural employment (Neill & Taylor, 2002). Thus, the concern for the educational institution and rural facility is to ensure an effective preceptorship experience. The determinant for a positive experience is largely the student-preceptor relationship and implicit in this relationship are the development and maintenance of professional boundaries. The need for the development of these boundaries is paramount in a setting which relies heavily on teamwork and exists in a small, isolated community where visibility is high and confidentiality low. As there has been little exploration of these issues, this research seeks to identify the processes by which professional boundaries are set, challenges that arise in relation to boundary issues and other factors that determine a positive rural placement experience. REVIEW OF THE LITERATURE The literature has discussed rural preceptorship placements as an educational strategy designed to address rural nursing shortages (Bushy & Leipert, 2005, Edwards, Smith, Courtney, Finlayson, & Chapman, 2004, Van Hofwegen, Kirkham & Harwood, 2005, Neill & Taylor, 2002). Nursing shortages have a devastating impact on rural areas (Neill & Taylor, 2002) particularly for women and children (Bushy & Leipert, 2005). Bushy and Leipert (2005) assert that “the intrinsic value of having an adequate number of adequately prepared nurses in rural communities cannot be overstated”. It has also been found that graduates are more likely to seek employment in areas where they have had previous positive experience (Talbot & Ward, 2000). Students choosing a rural employment most likely have rural backgrounds which have influenced their desire to pursue a rural lifestyle, however, strategies may be developed to provide students with urban backgrounds ‘rural experience’ prior to graduation (Edwards et al., 2004). Additionally, as the majority of clinical placements are centered in urban areas and as nursing graduates are generally unprepared for rural practice, it may be necessary to give students rural exposure or training in rural nursing theory before the opportunity to select placements arises (Edwards et al., 2004). However, Neill and Taylor (2002) found that 59% of their sample chose rural or remote employment after graduation following a rural clinical placement. Though rural areas typically face challenges unique to the rural setting such as isolation, fewer health services, lack of updated resources, and a unique community structure, these paradoxically become assets to student learning and provide a rich variety of learning experiences (Van Hofwegen et al., 2005). Although presenting students with the issues of confidentiality in a small community and isolation from health service colleagues and resources, students are given the opportunity to become ‘expert- generalists’ and generally are offered a greater variety of learning experiences in the rural placement setting (Bushy & Leipert, 2005). Consequently, students reported greater confidence, competence and organizational skills both prior to and following a rural Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 7 placement experience (Edwards et al., 2004). In terms of education for community health, authors suggest that a rural placement offers students the ‘big picture’, giving them the view that they are nursing not merely an individual, but a community (Neill & Taylor, 2002). The rural setting is a nontraditional and innovative setting for learning concepts such as population health, health promotion and community development (Van Hofwegen et al., 2005). Furthermore, the rural setting allowed students to live and participate in the community in which they worked, giving them a sense of the community structure and the pattern of rural life (Van Hofwegen et al., 2005). Edwards et al. (2004) discovered that students improved their skills for rural work, appreciated the variety implicit in such an experience and increased their awareness of opportunities in rural placements and employment. Students that tend to choose a rural placement do so based on personal lifestyle choices, professional goals and personal financial, family and employment situations (Bushy & Leipert, 2005; Edwards et al., 2004). One major obstacle for students pursuing a rural placement is the financial burden involved in relocating to a rural area, transportation and the inability to continue part-time employment (Edwards, Courtney & Finlayson, 2001). Thus, it is necessary that adequate financial support be made available for students during these clinical placements (Neill & Taylor, 2002). Lastly, students reporting high levels of confidence and competence in their abilities prior to their placement experience were more likely to choose a rural placement, reflecting the perception of rural nursing as a specialty requiring high levels of initiative, competence and self-confidence (Edwards et al., 2004). Thus, incorporating rural theory and practice perspectives into nursing curriculum, inviting rural practitioners as guest lecturers to speak with students, and exposing students to the rural context through short-term placements are suggested strategies that may increase familiarity and confidence, encouraging more students to choose a rural placement (Bushy & Leipert, 2005). There is very little research either on the preceptor-student relationship while in the rural placement setting nor on boundary issues that may arise. Thus the research question for the students was, "How do you create and maintain professional boundaries while learning nursing in a rural setting?" METHODS Seven nursing students in their final clinical placement were recruited through in- class presentation and asked to participate in the study. Written consent was granted before interviews commenced and before transcripts were released to researchers. Permission was granted from the Dean of the Faculty of Nursing and the Ethics Review Committee. Data was collected through semi-structured interviews following an interview guide consisting of open-ended questions. This helped to facilitate participants’ freedom of response and allowed for the researcher to clarify responses. To reveal “what is actually going on rather than what ought to be going on”, the researcher chose a grounded theory method (Glaser, 1978, p. 14). Two reasons that support the use of grounded theory is the general lack of research in the area of preceptorship particularly in the area of boundary formation and the need for more Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 8 middle-range theories in nursing education that can be empirically tested (Streubert & Carpenter, 1999). To maintain rigour, four specific criteria were used: credibility, fittingness, auditability, and confirmability (Guba & Lincoln, 1989). Preceptors reviewed transcripts, two independent external researchers reviewed the transcripts for themes, participant observation was used and field notes captured when saturation was achieved. The limitations for grounded theory are the inability to generalize to other settings. The data captures the experience of these nursing students at a particular moment in their program. SAMPLE Seven female students in their final year of a four-year Bachelor of Science in Nursing degree were interviewed. Their work experience in the field of nursing was primarily in acute care in the context of university placements, though they had limited experience in the emergency, maternity, surgery, community and mental health. They were completing their final clinical placement of 340 hours at various rural hospitals and community health centres. RESULTS The core variable for the student was learning. They viewed the rural location as an excellent opportunity to learn everything from everyone. Given this was their last course prior to graduation, they realized this was their last opportunity to say "I am only a student nurse". They soon would become registered nurses and hoped they would be ready to assume the responsibilities concomitant with this title. The psychosocial process was the relationship they formed with their preceptor and the rest of the healthcare team. Through these relationships they gained entry into learning about nursing and health care systems. They had a high level of professionalism recognizing they would be evaluated by their preceptors and so needed to be friendly with them but not their friend. She would start by easing back a bit, and then just kind of watching over me, standing in the room and watching what I’m doing, pointing out anything I’m missing, and now it’s got to the point where she just stays out and only comes if I need her. I think that is making me feel more self- confident, being alone, but I always know that she’s there. A major theme that emerged regarding the role of the preceptee was students felt their goal for the experience was to achieve independence, they were responsible for learning as much as possible and they often had to pursue learning opportunities proactively. One student expressed her goal as “learn as much as I can”, and stated that as “a student, I kind of have to get in there and learn what I want to learn”. The preceptor was viewed as a guide after whom they were to model practical methods and professional behaviour. Two students spoke of the preceptee role as a dynamic one, stating “the first day it was to get in the way as much as possible. . . [now] we’re a very strong team.” Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 9 When it comes to learning, sure, I’m still her student, I’m still learning, I’m still green, I’m still wet behind the ears, but she treats me as a colleague and a professional. As a student nurse, she swaddles me a little bit and helps me do growing and all those sorts of things. That’s part of our professional relationship. Regarding the learning/teaching process, the students described any planning, discussion, implementation or evaluation of tasks as very informal. In many situations learning experiences were merely spur of the moment with little opportunity for planning or evaluation. However, all students stressed good communication as essential for building a working relationship and fostering a team-work environment as compensation for the lack of formal discussion time and space. One student particularly noted the lack of time to evaluate and reflect and dealt with a difficult day by “going home and thinking about things and having a good cry. . . there’s no sounding room for that [at the hospital]”. If something comes in interesting, they’ll let me watch, and then the next time that same thing comes in, I can be expected to be- or feel- confident enough to take part in the situation and not just stand back and watch. Students were taught in a three-step process. Firstly by watching the preceptor perform the task and occasionally complimenting this knowledge with background reading or a reference. Secondly, the student would perform the task under the preceptor’s supervision. Lastly, the student was able to complete the task independently using the preceptor as a resource person. Many students appreciated constant constructive feedback so as to know “how they were doing”. Nearly all students noted that they were “comfortable” in their role as a student nurse and felt that they could ask questions when unsure and set limitations on what they felt capable performing. One student described a situation where a doctor asked her to perform a task in his place. With coaching from her preceptor, she was able to set boundaries on what she felt uncomfortable performing. I thought you’d have to be very professional. But it just developed to the point . . . she almost treats me like her child . . . Very caring. If I’m sick, she’s phoning and making sure everything’s okay. She’s just like such a mother to me or a mother-nurse. . . Always looking out for my best interests. Another major theme that arose was that although professionalism must be maintained, students stressed that a personal relationship must also coexist in this type of working environment. One student noted however, if “the relationship has crossed a boundary where you’re friends . . . then some things can get missed, and maybe I might not be evaluated as strictly”. Factors that promoted a positive professional relationship were primarily related to communication and honesty. Some of the students also stressed the need for personalities and learning styles to match. Most students expressed the wish to keep in touch with their preceptors, frequently acknowledged their preceptor as both a Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 10 teacher and colleague in the form of small gifts, lunches and encouragement, but most restricted personal disclosure to a level appropriate for a professional setting. They’ve been really thoughtful and respectful to my learning in offering me a lot of different experiences. Four of the students had requested rural placements or recognized their rural experience was unique in that it allowed them to “get a taste of everything”. One student characterized urban hospitals as being “segmented” into specialized teams and appreciated the breadth of experience her rural placement afforded her. A couple of students recognized the possibility for recruitment to rural areas, but insisted that successful recruitment depended more on lifestyle choice and location of family. Some of the challenges the students identified in the rural setting included gossip, culture bashing (i.e. natives), and occasional lack of updated resources. One student noted, “I ran into so many people at Superstore and stuff that I worked with here- clients- and it’s just different”. DISCUSSION Surprisingly, unlike the focus of all the current literature that has studied rural placements, none of these students had employment opportunities in mind nor were they aware of their placement as a recruitment strategy. They were instead focused on their role as a preceptee and recognized the ultimate goal of any preceptorship experience as the achievement of independence as a graduate nurse. Thus, they actively sought learning opportunities. The desire for students to experience the widest range of learning experiences could be capitalized upon for recruitment to rural placements as they can offer the ‘generalist’ perspective of nursing (Bushy & Leipert, 2005, Van Hofwegen et al., 2005). Students appeared to be highly aware of professional boundaries within the preceptor-student relationship. Their anecdotes also highlighted the importance of setting these boundaries- for instance, in the scenario between the doctor and the student, the student nurse was encouraged by her preceptor to set limits upon the tasks she could safely and comfortably perform. Another area where students recognized the importance of professional boundaries was the area of evaluation. Although a friendly working relationship creates a good working environment, the shift from friendly to ‘friends’ may entail a biased evaluation and an inaccurate assessment of a student’s nursing abilities. In areas where boundary crossings are common- such as gift-giving and self-disclosure- students maintained a level of professionalism appropriate to their workplace. However, these minor boundary crossings should not be seen as negative, but as paving the way for a mentoring relationship to form, further influencing a student to consider rural employment. Students generally identified the rural placement as unique both in the opportunities and challenges it presented them (Van Hofwegen, 2005). However, they felt that factors such as family, the employment of a spouse or lifestyle choice were much more important factors when considering rural employment than their professional experience. This is supported in the literature with students from rural backgrounds and Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 11 students who value rural lifestyle opting for rural employment (Bushy & Leipert, 2005, Edwards et al., 2004). CONCLUSION The opportunities for recruitment to rural areas cannot be explored without giving students an appreciation for the uniqueness and benefits of working in a rural setting. Promoting rural nursing theory and exposure within undergraduate programs may encourage a greater number of students to choose rural placements and for those that do, give them a greater awareness of the opportunities their placement has to offer. However, once in the placement setting, both students and preceptors must be made aware of boundary issues, especially in the rural context, to create a positive student- preceptor relationship. It is this relationship that has the greatest power to influence students while they gain their rural work experience and to sow the seeds for a continuing mentoring relationship that could make the possibility of rural employment much more enticing. However, the key is in the relationship as reflected in this student’s words: I’ll miss her a lot. She’s just been so good to me. She’s so caring and patient. I think that I would never lose contact with her completely, and I’d always like to just stay in touch with her. ACKNOWLEDGMENTS The author would like to acknowledge the following for their assistance: the University Teaching and Research Fund, and Quinn Grundy, Research Assistant. REFERENCES Bushy, A., & Leipert, B. (2005). Factors that influence students in choosing rural nursing practice: A pilot study. Rural and Remote Health, 5, 387. [MEDLINE] Edwards, H., Smith, S., Courtney, M., Finlayson, K., & Chapman, H. (2004). The impact of clinical placement location on nursing students’ competence and preparedness for practice. Nurse Education Today, 24, 248-255. [MEDLINE] Glaser, B.G. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, CA: Sociology Press. Kaviani, N., & Stillwell, Y. (2000). An evaluating study of clinical preceptorship. Nurse Education Today, 20(3), 218-226. [MEDLINE] Neill, J., & Taylor, K. (2002). Undergraduate nursing students’ clinical experiences in rural and remote areas: Recruitment implications. Australian Journal of Rural Health, 10, 239-243. [MEDLINE] Öhlring, K.H., & Hallberg, I.R. (2000). Nurses’ lived experience of being a preceptor. Journal of Professional Nursing, 16, 228-239. [MEDLINE] Smith, S., Edwards, H., Courtney, M., & Finlayson, K. (2001). Factors influencing student nurses in their choice of a rural clinical placement site. Rural and Remote Health, 1(1), 89. [MEDLINE] Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=15885026%5BUID%5D http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=15110433%5BUID%5D http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=10820576%5BUID%5D http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=12230431%5BUID%5D http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=10932997%5BUID%5D http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=15869369%5BUID%5D 12 Streubert, H.J., & Carpenter, D.R. (1999). Qualitative research in nursing: Advancing the humanistic imperative (2nd ed.). New York: Lippincott. Talbot, J., & Ward, A. (2000). Alternative Curricular Options in Rural Networks (ACORNS): Impact of early rural clinical exposure in the University of West Australia medical course. Australian Journal of Rural Health, 8(1), 17-21. [MEDLINE] Van Hofwegen, L., Kirkham, S., & Harwood, C. (2005). The strength of rural nursing: implications for undergraduate nursing education. International Journal of Nursing Education Scholarship, 2, Article 27. [MEDLINE] Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=11040575%5BUID%5D http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=16646922%5BUID%5D