Microsoft Word - Oosterbroek_430-2584-3-ED.docx Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 23 Rural Nursing Preceptorship: An Integrative Review Tracy A Oosterbroek 1 Olive Yonge, RN, PhD, RPsych 2 Florence Myrick, PhD MScN BN RN 3 1 Nursing Instructor, University of Lethbridge & Doctoral Student, University of Alberta, tracy.oosterbroek@uleth.ca 2 Professor, Vargo Teaching Chair, Faculty of Nursing, University of Alberta, oyonge@ualberta.ca 3 Professor Emerita, University of Alberta, amyrick@ualberta.ca Abstract Introduction: Canadians living in rural and remote areas experience lower health outcomes and life expectancy than their urban counterparts. Registered nurses employed in rural and remote areas are often the sole health care provider and are crucial to the delivery of high quality health care. Adequate preparation of future nurses who will work in rural and remote communities is thus essential to ensure access to safe, competent nursing care. Nursing preceptorship is the vehicle through which nursing students become immersed in a particular setting over an extended period of time. The purpose of this literature review is to determine the state of knowledge regarding rural nursing preceptorship. Methods: An integrative review of the literature was conducted using the SPIDER Tool for analysis of qualitative evidence. From a limited pool of relevant articles, over 40 were retrieved published between 2004 and 2015. Of these, 19 articles met the inclusion criteria and were Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 24 included in the review and analysis. Each article was evaluated for adherence to the criteria of ethics and rigor using the Research Appraisal Checklist (RAC) tool of appraisal. Results: Of the 19 articles reviewed, various definitions of rural practice were provided. Standard definitions of rurality and rural practice is currently lacking. Four main themes emerged from the review of the literature around the nature of the rural experience interprofessional collaboration, recruitment and retention of nurses to rural communities and student performance evaluation and feedback. Conclusions: Preparation of future nurses who are competent and confident to practice in rural settings is crucial. Support and preparation required by faculty advisors and preceptors to ensure successful preceptorship experiences is not clearly understood. Recruitment and retention strategies aimed at the shortage of the nursing workforce in rural settings should highlight the unique nature of rural practice. Future research should focus on the challenges experienced by nursing students that may prevent them from seeking employment in rural communities. Keywords: rural nursing, preceptorship, rural preceptorship, rurality Rural Nursing Preceptorship: An Integrative Review The health care needs of rural individuals is an international challenge. In Canada, a country that is largely rural, adequate health care is viewed as a health priority and a right for all residents (Kulig, Kilpatrick, Moffitt, & Zimmer, 2015; Kulig & Williams, 2012). Approximately 30% of the total Canadian population resides in rural communities where significant barriers to health care access are being reported and registered nurses are often the only primary health care providers (Health Canada, n.d.; Kulig, et al., 2015; Kulig & Williams, 2012; Macleod, Browne, & Leipert, 1998; Tambly, 2011; White, 2013). The socioeconomic status of rural residents is Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 25 reportedly lower than in urban communities across Canada (Canadian Institute for Health Information [CIHI], 2002; Jackman, Myrick & Yonge, 2010; Sorenson & DePeuter, 2002). Furthermore, rural Canadians are reportedly the least healthy of the Canadian population, as measured by shorter life expectancy and higher rates of chronic disease, mental health conditions, smoking, and substance abuse (CIHI, 2002, 2006; Kulig, et al., 2015; Kulig & Williams, 2012; CIHI, 2006; Grol, Wensing, Eccles, & Davis, 2013). Kulig et al., (2015) lament a shortage of nurses in rural and remote areas and posit that this occurrence is compounded by the lack of educational preparation of nursing students for rural practice. As few as eight percent of nursing students are exposed to rural practice in undergraduate programs (Edwards, Smith, Courtney, Finlayson, & Chapman 2004). Failure to adequately prepare nurses for the complexity of the rural environment has resulted in poor job satisfaction and poor staff retention (Sedgwick & Yonge, 2008). High levels of staff attrition can be detrimental to the health of rural citizens and more likely to occur when nursing, and other health professionals lack investment in the overall health of the community. Hence, educational preparation of nurses for rural nursing practice is urgently required (Jackman, Myrick, & Yonge, 2010). Rural-based nursing research is increasing but significant gaps continue to persist (Greiner, Glick Kulbok, McKim-Mitchell, 2008). Laurent (2002), for example, identifies that recruitment and retention of health care providers to rural communities has focused largely on physicians. He found rural health professionals work longer hours with fewer resources which, in turn, has a negative impact on work-life balance and employment retention, concluding that educational Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 26 preparation of health professionals who are equipped for the specificity of rural settings is insufficient. Preparation of nursing students for the rapidly changing health care environment, coupled with the ever increasing complexity of knowledge is an ongoing challenge for nursing educators (Yonge, Myrick, & Ferguson, (2011b). The health care needs of individuals and families who reside in rural settings require care from health professionals who are responsive to their unique needs. Geographical distance from primary health care centers and limited resources influence both community needs and the ability of health care service providers to address local health care priorities. Preparation of health care professionals for rural practice is thus essential in identifying and effectively addressing the needs of residents and the promotion of the overall health of the community. Researchers have found that nursing curricula lack integration of contextual values and beliefs specific to rural communities (Dowdle-Simmons, 2013). Other researchers agree that a sustainable rural nursing workforce is dependent upon the educational preparation of nurses specific to the rural environment (Hunsberger, Baumann, Blythe, & Crea, 2009). Not only is the preparation of rural nurses challenging, but the shortage of nursing and other health team members is critical to effectively meet the complexity of rural health care needs (Forbes & Edge (2009). These findings are noteworthy inasmuch as a national nursing shortage looms and strategies for recruitment and retention are urgently required for all settings (Health Canada, n.d.; CIHI, 2002, 2015, 2016; Canadian Nurses Association [CNA], n.d.). Preceptorship provides the vehicle through which students become immersed in a particular setting over an extended period of time (Jackman, Myrick & Yonge, 2012). The preceptorship Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 27 typically occurs in the last year of baccalaureate nursing programs and affords students the opportunity to consolidate their learning. The preceptorship is completed prior to the student’s entry into professional practice and provides full-time immersion in a specific area of practice while being supervised by an experienced registered nurse who is available to them on a one-to- one basis. Preceptorship offers a contextually specific nursing practice experience that is uniquely relevant to the particular setting or nursing practice area. Definitions of Terms To guide the search, the definitions of nursing preceptorship, rural, rurality preceptor and faculty advisor have been provided to clarify the context of the terms. Nursing preceptorship is typically a consolidated nursing practicum that occurs at the conclusion of the undergraduate nursing program. Students are assigned one-to-one with a Registered Nurse (RN) and a faculty advisor from the educational institution. Nursing students are often permitted to self-select the placement settings in which they would like to complete the preceptorship based upon availability of the requested placement. There is an absence of a universally accepted definition of what constitutes rural (Pitblado, 2005; Pitblado, Koren, MacLeod, Place, Kulig, & Stewart, 2013). For the purpose of this review, rural was defined as a community with a population of less than 50,000 residents at least 20 km distant from the nearest urban community (Kulig, et al., 2015). Rurality is viewed as a sense of place and way of life associated with living in a rural community (Balfour, Mitchell, & Molestane, 2008). The preceptors are Registered Nurses (RN), who are employed in acute in-patient or community-nursing role in a rural community. Preceptors are assigned one-to-one with undergraduate nursing students and provide supervision and evaluation of the student’s performance throughout the preceptorship placement. The faculty Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 28 advisors role is to liaise between the nursing students and preceptors. Typically, the faculty advisors orient and provide support to preceptors and students during the practicum and meet with the students and preceptors for evaluations, either face-to-face or remotely via Skype or other mobile technology. Methods The purpose of this literature review was to ascertain the state of knowledge regarding rural nursing preceptorship. The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) Tool (Table 1) for qualitative evidence synthesis was utilized for the purpose of this literature review. Table 1 SPIDER Tool S (Sample) Nursing students in the final practicum (preceptorship) course of a four-year baccalaureate program PI (Phenomenon of Interest) Rural undergraduate nursing preceptorship D (Design) Interview, focus group, ethnography, phenomenology, thematic analysis, grounded theory E (Evaluation) Student, preceptor and faculty advisor experiences related to the challenges or opportunities experienced during the course of rural preceptorship placements R (Research Type) Qualitative, quantitative and mixed methods studies Search Strategy The review was integrative in nature and consisted primarily of automated searches of electronic databases including Academic Search Premier (1995-2015), CINAHL (1995-2015), ERIC (1995-2015), Cochrane Database (2005-2015) and Ovid MEDLINE In-Process and other Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 29 (1995-present), Journals@Ovid Full Text (July, 2015), Your Journals@Ovid, Health and Psychosocial Instruments (1985-2015), OVID Healthstar (1999-2015). Following electronic searching, manual reference checking of selected articles as well as citation searching was conducted. In an attempt to capture seminal publications, current literature and research published in the past ten years was acquired with the search extended beyond this date to 1995. Search terms applied included nursing education, preceptorship, nursing preceptorship, rural preceptorship, preceptorship challenges, preceptorship opportunities, rural and rurality. Truncation and search syntax were applied as per the applicable database to accommodate variations in spelling and word usage. All references were imported and stored using Endnote reference manager. Data Evaluation and Analysis Limited scholarly activity in the area of rural preceptorship was discovered during the search process. Initially, 41 references related to rural preceptorship were retrieved. The studies were reviewed by reading the abstract and scanning the article for inclusion using pen and paper evaluation with the Reporting Assessment Checklist (Carroll, Booth & Lloyd-Jones, 2014). Of these, 19 original research articles were selected for applicability and review. Evaluation of the selected articles was completed to promote clarity, consistency and accuracy of the data extraction process and included the selected references (Table 2). Thematic analysis was conducted by the authors to synthesize extracted data (Walker, Rossi, Anastasi, Gray-Ganter, & Tennent, 2016) from which the main themes and subthemes emerged from the individual articles and across articles. Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 30 Results A slowly growing number of articles have been published on rural preceptorship. The majority of authors focused on operationalization of rural preceptorship. Evaluative research studies remain limited. Student, faculty advisor and nurse preceptor perspectives of rural preceptorship, its benefits to interprofessional collaboration and recruitment and retention, and the issues related to students’ evaluations were commonly found in the existing research. Table 2 Rural Nursing Preceptorship Research Articles # Author/Date Sample Design Ethics/Rigor Outcomes 1 Charleston & Goodwin, 2004 n=167 quant survey NA/NA Rural preceptorship (RP) workshop imp/evaluation 2 Jackman 2011 n= qual GTb √/√ Relational process r/t RP 3 MacDowell, Glasser, Weidenbacher- Hoper, & Peters, 2015 n=52 quant PPc √/NA Interprofessional RP 4 Meyer Bratt, Baernholdt, & Pruszynski, 2014 n=468 quant LCa NA/NA Rural/urban preceptorship outcomes 5 Pront, Kelton, Munt, & Hutton, 2013 n=7 qual CSd √/NA RP and student learning 6 Schoo, McNamara, & Stagnitti, 2008 n=110 qual PP √/√ Recruitment/retention r/t RP 7 Sedgwick 2011 n=8 qual EDe √/√ Rural interdisciplinary preceptorship 8 Sedgwick & Rougeau 2010 n=32 qual CITf √/√ Belonging r/t rural preceptorship 9 Sedgwick & Yonge, 2008 n=12 qual FEg √/√ Meaning of socialization r/t rural preceptorship 10 Sedgwick & Yonge, 2009 n=12 qual FE √/√ Student perception of faculty involvement in R/P 11 Sedgwick, Yonge, & Myrick, 2009 n=12 qual FE √/√ Multidisciplinary approach 12 Yonge 2009 n=11 qual GT √/√ Boundaries r/t rural preceptorship Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 31 13 Yonge, Ferguson, Myrick, 2006 n=49 qual GT √/√ Preceptor/student RP experiences 14 Yonge, Hagler, Cox, & Drefs, 2008 n=12 qual SRh √/√ Limited evidence r/t preceptor development 15 Yonge, Myrick, & Ferguson, 2011(a) n=23 qual GT √/√ Evaluation framework for rural preceptorship 16 Yonge et al., 2011(b) n=23 qual GT √/√ student perspectives of feedback during RP 17 Yonge et al., 2011(c) n=26 qual GT √/√ Evaluation processes r/t RP 18 Yonge, Myrick, Ferguson, & Grundy, 2013(a) n=8 qual PARi pv √/√ Rural context r/t team preceptorship 19 Yonge et al., 2013(b) n=8 qual PAR pv √/√ Rural landscape perspectives r/t RP Note: a longitudinal cohort design; b grounded theory; c pre-posttest; d case study; e exploratory descriptive; f clinical incident technique; g focused ethnography; h systematic review; I participatory action research Examination of the challenges experienced by the members of the preceptorship triad engaged in rural preceptorships were not evident in the existing literature. The four main themes which emerged from the analysis of the current literature entailed the nature of the rural experience, the importance of interprofessional collaboration, issues related to recruitment and retention of nurses to rural communities, and factors associated with student performance evaluation and feedback. Within each of the main themes, patterns of subthemes were identified and found across articles (see Table 3 – Themes and subthemes). The Rural Experience In a study by Yonge et al. (2013a) the rural experience was captured vividly through the use of photographs. These researchers supported previous findings regarding the urgent need for increasing opportunities for nursing students in rural practice settings, more curricular emphasis on rural health, and context specific preparation related to content and skills. Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 32 Table 3 Themes and subthemes Rural experience Interprofessional Collaboration (IPC) Recruitment and Retention Evaluation and feedback Coping with challenges Belonging to community Nature of teaching and learning Benefits of IPC Belonging to the team Understanding of roles Relational process and authentic rural experience Inconclusive trends data related to undergraduate placements and employment statistics Preceptor preparation and support Relationship between student-preceptor- faculty advisor Challenges They found the rural landscape as being representative of the physical environment of the rural community signifying the essence of the rural identity that served to inform student and preceptor’s perceptions of the rural community (Yonge et al., 2013b). Space and distance were key findings illustrating the time required for rural residents and health care providers to travel to access local services such as schools, and health services. Belonging was found to be a defining factor of rural preceptorship in three of the articles reviewed. Students must find their way into the close-knit culture of the community that exists in the rural settings (Sedgwick & Rougeau, 2010). These researchers found that the spirit of community was a central tenet of rural life and concluded that successful teamwork was the key to successful rural preceptorship. Meyer Bratt et al., (2014) affirmed the importance of a sense of belonging as being influential to one’s intention to seek employment upon completion of the nursing placement. Sedgewick and Yonge (2008a) concluded that experiences of belonging significantly impact the preceptorship experience for both students and preceptors alike. Hence, students who are supported in learning, feel safe to ask questions and learn from errors. In 2011, Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 33 Jackman explored the relational process of teaching and learning during rural preceptorships from the perspective of the students, preceptors and faculty advisors. She found students whose rural preceptorships exemplified an authentic rural experience were more likely to remain and practice in the rural setting following completion of the preceptorship. Challenges of living and working (learning) in a rural community was a finding in three of the articles reviewed. Yonge et al., (2006) found that most, but not all of the students involved in their study, requested a rural placement for the preceptorship, motivated by their desire to live and work there after graduation. However, even those who did not request rural placements reported the experience as one that was positive, thus rejecting their preconceived ideas about rural nursing. While the purpose of this research study focused on the teaching and learning process, some of the students reported challenges they experienced during rural preceptorship, for example, limited technology, a sense of isolation and unpredictability of patient census. The level of complexity of patient care pleasantly surprised the students and was viewed as a benefit of rural preceptorship by their preceptors. These findings reinforce the importance of developing a sustainable rural preceptorship placement as a recruitment and retention strategy. In their study, Pront et al., (2013) reported similar findings related to living and learning in the rural environment. They found that preceptorship in rural communities provided many of the same learning opportunities as corresponding urban experiences. The students were surprised by the level of complexity in rural nursing. However, students described the high levels of complexity at times as “chaotic” and “overwhelming” (Pront et al., 2013, p. 284) which, in turn, had at times a negative impact on their learning. Professional relationships and boundary issues Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 34 were also reported by students as adding to the complexity of the rural preceptorship experiences (Pront et al., 2013; Yonge, 2009). Interprofessional Collaboration Eight research teams reported that interprofessional collaboration is intrinsic to effective health care service delivery in the ability of health care providers to interact and collaborate with other team members in the planning, provision and evaluation of service delivery. MacDowell et al., (2015) found dysfunctional teamwork as one of the leading causes of health care errors while increased knowledge regarding the roles of other health care professionals resulted in an attitudinal change toward working within interprofessional teams. These findings are supported by other nursing researchers who have explored the benefits and necessity of interprofessional education in nursing education, in particular during preceptorship (Sedgwick, 2011; Sedgwick & Rougeau, 2010; Sedgwick & Yonge, 2008; Sedgwick et al., 2009; Yonge et al., 2013a). In 2009, Sedgwick and Yonge conducted an ethnographic study in rural communities examining precepted students’ perceptions of learning in a rural-based hospital. Overwhelmingly, the students reported feeling as authentic members of the interprofessional team in the rural placement unlike their former supervised clinical experiences in urban settings. However, another study conducted by Sedgwick (2011) found integration with members of the interprofessional team required deliberate planning by preceptors and faculty advisors to ensure students were allocated time to spend with different members of the health care team. Sedgwick (2011) found it was essential that students and healthcare team members be provided information regarding roles and responsibilities of each of member of the team. How best to plan and implement interprofessional experiential learning opportunities aimed at a number of improvements such as recruitment, retention, and improved patient outcomes was Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 35 identified in five of the research articles reviewed. Researchers explored the benefits and necessity of interprofessional education in nursing education, in particular during preceptorship (Sedgwick, 2011; Sedgwick & Rougeau, 2010; Sedgwick & Yonge, 2008; Sedgwick et al., 2009; Yonge et al., 2013a). The ways in which rural and urban preceptorship differ may have an impact on the student’s experience of belonging and the efficacy of the interprofessional team. Recruitment and Retention Whether or not rural preceptorship influences future employment is, to date, poorly understood but was identified as a focus of three of the articles reviewed. On average, 12-50% increased interest has been noted following rural clinical experiences, although these findings are not limited to nursing preceptorship placements (Courtney, Edwards, Smith & Finlayson, 2002; Schoo et al., 2008). The placements included supervised clinical placements and non-nursing, allied health student placements (Courtney, et al., 2002; Schoo et al., 2008). While these placements are recognized as a recruitment strategy for nursing units in rural and urban centers, Schoo et al. (2008) noted post-preceptorship employment data is inconclusive. Retention of rural nurses, especially in specialty areas such as psychiatry, is an ongoing challenge internationally (Charleston & Goodwin, 2004). These researchers propose that successful preceptorship in rural and specialty practice areas may be effective as a recruitment and retention strategy. They identified some challenges related to the logistics of rural course delivery, most specifically evaluation and feedback, and found support for students to be one of the key indicators of a successful preceptorship experience. Evaluation and Feedback Of the articles reviewed, issues related to students’ performance evaluation emerged as a finding in four articles. Student evaluation during preceptorship is a combined effort which takes Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 36 place among members of the preceptorship triad: the student, preceptor and faculty advisor. Students may be required to complete some type of self-evaluation, however, the evaluation of their progress typically is a joint endeavor among the triad. The determination of the final grade whether it be pass/fail or a letter, is usually the sole responsibility of the faculty advisor (Sedgwick & Yonge, 2009). Throughout the process, it is important students and preceptors feel supported by the faculty advisor despite the lack of physical distance and presence. Thus, a variety of resources such as texting, telephone, Skype, teleconference or videoconference are used. This study by Sedgwick and Yonge was limited to student perceptions of faculty involvement during preceptorship. Other researchers have found preceptors report that ongoing and consistent contact with the faculty advisor enhances their feelings of confidence and preparation for the preceptor role (Yonge et al., 2008). In a study examining evaluation between students and preceptors, students reported formative evaluation to be the most frequently used and most effective form of feedback from their preceptors (Yonge, et al., 2011b; 2011c). The students were less clear about their role in the evaluation process but identified receptivity to feedback as their responsibility. Preceptors, on the other hand, identified challenges related to student evaluation, stating they often felt ill equipped to conduct and document evaluation feedback. The preceptors indicated they often sought assistance from the students with the actual use of the evaluation tool and required orientation to the evaluation process that was context specific. In the second phase of the same study, Yonge et al., (2011b) investigated the most effective evaluation tools and models for use by preceptors during the rural preceptorship. They found rural preceptors require more support than their urban counterparts. Physical distance makes it Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 37 difficult for faculty members and preceptors to meet frequently in person. As a result, the rural preceptor may, in fact, receive less faculty support than urban preceptors. An outcome of the research was a framework depicting the roles and expectations of each member of the preceptorship triad that need to be explicit prior to commencement of the preceptorship. Other key concepts the researchers addressed, included criteria with regard to what is evaluated, by whom, when, where, why and how. The framework was developed to provide preceptors with distinct strategies to address each of the components. Discussion The themes that emerged from the analysis of the data provide the foundation for the current state of the knowledge concerning rural preceptorship (see Figure 1 – Results model). These themes reportedly influenced students, preceptors and faculty advisors’ perceptions of preceptorship success in the rural context and in some studies were suggestive of an enhanced desire of graduates to seek permanent employment in the rural setting. Students, preceptors, and faculty advisors’ preparation and support throughout preceptorship, are concepts gleaned from the analysis of the data as being integral to mitigating the challenges associated with rural preceptorship. Adequate preparation of each member of the preceptorship triad is essential to the success of the preceptorship. Preparation for preceptorship in rural settings is still not clearly understood. Orientation of each member of the preceptorship triad is essential for success in any preceptorship setting. Inadequate understanding of the roles, responsibilities and expectations of each of the members of the triad can lead to miscommunication and unrealistic expectations. Strategies to provide Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 38 orientation for preceptors in rural locations who do not necessarily meet face-to-face with the faculty advisor present unique challenges. Figure 1 Results Model Challenges experienced by students during preceptorship have the potential to impede their ability to cope with rural preceptorship. Issues related to isolation are vast and range from travel concerns to accessibility of a student’s psychosocial support system during the preceptorship. A review of the literature conducted by Killam and Carter (2010) addressed the challenges of rural Student Preceptor Faculty Advisor Rural Experience Interprofessional Collaboration Recruitment and Retention Evaluation and Feedback Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 39 nursing clinical placements. They concluded the most common sources of challenges for nursing students fall into seven categories: political, environmental, community, nursing, organizational, relational and personal. While these researchers identified a variety of challenges that nursing students face, they affirm that more research must be conducted to purposely address the specific challenges unique to rural practice placements. Doing so, they concluded, has the potential to positively influence long-term recruitment and retention of rural nurses. What is more, researchers have found that students who report positive rural preceptorship experiences are inclined to stay and work in the rural setting (Crow, Conger, & Knoki-Wilson, 2011; Edwards, et al., 2004; Hunsberger, et al., 2009; Killam & Carter, 2010; Webster, Lopez, Allnut, Clague, Jones & Bennett, 2010). Only one study (Yonge, et al., 2011b) identified challenges of evaluation experienced by preceptors and students concerning conflicting perceptions of students’ progress. However, strategies to address these challenges have not been specifically explored. Moreover, the evaluation process during the rural preceptorship may create unique challenges for students and preceptors who are only able to communicate remotely with their faculty advisors. By lacking face-to-face meetings, students may feel isolated and unsupported when receiving difficult feedback, while preceptors may experience difficulty in delivering feedback to the struggling students. More research is needed to understand the perspective of preceptors and students regarding the evaluative component of preceptorship. Recommendations for Future Research High quality health care delivery is a Canadian priority (Canadian Health Services Research Foundation [CHSRF], 2006; LoBiondo-Wood, Haber, Cameron, Singh, 2012). Further Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 40 research is needed to address gaps that exist in the current literature regarding rurality and rural preceptorship. Preceptorship is inherently a high stakes clinical placement that takes place at the completion of the undergraduate nursing program. Failure or inability to successfully complete the preceptorship can result in a devastating cascade of events for students that includes a potential delay of graduation, inability to write the licensure exam, and failure to secure employment. Nursing students who complete practice placements in rural settings may be faced with challenges that are unique to the rural setting and irrelevant in urban settings. An increased understanding of the challenges and opportunities nursing students or future nurse’s experience as part of rural nursing practice can: a) foster an environment conducive to the creation of strategies to address these challenges; and b) maximize the opportunities to enhance not only student learning, but recruitment and retention of nurses to rural communities. This approach has the potential to increase students’ motivation to choose rural placements that not only expose them to rural practice, but also provide incentive for rewarding employment opportunities (Edwards, et al., 2004). Students who request preceptorship in their home rural community are faced with challenges unique to the rural setting regarding confidentiality and boundaries. More research is needed to address both the challenges and opportunities experienced by these students and preceptors as well as development of strategies to assist these students to navigate the unique nature of close personal relationships that are common in small rural settings. Whether or not the challenges experienced by students during rural preceptorships deter them from seeking Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 41 employment in that setting is unclear. Research is thus required to develop a more coherent understanding of the relationship between rural placements and rural employment. Other factors that have not as yet been examined include the current job and employment market in the rural and corresponding urban centers, as well as student motivation to seek rural placements and preceptorships beyond the students’ desire to return to their home community. The degree to which consistent support received by students and preceptors from the faculty advisors throughout the preceptorship influences overall satisfaction with the preceptorship and intent of graduates to seek employment, is not clearly understood. Challenges faced by nursing students during rural preceptorship and the supports required to ensure success have not been examined. For example, how students experience belonging in rural preceptorship and how belonging influences interprofessional team effectiveness. Lastly, how nursing students cope with the isolation of rural practice has not been thoroughly examined. Recently, researchers examined the learning needs of newly graduated nurses and found that preparation for rural practice in addition to support and mentorship for new graduates in the rural setting is indeed required for successful recruitment and retention of a rural nursing workforce (Sedgwick & Pijl-Zieber, 2015). However, lack of clarity concerning preparation is two-fold: whether nursing students are prepared for preceptorship in rural settings and whether the rural preceptorship prepares them for entry to practice in the rural settings. Hence, preparation of nursing students prior to rural preceptorships requires examination. What’s more, support and preparation required by preceptors and faculty advisors related to evaluative processes of preceptorships is not clearly understood. Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 42 Further research is need to generate solutions to the aforementioned points as well as the following questions: 1. What are the factors unique to the rural experience and how do these factors directly influence students learning and success? 2. What are the challenges and opportunities experienced by nursing students, faculty advisers and preceptors during rural preceptorships? 3. How do nursing students cope with the isolation of rural practice? 4. What are the motivators of nursing students who seek employment in rural communities? 5. How does the undergraduate nursing curricula prepare nursing students for preceptorships in rural communities? 6. Do nursing students and preceptors in rural communities have unique preparatory needs that are significantly different from their urban counterparts? Recommendations for Nursing Education The purpose of this integrative review was to assess the state of the current knowledge regarding undergraduate nursing preceptorship in rural communities. The following recommendations are offered based on the themes and subthemes that emerged as a result of this review and are intended as a basis for collaborative endeavors between the educational institution and practice partners: 1. Identify strategies to circumvent the challenges intrinsic to practice in rural communities that have the potential to negatively impact student learning. 2. Create and implement specific strategies to ensure consistent support for students and preceptors throughout the duration of the preceptorship. Online Journal of Rural Nursing and Health Care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 43 3. Delineate the roles and responsibilities of each member of the interprofessional team and provide these definitions for students and preceptors during site orientation. 4. Ensure site-specific orientation as an essential component for nursing students prior to commencement of the preceptorship. 5. Explore the potential to increase opportunities for supervised practice placements in rural communities. 6. Develop and deliver annual preceptor-orientation sessions or workshops to address issues related to rural preceptor preparation. 7. Address issues related to entry-to-practice transition to enhance students’ interest and desire to “go rural, and stay rural” (Sedgwick & Yonge, 2008). Conclusion The body of knowledge concerning rural nursing preceptorship is growing but gaps persist. To date, it remains unclear as to how best to effectively prepare and support students and preceptors in rural settings. The challenges and opportunities in rural preceptorships need to be examined to improve the preceptorship experience for the student and preceptor, assist in developing recruitment strategies for the new graduate and address challenges such as a sense of isolation. Researchers have identified the importance of forming relationships, belonging to a team and being in a community. There are significant teaching and learning opportunities when students are placed in a rural setting for their preceptorship practicum. 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