Oosterbrock_548-Article Text-3534-1-9-20190228 Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 64 “Everybody knows your name”: Belonging in Rural Preceptorship Tracy A Oosterbroek, RN, PhD 1 Olive J. Yonge, RN, PhD 2 Florence Myrick, BN, MScN, RN, PhD 3 1 Assistant Professor, Faculty of Health Sciences-Nursing, University of Lethbridge, tracy.oosterbroek@uleth.ca 2 Vice Dean – Professor, Faculty of Nursing, University of Alberta, oyonge@ualberta.ca 3 Professor Emerita, University of Alberta, flo.myrick@ualberta.ca Abstract Background: Inherently, preceptorship, is challenging and stressful for nursing students. To date, there is a dearth of literature concerning the challenges and opportunities experienced by members of the preceptorship triad namely the nursing student, their faculty advisor, and the preceptor. Purpose: The purpose of this study was to explore the challenges and opportunities associated with rural preceptorship by nursing students, their faculty advisors and preceptors. Method: Photovoice was drawn on as a creative approach to participatory action research (PAR). This method has been found to empower and engage participants as co-researchers with the ultimate goal of implementing change derived from the priorities of the community, in this case, the teaching and learning experiences of nursing students (n=9), their preceptors and their faculty advisors (n=5). Findings: As participants described their experiences throughout the rural preceptorship placement, belongingness emerged throughout the data as a predominant theme. Moreover, the Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 65 experience of belonging had a significantly positive impact on student learning and overall rural preceptorship experience. Conclusions: Relationships between the nursing student and members of the health care team were found to be critical to preceptorship success in rural communities and the motivation among new graduates, to seek permanent employment in the rural community post-graduation. Keywords: Rural nursing education, Rural preceptorship, Rural preceptorship, Photovoice “Everybody knows your name”: Belonging in Rural Preceptorship Rural communities, home to more than 30% of the total Canadian population, face significant barriers to health care access, often relying on registered nurses as the only primary health care providers (Kulig & Williams, 2012; Macleod, Browne, & Leipert, 1998). It follows that educational initiatives for rural nursing practice are urgently required (Jackman, Myrick, & Yonge, 2012). Nurses working in rural settings are well positioned to inform and guide knowledge development in this area of nursing practice. The current study presented in this manuscript was guided by the following, broad question: What are the challenges and opportunities experienced by nursing students, preceptors, and faculty advisors during nursing preceptorship placements in rural communities? Additionally, questions addressed connections between rural preceptorship and rural employment factors, particularly recruitment and retention of new nursing graduates in rural settings? Literature Review Socioeconomic status and geographical location are linked to disparities in Canadian health outcomes, the poorest of which are to be found in rural and remote areas (Shields & Tremblay, 2002). While rural nursing research is growing, significant gaps continue to persist (Greiner, Glick, Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 66 Kulbok, McKim-Mitchell, 2008). Laurent (2002) explains that the recruitment and retention of rural health care providers has focused primarily on physicians; and that long hours and scant resources have influenced, negatively, the work-life balance and employment retention of rural health professionals. Specifically, education in rural jurisdictions for most health professionals is insufficient (Laurent, 2002). Numerous barriers may impede rural health professionals’ ability to attain education, related to time, cost and access to basic and continuing educational programs (Francis & Mills, 2011; Leipert & Anderson, 2012). Rural Recruitment and Retention. The influence of rural preceptorship on future employment has yet to be fully understood. On average, 12-50% increased interest has been noted following rural clinical experiences, although this finding encompasses supervised clinical placements and non-nursing, allied health student placements (Courtney, Edwards, Smith & Finlayson, 2002; Schoo, McNamara, Stagnitti, 2008). While these placements are recognized as a recruitment strategy for nursing units in rural and urban centers, post-preceptorship employment data remains inconclusive (Schoo et al., 2008). Meyer Bratt, Baernholdt, and Pruszynski (2014) suggest that differences between urban and rural practice settings must be recognized and specifically addressed. To reduce new staff turnover, and preserve operational resources, it must be determined how rural-specific education influences patient and organizational outcomes (Meyer Bratt et al., 2014). Preceptorship immerses nursing students in a particular setting over an extended period of time (Jackman et al., 2012); nonetheless, the contextual values and beliefs specific to rural communities are frequently absent from nursing curricula (Dowdle-Simmons, 2013). A sustainable, rural nursing workforce is dependent upon educational preparation specific to this environment (Hunsberger, Baumann, Blythe, Crea, 2009). Forbes and Edge (2009) point out that Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 67 the challenges of rural nursing education and rural health care are exacerbated by the shortage of nurses and other health care team members. Such findings continue to be relevant in 2018, where a national nursing shortage, including specialty nursing, nursing faculty, and nursing leadership, exists in many settings, necessitating continuous exploration of strategies related to recruitment, and retention. Edwards, Smith, Courtney, Finlayson and Chapman (2004) posit that the shortage of nurses in rural and remote areas is compounded by nursing students’ lack of educational experience in these settings. The failure to adequately prepare nurses for the complexity of rural environments has resulted in poor job satisfaction and poor staff retention (Sedgwick & Yonge, 2008a). Additional research is required to increase understanding of the factors that may contribute to retention challenges, such as lack of support for professional development as well as lack of resources for spouses and partners. It is, therefore, important to identify effective strategies that prepare nursing students for the diversity, acuity, and complexity of rural nursing practice. The findings reported in this manuscript illustrate some of the challenges and opportunities of rural preceptorship that may impact rural recruitment and retention. Belonging, and Learning. Belongingness, while a relatively recent concept in the nursing literature has been conceptualized extensively by social scientists and psychologists (Anant, 1967; Baumeister & Leary, 1995; Hagerty & Patusky, 1995; Leavitt-Jones, Lathlean, Maguire, & McMillan, 2007). Maslow (1987) conceptualized belonging as a basic need, required to progress along the path to self-actualization. Others theorized similarly, suggesting that humans are fundamentally motivated to achieve belongingness (Buameister & Leary,1995). Their view differed somewhat from that of Maslow, in that lack of belongingness as a fundamental need would result in detrimental health Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 68 effects similar to the consequences of similar unmet basic needs. Whether a fundamental basic need or fundamental motivational factor, experiences of belonging has been found by researchers to have a positive impact on student learning, and the lack of belongingness has resulted in detrimental psychological impacts including stress, anxiety, depression, alterations in self-esteem that some authors suggest may impede learning (Grobekcer, 2016; Levett-Jones et al., 2007). While some students undertake final preceptorships in their home communities, they may find themselves inadequately prepared nonetheless, especially in rural settings (Sedgwick & Yonge, 2008a). A sense of belonging significantly influences the preceptorship experience, for both students and preceptors alike; students who feel supported in their learning, in turn, feel safe to ask questions and make errors (Sedgwick & Yonge, 2008b). Students are empowered by the authentic relationship that develops between teacher and student; in the case of preceptorship, the nursing staff and preceptor assigned to the student. More recently, this authentic relationship has been described as a genuine partnership that facilitates student learning through collaboration and the mutual sharing of ideas (Perry, Henderson, & Grealish, 2018). Experiences of belonging to the team has been found to have numerous benefits including self-directed, self-motivated learning, and feelings of empowerment among students. A sense of belonging to the rural community has been associated with increased job satisfaction and the intention to seek employment upon completion of the nursing placement (Borrott, Day, Sedgwick, & Levett-Jones, 2016; Meyer Bratt et al., 2014). These findings link successful rural placements with nursing recruitment. In an ethnographic study, Sedgwick, Yonge, and Myrick (2009) examined students’ perceptions of learning in a rural-based hospital. Overwhelmingly, the students reported feeling as though they belonged to the team, in contrast to their previous, urban clinical experiences. Rural preceptorships engage all members of the health Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 69 care team in supporting student learning. This approach differs from urban settings, wherein the registered nurse is primarily responsible for support and supervision of the student (Sedgwick & Myrick, 2009). Jackman (2011) explored the relational process of teaching and learning during rural preceptorships, from the perspectives of the student, preceptor and faculty advisor. She found that health care staff and community members adopted supportive roles, similar to those of the preceptor and faculty advisor. Students who experienced authentic rural experiences were more likely to remain and practice in the rural setting following the preceptorship. Negative consequences of social exclusion or absence of belonging, include anxiety or depression, distract the student, while drawing their attention away from learning, hence compromising their learning potential (Grobecker, 2016; Leavitt-Jones & Lathlean, 2008). A mixed-method study that examined minority students’ experiences of belonging during clinical experiences found that nursing students avoided nursing staff who were unfriendly, or unwilling to support their learning (Sedgwick, Oosterbroek, & Ponomar, 2014). Method Participatory Action Research and Photovoice (PAR) PAR initially emerged from the discipline of adult education as both a philosophy and an approach to qualitative research, one in which the research participants assume role as co- researcher, one in which they are authentically and actively engaged in the research process and not merely passive contributors to the data (Bargal, 2008; Cornwall & Jewkes, 1995; Khanlou & Peter, 2005; White, Suchowierska, & Campbell, 2004). Persons living and working in rural communities are best positioned to articulate the strengths and challenges of rural life. Nursing preceptorships provide an extended placement in the rural setting that comprises not only day-to- Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 70 day nursing practice, but the complexity of the work and the unique social environment. Nursing students who complete the final preceptorship course in rural settings have the opportunity not only to consolidate their undergraduate of nursing education, but also to develop sophisticated knowledge and skills that are important to the successful navigation of the complex, rural practice environment. PAR centers on the collaborative determination of goals: what is important, and what requires improvement or change, from the perspective of participants. Participants were given inexpensive point-and-shoot digital cameras and instructed by the researcher to take photographs frequently and uncensored throughout that represented a challenge or opportunity associated with rural practice. Images could be captured throughout the preceptorship both during clinical time but also during time spent in the rural community separate from the rural preceptorship. Participants, as co-researchers, are engaged throughout the research process in the co- creation of knowledge (McTaggart, 1991; Hall, 1984). Their sustained engagement throughout the duration of the project aims to represent their unique participant perspective with some expectation of benefit from the research activity. The focus of the research activity shifts from researcher to participant; research is conducted by and for the participants, generating knowledge for action rather than understanding (Cornwall & Jewkes, 1995). Using photovoice, the participants in this study provided a photographic representation of the challenges and opportunities they experienced throughout the rural preceptorship. Participants were instructed to capture images, frequently, uncensored, that elucidated their experience in terms of the purpose of the research. The images provided a canvas for meaning from the perspective of the participant, authenticating the perspective of the participant experience. This study revealed the ways in which participants addressed the challenges and built on the opportunities of rural practice. Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 71 Ethical approval (protocol # 00060961 was granted by the Research Ethics Office (REO) at the academic institution. The criteria of the Tri-Council Guidelines for Human Subjects Research were followed. The right to withdraw at any time, without risk of harm or consequence, was explained to all participants. Written, informed consent was obtained from each of the study participants. Each participant was required to obtain signed consent from individuals appearing in their photographs, such as community members, patients, families, friends, and colleagues. All participants were assigned pseudonyms; however, anonymity could not be guaranteed in this type of study, as participants may be the subjects of their own photographic data. Data collection and analysis were carried out concurrently, throughout the academic semester, in four phases. In keeping with the principles of PAR, the participants selected their own images to represent the challenges and opportunities they experienced. These images mobilized conversations during one-to-one interviews between the participants and the researcher. Setting This study took place in seven rural, southwestern and central regions of a western Canadian province, in communities with no more than 50,000 residents, at least 20 km distant from the nearest urban center. The communities provided various levels of care, including inpatient and outpatient community health services. Each of the communities were diverse; representing various cultural, religious, and ethnic groups. Students were randomly assigned to inpatient or community settings based on preceptorship capacity. Inpatient services varied as much as each community offering acute care and long term or continuing care. Acute care services equally varied, in some communities including maternal/child, labor and delivery, operating room, intensive care, pediatric, day treatment, and diagnostic imagining services. Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 72 Sample The non-probable, purposive sample was comprised of all fourth-year nursing students and their assigned faculty advisor. The fourth year nursing students were in their senior nursing practical, assigned one-to-one with an experienced RN. Each student was assigned a faculty advisor who provided support to the student and faculty advisor. Often this support was provided remotely, as a result of the distance among practice sites, but faculty advisors were expected to meet with the student and preceptor at least twice throughout the preceptorship for evaluative meetings. Initially, the sample also included RN preceptors assigned to support the students throughout the preceptorship, Three preceptors initially agreed to participate but withdrew shortly after the study commenced. The remaining sample consisted of nine (n=9) nursing students, and five (n=5) faculty advisors who agreed to participate. Data Collection and Analysis At the commencement of the preceptorship, the researcher oriented the students, preceptors and faculty advisors, explaining the study purpose and data collection process. Participants were provided with point and shoot automatic cameras and instructed to record images as frequently as they desired while mindful of the challenges and opportunities they experienced during the preceptorship. The researcher met with each participant midterm. The participants were instructed to self- select 20-25 photographs that most meaningfully portrayed the challenges and opportunities they had experienced thus far during the rural placement. The participants were asked the following open-ended questions pertaining to; why they photographed a particular image, where they were when they took the image, and; the ways in which the image represented a challenge or opportunity Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 73 for rural practice. In keeping with the PAR method, the data collection process was driven by the research participants, reflecting their unique perspective relative to the research purpose and research questions. While the researcher facilitated the face-to-face interviews, the participants were encouraged to speak freely and openly about their selected images. At the completion of the preceptorship, the researcher met again with each participant. Participants self-selected additional photographs (approximately 20-25) to discuss for a final interview. The researcher asked the original open-ended questions, as well as allowed the participants to direct the interview conversations around the descriptions of their rural preceptorship experience. The final phase of the study involved verification of the data by participants. A slideshow was created by the researcher from amongst participants’ selected images and sent to each participant via email. The participants were invited to add further remarks or final thoughts on their images. Thematic data analysis was carried out concurrently with data collection (Braun & Clark, 2006) commencing during initial data collection and involved searching for themes or patterns of meaning across multiple data sources. Additionally, thematic analysis allows for contextual description of experiences, events, and meanings, without attachment to a pre-existing theoretical framework (Braun & Clark, 2006). NVivo10, qualitative analysis software was used for data management and coding. Findings and Discussion The challenges and opportunities experienced by participants, were discussed within the context of every photographic image selected. Rurality was described by these participants as more than a geographic location (Jackman, Myrick, & Yonge, 2010; Kulig et al., 2008; Kulig, Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 74 Kilpatrick, Moffitt & Zimmerman, 2015) but as a sense of place, and a way of being and doing, that represented rural life. Rurality, relationships, and, belongingness emerged predominantly throughout the data; a sense of belonging to both the rural community and the health care team emerged as both an advantage of rural practice, as well as a strategy for coping or addressing challenges intrinsic to rural practice. Recruitment and retention emerged embedded in the predominate themes. Previously, researchers have found that extended clinical placements in the rural communities enhanced student learning as they became immersed in the rural community and rural way of life (Meyer Bratt et al., 2014; Sedgwick & Rougeau, 2010; Webster et al., 2010). Connection with the faculty advisor is essential to student success. Carol described challenges she experienced as a result of travel required between her community and the various rural communities where students were placed. James emphasized the reliance on technology to facilitate communication and connection with students when face-to-face meetings were not necessary or possible. Beth reflected on the opportunities she experienced during her rural preceptorship, recalling an emphasis on “getting together, de-stressing, (going) outside, and enjoying nature. We had a campfire the one day and a crib group…people are more willing to do stuff with you.” Claire described a similar experience: “we actually had a staff mixing party and I ended up going…it was out on a farm. There was a campfire…it was super fun (Figure 1).” This finding is noteworthy as many precepted students were not themselves from rural communities. Welcomed by community members and staff, the students felt supported both personally and professionally throughout their preceptorships, decreasing their sense of isolation in unfamiliar rural settings. Such a safe supportive learning environment is conducive to student learning throughout the inherently stressful, high stakes preceptorship (Sedgwick & Pijl-Zieber, 2015). Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 75 Figure 1. Campfire Some students observed that the relationships among staff were closer in the rural setting than in urban centers and these relationships extended to the students as well. Said Jenn, “it wasn't just one unit, one teacher; you work with the whole team.” While she was initially assigned to three preceptors, she rarely worked solely with them. “Everyone just kind of took me on as a student,” she remarked. “If something was happening, they’d say, you’re coming with me and I’ll walk you through it.” Claire described the relationship she developed with the staff at the rural hospital, near the completion of her preceptorship (Figure 2): This is a card that I got from my preceptor when I finished my hours. I thought it was a good reflection of rural nursing because of the relationships you make and how personable it can be… we got gifts for each other. I thought this was maybe a unique aspect of rural nursing… you really are one-to-one, and everyone knows you; and everyone was sad to see me go. Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 76 Figure 2. Greeting card Becky described how her experience as a student in a rural setting differed from her previous experience in a larger, urban center. “Most of the doctors (here) know your name; call you by your name,” she said. “It’s kind of communal; you work together (Figure 3).” Figure 3. Working together (staff and student) Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 77 Hannah likewise described how she was supported by the staff throughout the preceptorship, recounting a particular instance during her last week: “I have been super-spoiled here. I scrubbed solo for the first-time last week, so they bought me pizza to celebrate. I don't know if you get that in an urban centre.” She went on to reflect on how consistent staff support impacted her learning throughout the preceptorship: I feel incredibly supported here… even if you do something that is not quite right, they're not yelling at you or making you feel like you're stupid. From the anesthetists to the surgeons… everybody was willing to teach me. Everybody taught me a lot, and not just so their job is easier, but so that I know more and I am more informed. It was really great. These findings attest to the nature of professional working relationships in the rural settings. Overwhelmingly, the participants in this study agreed they felt supported throughout the preceptorship, thereby benefiting their learning and the overall process. Helen, a faculty advisor described it as a “network of support,” integrating students during rural preceptorship placements and differentiating rural from urban practice. In their study, Sedgwick and Rougeau (2010) found that rural practice relationships are close-knit and complex, presenting a navigational challenge for nursing students and new graduates. However, they found that a supportive learning environment enhanced learning and feelings of belonging which, in turn, have a significant impact on newly graduated nurses’ feelings of confidence and competence. These authentic collaborative experiences are especially important in rural practice settings, where new graduates commonly practice alone or with minimal staff support. It is widely acknowledged that rural practice juxtaposes tight-knit community spirit with social and professional isolation (Jackman, 2011; Jackman et al., 2012; Leipert & Anderson, 2012; Sedgwick & Rougeau, 2010; Sedgwick & Yonge, 2009; Yonge, Myrick, Ferguson, & Grundy Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 78 2013). The students provided detailed descriptions of how each challenge or opportunity influenced their learning and ability to cope with the unexpected, unique to rural practice. For a time, Beth struggled to cope with the demands of the preceptorship. She photographed an image of her pet who was left at home in the city for the duration of the preceptorship. She indicated that the image of her pet represented an attachment and connection to home that was missing while living in the rural community (Figure 4). Figure 4. Pet The absence of nearby familial support was particularly painful. “I could call them, I could drive, but when you live in a rural setting, and you don't live near your family because you moved away… you don't have that support available when you want it,” she admitted. “When things were going downhill, I would rather have [had] my family right there. Even for a couple of days.” Beth’s powerful recollections illustrate the potentially devastating consequences of physical and emotional isolation, and the importance of the faculty advisor in providing both emotional as well as educational support, especially in rural settings. “[You’re] kind of like a lifeline,” said James of Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 79 his role as faculty advisor. “If they're from the city, they are just isolated… and living isolated… may cause students to feel alone, even though we provide support.” Daniel completed his preceptorship in his home community, one with less than three hundred residents. He described the dichotomy of rural living, explaining that the aspects of rural living, such as rodeo, bring the community together, and yet the lack of amenities would likely be less appealing to new nurses “who would think there’s nothing to do in the town”. Similarly, Becky, having lived and worked for many years in the same rural community expressed her concerns recruitment and retention of new staff, stating: “there’s lots of run-down things… and more and more For Sale signs”. These findings shared between student and faculty advisors illustrate ongoing issues that may impact rural recruitment and retention. A sense of belonging underlay the supportive faculty and preceptor relationships and learning environment that pervade these findings. Faculty and staff support was critical not only to the students’ success, but to their willingness to ask questions and seek out assistance. Faculty advisors recognized their primary responsibility was to support students. Fittingly, Helen (faculty advisor) drew a parallel between her professional role and that of a rural farmer: to nourish and support students to be strong, to produce, and to thrive in the rural setting. Limitations Inherent in any research activity are certain limitations that reduce transferability of the findings to other settings. This study was limited by the homogeneity of the sample, in spite of the differences that existed among rural communities and the unique nature of the preceptorship. Personal judgement and self-censure must be considered when using photographic data, hence the researcher employed multiple, separate data collection times over a three-month period. Perhaps the most significant limitation is the lack of preceptor perspective. The inability or lack of Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 80 willingness of preceptors to participate in research may be indicative of underlying issues RNs experience in rural practice in relation to preceptorship, including lack of preparation, an already over-taxed workload, and lack of support or recognition for preceptorship service (Bowen, 2018; Rebholz & Baumgartner, 2015). Recommendations Rurality remains an elusive concept, difficult to define. Nevertheless, in this study, the participants’ photographs and comments captured the sense of community spirit, patterns, habits of communication and cultural contexts that comprised the distinct nature of each rural community to which they were assigned. The nature of interpersonal relationships and support, and the inherent challenges and limitations experienced throughout the preceptorship, dominated the findings. The students were surprised by the breadth and unpredictability of practice, which put their clinical skills to the test. They, nonetheless found they were able to adapt to the rapidly changing work environment, aided in no small measure by positive and supportive relationships with their assigned preceptors, faculty advisors, and other health care team members. Differences between rural and urban preceptorship may have an impact on students’ sense of belonging, and the efficacy of the interprofessional team. As a result of this study, it is evident that additional research is needed to understand how students experience belonging in rural preceptorship, and how belonging influences interprofessional team effectiveness. Interprofessional, experiential learning opportunities aimed at recruitment, retention, and improved patient outcomes, require deliberate planning and implementation. Gaps persist in the growing body of knowledge on rural nursing preceptorship. The findings from this study suggest that newly graduated nurses do not lack interest or employment opportunities in rural communities. Comparative research in non-rural settings, during Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 81 preceptorship, would extend the findings of this study. Moreover, it is unclear whether the challenges and opportunities experienced during supervised, clinical courses in rural settings are comparable to those experienced during the same courses in urban settings and how experiences of belonging between nursing students and their instructor versus nursing staff influence their learning and motivation to seek employment in the clinical area. Ineffective transition to practice is an ongoing predicament for newly graduated nurses (Meyer Bratt et al., 2012; Sedgwick & Pijl-Zieber, 2015), seriously compounding the nursing shortage. Previous research supports implementation and maintenance of professional mentoring programs (Cochrane, 2017; Dowdle-Simmons, 2013; Sedgwick & Pijl-Zieber, 2015) to enhance authentic professional relationships and experiences of belonging among newly graduated registered nurses. This study demonstrated that the development of authentic professional relationships and experiences of belonging are vital to successful retention of new staff, especially recent graduates who report high levels of stress throughout the first-year post-graduation. The findings of this study revealed areas of concern for nursing students and newly graduated nurses that potentially compound existing recruitment and retention issues. The student participants were focused on maximizing opportunities for learning and success of the preceptorship. However, many of the students were offered relief employment upon completion of the preceptorship and those offered positions, accepted. However, students from urban centres stated that they would follow the jobs, starting with those closest to home. Conclusions The purpose of this study was to explore the challenges and opportunities associated with rural preceptorship from the perspective of the nursing students, preceptors and faculty advisors. Preceptorship in rural settings provides nursing students with an introduction to the role of the Online Journal of Rural Nursing and Health Care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 82 rural nurse. This role is unique in that it affords the nurse the opportunity to develop meaningful connections with the community. Numerous challenges were described by the participants. However, in describing the challenges, the participants talked through how they managed and overcame these challenges. A strong sense of belonging experienced both within the rural practice setting and community, contributed to their growing appreciation for rural practice, and their ability to face and conquer challenges, in turn enhancing their learning and empowering their ability to develop independence and confidence. The findings of this study confirm that authentic professional relationships between the nursing student and preceptor and the staff enhance student learning. Rural practice placements have the potential to enrich undergraduate nursing education and introduce the role of the rural nurse to undergraduate nursing students. This role is unique in that it affords meaningful connections with the health care team and the rural community at large. Students who successfully navigate the close-knit, rural practice community experience were empowered by a sense of belonging that enhanced their learning throughout the preceptorship. 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