Sultan Qaboos University Med J, November 2014, Vol. 14, Iss. 4, pp. e530−536, Epub. 14TH Oct 14 Submitted 28TH Feb 14 Revision Reqd. 16TH Apr 14; Revision Recd. 3RD May 14 Accepted 15TH May 14 Departments of 1Fundamentals & Administration and 2Maternal & Child Health, College of Nursing, Sultan Qaboos University, Muscat, Oman *Corresponding Author e-mail: gamandu@squ.edu.om التحديات واالسرتاتيجيات املستخدمة لبناء واستدامة العالقة الفعالة بني املدرس والدارس العالقة ما بني املمرضات جريالد اأماندو ماتوا، فيدايا �سي�سان، رامان �سافيرثاي، دين�س كايابان فروندا abstract: Objectives: This study aimed to determine the challenges encountered and strategies used by nurse preceptors to build effective professional relationships during the preceptorship of final year nursing students. Methods: This study was conducted in November 2012 at the College of Nursing in Sultan Qaboos University, Muscat, Oman. A qualitative research design consisting of focus group discussions was used to investigate the challenges that preceptors encounter and the strategies that they use to build effective relationships with preceptees. A total of 21 preceptors from Sultan Qaboos University Hospital participated in the study as part of a training workshop for nurse preceptors. The interviews were audio recorded, transcribed verbatim and thematically analysed. Results: The main challenges faced by preceptors included discrepancies in applying theory to practice; lack of trust; lack of time, and perceived lack of knowledge. The effective strategies identified by the preceptors to be used in building a healthy preceptor-preceptee relationship were proper orientation; effective communication; preparation for complex situations; appreciation and acknowledgment; positive feedback; assurance of support; spending time together; knowing preceptors personally; giving breaks, and encouraging self-commitment. Conclusion: Preceptors should be encouraged to identify challenges that hinder the building of effective relationships with preceptees early during their preceptorship. The incorporation of appropriate and evidenced-based strategies, such as those identified in this study, can transform the preceptorship experience into one that is fulfilling for both preceptors and preceptees. This may lead to greater job satisfaction, personal and professional growth as well as higher self-esteem levels for preceptors and the realisation of clinical objectives for preceptees. Keywords: Preceptorship; Nursing Students; Mentorship; Socialization; Communication Barriers; Oman. امللخ�ص: الهدف: تهدف هذه الدرا�سة اإىل تقدير التحديات واال�سرتاتيجيات املتبعة من قبل مدر�سي التمري�س لبناء عالقات مهنية فعالة خالل مرحلة التدري�س لطلبة ال�سنة االأخرية من التمري�س. الطريقة: اأجريت هذة الدرا�سة يف نوفمرب 2012 بكلية التمري�س، جامعة ال�سلطان قابو�س، م�سقط، عمان. �سمل ت�سميم البحث الكيفي على مناق�سات جماعية للتحقق من التحديات التي تواجه املدر�سني واال�سرتاتيجيات امل�ستخدمة من قبلهم لبناء عالقات فعالة مع الدار�سني. جمموع 21 مدر�س من م�ست�سفى جامعة ال�سلطان قابو�س �ساركوا يف هذه الدرا�سة التي التحديات اأكرث النتائج: وحتليلها. مبح�رض ون�سخها �سوتيا ت�سجيلها مت املقابالت التمري�س. ملدر�سي التدريب ور�سة من كجزء واجهت املدر�سني �سملت التباين يف تطبيق املمار�سات النظرية اإىل عملية، انعدام الثقة، غياب الوقت، اإدراك انعدام املعرفة. اال�سرتاتيجيات والعرفان، والتقدير ال�سكر املعقدة، لالأو�ساع اجليد التح�سري الفعال، التوا�سل اجليد، التوجيه هي املدر�سني عليها تعرف التي الفعالة ال�سخ�سي. االلتزام وت�سجيع ا�سرتاحة فرتات اأعطاء �سخ�سيا، املدر�س معرفة م�سرتكة، اأوقات ق�ساء الدعم، �سمان االإيجابي، االإرجتاع اخلال�صة: يجب ت�سجيع املدر�سني على اإدراك التحديات التي تعيق بناء عالقات فعالة مع الدار�سني يف املراحل االأوىل من التدري�س. دمج اال�سرتاتيجيات املنا�سبة واملبنية على االأدلة مثل امل�سار اإليها يف هذه الدرا�سة �سي�ساعد على حتويل جتربة التدري�س اإىل جتربة متكاملة بالن�سبة للمدر�س والدار�س. هذا �سيوؤدي اإىل زيادة الر�سا الوظيفي، والنمو املهني وال�سخ�سي، واأرتفاع معدل الثقة عند املدر�س و اإدراك اأهداف التدريب ال�رضيري لدى الدار�سني. مفتاح الكلمات: مرحلة التدري�س؛ طلبة التمري�س؛ االإر�ساد؛ التن�سئة االجتماعية؛ موانع االت�سال؛ عمان. Challenges and Strategies for Building and Maintaining Effective Preceptor-Preceptee Relationships among Nurses *Gerald A. Matua,1 Vidya Seshan,2 Raman Savithri,2 Dennis C. Fronda1 CLINICAL & BASIC RESEARCH Advances in Knowledge - This study highlights the challenges encountered in establishing preceptor-preceptee relationships. These obstacles negatively affect clinical teaching practices for the preceptors and skill acquisition on the part of the preceptees. - Remedial strategies are presented in this study to encourage relationship-building efforts between preceptors and preceptees within the prevailing sociocultural environment of Oman. Application to Patient Care - Understanding and addressing preceptors’ unique challenges in preceptorship relationship-building is vital for patient care. Preceptees Gerald A. Matua, Vidya Seshan, Raman Savithri and Dennis C. Fronda Clinical and Basic Research | e531 Preceptorship refers to the transitional process that many final year nursing students undergo as they enter into the workplace and is designed to help them function as qualified professionals in a clinical setting.1,2 This has become an alternative teaching method to the traditional clinical approach that is still used in some nursing programmes.3 Within nursing, preceptorship occurs as part of the regular clinical working hours.4 Senior students are assigned to experienced nurses who guide, act as role models for and support the students on a one-to-one basis.5,6 Preceptorship facilitates the development of the preceptees’ clinical knowledge and skills as well as their attainment of professional competencies, to ensure they are fit to enter professional practice after they have concluded their supervised clinical practice.2,4 This approach bridges the gap between theory and practice and reduces the potential ‘reality shock’ that occurs when preceptees enter the work force for the first time.7,8 Preceptorship is effective if it promotes learning and supports the development of future generations of health professionals by exposing preceptees to unique learning opportunities. It also helps to orientate them to the prevailing work environment and its culture.8 Successful preceptorship programmes enable preceptees to settle into clinical placements quickly and gain greater confidence in their clinical skills.9 If successfully implemented, the preceptorship experience is rewarding for both preceptors and preceptees. A successful preceptorship experience may positively influence preceptees to remain in the nursing profession for the entire length of their careers, while for preceptors it may enhance the enjoyment of their role and bring greater job satisfaction.10,11 Success for both preceptors and preceptees may also mean personal and professional growth as well as higher self-esteem and confidence levels.12,13 Effective preceptorship has also been linked to more positive patient outcomes through the carryover effect of enhanced student competencies.14 Additionally, a rewarding preceptorship experience may also result in the continued mentorship of the preceptee by the preceptor, maintaining their support and contributing to the preceptee’s long-term professional growth and development.4 However, any significant challenges encountered during the preceptorship period tend to undermine the realisation of the full potential of this approach for both the preceptors and preceptees.5,8 The literature on this topic has highlighted a number of challenges encountered by preceptors, including high workload; lack of support from peers; inadequate preparation for taking on the role of preceptor; lack of time spent with the student; lack of support from and ineffective communication with the faculty, and being made to feel responsible for the preceptee’s success or failure.8,14–16 In Oman, preceptorship in nursing is implemented at the Sultan Qaboos University Hospital (SQUH) in Muscat, a tertiary hospital that emphasises teaching, service, research and leadership development within the country and surrounding region. SQUH is accredited by both the International Organization for Standardization and Accreditation Canada International. The hospital is served by over 1,200 registered nurses. As a teaching hospital for medical, nursing and health science students, preceptors play an important role in facilitating clinical training for the students. In the case of nursing, preceptors are selected on the basis of their educational qualifications and experience; the minimum requirements include a diploma and at least three years of clinical experience. Through the use of a specially designed course known as the Advanced Clinical Nursing Course, the preceptors at SQUH play an important role in aiding final year nursing students at the College of Nursing of Sultan Qaboos University (SQU) to transition from the role of student to professional. Each student is assigned to a preceptor during their last semester and SQUH and the College of Nursing at SQU mutually collaborate to ensure these preceptors are supported and trained for this vital role. Although preceptorship arrangements at SQUH have been in place since 2003, there are no published studies in Oman to date highlighting the challenges preceptors encounter when implementing this approach. Understanding such challenges is vital because problems experienced during this period can negatively affect the clinical teaching and preceptorship experience, leading to preceptor fatigue, frustration and burnout as well as insufficient support and guidance for preceptees.8,16 This study therefore who have supportive preceptor-preceptee relationships often become more competent nurses, leading to better patient outcomes. The results of this study will help identify areas for improvement in the preceptorship of final year nursing students. - This study indicates that when challenges hindering preceptorship relationships are identified, preceptors should implement evidence- based strategies to build or improve their relationships with preceptees. - Furthermore, improving preceptorship will have a beneficial effect for preceptors as well as preceptees. Preceptors who have rewarding preceptee relationships will be motivated to continue providing exemplary patient care, as they act as role models for their preceptees. Challenges and Strategies for Building and Maintaining Effective Preceptor-Preceptee Relationships among Nurses e532 | SQU Medical Journal, November 2014, Volume 14, Issue 4 sought to explore the challenges nurse preceptors at SQUH encounter and the strategies they could use to establish and maintain effective professional relationships with their preceptees. Methods This study was conducted in November 2012 at the College of Nursing at SQU and used a two-group modified focus group discussion method. This qualitative research design allowed participants to discuss their ideas and experiences more easily by using their own words.17 In addition, this technique is inexpensive, flexible and stimulating and facilitates information recall, resulting in rich data.18 This method is also known to promote self-disclosure among participants, especially when sensitive topics are discussed, as they were in this study.18,19 While there are no general guidelines on the optimal number of focus groups, even a single focus group may be enough, depending on the circumstances, as long as group homogeneity and data saturation or redundancy have been accounted for.17 Participation in the study was limited to preceptors working in either the neonatal and intensive care units or the Departments of Emergency Medicine, Medicine and Surgery of SQUH (n = 21). As preceptors, all of the participants either had a bacclaureate degree or a nursing diploma and at least three years of clinical experience. The data collection occurred in two phases. Initially, the following questions were asked to a small group of preceptors (n = 5): What issues have you encountered when initiating relationships with preceptees at the start of the clinical rotation? and What strategies do you use to build and maintain an effective relationship with the preceptees? Only five participants were included in this initial group in order to accommodate the sensitive nature of the questions and to ensure an orderly discussion and facilitate idea generation. After two hours of analysis, the main findings from this initial discussion were then shared with and examined by the second group of preceptors (n = 21); this group included the five preceptors from the initial group. Modifications were then made to these findings to ensure agreement from the whole group. This allowed the initial interviews to be validated and provided a second opportunity for participants to express new ideas. Following this, the original questions were paraphrased as follows: Of the issues identified above, what issues have you encountered when initiating relationships with preceptees at the start of the clinical rotation? and In addition to the strategies already identified, what strategies do you use to build and maintain an effective relationship with the preceptees? These questions were then the subject of the remaining discussion period among the large group of preceptors. In both groups, prompts were used to facilitate information flow and to ensure the consistency of the data. The same researcher led the discussion sessions for both focus groups. These discussions lasted for a total of 66 minutes; 46 minutes for the first group and 20 minutes for the second group. The group discussions were audio recorded and field notes were also taken to ensure data security and accuracy. The data was analysed after the verbatim transcription of the focus group audio recordings. Initially, the analysis involved the individual reading and re-reading the transcripts several times in order to become familiar with the data and enable the comprehension of any unfamiliar concepts. Thematic statements were then isolated using van Manen’s line- by-line and highlighting approaches.20 These thematic statements were then compared and discussed in-depth by two doctoral-level researchers until a consensus emerged, at which point the given theme was finalised. No outlier themes emerged as a result of this comparison and discussion. Prior to the data collection, details of the study (including the study’s purpose and methods) were explained to the participants and written consent was obtained from each participant. In addition, participating preceptors were assured of complete confidentiality, anonymity and the right to withdraw from the study without penalty. Ethical approval for the study was received from the Research & Ethics Committee at the College of Nursing at SQU (CRC#2012/11.07.2012). Results A total of 21 preceptors participated in the study. Of these, 86% were female and 14% were male. The majority (76%) had over ten years of clinical experience and 71% had worked at SQUH for more than three years. Approximately half (52.5%) of the preceptors were qualified at the diploma level of nursing education, while the remaining 47.5% had baccalaureate degrees. The participants had an average of four years of preceptorship experience at SQUH. The study identified four challenges to preceptorship and ten strategies to encourage relationship-building between preceptors and preceptees. The challenges included discrepancies related to the application of theory to practice; lack Gerald A. Matua, Vidya Seshan, Raman Savithri and Dennis C. Fronda Clinical and Basic Research | e533 of trust and readiness to commit to a preceptorship relationship; insufficient time to invest in relationship- building, and a perceived lack of knowledge in nursing trends. Preceptees often disagreed with the way their preceptors carried out certain clinical procedures, maintaining that such approaches were different from what they had expected or were not consistent with what they had learnt previously. Such disagreements hindered relationship-building efforts. As one participant (P1) observed, “Sometimes there will be differences in the way we are doing [certain tasks]... It is not that we are wrong, but it is because sometimes there are good reasons. So we expect the student to understand”. Moreover, preceptees were noted for their lack of trust and readiness to commit to the relationship, with some preferring to perform given tasks on their own. This frustrated preceptors’ attempts to build professional relationships. A participant (P4) explained that “There are some students who prefer to do things different from you, they will search and sometimes they will fight... some become confrontational, talking simultaneously… as you advise them”. Time constraints were a major challenge faced by preceptors: the participants claimed that they were frequently preoccupied with patient care duties. In view of this, they were unable to devote sufficient time to the preceptees, thereby hindering relationship- building. This was evident from a comment by one of the preceptors (P4): “We have a lot of work. Also you find… you need time to know each other first, what is expected from them… All these take time and yet we have other responsibilities… you do not find enough time”. Lastly, the final challenge identified by the focus group was a perceived lack of knowledge. Some preceptors perceived themselves as being less knowledgeable than their preceptees, especially with regards to the latest trends in nursing practice. This negatively influenced their self-confidence and interfered with their relationship-building efforts. As one preceptor (P2) admitted, “I never blame the students… they are more trained than us… our knowledge is old now. What we do, we learned 10 years back… and… I cannot say I am not doing anything wrong”. Remedial strategies that preceptors could use with their preceptees during preceptorship were also identified. These included thorough orientation; effective communication; preparing for complex situations; appreciating and acknowledging preceptee success; offering positive feedback; assurance of support; spending time together; knowing preceptees personally; allowing recess periods, and encouraging preceptees to commit themselves to the nursing profession. Preceptors reported that thoroughly orientating preceptees to their clinical environments enabled them to cultivate friendly relationships with the preceptees and was also noted for minimising the likelihood of preceptees feeling lost. As a preceptor (P1) noted, “We should orientate [them], then the student is clear what we expect from them, so they will not be lost and there will be no problems later on”. Ensuring open communication throughout the preceptorship period was also considered to be a critical strategy in preceptor-preceptee relationship-building. Allowing preceptees to be open about their feelings was emphasised by one of the preceptors (P3): “We should give them the freedom to express their feelings... This makes them [feel more] comfortable with us, which is good for supervision”. Preparing preceptees in advance with regards to unfamiliar and complex clinical nursing situations was another strategy identified by the preceptors. Preceptors believed that this would help increase preceptees’ confidence levels, motivate them to take their assignments seriously as well as cultivate positive relationships between preceptees and preceptors. A participant (P4) observed, “Yes, before we do a complex procedure we explain... This way they will know what to do when they are doing the actual procedure”. Preceptors found that appreciating preceptees and acknowledging their successes facilitated the building of a healthy and supportive relationship with the preceptees: “We should praise them if they are doing good things. We should appreciate [them]... they will be happy... [and] will do more next time” (P4). Preceptors also observed that giving positive feedback to preceptees led to better relationships and improved supervision outcomes: “When you give them quality feedback… they are normally happy to hear that and they will have more initiative in performing their duties” (P4). Additionally, assuring preceptees of their preceptor’s support was thought to be helpful in gaining their trust and increasing their interest in learning, leading to better student learning outcomes. Specifically, one preceptor (P4) stated that “Students are more interested in their evaluation. If we show interest in what the student is going to be assessed [on]... they will do even better next time.” Furthermore, spending sufficient time with preceptees was emphasised as a way of maintaining a friendly relationship as well as ensuring close follow-up while preceptees were performing their duties: “When students are placed under your care, it is important not to leave the student alone but you have to watch what she [or he] is doing... this adds to [their] confidence…as a kind of follow-up” Challenges and Strategies for Building and Maintaining Effective Preceptor-Preceptee Relationships among Nurses e534 | SQU Medical Journal, November 2014, Volume 14, Issue 4 (P1). Additionally, one preceptor (P4) reported that getting to know preceptees on a personal level would aid in gaining a deeper understanding of their personal attributes and ensure a better exchange of information: “We also sometimes share personal things like about parents and siblings. We found that by knowing the student personally also it kind of helps to build a good relationship and makes you… go along well”. Allowing preceptees to rest and refresh between shifts was considered by the preceptors to be a good strategy. This evidence of flexibility made them more comfortable, leading to better professional relationships, as noted by one of the preceptors (P5), “We as preceptors are working continuously but they are new to the ward so we tell them to go for a break in between... by giving [them a] break they kind of feel comfortable and it works”. Encouraging preceptees to commit to and show interest in their profession was also thought to strengthen their interest in bedside learning, which would result in improved preceptor- preceptee relationships in the long term: “I used to tell them about the commitment to nursing… to learn to take care of.. [their] own people—parents, brothers and sisters” (P4). Discussion Nurturing supportive relationships with preceptees may be both a challenging and rewarding experience for preceptors.8,21 In this study, various challenges, such as discrepancies in knowledge or in the application of theory to practice, were found to have a negative impact on preceptor-preceptee relationships. These findings are consistent with earlier studies; such difficulties were noted to delay the formation or hasten the breakdown of preceptor-preceptee relationships.8,22 When these challenges persist, preceptees may even fail to achieve their learning objectives, thereby increasing the likelihood of have a strained relationship with their preceptor.5,23 While these challenges exist, several strategies were identified by the preceptors in the current study to help create and maintain healthy relationships with preceptees. For instance, preceptors reported that appropriate orientation procedures would help integrate preceptees into a specific clinical setting. Remedies such as these have been shown to enable preceptees to relate positively with their preceptors, as a result of a supportive learning environment and a beneficial and educative relationship.24 Other strategies identified, for instance communicating with preceptees in a friendly manner and allowing them to express their feelings without fear of compromising their relationship with the preceptor, also appear to have a positive impact on learning and should be encouraged.25,26 Research shows that advance preparation for unfamiliar or complex situations enables preceptees to develop professional competencies, which in turn prepares them for professional practice.26 This preparation, when provided through a strong preceptorship programme, also nurtures positive preceptor-preceptee relationships by progressively building the preceptees’ confidence during the learning process. Furthermore, spending more time with preceptees and endeavouring to know them on a personal level also helps in building and sustaining positive relations between preceptors and preceptees.11 These approaches were identified by preceptors in the current study as methods to improve preceptor- preceptee relations. Carlson found that the allotment of ‘protected time’ to preceptees by preceptors was supportive of their overall learning, leading to greater trust among the preceptees.26 A study by DeWolfe et al. revealed that appreciating and acknowledging the success of preceptees through positive feedback and support also resulted in more productive professional relationships.27 The results of the current study were consistent with those of a study by Atack et al. which reported that treating students as colleagues created a positive relationship with clinical staff, resulting in open communication, mutual courtesy and respect.28 The focus group discussions of the current study identified that the strategy of encouraging preceptees’ commitment and interest in their profession enhanced the development of supportive relationships with preceptors by facilitating the professional socialisation of preceptees. Research has shown that this professional socialisation occurs best when students are made to feel part of the nursing team, which helps them to gain confidence and interest in their profession.26,29 While it is true that the aforementioned strategies would have different success rates depending on the people involved, previous studies show that using these strategies appropriately, either individually or in combination, can help to build and maintain healthy and effective preceptorships in the clinical setting.5,8,30 These positive relationships have the potential to make the clinical learning experience more rewarding and fulfilling for all those involved.5,8,30 In order to enhance preceptorship outcomes, the authors of this study recommend that preceptees undergo a half-day workshop prior to clinical allocation, during which former preceptees and preceptors share their past experiences. It would also be beneficial to explore the views of preceptees involved in existing preceptorship programmes. Gerald A. Matua, Vidya Seshan, Raman Savithri and Dennis C. Fronda Clinical and Basic Research | e535 Further studies are recommended to explore preceptors’ expectations of preceptees as this could help to strengthen future preceptorship programmes. In addition, clinical nurse managers at SQUH should encourage preceptors to identify any challenges they face in building or maintaining a positive relationship with their preceptees and then implement relevant remedial strategies. Preceptors should be trained on a regular basis to ensure that they are prepared for the role, especially with regard to building and maintaining effective relationships with preceptees. The proper implementation of training will likely lead to a stronger preceptorship programme. In the long-term, this would benefit the organisation or hospital by reducing the period of acclimatisation for new graduates and limiting potential errors in patient care. Furthermore, a strong preceptorship programme is likely to lessen the need for a lengthy internship programme, with the further advantage of reducing the workloads of both staff nurses and managers. This would allow nurses more time to focus on other roles, potentially leading to improved patient outcomes. As this study involved a group of preceptors from a single teaching hospital, the findings cannot be generalised to the overall population. Additionally, due to the small sample size, the views expressed in this study may not reflect those of all preceptors within SQUH. However, despite these limitations, the researchers believe that the results of this study still offer significant insight into preceptorship relationships. Conclusion Building and maintaining professional relationships during preceptorship is vital and both preceptors and preceptees should be adequately prepared for the experience. To this end, educational institutions need to thoroughly equip preceptees for the preceptorship experience in order to avoid discrepancies when they enter clinical practice. As with the current study, preceptors should be encouraged to identify any challenges impeding their relationship-building efforts and adopt appropriate remedial strategies. To better understand the dynamics of preceptor-preceptee relationships and to improve preceptorship experiences, further studies are recommended exploring the views of preceptees as well as examining preceptors’ expectations of preceptees during preceptorship. c o n f l i c t o f i n t e r e s t The authors declare no conflicts of interest that may have inappropriately influenced this research. a c k n o w l e d g e m e n t s The authors of this study wish to thank the SQU College of Nursing for making this study possible and Dr. Joshua K. Muliira for coordinating the Advanced Clinical Nursing course and helping to bring the preceptors together. The authors are also grateful to the preceptors for sharing their views and experiences. a u t h o r s tat e m e n t Gerald A. Matua, Vidya Seshan and Raman Savithri contributed to the study design. Gerald A. Matua, Raman Savithri , Vidya Seshan and Dennis C. Fronda were involved in the data collection and analysis. Gerald A. 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