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Preceptor Handbook

• Clinical Site Requirements
• Student Requirements
• Clinical Instructor/Liaison Requirements
• The Role of the Preceptor
• The Role of the Nursing Student
• "Reality Shock" or "From Novice to Expert"
• The Phases of Preceptorship
• The Learning Process
• Principles of Effective Communication
• Steps in Problem Solving
• Steps in Decision Making
• Methods of Conflict Resolution
• Some Tips from Expert Preceptors
• Resources

Clinical Site Requirements

• Orient the student to the facility and to the unit as necessary.
• Facilitate student involvement in daily nursing staff activities as appropriate for level and objectives.
• Recognize that the student needs an environment of support, feedback and inquiry.

Student Requirements

• Arrive promptly when scheduled to work; BE SURE to call the unit and your clinical faculty if you cannot attend clinic.
• Provide safe, basic nursing care at the highest level of your knowledge
• Participate in daily patient care and unit activities as delegated by the assigned staff
• Share your objectives with your preceptor
• Review your competency achievements on a regular basis (weekly) with your preceptor and your clinical faculty liaison

Clinical Instructor/Liaison

• Seek regular feedback from the student and the agency/preceptor on progress and developments
• Provide regular feedback to student and agency/preceptor on progress and development; keep written records at least at midterm and final point of experience
• Be available for questions, problem identification and resolution
• Meet regularly with student(s) for clinical conferences

The Role of the Preceptor

• Participate in identification of learning needs of the nursing student
• Set goals with the student in collaboration with the faculty and curriculum
• Act as a role model:
• Provide patient care in accordance with established, evidence-based nursing practice standards
• Fulfill nursing duties according to hospital and unit policies and procedures
• Maintain mature and effective working relationships with other health care team members
• Use resources safely, effectively and appropriately
• Demonstrate leadership skills in problem solving, decision making, priority setting, delegation of responsibility and in being accountable
• Recognize that nursing role elements may be new to the student
• Facilitate the student's professional socialization into the new role and with a new staff
• Provide the student with feedback on his/her progress, based on preceptor's observation of clinical performance, assessment of achievement of clinical competencies and patient care documentation
• Plan learning experiences and assignments to help the student meet weekly professional and clinical goals
• Consult with the clinical faculty liaison as necessary
• Participate in educational activities to promote continued learning and professional growth
• Participate in ongoing evaluation of the program

The Role of the Nursing Student

• Participate in the identification of his/her learning needs
• Participate in the planning and implementation of learning experiences
• Demonstrate self-direction by actively seeking learning experiences and being prepared to accomplish the learning objectives for the experience
• Accept and act in accordance with the direction provided by the preceptor
• Participate in ongoing evaluation of progress with the preceptor, program director and faculty clinical liaison
• Participate in ongoing evaluation of the program

"Reality Shock" or "From Novice to Expert"

The term "reality shock" is sometimes used to describe the reaction of students when they discover that the clinical experience does not always match the values and ideals that they had anticipated. There are four phases of adaptation to this reaction: the honeymoon, the shock, the recovery and the resolution. This same paradigm is described by Patricia Benner and her colleagues in the classic text From Novice to Expert: Excellence and Power in Professional Nursing Practice.

Stage	Behaviors	How to Help
The Honeymoon	perceives everything as being wonderful fascinated by the newness of the experience focused on mastery of skills, routines and integration with the staff	harness the student’s enthusiasm for skills and routines be realistic but don’t stifle the enthusiasm introduce the student to the staff, be inclusive
The Shock/Crisis	sets in when needs and goals are not met experiences outrage rejects school and work values preoccupied with the past globally negative	be a good listener have the student record his/her suggestions for improvement provide opportunities to vent assist the student to see more of the situation and view it more objectively
The Recovery	sense of humor returns tension lessens discrimination between effective and ineffective behaviors	assist student to see positives talk about ways to improve the work environment verify and support critical thinking efforts
The Resolution	conflicts in values resolve in either constructive or destructive ways (crisis doesn’t last forever) could see rejection of role/nursing or burnout, or new ways to cope positively	assist the student with constructive problem solving help the student with new, more helpful coping mechanisms acknowledge and manage conflicts that persist

The Phases of Preceptorship

I: Establishing the Relationship
Establishing trust is one of the most crucial steps in the preceptor-student relationship and provides the foundation upon which the learning experience will develop. The student frequently experiences anxiety in this new learning situation and can benefit from structure provided by the preceptor in the form of carefully scheduled meetings and conferences. The preceptor’s availability at the beginning of the student’s placement is crucial in planning the student’s experience.

In the first few weeks of the semester, the focus of the relationship is to clarify roles, discuss mutual experiences, review the student’s background, career goals and learning objectives and to discuss agency policies. Orienting the student to the clinical setting, especially if the student has not been there before, promotes entry into the system and communicates respect and acceptance. The preceptor and student negotiate and determine the frequency of scheduled conferences that best meets the needs of the student and the schedule of the preceptor. Weekly or bi-weekly conferences are recommended.

II: The Working Phase
The implementation of an educational plan is the main focus of the working phase. Reviewing the student’s experience, discussing patients, exploring feeling regarding the experience and identifying the meeting of learning objectives are all appropriate areas that can be discussed. Feedback from the preceptor on a regular basis assists the student in maximizing his/her strengths and systematically addressing problems that may interfere with the achievement of the professional role.

During this phase, the preceptor serves as role model, resource person and consultant to the student. By demonstrating his/her own skills as an expert clinician, the preceptor assists the student in role development, application of theory and science, problem solving and decision making. An effective strategy is to encourage the student to observe and analyze the preceptor’s role as s/he works with patients and families and interacts with colleagues and staff members. Mutually sharing observations and discussing strategies for nursing practice enables the student to enrich his/her own understanding of how the role is operationalized and how problems are solved.

By applying the principles of adult education, the student’s self-direction and autonomy are fostered. Over time, utilization of the preceptor changes: the preceptor becomes less directive and the student becomes more independent and self-reliant. A loss may be felt by the student and preceptor as the relationship changes.

Evaluation is an ongoing process to assess how the learner is achieving his/her goals. At least daily verbal feedback is helpful. Students, through their clinical logs and competency check lists, should track their own progress and accomplishments. Formal, written evaluation procedures should occur at midterm and at the end of the experience, using the program evaluation forms provided. The clinical faculty liaison is responsible for the grade but the input of the preceptor is invaluable. Nevertheless, the final responsibility for the grade belongs to the faculty member. Even if the student does not agree with the evaluation received, all parties involved should sign the evaluation form. The student has the opportunity to write a response.

There are many aspects of being a preceptor to a nursing student. Each student in the ETP program is an adult learner. Recognizing this as well as the steps involved in learning a new role that are specific to an adult learner will assist you in being a successful preceptor. Following are several tips on problem solving, decision making, communication, conflict resolution and advice from other preceptors.

The Learning Process

• Learning is an active and continuous process manifested by growth and changes in behavior.
• Learning styles vary from one individual to another.
• Learning is dependent on the readiness, emotional state, abilities and potential of the learner, as well as his/her life experiences.
• Learning happens when the material to be learned is relevant to the learner.
• Learning takes place ‘within’ the learner: unless a new behavior or competency has been ‘internalized,’ it hasn’t been ‘learned.’
• Moving from simple to complex and known to unknown facilitates learning.
• Learning is facilitated when the student has an opportunity to test ideas, analyze mistakes, take risks and be creative.
• Learning how to learn and that learning is a life-long process enables the students to deal with expansion of knowledge and changes in nursing and society.
• Learning is facilitated when the learner has feedback of his/her progress toward the goal.
• Learning takes place more effectively in situation where satisfaction is derived: good work deserves praise just as problem performance requires correction.
• Interpersonal relationships are important in determining the kind of social, emotional and intellectual behavior that emerges in the learning situation.
• Recognition of similarities and differences between past and current experience facilitates the transfer of learning.

Principles of Effective Communication

• An active listener shows interest and acceptance.
• Eye contact is important.
• Be open-minded and avoid prejudging the speaker or the message.
• Tune into words, meanings and feeling conveyed.
• Focus on the central message or the message being sent.
• Note the other person’s body language (and your own...).
• Avoid interrupting.
• Listen first, then respond.
• Respond to what is communicated rather than how the message is sent.
• Ask questions to verify your understanding of the message: ‘Do I understand you correctly that...’ ‘What I hear you saying is...’.
• Communication involves both the sending and receiving of a message.
• ‘I’ messages (I think, I feel) are more effective than ‘you’ messages; they minimize defensiveness and resistance to further communication. ‘Shoulds’ and ‘Oughts’ hinder communication.
• Communication is more effective when it involves talking with and to rather than at the listener.

Steps in Problem Solving

• Define the nature of the problem.
• Identify possible causes of the problem.
• List a number of possible solutions for each cause: identify the evidence for each one.
• Select the best solution.
• Decide on necessary actions and implement them.
• Reassess, evaluate and replan as necessary.

Steps in Decision Making

• Determine situations that require some action be taken.
• Analyze possible courses of action and the potential effects (determine pros and cons, gather facts and opinions).
• Select the best course of action from the available alternatives.
• Implement the selected action.
• Monitor the effect of the decision.
• Reevaluate the decision in the light of the effects.

Methods of Conflict Resolution

• Denial or Withdrawal
  Using this approach, the person attempts to get rid of the conflict by denying that it exists. S/he simply refuses to acknowledge it. Usually the conflict does not disappear but will grow to the point where it becomes all but unmanageable. When the issue or the timing is not critical, denial can be a very productive way of dealing with conflict.
• Suppression or Smoothing Over
  A person using suppression plays down the differences and does not recognize the positive aspects of handling conflict openly. Again, the source of the conflict rarely goes away. Suppression may be used when it’s more important to preserve a relationship that to deal with an insignificant issue through conflict.
• Power or Dominance
  Power is often used to settle differences. The source of power may be vested in one’s authority or position. Power may take the form of a majority, or of a persuasive minority. Power strategies result in winners and losers, and the loser will not usually support the final decision in the same way winners will. Future meetings of the group may then be marred by the conscious or unconscious renewal of the struggle previously ‘settled’ by the use of power. In some instances, where other forms of handling conflict are clearly inappropriate, use of power can be effective.
• Compromise or Negotiation
  Although often regarded as a virtue, this method has some drawbacks. Bargaining often causes both sides to assume an inflated position, since each is aware that the other is ‘going to give a little.’ The compromise solution may be watered down or weakened to the point where it will not be effective, and there is often not enough commitment by any of the parties. There are times when compromise makes sense, such as when resources are limited or when it is necessary to avoid a win-lose situation.
• Integration or Collaboration
  This approach requires that all parties recognize the abilities and expertise of the others. Each individual’s position is well prepared, but the emphasis of the group is in trying to solve the problem at hand, rather than in defending particular positions or factions. All involved expect to modify their original view as the group’s work progresses. Ultimately the best of the group’s thinking will emerge. The assumption is that the whole of the group effort exceeds the sum of the individual member contributions. If this approach is allowed to become and either/or statement or if because of lack of resources the conflict is resolved by the use of power, the final decision will suffer accordingly.

Some Tips from Expert Preceptors

• Remember how you felt when you started a new job and how incompetent you felt. If you can remember how overwhelmed you felt, then you can understand the student.
• Make the student feel welcome by introducing him/her to other staff members.
• Listen to what the students need or want to learn, and don’t present only what you want to teach. One teaches more by what one does than by what one says.
• Take time in the beginning to explain explicitly what will be expected. This decreases anxiety and helps both parties know what to expect of the other. Be sure you are accurate in what is expected...
• Remember that every individual is unique and that you must tailor the learning to the individual.
• Get to know the student’s strengths and weaknesses as soon as possible, and then help find experiences to address the weaknesses and capitalize on the strengths.
• Learn from your student: they usually bring a wealth of information with them.
• Be patient and understanding.
• Give the student some independence; don’t do too much for them.
• Don’t rush the teaching.
• Communicate!
• Be open and honest.
• Encourage the student to either ask for advice or consult with any member of the staff if unsure of his/her assessment of a patient.
• Let people make mistakes - as long as it doesn’t jeopardize patient safety. This is an excellent way for learning to have an impact.
• Encourage questions, and make sure the student understands that no question is stupid.
• Make sure to take 10-15 minutes at the end of the shift to review what was learned, answer questions and set goals for the next time.
• Go step by step: students cannot be taught short cuts - they first need to learn things the established way. On the other hand, if there is a safe short cut, share it!<
• Build on previously learned knowledge.
• Create a non-threatening environment that is friendly because learning can be stressful.
• Give feedback along the way - find the positives and share them; don’t wait to ‘drop a bomb’ till the end of the experience.
• Keep a brief outline of what was covered each day - better still, have the student do it!
• Set clear goals with time for feedback in both directions.
• Be open and available after the new training time has ended.
• Have fun! Laughter can be most helpful sometimes.
• Remember that everyone has a contribution to make.

Resources

Benner, Patricia (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Jossey Bass, San Francisco CA.

Ferszt, Ginette (1987) Clinical Preceptor’s Manual, University of Pennsylvania School of Nursing, Philadelphia, PA.

Alspach, Jo Ann Grif. [2000]. From Staff Nurse to Preceptor: A Preceptor Development Instructor's Manual [2nd ed.]. Aliso Vieji, CA.  American Association of Critical Care Nurses.

Rodrigues, L. (March/April 1992) Nursing Staff Development Insider (2) 2.

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