A report on the development and implementation of a preceptorship training programme for registered nurses

Copyright: © 2013. The Authors. Licensee: AOSIS OpenJournals. This work is licensed under the Creative Commons Attribution License. Background: Clinical supervision represents an important aspect in the development of nursing students’ clinical skills. At the School of Nursing (SoN) the clinical supervisors employed by the University of the Western Cape (UWC) have limited contact sessions with students in the clinical setting. However, with the increase in student numbers a need was identified to strengthen the support given to nursing students in the service setting.


Introduction
A preceptor is defined as a competent practitioner who, for a limited period of time, provides professional guidance to students in a service setting (Yonge et al. 2007:9).According to Hyrkas and Shoemaker (2007:516), preceptors generally provide support and assist students to become familiar with the clinical environment and provision of patient care.Support from preceptors enables student nurses to apply knowledge, skills and attributes in the clinical setting to facilitate the move from novice to expert.Preceptorship refers to 'an individualized period of support under guidance of an experienced clinical practitioner which attempts to ease transition into professional practice or socialization into a new role' (United Kingdom Department of Health 2009:11).
The literature reveals that the preceptorship model eases the students' transition from a simulated to the service setting (Maginnis & Croxon 2007:218).Increasing the number of trained preceptors could therefore impact positively on the professional support provided to students.Preceptorship models are widely used in nursing education programmes.Udlis (2008:20) reviewed 16 research studies examining measurable changes in students' performance when exposed to a preceptorship programme.This review revealed that 56% of the studies supported the use of preceptors in undergraduate clinical nurse education and that only 4% of studies found no significant differences in student performance after being exposed to preceptors.Hallin and Danielson (2008:161) state that 'a preceptorship model offers a way to support and facilitate preceptors' training and to develop cooperation between university and hospital'.According to the authors, various preceptorship models proposed in the literature focus on the learning environment and preceptor's preparation based on local needs and conditions.In other words, preceptorship models are developed for a specific context according to the needs and conditions of that context.Maginnis and Croxon, (2007:218) found that the preceptorship model that assigned one student to one preceptor in the setting proved to be problematic due to the shortage of registered nurses and their demanding workloads.This led to a trial where a 'cluster' model was used to assign eight students to a university-based supervisor who was familiar with the clinical setting.During the trial, the forty nursing students (five groups of eight students) found it easier to adapt and gain confidence when they worked together as part of the group.
A key finding in the review of theories and models about preceptorship training was that any programme that is designed should fit the unique context.This article aims to share our experiences in developing and implementing a continuing education preceptorship training programme in the context of the Western Cape Province, South Africa.The programme focuses on strengthening the clinical teaching expertise of professional nurses in order to provide support to nursing students in the service setting.Happel's (2009:372) preceptorship model was used to underpin the development and implementation process.

Background
In 2002 the Ministry of Education released the National Plan for Higher Education to negotiate the tensions of transition and meet the higher learning needs of South Africa.The University of the Western Cape (UWC) was the only one of the four historically disadvantaged universities to retain its autonomous status (Asmal 2002:2).Through careful strategic planning, UWC decided to focus on certain areas of research and teaching, with health disciplines being one of them.At that time, the Minister of Education announced that UWC and the Cape Peninsula University of Technology would be the only institutions to offer first degree nursing in the Western Cape Province.Following this decision, the student intake for UWC Nursing changed from 120 first-year students in 2003 to 320 in 2004, and the challenge revolved around improving the retention and success rates of students enrolled for the B.Cur. programme.
The undergraduate nursing programme at UWC is presented over a period of four years, as is the case in many countries worldwide.The nursing programme is accredited by a professional body, i.e., the South African Nursing Council (SANC), and students are placed in accredited service sites to attain their clinical learning objectives.The student profile reflects students with an average age of 35 years, from diverse backgrounds and from rural and urban areas in South Africa as well as elsewhere in Africa (UWC 2010).The School of Nursing (SoN) at UWC uses the facilitator model (Mannix, Wilkes & Luck 2009:60), where students are under the supervision of a clinical supervisor employed by the university for a limited period whilst placed in the service unit.For the remainder of the time, the students are supervised by the professional nurse(s) in the unit.
The SANC regulates nurse training in South Africa and prescribes the minimum period of clinical learning over the four-year period.The Council also specifies the number of hours of supervised clinical learning per student per week (SANC 1985).With large student numbers, the studentsupervisor ratio may negatively impact on the quality of accompaniment and supervision that students are offered (Mannix et al. 2009:63)

Operational definitions
Conceptual framework: A collection of interrelated concepts that provide direction for nursing education or practice (De Vos, Strydom, Fouche & Delport 2011:35).
Preceptor: A competent practitioner who provides guidance and support to novices in the clinical setting (Yonge et al. 2007:2).

Preceptorship:
The teaching-learning relationship between the skilled professional and the student nurse to improve the professional development of the student nurse (Happel 2009:375;Yonge et al. 2007:3).
Training programme: Structured continuing education offering to improve the clinical teaching expertise of professional nurses in the service setting (Happel 2009:374).University: An institution of higher education that offers undergraduate and postgraduate qualifications for nursing students (Happel 2009:373).
Clinical learning facility: An institution that has been approved by the South African Nursing Council for a specific nursing education and training programme (SANC 2001).
Clinical setting: An environment in which a registered nurse and student are involved in client care and where learning opportunities present themselves (Mochaki 2001:13).
Service setting: Specified areas where healthcare services are provided to clients (Mochaki 2001:13).For the purpose of this paper, these services include the primary, secondary and tertiary provision of health care.

Clinical units:
A division within a service setting where specialised health care services are provided, for example, intensive care units or medical-surgical units (Jooste 2010:84).Happel's preceptorship model (2009:373) was contextually adapted to form a conceptual framework for the development and implementation of a preceptorship training programme for nurses at the SoN, UWC.The model (Figure 1) illustrates the complex relationships between the individuals and institutions involved in the development and implementation of the programme.The programme refers to the continuing education programme presented by the university to enhance the clinical teaching expertise of professional nurses in the services.This continuing education program was planned as an 80-hour, 8-credit short course that included a clinical component.Following an internal review of a pilot programme in January 2010, the relevant adjustments were made and the first training was offered to registered nurses in the Western Cape Province in July 2010.

Preceptorship model
According to Happel (2009:373), the success of preceptorship in nursing is determined by the strength of the preceptorstudent relationship.In order to fulfill their role, preceptors need to be competent practitioners who hold a teaching, advisory, supervisory or evaluator role in the service setting and who have to maintain communication with the educational institution.Their relationship with the student is short-term and is often an assigned role (Yonge et al. 2007:6).The preceptor must be able to identify the clinical learning opportunities and also requires an overview of the learning needs of the student (Happel 2009:374).Preceptors need to participate in the orientation of students to the clinical environment, actively facilitate clinical learning, carry out assessment of clinical skills and provide constructive feedback to students in the service units (Yonge et al. 2007:6).
The literature shows that students generally need to feel welcome in the clinical placement setting.Students appreciate the opportunity to participate and feel valued by patients in the services.They regard professional behaviour and competence as very important attributes of professional nurses in the field (Abubu 2011:70).Students also expect professional nurses to be willing to provide constructive feedback about their performance (Happel 2009:273).Happel (2009:374) suggests that the clinical facility should have a philosophy of service delivery and display a commitment to clinical education.This could be operationalised by releasing professional staff to attend the continuing education programme and providing opportunities for them to practice their newly acquired skills in the service units.
The university should ideally display the same level of commitment to clinical teaching and learning as the clinical facility.It is also imperative for the university to engage collaboratively with the health services during the planning and implementation of the preceptorship training programme (Happel 2009:373).

Preparatory phase
This phase included establishing relationships between the institutions, namely, the university and the clinical facility.At the university, literature was sought about theories and models related to clinical skills training as well as various ways to provide professional support to students in the field.A continuing education programme was designed and submitted to the relevant university structures.The clinical facilities were approached and a commitment was negotiated from the Director of Nursing Services in the province to support the training of preceptors.The Provincial Government of the Western Cape (PGWC) undertook to release the professional nurses to attend the short courses.The initial collaborative engagement between the SoN and the PGWC took the form of meetings and various types of electronic communication.

Planning of the teaching and learning activities
Kolb's theory: The experiential learning theory of Kolb (1984) fits clinical skills training very well.The generic adaptive abilities that are crucial for effective clinical learning include: The skills laboratory method used to facilitate simulated skills training presents a good fit with Kolb's experiential learning model (Jeggels et al. 2010:53).It also translates well into the real service setting, i.e., much of the learning in the field relates to the students' adaptive abilities, in no specific order.Clinical learning may be triggered when students observe an activity in the service unit.They may then immerse themselves in the experience and reflect on it.Students may then link these experiences to existing knowledge and through active experimentation choose to perform the activity in the real service setting (Kolb 1984:21).It is important that prospective preceptors familiarise themselves with the clinical teachinglearning methods used by the educational institution in order to make appropriate referrals.

Institutional collaboration
Training of preceptors was a recommendation made in a research report of the Director of Nursing Services in the province (Mabuda et al. 2008:26).The SoN supported this proposal and set out to secure funding for a collaborative initiative which would drive the SoN's professional outreach agenda and enhance their relationship with the PGWC.Funding was secured from the University-based Nursing Education South Africa (UNEDSA) initiative to establish a Centre for Teaching and Learning Scholarship in the SoN.
One of the objectives of the centre was: to strengthen the expertise of 60 professional nurses in providing clinical support to students in the selected health services.A meeting was scheduled with the Director of Nursing Services in 2009 to negotiate and obtain the commitment of PGWC to support the training programme.
Several meetings were scheduled between the SoN and the PGWC to finalise the planning process.The meetings were scheduled to share out the responsibilities related to the planning and implementation phases.For example, the convener would present the proposal at a nursing service managers' meeting; the PGWC would disseminate information about the course to all the districts and call for nominations; the SoN would develop the course-work material and present the course; the selection of candidates would be a joint process; and the PGWC would allow access to their facilities for the clinical component of the course.

Resource development
A course descriptor was developed by the convener of the continuing education course and submitted to the Division of Life-long Learning (DLLL) for review and approval by the Senate Life-long Learning Committee.The DLLL is an institute at UWC that provides opportunities for life-long learning through alternative access, continuing education and part-time studies.The course guide was drafted by the convener and reviewed by the presenters.The material developer of the Centre for Teaching and Learning Excellence assisted with finalisation of the course-work material.Since the participants could not access the library resources, a comprehensive reader was compiled and reading tasks were included in the course.
The course outcomes included the following: • Apply the principles of clinical teaching, learning and assessment within the context of adult education • Demonstrate an understanding of the role of the preceptor in clinical teaching and learning • Effectively manage a preceptor-student encounter in simulated and service learning settings • Apply relevant knowledge, skills and attributes in the process of clinical teaching and learning • Initiate, monitor and evaluate a tailor-made skills training programme, and • Motivate students to maintain an interest in learning through the use of creative approaches to teaching and learning.
The course outcomes were developed from the literature related to preceptorship training models and programmes (Happel 2009;Hallin & Danielson 2008;Maginnis & Croxon 2007;Yonge et al. 2007).Smedley (2008:189) suggests that the following be included in the training of preceptors: knowledge about adult learning; skills for teaching and learning in a clinical context; a desire to support and motivate others to learn; and the ability to display positive attitudes towards students.

Securing venues
Seminar rooms were booked and the skills laboratory reserved for simulated activities.Permission was sought from at least four healthcare facilities to accommodate the preceptors in completing their tasks in the service settings.Securing venues for a period of two weeks proved to be more problematic than had been anticipated because the SoN did not have dedicated seminar rooms.The UWC skills laboratory could only be used for continuing education purposes during the university vacations.Access to computer and printing facilities was not available for the pilot programme.Currently, information technology is more accessible to the participants.

Selection
The selection of preceptors is aimed at determining which individuals would best match the preceptorship role.However, in most programmes the prospective preceptors are qualified professional nurses with clinical experience.Yonge et al. (2007:5) suggest that the specific attributes of the role be considered during the selection process, namely, a willingness to facilitate clinical learning, good communication skills and being a competent practitioner.Smedley (2008:185) cites the characteristics of prospective preceptors according to O'Malley, Cuncliffe, Hunter and Breeze (2000:45) as, amongst others, experience and expertise in the clinical field, good communication and decision-making skills, a desire to teach and an interest in professional growth.However, to match the person to the role may require a structured selection process to include specific selection criteria and a screening interview (Jooste 2010:167).Ideally, the selection of prospective candidates should be carried out by the stakeholders involved in the clinical teaching endeavour.
In the Western Cape Province, the recruitment of the participants was performed by the PGWC.This allowed the Director to identify the facilities where the need for training was considered a priority.The directorate also coordinated the application process to prevent the professional nurses from applying directly to the SoN and thereby complicating the selection process.The selection of participants was carried out at a selection meeting with representation from the SoN and the PGWC.The criteria specified that registered nurses from selected health services be considered to attend the continuing education programme.Ten participants in total were selected for the pilot programme and subsequent cohorts of 15 were selected.All the selected participants attended the pilot programme in January 2010.Sixteen participants attended in July 2011 and only six of the fifteen selected attended the training programme in March 2012.
The registered nurses cited workload and miscommunication as the main reasons for non-attendance.A letter was sent to all the selected participants informing them about the requirements for the course, for example, protective clothing and distinguishing devices.Participants were also encouraged to bring their own laptops to the classroom sessions.

Implementation phase Presentation of the course
The two-week short course was presented during university vacations and had a credit weighting of eight credits.The course was not available online as it included a clinical component, and participants had to submit a portfolio of evidence for the summative assessment.The continuing education course was approved by the relevant university structures and piloted in January 2010.
The course was presented by staff members of the SoN.Academics and clinical supervisors accompanied the participants to service settings and facilitated the completion of clinically related tasks.The two-week programme was interspersed with interactive lectures, small group activities and preceptor-student encounters in simulated and real service settings.The facilitation of small groups and some of the simulated preceptor-student encounters were video-taped and projected to stimulate reflective discussions.An important component of the course was structured reflective discussions and reflective journaling.Students in the service settings were requested to complete a questionnaire to evaluate the preceptor-student encounters.
To date, 54 professional nurses have attended the course.Fifty participants successfully completed the course, two submitted incomplete portfolios and two dropped out of the course, citing work pressure as the reason.

Assessment of the course
Participants had to compile a portfolio of evidence for assessment purposes.The evidence included assignments related to the identification of learning opportunities in the services and alignment of the students' learning needs to opportunities in the setting.Participants also had to facilitate small group work and write reports on preceptor-student encounters.They also had to do an assessment of a clinical skill in the service setting.On completion of the course, a course evaluation tool was administered to the participants.

Quality assurance measures
Quality assurance measures were included during the planning and implementation phases of the programme, i.e., the course was accredited as a continuing education course with the DLLL at UWC; the convener of the course was the head of the clinical programme at the SoN; portfolios of evidence were submitted by participants, examined internally and moderated externally; a pilot programme was presented in January 2010; feedback from an internal review committee on the pilot was incorporated into the first course in July 2010; and quality assurance files were compiled to monitor the quality of the programme, including copies of marked portfolios, mark schedules, examiner's and moderator's reports, certificates and the original course evaluation forms.Modifications were made to the course following an annual review of the course material, course evaluations and comments from the examiners.

Evaluation
Course evaluations and reflective journaling by participants revealed that all of the desired outcomes of the course had been achieved.Positive feedback was also received from some of the managers who nominated their staff to participate in the continuing education offering.A formal programme evaluation is currently being conducted by the SoN's research unit.Singer (2006:628) suggests that the evaluation of the preceptorship training programme should include input from all the stakeholders.

Conclusion
Lessons were learned during the planning and implementation of the continuing education course 'Preceptorship training for professional nurses' at the SoN, UWC, as outlined below:

Best practices
The enabling issues were varied and started with a consultative process between the SoN and PGWC to agree on the need to train preceptors in the province.The planning phase was completed over a period of one year, which allowed for the development of good working relationships between the partners.The SoN was fortunate to secure funding to facilitate the planning and implementation of the continuing education course.This collaborative initiative has improved collegial relationships at many levels.The participants, i.e., academics and professional nurses from the service units, have an opportunity to share contextual issues that impact on the clinical training of students A short communication entitled 'Preceptorship training for professional nurses' was presented by the convener of the course at a conference in 2010.Following the presentation, delegates from other higher education institutions expressed an interest in attending the course.To date, six participants from higher education institutions of other provinces have participated in the preceptorship training programme at UWC.
The training commenced with professional nurses in service units and those who work in nursing education units, but will be extended to all service learning sites in the long term.The expectation is that the training will have a direct impact on the quality of student support in hospitals and an indirect impact on the quality of patient care delivery.
Student nurse: A person undergoing education or training in basic nursing (Department of Health 2008).

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Concrete experience, where students immerse themselves in the experience (feeling) • Reflective observation, where students observe and reflect on the experience (watching) • Abstract conceptualisation, where students create concepts that integrate their observations into theories (thinking) • Active experimentation, where students apply these theories in new situations (doing)(Kolb 1984:21).Kolb's theory was used to plan the teaching learning activities included in the course outcomes, by including opportunities for the participants to feel, watch, think about and perform specific tasks related to clinical teaching and learning.