The Term Preceptor: Its Interpretation in South African Nursing Colleges and International Nursing Literature

The purpose o f this study was twofold , namely: I) to obtain clarity on the meaning o f the term preceptor, and 2) to establish how the term preceptor is interpreted in the nursing colleges o f the RSA and to ascertain whether this interpretation is consistent with the general connotation o f the term in contemporary nursing literature. Dictionaries and relevant contemporary nursing literature fo rm ed the unit o f analysis fo r obtaining clarity on the meaning o f the term preceptor, while the unit o f analysis fo r the second section o f the study comprised responses o f nursing college principals to a questionnaire. The data obtained in the investiga­ tion indicate that the term has acquired a specific connotation within the international nursing context and that specific defined attributes distinguishes it fro m the broad and general definition fo u n d in standard dictionaries. Within the South African nursing context the term preceptor has not yet acquired a specific connotation, but appears to mean different things to different people. Opsomming Die doel van hierdie studie was twee-ledig, naamlik 1) om duidelikheid omtrent die betekenis van die term preseptor te verkry, en 2) om vas te stel hoe die term preseptor in Suid-Afrikaanse verpleegkolleges ge'mter-preteer word en o f hierdie interpretasie ooreenstem met die algemene konnotasie van die term in eietydse verpleegliteratuur. Woordeboeke en toepaslike eietydse verpleegliteratuur was die spesifieke eenhede van ontleding wat bestudeer is om meer duidelikheid omtrent die betekenis van die term preseptor te verkry, terwyl die responsies van verpleegskoolprinsipales op 'n vraelys as ontledingseenheid vir die tweede gedeelte van die studie gebruik is. Bevindinge dui aan dat die term preseptor ' n spesifieke konnotasie binne die internasionale verpleegkonteks verkry het, wat wel verskil van die algemene en breë definisie soos in standaard woordeboeke aangedui. Binne die Suid-Afrikaanse verpleeg­ konteks het die woord egter nog nie ' n spesifieke konnotasie verkry nie. IN T R O D U C TIO N The m ajor focus of this study is centered on the task of clarifying the term preceptor as used within the nursing context. Until quite recently this term was not com mon in the vocabulary of South African nurses. Searle and Mellish had occasionally used it in their writings. Since 1975 the Unisa nursing lecturers used it to refer to the group of experienced registered nurses in the …


Dictionaries and relevant contemporary nursing literature fo rm ed the unit o f analysis fo r obtaining clarity on the meaning o f the term preceptor, while the unit o f analysis fo r the second section o f the study comprised responses o f nursing college principals to a questionnaire.
The data obtained in the investiga tion indicate that the term has acquired a specific connotation within the international nursing context and that specific defined attributes distinguishes it fro m the broad and general definition fo u n d in standard dictionaries.Within the South African nursing context the term preceptor has not yet acquired a specific connotation, but appears to mean different things to different people.

IN T R O D U C TIO N
The m ajor focus of this study is centered on the task of clarifying the term preceptor as used within the nursing context.Until quite recently this term was not com mon in the vocabulary of South African nurses.Searle and Mellish had occasionally used it in their writings.Since 1975 the Unisa nursing lecturers used it to refer to the group of experienced registered nurses in the health services who assisted with the supervision of a proportion of Unisa nursing students practica in the clinical field.O ther than the above the term preceptor was seldom used within the nursing context in this country.However, in international nursing literature reference was made to preceptors with increasing frequency from the late 1970s onwards.
With the re-organisation of nursing education in South Africa into the system of tertiary education during the early 1980s several Nursing Colleges implemented the use of preceptorship experiences for their students.Consequently the term preceptor was heard more com monly in nursing conversations.However, it appeared to lack clear and concise definition and the impression was gained that it meant different things to different people and that considerable confusion surrounded the term.Collingwood (1938:2) stated that when a term is com m on in usage and confusing in meaning, it is not possible to decide privately when to apply and when to refuse it, nor is it helpful to continue its use w ithout clarification.It is furtherm ore generally accepted that m isunderstanding, bad theory and practice can result when words in use are inadequately explored and understood.One cannot achieve an accurate exchange of views and read a meeting of the minds unless one is talking the same language.
A need was therefore recognised to obtain clarity on what the term preceptor m eant to all who were involved in implementing preceptorship and whether it meant the same to all.There was also a need for com parison of the local interpretation of the term with its use in the international nursing literature.Clarification of term inology is im portant because for example, should ambiguities and inconsistencies be found in its interpretation these could be cleared, misunderstanding could be corrected and com m unication improved am ong all those using the term.

P U R PO S E OF TH E STUDY
The purpose of the study was two-fold, namely 1) to obtain clarity on the m e a n i n j ^ of the term preceptor and 2) to establish how the term preceptor is interpreted in the Nursing Colleges of the RSA and to ascertain whether this interpretation is consistent with the general connotation of the term in contem porary nursing literature.
The following research questions provided direction to the study.
W hat is the com m on usage of the term preceptor as defined in a standard dictionary?W hat is the general connotation of the term preceptor in contem porary nursing literature?
Does the com m on usage of the term preceptor as defined in the dictionary differ from its use in the nursing literature?
W hat is the meaning of the term preceptor according to its interpretation in nursing colleges in the RSA? Are there differences in the interpretation of the term preceptor among nursing colleges in the RSA? • the purpose.D ictionaries and relevant contem porary nursing literature formed the unit of analysis for the first section of the study, while the unit of analysis for the second section of the study comprised responses of nursing college principals.A convenience sample of dictionaries and relevant nursing literature was selected, while a questionnaire was sent to the principal of each nursing college recognised as such by the South African Nursing Council (SANC) during 1987.A com puter list containing the names and addresses of each one of these colleges (n = 27) had been obtained from the SANC.
Principals were informed of the objectives of the study and were assured that the inform ation given would not be linked to their names and colleges and that anonym ity would be respected.A response would be regarded as consent for the inform ation to be used in the study.^^I 'h e questionnaire used to obtain ^^o r m a tio n from the nursing college principals on how the term preceptor was used and interpreted in their colleges was self-designed.An interview would probably have been more effective in meeting the purpose of the study, as it would have perm itted in depth probing.The latter method was however considered impractical and cost ineffective for this particular study as nursing colleges are widely dispersed across the whole country.D ictionary (1953; 1961).includes the com mon definition of tutor, teacher and instructor but also presents additional and more specific definitions, namely "A practising physician who takes an undergraduate medical student and gives him personal training in the practice of medicine."(1953:1943; 1961:1784); and "A specialist in a branch of medicine or surgery who takes a young physician as a resident student and gives him personal training in his specialty -for example obstetrics and gynaecology." (1961:1784) From the latter definitions it is clear that the term preceptor has both a general and a specific connotation and that the specific connotation is context bound.It can thus be inferred th at the meaning of the term should always be examined within the context in which it is used.According to W ebster's definition the specific connotation of the term preceptor appears to have been acquired within the medical context.This suggests that the word was already well established in the medical vocabulary before the 1950's.
From reports in the nursing literature it appears that the term preceptor was adopted in the nursing vocabulary in the U.S.A. when nurse practitioner programmes were introduced during the early 1960's.Physician preceptors were co opted to give registered nurses personal training in the skills required of nurses in expanded roles (Mon.nig 1983:39;Myrick 1988:589).As the nurse practitioner role became more accepted, but few nurse practitioners were specifically prepared to teach in such programmes, a variety of continuing education programmes were developed to enable nurse practitioners to acquire the necessary knowledge and skill to teach in practitioner programmes.Nurse practitioner clinical preceptors began to replace physician preceptors in the nursing programmes (Brykczynski 1985:82).
Since'this time the concept of preceptorship is said to have acquired and continues to gain increasing impetus as a method of clinical teaching in nursing (H elm uth and Guberski 1980:36-39).In 1975 the term preceptorship appeared for the first time as a classification in the International Nursing Index (Sham ian and Inhaber 1985:79).By this time a total of 58 preceptorship program m es were reported for nursing students in the United States.By 1985 the num ber had escalated to 109 (Spears 1986:4).Also in C anada several university and com m unity college schools of nursing were adopting preceptorship programmes as a method for the clinical teaching of their students (M yrick 1988:136).Preceptors were found in a variety of health service settings -general nursing units, am bulatory units and critical care units, to name but three (Sham ian and Inhaber 1985:89).The term preceptor had acquired a specific connotation within the nursing context similar to W ebster's New International Dictionary definition pertaining to the medical practitioner, but adapted and modified within the nursing context.It was not used in the broad sense as defined in standard dictionaries as a synonym for teacher or instructor, therefore it did not serve as merely an alternative name for any of the many categories of nurses engaged in teaching.Specific defined attributes distinguished the use of the term preceptor from other teaching categories.
Even though there are certain variations reported in the international nursing literature with regard to purpose, role, selection and preparation of preceptors there appears to be general consensus that the term preceptor refers to a person who meets the following criteria: -is service or unit based in other words, one who functions in a clinical setting (for example, as a clinical supervisor of a unit, ward sister or even another health practitioner) and is seen as a valued member of the staff; -possesses clinical com petence and expertise in her area of practice, has a good conceptual base of nursing, is prepared for teaching and shows interest in student education; -is specially selected or appointed to work for nurse learners and is allowed time for this in addition to her regular duties; -serves as a role model and resource person for nurse learners through a one-to-one relationship in a carefully planned and structured system of learning (Goldenberg 1986:11;Reilly and 'Oerman 1985:137;Sham ian and Inhaber 1985:79;Turnbull 1983:10).

W HAT A RE TH E FU N CTIO N S AND RE SPO N SIB IL IT IE S O F TH E PR E C E PTO R ?
The responsibilities of the preceptor as described in the literature are multiple and varied and may differ slightly from one situation to the next.Assigned responsibilities depend to a large extent on which and how many other categories of nurse teachers are involved in the clinical teaching of the student and the definition of the specific responsibilities of each one of these categories.Limon Bargagliotti and Spencer (1982:17) and Reilly and Oerman (1985:138)  O ther responsibilities mentioned are pro gramme planning, assisting in the establishment of objectives and priorities, evaluating, as well as com m unicating with superiors regarding the progress of preceptees (Dobbie and Karlinsky 1982;Shamian and Inhaber 1985).The role of the preceptor is said to decrease as the preceptee takes on more and more respon sibility.The responsibility is both com plem entary and changing: as the student or orientee becomes more com fortable in the u nit's function, the preceptor steps back as teacher and assumes the role of resource person a n d /o r facilator (Sham ian and Inhaber 1985:82).Preceptors in general are expected to fulfill their roles in mutual negotiation with the student and the tutor responsible for teaching the theory for that particular practica, and do not function as formal teachers per se (M cG rath and Princeton 1987:133).

SELECTIO N OF PR E C E P T O R S
There is no absolute agreement in the literature as to who should select the preceptor.The selection may be carried out by nursing management of the hospital responsibilities of a preceptor it should have become clear that preceptor is not an alternative name for college tutor, clinical instructor, ward sister or mentor.When the nursing college tu to r or the lecturer from the university nursing departm ent carries out her teaching responsibilities in the clinical situation she does so as a tutor or lecturer and not as a preceptor.She is not part of the service or unit and with a few exceptions not necessarily experienced or clinically expert in the clinical setting in which she teaches.Hence she does not qualify to be called a preceptor.The clinical instructor is also not necessarily a preceptor even though she may be serviced based.Unless she is assigned to one specific practice area in which she is experienced and highly com petent, practises in and confines her clinical instruction to th at particular area, functions in a one-to-one relationship with students on a daily basis and meets the other criteria specified for a preceptor, she is not a preceptor.As a rule the clinical instructor covers not only one particular clinical area, but covers a num ber of clinical areas and is mainly responsible for dem onstrations.She seldom finds time to enter into a one-to-one relationship as the clinical instructor-student ratio may be as high as 1:50.She seldom serves as a role model with regard to interactions with staff members, com m unity members and family of patients or decision-making in the practice situation.She does not actively practise nursing -her responsibilities are confined to instruction.The ward sister is the most likely person to function as preceptor but does not autom atically become a preceptor on appointm ent as a ward sister.She has to meet the required criteria for a preceptor and be specifically assigned to this function.
A m entor is not the same as a preceptor.Preceptors provide an opportunity for the development of a m entor relationship; however, not all preceptors necessarily become m entors (Ruetz 1987;Reilly and O erman 1985).Deane and Campbell (1985:144)

draw attention to the following differences between the concepts preceptor and mentor:
-There is no free choice involved in the preceptor-preceptee relationship whereas there is such a choice in the m entor-protegé relationship.The preceptee or student is assigned to a specific preceptor while either the m entor or protegé can initiate the m entor relationship.-The preceptor and preceptee work in the same setting within a structured set of expectations and their relationship is limited to a specific period of time.The relationship ends when the preceptee moves to another practice area or unit.The m entor and protege need not work in the same setting.Learning expe riences are unstructured, expectations are not formally stated, but there is usually a long term relationship.-M entors are likely to enhance career planning, advancement and satisfaction.
Rather than supervision they provide guidance, support and advice on personal and professional m atters to help the protege meet the dem ands of her course or career.

IN T E R PR E T A T IO N O F TH E TE R M P R E C E P TO R AT SOU TH A FR IC A N N U RSIN G COLLEGES
Twenty-three of the 27 questionnaires (85,2%) which had been sent to the nursing college principals were returned.However, one of the questionnaires was returned unanswered with a note that the term preceptor was unknow n to all members of the staff of that particular nursing college.
The responses to the remaining 22 questionnaires (81,5%) were analysed by hand and are presented below question by question.
The responses to question 1 "W hat does the term preceptor convey to you? Please describe in your own w ords", are presented in Table 1.The data depicted in Table 1 suggests that the term preceptor has not yet acquired a specific connotation within the South African nursing context and that there is very little agreement am ong the respondents with regard to its meaning.With the exception of two interpretations, the meanings attached to the term were generally broad and vague.Almost onehalf of the respondents used the broad general meaning as defined in standard dictionaries, while one-third linked the meaning to the clinical situation, but not specifically.
Table 2 presents the responses to question 2 in which respondents were asked to indicate who, in their opinion, should act as a preceptor in nurse training programmes.Here, too, many different opinions were received, which further strengthened the inference made previously that very little clarity exists with regard to the meaning of the term preceptor and the Zone nursing manager or a member from the college clinical department I

Clinical instructor 1
The principal or student counsellor 1 functioning of preceptors within the South African nursing context.With regard to question 3 "Should preceptors be directly responsible to the principal of the college?" ten ( 10) respondents replied in the negative, eight (8) in the affirmative, one was undecided and three (3) stated that it depended on who the preceptor was, for example, if she was a m atron she should not be, but if she was a clinical instructor she should be.
In response to question four (4) "Should preceptors be specially appointed or selected?",twelve ( 12) respondents indicated that they should, while ten ( 10) were of the opinion that this should not be the case.Of the latter group, seven (7) indicated that teaching was an established function of every ward sister and no additional persons were needed to fulfil this function.One (1) respondent indicated • at by appointing a preceptor the itiative and responsibility of the ward sisters would be stifled.A nother respondent did not regard preceptors as formal teachers and hence saw no reason for them to be appointed or selected.
More than one-half of the respondents (12) refrained from answering question 5 "Who should appoint preceptors?"There was little agreement on this point among the ten ( 10) respondents who did respond.The following answers were obtained: both the principal and m atron (3); the principal (2); the selection com mittee of the college council (2); college personnel ( 1); hospital personnel ( 1) and senior staff ( 1).
With the exception of one respondent there was general consensus in the answers to question 6.The respondents believed that preceptors were active in the main areas of nursing, namely general, com m unity health and psychiatry and midwifery.The one exception indicated that preceptors were active only in the fields of general nursing and midwifery.
In response to question 7 relating to the functions and responsibilities of the preceptors, answers varied considerably.
Seven respondents limited their responses to three functions.One respondent listed fourteen functions.The latter were however all very non-specific.The data obtained are displayed in Table 3. Slightly more respondents (12) differentiated between preceptors and clinical tutors than those who did not ( 10).O f the latter group, four indicated that they did not use the term preceptor at all within their nursing context.
Question 9 "W hat is the m ajor difference in the functions of the preceptor versus the clinical instructor?", was applicable to the twelve respondents who had indicated in question 8 that they did differentiate between preceptors and clinical tutors.Only eleven respondents answered the question and a variety of answers were received.These are depicted in Table 4 below.
In response to question 10 " Have specific preceptors been appointed in the service with which you are concerned?",seven respondents answered in the affirmative, while fourteen said they had not and one was uncertain.
The final question, " Do you think it is essential to use preceptors in the clinical situation?",was answered with a "yes" by eighteen respondents, while four replied "n o ".The latter all com mented that ward teaching was a function of the ward sister and that it was quite unnecessary to appoint another category for this fuction.

D ISCU SSIO N O F F IN D IN G S
From the results of the findings it can be deducted that even though the m ajority of respondents were in agreement that preceptors should be used in the clinical situation, the term preceptor has not yet acquired a specific connotation in the South African nursing context and preceptorship has not yet gained acceptance in the majority of nursing education programmes in this country.At not even one-third (7) of the participating nursing colleges had the use of preceptorship experiences for students been implemented.Among the colleges using preceptors there does not appear to be a shared com m on interpretation with regard to the term preceptor.Differences exist with regard to who should act as preceptor, what her functions and responsibilities are and how she can be distinguished from the clinical instructor.
In fact it appears as though considerable confusion surrounds the term.In many instances the term is used in a broad and general m anner as defined in standard dictionaries.Furtherm ore, the responsibilities and functions ascribed to the preceptor are not specific or circumscribed but general and broad.This makes it very difficult for an outsider to obtain a clear impression of who and what the preceptor is.
The argum ent presented by more than one-third of the respondents who were against appointing or selecting preceptors was "Why change the status quo?Teaching was and is the function of every ward sister and no additional category is needed to take over this function".The practical implications of m aintaining the status quo is, of course, a m oot point.F or several decades the nursing literature has been replete with the shortcom ings of this system.Although it is generally accepted that teaching is vital at the ward sister's level and therefore one of her prim ary responsibilities, research has suggested that the teaching in the wards by ward sisters appears in many cases to be inadequate Several researchers have confirmed a relationship between workload, attitudes and leadership style of ward sisters and learning activities in the ward (Fretwell 1982;Ogier 1982;O rton 1981).In the light of these findings the necessity for innovation or alternative solutions is obvious.Preceptorship is one alternative that has been advocated and which, according to the international nursing literature, appears promising.Successful preceptorships contribute to quality patient care as well as quality student education.They facilitate collaboration between service and education (Turnbull 1983).Perhaps more clarity on the meaning of the term would prom ote a more positive attitude toward preceptorship.

CO N CLU SIO N AND R E C O M M EN D A TIO N
The data obtained in the investigation suggest that the term has acquired a specific connotation within the international nursing context and that specific defined attributes distinguishes it from the broad and general definition found in standard dictionaries.W ithin the South African nursing context the term preceptor has not yet acquired a specific connotation.The term appears to lack clear and concise definition and means different things to different people.No group consensus on the meaning of the term appeared to exist.The presupposition which prom pted this investigation was thus confirmed.There appears to be a lack of exposure to international nursing literature as only one person adopted the specific connotation described in the literature.
It is recommended that nurse educators be urged to adopt the specific interpretation of the term preceptor as used in the international nursing literature -this should eliminate confusion.It is further recommended that more attention be paid to specific definitions and clarity of meaning before adopting a term for com m on usage and that provision be made for college personnel to have reasonable access to international nursing literature and be encouraged to use it.
draw attention to the im portance of a written description that spells out the roles and responsibilities of the preceptors, tutors and clinical instructors particularly in relation to the selection of learning experiences, instruction in the setting, supervision and evaluation of learning.Nevertheless despite the variations in responsibility certain com m on responsibilities of preceptors could be identified.All preceptors described in the available literature function as teachers, resource persons and role models in the clinical setting.The preceptor is a realistic role model because she is part of the clinical setting(Dobbie  and Karlinsky 1982:40).There are two prim ary responsibilities mentioned in most reports, namely: 1) orientation of preceptees to the unit and to their work role and 2) socialisation of preceptees within the unit(Chickerella and Lutz 1981;   Crancer et al. 1975; Everson et al. 1981;   Friesen and C onohan 1980; Knauss 1980;  Haes 1983; May 1980; M cGrath and  Koewing 1978; M urphy and Hammerstad   1981; Patton et al. 1981; W alters 1981).

(
Crancer et al. 1975; Knauss 1980; W alters   1981), by educators from the teaching setting(Everson et al. 1981; Patton et al.  1981)  or jointly(Crancer et al. 1975;   Friesen and C onahon 1980; Reilly and  O erman 1985).P R E C E P T O R S V ERSUS O TH ER N U RSE C A TEG O R IES On considering the defining attributes and Interpretation o j the term preceptor by respondents(n = 22) Respondents' views on who should act as a preceptor in nurse training programmes(n ~ 22)

TABLE 3
Functions and responsibilities o f preceptors as described by respondents (n = 22)

TABLE 4 M
ain differences in the function o f preceptors versus clinical instructors as viewed by respondents (n = 11)

allocated to a specific unit Moves around from unit to unit 3 Role is informal Role is formal 2 Is a companion Is an instructor of practice 2 Is a facilitator Is an instructor of practice 1 Is synonymous to tutor and committed to teaching Is committed to practical demonstration and supervision 1 Is responsible for quality patient care Is responsible for education of the student 1 Is a clinical expert in a particular field Is a generalist 1
(Lelean 1973); that ward sisters are negating their educational functions and are not fulfilling their role of teacher, resource person and team leader(Brownlee  1983); that ward teaching often ends up being unplanned and ad hoc with little relevance to the total curriculum (Alexander 1983); that ward teaching is incidental and educational needs of students are subordinate to nursing needs of patients(M yrick 1988); and that student nurses work mainly without adequate supervision and guidance and their clinical experience lacks any systematic attem pt at the teaching of clinical competence (Bradshaw 1989).