An effective preceptorship programme has long-term effects on the confidence and preparedness of newly qualified nurses (NQNs) and, ultimately, the retention of these new members of the nursing workforce (Woodruff, 2017). Nursing workforce retention is a prominent issue across the NHS, with more than 41 000 vacant nursing posts across the service (Buchan, 2019). Ensuring that those tasked with shepherding NQNs or nurses new to a clinical area into the profession are knowledgeable and supportive is key in helping to keep nurses in post for longer. With a co-ordinated and streamlined approach, preceptorship can be a positive tool in aid of staff retention across the NHS.
This article posits that by changing the current named preceptor or group preceptor dynamic through allowing for a mutual choice between NQNs and their preceptors from an allotted pool, this would foster better preceptor–preceptee relationships and could mean a better chance of satisfaction with the programme and ultimately better retention of the workforce.
Similar to the practice supervisor role introduced by the Nursing and Midwifery Council (NMC) in 2018 to replace the role of a ‘mentor’, a preceptor requires no formal qualifications but simply ideally requires a minimum of 12 months of post-qualification experience. Preferably this should be in the same specialty as their preceptee as there is the requirement that all registered nurses should be able to supervise NQNs and other colleagues that are new to the department. (McCusker, 2013; NMC, 2018a; NMC, 2018b). Although there are formal preceptorship training courses, McCusker suggested that a staff nurse does not have to attend in order to be named a preceptor (McCusker, 2013). The nursing regulator concurs with this, but additionally states that those who are assigned to be preceptors are ‘expected’ to have undertaken a practice teacher or mentoring programme (NMC, 2006). Contradicting this norm, a qualitative case study of nurse preceptors by Forneris and Peden-McAlpine (2009) suggested that the effective training and engagement of nursing graduates by a preceptor is a learnt skill, and not the innate ability of all qualified nurses.
Nursing preceptorship often incorporates a formalised training programme (in the form of a document given to the NQN) with appropriate clinical and personal competencies, milestones and objectives to achieve. The preceptorship period lasts up to 18 months, and is a structured period of transition for NQNs from a student to a qualified and competent practitioner with good decision-making and critical thinking skills. A preceptorship period also allows nurses to orientate to a new department (Ciocco, 2016; King's College Hospital NHS Foundation Trust, 2020). Depending on the particular NHS Trust, preceptorship training programmes differ in content; however, set timeframes (within that 18-month period) for progress meetings with named preceptors and for achieving certain key competencies for fully independent practice would be commonly included. These competencies would be in subjects such as a Trust/local induction, IV/oral medication administration, basic and immediate life support training and other specialty-specific training. In addition to the NQN, established nurses moving to a new ward or specialty and nurses returning to practice can undergo this type of programme, which can be tailored depending on the education needs of the nurse in question (Health Education England, 2017).
With the arguably relaxed requirement of no formal training being deemed necessary by the nursing regulator, the ‘untrained’ nursing preceptor is the predominant standard. Preceptorship currently takes on two main forms. The first is that of a single named preceptor where one nurse is allocated to a NQN and the NQN mirrors the named preceptor's rostered shifts, ideally working with their named nurse for a set period (supernumerary period). Using a semi-structured interview approach to their research design, Wain (2017) found that NQNs reported clashes with their preceptor due to personality differences or that they spent insufficient amounts of time with their named preceptor due to rota and staffing issues. Despite Wain (2017) having a limited sample size, research that uses a qualitative approach, including interviews, provides depth and detail, recording often illusive feelings and attitudes (Rahman, 2017). The second form is group preceptorship where an NQN would work alongside multiple nurses on the same unit or team. This is a way of delivering what named preceptorship offers but without the reliance on one staff member spending ‘sufficient’ time with an NQN. However, this too has its issues as different team members have different ways of teaching as the systematic review by Quek and Shorey (2018) found. These differing methods; some effective and some not, have led to a lack of coordination and a patchy approach to NQNs' learning (Quek and Shorey, 2018). In all of this, neither the NQN nor the preceptor has a say in the initial allocation process, which is predominantly done by senior management (Dibert and Goldenberg, 1995).
The status quo
Nursing workforce retention has become a key issue for the health service and has been compounded by external factors such as Brexit and the scrapping of bursaries for nursing students (Buchan, 2019). EU applicants to nursing posts in the NHS have also fallen and nursing student numbers have also seen a significant fall (Buchan, 2019). For the students who make it through the rigorous training process and qualify into the profession despite the umbrella of reduced financial support, the ‘reality shock’ that is experienced in their first role highlights just one of the challenges they face on qualification.
The psychological impact of being a NQN (1-6 months post-qualification) is widely documented (Gerrish, 2000; Higgins et al, 2010). The introduction into the profession and the transition from being a student nurse to a qualified practitioner not only brings on immense emotional strain (Begley, 2007; Duchscher, 2009), it is also accompanied by the stark reality of now being an accountable professional, a concept one arguably has to experience in order to fully comprehend. According to Feng and Tsai (2012), NQNs often feel unprepared for the demands of the new role. For instance, the practice of having NQNs in areas previously reserved exclusively for nurses with 6 months of work experience is now widely accepted across the NHS. Having a preceptor and/or colleagues who are not only supportive during this difficult period, but who can impart the appropriate skills and knowledge in a non-judgemental, constructive and positive manner is important in helping the new nurse to gain confidence as a practitioner (Fenwick et al, 2012). The opposite can arguably lead to disenchantment with the not only the particular Trust, but at times the profession as a whole (Washington, 2013). Stress and dissatisfaction have many NQNs leaving within a year of qualifying (Edwards et al, 2015). The results of this include significant cost to hospital Trusts that will then have to provide temporary staffing until another nurse can be recruited, putting more pressure on existing staff, further perpetuating the cycle of pressures that nurses and the NHS as a whole face (Wray, 2017).
The benefits of preceptorship, such as protection and guidance for the NQN when just starting out in the new role, are well known (Marks-Maran et al, 2013). Preceptors are not simply clinical educators, they are also positive role models and ‘socialisers’, facilitating the NQN's psychosocial needs by orienting them to the new environment and offering emotional, social and mental support (Hautala et al, 2007; Wilson et al, 2013). Personality clashes, differences in preceptor–preceptee age pairings and cultural differences reported by preceptees have all meant the potential positives of preceptorship are being watered down or simply nullified (Poradzisz, 2012). Despite the personal and professional rewards that accompany being a preceptor (Tracey and McGowan, 2015), the lack of training and the constant stream of new starters has meant many preceptors are not committed to this pivotal role as it is usually assigned to them rather than a role they request. This is despite this being part of their role as a registered nurse (Cloete and Jeggels, 2014; NMC, 2018a). The skill involved in knowing when to loosen or tighten the reigns of preceptorship, the energy and time commitment of the role and the responsibility of being an emblem of clinical excellence leaves many preceptors feeling burnt out (Richards and Bowles, 2012; Lewis and McGowan, 2015).
A new way forward
The current paradigm surrounding the allocation of preceptors, whether named or group, could be altered to achieve better preceptor–preceptee pairings. This would facilitate more choice of who to work with for the NQN and, importantly, ownership of the preceptorship process by the preceptor. This would be achieved chiefly by allowing the preceptor to opt in or out of one or more of the multiple recruitment intakes (during which they will inevitably be assigned preceptees) that happen throughout the year. Preceptors are often burnt out by being repeatedly asked or, more accurately, assigned preceptees (Dibert and Goldenberg, 1995; Bodine, 2018). It could be argued that this opt-in/opt-out method could lead to more choice and ownership for preceptors over the preceptorship process, opting in when enthusiastic and energised about teaching and opting out when close to burnout.
For the NQN, having an engaged and willing preceptor is a strong foundation for a successful period of preceptorship (Chang and Hughes, 2006). This system would allow NQNs to work with members of this engaged pool of preceptors for a short initial period and eventually request that one individual is assigned as their named preceptor. In this way the NQN would have time to decide whether a particular nurse's teaching style suited them. This would be in addition to deciding whether they felt their mutual personalities, age and educational background were conducive to a successful preceptorship partnership (Park et al, 2011; Poradzisz et al, 2012; Richards and Bowles, 2012). Willing and engaged preceptors will arguably contribute to the success of initiatives to improve retention as highlighted earlier. Also contributing to the success of this way forward would be having trained preceptors who have had appropriate guidance on key aspects of their role, such as being aware of how to give constructive feedback. This is with the aim of appropriately managing preceptees who are failing to meet required standards to progress from a novice in a clinical area to a competent practitioner (Burgess and Mellis, 2015).
Practical considerations would include ward areas ensuring that their nurses have all received appropriate training to be a preceptor, therefore creating a sufficient pool of preceptors who may ‘opt in’. Issues may arise with this approach if the pool of available preceptors is small. To be a preceptor, a minimum of 12 months' experience in a clinical area is recommended by the NMC and this should still be the case for the allotted pool of available preceptors. This would ensure the assessment of competencies is carried out to a standard befitting that clinical area.
Conclusion
The success or failure of a NQN preceptorship programme has been shown to impact nursing retention and facilitating a better kind of preceptorship where named preceptors are engaged and willing and the preceptee has a choice of who to work with could turn the tide of disenchantment and burnout within the nursing profession (Lavoie-Tremblay et al, 2011).
The impact of untrained and unprepared preceptors has been widely documented (Smedley, 2010; Lalonde and McGillis, 2017) and to deliver on the benefits of preceptorship, further training and development of preceptors is needed as well as a change in the current allocation paradigm so that the preceptor, the preceptee and the Trust profit from the process.