Preceptorship was introduced to nursing as part of the Project 2000 reforms, when it was recognised that the transition period from student to registered nurse was an extremely valuable period for developing nursing practice. The Nursing and Midwifery Council (NMC) defines preceptorship as about:
‘Providing support and guidance enabling new registrants to make the transition from student to accountable practitioner.’
The Department of Health (DH) defines preceptorship as:
‘A period of structured transition for the newly registered practitioner during which he or she will be supported by a preceptor, to develop their confidence as an autonomous professional, refine skills, values and behaviours and to continue on their journey of life-long learning’
According to NHS Employers, a quality preceptorship programme is essential to ensure the best possible start for newly qualified nurses, midwives and allied health professionals (NHS Employers, 2018).
There are a number of benefits associated with the delivery of a robust preceptorship programme. Preceptorship has been reported to provide effective and efficient learning experiences to preceptees from diverse backgrounds, who may have varying learning needs, allowing a ‘tailor-made’ approach to learning (Forneris and Peden-McAlpine, 2009; Sandau et al, 2011). This is particularly relevant in the England, where 16% of the nursing workforce is made up of international nurses (Baker, 2019). The number of international nurses is likely to increase in the next few years as the Interim NHS People Plan confirmed the need to ‘increase international recruitment significantly’ to boost the supply of nurses (NHS Improvement, 2019:27). This is also reflected in The NHS Long Term Plan for England, where a ‘step change’ in the recruitment of international nurses was mentioned, aimed at bringing several thousand into the health service each year over the next 5 years (NHS England and NHS Improvement, 2019).
Although many studies have reported that nursing preceptorship has positive effects on new nurses' nursing competences (Komaratat and Oumtanee, 2009; Kowalski and Cross, 2010; Ke et al, 2017), it has also been reported to improve professional socialisation (Kowalski and Cross, 2010); and job satisfaction and retention rates (Chen et al, 2011; Owens, 2013; Chen and Lou, 2014). Having a high-quality preceptorship programme, therefore, is particularly important for employers in London where recruitment and retention is an ongoing challenge.
NHS Employers (2018) has suggested that investing in a preceptorship programme can deliver a variety of additional benefits for the preceptee and employer, such as:
NHS Employers therefore encourages employers to:
‘Track, measure and evaluate the success of their preceptorship programmes to be able to demonstrate value and make improvements where necessary’
The Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals (DH, 2010) suggests that all newly qualified nurses should have learning time protected in their first 6 to 12 months of qualified practice. This is to enable them to access support from a preceptor, an experienced practitioner, in order to develop their confidence as an independent professional. The overall outcome of a preceptorship programme is that it empowers practitioners to develop the knowledge and skills acquired during their formal training process and to become confident and competent members of the multidisciplinary team.
Benner (1984) identified five stages of skill acquisition for nurses in order to move from being a novice practitioner to becoming an expert (Figure 1). In order to practise as an expert, Benner suggests that one needs to have an in-depth knowledge base, which is informed by past clinical experiences.
According to this model a ‘novice’ practitioner would be a nursing student in their first year of clinical education, where their clinical experience is very limited. The ‘advanced beginner’ stage starts when the nurse completes his or her nurse training and is in their first job. At this level, nurses have had more experience, which enables them to recognise recurrent, meaningful components of a situation. They have the knowledge and the know-how, but not necessarily enough in-depth experience. To become ‘competent’, nurses have to gain more experience in their field of practice, which may take 2 to 3 years post-qualification. With continued practice, the competent nurse progresses to the proficient stage, where they start perceiving situations as ‘wholes’, rather than in ‘parts’. Through further clinical experience nurses can advance their skill acquisition to finally reach the ‘expert’ stage. Expert nurses have an intuitive grasp of a situation based on their deep knowledge and experience, and are able to focus on the most relevant problems (Benner, 1984).
It is recognised that, according to Benner's ‘novice-to-expert’ model, it may take many years of experience and skills development for a nurse to reach the ‘expert’ practitioner stage. The preceptorship programme provides the first steps to helping newly qualified nurses along their journey to move from being an ‘advanced beginner’ to becoming a more ‘competent’ practitioner.
The need for effective preceptorship features strongly throughout the Shape of Caring review, as Health Education England (HEE) emphasises in its response to the review (HEE, 2016:17), particularly in two themes:
Although the need for nursing preceptorship and its value has been well documented in national policies (HEE, 2017) and in the literature (Odelius et al, 2017), the way in which this programme is delivered varies significantly across the country and across different organisations.
In this article the authors will discuss a preceptorship programme implemented in a large integrated NHS Trust in north-west London and share their reflections and learning to date.
The preceptorship model
Formed in 2014, the authors' organisation is one of the biggest integrated healthcare trusts in the country, with 9000 staff delivering care at home, in the community and in hospital. As a result of a merger, there were variations in preceptorship practices with some areas not receiving any preceptorship at all. The Trust was committed to supporting staff development and wellbeing, as well as staff retention and high-quality service delivery. This led to the development of a robust collaborative preceptorship programme for nurses across the acute and community sector that was structured, innovative and added value to the forward-thinking nursing workforce. Recruitment and retention of the nursing workforce has often been a challenge, not unlike for other NHS trusts in London. A previous staff survey in the organisation had highlighted a number of areas that needed improvement. Staff reported a poor experience within the Trust, low staff morale, a lack of career pathway and a lack of development. This resulted in many newly qualified nurses feeling unsupported and consequently leaving the Trust.
To address the issues around staff satisfaction, recruitment and retention, extensive staff consultation took place, which informed the redevelopment of a Trust-wide preceptorship programme in 2015. The preceptorship programme was implemented by the service and practice development facilitators (SPDFs) who took on the role of preceptorship leads in the learning and organisational development team. Although the model for the acute sector and community were slightly different, the overall vision was similar.
The development of the preceptorship programme for the community coincided with the publication of the national Preceptorship Framework for Health Visiting by the Institute of Health Visiting (McInnes et al, 2014), of which some of the team were members. The team were therefore able to use this framework to influence the model of preceptorship in the community. The preceptorship programme for the acute sector was designed to promote a standard document which is relevant across the Trust, and in 2017 the document was reviewed and updated to comply with the standards set out in the Capital Nurse pan-London Preceptorship Framework (HEE et al, 2017).
The current model of preceptorship, which has been running since 2016, was developed by evaluating the previous models of delivery and gathering evidence from staff involved with the programme. The preceptorship leads co-ordinate and facilitate the study days and invite other practitioners to share the teaching and training, which also provides an opportunity for the trainers to enhance their own skills. The aim is to give each preceptee a named preceptor within the first 2 weeks of starting their new post. The preceptor then arranges an initial meeting. Following this, regular meetings are scheduled to discuss any practice issues, review learning progress and the achievement of set objectives. Throughout this process, a preceptorship competency booklet is completed, which includes reflective accounts from practice to enhance learning and also contributes to the NMC revalidation process.
In addition, all preceptees attend 6 study days, rolled out over a 6-month period. Action learning sets are also part of these days, which take place in smaller groups and offer the opportunity for peer support and sharing experiences in a safe environment. The topics covered in the preceptorship programme are presented in Box 1. The sessions are facilitated by the preceptorship leads and other nursing colleagues, experienced in facilitation, coaching and supervision. Newly qualified nurses attend a minimum of 90% of the study days to support their professional development in the first 6 months. The topics covered in the study days are continuously reviewed and revised based on the needs of the service and the feedback received from the attendees. The full preceptorship programme is completed over 6 to 9 months.
The programme was offered twice a year to cohorts of approximately 40 individuals. Since September 2019 this has increased to include 50 nurses on a programme every 4 months. This is to absorb an increase in the number of international nurses recruited, as well as the recruitment of 30 to 40 nurses every 6 months through the traditional route of employment. Although the international nurses may not be newly qualified, the NMC strongly recommends that all new registrants have a period of preceptorship when commencing employment. This includes those who enter the register from other countries. This has been addressed by the Royal College of Nursing (2020).
The aim of the preceptorship programme is to provide high-quality training and support to all the newly qualified nurses so that they feel empowered and confident to deliver the highest quality care to the public. It includes supporting newly qualified practitioners to be aware of their own personal and professional development and to enable preceptors to facilitate generic and explicit key skill progression in the first 6 to 12 months of working. This in turn enables better recruitment and retention within nursing, while promoting ongoing learning and development and enabling research, innovation and evidence-based practice for future nurse leaders.
The overall aim of the preceptorship programme is to:
Challenges and opportunities
The main challenge during the initial implementation process was to find enough experienced nurses wanting to take on the preceptor role. There was a general perception that this would add to their current workload and that clinical work would always take priority over preceptorship. It was therefore decided that preceptorship would be offered by the preceptorship leads within the learning and development department, who are all experienced nurses from various backgrounds (acute and community nursing). Developing others is also a fundamental part of the preceptorship leads’ role, which gave them dedicated time to deliver the programme across the Trust using a coordinated and standardised approach. Having senior management support from both the Trust's nursing and education services was essential to the implementation of this programme. This collaborative approach also enabled preceptees to have protected time to devote to their personal and professional development.
Although the preceptorship programme has been in place for some time, the authors are aware that further improvements need to be made, especially in relation to data collection. This would enable the programme leads to carry out a greater level of statistical analysis of the uptake and completion of the programme in the future. The programme is continuously reviewed to ensure that it meets the needs of the diverse nursing workforce.
Evaluation of the programme to date
The uptake of the preceptorship programme is generally high with more than 77% of nurses completing the full programme since 2016, as shown in Table 1.
| Cohort year | Number of nurses enrolled | Number of nurses completing the programme | Reasons for non-completion |
|---|---|---|---|
| November 2016 | 33 | 27 (82%) |
|
| June 2017 | 26 | 21 (81%) |
|
| December 2017 | 30 | 29 (97%) |
|
| June 2018 | 35 | 27 (77%) |
|
| December 2018 | 38 | 36 (95%) |
1 deferred to the next programme |
The main reason for nurses not completing the full programme is because they left the organisation. Only a small number of nurses offered the programme failed to attend. The main reasons given for this includes nurses not thinking they need the programme, lack of support from their managers and increased work pressures. In cases where nurses do not attend, several reminders and emails are sent by the preceptorship leads to encourage participation.
An evaluation is carried out after every cohort completes the preceptorship programme. The programme is generally highly rated and valued by newly qualified staff as shown in Table 2.
| Area of support | Rating (5=extremely supportive; 1=not supportive at all) |
|---|---|
| Support from the preceptor | 4.5 |
| Support from staff in the clinical area | 4.5 |
| Support from the manager | 4.3 |
| Support from learning and development team | 4.3 |
| Support from clinical practice facilitator | 4.2 |
Although most of the participants rated the programme highly, some felt further improvements were necessary, as demonstrated in the following quotes from participants in the programme who provided feedback in their post-preceptorship evaluation forms.
‘This is a very good course. I had the opportunity to learn lots of things in order to develop my skills and knowledge. A big thank you to all staff.’
‘A few of the competencies were taught in our 3-year university degree course, which is mandatory to be a trained nurse and we had to pass at university. Due to the high pressure of our job I feel some of the competencies should either be combined or removed.’
The five key aims for the preceptorship programme are:
The nursing preceptorship programme was a finalist in the ‘Preceptorship of the Year’ category in the 2019 Nursing Times Workforce Awards and were highly commended by the judging panel. The Trust has now achieved the pan-London Capital Nurse Kitemark for preceptorship, which the team hopes will attract more nursing staff to the Trust.
Future plans
The future plan is to continue to roll out a new model of preceptorship, based on the feedback from staff. The previous programme was reviewed and revised to ensure it better meets the needs of the Trust's newly qualified nursing staff. For example, staff felt that some study days offered as part of the programme was repetitive as they had covered them in mandatory training. Therefore the new programme has taken this into account and incorporates more sessions on staff mental wellbeing, and research and development. The roll-out of the new programme began in May 2019. Aspirations for the future include:
Conclusion
The authors' advice to anyone wanting to set up a nursing preceptorship programme would be to ensure that there is organisational engagement and buy-in at board level in the first instance. It is important for senior managers to be supportive and send clear messages about how much they value the process. Preceptors need to have the right level of knowledge and skills in order to support newly qualified nurses and therefore this role should be taken up by senior practitioners. Although acting as a preceptor might be an expectation of all senior nursing staff, their own motivation and aptitude for this role is absolutely key to the delivery of an effective preceptorship programme, and making it a success. A clear evaluation process should be planned at the outset, incorporating feedback from the preceptor and preceptee in order to make further improvements to the programme in the future.