I interviewed two nurse colleagues, wrote up what I found then did a summary report of the interviews. I would strongly recommend qualitative researchers to do practice interviews and go through the process of transcribing the interviews, analyze the interviews and report the findings before embarking on a qualitative study.
Title
A Qualitative Study to Uncover and Illuminate how Experienced Nurse Preceptors Teach Clinical Competencies and Evaluate these Competencies
Introduction
During clinical training, the quintessence of where nurses learn about nursing (Madhavanpraphakaran, Shukri, & Balachandran, 2014; Paton, 2010), nurses function as preceptors for undergraduate nursing students. The preceptor is a nurse who teaches and supports the student nurse and is seen as pivotal to student learning within the clinical environment. Significant research has been conducted and disseminated on preceptorship as an essential component in teaching and evaluating student clinical competencies (Paton, 2010) as well as providing opportunities to apply theory to the real world (Madhavanpraphakaran et al., 2014) and pedagogical competencies for facilitating learning during clinical practice (Elisabeth, Christine, & Ewa, 2009). Preceptorship has also been shown to be an effective method of clinical education because it assists students in developing clinical competence and confidence in making the transition to the role of professional nurse (Madhavanpraphakaran et al., 2014). Preceptors accrue practical, professional, and experimental teaching knowledge and yet there is a dearth of literature and research describing how nurse preceptors integrate these three forms of knowledge into their everyday preceptorship practice (Paton, 2010) and a scarcity of studies describing pedagogical competence; especially in terms of teaching strategies (Elisabeth et al., 2009). The need to identify and change nursing curriculums to infuse what could be seen as a registered nurse’s core competencies to close the practice theory gap is a feasible resolution based on nurse preceptors input into these programs.
Problem Statement
Various studies highlighted the teaching and assessment of nursing students in clinical practice as being challenging for instructors, clinical nurses, and nursing students (Msiska, Smith, Fawcett, & Munkhondya, 2015; Rafiee, Moattari, Nikbakht, Kojuri, & Mousavinasab, 2014) as well as the difficulties faced by nurse educators to correct this problem. This problem is compounded by the fact that even though hospital environments have drastically changed over the last 25 years, clinical nursing education has not (Beeman, 2001). Contributing to this conundrum is a lack of objective evaluation methods and tools to evaluate students’ clinical performance, lack of instructor feedback, use of subjective instructor evaluations, as well as preceptors and instructors lacking evaluation skills (Jackson, 2015; Vaismoradi & Parsa-Yekta, 2011). Seurynck, Buch, Ferrari, and Murphy (2014) found poor to slight agreement between instructors and preceptors in clinical performance evaluation. In order to meet the educational needs of the next generation of nurses a new approach is needed; one that will incorporate clinical education to promote holistic and systems-level thinking (Robinson, 2009).
A plethora of literature addresses preceptors’ perspectives and perceptions on knowledge preceptors acquire (Paton, 2010), strategies and techniques used to teach BSN students during clinical practice (Elisabeth et al., 2009), the role of the preceptor in pre-licensure nursing education (Raines, 2012), perception and experiences of preceptors regarding student nurses in practice (McIntosh, Gidman, & Smith, 2014), and perception of the clinical-teaching processes of final year undergraduate students (Madhavanpraphakaran et al., 2014). These studies are consistent with findings from Richards’ (2009) qualitative research review of preceptorship-related literature which revealed the bulk of sampled articles addressed nursing education. Paton (2010) recommends further research and interpretations highlighting and acknowledging the everyday professional practice of nurses in this role.
There have been limited studies aimed specifically at interviewing nurse preceptors to find how experienced nurse preceptors teach clinical competencies and evaluate these competencies in the clinical training of student nurses. Therefore, the researchable problem was a need to identify exceptional nurse preceptors to uncover and illuminate how experienced nurse preceptors teach clinical competencies and evaluate these competencies. Preceptors’ perspectives on how they teach and evaluate students’ clinical practices will yield credible information that can help in revising clinical courses in the nursing curriculum.
Purpose
The purpose of this mini-basic qualitative study was to uncover and illuminate how two experienced nurse preceptors develop nursing skills’ clinical competencies and how they evaluate them. Uncovering the instructional techniques, strategies, and processes nurse preceptors use to incorporate these practices into their teaching and evaluation methods will provide valuable insight that can be infused in ongoing professional development and evaluations for nurse preceptors who teach clinical competencies. The findings that emerge will also help nursing education leaders and educators who want to incorporate excellent teaching techniques into their teaching and evaluation practices.
Central Research Question
How do two experienced nurse preceptors teach clinical competencies and evaluate these competencies in the clinical training of student nurses?
Interview Questions
- How do you teach clinical competency to student nurses?
- What instructional techniques, strategies, and processes have you found most useful in teaching clinical competencies to student nurses?
- What instructional techniques, strategies, and processes have you attempted but found not useful in teaching clinical competencies to student nurses and why not?
- How do you evaluate clinical competency in student nurses?
- When is the best time to provide students feedback on clinical competency and why?
- How has the clinical environment changed over the last decade?
- Did these changes cause you to change how you teach and assess student clinical competency?
- How are you supported in teaching and evaluating clinical competencies?
- What lessons have you learned in teaching and evaluating clinical competencies?
Participants
A purposive group of two nurse preceptors comprised the convenience sample for the mini basic qualitative study conducted for the course project. Merriam (2009) identified that convenience sampling is not always the most credible type of sample; however, it is an appropriate choice in the context of the course project for which this study is proposed. The most important inclusion criterion is nurse preceptors’ self-reported inclusion of clinical teaching and assessment practices in training nursing students. One of the participants described herself as a nurse preceptor and self-reported that she has incorporated lessons learned from nursing experience and from being a former preceptee herself, in teaching and evaluation practices. This nurse preceptor has a reputation among students and fellow nurses as being an excellent preceptor which is reflected in informal conversations and in formal course evaluations. The first preceptor member is the nurse manager of the general surgical service in the operating room and identified a second nurse preceptor as being an excellent preceptor who incorporates lessons learned from her nursing experience, background, and from being a preceptor into her teaching and evaluation practices. The second nurse preceptor was approached and asked to participate in the course project based on the referral from the first nurse preceptor. The second nurse preceptor was eager to participate and shared her experiences.
Patterns
The constant comparative method of qualitative data analysis was used in this mini-basic qualitative project. This method “…is inductive and comparative and so has been widely used throughout qualitative research without building a grounded theory” (Merriam, 2009, p. 175). Open coding is the initial organization of the data and is used to identify segments and concepts of the translated data. The codes are then condensed and analyzed for commonalities that could reflect categories or themes. Once the data has been categorized it can then be examined for properties that characterize each category.
The time between coding and categorizing the first interview and conducting the second interview was sufficient enough to allow any bias developed during the first analysis to dissipate. Review of the first interview’s coding and categories was avoided until the coding and development of categories from the transcription of the second interview was completed as shown in Table 2. Comparative analysis of the developed and defined categories identified several overlapping categories such as competence, communication, recognition, teaching, evaluation, changes, and preceptor, although the categories practice, students, and patients were not shared concepts of teaching and evaluation were. Also notable was that the category descriptions were significantly modified based on the coding data that led to the category development as shown in Table 3. Reviewing the modified categories led to an understanding that each participant’s meaning of the term teaching and evaluation is inherently different.
Table 1
Categories: Interview One
| Category | Category Description |
| Competence | Team effort, observation, supported by unit educator and doctors.
|
| Observation | Evaluate, assess, teach, comfort level, competence level.
|
| Communication | Encouragement, feedback, debrief, talk about feelings.
|
| Recognition | Nurse is significant member of team.
|
| Teaching | See one, do one, teach one, trial and error, assess then plan, assess at the end of the day, organized versus chaos, sink or swim.
|
| Evaluation | Relationship and comfort level, confirm students know skills before check off.
|
| Change in 10 years | Nurse role, products, and instruments used.
|
| Preceptor | Supported by unit educator and doctors, socialize students to be proud of what they do. |
Table 2
Categories: Interview Two
| Category | Category Description |
| Competence | Concerted effort, observation, supported by unit clinical nurse specialist, instructors, and champions.
|
| Observation | Teaching, assessment, return demonstration, evaluation.
|
| Practice | Sims lab, steps involve with skills, assess, teach, competence level.
|
| Communication | Encouragement, feedback, discussion, explanation.
|
| Recognition | Nurse is significant member of team, more autonomous, more respected, nurse lead research projects.
|
| Teaching | See one, do one, teach one, use champions, teach back, practice in sims lab before touch patients, use of cheat sheets for organization, organize system of teaching, exclusion, immersion, inclusion, set clear expectations, observation.
|
| Evaluation | Relationship, use of criteria to check off skills, return demonstration, checklist, nursing books.
|
| Change in 10 years | Nurse role, products and equipment’s, student role, addition of technology, more task driven, step back from critical thinking.
|
| Preceptor | Supported by unit clinical nurse specialist, nursing books, policies, reduce patient load.
|
| Student | Respect, praise, build confidence and trust, know when to intervene, not prepare for clinical.
|
| Patients | Intervene and make judgment call for patient safety, feedback outside patients room. |
The category teaching illustrates the significant differences between the participants. Tracey, a staff nurse at a large Community hospital describes the teaching process as, “…if I show you how to do a surgery or if I show you how to take care of perioperative patients you watch me, we go through, and we teach, and then you do it yourself.” Tracey goes on to explain that she teaches through a trial and error method, “…you try what your preceptor shows you and then you make it your own.” On the other hand, Mel, who was a preceptor but whose role has changed to support preceptors in a Magnet designation hospital, explained that part of teaching nursing students is through respecting, praising, and building confidence and a trusting relationship with the students. Also, knowing when to intervene and make a judgment call while directly caring for a patient is important. Mel further explained that during the teaching process it is important to talk the student through the skill, have them practice the skill, and have the student do a return demonstration in a sims lab before touching a patient.
Furthermore, elaborating on strategies used to teach students in the clinical setting Mel stated, “I have to be humble enough to say to somebody that I don’t know let us find out together” and she would find a champion nurse who has been recognized as the expert on the skill. Unlike Tracey who mentioned a few teaching strategies, techniques, and instructions as described above, Mel offered a plethora of other teaching strategies in addition to what was already mentioned. Other teaching strategies, techniques, and instructional activities mentioned by Mel were teach back, practicing in a simulation setting before touching patients, setting clear expectations, using cheat sheets, and index for organization, taking an organized approach to teaching, and a strong preference for immersion and inclusion for teaching students in the clinical setting.
One teaching method that was found not to be useful is the exclusion method. According to Mel, she has observed other preceptors using the exclusion method of teaching. Mel described this teaching method as preceptors going in a patient’s room and excluding the student from doing meaningful tasks. Another teaching method Mel found was not productive were preceptors not keeping abreast of changes in hospital policies and teaching outdated information even though students are being educated on new methods. Tracey, on the other hand, mentioned the sink or swim method has not been beneficial in teaching students. Tracey explained that in her observations of the sink and swim teaching method, “I’ve seen nurses that throw the student nurse in there and said well you are going to do this and you’re going to do that and they think that throwing them in the water it will make them swim.” Both nurse preceptors mentioned using the see-one do-one teach-one teaching method as being effective in training students in the clinical setting. Good communication for both Tracey and Mel involved encouraging students and providing timely feedback. Tracey believes that a debriefing session at the end of the day assists students in comprehending and reinforcing their learning on clinical skills. Mel believes discussion and explanation threaded throughout the clinical day will reinforce clinical skills.
Recognition was a category that had several common identifiers as well as differences. Both nurse preceptors stated the nurse is recognized as a significant member of the team and is more autonomous and respected. A major difference could be noted in the environments where these nurses work. Nurse preceptors in the hospital environment with a Magnet designation are recognized for nurse lead research projects whereas, in the Community hospital environment, Tracey did not mention this aspect of recognition for the nurse. In this regard, the researcher would have to clarify with Tracey if nurse preceptors are recognized for nurse lead research projects.
The comparative analysis identified patterns between the two interviews that resulted in illuminating the differences between the techniques and attitudes of the participants. The process highlighted the limits of utilizing categories to evaluate the central research question and the sub-questions. Deriving a conclusion based on the comparative analysis results, in this case, would lead to inaccurate findings. Patterns help to determine how to analyze the data and determine if the research question can be answered adequately with the data available.
Table 3
Categories: Common Definitions
| Category | Category Description |
| Competence | Concerted effort, observation, supported by unit clinical nurse specialist, instructors, and champions.
|
| Observation | Teaching, assessment, returns demonstration, evaluation.
|
| Communication | Encouragement, feedback, discussion, explanation.
|
| Recognition | Nurse is significant member of team, more autonomous, more respected, nurse lead research projects.
|
| Teaching | See-one, do-one, teach-one, use champions, teach back, practice in sims lab before touching patients, use of cheat sheets for organization, organize system of teaching, exclusion, immersion, and inclusion, set clear expectations.
|
| Evaluation | Relationship, use of criteria to check off skills, return demonstration, checklist, nursing books.
|
| Change in 10 years | Nurse role, products and equipment’s, student role, addition of technology, more task driven, step back from critical thinking.
|
| Preceptor | Supported by unit clinical nurse specialist, nursing books, policies, reduce patient load. |
Interview Finding and Summary Report Summary of the Two Interviews
In the interviews, both nurses were asked to describe their experiences when teaching and evaluating student nurses in the clinical area. From the analysis of the data presented the researcher uncovered several teaching strategies and techniques used by the preceptors to teach and evaluate clinical competencies. The teaching strategies and techniques described were see-one do-one teach-one, use of champions, teach back, practice in sims lab before touching patients, use of cheat sheets for organization, utilizing an organized system of teaching, setting clear expectations, and using immersion and inclusion. Techniques that were not recommended as useful in teaching and evaluating clinical skills were sink or swim and exclusion.
Both Mel and Tracey mentioned using the see-one do-one teach-one technique; however, the description of how the technique was used was different which lead to the question, could the difference of using this teaching technique be due to the nursing unit or the history behind how these nurses were taught nursing practice. Tracey works in a community hospital and is an operating room nurse and describes the technique see-one do-one teach-one in the context of, “If I show you how to do a surgery or if I show you how to take care of perioperative patients you watch me, we go through, and we teach and then you do it yourself.” On the other hand Mel who was a preceptor but whose role has changed to support preceptors in a Magnet designation hospital, describes the see-one do-one teach-one technique in the context of “…sometimes you give all the information you need to give upfront and talk about the big picture thing, then you show them how to do it, then you watch them do it then you either watch them do a return demonstration. In the watching, they are either doing a return demonstration or something call teach back, if I explain something to you then you explain it back to me using your own words.” The differences seen with using the see-one do-one teach-one technique could be due to the fact that most of the teaching in the operating room is done without the direct involvement of the patients. Students are taught more about equipment, processes, instrumentation, sterilization, etc. Although, on the medical-surgical floor students are directly involved with patients most of the time during their clinical training.
One teaching method that was found to not be useful is the exclusion method. According to Mel, she has observed other preceptors using the exclusion method of teaching. Mel described this teaching method as preceptors going in a patient’s room and excluding the student from doing meaningful tasks. Another teaching method Mel found was unproductive was preceptors not keeping abreast of changes in hospital policies and teaching outdated information even though students are being educated on new methods. Tracey, on the other hand, mentioned the sink or swim method has not been beneficial in teaching students. Tracey explained that in her observations of the sink and swim teaching method, “I’ve seen nurses that throw the student nurse in there and said well you are going to do this and you’re going to do that and they think that throwing them in the water it will make them swim.”
Good communication for both Tracey and Mel involved encouraging students and providing timely feedback. Tracey believes that a debriefing session at the end of the day assists students in comprehending and reinforcing their learning on clinical skills. Mel believes discussion and explanation threaded throughout the clinical day will reinforce clinical skills. Mel further stated in communicating with a student that, “I have to be humble enough to say to somebody that I don’t know let us find out together” and she would find a champion nurse who has been recognized as the expert on the skill to teach the student that skill.
When asked the question, how do you evaluate clinical competency in student nurses both Mel and Tracey believe that building a relationship with the student was an important aspect of evaluating clinical competence. Tracey commented that “It comes with knowing them and building a relationship with them and being comfortable.” Mel stated, “It is like any other relationship in which you have to gauge you [sic] feeling with that person.” Mel expounded on this relationship in regards to lessons learned in teaching and evaluating students. This was a profound moment in the interview with Mel. She stated, “When a person comes in they are not just a student or a nobody, this is somebodies child, wife, girlfriend or boyfriend this is a person. So just like the person in the bed you have to treat the person that you are responsible for developing their competencies like a person.” This relationship is not always feasible to develop in the clinical training of students because there is no standard or structure in most clinical settings which provide clear guidance in how to establish a solid preceptor and preceptee relationship.
There were several distinct differences in teaching approaches between Mel and Tracey. For example, as explained by Mel in relation to an IV start, “…they may do a practice first in a sims arm before we actually touch a patient.” Tracey did not mention the use of simulation practice for students before they touch a real patient. Another distinct difference was how preceptors were supported in teaching and evaluating students. Mel described pulling up a Lippincott manual and printing off the competencies in order to evaluate students’ skills on a particular skill set. Additionally, Mel explained decreasing preceptors’ load when it is anticipated they will be precepting students. Mel also explained it takes a concerted effort to ensure preceptors’ know in advance when they will have a student to precept. Tracey, on the other hand, explained that preceptors have no direct support for precepting students; however, a unit educator assists the nurses in doing their personal competencies. These distinct differences in approaches were striking and brought to light more questions. One such question was, are the differences between teaching and evaluating students related to the culture of the unit or to the hospital environment? Or, maybe the difference in teaching is due to how preceptors are supported during the time in which they are precepting students, or in how they are prepared for the role of preceptor to teach and evaluate student clinical competencies.
It is clear to see from the analysis the complexity involved in teaching and evaluating novice students in the clinical setting. It is also clear to see the level of involvement that is necessary in order for preceptors to be effective in teaching and evaluating student nurses clinical competencies in the clinical environment. Preceptors need to be supported with readily available resources to assist in their development so they can be better prepared to teach the next generation of nurses to be autonomous practitioners when they enter the workforce.
These findings are useful for increasing nurses’ understanding of preceptors’ experiences into how they teach and evaluate clinical skills in student nurses. The result of this study could eventually lead to recommendations that using the see-one do-one teach-one technique, use of champions, teach back, practice in sims lab before touching patients, use of cheat sheets for organization, utilizing an organized system of teaching, setting clear expectations, using immersion and inclusion methods of teaching, and evaluating clinical competence be included in preceptor-preceptee training programs. The findings from the mini-study also revealed the sink or swim and exclusion techniques are not recommended for teaching and evaluating clinical skills.
Kearney (2001) made explicit statements regarding the ways in which qualitative findings directly impact nursing practice. In the simplest mode of application, nurses can learn what it feels like to be in a given situation, the common factors encountered by preceptors and students in that situation, and the different ways in which a situation can be viewed. Armed with this understanding the nurse preceptor can pay closer attention to cues from student nurses, can make sense of certain presumably aberrant behaviors, and provide support in a more informed way. These findings can be executed into practice directly and lead to improved outcomes for training students in becoming autonomous nurses after they graduate nursing school.
References
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