Preceptorship refers to the period in which newly qualified staff nurses receive support from a qualified and more experienced nurse to smooth their transition into the service (Higgins et al, 2010). A poor transition from student nurse to newly qualified nurse may result in nurses leaving the profession (Park and Jones, 2010) or leaving their job within the first 12 months (Beecroft et al, 2001), and this problem has been a global concern within the profession (Dearmun, 2000; Gerrish, 2000; Butler and Hardin-Pierce, 2005). Duchscher (2009) found that nurses experienced anxiety, insecurity, inadequacy and instability when, after studying for several years, they find that the professional reality is different from what they expected or had been described.
Edwards et al (2015) discussed formal and informal strategies that could have a direct impact on increasing confidence and reducing anxiety and stress in the individual, decreasing turnover rates and improving retention in organisations. Programmes using multiple strategies over an extended period have been shown to be useful (FitzGerald et al, 2001). A more recent systematic review of preceptorship in nursing by Irwin et al (2018) identified four themes, namely, measurement; knowledge and experience; support; and structure, and concluded that preceptorship programmes have a greater impact than the individual preceptor. Preceptorship support for newly qualified staff has been associated with greater confidence, competence, workforce retention (Park and Jones, 2010) and a sense of belonging (Gerrish, 2000). It also reflects newly qualified nurses’ commitment to the Nursing and Midwifery Council (NMC)'s requirement of being a lifelong learner (Royal College of Nursing (RCN), 2016). However, due to limited empirical research, the evidence that preceptorship has a direct impact on confidence or competence is limited.
Preceptorship within community settings entails providing support and education to newly qualified members of staff facilitated by district nurses (DNs). In fact, one of the roles of the DN is to foster a learning environment while bearing in mind the responsibility of role modelling for the team (Barrett et al, 2007). Nursing in the community setting requires specific skills related to the different modes of care and presents unique challenges. However, it also allows nurses to identify patient-centred goals and devise creative and informed ways in which these goals can be reached (Price, 2014).
The role of the qualified DN in practice may differ greatly from the role of the student DN in practice. This is not surprising, considering the depth and diversity of skills required of a contemporary DN. Indeed, the numbers of DNs working has dropped by almost 43% in England alone in the last 10 years (Queen's Nursing Institute (QNI) and RCN, 2019). At the same time, the demand for their service is increasing due to the growing ageing population, with one in four people aged over 75 years requiring district nursing care at home, which rises to one in two people aged over 85 years (QNI, 2012). Although the attrition rate among DNs cannot be entirely attributed to the reality shock experienced as new DNs enter the community nursing workforce, a preceptorship programme for newly qualified DNs may be warranted.
Within the authors’ trust, district nursing teams identified gaps in knowledge regarding how to manage team issues and caseloads. Newly qualified DNs from the trust articulated feelings of isolation and anxiety due to the perceived lack of preparedness for the transition from their educational programme to their new role. This was despite the fact that the district nursing degree and post-graduate diploma completed by community trust staff had provided the educational basis and competence for the Specialist Practitioner Qualification in District Nursing (SPQDN) standards, and a consolidation period was built into the university DN programme in an attempt to minimise the abrupt transition from university to their first post as newly qualified DNs. Informal discussions among staff in the early stage of their DN career revealed that they felt under-confident, had unrealistic expectations of themselves and that they needed practical and emotional support. They expressed the need for a formal structured DN preceptorship programme for newly qualified DNs instead of the existing contact sessions.
Structured preceptorship programme
A preceptorship framework was developed by the trust with competency statements to demonstrate progression by the preceptee during the preceptorship phase. Competence refers to specific capabilities, such as leadership, which are made up of knowledge, attitudes and skills (Burton and Ormrod, 2011). Thus, competence may represent the potential to perform, not actual performance. The NMC describes competence as the skills and ability to practise safely and effectively without the need for supervision (NMC, 2015). The framework of competency statements mirrored the trust's values and key areas of district nursing practice, such as caseload management (Box 1). The framework tool was shared with experienced DNs, the human resources department, senior community service managers and university academic staff. The underpinning concept was Miller's pyramid (1990). Although Miller's (1990) work focused on competence in relation to clinical skills and knowledge development, the model seemed to be transferable to other disciplines, such as nursing. The initial stages of the model (knows and knows how) are linked to cognition while the subsequent behavioural stages (defined by shows how and does) are linked to development.
The main rationale for this service initiative was twofold: first, the project aimed to enhance the service provided by DNs as practitioners with a structured preceptorship programme enabling them to be more efficient. Second, it aimed to develop supporting roles and networks.
On commencement of the programme, each preceptee was supplied with a programme booklet identifying the time, date and venue of each session and the aims and objectives of each teaching session. The sessions were held over an 8-month period, with each session addressing practical aspects of district nursing. The preceptees were given protected time to complete the programme and to meet with their preceptors. Each session was then evaluated individually and collectively by the preceptees and preceptors.
Evaluation
The evaluation aimed to collect feedback on the district nursing preceptorship programme from preceptees as well as preceptors, in order to better understand the perceptions of both groups towards preceptorship and the structured preceptorship programme and how it might be improved. The evaluation comprised separate semi-focused interview focus groups for the preceptors and preceptees and a small survey using an eight-item questionnaire with a four-point Likert scale. The focus group data were analysed thematically using Burnard's (1991) approach of coding and categorisation to support the emerging themes, and descriptive statistics summarised the survey data.
The participants were recruited from among community nursing staff at the authors’ trust. Newly qualified DNs comprised the preceptee group, while more established DNs comprised the preceptor group. Most preceptees in this study had completed their university SPQDN in July 2017. The remainder of the preceptees had been in post for over 1 year and had not completed a preceptorship programme. The preceptors were DNs with over 2 years post-qualifying experience.
Themes of preceptee evaluation
Three themes emerged from the preceptee focus group data (n=13), namely, support and guidance, emotions and professional identity. Almost all of the preceptees interviewed reported the importance of support and guidance, reassurance and permission to ask for support. In addition, they considered having a named preceptor vital, and reported that having a point of contact enhanced their level of engagement. The ‘support and guidance’ theme had three sub-themes, which were change/role transition, relationship and structured support.
‘Having the structure gives you that confidence, that you've actually got that time to transition, you're not expected to know everything, which I think we all put pressure on ourselves to do’. (Preceptee 5) ‘I've found having a named preceptor really useful, because I think if you're assigned to somebody just off the cuff, you might feel like you were bothering them, but when they are expecting to hear from you, it makes you feel much more comfortable about the relationship when you do get in touch’. (Preceptee 14)
For many preceptees, a potential lack of support compounded feelings of vulnerability, while having a structured support relationship addressed and promoted feelings of belonging. Some preceptors spoke about their preceptorship experiences prior to their district nursing career, referring to their stress, anxiety and lack of direction as a newly qualified nurse working as a community staff nurse.
‘Because a lot of the time, you are just left alone to get on with it…I just think staff feel a lot more valued having this in place. I’m getting supported’. (Preceptee 4)
Peer support was an important factor for many preceptees, and many mentioned the complexity of the DN role.
‘It's not about being told by anybody what to do, it's about having somebody there to guide you through the processes, decision making and any problem solving. It's about learning’. (Preceptee 8) ‘I think as district nurses, I think we are faced with a lot of variables, uncontrolled circumstances. As a preceptee, I feel that others on this [preceptorship] programme are in the same boat, I feel we have support from each other as well’. (Preceptee 13)
Themes of preceptor evaluation
Four themes emerged from the preceptor focus group data (n=14), namely, belonging, qualities of a preceptor, professional identity and the value of a structured programme.
All preceptors mentioned a sense of belonging when considering their role as both preceptor and qualified DN.
‘I think district nursing is unique. As a qualified DN, you are in the middle. You have the trust on one side and the GPs on the other, you've got the staff [preceptee] and you've got the patients. Trying to balance all of that, so that the patients get the right care at the right time. Managing staff expectations. To manage all of that is a unique role’. (Preceptor 1) ‘Sharing experiences. You can learn so much from that, you work through it with colleagues and preceptees’. (Preceptor 14)
Many preceptors described their perceptions of the qualities of an effective preceptor, such as having a trusting nature and trusting the process. Some said that it made them happy to empower preceptees to develop while on the preceptorship programme.
‘I think it's about being supported from the very beginning and being able to link into that support, to help get you through it [preceptorship]’. (Preceptor 13) ‘I found being a preceptor very rewarding. It's lovely to see someone just flourish in their role and be able to think outside the box…’ (Preceptor 11)
The value attached by preceptors to a structured preceptorship programme and the impact that it had on enhancing district nursing practice and professional identity was evident from their evaluation.
‘I didn't have any formal preceptorship when I qualified as a DN, 10 years ago. I think what the students get now is really valuable, to look back and reflect on your new role’. (Preceptor 01) ‘I think it's about learning from your best practice, rather than your mistakes’. (Preceptor 14)
All interviewed preceptors agreed that having protected time to foster this relationship, the role and a structured preceptorship programme were vital.
‘…it standardises learning, if you've got a structured approach it means everybody is aiming to achieve a similar standard and similar outcomes, that's really important. But staff need protected time for this to work’. (Preceptor 11) ‘….we discuss things on a daily basis about what she's doing (preceptee), what's coming in that's current every day, because we are co-located’. (Preceptor 01)
Retention data
Lastly, as part of the study, retention data for staff in the DN service of the trust were examined (Table 1). Although the data suggest an improvement in DN retention for the 2016/17 period, this may have been due to normal variation, and further research on larger cohorts is needed to confirm a trend.
| Year of SPQ training | Number of students in SPQ programme | Number of students completing SPQ programme | Number remaining in DN service |
|---|---|---|---|
| 2014/15 | 8 | 8 | 5 |
| 2015/16 | 8 | 8 | 5 |
| 2016/17 | 9 | 9 | 9 (first structured preceptorship programme) |
SPQ: specialist practice qualification; DN: district nursing
Discussion
In the evaluation, both preceptors and preceptees reported that it was important to have a formalised, structured preceptorship programme for newly qualified DNs. This may be because the DN role often involves lone working, and working in isolation would naturally be a challenge for newly qualified DNs. Another shared theme from both the preceptor and preceptees focus group responses was professional identity. The networking opportunities and ‘sharing of best practices’ during formalised preceptorship sessions among both preceptors and preceptees could explain the high value placed on this initiative. The preceptorship programme was also recognised by the trust as adding to its recognition.
The preceptors’ focus group data noted the complex nature of contemporary DN practice, which echoes the recent QNI report (2019) highlighting the unpredictable nature of the DN role, the risks associated with lone working and the requirement to have the right skills and professional competence to make decisions. The preceptors described the specialist nature of the DN role and the need for a structured and standardised framework for measuring the progress of preceptees.
Delivering a structured preceptorship programme does have its challenges, with both preceptees and preceptors noting that having protected time was important, yet difficult to ensure. The reality of balancing roles with service delivery and achieving protected time in practice was also not easy. Having ‘buy-in’ from service managers in terms of protected time may be the key to successful delivery of preceptorship programmes for DNs. This may include other members of the DN team adopting a more holistic approach to support and release preceptors to undertake their role fully.
In the context of district nursing, where there are frequently unexpected service needs, the preceptor may need to ‘wear several hats’ if they are to be an effective educator and guide and prioritise the learning environment. One way of achieving this may be to have a coordinated approach between human resources departments, workforce planning and caseload profiling. Maximising protected time for preceptor and preceptee dialogue is crucial if the full benefits of a preceptorship programme are to be realised. Having a preceptorship framework to structure the preceptee's journey requires further testing and refinement using multiple cohorts.
Conclusion
The retention of newly qualified staff is a key outcome measure of the success of any preceptorship programme. The evaluation of this initiative indicates the positive impact that the structured preceptorship programme had on the trust's new DNs. A large-scale study of preceptorship programmes and their frameworks of competence across multiple district nursing teams could help develop a national consensus on the structure and content of preceptorship programmes for district nursing.