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Earn credit: Registrants who read this self-study article and score at least 75 percent on the accompanying test will receive one free continuing education credit certificate from the Texas Nurses Association, District 4 through Aug. 1, 2006. See page 29 for details. This article is approved through May 1, 2008.

Photo by STEVE REED

Dr. Tony Paterniti says their ability to combine theory and practice makes nurse preceptors invaluable educators of newly graduated nurses who are transitioning from the classroom to the hospital room.

The successful nurse preceptor Objectives: After completing this CE program, the participant will be able to: ●

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List three strategies for improving the new nurse’s orientation. Discuss two ways to determine how patient assignments for new nurses should be determined. List two factors to consider when identifying a preceptor for a new nurse. Discuss the differences between summative and formative evaluations. List two ways nurse managers can establish a positive rapport with new nurses. Discuss the chief nursing officer’s responsibility to support the preceptor.

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BY TONY PATERNITI, PH.D., RN, NURSE EDUCATOR, METHODIST HEALTH SYSTEM INTRODUCTION The importance of nurse preceptors in helping to educate new nurses cannot be overemphasized. They mentor new nurses and help them visualize the range of roles they will perform in a variety of clinical settings. Preceptors guide new nurses as they transition from academic institutions to the professional world — and, in some cases, from one nursing specialty to another. Nurse preceptors use the standards of professional practice and patient care experience as a framework for clinical teaching. They draw on their own memories of providing patient care to anticipate and understand patient conditions students will encounter. The nurse preceptor’s academic training provides the theoretical foundation, while practical experiences at the bedside translate theory into action. Nurse preceptors are charged with translating this combined knowledge into a format that makes sense to new nurses who are under their guidance in a patient-care setting, whether it involves administering care to an infant in the newborn nursery or to an adult returning from the post-anesthesia care unit. Achieving the expected outcomes within the allotted time, and with the available tools, is the ultimate goal. The purpose of this continuing education program is to share information about the

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role of the preceptor, as well as to explore issues related to the preceptor’s success. The overall goal is to advance general understanding of the nurse preceptor role, to encourage others to support this role and to highlight the preceptor’s importance to new nurses.

We invite you to join the dynamic team of Professionals at the new Mesquite Specialty Hospital We are a state-of-the-art 40 bed long term acute hospital that is the first of its kind in Mesquite. We offer competitive salaries and excellent benefits. Nursing: 7a-7p/ 7p-7a Charge Nurse: Current Texas license. Current CPR certification. ACLS certification preferred. One year of acute care experience. One year of charge nurse experience preferred. RNs: Full-time and PRN: Current Texas license. Current CPR certification. ACLS certification preferred. One (1) year of recent experience in acute care setting preferred. ICU and/or telemetry and LTAC experience preferred. LVNs: Full-time and PRN: Current Texas License. Current CPR certification. One (1) year of recent experience in acute care setting preferred.

Physical Therapist (PT and PRN) Current licensure as a Physical Therapist in the state of Texas. Current BLS. One year of experience in the care of patients in a rehabilitation or acute care hospital setting preferred.

Nurse Manager Bachelor’s degree preferred. One (1) year of recent nursing management experience in an a acute care setting preferred. Responsible for the day-to-day patient care operations. Responsible for personnel and process needs of the unit. Facilitates communications and patient care needs inter/interdepartmentally. Good interpersonal skills. Handle multiple priorities and make decisions independently. Coder Two years of medical coding experience in ICD-9 preferred. Provides moderate to high complexity coding and entering these codes into our billing software. Medical Coding Certification preferred. Knowledge of Medicare’s PPS guidelines preferred. Working knowledge of medical terminology, anatomy, and physiology preferred. Director of Human Resources Bachelor’s degree of five (5) years of equivalent work experience. PHR or SPHR preferred. Responsible for all pre-employment procedures, processing new hires, maintaining personnel files, resolving employee issues, and maintaining records as required by state or federal regulations. Chief Financial Officer Three years of healthcare accounting experience preferred. A bachelor’s degree in Accounting, Finance or related field. Provides financial advice to the Hospital Administrator. Assures compliance with external financial reporting requirements. Maintains and adequate accounting system to provide for the proven recording and reporting of all Hospital transactions. Director of Marketing Bachelor’s degree in healthcare field or marketing preferred. Three to five years current experience in healthcare, preferably in a hospital setting or sales preferred. Ability to develop and implement strategic sales plans. High level of organizational/follow-up skills required.

SPECIALTY HOSPITAL Email resume to: [email protected] or fax to: (214) 594-0058. EOE 26 PULSE

THE NURSE PRECEPTOR ROLE AND SUPPORT BY OTHERS Preceptors must have the knowledge, skill and patience to guide nursing students through a series of simple and complex exercises, but the institution must be responsible for providing the authority and the tools to accomplish the desired results. The process must be clear and expectations must be well-defined (Cardillo, 2001). Additionally, each colleague must understand that the preceptor’s mission is to advance the new nurse to a level of functioning that safely meets the needs of patients now and in the future. Unless colleagues understand the preceptor’s role and needs, the preceptor risks being drawn into the role of staff nurse, which is a care-giving versus a care-teaching role. The preceptor must be the clinical teacher and not the staff nurse, the charge nurse, or the nurse who is chosen to float to another nursing unit. Preceptors cannot teach nurses how to safely administer an IV with a narcotic if they are in another room caring for another patient or making patient assignments for the next shift. They cannot be assigned multiple patients on their first day as a preceptor and be expected to teach, direct, guide and support a new nurse. Assigning preceptors to patient care forces them into the role of caregivers and reduces the nurse-in-training’s experience to that of an observer and doer of menial tasks. New nurses are not prepared to manage the care of multiple patients at the beginning of their orientation, nor are preceptors prepared to manage multiple patients while teaching a new nurse to care for them. Giving preceptors patient-care assignments while they are expected to mentor places them at the center of patient care — in the very role the new nurse is expected to assume. This is not to suggest that preceptors can never provide direct patient care during the orientation period. Instead, they must decide when it is appropriate to move from direct to indirect clinical instruction. After the student has advanced from needing hands-on assistance to verbal cuing and direction, the preceptor may begin providing direct patient care on a limited basis. However, it is important for preceptors to control the number of the patients they are assigned and the level of their needs (Flynn, 2006). Preceptors should not be expected to provide care to any patients during the beginning phase of the orientation, but may eventually take patient care assignments as the new nurse becomes more capable and confident. As the new nurse is assigned additional patients and patients with more serious illnesses, the preceptor must spend more time in direct instruction. This cannot occur if the preceptor is involved in direct patient care. Preceptors must provide feedback about what they observe new nurses doing, not about what they’ve been told after the fact. RESPONSIBILITIES FOR PATIENT CARE ASSIGNMENTS While preceptors should not have patient care responsibilities, they must be given complete control over the new nurse’s assignments. They must have “first pick” from the patient list, because the new nurse’s experience must be driven by objectives and desired outcomes, not by random cases that are assigned for any given shift. It makes no educational sense to assign a new nurse to the same patient for four consecutive days, for instance, when the new nurse may have mastered the care of that patient after two days (Myrick, 2005). However, when assignments are not under the control of the preceptor, they are generally under the control of the charge nurse, who has a different set of criteria from the preceptor for determining shift assignments. The charge nurse is more [MAY 2006]

concerned with the smooth operation of the nursing unit, and is not always knowledgeable about the abilities and learning objectives of the nurse who is undergoing orientation. WORKLOAD DECISIONS Preceptors must not only control selection of patients, they must have equal control over the workload of the new nurse. It is the preceptor, and not the charge nurse, who must decide when assignments can be increased in number and complexity. Assigning a new nurse to three patients when the nurse has not mastered the care of two, will only exacerbate weaknesses and liabilities. The nurse’s behaviors will become rushed and the nurse will not be preempted by the type of critical thinking that should drive all nursing actions. Nurses who are rushed may not finish assignments on time and may be criticized for lacking time-management skills. If the preceptor has a “rescuer” personality, and relinquishes the mentoring role for that of staff nurse, it may create the illusion that the new nurse is able to “get it all done.” This further reinforces the charge nurse’s actions, which may result in the continued premature increase in the number of patients. There is an added danger that the new nurse will slip into a state of temporary denial, believing that he or she can manage the care of multiple patients. On the first day without a preceptor, the new nurse will likely be given a full compliment of patients, only to have the existing liabilities and weaknesses surface, causing chaos and confusion. This may lead to serious feelings of inadequacy for the new nurse. As anxiety heightens while the new nurse works through the day, performance may become confused, disorganized and inefficient. Not understanding the dynamics that led to this performance, the new nurse’s colleagues may view the nurse as being unable or unwilling to do the work. If they perceive the new nurse as needy, they are likely to isolate themselves from the nurse, adding to the new nurse’s insecurity. This may lead the new nurse to develop defense mechanisms such as denial, rationalization and projection. The new nurse may become critical of staff, management and anyone else in a position of authority, beginning a downward spiral that often results in the nurse voluntarily departure or dismissal (Arnoldussen, 2004). Therefore, there is little to be gained by systematically increasing a new nurse’s workload without carefully assessing the nurse’s abilities and monitoring his or her progress. The outcome of the assessment may even be that the assignment should be decreased, especially when it becomes apparent that the nurse is overwhelmed. ATTENTION TO PERSONALITIES AND LEARNING STYLES Managers should select preceptors for new nurses based on compatibility, similarities in personality and temperament. Attention also should be given to learning styles. Pairing a young, high-energy, verbal preceptor who can easily multitask with a methodical, slow-paced, visual learner who must complete one task before moving to the next may result in an inability to get the learning process started and to keep it moving in a positive direction. The mismatched relationship between preceptor and student can deteriorate into a constant struggle, with the preceptor increasing pressure and the new nurse offering greater resistance. This could lead to a difficult working relationship, with the preceptor’s negative observations impacting the opinions of other staff members before they have an opportunity to form their own impressions through direct contact (Green, 2002). FORMATIVE AND SUMMATIVE EVALUATIONS To effectively mentor a new nurse, preceptors must be knowledgeable in the process of formative and summative evaluations. Conversely, new nurses should understand the difference between the two forms of feedback. The purpose of a formative [MAY 2006]

evaluation is to provide feedback that helps to further develop a nurse’s abilities. It is suggestive, providing constructive criticism in a non-threatening tone. Feedback of a formative nature is usually tied to a particular event or procedure. It’s the critique one gives after watching a new nurse perform a procedure, and it sometimes is followed by suggestions for improvement. For instance, a preceptor might say: “You might try doing it this way next time.” The summative evaluation is more global and encompassing. It addresses the nurse’s overall performance. It aims to address a category of nursing actions. For example, a preceptor may discuss a new nurse’s general ability to perform shift assessments, but without calling attention to a specific assessment. Or a preceptor may discuss how new nurses organize their assignments. Formative evaluations relate to an event, while summative evaluation reflects performance over time. Formative evaluations should be conducted immediately after an event. These may follow procedures, transcribing orders, administering medications, etc. Summative evaluations should be done at least weekly, and should be followed by the development of specific goals for the following week. While the manager should support the preceptor and the new nurse by participating in these evaluations, it is also imperative that the manager have contact with the new nurse in a more relaxed environment and on occasions when the preceptor is not present. Managers who fail to establish a rapport with a new nurse on a one-on-one basis also put their own professional reputations at risk, particularly if other nurses predispose the new nurse to impressions and opinions about the manager. This can range from positive impressions such as “She’s great, you can approach her at any time,” to negative ones such as “Stay away from her because she’ll drag you down.” THE SUPPORTIVE ROLE OF THE CHIEF NURSING OFFICER Support for the preceptor does not rest solely on the preceptor’s colleagues and/or manager, but extends to the chief nursing officer (CNO). The CNO must find ways to avoid the traditional practice of counting the preceptor as part of the general staff when budgeting for the nursing unit. An alternative practice would be to include the new nurse in the staffing count, reflecting the reduced patient load during the orientation period. Another supportive gesture on the part of the CNO would involve the de-emphasis of rigid timeframes for completing orientation. Nurses differ in ability and learning styles. Some nurses may be able to function independently sooner than expected, while others may require additional time. The emphasis should not necessarily be on the duration of the orientation, but on the potential of the new nurse and the nurse’s ability to make an effective transition. If the preceptor is confident that the new nurse has the potential to become a fully functional staff nurse whose efforts and contributions will benefit patients and the unit, it should not matter if it takes an additional two or three weeks. The front-end costs may be higher, but losing a nurse after three or four months of employment will cost a great deal more when it becomes necessary to recruit and train another nurse or orient an agency nurse to temporarily fill the vacancy. In addition, the preceptor may personalize the loss and be very reluctant to precept the next new nurse. The loss may even extend to the staff, causing discouragement and low morale. SUMMARY The preceptor’s relationship with the new nurse is key to the successful functioning and socialization of the nurse on the unit. The support by the preceptor’s colleagues, the nurse-manager and the CNO is imperative to meeting the organization’s expectations to prepare the new nurse to function independently. The process requires a departure from outdated practices that were more effective during an era when the typical patient’s length of stay was longer and PULSE 27

when illnesses required less care. There is no basis or reason to compare how a nurse was oriented 25 years ago to how a nurse is oriented today. It is unfortunate that many health-care organizations have preserved an outdated orientation process, which continues to create unrealistic expectations of the preceptor and the new nurse. The result is often substandard clinical training and an inadequately prepared nurse, as well as frustration by all who are involved. ■ REFERENCES Arnoldussen, B. (2004). What I wish I had known my first 100 days on the Job: Wisdom, tips and warnings from experienced nurses. Chicago: Kaplan Publishing.

Cardillo, D. (2001). Your first year as a nurse: Making the transition from total novice to successful Professional. Roseville: Three Rivers Press. Flynn, J. P. and Stack, M. (2006). The role of the preceptor: A guide for nurse educators, clinicians and managers. New York: Springer Publishing Company. Greene, M.T. and Puetzer, M. “The value of mentoring: A strategic approach to retention and recruitment.” Journal of Nursing Quality Care. Oct. 2002: 63-70. Myrick, F. and Yonge, O. (2005). Nursing preceptorship: Connect practice and education. Philadelphia: Lippincott Williams & Wilkins.

CE Test Questions Complete the following test questions: 1.

The most important relationship for a newly employed nurse is with which of the following personnel? a. Staff nurse b. Manager c. Preceptor d. Nurse recruiter

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Which of the following is most likely to occur when the preceptor’s colleagues do not believe that the preceptor role is legitimate? a. The preceptor may be alienated from her colleagues. b. The preceptor may be forced to function as a staff nurse. c. The preceptor may serve in the role of charge nurse. d. The preceptor will most likely resign.

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Mary is the preceptor for a new graduate nurse who worked as a nurse technician during college. During week two of the orientation of the new nurse, how many patients should the manager expect Mary to care for? a. One b. Two c. Three d. None The charge nurse assigns three patients to the new nurse in orientation without conferring with the nurse’s preceptor. How should the preceptor handle this situation? a. Allow the new nurse to care for the patients. b. Report the incident to the nurse manager. c. Explain to the charge nurse that the preceptor knows the most about the learning needs of the new nurse and should therefore make the assignment. d. Ask some of the staff nurses to trade patients with the new nurse so that the assignment better meets the nurse’s learning needs.

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Georgia is a new nurse in orientation and her preceptor has assigned her more patients than she can manage. Which behaviors would Georgia most likely manifest? a. She would probably complain to the other nurses on the unit. b. She would very likely refuse the assignment. c. Her behaviors would become rushed and her decisions would be affected. d. She would most likely resign. During her interview, Jane tells the manager that she enjoys quiet activities like reading and movies, and that she always wants to see a procedure done before attempting it. Which of the following preceptors would be most suited to work with Jane? a. Mary, an avid swimmer, who can decipher any hospital policy she reads b. George, who has a bellowing laugh and is in constant movement from the time he starts his shift c. Betty, who loves to read cookbooks with lots of pictures and practices yoga d. Martha, who has been out of school six months and has already gained the respect of her peers Which of the following factors is the most important in the pairing of a preceptor with a new nurse? a. Age b. Sex c. Ethnicity d. Personality What is a reasonable length of time to prepare a new nurse to become a functioning member of the team? a. Two weeks b. One month c. Depends on the preceptor’s abilities d. Depends on the new nurse’s abilities

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Critiquing a nurse’s performance after she inserts a Foley catheter is known as which type of evaluation? a. Positive b. Negative c. Formative d. Summative

10. The nurse manager hires a new nurse to be employed in ICU. How should the manager establish rapport with the nurse during the orientation period? a. Participate in all evaluations by the preceptor b. Participate in the summative evaluations by the preceptor c. Meet informally with the nurse one-onone d. Get regular progress updates from the preceptor 11. Michelle is the CNO of a large metropolitan medical center. Which of the following strategies best indicate that she understands the role of the preceptor? a. Budget for the preceptor to take half the patient load of a staff nurse b. Budget for the patient load the new nurse will manage c. Restrict the number of admissions to the unit during orientation d. Exclude the preceptor and the new nurse when developing the budget 12. Which of the following statements regarding pre-empting a new graduate is untrue? a. Most graduate nurses need a consistent preceptor to assist and instruct them. b. The preceptor should never be assigned more than three patients while preempting. c. Nurse preceptors should not perform as the charge nurse. d. Nurse preceptors should not be required to perform patient care.

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Texas Nurses Association, District Four CE instructions for self-study TITLE: “The successful nurse preceptor” PURPOSE: This self-study is designed to share information about the role of the preceptor and issues that relate to the success of the preceptor. The overall goal is to provide information about the nurse preceptor role, the need for support of the role by others and the importance of the role to the new nurse. To receive continuing education credit, the registrant must: 1. Read the self-study. 2. Complete the post-test (score of at least 75 percent). 3. Complete the evaluation form. 4. Prior to Aug. 1, 2006, mail the post-test and evaluation form to TNA, D4. After Aug. 1, 2006, please include a $10 processing fee. Upon receipt of the required forms (the post-test with a score of at least 75 percent, and evaluation form) by TNA, D4, the registrant will be mailed a CE certificate. This activity provides 1.0 contact hours for the nurse. TNA, D4 is an approved provider of continuing nursing education by the Texas Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. This activity meets Type 1 criteria for mandatory continuing education requirements toward re-licensure as established by the Board of Nurse Examiners for the State of Texas. EVALUATION FORM: “The successful nurse preceptor” OBJECTIVE: To provide information about the nurse preceptor role, the need for support of the role by others, and the importance of the role to the new nurse. NAME: _____________________________________________________________ TELEPHONE: _________________________________________ ADDRESS: __________________________________ CITY:___________________________ STATE:_________________ ZIP:_________________ LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER ________________________________________________________________________ PROGRAM EVALUATION: Please rate how well objectives were met by circling the appropriate number: 1 — Not Met 2 — Partially Met 3 — Met 4 — Well Met 1. List three strategies for improving the new nurse’s orientation. 2. Discuss two ways of determining how a new nurse’s patient assignments should be determined. 3. List two factors that should be considered when determining who should be the preceptor for a new nurse. 4. Discuss the differences between summative and formative evaluations. 5. List two ways the nurse manager can establish a rapport with the new nurse. 6. Discuss the CNO’s responsibilities in supporting the preceptor. Please rate the quality of teaching materials by circling the appropriate number: 1 — Strongly Disagree 2 — Disagree 3 — Agree 4 — Strongly Agree 1. The objectives were relevant to overall purpose. 2. The teaching/learning materials were effective. 3. The program was organized. 4. The program was easy to follow.

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If you answered 1 to any of the above, please provide comments. How long did it take to complete the program?_________ Date completed:___________ For one free CE credit courtesy of Medical Center of Plano, materials must be postmarked by Aug. 1, 2006. Mail the post-test and evaluation form to: TNA, D4, P.O. Box 35503, Dallas, TX 75235. Materials mailed after Aug. 1, 2006, will require a $10 processing fee, made payable to TNA, D4.

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