published since 2000, available online via the University of Derby library link to ...... St. Louis,. MO: C. V. Mosby. Landers, M. G. (2000). The theory-practice gap ...
PERSONAL DETAILS & MODULE ASSIGNMENT
University:
University of Derby (Online)
Course Title:
Bachelor of Science (Honours) in Nursing Studies
Course Code:
UDOL-B700
Module Title:
Theory and Reflection to Support Practitioners Undergoing Preceptorship
Module Code:
6NU517
Module Leader:
Stefanos Mantzoukas
Name:
Robert Geoffrey Calderwood
Student Number:
100339012
Date:
July 2014
Workplace and Trust:
Saudi Arabia. A company contracted to provide remote healthcare services for a large oil producing company.
Supervising Mentor:
Wahid El Kaissi (NMC (exp) 02A13360)
Word Count:
3285 (excluding the title sheet and references)
Do nurse preceptors perceive their level of preceptor training, provided by the Education department, sufficient to assist them in their role training newly hired nursing staff? – Could we improve?
Introduction “It cannot be assumed that practitioners can automatically function as preceptors” Coates and Gormley (1997). “Quality preceptorship is dependent upon skilled and knowledgeable preceptors who are committed to this role”. Haggerty et al (2012). This essay examines the concerns of the Education Coordinator responsible for training new staff, with limited emergency room experience in their home countries, to work in one of forty-‐five nurse led, remote area urgent care clinics as defined by the Institute of Remote Healthcare (2013), enabling them to reach the minimum standards of care required by the client. Newly employed nursing staff receive fifteen days induction in the Company’s main office involving: a welcome to Saudi Arabia; Cultural awareness; Company administration and by tradition, minimally interactive nursing sessions covering the skills and knowledge required by the client. Following the office based induction the nurses, who have at least two years experience in emergency rooms in the Philippines and India, are then deployed to one of forty-‐five remote area clinics around Saudi Arabia and are allocated a preceptor. Robert Geoffrey Calderwood (100339012)
2
The Company defines preceptors as senior nurses who have undertaken a two-‐day self-‐ study programme and have successfully completed a ten question multiple-‐choice paper. Operationally it isn't always possible for the allocated preceptor to remain with the new nurse throughout their clinic time prior to their ninety-‐day assessment and when they do, the preceptor nurse becomes fiercely protective of their students’ success record at the ninety-‐day evaluation. The five training staff whose role is to evaluate and maintain the client’s required standards of care for all clinic nurses throughout the project are also responsible for supporting the preceptors. Their role is hampered by their level of understanding of a preceptor’s role; their personal training in education and the logistics involved in visiting each remote area clinic a minimum of once every two months. The concerns raised after evaluating the support preceptors receive up to the students’ ninety day assessment include: The limited education time available during the first fifteen days for up to twenty-‐five new staff and the very dependent roles emergency room staff occupy in their home environment. Traditionally the education and training model in India and the Philippines is patriarchal where the teacher is always right and not to be questioned; an inference derived from Hofstede (2011), a ‘Power Distance’ comparison between the United Kingdom, the Philippines and India. This indicates a workforce with an acceptance of inequality between the powerful (knowledgeable) and Robert Geoffrey Calderwood (100339012)
3
weaker (inexperienced) members of society (nursing staff). Also of concern is the transformation required by the client, that is, an expectation of staff becoming the equivalent of a Practice Nurse and Paramedic; the lack of formal training, evaluation and support preceptors receive from the company; the expectations of the Company's management of the new staffs’ assessment and the consequences the preceptors assume will befall them if a new nurse fails to reach the expected standard. This last statement relates directly to defensive and negative comments made by several preceptors throughout the later half of the seventy-‐day clinic training the new nurses receive. “I won’t be held responsible if this student fails as I wasn’t given enough guidance by education.” Reflection Further questioning of the preceptor and analysis of, and reflection on the preceptor’s statements using Gibbs’ reflective cycle, Gibbs (1988), produced areas for further research, the main focus being on training and support. Description At the end of the three-‐week initial induction the nurse, one of a group of twenty-‐five joining the company, had been evaluated as knowledgeable and as having good potential for a successful final 90-‐day evaluation. Two weeks prior to the assessment the preceptor highlighted the nurse as failing to meet expectations and likely to fail. The Robert Geoffrey Calderwood (100339012)
4
nurse was therefore brought to the office for a two-‐day review of skills and knowledge prior to sitting the final 90-‐day assessment. If the preceptor’s evaluation of his student came to fruition, it would, in the view of the Company’s Management, indicate a failing of the Education Coordinator, the training programme and jeopardise the Education Coordinator’s position both within the Company and with the client. Feelings The Education Coordinator was stressed and anxious for the nurse to perform well but concerned that he would fail because of his preceptor’s perceived lack of support from Education. The Education Coordinator was relieved and pleased that he successfully completed the mock assessments carried out during the two days review but concerned by the preceptor’s feelings. Evaluation Evaluating the cause of the Education Coordinator’s initial feelings of stress and anxiety produces multifaceted results which include: the perceived and actual lack of preceptor training and support prior to and during new staff clinical placements; the negative scrutiny of the Education Coordinator by his office peers and senior management; a micro-‐management style where hierarchical communication is poor in both directions
Robert Geoffrey Calderwood (100339012)
5
and, the possibility of losing the support of the client’s management team because of a poor outcome of the training. Analysis Analysing the Education Coordinator’s feelings brought about by having previously updated the Company’s training plan from task orientated to an ‘entry-‐level’ critical thinking approach, the stress and anxiety caused by one student possibly failing the assessment was understandable and in part due to poor communication, training and support provided to the preceptors. On further review and observational study, the intended teaching model had not been fully adopted by all trainers or preceptors. This was given further weight by the analysis of an evaluation of training and support provided by Education, completed by the preceptors after the nurses had taken their assessment and summed up by the following three statements representing the overall response. “I didn’t understand what was meant by critical thinking and reflective practice.” “I felt Education expected too much of us preceptors without giving us the support in the clinic.” “This is an extra role for us and we are not appreciated or rewarded for preceptoring the new hires.” Robert Geoffrey Calderwood (100339012)
6
Conclusion Positive written and verbal feedback given to preceptors during the newly employed staffs’ clinic placements did, at the time, seem to enhance their active participation in the training but this was not supported by the results of the anonymous evaluation. The results of that evaluation indicate that the Education Coordinator and Education failed to provide sufficient support to Education’s training team and hence the preceptors and that Management support failed because of a perceived lack of reward and appreciation of preceptors. Action Plan To address the apparent failure of Education to adequately support the trainers and clinic staff as preceptors, a literature review has been conducted evaluating preceptors’ perceptions of the training and support they receive in other facilities; the current professional trends in preceptor training and a determination of what improvements can be made to the current preceptor training and support provided by Education. Management support will be elicited through formal recommendations following the review of Education’s role. Robert Geoffrey Calderwood (100339012)
7
What the literature reveals In stark contrast to the Company’s current practice of expecting all senior staff to be preceptors, Al Shehri (2003) states, “The assumption that any good medical practitioner has the ability to teach no longer holds.” Current newly hired nurse induction is predominantly preceptor focused and like EMS education, “centred upon rote learning”, Gandy (2009), or competency based training (CBT). This has been recognised by the client who has highlighted a lack of reflective practice and critical thinking in the Company’s newly hired nurses at day ninety. Price (2004) states, “For reflection to become a skill that is used in practice, practitioners need to learn how to combine this skill with critical thinking.” This approach requires trainers and preceptors to be appropriately trained and to receive adequate in-‐clinic guidance and support. Hackett (2001) states that, “there exists at least the potential for them (CBT and reflection) to be designed and developed so as to be complimentary.” Haggerty et al (2012) indicate that ad hoc selection may lead to inappropriate preceptor allocation and propose the development of guidelines for preceptor selection and training. Robert Geoffrey Calderwood (100339012)
8
For logistical reasons, new staff are allocated preceptors by Operations making no reference to their learning needs nor possible personality conflicts between preceptor and student. Learning Needs, Aims and Objectives This paper compares current preceptors’ perception of their training and support versus studies on preceptors’ perceptions available in academic literature. By researching current trends in preceptor training, the Education Coordinator will be able to enhance preceptor training and support by incorporating ideas from published academic evidence on current training, evidence based reflective practice and critical thinking for all levels within the Company. The Clinical Question and PICO Focusing on the preceptors’ perceived level of training and support a clinical question was posed: ‘For preceptors with limited training in the role, would further preceptor and reflective practice training, compared to the current level of training, lead to greater levels of reflection by nursing staff, improve the preceptors’ perception of the support they
Robert Geoffrey Calderwood (100339012)
9
receive, their perception of the preceptor role and improve the outcome of new staff nurses probationary 90 Day Assessment?’ The question was then broken down using the PICO structure to provide key words, shown in italics and parentheses, for the literature search. Problem Preceptors have limited preceptor training, reflective practice experience and limited support for their role. (Preceptor training, Preceptor support, Preceptor perceptions of support, Preceptor role) Intervention Further preceptor training, reflective practice training and support. (Reflective practice training) Comparison Current training using only the self-‐study module. (Preceptor self-‐study training) Outcome Increased reflective practice; improved preceptors’ perception of their role and the support they receive and improved outcome of new staff nurses probationary 90 Day Assessment. Robert Geoffrey Calderwood (100339012)
10
The key words were chosen having been directly derived from the PICO structure of the clinical question and to limit the search results to nursing preceptors. Key Words Nurse; Nursing; Preceptor training; Preceptor support; Preceptor training self-‐study; Preceptor perceptions of support; Preceptors’ role; Reflective practice training. To focus on specific concepts and limit the literature retrieved, the Boolean operator ‘AND’ was incorporated in the search parameters. Key words ‘Nurse’ and ‘Nursing’ were truncated to ‘Nurs*’, ‘Preceptor’ and ‘Preceptors’ truncated to ‘Preceptor*’ which incorporates ‘Preceptorship’ and each search was limited to full text, academic journals, published since 2000, available online via the University of Derby library link to EBSCO Medical Databases Library Plus, with the search parameters appearing in the title of the academic papers retrieved, providing linked full text articles in English. A summary of the search result is displayed in Table 1 below.
Robert Geoffrey Calderwood (100339012)
11
Table 1 : UoD Library EBSCOhost Search Summary
An additional search utilising Google Scholar was conducted and the top ten results retrieved were reviewed for applicability in the study. After removing duplicates and rejecting papers not directly related to adult general nursing, seven papers were “read and re-‐read to achieve an in-‐depth understanding and to achieve data saturation.” Booth (2001), Jones-‐Lloyd (2004) in Mantsoukas (2008). One article was subsequently selected for further review. Research Article Critique The article chosen was Henderson and Malko-‐Nyhan (2008), and a systematic approach described by Provenzale and Stanley (2006) was used as a critique guide.
Robert Geoffrey Calderwood (100339012)
12
Education has a responsibility for “supporting the teaching and learning activities of the preceptor.” Billay and Myrick (2007). The critique will indicate whether conclusions drawn from the study can be incorporated in to the Company’s education programme to improve the support preceptors’ receive and hence improve their performance and increase the level of reflective practice and hence critical thinking within the newly employed nursing workforce. Title & Abstract The title and abstract clearly indicate the purpose of the study. The objective is unambiguous. The methodology is stated as a longitudinal descriptive study involving focus groups and interviews. Thirty-‐six respondents from a potential pool of more than seventy preceptors took part providing an adequate number of responses to ensure data saturation. Rebar et al (2011) and Fink (2009, p95). The authors’ credentials provide the study with credibility although conflict of interest was not detailed. Introduction Coughlan et al. (2007), state that an article must be written concisely, be grammatically correct, avoid the use of jargon and be well laid out and organised. The introduction provides a rationale for the study but doesn’t state the exact timing of the study. The authors state the study is to evaluate the preceptors’ perceptions from which to formulate recommendations for future training and support. Robert Geoffrey Calderwood (100339012)
13
Methods The study used a longitudinal descriptive design involving fifty percent of the potential preceptors in one organisation, interviewed two to three months and six to nine months after an initial two-‐day training workshop. No indication of the preceptors’ willingness or desire to be a preceptor was provided with the study’s population being described as already having attended a preceptor workshop and subsequently worked as a preceptor. Preceptors in the study were invited to be participants. Focus groups and one-‐to-‐one interviews ensured that all participants had their views heard, recorded and transcribed for reliable analysis. The authors elicited experiential insights by using open-‐ ended questions to guide the direction of the discussions and interviews although the length of the sessions was not indicated and “question fatigue”, inferred from Parahoo (2006, p298), was not considered. A pilot study was not conducted to refine the questions however this study does provide the opportunity for further studies to be carried out. The study received the hospital ethics’ committee’s approval and all participants provided informed consent. Participants were able to withdraw from the study at any time without repercussions. Anonymity was, as far as possible maintained and all data collected was stored in accordance with prescribed national guidelines. Focus groups are by design open discussions where anonymity cannot be guaranteed but participants in the study were aware of this limitation. Robert Geoffrey Calderwood (100339012)
14
Results Themes resulting from the data analysis were consistent across both time periods of the study and between the focus groups and interviews. Responses were subsequently grouped together and analysed dividing them into the most prevalent themes that emerged. The three broad themes are summarised as: ‘Satisfaction with preparation prior to undertaking the role’; ‘satisfaction with their role’ and ‘lack of satisfaction with practice support’. It was reported that preceptors were generally satisfied with the preparatory training they received; that the personal growth obtained from being a preceptor by extending their role provided them with it’s own intrinsic reward and through the two-‐way transfer of knowledge with their student they gained new knowledge and satisfaction. In contrast there was distinct dissatisfaction with organisational support with a lack of time; perceived organisational commitment and reward being highlighted. Discussion Parahoo (2006, p.405) states, “… it is important that results are explained, discussed and interpreted.” Provenzale and Stanley (2006) state the discussion should not be lengthy, rambling or unfocused, should review medical literature around the subject, attempt to explain the unexpected and discuss the limitations. Robert Geoffrey Calderwood (100339012)
15
The authors provide reasons for the study, possible limitations and the implications for continuing staff development. The discussion is logical to follow and the question posed was answered. The findings are acceptably generalised and the recommendations are based on those findings. Three key points from the study are detailed. ‘Preceptors require both training and management support’; ‘lack of organisational support is a barrier to effective preceptorship’ and ‘there is a need to develop strategies to improve organisational support and to offer tangible rewards’. Limitations of the study include that it relates to one specific programme and was conducted in only one institution. This does not invalidate it as a supporting document to answer this paper’s clinical question as both the questions and recommendations reflect the current preceptor statements and organisational environment experienced by the Education Coordinator. References As recommended by Provenzale and Stanley (2006, p.95), four of the thirty-‐two citations were checked. All four cited, adopted the publisher’s format, Wiley (2013) and were easily accessible through the University of Derby Library On Line catalogue, EBSCO Library Plus database and Google Scholar (http://scholar.google.co.uk/). The cited articles were all relevant to the paper and the authors used cited articles to support the discussion. Robert Geoffrey Calderwood (100339012)
16
Summary Opinion Results from this study are useful to guide further research within the organisation to provide the Education Coordinator with an answer to the clinical question; to provide guidance for the development of preceptor education and to support recommendations to management to improve the perceived support preceptors receive. Personal Learning Experience To ensure appropriate guidance was provided, the preceptor was chosen as he met the criteria set out in 2.1.1 NMC (2008). Both student and preceptor are characterised by Benner (1984) as proficient or expert and built further on the egalitarian, collaborative partnership model already in operation by regular focused discussions and free exchange of knowledge and ideas. The relationship followed a true student-‐preceptor partnership espoused by Nelson (2012) and was constantly questioning methodology and techniques employed in training and supporting the Company’s preceptors. Richardson (2005) in Annan (2013) concludes that students’ evaluation of teachers “can be important indicators of what would help students to learn” and Norcinci and Banda (2011) state that a student’s level of attainment should be objectively evaluated and appropriate feedback given, early recognition of deficits addressed and both material Robert Geoffrey Calderwood (100339012)
17
and teaching style modified accordingly. The humanistic approach allowed both student and preceptor to individually and independently research a topic under discussion and present findings in an open and non-‐judgemental environment, question the methodology and judgements of each other leading to an eventually agreed upon outcome with areas for further research and development. Cross (1999) wrote, “however good the intentions, the quality of mentoring is still very much dependent upon the amount of time that the mentor can devote to it.” While Cross was examining the relationship between mentor and student, consideration of time needed by the mentor or preceptor to ensure they remain current in their own practice is just as important. The collaborative partnership between student and preceptor allowed this time and both consider the learning undertaken to have great benefit for both personal development and the future of Education within the Company. Levett-‐Jones and Lathlean (2009, p 348) in Epstein and Carlin (2012) state that, “Questioning, assertive practitioners are an asset to a profession that seeks to be innovative and forward-‐thinking.” Although both preceptor and student consider this statement applicable to their own role, much work remains to be done to encourage this attitude amongst the majority of the Company’s nurses.
Robert Geoffrey Calderwood (100339012)
18
Evaluation of Learning The Education Coordinator considers the knowledge gained and experience of working closely with a preceptor/mentor to have been invaluable. A study conducted by Atack et al (2000), on preceptor practice and it’s impact on learning “…identify practices that enhance student learning and professional staff practice.” The benefit of a well thought out preceptor programme with appropriate organisational support can have positive effects on preceptor perceptions of their role and preceptor perceptions of themselves and an updated preceptor programme is being developed in parallel with a concerted effort to elicit support from management. Throughout the programme objectives were set, developed and revised as learning progressed. The initial learning objectives evolved reaching the objectives stated in the appendix late in the programme. Additional learning undertaken in parallel included improving literature search techniques from which a future search would replace “self-‐ study” with “self-‐directed learning.” The Department of Health (2004), Knowledge and Skills Framework, six core dimensions of improved Communication; Personal and people development; Health safety and security; Service improvement; Quality and Equality and diversity have all been positively addressed. Robert Geoffrey Calderwood (100339012)
19
The aim of the Education Coordinator is to now develop and implement the revised preceptor programme and allow the patients and Company to benefit in the same way. “Could we improve?” Emphatically yes.
Robert Geoffrey Calderwood (100339012)
20
References Al Shehri, M.Y. (2003) Current issues in medical education. West African Journal of Medicine. 22(4) 329-‐333 Annan, S., Tratnack, S., Rubenstein, C., Metzler-‐Sawin, E., & Hulton, L. (2013) 'An integrative review of student evaluations of teaching: Implications for evaluation of nursing faculty'. Journal Of Professional Nursing. 29(5) e10-‐e24, Atack, L., Comacu, M., Kenny, R., La Belle, N., Miller, D. (2000) Student and Staff Relationship in a Clinical Practice Model: Impact on Learning. Journal of Nurse Education. 39(9) 387-‐392 Benner, P. (1984) From Novice to Expert. Addison-‐Wesley Publishing Billay, D., Myrick, F. (2007) Preceptorship: An integrative review of the literature. Nurse Education in Practice. 8(4) 258-‐266 Chan, S.W.C., Wai-‐Tong, C. (2000) Implementing contract learning in a clinical context: report on study. Journal of Advanced Nursing. 31(2) 298-‐305
Robert Geoffrey Calderwood (100339012)
21
Coates, V., & Gormley, E. (1997) Learning the practice of nursing: views about preceptorship. Nurse Education Today. 17(2) 91-‐98. Coughlan, M., Cronin, P., Ryan, F. (2007) Step-‐by-‐step guide to critiquing research. Part 1: quantitative research. British Journal of Nursing. 16 (11) 658-‐663. Cross, R. (1999) What Time Constraints Face the Junior School Teacher Taking on the Role of Student Mentor? Mentoring & Tutoring: Partnership in Learning. 7(1) 5-‐21,
Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process [online]. London: National Health Service. [Accessed 27 June 2014]. Available at: Epstein, I. Carlin, K. (2012) 'Ethical concerns in the student/preceptor relationship: A need for change', Nurse Education Today. 32(8) 897-‐902 Fink, A. (2009) Conducting research literature reviews. 3rd ed. London: Sage Publications Ltd.
Robert Geoffrey Calderwood (100339012)
22
Gandy, W.E. (2009) Why We Need Critical Thinking in EMS: The concepts of Bloom's domains can help EMS educators develop caregivers who think critically. EMS World [online]. [Accessed 6 June 2014]. Available at: Gibbs, G. (1998) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford Centre for Staff and Learning Development, Oxford Polytechnic. Oxford. Hackett, S. (2001) Educating for competency and reflective practice: fostering a conjoint approach in education and training. Journal of Workplace Learning. 13(3) 103-‐112 Haggerty, C., Holloway, K., Wilson, D. (2012) Entry to nursing practice preceptor education and support: Could we do it better? Nursing Praxis in New Zealand. 28(1) 30-‐ 39 Henderson, A., Malko-‐Nyhan, K. (2006) An evaluation of preceptors’ perceptions of educational preparation and Organisational support for their role. Journal of Continuing Education in Nursing. 37(3) 130-‐136 Hofstede, G.H. (2011) New Software of the Mind 2010 Edition. Available at: http://www.sietareu.org/activities/webinars. Last accessed 27th Mar 2014. Robert Geoffrey Calderwood (100339012)
23
Holland, K., & Rees, C. (Eds.). (2010) Nursing Evidence-‐Based Practice Skills. Oxford University Press. Institute of Remote Healthcare (2013) Remote Healthcare Guidance Document for Energy and associated Maritime activities. IRHC Remote Healthcare Workshop. 14th January. Bergen, Norway. Institute of Remote Healthcare. Mantzoukas, S. (2008) A review of evidence based practice, nursing research and reflection – leveling the hierarchy. Journal of Clinical Nursing. 17(2) 214-‐223. Nelson S. (2012) The lost path to emancipatory practice: towards a history of reflective practice in nursing. Nursing Philosophy. 13 202–213 Norcini, J., & Banda, S. (2011) 'Increasing the quality and capacity of education: the challenge for the 21st century'. Medical Education. 45(1) 81-‐86 Nursing and Midwifery Council (2008) Standards to support learning and assessment in practice. London: NMC. Parahoo, K. (2006) Nursing research. Principles, process and issues. 2nd ed. London: Palgrave Macmillan Robert Geoffrey Calderwood (100339012)
24
Price A. (2004) Encouraging reflection and critical thinking in practice. Nursing Standard. 18(47) 46-‐52. Provenzale, J.M., Stanley, R.J. (June 2006) A systematic guide to reviewing a manuscript. Journal of Nuclear Medicine Technology. 34(2) 92-‐99 Rebar, C.R., Gersch C.J., Macnee, C.L., McCabe S. (2011) Understanding Nursing Research 3rd ed. London: Lippincott Williams & Wilkins. Turner, S., Beddoes, L. (2007) Using reflective models to enhance learning: Experiences of staff and students. Nurse Education in Practice. 7(3) 135–140 Wiley Online Library. Author Guidelines [online]. [Accessed 1 August 2013]. Available at .
Robert Geoffrey Calderwood (100339012)
25
An Evaluation of Preceptors’ Perceptions of Educational Preparation and Organizational Support for Their Role Amanda Henderson, RN, RM, PhD, Robyn Fox, RN, RM, MNsgLdrship, and Kristina Malko-Nyhan, RN, PhD
abstract Background: This longitudinal, descriptive study evaluated nurse preceptors’ perceptions of a 2-day educational workshop and subsequent organizational support offered to prepare them for their roles as preceptors. Methods: Thirty-six registered nurses who attended preceptor workshops and then acted as preceptors participated in focus groups or interviews 2 to 3 months and 6 to 9 months after their educational preparation to identify the usefulness of the preparation, the subsequent support by management, and the potential changes in their perceptions. Results: Respondents identified intrinsic rewards and opportunities for growth for nurses who take on the preceptor role. However, adequate preparation and organizational support are essential to effectively perform their duties as clinicians and preceptors. Conclusion: Although a 2-day educational preparation program was perceived as adequate, the practice setting must be reorganized to provide greater support for preceptors. Preceptors should be supported by providing continuing education, effective scheduling, and adequate time for learning and feedback in the clinical environment.
T
he importance of the preceptor role played by nurse clinicians in the transition of new staff into the workplace is clearly identified in the literature (Calpin-Davies, 2003; Chenoweth & Lo, 2001; Clare, White, Edwards, & van Loon, 2002; Ohrling & Hallberg, 2001; Owens et al., 2001). Preceptorship commonly describes a supportive relationship designed to orient new staff to a specific work environment. It is provided through a one-on-one relationship between a designated experienced nurse and a new staff member (Usher, Nolan, Reser, Owens, & Tollefson, 1999). The time frame is flexible and the relationship ideally continues until the new staff member achieves a predetermined level of competence. 130
The role of the preceptor is crucial in teaching and facilitating skills development, as well as in assessing, coaching, guiding, role modeling, counseling, inspiring, and supporting growth and development of new staff, especially for new graduate nurses who have no prior experience working as registered nurses (Andrews & Chilton, 2000; Bain, 1996; Chenoweth & Lo, 2001; Clifford, 1993; Davies, Turner, & Osborne, 1999; Gray & Smith, 2000; Grealish, 2000; Hart & Rotem, 1994; Jeffreys, 2001; Ohrling & Hallberg, 2001; Spouse, 2001; Watson, 1999). The purpose of this study was to identify the appropriateness and usefulness of educational and managerial support provided to preceptors in the study organization. SCOPE OF THE PRECEPTOR ROLE The scope of the preceptor role is diverse. One facet of it is socialization. Preceptors introduce new staff members to other health team members and to the general social processes unique to that work area. Knowledge of the clinical area and experience are reported to be preceptors’ greatest assets (Coates & Gormley, 1997). Preceptors help new employees to identify what they do not know and create the opportunities to learn. They create a climate that nurtures new graduates by using open, honest, and sensitive communication that allows for discussion and understanding of graduates’ perceptions, needs, goals, and aspirations. Preceptors also take Dr. Henderson is Nursing Director, Education, Nursing Practice Development Unit, Princess Alexandra Hospital Health Service District, Woolloongabba, Australia. Ms. Fox is Nursing Director, Education, Centre for Clinical Nursing, Royal Brisbane and Women’s Hosptial Health Service District, Herston, Australia. Dr. Malko-Nyhan is Education Research Consultant, Brisbane, Australia. The authors thank the Queensland Nursing Council for providing the financial support to make this project possible. They also thank the staff at the Royal Brisbane and Women’s Hospital Health Service District for their time and valuable contributions to the project. Address correspondence to Amanda Henderson, RN, RM, PhD, Nursing Director, Nursing Education and Research Unit, Princess Alexandra Hospital, Ipswich Road, Woolloongabba 4102 QLD Australia.
The Journal of Continuing Education in Nursing · May/June 2006 · Vol 37, No 3
on a mentoring role, which most commonly has an additional aspect that involves a mutual commitment to teaching and learning by both parties. The key elements of mentorship, which are similar to those recognized in the preceptorship role, are teacher, nurturer of performance, facilitator, motivator, and friend (Baillie, 1994; Clare et al., 2002; Coates & Gormley, 1997; Gray & Smith, 2000; Madjar, McMillan, Sharkey, Cadd, & Elwin, 1997; Neary, 1997). Consistent with these attributes, preceptors should also have the capacity to convey their embedded knowledge and know when to give preceptees increasing independence (Nehls, Rather, & Guyette, 1997), as well as the ability to facilitate learning by encouraging reflection and organizing a variety of experiences (Baillie, 1994). Spouse (2001) supported this view when she highlighted the importance of supervisors in the clinical area to coach new graduates through the more subtle activities that are taken for granted by experienced registered nurses. When supervisors in the clinical area are positive and interested, they are far more likely to act as facilitators of learning by organizing a variety of relevant experiences and taking advantage of all learning opportunities (Spouse, 2001). Of significance in the literature is the limited practice of assessing the effectiveness of preceptors (Letzia & Jennrich, 1998). Feedback related to preceptors’ progress and performance should be provided regularly, in an ongoing, open, and supportive manner (Hart & Rotem, 1994). Although there appears to be universal acceptance of the importance of preceptors (Bowles, 1995), it cannot be assumed that practitioners can automatically function as preceptors (Coates & Gormley, 1997). With such a list of essential qualities, it is imperative that preceptors are appropriately selected and developed using education programs designed to assist them in this expanded role (Lo & Brown, 2000; Owens et al., 2001). Clinicians experience substantial pressure to gain further qualifications and expertise, facilitate learning, and still function in an increasingly complex, dynamic, and stressful healthcare environment. This view is supported by Spouse (2001) and Andrews and Chilton (2000), who found that supervising in the clinical setting can be a negative experience for some who undertake this role, particularly if they do not take it on willingly but have it thrust on them as part of their clinical work. Dunn and Burnett (1995) and Hart and Rotem (1994) indicated that the attitudes and supervisory styles of senior personnel in the healthcare agency and the ethos of the clinical environment have a marked influence on both the professional development of clinical staff and their acceptance of students and new graduates (Landers, 2000). Preceptor Education · Henderson et al.
PRECEPTORS’ NEED FOR EDUCATIONAL AND MANAGERIAL SUPPORT The appointment of suitable preceptors and development of programmed structures that support their roles are major problems that continue to create difficulties for universities, students, new graduates, employers, and the nursing profession in general. Personal attributes of preceptors influence the way they perform their roles. They need to be taught how to provide positive mentoring, infuse socialization processes, ascertain graduates’ learning styles, and give appropriate feedback. Consequently, the best clinicians are not always the best preceptors, because they may not be able to teach or communicate effectively with novices (Bain, 1996). Duffy (1995) reviewed horizontal violence (i.e., hostile behavior between members of similar groups) and the lack of cohesion within the nursing profession, and indicated that both can be reasons clinical staff are reluctant to recognize their supervisory responsibilities. Further problems relate to the conflict between the competing demands of preceptoring and of providing patient care caused by high workloads and the multiplicity of roles expected of clinical nurses who are involved with new staff (Bartlett, Simonite, Westcott, & Taylor, 2000; Neary, 1997; Winter-Collins & McDaniel, 2000). When this is accompanied by increased staff turnover and the use of an increasing number of casual and agency staff to overcome shortages, those who undertake preceptor responsibilities may feel pressure from being in a continuous teaching mode (Clare et al., 2002). Accordingly, organizational factors have been identified as influencing a supportive environment for transition. These include the organizational culture, the morale of the organization, and the type of transition program offered (Gattenhof, 1998). However, of primary importance is the level of support provided within preceptor relationships, which are established as a core component of the transition program. Ideally, this support should include effective educational preparation for those who choose to undertake the preceptor role and consideration of management issues to compensate preceptors for their increased workload and responsibility. Support for Preceptors in the Study Organization The preceptor preparation provided at our tertiary facility is open to all registered nurses who have been employed by the organization for at least 1 year and who demonstrate an interest and aptitude for undertaking the preceptor role. The initial preparation is a 2-day workshop. Although the introduction to the role involves mainly dissemination of information, the remainder of the workshop focuses on interactive sessions such as 131
ing in general medical and surgical wards, including oncology, in an acute tertiary referral center with more than 500 beds.
TABLE 1
QUESTIONS POSED TO PRECEPTORS DURING THE FOCUS GROUPS Questions asked of preceptors after 2 to 3 months: 1.
What were your expectations of being a preceptor?
2.
Were these expectations able to be realized?
3.
What difficulties did you face in your preceptor role?
4.
What were some of the factors that helped you to fulfill your expectations?
5.
Were there any factors that might have limited you in realizing your expectations?
6.
Do you believe these factors were beyond your control?
7.
How could you have been assisted more in your role?
Additional questions asked of preceptors after 6 to 9 months: 8.
Have you noticed a change in the individuals whom you have been precepting?
9.
Why do you think this has occurred?
10.
What changes do you perceive in your work environment as new graduates progress through their transition?
Ethical Considerations The study was approved by the Hospital Research Ethics Committee. Throughout the study, the needs of the patients and the interests of the staff involved were placed before those of the study. Participation was voluntary. Informed consent was obtained from each participant before data collection commenced. Participants could choose to withdraw from the study at any time without repercussions. All data were confidential and kept in secure storage. All reasonable attempts to protect anonymity were made, but because of the nature of focus groups, participants were aware of their own group’s processes and outcomes. On completion of the project, data were stored in accordance with national research guidelines.
role playing, discussions, and demonstrations designed to maximize learning opportunities. The content areas covered during the workshop focus on the roles and responsibilities of preceptorship, preceptee needs, adult learning, effective teaching, performance assessment, and strategies for effective preceptoring that provide general guidelines about support within the organization. Participants are provided with a resource book. Subsequent support is available by directly accessing nurse educators and also by 2-hour update sessions. Nurse unit managers commit to organizational support at the ward level. The intention of such support is appropriate scheduling and assigning of patients that maximize opportunities for the preceptor to effectively guide and support new staff.
Sampling Potential participants were identified from the database of attendees at the preceptor educational workshop. More than 70 registered nurses were identified as potential participants. Those nurses who had recently (within the past 3 months) attended a workshop were sent an invitation to participate in focus groups. Flyers advising the intent and details of preceptor focus groups were sent to these individuals and also to the relevant senior registered nurses who were in a position to encourage and facilitate their attendance at the focus groups. A small number of staff members who were unable to attend the focus group sessions but expressed an interest in contributing to the study were offered the option of one-onone interviews that followed the semi-structured format used in the focus groups. Thirty-six registered nurses who attended preceptor workshops and then acted as preceptors participated in the focus groups or interviews. Each focus group contained two to four nurses.
METHODS Study Design This longitudinal, descriptive study used focus groups to evaluate preceptors’ perceptions of a program in terms of educational preparation and subsequent support by management in the clinical setting. Focus groups were conducted with preceptors at 2 to 3 months and repeated at 6 to 9 months (after their educational preparation) to investigate perceptions of the usefulness of the preparation and the support by management during an extended period. The study was conducted with preceptors work-
Focus Groups and Interviews Six focus groups were conducted at 2 to 3 months and four at 6 to 9 months after the workshops. Focus groups lasted approximately 1 hour. Interviews took from 30 to 45 minutes. Focus groups were selected for this research study because the explicit use of group interaction produces data and insights that may be less accessible without the interaction found in groups (French et al., 1996). The researchers were interested in eliciting experiential insights that would provide a greater depth of information than
132
The Journal of Continuing Education in Nursing · May/June 2006 · Vol 37, No 3
that obtained from surveys when investigating the preceptoring experience and the influence of education and organizational support for this role. The methodology facilitated a reflective process arising from a set of questions designed to encourage reflection across a broad range of areas (Table 1). All interviews and focus groups were audio-taped with participants’ consent and later transcribed verbatim to assist in data analysis. The data were analyzed thematically by listening to tapes and reading and rereading transcripts to identify broad themes. RESULTS Findings from the interviews and the focus groups were collected and are reported together in this article because themes were consistent. Furthermore, because the themes did not differ between the two time periods, all focus group and interview findings have also been grouped together. Responses have been categorized into the most prevalent themes that emerged. These were: satisfaction with preparation prior to undertaking the role, satisfaction with their role, and lack of satisfaction with practice support. Satisfaction With Preparation Prior to Undertaking the Role Overall, preceptors were generally satisfied with the preparation provided by the preceptor course. Satisfaction was evident through comments such as: “The content covered during the training program prepared me for my role as a preceptor,” “I’m more aware of my strengths and [it] has improved my techniques (i.e., organization and preparation),” and “My practice is now directed at educating new and junior staff where possible with greater understanding.” Satisfaction With Their Role The views expressed by the preceptors were readily categorized into personal growth and a symbiotic relationship in which preceptors learned from those they were assisting. Satisfaction With Personal Growth. The outstanding feature identified by preceptors was the feeling of satisfaction they obtained from acting as a preceptor for new graduates and transferring staff. They believed they played a significant role in terms of molding new staff members. Almost all preceptors who participated were highly committed to that role and enjoyed the extension of their activities and the interaction with the new staff members. They thought the role provided considerable intrinsic rewards. The following are examples of the many views expressed: Preceptor Education · Henderson et al.
Overall the experience has been very positive for me. I did not think I would have the skills to be a preceptor; now I see myself moving into some educational role professionally but staying in the clinical area if I can. The general attitude towards grads and preceptors is good. People try to be helpful and support you. I enjoy being a preceptor. It enables me to give more of myself and increases my personal self-confidence.
Satisfaction From Learning Opportunities. One of the benefits perceived by the preceptors was their opportunity to learn from others. Some found that they learned from both new graduates and more experienced transfers. This was evidenced by comments such as: “I have learned a lot from the grads. It is a two-way process. I got a lot from it personally,” and “It keeps me on my toes, and ensures that I keep up to date with new things.” Overall, participants viewed learning opportunities as positive staff development outcomes that should be fostered. Lack of Satisfaction With Practice Support Negative comments primarily related to the organization’s lack of recognition of their important roles. Their perception was seemingly verified by a lack of organizational structures and the allocation of sufficient time for preceptors to provide effective support and guidance. Comments included: “[There] needs to be organizational commitment to preceptorship with increased funding and budgeting at a departmental level,” “Nurse management needs to make an effort to coordinate preceptors/preceptees on a long-term basis,” and “Pulled away from time with my preceptor by Level 3 due to other priorities.” Lack of assistance in facilitating learning in the practice setting was also verbalized by comments such as “The ward educator needs to provide more support,” “We need twice yearly preceptor update sessions rather than once,” and “[There is] no follow-up support from senior staff.” Lack of Time. A major issue was a perceived lack of time to perform the preceptoring role effectively. The need for preceptors to be allocated time away from direct clinical activities (offline time) was a prevailing concern. There was often “no time allocated to review progress or to fulfill expectations with preceptee.” Participants recognized that “‘offline time’ is required during transition but poor staffing and heavy workloads do not allow for this,” and suggested that “senior staff need to create more ‘offline time’ so preceptors are able to go through modules with graduates.” 133
Some assistance in the form of recognition for going the extra yards as a preceptor is required or more of us will start refusing to do it as there is great inequity in workloads when you are a preceptor.
TABLE 2
STRATEGIES FOR ORGANIZATIONS TO SUPPORT PRECEPTORS • Schedule preceptees to work with their preceptors as frequently as possible, and, when this is not possible, provide preceptees with an appropriate alternative with effective preceptoring skills. • Establish a system where preceptees and preceptors are provided with offline time to facilitate debriefing, reflection, and completion of education-oriented documentation. • Provide learning support and guidance for the preceptor in the clinical practice setting through establishment of peer networks and accessibility of ward-based educators to review and monitor activities in the clinical setting. • Create a reward system for those who undertake the additional activities associated with the preceptoring role. This could be in the form of opportunities to undertake educational activities associated with their clinical area of interest as opposed to direct monetary rewards. • Develop effective communication strategies to ensure key stakeholders are aware of all initiatives that influence the work environment, and that appropriate communication channels are used so issues that arise may be handled in an effective and timely fashion.
One participant noted that even when offline time was provided, clinical duties often interfered: “Sometimes due to busy ward we get pulled back from our ‘offline’ time.” This was such a strong sentiment with some that it resulted in feelings of frustration: There is not enough time to spend with the new grads. I feel really frustrated because there is barely enough time to give good, quality care to your patients and you have these new people hovering there and you know they need help, and you are torn between your work demands and helping them. I felt I had no control in my preceptoring role, mainly due to patient care commitments, and would have liked to have more opportunity to be of assistance in this role. We have an equivalent patient load and then also have the students and grads, which I love but it makes life hard and you get really tired and are not able to provide your best in these circumstances.
Preceptors wanted support that would indicate the organization was committed to facilitating effective preceptoring, including some form of reward system and support for learning in the practice setting: We need some reward system (which is not necessary related to money) as it gets very draining having students and new grads all the time. Some of us who are committed get a really hard time compared to the others. 134
Reference was also made to a support network for motivation and sharing knowledge, and the need to establish a preceptors’ network within the unit to maintain direction, encourage enthusiasm, and coordinate efforts. DISCUSSION Significant implications for continuing staff development arose from the study. Findings were relatively consistent at both the 2 to 3 month and 6 to 9 month periods. Preceptors enjoyed their roles and demonstrated a clear understanding of the characteristics necessary for effective preceptoring as identified in the literature (Chenoweth & Lo, 2001; Gray & Smith, 2000; Spouse, 2001). The education program positively impacted preceptors’ practice through the provision of guidance. Respondents’ comments supported research findings that draw attention to the importance of developing and implementing appropriate education programs for those who incorporate preceptorship into the clinical environment. Many positive aspects were noted by those undertaking a preceptor role in terms of benefits of their participation. However, of particular note were the concerns expressed by respondents regarding their perceptions of a lack of practice support for their roles. This support largely pertained to the structure and organization of practice in the clinical setting. Reference was made to inadequate time to effectively undertake their preceptoring duties because of patient load, poor organization of opportunities to partner with the preceptor, and limited assistance with how to guide and support within clinical demands. This lack of practice support resulted in many respondents reflecting on their experiences negatively, as outlined in the literature (Andrews & Chilton, 2000; Clare et al., 2002; Landers, 2000; Winter-Collins & McDaniel, 2000). Positive suggestions made by respondents included decreasing clinical workloads for those undertaking preceptoring responsibilities, ensuring that preceptors and preceptees are scheduled on the same shift, and establishing clinical networks to support preceptoring activities within the practice setting. These findings are consistent with those outlined in the international literature during the past 30 years (Bartlett et al., 2000; Chenoweth & Lo, 2001; Clare et al., 2002; Kramer, 1974; Usher et al., 1999; Winter-Collins & McDaniel, 2000). Participants also identified a reward system as being of value; however, it was believed that this should not be a direct monetary reward but could be linked to opportu-
The Journal of Continuing Education in Nursing · May/June 2006 · Vol 37, No 3
nities for individuals to further develop their capacity to undertake this role. Limitations The study has identified particular trends and areas for further development in the study hospital. Because the study relates to a specific program in one organization, results cannot be generalized to different programs in other organizations. Additionally, it needs to be recognized that there may have been different findings from a group that did not include volunteers. Although the study offers valuable insights into the experiences of registered nurses who undertake a preceptoring role and broad recommendations are suggested, the study does not make any recommendations regarding the precise requirements of time and support that would be required to meet the identified needs. Recommendations This study demonstrated the value of educational preparation for preceptors in that nearly all preceptors commented on its value. However, it also highlighted the critical role that the organization plays in effective preceptoring. Senior staff may give “lip service” to supporting the preceptor role, but in many instances the only compensation is the intrinsic reward from the professional relationship and the growth observed in the preceptee. Senior management in the development of organization structures and processes need to recognize preceptorship as part of their core business because it is increasingly being recognized as invaluable to employees. Table 2 provides recommendations for supporting preceptors. CONCLUSION Preceptors play a significant role in the preparation of staff and the effective functioning of ward or unit teams. Preceptor preparation and continuing education and support are vital for these experienced and valuable staff members. It contributes in no small measure to improving the job satisfaction and chances of retention of new graduates in a supportive clinical environment. Although many hospitals routinely provide preparation for nurses so they are educationally prepared to fulfill their role, the organization needs to recognize the positive contribution of preceptoring and ensure that it is supported through the provision of appropriate education, effective scheduling, and adequate time for learning and feedback in the clinical environment. Reliance on the purely intrinsic rewards and opportunities for nurses who take on this role will probably be insufficient to sustain continuing education in the clinical setting. Preceptor Education · Henderson et al.
key points Preceptor Education Henderson, A., Fox, R., Malko-Nyhan, K. An Evaluation of Preceptors’ Perceptions of Educational Preparation and Organizational Support for Their Role. The Journal of Continuing Education in Nursing, 37(3), 130-136.
1
Nurse preceptors play a key role in helping new staff to transition to the workplace, and require both training and management support to balance their roles as clinician and mentor.
2
A major barrier to effective preceptorship is lack of organizational support, particularly insufficient time for the preceptor and preceptee to interact away from clinical responsibilities.
3
Strategies to improve organizational support of nurse preceptors include providing training and feedback on performance, coordinating schedules of preceptors and preceptees, and offering tangible rewards for their efforts.
REFERENCES Andrews, M., & Chilton, F. (2000). Student and mentor perceptions of mentoring effectiveness. Nurse Education Today, 20, 555-562. Baillie, L. (1994). Nurse teachers’ feelings about participating in clinical practice: An explanatory study. Journal of Advanced Nursing, 20, 150-159. Bain, L. (1996). Preceptorship: A review of the literature. Journal of Advanced Nursing, 24, 104-107. Bartlett, H. P., Simonite, V., Westcott, E., & Taylor, H. R. (2000). A comparison of the nursing competence of graduates and diplomates from UK nursing programmes. Journal of Clinical Nursing, 9, 369379. Bowles, N. (1995). A critical appraisal of preceptorship. Nursing Standard, 9(45), 25-28. Calpin-Davies, P. J. (2003). Management and leadership: A dual role in nursing education. Nurse Education Today, 23(1), 3-10. Chenoweth, L., & Lo, R. (2001). Mentoring the new graduate. In E. Chang & J. Daly (Eds.), Transitions in nursing: Preparing for professional practice (pp. 279-294). Philadelphia: F. A. Davis Company. Clare, J., White, J., Edwards, H., & van Loon, A. (2002). Curriculum, clinical education, recruitment, transition & retention in nursing: AUTC final report. Adelaide, Australia: Flinders University. Clifford, C. (1993). The clinical role of the nurse teacher in the United Kingdom. Journal of Advanced Nursing, 18, 281-289. Coates, V. E., & Gormley, E. (1997). Learning the practice of nursing: Views about preceptorship. Nurse Education Today, 17(2), 91-98. Davies, E., Turner, C., & Osborne, Y. (1999). Evaluating a clinical partnership for undergraduate nursing students. Collegian, 6(2), 23-27, 40. Duffy, E. (1995). Horizontal violence: A conundrum for nursing. Collegian, 2(2), 5-17. Dunn, S. V., & Burnett, P. (1995). The development of a clinical learning environment scale. Journal of Advanced Nursing, 22, 1166-1173. French, P., Anderson, J., Burnard, P., Holmes, C., Mashaba, G., Wong, T., et al. (1996). International comparison of baccalaureate nursing degrees: Collaboration in qualitative analysis. Journal of Advanced Nursing, 23, 594-602.
135
Gattenhof, P. (1998). New graduate nurse recruitment consortium: 1997 report. Sydney, Australia: NSW New Graduate Recruitment Consortium. Gray, M. A., & Smith, L. N. (2000). The qualities of an effective mentor from the student nurse’s perspective: Findings from a longitudinal qualitative study. Journal of Advanced Nursing, 32, 1542-1549. Grealish, L. (2000). The skills of coach are an essential element in clinical learning. Journal of Nursing Education, 39, 231-233. Hart, G., & Rotem, A. (1994). The best and the worst: Students’ experiences of clinical education. The Australian Journal of Advanced Learning, 11(3), 26-33. Jeffreys, M. R. (2001). Evaluating enrichment program study groups: Academic outcomes, psychological outcomes, and variables influencing retention. Nurse Educator, 26, 142-149. Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: C. V. Mosby. Landers, M. G. (2000). The theory-practice gap in nursing: The role of the nurse teacher. Journal of Advanced Nursing, 32, 1550-1556. Letzia, M., & Jennrich, J. (1998). A review of preceptorship in undergraduate nursing education: Implications for staff development. The Journal of Continuing Education in Nursing, 29, 211-216. Lo, R., & Brown, R. (2000). A clinical teaching project: Evaluation of the mentor-arranged clinical practice by RN mentors. Collegian, 7(4), 8-42. Madjar, I., McMillan, M., Sharkey, R., Cadd, A., & Elwin, C. (1997). Project to review and examine expectations of beginning registered nurses in the workforce. Sydney, Australia: NSW Nurses’ Registration Board.
136
Neary, M. (1997). Defining the role of assessors, mentors and supervisors: Part 2. Nursing Standard, 11(43), 34-38. Nehls, N., Rather, M., & Guyette, M. (1997). The preceptor model of clinical instruction: The lived experiences of students, preceptors, and faculty-of-record. Journal of Nursing Education, 36, 220-227. Ohrling, K., & Hallberg, I. R. (2001). The meaning of preceptorship: Nurses’ lived experience of being a preceptor. Journal of Advanced Nursing, 33, 530-540. Owens, D. L., Turjanica, M. A., Scanion, M. W., Sandhusen, A. E., Williamson, M., Hebert, C., et al. (2001). New graduate RN internship program: A collaborative approach for system-wide integration. Journal for Nurses in Staff Development, 17, 144-150. Spouse, J. (2001). Bridging theory and practice in the supervisory relationship: A sociocultural perspective. Journal of Advanced Nursing, 33, 512-522. Usher, K., Nolan, C., Reser, P., Owens, J., & Tollefson, J. (1999). An exploration of the preceptor role: Preceptors’ perceptions of benefits, rewards, supports and commitment to the preceptor role. Journal of Advanced Nursing, 29, 506-514. Watson, N. A. (1999). Mentoring today—The students’ views: An investigative case study of pre-registration nursing students’ experiences and perceptions of mentoring in one theory-practice module of the Common Foundation Programme on a Project 2000 course. Journal of Advanced Nursing, 29, 254-262. Winter-Collins, A., & McDaniel, A. M. (2000). Sense of belonging and new graduate job satisfaction. Journal for Nurses in Staff Development, 16, 103-111.
The Journal of Continuing Education in Nursing · May/June 2006 · Vol 37, No 3
