In their seminal work on clinical judgement, discernment, and reflection, Benner, Hooper-Kyriakdis, and Stannard (1999) devoted one chapter to the coaching and mentoring roles within nursing. They suggest that the "skilled know-how of clinical leadership and the coaching and mentoring of others" (p490) include the following activities: "facilitating the clinical development of others, coaching others in interpreting, forecasting, and responding to patient transitions, bridging the gaps in patient care, building and preserving collaborative relationships, and transforming care delivery systems."(p490) They interviewed and observed expert clinicians as they demonstrated these behaviors. Their stories are captured in the book Clinical Wisdom and Interventions in Critical Care so that we can learn to refine and appreciate the preceptor's role in our work environment.
How is the exceptional preceptor's wisdom preserved and disseminated in your organization? The most common practice is by word of mouth: one preceptor tells another and so on. Sometimes, like the game of "telephone" from our youth, the strategy or advice no longer resembles that which was initially proposed. How do nurses decide to become preceptors? Perhaps it is because they are indebted to the men and women who devoted their time and expertise to them and wish to create that same experience for future nurses. How do they learn to be preceptors? By observing preceptors in the role, acquiring knowledge and skills, and anticipating situations they might confront. They discover very quickly that their beginning understanding was really "just a beginning" understanding. Through experience, they refine and extend their learning and practice.
Although much of learning is by trial and error, imagine what could be accomplished if novice preceptors were able to incorporate the sage wisdom of skilled and learned preceptors! As educators, we need to keep in touch with experienced preceptors, learn from them, and help share their knowledge with others. In this column, we thought we would share some reflections from expert preceptors with you. We each selected preceptors from our hospitals that have been identified as exceptional preceptors and asked each preceptor four questions. We would like to share some of their responses with you.
What is one piece of advice you wish someone would have given you before you started precepting?
I wish someone would have told me to come up with a keyword or phrase to use that would not startle a patient or family member. This word or phrase would be one that I could use when I need the orientee to step back and let me take over care during a critical situation.-Bobbie Solarski, RN, Orthopedic Unit, Providence Portland Medical Center, Portland, Oregon.
You need a lot of patience and a calm demeanor. You must look at each person individually. What works for one may not work at all for another person. It may be demoralizing to realize that you may not be the BEST preceptor for every new nurse.-Irene Kato, BSN, RN, Colorectal Surgical Unit, Cleveland Clinic, Cleveland, Ohio; 2003 recipient of Clinical Excellence Award for Precepting.
Some days you'll wish you never came to work, but it will get better. Never give up. It is worth the price of gold to know how you have made a difference in the lives of not just the orientee, but all the patients they will ever care for.-Jane Brinlee, RN, Respiratory Unit, Providence Portland Medical Center, Portland, Oregon.
What is one successful strategy that you use in dealing with a novice nurse who is feeling overwhelmed and disorganized?
I try to set a goal for each day and focus on that; for example, choose one diagnosis/surgery type to focus on that we are caring for and not try to cover all of them at once.-Bobbie Solarski, RN, Orthopedic Unit, Providence Portland Medical Center, Portland, Oregon.
I typically tell any RNs that I am working with that it is OK to feel overwhelmed, disorganized and not to be able to figure out the next step. I would really like them to tell me when they feel overwhelmed. I find that if I give them "permission" to feel overwhelmed, it allows a dialogue to occur and we can develop a plan to advance their skills.-Brian Wong, RN, Cardiovascular Intensive Care Unit, Providence Portland Medical Center, Portland, Oregon.
In today's practice, the ability to multitask nursing care is a reality[horizontal ellipsis]for a new nurse who is feeling overwhelmed, the thing that ALWAYS works for me is to tunnel her focus on ONE THING[horizontal ellipsis]one patient and one aspect of the patient's care at a time[horizontal ellipsis]or one area that needs to be learned or mastered[horizontal ellipsis]if a new nurse can leave feeling that she's successfully completed one thing[horizontal ellipsis]the day was successful.-Rita Hanuschock, MSN, RN, Chemical Dependency Unit, Cleveland Clinic, Cleveland, Ohio; 1998 recipient of Clinical Excellence Award for Precepting.
I watch how they communicate with me the first day I meet them. I can always tell when they get overwhelmed as they clam up. I then step in and say "let me help you here." I truly believe in debriefing daily on what went well, what did you learn and would you have done anything differently.-Jane Brinlee, RN, Respiratory Unit, Providence Portland Medical Center, Portland, Oregon.
I relate to them that when they were infants they couldn't walk at first and they took one step at a time when they first walked, so it will take some time to become clinically proficient. If they focus on one area at a time, it will all come together.-Anna Marie Taylor, BSN, RN, Operating Room, Cleveland Clinic, Cleveland, Ohio; 2004 recipient of Clinical Excellence Award for OR Nursing.
Describe behaviors exhibited by your management team that have helped you be successful as a preceptor?
There are a variety of behaviors that my management team uses to support me in my role as preceptor. The success for my role is the unwavering belief of my managers in the value of the preceptor and the knowledge of the time required to ensure a successful orientation. They facilitate my attendance at conferences so I can continue to grow professionally. They display a strong commitment to the interviewing process. A great deal of time is spent identifying the applicant's strengths and weaknesses, career goals, demeanor, enthusiasm for learning, and potential to be a future preceptor. A lot of thought is spent in matching preceptor and orientee. The preceptor gets information about the new orientee before he or she arrives on the unit. "Class time" is assigned away from the clinical area so that the orientee and preceptor can regroup and discuss issues. Finally, meetings are scheduled regularly with the managers, preceptor, and orientee to address any concerns before they escalate.-Irene Kato, BSN, RN, Colorectal Surgical Unit, Cleveland Clinic, Cleveland, Ohio; 2003 recipient of Clinical Excellence Award for Precepting.
They value me as a person and an expert nurse. If I feel orientees need more time, they are usually given it. I have done this for over 25 years and truly believe in my "gut" feeling when precepting to know if they are a good fit or not. If you don't have the support-don't be a preceptor. And YELL loudly when no one hears your words of concern.-Jane Brinlee, RN, Respiratory Unit, Providence Portland Medical Center, Portland, Oregon.
Typically, I receive a lighter patient assignment so I have extra time to spend teaching. Additionally, in my patient assignment, the charge nurse generally tries to assign patients that would give a new nurse a broad range of experiences.-Sarah Howard, BSN, RN, Palliative Care Unit, Cleveland Clinic, Cleveland, Ohio; 2007 recipient of Clinical Excellence Award for Precepting.
The one behavior that my management team gave to me was the gift of flexibility[horizontal ellipsis]they let be me flexible with my work, my time, my responsibilities; they also were generous with their spirit[horizontal ellipsis]they let me know that they trusted me and my work[horizontal ellipsis]they consulted me for my expertise and they rewarded me for a job well done.-Rita Hanuschock, MSN, RN, Chemical Dependency Unit, Cleveland Clinic, Cleveland, Ohio; 1998 recipient of Clinical Excellence Award for Precepting.
How do you cope with the stress of precepting?
I always try to remember that I was new once.-Bobbie Solarski, RN, Orthopedic Unit, Providence Portland Medical Center, Portland, Oregon.
I am glad you asked this question. I find precepting, while rewarding, to be very difficult at times. The best solution I have is to take breaks from precepting. This allows me to recharge, re-establish my routine, and quantify new information I gained from precepting. The last piece being one of the best things about precepting, I always learn something new either from a researched question of a preceptee or the preceptee sharing knowledge gained from instruction or experience.-Brian Wong, RN, CICU, Providence Portland Medical Center, Portland, Oregon.
I love precepting. I get the chance to mold new people to be who I would want caring for me. These are my teammates and I want them to be supported and welcomed on the floor, but more importantly provide safe, knowledgeable care to the patients. OK back to coping. Bad day CHOCOLATE-good day workout at club or yard work. Weekly debriefing with myself, management, and the new hire stops a lot of the stress before it gets to be overwhelming. And if personalities don't match-get a preceptor who fits the new hire's needs.-Jane Brinlee, RN, Respiratory Unit, Providence Portland Medical Center, Portland, Oregon.
I recall being brand new in the OR and how helpful everyone was. I want this for my orientee. I want this new person to give the best care possible so I pray each day to be the best for my orientee.-Anna Marie Taylor, BSN, RN, Operating Room, Cleveland Clinic, Cleveland, Ohio; 2004 recipient of Clinical Excellence Award for OR Nursing.
Precepting is my way of dealing with the stress that comes from being a nurse in the 21st century. Teaching is something that I LOVE!!! There is no greater joy then teaching a new nurse about our work and the rationale for the decisions I make. Precepting is not stressful[horizontal ellipsis]the computer is!!!-Rita Hanuschock, MSN, RN, Chemical Dependency Unit, Cleveland Clinic, Cleveland, Ohio; 1998 recipient of Clinical Excellence Award for Precepting.
From these preceptors' comments, it is clear that precepting new nurses is demanding work, yet very rewarding. Their practical advice may be just what beginning preceptors need to hear. Preceptors, like orientees, evolve. The process requires more than "a village," it requires a profession dedicated to the intellectual growth, skill acquisition, and emotional support of each of its members. That's a story worth telling! Feel free to share this advice with your preceptors and managers.
Mary Beth
Mary
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