8 Preceptors Essential to Learner Success

As described in Chapter 1, Malcolm Knowles (1984) is credited with naming the theory of andragogy in relation to adult learning. Andragogy emphasizes how adult learners differ from child learners in being self-directed and taking responsibility for their learning decisions. Furthermore, according to Knowles, adults want to know why they are learning something, need to learn experientially (including having the opportunity to make mistakes), use problem solving to learn, and learn most effectively if they can apply what they learn immediately. Knowles states that adults learn best if their teacher is primarily a facilitator or resource person. Smith (2002) discusses Knowles’s theory, highlighting the ideas that learners move from being dependent to self-directed, accumulate a reservoir of experience and knowledge, and are internally motivated to learn. Given these principles of adult learning, teaching strategies such as simulations, role-playing, and case studies are considered useful. Likewise, clinical practicum learning opportunities with the student working alongside a preceptor are compatible with the principles of andragogy. Practicum students are directed by a more knowledgeable person (the preceptor) until they can accumulate experience and knowledge to be independent practitioners.

Sandlin et al. (2013) further our understanding of Knowles’s theory with additional focus on his beliefs that adult learners are autonomous, rational, and capable of action and on the assumption that autonomy and rationality are desirable and attainable in adult learners. Their perspective on Knowles’s fundamental views provides an interesting contrast in considering the role of preceptor in the clinical environment. The tenets of Knowles’s adult learning theory offer no substantive role for the preceptors who hold responsibility for overseeing, guiding, and evaluating the work of the preceptee, for learners are thought to be totally autonomous and capable of independence. In contrast, as Sandlin et al. propose, adult learners might actually be at various levels of autonomy and rationality, and thus a skilled preceptor does have a role in adult learning.

As explained in Chapter 1, Jack Mezirow (1995) is credited with making significant contributions to the theory of transformative learning. The essence of this theory is that learners must engage in critical reflection on their experiences in order to transform their beliefs, attitudes, and perspectives, which Mezirow terms their “meaning schemes.” Others have critiqued some of his assumptions and views. Boyd and Myers (1988) note that learners must be open to changing their meaning schemes; to adopt new perspectives, they must realize that their old perspectives are no longer relevant. Dirkx et al. (2006, p. 123) emphasize the self-actualization possibilities of transformative learning with the statement that “learning is life—not a preparation for it.” They note the importance of a relationship between the learner and others, which is required to make sense of one’s perspective and to become aware of (and transform to) new meanings.

For Mezirow, the essence of learning is change. To be truly transformational, learners must engage in inquiry, critical thinking, and interaction with others. Brookfield (2000) adds that transformative learning must include a fundamental questioning of one’s thoughts and actions. Reflection alone does not result in transformative learning unless this reflection includes an analysis of taken-for-granted assumptions.

The entry-to-practice competencies for health-care professionalsinclude elements of critical reflection; adoption of professional values, beliefs, and attitudes; and ongoing questioning of taken-for-granted assumptions and values. If Mezirow is correct that acquiring a competency does require the involvement of others, then this becomes part of the role of the skilled preceptor. Preceptors might be well placed to encourage honest self-review and critical reflection that ends in learner transformation. In this view, preceptors need to be aware of strategies to engage learners in reflection, causing them to gaze deeply into long- and deeply held values and biases that they might not even be aware they hold.

Benner’s (1984) well-used and much-respected From Novice to Expert model has implications for understanding the role of an effective preceptor for health-care learners. Although Benner focused on nursing students in the clinical setting, her theory likely applies to learners in other health-care disciplines. This model holds that nurses develop skills over time from both education (including clinical experience) and personal experience. The model identifies five levels of nursing experience: novice, advanced beginner, competent, proficient, and expert. Novices are beginners with no experience—they learn rule-governed tasks by following instructions. Advanced beginners have gained experience in actual nursing situations and recognize recurring elements that create principles that they can use to guide actions. Competent nurses have more clinical experience and use it to become more efficient in providing care. Proficient nurses have an understanding of the bigger picture that improves decision making and allows for changes in plans as needed. Experts no longer need principles or rules to guide actions—they use intuition to guide their flexible, highly proficient clinical approaches. As learners transition from novice to expert, they rely less on principles, they see a situation more holistically, and they engage in situations from the inside rather than the outside.

Preceptors can play a vital role in this transition. Benner’s (1984) model requires clinical experience for the transition to occur, and guidance in the clinical situation is essential for successful transition. Preceptors need to have awareness of the needs of learners at various stages of the continuum and be attuned to the stage(s) at which their students are functioning. For example, a novice student needs a preceptor who provides more direct guidance in learning the rules to guide her or his actions. A preceptor for advanced beginners helps them to recognize recurring patterns and develop them into principles of effective care.

Benner (1984) also comments that expert clinicians might not be the most effective in preceptoring roles. They might have difficulty explaining their actions in a step-by-step manner because they function by intuition and might not be consciously aware of the rules and principles that they use to make clinical judgments. Analogous to riding a bike, beginners are aware of the steps needed to balance the bike, propel it forward, stop it, and avoid obstacles. An expert cyclist is able to ride without thinking about how to ride and thus might have a challenge in teaching a new cyclist.

You are invited by your manager to be a preceptor. You are both honoured and terrified. If this is your first time formally in this role, then you have a lot to learn. To begin, recognize that becoming a really good preceptor takes experience, just as becoming a competent (even expert) care provider takes experience. Reading this chapter and other resources will help. You might be fortunate that the agency you work for provides preceptor education. The first step is to determine what is available in the form of lectures, workshops, preceptor manuals, et cetera and to engage with them before your preceptee arrives. You cannot possibly be fully prepared on the first day no matter how much homework you do, so begin with a positive attitude and a sense that you will learn every day through reflection, experience, and ongoing formal learning. Know that your apprehension is normal—with preparation, this apprehension can be lessened. With a positive approach, being a preceptor can be a fulfilling experience for you and a gift to a learner.

I was delighted to be asked to be a preceptor! This would be my first time. I thought, “Wow, they think I am good enough to teach a new person—that’s super!” My sense of excitement was soon drowned out by horror. What if I made a mistake? What if my student asked a question that I couldn’t answer? What if . . . ? I didn’t sleep a wink the night before our first shift together. I just did my best to have a positive attitude and kept reminding myself—my student and I will learn together.

BETH PERRY, PROFESSOR, FACULTY OF HEALTH DISCIPLINES, ATHABASCA UNIVERSITY

Once you overcome the initial challenge of self-doubt about your ability to be a preceptor, you can become aware of some of the realities and challenges faced by preceptors. One important challenge is that preceptors must balance the needs of preceptees with the needs of patients for whom they are caring and the realities of the workplace. Patients might be seriously ill (or become seriously ill during a shift), and work environments can have high staff turnover and other challenges (Hallin & Danielson, 2009). As a preceptor, you might feel torn between the needs of your patients and the needs of the preceptee. The reality is that patient safety always supersedes anything else. If you keep that in mind, then you will know what to do. If you do have to make a choice and the preceptee’s needs are not addressed at that point, then explain the situation later to the learner and use it as a learning moment to help them understand priorities.

Not all students are going to succeed (at least not at first). You might have a learner who lacks appropriate knowledge, skills, and attitudes to perform safe, competent (for her or his level), and ethical care in the clinical environment. You might be the only line of defence for the patient, and your responsibility to, and advocacy for, the patient and society might become your priority. As Luhanga et al. (2008, p. 214) write, preceptors must be able to recognize and manage unsafe practices by students—preceptors are the “gatekeepers for the profession.” If you have a learner who is disruptive and exhibits other problematic or unsafe behaviours, Luhanga et al. provide strategies gathered from preceptors with experience in such situations. Their first recommendation is to catch unsafe practices early or even prevent them if possible. A key first step is giving the learner a complete orientation to the learning environment and establishing clear expectations. Preceptors need to make their own expectations clear, ask learners about their expectations, and understand the expectations of the program before the learning experience begins. Clear expectations, understood by all involved, can prevent issues and problems. One preceptor in the Luhanga et al. study describes how she presents her expectations: “I try to nip it in the bud pretty quickly so as to prevent it. Upfront, I tell students what I expect. Like, I expect you to know every med you give. I expect if you don’t know something to ask me, we’ll look it up. I don’t expect you to know everything, so don’t feel pressured” (p. 216).

Actively involved preceptors often prevent problem behaviours and unsafe practices by learners by providing them with demonstrations, chances to practise, cues, prompts, and frequent feedback throughout the learning experience (Hendricson & Kleffner, 2002). Such active involvement of the preceptor, including close observation especially in the early days of the relationship, can give learners the best chance for success. As they gain confidence and competence, preceptors can step back and encourage more independence within agency guidelines. However, that initial investment of time and energy by the preceptor can be crucial as learners stretch toward practising at their full scope.

Preventing unsafe and disruptive behaviours is not always possible. If a learner is doing something that jeopardizes the safety of another person (or even himself or herself), then the preceptor must stop the behaviour immediately. Further actions (Luhanga et al., 2008) include (1) communicating concerns directly to the learner to determine whether the learner is aware of the problem, (2) working with the learner to set up a detailed plan for improving performance, and (3) involving the faculty adviser if the learner is a student.

Preparing preceptors for their role is important to the success of the preceptor-preceptee relationship. Ensuring that preceptors are enthusiastic about being preceptors is essential. Careful preparation can fuel this enthusiasm and prepare preceptors for positive outcomes from their preceptoring experiences, encouraging them to continue in this role. Hallin and Danielson (2009) note that, in some clinical environments in which students are preceptored, turnover is high. Preceptors might be placed in the role before they have appropriate orientation, appointed not because they are ready to be preceptors but because it is their turn. If you are asked to be a preceptor and do not, after careful reflection and self-assessment, feel safe in this role, then discuss your concerns with your manager before agreeing to it. Again, the principle of patient safety overrides all else.

Research has been carried out on the qualities of effective preceptors in various health-care disciplines. Effective preceptors in pharmacy have professional expertise, actively engage learners, create a positive learning environment, are collegial, and discuss career-related topics and concerns (Huggett et al., 2008). Pharmacy students value preceptors whom they perceive as role models, who are interested in teaching, relate to learners as individuals, are available to provide direction and feedback, and spend time with learners (Young et al., 2014). Medical students note that effective preceptor behaviours include openness to questions, constructive feedback, enthusiasm, review of differential diagnoses, and delegation of patient responsibilities (Elnicki et al., 2003). Nursing learners value experienced, knowledgeable professionals who guide them to think critically and create a supportive and nurturing environment (Phillips, 2006).

Although these studies emphasize slightly different characteristics of effective preceptors, some commonalities are clear. First, excellent preceptors want to be preceptors or at least can be perceived as wanting this role. Students are attentive to the level of enthusiasm and support that preceptors bring to the relationship. Second, effective preceptors have expertise to share and do so willingly with learners. Learners appreciate preceptors who share their knowledge by involving them in the learning process: that is, preceptors who make learning interactive and two-way, challenging learners to think critically. Third, we can note openness, collegiality, support, respect, and nurturing. Students report learning best in a positive learning environment infused with these attitudes.

So, on those days that you just don’t want to be a preceptor, fake it until you can get this positive cycle started. The result might be a great day after all!

You can use multiple strategies to become an outstanding preceptor. First, be sure that you have the support you need to succeed. Being a preceptor can be stressful, but you can be more effective if you receive support from faculty advisers, managers, colleagues, and clinical educators on the unit (Yonge et al., 2002). Support can come in many forms, including formal education programs and workshops through your agency, opportunities to meet with faculty advisers to learn about their expectations of a preceptor, discussions with colleagues about how they enhance their success as preceptors, or informal chats with clinical educators for teaching tips. You can identify the forms and sources of support most useful to your knowledge gaps. Do reflect on your needs and ask for the support that you need to perform your role well.

A second important strategy is preparation. Less experienced preceptors might feel unprepared for and unsure of their roles and responsibilities, adding to the stress of the role. Hallin and Danielson (2009) recommend that, in addition to the preparation outlined earlier in this chapter, preceptors confirm that they have clear guidelines on the expectations of their role and what students are allowed to do in clinical settings. They suggest that, in part to gain this knowledge and to learn the more subtle skills of being an effective preceptor, inexperienced preceptors be preceptored by experienced preceptors. This requires team preceptoring rather than initially being a preceptor on your own and can be effective for some individuals. In particular, new preceptors must be specifically prepared for student evaluation, which can be idiosyncratic to each student’s agency, complex, and demanding.

Preceptors can encounter difficulties in their relationships with students through personality or value differences or seemingly limited skill or interest of learners (Cederbaum & Klusaritz, 2009). A strengths-based approach focuses on learners’ self-determination and validates the unique strengths that learners bring to their learning (Melrose, 2018). This can be a useful strategy for preceptors who encounter difficult relationships with learners (McCashen, 2005). In a strengths-based approach, the preceptor emphasizes discovering, enhancing, and promoting the interests, knowledge, and goals of the learner. The preceptor facilitates self-discovery and clinical reflection, creating a learning environment with mutuality and respect and a focus on strengths over deficits. If a strengths-based approach is used effectively, then learners feel empowered and affirmed. Some learners who are more familiar with a deficit model might feel uneasy at first if they expect a teacher-centred, top-down teaching approach. The strengths-based perspective can provide an innovative framework for working with students, one that emphasizes student empowerment, collaborative learning, and mutual growth (Cederbaum & Klusaritz, 2009).

How can preceptors enact a strengths-based approach? One strategy is to use a learning contract, as explained in Chapter 6. This contract can be verbal or written, outlining by mutual agreement the roles and responsibilities of the preceptor and preceptee and emphasizing the mutuality of the learning experience. Another strategy is to express concerns positively and frame the resolution of problems as adding to existing strengths rather than overcoming deficiencies. Preceptors who embrace strengths-based approaches view the clinical situation from the perspective of the learner and try to create a positive learning space (Cederbaum & Klusaritz, 2009).

Halfer (2007) calls debriefing a magnetic strategy for preceptoring learners. Preceptors can use debriefing as a teaching strategy and an example of guided discovery learning. Usually, debriefing is a short exchange between the preceptor and the preceptee after a caregiving experience. Ideally, debriefing occurs in a private and safe location away from others who are not involved in the experience (Wickers, 2010).

Debriefing has four elements: reflection, rules, reinforcement, and correction (Roberts et al., 2009). Initially, a preceptee is invited to reflect on their performance, giving the preceptor an opportunity to gain insight into the learner’s perspective. This reflection requires learners to gather their thoughts and share them, often a learning experience in itself. Next the preceptor teaches general rules about the procedure, reinforces them, and corrects errant thinking expressed or demonstrated by the learner. Wickers (2010, p. 83) emphasizes that “structuring a seemingly unstructured learning event is paramount to the effectiveness of the debriefing session” and reminds us that positive support is part of the successful debriefing model.

Preceptors can use the instructional strategy of reflective time to enhance the consolidation of theory and practice (Duffy, 2009), encouraging students to assess their practice through guided reflection. Schon (1983) suggests that the capacity to reflect on action as part of engaging in a process of continuous learning is one of the defining characteristics of professional practice. Schon differentiates the capacity to reflect in action (while doing something) from the capacity to reflect on action (after you have done it). To elicit real reflection, the preceptor must ask appropriate questions that move the reflection beyond self-justification or self-indulgence. The desired result is learning or perhaps behavioural change or enhanced skills proficiency.