Nurse preceptors and new graduate success

Author(s): Kelly Powers, PhD, RN, CNE; Julie Pagel, MSN, RN, CCRN, SCRN, CNE-cl; and Elizabeth K. Herron, PhD, RN, CNE, CHSE

Use these strategies to enhance new nurse clinical reasoning skills.

Takeaways:

  • The stress associated with the transition from nursing school to clinical practice can lead many new graduates to leave the profession.
  • A hospital transition-to-practice program has been identified as a strategy for improving new nurse preparation.
  • By offering support and feedback (including positive reinforcement), preceptors can help reduce new nurses’ anxiety and increase their self-confidence so they can become progressively more independent and successfully adjust to their new role.

Transition to practice for new graduate nurses is challenging. The stress associated with learning the full scope of their new role can lead them to leave the profession, and lack of experience can result in errors. A focus on new nurse success is essential to improving retention rates and ensuring patient safety. Enter nurse preceptors, who can help promote new nurse success by providing support and using strategies to enhance clinical reasoning.

The preceptor role

Nurse preceptors play a vital role in promoting new graduate nurse success. By offering support and feedback (including positive reinforcement), preceptors can help reduce new nurses’ anxiety and increase their self-confidence so they can become progressively more independent and successfully adjust to their new role. Preceptors begin providing support by getting to know the new nurses they’re precepting. What are their prior experiences (school, work, life)? What are their goals for orientation and beyond? Each new graduate will come to practice with different experiences and learning needs, so they’ll progress through orientation at different paces.

Next, preceptors should socialize their preceptees to their new role as members of the unit’s intra- and interprofessional teams and connect them with others they can reach out to for additional support and assistance when needed. Because preceptors have an ongoing, close working relationship with their precep­tees, they can watch for signs of transition shock (sleeplessness, exhaustion, doubts about their abilities, and fear of failure or disappointing others) and implement additional support strategies in collaboration with unit managers and educators.

Another crucial component of the preceptor role is helping new graduate nurses develop their clinical reasoning skills so they can recognize changes in a patient’s condition and determine the best way to respond. (See What is clinical reasoning?)

What is clinical reasoning?

Clinical reasoning is the ability to think critically and make sound decisions during changing clinical situations. To make sound judgments about patient care, nurses must

  • generate alternatives
  • weigh them against the evidence
  • choose the best course of action.

The ability to clinically reason develops over time and is based on knowledge and experience. New graduate nurses’ knowledge and experience frequently is limited to books and carefully assigned and monitored patient care, making it difficult for them to clinically reason during changing patient care situations (such as a decline in health status) while also caring for multiple patients, completing full documentation, and working with other healthcare team members. As a result, overwhelmed new nurses may focus on tasks that require following orders without using clinical reasoning.

Strategies to build clinical reasoning skills

Preceptors can use various strategies to help new graduate nurses develop their clinical reasoning skills and as a result prevent failure-to-rescue events that occur when signs of patient deterioration aren’t recognized or are acted upon too late or not at all. (See Precepting in action.)

Precepting in action

Cameron* is a new graduate nurse who started on the postsurgical unit 2 weeks ago. He’s working with his assigned preceptor, Tamara. After receiving change-of-shift report, Cameron and Tamara review patient information to create a plan for the day. One patient has a low urine output, and Cameron says that he thinks additional I.V. fluids are needed. Tamara asks him to notify the provider. Cameron suddenly appears nervous and confides that he’s never called a provider before.

Tamara uses these strategies to encourage Cameron’s clinical reasoning:

  • Tamara provides Cameron with formative feedback by stating, “Good job identifying the need for I.V. fluids.”
  • She discusses the steps for calling a provider and reviews SBAR (situation-background-assessment-recommendation) format.
  • Cameron says he’s still very nervous, so Tamara provides support by saying she’ll be by his side when he calls. She also provides encouragement by sharing that she was nervous at first too but became more comfortable after a few experiences.
  • Tamara asks Cameron to write an outline of his SBAR report and then asks him to practice it with her using role play.
  • After a successful role play, Tamara provides positive feedback, and Cameron calls the provider.
  • The call goes well, and Cameron hangs up the phone, expressing relief. They continue with their day.
  • Later, Tamara and Cameron sit down to discuss the day. Tamara uses questioning to enhance Cameron’s clinical reasoning: “What would you have done if the provider chose not to order I.V. fluids when you called about the low urine output?”

*Names are fictitious.

Feedback

Feedback can take many forms. For example, formative feedback allows preceptors to offer ongoing feedback so new nurses can identify what they’re doing well and where they need improvement. Summative feedback, on the other hand, occurs at the conclusion of a learning activity (such as an evaluation completed at the end of orientation). Providing positive feedback is important to help prevent and address transition shock, and constructive feedback is essential for improving performance.

Preceptors should provide ongoing feedback, both informal (for example, when leaving a patient room, saying, “You did a great job maintaining sterile technique.”) and formal (such as sitting down at the end of each day to collaboratively complete paperwork outlining accomplishments and areas to work on). This feedback helps new nurses grow and improve throughout their orientation.

Discussion and assessment

Making time to debrief, reflect, and discuss gives new nurses an opportunity to deeply assess their thinking and reasoning. Using these meetings to focus on clinical reasoning can involve discussing case studies (from journals or created by the preceptor) or patients the new nurse is caring for.

Meetings at the beginning of a shift to review patient information, discuss concerns, and formulate plans to prevent deterioration can help prepare new nurses to successfully provide safe patient care. Meeting later in the day for reflective discussions after an event (for example, an error or complication) can help new nurses learn from what occurred and apply the experience to future situations. New nurses may feel embarrassed and sensitive about their performance, so preceptors should find a private area for these discussions.

Questioning

Questioning can help new graduate nurses use clinical reasoning. Preceptors should frequently ask open-ended questions to encourage deeper thinking and a wider view of patient situations. Questions that encourage new nurses to consider the effectiveness of current care and other options can prepare them to prevent patient deterioration.

“What if…” questions (for example, “What if your patient was also tachycardic? How would that change your assessment of the situation and your plan of care?”) can help new nurses link current situations to their previous patient care experiences and think about future possible scenarios. These types of questions allow nurses to reason through a variety of situations and preceptors to provide feedback on the analysis and plan. Orientation probably won’t provide exposure to every possible patient situation; questioning can fill this gap in experiential learning.

Think aloud and role play

Preceptors can use active teaching-learning strategies, such as thinking aloud and role playing, to help new graduate nurses develop clinical reasoning skills.

Thinking aloud involves talking through analysis, decisions, and actions as they occur. New nurses can talk through their patient assessment, priorities, care plan, and the rationale for actions they take and care they provide. For example, as a nurse is applying a blood pressure cuff, they can say out loud: “I know the nursing assistant just recorded the blood pressure, but the reading was much different than it was before, so I’m going to recheck it now.” This allows the preceptor to understand the new nurse’s thinking and is an opportunity to provide feedback or ask questions as the situation warrants. Preceptors can model thinking aloud to help the new nurse feel more comfortable doing it and to enhance learning from hearing the preceptor’s analysis and rationale.

Role playing can help reduce new graduate nurse anxiety and prepare for actual practice. For example, if the new nurse is anxious about caring for a patient who is dying, the preceptor can role play the patient (or family member) to give the nurse an opportunity to practice communication. Role playing in this situation helps the new nurse plan and practice a new component of patient care and receive immediate feedback.

Preceptor support

Incorporating strategies to encourage clinical reasoning may take additional time and effort, especially at the beginning, but repeated experiences will help nurse preceptors develop their new graduate nurse coaching skills. Over time, these strategies will become a routine component of precepting.

Managers and educators should support preceptors as they learn and practice their role. Creating easy-to-access resources, such as a checklist or preceptor guide with teaching strategy information or tools such as the One-Minute Preceptor, may be helpful. And just like new graduate nurses, preceptors need support, including success recognition and feedback.

Promoting success

Nurse preceptors are vital for promoting new graduate nurse success during transition to practice. By using support strategies to prevent or alleviate transition shock and enhance new nurses’ clinical reasoning, preceptors can help improve new graduate nurse retention and patient outcomes.

References

Berkow S, Virkstis K, Stewart J, Conway L. Assessing new graduate nurse performance. J Nurs Admin. 2008;38(11):468-74.

Boychuk Duchscher JE. Transition shock: The initial stage of role adaptation for newly graduated registered nurses. J Adv Nurs. 2009;65(5):1103-13.

Herron EK. New graduate nurses’ preparation for recognition and prevention of failure to rescue: A qualitative study. J Clin Nurs. 2018;27(1-2):e390-401.

Innes T, Calleja P. Transition support for new graduate and novice nurses in critical care settings: An integrative review of the literature. Nurse Educ Pract. 2018;30:62-72.

Kertis M. The One-Minute Preceptor: A five-step tool to improve clinical teaching skills. J Nurses Staff Dev. 2007;23(5):238-42.

Kovner CT, Brewer CS, Fatehi F, Jun J. What does nurse turnover rate mean and what is the rate? Policy Polit Nurs Pract. 2014;15(3-4):64-71.

Makary MA, Daniel M. Medical error—The third leading cause of death in the US. BMJ. 2016;353:i2139.

National Council of State Boards of Nursing. Transition to practice. ncsbn.org/transition-to-practice.htm

Nielson A, Lasater K, Stock M. A framework to support preceptors’ evaluation and development of new nurses’ clinical judgment. Nurse Educ Pract. 2016;19:84-90.

Pillai S, Manister NN, Coppolo MT, Ducey MS, McManus-Penzero J. Evaluation of a nurse residency program. J Nurses Prof Dev. 2018;34(6):E23-8.

Powers K, Herron EK, Pagel, J. Nurse preceptor role in new graduate nurses’ transition to practice. Dimens Crit Care Nurse. 2019;38(3):131-6.

Quek GJH, Shorey S. Perceptions, experiences, and needs of nursing preceptors and their preceptees on preceptorship: An integrative review. J Prof Nurs. 2018;34(5):417-28.

Schuelke S, Barnason S. Interventions used by nurse preceptors to develop critical thinking of new graduate nurses: A systematic review. J Nurses Prof Dev. 2017;31(1):E1-7

Spector N, Blegen MA, Silvestre J, et al. Transition to practice in hospital settings. J Nurs Regul. 2015;5(4):24-38.

Tanner CA. Thinking like a nurse: A research-based model of clinical judgment in nursing. J Nurs Educ. 2006;45(6):204-11. 

Kelly Powers is an assistant professor at the University of North Carolina at Charlotte School of Nursing. Julie Pagel is a service line educator at Atrium Health’s Carolinas Medical Center in Charlotte, North Carolina. Elizabeth K. Herron is an assistant professor at the James Madison University School of Nursing in Harrisonburg, Virginia.

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