Enhancing Nursing Education and Practice through Structured Preceptor Training in the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria ()
1. Introduction
Traditionally, students learn to be nurses by taking care of actual patients in the clinical areas, wards or patient care units. These experiences begin in the classroom learning the theory followed by skills laboratory exercises, which may include case study simulations (AACN, 2014). These skills are necessary for nurses to function competently in the present complex healthcare environment. Criticism of students not able to meet the current demands of healthcare and/or readiness for workforce poses concerns to graduating nursing students, faculty and hospital administrators. Lack of qualified nursing tutors and students’ perception that they do not learn and/or get adequate clinical preparation buttress the need to consider ways to improve nursing instruction to help students gain knowledge, skills and confidence prior to graduation.
Skills development through clinical learning is the core of nursing education and practice. Limited competencies result in poor patient outcomes. Researchers found that 35% of new graduates met professional entry-level expectation for clinical judgment while 38% were able to identify acute change in a patient’s condition, prioritize action and/or initiate independent action to minimize risk to the patient (Hagler et al., 2012). Inadequate supervision of students in the clinical area as well as lack of resources contributed also to not achieving learning outcomes (Gemuhay, Kalolo, Mirisho, Chipwaza, & Nyangena, 2019). Faculty reports that students do not go to assigned clinical postings further influenced students’ ability to achieve the learning outcomes (SONUNTH Faculty, personal communication, August 4, 2017). Potential impact on lack of competence and practice readiness was the basis for proposing setting up structured train the trainer-training program to prepare experienced clinical nurses at the bedside to supervise nursing students enrolled in a basic nursing program consistent with the role of a registered professional nurse.
Clinical practice models include faculty-supervised practice, use of preceptors, dedicated education units, service-academic partnerships, internships, nurse residency programs and use of experienced staff to serve as mentors (Agbedia, 2012; Sedgwick& Harris, 2012; Miller, Wagenberg, Loney, Porinchak, & Ramrup, 2020). Each model has unique benefits and challenges, but this work focused on the use of preceptors to improve student learning in the clinical area through collaboration between the school of nursing instructors and the hospital bedside nurses. Specifically, innovative workshop was developed to train qualified bedside nurses in the role of clinical preceptors. Having the required teaching skills and awareness of role expectations is necessary to facilitate student learning (Okoronkwo, Onyia-Pat, Agbo, Okpala, & Ndu, 2013). This project aim was to train registered professional nurses to advise and supervise nursing students in a hospital-based diploma program in University of Nigeria teaching hospital (UNTH), Enugu, Nigeria. The goal was to improve students’ learning in the clinical area through collaboration between the school of nursing instructors and the hospital bedside nurses. The program built upon prior learning of the clinical nurses with participants gaining better understanding of their role as clinical preceptors. In addition, the workshop activities enhanced service delivery by providing participants—professional nurses and student nurses with current knowledge and best practices, which are evidence based strategies proven to promote patient outcomes. Overall, the training provided essential information on the role and responsibilities of a preceptor, the student, as well as the faculty (Instructors), including helpful teaching strategies and several resources.
2. Materials and Methods
The researchers adopted the cross-sectional descriptive survey for the study to explore the phenomenon of interest and situation as it was without manipulating any of the variables. The study setting was the University of Nigeria Teaching Hospital (UNTH), located in Ituku Ozalla, Nkanu West Local Government Area of Enugu State in the South East Geopolitical zone of Nigeria. UNTH is a tertiary hospital funded by the Federal government, has 27 wards and 19 clinics that specialize in various aspects of patient care (such as medicine, ophthalmology, oncology, neurosurgery, orthopedic, intensive care,); and is a designated center for excellence in cardiothoracic surgery and management. In addition, UNTH have basic and several post basic nursing schools. The school of nursing is a hospital-based diploma program accredited by the Nursing and Midwifery Council of Nigeria to offer basic education leading to initial Professional Nursing licensure. Consistent with the (NMCN, 2020) guidelines, students who enrolled in the program were at least sixteen (16) years of age. All completed equivalent of Secondary education (high school) and obtained at least five (5) credits in Mathematics, English Language, Physics, Chemistry and Biology in no more than two (2) sittings from any of the national examination bodies: West African Examination Council (WAEC), National Examination Council (NECO) or National Business and Technical Examinations Board (NABTEB).
2.1. Selection of Participants
In order to implement the project, the support of the management of the University of Nigeria Teaching Hospital (UNTH) Enugu was sort to allot time and resources for professional staff development. Several discussions with the Chief Medical Director, the Head of Nursing Services and the Principal of the School of Nursing occurred to notify these leaders of the objectives and scope of the proposed project. The leadership of the nursing services and the school of nursing was sort to help identify qualified clinical staff who are willing to serve and train as preceptors. Furthermore, the qualifications of potential candidates were aligned to the standards of the code of professional conduct stipulated by the Nursing and Midwifery Council of Nigeria (NMCN) while setting up recruitment criteria, and flyers were created to announce the project calling for volunteers. Inclusion attributes are as follows:
1) Earned minimum of Bachelor’s degree in nursing (BSN) but a Master’s degree in nursing (MSN) is preferred.
2) Minimum of two (2) years of clinical experience.
3) Demonstrated knowledge, skills and enthusiasm for patient care and interest in teaching.
4) Not close to retirement (has minimum of five (5) years to retirement).
Upon the recommendation of the nursing services and/or the school of nursing, 30 nurses, two from each nursing unit (ward) who met the criteria to participate in the pilot preceptor-training workshop were invited to the workshop. Students’ participation in the project comprised of all current students enrolled in the SON UNTH from year one to year three, a total of one hundred and sixty-three (N = 163) students.
2.2. The Workshop
Over a period of six (6) months, the project director, a nurse educator based in USA worked with the faculty, preceptors and students remotely and face-to-face. The activities include reviewing copies of the course and skills lab instruction syllabi from the school of nursing, developing workshops to guide the faculty and lead preceptors to align the course objectives with the student learning outcomes, and developing the modules for the preceptor training workshops. In the face-to-face workshop, the group (faculty and lead preceptors) identified the essential skills needed for practice, grouped them into modules and generated the formative and summative evaluations checklist for each skill set. In addition, the group revised the students’ handbook. An Interdisciplinary Clinical Committee comprising of representatives from the school of nursing, nursing services, and allied health convened, revised and updated the Institution’s Clinical Procedure Manual. This allowed for a consistent use of one procedure manual for teaching in the school of nursing demonstration lab as well as used to render care to patients in the clinical wards and clinics.
The workshop modules consisted of topics relevant to the project and patient care. Twenty-two (22) preceptors, two (2) school of nursing Coordinators and two (2) observers from the university-based nursing program of the institution participated in a 3-day workshop given January, 2018. Participants received education about the objectives of the project with emphases on the roles of the course faculty, skills lab instructors, and preceptors, including strategies to engage and evaluate the students as well as instructional resources. Patient care topics covered include review of the focus assessment, communication techniques, update on management of common diseases such as Diabetes Mellitus, Hypertension, Respiratory illnesses; and use of internet-based technology as disease management tool to keep abreast of innovations in healthcare and nursing education. The students’ version of the workshop included overview of the concept of clinical preceptorship—highlighting the objectives, benefits, expectations, and student evaluation processes. Other topics include protocol to communicate with the preceptors and faculty, attendance policy, absenteeism and make up of missed clinical day (s). The entire student body N = 163 and the faculty of the school of nursing participated in the students’ workshops at the initiation of the preceptor program prior to students’ postings to the clinical wards. The evaluation of this Pilot Preceptorship Program initiated in the hospital planned for August, 2018 was moved to 2019 due to prolonged strike action of the national Joint Health Workers’ Union (JOHESU), which interfered with the students’ posting requiring a restart of the program.
3. Key Players in the Project
The key players in this project are the project director; project coordinators, lead preceptors, faculty and the preceptors. Below is the description of each role.
1) Project Director: The project director, a nurse educator and president of the school of nursing alumni in Diaspora (SONUNTH Alumni USA) handled all aspects of the project including delegating and assigning roles, interacting with stakeholders (faculty, clinical staff, students, and hospital management), mentoring faculty, developing and facilitating the workshops, and creating the reference manual (Preceptor Handbook) for the preceptors and students with input of the faculty and lead preceptors.
2) The Principal of the School of Nursing and the Head of Nursing Services in the hospital helped to identify qualified staff who participated in the project. Both leaders received reports from the Project Coordinator and offered resolution to issues when necessary.
3) Project Coordinator: For sustainability and leadership succession, appointed two project coordinators, a seasoned retired faculty on contract to mentor a faculty who will assume the role when the contract expires. The Project Coordinators saw to the day-to-day activities of the project; liaised with the faculty and preceptors, resolve issues and reported as deemed appropriate to the School and Nursing Service Leaderships as well as to the Project Director.
4) Course Team Leader: Guided by the Project Director, the School of nursing Course Faculty worked together in their Course Teams to identify course objects, students’ learning outcomes and developed checklists for formative and summative evaluations of students’ skills. These instructors liaised with the Clinical Preceptors, but the Course Team Leader reported formally to the Lead Preceptors and Project Coordinators.
5) Demonstration Lab Instructors: These Lab Instructors offered the initial skills teaching and liaised with the Didactic Instructors in the SON and Preceptors in the wards. Students who were unable to perform skills in the Wards or lacked comprehension of issues in the clinical areas came back to the Skills Labs for additional practicing and/or remediation on recommendation of the Preceptor.
6) Lead Clinical Preceptor: As in leadership succession of the project coordinator, two Lead Preceptors, a champion retired clinical nurse expert on contract identified a qualified staff nurse she can mentor who will take over upon her retirement. The two lead preceptors helped to identify their peers who are qualified and willing to train as preceptors, liaised with the SON faculty, coordinated the preceptors and reported to the Project Coordinator. In addition, the Lead Preceptors, upon arrival of each student class or cohort to clinical area and following the orientation to the hospital, gave students unit specific orientation highlighting the rules and expectation of the Clinical Rotation.
7) Clinical Preceptors: The Preceptors are unit-based clinical nurse experts who expressed their willingness to help students gain knowledge, skills and confidence prior to graduation. The Preceptors oriented assigned students to the wards at the beginning of the clinical rotation and gave students assignments based on patient needs, course objectives and learning outcomes; guided students to render patient care providing prompt feedback, thereby exposing the students to real life issues. In addition, the preceptors reported students’ and/or logistic issues to the Lead Preceptors and served as role models for the students while creating an atmosphere conductive for learning.
8) Continuing Education (CE) Staff: The Continuing Education Staff participated in the Policy and Procedure Manual Revision and Update. In addition, the CE Staff oriented other clinical staffs that were not preceptors to the Revised Procedure Manual, coordinated planned in-service education for nurses and reported to the Head of Nursing Services. The CE Staff conducted the hospital-wide orientation to student cohorts upon arrival to the hospital for a clinical rotation.
4. Data Collection
In order to evaluate the effectiveness of the preceptor-training project, permission was sort and obtained from the research and ethics committee of the institution while the preceptors and students gave written consent to participate.
Method used to select the preceptor and student participants was purposive sampling based on their availability in the clinical areas. Inclusion criteria were participation in the pilot training workshops, serving as a preceptor or a student assigned a preceptor for up to four (4) weeks, worked on the ward during the clinical posting, and on duty during the data collection period; as well as willingness to participate in the study. Of the twenty-two (N = 22) clinical preceptors in the pilot preceptorship training program, seven (N = 7), one each from the seven (7) pilot wards (Orthopedic, Male Surgical, Male Oncology, Female Medical, Male Medical, Pediatric Surgical, and Female Surgical) were selected. In addition, twenty-one (N = 21) students, seven (7) each from the three (3) sets of students (year 1, year 2 and year 3) on clinical posting to the wards during the period of study were selected. Exclusion criteria were unwillingness to participate, not being on duty during the evaluation period and/or redeployment to the clinics.
The first point of data collection was a silent observation of the activities of the preceptors and students on the seven (7) wards designated as “exam wards”. The observation involved looking at three points of variables from the preceptor, the student and the organization. These observations include the Preceptors’ knowledge/skills transfer, commitment to the roles as well as recognition by the institution’s nursing services. Students’ variables include attendance, interest, willingness and accuracy in skills performance, while the Institution’s variable includes availability of instruments and equipment for student teaching.
Second point of data collection involved unstructured face-to-face and telephone interview of seven (7) clinical preceptors and twenty one (21) students at various levels in the nursing program (junior, intermediate and senior); to gather information about the clinical learning and challenges facing them. Responses were transcribed and grouped into themes. The data presentation below reflected the frequencies and percentages.
Tables
Validation of Preceptor knowledge, and skills transfer
Given the number of preceptors (N = 7) who participated in the evaluation of the pilot training program, validation of their knowledge and skills transfer were by observation of their interactions with the students. During impromptu checks and at the time under review, five (71.1%) of the preceptors were observed supervising and engaging with students. In addition, students reported these same preceptors as engaging, supportive and committed to their roles of promoting students learning (Tables 1-7).
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Table 1. Nominal roll of students enrolled in SON UNTH by level/year in the program.
Table 1 showed the number of students enrolled in the school of nursing who participated in the pilot workshop.
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Table 2. Socio-demographic data of students.
Table 2 above shows that thirteen (62.0%) of the students representing majority were in the age range of 18 - 30 years; six (28.5%) were in the age range of 31 - 45 years while two (9.5%) representing the lowest minority were in the age range of 46 years and above. Seven each of the students 100% were in years 1, 2 and 3 respectively and 20 (95.2%) of them are females and one (4.8%) is male.
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Table 3. Socio-demographic data of preceptors.
Table 3 above showed that no preceptor was within the 18 - 30 years. One (14.23%) was in the age range of 31 - 45 years while six (85.8%) representing the majority, were in the age range of 46 years and above. One (14.3%) each of the preceptors were Senior Nursing Officer (SNO), Principal Nursing Officer (PNO) and Chief Nursing Officer (CNO) respectively, while majority four (57.1%) were Assistant Chief Nursing Officers (ACNOs).
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Table 4. Activities performed by students during clinical postings.
Table 4 above shows that majority of the students 18 (85.7%) responded that activities performed by them during clinical posting included “all procedures”. According to the respondents, they do what they are supposed to do such as assessment, checking of the vital signs, wound dressings, feeding of patients, serving of meals, administering all forms and routes of drugs, calculating fluid chart and bedpan rounds. One (4.8%) each identified other activities they performed to include accompanying patients to theatre, running errands for nurses and going to the Central Sterile Supplies Department (CSSD).
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Table 5. The activities engaged with the preceptors during students’ clinical posting.
Table 5 reported students’ perception of engagement with the preceptors during a typical clinical day. The report showed that majority of the students N = 15 (71.4%) indicated that the preceptors gave them assignments, and nine (42.9%) received formative constructive evaluation of their performance. In addition, 3 (14.3%) reported being guided to make case presentations while 12 (57.1%) were taught several procedures.
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Table 6. Opinion of students about preceptors knowing their role, skills and attitudes.
Table 6 reflected the views of the students when asked to comment on their perception of the preceptors knowing their roles, skills and attitude towards students based on their interaction. On their opinion and perception, majority of the student participants N = 14 (66.6%) stated that the preceptors demonstrate knowledge, skills and right attitudes while interacting with them. Twelve (57.1%) of students indicated that the preceptors demonstrated good attitude, while 11 (52.4%) indicated some of them lacked commitment, and six (28.6%) believed that they communicate poorly, in addition to nine (42.9%) stating that some preceptors failed to document their activities and/or session with the students. Furthermore, 12 (57.1%) are of the opinion that they do not attend meetings regularly to keep abreast of new information.
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Table 7. Opinion of the preceptors regarding the pilot program.
Table 7: On the opinion of the preceptors regarding this pilot preceptor program, all seven; one hundred percent agreed the program was good and fulfilling. Six (85.68%) further viewed the program as a welcome development that have helped them to read to keep abreast of new information which is helpful to students, preceptors and the profession. On formative evaluation of the students, only four (57.12) reported using the evaluation checklists at times to rate students’ performance, but concluding noticing improvement in the students’ performance. The preceptors reported the issue of lack of recognition by the institution’s nursing services as a challenge tied with short staffing, increased workload, frequent night duty-shifts and lack of resources such as materials and instruments.
5. Discussion
Socio-demographic data of the students showed that majority 13 (62%) of the students were in the age range of 18 - 30 years. This age is consistent with the requirement of completing secondary education before enrolling in a basic nursing program (NMCN, 2020). The preceptors selected for this training completed at least a BSN in a program approved by the NMCN as well as the Nigeria University Commission (NUC), passed the licensure exam, have practiced for a minimum of two years while continuing to meet the standard of nursing set up by the Council. Given the length of time to complete secondary education, basic nursing training and post basic BSN, practicing professional nurses considered knowledgeable and able to demonstrate skills and ability to render effective safe care without direct supervision are older. Majority (N = 6) or 85.8% of preceptor participants in the project aged 45 years and above.
The respondents’ gender indicated that 95.2% of the students and the entire preceptors (100%) were females. This female dominance in the study is because of the female dominance in nursing which is predominantly a female profession. This results from the fact that women by virtue are biological and physiological, nurturing, protective, loving, empathetic, patient and kind hearted, hence they engage in a nurturing and caring profession as nursing (Waugh, Ross, & Schipper, 2019).
On the activities performed by students during clinical posting, majority, N = 18 (85.7%) reported doing all procedures. Fifteen (71.4%) and 12 (57.1%) respectively said the preceptors gave them assignment and guided them to do or taught them to do procedures. These are consistent with Shiners & Franqueiro (2015) who stated that preceptors (facilitators) guide, teach and assess students and new nurses and give necessary feedbacks. The preceptors provided necessary guidelines to students for positive behavioural or attitudinal change necessary to promote academic, clinical and professional excellence. The preceptors also assessed students’ performance within and at the end of each clinical posting as part of their clinical continuous assessment, including all nursing care procedures. Although, literature is sparse regarding previous studies on activities of student nurses during clinical posting this result is in line with Amponsah et al. (2020) who posit that students are guided on activities like vital signs checking, bed making, serving of meals, report writing, intake and output monitoring among other activities which represent the nursing procedures carried out on patients. Procedures observed taught accurately by the preceptors include use of nursing process in patient care, taking vital signs, intravenous infusion, medication administration, oral, including insulin and other injections, wound dressing, collection of specimen, insertion and care of indwelling catheter, serving of therapeutic meals, documentation, writing and endorsing reports. According to the students, some Preceptors N = 9 (42.9%) however, had no documentation of their activities and/or sessions with students while many N = 12 (57.1%) did not attend meetings regularly and hence not abreast with briefing or new information.
When students engage in all procedures, it means the preceptors guide them through them and thus will enhance development of competence and independent practice by the students. In line with this, Baraz, Memarian, & Vanaki (2015) reported that students’ activities include routine jobs like medication administration and gastrointestinal feeding. Again, literature is sparse about the opinion of students about their preceptors in terms of knowing their roles, having the skill and their attitude. Majority (66.6%) of the students were of the opinion that their preceptors demonstrated the knowledge, and skills and right attitudes. This is consistent with Tracy & McGowan (2015) who reported that preceptors were prepared for the roles. When preceptors demonstrate the knowledge and skills, this indicates that they are prepared indeed for the work selected to do. Demonstrating the right attitude is very necessary for preceptors and students because it may affect students’ interest in being supervised with subsequent zeal to learn which may enhance growth, while the reverse may be the case if preceptors did not demonstrate the right attitude, which is simply a bad example for the students. Lack of commitment by some preceptors N = 11 (52.4%) however disagrees with Omer & Moola (2018) who reported that preceptors were committed and trained to teach and fulfil their roles. This contradicts Tracy & McGowan (2015) who reported that preceptors were prepared and demonstrated the right attitude toward their roles. Preceptor commitment to her roles promotes preceptor’s confidence and competence with resultant good practice and patients’ outcomes.
Students’ truancy rate reduced from 33% to 14%. Eighty-five (85%) of students performed well in procedures such as taking vital signs, and 71% in administering medication. Some students (14%) displayed lack of interest, resisted guidance or teaching and as such did not know their preceptors nor did they assume their postings. These student truants made up the missed clinical rotation days according to the established rules for clinical make-ups.
Challenges: Some of the challenges voiced by preceptors include heavy workload and frequent night shifts, which made it difficult for adequate student teaching, uncertainties and poor communication with the school staff in relation to student postings such as withdrawing students from the wards without notice just prior to start of clinical assessment. Again, the Joint Health Workers’ Union (JOHESU) strike action caused disruption to students’ rotation as no activities occurred during the period of strike action.
6. Conclusion
Providing quality educational experience encourages the students to apply theory to practice by immersing students into the professional role, which will result in knowledge and skills acquisition overtime, thereby enhancing professional growth. Students gain more confidence and competence in clinical practice when supported by preceptors (Phuma-Ngaiyaye, Mcur, & Chipeta, 2017) and thus achieve their learning outcomes. Workload of each individual preceptor may inhibit effectiveness of engagement with students and achievement of students’ clinical learning outcomes. This buttresses the need to train additional clinical preceptors, reduce and balance individual workload appropriately to prevent burnout. Preceptors need support of the ward managers as well as appropriate recognition of their contributions. Having clear policies and guidelines in place such as reducing frequency of the night shifts could lead to positive outcomes for both the preceptors and student nurses who will graduate with better clinical nursing skills. Communication is the backbone of the preceptorship model. Collaboration between training institutions and clinical settings is very important, because it improves nursing education, thereby ensuring achievement of learning outcomes. Poor synergy among faculty, clinical staff and students may militate against student nurses’ skills acquisition. Inconsistent exposure of students to the clinical learning environment through interruptions in the clinical postings can lead to increased dropout rates. Synergy between the school and clinical setting in order to facilitate a supportive positive clinical learning environment will contribute to students becoming professionals as well as enhance their professional survival. Sustaining this preceptorship program may consistently influence student performance and skills acquisition, which culminates into quality patient care. When patients receive quality care, they achieve their aim of accessing the hospital and are satisfied. Nursing may regain and maintain her glory when expert clinicians guide student nurses to become future competent professionals.
Limitations
The researchers encountered difficulties in the course of the study. It was a challenge getting all the chosen preceptors together for the interview due to frequent night shifts that kept them away from day shifts. Secondly, the Joint Health Workers’ Union (JOHESU) strike action interfered with the students’ posting duration. There might also be some bias in the responses recorded from the respondents. We recommend replicating the study using larger samples.