Teaching roles in critical care - the mentor and preceptor

Helen Ellis

Mentorship and preceptorship have been terms used indiscriminately throughout the literature. The English National Board has used the term ‘mentor’ in all educational material and the term has slipped into current usage. Despite this, very little preparation and thought has been given to the role. Confusion has arisen as the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) Post Registration Education and Practice Project (PREPP 1990) proposals have outlined the need for a preceptor to support new practitioners to move confidently into a period of primary practice. This paper discusses the development of the mentor role and provides a definition of classical and formal mentoring. The preceptor role is viewed as one of the elements that enable the full development of mentorship. As a functional role, preceptorship can be clearly defined and utilised to support new staff into new areas of clinical practice. It crystallises the teaching, assessing and evaluative element of clinical nurse education and provides a firm foundation for the development of mentorship within the nursing profession.

INTRODUCTION

It is generally accepted that clinical practice and education for clinical practice should be closely linked. Yet there is discussion in the nursing literature regarding the theory-practice gap (Orton 1981; Ogier 1982; Alexander 1983). The closure of the theory-practice gap is directed towards ensuring that what is learned in both the classroom and the clinical setting corresponds,

Helen Ellis BSc, MSc, RGN, DipN, ENB 100, ENB 100 Course Teacher Lancashire College of Nursing and Health Studies, Preston Health Authority, Fulwood, Preston PR2 4DX, UK

(Requests for offprints to HE)

Manuscript accepted 21 April 1993

152

and that knowledge gained is validated through research. Up until the 1980s the role of the clinical teacher was developed to act as a step- ping stone between theory and practice. Not an easy role, it suffered from the conflicting demands of the service and educational sides of the health service. At the same time in the clinical setting there was a degree of support present in the wards from the senior staff. This support tended to be unstructured and varied tre- mendously in its process and goals. As the role of the clinical teacher shrank the teaching and educational role became focused on the ward sister.

The emphasis previously laid ul!ron the ward sister’s role in teaching is increasingly being delegated down to staff nurses of all grades through the development of mentor and pre-

INTENSlVEAND~;RITI<:AL<;ARENURSING 153

ceptor roles. The English National Board (1987)

recommended that each learner nurse should

have a mentor on each ward to support and

facilitate learning and the concept slipped into everyday use for student nurses and for nurses

on post-registration courses. The recom-

mendations of the Post Registration Education

and Practice Project (PREPP 1990) highlighted

the development of a ‘preceptor’ role for each

newly registered nurse or nurse in a new clinical

environment. Despite the increasing usage of

the terms there is confusion as to their de&

nitions and it has been argued that a description

of both the mentor and preceptor role will require clarification (Burnard 1990; Morle

1999). In the UK, the English National Board

has variously described a mentor for student

nurses as a ‘wise reliable counsellor’, an ‘experi-

enced, trusted advisor’ and as ‘supervisors, ass-

essors and if possible, mentors’!

MENTORSHIP

On examination of the mentor role, it appears

that there is little consensus as to what it is and

how it can be defined usefully (Merle 1990).

Historically, Mentor was the advisor of the

young Telemachus in Homer’s Odyssey and his role encompassed elements of guardianship,

tutoring and support. These roles have become

accepted elements of mentorship and in this

form mentorship has been used and developed

by many different people and professions. Nur-

ses in the UK have borrowed the concept from the US where it had earlier been adopted from

the economic business schools, where many

successful business people attributed their success in the world of business to the presence

of a mentor throughout their apprenticeship

and consequent life. A classic mentoring relationship develops and

grows between two individuals over a long period of time. Such relationships have lasted for 2-15 years and provided professional and emotional support for both individuals. Classic mentoring provides an informal link between two people who are willing to work with each

other and provide wise advice, with no financial

gain on either side (Palmer 1987). Various

subroles have been identified in a mentoring

relationship. They are those of ‘advisor’,

‘teacher’, ‘counsellor’, ‘guide and networker’,

‘role model’ and ‘sponsor’. The benefits gained

from such relationships are obviously attractive

and a more formal mentoring provision has

grown up within the nursing profession. In the

US the term ‘mentor’ was seized upon as a means

of reducing ‘reality shock’ (Kramer 1978) which

occurs when the values instilled in newly regis-

tered nurses by the school come into conflict with

the bureaucratic values of their workplace. This

was compounded by informal, ad hoc ori-

entation to the workplace which led to rapid staff

turnover, early burnout and a lack of pro-

fessional satisfaction at all levels of nursing (Shamian & Inhaber 1985).

In applying it to the world of nursing, the concept of mentorship requires a different defi-

nition as it is rare for a nurse to have one mentor

throughout her career. Formal mentoting has

created specific relationships which are related

to the education of nurses and to the develop-

ment of professional nurses within the

workplace. Increasingly programmes are

devised which outline specific purposes and

functions for the mentor and specific student

groups. Formal mentoring within nursing has

not taken into account the willingness of the

more able or ‘wise’ nurse to act as a mentor, and

in fact many students are assigned mentors with

little thought for the true nature of mentoring.

Inevitably these relationships are time-con-

strained and related to specific clinical scenarios

and outcomes. In fact it could be said that the

proposed role of formal mentor has more in common with the preceptor role.

PRECEPTORSHIP

Palmer (1987) breaks down a mentor role into three subsections. The first describes a personal element wherein the mentor encourages confi- dence, creativity, risk-taking and fulfilment of potential within the student. The second func-

154 INTENSIVE AND CRITICAL CARE NURSING

tional element deals with the practical issues of

teaching, instruction, support and advice-giving.

The third element supports the development of

an enabling relationship between the mentor

and student which encompasses interpersonal

skill development, networking and sponsorship.

By concentrating on the functional element

exclusively, the preceptor role emerges. In the US the term ‘nurse-preceptor’ is used to describe a unit-based nurse who carries out one-to-one

teaching of new employees or nursing students in addition to her regular unit duties (Shamian

and Inhaber 1985). It is related to the teaching

role within every nurses’ work wherein a skilled

practitioner helps a less skilled/experienced

practitioner to achieve professional abilities

appropriate to their role. The UKCC recommended the development

of a preceptor role in the Post Registration

Education and Practice Project (PREPP) propo-

sals. This role is considered to be one of ‘good

practice’ and they expect steps to be taken to

ensure that preceptorship is implemented from

1 April 1993 (Registrar’s Letter l/1993). All

newly registered nurses, midwives and health

visitors should be provided with a period of

support for approximately the first 4 months of their professional practice. Any practitioner

returning to practice after a break of 5 years or more should also receive support from a precep-

tor. Within the discipline of critical care nursing

preceptors could be supporting newly qualified staff, staff returning after a break in practice,

staff moving from another specialism and staff

changing jobs within the same specialism. It is

important to remember that all practitioners are accountable for their practice from the point of

registration onwards regardless of any support system.

Developing preceptors

Shamian & Inhaber (1985) reviewed the litera- ture in the US relating to the role of nurse preceptor. They identified the following func- tions for the nurse preceptor:

0 to orientate the new nurse to the unit

0 to function as a teacher and a role model

0 to plan a programme for the new nurse

0 to carry out an evaluation of the new

nurse’s progress

0 to socialise the new nurse to the philosophy

of the unit, to integrate into the team and to inform relevant personnel of progress.

The nurse preceptor role was seen to decrease as

the new staff member became more confident

and skilled in the role. The preceptor steps back

and acts more as a resource person. In the UK we hav usually called this men-

torship. What it has always been is preceptorship.

The above functions have generally been rel-

evant to critical care staff who act as what we have

referred to as ‘mentors’ to nurses on a post-regis-

tration course such as the English National

Board 100 (general intensive care nursing) course. On such a course the role is of short

duration, 2-6 weeks. Due to the intense nature

of such courses the nurse ‘mentor’ will not

become solely a resource person. All the above

functions are compressed into the short time-

scale. Such is the additional pressure of taking on

this role that many units utilise a team approach.

One course member may have two or three unit staff allocated to her. One will be recognised as

having the final responsibility for the support of

the course nurse, one will act as ‘mentor’ when

the first nurse is off duty or has to work night

duty, and the third may well be a fairly junior

unit member who is observing the role. The preceptor role outlined by the PREPP

proposals will relate to a longer period of time - 4-6 months. In many critical care units in-house

training programmes already exist. These pro-

grammes may be formalised with the appoint- ment of a sister with responsibility for new staff development, or be informal with a senior staff member overseeing and demonstrating particu- lar skills that any new nurse needs to know. The aim of the preceptor is to ensure that the new staff member functions effectively and effi- ciently as a team member. The emphasis may well be on training, rather than education, as a pragmatic approach is needed to develop quickly a staff member who can work alone without constant supervision.

Who can be a nurse preceptor?

Shamian 8c Inhaber (1985) summarise the attri-

butes of a nurse preceptor as:

0 a nurse who has years of experience l a nurse who demonstrates leadership skills

l a nurse with the ability to communicate

clearly and effectively l a nurse with decision-making abilities

0 a nurse with an interest in professional

growth.

The UKCC proposes that preceptors will be

first level practitioners who have had at least 12

months (or equivalent) experience within the

same or associated clinical field as the prac-

titioner requiring support (Registrar’s Letter

l/1993). Up until the present time, for post

registration course nurse support, staff have been required to hold the same certificate as the course leads to in order to act as mentorslprecep-

tors. However, many staff have not been able to

attend a specialist post-registration course in

critical care nursing, and it is now being recog-

nised that such staff with many years of experi-

ence can still act as mentors/preceptors. All are

encouraged to gain extra teaching qualifications such as the English National Board 998

(Teaching and Assessing) course certificate, but

the development of the preceptor role still

requires planned programmes. Shamian &

Inhaber (1985) recommend that nurse precep- tors should:

0

0 l

0

attend workshops in order to prepare for the role

have a role description

have ward-based manuals to explain the role and functions of the preceptor

receive some kind of reward for the role as

it requires preparation, practice and expertise.

The UKCC recommend specific preparation for the preceptor role. Recognising that many practitioners will already have acquired some, if not all, of the required skills a 2-day programme is all that should be required. Each preceptor

INTENSIVE AND CRITICAL CARE NURSING 155

have sufficient knowledge of the prac-

titioner’s programme leading to regis-

tration to identify current learning needs

help the practitioner to apply knowledge to practice

understand how practitioners integrate

into a new practice setting and assist with

this process understand and assist with problems in the

transition from pre-registration student to

registered and accountable practitioner

set, with the practitioner, objectives for

learning to assist with this transition.

(Registrar’s Letter l/1993).

Benefits of preceptorship

The development of the nurse preceptor role

within critical care could have benefits for both the identified preceptors and the unit as a whole.

For the individual nurse it could:

0 provide a way of teaching nursing care strategies and facilitate the development of personal and social skills

0 enable the clinical role of the staff nurse to be expanded through the addition of edu-

cational and training skills

0 enable personal reflection and a recogni- tion of further educational needs.

For the unit as a whole the roles could:

clarify the philosophies and values of the

unit staff

assist in personal development plans and

staff appraisal

encourage the development of an edu-

cational learning climate which encourages

all staff to progress and develop

lead to a higher standard of care which is both demonstrated and articulated by all staff.

Shamian & Inhaber (1985) argue that such roles can only improve the situation all round:

l the college of education wins as its students are better prepared

0 the hospitals may gain due to improved -_

will: staff retention and development

156 INTENSlVEANDCRITlCAL<:ARENURSIN(~

0

0

the nurse preceptor wins as he/she grows

professionally the new nurse wins as her adjustment to the

new unit is smooth and uncomplicated.

At the present time, there has been very little

research into these roles of mentor and precep-

tor in the UK. The UKCC requires the develop-

ment of the preceptor role and therefore it

would appear to be self-evident that the role is

beneficial and as such it will continue in all

clinical settings. Further study and investigation

is needed to examine the influence of both classic

mentoring and functional preceptorship within

nursing.

preceptor role for new staff may well be the foundation upon which future standards of

clinical practice will rest. Both ‘mentor’ and ‘preceptor’ terms will con-

tinue to be used throughout pre-registration and

post-registration practice. How these are

actually defined and used in practice will reflect

the curricular needs of individual Colleges of

Education and clinical settings. But however

mentorship and preceptorship are defined and utilised they are both useful, yet different, con-

cepts which should provide a range of support strategies and opportunities for all registered

nurses.

CONCLUSION References

Anecdotally, the development of the ‘mentor’

role has led to an extra burden being placed

upon the clinical staff. Staff shortages, rapid

throughput of patients and a numerous array of

changes having to be managed throughout the

health service are all combining to form extra

pressures upon the clinical work of the staff,

which is essentially the care of patients.

Although students and registered nurses on continuing education courses receive the bulk of

theory in the classroom, it has to be applied and

refined through practice. Nurse preceptors are

needed to facilitate this. For a new nurse

working in a critical care unit with its bewildering

array of technology and highly dependent patients, the preceptor role is essential to enable

rapid transition from novice to at least that of

competent nurse. The preceptor role for the

support of new staff members may well prove to be an effective tool for staff retention and development. The emphasis laid upon the clinical unit as a learning and developmental environment is a fixed one and staff will have to continue to juggle their roles. The development of the preceptor role for learners and the

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