Jim, a clinical nurse in the ICU, turns around and realizes that the new graduate he is precepting has rushed to hang an IV bag of a high-alert drug without checking drip calculations with him. Jim’s rapid intervention averts a serious outcome, turning a potential medication error into a “near miss.”

Sue is orienting a newly hired, experienced nurse to her L&D unit. While verifying the nurse’s competency to care for a high-risk diabetic mother in labor, Sue realizes the nurse has no experience with this type of patient and shows significant skill deficits. Working with her educator, her manager, and the new nurse, Sue sets goals and plans a more detailed and extended orientation to ensure that the nurse has the supervised experience needed before assuming the responsibility of an independent assignment. 

Jim and Sue are preceptors, nurses who have formally agreed to ensure an employee is oriented, or student educated, to the responsibilities and skills of a new position.¹ Preceptors are role models for professionalism and best practices in the clinical setting, socialize nurses into the work group, and educate and orient. These complex functions include assessing learning needs, planning learning experiences, instructing according to the plan, and evaluating how well the nurse is able to perform safely.²

Although the preceptor role has some components of mentoring, such as sharing knowledge and expertise, it’s a unique, intense relationship that may be an assigned responsibility and that usually lasts only during the orientation. The mentor relationship, in contrast, is a significant long-term partnership, and the mentor and mentee choose to be in the relationship.³

Preceptors are in demand in most health care settings, given the number of nurses in the U.S. and the turnover rates. About 3.06 million RNs were licensed in the U.S. in 2004.⁴ Of these, about 86,700 were newly licensed first-time candidates who passed the NCLEX exam.⁴ The turnover rate for all nurses is about 14.6%⁵ to 21.3%.⁶

Nurses who change positions, moving within an organization when switching specialties or entering a new facility, should receive a preceptor for orientation. Newly licensed graduate nurses, the second group requiring preceptors, have special needs during transition into practice, including an extended orientation. The need for preceptors increases when nursing students receive education in the facility through clinical experiences such as senior practicums. The demand for preceptors is particularly high in academic hospitals because of the volume of orientations and education.

Before the role of preceptor was formalized, each clinical facility had a unique way of orienting new personnel. Then in the 1970s and 1980s, advances in technology and treatment made care more complex. With the development of specialty units, a different type of orientation became necessary to ensure that newly hired nurses could safely manage patient care in complex environments. Preceptorship now includes educational programs, curriculum, and models to provide a framework for functioning in the role.^2,7,8 Since the 1980s, a consensus has emerged on the competencies that preceptors need.^9,10 (See “Preceptor competencies” sidebar.) 

The relationship between the new employee and the preceptor lasts about four to 20 weeks and can have significant benefits for the preceptee. Nurses describe the best preceptors as patient, kind, clinically astute, excellent communicators, and extraordinary role models who possess the qualities one aspires to as a developing professional. One nurse leader noted that a novice nurse learns by working with a “master” who artfully instructs the novice on how nursing practice changes with each patient and clinical situation, revealing the discipline of nursing to be “constant attention to difference and unpredictability.”¹¹ Nurse preceptors are called on to nurture and cultivate the development of another over time, a challenge in the current fast-paced health care environment.¹² Despite the challenges, many nurses become preceptors for the rewards of sharing expertise and knowledge, the personal growth gained from teaching others, and the satisfaction of seeing nurses develop professionally.¹³

Select the best

Finding sufficient clinical nurses who are patient and inspiring teachers and have the required competencies to be preceptors can be a challenge. Ideally, the preceptor should be motivated to support the newly hired nurse during orientation and be an expert clinician and a positive role model for the clinical service and the profession. Many institutions have rigorous criteria for selecting preceptors, including a requirement of three years of employment within the clinical service and the approval of the nurse manager. But as many institutions experience nursing shortages, less stringent criteria have become more commonplace. Some hospitals make serving as a preceptor part of nurses’ job descriptions, particularly if teaching is a part of the hospitals’ mission. Other settings just tell nurses they must be preceptors.¹⁴ One expert in nursing staff development believes that orientation needs to be viewed as an investment rather than a task to be performed by any available nurse.¹⁴ 

Today’s environment may challenge the ideal criteria in complex clinical staffing situations. In a crisis, nurses who thought they did not want to be preceptors may be called into service and then find the role surprisingly rewarding, performing with skill despite earlier reservations. Managers and educators face challenges in covering preceptor needs daily. The quality of a preceptor has a significant effect on a clinical setting, nurse performance, and retention. The selection process deserves careful examination to determine how the various elements affect the outcomes of nursing orientation, turnover, and patient care. However preceptors are selected, they should be further developed through educational programs that address the competencies needed to work with new employees.

The quality and safety of orientation can be maintained through the support of the clinical nurse educator. This staff development specialist, who functions under the ANA’s Standards for Professional Nurse Development,¹⁵ provides the educational and clinical expertise to oversee the precepting process, acting as a resource for both the preceptor and the newly hired nurse or student.¹⁶ While the role may vary from setting to setting, educators or staff development specialists keep preceptors up to date on all facets of their role to ensure a seamless orientation.

Learning the ropes

Many health care institutions have developed extensive programs to instruct and support preceptors. The programs usually include instruction on preceptor learning styles, conflict management, instructional techniques, critical thinking, and ways to manage and document performance issues. Through these programs, many seasoned nurses are able to change their thinking from “New nurses need to learn the hard way, like I did” to “I need to consider how to support their learning.”

One staff development expert has outlined a centralized program that includes preceptor selection criteria, an outline of expectations for the role, an ongoing staff development program to provide educational support, guidelines for staffing when precepting, ways to recognize preceptors, ongoing evaluations, and an oversight committee.¹⁷ One institution holds “preceptor action days,” a program to support and retain preceptors by providing training, teaching methods, role playing, and interactive sessions for sharing among preceptors.⁵

Many instructional methods are available for preceptor development, including classroom instruction, vendor-generated CDs, online programs,¹⁸ textbooks, and journal literature. Academic institutions may also provide education for preceptors as partnerships develop between programs of nursing and clinical facilities.¹⁹ Academic nurse educators have become increasingly involved in preceptor role functioning as health care institutions assume a more active role in supervising student clinical experiences.

When challenges occur

Sometimes special issues arise that require additional support and interventions to prevent preceptor burnout and dissatisfaction. Common ones include stress, difficult orientations and orientees, and the added responsibility for supporting a graduate nurse during orientation.

When preceptors feel their increased responsibilities are a burden, the new nurse orientees or students may be aware their preceptors are not pleased to be in the role and may feel anxious about the outcome. One survey revealed that 75% of the 295 nurse preceptors studied rated precepting as mildly to moderately stressful.²⁰ The most common sources of stress were perceptions of having added responsibilities and the increased time it took to be a preceptor while managing a heavy patient workload.²⁰ One way to reduce stress is to rotate preceptor assignments by providing a scheduled “vacation” from precepting to interrupt the stress, particularly when graduate nurses and nursing students are numerous on a unit. Another option is alternating types of assignments, such as giving the stressed preceptor a short student practicum assignment rather than a series of more intense graduate nurse resident orientations. In addition, the preceptor should meet periodically with the nurse educator/manager to share concerns and develop strategies to reduce stress, which in turn will help health care institutions retain high-performing preceptors.

The role of the preceptor becomes particularly challenging when the orientation of a new nurse does not proceed as expected. The problem may relate to preceptor-orientee incompatibility, a gap between the résumé of an experienced nurse and his or her actual knowledge and skills, or language or cultural issues.²¹ In the case of incompatibility, another preceptor may be assigned. If an experienced nurse enters a care setting with skill deficits, an education plan may be developed and knowledge and skill gaps remediated by extending orientation.

New employees have responsibilities during orientation, as well. They need to ask questions, be willing to learn how things are done in the new organization, and be open to feedback.⁸ The preceptor, the educator, and the manager become partners, working with the orientee as a team to resolve problems so that regardless of the outcome, patient safety is maintained. Graduate nurses require a significant commitment from the preceptor in both time and development. These entry-level nurses — advanced beginners — require substantial education and support until they become competent nurses.²² Many programs have been developed to improve their orientation through the use of preceptors, internships, support groups, and, recently, residency programs.^23-25 Research indicates that graduate nurses do not feel confident and competent until nine to 12 months posthire, reinforcing the need for extended orientations and support after orientation.²⁶

Nursing is complex and cannot be learned in a brief orientation. A preceptor’s patience, support, and guidance are essential for graduate nurse development or the result will be costly: high nurse turnover.²⁷ Keeping the same preceptor and orientee together is important to a successful orientation since graduate nurses become less confident with inconsistent leadership in the initial stages of orientation.^26,28 Shortening orientation or placing the graduate nurse in demanding clinical situations prematurely may compromise patient safety and undermine the nurse’s confidence and competence.

After a graduate nurse’s orientation, the preceptor often becomes a formal or informal coach during the period when the graduate nurse feels the need for continued support to manage a full assignment. Graduate nurses’ job satisfaction is correlated with a sense of belonging gained through relationships developed in the clinical service.²⁹ Preceptors who continue relationships with graduate nurses can build on this sense of belonging and integration into the team over time.

Celebrating good work

Supporting preceptors is critical to sustaining the participation of these valued employees. Recognition and support can be created in many ways, from establishing networking opportunities to providing monetary incentives. Hospitals with units using many preceptors can establish unit education or preceptor councils, a forum where preceptors can participate in decision making on orientation and education issues. A preceptor newsletter or hospitalwide group meetings can encourage networking. Some institutions include a “preceptor fair” in these meetings, with updates, skill stations, or speakers.

Recognition also can include events to honor preceptors, such as awards at Nurses Week celebrations; pins; certificates; or names on unit plaques. Some hospitals provide fiscal incentives such as credits toward continuing education courses or tuition reimbursement. Others provide additional pay for hours worked as a preceptor. Academic institutions may contribute to clinical agency preceptor rewards, such as tuition reimbursement toward a master’s degree and credits toward continuing education courses. The importance of recognition for preceptors cannot be overestimated.

Why are preceptors so important?

Most preceptors perform conscientiously, focusing on the immediate shift functions without realizing the larger impact of their work. But the stakes are high for each preceptor, the health care institution, and the nursing profession. Preceptors must be aware of the influence their performance may have on their organization. Turnover represents a significant cost for health care institutions, reported to range from $10,098 to $64,000 per nurse.³⁰ This can add up to millions of dollars annually per organization. Turnover costs include the direct expenses of advertising, recruiting, temporary labor, and time for the hiring process. Indirect costs may include low morale, constant orientation and training, instability caused by the use of contract labor, and the time needed to precept new employees. Patient safety may also be compromised with the increased use of contract labor. The cost of preceptor development is minor compared to the cost of unit instability and turnover. In addition, how preceptors interact and support student RNs can be a significant force for recruitment. In this cycle of critical nurse shortages, which includes a high number of pending retirements,³¹ student nurses represent a key pipeline for recruitment.

A preceptor checklist

All preceptors touch other nurses’ lives in unique and lasting ways through how they interact with new nurses, teach specialized skills, and role model professionalism. Preceptors must ask themselves —

• Do I introduce new employees to other hospital staff and physicians so they feel welcomed?
• Am I modeling the best practices?
• Do I search for the evidence and stimulate the new nurse to question practice?
• Do I guide the new nurse or student to look up standards, policies, and procedures?
• Do I stimulate critical thinking by asking questions about what is happening to the patient rather than telling the preceptee?
• Do I ask preceptees to differentiate care priorities and outline what should happen next, or do I just tell them what to do?
• Do I help new graduate nurses practice how to handle difficult situations, or do I just tell them how to do it?
• Do I welcome the experienced nurse by validating competencies during orientation in a way that demonstrates how glad I am that the nurse joined my team?

Precepting is a gift of self to another, a commitment to share that is part of the timeless tradition of nursing. Preceptors have an ability to take the newest nurses, “diamonds in the rough,” and go beyond teaching them the ropes to help them discover their self-identity and confidence to deliver outstanding patient care. Preceptors can teach independence, pride, and professionalism under a variety of conditions, always maintaining sensitivity to cultural diversity within the team and with patients. Preceptors, by their power and leadership, can create a caring environment in which nurses can grow and thrive, contributing to that next generation of professional excellence.