Are newly qualified nurses adequately supported in their first year of practice?

Introduction

The transition from student nurse to qualified practitioner can be a time of stress and anxiety for newly qualified nurses, and it is reported that many feel unprepared, lacking confidence, and often reporting feelings of isolation and uncertainty, which can result in them leaving the profession due to ‘reality shock’ (Tracey and McGowan, 2015). Despite this, however, it is argued that with support, newly qualified nurses can become valued members of the profession (Whitehead, 2013), and consequently, a period of preceptorship is stipulated by the Nursing and Midwifery Council (NMC, 2015), to facilitate this transition.

Preceptorship

Preceptorship is a tool to facilitate the transition from student to qualified practitioner; it is a short-term relationship between a newly qualified and an experienced practitioner, where individual support is given to the preceptee to increase confidence, knowledge and clinical skills (Lewis and McGowan, 2015). A period of preceptorship also helps the development of clinical competence, professionalism and professional values (Phuma-Ngaiyaye and Chipeta, 2017). Although such benefits of preceptorship appear impressive, it is argued that in practice, formal processes of support are often lacking (Irwin,2018). This paper will discuss preceptorship, and any barriers to its implementation, to determine whether newly qualified nurses are adequately supported in their first year of practice.

Although it is suggested any support is better than none, a structured preceptorship period, underpinned by a supportive culture can help to prepare a highly skilled workforce (Whitehead et al., 2016). However, it is argued that although the benefits of providing support in the first year of qualified practice are well documented, in practice the preceptorship process varies greatly, with wide differences in the experiences of newly qualified practitioners (Tracey and McGowan, 2015).

International research suggests that retention, stress and burnout are associated with newly qualified nursing staff (Rush et al, 2014); additionally, newly qualified nurses are expected to practice independently, make autonomous decisions, respond to complex health challenges, provide leadership, delegate and prioritise competing demands (NMC, 2015). Therefore, steps are required to support new registrants in the first year of practice to avoid the negative impacts that have been documented in literature.

It has been suggested that a structured support programme, with regular meetings between a preceptor and preceptee in the first year can benefit not only the preceptee, but also their patients, their employer and the nursing profession. Additionally, preceptorship meetings can reduce stress and issues of efficacy, improve retention and turnover, and in turn, avoid unnecessary costs to organisations as new nurses leave the profession. In contrast, it is also argued that newly qualified nurses cope well with the transition, and confidence and autonomy increases as their ability is demonstrated in their first year of practice with limited support (Hardacre and Hayes, 2016).

Preceptorship is often highly valued by newly qualified practitioners, and has been shown to reduce stress associated with the transition from student to qualified practitioner, and promote adaption to the new role (Marks-Maran et al, 2013). A study by Marks-Maran (2013) has echoed similar studies, suggesting that preceptorship helps to develop communication, clinical skills, and enhances professional development.

The role of preceptorship in nursing is to improve practitioners’ confidence and competence and support the provision of safe effective care (Department of Health, 2010). Additionally, preceptorship facilitates the development of knowledge and skills, resilience and compassion, and results in fewer errors and complaints (McInnes, 2015). It also helps the consolidation of verbal and written communication skills, self-confidence and professionalism (Shepard, 2014). Although it is argued that successful support for new registrants impacts positively on patient care and safety, it is also argued that evidence to confirm this is lacking (Lewis and McGowan, 2015). A period of preceptorship also helps to identify the strengths and weaknesses of newly qualified nurses and subsequently facilitates the identification of learning needs and formulation of learning plans, and ensures high standards of care are being demonstrated (Lewis and McGowan, 2015).

Preceptors are usually experienced practitioners tasked with educating and introducing new staff members to the clinical area, and it is reported that both preceptors and preceptees often report the preceptorship process to be both satisfying and rewarding (Ward and McColmb, 2017). The preceptor role facilitates the transition from novice to expert by role modelling and guiding newly qualified nurses, and therefore preceptors must demonstrate best practice, and effective decision-making skills (Panzavecchia and Pearce, 2014). However, it is argued that despite the expectation that experienced nurses will adopt the preceptor role, many are reluctant to do so as they report feeling ill-prepared and lacking confidence, and there is often confusion around the role (Sorrentino, 2013). Where confusion and trepidation exist, preceptees and preceptors often have differing expectations about the support available, and the outcomes that are to be achieved; all of which conflict with the intended outcomes of a positive preceptorship programme of support (Hardacre and Hayes, 2016). Additionally, despite the extensive responsibilities of the preceptor, it is argued that requirements to undertake this role are minimal, and it cannot be presumed that all registered nurses can act as preceptors (Panzavecchia and Pearce, 2014), and many may not possess adequate teaching skills that are required for this role (Henderson et al, 2015).

Many nurses are reluctant to adopt this role and are poorly prepared for it; in many cases there is a a lack of training for preceptors, despite literature stating that training should exist (Kamolo et al, 2017). Furthermore, preceptorship programmes lack formal standards, and there is an absence of best practice models to guide practitioners and organisations.

It is argued that support for newly registered nurses is often hindered by the lack of timely preparation and forward planning in allocating preceptors to preceptees in advance (Department of Health, 2010). Additionally, allocating a new registrant to an uninterested or indifferent preceptor could be harmful to new registrants (Price, 2014). Additionally, it is also argued that while the gold standard of support reflects structured support processes, programmes of support are often unpredictable and ad-hoc; they often lack conformity and standardisation (Lewis and McGowan, 2015).

Periods of preceptorship vary significantly across clinical areas, although Jones (2014) suggests support is at its most effective when it exceeds a four-month period. The availability of protected time for preceptors and preceptees is a considerable barrier to effective preceptorship (Wain, 2017), which is exacerbated by staffing challenges and heavy workloads affecting many nursing disciplines and settings, as well as preceptors and preceptees regularly not working the same shifts, with little recognition given to its importance (Tracey and McGowan, 2015; Ward and McColm, 2017).

Recommendations

It has been recommended by Francis (2013) as well as the Willis Commission (2012) that organisations should be working towards fostering cultures that support learning and candour, and which prioritises safe staffing levels. However, staffing challenges persist in the UK, resulting in a reluctance to support junior members of staff, and an absence of experienced practitioners available to support nursing graduates (Harrison-White and Simons, 2013).

The Flying Start Programme is a package of support for newly qualified nurses which has been embedded into UK healthcare organisations for several years, comprising of online work packages (Education for Scotland, 2018). Despite this being a commitment by NHS England to support newly qualified nurses, evaluations have indicated that staffing shortages and work pressures, and varying levels of engagement have limited its effectiveness. Additionally, it is argued that further government recognition is required to provide financial investment to support new practitioners and preceptors. The lack of financial support for preceptors to undertake the role has been argued to be partly responsible for the lack of motivation by experienced nurses to take on this role (Harrison-White and Simons, 2013); however, it is also argued that teaching and role modelling is already an expectation under the NMC Code (2015).

Although preceptorship is recognised as a sustainable method to support the transition from novice to expert, and the benefits have been well documented, preceptorship is still not mandatory to help new nurses integrate into their new roles (Monaghan, 2015). This has led to organisations being selective of how they chose to implement it. Further difficulties arise from the lack of robust research data that confirms its value across a wide variety of healthcare settings (Monaghan, 2015).

Conclusion

National policy and research evidence suggests that a period of preceptorship support for newly qualified nurses in their first year of practice is beneficial in facilitating the transition from novice to expert; it enhances the development of clinical skills, communication and decision-making skills, and helps practitioners to feel supported, with fewer reported instances of anxiety and isolation (Irwin, 2018). However, despite the potential benefits of preceptorship, it is argued that there is inequitable delivery of preceptorship programmes, and inadequate preparation for preceptors taking on the role (Panzavecchia and Pearce, 2014). Additionally, there are a variety of barriers arising from poor staffing, inadequate resource provision which also suggests that provision of support can be limited. Therefore, while it is recognised in literature and policy that newly qualified nurses require support, there is a requirement for financial resource provision to ensure its implementation in practice. Furthermore, training and support for preceptors taking on this role is required to ensure new registrants feel supported, and to retain them in the profession.

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