Nurse Education in Practice

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1 Nurse Education in Practice 10 (2010) Contents lists available at ScienceDirect Nurse Education in Practice journal homepage: Preceptorship and practical wisdom: A process of engaging in authentic nursing practice Florence Myrick *, Olive Yonge, Diane Billay University of Alberta, Edmonton, Alberta, Canada T6G-2G3 article info summary Article history: Accepted 20 March 2009 Keywords: Preceptorship Practical wisdom Authentic nursing practice Preceptorship is a teaching/learning approach, in which learners are individually assigned to staff nurses in the practice setting. Practical wisdom is a discerning process of evaluating and applying ideals or principles often in a moral context. The nurse who is practically wise recognizes that actions are always constrained to some extent by chance or context and yet precisely under such circumstances, acts to preserve and enhance the wellbeing of the patient. The purpose of this study was to examine the process used in the preceptorship experience to nurture practical wisdom. A grounded theory study was conducted with fourth year undergraduate nursing students and their preceptors in an acute/tertiary care setting. Data collection comprised a series of semi-structured interviews, documentation of field notes and journaling. Findings reveal that preceptors who nurture practical wisdom in the practice setting do so by engaging in a process of authentic nursing practice. Ó 2009 Elsevier Ltd. All rights reserved. Preceptorship and practical wisdom A process of engaging in authentic nursing practice In nursing education preceptorship is designed to ensure that learners acquire experience on a one-to-one basis with role models and resource persons who are immediately available to them as they carry out their practice (Kaviani and Stillwell, 2000; Ohrling and Hallberg, 2000a,b; Myrick and Yonge, 2005). Intrinsic to this experience is learning about the complexity of a profession in a dynamic health system. In higher education, the learning environment encompasses the practice setting in which preceptorship is most often the teaching/learning approach of choice. Preceptorship offers socialization into the profession or work culture, patient care-oriented learning, and a cost-effective approach to educational programs. Undergraduate nursing students are taught by preceptors who provide them with the opportunity to learn through role modeling and questioning, who create a climate for learning and impart knowledge or a way of knowing about nursing. We contend that central to the student experience is the fostering of practical wisdom. The objectives of this study were to: (a) explore the process that nurtures practical wisdom in the preceptorship experience; (b) examine how practical wisdom is manifested in the preceptor student relationship; and (c) generate data that would contribute * Corresponding author. Tel.: addresses: flo.myrick@ualberta.ca (F. Myrick), Olive.myrick@ualberta.ca (O. Yonge), dianew@ualberta.ca (D. Billay). to an understanding of practical wisdom within the contextual reality of preceptorship. Significance of the study In nursing, there is a need to begin to nurture an approach to practice that entails but is not limited to critical thinking. In two recent studies (Myrick, 2002; Myrick and Yonge, 2004) it became apparent that while critical thinking is pivotal to effective problem solving/decision-making, responsible action and competent practice require a discernment that encompasses but is not limited to critical thinking. Indeed, the pervasive emphasis on the discourse of critical thinking is in danger of lapsing into a form of moral escapism wherein all we (professionals) are rationally responsible for is thinking correctly (Phelan, 2001, p. 41). Practical wisdom is a discerning and ongoing interpretive process of evaluating the means and the ends and applying ideals or principles that emerge as they occur in the context of the action itself, (Gadamer, 2002 [1960]). It is the practically wise nurse who recognizes that actions are always constrained to some extent by chance/context and yet under such circumstances acts to preserve the wellbeing of the patient (Statler and Roos, 2005, p. 5). Nursing practice requires the making of deliberate choices/actions that display the most effective and appropriate responses under challenging circumstances (Flaming, 2001; Gillespie, 1996; Lauder, 1994). We contend that practical wisdom is intrinsic to ethical, safe, competent nursing practice. In preceptorship, nursing students are thrust into the everyday realities of nursing practice where they begin to internalize the values of the nursing profession /$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi: /j.nepr

2 F. Myrick et al. / Nurse Education in Practice 10 (2010) And, as research has shown, it is often their preceptors who have the greatest influence on those values (Myrick and Yonge, 2005). For this reason preceptorship provides an excellent vehicle for nurturing practical wisdom. Because of its widespread use, therefore, it is important to examine preceptorship empirically to determine its appropriateness for nurturing practical wisdom. Through such scrutiny educators can: (a) ensure the quality of education to which learners are entitled; and (b) graduate nurses who act to preserve and enhance the wellbeing of their patients. Purpose of the study The purpose of this study was to explore the process used by preceptors to nurture practical wisdom and to develop an understanding of its relevance within the contextual reality of preceptorship. Literature review: state of knowledge Numerous studies have been conducted to examine the role of preceptorship in nursing education. The socialization of learners into the profession was of considerable interest when preceptorship was first introduced to nursing education and continues as a source of inspiration to many researchers (Estey and Ferguson, 1985; Dobbs, 1988; Brasler, 1993; Goldenberg and Iwasiw, 1993). Others have focused on the impact of preceptorship on clinical performance and student competence. These studies have rendered interesting, although disparate results ranging from no difference to some difference in student nurse performance (Myrick and Awrey, 1988; Scheetz, 1989; Laschinger and McMaster, 1992; Yonge and Trojan, 1992; Brasler, 1993; Ridley et al., 1995). Recent studies reveal that preceptor behaviors such as compatibility, role modeling, and feedback contribute significantly to student learning and to the ultimate success/failure of the preceptorship experience (Coates and Gormley, 1997; Myrick and Yonge, 2001). More recently, researchers have examined the evaluation of preceptorship (Hsieh and Knowles, 1990; Kaviani and Stillwell, 2000), and conducted studies on the preceptors lived experience (Ohrling and Hallberg, 2000a,b). Others have explored preceptorship and moral reasoning (Andersen, 1991), preceptor role perception (Stevenson et al., 1995; Yonge et al., 1997), and the promotion/ enhancement of undergraduate and graduate critical thinking (Myrick, 2002; Myrick and Yonge, 2004). While others have explored the student nurse, nurse clinician relationship and its impact on student learning (Vallant and Neville, 2006), researchers are now examining the role of online learning in preceptorship (Phillips, 2006; Myrick and Caplan, 2009). To date, it is evident that little research has been conducted to explore the process that nurtures practical wisdom in the practice setting. In 1999, Litchfield completed two sequential studies in which she used the term practice wisdom as opposed to practical wisdom to refer to the process of reflexivity within nursing practice. In the first study she explored how practice might be and how she might articulate it. The praxis framework emanating from the initial study then enabled her to identify in the second study the values of vision and community through a nursing lens. As a result of these studies, Litchfield (1999) proffers an understanding of practice wisdom as a reflexive process in which health is an expanding consciousness. In the same year, Woods (1999) conducted a study derived from the premise that there lies within nursing practice a rich and profound thread of reflective interpretation and practical wisdom that is fundamental to the experiences of every nurse. This study revealed that the value of appropriate moral decision-making is essential to good nursing care. Such research can promote a clearer understanding of the moral voice of a nursing ethic and support the moral responsiveness of the profession in an ethically complex health care system. An earlier survey study was conducted with public health nurses, health professionals and paraprofessionals to examine practical wisdom related to strategies that encourage participation in care, education, and behavioral change (Peoples-Sheps et al., 1989). While the term practical wisdom is used in the title of the research, nowhere in the actual study is there any indication as to exactly how the researchers perceive practical wisdom. It can be gleaned from the nature of the study and the subsequent findings that the term practical wisdom is utilized to refer to the practicality of participant decisions and approaches regarding prenatal care and home visits. In reviewing the current state of knowledge regarding preceptorship and practical wisdom, clearly there has been no research study conducted to date to ascertain any link between the two. Owing to its widespread application as an approach to teaching in the practice setting and the fact that nursing students are expected to be able to reflect the competencies required of safe practitioners, it is of particular significance that preceptorship be examined to determine if, in fact, it is nurturing practical wisdom in the practice setting and is not simply a modern day version of the apprenticeship model (Andersen, 1991, p. 17). Assumptions It is the assumption of the researchers that practical wisdom is pivotal to safe, competent, nursing practice. Without it, nurses run the risk of behaving in a task oriented objectivistic manner. Inherently, practical wisdom is required of those disciplines concerned directly with human interaction and in particular human intervention. It is especially salient in professions that routinely require responses to individuals and aggregates at their most vulnerable. Through practical wisdom professionals can respond to such vulnerability in a competent manner thereby preserving the wellbeing of others. Practical wisdom is grounded not only in the theoretical but in the actual doing good for the other, in this case it is reflected in the nurse s actions to preserve the patient s best interests, or as Lauder aptly states: Practical wisdom is a form of knowledge that can be claimed by those who purport to deal with human good. Unlike theoretical knowledge, practical wisdom ends not in an intellectual conclusion but in the actual performing of some action designed to produce good for fellow humans (Lauder, 1994, p. 91). Research questions The research questions that guided this particular study were: (1) What is the process used to nurture practical wisdom in the preceptorship experience?; (2) How do preceptors and preceptees perceive practical wisdom and the process that is entailed therein?; (3) How is the preceptorship experience shaped to nurture of practical wisdom? Research design Owing to the lack of research in the area of preceptorship and practical wisdom, a grounded theory approach was considered the most appropriate method for this study. It allowed the researchers to deal directly with what was actually going on in the preceptorship experience regarding the nurturing of practical wisdom rather than what ought to have been going on (Glaser, 1992). The grounded theory method tells it like it is (Glaser, 1978, p. 14). The purpose of this study was to develop an under-

3 84 F. Myrick et al. / Nurse Education in Practice 10 (2010) standing of the process used in the preceptorship experience to nurture practical wisdom. Data collection Prior to commencing the study, the researchers sought permission from the Dean of the Faculty of Nursing, and the clinical agencies in which the preceptorship took place. Ethical approval was sought and granted from the appropriate Ethics Review Committee. Data collection comprised semi-structured interviews, field notes and journaling. Prior to the interviews, demographic data were obtained from all participants. Forty-one interviews of min were conducted with 22 participants including 10 students and 12 preceptors. Twenty participants were interviewed twice and one participant once. Interviews were conducted in accordance with emergent data saturation. During the interactions, an interview guide/framework was used and contained open ended questions some of which included, Tell me about your role as preceptor/preceptee. How would you (preceptor) describe the process you use when guiding the preceptee to care for patients? or How would you (preceptee) describe the process your preceptor uses when guiding you to care for patients? What do you (preceptor/preceptee) think is meant by the term practical wisdom? These questions were a beginning guide only and were revised as data emerged. Documentation of field notes augmented data collection and represented what the researchers were actually thinking, observing, and experiencing throughout data collection thus contributing to accurate interpretation of the data (Field and Morse, 1985). Journaling was integral to the study because it was in the process of recording personal experiences that the researchers came to recognize the influence of any personal biases, feelings and reactions that might have been influencing the research findings. The act of journaling kept the researchers honest and true to the data. Data analysis The first level of analysis, open coding, commenced as soon as the data collection was undertaken. This immediate analysis of carefully examining and comparing each phrase or aspect of the data with other data allowed the researchers to be guided by the data and not be inclined to direct the data (Glaser, 1978; Glaser & Strauss, 1985). This process of open coding generated approximately 200 substantive codes or categories and their characteristics from indicators such as actual events, definitions, and meanings derived directly from the research data (Mullen, 1975). When the first level of analysis was exhausted, the second level, theoretical coding, commenced. This phase of the analysis involved the interfacing between substantive codes and the ordering of the data. The discovery process or the generation of the core variable derived significantly from the next level of analysis or selective coding. It was at this point in the analysis, that coding was restricted to only those categories that related directly to the core variable, which accounted for the process of nurturing practical wisdom in this preceptorship experience. Owing to the importance of rigor in the completion of this research endeavour, specific criteria were used against which the rigor of this study was gauged. These criteria included credibility, fittingness, auditability and confirmability (Guba and Lincoln, 1989). A variety of mechanisms were instituted to safeguard the rigor of this investigation. Findings and discussion The process identified as engaging in authentic nursing practice was revealed in this study as being intrinsic to the nurturing of practical wisdom in the preceptorship experience. This process was reflected in a form of practice in which the preceptor and/or student expressed discernment regarding their actions, actions consistent with a particular approach to care and a way of being human in the nurse patient encounter (Lonergan, 1972; Perry, 2004; Taylor, 1991). According to Taylor (1995), authenticity is described as being true to (oneself) and (one s) own particular way of being (p. 227). Engaging in authentic nursing practice was reflected in the preceptor or student s genuine commitment to the role of nurse, being true to that role, and in their persistence in promoting the wellbeing and enhancement of the patient, notwithstanding the particular context or circumstances. Engaging in authentic nursing practice as a process of nurturing practical wisdom was reflected on two levels: (a) the approach to patient care; and (b) the dynamic of the preceptor student interaction. Inherent in the approach to patient care were two ambient conditions that involved doing good in the moment/patient situation and being sensitive to the unspoken. Affirming the student role and realizing student potential were found to be intrinsic to the preceptor student interaction or dynamic. Approach to patient care Doing good in the moment Doing good in the moment involved an ethical and a moral approach to providing care, behaving in a compassionate and supportive manner and role modeling on the part of the preceptor. As described by one preceptor The patient is the goal. The end goal is to do the best we can for our patients and have positive outcomes. Another reflected, you have to practice morally and ethically. One preceptor stated: [We are] advocates for the patients...really we are all they have sometimes. The patient needs good nursing care and they need somebody to care for them. This patient is here at this time and this patient is more important than how I m feeling. Such statements inhere what Nortvedt (2004, p. 447) describes as altruistic emotion or the genuine personal human involvement in another person s situation a quality essential to good nursing care. Indeed, Nortvedt further suggests that such emotions are central to moral reasoning and moral behavior in nursing, reflected in this instance by these preceptors intentions to provide good nursing care. Role modeling was also key to doing good in the moment. The term role model implies a particular individual whose style, behavior, way of speaking, and thinking we would inevitably like to emulate (Myrick and Yonge, 2005, p. 34). When broached with students, the preceptor is the person with whom they expressed they would most like to identify professionally. In this study role modeling was found to be key to nurturing student propensity for practical wisdom. For example, one preceptor described how she role modeled in this way: She s following me around and she s learning from what I m doing, and I m talking to her the entire time, telling her why we do it this way...if you do it this you ll never have this happen, but if you don t, this is a possibility, and you don t want that to happen. A preceptee stated, Just by watching her [preceptor], what she does and asking her questions on why she did what she did. Another preceptee stated, Taking in a lot of what the preceptor is saying, and listening to her experience and what she says.

4 F. Myrick et al. / Nurse Education in Practice 10 (2010) Or, as one preceptee described, Watching her perform different activities and things and taking that back with me and applying it when I go out on my own. How preceptors carry out their nursing care, assess patient situations, and arrive at particular decisions, all serve to influence the preceptee s behavior in similar situations. Moreover, the preceptor becomes the role model for the kind of behavior and care that the preceptee will ultimately emulate (Myrick and Yonge, 2005). Being sensitive to the unspoken This aspect of the process was reflected in the ambient conditions described as reading between the lines, being intuitive and availing of common sense. When describing her perception of practical wisdom, for example, one preceptor indicated: There is a lot of reading between the lines. Reading the facial expression of your patient or the student or the surgeon. You re reading body language... sensing...the personality and atmosphere. Another preceptor reflected, There s a lot of being intuitive involved in practical wisdom. One of the preceptees intimated, You gain a deeper understanding of the process and the patient s experience and your experience. According to Banonis (1995), the human experience is complex, creative, and uniquely personal in meaning (p. 88). The ability on the part of the preceptor and student to be able to be sensitive to the unspoken reflected an honoring of the patient as an individual who possessed his/her own meaning beyond the obvious or the spoken word. Common sense emerged also as being important to engaging in authentic nursing practice. As stated by one preceptor, With nursing you have a knowledge base that supports your common sense. Another preceptor reflected, It s what we re teaching. By the way that we re being, how we do things, why we do things. Thus common sense was manifested as a shared knowledge intrinsic to the role of the nurse, a knowledge that contributed to the preceptor s ability to be able to nurture student discernment and engage in authentic practice. The preceptor s ability to be able to share her/his knowledge so that the preceptee developed a better understanding of the patient situation rested not only on how the preceptor responded verbally to the patient but also was projected in the manner in which the preceptor displayed sensitivity to the patient on different levels. Being sensitive to the unspoken, for example or reading between the lines when the patient expressed him/herself was integral to the process of authentic engagement. In observing the preceptor being sensitive, caring and compassionate in providing nursing care, students witnessed practical wisdom firsthand. The preceptor student interaction or dynamic Inherent in this aspect of the process were two ambient conditions that included affirming the student role and realizing student potential. Affirming the student role In affirming the student role, the preceptors consistently displayed willingness to: facilitate the learning experience; provide support; establish trust; encourage professional development; instill confidence; and foster mutual respect. One preceptor described the following, I try to imagine what it would be like to be a student...i think it s a little overwhelming to just go into a work setting and expect that everything s going to go fine...that s a bit stressful. Or, as another reflected, I provide the right environment for [the student] to be able to grow and get out of the experience what it is they need to get out of it. In encouraging student development, one preceptor clarified it this way, Giving a greater sense of self-confidence is nurturing so they can stand up for themselves and advocate for their patients...taking them from a state of being a little unsure or not really competent to a greater competency and greater confidence. Being facilitative of student learning was found to be pivotal in affirming the student role. One preceptor stated, If there s an educational opportunity she comes with me. We have palliative rounds on Fridays, for example. She comes. She s not expected to hang out with the paperwork. Fostering mutual respect was also found to be important. One preceptor explained, I say right away if my style of teaching is not good for you, you need to tell me so that we can hook you up with somebody else because this is supposed to be your learning experience. Another preceptor described, I don t want them to be afraid of being there, or being afraid of me because that will impede their learning, and they won t get anything out of it. Yet another stated, We should be empowering each other...and we should be proud to be who we are. A supportive learning environment is one in which preceptees are validated by their preceptors as being an important part of the health care team (Myrick and Yonge, 2005). Part of that validation also derives from a compatibility that exits between preceptor and student and how well they interact with one another throughout the preceptorship experience. The (preceptor) has first of all to reveal, to take away the veil covering many students intellectual life, and help them see that their own life experiences, their own insights and convictions, their own intuitions and formulations are worth serious attention (Nouwen, 1966, p. 61). Realizing student potential Key to the process also was the preceptors ability to be able to realize student potential and included in that process was the preceptors predilection for promoting student autonomy or being willing to let go. For example, one preceptor explained it in the following way: And then as time progresses you can let them do things on their own. And they love that because it s sort of a solo flight. It means that they ve accomplished something. And that s the nice thing when you see them take off and do well. I think you have to come with lots of patience...and I think you have to be willing to let them do things and just guide them where you can and where there are things to be guided and let them find their own way. Another preceptor stated, As their confidence and their skill increases you can give them greater challenges and a sense of accomplishment.

5 86 F. Myrick et al. / Nurse Education in Practice 10 (2010) One preceptor explained, Taking the initiative, like rather than me just giving directions and directives, I see it as I need to give that student an opportunity to take the initiative, take responsibility, and not just be my shadow. And one preceptor described, I think they have to learn that they re in control of the environment and that they have to be proactive for themselves. The exception: the negative case The examination of negative or deviant cases challenges the researcher to develop fuller understanding at a higher level of abstraction of the phenomenon (Schreiber, 2001, p. 79). A negative case is one that refutes the emerging conceptualization and forces the researchers to explain or account for the fullest range of data. In this study, a negative case was revealed in the nature of one student s experience from two perspectives: (1) the fact that she was assigned to two preceptors and not one preceptor, an assignment from which ensued an unsettling experience, and; (2) the quality of care that she observed being provided by the nursing staff. As a consequence of being assigned to two preceptors, this student was routinely challenged by preceptor inconsistency in their individual approaches to her learning, an experience that proved to be particularly disquieting for her in the context of her practicum. She described the experience in the following way, One s (preceptor) approach was very much a holistic kind, not too excited about details or doing things at a specific time, or things like that. And the other was extremely detail-oriented and very procedure focused. And they both had a lot of strengths. But it was very hard to be a student with each of them because the one would say, oh well you didn t know that? And the other would say, well, why are you doing that...one nurtured my confidence...the other preceptor seemed to entirely lack confidence in me...so I was left confused as to what it was about me. I m glad its (preceptorship experience) over. This same student expressed a sense of dissonance throughout the preceptorship experience related to the way staff on the unit provided care, a manner contrary to the use of practical wisdom, in other words, a lack of engaging in authentic nursing practice. As she stated, I find the nursing staff doesn t always take a stand on everyday ethics. They just seem to continue on with their job without question. So although it may not be behaviour that I want to do in practice, I m still learning how not to be, I guess. Upon further exploration with her, she expressed a disconnect or dissonance between the way in which she had come to understand nursing, as being a process of engaging in practice that would sometimes involve taking a stand ethically and morally, and what she was actually observing while on the unit for her practicum. She also intimated that she would, unlike the nurses she was observing, take such an ethical and moral stand under similar circumstances. In other words, she would engage in authentic nursing practice. The preceptorship experience for her, however, was proving to be both a challenge and a revelation in this regard. In the grounded theory method it is important for the researchers to recognize evidence of differences in the findings. In this instance, such findings revealed to us that something about this particular student s preceptorship experience was different from the others thus forcing us to scrutinize the data more closely. This process subsequently contributed to the density and variation of our findings (Strauss and Corbin, 1998). On close examination of the data we found that this particular student learned how not to be both as a nurse and as a preceptor. Limitations Although mechanisms were instituted to ensure for the rigor of this study, limitations may still exist. In particular, reliance on interviews as the primary data source potentially may have resulted in serious constraints to data generated. Secondly, personal bias on the part of the researchers and participants is always an overriding factor. Conclusion The findings from this study can contribute to informing the way we prepare students throughout the preceptorship experience. Not only is it important for nurse educators and preceptors to focus on critical thinking, but it is equally important to focus on nurturing practical wisdom by engaging in authentic nursing practice. Through this process we can graduate nurses who will have had the opportunity to engage in promoting and enhancing the well being of patients regardless of the circumstance or context into which they are thrust. Future research is recommended in this area to further augment the findings of this study and to continue to elucidate the process required in preceptorship to nurture practical wisdom and to foster authentic nursing practice. Acknowledgement This research project was funded by a research grant from the Social Sciences and Humanities Research Council of Canada (SSHRC). References Andersen, S.L., Does student preceptorship affect moral reasoning? Nurse Educator 16 (3), Banonis, B.C., Metaphors in the practice of the human becoming theory. In: Parse, R.R. (Ed.), Illuminations. The Human Becoming Theory in Practice and Research. 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