Preceptorship: An integrative review of the literature

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1 Nurse Education in Practice (2008) 8, Nurse Education in Practice Preceptorship: An integrative review of the literature Diane Billay *, Florence Myrick Faculty of Nursing, Clinical Sciences Building, University of Alberta, Edmonton, AB, Canada T6G-2G3 Accepted 25 September 2007 KEYWORDS Integrative review of the literature; Preceptorship; Research; Field setting Summary The preceptorship model is as an effective teaching and learning strategy most frequently employed to educate undergraduate and graduate students in the practice setting. The purpose of this article is to discuss the current state of knowledge in preceptorship by way of an integrative review of the literature using [Ganong, L.H Integrative reviews of nursing research. Research in Nursing & Health 10 (1), 1 11.] framework. The objectives of this article are threefold: (1) to discuss the evidence in the literature related to preceptorship, (2) to describe the framework used to conduct this integrative review [Ganong, L.H ], and (3) to present the results. Two questions guided this review: (1) how is preceptorship described in the allied health literature between 1994 and 2005, and (2) what new knowledge/information related to preceptorship has emerged in the literature between 1994 and 2005? Ten defining characteristics specific to preceptorship were used to guide the data search. These included such terms as attributes, characteristics, education, health, nurse, nurturing, preceptorship, preceptor, preceptors, and teaching and learning. The findings reveal a pervasive trend in professional education toward an emphasis on the role of preceptorship in preparing students for competent practice. c 2007 Elsevier Ltd. All rights reserved. An integrative review of the literature is a nonexperimental design in which information derived from primary research is systematically categorized (Ganong, 1987). To that end, past research is summarized and overall conclusions are drawn from many different studies that reflect the past * Corresponding author. Tel.: address: billayb@shaw.ca (D. Billay). and current state of knowledge pertaining to a particular subject (Cooper, 1989; Whitmore and Knafl, 2005). Integrative reviews have the potential build nursing science, informing research, practice, and policy initiatives (Whitmore and Knafl, 2005). This review is conducted to make a meaningful contribution to a body of knowledge, specifically, knowledge related to preceptorship. Such an approach is designed to inform rather than /$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi: /j.nepr

2 Preceptorship: An integrative review of the literature 259 overwhelm, to consider theory, and to ensure accurate, objective and thorough analysis of the subject. It is also designed to provide information about the studies reviewed and not to focus primarily on the results (Ganong, 1987). An integrative review represents a creative process used by researchers to help organize a body of knowledge and is conducted and reported as though it were primary research. To illustrate, the subjects are the studies examined, the methods are the reviewing procedures, the data are the elements of the studies, and the results are the conclusions drawn (Ganong, 1987). The purpose of this article, then, is to discuss the current state of knowledge in the area of preceptorship through the use of an integrative review of the literature. The specific objectives of this article are threefold: (1) to discuss the evidence in the literature related to preceptorship, (2) to describe the framework used to conduct this integrative review (Ganong, 1987), and (3) to present the results. These objectives will be achieved by way of a methodical analysis and presentation of past empirical and theoretical literature related specifically to preceptorship. Such a presentation, in turn, will provide a more comprehensive understanding of the phenomenon referred to as preceptorship (Broome, 1993; Whitmore and Knafl, 2005). Literature review An integrative review of the literature is important because it elucidates the term preceptorship and thus clarifies the concept for the discipline of nursing and other professional disciplines in which preceptorship is utilized. Such a review is also relevant for tool development and the advancement of knowledge regarding the preceptorship or practicum experience. A clear understanding of the concept of preceptorship is particularly important because of its prevailing usage within the practice professions, an understanding that can be strengthened by explicating the concept through such a process vis a vis an integrative review of the literature (Billay and Yonge, 2004; Kaviani and Stillwell, 2000; Morton-Cooper and Palmer, 1993; Nehls et al., 1997), In terms of a definition of preceptorship, Kaviani and Stillwell (2000) propose that it involves access to an experienced and competent role model and a means of building a supportive one-to-one teaching and learning relationship. This relationship tends to be short-term [and is aimed at] assisting the newly qualified...nursing student to adjust to the nursing role ( p. 219). Morton-Cooper and Palmer (1993) support this definition, as does Nehls et al. (1997). Others describe preceptorship as an intense, reality-based clinical rotation for a nursing student (Lockwood-Rayermann (2003)), thus indicating that a hands-on approach is used to socialize students to the role of the registered nurse. Further explicated, Chickerella and Lutz (1981) highlights important benefits the preceptorship experience has for students. These include: the nurturing and socializing of the student to the role of registered nurse; the opportunity for the student to discuss professional conflicts; a decrease in the theorypractice gap; and, student development of selfconfidence. Still others perceive preceptorship as an important means by which to promote student clinical competence (Letizia and Jennrich, 1998). In summary, then, the preceptorship model as an approach to the teaching and learning process within the context of the practice setting affords students the opportunity to develop self-confidence while increasing their competence as they become socialized into the profession of nursing. Within the preceptorship model the three participants the preceptor, the preceptee, and the faculty member each have responsibilities within the triad relationship. Specifically, the preceptor has a duty to role model and socialize the student to the role of the registered nurse, while maintaining ongoing communication with the faculty member. Similarly, the faculty is responsible for facilitating not only student learning, but also for supporting the teaching and learning activities of the preceptor. The student assumes the role of an active learner whose responsibility it is to become a safe, competent beginning nurse. Research questions Two primary questions guided this review: (1) how is preceptorship described in the allied health literature between 1994 and 2005, and (2) what new knowledge or information related to preceptorship has emerged in the literature between 1994 and 2005? Method Ganong s (1987) framework was used as the foundation for completing this study and includes 10 stages. It is worth noting there were six stages involved in the process as originally developed by

3 260 D. Billay, F. Myrick Ganong (1987), but were later expanded by Sparbel and Anderson (2000). These stages include the following: (1) formulation of the purpose and related research questions, (2) delineation of inclusion and exclusion criteria, (3) literature review (4) development of a data collection tool, (5) identification of rules of inference for data analysis and interpretation, (6) revision of the data collection tool as required, (7) reviewing the studies using the data collection tool for information gathering, (8) systematic analysis of the data, (9) discussion and interpretation of the data, and, (10) report the findings. Procedures Sample To address the first guiding question, English journal articles published between January 1994 and January 2005 were sampled. Inclusion criteria consisted of: (1) descriptive research articles including qualitative and quantitative designs, as well as theoretical articles; and, (2) articles retrieved by a computer search under the five broad key terms preceptorship, preceptors, preceptor, teaching and learning, and nursing. This process yielded a large volume of articles (N = 5311), which led the authors to sample every tenth article for evidence of current new themes and/or concepts evident within the preceptorship literature yielding a final sample of 313 (n = 313). Every tenth article was sampled to assist in data management of the overwhelming numbers of articles. To address the second guiding question, the inclusion criteria comprised English journal articles published between January 1994 and January 2005, and consisted of descriptive research articles, including qualitative and quantitative designs, as well as theoretical articles. In addition articles retrieved by a computer search guided by the aforementioned 10 key terms were included. For both guiding questions, inclusion of any one of the key terms in a title provided the impetus to scrutinize the article as a whole for reference to the concepts of preceptorship and characteristics of preceptors or pertinent defining attributes. This process also yielded a large volume of articles (N = 2102; n = 31), which led the authors again to sample every tenth article. For both guiding questions, unpublished books (with the exception of unpublished master s theses and doctoral dissertations), tapes or electronic media, and articles published outside the determined time frame, constituted the exclusion criteria. Search strategy The search strategy comprised the exploration of computerized periodicals (refer to Table 1) as well as grey databases (refer to Table 2). To address question one, all pertinent preceptorship literature was reviewed. In addition, starred (*) MeSH headings were used to identify preceptorship themes. Once all relevant articles were retrieved, the references were placed on an Excel spread sheet to better categorize and sort into themes. To address question two, computerized periodicals as well as grey databases were again searched. The ten aforementioned key terms were used to narrow the search field. A preceptorship data collection tool was designed with adaptations (Sparbel and Anderson, 2000) to gather the data. Items comprising the tool were derived from integral components of the research process that included the author, journal volume and number, date, title, etc. Content validity was corroborated via a literature review. Each article was thus reviewed for adherence to inclusion and exclusion criteria. Data recorded on the tool were examined for accuracy and completeness. The preceptorship data collection tool form was completed for each included article. Using a qualitative descriptive approach to synthesize research findings, common themes were noted. Descriptive statistics, aggregation of findings, and theme identification comprised the data analysis techniques. Table 1 Periodical databases searched All evidence based medicine Cumulative index for (EBM) reviews including nursing and allied health Cochrane literature (CINAHL) Educational resources information center (ERIC) HealthStar Education abstracts International pharmaceutical abstracts Education research abstracts Medline Canadian research index Dissertation abstracts PsychInfo EMBASE

4 Preceptorship: An integrative review of the literature 261 Table 2 Grey databases searched Campbell Conference collaboration papers index library OCLC world catalogue Findings and discussion Guiding question one OCLC proceedings first OCLC papers first NLM locators The research and theoretical articles comprising the sample (n = 313) reflect a wide spectrum of terms, themes and/or concepts related to preceptorship that include clinical competence, nursing education, curriculum, medical education, and pharmacy education (refer to Table 3). This finding, in turn, reflects a current trend in professional education toward an emphasis on the role of preceptorship in preparing students for competent practice. The disciplines of nursing (65 articles or 28%), medicine (40 articles or 12.8%), pharmacy (13 articles or 4.2%), and dentistry (seven articles or approximately 2%) are practice professions, which would account for the focus on clinical preceptorship and its emergence in the literature as being pertinent to these disciplines. Given the preponderance of preceptorship articles in the nursing literature (65 articles, 20.8%), it can be assumed with some confidence that preceptorship is valued as a legitimate model for professional preparation. Similarly, the emergence of 40 preceptorship articles (12.8%) in the medical literature would also imply its relevance to that profession as an approach to clinical teaching. Nursing and medicine s quest for knowledge regarding preceptorship would indicate a commitment to the importance of legitimizing preceptorship as an appropriate teaching learning model for student preparation and bridging the perceived theory-practice gap. Corlett et al. (2003), for example, conducted a factorial experimental design study to examine how the theory-practice gap could be narrowed. Specifically, this study was conducted to establish what combination of three factors would best promote the development of theoretical knowledge and practical skills (Corlett et al., 2003). The three factors under study included: Preceptor teaching, the process of collaboration between service and education, and sequencing of theory and practice (Corlett et al., 2003, p. 184). Of significance in this study was the finding that preceptors initially were better equipped in promoting theoretical knowledge related to their clinical area than were nurse teachers. By the time students had completed all clinical placements, however, those initially taught by a nurse teacher were found to possess knowledge and skills equal to those who had been taught by a preceptor (Corlett et al., 2003). A major recommendation emanating from this study is the need for partnership and collaboration between education and service providers. The greatest assets to student learning are a preceptor s knowledge and experience, while workloads, lack of time and adequate training all hinder the preceptorship experience (Coates and Gormley, 1997), thus impacting views about preceptorship. These findings are based on the results of a case study conducted following the introduction of the Preregistration Diploma of Higher Education in Nursing (Project 2000) course. The investigation involved a mixed method approach, with data being gathered through interviews and questionnaires. There were two objectives of this research. The first objective was to investigate preceptors views about their clinical teaching role with nursing students, with data being collected using a questionnaire. The second objective involved obtaining via interviews the opinions of nursing students, teachers and clinical managers regarding preceptorship. A convenience sample was used resulting in a study involving preceptors (n = 62), nursing students (n = 15), ward managers (n = 4), senior nurse managers (n = 2), and nurse teachers (n = 8). This case study research conducted by Coates and Gormley (1997) helps to explicate the benefits and the barriers experienced by all partners of the preceptorship relationship. What is interesting to note since this study was conducted, however, is that these same barriers still recur in present-day preceptorship experiences, which in turn poses several questions: what changes must occur within preceptorship to adequately address the barriers of lack of time and adequate training, and after these changes occur, what would this new preceptorship relationship/model look like? Just as the preceptor s knowledge is important to ensure the success of the preceptorship experience, so, too, are the educational strategies used by practice disciplines to ensure the clinical competence of the student. Traditionally, from the perspective of the medical discipline, clinical competence was ensured based upon specific sets of knowledge, attitudes, and skills used to accomplish tasks. Largely, these competencies were taught using didactic methods, such as lectures, discussions, and readings, as well as through clinical postings and the use of standardized patients (Brody et al., 2003).

5 262 D. Billay, F. Myrick Table 3 Results of guiding question one (N = 5,311; n = 313) Theme Results Nursing education Prominent theme in literature 65 (of 313 sampled articles) addressed nursing education Main journals published included: Nurse Educator (seven articles); Journal for Nurses in Staff Development (9 articles); Nurse Education Today (5 articles); Journal of Continuing Education in Nursing (5 articles) Key authors included: Myrick, F.; Yonge, O.; Trojan, D.; Haase, M.; Freiburger, O. A.; Krahn, H. Majority of articles (48 articles) were published after 2000 Teaching content: 22 articles related to curriculum Clinical competence Dental education Pharmacy education Medical education In conclusion 18 articles published Majority of articles were published in nursing journals (10 articles, 3.2%) Medicine, pharmacy and allied health each published one article Journals included: Nurse Educator (published 4 articles); Nursing Standard and Journal of Nursing Staff Development published two articles each The majority of articles (12 articles, 3.8%) were published after 2000, while the remaining articles were published between 1995 and 1997 Seven articles published: four published in 2004, three remaining articles published between 1996 and articles (4.2%) were written between 1994 and 2004, with the majority of the articles written after 2000 (10 articles, 3.2%) Three articles were written in 2003 and also in 2004 Comprised the next largest volume of articles 40 articles (12.8%) were published Journals publishing in this area included: Family Medicine (18 articles, 5.8%); Academic Medicine (nine articles, 2.9%); the Journal of General Internal Medicine (three articles, 1.0%) Majority of articles were published during two time periods: between 1996 and 1999 (15 articles, 4.8%) and between 2000 and 2004 (23 articles, 7.3%) In 2004 nine articles were published (2.9%), while 2003 saw six articles published (1.9%) This section has shown that the majority of published articles addressing the guiding question, where n = 313, speaks to in descending order nursing education (65 articles, 20.8%), medical education (40 articles, 12.8%), curriculum (22 articles, 7.0%), clinical competence (18 articles, 5.8%), pharmacy education (13 articles, 4.2%), and dental education (seven articles, 2.2%) The majority of articles were written between 2000 and 2005 (112 articles, 35.8%) However, if reinforcement of the classroom lessons did not occur, students would conclude the competencies learned were either not important nor they could not be practiced as described in the classroom setting (Brody et al., 2003). Revealing in this article was the belief held by third year medical students that the learning of medical competencies was a matter of practice, which they believed they could do on their own. Such a practice, in turn, however, could also foster continuous repetition of the same mistakes. This exemplar is not limited to the education of medical students. Rather, other practice professions, such as nursing, also experience this misconception held by students. To address similar beliefs held by third year medical students in an internal medicine clerkship, Brody et al. (2003) implemented a curriculum that would help students improve their ability to perform competently. This curriculum was designed to promote various practice-related tasks, such as knowledge, demonstration, feedback and reflection, in each of the following selected competencies. These included patient education, modification of maladaptive patient behaviours, involvement of patients in the decision-making process, counseling of patients with stress-related problems, promotion of costeffective decisions, prevention and resolution of inter-personal conflicts, and guidelines for understanding and responding to personal reactions when caring for patients. Subsequently, this innovative

6 Preceptorship: An integrative review of the literature 263 curriculum was found to improve student ability to perform competently. Within the medical discipline, literature also exists espousing the importance of preceptor teaching style has on medical students. One such study identified attitudes and approaches toward teaching and learning that distinguish preceptors who received high student ratings compared with those who received low student ratings. Through their qualitative study, Manyon et al. (2003) identified six attributes of high-scoring preceptors. These included learner participation in the practicum experience, monitoring of student progress during patient interaction including patient teaching and care, engaging of students in self-reflection, mentoring of students in discovering learning opportunities during patient contact, use of effective feedback to shape student performance, and the creation of a safe learning environment for students in which they can practice their new skills (Manyon et al., 2003). These findings also identified patterns related to differences in the instructional approach between preceptors rated high and low. Such patterns included: early and meaningful involvement, attentive listening to students, facilitation of patient learning opportunities, feedback impact on performance, encouragement of hands-on practice, and socialization of the student into the professional community (Manyon et al., 2003). These attributes and patterns were found to be significant in ensuring the success of the preceptorship experience. Similar findings regarding feedback (Anders, 2001; Yonge et al., 1997) and socialization of the nursing student into the professional role (Gray and Smith, 1999; Nesler et al., 2001; Reising, 2002) also emerged in the nursing literature. Just as the precepting activities of the nursing and medical disciplines emerged in this integrative review so, too, did precepting activities in clinical pharmacy emerge. Findings revealed 13 pharmacyrelated articles (4.2%) between 1994 and 2004, with the majority written after 2000 (10 articles or 3.2%). One notable article documented the research findings of the precepting activities of one full-time clinical pharmacist in a community-based family practice residency-training program. Specifically, Ables and Baughman (2002) documented over 2000 precepting encounters between February 1, 1999, and January 31, In summary, the importance of the findings of the first guiding question are many, but most significantly, they reflect the progression of the practice disciplines-nursing, medicine, pharmacy in their quest for new knowledge related to the teaching and learning relationship. Clearly, nursing and allied health scholars value the importance of clinical teaching to which this integrative review of the literature attests. Guiding question two To address the second question, each of the 21 items of the preceptorship data collection tool (adapted from Sparbel and Anderson, 2000) was examined for themes, relevancies, and availability of data. To that end, the literature search produced 2102 articles (N = 2102) resulting in a sample of 31 (n = 31). The preceptorship data collection tool proved an invaluable resource when collecting data, in that it ensured for logical and systematic data collection. Specifically, items from this tool include researcher(s), year of study, journal, focus, definitions, study purpose, conceptual model, research question/hypothesis, type of research design, instrument/tool use, validity and reliability, creditability and fittingness, study conclusions, and research recommendations/gaps (refer to Table 4). The data generated by the preceptorship data collection tool provided an interesting array of findings. To illustrate, of those researchers who published most frequently, either as single or coauthor, the majority were found to be in nursing. This finding illustrates the value that the nursing discipline places on knowledge related to teaching and learning in the practice environment. A large portion of the publications derived from Canada and the United States, followed closely by the United Kingdom and Australia, which would indicate a growing recognition by researchers in these countries about the importance of the preceptorship model of teaching. Of the 31 articles sampled, the predominant three groupings of terms focused on preceptor, preceptors, and preceptorship, with the remaining articles focusing on a combination of related terms. This finding would indicate an understanding and beginning consensus by researchers regarding the concept of preceptor and its related terminology. Only 45.2% (14) of the articles accessed, however, provided the reader with a specific definition of preceptorship, which would in turn indicate a greater consensus amongst researchers regarding a common understating of the concept itself. While the focus of the sampled articles was perhaps clearer than the definitions, the purpose of each article was to some extent less obvious. Therefore, a discussion of all the purposes of the combined articles is beyond the scope of this article. However, one commonality remains amongst all 31 articles: the use of action verbs. Stated differently, in all the sampled articles, the authors while reflecting markedly different purposes in

7 264 D. Billay, F. Myrick Table 4 Results of guiding question two (N = 2102; n = 31) Theme Results Researcher(s) Authors who published twice include: Öhrling and Hallberg; Krahn, Trojan, Reid, Haase The authors, who published four times, either as the single author or within a group, include Yonge and Myrick All publications occurred either in or after 2000 All the aforementioned researchers conducted nursing research related to preceptorship Year of study/ volume/ number Journals Focus Definitions Type of research design Instrument/ tool use Validity and reliability Creditability and fittingness Study conclusions Research recommendations/ gaps No articles were published between 1994 and 1996, nor were any published in 1999 Two articles were published in 1997 and again in 2004, for a total of four articles (12.9%) Three articles (9.7%) were published in 1998 Four articles (12.9%) were published in 2001 Five articles were published in 2000 and again in 2003 for a total of 10 articles (32.3%) Ten articles were published in 2002 (32.3%) Appearing twice included: Journal for Nurses in Staff Development, International Journal of Nursing Studies, and Journal of Advanced Nursing A journal that appeared three times was Medical Education A journal that appeared six times: Journal of Nursing Education A journal that appeared eight times: Nurse Education Today The 10 key terms searched included attributes, characteristics, education, health, nurse, nurturing, preceptorship, preceptor, preceptors, and teaching and learning Three groupings of terms focused on singular concepts such as preceptor (four articles, 12.9%), preceptorship (six articles, 19.4%), and preceptors (three articles, 9.7%) Remaining articles focused on: preceptors and behaviours; preceptors and preceptorship; preceptorship and preceptee; preceptor and teaching; preceptorship and clinical; preceptor and failure of the student; preceptorship and education; mentor and preceptor; preceptors and preceptee; preceptorship and stress; preceptor and critical thinking Less than half of the 31 articles (45.2%) supplied the reader with a definition related to preceptorship Supplied definitions included: preceptor and typology; preceptor; preceptor, mentor, evaluation research; mentoring and preceptorship; preceptors and preceptorship; preceptor, preceptee, mentor, concept analysis, educator, and preceptorship; theory and practice gap; learning environment and conflict; mentorship and preceptor; and mentoring A derivation of mentor was defined five times Nine (29.0%) studies used a qualitative design and eight (25.8%) used descriptive designs The majority (n = 11, 35.5%) of the designs were quantitative, while the rest of the designs included a mixed method (n = 2, 6.5%) approach The most common data collection techniques used were researcher-designed interviews and questionnaires (each n = 7, 22.6%) Eight (26%) researchers pilot tested their tools Eleven (35.5%) quantitative articles did not report validity, while six articles (19.4%) did 12 articles (38.7%) did not report reliability, while four articles (12.9%) did In only one Grounded Theory article (3.2%) was rigor addressed The entire sample discussed at length study conclusions, which should help future researchers determine future research questions and/or hypotheses Nine articles (29%) did not address gaps or provide any research recommendations 12 (38.7%) articles did provide some implications relative to the preceptorship experience Specifically addressed: support of the preceptor preceptee-faculty relationship is important; so too is preceptor orientation; and, recommendations specifically addressing the research process were made, such as increasing sample size and using valid and reliable tools. In addition, nine (29%) articles stated further research must be conducted in their particular area of preceptorship research

8 Preceptorship: An integrative review of the literature 265 most instances, tended to use action verbs to describe the purpose of each sample. For example, the most commonly used verbs were, in rank order, explored, examine, and determine indicating a desire on the part of the authors to gain knowledge about a phenomenon. To help a reader understand the purpose of a research project, it is important that the research questions and/or hypotheses be unambiguous. Interestingly, of the 31 articles sampled, 13 (42%) did not indicate a research question or hypothesis making it difficult for potential replication of the study vis a vis without explicit indication of the research questions and/or hypotheses. As well, because of this omission the validity and reliability of the study could also be in question. Moreover, if an important component of a research project fails to be reported, there may be some question as to the omission of other important aspects of the study. The quality of the data collection techniques used in a research project speaks to a study s validity and reliability as well. To illustrate, the majority of the data collection techniques in this sample of 31 articles were researcher-designed interviews, questionnaires and surveys. To a fault, none of the publications indicated specific data collection techniques addressing psychometric test results, thus leading the reader to ask if the tools used were indeed valid and reliable in gathering the necessary data? In addition to the methodological soundness, researchers also need to clearly stipulate the study limitations. To illustrate, of the sampled articles, 19 samples (62%) did not address real or potential limitations such as generalizability, representativeness, ethics approval process, sample size or power analysis. Of particular consideration in reviewing the various studies sampled, was the method of analysis used. Various research methods were and upon scrutiny appeared to be congruent with the question(s) posed. SPSS, factor analysis, descriptive statistics, non-parametric statistics, and ANOVA were sited as the choices for data analysis. Inn the qualitative studies reviewed, however, a specific research method was not always delineated. For example, researchers described the method as qualitative with no reference to the exact nature of that method other than its being qualitative in nature. To replicate a study the eager researcher reviews literature to determine the gaps and recommendations proffered regarding previous research studies. Such information is relevant in ascertaining how his/her current study might be designed. Of the 31 articles sampled in this review, however, while12 articles provided some research implications, nine (29%) did not address gaps or provide any research recommendations. Given the results of this integrative review of the literature related specifically to question two, it becomes discernible to the reader the degree to which the current state of preceptorship knowledge has grown and contributed substantially to the episteme of the nursing and allied health disciplines. It is accurate to state that research in the area of preceptorship has proliferated within the disciplines of nursing, medicine, and pharmacy in particular over the last decade. It is also interesting to note the quality of the various research studies and in some cases the need for more specificity regarding the research questions and hypotheses; ethical approval process; type of sample for both qualitative and quantitative designs; and, research recommendations and/or gaps. Implications for clinical practice This integrative review of the preceptorship literature demonstrates significant implications for clinical practice. Specifically, (1) clinical preceptorship remains a common teaching and learning method used by the practice professions of nursing, medicine, pharmacy and dentistry in teaching students, (2) the profession of nursing continues to use clinical preceptorship as the main teaching and learning method for socializing nursing students to the profession, (3) findings from this integrative review reveal the need for partnership and collaboration between education and service providers, (4) a major asset to student learning is the preceptor s knowledge and experience, (5) for a preceptorship model to succeed, a well developed and thoughtful curriculum is essential to accommodate clinical practice, (6) there are identifiable preceptor attitudes and approaches integral to successful student learning. These include: early and meaningful preceptor involvement, attentive listening, facilitation of learning opportunities, constructive performance feedback, and appropriate professional socialization. Limitations As with any method, limitations exist. The limitations inherent in this approach include: (1) lack of psychometric testing of the preceptorship data collection tool for use with this particular population, (2) a sampling of every tenth article might have contributed to an exclusion of key preceptorship articles, and thus increase the chance for sampling error, (3) key phrases used in published articles in

9 266 D. Billay, F. Myrick computer databases might have been inconsistently recorded, thus yielding unrepresentative samples, (4) author bias is always a potential limitation, and (5) time limitations may have also influenced the review process. Conclusion This integrative review of the literature provides an analysis of the current state of the literature in the area of preceptorship; identifies seminal researchers in the preceptorship field of inquiry; extrapolates key concepts and definitions related to preceptorship; and addresses the focus of key studies that emerged. The research designs, theoretical articles, and definitions of preceptorship reveal a variety of perspectives related to this model of teaching and learning in the practicum experience. Of the articles sampled, 75% address preceptorship within the context of the practice setting and its relation to teaching and learning. To date, research designs used to examine preceptorship include randomized control trials, grounded theory, phenomenology, and mixed method. An ethnographic study of preceptorship could lend an uncluttered view of preceptorship from a defined cultural perspective, which is that of health care professionals. As well, the use of a participatory action research (PAR) method to explore the preceptorship experience might also provide a different lens with which to view this method of teaching/learning. Specifically, PAR would enable the preceptorship participants namely the student, faculty, and preceptor the opportunity to fully engage in the research process. The authors recommend further research on preceptorship from an interprofessional perspective particularly within the helping professions vis a vis nursing, medicine, pharmacy, and dentistry. Such research would serve to further illuminate the nature of and the complexities inherent in this practicum/field experience and advance knowledge related to teaching/learning in the practice setting. References Ables, A.Z., Baughman, O.L., The clinical pharmacist as a preceptor in a family practice residency training program. Family Medicine 34 (9), Anders, R., Educational innovations. Feedback without fear. AORN Journal 74 (6), Billay, D.B., Yonge, O., Contributing to the theory developmentofpreceptorship. NurseEducationToday24(7), Brody, D.S., Ryan, K., Kuzman, M.A., Promoting the development of doctoring competencies in clinical settings. Family Medicine 36 (January Supplement), S105 S109. Broome, M.E., Integrative literature reviews for the development of concepts. In: Rodgers, B.l., Knafl, K.A. (Eds.), Concept Development in Nursing, second ed. W.B. Saunders Co., Philadelphia, PA. 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