The knowledge and skills of pre-registration masters’ and diploma qualified nurses: A preceptor perspective

Article Outline

• Abstract
• Introduction
• Method
• Findings
• Discussion
  • Limitations
• Conclusions
• Acknowledgements
• Appendix. Topic Guide
• References
• Copyright

Abstract 

The role of nurse preceptor in the UK functions to support and nurture newly qualified staff during transition to accountable practitioners. Transition is a stressful time for all new staff, whether diplomates or graduates. Preceptors are in a prime position to assess the competence and confidence of new staff, and observe their fitness for practice. Studies show variable evidence concerning the benefit to practice of nurses with degree compared to diploma education. This exploratory study investigated preceptors’ perceptions of differences in the knowledge and skills displayed by staff from a three-year Diploma programme (DNs), and four-year pre-registration Master in Nursing degree (MNs), run by one School of Nursing.

In the first months DNs were said to exhibit more confidence in practical skills while MNs showed academic and analytic skills. Although DNs related well to patients, MNs were better able to communicate with professional colleagues. By six months MNs overtook DNs in their overall confidence. Preceptors valued both DNs and MNs for the skill mix they brought to nursing and the benefit of patient care. Further exploration of preceptors’ views would inform education staff and advise preceptors and managers regarding newly qualified nurses.

Keywords: Fitness for practice, Nurse education, Degree, Diploma, Pre-registration Master’s level

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Introduction 

The recent decision in the UK to move towards an all graduate nursing profession by 2015 has support from both professional and political bodies (Girot, 2000, NMC, 2008). The decision follows extensive debate following the introduction of Project 2000 (UKCC, 1986) and a range of other nurse education programmes: advanced diploma; degree; and options to upgrade to degrees as students progress. Despite the enthusiasm for an all degree profession, there is limited evidence to indicate that the development will achieve its task of ‘driving up the quality of care’ (DH, 2008) with a positive impact on qualified practice and improved patient outcomes.

Most staff enter their first nursing post immediately after qualification. The ‘transition’ from student to practitioner is potentially challenging for nurses from all types of educational programme, and has historically been shown to be a stressful experience (O’Shea and Kelly, 2007). The Nursing and Midwifery Council, the UK regulatory body, recommended good practice is to assign new nurses to an experienced nurse, a preceptor, to be a role model and share clinical expertise (McCarty and Higgins, 2003, NMC, 2006), thereby building clinical confidence. Though studies examine the experience of newly qualified nurses, few take account of this experience through the eyes of preceptors. This qualitative study examined the preceptors’ perceptions of the knowledge and skills of pre-registration Master (MN) and Diploma (DN) nurses in two NHS Trusts after six months nursing post-qualification. The students had undertaken their studies within one Higher Education institution in the East Midlands. This project is part of a larger investigation of DN and MN career progression over 5 yrs which is nearing completion.

Preceptors being well placed to compare and contrast the abilities and aptitudes of nurses during this critical stage provide the rationale for this study. Moreover, preceptors’ views and consequent dealings with nurses might serve to exaggerate or suppress any competitive advantage evident between MNs and DNs.

The study was conducted involving students from the only Master’s level pre-registration nurse training course in the UK at that time. The Master’s course was an ‘undergraduate’ not a post-graduate course as students did not have a Bachelor level degree already, but we refer to it in this paper as a pre-registration Master’s programme to avoid confusion. This type of pre-registration Master’s education is not evident internationally and with a relatively small number of programmes now available nationally, there are no studies reporting on pre-registration Masters’ courses. Therefore in the literature review we make the assumption that this group is similar to the undergraduate Bachelor nursing groups as entry requirements and educational characteristics are similar.

Table 1 provides information about the Master’s and diploma courses to show how these groups are initially prepared and their educational backgrounds and experience. This provides some context on which to evaluate the comparisons and differences reported in the findings.

Table 1. Description of pre-registration master’s and diploma in Nursing courses.

Studies that compare experiences and career progression of diploma and degree qualified nurses cast doubt about any differences between them in terms of nursing competence. Clinton et al. (2005) found no significant difference using a Nursing Competence Questionnaire. Similarly, Robinson et al. (2003) found little impact of course type upon perceived competencies. In contrast, Bartlett et al. (2000) suggest that graduates overcome any initial limitations, and become more competent than diplomates. Likewise for Swindells and Willmott (2003) degrees provide improved cognitive and reflective abilities and professional practice, education purchasers report enhanced leadership, assertiveness, reflective and critical skills (Burke and Harris, 2000) and patient care and survival may also be affected (Aiken et al., 2003). While et al. (1998) in a triangulation design showed degree compared to diploma students as more systematic in seeking information, better at care planning and had higher quality nurse performance.

Preceptorship is not unique to the UK (Bain, 1996), the generic features of the role internationally being linking theory to practice, encouraging team membership and enabling consolidation of skills to build clinical confidence. In North America preceptors are usually defined as unit-based nurses who carry out one-to-one teaching of new employees or nursing students, in addition to their regular duties (Shamian and Inhaber, 1985). In Australia, preceptorship is regarded as a key component of the graduate nurse programmes that comprise a transitional year following the three-year generic nursing degree (Hayman-White et al., 2007). This study employs the definition of preceptors as those involved with newly qualified nurses during their transition from student to registered nurse rather than those involved with students during their education programme, or staff in new posts.

Terms coined to express the changes that occur around transition include reality shock (Kramer, 1974), development of the professional self (Bjorkstrom et al., 2008) and self-concept (Cowin and Hengstberger-Sims, 2006). The stresses affecting transition include individual accountability, risk of making errors and management issues such as prioritising (Gerrish, 2000). Lack of support for newly qualified nurses is linked to high turnover (Suzuki et al., 2008) while retention is predicted by development of graduate self-concept (Cowin and Hengstberger-Sims, 2006). Nurses experience a less stressful transition when buoyed up by preceptors’ support as they adapt to responsibilities and expectations, gain confidence in clinical judgement and acclimatize to being accountable practitioners (Gerrish, 2000). Preceptorship time is recommended (Maben & Macleod Clark, 1998), and following the outcome of its consultation on pre-registration nurse education, the NMC (2008) recommended a mandatory period of preceptorship and in the new framework of pre-registration education (NMC, 2009) preceptorship was included as one of eight confirmed principles to support.

Turner (2007) suggests that qualities brought by the best preceptors include: a desire for the role and sharing in nurses’ development; good communication skills and clinical expertise; self-reflection; a sense of humour; ability to critically evaluate; and provide appropriate feedback with a caring supportive attitude. Attributes of preceptors show a significant link to role performance (Yoshitomi et al., 2008). However preceptors’ ability to engage in this partnership can be confounded by shifts and workload.

The partnership between preceptor and preceptee provides the preceptor with insight into strengths, weaknesses and individual development in clinical practice. Preceptors are therefore ideally placed to evaluate the similarities and differences between nurses from different educational backgrounds. Literature comparing diploma and degree qualified nurses from the preceptors’ perspective is sparse. McNiesh (2007) describes how preceptors interpret new graduate nurses’ clinical judgement in the specific circumstances of labour and Carlisle et al. (1999) outline nurse managers’ views of skills competency of diplomates. The research reported below seeks to rectify this omission by exploring, in terms of practice-related knowledge and skills, the perceptions of preceptors responsible for supporting nurses entering the workforce. The aim of the study was:

To explore preceptors’ perceptions of the knowledge and skills of newly qualified pre-registration diploma and pre-registration Master’s trained nurses.

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Method 

A semi-structured topic guide, informed by the literature on the attributes of graduate and diploma qualified nurses (While et al., 1998, Bartlett et al., 2000, Burke and Harris, 2000, Aiken et al., 2003, Robinson et al., 2003, Swindells and Willmott, 2003, Clinton et al., 2005) and our previous study (Park et al., 2007), was piloted (with three lecturer-practitioners) and used with minor modifications. Open-ended questions allowed preceptors to describe experiences and gave flexibility for exploration of topics, use of prompts, and requests for illustrative examples. Following an introductory section relating to the preceptor’s role interviewees described, in turn, their expectations of DNs’ and MNs’ nursing practice. Thirteen issues were then addressed separately (Appendix).

Approval was obtained from the Local Research Ethics Committee and Trust Research and Development departments. Senior staff being approached for names of suitable preceptors, was supplemented by the snowball method, as insufficient interviewees were available. Preceptors were sent information sheets and requested to sign consent forms prior to the private tape-recorded interviews, which were conducted in the workplace.

Ten preceptors were interviewed (three adult (A, B, C), three child (E, F, H) and four mental health branch (D, G, I, J)). Four preceptors had certificate level; three diploma, including one with a subsequent degree, and three degree level academic qualifications. Eight had been qualified for 10+ yrs with seven in the preceptor role for 4+ yrs. All interviewees had preceptored both DNs and MNs who had similar experiences of practice and training environments (Table 1). Recorded interviews were transcribed and analysed using NVivo v2.0.

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Findings 

Preceptors, bar one, enjoyed their role, it enabled new nurses to integrate and avoid future problems. Recalling their own difficulties preceptors wanted to improve the experience for their preceptees.

When preceptors were asked, in general, about their expectations of DN and MN nurses’ nursing practice (Topic guide a, b), half reported no differences, others were less sure.

‘You tend to forget what people did, they are just another nurse, just a colleague. It doesn’t matter what they did, they just have to get on and do their job.’ (A)

Describing particular aspects of nursing (Topic Guide c) some preceptors initially indicated no difference but on further reflection described subtle or small variations. When systematic differences were not apparent, preceptors usually ascribed variations to individual characteristics rather than training.

Where differences were identified these were attributed to first, the wider recruitment pool for DNs, many were older with more life experience, possibly care work or study. Second were course characteristics: duration (3/4 yr), placement lengths, academic nature of the Master’s and, although there is actually no difference, total time in placements.

‘There are little differences, subtle differences, and again it is hard to work out if it is the training they’ve been through or it’s about the recruitment pool that they’ve come from’ (I)

Preceptors’ perceptions of difference between the DN and MN nurses are reported in Table 2. Some of the emergent themes match the topic guide, other themes however emerged from the data. Also indicated are areas of greater unanimity.

Table 2. Themes and quotations from preceptor interviews.

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Discussion 

Preceptors valued the variation in the quality of nursing practice a mix of backgrounds contributed. They disagreed about whether the DN or MNs were indistinguishable or differed in particular aspects of professional performance. Certainly, the majority of preceptors agreed with the findings of Clinton et al. (2005) and Robinson et al. (2003) that differences in the competence of DN and MN nurses were not readily apparent. Bartlett suggested that over the first 6–9 months of employment graduate nurses become more competent than diplomates. Gerrish (2000) described nurses’ competence increasing alongside their confidence under the tutorage of preceptors. Preceptors unanimously agreed that MNs confidence ((3) – refers to Table 2, theme 3) if not their competence (4), around 6 months, exceeded that of DNs. The MNs confidence was attributed to their work being underpinned by greater academic knowledge (2).

There is considerable agreement in the literature that nurses demonstrate substantial development during the early transition period of their careers. Preceptors mostly felt that DNs fitted into their nursing role earlier than MNs, relating and interacting well (1) and being sensitive to patients’ needs. This perhaps equates to While et al.’s (1998) description of DNs having a ‘professional focus’. In comparison preceptors regarded MN’s as more holistic (5) having a view of the patient within an academic perspective, alert to changes in their condition (6), (as in While’s term a ‘client focus’ While et al, 1998) with strengths in care planning, information seeking, clinical performance and time management (13). Preceptors thought MNs confidence was demonstrated in clear and concise effective communication with senior practitioners (9). MNs also showed greater enthusiasm (8) and willingness to volunteer perhaps buoyed by their academic skills. In Carlisle’s study (Carlisle et al., 1999) DNs showed practical skills below expectations of nurse managers, which compares with this study where MNs initial weaker practical skills improved (11).

Explanations for MNs becoming more practical and less theoretical during transition (12) are various: this is necessary to accommodate practical nursing; MNs become less inquisitive because they lack time or are expected to follow ward practice without question; acceptance of the status quo is more acceptable; preceptors contribute to nurses’ ‘dumbing down’ to fit in; established staff may not have a degree or be trained in evidence based practice therefore MNs are inhibited about questioning their practice. We have previously reported some degree nurses feeling that colleagues were threatened by their qualification (Park et al., 2007). Considerable evidence suggests that the qualities of higher education are valued in practice (Swindells and Willmott, 2003). It is perhaps appropriate to speculate that as new employees MNs first conform while gaining the respect of colleagues and over time are able to make greater use of their academic abilities. These ambiguities could contribute towards the stress experienced during transition as nurses develop a professional self. In this study the preceptors would only rarely have qualified via a different route to their preceptees. With the move to all graduate nursing, and for some time afterwards, newly qualified graduate nurses will be preceptored by diploma qualified nurses (Robinson and Griffiths, 2009). The forthcoming increase in graduate numbers will eventually enhance the proportion of preceptors and other role models with higher level critical and research skills able to influence ethos and nursing practice.

Preceptors echoed the opinion of Swindells and Willmott (2003) and Burke and Harris (2000) that degree level training adds value to nurses’ ability to practice with Master’s training being beneficial. Both tiers of training increase nurses’ cognitive ability, assertiveness, critical and reflective skills (14). Preceptors considered MNs typically adopted a questioning academic approach (10), and applied their knowledge to generate a level of understanding passed on when in supervisory roles (17). MNs’ research skills helped ground their practice on a secure evidence base (7). Nurse managers value DNs research skills and ability to question (Carlisle et al.’s, 1999), qualities described here as typifying MNs more than DNs (12). Career ambition and enthusiasm (15,16) also characterised MNs alongside the ability to write well (9), although sometimes slowly.

Limitations 

The small size of this exploratory study is a limitation. It is worth noting that it was difficult to find enough preceptors with appropriate MN supervisory experience to interview. The study relied on the preceptors’ ability to be reflective, a quality together with enthusiasm ascribed by Turner (2007) to the best preceptors, and is limited by preceptors’ recall of their preceptees. Preceptors found difficulty supporting their assertions and interpretations with specific examples. To avoid findings being criticised as being based on preceptors’ preconceived ideas, a future study could interview preceptors about current preceptees, thereby improving recall of specific examples. As preceptors, most with considerable experience, interviewees are likely to be objective although their own routes to qualification may have caused some bias. As one preceptor remarked of MNs, ‘Quite obviously people aren’t going to put a dampener on their kind of training’. Nevertheless, despite these difficulties and the need to address them in future research, the findings merit attention and further enquiry. The topic guide was seen as an effective tool for further exploratory investigations.

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Conclusions 

The aim of this study was to explore preceptor’s perceptions of the knowledge and skills of newly qualified nurses who had undertaken study at differing academic levels. The driving factor here was the belief that providing differing approaches to the education of future nurses would provide different outcomes. However it appears that preceptors typically attribute nurses’ proficiency not to training but to individual characteristics and personality. The interviews demonstrate preceptors associate practical skills and a ‘common sense’ approach with DNs and academic and analytical skills with MNs. By 6 months MN generally overtook DNs in confidence due to their wider academic skills. DNs related well to patients whereas MNs were better able to communicate with senior and inter-professional colleagues. Triangulation of data collected from a larger investigation nearing completion of DN and MN career progression over 5 yrs may help validate some of these assertions. The findings suggest that further exploration of preceptors’ views could be valuable in relation to curriculum design, preceptor training and in terms of targeted advice to mentors and managers employing newly qualified nurses.

‘It’s not about whether you have done a Master’s or a Diploma but it’s about the staff nurse that you become’ (G)

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Acknowledgements 

We are most grateful to all interviewees and the two NHS Trusts involved with this project.

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Appendix. Topic Guide 

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