A Proactive Approach to Orienting with a Preceptor

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This course expires on July 5, 2019.

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First Published: August 10, 2006

Revised: August 10, 2009
Revised: August 10, 2012

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Acknowledgements
[Link] acknowledges the valuable contributions of...

Bette Case Di Leonardi, PhD, RN-BC

Lindsey Ryan, MSN, RN, CCRN-K, ACNS-BC

Purpose and Objectives

The purpose of this course is to introduce the learner to key concepts for an effective
preceptor relationship. Methods to facilitate meaningful communication with a preceptor will
be discussed. Essential precursors necessary to develop sound clinical judgment will also be
provided.

After successful completion of this course, you will be able to:

1. Identify two ingredients that researchers have found to be important as precursors of
developing clinical judgment.
2. Describe two important behaviors that are key to the success of the preceptor-orientee
relationship.
3. Identify examples of ways to facilitate continuous asking and sharing in the preceptor-
orientee relationship.
4. Recognize conditions in a healthcare organization that support effective preceptorship.

Introduction
Effective preceptorship is absolutely critical to your success in your new environment –
whether you are a new graduate, a nurse returning to practice, or a nurse beginning
an assignment on a unit or specialty that is new to you.

Regardless of your previous experience, your relationship with your preceptor can greatly
facilitate your success:
• This does NOT mean that you will succeed only if you and your preceptor develop a
close personal relationship.

• It DOES mean that certain elements in your professional relationship need to be present
to facilitate a successful transition into your new role.

Get to Know Your Preceptor

As part of the orientation process you will be paired with at least one preceptor to assist you
in transitioning into your new role. Since you will be working closely together you will need to
know the expectations of your preceptor and establish a method of communication that works
for you both.

Ask your preceptor about their experience in transitioning onto the unit and any tips they have
to offer. Share your professional experience(s) with your preceptor and inquire about their
Material protected by copyright own experiences as well. If you have an experienced preceptor,
inquire about the characteristics of successful transitions to have a better understanding of
what it may take to become successful yourself.

Developing Clinical Judgment

From the moment you first connect with your preceptor an exchange begins that can lead to
a productive, effective professional relationship. This relationship plays a key role in helping
you develop and exercise critical thinking and clinical judgment in your new setting.

Studies of newly graduated nurses have shown that developing good clinical judgment and
critical thinking skills depend upon a sense of:
• Belonging with staff and patients
• Confidence in performing basic skills

(Benner, Hughes, & Sutphen, 2008)

Think About It
How can you develop a sense of confidence and belonging in your new environment?

Ask for Clarification

In your previous experience you may have used different terms for particular pieces of
equipment, procedures, or other important items. You will likely encounter new terms,
practices and behaviors in your new setting. Ask your preceptor for clarification, lear
communication is vital.

Your team wants you to succeed in delivering safe patient care. Take the initiative to ask
questions, this will help build trust between you and your colleagues.

Ask For Opportunities

Seek out opportunities for learning outside of your own patient assignment. Be alert
for situations, treatments, and procedures that you might observe.

Pay attention to the way colleagues other than your preceptor organize their assignments,
perform procedures, or other aspects of care. In many cases, you do not even need to ask –
just keep your eyes and ears open.

For example a conversation with your preceptor may sound like,

“I know I’m going to need to learn how to orient patients to the CPM (continuous passive
motion) machine. I know Charles will be setting it up with Mr. Mason in a few minutes. I’m
pretty much caught up and I’d like to watch him do it.”
Share your Self-Assessment
Share your own self-assessment of your progress. Let your preceptor know which
activities you feel comfortable and confident in performing and which activities you still
need some support.

For new graduates this skill may need to be developed with help from your preceptor.
Developing learning activities that are clearly defined, measurable and observable bring
greater awareness to the process (Buck, Wilkinson & Phillips, 2014).

For example, a conversation with your preceptor may sound like,

“We had a lot of central lines in the unit I worked on before, so I am very familiar with drawing
blood. I’m not sure how you do your dressing changes here though.”

Share Your Previous Experience

Share what you have done and what you do know. You may not have used a particular
piece of equipment, but you may have experience with something similar.

You are new to the unit, but you are not completely new to nursing. You have experience that
is relevant, even if you have done things in a different way or if you have had less
responsibility for certain aspects of care. You are not a blank slate.

Your preceptor can be more helpful to you when you indicate what you know about specific
nursing activities. If you are an experienced nurse who has had experience as a preceptor,
let your preceptor know about it. You may want to ask your preceptor to use some
techniques with you that you found effective when you were precepting.

“I did some precepting when I worked oncology. One thing that seemed to help the orientees
was 2 minutes of feedback from me at the end of every shift we worked together. Could we
try that?”

Share Your Perception of the Precepting Process

Share your own reaction to your preceptor’s help. Different people favor different ways of
learning. Let your preceptor know what is most helpful for you. For example, tell your
preceptor, “It really helped me when you talked me through that dressing change.”

Your learning style and previous experience may differ from other orientees your preceptor
has precepted in the past. What has worked well for others may not be helpful to you.

“I read the procedure and you gave me a great explanation, but I’m one of those people who
has to actually see it and touch it to get it right. I know Andy’s patient is getting blood this
morning – can I watch him go through the procedure?”

Prompt Your Preceptor to Ask and Share

If you are fortunate, your preceptor will have had preceptor training and experience
precepting. Such a preceptor will consistently ask and share in a way that helps you to feel
confident, comfortable, and promotes your learning.

However, even the best preceptors are not mind readers.

At times, your preceptor may be preoccupied with other priorities and fail to ask or share
information. In the least fortunate situation, your preceptor may not have received
preceptor training or may not enjoy a preceptor role.

One skill that preceptors practice in most preceptor training programs is recognizing when the
orientee does not understand and asking themselves, “How else can I say this?” If your
preceptor has not mastered this skill, you may need to say, “I’m sorry but I’m having trouble
understanding. Is there another way you could explain that?”

For any of these reasons, there may be times when you need to prompt your preceptor to ask
and share. (Anderegg & Christenson, 2014).

Troubleshooting Your Relationship with Your Preceptor

You and your preceptor each have responsibility for making your orientation a success. The
screens that follow will explain how to get what you need from your preceptor even when
your preceptor fails to take the initiative to:

• Ask open-ended questions

• Ask about your previous experience
• Ask you to clarify
• Ask for feedback on how you work together
• Demonstrate
• Explain acronyms, abbreviations, and other terms
• Give you feedback on your performance
• Share experiences
• Give you support and feedback on interpersonal interactions

If your preceptor does not ask for feedback, take the initiative and share. If your preceptor
does not share information, take the initiative and ask.

When Your Preceptor Fails to Ask Open-ended Questions

If your preceptor fails to ask open-ended questions, share open-ended answers. If your
preceptor’s questions allow you to answer with a simple “yes” or “no” answer, your preceptor
can’t make a full assessment of your progress and understanding.

Patient safety may be at stake if you thought you understood correctly, but actually
misunderstood an important point.

If your preceptor gives instructions and asks, “Do you understand now?” or “Are you OK with
that?” Instead of answering simply “yes” or “no,” state what you understood.

“Got it. You said that with Dilantin, it’s important to push it slowly through a side port in a
saline line. Correct?”

When Your Preceptor Fails to Ask About Previous Experience

If your preceptor fails to ask you for specifics about previous experience with
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For example if your preceptor asks, “Have you cared for a patient on PCA (patient controlled
analgesia) before?” A simple “yes” or “no” from you could be very misleading. Maybe you
cared for a post-operative patient who was already using the PCA pump and managing pain
satisfactorily when you took over the patient’s care.

That’s quite different from receiving the order, programming the pump, instructing the patient
and family, and assessing pain management after initiating PCA.

In addition, the documentation may differ from your previous experience. Describe
specifically the experience that you HAVE had.

“I’ve taken care of patients who had the PCA already set up, but I’ve never programmed the
pump or taught the patient how to use it. We went over a PCA form in the orientation class;
let me be sure it’s the same as what you’re using.”

When Your Preceptor Fails to Ask You to Clarify

Go ahead and clarify if you think what you said might have been unclear, or you think
that your preceptor may have misunderstood. Your preceptor may fail to ask you to
repeat or clarify your statement.

If your preceptor responds with a puzzled look or says or does something in response that is
inconsistent with what you just said, your preceptor may have misunderstood you.

For Example:

You tell your preceptor, “I just went to check Mrs. Samson’s dressing.” You intend to continue
telling her that the dressing is dry and intact. But your preceptor turns away and heads for
Mrs. Samson’s room.

You clarify, “I checked her dressing just a minute ago. It’s dry and intact.”

Your preceptor had misunderstood and thought you said, “Check Mrs. Samson’s dressing.”
Because she knew that you were going to do that, she thought that you had observed
something that she needed to check.

You are not questioning why your preceptor might want to go to the patient's room. She may
want to validate your assessment or she may have other reasons. You are just affirming that
she understood your message clearly.

When Your Preceptor Fails to Ask for Feedback

If your preceptor fails to ask you for feedback while you are working together, go
ahead and give feedback. Different people learn best in different ways.

Some nurses learn best by reading the procedure first.

Some learn better by first being coached through a procedure and reviewing the procedure
afterward.

If your preceptor doesn’t ask about how you learn best, supply that information.
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“Thanks for talking me through that irrigation. I think I would have done better if I’d read the
procedure more closely. What are some of the most common procedures that come up here?
I’d like to be better prepared next time.”

When Your Preceptor Fails to Demonstrate

If your preceptor fails to demonstrate, ask your preceptor to demonstrate. Your
preceptor will demonstrate technical skills and procedures for you. Keep in mind there will be
additional important unit-specific nursing activities that you will benefit from observing, such
as:

• Questioning patients about response to treatment

• Confirming provider orders
• Reviewing procedures for calling the provider
• Giving report

You may need to ask and simply be alert for opportunities to observe these nursing actions.

When Your Preceptor Fails to Think-Out-Loud

Successful preceptors make a habit of thinking-out-loud. That is, as they demonstrate, they
explain the rationale for what they are doing and emphasize the most important or most error-
prone points.

Ask your preceptor to think-out-loud and explain rationales and critical points for unfamiliar
procedures whenever it is appropriate and would not be disturbing to a patient.

Ask about the risks, common problems you are trying to prevent, and other things that may
not be obvious to you as an observer.

When it is not appropriate to think-out- loud, follow up with your preceptor as soon as
possible after you observe. Confirm what you have perceived to be priorities.

Clarify procedures and ask for instructions in advance to alert you to the most important
aspects of the activity, for example, “What could potentially cause a problem here?”

“I noticed that you used a transparent dressing instead of using the same kind of tape that
you removed from that IV site. Is that just another way to secure it or should the transparent
dressing have been used in the first place?

When Your Preceptor Fails to Explain Terms

If your preceptor fails to tell you what abbreviations mean, ask!

Your organization maintains a list of approved abbreviations. Know your facility’s policies
regarding abbreviations. There may be additional unit-specific or specialty-specific
abbreviations in use on your unit.

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Never assume that you know the intended meaning. Review any organization-specific or unit-
specific list of abbreviations and forbidden abbreviations.

The first time you encounter an unfamiliar abbreviation, ask what it means or verify with your
preceptor or other credible source that your interpretation is correct.

“I heard the docs say they might be taking Mrs. Ennis for a PTCA (percutaneous transluminal
coronary angioplasty). Is that a diagnostic test they do in the cath lab?”

When Your Preceptor Fails to Give you Feedback

If your preceptor fails to give you feedback on how you’re doing, ask for feedback.
Use the guideline of getting feedback on three activities done well and three that need
improvement EVERY DAY.
Ask for feedback as soon as possible, either during or immediately following the event.

Ask for feedback on one situation at a time. You’re more likely to get helpful feedback if
you ask, “Any suggestions for me the next time I document a post-op assessment?” than if
you wait until the end of the shift and ask, “Any pointers for me on what I did today?”

More Information
Many healthcare organizations have established residency programs to assist new graduates to gain confidence
and competence (Maresca, Eggenberger, Moffa & Newman, 2015; Ulrich, et al., 2010 ). Residency
programs have proven to be cost-effective
(Hansen, 2012; Lynn, Krsek, & Bednash, 2009), have suggested that organizations should receive federal
reimbursement for nurse residencies as they do for MD residencies (Lynn, et al, 2009).

Your organization may not have such a program, or if it does, you may not be eligible to participate if you are an
experienced nurse. However, you can ask and share in ways that exemplify some of the effective practices of
residency programs: ask for feedback; reflect on your experience daily and share with your preceptor specific
feedback about how effectively you and your preceptor are working together; seek out opportunities to interact
with others who are new to your organization – perhaps colleagues whom you met in orientation.

When Your Preceptor Fails to Give You the Specifics

If your preceptor suggests that you need to improve or need to “work on that,” find out
specifically what and how to improve.

When your preceptor gives corrective feedback, be sure you understand what risk or problem
you created by the approach you used.

When your preceptor tells you, “Good job,” be sure you understand what was good about
it. Ask your preceptor to explain what about the performance was good and what effect it
had on patient care.

“Thanks, I felt pretty good about that conversation with Mr. Harris’s family. Was there
anything particular I said that you thought was helpful to them?”

When Your Preceptor Fails to Share Previous Experiences

• If your preceptor does not share his/her experiences as a new nurse on this unit,
ask about them. Your preceptor’s experiences may be entirely different from your own,
but asking your preceptor to reflect on and share early experiences on the unit will likely
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 build rapport and preempt problems or frustrations.

“Tiffany, what were some of the things that puzzled you when you first started here? What
were some of the things you found most difficult to adapt to? I really want to benefit from your
experiences.”

When Your Preceptor Fails to Help with Interpersonal

Interactions
If your preceptor fails to give you support and feedback on interpersonal interactions,
ask!
• Ask your preceptor how effective you are in interactions with both patients and staff.

• Ask your preceptor to occasionally observe your interactions with others. Seek your
preceptor’s feedback especially about how you handle particularly challenging situations.

• Ask your preceptor to assist with effective communication and provide moral support, but
not to intervene unless it is absolutely necessary. After the incident, ask for coaching
about your strengths and ways to improve your communication.

• Share your feelings about difficult interactions. Your preceptor may ask how you felt in
the situation, but if not, share those feelings with your preceptor.

“I’ll admit it, I get a little intimidated by that Respiratory Therapist who comes in and changes
the vent settings. He has such a superior attitude. The way he asks me all those questions
makes me nervous. Would you just listen to what goes on between us today and give me
some pointers about relating to him?”

Beyond Your Control: The Wisdom to Know the Difference

You cannot control all of the circumstances that affect your relationship with your preceptor.
Sharing information and self-evaluation will help you develop the wisdom to know the
difference between things you can change and things you cannot change.

Such wisdom is the plea of the well-

known Preceptorship Works Best When . . .

• The same person consistently precepts the nurse. If for an unavoidable reason
another person must substitute, the preceptor communicates with the substitute
about the nurse’s progress.
• The preceptor has received preceptor training.
• The preceptor is a member of the core staff who has more than one year experience.
The preceptorship is tailored to meet the needs of the experienced nurse who is new
to the specialty or to the organization. (D’Alessandro, 2015)
•

More Conditions for Effective Precepting

• The patient assignment is adjusted to allow the preceptor to focus on your learning
needs.

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• Other nurses take more patients. It is an investment to spend time to bring you up-to-
speed as a fully functioning colleague. It takes a unit to raise a new nurse.
• Preceptors and orientees are provided with offline time to facilitate debriefing,
reflection, and completion of education-related documentation.
• Preceptors participate in peer networks and have access to unit-based educators
• Preceptors receive meaningful rewards for precepting.
• The organization purposefully develops initiatives to promote effective communication
and timely responses. (Sandau & Haim, 2011).

Your preceptor or manager may assertively request some of these conditions. There may be
times when these ideal conditions may not be met. Teamwork amongst staff can help to
make the best of a situation that may be less than optimal.

Summary: Ask and Share Your Way to Success

This course has presented examples of how to take a proactive approach to your orientation
process in a new work setting. Recommendations include asking and sharing with your
preceptor and taking full advantage of learning opportunities on the unit.

Conclusion
This course has introduced key concepts for an effective preceptor relationship and
explored ways to facilitate meaningful communication with a preceptor. The course has
presented essential precursors necessary to develop sound clinical judgment.

By studying this course, you have learned:

• Two ingredients that researchers have found to be important as precursors of
developing clinical judgment.
• Two important behaviors that are key to the success of the preceptor-orientee
relationship.
• Examples of ways to facilitate continuous asking and sharing in the preceptor-orientee
relationship.
• Conditions in a healthcare organization that support effective preceptorship.

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References
Anderegg, S. V., & Christenson, J.C. (2014). Preceptor Development Series. Hospital Pharmacy,
49(8), 713-716.

Benner, P., Hughes, R.G., & Sutphen, M. (2008). Clinical reasoning, decision-making, and action:
thinking critically and clinically. In: Hughes RG, editor. Patient safety and quality: an evidence-
based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (US);
2008 Apr. Chapter 6. Retrieved from: [Link]

Buck, B., Wilkinson, S., & Phillips, H. (2014). Preceptor development: Providing effective
feedback, Part 2. Hospital Pharmacy, 49(6), 521-529.

D’Alessandro, M., 2015, November. Does preceptor training improve new graduate performance?. In
43rd Biennial Convention (07 November-11 November 2015). STTI.

Hansen, J. (2012). The financial case for nurse residency programs. Boston, MA: Presented at the
NNSDO Convention July 13, 2012.

Lynn, M.R., Krsek, C., & Bednash, G.D. (2009). Nurse residency programs: An essential
requirement for nursing. Nursing Economic$, 27(3)[, 142 – 148, 159.

Maresca, R., Eggenberger, T., Moffa, C., & Newman, D. (2015). Lessons jearned: Accessing the
voice of nurses to improve a novice nurse program. Journal for Nurses in Professional Development,
31(4), 218-224.

Sandau, K.E. 7 Haim, M. (2011). Effect of a preceptor education workshop: Part 2, Qualitative
results of a hospital-wide study. The Journal of Continuing Education in Nursing, 42(4), 172 – 181.

Ulrich, B., Krozek, C., Early, S., Ashlock, C.H., Africa, L.M., & Carman, M.L. (2010). Improving
retention, confidence, and competence of new graduate nurses: Results from a 10-year
longitudinal database. Nursing Economic$,28(6), 363 – 375

© Copyright 2012, AMN Healthcare, Inc.

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