Interprofessional Learning Unit 2

Group Number: 87

Confidentiality has been respected throughout this work and no names of people or places have been included This report is entirely our own work Group 87 confirm that we fully understand that this report remains the property of the host organisation and we may not personally/professionally share or use any part of it, without the express permission of the host organisation. We appreciate that no member should retain copies subsequent to successful completion of IPLU2/IPLU3 and if we wish to evidence our success we know we may use/refer to the Group Project Assessment Report. Indicate Word Count: 3086 Executive summary: 464

Executive summary 1) Background

A Preceptorship programme is designed to aid and support the transition from

student to fully competent professional. It involves a newly qualified registrant

(NQR) within many areas of healthcare being assigned a “mentor” or

preceptor who will monitor and assist them to grow in professional and clinical

confidence thus providing the NQR with stability and better patient care. The

aim was to decipher whether the minimum corporate standards for

preceptorship were being met across all healthcare profession throughout the

acute trust.

An audit is carried out as a means of measuring the levels of achievement in

relation to the standards set out. A strict audit cycle is followed to ensure that

all areas are covered. The audit was carried out ensuring data protection and

confidentiality was maintained at all times.

2) Methodology

A questionnaire was designed in order to quantify how the level of

preceptorship in practice met the minimum corporate standards. A sample

size of 55 NQRs was used. A pilot study was carried out to ensure that the

questionnaire used was an unbiased analysis and as a result led to some

rewording of questions. The questionnaire was distributed. All quantitative

data was visually represented using charts and qualitative data was

thematically analysed.

3) Results

The results revealed that NQRs were not always beginning their training at

the start of their employment, although most had been assigned a preceptor.

Some did not have a preceptor at all or their preceptor had left. The majority

received intensive training in their first week; more than half thought that they

did not receive the sufficient study days required. Those that did thought it

was mainly constructed through formative teaching, most agreed that they

had competencies to complete and over half said they did not have regular

3

meetings with their preceptor. Of those eligible for the six month appraisal,

lest than half said this had occurred. The majority of preceptors were rated

better than satisfactory. The Flying Start scheme received positive comments.

4) Discussion

It is a concern that some NQRs were not commencing the preceptorship

programme immediately, causing them to be unaided during the significant

first weeks; some were without a preceptor at all. This could be due to the

NQRs being trained within the trust and already deemed competent. Although

most disagreed that they were receiving the full allocated study time, they

may not have been aware of how study days could be constituted.

We recommend that all NQRs are assigned a preceptor regardless of whether

or not employment starts within the annual recruitment period. All NQRs and

preceptors need to be made aware of the corporate standards.

For a future re audit it would be beneficial to break down the analysis by

divisions to illustrate differences and preceptor programme strategies.

4

Contents

1. Introduction

1.1 Background 5

1.2 Aims and objectives 5

1.3 Understanding the audit process 6

1.4 Steps of the audit 7

1.5 Ethical considerations 9

1.6 Understanding audit standards 10

2. Methodology

2.1 Data collection 11

2.2 Sample size 11

2.3 Pilot study 11

2.4 Data analysis 11

3. Results 12

4. Discussion

4.1 Conclusion 18

4.2 Recommendations 20

4.3 Action planning 21

5. References 23

6. Appendices

6.1 Minimum corporate standards 24

6.2 Questionnaire 25

5

1. Introduction

1.1 Background

Preceptorship was introduced into clinical practice following the outcome of a

nurse education review, resulting in Project 2000 in the 1990s (DoH, 2009).

Preceptorship is a programme designed for newly qualified registrants (NQRs)

in Band 5. The aim of the programme is to develop competence and

confidence within the professional role, in order to benefit the patient and

service as a whole (Ashurst, 2008). A support system is provided to enable

NQRs to further develop skills in the first few months of employment. NQRs

are supported whilst achieving their relevant competencies, enabling faster

progression to the next pay band (DoH, 2004).

Since 2008 there has been a push within the health service to develop and

understand the benefits of Preceptorship for NQRs (DoH, 2008). The Acute

Trust we audited set out “Minimum corporate standards” (see appendix 1),

outlining the requirements for their preceptorship programme. The standards

were designed to enable NQRs to have an understanding of the education

and support they should receive and competencies they need to achieve.

Within the minimum corporate standards there was the implementation of the

pilot scheme “Flying Start”. This is an online scheme which is designed to aid

the preceptorship programme and provide a constant form of support.

1.2 Aims and objectives

The aim of the audit was to find out whether NQRs, including nurses and

allied health professionals, were on a preceptorship programme which met

the minimum corporate standards set by the Acute Trust.

6

This was a new audit with a key objective to review the preceptorship

programme and make appropriate recommendations for future practice based

on analysis of our findings.

1.3 Understanding the Audit Process

An audit is a common method used by health professionals to assess,

evaluate and improve the care of patients in a systematic way, enhancing

their health and quality of life (Irvine and Irvine, 1997). A clinical audit is a

continuous cycle of quality improvement. The diagram below shows an

overview of the steps necessary to carry out meaningful audit.

Action

Audit

Planning

7

Figure 1: The Audit Cycle (from East Kent Clinical Audit Service; available from http://www.ekclinicalauditservice.nhs.uk)

1.4 Steps of the audit

Step 1:

Audit topic selected: Minimum Corporate Standards Preceptorship

Programme.

Step 2:

Agreed standards of best practice: Minimum corporate standards produced by

the acute trust incorporating a multi disciplinary approach. (See appendix 1)

Step 3:

Methodology: Audit tool designed to obtain quantitative and qualitative data

on how the preceptorship programme is being delivered across the acute

trust. The tool aims to investigate the extent to which the minimum corporate

standards are being met. (See appendix 2)

Step 4:

Pilot study and Data Collection: A pilot study was completed using a sample

size of 8 NQRs to test the validity of the audit tool. Data was collected by

distributing questionnaires to different ward settings over a period of four

days.

Step 5:

8

The data obtained was analysed in Excel and presented in graph form. The

qualitative data was interpreted by the audit team.

Step 6:

Recommendations: not all standards were met and future recommendations,

include more study days and a designated member of staff to oversee the

preceptorship programme.

Due to time constraints, step 7 (implementing change) and step 8 ( re-audit),

were not carried out but it is recommended this is completed in the future,

continuing the audit cycle.

NICE guidelines state that audit is important for improving patient care and

outcomes through a systematic review of care against explicit criteria. In

addition, audit should promote implementation of change (NICE, 2002).

Clinical audit needs:

• Evidence based standards

• A team/ multi-disciplinary approach

• Monitoring of practice

• Commitment to change

Audit standards are to ensure health professionals participate in regular

clinical audits and review services to ensure best practice and patient care

delivery is improved, raising standards (Clinical Audit Support Centre, 2010).

The audit followed the steps outlined in the cycle above, excluding the re-

audit, which is a step that we would recommend is carried out in the future.

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1.5 Ethical Considerations

This audit was undertaken with consideration to data protection and

confidentiality to maintain participants’ anonymity. This was necessary to

ensure that participants would feel comfortable divulging what could be

considered sensitive information to us.

The NHS Confidentiality Code of Practice (DoH, 2003) outlines a

confidentiality model based on four key principles: Protect, Inform, Provide

Choice and Improve. Our investigation adhered to these principles as follows:

Protect: Data was stored in accordance with The Data Protection Act (1998)

and all data was destroyed after analysis. The location and name of the trust

in which our audit took place was removed from any written work, to ensure

maximum protection and confidentiality.

Inform: All participants were informed of what we were auditing and why we

were doing it.

Provide Choice: To ensure confidentiality, data collection was anonymous

and participants had the right to refuse to complete the questionnaire.

Improve: We performed a pilot study to test our method of data collection.

This resulted in a few minor changes which improved confidentiality

throughout the questionnaire.

Furthermore our audit met the criteria of SMART guidelines, whereby the

audit was specific to preceptorship. Our results were measurable and

achievable through a questionnaire, carried out in a realistic and timely

manner.

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1.6 Understanding Audit Standards

The minimum corporate standards (See Appendix 1) were set out by the

Acute Trust in 2009 and each Division was invited to apply for funds to

develop a preceptorship programme.

The minimum standards were developed in accordance with

recommendations arising from Lord Darzi’s report “High Quality Care for All”

(DoH, 2008). The report identifies the importance of improving NHS education

and training for both service users and healthcare professionals.

Preceptorship programmes are an element of education where NQRs are

supported through consistent opportunities to update and develop their skills.

The report also states investment funds will be increased with regards to

preceptorship to ensure NQRs can learn and be supported by senior

colleagues.

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2. Methodology

2.1 Data Collection

To investigate how the current preceptorship programme in practice

compares to corporate minimum standards, a questionnaire was designed to

obtain quantitative and qualitative data. This method of data collection would

provide results, achieving our aims and providing further recommendations to

improve the preceptorship programme.

2.2 Sample Size

The total sample size was 55 NQRs, 3 of which were on the Flying Start

programme, including nurses, midwives, occupational therapists,

physiotherapists and dieticians. Within the trust, 232 post qualified

professions had been employed. A random sample size of 55 was seen as

sufficient due to time available and convenience.

2.3 Pilot Study:

A pilot study of our questionnaire was given to 8 NQRs to check the feasibility

and to improve the research design. From this study a few questions were

altered, in order to maintain confidentiality and improve specificity.

The questionnaires (see appendix 2), consisting of 8closed and 3 open

questions, were distributed by the audit team to different professions in

different ward areas over a period of 4 days. The NQRs self completed the

questionnaire to prevent researcher bias. Aware of time constraints our

questionnaire was concise and clear with no leading questions.

2.4 Data analysis

Data was analysed using Excel. Quantitative data was graphed to provide a

visual representation of our findings. Thematic analysis was carried out on the

qualitative data.

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3. Results

The results were compiled from the audit tool, demonstrating the views of

NQRs from a range of professions.

The pie chart above shows the proportion of each profession completing the

audit tool.

Figure 3

13

This graph compares the length of time since qualifying (and duration of

employment) against the amount of time participants have been undergoing

preceptorship. It clearly demonstrates that although people are receiving

preceptorship, the length of time does not match their time qualified. 74% of

NQRs have been working for a 6 month period, with only 45% of these having

been on the preceptorship programme for the required 6 months. Analysis of

written comments revealed this was due to NQRs not always beginning their

preceptorship at time of qualification/employment. Many said they worked

unaided for the first month.

All the participants questioned, according to minimum standards, should have

been assigned a preceptor. However, this criterion was not met. A proportion

of NQRs commented that they had no specific preceptor but were aided by all

of the ward staff. Others had no preceptor or support and felt this would be

valuable to the learning experience.

14

The results show that most NQRs received intensive support in their first

week of employment, with only 9% reporting no support. The questionnaire

did not ask whether NQRs had trained at the Acute Trust, which may explain

this finding. Trust-trained NQRs may be deemed more familiar with Trust

standards, policies and procedures and thus may not need to undergo a full

induction.

15

When participants were asked if they were receiving 1.5 study days per month,

most NQRs stated that they did not receive full entitlement.

More than 50% of study days consisted of formal teaching, with the second

biggest percentage devoted to directed study. Many participants added

comments stating that the study days were not constructed in a suitable

manner. Alternatives suggested included shadowing more highly qualified

staff or studying around the cases they were currently working on, for

example learning about heart disease when working with a cardiac patient.

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Most participants had suitable and achievable competencies to complete,

however many of them said that they wanted a more structured work book,

out laying the specific tasks.

The pie chart above demonstrates NQRs did not always have regular

meetings with their preceptor. NQRs stated that they found it difficult to make

their preceptors understand their feelings. Some mentioned they would like to

attend more informal meetings in groups or would like to get involved in a

network with other staff members at the same stage as themselves.

Figure 10

n=44

17

The majority of the NQRs had not been employed for 6 months. This meant

we only captured a small number who were due for their 6 month appraisal.

Over half of NQRs rated their preceptor as “better than satisfactory” or

“excellent”. The NQRs who had not received a preceptor put poor as their

response. Some of the NQRs who had lost their preceptor, either by the

preceptor leaving or moving division, rated them on the period of contact.

There was no quantitative way of measure how effective the flying start

scheme was as the sample size was too small. The qualitative analysis

revealed that those using it were very positive about it. They stated that it was

easy and effective. They appreciated that it was accessible at anytime where

as their preceptor was not.

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4. Discussion

4.1 Conclusion

Our audit aimed to ascertain whether NQRs at an Acute Trust were on

preceptorship programmes that met the minimum corporate standards set by

the Trust. Our survey of 55 out of 232 NQRs, employed in the Trust, found

that some of the standards were adequately met across all professional

groups, however there were some standards not achieved. The reasons for

this seem to lie with both the Trust itself, and the NQRs, who may not have

understood what their entitlement was.

Under the minimum corporate standards, each NQR should be assigned a

preceptor, have a preceptorship period of at least 6 months duration, and

should receive intensive support in week 1. NQRs were asked how long they

had been qualified and thus employed for, and also how long they had been

on their preceptorship programme. Figure 2 demonstrates that NQRs don’t

always embark on their preceptorship period at the commencement of

employment. This is of concern because the first few months of employment

can be very stressful for an NQR (Hickie et al, 2007). This is when

preceptorship is most important and maximum support should be available.

Even more concerning is the number of participants who claim not be on a

preceptorship programme at all. Some NQRs commented that although they

had not been assigned a specific preceptor, they were aided informally by all

of the staff on the ward. There was however some who stated they had no

preceptor at all, even though they felt they should. Unfamiliarity of the term

preceptorship may have affected the way participants answered this question,

as some NQRs may have been assigned someone referred to as a Mentor or

Tutor rather than preceptor. Lack of awareness of this term and its process

may be associated with not receiving an induction and guide to preceptorship

in the first week of employment. Whether it is due to a lack of awareness on

the NQRs’ behalf, or whether it is down to staff shortages, the fact that some

19

NQRs perceive that they are working without support does need to be

explored further.

The majority of NQRs are receiving the appropriate intensive support in the

first week of employment. 9% did not, and analysis of written comments

suggest that this may be due to the fact that they trained at the Acute Trust,

thus were familiar with the Trust standards, policies and procedures. The

minimum corporate standards state that each NQR is to receive intensive

support in week 1 (linked to induction period, including a guide to

preceptorship). All NQRs should receive intensive training in their first week

regardless of their training background.

NQRs are entitled to 1.5 days per month of teaching/study time, which can be

either formally taught/directed study or 1:1 supervision in practice. Figure 4

shows that the majority of NQRs did not receive their 1.5 days per month.

These findings may not be a true reflection of current practice as it is evident

from the additional comments that many NQRs were receiving at least one

study day. Allocated meetings with their preceptor were recognised as study

time by the preceptor, but NQRs were unaware of this. In conclusion, many

NQRs may in fact be receiving their study entitlement, as the minimum

corporate standards state, as teaching can take a number of forms. This

needs to be reinforced to NQRs.

The majority of NQRs were aware that they had competencies to complete,

and this did not appear to be an area of concern for anyone. Competencies

and progress reviews are linked with the appraisal cycle. Very few NQRs

were due for their appraisal, so are unable to comment on whether this was

being done in a timely manner.

More than half of NQRs do not have regular meetings with their preceptors to

review progress. This is despite the fact that the vast majority of NQRs rated

their preceptor as satisfactory or above (See figure 10), which would indicate

that they have a good working relationship. With some NQRs commenting

20

that they found it difficult to express their feelings to their preceptor, it would

seem that encouraging more regular, structured contact may improve

communication and a feeling of support. Some NQRs lost their preceptor

when they left the ward or Trust. In such a situation it is imperative that a new

preceptor is assigned so as to ensure the NQR receives their full 6 months of

preceptorship.

Of the very small sample size of participants on the Flying Start Scheme all

the feedback was positive and showed that it was a useful tool. This may not

be a valid representation however as there are 15 NQRs in total on the

scheme but due to annual leave they were difficult to audit.

4.2 Recommendations

The data collected indicates that NQRs who commence their employment

outside of the main recruitment period are less likely to receive an adequate

form of preceptorship. Adequate by our definition is a programme that

adheres to the minimum corporate standards. This issue needs to be

addressed immediately, and it is recommended that every NQR who begins

employment outside of the main recruitment period(s) is to have an

appointment with a member of their administrative team within two weeks of

the commencement of their employment. This aims to ensure that a) they

have been assigned a preceptor, and b) they have also actively started their

preceptorship programme. It is imperative that they are made aware of ALL of

the corporate standards. Ideally there should be a designated person within

each division who would monitor NQR enrolment and continued participation

on the preceptorship programme.

Misinterpretation by NQRs of what constitutes study days could account for a

portion of the sample not meeting this particular standard. Clearer assignment

of study days and emphasis that a NQR doesn’t have to leave a clinical

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setting to be taking part in a study day may lead to different responses in a

future re-audit.

The audit captured a range of different professions, and the findings enabled

the analysis of how broadly the preceptorship programme was being utilised.

If a re-audit was to take place however, information on participant divisions

should be obtained to explore the benefit of additional funding. This could give

an indication of whether the reach of the preceptorship programme is related

to how much money each division allocates to it.

4.3 Action planning

Study Days

It is recommended that NQRs are allocated additional study time, and that a

new protocol is established to ensure study days are documented to meet the

monthly allocation. Ideally study time should be relevant to the NQR’s

respective field.

Assignment of Preceptors

The assignment of preceptors to NQRs should coincide with the

commencement of employment.

Duration of Preceptorship

The minimum 6 month period of preceptorship needs to fulfilled by every NQR.

If, for some reason, a preceptor is unable to perform their duty for reasons

such as annual leave, then an alternate preceptor must be assigned.

Designated Preceptorship Supervisor

Another recommendation is that within each division there is a designated

person to oversee the preceptorship programme. This person would be

22

responsible for ensuring that each NQR receives the adequate support and

encouragement they are entitled to.

Preceptor Meetings

It is recommended that meetings with preceptors should be more regular and

in a more informal manner to give NQRs an opportunity to express various

issues they may be experiencing during their preceptorship.

Network for NQRs

It is suggested a network is available for NQRs to contact each other and

share various problems, as well as solutions for their clinical experiences. An

online group or weekly meetings within the Acute Trust may be suitable.

Flying Start

It is recommended that in a future re-audit those on the Flying Start

programme should be compared with those who are not. This is in order to

verify the success of the scheme.

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References

Ashurst,A .(2008) Career development: the preceptorship process. Nursing

and Residential Care 10:307-309

Clinical Audit Support Centre (2010) What is clinical audit?

http://www.clinicalauditsupport.com/what_is_clinical_audit.html (Accessed on:

5th March 2010)

Doh (2003)The NHS Confidentiality Code of Practice. London: Department of

Health.

DoH (2004) Agenda for change: final agreement. London, Department of

Health.

DoH (2008) High Quality Care For All. NHS Next Stage Review Final Report.

London, Department of Health.

DoH (2009) Preceptorship Framework for Nursing. London, Department of

Health.

East Kent Clinical Audit Service (2010) Clinical Audit Cycle.

http://www.ekclinicalauditservice.nhs.uk (Accessed on: 5th March 2010)

Hickie S, Lyttle CP and Harris LE (2007) Structured learning for newly

qualified nurses. Nursing Times 103: 28-29.

Irvine, S. and Irvine, D. (1997) Making sense of audit. Radcliffe Medical

Press, 2nd edn. Abingdon, UK.

NICE (2002) Principles for Best Practice in Clinical Audit. Radcliffe Medical

Press. Abingdon, UK

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Appendices

Appendix 1

Minimum corporate standards: Preceptorship

• Each newly qualified assigned a preceptor.

• Preceptorship period to be a minimum of 6 months.

• Each newly qualifier to receive intensive support in week 1 (linked to

induction period to include guide to preceptorship)

• Each newly qualifier to be supported for one and a half days per month

in either formal taught/directed study or 1:1 supervision in practice.

• “Flying start” programme to be piloted in line with the national

programme on a separate cohort of New Qualifiers in Unscheduled

Care Division.

• Competency programmes to reflect the `Practioner, Partner, Leader`

model.

• Competency programmes must meet the minimum required KSF.

• Preceptorship competencies and progress reviews to be linked into

existing appraisal/review cycle.

• Assigned preceptors to meet the skills defined in the SCSHA

Preceptorship Framework (preferably existing mentors)

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Appendix 2

Questionnaire for NQRs

We are a group of students investigating the efficacy of the preceptorship

programme for NQRs in health care. Throughout our data collection and

storage confidentiality will be maintained. Questionnaires will be destroyed

at the end of the project and staff have the right to refuse to participate.

Please circle appropriate answers where applicable.

1) What is you professional group?

……………………………………………………...

2) How long have you been qualified?

……………………………………………………...

3) Have your been assigned a preceptor?

………………………………………………………

4) How long have you been on your preceptorship programme?

………………………………………………………..

5) Did you receive intensive support in week one of employment?

Yes / No

6) Are you getting 1 ½ study days per month?

Yes / No

7) How are your study days constructed?

0) formal teaching

1) directed study

2) one to one supervision in practice

3) other please specify

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…………………………………………………………………………

8)

a) Do you have competencies to complete?

b) Do you or your preceptor have regular meeting to review progress?

c) Have you had your 6 month appraisal or is it booked?

9) How you rate your preceptor?

1) Poor

2) Less than satisfactory

3) Satisfactory

4) Better than satisfactory

5) Excellent

10) Are you a participant of the flying start programme?

If yes please specify the benefits

……………………………………………………………….……………………

…………………………………………………………………………………….

11) Would you make any future recommendations to improve the

preceptorship programme?

………………………………………………………………………………………

………………………………………………………………………………………