Rising of a Novice clinician

Raising of a Novice clinician: a grounded TheoryBrent MacWilliams ANP PhD(c)ACCEL Option Leadership team: Research and EvaluationUniversity of Wisconsin-Oshkosh

IntroductionACCEL Option overviewOffering students with another bachelors degree the opportunity to obtain a to BSN in one year since 2003Didactic learning is delivered all online at a rate of 1 credit per week Three trips to campus, orientation, bootcamp and capstone week all in twelve monthsWith students working at a distance and in accelerated learning formats; a new clinical model has been employed....

Precepting ModelThe one-to-one precepting model match's an experienced BSN prepared RN one-to-one with a student nurse during each of clinical experiences throughout the students clinical rotations

ACCEL students spend a total of 672 clinical hours working one-to-one with an agency provided preceptor and university clinical supervisor

Precepting ModelStudents have consistently identified the one-on-one precepted clinical experience as the most significant and meaningful part of their educational learning experience in the ACCEL option

Leaving the leadership team asking.... what is the nature of the process.A dissertation is born....

Classic Grounded Theory (CGT) was employed as a methodology to explore precepting processThe CGT process emerged in 1967 in the seminal work by Glaser and Strauss in the book The Discovery of Grounded Theory

CGT generates theory from data and if successful serves to provide a transcending view of a given process.

Guided by Barney Glaser along with the Grounded Theory Institute the study was designed and approved....PurposeTo explore the one-to-one precepted undergraduate clinical experience from the preceptors view to develop a theory to guide practice...

6Data collectionA purposeful sample of 23 clinical preceptors, who have precepted one-to-one in the ACCEL nursing option within the past 2 years, was obtained.

The preceptors ranged in age from 26 to 61 years of age, and their years of nursing experience ranged from 2 years to over 35 years. Data collectionThe preceptors were working in a variety of settings: seven were employed in public health offices,five were in mental health facilitiesfour were in a hospital-based medical surgical areatwo were in a hospital-based intensive care areaone was in a hospital-based pediatric care areaone was in a hospital-based surgical settingone was in a primary care clinic/corrections facilityone was in an elderly long-term care facilityone was in an outpatient home health care agencyData collectionThe preceptors were interviewed face-to-face over a six month periodThe interviews were completed at a place of the preceptors choosing and lasted from 45 minutes to 90 minutes. The interviews were all audio-taped to ensure the researcher was able to capture the line-by-line coding needed to identify the indicators as they emerged during the open coding period (Glaser, 1978). Data collectionThe verbatim transcription of six interviews was obtained for the purpose of running the data open as a part of the open coding process (Glaser, 1992, p. 41). Line-by-line coding of the interviewees conversation allowed hundreds of indicators or incidents to be compared and conceptual patterns to emergeThe result was sets of interchangeable indices and conceptual emergence for comparisonTheory emergenceRaising of a Novice clinician emerged as the Basic Social Process (BSP)Why is BSP important?It serves to explain how clinical preceptors resolve their main concern which focused on closing the practice gap

With BSP emergence the post-emergence literature review was completed...

Constant comparative analysisPost-emergence literature reviewServed to clarify and integrate the emerging theory which focuses on raising as a rite of passage or transitionThe review also demonstrated the ability of the emerging BSP to provide a conceptual organization of the precepting literature.The substantive theory appeared to be a status passage or transition as a type of social and/or developmental maturation process.

Rite of PassageThe phenomena of status passages and transitions had been under study since the early 20th century when Arnold van Gennep (1960) wrote the book Les rites de passage, which looked at maturational passages like (birth and childhood).

The developmental maturation process or raising appeared to have been first experienced by the preceptor during his/her own nursing school experience, and now have taken the responsibility to help his/her preceptee make the same passage or transition into practice.

Raising as a BSP The study resulted in the discovery of raising of a novice clinician as the BSP and accomplished within the basic social structural process of experience brokerage.

The raising process appears to bridge the gap between the ideal or knowing about clinical practice and the reality or knowing how to perform in clinical practice.

The nature of theoryOne basic tenet of Glaser related to theory is that theory must be accessible to the people involved in the process.He states in the preface of Status Passage: (W)hile the book is written at a fairly abstract level we think that even the layman who is willing to follow the development of the theory, point by point, may profit in his understanding of society and possibly even in the management of his own life. (Glaser & Strauss, 1971, p. vi) Lets look at the findings in an emerging model...

High level of EngagementArriving to the clinical maturation ProcessHigh perceived self-efficacyLife Experience MatureACCEL Student arriving to the clinical sceneClinical Preceptor(Broker) Preceptee(Agent)RelationshipGood/bad Precepting HistoryArriving to the clinical maturation ProcessNursing specific Experience Desire to TeachClinical Preceptor arriving to the clinical sceneClinical Preceptor(Broker) Preceptee(Agent)RelationshipEngaging in the clinical maturation ProcessSharing agency or engaging in within the experience brokerageClinical Preceptor(Broker) Preceptee(Agent)Patient Engaging in the clinical maturation ProcessSharing agency or engaging in within the experience brokerageClinical Preceptor(Broker) Preceptee(Agent)Patient Self-care deficient(Orem) Experience brokerageExperience is the currency of maturationClinical Preceptor(Broker) Preceptee(Agent)Patient Self-care deficient(Orem)RaisingBridging transactions the clinical maturation ProcessWorking one-to-one provides unique learning Clinical Preceptor(Broker) Preceptee(Agent)Bridging transactions Brokerage environment OwnershipRole reversal as a status passgage or transitionPreceptee(Novice Clinician)Clinical Preceptor(Broker)Patient Self-care deficient(Orem)RaisingI have my own patientsBenners Novice to ExpertClosing the Gap the clinical maturation ProcessBridging the gap between the ideal or knowing about clinical practice and the reality or knowing how to perform in clinicalClinical Preceptor(Broker) Preceptee(Agent)Clinical MaturationResults The substantive theory that emerged appears to be a status passage or transition as a type of social and/or developmental maturation process.

The developmental maturation process appeared to have been first experienced by the preceptor during his/her own nursing school experience, and now they had taken the responsibility to help his/her preceptee make the same passage or transition into practice. Implications By looking at the most basic assumptions related to clinical precepting we can begin to understand the most basic nature of the precepting process to inform practicePreceptors need to self-reflect and become aware of their own raising history to understand how their individual personage effects our professional youth.How were each of us raised into the profession?

Perhaps raising offers a new diversity model...

Working out of theory Before I got married I had six theories about bringing up children; now I have six children, and no theories. ~John Wilmot

When clinical preceptors were questioned regarding the theories that they worked out of they were at a loss....We as professional nurses appear to simply be individuals raised into the profession and work out of our nursing values.

Diversity The raising of novice clinician conceptually includes culture, gender and sexual orientation, and offers a focus on clinical precepting as an inclusive process.

We all arrived to nursing school as individuals with raising history and then are raised into the profession by faculty and preceptors.

Eating our young as Google search revealed 12,500,000 hits with page after page of nursing references....We appear as a profession to be poor parents

Marginalization Professional identity in the form of stigmatization or the marking of an outsider is an identified aspect of marginalization in the literature

Labeling by senior staff of Nursing graduates was identified as the stigmatization of new nurses through value laden names such as new graduates, kids, young nurses, and novices which seem to create the perception of a hierarchy or social peeking order (Duchscher & Cowan, 2004, p. 292). In the extreme, this type of dominant social behavior could be construed as bullying and only serves to drive the new nurse from the profession of which male nurses maybe more susceptible.Healthy TransitionHealthy transition of new graduate nurses into practice is marked by reports from the person in transition as the feelings of distress giving way to a sense of well being.

The subjective feelings of the ability to cope, a sense of dignity, personal integrity, self-esteem, and empowerment were all identified in the literature (Allanach & Jennings, 1990; Duchscher & Cowan, 2004; Bradby, 1990; Louis, 1980; Mayne, 2007; Schumacher & Meleis, 1994).

DiscussionIt would appear that men in nursing would be particularly susceptible to dysfunctional raising process.

What is your good or bad stories of clinical precepting experiences as a student nurse or new graduate?

The guys who fear becoming fathers don't understand that fathering is not something perfect men do, but something that perfects the man. The end product of child raising is not the child but the parent. ~Frank Pittman, Man Enough