The Theory of Interpersonal RelationsApplied to the PreceptorYNewGraduate Relationship

Georgita T. Washington, PhD, RN-BC

This article presents research results applying Peplau’s

Theory of Interpersonal Relations to the preceptorYnew

graduate relationship and describes implications for

successful transition. These results will help nursing

professional development educators with more appropriate

preparation and assignment of preceptors.

O f all the nurses employed in nursing in the UnitedStates, 62.2% work in hospitals (Health Resourcesand Services Administration, 2010). With the de-

creasing supply of experienced nurses, hospitals have con-centrated on hiring new graduate nurses representing asmuch as 10%of the nursing staff (Berkow,Virkstis, Stewart,& Conway, 2009). As they enter theworkforce, newnursesface a challenge experienced by every graduate nurse: suc-cessful transition from student to professional nurse.Studies show that preceptors have a great influence on thattransition (Chesnutt & Everhart, 2007; Everhart & Slate,2004; Oermann & Moffitt-Wolfe, 1997). Nursing profes-sional development educators can be instrumental inevaluating this relationship and facilitating a successfultransition for new graduates.

The preceptorYnew graduate dyad will typically be to-gether for the length of orientation. Preceptors may not beaware of the nature or importance of this relationship andmay not always make the conscious effort to nurture it.Being prepared mentally, physically, and emotionally tobe a preceptor is necessary to set the environment fornew graduates. Nursing professional development educa-tors are in the position to monitor these relationships tomaximize their positive effect on new graduates.

The manner in which new graduates are socialized andoriented into the unit and facility is essential. This relation-ship with preceptors can have a positive or negative influ-ence on how new graduates perform and therefore affecttheir turnover rates (Hyrkas & Shoemaker, 2007; Lavoie-Tremblay, Paquet, Marchionni, &Drevniok, 2011). Precep-tors must be nuturing, socially supportive, and authenticleaders and caring rolemodels. The qualifications andwill-ingness of the preceptor to serve in this very important roleof teacher, coach, evaluator, learning facilitator, and clini-cal and knowledge expert will have amajor impact on newgraduates’ successful transition (Giallonardo, Wong, &Iwasiw, 2010; Phillips, 2006).

Newgraduates have said that theyneed guidance, accep-tance, and support from preceptors; help with preparationfor the responsibilities theywill assume; and assistancewithpractical knowledge and confidence building (Godinez,Scheiger, Gruver, & Ryan, 1999). The dynamics of this re-lationship affect their socialization into the unit, theirprofessional development, their self-concept, and their re-tention in the workplace and profession (Kelly & Courts,2007; Lavoie-Tremblay et al., 2011).

Statements such as ‘‘What am I going to do with you,’’‘‘I hate precepting,’’ and ‘‘I don’t know why they gaveyou to me’’ do not make transition easier, particularlywhen such statements are made to or in the hearing ofnew graduates. These sentiments show a lack of under-standing of the need for relationship building (Romp &Kiehl, 2009) and illustrate one problem that may lead toan unsuccessful transition. The purpose of this study wasto determine if the theory of interpersonal relations couldbe applied to the preceptorYnew graduate relationshipand to quantitatively measure the presence, strength, di-rection, and magnitude of that relationship.

THEORETICAL OVERVIEWThe theory of interpersonal relations was originally in-tended to help nurses intervenemore intelligently and sen-sitively in situationswith patients (Penckofer, Byrn,Mumby,& Ferrans, 2011; Peplau, 1997). The theory of interpersonalrelations includes a series of four overlapping phases: orien-tation, identification, exploitation, and resolution (Forchuk,1993; Peplau, 1952/1991). Orientation can last from min-utes to months and is the time in which the nurse and the

Georgita T. Washington, PhD, RN-BC, is Clinical Nurse Specialist, AcuteMedicine Division, Johnson City Medical Center, Johnson City, Tennessee.

Partial funding for this research was received from Epsilon SigmaChapter, Sigma Theta Tau International Honor Society of Nursing, EastTennessee State University, Johnson City, Tennessee.

The author has disclosed that she has no significant relationships with, orfinancial interest in, any commercial companies pertaining to this article.

ADDRESS FOR CORRESPONDENCE: Georgita T. Washington, PhD,RN-BC, Mountain States Health Alliance, 1106 West Market Street,Johnson City, TN 37604 (e-mail: washingtongt@msha.com).

DOI: 10.1097/NND.0b013e31827d0a8a

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patient come to know and trust each other. The patient be-gins to recognize and understand the need for help. In theidentification phase, the patient identifies opportunities forimprovement and responds to thosewho can provide help.In the exploitation phase, the patient uses the nurse as a re-source and support to helpwith those improvements aswellas recognize other available resources. The resolutionphaseoccurs when former dependencies no longer exist, identi-fied goals are achieved, and ongoing interpersonal relationscontinue for further developmental change (Forchuk, 1993;Peplau, 1952/1991).

The Theory Related to the Preceptor and NewGraduate RelationshipThe phases of Peplau’s theory of interpersonal relations areapplicable to the relationship betweenpreceptors and newgraduates (C. Forchuck,personal communication, September9, 2007, and November 20, 2011). During the orientationphase, the preceptor and new graduate come to know eachother and learn how to work together as the new graduaterecognizes the need for help with the transition. The identi-fication phase is the time to discover opportunities for learn-ing and improvement for the newgraduate and to recognizethe preceptor as a resource. During the exploitation phase,the new graduate uses the preceptor as a resource and sup-port to helpmeet identified learning needs.When resolutionoccurs with the achievement of goals, mentoring can con-tinue as the new graduate becomesmore andmore compe-tent and continues the transition to be a professional nurse.

There are many similarities between the nurse and pa-tient relationship and that of the preceptor and new grad-uate. Both the nurse caring for the patient and the preceptorwith the new graduate must be competent in their roles andbe able to provide individualized structured plans of care ororientation programs (Peplau, 1997; Wright, 2002). Thefunctions of the preceptor are comparable with those ofthe nurse including being a rolemodel, teacher, and supportperson; having a desire to teach; and having good commu-nication and interpersonal skills (Chesnutt & Everhart, 2007;Everhart & Slate, 2004; Forchuk, 1991; Peplau, 1997;Wright,2002). Both thenurse and thepreceptor have conferences toassess progress; manipulate the environment for the bestoutcomes; are part of an interactive, dynamic process; andcan affect the relationship with their attitudes. The level ofexperience of the nurse or preceptor will also affect the rela-tionship and the outcomes (Delaney, 2003; Godinez et al.,1999; Peplau, 1997; Wright, 2002).

New graduates depend on the preceptor to assist withlearning during transition just as the patient depends onthe nurse. Patterns of communication between the precep-tor and new graduate are very important. By virtue of theteacher and learner relationship and the need for nurturing,this communication is often therapeutic. Thewell-being andgrowth of new graduates are the foci of this professional re-

lationship. Because preceptors can have such a major im-pact on new graduates, Peplau’s theory helps explain thenature of the preceptor and new graduate relationship.

LITERATURE REVIEWInterpersonal RelationsUsing questioning, careful analysis of the individual’s words,and verbal exchanges, multiple research studies haveshown that therapeutic relationships between nurses andindividual patients or clients do exist. In these relationships,nurses canhelp the individuals address challenges and solveproblems (Forchuk, 1994a; McNaughton, 2005; O’Toole &Welt, 1989). Interpersonal relationships with preceptorshave been found to be associated with developing a senseof belonging and higher job satisfaction in new graduates(Shermont & Krepcio, 2006).

ResearchbyMcNaughton (2000, 2005) supportedboth thepresence and importance of interpersonal relationships. In anintegrated review of the literature and a qualitative study ofdata from audio recordings, one study showed that the rela-tionship develops over time and that the longer a relationshipexists, the stronger the relationship and the more work ac-complished. It was determined that one-sided or difficultrelationships are unproductive in solving problems. The keyto mutual problem identification is building relationshipsandusing appropriatebehaviors todevelop solutions to thoseproblems.

Quantitative studies (Forchuk, 1994b; Poorman,Mastorovich, Malcan, &Webb, 2009) determined that eachrelationship is unique and that, if aworking relationship is notestablishedwithin 6months, it is unlikely todevelop. Forchuk(1994a) determined that preconceived notions influencedhow long the orientation phase lasted and how long it took,if ever, for the relationship to reach the working phase as de-scribed byPeplau. Itwas noted that the impression formed atthe beginning of the relationship, positive or negative, wasthe impression that lasted; there was no change over a3-month period. Forchuk et al. (1998) determined that, if thenursewas unavailable or distant, progresswas slowed, if nothalted. If the relationshipprogressed to theworkingphase, itwas considered powerful and successful.

Preceptor and New Graduate RelationshipThe preceptor model is the most common method of fa-cilitating the transition of new graduates. This modelfacilitates development of competence and confidence, ac-ceptance, and retention in new graduates (Fox, Henderson,& Malko-Nyhan, 2006). Although there is no published re-searchmeasuring the strength of this relationship, researchdoes exist explaining the effects of the relationship and itseffect on the new graduates’ work environment, which mayinfluence job satisfaction and turnover (Lavoie-Tremblayet al., 2011; Romp & Kiehl, 2009).

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Roche, Lamoureux, and Teehan (2004) conducted re-search evaluating an orientation program in collaborationwith a healthcare system. They reported strong negativecorrelations between satisfactionwith orientation andwork-ing with more than four preceptors. Contrary to Delaney’s(2003) findings, these new graduates indicated that one tothree preceptors gave themopportunity toworkwithmorethan one practice pattern.

A phenomenological study investigating newgraduates’transition experiences revealed that, when they had posi-tive relationships with their preceptors, both their thoughtsand progression in orientation were positively affected.Less experienced or inconsistent preceptors led to negativethoughts, slower progression, and confusion and frustra-tion for the new graduates (Chesnutt & Everhart, 2007;Delaney, 2003; Peplau, 1997;Wright, 2002). Several studiesindicated that preceptors helped with confidence buildingand ease of transition, provided emotional support, andhelped with learning and advice on professional issues(Fox et al., 2006; Sorensen & Yankech, 2008).

Kramer (1974) and Farnell and Dawson (2005) con-cluded that new graduates needed to spend time withpreceptors to feel supported and to take advantage of thepreceptor’s knowledge and skills. They, too, concluded thatworking with multiple preceptors decreased the ability tobuild a relationship, which does affect the ability to attaincompetency. The theoryof interpersonal relations also statesthat time spent in a therapeutic relationshiphelps individualsdevelop the competencies needed for personal develop-ment and problem solving (Forchuk, 1993).

METHODSDescription of the Sample and SettingAfter receiving institutional review board approval, thisstudy was conducted at the Level 1 trauma center flagshiphospital of a 15-facility healthcare organization, located inthe southeastern United States. The new graduates partici-pating in the studywereworking in patient care areas in allfacilities across the organization.

The organization implemented a revised graduate nurseorientation, which included a nurse residency program, tofacilitate the transition from student to professional nurse.Therefore, experienced registered nurses new to the orga-nizationwere not included in the residency program or thissample. The nurse residency program was 6 months inlength and based on the University Healthcare and theAmerican Association of Colleges of Nursing collaborativenurse residency model for new graduates.

Using nonprobability purposive sampling and a pretest-posttest design, the principal investigator approached thenew graduates participating in the nurse residency pro-gram during the first session offering the opportunity toparticipate in this study, providing responses to questions

and obtaining written consent. Those agreeing to partic-ipate completed the relationship form at the beginningand end of the 6-month program.

Relationship FormThe relationship form measures the patient’s perceptionof the phase of their relationship with the nurse. The fourphases between orientation and resolution phase aremeasured on a 7-point Likert scale, with midpoints betweeneach phase (Forchuk, 1994b; Forchuk & Brown, 1989).

The components of each phase of the nurseYpatient re-lationship were identified directly from Peplau’s theory,providing construct and content validity. Three mentalhealth clinical nurse specialists with theory-based practicesevaluated the relationship form for content validity. Inter-rater reliability for this form was found to be 91% (Forchuk& Brown, 1989).

The relationship form was adapted for use with pre-ceptors and new graduates with the permission ofC. Forchuk (personal communication, December 10,2007, and November 20, 2011). The adaptation includedchanging ‘‘nurse’’ to ‘‘preceptor,’’ ‘‘client’’ to ‘‘new gradu-ate,’’ ‘‘integrates illness’’ to ‘‘integrates new RN role,’’‘‘initiate rehabilitation plan’’ to ‘‘initiate orientation plan,’’‘‘help plan for total needs’’ to ‘‘helpplan for total orientationneeds,’’ and ‘‘teach preventive measures and self-care’’ to‘‘assists preceptee to be self-directed.’’ ‘‘Uses work stimuli’’was deleted for this context, as suggested by Forchuk. Theadapted form was used to determine new graduates’ per-ception of the phase of the relationship with preceptorsat the beginning and end of the program (see Figure 1).

The new graduates were instructed to circle the behaviorsthat applied to themselves to determine their perception oftheir relationship with their preceptor in terms of the phasesdescribed by Peplau. They also circled those characteristicstheyperceived aspertaining to their preceptors.On thebasisof the phase where most of the circles fell and using theLikert scale, a numerical score of 1 through 7 was assignedby the principal investigator to reflect the perceived phaseof the relationship (C. Forchuk, personal communication,December10, 2011;McNaughton,2000). The points betweenthe phases were used when the circles fell equally acrosstwo phases (Forchuk&Brown, 1989). In the event the newgraduate was assigned more than one preceptor, the newgraduate was asked to complete the form based on the pri-mary preceptor or the one with whom they spent most ofthe time.

RESULTSThe quantitative data were coded, entered into the com-puter, and analyzed using the statistical package for socialsciences (SPSS) GradPack version 17. This sample of newgraduates (see Table 1) did not have statistically significant

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FIGURE 1 Phases of the preceptorYnew graduate relationship.

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differences between preorientation and postorientationscores, suggesting that the relationship remained in theidentification phase (see Table 2).

DISCUSSIONAccording to the scores on the relationship form, at the endof the 6-month residency program, this group of new grad-uates did not progress beyond the identification phase,where the preceptor and the new graduate identify learn-ing needs. The participants were primarily young womenwho were professionally inexperienced. In addition, mostwere first degree students, so these factors could be influ-ential in the inability to build a professional workingrelationship.

LimitationsThis study is limited by its small sample size and the in-ability to control the number of preceptors for each newgraduate. There was no information available about thepreceptor related to clinical experience or preparation andexperience as a preceptor, all of which could have influ-enced how the preceptor related to the new graduate.

Limitations related to the form are related to its develop-ment to measure the nurseYpateint relationship and itsadaptation for use with preceptors and new graduates. Theform was not pilot tested.

Therewas no information aboutwork schedules, partic-ularly which shift the the new graduates worked most ofthe time. A combination of multiple preceptors along withworking a less-desired shift may also have influenced theprogression of the relationship.

ImplicationsThese results objectively verified that a relationship is pres-ent between new graduates and preceptors, which could beuseful to nursing professional development educators who

are involvedwith new graduate transition programs. Educa-tors could use the tool to periodically measure the relation-ship during the orientation process. If progressing, then theeducator will have data to continue to support the dyad andthe continued progress of the relationship to the resolutionand the end of orientation. If not progressing, objective datawill be useful in evaluating the viability of the relationshipand searching for factors that are inhibiting its progress.

Depending on factors identified, the relationship formresults would also be useful in determining if orientationneeds to be extended to allow for the identification and res-olutionofmore learningneeds. The itemson the formand theconcepts of the theory may also be useful as content for pre-ceptor development.

Further research should be conducted to determine thereliability and validity of this adapted tool used with precep-tors and new graduates. A larger sample size, mechanisms tocontrol or account for varying numbers of preceptors, wouldalso be a worthy investigation. Finally, the preceptor’s clini-cal and precepting experience and preceptor preparationshould be investigated to determine the influence of anyof these factors on the preceptorYnew graduate relationship.

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TABLE 2 Relationship Form Scores, n = 31

Variable andMeasurement

Mean(SD)

Meandifference

Paired ttest: t

(df ), sig 95% CI

PreceptorYnewgraduaterelationship

j0.032 j0.092(30),.928

[j0.750,0.686]

Preorientation 3.74(1.788)

Postorientation 3.77(1.543)

Abbreviation: sig = significance level.p G .05.

TABLE 1 Demographic Statistics, n = 31

CharacteristicFrequency

(%) CharacteristicFrequency

(%)

Women 28 (90.3) Flagshiphospital

14 (45.2)

Age: 20Y29years

21 (67.7) Medicalsurgical unit

12 (38.7)

RN G 3 months 21 (67.7) One preceptor 12 (40)

ADN 16 (57.1) Two or morepreceptors

18 (60)

First degree 23 (74.2) Attended fiveof six sessions

18 (58.1)

Abbreviations: RN = registered nurse; ADN = Associate Degree in Nursing.

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