(1) Participants
Through the nursing departments of the two university-affiliated hospitals, the researcher asked the ward managers to name the target pairs, obtained the informal consent of both pairs, explained the results to them, and obtained their written consent. Consequently, 10 pairs consented to the study. The status of each pair is described below (Table 1).
<Table 1 The status of preseptees and preseptors> insert
(2) Difference in perception between the preceptee and the preceptor
From the interviews, the following six themes were extracted about the perceived differences between preceptees and preceptors regarding the former’s clinical practice:
Theme 1: Preceptee’s ability to carry out their work
Theme 2: Directing preceptee’s awareness (attention) during work
Theme 3: The ability of the preceptee to apply knowledge
Theme 4: Preceptee’s self-evaluation ability
Theme 5: The nature of communication in the learner-instructor relationship
Theme 6: Conducting business in a collaborative manner
Next, we summarize the definitions by themes and the descriptions of the preceptee and preceptor pairs. The following table summarizes characteristics of the pairs that showed cognitive differences in Themes 1 to 6 across both interviews (Table 2).
< Table 2 Emergence of a theme for each pair> insert
Theme 1: Preceptee’s ability to carry out their work
Definition of Theme 1
Performing nursing clinical work in a methodical manner is important, and both parties recognized that this requires good handedness, manual dexterity, and the ability to learn to complete the work in a timely manner. Generally speaking, with practice and experience, a person can gradually improve their ability to perform the job and complete it in less time. However, both parties understand that an inexperienced and unaccustomed preceptee’s job performance may neither be adequate nor timely; compared to the nurses that the preceptor has taught in the past, this preceptee might be taking longer than is acceptable.
Sub-theme (1): Perceived differences in manual dexterity when performing tasks
Both pairs were aware of the preceptee's manual clumsiness.. However, the preceptee had a hard time accepting this lack of manual dexterity, exhibited a strong desire to improve, and often felt impatient, saying “I can do it” when unable to do something.
In contrast, the preceptor felt that the preceptee is too clumsy and takes more time than assumed; this feeling can be regarded as dismay. In addition, the preceptor judged the workflow as “disorganized” and “not memorized.”
Pair E
Preceptee
“When I was doing detailed work, I was awkward or not to the point, or maybe I am not good at detailed manual skills (I think). I thought it was natural that my level would increase after the first year, but I could not do it. I could not admit that I could not do it because I saw my peers who were doing so well. I did not want to admit that I could not do it. I was so impatient that I did not want to drop out, so I said that I will do it even when I could not do it. I thought I was being too tall for my own good.”
Preceptor
“She/he was very clumsy with her/him hands; for example, a pubic wash would take 40–50 minutes. She/he was so nervous and sweaty that she/he could not put the gloves properly, and the items were not properly positioned—the patient kicked and spilled them; she/he could not connect the instruments properly for the intravenous drip or the blood collection. It was like she/he could not do it smoothly and it was a mess. In the end, I think she/he did not remember the procedures perfectly, and in April (right after she joined), she/he already had a gap with her peers, which we both knew and were worried about.”
Sub-theme (2): Differences in perceptions of time allocation and pace of completing tasks
Both pairs were aware that it takes the preceptee a very long time to complete the day’s work. The preceptee was aware that this was due to the fact that there were many tasks. In addition, the preceptee was underinformed about the work and in a state of anxiety when performing it. In contrast, the preceptor worked as usual, but was concerned that the preceptee was not able to match this pace. The preceptor felt that the preceptee’s work was slower than the required pace.
Pair D
Preceptee
“The routine was too busy for me to keep up with, and I had to do my daily work. It was common to work overtime until 8 or 9 pm. I wish I had been taught nursing skills hands-on. Once I had learned how to perform a bed bath; I was forced to do it alone. I was never given a checklist to confirm my skills, and if I said I could do it, I was forced to do so alone.”
Preceptor
“It was the first day I worked with her/him. I walked with the her/him to the patient room, but when I turned around, she/he was not following me. She/he and I did not have the same flow of time or did not match or (she/he) was very slow, and I wondered if it was okay. She/he is quiet and does not talk unless I talk to her/him, so I was a little confused about dealing with someone with that personality. When I thought that I could do things at this pace, or that other new nurses could do things at this pace, I compared myself to her/him, recognizing that she/he was slow. It takes me a long time to do each thing with her/him, and I think I am not quite to the point.”
Sub-theme (3): Differences in perceptions of procedures for learning
Both pairs were aware that the preceptee was working hard to learn the job. However, the preceptee did not think that the learning was time-consuming and presumed, on the contrary, that trying to find a way to remember things in an organized way is not an advisable way to learn. In contrast, the preceptor recognized that the preceptee’s learning method was not appropriate, and that concepts, unless stored in an organized manner, cannot be retrieved from memory.
Pair A
Preceptee
“I told one staff member that it took me about five hours to learn, and he asked, ‘Why does it take you five hours to do that?’ When I told him, ‘This will take you about 20 minutes to learn,’ he said, ‘That takes five minutes, doesn't it?” He said, "No, I do not think so. I was trying my best to remember, but it seemed to take me four times longer than others. I used to think that being to the point was not a very good thing, but I thought that is what you need to do to get a lot done."
Preceptor
“I have a marker line through all of my disease standards, and I have heard that she/he color-codes them as, but this makes me wonder if she/he knows what is important. Even though I told her to summarize the important points by handwriting, I often wondered if this was the point of view to summarize. It is understandable that she/he did not know because it was his first time, but he did not remember what I taught, and she/he did not remember if he wrote it down or not. If he had considered it important and written it down, he would remember it, but she/he did not, or perhaps, he could not recall it from of memory. I was patient with him at first, but then I got frustrated, and then I just gave up.”
Theme 2: How to direct preceptee’s awareness (attention) during work
Definition of Theme 2
It is important to maintain a broad perspective in nursing clinical work, such as planning ahead for the next step and observing the overall situation. The preceptee was motivated to perform his/her work and role. Conversely, the preceptor’s evaluation stated that the preceptee is distracted, neglects important perspectives, and is unable to fulfill his/her role.
Sub-theme (1): Differences in perception of focused concentration
Both pairs recognized that it was important to perform nursing tasks while taking a broad perspective and responding to situations. However, they were aware that the preceptee was not able to do so; the preceptee was overloaded with work and oblivious to her/him environment, and she did not recognize that she/he forgot something when doing something else quickly. The preceptor judged that the reasons for this were the preceptee’s inability to focus on anything else besides the present task and excessive focus only on the execution of his/her work, ensuring that other things do not come into view.
Pair H
Preceptee
“I have multiple assignments where I do not do more than one care task at a time, and I am not good at that. I have never worked in an overcrowded schedule before, and I did not expect this job to be that busy. If I try to rush things, I fail, so I cannot do things quickly. But if you do not do it quickly, you will not finish. When I would be thinking about doing something and something else would come in, I would forget what I was trying to do initially; later, the staff would tell me that I had not done it, and then I would finally remember.”
Preceptor
“I was very shocked when a post-op patient was complaining of pain right in front of she/he, and she/he were asking the patient if she/he was numb, and they did not think of doing something about the patient’s pain. Normally, I would try to do something about the patients’ pain. However, they are thinking about other things, or can only do one thing at a time. When I ask, ‘What did the patient just say to you?’ or if I ask, ‘What did you say?,’ they say, ‘I am going to go back and ask again.’”
Sub-theme (2): Differences in perceptions of handling urgent situations
Both sides recognized that the preceptee was trying to respond to urgent situations as quickly as possible. The preceptee felt that it was his “role and responsibility as a newcomer” to respond to urgent tasks, and she/he tried to do so. However, the preceptor did not expect the preceptee to respond in such a way and instead, expected the preceptee to first develop the responsibility of completing his own work.
Pair F
Preceptee
“When I am in charge of a patient who needs a lot of work, I wish there was another person to help. I feel like I have to do this and that while I am doing my duties. When I have my own work to do, and the nurse call rings and says, ‘It is someone from B team,’ I feel like I have to go. When I heard a senior nurse in the staff room say, ‘Newcomers do not see many patients, so you should at least take nurse calls,’ I knew I had to. In my head, I know I do not have the time to do that. It is not my patient, and I do not really want to go, but I think the new guy has to go.”
Preceptor
“When I ask someone to run an errand, she/he takes the initiative but the rest of the staff is worried if she/he can manage it. I try to talk to she/he on the assumption that she/he has finished her/him work, but I have to check first. I need to be sure. I can do what I say, and I can order the care and duties, but if there is a sudden event or I help someone else, I forget about myself. I am often so focused on what I am doing that I do not do my own things. She/he does not mind being asked to do things, so she/he takes the initiative, but when that happens, she/he inevitably neglects her own tasks.”
Theme 3: The ability of the preceptee to apply knowledge
Definition of Theme 3
In clinical nursing practice, it is important not only to recall and understand what has been learned, but also to think in terms of application from learning to practice. Preceptee and preceptor both recognized that knowledge at the level of recall using a textbook was not an issue for the preceptee. However, the preceptee did not know how to apply that knowledge to practice and was instead focused on increasing the hours of study. In contrast, the preceptor felt that the preceptee’s knowledge is limited to the textbook and not connected to the patient’s clinical condition.
Pair F
Preceptee
“Studying is not my weakness; I can do it if I try, but I often cannot use it (factual knowledge) in patient assessment and practice. When asked by the preceptor, ‘What is your reasoning? ’I can tell that the patient has a symptom, but I cannot make a care plan. ”
Preceptor
“I think she/he is fine and able to do. I can sit in front of the computer (nursing record) and say, ‘What about this observation item?’ or ‘Is this associated factor correct?’ I would say, ‘Oh, this is it. No, it is not. I think you know what I am talking about. But I cannot apply it to practice, and I often cannot do it with my patients.’”
Pair B
Preceptee
“I study because I think I am not good enough, but I cannot apply the knowledge in my head to what I am doing. Even if I study, I cannot make use of it; it is like a spiral. I try my best, but there are patients from many different departments (in the ward); so, no matter how much I study every day, I cannot keep up. I do not feel like I am nursing, but rather just doing what I am told on the spot. (The preceptor) told me that what I am doing and what I am studying are not connected and I understand that, but I do not know how to connect them.”
Preceptor
“I encouraged her/him to look back at today’s patient and draw a related diagram, but I got back a diagram that was so far removed from the current problem that it looked like something from a textbook. The report was quoted directly from the textbook and copied verbatim.”
Theme 4: Self-evaluation ability of preceptee
Definition of Theme 4
In nursing clinical practice, the ability to accurately self-evaluate is important for advancing and deepening learning. In the review and evaluation of the preceptee’s practice to date, the preceptee stated that there are no problems in learning and growth. In contrast, the preceptor was concerned that the preceptee had not sufficiently mastered the skills to be able to function independently.
Sub-theme (1): Differences in evaluations of my growth as a learner (satisfied with my growth)
Both parties have been working very hard in their nursing clinical practice. The preceptee mastered nursing skills through practice, did not feel clumsy, and had a relatively high self-evaluation. However, the preceptor’s evaluation of the preceptee’s skills was low; the preceptor continuously monitored the preceptee due to unsurety about the preceptee performing nursing skills without supervision.
Pair H
Preceptee
“I think I was able to take blood samples after doing it a few times, rather than being taught. As for the finer techniques, that is how I got better at most of it. The manual skills were not that much of a problem.”
Preceptor
“She/he had mastered very few nursing skills and I was worried about letting her/him work independently because sometimes she/he could use the intravenous drip and infusion pump, but sometimes she could not. There were times when I wondered why she/he could not do something today that she/he could yesterday. The blood collection was almost independent in the second half (of the year), but I was continuously supervising because there was always something that would be left out.”
Sub-theme (2): Differences in the evaluation of actual work performance (low evaluation standards for new nurses)
We recognized that both parties had been working very hard in their nursing clinical practice. The preceptee was unaffected by the fact that she/he was being properly taught nursing skills and felt that she was growing. The preceptor, in contrast, perceived no growth in the preceptee’s nursing skills and was embarrassed by the staff’s ridicule of slow growth.
Pair G
Preceptee
“I was taught the techniques whenever required from time to time, and I did not have that much trouble because of my training, so I did not have any difficulty with them. I think I adequately managed the procedures.”
Preceptor
“I was asked to take the same patient the next day because I could do it yesterday. However, it was reset, or rather, there were times when I forgot the next day even though the skill was done the day before. When no signs of progress (in nursing skills) were shown, the people around me started to wonder, ‘How are you going to teach them?’”
Theme 5: The nature of communication in the learner-instructor relationship
Definition of Theme 5
Communication (reporting, communication, and consultation) with other staff members is important when there is uncertainty about how to perform a task. The preceptee does not feel that there was a problem with his way of communicating. The preceptor, however, felt that the preceptee’s way of communicating as a learner is not satisfactory.
Sub-theme (1): Differences in attitudes toward learning in learner-instructor relationships
The preceptee never had any problems with interpersonal relationships. However, preceptors felt uncomfortable that the preceptee did not exhibit a learner-appropriate attitude and pretended to understand even though that was not the case.
Pair I
Preceptee
“I thought I had no problems with it (communication). I do not remember ever having that much trouble with interpersonal relationships either.”
Preceptor
“When I am talking to her/him, her/him reaction is always different than what I expect from a preceptee. When I provided advice in an educational capacity, the other new nurses would respond ‘yes,’ she/he would respond ‘yes, I knew that.’ So, I thought she said so because she/he was advised something she/he knew, but she/he did not know.”
Sub- Theme (2): Differences in perceptions of how to check operations
The preceptees paid attention to the preceptor to know when to report work and how to react. In addition, they found it difficult to respond to a preceptor’s inconsistent responses.
However, while the preceptor acknowledged the preceptee’s hard work and desperation, the preceptor perceived that important information was not communicated. The preceptor did not know how to respond to the preceptee, and the responses became more withdrawn.
Pair J
Preceptee
“If I say, ‘I am going to go do this,’ and you answer, ‘Well, I will do some other work while you doing that,’ it would go relatively smoothly. I do not know whether you can hear me or whether I am getting through to you while I am looking at the (computer) screen, but I am not sure whether I should say it again. I thought the preceptor was concentrating, so when I said it again, he sometimes would reply, ‘I heard you earlier.’ Another time (in the middle) I did not get a response, but I tried to go with the idea that he heard me (because of the last time), and he said, ‘If I did not respond, then he did not hear me, so it is like (you) did not say it.’”
Preceptor
“She/he greets me well and asks me anything freely, but sometimes important things are left out; so, I feel like, ‘What are you saying every single time?’ I can tell that they are desperate and want to do their best. However, since they are missing something important, they are spinning their wheels, they cannot do even the most trivial duplication of work, and they do not know what to do first. I do not know what to do first, and tend to be hard on them.”
Theme 6: Conducting business in a collaborative manner
Definition of Theme 6
In the same ward, it is important to perform tasks in a collaborative manner. However, the preceptee was self-directed and had little awareness of working with the team and supervisor. Conversely, the preceptor was a member of the team and had a high sense of collaboration, and this was also expected of the preceptee.
Sub-theme (1): Differences in perceptions of the significance of asking for help from the team
The preceptee believed that when a problem arose, she/he would solve it without asking for help. At the root of this was a desire to not be considered inferior. The preceptor, however, perceived that the preceptee’s inability to seek help was due to a lack of understanding of the impact on patients and their needs.
Pair G
Preceptee
“I thought I had to (figure it out myself), so I thought I could not just say, ‘I do not know,’ or ‘I have never done it before.’ I mean, I did not think of asking. The preceptor said to me, ‘If you have never done it before, you have to tell me, right? Do you understand?’ I said, ‘I don't know,’ and preceptor said, ‘You have to tell me what you do not know, don’t you? I do not know. However, you are still at this level.’ I could not say it because I was afraid of what would happen if the preceptor thought that I was still at this level.”
Preceptor
“I told her/him to call someone on the nurse’s call when the patient got up from the wheelchair on the bedside table, but I do not know if everyone was too busy to call, or if she/he did not call, but she/he started to help the patient herself. The patient had a deteriorated cognitive condition, and the chair was placed in a halfway position. So, I told her/him, ‘That kind of thing is scary,’ and she/he cried a lot, so I thought that she/he understood how scary it was (to assist alone) and the need to report it.”
Sub-theme (2): Differences in interpretation of team collaboration
The preceptee was unappreciative of other staff members shouldering the work he was unable to do. Conversely, the preceptor coordinated the work behind the scenes so that the preceptee was not overburdened. However, she/he felt pressure from her/his staff, which resulted in more work for her/him, and she/he felt that he was burdening her/his staff with more work.
Pair A
Preceptee
“I think the pair probably did a lot of work, but they did a lot of things that I did not do, and I was thought, ‘Oh, it was over before I knew it.’”
Preceptor
"She/he was taking so much time to get basic information about the patients. She/he would drastically reduce her/his duties or fix the duties and tell her/him to focus only on that. I told them to return to the station at 4:00 (in the evening) so that there would be no overtime. It might have been difficult for the staff around me because they had to take on that much work. So, I felt that (the other staff) had an atmosphere of not wanting to be under my guidance.”