Raising of a Novice clinician: a grounded Theory

1. Raising of a Novice clinician: a grounded Theory Brent MacWilliams ANP PhD(c) ACCEL Option Leadership team: Research and Evaluation University of Wisconsin-Oshkosh

2. Introduction • ACCEL Option overview • Offering students with another bachelors degree the opportunity to obtain a to BSN in one year since 2003 • Didactic 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 months • With students working at a distance and in accelerated learning formats; a new clinical model has been employed....

3. Precepting Model • The 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 student’s clinical rotations • ACCEL students spend a total of 672 clinical hours working one-to-one with an agency provided preceptor and university clinical supervisor

4. Precepting Model • Students 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.”

5. A dissertation is born.... • Classic Grounded Theory (CGT) was employed as a methodology to explore precepting process • The 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 transcendingview of a given process. • Guided by Barney Glaser along with the Grounded Theory Institute the study was designed and approved....

6. Purpose • To explore the one-to-one precepted undergraduate clinical experience from the preceptor’s view to develop a theory to guide practice...

7. Data collection • A 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.

8. Data collection • The preceptors were working in a variety of settings: • seven were employed in public health offices, • five were in mental health facilities • four were in a hospital-based medical surgical area • two were in a hospital-based intensive care area • one was in a hospital-based pediatric care area • one was in a hospital-based surgical setting • one was in a primary care clinic/corrections facility • one was in an elderly long-term care facility • one was in an outpatient home health care agency

9. Data collection • The preceptors were interviewed face-to-face over a six month period • The interviews were completed at a place of the preceptor’s 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).

10. Data collection • The 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 interviewee’s conversation allowed hundreds of indicators or incidents to be compared and conceptual patterns to emerge • The result was sets of interchangeable indices and conceptual emergence for comparison

11. Theory emergence • “Raising 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...

12. Constant comparative analysis • Post-emergence literature review • Served to clarify and integrate the emerging theory which focuses on “raising “as a rite of passage or transition • The 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.

13. Rite of Passage • The 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, whichlooked 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.

14. “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.

15. The nature of theory • One 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...

16. “Arriving to” the clinical maturation Process High perceived self-efficacy Clinical Preceptor (Broker) ACCEL Student “arriving to” the clinical scene High level of Engagement Relationship Preceptee (Agent) Life Experience Mature

17. “Arriving to” the clinical maturation Process Nursing specific Experience Clinical Preceptor (Broker) Clinical Preceptor “arriving to” the clinical scene Good/bad Precepting History Relationship Preceptee (Agent) Desire to Teach

18. “Engaging in” the clinical maturation Process Clinical Preceptor (Broker) Sharing agency or “engaging in” within the experience brokerage Patient Preceptee (Agent)

19. “Engaging in” the clinical maturation Process Clinical Preceptor (Broker) Sharing agency or “engaging in” within the experience brokerage Patient Preceptee (Agent) Self-care deficient (Orem)

20. “Experience brokerage” Clinical Preceptor (Broker) Experience is the currency of maturation “Raising” Patient Self-care deficient (Orem) Preceptee (Agent)

21. “Bridging transactions” the clinical maturation Process Brokerage environment Clinical Preceptor (Broker) Working one-to-one provides unique learning “Bridging transactions” Preceptee (Agent)

22. “Ownership” Benner’s Novice to Expert “I have my own patients” Preceptee (Novice Clinician) Role reversal as a “status passgage” or “transition” “Raising” Patient Self-care deficient (Orem) Clinical Preceptor (Broker)

23. “Closing the Gap” the clinical maturation Process Clinical Preceptor (Broker) Bridging the gap between the “ideal or knowing about” clinical practice and the “reality or “knowing how to perform in” clinical Clinical Maturation Preceptee (Agent)

24. Results • 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.

25. 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 practice • Preceptors 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...

26. 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.

27. 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

28. 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.

29. Healthy Transition • Healthy 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).

30. Discussion • It 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?

31. 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