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Nurse Education in Practice 11 (2011) 76e80

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

The process of developing a framework to guide rural nurse preceptors in theevaluation of student performance

Olive Yonge a,*, Florence Myrick a, Linda Ferguson b

aUniversity of Alberta, CanadabUniversity of Saskatchewan, Canada

a r t i c l e i n f o

Article history:Accepted 1 January 2011

Keywords:PreceptorshipRural nursingEvaluationClinical experience

* Corresponding author. Tel.: þ1 415 652 8390.E-mail address: quinn.grundy@gmail.com (O. Yon

1471-5953/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.nepr.2011.01.001

a b s t r a c t

Increasingly, rural preceptorships are sought out for their rich learning opportunities and as an alter-native to often over-subscribed urban placements. While rural preceptors view teaching students asa gratifying experience, student evaluation remains an ongoing challenge. Frequently, rural preceptorsoften lack access to preceptor preparation, faculty support, and other forms of professional development,particularly those learning experiences that are specific to the unique rural setting and nursing culture. Inthis article, the authors describe Phase Two of a four-phase study which sought to develop and validate,in collaboration with rural nurse preceptors, a framework for conducting student evaluations. Followinga grounded theory phase of the study in which the experience of preceptors and students in ruralplacements were explored, the researchers, project staff, and three rural nurse preceptors met duringtwo working sessions to collate the study results, the nursing education literature, and the preceptors’own experiences to develop a framework for the evaluation process during a rural preceptorship. Thisframework, using a Who, What, Where, When, Why, and How approach, supported a broaderperspective of evaluation of student performance, and provided preceptors with useful strategies formaking evaluation an effective component of student learning.

� 2011 Elsevier Ltd. All rights reserved.

Preceptorship, the one-to-one pairing of a student nurse witha Registered Nurse for a time-limited clinical experience, is nowa widely used model of teaching and learning in nursing education.Preceptorship is designed to facilitate the transition from student tograduate nurse and thus, students rely heavily on their preceptors forconstructive feedback during this process (Clynes and Raftery, 2008).Faculties, too, rely on preceptors to provide accurate assessment ofstudents’ clinical competence in order to ensure that graduates aresafe, competent practitioners (Dibert and Goldenberg, 1995). In thisarticle, the term student evaluationwill be used to describe “both theprocess of systematic collection and interpretation of data gatheredfrommultiple sources about clinical competence and the product oroutcomeof that processethe decision aboutwhether the student haspassed the course” (Oermann et al., 2009, p. 353).

To facilitate the evaluation process, a preceptor must beprovided with a framework for evaluation as well as appropriatetools (Qualters, 1999). Common tools used in preceptorship involveboth formative and summative evaluation. Formative evaluation,also known as feedback, is known to boost a student’s confidence,

ge).

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and increase their motivation and self-esteem (Clynes and Rafferty,2008). Summative evaluation, or grading, is a responsibility oftenshared by preceptors and faculty members, and one in whichpreceptors require a great deal of support (Dolan, 2003; Walshet al., 2008; Yonge et al., 1997). The discrepancy between theevaluative role that preceptors are required to fulfill and thepreparation and tools they are provided in order to fulfill that role,continue to be a major challenge for preceptors (Dolan, 2003;Ferguson and Calder, 1993; McCarthy and Murphy, 2008;Seldomridge and Walsh, 2006; Yonge et al., 1997).

Rural clinical placements are increasingly recognized as richlearning settings for students owing to the nature of generalistpractice, the breadth of learning opportunities, and the leadershipskills required (Schoenfelder and Valde, 2009; Sedgwick and Yonge,2008). Due to long distances from urban centers and a relativelysmall number of students dispersed over a wide geographical area,preceptors have much less access to faculty support, preceptorpreparation programs, networking opportunities, and otherteaching-learning professional development. When these oppor-tunities are accessed, the content of the professional developmentis seldom rural-specific. If nursing faculties are to continueto explore rural preceptorships as desirable teaching-learningopportunities, it is critical that rural nurse preceptors be afforded

O. Yonge et al. / Nurse Education in Practice 11 (2011) 76e80 77

access to rural-specific preceptorship support, particularly for keychallenges such as performance evaluation.

Thus, the research questions for this study were: “What is themost effective model for rural preceptors to use when evaluatingnursing students?” The sub-questions are: “How do rural precep-tors evaluate nursing students?”, “What are students’ perceptionsof preceptor evaluation?”; “What model of evaluation is best forrural preceptors?”, and “How effectively does the model guideevaluation in practice?”

Phases of the study

The overarching question, “What is the most effective model forrural preceptors to use when evaluation nursing students?” guideda four-phase study, funded by the Social Sciences and HumanitiesResearch Council of Canada (SSHRC). Due to the lack of research inthe area of preceptorship and evaluation, grounded theory wasemployed during Phase One to develop a middle-range theory thatcould be empirically tested (Glaser, 1978, p.14). The core variablesthat resulted from this phase were: the importance of feedback forstudents, and the challenge of evaluation for preceptors. In PhaseTwo, the researchers aimed to develop a preceptor evaluationframework based on the grounded theory previously developed(Yonge et al., 2006). The study findings were then integrated withevaluation theory and the nursing education literature on clinicalpractice and performance evaluation to develop the framework.Phase Three encompassed the framework testing phase. Subse-quently, the framework was piloted with a small group of ruralpreceptors in a workshop format. Following revision, the workshopwas offered to 12 rural preceptors at seven sites in western Canada.Once the framework had been used in a preceptorship experience,telephone interviews were conducted with preceptors to validatethe framework- Phase Four. This article will focus on Phase Two, theprocess of developing the framework.

The study was granted approval by the University ResearchEthics Board and by the Health Region in which the rural facilitywas situated with access granted by the hospital administrator.Written informed consent was obtained from all participants at theoutset of the working session.

Background/Literature

The potential for rural preceptorship as a vehicle for recruitmentof nurses to rural areas has been established and realized thusmotivating both faculty and practitioners to undertake ruralpreceptorships (Sedgwick and Yonge, 2008; Shannon et al., 2006).Despite initiatives such as the Rural Clinical Nursing LeadershipPracticum, however, (Schoenfelder and Valde, 2009) and a studyconducted in south Australia which evaluated the motivation andexperiences of rural health professional preceptors (Shannon et al.,2006), the issue of evaluation during rural nursing preceptorshiphas not yet been explored. One study surveyed the needs of ruralGeneral Practitioner preceptors of medical students and developeda series of workshops (Rural POPPIES) based on their responses(Baker and Walker, 2003). Workshop content placed specificemphasis on the preceptor’s role in student assessment and evalu-ation, and included strategies todealwithpoor studentperformance,personality clashes between preceptors and students, and inappro-priate expectations and non-attendance (Baker andWalker, 2003).

Evaluation Frameworks in Nursing Education

In Sweden, a clinical preceptor model was developed thatclearly outlines the roles with regard to evaluation for five differentstakeholders (student, Personal Preceptor, Head Preceptor, Link

Teacher and Clinical Teacher) during preceptorship (Hallin andDanielson, 2009). Following the distribution of worksheets forfeedback and formal evaluation and the delivery of workshops andcollaborative opportunities for preceptors with the university,preceptors reported a statistically significant increase in feelingsof preparedness for their role and perceived levels of support(Hallin and Danielson, 2009). Understandably, preceptors articu-lated the need for feedback on their role as preceptors (Hallin andDanielson, 2009).

Recognizing the difficulties many nurses face in relation tocontinuing education, Riley-Doucet (2008) developed a PreceptorOrientation Self-learning Education (POSE) module that was basedon principles of flexible delivery. The goals of this module were toenhance preceptor’s confidence in their roles and to increasefaculty member’s confidence in the preceptor’s ability to consis-tently evaluate students (Riley-Doucet, 2008). Additionally, thePOSE module became the vehicle for supportive facultyepreceptorinteraction (Riley-Doucet, 2008).

The formal evaluation tool is an entity with which preceptorsconsistently struggle due to vaguely worded competencies,academic language and a lack of familiarity with working withevaluation tools (Seldomridge andWalsh, 2006; Yonge et al., 1997).Walsh et al. (2008) sought to develop an evaluation tool that wouldprovide accurate assessment of student performance whiletargeting indicators of importance to preceptors. They developeda tool that used clinical behaviours that preceptors routinelyperform in their day-to-day care as indicators for assigning ratingsto clinical competencies (e.g. accountability, attitude, judgment,communication) (Walsh et al., 2008). The authors suggest thata face-to-face evaluation workshop would be an ideal way toprepare preceptors for evaluation and to ultimately ensure accu-racy and consistency among student evaluations.

The relationship between preceptor and preceptee is of utmostimportance in determining the success of the preceptorship in termsof student learning (Vallant and Neville, 2006), recruitment, andsatisfaction of all stakeholders. However, its role in the evaluationprocess has been viewed from different perspectives. In a precep-torshipmodel designed by Blum (2009) preceptorswere encouragedto develop a personal relationship with students over the course ofpreceptorship and pairs were matched based on personalities andlearning styles. Although final grading remained the responsibility ofthe faculty, greater involvement of preceptors in evaluation wasa way of honouring their contributions to the student’s educationand socialization (Blum, 2009). Conversely, Walsh et al. (2008)hypothesize that the preceptorepreceptee relationships gets in theway of objective evaluation and suggest that future developmentssurrounding formal evaluation include a depersonalization of theevaluation process with the face-to-face summative evaluationdelivered by faculty members instead of by preceptors.

Evaluation frameworks in other disciplines

Kemper et al., (2004) described a three-part process of studentevaluation: 1) the process (demonstration of professionalism anda commitment to learning); 2) the impact (growth of knowledgeand competency); and 3) the outcome (achievement of professionalgoals). Before the evaluation process can begin, however, it isessential that learning objectives be first set out (Kemper et al.,2004; Glover, 2000; LeBaron and Jernick, 2000). LeBaron andJernick (2000) suggest framing the evaluation process around thequestion: What would you like to say about this student at the endof the rotation?

In summary, despite the recognition that evaluation is a chal-lenging process for preceptors, very little has been written on theuse of frameworks for evaluation during the nursing preceptorship

Table 1Questions used to stimulate brainstorming during working session.

1. Do you see evaluation as a part of your role as preceptor?2. Do you clearly understand evaluation? What is your definition of

evaluation?3. Do you see a difference between evaluation and feedback?4. What strategies do you use to evaluate?5. What are some barriers to evaluating preceptees in the rural setting?6. Given that the current evaluation form will not be changed at this time, do

you feel you have enough knowledge of the categories to provide aneffective evaluation

7. Do you understand theminimum standard to enable you to provide ongoingfeedback and final evaluation in each category?

8. Please comment on student ranking or grading. How do you come to thatnumber?

9. Have you ever felt your evaluation values differ from your preceptee’s?10. When you agree to be a preceptor, what are your goals and objectives? Do

they vary with each individual student? Tell us about precepteeexpectations for their rural experience.

11. Do you always work with the students? If not, how do you get informationabout them and their performances?

12. Themost difficult evaluation is one involving a weak or failing student. Haveyou had to deal with this situation? If so, how did you manage it?

O. Yonge et al. / Nurse Education in Practice 11 (2011) 76e8078

experience. To date, there is no literature pertaining specifically tothe rural setting or for rural-based nurse preceptors.

Methods

Design

The research team and three rural preceptors engaged in twoworking sessions to develop a model of evaluation that is clear,concise and user friendly. A set of guiding questions for a brain-storming session was developed (see Table 1). The first workingsession was conducted at a rural hospital in October, 2006. Thesession opened with an explanation of the consent forms, collec-tion of demographic data, and filling out of expense and hono-rarium forms. The project coordinator presented the researchquestion, described the four phases of the research project, anddiscussed potential outcomes for the research. A discussion wasgenerated based on the set of brainstorming questions. Theoutcome of this session was a rich discussion of issues related to

Fig. 1. A framework for preceptor evaluation

evaluation of precepted students in rural settings, and possiblestrategies to address these issues.

In the second session, the research team discussed the corevariables and emergent themes from the grounded theory data,evaluation models used by other disciplines (Stake, 1986), evalua-tion models in the nursing education literature, and the minutesfrom the first working session were reviewed. Through discussion,analysis, and integration of all findings, the rural preceptor evalu-ation framework was developed, described in narrative form anddepicted visually (see Fig. 1). The working group then developeda 3 hour workshop centered on the framework. The framework andthe supporting workshop were piloted with a small group of ruralpreceptors at their rural facility and was revised according to theirfeedback.

Setting and sample

Students and preceptors were recruited from two nursingprograms at two western-Canadian universities. Both programsrequire students to complete a structuredpreceptorship (one-to-onepairing of a student with a Registered Nurse) in the final semester oftheir four-year program. One program is a nine week, full-timepreceptorship in a setting of the student’s choice during whichsummative evaluation occurs twice: at midterm and at the culmi-nation of the preceptorship. The faculty member, preceptor andstudent each completes an evaluation of the student (or self-evalu-ation) using a formal evaluation tool provided by the university. Thetool is based upon professional competencies identified by theprofessional regulatory body. The second program is a six weekpreceptorship, three weeks in a community setting (with onepreceptor) and three weeks in an acute care setting (with a secondpreceptor). Preceptors in both programs are prepared for the expe-rience through optional preceptor courses, a preceptor manual andare guided by the course outline and final evaluation form providedthem. Interactions with faculty via telephone or email are alsoavailable at the preceptor and faculty member’s initiative.

Rural acute care facilities within a 150 km radius from the urbancenter in which the university is located were selected as possiblesettings for the study. All facilities had existing relationships withuniversity faculty through ongoing placement of students for ruralpreceptorships in these settings over an extended number of years.

of student performance in rural settings.

O. Yonge et al. / Nurse Education in Practice 11 (2011) 76e80 79

The site where the working sessions occurred was chosen out ofthese facilities due to the support volunteered by the nursepreceptors employed at the facility and the hospital administrator.Experienced nurse preceptors were invited to participate in thisphase. This facility comprises 10 rehabilitation, 2 respite and 12acute care beds. It is situated in a farming community in westernCanada and provides medical services to a community of 800people as well as surrounding areas.

The working session

First, discussion was stimulated regarding the role of thepreceptor as an evaluator. The preceptors asserted that by the timestudents are in their fourth year of the nursing program preceptorsshould “encourage” instead of “evaluate”. The preceptors generateda variety of conceptions of their role that included: ensuring thestudent is able to cope with their skills and has the right kind ofthinking; confirming the student has a basis for problem-solving;assessing a student’s level of organization; providing confirmationto the university that the student has completed another piece ofthe greater program; and encouraging the student in their choice ofprofession, building confidence and helping students to grow.Preceptors emphasized it is not their role to pass or fail a student,but to provide feedback. They noted it is very difficult to affirmwhether a student is “cut-out” for rural nursing after only twomonths of clinical experience because students generally do notpossess the adequate technical skills to participate fully or becauseexperiences tend to be so variable that students do not gainadequate experience in any one area. They concluded that as thepreceptor, they could not evaluate technical skills or level ofexperience but could evaluate participation, communication, will-ingness, questioning and other similar attitudes and behaviours.This finding is consistent with the findings of Ferguson and Calder(1993) which revealed a discrepancy between the values ofpreceptors and the educational institution.

After clarifying the role of the preceptor, the role of the studentcame into question. The preceptors felt it was important tounderstand the student’s learning objectives for the rural place-ment and that it was the student’s responsibility to arrive withconcrete objectives. In their experience students choose to ‘gorural’ for the variability of experiences. Eager and socially adeptstudents tended to receive more teaching and feedback. Studentswho ‘gave back’ in the way of presentations or continuing educa-tion for staff were treated favourably. They expected that by thecompletion of the rotation the student should be able toadequately cope with a routine day. For them, the differencebetween a good student and a student they would want to hirelies in the student’s confidence, organization and above all theirwillingness to learn.

The preceptors were asked to describe their methods of evalu-ating students. They responded by explaining that their processincludes establishing concrete learning objectives in collaborationwith the student, and assessing whether the student is eager tolearn. Journaling, feedback sessions, and daily diaries were strate-gies cited. They acknowledged the lack of time during most shiftsand consequently indicated they often left it to the student toapproach them for feedback or with questions. They differentiatedbetween feedback and evaluation. Feedback is easier, daily, andimmediate. Evaluation is more formal and difficult as they did notknow how to evaluate someone without skills. Additionally, theyfelt the evaluation form provided by the academic institution to besomewhat repetitive, vague, that they did not have the language towrite a formal evaluation and that it was time-consuming. Theyliked space on the form so that they could provide specific exam-ples. They found that having student objectives to which to refer

and relying on documentation of daily feedback was extremelyhelpful.

The question was asked whether evaluation methods differedwhen working with a difficult or unsafe student. The preceptorsexplained they approached the student before too much timepassed and gave immediate feedback where possible. If behaviourdid not change, they would confidentially discuss the student’sbehaviours with peers to validate their observations, document,and then report to the nursing manager or faculty member.Preceptors noted that contact with faculty was frequent (at leasttwice during the rotation by telephone with one final visit) in thecase of unsafe students.

Preceptors were asked to reflect on rural nursing and its benefitsand challenges for practice and preceptorship. They explained thatrural nursing presents many new situations to a student but thatmany more skills are required which in turn can cause students tofeel overwhelmed. They suggested that students require a ruralnursing course prior to placement to cope with this skill deficit.They also noted there is a great spectrum of experience among‘rural hospitals’. For example, in the hospital where the workingsession was convened, all specialties are located on one floor. Thenurses reflected on challenges of rural practice such as confiden-tiality and multiple role relationships. A recent focus for profes-sional development at their hospital was confidentiality and theyattempted to promote this heavily throughout preceptorship. Also,they acknowledged they are often in multiple role relationshipswith students. They differentiated this occurrence from themultiple role relationships with patients because the patient “isn’tdoing your annual evaluation”. They related the experience ofevaluating a student who was related to a supervisor and thechallenges this posed for objectivity. On the other hand, theteamwork in rural nursing was viewed as a potential benefit toevaluation in preceptorship as preceptors relied heavily on thefeedback of colleagues and felt the evaluation would be moreeffective as a result. Regarding recruitment to rural areas, there wasconsensus that urban centers were “black holes” for new graduates.Unless a student had existing ties to a rural area, they felt there waslittle incentive for a new graduate to consider rural practice.Preceptorship, however, was considered an excellent recruitmentstrategy.

When asked to contribute ‘key’ points for workshop develop-ment, preceptors emphasized thinking “forwards, not backwards”.This implied reviewing the evaluation tool at the commencementof the rotation, defining objectives and documenting along theway.They also noted they had never received feedback as a preceptorand wondered what channels a student would utilize if unhappywith their preceptor. They felt feedback would help to buildconfidence in their role as preceptor.

The framework

Based on the grounded theory findings, feedback from thepreceptors during the working session, and the body of evaluationliterature, the following framework for evaluation during a ruralpreceptorship was developed (Fig. 1). It identifies the triad involvedin the process of rural preceptor evaluation but acknowledges thedistant participation of the faculty in the process (preceptee, facultyand preceptor) (WHO); discusses the importance of goals andobjectives for both the preceptor and preceptee and also addressesthe educational program’s expectations of graduates and how thesestandards can be incorporated (WHAT); brings awareness to thetimes and settings where evaluation can be achieved in a smallrural facility (WHEN/WHERE); increases the understanding of thevalue of evaluation in the preceptee rural learning experience(WHY); and discusses strategies for performing evaluation (HOW).

O. Yonge et al. / Nurse Education in Practice 11 (2011) 76e8080

Overall, the independence of the rural preceptor in evaluatingstudent performance when only in contact with faculty throughphone or email contact is acknowledged. Rural preceptors areprovided with a framework for this evaluation along with indica-tors for the need for greater faculty involvement.

The framework gives preceptors a ‘big picture’ view of theevaluation process during the entire preceptorship. For example,the WHO needs to be adapted based on the student’s individualstrengths and areas for development, the teaching and learningstyles of both preceptors and students, and the level of supportoffered by the faculty. The WHAT, or educational program expec-tations (as expressed through course objectives) and the student’slearning objectives are to be established at the outset, but referredto constantly throughout the preceptorship. The WHEN/WHEREare often unique to the clinical setting- for rural preceptors, ‘cartime’ between home visits or the bench next to the helipad wereimages they could relate to and which made the framework rele-vant to their particular setting. The WHY is clarified through thedifferentiation between formative and summative evaluation andthe needs of each member of the WHO. Lastly, several concretestrategies derived from the literature compiled into a workshopformat provided for the HOW of evaluation.

In summary, the framework was coherent, simple and easy bothto understand and to recall to memory. Most importantly, theframework development was preceptor-driven and grounded inrurality. The preceptors expressed their enjoyment in beingcollaborators in the research process and felt strongly that moreopportunities for rural nurses to be involved in research originatingin urban centers be created.

Conclusion

It was the intention of this study to develop a framework forevaluation in collaboration with rural preceptors and to design anintervention that incorporated the framework that would be rural-specific and relevant to rural nurse preceptors. Thus, the frame-work may not be generalizable to other groups of preceptors.However, this study highlights the need for a comprehensiveframework for evaluation so that preceptors can consistentlyunderstand why evaluation is important, what criteria studentsare being evaluated against, be equipped with the tools to performevaluation and have access to professional development in thearea of evaluation during preceptorship that is relevant to theirspecific needs.

Acknowledgments

The authors would like to thank the Social Sciences andHumanities Research Council of Canada (SSHRC) for funding this

project and Quinn Grundy, Research Assistant, for her assistance inpreparing this article.

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