Between challenges and support: Preceptors run clinical nursing training amidst unprecedented crisis

Aim This study aimed to address challenges facing nurse preceptors related to multifaceted educational roles, academic and institutional support during the COVID-19 pandemic in the Kingdom of Bahrain Background Clinical nurse preceptors have faced great challenges since the influx of the COVID-19 pandemic. At this unprecedented time, they are overwhelmed with additional responsibilities to follow the COVID-19 precautionary measures alongside their usual educational role. So, they require careful preparation and massive institutional support. Design A descriptive study was conducted in different clinical settings in the Kingdom of Bahrain. Methods A sample of 125 clinical nurse preceptors who participated in the students' training for at least one full clinical rotation during the COVID-19 pandemic responded to two questionnaires regarding the clinical nurse preceptor role, preparedness, and institutional support provided to them during the COVID-19 crisis. Result It is revealed that 40.8%, 51.0%, and 53.0% of the preceptors faced major challenges regarding the teacher, facilitator, and feedback provider/evaluator roles during the COVID-19 pandemic. Moreover, 71.2% of the preceptors were incredibly overwhelmed with additional instructions related to COVID-19 precautions alongside covering course learning objectives for the students. However, most of them did not perceive challenges concerning both academic and institutional support. Conclusion The clinical nurse preceptors declared they received adequate pedogeological preparation, academic and institutional support throughout the COVID-19 pandemic. They also encountered moderate and minor challenges while mentoring nursing students during such a critical era.


Introduction
Nursing is a performance-based profession, where clinical training is integral component of nursing education programs (Rashwan et al., 2022). Globally, the COVID-19 pandemic resulted in a universal health crisis and impacted every aspect of life, with specific devastating implications for the clinical nursing educational system. Since many health institutions worldwide rebuffed the clinical training of nursing students amidst the COVID-19 outbreak, the acquring of clinical nursing skills and achieving of course-specific competencies have become the utmost curricular challenge (Agu et al., 2021). In order to minimize the physical contact between students during the pandemic, higher education institutions opted to find alternative flexible learning and teaching methods other than the usual face-to-face learning approach (Ratten et al., 2021). Internationally, most academic nursing institutions have shifted completely to distance learning during the COVID-19 crisis (Singh & Haynes, 2020). Online demonstration videos, blended learning, and high-fidelity simulation were utilized as alternative solutions to such challenges. Similarly, the nursing department at the College of Health and Sport Sciences, University of Bahrain utilized a wide variety of distance learning approaches during the peak of the COVID-19 pandemic. These approaches include, but not limited to, online/offline session through learning management platforms (Blackboard, Microsoft Teams), virtual simulations, remote case-study discussion, and online OSCE. However, it was acknowledged that the real-world clinical experience is essential and irreplaceable. Therefore, the department took the initiative and decided to complement the online teaching with real clinical opportunities and partially replace the missed clinical rotations. They designed a compensatory clinical training plan that focus on achieving the minimum course clinical requirement in September 2020.
Nurse preceptors have a pivotal and integral role in academic nursing education and healthcare organizational structures (Donley et al.,.2014). A clinical preceptor is a trained registered nurse (RN) who guides and supervises students' clinical experience, and facilitates their learning within a complicated clinical environment. Moore (2009) highlighted that nurse preceptors play a multifaceted role. These roles include, but are not limited to, (a) teacher, (b) facilitator, (c) role model, (d) feedback provider, (e) adult learning principles adaptor, (f) socializer, and (g) advocator roles (Rashwan et al., 2022). Unlike the usual clinical training experience, preceptors struggled to maintain the patients and students' safety during the COVID-19 era (Eweida et al., 2020). At this unprecedented time, the nurse preceptors had additional responsibilities to follow the institutional policies regarding COVID-19 precautionary measures alongside their usual educational role. Therefore, the nurse preceptors required careful preparation and immense institutional support during this critical period (Phillips, 2016;Henderson et al., 2006).
Traditionally, an academic partnership with health institutions was established to deliver a series of educational workshops. These workshops focused on preparing the preceptors for their instructional role as well as empowering them to incorporate the evidence-based nursing practice into students' clinical training (Hagler et al., 2012;Kamolo et al., 2017). To cope with the COVID-19 pandemic situation, it was necessary to switch the preceptors' pedagogical preparation workshops from a face-to-face to a virtual learning strategy (Fuller et al., 2020;Krampe et al., 2013).
As the COVID-19 disturbances escalated, more intra-professional collaboration and support are required by nursing faculty, administrators, and colleagues. Such academic and institutional support would facilitate nurse preceptors' recruitment, cultivation, and retention in their educational roles (Louiselle et al., 2020). Once this foundation is laid, the preceptors will be able to perform their roles effectively and efficiently. Therefore, preceptorship can hit the mark, and positive outcomes can be gathered (Happell, 2009). The COVID-19 pandemic eventually passed, but academicians and administrators need to provide extensive support for the preceptors working with the students amidst the great challenges aroused by the unexpected circumstances (Tolsgaard et al., 2020). In that sense, all the efforts and sacrifices taken today would arm the clinical preceptors with adaptive coping strategies and motivation to participate in the nursing students' training during future outbreaks. This will ultimately be reflected in the quality of nursing education through optimizing clinical learning outcomes and developing a new generation of trained nurses who can make a difference and advance the nursing profession. (Eweida et al., 2020)

Aim of the study
This study aimed to address challenges facing nurse preceptors related to multifaceted educational roles, academic and institutional support during the COVID-19 pandemic in the Kingdom of Bahrain.

Methodology
Design and setting: A quantitative, non-experimental descriptive cross-sectional study was conducted at College of Health and Sport Sciences in the Kingdom of Bahrain.

Participants
A non-probability convenience sampling of nurse preceptors who are responsible for students' training. All clinical nurse preceptors who were assigned to train the Bachelor of Science in Nursing program students (n = 149) for at least one full clinical rotation during the COVID-19 pandemic were invited to participate in the study. After questionnaire distribution, there were 125 (83.8%) responses.

Measurement tools
Challenges facing clinical nurse preceptors regarding their educational role structured questionnaire This tool was adapted from Rashwan et al. (2022) to assess the perception of nurse preceptors of their clinical educator role. The questionnaire encompasses 40 items that concerned with inquiring seven basic dimensions of role as (a) teacher (13 items), (b) facilitator (4 items), (c) adult learning principles adaptor (3 items), (d) role model (4 items), (f) Socializer (6 items), (e) Advocator (4 items) and (f) feedback provider (6 items). The Likert scale of the original questionnaire ranged from very much (5), moderate (4), slight (3), minimal (2), and not at all (1) for the positive items, whilst the negative items were reversely scored. In the current study, the heading of the Likert scale changed to very easy to manage (1), easy to manage (2), face minor difficulty to manage (3), face moderate difficulty to manage (4) face great difficulty to manage (5) to suit measuring the challenges facing clinical nurse preceptors during their educational role in the clinical setting. In addition, the total mean score of each dimension was calculated and classified into three levels of challenges (Džafić et al., 2011) as follows; Major: challenge reflects considerable difficulty for doing preceptor role (average score 3.50-5.00); Moderate challenge reflects certain difficulties for doing preceptor role (average 3.00-3.49); Minor challenge can be neglected -(average is less than 3.00). Clinical nurse preceptors' socio-demographic characteristics and work experiences, including variables related to age, gender, specialty, nationality, clinical setting and duration of working experience in the current clinical setting, duration of precepting nursing students were attached to this tool.

COVID-19 pandemic-related challenges facing clinical-nurse preceptors structured questionnaire
The investigators developed this questionnaire after a thorough review of recent literature (Pasani, 2020;Singh & Haynes, 2020) to explore data regarding the additional challenges facing clinical nurse preceptors during the COVID-19 situation in clinical settings. The questionnaire is composed of 9 items. It includes three main types of challenges related to clinical training (3 items), academic support (3 items), and institutional support (3 items). The preceptors' responses were rated on a three-point Likert scale; a minor challenge scored one, a moderate challenge scored two and a major challenge scored three. The questionnaire was submitted to a panel of 5 experts in the Nursing Education field and it demonstrated high validity as the S-CVI was 0.97. A pilot study was done on 15 preceptors to test the feasibility, applicability, and clarity of the tool. The internal consistency of the final version was high (Cronbach's Alpha Coefficient = 0.85).

Ethical considerations
Approval from the Scientific Research and Publication Committee of College of Health and Sport Sciences, University of Bahrain was obtained. Also, official permission for conducting the study was obtained from the directors of the previously mentioned settings. Participation in the study was completely voluntary. Online informed consent was obtained from the participants after explaining the aim and objectives of the study. The confidentiality of the obtained data was assured, and participants' anonymity was respected. The rights to refuse to participate or to withdraw from the study were emphasized.

Data collection procedure
A list of the nurse preceptors was obtained, and their names were arranged alphabetically. Then, the study participants were randomly recruited using a random number generator program. The researchers/ academic faculty members developed an electronic form of the research tools. The researchers directly sent the relevant link to the selected preceptors via their official emails. The study's aim was clearly stated in the first section of the form, then followed by the online consent form. Once the participants clicked the agree button, they were able to proceed to fill out the questionnaires. Only one response per participant was allowed. The senior investigators checked the collected questionnaires daily and downloaded the final Excel file of the participants' responses after the due date (one-month duration). Data were collected from the beginning of September till the end of December 2020.

Statistical analysis
The Statistical Package for Social Sciences (SPSS) version 21 was utilized for data analysis. Descriptive statistics included number, percentage, mean, and standard deviation to describe preceptors' demographic characteristics, working experience, level of the perceived challenge regarding their educational role, and COVID-19-related Challenges. The Kolmogorov-Smirnov test was used to check the normality of study variables, showing that they were not normally distributed. In Analytical statistics, Kruskal-Wallis tests (χ2) and Mann-Whitney (Z MW ) were used to compare the differences between the total mean scores of preceptors' COVID-19 related-Challenges and preceptors' demographic characteristics. Ordinal regression analysis was performed to predict the influencing factors for the perceiving challenges, and Odds Ratios (ORs) with 95% confidence intervals were obtained. All of the statistical analyses were considered significant at P ≤ 0.05. Table 1 illustrates that 40.8%, 51.0%, and 53.0% of the preceptors faced major challenges regarding the teacher, facilitator, and feedback provider/evaluator roles during the COVID-19 Pandemic. On the other hand, 58.4%, 68.8%, and 80% of them perceived the Adult Learning Principles Adaptor, role model, and socializer as minor challenges. Fig. 1 highlights nearly half of the clinical-nurse preceptors (43.2%) perceived moderate challenges regarding their educational role during the COVID-19 pandemic. While 28.8% of the participants perceived meeting those roles as a major challenge and perceived meeting those roles as a minor challenge.

Results
Regarding the nurse preceptors' demographic characteristics and working experience, Table 2 illustrates that the age of 45.6% of preceptors ranged from 35 to less than 45 years, and the vast majority of them were females (94.4%). Regarding working experiences, 61.6% of the nurse preceptors held a bachelor's degree, and 63.2% had less than five years of experience in supervising nursing students' clinical training.
Regression analyses of nurse preceptors' level of the perceived challenges and their demographic characteristics and working experience revealed that preceptors' level of education is a protective factor against developing clinical educational role-related challenges during the COVID-19 pandemic where preceptors who held BSN perceived fewer challenges than those who had diploma degree (OR = 6.13, 95% CI: − 3.02, − 0.35, p = 0. 013). On the other hand, the working experience in the nursing field, as well as the duration of supervising students' training, were significant protective factors for perceiving challenges (OR = 3.27, 95% CI: 0.57,2.12, p = 0.026 and OR = 2.78, 95% CI, − 2.32, − 0.86, p = 0.035, respectively). Table 3 shows COVID-19 pandemic-related challenges encountered by clinical nurse preceptors. Concerning clinical training challenges, it is revealed 71.2% of the preceptors were incredibly overwhelmed with additional instructions related to COVID-19 precautions alongside covering course learning objectives for the students. Besides, 68.8% of them faced the major challenge of monitoring students' compliance with COVID-19 precaution guidelines, and those who had a major concern about the transmission of the virus to themselves and the students represented 75.2%from the total study subject. Table 4 clarifies that there are no significant differences between the preceptors' overall mean scores of COVID-19-related challenges and their demographic characteristics and working experience. As most of the preceptors reported major challenges concerning the clinical training. However, most of them did not perceive challenges concerning both academic and institutional support.

Discussion
During the COVID-19 pandemic, nursing education particularly in- service clinical training, was drastically disrupted across the globe (Eweida et al., 2020). The Kingdom of Bahrain was correspondingly affected by the outbreak, as the practicum portion of the nursing courses was disrupted. Undoubtedly, clinical nurse preceptors faced challenges on a multitude of levels. These levels mostly revolve around their different educational roles (Omer et al., 2016). Clinical nurse preceptors were accountable for maintaining the quality of students' clinical nursing training amidst the COVID-19 crisis. This can be confirmed by the findings of the current study, where most clinical nurse preceptors reported that one of the major challenges in adopting the teacher role. More specifically, they struggled with demonstrating the new procedures in front of the students while wearing PPE and maintaining social distancing. In addition, they were challenged by reviewing the clinical logbook on a daily basis in order to plan the students' clinical learning experiences. The findings of a study conducted by Kaniaru et al. (2016) showed that the majority of student nurses reported the need for qualified nurse preceptors to guide them in their clinical learning activities to gain more confidence while performing nursing procedures. In light of the COVID-19 situation, maintaining a balance between such students' needs and patient care duties, especially in complex critical care settings, represented a great challenge to the preceptors' clinical teaching role. In such a scenario, both patients and students demand the instantaneous preceptors' vigilance and prompt intervention (Weberg et al., 2021). In other words, the clinical nurse preceptors had to fulfill these equally important roles by ensuring that clinical teaching activities are accomplished while simultaneously providing quality patient care (Yang & Chao, 2017).
As facilitators, the preceptors strive to find appropriate cases that directly fit both the theoretical and clinical course objectives. In this regard, Omer et al., (2016) emphasized that preceptors should facilitate the students' clinical education. Such facilitation would enable students to integrate theory into practice, adjust to the new clinical environment, organize learning activities collaboratively, designing and implement plans (Agu et al., 2021). This lent further support to the present study findings, where more than one-third of the nurses in this study perceived their facilitator's role as a major challenge amid the COVID-19 crisis. This goes in accordance with the findings of the current study, where the majority of the clinical nurse preceptors rated their major clinical training challenges related to several factors such as; (a) being overwhelmed with additional instructions during the COVID-19 precautions alongside (b) covering the course's learning outcomes, (c) being concerned with protecting themselves and their students from COVID-19 infection and (d) monitoring students' compliance with COVID-19 precaution guidelines.
The environment of uncertainty that has been imposed by the COVID-19 pandemic, let the nursing students feel lost in the chaos of the pandemic. They have struggled to deal with the shock of reality, especially due to the daily increase in infected cases and the high mortality rate associated with such novel virus (Eweida et al., 2020). These include, but are not restricted to, the increased workload, adapting to several technological innovations, working while wearing PPE, managing workload with inadequate clinical experience, and meeting professional standards in their workplaces (Fernandez et al., 2020;Greenberg et al., 2020).
According to Mustafa and Azize (2021), the pandemic forced undergraduate nursing students to take on new responsibilities earlier than usual such as following precautions and wearing PPE…etc. So, they have a strong urge to be supported, heard, prepared, and expected to receive continually constructive feedback from their clinical preceptor, who is already overwhelmed with an additional requirement (Shanafelt et al., 2020). This fact complied with the current studys' findings, where more than half of the preceptors perceived their role as feedback providers as quite challenging during the COVID-19 pandemic. This could be due to the limited time available for the preceptor to supervise and coach the students and their clinical training needs. Preceptors are also required to mentally prepare the preceptee to deal with such unprecedented circumstances of COVID-19 (Shaw, 2020). Similarly, Broadbent et al. (2014) documented that the clinical nurse preceptors were not satisfied with the time they had to devote to their students whilst achieving their feedback provider role. Unfortunately, the combination of the stressful environment along with lacking students' compliance with the COVID-19 precautions is a recipe that could threaten the students' learning and clinical outcomes (d 'Aquin, 2020). In that sense, there is a tremendous need for XXX College and health care institutions to OR = odds ratio; CI = Confidence Interval *Significant at *P ≤ 0.5.
incorporate these duties into the job description of the clinical nurse preceptors. Additionally, they should support and guarantee the accessibility and willingness of the preceptors to devote more time to their preceptees. However, such recommendations are contradicted by the obtained results of the present study, where only one quadrant of the participants claimed that receiving adequate support from the academic faculty during this critical time is perceived as a major academic support challenge. Similarly, the participants declared that the institutional support and cooperation of XXX in scheduling, organizing, and facilitating students' clinical training during this critical situation were beneficial in accomplishing their preceptor's multifaceted roles. Unsurprisingly, the findings of the current study revealed that the majority of the preceptors envisioned their preceptorship role as a role model as a minor challenge amid the COVID-19 outbreak. The clinical nurse preceptors are deemed the center of the clinical training and play a crucial role in guiding students with knowledge, skills, and practice (Girotto et al., 2019). They allow them to be active participants through engagement in autonomous decision-making related to practice (Girotto et al., 2019). Clinical nurse preceptors inspire and promote the development of their students through close professional relationships. Throughout this professional relationship, the preceptee could be, by virtue, shift into a role model who is able to move the nursing profession forward (Chang et al., 2017). In this context, the scientific evidence, across decades, asserted that clinical nurse preceptors act as professional role model who has clinical knowledge and the ability to lead and support the next generation of preceptee (Heffernan et al., 2009;Panzavecchia et al., 2014). Moreover, Omer et al. (2013) cited that the preceptor's function as a role model entails educating, safeguarding, socializing, and evaluating students. This is evident in the results of the present study, where the vast of the preceptors did not perceive a major challenge to serve as a role model for the nursing students even during the exception COVID-19 situation.
Equally important, the clinical nurse preceptors rated their role as evaluators as one of the major challenges that they faced during the outbreak. This is congruent with Riden et al. (2014) study, which argued that many preceptors felt compelled to report evaluations of students with whom they disagreed. More specifically, it might be persuaded by  the widespread of pandemic exacerbating the shortage of nursing staff and sending preceptors to work in COVID-19 critical care units, the release of novice preceptors to be trained for their role as preceptors are becoming impossible day by day. O'Brien et al., (2014) reported that an overloaded working environment interferes with the influntial preceptorship role, and jeopardizes nursing students' capacity to achieve the intended clinical learning outcomes. The researchers in the present study also observed that around onequarter of the studied participants addressed their advocator role as a major challenge. However, this finding is analogous to Boyer's model (2008), which displayed that the most significant challenge corresponds to the advocator role, as reported by preceptors. This also supports evidence from prior studies which confirmed that the preceptor role was accomplished through the protection of both patients from healthcare errors and protecting the undergraduate students from making faults that might threaten themselves or others (Chen et al., 2012;Hilli et al., 2014;Vaismoradi et al., 2014). This may be explained by the fact that preceptor roles during the COVID-19 outbreak are dramatically changed, where they struggled to fulfill their caring and teaching roles without jeopardizing one another (Singh & Haynes, 2020).

Conclusion
The clinical nurse preceptors received adequate pedagogical preparation, academic and institutional support throughout the COVID-19 pandemic. Therefore, they perceived moderate challenges while assuming the clinical nurse educator role during such a critical era. However, they faced major challenges regarding the facilitator and feedback provider/evaluator roles. Regarding the clinical components, preceptors encountered minor challenges as role models and socializers.

Recommendation
It is recommended that the responsible authorities legitimize the clinical nurse preceptors' multifaced roles. Continuous academic and institutional support should be provided to the current and the new generation of preceptors to enhance the quality of clinical nursing education. These could be achieved by continuing to offer educational training programs to equip them with updated and innovative clinical teaching and evaluation strategies. All health institutions in the kingdom of Bahrain also may facilitate the preceptors' mission and provide a productive clinical learning environment that will contribute to graduating highly qualified nurses who would be able to provide high-quality, culturally sensitive, and patient-centered care.

Limitations of the study
The study has limitations related to the small sample size, so conducting the study on a larger sample could provide a more generalized finding. An additional limitation is using the non-probability convenience sampling due to the limited number of clinical nurse preceptors that interfered with generalizing the study findings. In order to restrict the dual role, all the responses were kept anonymous and the electronic form did not include any personal information such as name, National ID, email address, or telephone number.

Declaration of Competing Interest
No conflict of interest has been declared by the authors.