Competency domains for registered nurse preceptor professional development: Evidence from a modiﬁed e-Delphi study

Aim: To develop an evidence-based framework of nurse preceptor competency domains and competency descriptors for use in nurse preceptor professional development


Introduction
Clinical placements provide preregistration nursing students with learning opportunities to integrate theoretical and practical knowledge while under professional supervision (Luders et al., 2021).The professional supervisors are registered nurses, and a common model of clinical supervision is preceptorship.Titles applied to these nurse supervisor roles can vary; preceptor, mentor, buddy nurse and coach (Cant et al., 2021;Henderson and Eaton, 2013;Mikkonen et al., 2022;Ulrich, 2019) are commonly applied.In this paper, we use the term preceptor in its classic sense to refer to a registered nurse who coaches, supports and assesses nursing students while tasked with caring for patients.This dual focus of nurse as clinician and educator, requires preceptors to develop teaching know-how, facilitation and coaching competencies while displaying expert interpersonal and relationship skills (Ryan and McAllister, 2020); all known to enhance preceptorship.However, preceptor preparation is often overlooked because nurse as teacher is an assumed role for registered nurses.For example, registered nurses are expected to evaluate their own and others practice (American Nurses Association, [ANA], 2021) and be life-long learners, responsible for their own and others professional development (Nursing and Midwifery Board Australia, [NMBA], 2023).

Background
A large body of research is focused on essential nurse preceptor skills.For example, a preliminary search through Google Scholar yielded over 4000 contemporary studies.Many studies, including a review of the literature (Quek and Shorey, 2018) report the need for improved preceptor professional development.Recent studies involve preceptors in Australia (McLeod et al., 2021), Europe (Mikkonen et al., 2022), Ireland (Hardie et al., 2022) and the USA (L'Ecuyer et al., 2022), suggesting that this is an international concern.Ensuring high quality preceptorship though, is fraught as there is little consistency in role preparation.Whilst studies have articulated key role expectations, few define or describe the skills and attitudes to the level of detail needed to enact these in assessment and measurement of preceptor competency.It is imperative then, that the nursing preceptor role is championed through clearer definition of the required competencies to shape quality, meaningful and contemporary professional development programme design.
To inform the design of evidence-based preceptor professional development, Ryan et al. (2023) completed a literature review.The objective of the present study is to synthesise the aforementioned work and develop an evidenced framework of nurse preceptor competency domains and descriptors, to inform nurse preceptor professional development.This literature review of quantitative studies identified ten (10) nurse preceptor role domains and more than 200 accompanying competency descriptors.The evidence was then mapped to Ulrich's (2019) seminal nurse preceptor model, that has seven (7) preceptor domains, validated as essential for mastering nurse preceptorship in the USA (Harper et al., 2021).This present study was informed by the results of this earlier literature review.The study aim was to develop an evidence-based framework of nurse preceptor competency domains and competency descriptors for use in nurse preceptor professional development.

e-Delphi study design
An e-Delphi study was chosen as the appropriate method for this study that aimed to develop an evidence-based framework to inform nurse preceptor professional development and was conducted over several phases.Using e-Delphi methods allowed for diverse groups of nurse preceptors to participate, compared with traditional Delphi methods that may seek only to convene workshops or survey localised groups of participants (Beiderbeck et al., 2021).The Conducting and REporting DElphi Studies (CREDES) reporting guideline was followed (Jünger et al., 2017).
Seeking the opinion of experts is a common approach to developing training competencies (Barrett and Heale, 2020).Delphi studies in nursing education seek to inform policy and curriculum development and, commonly, like this one, to define skill sets (Foth et al., 2016).Delphi studies use questionnaires to combine expert opinion with larger expert or stakeholder consensus and across diverse locations, commonly via three rounds however this is at the discretion of the researchers and should be informed by the study aims (Fink-Hafner et al., 2019;Foth et al., 2016).The e-Delphi approach advances these conventional methodology using emails, electronic platforms, online surveys and social media to conduct the study (Hai-Jew, 2019).This study adopted an e-Delphi approach with a preparatory phase and two rounds, shown in Figs. 1 and 2.

Participants
The expert panels were purposively sampled and selected on the basis of their capacity to respond to the nuanced aims.

Preparatory group members
A preparatory group involved registered nurses and researchers with experience working as preceptors and other clinical nursing educator roles and are all actively researching in nurse preceptorship and associated nursing education topics.

Round 1
Participants were registered nurses with at least three years of preceptorship experience in Australia.A registered nurse is a person who has met regulatory requirements and is authorised to practice nursing under the title of Registered Nurse (International Council of Nurses, [ICN], 2023).Participants self-reported their eligibility for the study, including their expert status and thus their contributions are considered valid.

Round 2
Nurse preceptors who provided their email contact details in Round 1, indicating their willingness to be contacted to participate in Round 2.

Preparatory phase
The expert group of six rated and synthesised the results of the previous literature review.To achieve consensus CR and RC first removed duplicate competency descriptors as well as any considered too broad to apply to practice, from the original set of 200.Then all six group members independently rated the remaining list of 89 competency descriptors for importance.After several online discussions, consensus was reached on 57 competency descriptor statements arranged as six (6) preceptor domains, Role model, Facilitator, Leader, Evaluator, Teacher and Coach.The six domains and the 57 competency descriptors informed the design of an online Qualtrics (Qualtrics Provo, UT) questionnaire (Q1) (see supplementary data file A).

Round 1
Recruitment for Round 1 was via the Qualtrics generated weblink and QR code, posted on social media and shared via email with the research team and key organisational bodies.Survey reminders were sent monthly, and the survey remained open between July and September 2023.The Q1 survey design used a four-point Likert scale anchored by 1= not important and 4 = very important for participants to rate the competency descriptors.Free text boxes were included for comments.Participants volunteered email contact details for invitation to participate in Round 2.
At close of survey, two researchers (CR, RC ) synthesised the results.The measure of consensus for descriptor items was participants' percentage agreement ratings ≥70% (Barrios et al., 2021).Items reaching consensus informed a second questionnaire for use in Round 2.

Round 2
The Qualtrics generated weblink and QR code was emailed only to those nurse preceptors who provided their email contact details in Round 1. Round 2 participants confirmed their agreement (agree /disagree/unsure) with each competency descriptor.Open text comments were again invited.The ≥70% agreement rating method was again applied to identify outcomes.

Ethical approval
This study gained University Human Research Ethics Committee (HREC) clearance number 24238.

Data analysis
Round 1 and 2 data were analysed by CR and RC using descriptive summary reports from IBM-SPSS Statistics (Version 27).Recommendations for conducting Delphi study analytics were also considered (Hai-Jew, 2019).In Round 1, all documented scale responses were included in the analyses.Missing data were noted to be minimal and were not replaced.Interquartile ranges to ascertain variability in participant responses were also calculated for Round 1 (Beiderbeck et al., 2021).Descriptor items with participant percentage agreement ratings ≥70% were retained as the measure of consensus.Percentage ratings at the upper extremities of the Likert scale are acceptable for reporting consensus in Delphi design studies where responses are positively skewed, as in the Round 1 of this study (Barrios et al., 2021).In Round 2, the responses had missing data in five individual items (<1.0%) which were replaced by the median value ('1').Open text responses from participants in both surveys were read from the survey reports.

Round 1 nurse preceptor sample
Eighty-nine nurse preceptors responded to the first survey.All declared a minimum of three years of preceptorship experience.Participants comprised a nationwide sample from five of the eight Australian states and territories.More than half (54%) were employed in the state of NSW while the remainder (in descending order) worked in  Queensland, Western Australia, Victoria and South Australia.
Most participants were female (85.2%; n= 75).Most (58.5%) were aged over 40 years.The highest qualification was a master's degree (n=17).More than one-third (n=31) held a postgraduate diploma or certificate.Thirty-eight (42.7%) held a bachelor's degree.The remaining three participants had hospital nursing certificate qualifications.Almost two-thirds (63.0%) had completed a preceptor training package.Nearly all (93.4%) were preceptors for students placed in a public or private hospital.While all declared more than three years in the role 27 (30.3%)had more than 10 years role experience (Table 1).

Round 1 outcomes
Survey response data from the 89 nurse preceptors revealed high ratings and demonstrated strongly positive skewed data (Skewness = − .887 to − 3.813).All 57 items had a median value of 4 (on a 4-point scale) and all except one Teacher competency descriptor, 'I gradually decrease my involvement in teaching/ as the student's skills increase' had means higher than 3.25/4.Very few responses (0.02%) were rated 'not important'.The interquartile range (IQR) was calculated with a minimum value of 2.81 and a maximum of 5, (IQR =3.58, 4.360), indicating minimal variability between agreement on competency descriptors.This lack of variability indicated that mean or median values were not able to discriminate among item responses, requiring an alternative analyses (Barrios et al., 2021).
Post hoc Round 1 analysis showed a non-significant difference between the two groups, preceptors who had completed a preceptor training package and those who had not, for competency descriptors (p= 0.298).Age (over or under 40 years) also did not significantly affect ratings totals (p= 0.906).
There were 20 textual comments received in Round 1.The following data captures common views.First, participants rated the preceptor evaluator competency descriptor assessment as vital: "…it is very important to know assessment to identify if student's performance is meeting the standards of practice….and to provide the student support to become an RN." This preceptor confirmed the importance of every presented  "Almost all of the items identified are important to me as they all are needed in order to be a well-rounded, empathic, safe and thoughtful preceptor." And this participant agreed stressing the key role preceptors play in student professional development: "Preceptoring plays a crucial role in student development…" Some participants strongly advocated for preceptor education: "preceptors need education too…in 7 years of preceptoring I have never received any training… I have found my own way to teach".

Round 2 outcomes
Thirty of the 48 nurse preceptors who provided their email addresses in Round 1 completed Round 2: a 62.5% response rate and an overall percentage agreement ranging from 91% to 100%.Thus, all participants recorded response percentages exceeding the consensus measure of ≥70%.Twenty-one (21) recorded 100% agreement across all 34 descriptors with the remaining nine recording between one and three item variations ('disagree' or 'unsure').
All six domains, Role model, Facilitator, Leader, Evaluator, Teacher and Coach (Fig. 3) and the 34 related competency descriptors (Table 2) were confirmed as important for nurse preceptorship practice.Although free text comments were again invited none were received in this round.

Discussion
This e-Delphi study aimed to develop a competency framework for use in preceptor professional development.Consensus evidence is shared, and in this study gathered from two consensus rounds completed by Australian nurse preceptors.The results inform a nurse preceptor competency framework of six domains: Role model, Facilitator, Leader, Evaluator, Teacher and Coach.Thirty-four related competency descriptors accompany the six domains as reported in Table 2 and Fig. 3.An expert group of nurses including 89 nurse preceptors reached 100% consensus agreement, with minimal variability on the final six domains and competency descriptors reported here.
The results of our study further advance previous nursing preceptor models, confirming that the role is complex and requires more than just clinical supervision of students and new graduates.The agreement reached also suggests that the consensus of Australian nurse preceptors' closely parallels and validates domains in other international studies.Importantly, this study refines the results of our earlier review of literature that identified nurse preceptor models reporting up to ten domains and more than 200 competencies.Each of the domains in our framework is now discussed.
Preceptors are engaged in healthcare settings for their modelling of professional roles and supervision of learners' practice, assisting learner development into a professional fit for practice (Bartlett et al., 2020).Role model domain competencies in our framework align with recent descriptions of preceptors as expert communicators, able to build professional patient relationships, who are caring, friendly and respectful and able to justify their decision making (Chen et al., 2021a;Quek and Shorey, 2018;Tuomikoski et al., 2018).Some preceptor models differentiate some of these competencies describing preceptors as socialisation agents who welcome and support student and learner transition to practice by explaining the rules (Al Adawi et al., 2022;Ulrich, 2019).
The preceptor domain Facilitator reported in many preceptor models should not be confused with the clinical placement model of the same name.The Facilitator practice model endorses registered nurses (facilitators) to work in a supernumerary capacity (no patient load) whilst overseeing and assessing a group of nursing students' clinical practice (Ryan and McAllister, 2020;Walker et al., 2013).Burrows' (1997) seminal work defined nursing facilitation as a goal-orientated, dynamic, mutually respectful relationship where learning takes place through critical reflection (p 401).Nurse preceptors are responsible for orientating students to the learning environment, setting learning goals and creating a positive learning environment, (Al Adawi et al., 2022;Botma, 2016;Ulrich, 2019).Further, our work identified duplication/overlap between the previously identified socialisation domain and the facilitator domain; note the facilitator competency descriptors included here referring to orientating to the ward and encouraging use of ward protocols.Thus, the socialisation domain has been omitted from our framework.
An interesting finding from this study was the consensus on nurse preceptor as Leader.It seems that Australian nurse preceptors recognise the importance of leadership skills in the role and in supporting new nurses to develop essential leadership skills.While no participants in this study commented on the need for development of leadership skills, other authors have previously called for nurse preceptors to be better supported in this domain (Chen et al., 2021b).Other studies suggest nurses supervising students could demonstrate clinical leadership through participating in more research (Ryan and McAllister, 2020) and take the lead in translating evidence-based practice in clinical settings (Cranley et al., 2017).Bryan and Vitello-Cicciu (2022) argued that preceptors who demonstrated leadership skills significantly positively impacted student and new graduate retention.
With reference to the Evaluator domain, evaluating or assessing learner clinical performance and knowledge is a legislated requirement for nursing programmes (Leighton et al., 2022) and the responsibility of all registered nurses working with students, including preceptors  (Kantar, 2021).Hughes et al. (2021) reported practice-based assessors felt more empowered and were more likely to undertake appropriate and accurate student assessments after learning about assessment.Given this evidence and the support from nurse preceptors to learn more about assessment, it is fitting that the importance of nurse preceptors as evaluators is a standalone domain.This confirms international results, further aligning our competency framework to international models (L' Ecuyer et al., 2022;Quek and Shorey, 2018).
Our framework refers to the need for preceptors to be Teachers.Teaching has always been considered a key competency of nurse preceptors (Ulrich, 2019).In previous work, studies have included numerous competency items in the teaching domain, more than 30 in some cases (Al Adawi et al., 2022;Ryan et al. 2023).Our results synthesise and refine these critical competencies into a manageable set of six clearly articulated competency descriptors.However, it may be that the descriptor use appropriate teaching methods is somewhat broad and could be further expanded on in future work.Validated clinical teaching methods appropriate for nurse preceptors such as the' one-minute preceptor' (Gatewood and De Gagne, 2019), teaching on the run (Lake and Hamdorf, 2004) and emerging bedside pedagogies such as patient as educator (Tredinnick-Rowe, 2018) may enhance nurse preceptor teaching know-how.
The Coach and supportive role of nurse preceptors has been successfully strategised to address nurse retention (An et al., 2022).Our participants confirmed the key role preceptors play in supporting students' professional development.Important competencies included in this domain include the preceptor coaching and supporting students to develop critical thinking and clinical reasoning that are recognised globally as core nursing professional practice standards.Preceptors in this study also recognised that using probing and questioning helps to develop students' critical thinking and prioritise important patient information.Learning to prioritise important details when formulating patient care is a key critical thinking skill required by nurses to act on relevant patient information and to determine pressing problems (Levett-Jones et al., 2010).
There were no differences in any of the results noted between the two groups, preceptors who had or had not completed preceptor education.However, there is evidence that preceptor preparatory courses build teaching confidence assisting with employing educational theory rather than teaching intuitively (Mårtensson et al., 2016).Some participants in this e-Delphi study requested more educational opportunities, sharing they had not learnt how to teach, instead had to find their own way to teach.As well as teaching know-how, preceptors need to learn the more complex skill sets such as coaching and leadership, included here as key competencies.Further, studies suggest that preceptors now require specific skills for orientating students to the practice environment (Pohjamies et al., 2022), for evaluating diverse students and those at risk of failing the clinical placement (Hughes et al., 2021) and conceptual studies explain the importance of understanding RN personal attributes to ensure quality preceptorship (Mikkonen et al., 2022).Buerhaus (2021) urged nursing leaders and employers of nurses who supervise students and new graduates in clinical practice to approach things differently.Suggestions to formally recognise preceptor credentials (Ryan et al., 2022) and diversifying reach of preceptor development programs through web-based programs (Wu et al., 2022) are reported.We urge organisations to align their preceptor development programmes with the consensus driven evidence base reported here.Further given nursing legislative requirements imply all registered nurses must teach (ANA, 2021; NMBA, 2023), we strongly suggest that all registered nurses complete preceptor education before supporting student and new staff learning.This sentiment is supported by nurse preceptors themselves, as reported here, who stressed the need for more preceptor professional development.

Limitations
Delphi designs have a known constraint of potential bias of researchers in shaping the preliminary statements (Fink-Hafner et al., 2019).To mitigate this concern, the initial statements were exclusively crafted from preceptor competency domains and descriptors sourced from the international extant literature.Self-reported ratings may be prone to response bias and this should be acknowledged (Barrios et al., 2021).A strength of this study is the e-Delphi approach that encourages anonymity through online surveys, thus perhaps inviting more honest responses, and reducing the influence of participants over one another which is more likely when adopting other consensus rating methods (Beiderbeck et al., 2021).
The 70% agreement rate may be considered low compared with other Delphi studies, however it aligns with published methods and broad sampling of nurse preceptors nationally has strengthened the research findings.As only Australian nurse preceptors contributed to this study, the generalisability of the agreed domains and descriptors beyond the Australian context should be considered prudently, although applicability across jurisdictions may be reasonable.

Conclusion
Supporting the learning of others in the clinical environment is a well-recognised aspect of nursing practice.Nurses who supervise, coach, and assess learners (new staff or students) are commonly referred to as preceptors.The specialist and complex nature of the knowledge and skills nurses drawn on when engaging in the preceptor role is illustrated in our RN Preceptor Professional Competency Framework.The results strongly suggest that preceptors resonate intuitively with the domains Role model, Facilitator, Leader, Evaluator, Teacher and Coach and the related descriptors.
The findings of this e-Delphi study have generated a concise set of professional competency descriptors further validating established internationally evidence-based preceptor domains.It is posited that the descriptors can be used as a self-assessment measure by RN preceptors, and those entering the role, to propel meaningful and contemporary professional development to enhance their capabilities/skill set.A next step is to understand how students perceive the contribution of the professional competency domains to assist their learning.

Fig. 1 .
Fig. 1.Three e-Delphi methods used in this study.