Preceptorship as part of the recruitment and retention strategy for nurses? A qualitative interview study

Aim: To explore aspects that are important for the integration of preceptorship and processes for recruitment and retention of nurses. Background: The shortage of nurses is a global concern that has a major impact on health care systems around the world. However, earlier research has not considered whether preceptorship of nursing students can be an integral part of recruitment and retention of nurses. Method: A descriptive design with a qualitative approach was used. Semi- structured interviews were conducted with ten preceptors and six ward managers in different health care specialties in Sweden. Results: Three aspects were found central for integrating preceptorship with recruitment and retention: perceptions of preceptorship, the organisation of preceptorship and the way preceptorship operates in relation to recruitment and retention strategies. Conclusion: The findings suggest that preceptorship and recruitment strategies could both benefit from being integrated. Implications for Nursing Management: It is central for nursing managers to develop organisational practices that enable the integration of preceptorship with recruitment and retention of nurses. This could increase the quality of both preceptorship and the work environment in general.


| Preceptorship and recruitment
Ward managers are responsible for ensuring the quality of care by recruiting, retaining and developing ward staff (Drennan et al., 2016).
To date, preceptorship and recruitment have largely been regarded as separate processes in health care organisations. A recent review (Irwin et al., 2018) found that team preceptorship has a greater impact than an individual preceptor on students' confidence and competence. This suggests that preceptorship needs to be considered as an organisational rather than an individual matter.
This study argues that preceptorship of nursing students is relevant for recruitment and retention of nurses for at least two reasons: (a) It is a practice where the organisation meets and has the opportunity to attract potential employees; and (b) it is a process related to development and retention of employees because it is often described as a highly positive experience, where preceptors have the opportunity to see students develop, and can convey the importance of their profession and strengthen nursing knowledge while updating and increasing their own knowledge base (Chicca, 2020;Foley et al., 2012).
The shortage of nurses and the dropout rate among nursing students (Bakker et al., 2019;UKÄ, 2017) means it is important to take measures to retain nursing students in the health care system. One way of doing this could be by integrating preceptorship of nursing students as an explicit part of future recruitment. The aim of this study was to explore aspects that are important for the integration of preceptorship and processes for recruitment and retention of nurses.

| ME THODS
Precepting of nursing students traditionally involves one student nurse being precepted by one registered nurse. In Sweden, as well as internationally, the increasing number of student nurses has led to a pressing need for additional preceptors and clinical placements (Stenberg & Carlson, 2015). In the health care setting, the ward manager is usually the one responsible for allocation of students to preceptors. Undergraduate nursing students enrolled in a 3-year bachelor programme have clinical practice during the 2nd semester (10 weeks), 4th semester (12 weeks) and the 6th and final semester (14 weeks).

| Design and sample
We used a descriptive design with a qualitative approach. To explore what aspects are important for the integration of preceptorship and recruitment and retention of nurses, we conducted semi-structured interviews with ten preceptors and six ward managers from different health care specialties (see Table 1). The participants were all nurses and were recruited by the central HR Department of the organisation responsible for all public health care in one of the regions in Sweden.
Criteria for sample selection for the preceptors were registered nurses with experience from preceptorship, and criteria for sample selection for the ward managers were those with a current position as manager.

| Data collection
The interviews were conducted between 8 April and 30 June 2019.
All but one took place at the participants' workplaces, and the remaining interview took place at the researchers' workplace. They ranged between 40 and 90 min in duration. The interviews were based on a guide focusing on the content of the process of being a preceptor, incentives and challenges, roles and responsibilities, and the development of the role. The interviews were recorded, with informed consent, and were later transcribed verbatim.

| Ethics
Before the study began, the participants provided oral and written informed consent to participate. They were informed about the research and its purpose, that they had the right to withdraw at any stage and that the data collected would be treated as confidential.

| Data analysis
Qualitative content analysis was guided by Graneheim and Lundman (2004). The focus of the analysis was to identify expectations, perceptions and approaches that could enable or hinder integration of the preceptorship process with the recruitment and retention strategy. The verbatim interview transcriptions were read thoroughly, and meaning units based on the study aim were extracted and labelled with codes. Codes were sorted into six subthemes, which were abstracted into three main themes (see Table 2).
Collection and analysis of data was a sequential and simultaneous process and continued until data could add no new information to the emerging themes, and so-called saturation was met (Glaser & Strauss, 1967).

| Professional perspectives
Preceptorship has a long history in nursing and is therefore regarded by many as a natural part of the profession. All nurses are expected to be able to provide this type of guidance, and it is considered to be part of the role. However, not everybody is considered suitable as preceptor, this can be due to the lack of interest in the role, or because they have a complicated or 'heavy' situation in their private life. This means that the nurses who are most interested in preceptorship are most likely to do it.
All the nurses are supposed to provide preceptorship, it is part of the job. However, there are nurses that say no to it and they get away with it as there is a risk that preceptorship will not be successful with an unmotivated preceptor. So, it is often the most dedicated nurses that become preceptors.

(Preceptor)
Nurses perceived preceptorship as rewarding for several reasons: it is fun, students bring new knowledge, and it provides an opportunity to reflect upon their own knowledge and work as a nurse. The nurses maintained that they were intrinsically motivated to become preceptors, and did not do it for external rewards. The role of being a preceptor was viewed positively and was seen as closely linked to nurses' professional identity.
The students ask a lot of questions so one has to be alert as a preceptor; they make us aware of things that we normally do not reflect upon. (Preceptor)

| Organisational perspectives
The interviewees discussed different aspects of preceptorship and its organisational prerequisites. First, they noted that wards are obliged to provide preceptorship for nursing students, and it is not negotiable. This applies even though nurses may perceive preceptorship as demanding.
Preceptorship can unfortunately be perceived as demanding and taxing, but it is part of our role. We have to admit students.

(Ward Manager)
Nurses pointed out that providing preceptorship meant extra work on top of their everyday tasks. It became especially taxing if it was not well organised and planned. However, some of the ward managers were keen to point out that they did not tolerate any discussion of 'students as burden' among nurses and that it was important that all students were treated with respect. I wouldn't like to call preceptorship a burden, but it means extra work … And from an organizational

TA B L E 1 Description of the interviewees
Some of the managers were not directly involved in providing preceptorship but highlighted that preceptors have significant responsibility. They are viewed as ambassadors for the ward, which is liable for the quality of preceptorship, so that patient safety can be guaranteed.
Preceptorship includes a great responsibility -being a preceptor is like being an ambassador for the organization.

| Responsibilities and functions
The managers usually make decisions about the number of students and, in some cases, the allocation of students to preceptors.
However, they may appoint one person to take overall responsibility for students and their education.
I have two people who are responsible for the students. They handle this very well. I do not go in and interfere. The only thing I do in relation to students is that I am in charge of the allocation of preceptors.
And it's a lot about making sure that's fair… my decision is respected … there are never any protests.

(Ward Manager)
During the process of preceptorship, the clinical teachers and other preceptors play an important role in inspiring and motivating preceptors, which compensates for any lack of structure and planning.
I try to show that I see them and reward them in my own way. They usually get a summer gift and a Christmas present, and I invite them to lunch. At the meetings, I see them, and I acknowledge them…. but the manager must also reward them and acknowledge them for their qualities.
(Clinical teacher) In addition to appointing preceptors, the ward managers are involved in preceptorship in any situations of conflicts, when there is a need to change preceptor or when a student is not meeting their objectives.
This does not happen often, but we have had students where it has not worked out very well…. I have a dialogue with the clinical teacher, where she and I jointly make a plan for how to deal with the situ-ation….and sometimes there has been a change of preceptors… then I get involved in that dialogue.

(Ward Manager)
It is not always clear to managers and preceptors how preceptorship is organised. A common feature is that the preceptors take a lot of individual responsibility and, when faced with uncertainty or lack of planning, find a way to deal with the situation. The preceptors' main focuses are the students and making sure that they meet the course objectives. Preceptors themselves therefore compensate for the lack of planning by their flexibility, loyalty and engagement. This is linked to their sense of responsibility as ambassadors for the profession.

| Planning and communication
Responsibility for preceptorship is closely related to aspects of planning and communication. In some hospital units, there is a plan for preceptorship, which is clearly communicated to the preceptors and more widely.
We are very eager to include the students in our team…. we talk to the students in the same way as we talk to each other… they are welcome to attend our internal lectures and they can participate in workplace meetings etc.

(Ward Manager)
The ward managers had different ways of planning preceptorships. Some ensured clear organisation with responsibility for the process; that is, they create a team with crucial actors or delegate the responsibility to a colleague. In other cases, the managers deal with these issues themselves. Some of the managers are involved in the process of preceptorship and have an ongoing dialogue with the appointed preceptors, while others do not prioritize work on preceptorship, usually because of lack of time and resources. In

Main themes Subthemes
Perceptions of preceptorship -Professional perspectives -Organisational perspectives

Organising preceptorship -Responsibilities and functions -Planning and communication
Preceptorship in relation to recruitment and retainment of nurses -Marketing of the profession -Marketing of the workplace TA B L E 2 Main themes and subthemes identified in the interviews some cases, planning is more ad hoc, and in a few cases, preceptors had neither been asked nor informed about the arrival of a student: Sometimes it happens, that when I come into work, there is my name plus someone else's name on the board…. that means that I will be someone's preceptor that day.
The majority of the preceptors felt that they did not have enough time to prepare for the student. It is up to individual nurses to find the time, and this can sometimes be frustrating.

| Marketing of the profession
There was a consensus among both ward managers and preceptors that preceptors are role models and ambassadors for the profession.
Several of the preceptors enjoyed the work with the students and considered preceptorship as an opportunity for learning and development. It was seen as a crucial part of the job, and nurses believed that it was important to do it properly.

| Marketing of the workplace
Recruitment and retention of nurses is formally the responsibility of managers. During the analysis of our data, it became clear that some managers see preceptorship as a natural part of the recruitment process, while others perceive and work with these two processes separately. This was also visible among some of the preceptors, who viewed the process as a way to recruit future colleagues.
When they have been here for a few days, they think that this is the best (work) place…and can definitely imagine working here.

(Preceptor)
It can also be seen as an opportunity to 'test' new colleagues and in some way 'take control' of the somewhat turbulent and challenging recruitment situation. If students have a positive experience of the preceptorship and the workplace, they can play an important role in promoting the workplace.
I think that students are an important part of marketing our workplace and our type of care, because it is quite specific… but I also see students as a very important part of being able to recruit new nurses… even if you do not recruit that particular nurse… if they have a good experience of clinical practice, you will still get external marketing and external advertising.

(Ward Manager)
Managers who viewed preceptorship as connected to recruitment thought it was important for all employees to have a professional approach to students. This applies both to preceptors and to the other employees at the workplace. In some cases, the preceptors experienced this as a dilemma because they felt it was important to show a full picture of the workplace, with both positive and negative aspects.

| D ISCUSS I ON
Both in research and in the organisation of health care, preceptorship and strategies for recruitment and retention of nurses have traditionally been handled as two separate processes. Preceptorship is viewed as part of the nursing profession (Chicca, 2020), and recruitment is regarded as managers' responsibility (Drennan et al., 2016).
However, the global shortage of nurses means that it might be beneficial for recruitment and retention of nurses if these two processes were integrated. The aim of this study was therefore to explore aspects that are important for the integration of preceptorship of nursing students and recruitment and retention of nurses.
Previous studies on preceptorship have identified different factors, such as the image of the individual preceptor as a role model for the prospective nurse (Omansky, 2010) and the preceptor being responsible for the student's clinical learning and socialization in the profession (Happel, 2009;Hilli et al., 2014). Several studies have highlighted the importance of different organisational aspects for meaningful and positive preceptorship (Kalischuk et al., 2013;Panzavecchia & Pearce, 2014). Others show that preceptors face organisational challenges such as no real reduction in their clinical work to reflect their additional responsibilities and no adequate preparation (Dodge et al., 2014;Tracey & McGowan, 2015). These aspects were also mentioned in our study. However, when we apply a more holistic approach and look at preceptorship in the light of recruitment and retention processes, the results can be understood from a different perspective. We identified three overarching themes: perceptions of preceptorship, organising preceptorship and preceptorship in relation to recruitment and retention of nurses.
The first theme, perceptions of preceptorship, illustrates how integration can be hindered by viewing preceptorship as a professional rather than an organisational issue. Providing preceptorship is an obligation for individual nurses and is expected to be carried out without complaint, even though it is additional to nurses' everyday duties. Preceptorship is mainly viewed positively by preceptors because working with students provides an opportunity for development and learning. Some of the managers emphasized the importance of the quality of preceptorship and how it adds value to the whole organisation including patient safety. Managers, together with preceptors and other colleagues, are responsible for the values and norms that shape the conditions for preceptorship and the success of the process from the recruitment point of view.
Within the second theme, organising preceptorship, a crucial factor for integration emerged as a well-defined organisation with clear functions and responsibilities for preceptorship. Integration also requires a continuous dialogue between the key functions (i.e. managers, clinical teachers and preceptors) and planning using a long-term perspective. It is also important to make sure that providing preceptorship is perceived as a joint effort and a shared responsibility by everyone in the workplace.
The third theme, the role of preceptorship in the work with recruitment and retention, implies that it is better for integration if students are welcomed into the workplace as a whole. It is also helpful if students are viewed as possible (future) colleagues, and preceptorship is seen as an opportunity for feedback. To support integration, preceptors also need to see themselves as ambassadors for both the profession and the workplace.
We suggest that the integration of preceptorship and recruitment is not a question for either individual ward managers or individual preceptors. Instead, it needs to involve the whole organisation and be considered as a collective responsibility. Managers who perceive preceptorship as part of their responsibility to lead and organise also seem to establish the necessary conditions for this. They appear to view the provision of preceptorship as an important part of the work environment and a collective responsibility. Integrating the processes of preceptorship and recruitment should therefore have a positive impact not only on both areas, but also indirectly on the work environment and the organisational culture.
One of the limitations in this study is that participants were recruited by the HR department of the organisation. They may therefore be more engaged and more positive about preceptorship than 'the average' ward manager or preceptor. As a qualitative study, the results can also only be generalized at the theoretical level (Crotty, 1998). However, the study offers insights that could be tested in other nursing contexts.

| CON CLUS IONS
In the literature, organisational support has mainly been seen as contributing better conditions for preceptors and preceptorship. Examining both managers' and supervisors' views on preceptorship in relation to recruitment suggests that the relationship can work both ways. In other words, preceptorship can make a positive contribution to both the work environment and future recruitment.
We therefore suggest that both preceptorship and recruitment strategies could benefit from being integrated, particularly because this should result in a more holistic perspective. Students need to be seen by ward staff as future colleagues. This implies the need for better organisational prerequisites for the preceptors, so that they can fully engage in the process of working with students. Preceptorship should also be viewed as a collective and organisational responsibility, rather than the responsibility of individual preceptors. Creating a work environment that is welcoming for students might therefore require changes in leadership, organisational culture and structure.

| IMPLI C ATI ON S FOR N UR S ING MANAG EMENT
The global shortage of nurses means that it is essential for nursing managers to develop organisational practices that enable the integration of preceptorship with recruitment and retention of nurses.
This might also increase the quality of preceptorship and the work environment in general. Managing preceptorship as an organisational and collective responsibility rather than an individual concern could also contribute to a more sustainable recruitment strategy.

ACK N OWLED G EM ENTS
We thank Melissa Leffler, MBA, from Edanz Group (https://en-autho rserv ices.edanz group.com/ac) for editing a draft of this manuscript.

CO N FLI C T O F I NTE R E S T
The research has been conducted independently by the authors.
The funding organisation, a public organisation responsible for the health care in one of the regions in Sweden, assisted in the recruitment of the participants, but the funders had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

DATA AVA I L A B I L I T Y S TAT E M E N T
Author elects to not share data.