Supporting our graduates – but how?

Preceptors could benefit from having a structured way of thinking about their students skills, writes Peter Kieseker.

Stephanie Fox-Young, RCNA president recently wrote in an editorial how graduates needed to be supported as they start their practice and that access to e-health data would be one way to offer such support. As a third year student in the midst of practicum's my concern is the quality of support given not only to graduates but also to students.

Putting aside those nurses who still resent university students, despite the fact today it is the only way one can become an RN, the willingness to share knowledge and the instructional support given by most RNs and ENs has come as a welcomed surprise to students at the University of the Sunshine Coast. Unfortunately these good intentions are often sub-optimized due to a lack of methodology for providing such support. This article is a suggestion that the world of business has many tools to assist preceptors, and that one in particular, Situational Leadership II, is ideal for working with students and new graduates.

Firstly a little context. There are two forms of leadership: transformational and transactional. Transformational leadership is a form which, as its name suggests sets about to transform a person, a team, a department, an organisation, a country.

It is the visionary leadership and the cultural metamorphosis practiced by such persons as Ghandi and Mandela and in our world of nursing, by Florence Nightingale, Hilda Peplau, and Sister Elizabeth Kenny. It is the type of leadership that, in the writers view, is sadly lacking in most of our health departments.

A NUM might use transformational leadership practices to develop a unit culture but transactional leadership is what is required when working with students. It is the tool to develop their skills and abilities. In transactional leadership the leader (in our case the RN supporting and instructing the student) transacts to provide their knowledge and support in exchange for the student's willingness and application. A leading transactional leadership model and methodology is Situational Leadership II and it is this model, developed by leadership guru Ken Blanchard that has much to offer those who would support student nurses.

Situational Leadership II has two essential elements. The first is that there are four basic leadership styles and that a true leader RN will adjust their style to fit the situation of their students (hence the name, Situational Leadership). The other essential component of Situational Leadership II is that that development of a person is a journey.

There are only three ways to ensure a highly competent, committed team member in your nursing unit. One is to hire such a person. This is hiring a winner and just like hiring a winner in sport, such people are rare, costly and they can usually pick and chose whom they play for and where they work. They are winners, people want them. Few university nursing student or new graduate will be a winner; they just don't have the experience.

The second way to have competent committed people staffing your ward is to pray to whatever divinity you believe in: "Please (insert divinity) send me a peak performing self-reliant achiever to fill my vacancy." You might have a direct line for divine intervention but it could be that God has other things on Her plate on the day.

The third way to provide your unit with a self-reliant achiever is to develop them through what are called the four development levels. This is where the tool of Situational Leadership II has much to offer.

Any nursing student will go through four development levels. It is important at the outset though to understand no student is at a single development level. Development levels are task specific. A student could be at development level 1 for giving interossea injections, but at development level 4 for bed making. So what are the development levels?

Development levels are determined by two aspects: competence and commitment. The interplay of these two provides the four levels of the development journey.

Development Level 1: When a student first starts out they are usually very committed (sadly the word 'usually' is used because unfortunately some students just mooch into nursing without passion or desire but simple because it was the first course that accepted them - so let's just talk about those who are passionate and who purposefully set out to be the best nurse they can be).

Like a bride and groom on their wedding night, or young Sarah or Billy at their first karate lesson, the student nurse is full of enthusiasm and commitment; but little competence. In Situational Leadership II this is known as Development Level 1: The Enthusiastic Beginner - they are all excited and fired up but do not really know what to do. Their commitment is high, their competence is low.

Development Level 2: Unfortunately after a couple of months of marriage - the honeymoon period - the gloss wears off a little. She won't let me go out with my mates and he leaves the toilet seat up. Likewise Sarah and Billy are not so sure about karate anymore. It is harder than they thought, they feel awkward and are not really getting it, and besides all this hitting and kicking hurts. So it is with the student nurse.

Their enthusiasm wanes as they experience resentful staff and hostile patients, and they make embarrassing mistakes by bringing the wrong sized syringe, not understanding an instruction, or fall foul of the pan room Nazi.

They too feel awkward and inadequate, and start to think they will never make it as a nurse. There just seems too much to know. They have arrived at Development Level 2: The Disillusioned Learner - they have learnt a few skills but are a long way from competent and start to wonder if nursing is really for them. Both their commitment and competence is low.

Development Level 3: At this development level Sarah and Billy have mastered the skills of karate.

They may not be world beaters but they can hold their own, skill wise, in a competition. What happens though is they may often doubt themselves. They need their Sensei standing by to support and encourage them to do what they already have the skills to do. It is similar when people learn public speaking. People can master the skills involved, even demonstrate them in a 'safe' environment, but have limited self-confidence when it comes to making a public speech. They need support to put into action what they already know how to do. Nursing students are often at this level of development. They know the skills, have demonstrated competency in OSCA'S, but doubt themselves when on a real ward with real patients.

Students often arrive on wards at Development Level 3 in multiple skill areas; but they need their RN to provide them the support and encouragement to put their skills into action. They are what Situational Leadership II calls Capable but Cautious Performers.

Development Level 4: This is the level that a RN preceptor/mentor wants their student to be at. Here the student knows the skill - they are competent at it - and they have the commitment, comprising of both motivation and self-confidence, to perform the skill.

The student achieves, they have become what the ward needs, a peak performer. At this development level the RN can task them with the assurance the task will be done, and done correctly.

Like a top karate athlete they do not need a Sensei telling them what to do or how to do it, nor do they need support to do it. They know what to do and they are self-confident and self-motivating enough to do the skill themselves. They fuel their own performance. In nursing this translates to a student who is capable of making autonomous, correct decisions and has the skills and self-assurance to act on those decisions. They are also fully aware of their limitations and are not prone to allowing their enthusiasm lead them to exceeding their scope of practice. They have arrived at Development Level 4 - The Self-Reliant Achiever.

So the RN who would give quality support to their student or graduate nurse benefits from recognizing where their mentee is at on their development journey.

Then they match the student's development with appropriate leadership style. There are four leadership styles and they vary in the amount of direction and support provided by the RN to the student. In Situational Leadership II direction means teaching, controlling, supervising, structuring and instructing while support means listening, encouraging, praising, and facilitating.

A student at skill Development Level 1 receives what Situational Leadership II calls Style 1, Directive Leadership. This is leadership that provides firm, clear directions on how a skill is to be done, when and where it is to be done, and what represents it done correctly. The student does not need support at this stage because they get support from their own enthusiasm and passion to do a good job.

Like Sarah and Billy, if the karate instructor directs them to do 50 sit ups and 25 push ups they will throw themselves into it because they are keen and want to achieve.

A lack of support does not mean the RN is not interested in the student, it simply means they don't need a metaphorical arm around the shoulder because the student wants to achieve and will motivate and supports themselves. A mistake RN preceptors are prone to make here is to mistake youthful eagerness with capability. The student may overstep their skill and competency level because of their eagerness to try, to please their preceptor, and to fit into the ward. If an RN delegates a job to a student who is not yet competent in it, it is the RN who is at fault. Unfortunately many drug miss-administrations will attest to this.

The student's journey will now move them into Development Level 2. Here they have some competence for the skill, but disillusionment starts to set in. They can't seem to master the skill quick enough to meet the demands of the ward, patients and other staff. They make honest mistakes and castigate themselves. So here Style 2, Coaching Leadership is needed.

The RN preceptor continues to give clear directions because the student has still not mastered the skill. Such direction though should be less forceful, with more asking than telling (e.g. "Why do you think we would do it this way?" rather than "Do it this way!").

What the RN must also do at this stage is offer genuine support. The student nurse needs to be encouraged and assured they can and will master the skill, and that they can and will 'fit in' to the ward and the profession.

Unfortunately many RN preceptors who daily use nurturing skills for patients and consumers, fail to apply such skills to their students. Students are made to feel useless, or directly told they are, with their education and themselves criticised.

I watched two promising second year students give nursing away because their RN preceptor didn't understand enough, or didn't care enough, to give the right balance of direction and support to move them to Development Level 3.

The student at Development Level 3 does not need direction. They have the skill and competency to do the task. What they lack is a critical component of commitment: self-confidence. Frequently misunderstood by RN preceptors is the student's seemingly variable commitment to their tasks.

This variability is because sometimes the student might feel confident and at other times they might doubt themselves. It is difficult to do a good job if you doubt yourself. So the effective RN preceptor offers encouragement, and support.

They back the student up and build their confidence in applying the skills they already have. The RN becomes a mini cheer squad. How many of us could have achieved so much more if only someone had expressed trust and confidence in us?

With such patient support, a nursing student will continue their journey to development level 4.

The student at Development Level 4 is a peak performer. They know how to do the skill and are committed to doing it well. The RN preceptor just needs to task them, remove any obstacles for them, and get out of their way so they can achieve.

Occasionally the preceptor might offer them a new challenge to stop them from becoming bored or complacent, but essentially the student has been developed to a valuable, fully competent and committed member of the ward team.

They become so because their RN preceptor matched their development level with the leadership style necessary to support the student's journey from Enthusiastic Beginner to Self-Reliant Achiever.

Two last issues. Remember no one is at a single development level. A student might be a self reliant achiever (D4) in taking observations, an enthusiastic beginner (D1) at doing a primary assessment, and a disillusioned learner (D3) at inserting a catheter because last time they tried they failed. Development level is person and skill specific and so the smart RN matches their student's development level with the style of leadership that they need at that time.

Lastly most people in business, and probably many RN preceptors, get it wrong. They over supervise a student who can effectively do the skill and only succeed in alienating the student, creating resentment, or imparting a feeling of distrust.

They are in the students face and it is annoying and condescending. Or the RN under supervises the student whose enthusiasm and willingness might make it seem they actually have the skill. In such cases the student will fail, causing angst between themselves and the RN, and possibly hurting a patient. The amount of direction and support given must match where the student is at, and it needs to be a leadership that changes as the student develops and learns.

Situational Leadership II is one method, borrowed from business, that could provide a tool for RN preceptors to quickly and effectively develop students and graduate nurses. It is a tool that this third year hopes to see in use on his next placement.

Peter Kieseker is third year student Bachelor of Nursing (Graduate Entry), University of the Sunshine Coast.

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