Preceptorship versus Clinical Teaching Partnership : Literature Review and Recommendations for Implementation in Ghana Confidence

Clinical education is an essential component of the education of nursing students. However clinical nursing education in Ghana is currently facing challenges of poor working relations between hospitals and health training institutions, inadequate preceptor preparations, and inadequate faculty supervisions. Although the dominant clinical education model used in Ghana is the preceptorship model, health service and education industries are faced with challenges of lack of qualified staff, inadequately prepared preceptors, and inadequate supervision from faculty.These challenges undermine the effectiveness of the clinical learning environment and the use of the preceptorship model. The purpose of this paper was to review preceptorship and clinical teaching partnership (CTP) and make recommendations for improving clinical nursing education in Ghana. A literature review was undertaken through a search of databases that included Google Scholar, EBSCOhost, CINAHL, and HINARI. A literature review identified advantages for using clinical teaching partnership (CTP) in clinical nursing education in Ghana. Recommendations were made for the use of CTP in Ghana.


Introduction
Mantzorou [1] defined clinical education as teaching and learning which takes place near a patient.Clinical nursing education prepares students for their professional roles and affords them opportunities for applying the knowledge, concepts, and skills they have learned in classrooms [2].Clinical education is a fundamental phenomenon that holds great importance for nursing education [2].Although nursing care has changed significantly over the past 30 years, methods to clinically educate nursing students have not [3,4].The dominant clinical education model used in Ghana is the preceptorship model [5].However, poor working relations between hospitals and health training institutions in many regions, inadequate preceptor preparations, and inadequate faculty supervisions result in an unstable clinical environment for students [5].A need exists to find an innovative way to effectively educate nursing students to better prepare them for today's health care environment [3].

Materials and Methods
A review of the literature was undertaken through a search of databases that included Google Scholar, EBSCOhost, CINAHL, and HINARI.Key words used in literature search included clinical setting of nursing education; clinical practice in sub-Saharan Africa; preceptorship in Europe; preceptorship in America; preceptorship in Africa; preceptorship in Ghana; clinical nursing education in Ghana; and clinical teaching partnership in nursing.The literature written in English was considered in this review.Papers used in this review were published between 1984 and 2016.Forty articles were identified; however, twenty-seven articles that were written in English and were published between 1984 and 2016 were reviewed.The literature review focused on preceptorship and clinical teaching partnership (CTP) models of clinical nursing education.

Results and Discussions
Several clinical nursing education models were found in the literature.However review considered two common 2 Advances in Nursing applicable models in Ghana.These clinical education models were preceptorship and clinical teaching partnership (CTP).

Preceptorship.
Preceptorship is a one-on-one clinical education model in which an educational relationship provides preceptees with access to proficient role models within a fixed and limited time frame [6].A preceptor is a registered nurse who has been prepared for his or her role in supervision, teaching, assessment, and provision of continuous feedback by completing a preceptorship programme [7].Preceptorship is particularly useful for senior level and graduate nursing students in advance practice roles [7].In preceptorship, the role of faculty is not lost [8].In the past decade, several investigators reported positive findings of collaborative preceptorship models between schools of nursing and health service agencies where nursing students had a positive experience, expanded their knowledge, increased their confidence, and integrated their skills with real-life situations [9][10][11].In a collaborative model of preceptorship, the preceptor, faculty, and student form a triad to facilitate the student acquisition of clinical competence [12].The preceptor and student meet before the first clinical experience to discuss learning styles and goals for competency attainments and the desired outcome of the clinical experience [8].Although the faculty member has ultimate responsibility for student learning outcomes, the preceptor is empowered to conduct formative and summative evaluations of the student's clinical performance and learning outcomes [8].Preceptors are expected to be clinical experts, willing to teach and to be able to teach effectively [13].The use of preceptors requires that planning and education be done to ensure an understanding of the roles of preceptors and faculty [8].Planning and education are facilitated through planned orientations and educational sessions [8].These sessions provide a forum for sharing information related to the philosophical perspectives of preceptorship, expected outcomes, teaching strategies, and methods of evaluation [8].In Thailand, preceptors are educated by a curriculum on preceptorship by the Nursing and Midwifery Council [14].Although preceptorships are widely used in nursing education, empirical data to substantiate the effectiveness of the strategy is limited and conflicting [8].The literature supports projects that have been developed to prepare students and preceptors for the preceptorship experience [15].Benefits that have been derived from preceptorship after adequate preparation of preceptors and students include enhanced ability to apply theory to practice, improvement in psychomotor skills, increased self-confidence [16], and improved socialisation [17,18].One reported project included the use of two self-paced learning models, one for students and one for preceptors [8].The reported outcome was that both students and preceptors felt more prepared for the preceptor experience [8].These findings are in agreement with results of studies conducted by Scheetz, 1989 [19], and Myrick and Awrey, 1988 [18], who reported enhanced students' performance through testimonial documentation of students, faculty, and preceptors.However a study conducted by Olsen et al. [20] and Myrick [21] which included control and experimental groups to determine whether clinical preceptorship would enhance students' perception of competence found no difference in the performance of students assigned to a preceptor group and those who did not have a preceptor.The findings are congruent with findings of Marchette and Merker [22].In Ghana, formal clinical nursing education started in the early 1990s in the form of preceptorship, when nurses were invited from various regions by the Nursing and Midwifery Council (NMC) of Ghana in collaboration with the Ministry of Health (MOH) of Ghana to participate in a preceptorship workshop [5].The nurses who were prepared as preceptors were supposed to prepare more preceptors in their various regions to enhance the clinical teaching of nursing [5].Preparation of other nurses as preceptors did not take place in many of the regions [5].However, evidence in the literature shows that preceptors perform better when they are educated through a preceptorship programme.Al-Hussami et al. [23] conducted a study with the purpose of implementing and evaluating a preceptor training program among nurses.Results showed participants' knowledge on preceptorship improved significantly after a preceptorship education programme.Currently, there is no formal structure of educating preceptors in Ghana [5].For preceptorship to become an effective clinical component of nursing education in Ghana, there must be a strong collaboration between nursing schools and health service, where preceptors and faculty members are regularly educated on the collaborative preceptorship model.Regular education on collaborative preceptorship will encourage preceptors, faculty, and students to work together in establishing clear objectives, implementation procedures, and evaluation measures in the preceptorship teaching experience [5].A survey by Aguwe et al. [24] concluded that motivations for physicians participating in preceptorship programs were opportunities for continuing medical education credits, faculty development, and other academic-related benefits.In contrast, the roles of nursing preceptors in Ghana have not been defined or recognised and accountability for student learning is diffused among staff nurses [5].Agbavor [25] said that though he was trained as a preceptor, it was difficult to combine his role as a preceptor and as an employee of the Ghana Health Service (GHS) since there was no additional motivation from the training institutions and hospital.Currently there is no common understanding between nursing schools and health service for implementation of the preceptorship model in Ghana.Preceptorship should be redefined by nursing education programs in partnership with the Ministry of Health and representatives from health care agencies.Collaborative preceptorship in which preceptors, faculty, and students combine efforts is important in helping students achieve their clinical education goals which is crucial to the education of nursing students.There is need for nursing schools and health service to provide motivations for preceptors and faculty through continuing nursing education credits for nurse preceptors and faculty development opportunities for faculty in order to ensure effective participation by preceptors and faculty in preceptorship.As a result of staff shortages, it is not uncommon to have more students than staff assigned on a particular unit.The inability to provide personalized attention influences student's satisfaction with the clinical experience and subsequent learning.Fewer staff may reduce opportunities for students to be exposed to effective role models and mentors so vital to professional role development.Standards for preceptors can be set by the Nursing and Midwifery Council through a curriculum for preceptorship [14].Nurses who wish to become preceptors should pass an examination by the council and be recognised officially as preceptors in the clinical setting.Additionally, workload of preceptors must be reduced to make it easier to perform their preceptorship responsibilities effectively.There is need for increased research on preceptorship in terms of its effectiveness on students learning in Ghana.

Clinical Teaching Partnership.
Clinical teaching partnership (CTP) is a collaborative model shared by service and academia [8].In a CTP, a clinical nursing specialist (CNS) from the service institution and a faculty member from the university work together to clinically educate students [26].The CNS provides students with client assignments [8].The academic faculty member schedules the experiences [8].Jointly CNS and faculty collaborate in evaluating assignments and performances [8].Communication is reciprocal and essential to the success of CTP [8].The faculty member shares information about problems that may influence the performance of students [8].The CNS keeps the faculty abreast with current student performances [8].Both CNS and faculty schedule clinical conferences to discuss anecdotal records of students [8].Shah and Pennypacker [26] identified benefits of clinical teaching partnership to the CNS and faculty.Benefits to the academic faculty include increased time to pursue scholarly activities and a direct link with clinical staff for purposes of communication about policy procedural changes and new equipment [26].Benefits for the CNS include joint involvement with academic settings, direct avenues for collaborative projects such as writing and publication, and satisfaction in observing students development [26].Feedbacks from students about CTP are positive [8].Reports indicate that students learned several roles assumed by nurses and different ways of performing clinical skills and that their ability to transfer theory learned in the classroom to clinical practice is enhanced in CTP [8].A study conducted by Jackson [27] showed that students who were taught by faculty involved in clinical practice of CTP scored higher in three areas: integration of theory into practice, realistic perception of the work environment, and use of nursing research.In addition a higher degree of autonomy, great self-concept, and self-esteem and enhanced professional and bicultural role behavior were reported [27].Araújo and Koeppe [28] described teaching-learning experiences of nursing undergraduate students in a CTP providing care for clients on substitutive renal therapies and concluded that experiences of students during CTP indicated great interest and good performance of students.The study by Araújo and Koeppe [28] was supported by Penman et al. [29] in which they found an overall satisfaction with CTP in teaching and learning mental health.In a clinician and student evaluation of CTP, clinicians and students perceived CTP as a platform where students and academics were accepted as members of the clinical team and this resulted in increased collaborative relationship between clinicians, students, and academics [30].
The literature did not expose any weakness in the application of CTP in clinical nursing education.In the face of challenges faced in the application of the preceptorship in Ghana and in view of advantages of CTP found in the literature, the use of CTP should be explored in the clinical education of nursing students in Ghana.CTP will prevent situations where faculty is seen as intruders or strangers in the clinical setting because faculty will always be working with a clinical nurse.Practicing CTP in Ghana will keep faculty clinically updated on changes in the clinical setting since his or her clinical teaching partner will always be available for any clarifications on clinical practice.

Recommendations for Implementation of Clinical Teaching
Partnership as a Suggested Model for Ghana.In the face of challenges faced in the application of the preceptorship in Ghana and in view of advantages of CTP found in the literature, clinical nursing education can be improved in Ghana through the use of CTP in which a clinical nursing specialist (CNS) from the hospital and faculty member from the nursing school work together.The problems of inadequate preparation of preceptors and inadequate faculty supervision in preceptorship can be addressed with the use of CTP.However clinical nursing education must be redesigned by nursing schools in collaborations with the Ghana Health Service, National Accreditation Board (NAB), Nursing and Midwifery Council (NMC), and Ministry of Health (MOH) to incorporate CTP in the education of student nurses.The GHS in collaboration with the fair wages and salaries commission (FWSC) will need to create a salary structure for advance practice nurses (APNs) with Master's degrees in nursing who can act as CNS.APNs should have a placement on the salary structure with improved remuneration.Improved remunerations will encourage APNs to collaborate with lecturers in a CTP and work effectively in a CTP.Responsibilities of APNs and nursing faculty in a CTP should include organising regular workshops and seminars for nurses on clinical nursing education and establishing clinical practice calendars to prevent current overcrowding of students in the clinical setting during vacations.APNs in collaboration with faculty will be in the ideal position to provide leadership in implementing clinical research, which is severely limited in Ghana.Nursing schools should also modify their policy of clinical nursing education to incorporate CTP.The NAB and NMC should only give accreditation to new schools with a CTP programme and only renew licenses of existing nursing schools with an effective CTP programme.Promotion of nursing faculty should be associated with faculty activities in a CTP.

Conclusion
Nursing has advanced on many fronts but has seen little progress in clinical nursing education [2].Despite the fact that preceptorship has become the leading teaching strategy of choice in the practice setting [31,32] there is no evidence to support the notion that preceptorship provides students with the opportunity to develop critical thinking.While preceptorship has been shown to facilitate the transitional socialisation of student nurses to graduate nurses [33], there still remains inconclusive evidence regarding the effect of preceptorship on the clinical performance of nursing students in the practice setting [34].Though the predominant clinical education model used in Ghana is the preceptorship model, preceptorship in Ghana is currently facing challenges, with many preceptors precepting by virtue of length of service [5].Though clinical teaching partnership (CTP) is regarded as positive, its application in Ghana is yet to be explored by nursing schools.The current practice of clinical nursing education in Ghana has to be examined collaboratively and modified appropriately by the Ministry of Health, Ghana Health Service, Nursing and Midwifery Council, National Accreditation Board, and nursing schools to ensure effective clinical nursing education.The concept of having APNs with Master's in nursing backgrounds working with lecturers in a CTP will help advance the course of clinical nursing education in Ghana.In a constantly changing situation, where reliance on static knowledge does not advance nursing and may affect patient outcomes, nursing schools in Ghana must explore the use of CTP in teaching students clinically to enhance their ability to think critically, solve problem, make decisions, and reflect on practice [1].