EP 37: How Preceptors Can Prevent New Nurses from Quitting

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Renee Thompson:
Plants thrive and grow in a peaceful, nourished environment, right? Well, it's the same with human beings. But what if that environment is not so peaceful? What if it's toxic? Welcome to Coffee Break: Breaking the Cycle of Bullying in Healthcare – One Cup at a Time. In this podcast, you'll get practical, evidence-based strategies to help you cultivate and sustain a healthy and respectful work culture by tackling an age-old problem in healthcare: bullying and incivility. I am your host, Dr. Renee Thompson.

Renee Thompson:
Hi everyone! Welcome back to the Coffee Break podcast. I hope that wherever you are, whether you're listening or you're watching, you're having a great week. As you know, bullying and incivility are on the rise, and in this podcast, our focus is on equipping you as healthcare leaders with the knowledge, skills, and tools that you need to actually stop it. I mean, we have important work to do in healthcare and no time for these shenanigans. Okay, let's talk. If you have a graduate nurse, a newly graduated nurses, if you have a retention problem right now, you have a preceptor problem. Yes, I just read this study that shows 40% of all newly graduated nurses quit in their first year, many of them quit within a few weeks after completing orientation. And again, I'll just say this: we know it's happening. If you have a retention issue with your newly graduated nurses, you have a preceptor problem. And that's what we're going to talk about today is your preceptors and really what you can do to make sure, number one, that they are protecting your newest nurses. Number two, that they are addressing any incidence of disruptive behaviors that they see from these new nurses, because, you know, you want to make sure they don't become the next generation of bullies. And number three, you want to make sure that your preceptors are not a part of the problem, as what I've seen sometimes they are. So that's what we're going to talk about today. So background: before I started this company, I was in a corporate position for a large health system, and I was responsible for all things really related to student nurses, new nurses, looked at professional development. So I spent a lot of time looking at student nurse internship programs and developing them, new nurse residency programs, receptor development programs, so I had that expertise. And I was hired shortly after I started my company by an organization who basically wanted to hire 100 nurses in 100 days, and they asked me to come and assess whether or not they were ready for that. This was, gosh, 11, 12 years ago? And so I went, and I talked to a lot of people. I talked to HR, I talked to their managers, I talked to, you know, the executives. And it was all about, Are we ready? Do we have a good interview process? Do we have a good hand-off process when we have good candidates? Then, you know, HR would say, Do we have a process where we then hand them off to the managers because sometimes, you know, people slip through the cracks? And as they were talking all about what they were doing on their end to make sure that they were equipped, all of a sudden, I realized nobody mentioned making sure they had preceptors to actually onboard these 100 nurses and that their preceptors were equipped, that they were developed. And when I said that, the look on their faces was shock: Oh my goodness, we didn't even think about the preceptors. Here's the deal. Your preceptors are one of the most important people in your organization because think about their role. They're helping to onboard your newest graduate nurses. Well, and it's not just nurses. If you hire anyone, they usually have some preceptor person, some mentor to help them learn the ropes. But it's not just learning the skills that they need to safely care for patients or, you know, think about their role, but it's also making sure that they fit into your culture, okay? And so what we did was we recognized in this organization that they were ready from an HR perspective. They were not even closely ready, I don't know if that's, if I'm saying that right, because they didn't consider their preceptors. So what we ended up doing was putting together a preceptor development program, making sure that they were equipped so that they could handle these 100 nurses. And we did. So, I built a lot of preceptor development programs. And usually, the first question I ask the group is raise your hand if you participated in some type of preceptor development course. About half of the people in the room raised their hand. And then I asked, How many of you attended a class and continued learning, continued becoming developed as a preceptor? So it wasn't a one-and-done. Half of those people lowered their hand. So there's really only a small percentage of nurses, and this is what I've seen, that learn to be a preceptor, they went to a class, and that they received ongoing development as a preceptor. So first of all, and that's a whole other conversation, it can't just be a one-time bring them in together, teach them how to be a preceptor, and then you're done. They need ongoing development. Okay, so if you're not doing that, please take a look at that, put that on your list. What I have learned through my work with student nurses, new nurses, preceptors is that new nurses have two fears. Their first fear is that they're going to hurt a patient, and I've talked about this before on the podcast. They're going to hurt a patient. But their second fear is their preceptor. Does my preceptor want to be a preceptor? Does my preceptor know how to be a preceptor? Is my preceptor nice? These are the questions that I would always hear from these student nurses before they were starting their work in clinical practice. So, I'm going to give you one bonus tip right now. And then we're going to get into the strategies for protecting and making sure they don't become the next generation of bullies and, you know, what if your preceptor is a problem? But something that I implemented with our preceptor program is that we had the preceptors contact their new hire a week before they were to start, and the preceptor would say, Hi Amy, my name is Renee. I'm going to be your preceptor. I'm really excited. I heard you're going to be starting with us. Yeah, I heard you're starting on Monday. Do you know where to go? Do you know where to park? Do you know what to wear? What questions do you have? And it was just an introduction. My name is Renee. I'm going to be your preceptor. I'm really excited that you're going to be working with us. Do you have any questions? Just that alone is so powerful and alleviating their second biggest fear when they start working. Because my preceptor calls me and tells me that they're excited that I'm going to be working with them. Now, I can just focus on, okay, patient care. Okay, so that's your bonus tip. Let's talk about why your new nurses are leaving. Study after study after study shows that the number one cause of turnover right now in burnout actually is that behavior: toxic workplaces. The McKinsey report came out the end of 2022, and they said, You people have it all wrong. People are leaving not to make $2 an hour more down the street; they're leaving because of how badly they're being treated by their coworkers. And when you take a look at the newly graduated nurse population, what we know about this generation, they won't put up with it. If they're being treated with cruelty by the people they work with, they're like, I'm not putting up with this, out of here, and they will leave you. So they're not leaving because they're being lured by extra money down the road. They're leaving because of how your people are treating them. So, how do you help your preceptors to protect them? Well, first of all, we already talked about you have to develop your preceptors. They have to understand like how to give feedback, okay, so that it's not perceived as criticism. They have to know how to educate. They have to know how to socialize. We use a lot of Susan Boyer's work where it's the roles of the preceptor, you know, socializer, role model, evaluator, educator. They need to understand their role. But when you look and protector is one of their primary roles, so their role of protector, there are two times during a shift, we'll just say it like that, that new nurses are most vulnerable to getting attacked. One of them is during shift report, you know, when all the weapons come out. And what I've seen and what I've experienced is that's when some of the nurses and it's not just the older, experienced nurses, I see nurses doing this who've only been there for a year or two, who tend to pick on, let's just say, nitpick the new nurse to death, and they question them. And it's almost like, and I experienced this as an educator standing in front of a group of people, and I used to teach Med Surge certification review courses. Loved teaching clinical topics. I was really, really good at it. But unfortunately, I don't do that anymore because my work with bullying and incivility has grown so much. But I miss teaching blood gases, I miss talking about diabetes because I know it so well. But there will be times where there'll be a student or, you know, a nurse, a learner in my audience who would start questioning me on, I swear, every slide. And I would get to the point where I would ask myself, Do they really have a question and they want to learn, or are they challenging me? There's a difference, and sometimes you don't know it right away. Are they questioning me because it's an important question, and I need to be able to answer it, or are they challenging me, they testing me to see if I know? And that's what I find a lot during shift report. You have some nurses who are incredibly nitpicky, and when you've got a brand new nurse, they tend to be easy targets, and they will nitpick to see what they know. Now, I actually wrote an article about this how to deal with a nitpicky nurse, and I'll make sure I put a link in the show notes, because again, that's a whole other conversation. You need to be there during shift report. Do not walk away or teach your preceptors this. The preceptor needs to be there. And if that nurse on the receiving end of a report starts nitpicking, they need to stop it. Like, oh, whoa, whoa, whoa, wait a minute here. Let's say you have a nurse who is notoriously known for nitpicking and report. Your preceptor needs to have a conversation with them ahead of time. Say, look, we're not going to do this, okay? We're all trying to help this person learn, grow, become safe to practice, to become part of our team. So, no nitpicking today, okay? No nitpicking tomorrow. How about no nitpicking ever? So shift report is one of those critical times. The other critical time where they get picked on is in making assignments. So I want you to look at your charge nurses and how they're making assignments and what ends up happening sometimes when on orientation, the charge nurse will give the preceptor and their orientee, harder patients, sometimes more patients, because, well, there's two of them. Well, let's just say it takes twice as long and takes twice as much energy to teach someone than to just do it yourself. So, actually, they need one less patient. I know if you go and recommend that, you'll probably have mutiny in your department, but if we're looking at how to help somebody truly learn, become safe to practice, master the basics, they need time spent with their preceptor, especially if they're a newly graduated nurse and learning the skills, and that takes time. But what then happens after orientation? They get the worst patient assignments. They get the difficult patients or difficult family members. And sometimes the mindset is, Well, they got to learn. Throw them in the deep end of the ocean without a life vest. That's how I learned to be a great nurse. So you have to be really careful about that. And again, pay attention to how assignments are being made. Technically, your newly graduated nurse is off of orientation, should get one less patient than everyone else. Should get the easiest patients first until they master the easy. Then you layer, the more difficult. I know that's not always easy to do. However, it's what's best for them so that they can become again safe to practice and a member of your team. The third thing that I'll give you as far as a strategy for how your preceptors can protect your newest nurses, is they need to shut down any negative gossip. Nurses love to talk about each other in a negative way, especially these newer nurses who, let's just say, are not as prepared as new nurses in the past. Well, it's because they learned how to be nurses during a pandemic where we didn't even let them in the building. And I hear this over and over again, where experienced nurses are complaining to their managers about how they have to teach them the basics. Well, yes, here's the deal. It's not their fault. Quit being mean to them. They are not as prepared, but they learned during the pandemic. So you have to just have that conversation with your experienced nurses. But this is where your preceptor can really step up and protect them by saying, Hey, time out. You know, sitting here complaining about what they don't know is not helpful. Why don't we talk about what they don't know and what we can do to help them, okay? They don't know everything. They learned during a pandemic. None of us went through that. So, instead of criticizing them, let's support them. They need to shut it down. We spend so much time and energy complaining about other people. Just imagine if we could take the time and energy and use it for goodness. Okay? Oh my gosh, we get so much more done. But they need to shut down any negative gossip. So that's three: Protect them during shift report when assignments are being made and then shut down any negative gossip. Now, here's what's happening. You know how we used to say nurses eat their young? Well, I've been saying this for 13 years. Now we either young or old and everything in between, you know, we're just a bunch of eaters. Well, what we're finding is it's not just the older, experienced nurses who were eating their young. There's a whole generation, a new generation of bullies coming into nursing who are eating the quote-unquote old. When you interview someone, and this is a whole conversation that we've already had about making sure you don't hire a bully, and I'll put information up, that conversation in the show notes, we need to make sure we hire slowly because some people can look really good on paper, maybe very articulate. But you know, when you're interviewing someone, you're not meeting them, you're meeting their representative and they can bamboozle you. I know myself when I was a nurse manager, I was not good at interviewing people. People bamboozled me, I thought they were great, and they turned out to be, you know, like Attila the Hun, and other people that I thought weren't going to be a good fit were the perfect fit. So just be careful when you're interviewing that because you're short staffed; if you are, the tendency is to hire anyone who wants to work in your department, be very selective on who you hire. But let's say they tick all the boxes: they're articulate, they're eager, they're excited, and then you hire them, and then they start. Maybe they're being disrespectful about your support staff, maybe they're gossiping, maybe they're nitpicking. Your preceptor needs to know how to stop that behavior in the moment. So the first time they hear your new hire say anything disrespectful, especially about someone else, or treat someone in a way that's incredibly unprofessional, they need to stop it immediately. And in the show notes, I'm going to give you a link to one of our most popular resources called 33 Scripts to Address Disruptive Behaviors When You Don't Know What To Say. So have your preceptors, send them that link, have them download, or if you're a preceptor, download it. You've got 33 ways that you can address somebody's disruptive behaviors, because if they don't do anything, they're actually teaching that orientee that it's okay to treat people like that. So they have to immediately address, immediately confront any disruptive behaviors that they see from that newly graduated nurse. Then, they need to start a documentation trail. I know that people, when they are hired, they're usually in a probation period, depending on what state you're in, how your organization is run. I don't understand why we wait until after somebody's off of orientation, past a probation period, before we say, Yeah, they're a problem. You've got to nip it in the bud right from the beginning and start your documentation trail just in case you need it. Hopefully, by setting expectations for how people treat each other in your department and with some redirection, they will adapt their behavior. But if they don't, you need to be ready to actually put them through the corrective action path to termination if they're not willing to step up. If you're the preceptor and you start noticing some disruptive behaviors from your newly graduated nurse, please give your manager a heads-up. You're a manager listening to this: please tell your preceptors, Give me a heads-up if you notice anything. You don't want to be blindsided after they're off of orientation taking a full assignment. You want to know immediately if they start noticing anything that's concerning. So that's how to prevent the next generation of bullies. Immediately confront. Start a documentation trail in case you need it. Give the manager a heads-up. Give someone a heads-up that you've noticed this and how you're addressing it because it might be then that the manager has to get involved and have a conversation with that new nurse, too. And then, finally, What if the preceptor is the problem? I say this too when I talk about charge nurses is: What if the charge nurse is a problem? Here's the deal. With your preceptors, and you know this, not everybody wants to be a preceptor; not everybody should be a preceptor. But let's say you have a preceptor who you've heard complaints about before from their orientee. It's you sitting down with them and setting very clear expectations for their behavior, their conduct, while they're precepting this new nurse. If you continue to get complaints about them, and let's just say you don't have any other people to precept, I'd actually rather you take them out of the role of preceptor than have them continue in that role. Because again, when we look at why new nurses quit if your preceptor is the problem, your preceptor is why they're quitting. And so just to have that honest conversation and be as selective as you can with who you ask to be a preceptor. I was talking to a nurse who her preceptor, very experienced, been there for a really long time, nasty. Actually made her feel she was stupid. Never checked on her throughout the night, okay? She never saw her preceptor. She would have to go to other nurses to ask them, Is this okay? And I don't understand this. Well, it got to the point where they had an incident that there was an incident with a patient. I won't go into details. And it resulted in the manager making a decision to take the preceptor out of that role and actually never let a preceptor precept again because she had numerous complaints about her for years, okay? And she actually gave this new nurse a preceptor who had only been there for eight months, but had the right attitude, was competent. She just didn't have a whole lot of experience, but it completely changed her orientation because she felt that she was safe to speak up. The preceptor then checked in with her, and they actually did the work together instead of like, That's your patient, go for it. So I want you to think about that. Think creatively about if you have a preceptor who is part of the problem, you have to set behavioral expectations first, okay? I 100% recommend that. Don't just say, All right, you're not a good preceptor, you're a part of the problem; out! If you've never had an honest conversation with them, have an honest conversation with them. But then, if they're still not presenting themselves in a professional manner, remove them from the role. All right, last thing I do want to say is that mention this at the very beginning. You can't assume a preceptor knows how to precept. You can't assume that they can easily help onboard someone new to make sure that they're providing safe patient care, and that they're fitting into the culture of your team. You've got to develop them. And we recommend initial, these are the basics, what you need to know to be a preceptor, but then they need ongoing skill development. And it's your lucky day because we actually have a curriculum for preceptors. It's our cultivating a healthy work culture, you know, addressing bullying and incivility curriculum for preceptors. And then this curriculum, what you have is, first of all, they learn what bullying is, what it's not, how it shows up, and what they can do about it. But then in the curriculum, very specifically, it teaches them how to protect their newest nurses. It teaches them how to confront, how to give feedback in a way that's well received. And this curriculum is 100% designed to equip your preceptors with the knowledge: the skills and tools to make sure that they're protecting their newest nurses and making sure their newest nurses aren't the next generation of bullies. So, we'll have a link to that curriculum in the show notes. But if you're losing new nurses, again, I'm going to tell you, take a look at your preceptors, and if you want to actually make sure your preceptors are equipped, just check out the resource, and you can schedule a call with us. We'd be happy to show you this program. All right, so we talked about your newly graduated nurses and the fact that they're quitting and how you need to take a look at your preceptors. So, as we wrap up, I just want to thank you for being here. Thank you for listening or thank you for watching, and for truly doing your part to address disruptive behaviors and cultivate a healthy work culture. We have important work to do in healthcare and no time for any of these shenanigans. So, if you like this podcast, please make sure you review, rate, and share it with others. Thanks so much, everyone. Take care.

Renee Thompson:
Thank you for listening to Coffee Break: Breaking the Cycle of Bullying in Healthcare – One Cup at a Time. If you found this podcast helpful, we invite you to click the Subscribe button and tune in every week. For more information about our show and how we work with healthcare organizations to cultivate and sustain a healthy work culture free from bullying and incivility, visit us at HealthyWorkforceInstitute.com. Until our next cup of coffee, be kind, take care, and stay connected.

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