Introduction

Nursing preceptorship plays a central role in nursing education. Preceptorship is defined as a professional educational relationship situated within the clinical hospital environment, between a staff nurse (the preceptor) and a graduate or student nurse, involving the delivery of patient care [1]. Therefore, this professional relationship comprises a triadic relationship between the student nurse, preceptor, and the patient (SPP) [2]. The preceptor acts as a role model, supervises, provides guidance and learning experiences, facilitates the socialisation and development of the student in the nursing profession and provides patient care [3, 4]. Furthermore, student assessment and providing continuous ongoing feedback are incorporated within the preceptor role [5]. When students feel their presence is valued and part of the team, and 'preceptors' express empathy towards students, positive interpersonal relationships develop [6, 7]. The quality of the preceptorship relationship can significantly influence the student's integration into the nursing profession and the clinical environment and can affect the student's professional development and delivery of patient care [1, 8].

However, interpersonal attributes demonstrated by preceptors can negatively influence the relationship also, including a hostile cultural environment created by preceptors that imposes a hierarchical status on students [9, 10]. Additionally, preceptors that are dismissive and exclude students from daily activities on the ward result in sometimes hostile or resentful attitudes from students [11, 12]. Furthermore, ineffective feedback methods, i.e., inappropriate locations (In front of the patient) or unconstructive feedback [9, 13], can leave students feeling humiliated and negatively impact their relationship with their preceptor. Indeed, within the researcher's institution, each year, several students report difficulties regarding their lived experiences of preceptorship that occur in the clinical setting. These findings suggest that creating positive interpersonal attributes amongst preceptors is an issue that requires a stronger emphasis in preceptorship education programmes. Despite this a recent scoping review emphasised a lack of focus on interpersonal and communication skills training in current nursing preceptorship programmes internationally[14].

Similarly, positive student-patient relationships are fundamental to the quality of clinical education, delivery of patient care and nursing preceptorships. Patients have valuable perspectives that enrich students' clinical education [15]. However, a recent scoping review [14] highlighted the absence of patients' perspectives on being involved in the preceptorship relationship and the lack of Public and Patient Involvement (PPI) in designing and creating such educational programmes [14]. PPI focuses on the active and meaningful engagement of patients and public members in research processes and activities across a projects cycle [16]. In the UK, the National Institute for Health Research [17] defines PPI as researching with patients and the public, so they are not just participants in the research. Please see Additional file 3 GRIPP2 reporting checklist for PPI involvement in this study. The triadic relations involved in preceptorship include the patient; therefore, this project included patients in the co-design team.

Methods

This project aims to design a new practical "how to precept" based programme that will allow preceptors to actively engage and reflect on their developing interpersonal and communication skills associated with nursing preceptorship. Studies show that continuous reflection on practice facilitates the development of professional-pedagogical competence and positive interpersonal relations [18]. In addition, the developed educational programme will incorporate crucial skills such as teaching and feedback practices. It will also include the patient's voice and experiences for the first time to provide trainee preceptors with the knowledge and skills to effectively carry out their roles as preceptors and improve interpersonal relations.

Therefore, this study aims to identify key "touchpoints" to determine what SPP liked about their experiences of a nursing preceptorship, what worked well for them in generating positive interpersonal relationships or what caused anxiety or adverse reactions in the professional relationship. It also aims to co-design and co-produce an innovative preceptorship education programme with students, preceptors, patients and experts in nursing and nursing education, incorporating experiential knowledge (touchpoints) and scientific knowledge (literature and expert-based knowledge) applying a user-centred design EBCD approach.

Experienced Based Codesign (EBCD) is a form of participatory action research that involves healthcare professionals and patients/members of the public working collaboratively to develop practical service improvements and patient care improvements in healthcare [19]. It is a multistage process that involves exploring and sharing subjective experiences (narrative-based approach) to enhance healthcare professionals' and organisations' skills and knowledge [20]. In this research project, the team adapted an EBCD process to provide a systematic way to identify and prioritise real-world problems experienced by SPP in a nursing preceptorship to inform the co design and co-production of a new preceptorship educational programme.

Touchpoints play a central role in EBCD. Touchpoints represent critical points with an emotional tone within an individual experience of contact between a service user and any aspect of the service, including interpersonal interactions [21, 22]. Sharing and collaboratively discussing and reflecting on the participant's touchpoints provides an opportunity to see situations from different perspectives and better understand nursing practices [19] or, in the case of this study, nursing preceptorship experiences. Narrative interviewing is a method employed to allow the participant to narrate their experience and have their stories captured [23]. Employing a narrative interview methodology using open-ended questions followed by questions based on the key themes identified in a recent scoping review [14], the researcher aimed to capture the experiences and identify major touchpoints of students, preceptors, and patients (SPP) to later inform the co-design and co-production of the new educational programme.

Twenty-six co-designers were recruited (listed in the acknowledgements section). A small sample size of approximately five participants was present per workshop, in line with expert opinion for effective EBCD workshops [24]. Table 1 outlines the diverse sample achieved and the participant demographics. The University Human Research Ethics Committee granted this study's ethics approval.

Table 1  Co-design team demographics
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The EBCD process facilitated the involvement of all three members of the preceptorship relationship (SPP) in conjunction with Clinical Placement Coordinators (CPCs) (end-users; facilitators of the new educational programme), design experts, nursing experts, educational experts, and researchers at every stage of the design process from problem diagnosis to the design and development of this educational programme and its future implementation. The experiential knowledge SPP brings is essential to helping educators acknowledge multiple realities and meanings of nursing preceptorship relationships. It may also identify aspects of the professional relationship that are poorly understood. The co-design workshops employed a design thinking approach, a "human-centric" approach that involves the collaborative generation of ideas, defining and refining issues identified by the SPP. Resulting in iterated and generated solutions through brainstorming and prototype building [25].

Throughout the EBCD process, the researchers ensured authentic involvement from all -co-design team members by implementing Knowles et al.'s framework [26] for authentic co-production. This involved providing a "space to talk", a "space to change", and a "space to talk" again, creating space for shared dialogue and decision making while offering a supportive and friendly environment throughout the project. The project ran for 16 months, commencing in January 2021. Due to Covid-19 government restrictions, the researchers hosted co-design workshops virtually. Table 2 below summaries the steps and outputs using an adapted EBCD approach.

Table 2 Steps and outputs using EBCD
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Results

This study set out to identify critical touchpoints, i.e., personal or crucial memories that shape experiences of nursing preceptorship relationships, to identify key experiential knowledge that later informed the co-design of the new educational programme. Interestingly several similar touchpoints influence the experience and interpersonal relationships from all SPP perspectives, including first impressions, effective communication, and feedback. Other themes included psychological safety and attitude to teaching and assessing students. For full details on SPP Touchpoints and overarching target behaviours to include in the educational programme to address the SPP touchpoints (please see Additional file 2).

Secondly, this project set out to co-design and co-produce an innovative preceptorship education programme incorporating experiential knowledge (touchpoints) and scientific knowledge (literature and expert-based knowledge). It was collectively agreed that the new educational programme would adopt an active blended learning approach consisting of a series of online reusable learning objects (RLOs), face-to-face role-plays and a state-of-the-art virtual reality storytelling experience (Table 3). Two pilot studies previously led by the lead researcher influenced the blended learning programme, having identified that students felt prepared to engage in face-to-face simulation following exposure to RLOs [27]. In addition, his experience of VR storytelling offered the unique ability to provide an immersive storytelling learning experience to supplement learning [28]. RLOs are "a digital resource that can be reused to facilitate learning" [29]. It was collectively agreed that a series of RLOs would be created to promote flexible and autonomous learning online to support a proposed half-day face-to-face simulation. Six RLOs were developed, each addressing a specified learning objective (Table 3).

Table 3 Outline of active blended learning preceptorship educational programme
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Role Play Simulations will allow learners to practice the theoretical and practical information provided in the RLOs. It facilitates the practice of interpersonal and communication skills in a realistic yet safe learning environment [34]. Two role-play scenarios simulating fundamental interpersonal interactions in a nursing preceptorship requiring dynamic and practical interpersonal and communication skills were designed (Table 3).

In addition to the RLOs and role-play simulations, it was decided to develop a new state-of-the-art immersive storytelling experience. This pedagogy combines the emerging world of VR technology with the art form of classical storytelling. During the VR storytelling experience, the learner embodies the role of the patient, feeling the same sensation toward a virtual body within an immersive virtual environment as the biological body in the real world would experience [35]. This will permit trainee preceptors to step into a patient's shoes, experiencing the interpersonal dynamics of a preceptorship relationship from the patient perspective, creating a meaningful and memorable learning experience. It is planned that preceptors will engage with this experience as part of their face-to-face learning, followed by a structured debrief session.

Theoretical underpinnings of new educational programme

A constructivist approach was applied to the new educational programme, believing that active learners in their learning journey create new knowledge from experiences [36], Kolb's [37] experiential learning theory principles also guide the programme's design. In addition, the principles of Universal Design for Learning (UDL), an inclusive approach, were embedded in the programme to ensure that the programme offered all learners, including those with disabilities or required accommodations, providing equal opportunities to learn [38, 39]. Table 4 outlines Kolb's Experiential Learning Theory & UDL principles strategies for the Nursing Preceptorship Programme.

Table 4 Kolb's experiential learning theory and UDL principles strategies for nursing preceptorship programme
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Lastly, to improve the effectiveness and uptake of the new educational programme, the expert group suggested that the programme should also be underpinned by behavioural change theory. Identifying the behavioural barriers and enablers to facilitating positive interpersonal relationships would strengthen the likelihood that the new educational programme would act as a catalyst to change practices among established preceptors. Members of the expert group worked with the lead researcher to achieve this. Table 5 outlines the combined approach of behavioural change theory and EBCD and Kurt Lewin's Model of Change Principles and how they were applied to the new educational programme to promote change in preceptorship practice.

Table 5 Combined use of EBCD, behavioural change theory and Kurt Lewin's model of change principles
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Discussion

Several papers have discussed nurse preceptors learning needs from a preceptor's point of view [40, 41], while Tsai et al. [42] collected data from both preceptors and student nurses on their preceptorship experiences. However, there is no evidence to date investigating patients' experience of a nursing preceptorship to the best of the author's knowledge. Thus, this empirical research implementing an EBCD process to identify preceptor training needs from all three members of the nursing preceptorship relationship is a unique and novel approach to designing and creating a preceptorship education programme.

In keeping with previous research, this study found that first impressions and a welcoming and open disposition during the student's orientation period strongly influence the basis and ongoing premise of the professional relationship [43,44,45,46]. Similarly, patients in this study described the importance of being made feel welcome by a preceptor/student with an open and welcoming disposition as a critical touchpoint that positively influenced their experience by reducing anxiety and creating a feeling of self-worth. These findings align with Holst et al. [47], who reported that patient satisfaction emerged when preceptors made an excellent first impression, were polite and made eye contact. Furthermore, a nurse's body language and tone of voice are strong indicators of how the relationship will evolve at the initial meeting [48]. This study, therefore, further supports the importance of first impressions, including language, tone, and body language, suggesting it plays a vital role in a preceptor creating a positive interpersonal relationship and should be included in preceptorship education programmes.

Including patient in the co-design of the new educational programme identified unique results. The patient co-designers strongly emphasised person-centred communication as an influential touchpoint, citing its importance in facilitating a better patient experience and patient satisfaction. Previous research on patients' healthcare experiences has noted the same [49,50,51,52], reporting effective communication and high-quality patient information can result in better patient outcomes and patient satisfaction. In comparison, several studies have also found a correlation between poor nurse-patient communication and patient dissatisfaction [53,54,55]. Thus, the inclusion of practical interpersonal and communication skills to facilitate person-centred communication in a nursing preceptorship should be included as part of preceptors' education,

Furthermore, patient co-designers indicated the importance of seeking permission prior to a student's learning experience and engaging in student feedback. These results mirror those highlighted in Suikkala et al. [56] scoping review examining patients' involvement in nursing students' clinical education, in which some patients perceived themselves as active participants who facilitated students' learning by sharing knowledge and experience about their care and wellbeing as well as assessed students' performance by providing encouraging feedback. Therefore, it seems patients appreciate the opportunity to contribute to a student's learning process and provide feedback. However, permission should be sought prior to the student being present. Including these views and guidelines to including patients in teaching sessions and feedback in preceptorship education is therefore essential.

Creating bidirectional feedback opportunities was a crucial touchpoint for preceptors in this study. Previous studies also demonstrated an association between preceptor feedback and formulating an open and trusting interpersonal relationship with students [57, 58]. Preceptors in this study also iterated a link between student assessment/feedback and feelings of guilt and pressure when failing a student. Previous studies have demonstrated similar results, with preceptors reporting a reluctance to fail students and the emotional sense of guilt that goes with failing a student [51, 59]. Central to the process of failing a student is providing constructive feedback, yet several studies have highlighted that preceptors feel they need further education in the area of providing feedback to nursing students [51, 60]. Therefore, including practical feedback principles in the new educational programme was imperative to enhance the preceptor's understanding and skills in providing effective feedback.

The co-design team from this study established that a blended learning approach best suited the new preceptorship programme. Many preceptorship programmes are implementing a blended learning approach [20, 61,62,63] as it reduces the time required away from the ward and increases accessibility and convenience as it permits preceptors to complete a proportion of the programme in their own time [64].

In line with the literature [20, 27, 61, 63, 65] the co-design team selected the inclusion of online learning units as an active pedagogy to prepare preceptors for the half-day face-to-face simulation day of this educational programme. Cited benefits of online learning units (also referred to as reusable learning objects (RLOs) include their ability to present theoretical content interactively and promote autonomous learning that can provide on-the-spot feedback [66].

Similar to the current preceptorship programmes [67,68,69] this study identified role-play simulations as a practical pedagogy to develop preceptors interpersonal and communication skills.

Currently, there is no evidence of the application of VR storytelling in preceptorship education programmes. However, reported benefits of VR Storytelling in nursing education include learners finding VR more engaging than traditional teaching methods and allowing a 'safe' environment to practise skills without fear of making mistakes [28]. Learners have also reported its suitability for various learning styles and its more flexible mode of teaching [70]. It is hoped that the inclusion of this new innovative virtual reality storytelling experience will provide preceptors with an engaging and authentic learning experience. It will help foster greater empathy for patients involved in nursing preceptorships by walking in their shoes during the VR simulation and thus develop practical and effective interpersonal and communication skills associated with a nursing preceptorship.

To the best of researchers' knowledge, there are currently no published research papers examining the application of EBCD to co-design and co-produce an educational intervention within the context of nursing education. Therefore, this study adds unique insight into implementing an EBCD method to develop an educational intervention. In line with previous EBCD facilitators [71], the researcher found that individual interviews at the beginning of the project engaged the SPP co-designers and enhanced their commitment to the EBCD process. This study confirms that touchpoints are key to unlocking everyday experiences [72] and sparked a highly collaborative process amongst the co-design team when shared [21, 22]. Per the present results, previous studies have demonstrated that collectively reflecting on each group's touchpoints provides a real opportunity to see a situation from different perspectives and better understand practices [19, 73]. This project's approach to embedding the touchpoint narratives throughout the new educational programme signifies an innovative approach to utilising touchpoint narratives beyond the initial design phase of an EBCD intervention and creating an authentic educational programme.

This study suggests that EBCD can be adapted and implemented in a nursing education context and that EBCD can play a critical role in improving preceptorship education programmes by gathering the perceptions and views of SPP to then collaborate with nursing and educational experts to co-design and co-produce the new educational programme. Including SPP and other key stakeholders (CPC, Nurse educators) as co-designers throughout the EBCD process has proved advantageous; it has meant they were key drivers in the educational content of the new educational programme to ensure it spoke to real-world experiences of nursing preceptorships and practical implications to facilitating a preceptorship education programme.

This new education programme addresses some of the current limitations of preceptorship education programmes observed in the literature. Most notably, the inclusion of the patient voice and perspective throughout the programme. Furthermore, it addresses a key concern for both students and preceptors to incorporate foundational interpersonal skills such as creating positive first impressions or language to use when providing feedback that appears to be lacking in many preceptorship education programmes, including the new national mandatory online preceptorship programme, "Preceptorship in Practice" HSEland [74]. A primary focus of the HSE programme is the preceptor's role in assessing student competency and its associated documentation. Limited focus is placed on the practical skills required to facilitate a positive clinical learning experience, including practical interpersonal and communication skills associated with teaching and feedback, and the patient is not mentioned throughout the programme. Furthermore, this programme is online; therefore, preceptors are not offered the opportunity to apply new knowledge gained from completing the programme in a safe environment, such as role-play simulations included in this new programme. The preceptorship education programme designed in this study was recently approved as a Category 1 (CEU 8 points) by NMBI until Jun 2024. Therefore, it is hoped this new educational programme can support ongoing professional development and be implemented as a preceptorship update course, which NMBI recommend every 2–3 years for all preceptors [5]. It will benefit practising preceptors to reflect on their practice and develop their interpersonal and communication skills to ensure they facilitate positive interpersonal preceptorship experiences and create a positive clinical learning environment for their students. Furthermore, this programme will be available under creative comments and can be adapted for use by nurse educators internationally to suit local policies and procedures.

A significant strength of this study is the multiple methods design of the research, including qualitative interviews and a collaborative participatory design process. The project retained a user-centred design approach throughout, as their lived experience, expertise and knowledge of nursing preceptorship propelled the entire co-design and co-production of the new preceptorship education programme. Furthermore, the credibility and authenticity of the identified touchpoints were internally validated by the co design team. Although a diverse sample of SPP and professionals were recruited, most were female and of Irish nationality. An equal gender balance and representation of other diverse nationalities working and utilising general nursing hospitals in Ireland would provide a greater representation of cultural experiences and attitudes to nursing preceptorship relationships. However, hosting the one-to-one interviews and co-design workshops virtually facilitated broader demographic participation and increased transferability over a study carried out at a single hospital location. Overall, the co-design team actively engaged in the virtual co-design workshops. However, some voiced that they were uncomfortable with teleconferencing technology and preferred to engage over the phone. Bimonthly emails were therefore sent to all co-design members to keep the entire co-design team updated with all the latest outcomes of the workshops. Unfortunately, the researchers could not carry out observational studies in the hospital during the initial stages of the project due to Covid-19 restrictions. Direct observations could have provided further insight into behaviours and interactions during preceptorship. However, a comprehensive review of the literature identified and supported several key themes that emerged from the one-to-one interviews with each of the different cohorts suggesting that their experiences are universal and experienced internationally.

This is the first study to explore the EBCD of a new educational intervention. Replicating this study in other divisions of nursing education, such as care of older person education or surgical nursing education, would help to understand if the findings are generalisable and if EBCD is a suitable framework for co-design and co-development of other nursing education programmes and curricula. Furthermore, examining the co-designers’ experiences of partaking in this study could provide further insight into effective EBCD practices or limitations to creating a new educational programmes.

Conclusion

This paper outlines an innovative adaption of the EBCD method to develop a new preceptorship education programme. EBCD is a valuable framework for developing human-centred educational resources that combine experiential knowledge (touchpoints) and scientific knowledge (literature-based knowledge). It facilitated the opportunity for all participants to have ample opportunities to suggest, create and refine ideas. It brought together individual viewpoints of all involved in nursing preceptorship to create a unique educational programme that captures real-life experiences. Combining interpersonal and communication skills theory with nursing theory, educational theory and behavioural change theory resulted in the development of what is hoped to be an authentic learner-centred educational programme that will equip preceptors with the knowledge and skills to effectively carry out their roles as a preceptor and build positive interpersonal relationships.