Difference between perceptions of preceptors and newly graduated nurses regarding delay in professional growth: a thematic analysis

Background Smooth reciprocal relationships enable a preceptee’s growth, and it has been suggested that without such relationships, the preceptee may not be able to grow successfully. This study explored the differences in perceptions by matching the perspectives of both the preceptees who did not make progress in workplace adjustment and their preceptors. Identifying the differences in perceptions between the two groups is important for improving nursing education and the relationship between preceptees and preceptors. Methods A pair of nurses who had been with the company for less than 3 years and who had previously been transferred or had resigned due to poor workplace adjustment were designated as preceptees, and those who had directly supervised the preceptee during their first year of employment were included as preceptors in the study. A 50-minute semi-structured interview was conducted separately to examine the perceptions of the preceptee and preceptor. A thematic analysis was used to analyse the interview data. Results This study explored the differences in perceptions regarding the clinical practice of nursing between preceptors and their preceptees who did not make progress in workplace adjustment during nursing education; six themes were identified. After interviewing both sides, it became clear that the same event was interpreted differently depending on their positions, perspectives, and contexts. As the preceptees were nurses who had left or had been transferred, the existence of these differences in perceptions suggests that these factors may impact their departure or transfer. However, we do not aim to place blame on one side or the other for the preceptee’s turnover or transfer and would like to consider effective support, not only for the preceptee, but also for the preceptor. Conclusions It is necessary to examine nursing education on the premise that differences may occur depending on the position and role of nurses in the workplace and to look at curricular framework changes to bring in a systemic influence towards the training of young nurses.

within the first year of employment is an urgent issue [1,2]. However, in 2014, WHO and World Bank calculated a global shortage of nine million nurses and midwives [3]. Furthermore, currently in Japan, about 10% of new nurses leave the workforce early-within 1 year of starting work [4,5].
In general, the reasons nurses leave their jobs include organisational factors, such as the work environment and organisational culture, and personal factors, such as job satisfaction and burnout; these factors are complex and intertwined [6]. Factors related to the preceptor turnover (hereinafter referred to as "preceptor" for nurses who are educators) include psychological burden [7], problems related to nursing practice ability [8], reality shock [9] after joining the company, and organisational factors such as human relations and work environment [10,11]. In order to prevent such early turnover, the presence of a preceptor who supports the personal needs of newly hired nurses (hereinafter referred to as "preceptee" for new and young nurses) in the workplace and develops their nursing practice skills is vital. However, in reality, there are many preceptors who have difficulty dealing with preceptees [12,13]. Preceptors find it difficult to comprehend the level of understanding of the preceptees and to communicate smoothly according to the situation [14]. Thus, providing individualised guidance to new nurses is difficult [15].
To develop effective nursing education, it is important to examine the relationship-building process and perceptions of practice between preceptors and preceptees from their perspectives. This is particularly important for postgraduate nursing education because, while nursing students as preceptors before graduation can have a university faculty member who coordinates their relationship with their preceptor, after graduation, this changes to a one-on-one relationship. However, studies from such a comprehensive perspective are limited. In extant studies, when the preceptor and the preceptee were surveyed about their satisfaction with the preceptorship, their job satisfaction was high and the preceptor's strength was reflected in the preceptee's ability to fit in with the new unit, teach, and share knowledge. Conversely, the preceptee indicated interpersonal relationships, communication, and professional development as strengths of the preceptor and teaching, collaboration, and critical care as weaknesses [16]. They also stated that it is important for the personal characteristics and learning styles of both parties to match [16]. In one study that explored the perceptions, experiences, and needs of both preceptees and preceptors regarding preceptorship, it was found that the social role of the preceptor, providing autonomy to preceptees, communication and the use of technology, involvement of nursing managers, and learning styles were the most important factors [17]. Further, it was noted that the relationship between the preceptor and the preceptee was important, and when the preceptor was relationship-oriented, the preceptee's independence was hindered and when the preceptor was task-achievement-oriented, the relationship was tense and the feedback was critical [17]. Smooth reciprocal relationships enable the preceptee's growth, and it has been suggested that without such relationships, the preceptee may not be able to grow successfully.
This study explored the differences in perceptions by matching the perspectives of both the preceptees who did not make progress in workplace adjustment and their preceptors. Identifying the differences in perceptions between these two groups is important for improving nursing education and the relationship between preceptees and preceptors.

Study design
This study was designed based on an exploratory case study approach, which aims to gain an extensive and indepth description of a complex phenomenon that has not been fully studied. Yin [18] defines a case study as 'an empirical inquiry that investigates a contemporary phenomenon within its real-life context' . Being informed by the interpretivist paradigm [19], this study explored how and what perceptual differences between preceptees and preceptors occurred through social interactions in the processes of workplace adjustment. To enhance the methodological rigor and report writing, this study followed the consolidated criteria for reporting qualitative research (COREQ) which offers a 32-item checklist for interviews and focus groups [19] .

Participants
The pairs recruited in this study comprised those individuals who had newly graduated and had left the hospital within the first 3 years due to workplace transfers or workplace maladjustment (preceptees). Furthermore, the preceptors who had directly supervised them during their first year were also included.
We recruited participants with the cooperation of the Department of Nursing at two teaching hospitals with 600 or more beds. To be eligible for participation, nurses had to be qualified but exhibit a delay in professional growth for the first 3 years. In most hospitals in Japan, the Department of Nursing utilises a three-year training programme following the employment of newly graduated nurses as a means for developing nurses. To determine whether a nurse is competent, both teaching hospitals employ the training guidelines of the Japanese Nursing Association's (JNA) Clinical Ladder [20]. This guideline consists of training of new nurses, development of mentors for new nurses, training plans, and nurse evaluation based on the clinical ladder established in Dreyfus model [21]. In this study, we defined delayed professional growth as the nurse not meeting the standards outlined in the JNA Clinical Ladder training guidelines within 3 years of employment, as judged by their instructors and nurse directors, resulting in their resignation or transfer to another division. Here, we termed nurses with delayed professional growth as preceptees. The person who was in charge of educating that preceptee in the first year was designated as the preceptor, and the pair was targeted. Preceptors are nurses who have met the criteria of the Clinical Ladder (Level III, approximately 5 years or more after entering the profession) as indicated by the JNA and are appointed by the director of the nursing department of their hospital [20]. They then undergo, in total, approximately 1 week of teaching and learning support training, usually throughout the year, at their hospital or at the prefectural nursing association.
After obtaining informed consent verbally, the Department of Nursing scheduled interviews with each participant. The author (the interviewer) was introduced to the participants on the day of the interview. The author explained the study objectives prior to obtaining the respondents' written consent in order to ascertain their will to participate in the interview.
Ten pairs of participants from the two teaching hospitals participated, comprising a total of 20 participants.

Ethical considerations
This study was approved by the Institutional Review Board of Gifu University (Approval Number 25-385). As for the content of the preceptors' and preceptees' interview comments on the preceptees' work performance, confidentiality was assured.

Data collection
The interviews were conducted in Japanese by one lead author, who had enough experience of conducting interviews. Interviews were conducted from March to August 2014. A 50-minute semi-structured interview was conducted separately to examine the perceptions of the preceptee and preceptor. All interviewees were interviewed individually in a private room where psychological safety and privacy were ensured so that the content of the interview would not be overheard by others. The interviews were recorded after obtaining the interviewee's consent. In the interview, the preceptors were asked about memorable events in their corresponding preceptee's nursing clinical practice (work). The preceptees were also asked about memorable events in their nursing clinical practice (work). The interview guide was developed by the authors according to prior literature as follows [14][15][16][17]. The interview guide was as follows:

Preceptee
Looking back on your clinical nursing practice (work) in your first year of employment, is there anything that left a strong impression on you?
• Please tell us specifically about this event.
• What do you think were the positives/negatives (cause) of the event? • How did you feel about the incident?'

Preceptor
Are there any memorable events in the preceptee's nursing clinical practice (work)?
• Please tell us specifically what happened.
• What do you think were the positives/negatives (cause) of the event? • How did you feel about the incident?'

Data analysis
A thematic analysis with an inductive approach was used to analyse the interview data [22,23]. The recorded data was contracted to a professional transcription company, and its content was verified by the author. Two researchers (CK, TS) independently read the transcripts several times to understand the text, found the keywords in the text, coded the data from the keywords, and finally, organised these codes into themes by repeatedly discussing the initial theme to modify and integrate the final theme.
Step-by-step coding was done with reference to the literature [22,23]. Co-authors, whose areas of expertise were nursing and health professions education reviewed the data from a variety of perspectives. The validity of the analysis was verified by another researcher (RI), whose area of expertise was education, through a discussion of the final themes until a consensus was reached.

Participants
Through the nursing departments of the two universityaffiliated hospitals, the researcher asked the ward managers to name the target pairs, obtained the informal consent of both members of a pair, explained the results to them, and obtained their written consent. After all authors discussed the data gathered, it was confirmed that the data was saturated and no more new data would be generated, bringing the total number of participants to 20. Consequently, 10 pairs consented to the study. The demographic data of the participants were as follows: ten preceptors were female. The ages of the preceptors at the time they precepted ranged from 26 to 35 years (mean 28.7 years), and at the time they were interviewed ranged from 28 to 38 years (mean 30.6 years). Eight preceptees were female and two were male. They were between 23 to 25 years old at the time of precepting (mean 23.4) and between 24 to 27 years old at the time of interviewing (mean 25). The status of each pair is described below ( Table 1).

Difference in perception between the preceptee and the preceptor
From the interviews, the following six themes were extracted about the perceived differences between preceptees and preceptors regarding the former's clinical practice. Sub-themes and codes are also tabulated together (Table 2).
Next, we summarise the definitions by themes and the descriptions of the preceptee and preceptor pairs. The following table summarises characteristics of the pairs that showed cognitive differences in Themes 1 to 6 across both interviews (Table 3).

Theme 1: Preceptee's ability to carry out their work Definition of theme 1
Performing nursing clinical work in a methodical manner is important, and both parties recognised that this requires hand dexterity, manual dexterity, and the ability to learn to complete the work in a timely manner. Generally speaking, with practice and experience, a person can gradually improve their ability to perform the job and complete it in less time. However, both parties understand that an inexperienced and unaccustomed preceptee's job performance may neither be adequate nor timely; compared to the nurses that the preceptor has taught in the past, this preceptee might be taking longer than is acceptable.
Sub-theme (1): Perceived differences in manual dexterity when performing tasks Both members of a pair were aware of the preceptee's manual clumsiness. However, the preceptee had a hard time accepting this lack of manual dexterity, exhibited a strong desire to improve, and often felt impatient, saying 'I can do it' when unable to do something.
In contrast, the preceptor felt that the preceptee is too clumsy and takes more time than allocated; this feeling can be regarded as dismay. In addition, the preceptor judged the workflow as 'disorganised' and 'not memorised. ' Sub-theme (2): Differences in perceptions of time allocation and pace of completing tasks Both members of a pair were aware that it takes the preceptee a very long time to complete the day's work. The preceptee was aware that this was due to the fact that there were many tasks. In addition, the preceptee was underinformed about the work and in a state of anxiety when performing it. In contrast, the preceptor worked as usual, but was concerned that the preceptee was not able to match this pace. The preceptor felt that the preceptee's work was slower than the required pace.

Theme 2: How to direct preceptee's awareness (attention) during work Definition of theme 2
It is important to maintain a broad perspective in nursing clinical work, such as planning ahead for the next step and observing the overall situation. The preceptee was motivated to perform his/her work and role. Conversely, the preceptor's evaluation stated that the preceptee was distracted, neglected important perspectives, and was unable to fulfil his/her role.
Sub-theme (1): Differences in perception of focused concentration Both members of a pair recognised that it was important to perform nursing tasks while taking a broad perspective and responding to situations. However, they were aware that the preceptee was not able to do so; the preceptee was overloaded with work and oblivious to her/his environment, and did not recognise that she/ he forgot something when doing something else quickly. The preceptor judged that the reasons for this were the preceptee's inability to focus on anything else besides the present task and excessive focus only on the execution of his/her work, ensuring that other things do not come into view. In clinical nursing practice, it is important not only to recall and understand what has been learned, but also to think in terms of application from learning to practice. The preceptee and preceptor both recognised that knowledge at the level of recall using a textbook was not an issue for the preceptee. However, the preceptee did not know how to apply that knowledge to practice and was instead focused on increasing the hours of study. In contrast, the preceptor felt that the preceptee's knowledge In nursing clinical practice, the ability to accurately self-evaluate is important for advancing and deepening learning. In the review and evaluation of the preceptee's practice to date, the preceptee stated that there were no problems in learning and growth. In contrast, the preceptor was concerned that the preceptee had not sufficiently mastered the skills to be able to function independently.

Sub-theme (1): Differences in evaluations of my growth as a learner (satisfied with my growth)
Both parties have been working very hard in their nursing clinical practice. The preceptee felt they had mastered nursing skills through practice, did not feel clumsy, and had a relatively high self-evaluation. However, the preceptor's evaluation of the preceptee's skills was low; the preceptor continuously monitored the preceptee due to unsurety about the preceptee performing nursing skills without supervision. 'I was asked to take the same patient the next day because I could do it yesterday. However, it was reset, or rather, there were times when I forgot the next day even though the skill was done the day before. When no signs of progress (in nursing skills) were shown, the people around me started to wonder, "How are you going to teach them?"'

Theme 5: The nature of communication in the learnerinstructor relationship Definition of theme 5
Communication (reporting, communication, and consultation) with other staff members is important when there is uncertainty about how to perform a task. The preceptee did not feel that there was a problem with her/his way of communicating. The preceptor, however, felt that the preceptee's way of communicating as a learner was not satisfactory.

Sub-theme (1): Differences in attitudes toward learning in learner-instructor relationships
The preceptee never had any problems with interpersonal relationships. However, preceptors felt uncomfortable that the preceptee did not exhibit a learner-appropriate attitude and pretended to understand even though that was not the case.

'I thought I had no problems with it (communication). I do not remember ever having that much trouble with interpersonal relationships either. '
Preceptor 'When I am talking to her/him, her/his reaction is always different than what I expect from a preceptee. When I provided advice in an educational capacity, the other new nurses would respond "yes", she/he would respond "yes, I knew that. " So, I thought she/he said so because she/he was advised something she/he knew, but she/he did not know. ' Sub-Theme (2): Differences in perceptions of how to check operations The preceptees paid attention to the preceptor to know when to report work and how to react. In addition, they found it difficult to respond to a preceptor's inconsistent responses.
However, while the preceptor acknowledged the preceptee's hard work and desperation, the preceptor perceived that important information was not communicated. The preceptor did not know how to respond to the preceptee, and the responses became more withdrawn. In the same ward, it is important to perform tasks in a collaborative manner. However, the preceptee was selfdirected and had little awareness of working with the team and supervisor. Conversely, the preceptor was a member of the team and had a high sense of collaboration, and this was also expected of the preceptee. Sub-theme (2): Differences in interpretation of team collaboration The preceptee was unappreciative of other staff members shouldering the work she/he was unable to do. Conversely, the preceptor coordinated the work behind the scenes so that the preceptee was not overburdened. However, she/he felt pressure from her/his staff, which resulted in more work for her/him, and she/he felt that she/he was burdening her/his staff with more work.

Discussion
This study explored the differences in perceptions regarding the clinical practice of nursing both the preceptees who did not make progress in workplace adjustment and their preceptors during nursing education; six themes were identified. After interviewing both sides, it became clear that the same event was interpreted differently depending on their positions, perspectives, and contexts. As the preceptees were nurses who had left or had been transferred, the existence of these differences in perceptions suggests that these factors may have an impact on their departure or transfer. However, we do not aim to place blame on one side or the other for the preceptee's turnover or transfer and would like to consider effective support, not only for the preceptee, but also for the preceptor.

From the perspective of preceptors
The preceptor tended to ascribe the cause of the preceptee's poor performance to the preceptee alone. In other words, the preceptor tended to attribute the preceptee's inability to perform to internal factors such as personality traits, ability, and effort-a fundamental attribution error [24,25]. Furthermore, the educational repertoire did not match the individuality of the preceptee. For example, if there was no growth in the preceptee, Theme 1, Subtheme (1), preceptors attributed preceptees' inability to clumsiness, or to their nature or personality; Theme 1, Sub-theme (2), preceptors tended to use 'self ' or 'nurses in charge of education in the past' as the standard and then rated preceptees as not able; Theme 6, Sub-theme (3), measures to reduce the workload of preceptees have been attempted, but it is hard to say find an effective way to educate preceptees.
In a survey conducted by Gregg et al. [15], the most common difficulty for new nurse educators in fulfilling their role in nursing education was 'teaching to meet individual needs' . The preceptors in this study did not give due consideration to the individuality of the preceptee and erred in addressing the most significant area of development. Therefore, it is necessary to prepare several educational methods and scaffolds that can be adapted to the individuality and diversity of preceptees, especially nurses who grow slowly, and to train preceptors and educators in these methods.
The preceptor was disappointed with the preceptee's poor performance and negative feelings were associated with it. This suggests that preceptors and preceptees influence each other's relationship. The preceptor gives negative evaluations to the preceptee because the preceptee 'cannot do' more than she/he imagined, and this also causes negative emotions. For example, Theme 4, Subtheme (2), feeling uneasy about preceptee. Furthermore Theme 1, Sub-theme (3), Theme 5, Sub-theme (2), the preceptor is frustrated.
The preceptor understands that the preceptee is not able to do her/his work, but experiences negative affect because she/he is not able to do it as well as imagined (mood congruent effect) [26]. The preceptor understands that the preceptee is unable to perform the task, but experiences negative affect because the preceptee is unable to perform the task as expected. As a result, the preceptor's attitude may become harsher, and it may become difficult to maintain a good preceptor-preceptee relationship. As a result, an irreversible misalignment of the mutual relationship was identified. To prevent deterioration of the mutual relationship between preceptors and preceptees, training in emotional control (e.g. anger management) may be necessary [27].
In addition, the importance of developing a human resource environment in the workplace that is conducive to and supports the education of preceptors was clarified. Theme 4, Sub-theme (2), Theme 6, Sub-theme (2), the staff takes the position that they do not want to be involved, leaving the preceptor to educate the preceptee as if they were someone else.
Despite this, they feel that the responsibility of failure in educating the preceptee is placed solely on the preceptor. Hyrkas et al. [16] found that in the relationship between the preceptor and the preceptee, when the preceptor is in a situation where his efforts are rewarded, the preceptee's satisfaction also increases and the preceptor's commitment to the role is strengthened. Therefore, it is important to review the support system for preceptors and foster a culture of human resource development in the workplace.

From the perspective of preceptees
Preceptees seemed to blame their inability to perform their own work because they were not sufficiently educated. Theme 1, Sub-theme (2), they do not check the techniques with a checklist, and once you have experienced them, you are encouraged to be independent the next time. Theme 4, Sub-theme (2), this can be seen from her statement that she/he has been able to do this in her/ his nursing clinical practice rather than being taught. This is due to the self-serving bias [28,29], in which one's own actions are reasoned in one's own favour, and the preceptee places the blame for her inability on external factors (attribution), namely, that she/he was not properly taught by the preceptor.
In Theme 4, it was found that the preceptee's self-evaluation tended to be higher than the preceptor's evaluation of work performance. Theme 6, Sub-theme (1), the preceptee had never felt the need to communicate or build interpersonal relationships, and it seemed as if this was a difficulty she/he had only faced when she/he entered the workforce.
It can be said that this preceptee experienced the Dunning-Kruger effect [30,31], in which people with lower abilities tend to estimate their own abilities more highly. Furthermore, in Theme 1, Sub-theme (1) and Theme 6, Sub-theme (1), the preceptee is impatient and does not want to admit that he or she is not able. This is the self-evaluation maintenance motive, which is a universal basic motive for human beings to maintain their own evaluation [32]. In this self-evaluation maintenance model, in order to avoid self-evaluation, people maintain psychological distance from others who have high performance levels (in this case, the preceptor). As shown in Table 1, the preceptee may seek psychiatric treatment due to maladjustment in the workplace or personal relationships. Therefore, it is necessary for the preceptor and the preceptee to build a trusting relationship by collaboratively discussing goal setting and learning methods under an educational alliance [33]. For example, using the R2C2 model, consisting of the Relationship building, Exploring Reaction, Exploring Content, and Coating steps, may be recommended as a model that can resolve the mutual relationship through collaborative feedback and coaching [34].

Limitations of the study and future directions
The present study has several limitations: it was difficult to ask both the preceptor and the preceptee to reflect on the same past events and situations, and therefore, we could not match them to the same situations. In addition, since the data were collected at a limited number of sites, caution should be exercised when applying the results to other contexts-the relationship between preceptees and preceptors is not easily generalised. As a question for further research, the relationship between the preceptor and their preceptee who has shown appropriate growth as a nurse should also be explored. Furthermore, as the results were obtained in the field of nursing education, they cannot be generalised to other fields. Further research is needed to explore if the same results of relationship building can be obtained in other health professions.