Preceptorship in Critical Care: p pFacilitating Growth,

Empowering Potentialp g

Dynamics in Critical Care: Our KaleidoscopeDynamics in Critical Care: Our KaleidoscopeOctober 16, 2011

Colleen Collier Breen, RN, BScN, MScN(c), CNCCP(C)Karen Laidlaw RN, BScN, MN, CNCCP(C)

ObjectivesObjectives

To define preceptorship Describe a model for preceptorship Describe a model for preceptorship

development Identify key factors in developing y y p g

preceptorship relationships Describe a preceptorship experiencep p p p Outline communication tools for

preceptorship

Preceptorship: Our ExperiencePreceptorship: Our Experience

Based on clinical course for BScN Expert PCCU nurse as student doing preceptorship

for clinical course with preceptor, clinical educator Expert PCCU nurse working with a fourth year

nursing student incorporating the development of anursing student, incorporating the development of a comprehensive communication tool for feedback

Reviewed literature on preceptorships, matching of partners, structure of experience, and communication

Our RationaleOur Rationale

Shortage of experienced paediatric critical care nursescare nurses

No formal preceptor program in PCCU

We identified that this project hadWe identified that this project had the potential to provide structure for future

preceptorspreceptors

PreceptorshipPreceptorship

Structured relationship between an experienced nurse and a novice nurseexperienced nurse and a novice nurse

Short term Can evolve into a mentor relationship Can evolve into a mentor relationship Enhance the socialization of student

nurses(Carlson, Pilhammar, & Wann-Hansson, 2010)

MentorshipsMentorships

Exist between professionals Mutually beneficial Mutually beneficial Long term and supportive Results in positive professional outcome Results in positive professional outcome

Key Roles of PreceptorsKey Roles of Preceptors

Medical-technical Competence to perform skills Taught in ways that cannot be learned from books Taught in ways that cannot be learned from books

Administrative Reporting and documentation is complex and best taught by

a role model Cannot be learned in a classroom

CaringCaring Learning about competence in the unique care of patients

through assessment, communication, and care planning; Links theory to practice Links theory to practice

(Carlson et al., 2010, p. 766)

Key ComponentsKey Components

From the literature…

a successful preceptorship includesplanning and preparation advocacyplanning and preparation, advocacy,

communication, socialization, and feedback (Collier Breen, 2011)

Benner’s TheoryBenner s Theory

Benner categorizes knowledge and skill development in five progressive stages:

novice advanced beginner competent proficient proficient expert

Why Benner?Why Benner?

Preceptorship provides experiential learning,Preceptorship provides experiential learning, facilitating knowledge transfer from an expert to a novice

Benner’s Model emphasizes clinical nursing care learning by observing and usingcare, learning by observing, and using preceptors

Development of the expert takes place over time

Benner’s TheoryBenner s Theory

Levels are based on changes in three areas:Levels are based on changes in three areas: reliance on abstract principles to reliance on

experience development from segmental to holistic

assessments progression from observer to engaged care progression from observer to engaged care

provider

Learning occurs differently and tasks are carriedout differently at each level (Benner, 1982)

From Novice to ExpertFrom Novice to Expert

It is essential and important for novices to It is essential and important for novices to “know how”

“A new nurse begins with theory as a guide; an expert nurse refines theory through p y gpractice and proceeds to use past concrete experience as paradigms”

(B & W b l 1982 13)(Benner & Wrubel, 1982, p. 13)

From Novice to ExpertFrom Novice to Expert

It is only through experience that a nurse can It is only through experience that a nurse can move from one stage to the next

(Benner and Wrubel,1982)

Benner recognized a difference between the ideas of “knowing that” and “knowing how”ideas of knowing that and knowing how “know how” can exist without “knowing that”

(Altmann 2007)(Altmann 2007),

From Novice to ExpertFrom Novice to Expert

Growth from novice to expert does not always Growth from novice to expert does not always occur; not all nurses will become expert

(Altmann 2007)(Altmann 2007)

“Experience is not the mere passage of time p p gor longevity; it is the refinement of preconceived notions and theory” (Benner, 1982, p. 407)

Thoughts on PreceptorsThoughts on Preceptors

As preceptors: As preceptors: expert nurses role model the integration of

individualized patient assessments into a meaningful story, using technical and critical thinking skills (Dracup & Bryan-Brown, 2004).

In preparation for preceptorship: experienced nurses reflect on their experiences as experienced nurses reflect on their experiences as

novices, noting the stress that preceptees may experience (Dracup & Bryan-Brown, 2004).

Thoughts on PreceptorsThoughts on Preceptors

Must learn about the preceptee’s unique qualities and goals before they can effectively t h kill f ilit t l i t ititeach skills, facilitate learning opportunities, and increase socialization

(Dracup & Bryan-Brown, 2004, p. 450)

Must have vision, a positive attitude, and excellent communication skills to facilitateexcellent communication skills to facilitate preceptee confidence, accountability, and critical thinking (Dracup & Bryan-Brown 2004)critical thinking (Dracup & Bryan Brown, 2004)

Baby BoomersBaby Boomers

Competitive very dedicated and driven Competitive, very dedicated and driven Value life long learning and see education as

a means to further successa means to further success “What” and “how” come before “why” Demand respect for their experience and Demand respect for their experience and

believe that they know what they need to learn

Generation XGeneration X

Want to be successful, but want balance Recognize the need for continuous learning Comfortable with technology Want a casual, fun learning environment that

focuses on skill developmentfocuses on skill development Learn by doing, need to see progress Willing to work hard, but time off is time offg

Millennials (Gen Y)Millennials (Gen Y)

Deal in reality Technology-focused and view advances as

commonplace Collaborators, rely on networking, often have

contingency plans View job training and education as currency for their j g y

current and future jobs Free thinkers with strong views MultitaskersMultitaskers Desire respect Enjoy immediate and constant feedback

Intergenerational Challenges in P hiPreceptorships

Generations don’t understand one another or respect what each has to offer and are reluctant to learn from one anotherone another

Millennials are perceived as lazy, having a sense of entitlement and having no idea what they don’t know

G X i i d b i h d k d Gen X is perceived as being hard workers and dependable, but not willing to put in extra time

Boomers are perceived as being intolerant of the younger generations and those who don’t pull their weight

Lack of understanding creates tension as people feelLack of understanding creates tension as people feel undervalued or motives are misunderstood

Considerations for PreceptorsConsiderations for Preceptors

Each group brings different experiences, values, and work ethic to the team

Important to establish a collaborative relationship, toImportant to establish a collaborative relationship, to learn about individual values, goals, and experiences and to integrate diversity into the experience

Novice nurses experience considerable stress Novice nurses experience considerable stress, including generational stress, during preceptorship

There is a need for research to understand the i t f ti l di it t hiimpact of generational diversity on preceptorships, recruitment, and retention (Earle et al., 2008, p. 266)

RememberRemember…

“No one is a permanent expert”.Professional development requires us to beProfessional development requires us to benovices at certain stages in our careers. “Itis possible to become an expert at beingis possible to become an expert at beingnovice”. A true expert is expert at being

inovice. (Volpe Horii,2007, p. 372)

Preceptorship: Our ExperiencePreceptorship: Our Experience

Based on 4 month preceptorship Matching of preceptors and preceptees Matching of preceptors and preceptees Shared goals Learning plan development Learning plan development

Matching of PartnersMatching of Partners

Based on geographic location of both preceptor/student for pre-grad student

L f h i t t lit Less focus on her interests, personality,level of knowledge for ICU

P t h b i d d Preceptor chosen by experienced pre-grad post RN student based on personal areas needed for growthneeded for growth

Cheerleaders, Mentors, S k h ldStakeholders

Coordinator, charge nurses, colleagues notified from beginningS li it d th i t Solicited their support

Shared goals of experience

Preceptors Crossing GenerationsPreceptors Crossing Generations

Three generations involved in this project:

Baby Boomer (preceptor/student) Generation X (preceptor) Millennial or Generation Y (student)

Generational FactorsGenerational Factors

Preceptor (Clinical Educator) → Gen XPreceptor (Clinical Educator) → Gen X Want to be successful, but want balance Need for continuous learning-just finished MSN Comfortable with technology Willing to work hard

Preceptor/Post RN Student → Baby Boomer Strong work ethic Committed to learning-just finished BScN Outgoing and resilient

E i d Experienced Both finishing same degree

Nursing Student → Generation Y Novice Quiet, successful in school Lived at home Experienced with technology Liked work challenges

(Earle et al., 2008)

CommunicationCommunication

Influences the development of the relationship

Impacts the quality of learning Enhances socialization of the student Promotes self awareness and professional

development Promotes self confidence

Preceptorship ModelPreceptorship Model

Benners Model Developed the for learning in an ICU Gave experience structure Familiar to all of partners

I t d i l i t l Incorporated various learning styles Focused on various levels of expertise

Preceptorship GoalsPreceptorship Goals

1. To learn to care for children from NB to 18 yr2. To enhance assessment, care planning,

d d d t tiadvocacy, and documentation3. To implement philosophy of family centered

care4. To experience multiple ways of knowing5 T id t iti f i li ti f5. To provide opportunities for socialization of

student

#1 Patient Experiences#1. Patient Experiences

Tools to learn Advocate for a variety of assignmentsy g Based on the learning needs of the student Needed to focus on less complex eeded to ocus o ess co p e

assignments

#2. Assessment, Planning, Ad D t tiAdvocacy, Documentation

Flexibility to progress at her own pace Focused on patients who were stable with life

li iti ditilimiting conditions No patients who were unstable due to lack of

iexperience Wanted her to progress in independence

#3 Family Centered Care (fcc)#3. Family Centered Care (fcc)

Opportunity to family interaction and advocacy

Modeled therapeutic relationships and fcc Gave her time to be with patients/families

herself

#4 Multiple Ways of Knowing#4. Multiple Ways of Knowing

Empirical, esthetic, ethical, personal knowledge (Draycup & Bryan-Brown, 2004)

Attended a professional workshop together Observation days in ER, NICU, PMDU Family meetings Memorial End of life decisions and memory box

#5 Socialization#5. Socialization

Individuals gain skills needed to become member of group (Carlson, Pilhammar, & Wann-Hansson, 2009)

Tour of unit and hospital to meet team Introduced on rounds and shift change Social functions Afternoon tea at end of the rotation

Focus on CommunicationFocus on Communication

Communication Challenges Challenges of giving mutual feedback Busy ICU with high acuity patients-minimal

time for feedbackP t ft t ith hild Parents often present with children

Shift to shift report already time consumingS l d ff i Several days off in a row

Communication StrategiesCommunication Strategies

In the moment feedback End of shift review Website Formal evaluationso a e a uat o s

In the Moment FeedbackIn the Moment Feedback

Feedback provided at the point of care during the experience

Immediate, timely, brief Just the facts

ExamplesExamples

Hanging an IV bag Doing assessments Giving medications

Preceptee:“I appreciated how my preceptor would explainwhat to do but would still be there if I neededhelp. This helped build my self confidence…”p p y

End of Shift SummaryEnd of Shift Summary

Provide a brief overview of the shift in 5 minutes or less

a) Describe the shift in one wordb) What went well?c) What didn’t go well?d) Identify one goal for next shift.

ExamplesExamples

After a very busy shift with a little baby with a geneticAfter a very busy shift with a little baby with a geneticcondition who was ventilated and unstable. Had a familymeeting regarding end of life decisions during the day.

End of shift summary: Preceptor: ChaoticPreceptor: Chaotic Preceptee: Busy What went well? Discussions with family What didn’t go well? Not a lot for student to do What didn t go well? Not a lot for student to do. Goal for next shift: Give student more independence to

complete tasks

WebsiteWebsite

No confidential information or identifiers Only used by student and preceptor Content

a) An introduction page with information and lgoals

b) Discussion page for feedbackC l d f i t d l tic) Calendar for assignments and evaluations

ExamplesExamples

Preceptor:“The last shift was a good opportunity to organize care in a stable patient. Vital sign routines and medications and enteral feedings were done every 4 hours. More assignments like this would be helpful. Keep working on initiative to start routine care early, plan and organize what needs to be done and how to best complete all care. This will save you time and stress.

H NICU hift?”How was your NICU shift?”

ExampleExample

Preceptee:“I had my buddy day at NICU. I have never taken care of y y ychildren that tiny before: it was a bit scarey!. This baby is 24 weeks gestation and his skin bruised so easily that both the nurse and I wanted to minimize the amount of touching. The nurse explained how infants tend to rebound from dips in their oxygen saturations so the nurses on that floor are not that easily alarmed when their machines start to beep.”

Formal EvaluationFormal Evaluation

Standardized by university Identify goals and examples of completion Identify goals and examples of completion Used communication tools, especially

website for examplesp Ongoing evaluation No surprises No surprises Reciprocal feedback promoted

ExamplesExamples

Preceptee:“I learned about the complex history of a patient, did the

assessment and then worked with the child andassessment, and then worked with the child and family. By watching my preceptor, I learned about interactions to gain trust.”

Preceptor:“By the end of the shift she was laughing and playingBy the end of the shift, she was laughing and playing

with him. The preceptee noted that these are the kinds of experiences that you can’t learn from a book.”

SummarySummary

Successful preceptorship experience Excellent clinical course experience

G d l ti hi Good relationship Excellent communication Triage of preceptee could have been better Triage of preceptee could have been better Good relationships with clinical advisor and clinical

educator to support relationship Reinforced the need for flexible goals Anticipation of progress of student through Benner’s

t ti t dstages over-estimated

ConclusionsConclusions

Learning plan development multiple strategies Reciprocal feedback increased when

communication was identified in advance Research, based on these communication

tools, may be useful Preceptor recruitment and partner matching

is crucial to successful preceptorships

“Every interactionEvery interaction is an opportunity

to buildto build confidence and competence.”

ReferencesReferences

Altmann T (2007) An evaluation of the seminal work of Patricia Benner: Theory or Altmann, T. (2007). An evaluation of the seminal work of Patricia Benner: Theory or philosophy. Contemporary Nurse, 25(1-2), 114-123.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, California: Addison-Wesley Publishing.

Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(3), 402-407. Benner P Tanner C & Chesla C (1992) From beginner to expert: Gaining a Benner, P., Tanner, C., & Chesla, C. (1992). From beginner to expert: Gaining a

differentiated clinical world in critical care nursing. Advances in Nursing Science, 14(3), 13-28.

Benner, P. & Wrubel, J. (1982). Skilled clinical knowledge: The value of perceptual awareness, part 1. The Journal of Nursing Administration, 12(5), 11-14.

Benner P & Wrubel J (1982) Skilled clinical knowledge: The value of perceptual Benner, P. & Wrubel, J. (1982). Skilled clinical knowledge: The value of perceptual awareness, part 2. The Journal of Nursing Administration, 12(6), 28-33.

Billay, D. B. & Yonge, O. (2004). Contributing to the theory development of preceptorship. Nurse Education Today, 24(7), 566-574. doi:10.1016/j.nedt.2004.07.010

Billings, D. & Kowalski, K. (2004). Teaching learners from varied generations. The Journal of Continuing Education in Nursing 35(3) 104-105Continuing Education in Nursing, 35(3), 104 105

Canadian Nurses Association, Achieving excellence in nursing practice. October 2004. Retrieved from http://www.cna-aiic.ca/CNA/documents/pdf/publications/Achieving_Excellence_2004_e.pdf October 13, 2011.

Carlson, E., Pilhammarb, E., & Wann-Hansson, C. (2010). “This is nursing”: Nursing roles , , , , , ( ) g gas mediated by precepting nurses during clinical practice. Nurse Education Today, 30(8), 763- 767. doi:10.1016/j.nedt.2010.01.020

ReferencesReferences Dracup, K., Bryan-Brown, C. W. (2004). From novice to expert to mentor: Shaping the

future. American Journal of Critical Care, 13(6), 448-450. Retrieved fromfuture. American Journal of Critical Care, 13(6), 448 450. Retrieved from http://ajcc.aacnjournals.org/cgi/content/full/13/6/448

Earle, V., Myrick, F., & Yonge, O. (2008 ). Preceptorship in the intergenerational context: An integrative review of the literature. Nurse Education Today, 8(4), 258-266. doi:10.1016/j.nepr.2007.09.005

Feiertag, J. & Berge, Z.L. (2008). Training generation N: how educators should approach g, g , ( ) g g ppthe net generation. Education & Training, 50(6), 457-464.

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Quarterly, 25(2), 11-21.

Your ExperiencesYour Experiences

Questions

ContactsContacts

Colleen Collier Breencolleen collier@lhsc on cacolleen.collier@lhsc.on.ca

Karen LaidlawKaren Laidlawkaren.laidlaw@lhsc.on.ca