Sample Graduate Student Practicum Deliverables Libby Zamis Graduate Nursing Student University of Illinois at Chicago Fall, 2008 Practicum Deliverable

Sample Graduate Student

Practicum Deliverables

Libby ZamisGraduate Nursing Student

University of Illinois at ChicagoFall, 2008

Practicum Deliverable

Becoming a Nurse Mentor

Northwestern Memorial HospitalFebruary 12, 2009

Agenda

• Introductions

• Review the purpose and goals of the program

• Mentees – new grads and experienced nurses

• Roles of a Mentor:– Coach

– Consultant

– Relationship builder

• Active Listening

• Conflict Management Techniques

• The specifics of NMH’s program

Introductions

Learning Objectives

By the end of this 4 hour session, you will be able to:

1. Identify the needs of a nurse new to an organization

2. Distinguish the difference between a mentor and a preceptor

3. Describe attributes of each of the three primary roles of a mentor

4. Apply specific techniques the mentor uses for active listening

5. Use tools and steps to successfully manage or resolve conflict

6. Verbalize the expectations of a mentor

Nursing Best People and Professional Excellence Committee created a New Hires Socialization Program

• Idea of a program started in ????

• [process/steps – get information from Rachel]

• Sparked idea• Literature findings: (Journal for Nurses in Staff Development, 2006; JONA, 2006)

0 10 20 30 40 50 60

Replacement Costsper RN ($1,000)

Turnover Rate in FirstYear (%)

20%

Nursing Best People and Professional Excellence Committee created a New Hires Socialization Program

• Literature findings:– 30% turnover rate

– Replacing 1 RN costs ~$60K

• NMH data

0 10 20 30 40 50 60 70

% of New HiresBetween 22 & 30

Years Old

% of Turnoverwithin First 6

Months

% Turnover Ratewithin First Year

50%

The New EmployeeNew Grad and Experienced Nurse

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Scott, Engelke, & Swanson (2008)

Scott, Engelke, & Swanson (2008)

Reality Shock

• Marlene Kramer developed this concept in 1974

• It is when the student-turned-professional realizes that what they learned in school is not what is done in real life

• 4 Phases are:– Honeymoon

– Shock

– Recovery

– Resolution

Professional IdealsProfessional Ideals Work RealitiesWork Realities

Comprehensive, holistic care

Mechanistic, fragmented care

Emphasis on quality of care

Emphasis on efficiency

Explicit expectations Implicit expectations

Balanced, frequent feedback

Intermittent, often negative feedback

Experienced Nurses

• Patricia Benner – “From Novice to Expert: Excellence and Power in Clinical Nursing Practice” (1984)

– Novice

– Advanced beginner

– Competent

– Proficient

– Expert

• The meaning of experience– Each step builds on the other by refining and expanding abstract

principles through experience

– Do they have 10 years of experience or 1 year’s experience 10 times?

Experienced Nurses

• Novice– No experience with situations in which they are expected to perform

• Advanced Beginner– Starting to have experiences so they can see some recurring

components

• Competent– Have similar situations for ~2-3 years and sees their actions impacting

care plans and patient goals

• Proficient– They see the whole picture and are reactive to nuances

• Expert– Intuition that delves into problems with accuracy and without spending

energy on alternative diagnoses and solutions

Experienced Nurses

The Imposter Syndrome

There is something I don't know,That I am supposed to know.

I don't know what it is I don't knowAnd yet am supposed to know.

And I feel I look stupid if I seem to both not to know it,And not to know what it is I don't know.

Therefore, I pretend to know it.This is nerve-wracking since I don't know

What I pretend to know,Therefore, I pretend to know everything.

R. D. Laing (1970)

Break

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Congratulations on becoming a mentor!

Ulysses deriding Polyphemus - Homer's Odyssey by Joseph Mallord William Turner (1829)

“A mentor points to doors – they don’t open them. But they enable you to find the strength to open them yourself…”

(SCOPME, as cited in Dancer,2003, p.1)

Preceptor• “An instructional role in which

a nurse is paired for a specific time period with a new nurse in order to orient the new nurse to the organizational and professional practices and competencies”

• A structured process

Mentor• “An advisory role in which an

experienced, highly regarded, collegial person guides another individual in the development and examination of their own ideas, learning, and personal and professional development”

• An unstructured process

The University of British Columbia, 2004. Retrieved October 30, 2008 fromhttp://www.health-disciplines.ubc.ca/pm/managingprograms/precepting-vs-mentoring/continuum.htm

A Trusting Relationship

Used with permission from www.FreeFoto.com

Primary Roles of a Mentor

• Coach

• Consultant

• Relationship Builder

CoachA coach does not play in the game, but helps the players

identify areas to improve their game, andcelebrates the successes with them”- Byron & Catherine Pulsifer, 2004, “What does a coach do?”

• Provides encouragement• Encourages open discussion• Provides inspiration and motivation• Provides direction and shares the vision• Identifies needs and areas to improve• Is open to change, willing to try new ideas• Communicates expectations• Focuses on solutions not problems• Believes in people; sees their potential• Has high expectations; assists people to achieve their potential• Focuses on the “why” not the “how”

PICK a Mentoring Lesson

From Sharing Wisdom: The Practical Art of Giving and Receiving Mentoring, 2000

Consultant

• Helps to identify problems and develop solutions

• Promotes reflection and personal accountability

• They don’t:– Do all the thinking

– Provide all the answers

– Do all the work

Consultant

• Basic 6-step process for problem solving– Define problem

– Brainstorm ideas

– Prioritize ideas

– Develop action plan

– Implement ideas

– Evaluate the solution

–Rework the solution if it isn’t working!



Relationship Builder

• Assists the mentee in managing relationships

• Necessary to have:– Excellent communication skills

– Excellent listening skills

– Conflict resolution skills

– Negotiation skills


• Alternative Intelligence (Goleman, 1996)– Emotional intelligence

– Self awareness

– Self regulation

– Self motivation

– Social intelligence

– Social awareness

– Social skills

– Empathy

Relationship BuilderSocial Intelligence

• The competence/intelligence behind personal interactions and behaviors

• Concepts used to make sense of social relationships and rules used to draw conclusions:– What situation am I in and what kind of person is this who is talking to

me?

– What did he/she mean by that?

– What am I going to do about it?


• Social awareness– Empathy– Attunement– Social cognition

• Empathy– Understanding and developing others– Service orientation– Understanding diversity– Political awareness

• Social skills– Communication– Leadership– Conflict management– Collaboration and co-operation– Team capabilities



I, I, I, I, IYou’re a good/poor listener!

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Active Listening

• A complex and demanding activity

• It is a way of listening and responding that focuses on the speaker

– Overt messages

– Covert messages

• Responding is more than answering

Active Listening

• 5 key elements– Pay attention

– Show you are listening

– Provide feedback

– Defer judgment

– Respond appropriately

Active Listening

• Tip: if you find you are responding emotionally to what is being said, say so and ask for more information.

– “I may not be understanding you correctly, and I find myself taking what you said personally. What I thought you just said is ___, is that what you meant?”

(http://www.mindtools.com/CommSkll/ActiveListening.htm)

ParaphrasingLetting the mentee know that

you hear, understand, and care.

ClarifyingLetting the mentee know that you

hear, but you’re not sure of what youheard

• In other words…

• What I’m hearing…

• From what I hear you say…

• I’m hearing many things…

• As I listen to you, I’m hearing…

• So, you think…

• It sounds like you want…

• Let me see if I understand…

• To what extent…?

• I’m curious to know more about …

• I’m interested in…

• Tell me how that idea is like (or different from)…

• So, are you suggesting…?

From the Virginia Department of Education Mentor Training, 2007

Language of Support

MediatingAllowing the mentee to reflect

or raise awareness

ImaginingHelping the mentee to think

about alternatives.

• What’s another way you might ...?

• What criteria do you use …?

• What would it look like if …?

• When have you done it like this before …?

• What might you see happening if …?

• How was …different from …?

• How do you determine …?

• It’s sometimes useful to …

• A couple of things you need to keep in mind …

• Something you might try considering is …

• To what extend might … work in your situation?

• There are a number of approaches …

• What do you imagine might … ?

Language of Support

From the Virginia Department of Education Mentor Training, 2007



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Conflict Management

Crucial Confrontations: Tools for Resolving Broken Promises, Violated Expectations, and Bad Behavior, 2005

What is a Crucial Confrontation?

• “Confront: to hold someone accountable, face to face”

• When handled correctly:– Conversation is open

– Conversation is honest

– Both people are candid

– Both people are respectful

• Result:– Problems are resolved

– Relationships benefit

accountability


In a study, researchers posed as doctors, phoned nurses and asked them to medicate a patient.

Which percent of nurses tried to comply?

What’s A Crucial Confrontation?

A. 10 %

B. 30 %

C. 55 %

D. 95 %


Very often new employees are confronted with conflict between themselves and co-workers, preceptors, or managers


“I made a Freudian slip last night.I called my husband by the name of my first boyfriend

It was embarrassing!”

“I did the same sort of thing.I meant to say to my husband,“please pass the potatoes,” but

I said, “Die, loser, you’ve ruined my life!”

FESTER

FESTER

FESTER

FESTER

FESTER

FESTER

FESTER

FESTER

FESTER

FESTER

“Speak when you are angry,and you will make

the best speech youwill ever regret!”


Choosing What

• Signs you’re dealing with the wrong problem– The solution doesn’t get you what you want

– You’re consistently discussing the same problem

– You’re getting increasingly angry


How to choose WHAT

Break-up the problem bundle.

Look at what is really bothering you.

Shorten the issue into a single sentence.


Tools to Get to the Correct Confrontation

Content

Pattern

Relationship


Decide IF you ShouldHold the Confrontation

• Failed promises are clear cut

• Unclear situations?– Consider the consequences

• 2 ways to decide IF:– You are not speaking up and you should

– You are speaking up and you shouldn’t


Decide IF you ShouldHold the Confrontation

• You are not speaking up and you should– Am I acting out my concerns?

– Is my conscience nagging me?

– Am I choosing the certainty of silence over the risk of speaking up?

– Am I telling myself that I’m helpless?

• You are speaking up and you shouldn’t– Will you ever be in this position again?

– What are the “unwritten” rules for what is addressed and which issues slide?

– Do you want to differentiate yourself

– Are you willing to do that without the “social support”


Changing a what into a WHY

“What’s the matter with her?”

“Why would a reasonable, rational, and decent person do that?”


How to Start a Crucial Confrontation

• What NOT to do:– Don’t play games

– Don’t play charades

– Don’t pass the buck

– Don’t play read my mind

• What to do:– Start with safety

– Share the facts

– End with a question

“I’m sorry, but my osmosis is broken!”


What to do

• Start with safety– People feel unsafe when they believe:

1. You don’t respect them

2. You don’t care about their goals

• Share the facts– Don’t keep others in the dark

– Tentatively share your story

• End with a question– “What happened?”


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Mentoring vs. PreceptingThe Roles of a Mentor

The NMH Program

• Mentoring new employees between 22-30 years of age hired in December, January, and February 9th

– This is the at-risk group for voluntary terminations

• “Matching session” will be held this afternoon– Mentees have looked over your bios that you wrote in January

– “speed meeting” – mentors and mentees will talk one on one for 2 minutes to get to know each other

– Mentees will then write down their 3 choices in mentors

– A Best People Committee small group will compile matches and let mentors and mentees know who has been matched up

– Mentor will have ~3 mentees

Education and Outing Days

• Sessions will be held on the 3rd Thursday of the following months– February, March, April, May, June, July– October– January 2010

• See hand out for topics of educational offerings and outings• Mentors will be meeting with Jill Rogers and Deb Livingston

during the mentee’s education session– Support and continued education for mentors

• Lunch will be between mentors and their mentees• Outings will be with the whole group• Meet with your mentees once per month on your own

– Either individually or as a group depending on the need

Mentoring Toolkit

Sharing Wisdomby Robert J. Wicks

The practical art

of giving and

receiving mentoring

Mentoring Lesson 2:

Respect

The Necessary Ingredient


Mentoring Lesson 3:

Listening

Telling One’s Story


Mentoring Lesson 4:

Questioning

Just a Few Steps from Clarity


Mentoring Lesson 10:

Nonjudgmental

A Little Intrigue



Power

Put a Sweater On



Feelings

You Don’t Have to be Overwhelmed



Valuing

A Caring Presence



Detachment

You Have to Let Go of the Fish



Hope

Out of a Dark Hallway



Reflection

Your Quiet Little Placein the Garden



Freedom

Do You Want These Rules?



The 4 problems with hidden rules:

• They are distorted versions of what we believe we have been taught or have learned.

• They have been assimilated without critique or reflection – possibly because we embraced them when we were very young or impressionable.

• They have taken on the gravity of the 10 commandments – even through we were the ones who incorporated them into our belief system.

• They may be unconsciously guiding us in the very direction we do not want to go


Steps

A Logical Way



Letting Go

Scream, Understand,then Let Go!


Susan Eller, RN, BSN, CENGraduate Nursing Student

Loyola University, Chicago

Practicum Deliverable

Presented To

NMH Nursing Quality Peer Review Committee Members

October 27, 2009

By

Nursing Quality Peer Review Steering Committee

Nursing Quality Peer Review Education

Agenda

• Introductions

• Overview of Nursing peer review

• Define process of Nursing Quality Peer Review at NMH

• Some tools for giving feedback and avoiding biases.

• Practice case review.

Nursing as a Profession

• Requirements to be a profession:– Has a unique body of knowledge

– Has controlled entry into the group

– Demonstrates autonomy

– Respect of the community

– Self regulation (Hood & Leddy, 2006)

What is Clinical Peer Review?

• The evaluation of the delivery of nursing care in an objective and nonjudgmental manner when analyzing causative factors involved in medical errors with potential untoward events (Diaz, 2008).

• An organizational effort whereby practicing professionals review the quality and appropriateness of services ordered or performed by their professional peers (American Nurses Association (ANA), 1988).

• Relates to the identification of appropriate and willing peers for obtaining feedback on performance on a particular activity (Gopee, 2001).

• A process for evaluating performance and strengthening group communication, which also helps to maintain the integrity and self-governance of the nursing unit (Brooks, Olsen, Rieger-Kligys, and Mooney, 1995).

Defining Attributes of Peer Review

1. A peer is someone of equal standing in terms of education level, professional experience and/or employment status.

2. Evaluation of nursing care is measured against professional standards of practice

3. Non-biased feedback is provided in a manner that promotes professional development through positive communication

4. The goal of peer review is to develop individuals and systems (Morby, Concept Analysis 2009)

Why is Peer Review Important?

• To reinforce the self-regulating nature of the nursing profession

• Has potential to create a culture of safety (Diaz, 2008)

• Can be a mechanism through which the profession acts to assure quality nursing care (ANA, 1988)

• Can increase teamwork, creativity and a sense of ownership amongst nurses (Brooks, et al, 1995)

• Meets the ANA’s Peer Review Guidelines

– “Each nurse must participate with other nurses in the decision-making process for evaluating nursing care.”(ANA, 1988)

• Helps to maintain standards of nursing care

• Facilitates identification of system or practice issues or knowledge deficits.

• Promotes Transparency in nursing.

Our objectives for Peer Review at NMH

– Reinforce the professional status of nursing by demonstrating self-regulation and transparency

– Empower staff nurses who exhibit best practices to identify and address gaps in quality care.

– Develop mechanisms for advancing the quality of nursing care and documentation at NMH.

– Identify system or communication issues in order to advance a culture of safety.

– Professional development for all parties involved in review process.

Nursing Quality and Peer Review Committee

• Scope for committee will be organization-wide (not department or unit specific committees)

• Broadens the knowledge of the group when it includes people from all departments

• Creates a model for future peer review committees (possibly departmental or unit specific)

Guiding Principles

• Nursing Quality Peer Review fosters a culture of continuous learning, patient safety and best practice by having a process which is: Safe and fair Timely in providing feedback Objective Confidential Continuous and routine Educational

Committee Structure

Committee Member Profile

• Clinical knowledge and skills

• Serves as a resource to other nurses

• Honesty

• Integrity

• Team Work

• Respected by all members of the team

• Trustworthy

• Exhibits interdisciplinary collaboration

• Advocate for co-workers

• Conducts himself/herself with professionalism

• Has an excellent reputation

• Is a role model

• Willing to initiate constructive feedback

• Shows a commitment to continual learning and growth

Committee member commitment

• Attend monthly meetings (discussion point for group – should this be the same as SLC participation standards?)

• Act as liaison to staff nurses by explaining purpose of NQPR committee.

• Maintain confidentiality of all cases per NMH policy.

Confidentiality

Types of Cases

• Referrals from:– Quality

– Risk Management

– Safety briefings

– Nurses (self or peer)

– Members of the interdisciplinary team

Types of Cases

• These cases could include:– “Near misses”

– Unanticipated codes

– Falls (resulting in significant patient harm)

– Stage II-IV hospital acquired pressure ulcers

– Medication errors

– Unexpected transfer to ICU

– Unexpected codes outside of ICU

– Returns to surgery

– Patient/family complaints

– Cases that do not meet core measure expectation

– Lawsuits

Process flow of Case Review

• Cases can be referred to NQPR committee by downloading form off Nursing Website

• Cases referred to Peer Review are screened by Oversight Core Members:– Does it meet criteria, i.e. does not have exclusion criteria?

– Do they need Risk’s assistance in pulling together background information about the case

– Do they recommend that additional “experts” attend the review?


• Committee Facilitators and one member of department with clinical experience that aligns with nursing practice where the event occurred:– Prepare case summary

– Score the case using tools (preliminary)


• Invite nurse involved in the case to submit comments that are assertive in understanding the events

• Schedule 1-2 cases per meeting

• Immediate f/u: letters to nurse and manager, feedback to identified referrals

• Track all cases reviewed in Case Log including date, case findings, follow-up

• Oversight Core members will routinely review findings and process. Determine global communication opportunities including Friday CNE Mailings, Nursing Grand Rounds, SLC goals

Committee tools

• Letter to employee

• Letter to manager

• Scoring tool – ranking and mapping

• Database/Case log

Understanding Root Causes

Source: R Cook MD

Delivering the message

• Emotional Intelligence (Goleman, 1998)– Self- awareness

– Self-regulation

– Motivation

– Empathy

– Social skill

Emotional Competence

• Mindfulness

• Openness

• Impulse control

• Personal humility

• Appreciation of ambiguity

• Appreciation of willpower

• Compassion

• Resilience– (Porter –O’Grady, Malloch, 2007)

Constructive feedback(Rudolph et al., 2008)

Nursing feedback

• Need specificity on why behavior did or did not meet standards.

• Any system or communication issues should be addressed/referred and this should be communicated to the peer-reviewed nurse and nursing leadership.

• Suggestions and action plan for improvement given to nurse if indicated.

Practice Cases

References

American Nurses Association (1988). Peer Review Guidelines.

American Nurses Association. (2001) Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing.

Brooks, S., Olsen, P., Rieger-Kligys, S., & Mooney, L. (1995). Peer review: An approach to performance evaluation in a professional practice model. Critical Care Nursing Quarterly, 18(3), 36-47.

Diaz, L. Nursing peer review: Developing a Framework for Patient Safety. (2008). The Journal of Nursing Administration, 38(11), 475-479.

Gopee, N. (2001). The role of peer assessment and peer review in nursing. British Journal of Nursing, 10(2), 115-121.

Hood, L. J. & Leddy, S. K. (2006) Leddy and Pepper’s Conceptual Basis of Professional Nursing (6th Ed). Philadelphia: Lippincott Williams and Wilkins.

Institute of Medicine . (2001). Crossing the Quality Chasm: A New Health System for the 21st century. National Academies Press.

Kohn, LT, Corrigan, JM, Donaldson, MS. (Eds). (2000). To Err is Human: Building a Safer Health System. Institute of Medicine, National Academy Press.

Mantesso, J. Petrucka, P. & Bassendowski, S. (2008). Continuing professional competence: Peer feedback success from determination of nurse locus of control. The Journal of Continuing Education in Nursing, 39(5), 200-205.

Masso, M. (2004). Peer review of adverse events – a perspective on Macarthur. Australian Health Review, 28(1), 26-32.

Documents

Sample Graduate Student Practicum Deliverables Libby Zamis Graduate Nursing Student University of Illinois at Chicago Fall, 2008 Practicum Deliverable