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.
Johnson, S.A. & Romanello, M.L. (2005). Generational diversity: Teaching and learning approaches. Nurse Educator, 30(5), 212-216.
Mangold, K. (2007). Educating a new generation: Teaching baby boomer faculty about millennial students. Nurse Educator, 32(1), 21-23.
Stewart, D.W. (2007). Generational mentoring. The Journal of Continuing Education in Nursing, 37(3), 113-120.
Volpe Horii, C. (2007). Teaching insights from adult learning theory. JVME, 34(4), 369-376. Weston, M. (2001). Coaching generations in the workplace. Nursing Administration
Quarterly, 25(2), 11-21.
Your ExperiencesYour Experiences
Questions
ContactsContacts
Colleen Collier Breencolleen collier@lhsc on [email protected]
Karen LaidlawKaren [email protected]