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Comprehensive Exam - — Get a Free Blog Here

  1. 1. 1 Runninghead:COMPREHENSIVEEXAM Comprehensive Exam Adele Freestone, R.N. Idaho State University
  2. 2. 2 Runninghead:COMPREHENSIVEEXAM Comprehensive Exam Introduction A growing body of research concerning the connection between graduate nursing staff mentoring and staff retention as well as satisfaction indicates a need to address the impact this issue has and will continue to have on nursing. “Newly graduated nurses are entering the work force and finding that they have neither the practice expertise nor the confidence to navigate what has become a highly dynamic and intense clinical environment burdened by escalating levels of patient acuity and nursing workload.” (Duchscher, 2008). In a time where educational resources are shrinking and nursing educators are retiring or leaving the education system for more lucrative professional opportunities, the burden of continuing education and professional mentoring is becoming the responsibility of the hiring institution on a much greater scale. “The intense and dynamic transition experience for these newly graduated nurses should inspire educational and service institutions to provide preparatory education on transition as well as extended, sequential, and structured orientation and mentoring programs that bridge senior students’ expectations of professional work life with the reality of employment.” (Duchscher, 2008). Burns and Poster (2008) recognized the existence of what has been commonly referred to as the nursing theory/practice gap as it applies to new graduates entering the professional ranks. “The gap between a new registered nurse graduate’s education for practice and actual practice requirements of new registered nurses has long been an accepted fact in nursing.” (Burns and Poster, 2008) They go on to point out that “nursing students are rarely, if ever, required to make clinical judgments related to real patient conditions requiring urgent and emergent decisions to prevent irreversible physiological damage. The question was posed, if they did not have this
  3. 3. 3 Runninghead:COMPREHENSIVEEXAM experience in school, when and where would they get it? They would eventually be faced with their first potentially life-threatening crisis situation in the real clinical setting with little or no preparation and would be expected, as licensed registered nurses, to be able to intervene. (Burns and Poster, 2008) In most health care institutions a newly hired nurse undergoes an orientation period. This usually consists of being assigned to a more experienced colleague preceptor for a relatively short period of time during which the new nurse is expected to become familiar with the institutionally developed policy and procedures, the routine function of the position, and the expectations of employment. Documentation is usually in the form of a check list that includes a section devoted to nursing skills. The preceptor is most often a staff nurse with little or no special training for this role. Most institutions have no effective set standard that preceptors must meet before being considered for such an assignment despite research that indicates a need. Smith (2006) presents this explanation of the preceptor role. “Besides clinical expertise, a preceptor needs leadership and communication skills (such as assertiveness), critical thinking and problem-solving skills, an interest in professional growth and in the process of teaching and learning, a nonjudgmental attitude, and sensitivity to preceptees’ needs. Equally important are flexibility, adaptability, and a good sense of humor.” (Smith, 2006) She goes on to point out that “A preceptor can also contribute to her facility’s recruitment and retention efforts. During nursing shortages, a preceptor can help create positive morale and collegial working conditions, which helps to attract and retain staff. (Smith, 2006). Considering the importance of all these items, the informal role of staff preceptor deserves more attention than it currently receives in most health care institutions.
  4. 4. 4 Runninghead:COMPREHENSIVEEXAM Position proposal and description I desire to develop a position intended to address the practice/theory gap as it pertains to newly hired graduate nurses within the rural acute care setting. The “new staff preceptor” role differs from a clinical educator role due to the specific nature of the target students; newly graduated and newly hired nurses. The responsibilities of this position would include initial evaluations of skill and knowledge levels for each individual new nursing hire including certified nurse’s aides, the designing of a personalized orientation track that includes some standardized elements, formal professional mentoring throughout the orientation period, and both formative and summative evaluations including recommendations for further mentoring and orientation if needed. Similarities of a new staff preceptor to an undergraduate clinical instructor indicate that a master’s degree in nursing education is ideal for this new role, for an advanced practice degree in nursing education requires the development of many of the qualities Smith (2006) outlined. Not only does this role have the satisfying ability to launch new nursing careers of all levels in a positive fashion, it has the capacity to effect attitudes and morale. This, in turn, has the effect of increasing staff satisfaction and retention rates, and this objective is one of the justifications for the creation of the role. In the rural health care setting this becomes increasingly important when taking into consideration the shortage of nurses interested in entering the rural nurse specialty, the high cost of recruiting and training, and the low retention rates. “The cost of orienting registered nurses is high. Hospitals must provide an orientation that helps retain nurses as well as prepare them for employment.” (Ward, 2009). Retaining staff, once trained, is a fiscal necessity for the urban institution. It becomes even more important to the rural institution that does not have the resources of its urban counterpart.
  5. 5. 5 Runninghead:COMPREHENSIVEEXAM Theoretical framework for practice My personal belief system includes the idea that nurses are caring, ethical, altruistic individuals who are invested in lifelong learning, professional growth, and achievement. Nurses are invested in furthering professional competence and expertise as a whole, not just competing in individual accomplishment. This includes mentoring and precepting our fellows entering practice. The nursing theory I find most compatible with this view is Patricia Benner’s “Novice to Expert” theory of how nurses know nursing. Benner utilizes the Dreyfus Model of Skill Acquisition which defines five levels of proficiency; novice, advanced beginner, competent, proficient and expert. (Benner, 1984). This theory has the capacity, versatility and flexibility to be applied relatively easily even in a profession so diversely specialized as nursing has become. Thus, it can apply to a nurse who may be an expert in dialysis or interventional radiology but an advanced beginner or even a novice in labor and delivery or emergency. It can be applied to a new graduate entering the profession, or a nurse who has achieved a competent level after practicing two to five years. Dr Howard Gardner’s Theory of Multiple Intelligences (MI) is a good choice to team with that of Patricia Benner. His hypothesis presents the idea that there are many different ways that learning takes place and that teaching styles should address this diversity to enjoy expanded success. He identifies ways knowledge is learned; “Linguistic intelligence - the intelligence of a writer or orator, logical mathematical intelligence - the intelligence of a mathematician or scientist, musical intelligence - the capacity to create, perform and appreciate music, spatial intelligence - the ability to create mental images and build or manipulate them, bodily- kinaesthetic intelligence–he capacity to solve problems using the body, (athletes, actors,
  6. 6. 6 Runninghead:COMPREHENSIVEEXAM craftspeople, body workers, surgeons), interpersonal intelligence - understanding the moods, motivations and intentions of others, intrapersonal intelligence - the capacity to understand oneself, naturalistic intelligence - the ability to make accurate classifications in nature, and Gardner is also suggesting the presence of a ninth intelligence which is termed existential intelligence. This is the capacity to ask the ‘big questions’ e.g. when we ponder death, love, conflict, the future of the planet.” (Holland, 2007). Utilizing the expanded teaching and learning styles that are influenced by MI theory have positive impacts on learners. The broader view of intelligence influences the teacher to assess and teach using more than the two traditional teaching styles, linguistic and mathematical. This in turn allows expanded opportunities for successful learning to take place. “While Gardner's initial work was focused on helping students with attention deficit disorders or students with brain injuries, educators from elementary school to graduate study have found his theory to have relevance for classroom practices. When Ml- inspired instruction was implemented with adult learning, it was found to reduce teacher directedness, increase student control and initiative, increase the authenticity of the learning experience, and make learning more relevant for students.” (Holland, 2007). The choice to use these two theories to create my framework will guide me to be sensitive to the learning needs of those I wish to teach. Being open to the use of multiple teaching styles will allow me to tailor the learning environment to optimize the learners’ abilities to assimilate information and enjoy greater success. This in turn will influence staff satisfaction and will lead to better staff morale and higher retention rates. These are of great importance to rural practice, because smaller institutions have limited resources for staff orientation and education and will benefit greatly from increased staff retention rates.
  7. 7. 7 Runninghead:COMPREHENSIVEEXAM In seeking to facilitate a more organized and less chaotic and uncomfortable transition from student to clinical practitioner Burns and Poster (2008) identified ten high risk patient conditions that occur with frequency in acute and critical care. These conditions are acute myocardial infarction, congestive heart failure, cerebral vascular accident, diabetic ketoacidosis, shock, deep vein thrombosis, postoperative care (pain management), altered level of consciousness (e.g., head injury), pneumonia or severe respiratory distress and psychosis or dementia. As a new staff preceptor my first focus would be to develop a learning module to address each of these high risk conditions utilizing the personal framework outlined previously. Each module would include multiple teaching techniques such as interactive simulation, role playing, and illustration utilizing audio/visual methods, as well as traditional linguistic and mathematical-scientific techniques. These techniques will give the learner the opportunity to engage critical thinking and decision making skills in a learner friendly, safe, but realistic practice environment within the institution and using institution specific policies and procedures. Think of this process as something akin to a fire, disaster or code drill. These types of drills give the learner the opportunity to face a critical situation that requires correct decisions and quick response without the fear of actual negative patient outcomes. (A good existing example of this is the ACLS certification class.) Successful navigation of these modules will increase personal confidence levels in critical thinking and skill level and decrease the fears commonly associated with the initial thrust into the clinical arena. Rather than encountering a “baptism by fire,” the new nurse has the opportunity to practice a given scenario. “Giving nurses the right tools reduces their frustrations when new to practice and directly improves the care they deliver.” (Burns and Poster, 2008)
  8. 8. 8 Runninghead:COMPREHENSIVEEXAM Evidenced based practice In an effort to address the gap between nursing education and actual nursing practice the staff preceptor must be in tune with the prevailing research and have the ability to apply it to the position objectives of effective staff orientation, satisfaction and retention. Adherence to the value of lifelong learning is essential. Because of the constant evolution of the nursing profession both academically and clinically, the goal of success demands attention be given to keeping up with current research and new applications. Maintaining a good relationship with academia is an important component of this facet of the position. Membership in professional organizations will assist with providing venues for personal continuing education. Subscribing to and reading professional journals such as the Journal of Nursing Education and other publications will increase exposure to new ideas, new applications of old and proven ideas, and help to discard non relevant and obsolete material in favor of the more applicable. Continued practice within the clinical area to hone and perfect personal skills and knowledge levels is also necessary for success by lending credibility to the new staff preceptor’s role. Measurement of the achievement of the position objectives will be achieved in different ways. Consecutive increases in staff satisfaction survey scores over time are one way. Tracking staff retention rates is another. These are two relatively simple methods of showing hoped for progress and positive results. However, evaluation of effective orientation is more complicated and must include other methods. One possible method is the use of pre and post testing. Another is the completion of a self evaluation designed to illicit a learner’s comfort and knowledge levels with each area of practice as experienced before, within, and after the module educational experience previously proposed. A second subjective method would be a written evaluation with
  9. 9. 9 Runninghead:COMPREHENSIVEEXAM recommendations completed by experienced colleagues who have had opportunity to observe new staff in practice. It is likely that some combination of all methods mentioned would be the most effective. Taking each of these methods into account, a qualitative/quantitative study could be undertaken to document the level of success reached. Not only would statistical data from staff retention rates and satisfaction surveys be available, but also the written statements of perception from both new hire and experienced personnel could be analyzed for recurring themes supporting the effectiveness of the process and the existence of the position of “new staff preceptor”. Publishing this type of a study would lend strength and add to the body of literature supporting the existence of the proposed position as one answer to the problem of the theory to practice gap experienced by new nurses. Integration of position in the rural community Participating in a dual role such as a part time clinical instructor or program assistant within the nursing education system is an ideal way to support this position. Recent technology advances supporting distance and computer teaching and learning allow this to be a viable option. This partnership allows the new staff preceptor to maintain professional ties with both the education and rural clinical arenas and enables the preceptor’s heightened awareness of the two. In addition, it enhances the preceptor’s ability to form the necessary, more effective bridge between the two areas by maintaining the preceptor’s own lifelong learning commitment. In addition, the preceptor should take opportunities to be involved with institutional undertakings such as shared governance, policy development for quality improvement initiatives, continuing education and volunteer work that will expose the rural community to the role of the preceptor.
  10. 10. 10 Runninghead:COMPREHENSIVEEXAM Assisting with health fairs, community education classes, and assisting with health classes and screenings in the local schools at all levels will help to expose and educate the preceptor to the community and its needs specific to age, developmental stage and socioeconomic levels. As an advanced practice nurse within the rural community the reality of the responsibility to the community itself is large. The rural health care institution is often a major source of economic stability, and the continuing health and viability of said institution can have a huge impact on the health and viability of the community itself. The success of the preceptor role would mean the success of the health care institution in the area of staff satisfaction, retention and continuity. Not only does this enhance the financial and human resource stability, this would improve the level of trust between the rural community and the institution by strengthening and proving the commitment between the two entities. In their exploration of the rural nursing role and the benefits of social connection Lauder, Reel, Farmer and Griggs (2005) suggest that both economic and health outcomes can and will be better when people use their collective skills, abilities and knowledge in partnerships that include and ascribe to shared values and commitment. The rural new staff preceptor must show commitment by investing in the community she serves and reflect that investment in the performance of her role within the community itself, as well as within institution walls by participating in the activities mentioned above to achieve not only personal satisfaction but the satisfaction of the community as well. Summery Formalizing and defining the role of a new staff preceptor is an important step to addressing one of the large concerns in the nursing profession as well as the health care industry as a whole. Not only is it important to assist with achieving individual job satisfaction on the part of nurses
  11. 11. 11 Runninghead:COMPREHENSIVEEXAM entering the clinical arena, it is fiscally important to the institutions that require stable and productive nursing staff. It is important to nursing to retain the newly graduated nurses in a high pressure profession that has experienced huge and continuing shortages and now is experiencing professional attrition due to causes ranging from age and retirement to professional burnout and job dissatisfaction. These reasons are especially true when applied to the rural setting that is traditionally characterized as having fewer financial resources, fewer technological resources, less glamour, less opportunity and more difficult and complicated work situations. Assisting new staff to achieve a high level of job satisfaction in providing a well constructed, educationally integrated, innovative orientation to the clinical nursing experience will strengthen and benefit the profession as a whole by decreasing the depletion of fiscal as well as human resources available to the rural communities and their health care institutions. It is my belief this contribution will be shown to have positive repercussions in future assessments of the rural nursing specialty and its impact on health care at large.
  12. 12. 12 Runninghead:COMPREHENSIVEEXAM References Benner, P. (1984). From novice to expert: Promoting excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Burns, P., & Poster, E. (2008, February). Competency development in new registered nurse graduates: closing the gap between education and practice. Journal of Continuing Education in Nursing, 39(2), 67-73. Retrieved December 28, 2008, from CINAHL with Full Text database. Duchscher, J. B. (2008). A process of becoming: The stages of new nursing graduate professional role transition. Journal of Continuing Education in Nursing, 39, 441-450. Retrieved December 31, 2008, from CINAHL with Full Text database. Holland, F. (2007, October). Bringing the body to life: using multiple intelligence theory in the classroom. SportEX Dynamics, Retrieved May 31, 2009, from CINAHL with Full Text database. Lauder, W., Reel, S., Farmer, J., & Griggs, H. (2006, March). Social capital, rural nursing and rural nursing theory. Nursing Inquiry, 13(1), 73-79. Retrieved June 5, 2009, from CINAHL with Full Text database. Smith, L. (2006, September 2). The joys and responsibilities of preceptors. Nursing, Retrieved May 23, 2009, from CINAHL with Full Text database. Ward, C. (2009, February). Enhancing orientation and retention: one unit's success story. Journal of Continuing Education in Nursing, 40(2), 87-90. Retrieved May 30, 2009, from CINAHL with Full Text database.