Theory-Based Vascular Access Orientation
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This document outlines a theory-based orientation plan for vascular access specialists consisting of 5 stages: novice, advanced beginner, competent, proficient, and expert. Each stage includes objectives and activities targeting the cognitive, psychomotor, and affective domains of learning based on theories by Dreyfus, Benner, and Bloom. The goal is to equip new specialists with knowledge, skills, and values for providing high-quality vascular access services. Assessment involves direct observation, weekly meetings, competency checklists, and perceived readiness to advance stages over an average of 8 weeks to competency. The theory-based plan aimed to be more comprehensive and achieve success rates over 90% faster than the previous plan.
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Theory-Based Vascular Access Orientation
- 1. Lining Up to Infuse Excellence Equipped for Excellence A Theory-Based Orientation Plan for Vascular Access Specialists Sheila Hale, RN, CRNI, VA-BC Judy Smith, MSN, RN, CRNI Gwen Irwin, RN, CRNI
- 2. Lining Up to Infuse Excellence Financial Disclosures I have no financial relationships to disclose. I will not discuss off label use and/or investigational use in my presentation.
- 3. Lining Up to Infuse Excellence
- 4. Lining Up to Infuse Excellence Why Theory-Based Education? Promotes development of educational programs grounded in • Professional values • Empirical knowledge • Defined processes • Predictable outcomes Portrait of Florence Nightingale (1920). Source: http://en.wikipedia.org/wiki/File:Florence_Nighting ale.png
- 5. Lining Up to Infuse Excellence Theory Based Knowledge Acquisition Novice Advanced Beginner Competent Proficient Expert The Dreyfus Model (1980)
- 6. Lining Up to Infuse Excellence Dreyfus Model Applied to Nursing Patricia Benner, PhD, RN - Nursing Theorist Photograph of Patricia Benner (2009) http://nursing101.wikispaces.com/Nursing+Theorists Applied Dreyfus model to clinical practice, research, education, and administration.
- 7. Lining Up to Infuse Excellence Bloom’s Taxonomy Three domains of learning • Cognitive Domain – Impart knowledge • Psychomotor Domain – Develop skills • Affective Domain – Pass on values Benjamin Bloom http://epltt.coe.uga.edu/images/2/28/Bloom.png
- 8. Lining Up to Infuse Excellence Theory-Based Orientation Plan for Vascular Access Specialists Goal To equip new members of the Vascular Access Team with knowledge, skills and values for providing high quality, evidence-based vascular access services to the people of Central Texas.
- 9. Lining Up to Infuse Excellence Stage 1: Novice Objectives: At the completion of this stage of development, the learner will be able to • Complete web-based didactic training program and pass post-test with score of at least 90%. • List risks associated with PICC insertion and discuss strategies to minimize these risks. • Demonstrate use of ultrasound to locate and identify upper extremity vasculature and nerves. • Discuss personal response to a video about a patient experience with hospital acquired infection.
- 10. Lining Up to Infuse Excellence Stage 1: Novice Activities Cognitive Domain • Web-based course, P&P, EBP, case study Psychomotor Domain • Ultrasound, sterile technique, simulation Affective Domain • Case study, reflection, discussion
- 11. Lining Up to Infuse Excellence Stage 2: Advanced Beginner Objectives: At the completion of this stage of development, the learner will be able to: • Summarize national guidelines for vascular access. • Analyze chart data for absolute and relative contraindications to PICC insertion. • Demonstrate patient teaching related to PICC insertion. • Perform simple PICC insertions with supervision. • Demonstrate sterile field management. • Demonstrate safe sharps management. • Discuss patient rights related to PICC insertion.
- 12. Lining Up to Infuse Excellence Stage 2: Advanced Beginner Activities Cognitive Domain • National guidelines, EBP, ECG tip location course, case scenarios. Psychomotor Domain • Proctored PICC insertions, sterile technique, ECG/CXR checklist. Affective Domain • Discuss patient rights and responsibilities, own limitations, seek assistance as needed.
- 13. Lining Up to Infuse Excellence Stage 3: Competent Objectives: At the completion of this stage of development, the learner will be able to: • Perform PICC insertions with minimal supervision. • Discuss the value of certification in the field of vascular access. • Discover opportunities for growth and advancement as a Vascular Access team member. • Describe personal commitment to Vascular Access team values; list ways in which he/she contributes to the organizational and team mission.
- 14. Lining Up to Infuse Excellence Stage 3: Competent Activities Cognitive Domain • Information technology for data retrieval, EBP research related to prevention of PICC complications. Psychomotor Domain • Independent PICC insertions with vascular access nurse available, progressing to full independence. Affective Domain • Discuss value of certification and professional role development and advancement on team.
- 15. Lining Up to Infuse Excellence Stage 4: Proficient Objectives: At the completion of this stage of development, the learner will be able to: • Take and pass at least one of the certification exams in the specialty. • Serve as charge nurse. • Provide staff education on vascular access topics. • Participate on committees or contribute to projects related to vascular access. • Provide feedback on vascular access policies and procedures.
- 16. Lining Up to Infuse Excellence Stage 4: Proficient Activities Cognitive Domain • Review leadership expectations, case scenarios, prepare for certification exam. Psychomotor Domain • Observe and provide effective staff education on vascular access topics. Affective Domain • Reflect on the characteristics that you value in your preceptor; discuss those you want to develop in yourself.
- 17. Lining Up to Infuse Excellence Stage 5: Expert Objectives: During this stage of development, the learner will be able to: • Review and critique published studies for rigor and applicability to practice. • Create and develop vascular access policies and procedures. • Lead process improvement, EBP, and research projects. • Create and develop educational programs on vascular access topics.
- 18. Lining Up to Infuse Excellence Stage 5: Expert Activities Cognitive Domain • Literature review, graduate education, consultation with experts, research/EBP/education course work. Psychomotor Domain • Self-selected activities: Advanced clinical courses with simulation and preceptorship experiences Affective Domain • Ethics committee participation, share experiences with others, explore use of affective domain to influence behavior of others.
- 19. Lining Up to Infuse Excellence Assessing Competency Moving to the next stage in the continuum • Direct observation of practice by preceptor • Weekly meeting with manager and preceptor to assess progress and set goals • Assessment of learner’s perceived readiness • Completion of competency checklist with preceptor – Not based on number of insertions but on mastery of skills. Volume of procedures is key.
- 20. Lining Up to Infuse Excellence Lessons Learned • One preceptor? Or a variety? • Weekly meetings with manager & preceptor – Leadership connection and support • Develop relationships – Communicate confidence in preceptor and learner – Solve problems early – Celebrate wins
- 21. Lining Up to Infuse Excellence Outcomes • 12 weeks average time to competency • Less comprehensive • Longer time to success rate >90% • $15,000 (orientee salary only) Former Plan • 8 weeks average time to competency • More comprehensive • Shorter time to success rate >90% • $10,000 (orientee salary only) Theory- based Plan
- 22. Lining Up to Infuse Excellence Thank You! Questions? Contact information shale@seton.org Sean Dreilinger. Question from the audience for Jamie Macmillan of Linkshare - _MG_0191https://creativecommons.org/licenses/ by-nc-sa/2.0/legalcode
- 23. Lining Up to Infuse Excellence References Anderson, J. (2006). The work-role transition from expert nurse clinician to novice nurse educator in a baccalaureate nursing program. (Doctoral dissertation). Abstract retrieved from CINAHL. (2009711311) Bastable, S. (2008). Nurse as educator: Principles of teaching and learning for nursing practice. Sudbury, MA: Jones and Bartlett. Benner, P. (1984). From Novice to Expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall Health. Chinn, P., Kramer, M. (2008). Integrated theory and knowledge development in nursing (7th ed). St. Louis: Mosby Elsevier. Gentile, D. (2012). Applying the novice-to-expert model to infusion nursing. Journal of infusion nursing, 35(2), 101-107. Keating, S. (2006). Curriculum development and evaluation in nursing. Philadelphia: Lippincott Williams & Wilkins. Marble, S. (2009). Five-step model of professional excellence. Clinical journal of oncology nursing, 13(3), 310- 315. McEwen, M., Wills, E. (2007). Theoretical basis for nursing (2nd Ed). Philadelphia: Lippincott Williams & Wilkins. Moureau, N., Lamperti, M., Kelly, J., Dawson, R., Elbarbary, M., vanBoxtel, J, Pittiruti, M. (2013). Evidence- based consensus on the insertion of central venous access devices: definition of minimal requirements for training. British journal of anesthesia. Advance online publication. doi: 10.1093/bja/aes400
Editor's Notes
- This is our 12 member Vascular Access team including our manager and missing one member. We work for a hospital network system of 9 hospitals and we cover 7 of those, and place over 5,000 PICCs/year. We are not site-based, so we all travel between sites. As we continued to grow and add new nurses, several who had not placed PICCs before, we decided we needed to modify how we oriented new staff. We developed and trialed our new orientation plan based on nursing theory.
- So why theory-based education? Florence Nightingale was the first to use a theoretical foundation in nursing. As we all know, I’m sure, she is the founder of modern nursing, but she was also the first nursing theorist as well as statistician.
- So this is the Dreyfus model of skill acquisition. It is a model of how students acquire skills through formal instruction and practice. The five learning stages are novice, advanced beginner, competent, proficient and expert.
- Patricia Benner applied the Dreyfus model to nursing, using the 5 stages of learning and this is the model we used.
- Practically, we used Bloom's Taxonomy as a way to include learning activities, using each domain, to teach at each stage of Benner’s model. So these two components were used concurrently with good outcomes.
- So, this was our goal for our orientation plan, rather than just a check off list. We wanted to use theory as a foundation to build a comprehensive, structured, yet flexible, evidence-based orientation plan. Let’s go through the orientation plan with Patty PICC nurse.
- A new specialty area places the learner back in the novice category, where they must learn a new skill set. They have No situational context No experience in new area of practice and Need concrete rules
- These are the activities that were used at the novice stage For example, we use Nancy Moreau’s PICC Excellence online program for competency Team members volunteered to let orientees scan their arms using the ultrasound At this stage we showed a video of Victoria Nahum telling the story of losing her son, Josh, to a HAI. It also important to touch the heart
- So next we have the advanced beginner stage, moving from concrete rules to learning to recognize important elements of practice and apply guidelines. This stage is by far the longest, at about 6 weeks. This is where the novice gains valuable information needed to fully assess the patient, discuss contraindications for a PICC, such as chronic kidney disease, mastectomy, or skin integrity, as well as have the time for performing supervised PICC insertions. Also, in this stage the weekly meetings are very important, in order to assess the progress of the new vascular access nurse, to celebrate successes and help with any issues.
- Examples of activities in this stage include the orientee reviewing the national guidelines and evidence that supports our practice. Sterile technique is assessed during proctored PICC insertions, ECG tip locating system is taught and utilized, and patients’ rights and responsibilities are discussed. The preceptor encourages self-assessment and to seek assistance when needed. Continuing to impart knowledge, continuing psychomotor skills, pass on the values of our profession
- In the competent stage there is a feeling of mastery and the ability to manage complications and troubleshoot problems. The new vascular access nurse develops speed and flexibility, and confidence. PICC insertions are performed with minimal supervision and advance to independent Make this more conversational Maybe use a Patty Pick or Veronica Vein and talk about their progression
- (PICC Dashboard) CRNI Patty’s going to learn about the technology we use to track PICC insertions, complications, studies and move to independent insertions. They will also talk about certification and lifelong learning etc
- Perceives situations holistically, can determine what is most important and anticipate needs. Flexible and efficient
- Not everyone will choose to be an expert, and that’s ok. very learner directed
- These are examples of self-directed learning activities that might be considered by the Stage 5
- How do you know when it’s time and what criteria is used to decide when it is time to move on? When the preceptor, manager and orientee agree that each stage has been mastered
- One preceptor, one orientee from beginning to end, but with feedback, important early but then at competent stage it was valuable to work with other team members