Tips for Preceptors – The Preceptorship Support Platform

Orientation, Preceptorship Support Platform, Tips for Preceptors

Why is realizing consistent outcomes from the precepting process so hard?

Is it important to have consistent orientation/ residency training outcomes? How can you begin to improve consistency in the clinical performance of new staff at the end of your orientation /residency programs?

One answer is to consider the variability factors that are inherent in all unit-based nursing orientation programs. There is variability in the new hire nurses in terms of education and experience when the precepting process begins. There is variability in the attitudes, skills, and behaviors of the preceptors who work with the new hire nurse. There is variability in the patients’ number, acuity and diagnoses occurring on each shift and so on. The list is long.

According to the original creators (i.e. Joseph M. Juran, W. Edwards Deming, Kaoru Ishikawa, Walter A. Shewhart, et.al.) of process/quality management, eliminating or controlling sources of unwanted variability is critical to consistently producing desired outcomes.

Deming wrote that the variability could be attributed to both “common causes” and “special causes”. Common causes contributed in ways that were not under the control of the individuals involved and thus generally the responsibility of management whereas special causes related to differences in knowledge, skills, and performance of the individuals which is largely their responsibility. Dr. Shewhart, another pioneer in this field, split the causes of variability into assignable causes (which can be addressed) and chance causes (which cannot). Another guiding principle is that a few causes typically account for a large part of the problems in outcome consistency – known as the “vital few”.

All of these historical thinkers also had concepts of 1) planning the process, which included setting it up, 2) operating the process, 3) measuring the process operation and working with the outcome and related process measures to identify causes of inconsistency in desired outcomes and 4) modifying the process to improve it – a cycle that never ends. ‎Deming called this cycle the Shewhart cycle after his mentor but it is commonly known as: Plan, Do, Check, and Act (PDCA) or PDSA (Plan, Do, Study, Act).

Part of the first step, planning the process, is to clearly define what is the desired outcome or result and how can the result be measured. What is the desired outcome of the precepting process? (i.e. end product of the process that is acceptable for use and meets the intended needs)

A key “result” or “outcome” of the precepting process is the set of attitudes, knowledge, skills and the strength of the staff relationships of the new-hire nurse at the completion of the unit-based precepting process. Another result may be an assessment of the preceptor(s) changes in their attitudes, knowledge, skills, and relationships.

The most common operational definition of the desired outcome or result is that the preceptor signs off on a set of knowledge, skill and attitude items organized into checklists. These items are those deemed required for the new-hire nurse to safely work on the specific nursing unit. Is this adequate? Is there any better way to assess the outcome of the unit-based nurse orientation (precepting) process? We’ll discuss this in the next blog posting in this series.

Associated measures of performance of most processes include the elapsed time to produce the intended outcome, the cost (efficiency) of producing the outcome and in some cases the robustness of the process to changes in the environment (number of new hires on the unit, patient loads, etc.) that are not directly controllable.

Another part of planning the process includes documenting the steps, methods, decision points etc. so that appropriate measurements can be established. This level of process definition/description is more detailed than currently exists in many hospitals.

This is the first in a series of posts that will address first some options for defining and measuring the outcome of the precepting process for new-hire nurses, second documenting the process to establish measurement opportunities and third how to use the data from the measurements to identify key causes of inconsistency.

If you have thoughts on what you think might be one or more of the vital few causes of inconsistency in the outcome of the unit-based new hire nurse orientation (precepting) process or any other thought about improving the process, please post a comment.

Orientation, Preceptorship Support Platform, Tips for Preceptors

Preceptor as Coach

“Professional nurse coaching can be defined as a purposeful, results-oriented, relationship-centered interaction with clients for the purpose of promoting goal achievement” (Dossey).

The critical role of Nurse coaching in practice is increasingly recognized, and in 2013, the American Holistic Nurses Credentialing Corporation began a nationally recognized Nurse Coaching Certification program. Today, there are many formally recognized programs specifically related to healthcare coaching, usually associated with healthcare/well-being support of patients.

Preceptor as coach: It is critical that all of us recognize the importance of coaching skills required of a Preceptor. Have you thought of yourself as a coach? Have you taught coaching skills to your preceptors and do they get the credit they deserve for having achieved these skills? Do you have a way to evaluate the coaching expertise and needs of your preceptors? These are important questions to address.

Preceptorship is a time-limited partnership between new and veteran nurses that supports the new nurse as they move from dependent to independent levels of safe practice and integrate into the culture of the unit. In other words, it is a purposeful, results-oriented, relationship-centered interaction with the defined purpose of supporting the learning and confidence of the new nurse.

As with any coaching, the relationship is central; the relationship must cultivate a connection that is grounded in mutual respect, safety and trust.

The four pillars of a healthy supportive coaching relationship include:

Mindful presence. This involves giving full attentiveness during interactions with acceptance and non-judgmental communication. Presence is achieved through centering attention inward and intending to be attentive and connected. In a busy clinical setting, it is important to prepare for this by a simple moment of silence and naming your intention to yourself. You can further develop this capacity by practicing simple mindfulness-based centering meditation.

Authentic communication. Open honest communication that honors both people is essential. Coaching communication begins with deep listening and awareness of body language. Curious inquiry and reflective questioning encourages self-discovery by the preceptor which is such an essential aspect of deep learning. If you need to give constructive feedback, be frank, honest and direct – speaking from center.

Self-awareness. Both preceptor and preceptee are most effective when they practice self-awareness. One goal of precepting is to facilitate self-awareness and self-direction of the preceptee through self-care and self-reflection. Nurturing your own well-being is critical to your ability to remain present, listen deeply, and help the new person to successfully direct and evaluate their own learning. Thus it is important for both preceptor coach and preceptee to engage in self-reflection, silence, journaling, or meditating to develop self-awareness.

Sacred space. The preceptee should always feel that the relationship is sacred and that the space created is physically and emotionally safe with clear boundaries. In a busy clinical setting, you can achieve this sense of safety by designating a specific time and place for your goal setting and evaluation sessions. Enter this space with intention and start with a short centering exercise. In a precepting situation, not all communications can be held as confidential; thus It is important that you clarify what information if any may need to be shared and with whom (Lawson).

Transition into practice requires personal transformation as the new nurse moves through a process of change and “arrives” on the other side. The process can be uncomfortable. Preceptor coaching helps the young nurse through this journey to the rewards of discovery, wisdom and creating the story of who they are becoming.

Further reading

Transpersonal Nurse Coaching

CoachFederation.org

Sources: Kreitzer & Koithan (2014). Intewgrative Nursing. New York: Oxford University Press.; Dossey & Luck, (2016) “Nurse Coaching” in Dossey & Keegan, Holistic nursing: a handbook for practice (7^th). Burlington, MA, Jones and Bartlett.

Orientation, Preceptorship Support Platform, Tips for Preceptors, Wellness

The Relaxation Response

The relaxation response is a physiological state of deep rest. It is the opposite of fight-or-flight. The relaxation response is associated with decreased heart rate, blood pressure, and muscle tension, and increased energy and self-control. Regular practice of the relaxation response reduces anxiety and repetitive worry patterns, increases resistance to stress, and reduces symptoms of many medical conditions.

Nurses, especially new nurses, can benefit from practicing the relaxation response to help manage their stress. Some days can be incredibly overwhelming, and you can use this technique, or share it with others.

By adopting a daily practice, people can:

Develop a sense of purpose and wisdom. By turning down the outside noise of pictures, words, and sounds, we become more attuned to the silence within, and our own intuition. We can listen more deeply.
Create a space between stimulus and response. By increasing concentration, awareness, and centeredness, we become more able to listen, to hear, to reflect, and to respond out of choice. This is especially important during stressful days at work.
Align behaviors with life purpose and meaning. By transcending our self-defeating attitudes, beliefs, and assumptions that act as filters for the way we perceive, we are more able to override our conditioned response and behave in new ways.
Health and Renewal. Quieting the bodymind through relaxation helps to reduce pain and anxiety, promote deep rest and sleep, reduce muscle tension, increase blood flow and reduce blood pressure, improve immune function, improve overall sense of well-being.

Methods to Elicit Relaxation Response

Focused Belly Breathing
Repetitive Exercise
Meditation
Mindful Walking
Repetitive Prayer or Mantra
Imagery
Body Scan

Basic Components of Relaxation Response

Mental focusing, such as your focusing on the breath; repeating a word, phrase, prayer, or sound; or using repetitive muscular activity.
Passive disregard toward distracting thoughts, sounds, or intrusions.

Try it!

Find a comfortable position.
Take several deep breaths.
Begin to relax muscles and quiet the mind by being still.
Find and maintain a mental focus for 10 – 20 minutes.
Let go of distracting thoughts and judging attitude.

Orientation, Preceptorship Support Platform, Studies, Tips for Preceptors

What does the evidence say about nursing orientations?

Recently we conducted a review of current published articles (2015-2017) to evaluate evidence and recommendations for Transition into Practice programs including orientation and residency models. The evidence is clear in a number of areas:

New graduate RN retention in the first year of employment is a challenge for hospitals, ranging from a low of 25% to a high of 64% or greater. Furthermore, the decision to leave nursing is frequently related to dissatisfaction with orientation and begins within the first few months of hire. The most frequently mentioned barriers to a smooth transition included: Lack of consistent preceptor communication, Short staffing, high patient acuity, having to make critical decisions without help, little personnel support, lack of skills and knowledge, high variability in the orientation process in different institutions, and emotional stress of “reality shock”.

Implementation of residency/ internship models with multiple units and preceptors has been well documented to reduce turnover and increase retention of new graduates, increase nursing and unit satisfaction, provide significant cost savings for the hospital, and increase actual recruitment and desire for employment. The key factors contributing to success of residency programs can be incorporated into less formal orientation structures.

Investment in preceptor development through training and feedback is critical to their effectiveness. Specific learning needs include development of affirmative coaching, dealing with difficult communication, creating civility in the workplace, specific teaching strategies and learning styles, the role of emotional intelligence in learning and how to effectively manage change.

Effective preceptor coaching can significantly improve development of clinical reasoning and critical thinking.

Preceptors need structured support and consistency of feedback based on shared data. They also need time to precept, role clarification, and some formal reward or recognition system for the critical importance of their work to safe practice and patient care.

A few studies have begun to address the crucial need to support development of wellbeing and resilience skills of newly hired nurses. Transition stress has been documented for many years, and a strong preceptor relationship can help with this stress. There are other strategies that can be easily taught to new nurses and it is important to recognize the impact of supporting wellbeing on learning, competency development, and integration into the culture. Orientees can learn to manage their wellbeing and emotional/ physical stress; preceptors can help with this by tracking and coaching.

Research to improve efficiency and outcomes of transition into practice is increasing. While there is a need for ongoing correlational research the body of current evidence demands integration into our transition structures. One of the most comprehensive sites we have to support evidence based transition is the Vermont Nurses in Partnership (VNIP). Their website provides numerous resources, literature and concrete suggestions to improve transition process and outcomes. For more information visit their website or take a look at their Clinical Transition Framework Evidence Base.

Orientation, Tips for Preceptors, Wellness

Centering tips for orientees, residents, and preceptors

What is Centering?

Learning to Center your awareness is one of the most important skills you can develop as a caregiver. Centering is foundational to connecting deeply with others and developing your full healing potential. Centering is a mindfulness practice of learning to manage your attention so that you are aware of your inner reference of peace, calm and stability. Learning to center is developed over time with practice.

Imagine that the points of the star represent different parts of yourself. You have thoughts, emotions, a physical body with sensory input/ sensation, imagination, intuition and impulses and desires. Most of us perceive ourselves according to how we think, how we feel, what our body looks like, what we want or desire. These dimensions of ourselves develop as we grow and mature. While these “parts” of our personality help to define who we are it is important to recognize that we are more than these parts. Within each of us we have a core—a center of, peace, love, joy and deep connection that can be accessed. Accessing this deep part of our being may be viewed as a spiritual experience.

Centering is a practice that allows you to become more deeply aware of this inner core, this still point within. There is a deep sense of connecting to the “spirit” within. As you practice centering techniques, you are able to access this core self more easily and you begin to direct your life from this centered awareness of peace and connection. You become less reactive. This process can be thought of as disidentifying from the parts of yourself and identifying with your core being.

Thus, centering involves a process of moving the attention inward to that still point within—the centered self. There is an active and passive aspect of the centered self. You become aware of an inner reference of peace, stability, open awareness and connection. You are a pure, objective, loving witness to what is happening within and without. There is also an active part of the inner self, the “will-er” that can act from this deep level of awareness to instigate action in the world. So, at the center of the self there is a unity of love and will….action and observation.

How can the practice of Centering benefit you and your patients?

When you are centered, your awareness is grounded in the body. You are connected directly to your inner energy of love and peace; you have ability to be fully present to others and you have the ability to act with intent and compassion. Centered awareness provides you the power to freely choose how you will act in any situation. It allows you to choose how you want to “show up” in any given situation.

Having a centering practice benefits you and your patients. Benefits of centering include:

Calm Mind—ability to think clearly and calmly; ability to learn; more open observation and awareness of surroundings; connection with scientific reasoning and logic
Quiet emotions—ability to stand by someone who is expressing pain or anxiety without. reacting to the pain/ anxiety. Ability to remain present to the person and provide comfort.
Relaxed, grounded body—ability to be aware of internal stress and anxiety and self-regulate the autonomic nervous system so that you can manage your energy.
Receptivity to intuition and imagination—ability to listen to and respond from deep levels of knowledge that we call our intuition; creative insights and use of imagination to act—the ability to act artfully and create new ways of responding.
Choice about how and if to act on impulses or desires—freedom to act; freedom to choose action rather than reacting mindlessly from past experience.

How do I learn to center?

One of the most common ways to learn the skill of Centering is practicing awareness of the breath.

Try this exercise:

Get in a comfortable position and take a moment to just look around the room. Really see the light…the colors…the environment…

Now take a deep breath and close your eyes and let all of the visual awareness go.

And now be aware of the sounds…..and take a deep breath and let the sounds fade.

Scan your body from head to toe…..very gently… and if you need to move, do that now.

And now lightly put your attention to your breath and become aware of your breathing. With each out breath let go of anything you no longer need…..just be aware of your breathing without trying to change it.

Be aware of any thoughts, feelings or images come to mind just notice them and let them be. There is nothing you have to do about these feelings now….Do not hold onto them just let them pass and return your attention to the breath.

say to yourself—I AM AT PEACE.

As you focus on your breathing, allow your awareness to move into your center of silence within….say to yourself, I AM AT PEACE and just breathe in the peace and silence of this center….still….calm…deepening….

And now notice how it feels to be you in this moment. Say to yourself.

I have a mind, but I am not my mind….

I have emotions, but I am not my emotions…

I have a body, but I am not my body….

I AM a Center of Peace and Power…….. A Center of Love and Compassionate Action……

Take all of the time you need to experience your centered state of awareness and when you are completed, slowly bring your attention back to the breath and then the environment you are in.

There are many forms of breath awareness, relaxation, and guided imagery exercises that can help you learn to center your awareness into this relaxed, open state of awareness. The Ohio State University Center for Integrative Health and Wellness has a number of excellent resources you can try.

Tips for Preceptors

The 6 elements of a successful preceptorship

Preceptorships are a vital part of the nursing orientation process. While preceptees should always take responsibility for their own learning, there are a few things preceptors can do to help their new nurses succeed.

Building a relationship

Because the success of nursing preceptorships relies on the successful partnership of preceptors and preceptees, establishing a trusting relationship is one of the most important responsibilities for preceptors. Make it clear that both parties are partners working towards a common goal of expanding clinical knowledge. In the first meeting, clear goals and responsibilities should be established so that both preceptor and preceptee know what is expected of them, and that they can count on each other to fulfill them.

Throughout the nursing orientation period, encouraging preceptees to manage their own learning, while providing guidance and feedback, will prepare new hire nurses to smoothly transition out of the preceptorship.

Communication and conflict management

Developing competence in communication is a critical skill for novice nurses. Lack of clear communication can also be a source of stress or conflict encountered during the orientation/ residency program. Provide specific expectations of preceptee responsibilities and tasks each day; check on progress at midday and at the end of the shift have a quick review of key accomplishments; provide positive feedback and feedback and clarify any issues.

Giving feedback

A preceptor can initiate a feedback-friendly environment by demonstrating a sincere interest in their preceptee’s development as a nurse:

What is his/her background?
What are his/her career goals?

Knowing this, preceptors can show the connections between current skills and eventual requirements and expectations. Be sure preceptees can witness veteran nurses giving and receiving feedback from coworkers, physicians, and patients. Involve other co-workers: Ask others to let preceptors know about a preceptee’s positive performance so they can be included in evaluations. Ask them to give positive comments to preceptees as they observe them “doing the right thing or doing something right.” Also, ask co-workers to refer negative criticism directly to preceptors, not to others on the unit, so that preceptors can speak with the preceptee directly. This builds trust with the preceptee.

Holding effective meetings

Having a consistent meeting scheduled each week is extremely helpful to the preceptorship success. The predictability reduces anxiety and provides the structure needed for your preceptee to effectively prepare and participate in planning goals and evaluating their own performance.

Keep VARK in mind

VARK is a leaning inventory developed by Neil Fleming that classifies learning styles in four easy to remember categories: (V)isual learning, (A)uditory learning, (R)ead/Write learning & (K)inesthetic learning. Establishing effective teaching strategies for each type of learner will increase the success of every part of the preceptorship.

Developing well-being and resilience.

Retention rates for new nurses is almost always a concern for hospitals. Focusing on reflection and self-care during nursing orientation is one way to use preceptorships to improve retention. Preceptors should encourage their preceptees to take time to reflect on their experiences and take note of how they are feeling so they can avoid getting overwhelmed. There are many resources available on the web for learning mindfulness and relaxation techniques, including this guide from the University of Maryland, to share with preceptees.

Keeping detailed records of each area of training for preceptees will guarantee that there are no gaps in competency and will help reduce turnover for new nurses.

Did you know there is a new online tool to support a better nursing orientation that can help you manage all of these elements? The Preceptorship Support Platform provides a customizable tool to hospitals looking to improve their preceptorship outcomes.