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

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 (7th).  Burlington, MA, Jones and Bartlett.

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.

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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

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!

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

 

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Can nursing orientation costs be managed? Should they be?

Orientation for new-hire RNs in hospitals is costly. In an article in the journal of nursing economics, the average (16 weeks) unit-based orientation cost was estimated at $41, 624 – and this was published back in 2007.

Let’s update this a little using more recent salary related costs; according to KPMG’s 2011 U.S. Hospital Nursing Labor Costs Study, the total cost of a full-time RN averages $98,000 per year (or $1885 per week).  Thus, the average cost for the preceptee’s time would be a little over $30,000 (16 weeks at $1885 per week).  Adding another $30,000 for staffing the vacancy during the orientation the total cost reaches over $60,000.  So far, we haven’t included all of the cost factors yet. 

Factors impacting the costs include but are not limited to: 

  • Hospital policy on staffing the preceptor/preceptee patient load
  • Length and design of the classroom and unit-based orientation 
  • Salary for those involved in nursing orientation including the preceptor(s), preceptee, unit educator, orientation classroom trainer, orientation program manager, etc.
  • Salary for those brought in to cover the patient load for the vacant position while the orientation is underway
  • Payroll related costs such as social security and 401K contributions, unemployment and workers compensation insurance, health care and other benefits 
  • Orientation program support costs such as materials, maintaining the program due to equipment upgrades, regulatory or accreditation changes, and other changes in hospital policies and systems.
  •  The way the hospital allocates other general hospital overhead costs to the program.

 Can this cost be managed? 

Some of these costs could be managed by nursing management. For example, the policy on staffing load assigned to the preceptor(s) and preceptee determines a significant part of the salary costs.  The length and design of both the classroom and unit-based orientation components is also largely under the control of the nursing organization. Other cost factors cannot be managed directly such as the hospital benefits program.

How can cost be managed?

A classic process management approach would be to measure and take actions to improve:

  • Cycle time (length of the preceptorship),
  • Efficiency (cost of the resources used per preceptorship),
  • Effectiveness (outcome of the preceptorship); and some would add
  • Adaptability (variability of the other measures under different loads such having one new hire in orientation on a unit verses having three new hires in orientation).

 Can the high cost of nursing orientation be managed? Yes.  Should it be done? Yes; but only if you are able to lower costs while maintaining or improving effectiveness at the same time.  It can and has been accomplished for many other processes in a wide variety of organizations.  

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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.

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The importance of well-being in nursing practice

Why is well-being important?

Reality shock for nurses is a problem that shows no signs of going away. Self-care is so vital for new hire nurses, but it is also important that hospitals support reflective learning practices that support well-being. Because around 25% of new nurses leave nursing during their first year of practice, hospitals can build strong programs with less turnover by focusing on well-being during nursing orientation.

How to focus on well-being

Neuroscience evidence suggests mental training and learning skills in four key areas can make a difference in improving well-being and even rewire areas of the brain.

  • Sustaining positive emotion. Prolonging positive emotion has been shown to improve psychological well-being.
  • Rebounding from negative emotion. The second component of well-being is a person’s response to negative emotion. Science in this area suggests resilience, or how quickly a person recovers from adversity, can result in a person experiencing less negative emotion overall and may even have protective properties against mental health disorders.
  • Mindfulness and mind-wandering. Mindfulness-based practices of all types have now entered the mainstream. Data show that when people are really focused on what they’re doing, and their minds are not wandering, they actually feel better about themselves, perform better, and experience less negative emotion.
  • Caring for others. Prosocial behaviors such as empathy, compassion, and gratitude comprise another component of well-being. There’s substantial evidence to suggest that engaging in acts of generosity is a very effective strategy to increase well-being.

The first two points regarding staying positive and coping with negativity can be difficult for new nurses. This post from allnurses.com shows how quickly new hires can become overwhelmed and start questioning if they made the right career choice. Providing resources for both Preceptors and Preceptees to effectively give positive and negative feedback is one way to make this easier. Open lines of communication with their Preceptor will help new nurses feel supported, and if Preceptors are mindful about pointing out when their Preceptees are doing something well, staying positive about their experiences as a new nurse in a new hospital won’t seem so impossible.

Building self-care into nursing orientation

Encouraging new hire nurses to engage in reflective learning activities as a part of their orientation is a great way to help them manage their well-being and resiliency. The American Holistic Nurses Association provides a number of resources for nurses, including Holistic Self-Care information and exercises and Stress Management tips.

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