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Nursing in the 21st Century: Bridging the gap!
Susan A. Boyer, RN, M.Ed. Executive Director Vermont Nurses In Partnership, Inc
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Preparing for the Challenges of the 21st Century
Objectives: Discuss professional practice expectations & changes in healthcare Acknowledge barriers to role preparation Consensus on definition of ‘competent’ Consider collaborative support systems for effective transition into practice
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What do they have in common?
Microwaves Velcro ATMs Faster, easier way of doing something Did not exist 30 years ago!
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Would you have believed?
A single internship framework used across continuum of care Multiple sites using the same competence assessment tool Standardized preceptor education with same teaching plan statewide Work from a networking model, rather than traditional business framework In the
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What Gap? How has healthcare changed? Proactive vs. reactive response
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What Gap? How has healthcare changed?
Pair and share your answers to this question – jot down the results
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What has changed Work expectations Access to healthcare information
Changes in technology, medications & information management Acuity and intensity of patient care Timeframe of the patient stay Access to healthcare information Web-based resources Expectations of patients
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What has changed Competence Expectations
License equals competence? Expected length of employment at agency Use of traveling nurses to staff Qualifications of students coming into college Volume of instruction that is needed Clinical instruction – settings and who to teach Use of simulation and PDAs
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Adding more on . . . Are nurses taught the same content as 30 or more years ago? Are they taught in the same manner?
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What is taken out? Where is time added to address the additional content, concerns, needs of both patients and care providers? © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Focus on Competence Development Entry into practice
Ongoing competence validation We will target some of the specific changes – one of which is the focus on competence
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Preparing for the Challenges of the 21st Century
Objectives: Acknowledge the barriers to role preparation
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Academic Education - Foundation built in classroom
Agency-based Education - Experiential Learning Psychomotor Technical skills Naturalization Integrate related skills Become automatic Articulation Develop Precision Manipulation (follow instructions) Imitation or copy Affective Attitude/feelings Internalize values adopt behavior Organize personal value system Value-understand & act Respond or react to Receive (be aware) Look at what lies above and below the line. It is not realistic to expect more than the foundation from the academic process. Then the agency-based education needs to provide the experiential learning that addresses the higher level learning process – the skills and capability that are essential to nursing, critical thinking and reflective practice. Academic Education - Foundation built in classroom © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission. © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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Teaching Problem-solving?
A Simple Linear Model Some models suggest that problem solving is a set of clearly defined and prescribed steps. This is rarely the case. © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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Critical thinking model
© Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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Critical Thinking Model
Theoretical & Experiential Knowledge Critical Thinking Attitudes/ Behaviors - skills Technical Skills Interpersonal Skills 2002 R. Alfaro-LeFevre © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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Bridging the gap Continue the discussion:
We’ve started identifying the gap Now let’s consider how we bridge that gap – 2 minutes discussion What has changed/needs to change from the way we did it when
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Concept or Mind Mapping
Transition from care plans – linear To concept mapping – multidimensional Information becomes less important than the ability to select and weigh it, to discriminate, and to evaluate competing knowledge claims. © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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Concept Mapping Definition: Concept maps offer a method to represent information visually. There are a variety of such maps. Purpose: Harness the power of our vision to understand complex information "at-a-glance." The brain interprets incoming information to make meaning. It is easier for the brain to make meaning when information is presented in visual formats. Thus, a picture is worth a thousand words © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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Preparing for the Challenges of the 21st Century
Objectives: Consensus on definition of ‘competent’
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Competency Assessment?
HOW? What does competence look like? © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Clearly defined expectations
Tools include: Orientation and/or performance appraisal Reflection of professional role or a grocery list Minutia of practice Tasks and procedures Concepts and critical thinking Assessment, evaluation, planning Responsibility for our practice & knowledge
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Definition: Competency: The integration of knowledge, attitude, and skills needed to perform a specific job function. Knowledge: INFORMATION IN MIND: general awareness of information, facts, ideas, truths, or principles. assessing attitude is extremely subjective. it refers to your level of positive attitude toward performing the skill and while interacting with others. Skill: THE ABILITY TO DO SOMETHING WELL. Usually gained through experience and/or training. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Competence: other definitions
The individual’s capacity to perform job functions – possession of knowledge, skills, and ability to function in a given field (Battle Creek Health Systems) The effective application of knowledge and skill in the work setting. (del Bueno, 1990) The ability to perform a task with desirable outcomes under the varied circumstances of the real world. (Benner, 1982) I like the third definition. BUT it is way too broad to verify. If we called that our definition we would actually have to see the person in many possible circumstances before we could say that person is competent. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Competence vs. Competency
An individual’s capacity to perform his of her job functions. Competency: An individual’s ACTUAL performance in a particular situation. Actual performance is the gold standard for demonstration of competence © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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JCAHO definition: HR.3.10 – Assessing staffs’ ability to meet performance expectations “the systematic collection of practitioner- specific data to determine an individual’s capability to perform up to defined expectations” © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Orientation checklists
Job description – orientation – performance appraisal Does your documentation tool: Define the expectations of the role? Based on competency in practice? Critical thinking component? Interpersonal issues? © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Clearly Defined Expectations
Foundation - COPA model Essential Duties Example of How do you know that the individual meets it? Practice based, performance based Start with an action verb KISS principle © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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COPA model - 8 Core Practice Competencies
Assessment and Intervention Communication Critical Thinking Human Caring and relationship skills Management Skills Leadership Skills Teaching Skills Knowledge Integration Skills Lenburg, Carrie B. The Framework, concepts and methods of the competency outcomes and performance assessment (COPA) model. © 1999 Online Journal of Issues in Nursing. Sept. 30, © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Assessing Competency Critical behaviors are the supporting structures of the competency assessment and are the essential behaviors that one must demonstrate to validate competency. Initial and Ongoing assessment They must be measurable and specific. What we are talking about with precepting is initial competencies. For instance you must establish baseline level of competency so you can identify what needs to taught over a course of time. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Writing performance outcomes
What performance outcomes do you see in the workplace that give evidence of competence in selected core skill? Action based statement – start sentence with an action verb KISS principle © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Demonstrates the ability to complete a full cardio-vascular system assessment
VS Assesses cardiovascular system Completes cardiovascular assessment. Determines effectiveness of cardiovascular perfusion Identifies challenges to adequate perfusion Anticipates CV perfusion problems
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Verifying “Competence”
Time to observe care being provided To see if capable to perform clearly defined expectations = Performance Outcomes Evidence collection Competency Verification Methods Demonstration Verbalization Simulation There is that word again-EXPECTATIONS! Instructional strategies Test results Policy Review Case Study © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. © Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission.
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Transforming Nursing Transforming nursing through reflective practice
Transforming nursing education though problem-based learning Concept based vs. case based Focus on concepts within academia, within internship, within preceptor development Technology as a catalyst to transforming nursing care - Bradley, C. Nursing Outlook Volume 51, Issue 3, Pages S14-S15
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Technology as a catalyst:
Patient care technology as a priority Nurses’ involvement in technology Reducing physical demands of care delivery
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Support - Internship/Orientation
Susan A. Boyer, RN, M.Ed. VNIP, Inc
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Preceptor development and support
VNIP - What we learned Preceptors Preceptor development and support Clearly defined expectations Standardized performance outcomes (COPA) Clinical Coaching Plan - Development of Critical Thinking Interns
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Preparing for the Challenges of the 21st Century
Objectives: Consider collaborative support systems for effective transition into practice
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Nursing Requires: Benner writes that nursing requires both Techne and Phronesis Techne – explicit knowledge related to procedural or scientific knowledge Phronesis – is more complex; it is reasoned practice that is developed through experiential learning, where the nurse is continually improving her or his practice
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Phronesis - More than Just knowledge
To think about how and why we should act in order to change things, for the best. Gaining phronesis requires time, as one must gain both the habit and understanding of correct deliberation Phronesis is reasoned practice, employed through experiential learning, where the nurse is continually improving their practice
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Transforming the workplace
To a culture of nurture and support Teamwork Relationship-based care Preceptor supported orientation Preceptors prepared for role that they face Preceptor support systems
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Who is a Preceptor? Experienced practitioner who provides transitional role support and learning experiences to new staff. © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission. 42
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Preceptors require instruction
Communication Interpersonal Skills Teaching/Learning Theory How to provide experiential learning while protecting safety Instruction that is needed by ALL direct care providers Let ‘s teach & learn as a multi-disciplinary team
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© 2003 - 2008 Vermont Nurses In Partnership, Inc. All rights reserved
© Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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Supporting Protocols Orientation Competency assessment
Preceptor program Establish the timeframe Identify resources Time to teach © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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Collaborative approach
Preceptor use is collaborative School and practice are inter-related Let’s build new systems of collaboration to solve the challenges faced in today’s HC Clinical instruction – precepting Joint appointments or contracted services Offer courses to serve development and clinical instruction as recognition/reward
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Any fool can make things bigger, more complex, and more violent
Any fool can make things bigger, more complex, and more violent. It takes a touch of genius — and a lot of courage — to move in the opposite direction. - Albert Einstein © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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References: Technology as a catalyst to transforming nursing care Bradley, C. Nursing Outlook, Volume 51, Issue 3, Pages S14-S15 Alfaro-LeFevre, R. Critical Thinking Indicators- Evidenced based version Accessed on February 21, 2008. Gaffney, T. Regulation of Nursing Practice From the Nursing Risk Management Series: Article 2 (Web site accessed on February 21, 2008) Willoughby, C., Budreau, G., & Livingston, D. (1997). A framework for integrated quality improvement. Journal of Nursing Care Quality,--LI (3) 44 © Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission.
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