clinical transition framework for system implementationthe ctf responds to the ‘call for radical...

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Clinical Transition Framework - for System Implementation

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Sampling

A crucial goal of the model is to ensure a process that remains as clear, concrete, and concise as possible. With this goal in mind, competency validation engages sampling

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Accountability

Professional accountability is a core function that requires commitment from every licensed care provider (Krautscheid, 2014; Zittel, Moss, O'Sullivan, & Siek, 2016; Oyetunde & Brown,

2012). Inclusion of the accountability statement within the orientation form defines what

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Three high-end apprenticeships and use of coaching plans

The CTF responds to the ‘call for radical transformation in Educating Nurses’ as proposed by Benner, et al (2010). Based on her research, Benner calls for three high end apprenticeships as part of the education and development of nurses. The apprenticeships start with 1) developing the nursing education, science and specialty knowledge required

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This diagram shows the positioning of the three apprenticeships within the transition framework. In reality all are integrated synergistically, but this reveals the emphasis on their specific roles and positioning at distinct points in the new nurse’s development. Some development is sequential. The nurse cannot develop skilled know how until a solid foundation of nursing science and specialty knowledge is established. Fluency with clinical skills and reflective learning is developed over time, with repeated, deliberate practice with clinical skills and experience with recurring situational themes.



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A focus on Professional Practice Competency within professional practice is an elusive concept that is not a specific skill or task to be completed, but rather is based in attributes required to act effectively in a healthcare setting. True clinical competency is much more than skills proficiency and requires blended aspects of reasoning, judgement and decision-making.

The American Nurse Association (ANA) believes that competence is situational, dynamic, and is both an outcome and an ongoing process (Byrne & Waters, 2008). The situation, setting and challenges determine what competencies are necessary. With a focus on the

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Program success measures

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Integrated Preceptor Development and Support A unique feature of the CTF is integration of preceptor development and support as a crucial component of the competency program. Agencies have often implemented nurse residencies or new orientation programs without quantifying the challenges placed upon the shoulders of preceptors. I speak from personal experience when I consider the times that colleagues have engaged the attitude of “well, there’s two of them, so they can take the post op and 3 admissions!”.

Defining clinical competence for preceptors is core to the issue, as preceptors are called upon to create meta-cognitive knowledge through reflective practice and reflective learning (Botma, 2016). Critical thinking and reasoning lead to clinical judgement and decisions regarding optimal nursing care. To develop this judgement in others, a preceptor must engage core competencies in higher-order thinking, conducting assessment in a reliable, valid manner; effective communication; and supporting learners in evidence-based practice. Preceptors are the essential partners that facilitate the development of practical skills, communication, professional socialization, documentation, prioritization, and planning of daily activities (Parker, Lazenby, & Brown, 2012). They fill a crucial role in bridging the nurse education theory-practice gap when they have preparation and supporting structures for their specialized role.

For success of the overall program, preceptors require specialized education related to their roles as preceptors along with focused instruction that addresses the unique challenges presented by the CTF. Unique aspects within the framework include an emphasis on fostering critical thinking development, integrating professional accountability,

role development related to gathering evidence of competence, and both introduction to, and

practice with, the CTF unique tools. Use of coaching plans in the clinical setting is a new and

unique challenge for preceptors which has proven a positive experience with projects

implemented to date (Boyer, Valdes-Delgado, Huss, Barker, & Mann-Salinas, 2017; Delfino, Williams,

Wegener, & Homel, 2014; Robbins, et al., 2017).



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Formative and Summative Data Collection

A core concept within the CTF is rapid cycle quality improvement (Etchells, Ho, & Shojania, 2015; Leis & Shojania, 2016; Service, Loudon, & Sonius, 2012; Taras & Everett, 2017) . . .

VNIP RESOURCE FILES

VNIP shares all developed tools and resources via file folders that contain the essential elements within the CTF, along with many additional tools as submitted by VNIP Alliance members as they customize the framework for use in their facility.

VNIP Resources 2018 Files include, but are not limited to:

Preceptor Development resources of: Self-study module for preceptors – 5 CH – often used as a workshop pre-assignment Preceptor textbook in multiple versions as pdf files for your printing PP presentations that follow content delivery as per textbook Multiple activities that integrate with course content Sample teaching plans based on VNIP’s preceptor course delivery Access to VNIP web-linked modules with worksheets and facilitator guides Instructor guides for specific content Sets of Icebreakers, keys to teaching/learning and course ‘connectors’

Competency tools & Coaching Plans: A Core Competency Based Orientation (CBO) model that fits for all direct care providers,

provides development support, and documents clinical competency expectations. Diverse, matching Coaching Plans serve most specialty services and development of

work organization skills. There are over 180 coaching plans now available.

Protocols and Data collection resources include: Templates for policy statements



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Sample job descriptions: that work synergistically with the competency tools Survey tools for evaluating the program, preceptor course, preceptor, workplace

support for learning, and retention data.

BACKGROUND, THEORY AND USE OF CTF COMPONENTS

Policy statements, Evaluation forms and Data Collection

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Competency Folder: Clearly defined expectations

Competency tools include both 1) universal and 2) unit specific performance expectations. These are valid and reliable tools for competency verification that identify specific, measurable performance-based criteria for assessment. Competency criteria include aspects of caring, leadership, management, teaching, safety, accountability, knowledge integration, critical thinking, reasoning, and clinical judgment capability.

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COPA model

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Competency tool development and application

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Clinical Coaching plans

Coaching plans are individualized teaching plans developed specifically to support clinical and experiential learning within preceptor supervision. Each plan outlines specific goals, learning activities, and measurable outcomes. The plans must follow principles of teaching/learning, to foster the progression of the novice through all core competency requirements. Coaching plans guide reflective learning strategies for fostering critical thinking development, while providing communication of progress/challenges from one preceptor to another

The coaching plans and competency tools address acute, long term, clinic, and home care settings. Currently validated tools include target groups of RNs and LPNs, with some tools for Respiratory Therapy, Rehab professionals, medical assistants, and nurse aides. Others may be developed in collaboration with content experts

Lists of competency goal statements - outline nursing practice in each specialty

The lists are nursing goals framed in a patient-centered statement that reflects the manner in which nurses provide care. The tools clarify and simplify the work of the preceptor and new hire. The performance goals are the same for each new hire, no matter what prior experience. Each goal statement has a coaching plan that details the standardized knowledge, performance criteria and related reflective learning strategies.



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Writing coaching goals that are nursing/patient centric

Orientation and competency tools have often presented extensive lists of the tasks and procedures that are completed, but these are not inherent to professional nursing practice. What makes nursing care unique and valuable is the clinical reasoning and nursing judgement skills that are integrated within delivery of tasks, procedures, assessment and care. The nursing unique parts of our practice are related to the judgement that is applied within care delivery.

The coaching plan goal statements should target aspects of nursing care, while keeping the patient at the center of that care. Goal statements must also be presented in the manner in which care is provided. This presentation makes the preceptor’s documentation requirements easier, as the aspects of care that are performed are directly linked with the goal statement which was the center of the days/weeks performance development/validation.

Clinical coaching plans serve multiple functions:

1. Outlines the standardized knowledge required for that aspect of patient care

2. Establishes clearly defined expectations in measurable, observable performance terms

3. Tracks completion of critical elements of performance - with opportunity for positive

feedback as the learner progresses through, and completes each tool

4. Documents progression - and lack thereof – to clarify and ease the process of difficult

communications pertaining to performance issues.

5. Offers specific questions for fostering critical thinking development

6. Directs discussion and reflective learning

7. Ensures accurate, complete and concise ‘hand-off communications’ from one

preceptor to the next (or from preceptor to manager or educator)

8. Allows benchmarking of learner’s progress to establish expected completion times

9. Can be adapted for use as an action plan or performance improvement tool by adding a

time frame requirement for meeting specific goals

10. Provides effective, legal documentation of both the learning process and competency

validation within the domain of a specialty practice

Developed coaching plans are compiled into a set of resources in the same manner that we have had textbooks of standardized nursing care plans. The preceptor/orientee team then selects the optimal plans as based on learning needs assessment and specialty practice area. Selected plans are customized for the orientee and used on a daily basis to guide and track the preceptorship process. VNIP currently has more than 200 coaching plans that serve practice areas in acute care, physician clinics, medical homes, respite care facility, and home care settings.



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Coaching plans provide ‘hand-off’ communications from one preceptor to the next – how is this communication addressed in your agency?

Medical-Surgical Nursing Competencies - Family Care Ward 1. Adapts to unit workflow and patient management with professional resiliency 2. Provides geriatric patient care that integrates core issues unique to the population 3. Manages the surgical patient presenting with underlying medical issues 4. Manages the multi-patient assignment utilizing time management and organization skills 5. Manages care of patient undergoing orthopedic surgery or fracture stabilization 6. Ensures optimal health and preventative care for diabetic patient 7. Alleviates patient distress: pain, psychosocial, spiritual and physical 8. Addresses unique needs of patients presenting with substance abuse, withdrawal, or other mental

health issue. 9. Adapts plan of care to protect patients and the community when unique infection control issues

present 10. Provides pediatric patient care that integrates core issues unique to the population 11. Provides complex patient education based on identified need 12. Uses interdisciplinary teamwork, delegation and /or supervisory role to ensure safe, effective care of

patient populations.

Emergency Department Competencies 1. Adapts to ER workflow and ongoing patient management while transitioning patients from

admission to discharge. 2. Safeguards patient presenting with possible substance abuse, toxic ingestion, behavioral health

and/or withdrawal issues 3. Addresses priorities for patients presenting with abdominal pain, including various Gastrointestinal

or General Urinary maladies 4. Protects the cardiac patient via prompt, appropriate interventions for presenting symptoms 5. Ensures patient well=being during minor procedures with or without procedural sedation 6. Manages patient care with multisystem, endocrine, sepsis or hematologic dysfunction 7. Optimizes function and independence for the neurologically impaired patient 8. Stabilizes orthopedic injuries of patient presenting with possible fractures or dislocation 9. Ensures adequate oxygenation/comfort for patient presenting with respiratory compromise 10. Adapts patient care to the unique needs and issues inherent to the pediatric population 11. Directs attention to issues involving the patient’s ears, eyes, nose, throat, teeth and mouth 12. Protects patient and community from environmental, toxic, and communicable risks 13. Prioritizes care of the trauma patient

Home Health and Hospice care - Home rehab services

Clinic-Based Patient Care - Universal , Pediatric Clinic, Cardiology Clinic, Gastro-Intestinal Clinic

and many more . . . . .



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Preceptor development and support

Preceptors support transition to practice in both academic and practice settings. To be effective, they must understand the goals and objectives outlined by both nursing faculty and nurse professional development staff as related to development of clinical practice

(Lindfors, Meretoja, Kaunonen, & Paavilainen, 2017; McClure & Black, 2013; Ryan & McAllister, 2017). Preceptors are the essential partners that facilitate the development of practical skills, communication, professional socialization, documentation, prioritization, and planning of daily activities (Parker, Lazenby, & Brown, 2012). They fill a crucial role in bridging the nurse education theory-practice gap when they have preparation and supporting structures for their specialized role. Preceptors sustain learners as they select and incorporate best practice and evidence in the plan of care.

For optimal outcomes, the focus of precepting must shift from task to process and thinking practice (Windey, et al., 2015). A qualitative study outlined preceptor instructional needs as including a) tools for precepting, b) knowledge about clinical teaching, c) skills related to reflective reasoning, d) communication skills/models, e) academic partnerships, f) how to support, coach, train, g)competence in life-long perspective, h)teaching/learning models, and i) science of education (Bengtsson & Carlson, 2015; McClure & Black, 2013).

Cotter and Deinemann (2016) emphasize the benefits of having trained preceptors and recommend a structured preceptor selection process. The positive outcomes of that role preparation include competent patient care, quality improvement, improved patient outcomes and decreased nursing turnover rates

The literature informs us that Preceptor development and support is inconsistent and too often non-existent. A few of the core lessons learned by VNIP through nearly two decades of this work include the elements of:

1. Focus on the preceptor’s primary role of collecting evidence of clinical performance capability, while protecting both patient and learner.

2. Specific planning for critical thinking development through weekly meetings, case scenarios, documentation tools, discussion, and/or problem solving

3. Emphasis on appropriate assignment, appropriate supervision

Theory and research concepts are interwoven within the Preceptor development and support system. The specific theories are evidenced by the references and explanations with in the Preceptor Development Course and the course textbook. Course curriculum and content has been modified through formative data collection and Rapid Cycle Quality Improvement (Leis & Shojania, 2016).

Thoughts for the future of preceptor development . . .

VNIP faculty constantly adapt course content to increase the amount of delivered via independent study or self-learning modules so that group learning time can shift to group activities, simulation or interactive engagement tools.



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