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Running head: NURS 792 1
Practicum Synthesis Paper
Sheila Lucas
Ferris State University
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Abstract
Integration of practical knowledge and theory is fundamental for new nurse leaders as they begin
their transition into an advance specialty role. The purpose of this capstone practicum is for
application of these principles in a controlled learning environment. A variety of leadership
activities were completed to total 120 hours. The challenges, issues and concerns are described
as well as the solutions and evaluation of the overall practicum.
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Practicum Synthesis Paper
The purpose of this practicum is to integrate knowledge obtained throughout the Masters
of Science in Nursing (MSN) program at Ferris State University (FSU) into a clinical situation
within nursing administration. The intent is to apply the competencies and theories learned
throughout the academic program to planned learning activities. The FSU program requires
completion of 120 practicum hours within the role of nursing administration. The aim of this
practicum is to challenge the student in application of leadership principles. Conley, Branowick,
and Hanley (2007) discuss how nurse manager orientation programs are loosely structured and
do not adequately prepare nurses for their new responsibilities. Practicum experiences allow
students to individualize their educational goals and learning needs (Aduddell & Dorman, 2010).
This paper will be a synopsis of the completed practicum experience, goals, challenges, concerns
and analysis of outcomes.
Overview
American Nurses Association (ANA) Nurse Administrator Scope and Standards of
Practice (2009) was reviewed and four standards of practice were identified for areas of growth;
collaboration, resource utilization, leadership, and professional practice evaluation. The chosen
setting was an acute care hospital. Main focus for learning activities surrounded building and
validating a new nursing acuity tool, however time was spent on participation and collaboration
with various leadership committees, peer review boards, professional growth and reflection. The
goal of the identified standards of practice was more awareness and involvement in the
interdisciplinary process, have better understanding of resource utilization and project planning,
project identification, innovative thinking for solutions, action plan and policy writing, and
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growth in professional writing and organizational membership. Each of these goals was
addressed and will be detailed throughout the paper.
Issues, Challenges, and Concerns
Acuity Tool
Early concerns arose during the beginning of the practicum, when it was revealed that the
nursing leaders had already met with the nursing informatics coordinator to build the new acuity
tool and that it was already completed and being trialed on one of the units. This was not my
understanding when presented with the project and confused me regarding what my role in the
build. After meeting individually with the nurse leaders to discuss their plans, issues and desires
for such a tool, it was evident that, although the bulk of the scoring was completed, it was not a
reliable tool and the acuity numbers calculated did not value anything. The nursing staff was
familiar with the current acuity scale of one to six for their patients but this scale was from zero
to 150+. For example, a patient score of 34 did not have any real value for what the nursing
workload was because it was not understood. Some nurse leaders also wanted to have a reliable
way of tracking to validate changes in nursing ratios and flexible staffing. Barton (2013)
highlights the importance that appropriate acuity scoring and staffing can have financially for an
institution. The ideas for how global and wide reaching this could be became overwhelming and
difficult to comprehend because of the potential greater use.
Another issue within the build of the acuity tool was the individualization that each unit
director wanted. Some items were so specific and numerous that it would have completely un-
balanced the acuity scale. For example: scoring for refilling ice bags, braces coming on and off,
and joint camp activities. These are specific to an orthopedic unit but will not score if a patient is
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on a telemetry unit. Another thing to consider was which nursing tasks actually needed to be
scored. What was considered time consuming and how might each task be weighted?
Multiple changes were made to the original tool that was created and some stakeholder’s
continued to request changes which made data collection difficult. This was difficult because
any changes, such as adding additional nursing tasks or changing the weight of the score, would
change the acuity scoring so much that it made it difficult to validate trends.
The intensive care unit brought about many unique challenges related to the scoring
system. At times some patients would not score appropriately, however they were very heavy in
nursing workload. It was evident that something was not accurately capturing nursing workload,
even though the tool was scoring appropriately to the build. Hoi, Ismail, Ong, and Kang, (2010)
discuss this issue in relation to attempted to capture patient severity of illness and intensity of
treatment versus the level of assistance needed and nursing workload. This was a struggle to
separate and identify.
Prioritization
Challenges arose with time commitment needed from key players to move project along.
The hospital organization had just been though some rocky merger discussions that had held up
many projects within the organization and the acuity tool build was not at the top of stakeholders
lists. Although Concannon, Fuster, Saunders, Patel, Wong, Leslie, and Lau (2014) specifically
look at the lack of stakeholder engagement in research studies, their findings can be related to
multiple situations. Concannon et,al. (2014) suggest that poor stakeholder engagement can often
times slow or derail a project or research study possibly due a conflict of interest or knowledge
deficit. The lack of stakeholder interest, likely due to burnout and overwhelming back log of
work load contributed to poor engagement.
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Practicum Site
Although the chosen practicum site was convenient in demographic location, preceptor
identification, and flexibility with hours, choosing Metro Health Hospital also had some draw
backs. Because I plan to work at this organization after my academic work is completed and am
looking to transition into a leadership role, this added to the pressure and anxiety to do a good
job with the project and present a comprehensive tool, while looking at the education needed, the
financial benefits to the hospital, and policies revisions needed. I was creating a tool for
approval from people that would someday be my peers, which I found to be intimidating.
Strategies and Approaches to Challenges
Acuity Tool
The approach chosen after identifying and reviewing in depth the acuity tool created by
the nursing leaders and nursing informatics coordinator, was to meet with the leaders to identify
what they wanted to glean from the information populated and how did they envision putting it
to use for their departments (Meyers & Adkins, 2012). While this gave a better understanding of
the incite of the nurse leaders it also ushered in the idea that this tool will be used for something
greater than to just meet an accrediting requirement (Heathcare Facilities Accreditation Program,
2015. 16-5.) and assist nurses with staffing. As Barton (2013) also identified in her article, the
nurse leaders at Metro wanted to expand the use of this tool to include adjusting staffing ratios,
trend case mix index and nursing workload to justify budgetary needs.
Nursing leaders and educators assisted in weighting the nursing interventions to be
scored. They chose a scale of one through six and each item was scored on the amount of time
the intervention took to complete and skill mix needed to complete. Some interventions were
scored higher based on the number of times during a shift it was completed (example: number of
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times vitals were completed – increased amount could indicate unstable or post op patient).
Good communication, mediator, and transformational leadership skills were utilized during these
conversations.
Using transformational leadership to identify with each leader and openly communicating
with the nurses assisting in the build and refinement of the acuity tool, assisted in leaning out the
project and streamlining the team to keep the project moving forward. Some difficult
conversations were needed with persistent staff that insisted on specific changes, however the
communication was well received through identification of identifying of their passion to see a
successful tool built and clear reasoning to cease making changes to validate the work
completed.
The nurse leaders identified and based the acuity shell they created off an article by Kidd,
Grove, Kaiser, Swoboda and Taylor (2014). The leaders of this article used a similar scoring
system to validate the nursing workload but then broke that score down into an acuity category.
This same concept could be reproduced with the Metro acuity system and built into the tool. The
second challenge came into play when deciding what the range of score should be for each acuity
category. After reviewing data collected for each score and the current staffing patterns of
multiple units, a simple one to five acuity category was defined. For example: Patient has a
cumulative acuity score of 32 based off nursing documentation. This would equate to an acuity
category of three. Having a smaller acuity category that the staff nurses are already comfortable
with (previously used acuity scale was one to six), made the new tool more meaningful and thus
more likely for staff to be able to implement.
After some consultation with my preceptor, Susie Grubba, who is also the director of
intensive care services, it was decided that trying to capture the ICU patients at this time was
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hindering progress with the overall project. She allowed me to move forward with omitting the
ICU patients. After the completion of the medical/surgical unit acuity tool, she then asked me to
revisit the ICU patients to see what we were missing. This allowed me to really focus in on
those patients and delve into this subset of patients and shape how I was extracting data for this
particular subset of patients to show actual nurse workload for this type of setting. Kevin
Cashman (2012 as cited in Sherman 2013), invites leaders to pause and collect thoughts about a
project then move forward, experiment and be strategic with ideas. This pause should be a
reflection on direction, which was exactly what was needed in this situation. Susie also used
transformational leadership to identify and area where I was struggling. She offered a temporary
correction that supported the greater good of the tool while setting aside the needs of her own
unit and created a supportive environment (Doody & Doody 2012).
Prioritization
Clear, professional communication allowed for focus and advancement throughout the
practicum. I resisted contacting my preceptor for many situations and resolved to use the learned
transformational leadership skills to resolve conflict without much assistance. Each encounter
was approached professionally and directly regarding the need for their involvement and
direction and goals of the practicum. Communications such as this were necessary to halt
negative remarks about the complexity of the tool, prevent unit specific changes and discontinue
changes made to the tool. I did, however, rely on the assistance of the Chief Nursing Officer
(CNO) for assistance in justifying why our project needed prioritization over other items. She
utilized direct, factual information without having to plead for assistance. What I learned from
this encounter was to be authentic with my responses.
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Practicum Site
Patricia Benner’s theory on novice to expert (1982) has been applicable to the anxiety
related to working amongst peers (Nursing Theory, 2013). It is important to remind myself that
leadership is not something that I am an expert in and that it takes years of refinement and
reflection to be a good leader. Mentorship though Susie Grubba and other nursing leaders has
shown me that I have the skills to be a good leader but will need the correct avenue to apply
them. Through reflection on practice knowledge and needs, self-directed education and
mentorship seeking, nurse leaders grow to become more proficient in their leadership skills and
comprehension (Nursing Theory, 2013).
I had the opportunity to present the final drafted version of the acuity tool to the nursing
leadership committee (NLC). In creating this presentation, I kept it simple to not be redundant to
knowledge they already knew (example: accreditation standard, how the scoring was weighted),
but focused more on how their numbers equated to usable acuity categories and how they would
be able to track this. See Appendix A for presentation. The presentation was very well received
and I was able to answer all of the questions and comments without much intervention needed
from my preceptor. Policy revision and review was also presented to the NLC and was accepted
without many changes. This reassured me that I have the knowledge, skills and attitudes.
Evaluation
I am overall pleased with my practicum experience. In my consultation sessions with
Susie, I have had the opportunity to candidly express my observations and feelings which have
assisted in the further knowledge and growth of my leadership skills. See Appendix B for
student and preceptor evaluations. My professionalism and interdisciplinary collaboration have
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substantially benefited from the practicum through communication and more personal
involvement in hospital committees. I have been able to reflect on my weaknesses and foster
areas of improvement. My goals for leadership included promoting the nursing profession
through professional organization membership and publication. While I have yet to apply for
membership, the discussions with other nurse leaders have helped me to identify which
organization would provide me benefit as I enter a leadership role both currently and as I grow
professionally.
The article submitted for publication has been accepted and I have been working on the
revisions requested. Publication had never been a professional goal of mine, but I am very
excited about the prospect of this and would like to continue publishing as opportunities present
(Wachs, Williamson, Moore, Roy, & Childre, 2010.,Witt, 2011).
I was disappointed in the peer review process, however. While some interesting data was
reviewed during each of the five sessions I attending (two readmission peer reviews and three
coronary case reviews), I did not see much movement on areas of improvement that were
identified. The coronary case reviews did discuss where the breakdown or potential breakdown
in care happened but I did not identify a champion within this committee that was going to
provide education to prevent these occurrences. The readmission peer review was interesting to
evaluate the trend in data. However, at this time, data was not reported and there was no
education given to the nursing or medical staff on ways to prevent the readmission. These are
both relatively new peer review boards, so they may just be collecting data to see a trend at this
time before implementation, however, transformational leadership should be utilized to create a
atmosphere to move forward with educational opportunities to enhance patient care and safe
practice (Haag-Heitman, & George, 2011, Spiva, Jarrell, Baio, 2014)
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Conclusion
During the practicum, several challenging factors were experienced and growth
opportunities have been identified. Although the project focus was not what was originally
intended, the resulting product was spending less time on the groundwork and really focusing on
the meaning, implementation and use of such built project. Through flexibility, implementation
of nursing and leadership theories, interdisciplinary integration and mentorship, the practicum
was a challenging and excellent learning opportunity to exercise learned principles of nursing
leadership in a controlled learning environment.
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References
Aduddell, K., & Dorman, G. (2010). The development of the next generation of nurse leaders.
Journal Of Nursing Education, 49(3), 168-171 4p. doi:10.3928/01484834-20090916-08
American Nurses Association. (2009). Nursing administration: Scope and standards of practice.
Washington, D.C.
Barton, N. (2013). Acuity-based staffing: balance cost, satisfaction, quality, and outcomes.
Nurse Leader, 11(6), 47-64. doi:10.1016/j.mnl.2013.08.005
Concannon, T. W., Fuster, M., Saunders, T., Patel, K., Wong, J. B., Leslie, L. K., & Lau, J.
(2014). A systematic review of stakeholder engagement in comparative effectiveness and
patient-centered outcomes research. JGIM: Journal Of General Internal Medicine,
29(12), 1692-1701 10p. doi:10.1007/s11606-014-2878-x
Conley, S., Branowicki, P., & Hanley, D. (2007). Nursing leadership orientation: a competency
and preceptor model to facilitate new leader success. Journal Of Nursing Administration,
37(11), 491-498.
Doody, O., & Doody, C. M. (2012). Transformational leadership in nursing practice. British
Journal Of Nursing, 21(20), 1212-1218 7p.
Haag-Heitman, B. George, V. (2011). Nursing peer review: principles and practice. American
Nurse Today. 6 (9) 48-52
Healthcare Facilities Accreditation Program. (2015). Accreditation requirements for acute care
hospitals. American Osteopathic Association Healthcare Facilities Accreditation Program
(HFAP). Chicago IL
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Hoi, S., Ismail, N., Ong, L., & Kang, J. (2010). Determining nurse staffing needs: the workload
intensity measurement system. Journal Of Nursing Management, 18(1), 44-53.
doi:10.1111/j.1365-2834.2009.01045.x
Kidd, M., Grove, K., Kaiser, M., Swoboda, B., and Taylor, A. (2014). A new patient-acuity tool
promotes equitable nurse-patient assignments. American Nurse Today. Retrieved from
http://www.americannursetoday.com/wp-content/uploads/2014/03/ant3-Workforce-
Management-Acuity-304.pdf
Meyers, C., Adkins, S. (2012). Coalitions, collaboration, and compromise. Tennessee Nurse,
75(3), 5.
Nursing Theory (2013). From novice to expert. Patricia Benner. Retrieved from
http://currentnursing.com/nursing_theory/Patricia_Benner_From_Novice_to_Expert.html
Sherman, R. (2013). The power of pausing. Emerging RN leader. Found at
http://www.emergingrnleader.com/the-power-of-pausing/
Spiva, L., Jarrell, N., Baio, P. (2014) The power or nursing peer review. Journal of Nursing
Administration. 44 (11) 586-590. doi: 10.1097/NNA.0000000000000130
Wachs, J., Williamson, G., Moore, P., Roy, D., Childre, F. (2010). It starts with an idea!
Workplace Health Safety 8(5)177-181. doi: 10.1177/216507991005800502
Witt, C. (2011). Writing and publishing: why not you? Advances in Neonatal Care 11(5) 305-
306 DOI: 10.1097/ANC.0b013e31822b5d4f
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Appendix A
Double Click to open PDF file of presentation
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Appendix B
Final Semester Evaluation Tool for Sheila LucasFall 2015 – Ferris State University
NURS 792Completed by Sheila Lucas
Collaboration: Demonstrates collaborative efforts with interdisciplinary team
Greatly Exceeds Expectations
Exceeds Expectations
Meets Expectations
Occasionally Meets
Expectations
Unsatisfactory
Comments:I believe that my collaboration in this practicum has been sharpened and knowledge of the appropriate use of different disciplines in a project plan and implementation has grown throughout the project. Through thoughtful consideration, I have attempted to utlize all areas of the healthcare team through meetings with leaders on how the implementation of a EMR acuity tool will affect their unit.
Collaboration: Utilizes feedback form others into plan/tool development
Greatly Exceeds Expectations
Exceeds Expectations
Meets Expectations
Occasionally Meets
Expectations
Unsatisfactory
Comments:Continuation of above. Meetings held with various nursing and department leaders on how an EMR acuity tool could be helpful to each unit, how they plan to implement and use it, and what barriers they see to it. All ideas were utilizes and implemented when creating tool.
Resource Utilization: Demonstrates leadership through creating meaningful tool, action plan, and presentation to nursing leadership
Greatly Exceeds Expectations
Exceeds Expectations
Meets Expectations
Occasionally Meets
Expectations
Unsatisfactory
Comments:Mindful of the time and effort others were putting into this project and limited the amount of outside support was needed from leaders and mentor. Broadened scope of practice to include how the tool can be utilized for appropriate patient assignments. Presentation to nursing leaders and professional nursing counsel regarding implementation and practicality of tool use for staff nursing.
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Leadership: Contributes to nursing advancement through publication submission of relevant material
Greatly Exceeds Expectations
Exceeds Expectations
Meets Expectations
Occasionally Meets
Expectations
Unsatisfactory
Comments:Article submitted to journal for publication and changes made as requested from journal reviewers. Have not received further feedback regarding article needs and publication since mid-November. Unsure if article is good enough for publication, however process was insightful on how data is collected vs non collection throughout organization and how this process can be improved to improve organization outcomes.
Leadership: Facilitates personal and professional growth through membership to professional organization(s) and publication submission
Greatly Exceeds Expectations
Exceeds Expectations
Meets Expectations
Occasionally Meets
Expectations
Unsatisfactory
Comments:Did not join organization due to costs. However I do plan on joining when leadership role presents itself. Also would like to be able to tailor department leading into professional organization joined to gain greater insight on changes and evidence based practice for this area of nursing.
Professional Practice Evaluation: Demonstrates transformational leadership through peer review and collaborative efforts
Greatly Exceeds Expectations
Exceeds Expectations
Meets Expectations
Occasionally Meets
Expectations
Unsatisfactory
Comments:Participated in peer review for readmissions and corinary case studies. Interesting to see how each was run and if there were any meaningful changes made from the outcomes of these meetings. Although my participation was rather limited, I did gain insight on how nursing
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could become more involved in these review processes and should be active in ways to improve patient outcomes.
Professional Practice Evaluation: Demonstrates and verbalizes understanding and application of lifelong learning
Greatly Exceeds Expectations
Exceeds Expectations
Meets Expectations
Occasionally Meets
Expectations
Unsatisfactory
Comments:I have grand plans to continue my education by obtaining my MBA. While my original thought was to begin this program next fall, after some discussion with my mentor, I believe that putting this on the back burner should be necessary to become more comfortable in any new role in nursing administration. My timeline may be unreasonable if I choose to move into a leadership role that will take a significant amount of time to grasp a handle on and not overwhelm the lives of my family. While I still plan on continuing learning though higher education, I also would find value in professional organization and journal subscription to stay current with evidence in nursing.
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