Bridging the Gap to the Proficient Professional Susan A. Boyer, RN, M.Ed. Executive Director Vermont Nurses In Partnership, Inc. www.vnip.org susan.boyer 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Susan A. Boyer, RN, M.Ed. VNIP, Inc Objectives: Develop strategies for critical thinking development within the practice setting Discuss the framework for preceptor development Determine specific, measurable criteria for assessment of critical thinking, leadership, management and interpersonal relationship skills. 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Susan A. Boyer, RN, M.Ed. VNIP, Inc History of VNIP What we have learned Measurable outcomes - help to ‘sell the concepts/program’ The value of standardization and collaboration Expectations for the future of this collaborative project www.vnip.org 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

VT Nurses In Partnership - administration of internship Developed Internship for multi-agency use across the continuum of care Delivers programming that supports new grad, new to specialty & precepting staff. Incorporates Clinical Competency Development and Validation Goals Standardized preceptor & intern development susan.boyer@hitchcock.org www.vnip.org © 2001 – 2007 Vermont Nurses In Partnership, Inc.

Outcomes “Nursing literature reports that the inability to handle the intense working environment, advanced medical technology , and high patient acuity results in new grad turnover rates of 35% to 60% within the first year of employment.” (Beecraft, Kunzman, & Krozek, 2001) VNIP turnover rate – less than 10% for new graduates completing the internship © 2003 - 2008 Vermont Nurses In Partnership, Inc. All rights reserved. No copying without permission. vt-nurses@earthlink.net

Support - Internship/Orientation 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

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

Susan A. Boyer, RN, M.Ed. VNIP, Inc What are the goals ? What patients need – a safe and effective care provider! What does a ‘safe and effective’ care provider look like? What is most important in their practice? 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

CRITICAL THINKING: STRATEGIES FOR DEVELOPMENT What it is, what it looks like, how we do it, HOW TO FOSTER ITS DEVELOPMENT! Teach preceptors, teach interns First we need to clearly define and describe what critical thinking is 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

www.vnip.org susan.boyer@hitchcock.org Critical thinking? Think, Pair, Share: What does C.T. look like in your practice? How do we support the development of Critical thinking skills? www.vnip.org susan.boyer@hitchcock.org

STRATEGIES FOR DEVELOPMENT How do you know that it is occurring? How does critical thinking relate to competence development & validation? What does critical thinking look like in your clinical practice setting? 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Critical Thinking: Novice Expert Anticipates & Manages complications Checks accuracy of data Data gathering from multiple sources Distinguish relevant from irrelevant Extends thinking beyond the medical record Evaluates differing points of view Flexibility - change in assignment Identifies and examines alternatives Identifies missing information Predicts beyond the presentation Willingness to reconsider 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Promoting C. T. in the Novice Questions Anticipate questions that might be asked Explore possible consequences Focus on outcome – what is the goal? Focus on the rationale – why? Explore alternatives – what else? what am I missing Case presentations, telling your ‘stories’, sharing experiences Turn them into “what if” discussions Continue with the questions listed above susan.boyer@hitchcock.org © 2001 Vermont Organization of Nurse Leaders (VONL)

Promoting C. T. in the Novice Develop & use habits of inquiry Take enough time to explore situation Keep an open mind - Verify information Discuss What did I miss? How could this be made better? Why are we doing it this way? Thinking out loud Did you notice… How can I find out . . . . I could do x, y or z,…. but for this patient, I think this is best…. Why? susan.boyer@hitchcock.org © 2001 Vermont Organization of Nurse Leaders (VONL)

Fostering critical thinking skill development Assist with organization/prioritization Provide reflection regarding aspects of a clinical situation Focus on concrete critical thinking development questions/discussion Clearly defined expectations A plan for the learning process 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Susan A. Boyer, RN, M.Ed. VNIP, Inc What are the goals ? What patients need – a safe and effective care provider What a preceptor needs – evidence that this care provider can provide safe and effective care What will this evidence look like? 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Tool – orientation checklist List of tasks and procedures? Inclusive of critical thinking expectations? Relationship considerations? Ethics, leadership, other aspects? 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Competency Expectations Clearly defined expectations Performance outcomes statements What does a nurse do? What is most important? Tasks vs. Phronesis Procedures vs. Critical Thinking 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Concrete Teaching Plan Teaching is more effective when it is planned Components of a teaching plan Goals Clearly defined expectations Instructional strategies Teaching time is required for instruction, observation, allowing practice, giving feedback, documentation, discussion of case scenarios/stories/issues/what ifs. 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Clinical Coaching Plans Instructional Strategies Performance Expectations Met? Comments Reflection on practice/learning (concrete C.T. development) 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Susan A. Boyer, RN, M.Ed. VNIP, Inc COPA model Helps us to clearly define expectations! Expectations are worded in performance outcomes statements Goals, performance outcomes, specific subskills and critical elements 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

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, 1999 http://nursingworld.org/ojin/topic10/tpc10_2.htm © 2003 - 2008 Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. vt-nurses@earthlink.net

Write a performance outcome Statement of performance expectation What does a nurse do? What is most important? Tasks vs. Phronesis Procedures vs. Critical Thinking 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Write a performance outcome 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 – highest level action verb feasible KISS principle © 2003 - 2008 Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. vt-nurses@earthlink.net © 2003 - 2008 Vermont Organization of Nurse Leaders. All rights reserved. No copying without permission. vt-nurses@earthlink.net

Susan A. Boyer, RN, M.Ed. VNIP, Inc Performance outcome What is most important? Tasks vs. Phronesis Procedures vs. Critical Thinking 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Susan A. Boyer, RN, M.Ed. VNIP, Inc 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

COPA Model - Prioritizes concepts over cases Shifts the focus away from orientation to the “minutia of nursing” Provides the structural foundation for competency development & assessment Uses Performance Outcomes for validation of competence in clinical practice susan.boyer@hitchcock.org www.vnip.org © 2001 – 2007 Vermont Nurses In Partnership, Inc.

COPA framework Causes us to look beyond the tasks and procedures of nursing work Considers critical thinking skills in measurable, observable terms Includes specific performance outcomes for teaching, leadership, human caring relationships, management, & knowledge integration. susan.boyer@hitchcock.org www.vnip.org © 2001 – 2007 Vermont Nurses In Partnership, Inc.

COPA Model Clearly defines expectations for clinical performance Structural foundation for practice-based competency development & assessment Performance Outcomes for both development and validation of competence in clinical practice Clearly defines expectations for clinical performance susan.boyer@hitchcock.org www.vnip.org © 2001 – 2007 Vermont Nurses In Partnership, Inc.

Evidence of competence? Identify and explore resources Recognize limits of own capability Seek help/assistance/information Assessment of patient & situation Collect appropriate data What to do with the data? Anticipates potential issues and is prepared to address them 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Unique to nursing practice? Relationship-based caring Nurture and support Analyze, Evaluate, Synthesis Assessment Evaluation Planning 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Susan A. Boyer, RN, M.Ed. VNIP, Inc Teaching preceptors Communication Interpersonal skills How to provide experiential learning while protecting safety Teaching how to teach, how to foster critical thinking development 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

To determine "what to teach?" What do you want them to be able to do? How much if this is inherent knowledge? What are you having problems with? How much of this requires further instruction in ‘how to do it’? 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Susan A. Boyer, RN, M.Ed. VNIP, Inc 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc 34

Critical elements - For planning Performance expectations Instructional strategies Concrete Critical Thinking Development 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Precepting is another task Precepting takes time Protocols required to establish where/how time will be designated Core instruction - complete instruction, complete preparation for the role 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Susan A. Boyer, RN, M.Ed. VNIP, Inc Learning Environment What every learner needs – a safe learning environment Basic principles of teaching/learning Simple to complex Success builds success Allow practice, even failure Allow time for learning and discussing Feedback, Correction, Change direction Safety for patient and learner 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Experiential Learning Instruction in the clinical setting Differentiating between performance outcomes and instructional strategies Determining behaviors that foster Critical Thinking development 4/17/2017 Susan A. Boyer, RN, M.Ed. VNIP, Inc

Participant driven Participant focused Rather than instructor-driven VT Nurses In Partnership, Inc www.vnip.org vt-nurses@earthlink.net

Novice to expert Novice Advanced beginner Competent Proficient Expert

Traits and capabilities Framework, Berliner (1988); Years experience data from James Leach (1996)

Transition between levels Transition does not equal time/years Regression when faced with new situation/specialty Transition takes time and experience Experiential learning Reasoned practice Gain the habit and understanding of deliberation Move more quickly to next level Apply prior learning See what the core concepts are See how concepts can be applied in new situation

Application to competence Development & evaluation Performance Scoring Identified Limitation (Novice) Capable (Advanced Beginner) Performs Independently (Competent) Proficient Expert

Scoring key categories 1 – Identified Limitation requires direct guidance & support, little or no experience with skill 2 – Capable - familiar with skill/equipment, but may need assistance, seeks help when unfamiliar with process/skill BENNER’S Novice - Inflexible, rule-based. Little or no background understanding Advanced Beginner – start to use and make sense of situational elements & depend on the context. Temporal focus is immediate & present

3 – Performs independently Benner’s Competent Increased efficiency, planning is still conscious, abstract, analytic, and deliberate. -situations are perceived as a whole rather than as unconnected aspects - Understanding of task, also the decision of what to do next, is intuitive and fluid. 3 – Performs independently knowledgeable to perform these tasks safely as a result of training & experience 4 – Proficient extensive experience in this area/skill, able to teach and mentor others 5 – Expert all of the above; fluid performance; ensures evidence-based practice for clients and agency

Transition from novice What supports development and transition along these levels of capability?   

To develop capability, competence & confidence Use reflection, questioning, story- telling, feedback, experience and success to foster development Support holistic care Focus on concrete critical thinking development questions/discussion Clearly defined expectations A plan for the learning process

What are the goals ? What patients need – a safe and effective care provider What a preceptor needs – evidence that this care provider can provide safe and effective care What will this evidence look like?