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Running head: COMPREHENSIVE EXAM

Comprehensive Exam

Adele Freestone, R.N.

Idaho State University

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Comprehensive Exam

Introduction

A growing body of research concerning the connection between graduate nursing staff

mentoring and staff retention as well as satisfaction indicates a need to address the impact this

issue has and will continue to have on nursing. “Newly graduated nurses are entering the work

force and finding that they have neither the practice expertise nor the confidence to navigate

what has become a highly dynamic and intense clinical environment burdened by escalating

levels of patient acuity and nursing workload.” (Duchscher, 2008). In a time where educational

resources are shrinking and nursing educators are retiring or leaving the education system for

more lucrative professional opportunities, the burden of continuing education and professional

mentoring is becoming the responsibility of the hiring institution on a much greater scale. “The

intense and dynamic transition experience for these newly graduated nurses should inspire

educational and service institutions to provide preparatory education on transition as well as

extended, sequential, and structured orientation and mentoring programs that bridge senior

students’ expectations of professional work life with the reality of employment.”

(Duchscher, 2008).

Burns and Poster (2008) recognized the existence of what has been commonly referred to

as the nursing theory/practice gap as it applies to new graduates entering the professional ranks.

“The gap between a new registered nurse graduate’s education for practice and actual practice

requirements of new registered nurses has long been an accepted fact in nursing.” (Burns and

Poster, 2008) They go on to point out that “nursing students are rarely, if ever, required to make

clinical judgments related to real patient conditions requiring urgent and emergent decisions to

prevent irreversible physiological damage. The question was posed, if they did not have this

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experience in school, when and where would they get it? They would eventually be faced with

their first potentially life-threatening crisis situation in the real clinical setting with little or no

preparation and would be expected, as licensed registered nurses, to be able to intervene. (Burns

and Poster, 2008)

In most health care institutions a newly hired nurse undergoes an orientation period. This

usually consists of being assigned to a more experienced colleague preceptor for a relatively

short period of time during which the new nurse is expected to become familiar with the

institutionally developed policy and procedures, the routine function of the position, and the

expectations of employment. Documentation is usually in the form of a check list that includes a

section devoted to nursing skills. The preceptor is most often a staff nurse with little or no special

training for this role. Most institutions have no effective set standard that preceptors must meet

before being considered for such an assignment despite research that indicates a need.

Smith (2006) presents this explanation of the preceptor role. “Besides clinical expertise, a

preceptor needs leadership and communication skills (such as assertiveness), critical thinking

and problem-solving skills, an interest in professional growth and in the process of teaching and

learning, a nonjudgmental attitude, and sensitivity to preceptees’ needs. Equally important are

flexibility, adaptability, and a good sense of humor.” (Smith, 2006) She goes on to point out that

“A preceptor can also contribute to her facility’s recruitment and retention efforts. During

nursing shortages, a preceptor can help create positive morale and collegial working conditions,

which helps to attract and retain staff. (Smith, 2006). Considering the importance of

all these items, the informal role of staff preceptor deserves more attention than it currently

receives in most health care institutions.

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Position proposal and description

I desire to develop a position intended to address the practice/theory gap as it pertains to

newly hired graduate nurses within the rural acute care setting. The “new staff preceptor” role

differs from a clinical educator role due to the specific nature of the target students; newly

graduated and newly hired nurses. The responsibilities of this position would include initial

evaluations of skill and knowledge levels for each individual new nursing hire including certified

nurse’s aides, the designing of a personalized orientation track that includes some standardized

elements, formal professional mentoring throughout the orientation period, and both formative

and summative evaluations including recommendations for further mentoring and orientation if

needed. Similarities of a new staff preceptor to an undergraduate clinical instructor indicate that

a master’s degree in nursing education is ideal for this new role, for an advanced practice degree

in nursing education requires the development of many of the qualities Smith (2006) outlined.

Not only does this role have the satisfying ability to launch new nursing careers of all levels in a

positive fashion, it has the capacity to effect attitudes and morale. This, in turn, has the effect of

increasing staff satisfaction and retention rates, and this objective is one of the justifications for

the creation of the role. In the rural health care setting this becomes increasingly important when

taking into consideration the shortage of nurses interested in entering the rural nurse specialty,

the high cost of recruiting and training, and the low retention rates. “The cost of orienting

registered nurses is high. Hospitals must provide an orientation that helps retain nurses as well as

prepare them for employment.” (Ward, 2009). Retaining staff, once trained, is a fiscal necessity

for the urban institution. It becomes even more important to the rural institution that does not

have the resources of its urban counterpart.

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Theoretical framework for practice

My personal belief system includes the idea that nurses are caring, ethical, altruistic

individuals who are invested in lifelong learning, professional growth, and achievement. Nurses

are invested in furthering professional competence and expertise as a whole, not just competing

in individual accomplishment. This includes mentoring and precepting our fellows entering

practice. The nursing theory I find most compatible with this view is Patricia Benner’s “Novice

to Expert” theory of how nurses know nursing. Benner utilizes the Dreyfus Model of Skill

Acquisition which defines five levels of proficiency; novice, advanced beginner, competent,

proficient and expert. (Benner, 1984). This theory has the capacity, versatility and flexibility to

be applied relatively easily even in a profession so diversely specialized as nursing has become.

Thus, it can apply to a nurse who may be an expert in dialysis or interventional radiology but an

advanced beginner or even a novice in labor and delivery or emergency. It can be applied to a

new graduate entering the profession, or a nurse who has achieved a competent level after

practicing two to five years.

Dr Howard Gardner’s Theory of Multiple Intelligences (MI) is a good choice to team

with that of Patricia Benner. His hypothesis presents the idea that there are many different ways

that learning takes place and that teaching styles should address this diversity to enjoy expanded

success. He identifies ways knowledge is learned; “Linguistic intelligence - the intelligence of a

writer or orator, logical mathematical intelligence - the intelligence of a mathematician or

scientist, musical intelligence - the capacity to create, perform and appreciate music, spatial

intelligence - the ability to create mental images and build or manipulate them, bodily-

kinaesthetic intelligence–he capacity to solve problems using the body, (athletes, actors,

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craftspeople, body workers, surgeons), interpersonal intelligence - understanding the moods,

motivations and intentions of others, intrapersonal intelligence - the capacity to understand

oneself, naturalistic intelligence - the ability to make accurate classifications in nature, and

Gardner is also suggesting the presence of a ninth intelligence which is termed existential

intelligence. This is the capacity to ask the ‘big questions’ e.g. when we ponder death, love,

conflict, the future of the planet.” (Holland, 2007). Utilizing the expanded teaching and learning

styles that are influenced by MI theory have positive impacts on learners. The broader view of

intelligence influences the teacher to assess and teach using more than the two traditional

teaching styles, linguistic and mathematical. This in turn allows expanded opportunities for

successful learning to take place. “While Gardner's initial work was focused on helping students

with attention deficit disorders or students with brain injuries, educators from elementary school

to graduate study have found his theory to have relevance for classroom practices. When Ml-

inspired instruction was implemented with adult learning, it was found to reduce teacher

directedness, increase student control and initiative, increase the authenticity of the learning

experience, and make learning more relevant for students.” (Holland, 2007).

The choice to use these two theories to create my framework will guide me to be

sensitive to the learning needs of those I wish to teach. Being open to the use of multiple

teaching styles will allow me to tailor the learning environment to optimize the learners’ abilities

to assimilate information and enjoy greater success. This in turn will influence staff satisfaction

and will lead to better staff morale and higher retention rates. These are of great importance to

rural practice, because smaller institutions have limited resources for staff orientation and

education and will benefit greatly from increased staff retention rates.

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In seeking to facilitate a more organized and less chaotic and uncomfortable transition

from student to clinical practitioner Burns and Poster (2008) identified ten high risk patient

conditions that occur with frequency in acute and critical care. These conditions are acute

myocardial infarction, congestive heart failure, cerebral vascular accident, diabetic ketoacidosis,

shock, deep vein thrombosis, postoperative care (pain management), altered level of

consciousness (e.g., head injury), pneumonia or severe respiratory distress and psychosis or

dementia. As a new staff preceptor my first focus would be to develop a learning module to

address each of these high risk conditions utilizing the personal framework outlined previously.

Each module would include multiple teaching techniques such as interactive simulation, role

playing, and illustration utilizing audio/visual methods, as well as traditional linguistic and

mathematical-scientific techniques. These techniques will give the learner the opportunity to

engage critical thinking and decision making skills in a learner friendly, safe, but realistic

practice environment within the institution and using institution specific policies and procedures.

Think of this process as something akin to a fire, disaster or code drill. These types of drills give

the learner the opportunity to face a critical situation that requires correct decisions and quick

response without the fear of actual negative patient outcomes. (A good existing example of this

is the ACLS certification class.) Successful navigation of these modules will increase personal

confidence levels in critical thinking and skill level and decrease the fears commonly associated

with the initial thrust into the clinical arena. Rather than encountering a “baptism by fire,” the

new nurse has the opportunity to practice a given scenario. “Giving nurses the right tools reduces

their frustrations when new to practice and directly improves the care they deliver.” (Burns and

Poster, 2008)

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Evidenced based practice

In an effort to address the gap between nursing education and actual nursing practice the

staff preceptor must be in tune with the prevailing research and have the ability to apply it to the

position objectives of effective staff orientation, satisfaction and retention. Adherence to the

value of lifelong learning is essential. Because of the constant evolution of the nursing profession

both academically and clinically, the goal of success demands attention be given to keeping up

with current research and new applications. Maintaining a good relationship with academia is an

important component of this facet of the position. Membership in professional organizations will

assist with providing venues for personal continuing education. Subscribing to and reading

professional journals such as the Journal of Nursing Education and other publications will

increase exposure to new ideas, new applications of old and proven ideas, and help to discard

non relevant and obsolete material in favor of the more applicable. Continued practice within the

clinical area to hone and perfect personal skills and knowledge levels is also necessary for

success by lending credibility to the new staff preceptor’s role.

Measurement of the achievement of the position objectives will be achieved in different

ways. Consecutive increases in staff satisfaction survey scores over time are one way. Tracking

staff retention rates is another. These are two relatively simple methods of showing hoped for

progress and positive results. However, evaluation of effective orientation is more complicated

and must include other methods. One possible method is the use of pre and post testing. Another

is the completion of a self evaluation designed to illicit a learner’s comfort and knowledge levels

with each area of practice as experienced before, within, and after the module educational

experience previously proposed. A second subjective method would be a written evaluation with

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recommendations completed by experienced colleagues who have had opportunity to observe

new staff in practice. It is likely that some combination of all methods mentioned would be the

most effective.

Taking each of these methods into account, a qualitative/quantitative study could be

undertaken to document the level of success reached. Not only would statistical data from staff

retention rates and satisfaction surveys be available, but also the written statements of perception

from both new hire and experienced personnel could be analyzed for recurring themes

supporting the effectiveness of the process and the existence of the position of “new staff

preceptor”. Publishing this type of a study would lend strength and add to the body of literature

supporting the existence of the proposed position as one answer to the problem of the theory to

practice gap experienced by new nurses.

Integration of position in the rural community

Participating in a dual role such as a part time clinical instructor or program assistant

within the nursing education system is an ideal way to support this position. Recent technology

advances supporting distance and computer teaching and learning allow this to be a viable

option. This partnership allows the new staff preceptor to maintain professional ties with both

the education and rural clinical arenas and enables the preceptor’s heightened awareness of the

two. In addition, it enhances the preceptor’s ability to form the necessary, more effective bridge

between the two areas by maintaining the preceptor’s own lifelong learning commitment. In

addition, the preceptor should take opportunities to be involved with institutional undertakings

such as shared governance, policy development for quality improvement initiatives, continuing

education and volunteer work that will expose the rural community to the role of the preceptor.

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Assisting with health fairs, community education classes, and assisting with health classes and

screenings in the local schools at all levels will help to expose and educate the preceptor to the

community and its needs specific to age, developmental stage and socioeconomic levels.

As an advanced practice nurse within the rural community the reality of the responsibility

to the community itself is large. The rural health care institution is often a major source of

economic stability, and the continuing health and viability of said institution can have a huge

impact on the health and viability of the community itself. The success of the preceptor role

would mean the success of the health care institution in the area of staff satisfaction, retention

and continuity. Not only does this enhance the financial and human resource stability, this would

improve the level of trust between the rural community and the institution by strengthening and

proving the commitment between the two entities. In their exploration of the rural nursing role

and the benefits of social connection Lauder, Reel, Farmer and Griggs (2005) suggest that both

economic and health outcomes can and will be better when people use their collective skills,

abilities and knowledge in partnerships that include and ascribe to shared values and

commitment. The rural new staff preceptor must show commitment by investing in the

community she serves and reflect that investment in the performance of her role within the

community itself, as well as within institution walls by participating in the activities mentioned

above to achieve not only personal satisfaction but the satisfaction of the community as well.

Summery

Formalizing and defining the role of a new staff preceptor is an important step to addressing

one of the large concerns in the nursing profession as well as the health care industry as a whole.

Not only is it important to assist with achieving individual job satisfaction on the part of nurses

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entering the clinical arena, it is fiscally important to the institutions that require stable and

productive nursing staff. It is important to nursing to retain the newly graduated nurses in a high

pressure profession that has experienced huge and continuing shortages and now is experiencing

professional attrition due to causes ranging from age and retirement to professional burnout and

job dissatisfaction. These reasons are especially true when applied to the rural setting that is

traditionally characterized as having fewer financial resources, fewer technological resources,

less glamour, less opportunity and more difficult and complicated work situations. Assisting new

staff to achieve a high level of job satisfaction in providing a well constructed, educationally

integrated, innovative orientation to the clinical nursing experience will strengthen and benefit

the profession as a whole by decreasing the depletion of fiscal as well as human resources

available to the rural communities and their health care institutions. It is my belief this

contribution will be shown to have positive repercussions in future assessments of the rural

nursing specialty and its impact on health care at large.

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References

Benner, P. (1984). From novice to expert: Promoting excellence and power in clinical nursing

practice. Menlo Park, CA: Addison-Wesley.

Burns, P., & Poster, E. (2008, February). Competency development in new registered nurse

graduates: closing the gap between education and practice. Journal of Continuing

Education in Nursing, 39(2), 67-73. Retrieved December 28, 2008, from CINAHL with

Full Text database.

Duchscher, J. B. (2008). A process of becoming: The stages of new nursing graduate

professional role transition. Journal of Continuing Education in Nursing, 39, 441-450.

Retrieved December 31, 2008, from CINAHL with Full Text database.

Holland, F. (2007, October). Bringing the body to life: using multiple intelligence theory in the

classroom. SportEX Dynamics, Retrieved May 31, 2009, from CINAHL with Full Text

database.

Lauder, W., Reel, S., Farmer, J., & Griggs, H. (2006, March). Social capital, rural nursing and

rural nursing theory. Nursing Inquiry, 13(1), 73-79. Retrieved June 5, 2009, from

CINAHL with Full Text database.

Smith, L. (2006, September 2). The joys and responsibilities of preceptors. Nursing, Retrieved

May 23, 2009, from CINAHL with Full Text database.

Ward, C. (2009, February). Enhancing orientation and retention: one unit's success story. Journal

of Continuing Education in Nursing, 40(2), 87-90. Retrieved May 30, 2009, from

CINAHL with Full Text database.

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