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Orientating Experienced Nurses into a New Clinical Setting: A Case Study of a Critical Care Unit Pauline May Clinical Nurse Manager 2, Intensive Care Unit, Galway University Hospital Masters in Health Sciences (Clinical Education) NUIG - 2010 Background: Previous research on learning in critical care nursing describe orientation and post graduate programmes for novice critical care nurses. My study contributes further to our understanding of this process by focussing on skilled and experienced nurses entering a new clinical unit. It describes the reality of current induction practices – ‘the lived curriculum’. Background While an orientation programme for recruits is now a regular element of continuing professional development, harmonising standards of training is particularly challenging within current fiscal restraints for recruitment and education. This study aimed to explore to what extent the current apprenticeship model of orientation to critical care meets the needs of the various partners to the learning process (preceptors, clinical nurse managers and new recruits). This study also explored how new recruits were learning and how this learning should be assessed. Context: The site is a critical care facility employing 75 nurses. The nurse to patient ratio is 1:1 in the Intensive Care Unit (ICU) and 1:2 in the High Dependency Unit (HDU). There is one Clinical Facilitator funded for the area. New recruits were allowed 6 weeks in a supernumerary capacity and did not carry direct responsibility for patient care. The recruit worked as an apprentice alongside experienced staff nurses (preceptors). Context Each new recruit had a different academic and experiential background (20% of staff are at Masters level, 60% at Post- Graduate level). There was no performance assessment strategy or record of competence in place. The goals of orientation were that each nurse must demonstrate a minimum level of perceived competence, work autonomously and maintain standards of patient care. There had been no evaluation of whether the current system of induction was effective or efficient. What is Apprenticeship? Education and service blended together for professional growth through legitimate graduated, peripheral participation in a community of practice. It should involve- Role Modelling, Coaching, Articulation (including making tacit knowledge explicit), Scaffolding, Reflection, Exploration. The outcomes of Apprenticeship should develop the competence of the learner and also their professional identity and values. What is Preceptorship? Preceptorship is a period of professional help, advice and support for nurses entering a new clinical environment. A Preceptor’s role includes demonstrating competency, assessing learning needs and planning learning experiences helping the new recruit to amalgamate clinical and professional practice and integrate into the social culture of the unit. Preceptorship. The ultimate goals of the supervisory process are two-fold: the patient’s therapeutic or clinical improvement; and the practitioner’s professional development. The benefits are that it affords experienced clinicians the opportunity to share the art and science of nursing. Learning at work arises naturally due to the demands and challenges of the work itself. Conversely, the transfer of knowledge and multiple skills occurs in a busy and noisy environment, the processes are interrupted by other conversations or by the patient’s clinical needs. Competence Competence is a dynamic process that develops along a continuum as experience, knowledge and skills combine through and in practice. The important distinction between the constructs of competence and performance is rarely acknowledged. Methodology Situated within the interpretive or qualitative constructivist paradigm. The strategy adopted was a small indepth, single-site case study focusing on relationships and processes of orientation in one Critical Care Unit in an Irish public teaching hospital. Methodology: Principles of grounded theory and a qualitative approach informed this study which comprised of 3 focus groups (45 minutes in duration); 1 with Clinical Nurse Managers 2 with Preceptors Thirty minute semi-structured face to face interviews with six new recruits. Two recruits to HDU , 2 to ICU and 2 recruits who orientated initially to HDU then ICU. Competence Apprenticeship Roles Accountability Allocation Clinical Facilitator Autonomy Assimilation and Adjustment Collective Responsibility Confidentiality Critical Thinking Communication Experience of Local Knowledge Interactive Process Consistency/Inconsistenc y Learning Needs Assessment Effect of Culture on Learning Feedback on Performance Level of Knowledge Motivation Core Values/Standards Flexibility Framework Interdisciplinary Communication Self Learning Facilitator Expert Practice Problem Based Learning Fitness to Precept Relevance Personalities/Bad Teachers Resources Power Taken Away Sharing Learning Opportunities Integrity/Transparency Speciality/Experience Preparation Patient Safety Socialization Supernumery Professional Code of Conduct Timeframe Primary Nurse/Responsibility Strength of Writing it down Teaching on Nights Ways of Knowing Work Based Learning Safe Practice Right to choose to precept Ways of Learning Results Apprenticeship and Work Based Learning as a Model of Orientation Extremely relevant, focussing on how the new recruit needed to function at a practical level. Apprenticeship demystified the technical aspects of the role. Apprenticeship ensured safe practice. Experienced recruits felt that if they were working with many preceptors it gave variety to the experience. Less experienced recruits would have appreciated continuity with just a few preceptors. Results Apprenticeship and Work Based Learning as a Model of Orientation Not taking primary responsibility for patient care reduced stress by allowing the new recruit time to absorb information. It seemed to speed up integration and it helped facilitate learning. Apprenticeship appeared to be task focused with little time for problem solving or critical thinking approaches: There was limited time for reflection on the learning due to distractions. Learning was restricted to what was experienced – without an agreed format certain areas might be neglected. The more experienced nurses adjusted faster. Results - Competence and its Relevance During Induction The inexperienced recruit appeared less aware of or concerned about competence. The more experienced recruit and preceptors suggested that competence should relate to consistency, autonomy and to safe practice. Managers were concerned about competence from a level of accountability, standards of care, development of expert practice and consistency. Participants described competence as requiring lifelong learning. Results -Learning Needs Assessment The less familiar the new recruit was with the particular clinical environment the less they were able to identify their learning needs accurately. All recruits felt they should be afforded the opportunity to express their learning needs. Managers were more concerned with service needs and patient safety. There is little evidence that needs assessment alone enhances educational effectiveness and outcomes, so it must be placed within the wider process of planned learning, relevance to practice, and reinforcement of learning in the appropriate context. Different Learning Strategies Recruits with little critical care experience felt less pressurised away from the bedside and in a one-to-one learning environment. The recruits utilised several sources to verify their learning and graduates appeared more comfortable with self-directed learning. Results - Different Learning Strategies The experienced recruit valued learning at the patient’s bedside and believed that theory could not exist in isolation. They valued practice development as a way of learning and they were more inclined to utilise technological resources. Experienced recruits advocated that learning should involve a degree of critical thinking or problem solving. Preceptors acknowledged the intuitive element of expert practice. Results -Feedback Feedback on performance was highlighted by all participants as central to the induction process and to direct effective learning. The new recruits perceived that there was minimal feedback on performance proffered. As there were no competencies in the current orientation framework they felt it was difficult to assess their performance or progress. Results - Socialisation Socialisation to the unit culture was as important as adjusting to their new role, bridging the gap between education and practice. Developing social relationships may be critical for the establishment and continuation of peer support and mentorship in the critical care environment as well as promoting and teaching professional standards. Results -Roles in the Orientation Programme Various roles augmented the learning process the clinical facilitator facilitated learning impartially and objectively. All participants perceived the clinical facilitator as encouraging of critical thinking. There was a perceived collective responsibility to teach at the bedside as it impacted on the community of practice. There was much discussion about whether nurses could opt out of a commitment to be preceptors. Results -Roles in the Orientation Programme All participants acknowledged the potential negative impact of a poorly structured orientation programme on the morale and subsequent retention of staff. Managers felt that the mentoring role should be fairly distributed amongst all staff to prevent burnout. Preceptors acknowledged they were uncomfortable orientating recruits who were senior to them. Preceptors felt the clinical facilitator or the clinical nurse manager should deliver the feedback even though they may not have observed the performance Results -Roles in the Orientation Programme New recruits described their power or autonomy being taken away both in identifying their learning needs and in what the unit would ‘allow’ them to do during orientation. Recruits with decades of experience found their competency was questioned and had to prove themselves at a basic level. The new recruits found it difficult to challenge being placed in an observing role. Some nurses felt that managers did not utilise recruits previous areas of expertise. Results: Summary The system of apprenticeship in this critical care unit is; Effective in enabling the sharing of practical knowledge and ensuring safe practice. In facilitating new recruits socialisation and adjustment to the environment. Is cost effective. Supernumerary status of the new recruit reduces perceived stress and facilitates learning opportunities. Recommendations The framework needs to be revised, with the involvement of all stakeholders, to include assessment of the recruit’s individual learning needs and the documentation of agreed competency or performance assessments. Conclusion: Educators, clinicians and learners are urged to critically appraise the aim and role of existing educational programmes and the importance of responding to the learner’s level of practice knowledge and experience. While this study highlights some deficiencies of apprenticeship as a framework for orientation, it pointed to ways in which apprenticeship provides valuable support and guidance to the new recruit during a period of adjustment and assimilation into a very complex environment.