Mastering Clinical Dilemmas: A Newly Licensed RN Clinical Management Best Practice

Seven clinical nurse practice issues challenge the successful role transition and integration of newly licensed RNs (NLRNs) into acute care clinical nursing practice.  Of the seven--delegation, autonomous clinical decision-making, prioritization, RN-MD collaboration, restoring self-confidence through feedback, conflict resolution and getting work done--“getting my work done” was identified as the issue of greatest concern and the only one for which 907 nurses (NLRNs, experienced clinical nurses, managers, and educators) participating in a nation-wide nurse residency program study in Magnet-designated hospitals could not identify effective strategies. It is the management component of nurses’ clinical practice that was cited as causing the most difficulty. This presentation will discuss an evidence based management practice project conducted with NLRNs 6-8 months post-hire working in Magnet-designated hospitals. The purpose of the study was two-fold: analyze the interview data and literature to understand the dimensions of the “getting work done” issue and then implement a potential best management practice project and evaluate its effectiveness. Data analysis included asking NLRNs “what are the similarities and differences in your nursing practice now (6-8 months post-hire) and when you were with your preceptor?” A spontaneously NLRN-drawn sketch, conceptualizing differences in the clinical practice role when NLRNs care for patients assigned to their preceptor (transition stage of professional socialization—post-hire to 3 months) and when they are in the integration stage and assigned their own patients.  The sketch was later validated by 20 hospital site investigators. These differences in conceptualization of the nurse practice role, combined with interview data and  literature review, led to identification of the major challenge faced by NLRNs—managing clinical situations for multiple patients, simultaneously—labeled “multiple patient-simultaneity complexity” (MP/SC).  Mastering “simultaneous” responsibility for a multiple patient assignment is unique for nurses practicing in acute care inpatient settings and is different from “sequential” responsibility for a series of patients practiced by other professional health care providers.  NLRN perceptions of not making the “right” decisions when managing multiple, competing patient needs contributed to their feeling “bad about themselves” and feeling as if they “let their patients down” and was identified by some as the reason why they would leave nursing.  The literature review of complexity science and complex, adaptive systems provided the framework for the development and testing of a best management practice.  This practice consisted of NLRNs reading a clinical practice dilemma scenario, followed by individual action commitment and then a class discussion using principles of complexity science.  After reading the MP/SC scenario the NLRNs answered three questions:  what would you do in this situation?; how would you feel about yourself as a nurse after making and acting on the decision?; and what could you do, to prevent the situation from happening again?   The individual action commitment stimulated NLRNs to practice clinical reasoning and decision-making with the data at hand. At the end of the class discussion, NLRNs were asked for feedback on the activity and would they make a different decision after the class discussion.  Class educators were asked about the usefulness of the practice in helping NLRNs master MP/SC dilemmas. Educators reported that after the class, NLRNs did gain insight into the multiple, potential correct answers to the MP/SC dilemma and all but one educator in the nine Magnet hospitals reported plans to incorporate the practice into their residency program. Evidence also indicated a reduction in NLRNs negative feelings about the consequences of MP/SC decisions and an increase in collaboration after the class discussion.  Based on the results of the study, the investigators concluded that the residency class has the potential for resolving the MP/SC issue cited as the NLRNs major challenge in getting work done.