New graduate nurses transitioning from the student nurse role to the professional nurse role are struggling; the perceived academic-practice gaps discussed in the literature include critical thinking (or clinical reasoning), communication, teamwork, clinical knowledge, time management, professionalism, technical skills and physical assessment (Huston, et al., 2017). The purpose of this presentation is to showcase an innovative training program aimed at improving situated learning and action competencies in clinical practice and supporting new graduate nurses transition to practice.
Background:
The adoption of a new model of patient care delivery, the Acuity Adaptable Unit (AAU) in combination with support and guidance of a new Director of the Center for Education and Professional Development became the impetus for the design of a new education and training program. The AAU model of care combines the medical-surgical level of care and the intermediate intensive level of care within a single unit. This allows for staffing ratios to flex in response to the change in a patient’s acuity level while maintaining the same care team and physical location. This model of care requires all nurses to minimally have Intermediate Intensive Care (IIC) level experience.
Setting and participants:
Not-for-profit Academic Medical Center in Northern California. Learners in the Foundations of Acute and Critical Care (FACC) training program include nursing students, nurse residents, all inpatient new hires, and nurses in training programs (e.g. experienced nurses training to an intensive care unit (ICU)). This new training program replaced all other education and training programs that previously existed.
Competencies:
Our core competencies developed in FACC are Intermediate Intensive Care (IIC) level of care (or according to the learner’s track, e.g. Intensive Care (IC)), clinical reasoning especially in situations of breakdown or decompensation, effective team communication, compassionate affective communication, and dysrhythmia recognition.
Program Description/Methods:
Creating a pathway to successful practice requires the implementation of a standardized, innovative, and transformative nurse training program. FACC was created to exemplify the organization’s mission, vision, and core values of the professional practice model. The FACC program spans across 12-weeks and consists of five components: 1) pre-assessments (Basic Knowledge Assessment Test (BKAT) Dysrhythmia Assessment (DA), self-confidence scale); 2) interactive sessions; 3) assigned online modules; 4) case study sessions; and 5) precepted time. There are three main tracks of the FACC program: nurse residents, experienced new-hires, nurses in a training program (experienced nurse training to a new clinical area, e.g. ICU).
The BKAT (Toth, 2015) is a standardized, validated assessment administered to all new hires during general nursing orientation. The BKAT results provides an individualized baseline assessment on each new hire and defines knowledge. Online learning modules are then assigned based on the BKAT results, thus tailoring the learning modules to the individual. The Dysrhythmia Assessment (DA) is also administered to all learners of the program. This is a competency requirement of all nurses that care for patients on electrocardiogram (ECG) monitoring. Nurses that do not pass the DA with a score of 85% or greater follow a remediation plan that may include completing online ECG modules depending on the learner’s score. Learners were given a self-confidence scale adapted from the Australian Clinical Reasoning Model (University of Newcastle, 2009), Benner’s Practice Domains (Benner, 1984), Tanner’s Model of Clinical Judgement (Tanner, 2006) and White’s self-confidence tool (White, 2011) at the beginning and end of the FACC program.
The four, eight-hour interactive sessions build on physiologic concepts in the following order: 1) oxygenation and ventilation, 2) circulation and perfusion, 3) brain, behavior, mobility and sensation 4) endocrine/hormonal, immunotherapy, and palliative care. Utilizing a flipped classroom approach—instructional methodologies employed an interactive teaching-learning approach (e.g., interactive, games, and group-based problem-solving strategies, and case study presentations). Formative evaluations of the faculty instructor were given to the learners at the end of each “concept” based interactive session.
American Association of Critical Care Nurses (AACN) Essentials of Critical Care Orientation (ECCO) 3.0 are the online learning modules are assigned to each learner (AACN, 2016) based on their BKAT results. Following the introduction of the concepts in the interactive session, the learner completes the assigned ECCO modules that complement and reinforce concepts introduced in the interactive session. In addition, AACN’s ECG 2.0 essentials (AACN, 2012) online modules are assigned to all staff that ECG remediation per their pre-Dysrhythmia Assessment results. The modules are evaluated by the learner in the program summative evaluation.
Each of the four, eight-hour interactive sessions are accompanied by a case study session. Instructional methodologies, teaching/learning strategies include small group learner-focused case study, and observed affective-domain driven role play. Small group case study presentations focus on preparing the learners to care for patients through situated action at an Intermediate Intensive Care (IIC) level of care (often with an acutely decompensating patient) and the interactive lecture concepts are reinforced. Nurses attending the FACC series as part of a training program. The clinical reasoning cycle (University of Newcastle, 2009) is taught and enforced throughout the case study sessions to give staff a systematic process to critically think through changes in clinical patient situations. Utilization of the Situation-Background-Assessment-Recommendation (SBAR) communication model is taught, practiced and emphasized throughout the didactic and case study sessions and during the learner’s precepted clinical time (AHRQ Patient Safety Network, 2017; Haig, C., et al. 2006). Learners are evaluated on the core competencies discussed in the small group case study presentations by their facilitator using the Nursing Process Learner Evaluation Tool (NPLET), developed using Benner’s Practice Domains (Benner, 1984) and the Clinical Reasoning Cycle of Practice (University of Newcastle,2009).
One case study in every case study session is dedicated to compassionate affective communication, this allows for a safe space to role play challenging patient-family and nurse situation. This competency is evaluated using the affective competency tool by the facilitator and through peer evaluation. Interactive lab and learn sessions are also presented during each case study sessions to provide the learner with additional knowledge (e.g. role of the professional nurse, escalation of care (chain of command), suicide prevention). The interactive lab and learns are evaluated by the learner in the session evaluation for each case study session.
AACN ECCO 3.0 are the online learning modules are assigned to each learner (AACN, 2016) based on their BKAT results. Following the introduction of the concepts in the interactive session, the learner completes the assigned ECCO modules that complement and reinforce concepts introduced in the interactive session. In addition, AACN’s ECG 2.0 essentials (AACN, 2012) online modules are assigned to all staff that ECG remediation per their pre-Dysrhythmia Assessment results. The modules are evaluated by the learner in the program summative evaluation, created utilizing Lenburg’s eight core practice competencies (Lenburg,1999) and Benner’s Practice Domains (Benner, 1984).
FACC learners receive individualized precepted clinical time on their unit of hire that follows their FACC track. The concepts introduced in the interactive sessions are reinforced in the precepted clinical time. Precepted time is evaluated by the learner in the program summative evaluation.
Results:
The first group to go through the FACC training program consisted of 19 nurse residents and five experienced nurses training to an intensive care unit. Pre-Assessment evaluations were assessed using the results from the DA and self-confidence scale. Pre-assessment score of the nurse residents DA was 40.63%, post was 87% (six learners required ECG remediation and then passed the remediation DA). Results of the self-confidence scale showed that 91% of the learners increased their self-confidence rate among the clinical reasoning cycle steps to mostly confident (55%) or totally confident (36%).
The FACC program presented a valuable opportunity for immediate and real-time evaluation of program outcomes. The interactive learning sessions were rated as either agree or strongly agree: therapeutic interventions (78%), human caring and relationship (72%), diagnostic and monitoring (82%), in knowledge integration (90%).
ECCO modules were only rated with respect to therapeutic interventions and diagnostic and monitoring, learners rated the modules as either agree or strongly agree (89%) and (84%) respectively .
The case study sessions were rated in all areas evaluated as either agree or strongly agree 95-100%. Preliminary NPLET data show an increase in clinical reasoning from Novice to Advanced Beginner or Competent.
Learners rated clinical precepted time in the summative FACC program evaluations as either agree or strongly agree with respect to each area evaluated: therapeutic relationships (95%), therapeutic interventions (89%), diagnostic and monitoring (84%), human caring and relationship (100%), organizational and work role (94%), professional accountability (95%), patient teaching (95%), and knowledge integration (95%).
Summary:
In this first cohort of learners, we found an increase in clinical reasoning from Novice to Advanced Beginner or Competent through the NPLET evaluations FACC facilitators completed on behalf of each learner. FACC program evaluations by the learners were overwhelmingly positive as they rated all areas evaluated as either agree or strongly agree (Kirkpatrick, J. D., & Kirkpatrick, W.K., n.d). All learners passed the dysrhythmia assessment (DA). The FACC education program is fulfilling its aim of improving situated learning and action in clinical practice.