Bringing Adversaries onto the Same Team

1. Bringing Adversaries onto the Same Team Nursing Preceptorships for Clinical Clerks in Labor and Delivery Amanda Skoll and Ruth Dueckman

2. Nursing Preceptorships for Clinical Clerks • Introduction • Rationale • Planning • Implementation • Review • Troubleshooting

3. Introduction • Do you remember????

4. Why ? • LCCME report • Negative atmosphere in L & D • Decreased interest in maternity care after graduation • ?multidisciplinary group practice

5. Where? • B.C. Women’s Hospital • Tertiary level teaching hospital, providing specialized obstetrical care for British Columbia. • 2003/04 • 7164 Deliveries • 10730 Visits to Assessment/Triage Area

6. BC Women’s Hospital • 185 Nurses working in: • assessment & triage • high risk & low risk deliveries • single room maternity care • operating and recovery rooms

7. BC Women’s Hospital • Obstetricians • Perinatologists • Midwives • Pediatricians • Anaesthetists • Family practice physicians • Social workers • Physiotherapists

8. UBC Context • 6 weeks of clinical clerkship in Ob/Gyn • 3rd year medical students • 128 students / year → 200 /year

9. How? • Program Funding • ‘Discretionary Funds’ from the Chair • $33,000 for half time nurse-coordinator position • Workshop for nurse preceptors - $6000

10. Intervention • Nurse Preceptorship for medical students in Labour and Delivery • 2 x 12 hour shifts with a nurse • Evolved into 2 shifts with 2 different preceptors, with 1 being in the Assessment Room

11. Nurse Coordinator’s Role • Identify nurses interested and qualified • Organize existing resources (nursing educators, residents, clinical teaching fellow, unit clerks) • Collaborate with administrative assistant from UBC

12. Nurse Coordinator’s Role • Collaborate with nursing management /educators regarding staff utilization • Orient clinical clerks to the hospital and delivery suite • Develop an interactive, interdisciplinary workshop

13. Who? • Nurse Coordinator Qualifications • BSN • Experience: • working on the unit • with the infrastructure • teaching • preceptoring and mentoring

14. Benefits for Nursing • Nurses play an important role in facilitating the learning of medical and nursing students as well as modeling interprofessional collaboration • A supportive work environment can result in greater job satisfaction • Working closely with other health care providers builds trust and understanding

15. Benefits for Nursing (cont) • Provides nurses with knowledge and understanding to practice at their highest level of competence • Nurses can foster an environment of positive and supportive practice.

16. Benefits for Clinical Clerks • Provides an opportunity to be part of the “team” • Provides them with basic patient care skills • Provides a greater understanding and respect for roles and responsibilities of nurses • Increases the understanding of the patient experience (for eg., loss of independence, uncertainty and hospital culture).

17. What happened??

18. Challenges:Identified by Nursing • Workload issues • Problems with staff flexibility due to the shifting needs of the unit • Concern about the short time of the preceptorship

19. Challenges:Identified by Nursing • “Feelings of achievement” due to workload issues • Concern over the ability to assess the student’s knowledge • The disinterested student

20. Challenges:Identified by the Coordinator • The activity on the unit may not be conducive to learning • Nursing and Medical Staff fatigue • Number of students of various disciplines on the unit at one time.

21. Challenges:Identified by the Coordinator • Requests for 10-25 nursing students four times/year • Each request for 16-24 shifts • Requests to preceptor other disciplines • Paramedics • Midwives • medical students • BF lactation consultants

22. Issues Identified by the Students • Perception of wasting time • Overwhelmed with volume of info to be mastered • “Nurse stuff” • Scheduling and growing pains

23. Literature Review • No specific program like this • Research on med student learning needs

24. Medical Students Learn Best By Doing • Give all students an opportunity to see patient alone • Ask for student’s assessment prior to giving own • Allow the student to devise a care plan and challenge them to explain choices

25. Medical Students Learn Best By Doing • Allow the student to do the primary interview and wrap-up • Allow students to DO procedures (with proper supervision) Allow time for practice • Have students identify learning needs, and check whether the experience is meeting expectations

26. Medical Students Learn Best By Doing • Assist with prioritizing a focus • Use questions to allow the student to use some critical thinking skills • Delegate responsibility

27. Comparing Nursing and Clinical Clerks Preceptoring Experience: Orientation Process • Nursing: one 8 hour day orientation to the unit, meeting with the preceptor and assessing learning needs. • Clinical Clerks: orientation day includes one 4 hour intrapartum workshop, 90 minute suturing workshop, hospital orientation (for BCW & VGH), expectations of the rotation, infection control lecture and 20 minute tour of the wards at BCW.

28. Comparing Nursing and Clinical Clerks Preceptoring Experience:Length of Preceptorship • Nursing: varies from 15-24, twelve hour preceptorships with the same nurse. • Clinical Clerks: receive 2, twelve hour shifts usually with two different nurses.

29. Comparing Nursing and Clinical Clerks Preceptoring Experience: Learning Needs • Nursing: attempts to find situations for repetition so the student can gain confidence, and also new situations to gain skills and knowledge. • Clinical Clerks: attempts are made to provide a vast range of different experiences

30. Comparing Nursing and Clinical Clerks Preceptoring Experience: Learning Process • Nursing: • use of a learning skills inventory where the student • reads about the skill or procedure • observes the preceptor complete the skill • performs the skill with supervision • will eventually perform the skill independently by the fourth time. • “After a few days, the preceptor will be supervising and validating more than demonstrating in most situations.”

31. Comparing Nursing and Clinical Clerks Preceptoring Experience: Learning Process • Clinical Clerks: • a clinical pathway as a tool for all potential learning opportunities • review the skill together, then the student will perform the procedure with supervision • focus is on DOING a maximum number of procedures to gain knowledge and experience.

32. Comparing Nursing and Clinical Clerks Preceptoring Experience: Limitations • Nursing: students have limitations on their scope of practice • Clinical Clerks: do not have the same limitations on their practice (IV’s, phlebotomy, etc)

33. Workshop • 4 hour workshop for nursing preceptors • Interactive discussion about issues relevant to nursing • Input from medicine • perinatology, Ob and clinical teaching fellow • opportunity for discussion between disciplines • Nursing educators’ participation provided more support for nursing.

34. Workshop • Goodies and gratitude • Reviewed all the differences • Opportunities for new ideas • Framework for ongoing training

35. Workshop • Clarified expectations • Reviewed and finalized the Pathway • Tool for outlining potential learning objectives

37. Workshop • Student assessment • Satisfactory or Unsatisfactory • Assessment by student • Form detailing experience with preceptor / experience • End of rotation questionnaire includes questions on this experience / multidisciplinary collaboration

38. Our New Reality • More interaction between professions • Positive feedback from students and nurses

39. Troubleshooting • Ways to avoid problems: • Coordinator has to have a definite presence in L&D • Get the charge nurses on board • Identify key nurses who can act as resources

40. Troubleshooting • When problems arise: • Keep the lines of communication open • Quick review of issues with the student / nurse without confrontation