Merrily Evdokimoff, RN, PHD Sylena Keeping, RN, MSN, MBA

Paula McCartney, RN, BS Geri McCallig, BSN

Valerie Donnelly, RN,MS Susan White, RN

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DONNELLY & ASSOCIATESInternational Health Care Management ConsultantsSteering the Course to Quality Improvement

At the conclusion of the program, the participant will be able to:

1. Identify challenges in recruiting/retention within the current health care climate.

2. List critical components of a successful recruitment/retention program

3. Identify “critical thinking” competencies as well as procedural competencies included in a comprehensive employee orientation program.

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According to the AACN, “the purpose of the new grad is to provide holistic, compassionate care based on a foundation, among others, of altruism, ethics, honesty, integrity, and teamwork.”

AACN. (2016, Feb 3). The essentials of baccalaureate nursing education for professional nursing practice. Retrieved from the American Association of Colleges of Nursing.

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Nursing Shortage

Competitive environment

New grads , no jobs

Inexperienced applicants

Turnover rate 19%

Most were inexperienced in the field of Home Health

Job Satisfaction

Mentoring

Leadership Interest

In-depth Orientation

Lartey, Cummings & Profetto-McGrath, J. (2014). Interventions that promote retention of experienced registered nurses in health care settings: a systematic review. Journal Of Nursing Management22(8), 1027-1041. 6

Complexity

Complex knowledge base as generalist

Expansive competencies required

Uncontrolled environment

Autonomy

Critical Thinking (problem solving)

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Home Care Values (Smith-Toner & Markley, 2007)

Home care nurse values (autonomy, team, professionalism, fair wages)

Teamwork

Leadership

Care co-ordination

Communication

Resource Allocation

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Chronic Care Model

Critical Thinking

Coleman’s Transitional Care Model

Evidence Based Practice Guidelines

Benner’s Novice to Expert

(Summary of Generational ….)

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http://www.apiweb.org/API_home_page.htm

1. What surprises me?

2. What puzzles me?

3. Do you see any patterns or themes emerge?

4. Anything you should know immediately?

5. What things can wait?

6. Does anything else come to mind?

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1. Medication Self-Management

2. Patient Centered Health Record

3. Early, consistent communication with PCP/Specialists

4. Red Flags

Coaching

Motivational Interviewing (MI)

Teach Back

SBAR for Patients/Families

Use of Health Literacy Principles

Use of Personal Health Record

Identification of Patient Self-Management goals by patient/family

Use of Adult Learning Principles

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Sustaining critical thinking Relationship of clinical and didactic OASIS as an integral part of the assessment

process Value of supportive, non-blaming environment:

Just Culture Use of environment to support learning

(managers teach, simultaneous didactic and clinical

Based on principles of adult learning

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Safe environment

Learning organization

Mistakes may occur-how handled-non blaming environment

Whole agency must buy in to program and support of new staff

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“Organizations where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together.”

Peter Senge

Systems thinking

Personal mastery

Mental models

Building shared vision

Team learning

Quality

Outcomes

Service

Waste

Front Line is where the answer is

Team approach

Respect for all individuals on team

Power of the individual

Cut waste!

Sharing.

Open, respectful, and informed conversation is central.

“Understanding caring as a practice, rather than as pure sentiment or attitudes apart from the practice,

reveals the knowledge and skill that excellent caring requires.”

(Benner, 1984)

The central and most important part of an object, movement, or group, forming the basis for its activity and growth

Oxford Dictionary

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EBP is traditionally defined in terms of a "three legged stool" integrating three basic principles: (1) the best available research evidence bearing on whether and why a treatment works, (2) clinical expertise (clinical judgment and experience) to rapidly identify each patient's unique health state and diagnosis, their individual risks and benefits of potential interventions, and (3) client preferences and values.

(Wikipedia, 2016)

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Nursing leaders need to be aware of the differences in nurse’s age groups when planning transition programs. It is important to recognize and be aware of the benefits of each age group and that this diversity leads to a broader perspective of nursing care.

Birth Year Current Age Range

% of Current Workforce

Matures 1922-1943 69-90 5%

Baby Boomers 1943-1960 52-69 45%

Generation X 1960-1980 32-52 40%

Millennials 1980-2000 12-32 10%

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McNeill, 2012

Tech Knowledge

Social Skills

Work Mentality

Creativity

Energy

Knowledge Mastery

Recognizing the importance of cultural competence in our caregivers

Engagement in culture specific education and competency testing prior to patient contact

Cultural competency and linguistic training

Utilization of in house, community, and phone interpreters 24/7 to facilitate clear communication

“The principle of respect for persons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring relationships with colleagues and others with a commitment to fair treatment of individuals, to integrity preserving compromise, and to resolving conflict.”

(ANA, 2001.)

5 levels of nursing experience

Novice

Advanced Beginner

Competent

Proficient

Expert

(Benner, 2011)

“Understanding the five stages of competence can help nurses support one another and appreciate

that expertise in any practice depends on experiential, situated learning over time.”

(Saver, C, 2013)

Novice

“The phrase technical understanding refers to an assumption that all action can be determined through explicitly stated theories and directives.” (Benner, 1984)

No Experience

Has general rules that are applied universally

Behavior is rule governed and inflexible

(Benner, 2011)

Advanced Beginner

Has gained prior experience in actual situations

Rules begin to be applied based on experiences

Demonstrates ability to be proficient

(Benner, 2011)

Competent

More aware of long term goals

Gains perspective from planning own actions based on correlations of principles and outcomes

Displays higher level of organization and efficiency

(Benner, 2011)

Proficient

Holistic understanding: sees the whole picture

Knows from experience what to expect and tailors plans accordingly

Perceives deviations from the normal pattern

Sees what is most important in a situation

Decision-making is easier

Lester, (2005) (Benner, 2011)

Expert

No longer relies on rules to determine actions

Has an intuitive grasp

Performance is fluid, flexible and highly proficient

Recruitment

Managers

Preceptors

Orientation: Didactic/Clinical

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Four Legs of A Successful Program

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Welcome!

Assimilate into culture of the agency

Develop critical thinking & clinical judgment

Expand clinical skills

Refine time management and setting priorities

Teach COPs and agency Policies/Procedures

Develop excellent documentation

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Choosing the Right Preceptors Educator, Clinical Managers, Quality collaborate

Qualifications

Seasoned RNs who meet standards:

Excellent Clinical skills

Good Clinical Documentation, including OASIS

Knowledgeable re: COPs

Knowledge of and demonstrated compliance re: agency policies and procedures

MOTIVATED to participate in the program

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Set the expectation that all staff are to act as mentors / support system for new staff

eeeeeeeeeeee

Individual meeting with each potential preceptor to discuss willingness and motivation to participate

Consideration given on preceptors’ assignment / productivity to allow time to teach

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No more than 2 weeks before Orienteesarrive

One Class: Didactic & Discussion

Overview of the orientation program Expectations of the preceptor and orientee

roles

Principles of adult education

How to give constructive feedback

Novice to Expert

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New Grads

Rigorous process including application, resume, letter of interest, 3 references, transcripts, panel interviews

Nurses New to Home Care

Applications on line, resume, interview

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Agency Orientation with HR

Clinical Orientation with Education

Joint Visits with Preceptors

Begin prior to didactic and continue throughout classes

Give context to classes

Allow immediate application of new material

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Workshops to develop clinical skills

Wound Care with WOCN

Compression wraps

Venipuncture

CVAD

Pharmacology Education

Interspersed with didactic classes and practiced with preceptor oversight in the field

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Joint visits with Education Staff and Clinical Managers

Assess progress

“Fine tune” skills

“Sign off” on clinical skills

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Weekly feedback from Preceptors and Orientees

Designed to identify any needs we could address

Learning needs

Interpersonal needs

Emotional needs

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What was the best thing that happened this week? What made it a great experience?

What progress is your orientee making toward skills / documentation?

Did you experience any difficulties this week, either clinical or nonclinical?

What support did you receive to make it a positive learning experience?

What goals is your orientee working on for next week?

Is there anything else you would like us to know or that we can do to help you?

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What was the best thing that happened this week? What made it a great experience?

What types of patients did you care for this week? What skills did you see or do?

Did you experience any difficulties this week, either clinical or nonclinical?

What support did you receive to make it a positive learning experience?

Who was your preceptor this week? What are your goals for next week? Is there anything else you would like us to know

or that we can do to help you?

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Monthly support meetings

With Educator – No Managers or Preceptors

Time for New Grads to talk freely about challenges, successes, frustrations

Learn from one another

Motivate and support one another

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Resolve went into effect October 15th, 2015

COR Health 1st Agency in the State of Maine under the new law to receive

approval for a new grad RN preceptor program

Private Duty Nursing

Pediatric Care of Medically Complex Children

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Provide new grads tools and resources needed to provide quality home care

Seek to “raise the bar”

Evidence based program

Expert clinical guidance

Offers a pediatric core curriculum

New Grads and Return to Work RNs

1:1 mentor for 6 months-1 year

Individualized Learning Plan

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Experienced RNs who are new to home care receive components of the program

Pediatric Training Component

Skills competency

Specialized 1:1 Orientation to client specific needs

Experienced RNs assigned to a new client

Skills competency

Specialized 1:1 orientation to client specific needs

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Promotes full consideration of the physical, psychological, financial, emotional, cultural, and social well being of our clients.

Inclusion of family members and other home and community supports

Recognizes that “health” is more than freedom from disease & clients are more than a diagnosis.

Introduce to home health care

Integrate into culture/organizational structure

485 development

Critical thinking

Ensure compliance

Provide pediatric foundation

Develop competencies

Improve communications

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Agency Orientation

Home Health Orientation

Interdisciplinary

Pediatric Specific Training

Client Specific Competencies

CEU Requirements

Mandated Learning Sessions

Didactic Component

1:1 Preceptor in the Field (6-12 months)

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Resource Intensive Investment

Oversight/Implementation

Preceptor Selection and Training

Application/Selection of Program Participants

Matriculation/Support

Regular Review Sessions & Goal Setting

Evidence Based Procedures

Standardized Skill Demonstrations

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Visits with Preceptor

Visits with Clinical Specialists

Rotation through Departments

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Clinical: AM

2-3 hours

3 x/week

Outsourced

C

Didactic Lecture: PM

Closing Discussion Conducted by Education Co-ordinator

• Home Care Uniqueness• COP’s• Communication• Assessment• Care Planning/Critical Thinking• Case Management/Collaboration• Performance Improvement /OBQI,

OBQM• Putting the Pieces Together

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Agency organization

Nurses’ role in agency operations

Professional Boundaries

Advocacy

Autonomy

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Patient Care:

Loss of control over environment – guest in patient’s home

Negotiated autonomy

Patient self determination

Emphasis on patient/caregiver Self-Care

Special Challenges :

Pets

Hoarding

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Skilled need and medical necessity

Doctor’s orders

Scope of Home Health services

Intermittent Care

Medicare Benefit versus other payers

DPH

Certifying organizations and their roles

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Motivational Interviewing

Written and verbal communication

Telephone communication - SBAR

Teach Back

Adult Learning Principles

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OASIS/485

Admission visit

Assessments at all OASIS time points

Assessments on each re-visit

Documentation

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Historical importance of OASIS

Integration of OASIS data and physical assessments

Basis of care planning/development of 485

Emphasis on data collection, process and end-result outcomes

Importance to agency financial outcomes

Areas of focus: Systems reviews

Functional limitations

Ability of patient to achieve self management

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Care Planning - Characteristics of a Critical Thinker

Reflection – use of assessment data, weighing facts

Problem solving based on reasons- not prejudice, preference or fears

Intellectual skills – theory, knowledge

An inquiring attitude

Fairness without bias

Independent or autonomous thinking

Ability to draw a conclusion, make a decision

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Establishing Goals What outcomes do I/patient/family hope to

achieve Identifying Problems

What issues need to be addressed in order to achieve outcomes

What knowledge is required What resources are required or can help Whose perspectives must be considered

Formulating Interventions Professional standards and practice Based on clinical reasoning

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Thinking Critically

Collaboration with physician/other community providers

Case conferencing

Patient Self-Management Tools

Preventing hospitalizations

Discharge planning

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Collect Data

Outcomes /OASIS data

Home Health Compare

Satisfaction Surveys

Potentially Avoidable Events

Infections, incidents, complaints, and falls

Clinical record review

Identify Problems

Plan for Improvement

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Managing Your Day

Visit scheduling-patient needs

Geography

Documentation requirements

Needs of agency-productivity, extra visits

Organization of Car and Office

Supplies

Clinical Bag

Personal Safety

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Insurance regulations

HHA delegation, supervision, and care planning

Identifying abuse and/or neglect

Pain management/ responsibilities of clinicians

Eligibility for Hospice

Medication management and reconciliation

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Retention Rates /New Grad Satisfaction

Improved Engagement of Preceptors

Client/Family Satisfaction

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Routine feedback is integral to preceptee growth

Allowing for new grads to interact “normalizes” the experience

Adequate administrative support crucial

Learning sessions need to be relevant to practice

Tailoring learning plan according to individual needs improves engagement

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New Graduate Program

New graduates

Classroom education ~80 hours

Skills labs

Field Preceptor Model

1 year duration internship

Lower salary

Milestone achievements attached to salary increments

Budget $90,000.00

Nurses new to home care retention rate: 75%

New Grad retention rate: 75%

ROI

Professional stimulation for preceptors

Energy, enthusiasm influences morale

Highly functioning new staff nurses

Preceptor / orientee match is critical.

If you ask for feedback, you better be open to hearing it!

Still searching for the perfect schedule for classes.

Daily closing discussion

Would like to include other disciplines in the future.

Content collaboration between clinical and didactic is crucial

Class discussions, experiences and humor, help content “come alive”

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Questions?

AACN. (2016, Feb 3). The essentials of baccalaureate nursing education for professional nursing practice. Retrieved from American Association of Colleges of Nursing: http://www.aacn.nche.edu/education-resources/baccessentials08.pdf

Benner, P. (2016, March 12). Nursing Theories a Companion to Nursing Theories and Models. Retrieved from Current Nursing: http://current nursing.com/nursing theory/Patricia_Benner_From_Novice_to_Expert.html

Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Commemorative Ed. Menlo Park: Addison-Wesley Pub Co.

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Gordon, C. J., Aggar, C., Williams, A. M., Walker, L., Willcock, S. M., & Bloomfield, J. (2014). A transition program to primary health care for new graduate nurses: a strategy towards building a sustainable primary health care nurse workforce?. BMC Nursing, 13(1), 1-13. doi:10.1186/s12912-014-0034-x

Lartey, S., Cummings, G., & Profetto-McGrath, J. (2014). Interventions that promote retention of experienced registered nurses in health care settings: a systematic review. Journal Of Nursing Management, 22(8), 1027-1041. doi:10.1111/jonm.12105

McNeill, B.E. (2012.) Young whipper-snappers and old warhorses: understanding generational differences and finding common ground. Tar Heel Nurse. Pp 10-13.

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Patterson, E., Hart, C., Bishop, S. & Purdy, N. (2013).Deciding if Home Care Is Right for Me: The Experience of the New Graduate Nurse, Home Health Care

Management & Practice, 25(4),147-154.

Rush, K.L., Adamack, M., Gordon, J., Janke, R., Ghement, I.R. (2015.) Orientation and transition programmecomponent predictors of new graduate workplace integration. Journal of Nursing Management. Pp143-155.

Saver, C. (2016, March 12). Novice to Expert. Retrieved from Nurse.Com: http://ce.nurse.com/ce556/novice-to-expert-through-the-stages-to success-in-nursing/coursepage/

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Senge, P. (2006). The Fifth Discipline: The Art & Practice of The Learning Organization Paperback. New York: Doubleday

Smith-Stoner, M., Markley, J. (2007). Home Healthcare nurse recruitment and retention: Tips for retaining nurses: One State’s experience. Home Healthcare Nurse,25(3), 198-205.

DOI 10.1097/01.NHH.0000263438.15685.dd

Twigg, D., & McCullough, K. (2014). Nurse retention: A review of strategies to create and enhance positive practice environments in clinical settings. International Journal Of Nursing Studies, 51(1), 85-92. doi:10.1016/j.ijnurstu.2013.05.015

www.sinclair.edu/academics/.../crithink.pdf

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Wikipedia. (2016, April 21). Evidence Based Practice. Retrieved from Wikipedia: https://en.wikipedia.org/wiki/Evidence-based_practice

Welk, D. (2013). Newly-licensed nurses: excellent, ethical and engaging work. Penn Nurse, 12-18.

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Hallmark Health VNA and HospiceSylena Keeping: skeeping@hallmarkhealth.org

Paula McCartney: pmccartney@hallmarkhealth.org

Donnelly & AssociatesMerrily Evdokimoff: merrilyevd@gmail.com

Geri McCallig: gerimccallig@gmail.com

COR HealthSusan White: swhite@corhealthservices.com

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