792 PRACTICUM PAPER1
792 Practicum Paper
Marie Wendt
Ferris State University
792 PRACTICUM PAPER1
Abstract
Advancing from a nursing graduate student to nurse administrator is complicated. Most often staff nurses are promoted into leadership positions lacking any formal training. This synthesis paper illustrates one student’s nursing administrator learning practicum experience through developing a nurse manager orientation process (NMOP) at one MidMichigan hospital. Nursing theories of Transformational Leadership andPatricia Benner’s Novice to Expert, the four American Nurses Association Scope & Standards of Practice for Nurse Administration of Planning, Implementation, Education, and Professional Practice Evaluation were employed. Reviewing the challenges that created obstacles as well as the strategies for overcoming them is explored. An evaluation process was developed utilizing Bloom’s Taxonomy to determine achievement of identified outcomes.
Keywords: Competency, nurse administrator, nurse leader, orientation, outcomes, practicum, standards
792 PRACTICUM PAPER1
792 Practicum Paper
Mastering leadership competencies as a new nurse leader is both challenging and complicated. Adequately preparing nurse leaders who are entering the field is equally dubious. This paper will describe how a nursing administration practicum experience for one student,achieved the goals and objectives that were identified as personal weaknesses related to the four Standards from the American Nurses Association’s (ANA) Nursing Administration Scope & Standards of Practice. The Standards that were exercised for the learning practicum included;Planning, Implementation, Education, and Professional Practice Evaluation (2009, p. 28, 29, 36, 37). In order to accomplish all four outcomes simultaneously, a single project plan for a new nurse manager orientation process (NMOP) was developed at one MidMichigan hospital.
Scope of the Practicum
There is not one definitive method to ensure that informal nurse leaders are prepared for the role of nurse manager. Nurse leaders are often placed in managerial positions without the established qualifications(Omoike, Brooks, & Loyd Storfjell, 2011). The nursing administration learning practicum experience was developed in order out to accomplish two purposes for the author. First,to develop a learning practicum plan which assistednew nurse leaders within one hospital to complete an effective NMOP. Second, to enhance her knowledge and skillsrelated to the four ANA standards; planning, implementation, education and professional practice. Fennimore and Wolf advocate for practicing skills for learned in academia (2011).
The learning practicum took place at MidMichigan Health (MMH)-Midland. This organization is a 240 bed, acute care hospital in Lower Michigan. This site was chosen because the author had previous experience within the leadership team and had an understanding of the existing NMOP. Each of the four ANA Standards identified in the learning plan are defined inits achievement through outcome criteria taken from the ANA Standards, as well as activitiesand resources needed to achieve them. A three month timeline was developed to keep the practicum on course. At the conclusion of the practicum fourtangible items resulted; an orientation checklist, resource materials,a mandatory list of leadership courses, and an orientation evaluation tool.
The first ANA Nursing Administration Standard identified in the practicum, “The nurse administrator develops a plan that prescribes strategies and alternatives to attain expected outcomes” (2009, p. 28), is combined with two outcomes for skill development. These outcomes included creating a multidisciplinary procedures which addresses an inadequate process, while considering the economic effect(2009). The planning stage of the practicum involved developing an evidence based orientation process for the nurse manager group using an interdisciplinary approach at MMH. A Root Cause Analysis (RCA) was performed to determine common stressors and identify issues that would comprise an effective orientation checklist. Literature supporting best practice, in addition to the American Organization of Nurse Executives (AONE) and ANA Nursing Administration Scope & Standards, assisted in developing the orientation process with nursing and ancillary departments. Nursing theory was incorporated throughout the practicum using Pat Benner’s Novice to Expert as well as Transformational Leadership to guide in skill acquisition. Financial impacts were evaluated for time allotment and budget availability.
The second ANA Nursing Administration Standard, #5 “The nurse administration implements the identified plan” (2009, p. 29), incorporates two outcomes which assists with employing resources and collaborating with various colleagues and others to execute the project (2009). Collaborative meetings were set up with various stakeholders to identify available resources and established an ongoing process for execution after the project’s completion. Community colleges and universities were pursued for providing specific nursing leadership courses to new leaders, however this was not supported by administration. Therefore, MMH’s educational department’s leadership courses were incorporated into the project plan.
Utilizing the American Organization of Nurse Executives (AONE) Nurse Executive Competencies and the ANA’s Nursing Administration Scope & Standards of Practice allowed the student to utilize best practice competencies required for nurse leaders to be successful (2015, 2009). The AONE Nurse Executive Competencies focus on communication, knowledge, leadership, professionalism, and business skills (2005). Current orientation checklists were collected to determine if these competencies had been included. Through personal experience and upon review, these checklists were identified to not be prioritized and contained minimal information that was deemed useful.
The third ANA Nursing Administration Standard, #8 “The nurse administrator attains knowledge and competency that reflects current practice”, involved two outcomes. These included pursuing opportunities incorporating evidence when developing competencies of the administrative role as well as including methods to demonstrate competency (2009). Current educational offerings and learning opportunities were sought for new nurse manager education. Evidence suggests competency based structured orientation programs provide the best training and skill development (Radovich et al., 2011). To ensure the orientation process is properly documented for demonstration of competency, evaluation and checklist tools were developed. Technology transpired the project by integrating both an electronic version of the resource material as well as the orientation checklist and evaluation tool. (To view the orientation tool see appendix A).
The last ANA Nursing Administration Standard is #9, “The nurse administrator evaluates own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations” (2009, p. 37). The outcomes chosen for this standard were: developing professional practice and role execution by working with others and utilizing the evaluation procedure to achieve desired outcomes (2009). Project outcomes were communicated in a nonthreatening manner and were utilized to identify what was needed to enhance professional practice as leaders. An evaluation process for completing the NMOP was developed using evidence based methods. (To view the orientation evaluation tool see Appendix B).
Challenges
Challenges and obstacles are a normal process of any learning experience. There were three challenges that were encountered during the practicum experience. Carper’s patterns are demonstrated through professional practice(Bennette Jacobs, 2013) and are demonstrated here when confronted with the identified challenges. First, the practicum took place at an organization where the student had recently resigned possibly influencing the ability to obtain information technology (IT) clearance. Second, the distrusting culture of the organization impacted the author’s collaborative efforts. And third,lack of the ability to determine the overall economic impact the NMOP.
The author resigning from the organization prior to the practicum created an issue that prohibited the ability to obtain IT clearance. During the 3 month practicum the student did not have access to computerized information for the first six weeks.The Workforce Development Manager, who normally oversees students,appeared to avoid all attempts relating to contacts from the author. Since this avenue of obtaining access appeared fruitless,only basic IT clearance was requested and provided by the VP of nursing. Using Carpers patterns of knowing, reflecting back on the personal aspects of the situation, the author ascertained that there may have been underlying reasons for not providing the clearance needed. According to Carper, “An authentic personal relation requires the acceptance of others in their freedom to create themselves” (Carper, 1978 p. 28). The author reflected on the situation to accept the situation and to decide how to respond.
The second challenge involved the distrusting culture of the nurse manager team creating ambiguity and delays throughout thepracticum. The author knowing that managers were fearful to speak up in group situations was significant when executing the practicum activities. Using patterns of knowing in relation to aesthetics, identified hidden significance to the process (Chinn & Kramer, 2011). It is this example there may not be one method which is helpful for all situations (Chinn & Kramer, 2011). Using aesthetics in this situation allowed the author to change the RCA process to improve the findings of the information obtained during the meetings. In addition to this,the author identified that the manger group was quiet and amenable to everything that was brought forth in group meetings. The author utilized intuition to recognize their lack of authentic engagement and utilized other strategies to achieve outcomes.
The third challenge related to an inability to fully address the economic impact of the NMOP. The nurse leaders were queried to establish a list of things they sensed would be helpful to the success of attaining nurse manager competency. They were encouraged to not think of the cost of any suggested measure. A compiled catalogue of educational classes, books and courses were recorded. In an effort to gain an understanding of financial support from senior leadership, meetings with the Vice President of nursing included ongoing discussions related to budget availability for the proposed orientation process. Included in these discussions was establishing the return on investment for the NMOP. Using empirical knowing, the author sought evidence to support the financial impacts of nurse managers on an organizations bottom line. The evidence was found to not be present, despite the common statements regarding developing nurse managers as being one of the single most important investments executives need to consider(Kirby, 2010).
Strategies and Approaches to Challenges
Special considerations were employed when executing effective strategies with the current nurse manager group during the practicum experience. A strategy was adopted to overcome the need for computer access and to deal with face to face encounters with the individual involved concepts from Healthy Work Environments (HWE). According to the American Association of Critical Care Nurses (AACN) strategies to overcome unhealthy situations involves true collaboration and skilled communication (Samoya, Crutcher, & Pilon, 2015). The author employed self-efficacy, since these sorts of efforts were impeded. Self-efficacy influences the way in which a person behaves in a negative or a positive fashion (Schwarzer, 2014) in given situations. According to the American Nurses Association Code of Ethics, relationships with colleagues and others plays an important role and prescribes nurses to treat each other with dignity and respect ("ANA Code of Ethics," 2015). The actions by theWorkforce Development Manager were believed to be neither of these. By using self-efficacy the student was able to seek alternative methodsfor resolution and remain positive when face to face with this individual.
For the second challenge, the strategy of attending the nursing management meetings employed concepts from Patricia Benner’s Novice to Expert by being directly involved with the team’s formal workings on a monthly basis. Direct involvement allows the learner to attain meanings (Chinn & Kramer, 2008). It is in these meetings where the distrusting culture appeared. The challenge represented here is that transformational leadership cannot be effective without the trust between the leader and the team (Avolio & Yammarino, 2013). Collaboration requires mutual trust, respect and transparency ("ANA Code of Ethics," 2015). Therefor the author ethically had an obligation to the organization to pursue alternative methods for creating trust and working in partnership.
Since group meeting dynamics were believed to have an untrusting dynamic, an unconventional approach to performing the standard RCA was exercised. An RCA is normally conducted in multidisciplinary groups (Bowie, Skinner, & De Wet, 2013). The method of conducting one on one interviews with managers and directors separately was chosen to enhance open discussionto obtain genuineinformation to aide in the project’s success. There was reason to believe that the group’s dynamics could have been lacking openness and honesty if performed in groups. HWEs encourage an open dialogue in order to achieve the best possible outcomes for the good of the overall team (Studor, 2010). Transformational leadership guided meetings were conducted and performed in a non-threatening manner (Avolio & Yammarino, 2013). The nurse manager team had a vested interest in the subject and eagerly set up individual meetings with the author. Transformational leadership is established when the team is connected to the common goals of the advisor (Northouse, 2015). Respectable weaknesses of the current NMOP were ascertained during the RCA process, thereforethe information gathered was believed to be authentic.
The third challenge was determining the economic impact of the proposed NMOP. There were various approaches the student and the preceptor attempted in an effort to determine cost benefit ratios of implementing the proposed orientation project. The cost for planned classes, resource books, and nurse manager orientation time allocation were all assessed and approved by the Vice President of Nursing. It was agreed upon that the average cost for each new nurse manager, in addition to the usual onboarding costs, was under one thousand dollars. Thus, ongoing costs for the program were deemed minimal. The nurse manager turnover at MMH is twenty five percent over the last decade. Evidence based literature regarding nurse manager turnover costs is negligible. In comparison, staff nurse turnover costs are estimated at $48,000 (Trossman, 2013). According to the Bureau of Labor Statistics in the average nurse manager salary is $84,000 (United States Department of Labor, 2014). This was compared to staff nurse’s average salary of $34,000 (United States Department of Labor, 2014). Conceivably, the turnover cost could be two to three times staff nurse turnover estimates. Since there was negligible literature pertaining to turnover or hiring costs of new nurse managers, other opportunities for cost procurement were considered in the cost versus benefit analysis.
It can be said that a thoroughly prepared new nurse manager has the ability to positively impact patient outcomes, as well as increase revenue and financial reimbursements. Value Based Purchasing (VBP) is one method that has the potential to establish financial benefits of adequately prepared nurse managers. Nurse Managers who have acquired skills related to departmental budgets and charge modalities also conceivably have the potential to positively impact the organization’s bottom line. If nurse leaders are adequately educated regarding their influence on patient outcomes, their value can be appreciated in reimbursements related to patient care. However, there is really no evidence based literature to support this claim. In addition to this, research is now coming forth to indicate VBP has significant correlation to payments for hospital’s bottom line (Werner & Adams Dudley, 2012). Since the NMOP cost was deemed minimal (Radovich et al., 2011) and the evaluation of the return on investment proved unsuccessful it was eliminated from the practicum plan.
Evaluation
The learning practicum’s evaluation process utilized Bloom’s Taxonomy for assessing the six cognitive skills of knowledge, comprehension, application, analysis, synthesis, and evaluation (A model of learning objectives, 2015). Skill development utilizing Benner’s Novice to Expert evaluates the various levels exercised in the practicum. The five levels of skill acquisition are identified as novice, beginner, competent, proficient, and expert (Abraham, 2011). Using descriptors from the Office of Human Resources at the National Institute of Health’s evaluation descriptors, the preceptor and the student evaluated the student’s performance. These descriptors include fundamental awareness, novice, intermediate, advanced and expert (2009).
Overall, the formative and summative evaluations coincided between the preceptor and the student. The preceptor’s evaluation indicated expert level student skills related to incorporating theory and evidence into the practicum experience. It was also shown that the student was able to expertly identify gaps in process and opportunities for learning. These observations coincided with the student’s self-evaluation. However, the student’s perception of collaboration with the team as well as other stakeholders was different than the preceptors. Personal processof self requires an ongoing process of creating self (Carper, 1978). Applying personal knowing, the authors identified further opportunities for enhanced collaboration efforts. The author evaluated self in relation to the challenges that occurred during the practicum. Pursuing outside stakeholders was shown to be an area for further growth, as this aspect of the learning plan was deemed unnecessary by the executive team.