Tips for Your First Year of Transition

The Nurse Professional

Top 10 Tips for Your First Year of Transition

1. Think positively.

2. Develop weekly goals.

3. Find a mentor.

4. Engage in self-care.

5. Advocate for yourself.

6. Improve your time-management and organizational skills.

7. Apply for internships/residencies/fellowships.

8. Try to select an organization with a comprehensive orientation program.

9. Be an active participant in your orientation.

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Summary

This chapter focused on strategies for a successful transition. An overview of transition strategies was provided. The orientation process was described; included in this discussion was the role of preceptors and mentors. The importance of soft skills, such as time management and organization, was also included. Job satisfaction and its relationship to turnover were briefly discussed and an overview of the NCSBN’s TTP model, being piloted in three states, was described.

Discussion Questions

1. List and describe three transition strategies.

2. What is the role of the preceptor?

3. Describe the role of the mentor.

4. What are the different types of orientation programs?

5. List three ways you can improve time management.

6. List three ways you can improve organizational skills.

7. What are some factors that are related to job satisfaction?

8. What is the Transition to Practice model?

9. What are some self-care strategies you can employ?

10. Why is self-advocacy important?

Suggested Learning Activities

• Explore opportunities/requirements for internships and fellowships.

• Complete a self-assessment of your soft skills.

• Consider what you would like in a mentor and list at least three individuals who could serve as your mentor. After you develop a guide for what you would like your mentor to help you with invite one of your three choices to be your mentor.

• Write an essay about the NCSBN’s Transition to Practice model.

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10 Strategies for Successful Transition 169

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171

Chapter 11 Objectives

Clinical Practice

The most important practical lesson that can be given to nurses is to teach them what to observe.

—Florence Nightingale

At the end of this chapter, the reader will be able to:

• Identify key aspects of the nurse generalist’s role

• Understand the significance of clinical competency

• Describe professionalism in relation to role

• Understand the significance of teamwork and collaboration

• Describe cultural issues in the health care setting

• Understand his or her role as a patient advocate

• Describe patient safety and quality of care

D

uring the first 2 years of your transition into professional practice you will be applying the theoretical and clinical concepts you learned as a nursing student. As previously discussed you will begin this role as an advanced beginner (Benner, 1984), although you may still be a novice (Benner, 1984) in areas where you did not have adequate preparation. When you graduate from your nursing program you have the foundations on which to build. Therefore, during the next 2 years you will continue to develop your role as a nurse generalist. You will also need to demonstrate proficiency and competence in a wide array of clinical competencies. The orientation and transition are geared toward

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helping you to achieve these requirements. There are many aspects of your role that may have only been briefly reviewed in your nursing program. Furthermore, every organization is unique so you may need to relearn some of the policies and procedures you have previously been taught. This chapter will provide more details in some of the important areas that inform and impact your role as a registered professional nurse.

Roles and Responsibilities in CliniCal pRaCtiCe The roles and responsibilities in clinical practice will be somewhat variable based on the type of health care organization and unit on which you will be working. Clinical practice can take place within a hospital, community, or health care agency in patients across the life span with a plethora of illnesses. Although these settings are different and will require various types of nursing care they also have similarities. For example, you will be using the nursing process in all of these settings. You will also be focused on health and wellness promotion and teaching your patients how to manage their health.

Every day you will strive to deliver quality care and promote positive patient outcomes. You will also be serving as a patient advocate and collaborating with the interprofessional team. Theisen and Sandau (2013) identified psychomotor critical thinking as the two most important areas that nursing students must rapidly master.

There are so many areas you will be developing; however, many of these were experienced as a novice—you are now in the advanced beginner role (Benner, 1980).

The nursing process is widely embraced in nursing and was origi- nally developed by Orlando in 1958. The steps include assessment, planning, interventions, and evaluation and the process is used extensively. “It is a conceptual framework that allows a systematic evaluation of a patient’s current health status and needs” (Huckabay, 2009, as cited in Lubbe & Roets, 2014, p. 60). Assessment falls under the scope of practice for registered professional nurses. However, in a recent study that was conducted in South Africa, Lubbe and Roets (2014) found that 80%

of risk assessments were performed by nurses who were not licensed to do assessments. This is a serious issue as it is related to poor quality of care. The findings of the assessment influence the plan of care so it is vital to have a competent nurse complete the assessment. For example, Lubbe and Roets (2014) described pressure ulcers risk assessment and how it is an important competency for all nurses and new graduates to

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11 Clinical Practice 173 use the scale correctly. Assessing your patients, whether they are inpa- tient, outpatient, in a critical care or medical–surgical unit, is one of the most important things you will do as a nurse and you will continue to develop your assessment skills every day. According to Austin (2008)

“the five steps of the nursing process are recognized as a universal approach to nursing practice” (p. 35), and include assessment, nursing diagnosis, planning, implementation, and evaluation. A template for a brief head-to-toe assessment (known as the 5-minute assessment) is included in the Appendix. As a new nurse you will have to hone your skills and with time and repetition you will become more competent.

Certainly your preceptor will be helping you with this and other clinical skills. Planning and interventions will also be a priority and evaluating and revising your plan must be done on a continual basis.

Learning how to prioritize care requires critical thinking and rea- soning (Theisen & Sandau, 2013). One of the biggest challenges new nurses face is to manage a group of patients as this is very different from caring for two patients under the supervision and guidance of a clinical instructor or preceptor. When you have a group of four to six patients or more you need to prioritize who needs to be taken care of first. If all of them are stable, then you can proceed in a systematic manner. Oftentimes your patients will be in a district or in consecu- tive rooms so you can start in one room and continue from room to room until you are finished. However, there are times when one or two are unstable so you need to prioritize. You will need to use your critical-thinking skills, problem-solving skills, and your existing knowledge about the disease process and the unique needs of your patients.

Certainly, you will use the ABCs (airway, breathing, and circulation).

For example, if you are assigned six patients and one is experiencing dyspnea you must assess and treat that patient first. As a new nurse it is easy to be so hyper focused on completing your initial assessments that you may not consider which patient needs your immediate atten- tion. However, this is a vital skill and you must continue to learn how to prioritize your time.

Maslow’s hierarchy of needs (see Figure 11.1) can be very helpful in guiding your assessment and prioritization in regard to prioritiz- ing your patients as a whole and considering the individual needs of the patient. According to McCleod (2007), Maslow (1943, 1954) developed the original model to understand what motivates people.

Although this is a behavioral theory it certainly has applications in the clinical arena and may be used as a guide when meeting the needs of patients/families. Looking at the model you will see that the most important needs are on the bottom of the triangle. Physiological needs

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include breathing, food, water, sleep, sex, homeostasis, and excretion.

Next on the triangle are safety needs such as protection and security.

As nurses we are always focused on the safety of our patients. This is why it is important to develop a system for assessment, such as the one that is included at the end of this chapter. Love/Belonging is next on the list and although it is important for patients to have their family members present the bigger priority is to meet their physiological needs first. Self-esteem is next and you can meet the needs of your patients by being respectful and delivering patient-centered care. Self- actualization relates to developing self-fulfillment, which is unique to each individual; this level may never be achieved. Providing holistic patient-centered can help you to meet the patient’s needs and prioritize care.

Learning how to prioritize can be challenging, nonetheless it is an integral part of your nursing role. Remember this will take time so be sure to consult with your preceptor, instructor, manager, mentor, and experienced nurses on your unit.

The acuity and number of patients you are assigned will greatly impact your ability to prioritize and complete your assignment. The nurse/patient ratio, which has been extensively addressed in the liter- ature, varies based on the organization, geographic location, and type of unit. Evidence does support the relationship between staffing ratios and patient mortality. However, what is lacking is the evidence related

Self-actualization

Esteem

Love/Belonging Safety

morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

self-esteem, confidence, achievement, respect of others, respect by others

friendship, family, sexual intimacy security of body, of employment, of resources,

of morality, of the family, of health, of property breathing, food, water, sex, sleep, homeostasis, excretion

Physiological

FiguRe 11.1 Maslow’s Hierarchy of needs

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11 Clinical Practice 175 to best practices in actual ratios. For example, a 6:1 ratio in medical–

surgical units is common, however, some organizations have implemented a 5:1 or 4:1 ratio. Intuitively one could reason that a smaller nurse:patient ratio would lead to improved patient outcomes and decreased mortality, however, research is needed to identify best practices (Shekelle, 2013). Some states and countries have mandated staffing guidelines, or agreements with their bargaining unit, although this issue is fraught with controversy over whether it is best to have staffing guidelines or mandated staffing ratios. Some experts believe that one must consider acuity and other factors and staffing ratios may be too rigid (Allen, 2013), although in the states that have instituted manda- tory staffing ratios, such as California, the results have been favorable and include decreased burnout, reduced workload, and fewer deaths (Allen, 2013). Ideally, you should have explored this when selecting your place of employment.

CliniCal CoMpetenCy and peRFoRManCe evaluations The Joint Commission (TJC) has standards relating to competency and the American Nurses Association (ANA) also supports competency as a professional standard (Theisen & Sandau, 2013). Nurses must demonstrate clinical competence when they begin their nursing roles in an organization whether they are a new graduate or experienced nurse, albeit an experienced nurse will be able to demonstrate these competencies in a more timely fashion. Clinical competency is a broad term used to define expectations related to clinical skills, critical thinking, problem solving, and understanding and implementation of a wide array of policies and procedures. Clinical competency statements may include performance expectations in the psychomotor, affective, and cognitive domains. Some organizations have their nurses complete a self-assessment and use that as a guide to individualize the orientation.

As the nurse progresses through the orientation he or she is observed performing various tasks and will be deemed competent or not. If not, they will be given further instruction and practice and observed again.

The expectation is that nurses will achieve the competencies by the end of the orientation period. As per The Joint Commission (2014) nurses must demonstrate competency and be evaluated annually. A competency checklist with performance expectations is often used with a focus on adhering to the standard of care and promoting positive patient outcomes.

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CliniCal issues

A common complaint of new nurses is their perceived lack of preparation regarding the various clinical skills. As an advanced beginner new nurses must master many skills in a relatively short time. Many of the skills are taught and practiced during nursing school, so you will want to continue to build on the foundation begun there. Practicing assessment skills on friends and family members is a great way to hone your skills, especially if it has taken you a long time to find your first position. Another idea is to volunteer to mentor undergraduate nursing students in the skills lab at your nursing school. This is a great way to polish your own skills and something you can add to your résumé.

You can complete the skills checklist at the end of this chapter to help you develop a plan for review and practice. These are the most common ones you will be expected to complete when working on a medical–surgical unit. Some of the more advanced skills may not have been taught in nursing schools. For example, if you are assigned to an ortho- pedic floor you will most likely have to work with a continuous passive motion (CPM) machine, which is used for patients who undergo sur- gery for a total knee replacement (TKR). If you work in a specialty area, such as oncology, you will need to complete a course specific to the care of the oncology patient and the administration of chemotherapeu- tic agents. Some competencies are complex and require completion of a formal class, passing an exam, return demonstration, and observation.

Austin (2008) described seven key principles to promote patient safety and to protect you from a legal standpoint. The first principle is medication administration. Medication administration is a major responsibility of the hospital-based nurse, and you will spend a good portion of your shift administering medications to your patients.

Medication administration requires using the nursing process, comprehensive knowledge of medications, diligence, and adherence to policies and procedures. Not only must you follow the “five rights” of medication administration, you must also know why your patient is receiv- ing this medication and how it may interact with the other medications that have been ordered for the patient. You also need to evaluate the patient’s response to the medication. For example, you administer an oral pain medication at 2 p.m. so you should reassess the patient at 3 p.m., or as per the hospital policy. Some hospitals have implemented a “quiet zone” during medication administration to help reduce errors due to distraction.

The next principle is to “monitor for and report deterioration.” As a nurse you are expected to assess and reassess your patient throughout

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11 Clinical Practice 177 your shift, and to promptly follow up on any changes in patient status.

Failure to do so may place the patient in danger and put you at risk of legal action.

The third principle is to “communicate effectively” with patients, families, nurses, and other members of the interprofessional team. The Joint Commission has specific guidelines regarding reporting when transferring patients. Using “SBAR” (situation, background, assessment, and recommendation) is a helpful tool when notifying the licensed health care provider about changes in patient condition.

The fourth principle is “delegate responsibly,” which can be very challenging. Austin (2008) recommends checking with your state board of nursing for guidelines on delegating and following the “five rights”

for delegating. “The “five rights” for delegating to another caregiver provide an easy-to-remember guide: right person, right task, right circumstance, right direction, and right supervision” (Austin, 2008, p. 37). In the hospital setting you will most likely be delegating tasks to unlicensed assistive personnel, and as the licensed person you are responsible for supervising them and knowing their scope of practice, in addition to the hospital’s policy. For example, a nursing assistant may turn and position patients every 2 hours; however, the assistant cannot perform a pressure ulcer risk assessment. Furthermore, as the licensed nurse you must supervise the nursing assistant to be sure he or she is indeed performing the tasks that you have assigned.

The next principle is to “document in an accurate and timely manner” and follow your hospital’s policy. The medical record is a legal document and is used to document care, and helps to ensure continuity of care by communicating with other members of the health care team (Austin, 2008).

The sixth principle is to “know and follow facility policies and procedures” which should reflect current nursing standards of care and practice, and as long as they are followed correctly will help to protect you from legal actions.

The last principle is to “use equipment properly.” You should not use equipment unless you have been properly trained in its use and it is in perfect working order (Austin, 2008).

Providing holistic nursing care to your patients is a very serious responsibility and these seven principles can be used to inform your practice and help you to promote positive patient outcomes. Teamwork and collaboration, one of the QSEN (Quality & Safety Education for Nurses) competencies, is an essential in the delivery of holistic care.

In recent years experts have realized how important it is to break

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