1

Preceptor’s Guide to Orientation Updated July 2015

2

“The art of teaching is the art of assisting discovery.” – Mark Van Doren

Table of Contents Thank you! .............................................................................................................................................. 3

Objective ................................................................................................................................................. 5

Preceptor Definition ................................................................................................................................ 5

Expectations of the PICU Preceptor ....................................................................................................... 5

Goal Setting with Your Orientee ............................................................................................................. 6

Questions to ask in your initial meeting: ................................................................................................. 6

Questions to ask at the beginning of each shift: ..................................................................................... 6

Questions to ask at the end of each shift: .............................................................................................. 6

PICU Orientation Schedule for New Nurses .......................................................................................... 7

Orientation Schedule for Graduate Nurses / Nurse Resident ................................................. 7

Resourcing for Graduate Nurses / Nurse Residents .............................................................................. 7

Orientation Schedule for Experienced Nurses ....................................................................................... 7

Resourcing for Experienced Nurses ....................................................................................................... 7

Extending Orientation ............................................................................................................................. 7

Orientation Assignment List .................................................................................................................... 8

Sample Orientation Timeline for Experienced Nurses ........................................................................... 9

Sample Orientation Timeline for Graduate Nurses/Nurse Residents ................................................... 10

Orientation Classes and Schedule ....................................................................................................... 12

Paperwork: Core and Unit-Specific Orientation Competencies ........................................................... 13

Paperwork: Weekly Performance Assessment Form ........................................................................... 14

Paperwork: Weekly Clinical Performance Evaluation .......................................................................... 15

Paperwork: Core Orientation Competency Evaluation Grid ................................................................ 16

Paperwork: What do I do with all of it? ................................................................................................. 17

PICU Preceptor Resource Map ............................................................................................................ 18

Preceptor Teaching Points ................................................................................................................... 19

Documenting in the PICU ..................................................................................................................... 20

Contact Us ............................................................................................................................................ 21

3

Thank you!

Thank you for agreeing to precept! Preceptors are a fundamental part of the PICU and are the individuals that have the largest influence on improving the culture of our unit and help to ensure the maintenance of safe practice. Preceptors are leaders, role models, and mentors. You have been asked to precept because you are skillful, resourceful, and understand the significance of developing competent, compassionate nurses to take care of children with critical illnesses. We are so grateful to have you lead and nurture the next generation of nurses that will be working in the PICU.

There are many benefits to being a preceptor in the PICU! Some of these benefits include: 1. Preceptor pay differential after attending the hospital-wide Preceptor Workshop. 2. PACE recognition for precepting. 3. Points towards the new incentivized Professional Development Program. 4. Lasting relationships with orientees. 5. Direct impact on how the practices of our unit are learned. 6. The opportunity to promote a positive and healthy work environment. 7. The opportunity to continue to learn and grow with orientees.

Again, thank you for making the PICU a great place to work! This book was developed as a guide for preceptors to facilitate orientation and to support you while you do what you do best. Enjoy!

“A teacher affects eternity; he can never tell where his influence stops.” - Henry Adams

4

This page intentionally left blank.

5

Objective

This workbook provides the PICU preceptor resources and guidelines to help ease the orientation process.

Preceptor Definition

The preceptor is more than just a teacher. The preceptor equips the newly hired nurse with skills and knowledge in order to provide safe, high quality patient care in the pediatric intensive care unit. The preceptor understands that the orientee is an adult learner who needs individualized learning driven by problem solving and meaningfulness of content. The preceptor facilitates the transition into a Zero Harm culture through safe learning experiences. A few characteristics of successful preceptors include those that:

1. Establish a relationship with their orientee. 2. Set goals on a daily basis. 3. Make their expectations known. 4. Acknowledge and respect the orientee’s previous experiences. 5. Encourage the orientee to identify goals and responsibilities. (For example,

performing safety checks at the beginning of each shift, learning their responsibilities during certain procedures, etc.)

6. Create structured learning experiences. 7. Provide a safe environment for the orientee to learn. 8. Provide positive, constructive feedback frequently. 9. Understand the significance of the preceptor-orientee relationship and its lasting

effects. 10. Promote autonomy when it is safe for the orientee.

Expectations of the PICU Preceptor

As an informal leader and an individual who is directly impacting the culture of the unit, there are expectations that the PICU preceptor must abide by. Are you living up to these expectations?

1. Advocating for assignments appropriate to your orientee’s progress to promote growth.

2. Teaching skills and procedures while adhering to hospital and unit-specific policies. 3. Being aware that you “can’t know everything” and being knowledgeable of resources. 4. Role modeling safe and effective patient care. 5. Role modeling professional behavior towards patients/caregivers, co-workers, and

the organization. 6. Completing orientation paperwork in a timely manner. 7. Maintaining contact with the PICU educators in case of concern or conflict. 8. Actively participating in two-week, midpoint, final, and any informal evaluations with

the orientee and educator.

6

Goal Setting with Your Orientee

This section is meant to guide the preceptor in goal setting. Please feel free utilize or modify as you see fit. Regardless of whether you use these words, it is important

to set goals with your orientee throughout orientation.

Questions to ask in your initial meeting:

1. “What are your goals during your time with me?” 2. “What are your strengths and weaknesses?” 3. “What kinds of skills are you most interested in?” 4. “What kinds of skills do you feel like you can improve on?” 5. “What are your biggest fears about working here?” 6. “How can I support you through this experience?”

Questions to ask at the beginning of each shift: 1. “What do you want to focus on today?” 2. “What are your own personal goals for today’s shift?” 3. “Have we achieved the goals that we set from the previous shift?”

Questions to ask at the end of each shift: 1. “Do you feel like you achieved your goals today?” 2. “What are some things you did well?” 3. “What can we continue to improve on?” 4. “What can we improve on for next shift?”

Note: Remember to ask your orientee if there are ways you can improve your support for them during orientation. You can always improve being a preceptor, too.

7

PICU Orientation Schedule for New Nurses

Orientation Schedule for Graduate Nurses / Nurse Residents

New nurse graduates and nurse residents will have a 16-18 week orientation.

Eight weeks will be devoted to day shift and eight weeks will be devoted to night shift.

If scheduling allows, graduate nurses and nurse residents will first start on dayshift for their first eight weeks and will then transition to night shift for the remaining eight weeks. In some cases, orientees may have to start on night shift. These options may include:

o Option A: Day shift 8 weeks, Night shift 8 weeks

o Option B: Night shift 8 weeks, Day shift 6 weeks. Then, conclude on night shift for 2-4 weeks, depending on orientee needs.

Resourcing for Graduate Nurses / Nurse Residents

Resource week is now built-in to the last week of orientation (usually week 16).

Preceptors will continue to clock in as “Preceptor.”

Preceptors will still share an assignment with the orientee but may act as an informal “resource nurse” within their pod in order to safely facilitate independence but still continue to provide support for their orientee.

Orientation Schedule for Experienced Nurses

Experienced nurses will participate in an 8-9 week orientation.

They will spend four weeks on day shift and four weeks on night shift.

Ideally, they will focus on learning Cook Children’s policies and tasks specific to CCMC PICU and/or our patient population.

Resourcing for Experienced Nurses

Resource week is now built-in to the last week of orientation (usually week 8 or 9).

Preceptors will continue to clock in as “Preceptor.”

Preceptors will still share an assignment with the orientee but may act as an informal “resource nurse” within their pod in order to safely facilitate independence but still continue to provide support for their orientee.

Extending Orientation

There is no shame in extending orientation! If it is mutually agreed upon that you would benefit for additional time together, please notify your educator(s) immediately or discuss it in one of your evaluation meetings in order to formulate an action plan.

8

Orientation Assignment List This list is meant to be a guide and is not all-inclusive.

Level 1 Assignments (Acuity leve of 3-5)

Non-intubated patient with stable intubated patient

Stable Chronic Patient

Basic two patient assignment (non-intubated) Stable Surgical/Neurosurgical Admission

Stable Admission / Transfer to floor Discharge to Home

Stable patients with tracheostomy Stable road trip to MRI/CT

Level 2 Assignments (Acuity level of 5-8)

Diabetic Ketoacidosis Admission/Maintenance Ventilated assignment

Intubation Stable Cardiac Patient

Extubation Peritoneal Dialysis / Manual Dialysis

Stable patient with line placement and/or invasive procedures

Mid to high acuity (5-7) Oncology Patient

More complex admission than level 1 Cares for surgical patient pre-op and recovery

Management of stable patient with extra ventricular drain (EVD)

Special procedures (i.e. exchange transfusions, lumbar puncture)

Level 3 Assignments (Acuity level of 8-10)

High Frequency Ventilation (HFOV or VDR-4) Admission/management of unstable trauma

patient

High acuity patient (8-10) Admission/management of unstable septic

patient

CVVH Admission/management of unstable OR patient

Management of high risk neuro equipment (Bolt, EVD)

Death and dying (includes coordination with Life Gift)

Assistance with invasive procedures (line placement, chest tube placement, etc.) in

unstable patient Unstable road trip to MRI/CT/Surgery

Bedside code Hypothermia

9

Sample Orientation Timeline for Experienced Nurses This timeline is meant to be a guide. Census and acuity in the PICU are dynamic and assignments are never guaranteed. Orientee progress is also dynamic and will affect the timeline of assignments

and evaluations.

Week(s) Experienced Nurse Goals

1 - 2

LEVEL 1 ASSIGNMENTS

Orientation to Environment (Bed spaces, supply rooms, etc.)

Introduction to fellow staff members and co-workers o Intensivists and NP’s o Specialists and NP’s o PICU RT’s o PICU Care Partners o PICU Secretaries o PICU Director o PICU Managers o PICU Charge RN’s o Fellow PICU RN’s

Orientation to emergency equipment: o Crash carts o Intubation boxes o Airway Carts o Line/Special Procedures Cart

PICU flowsheet and report sheet

Short introduction to MEDITECH

Intro to dayshift/nightshift workflow Evaluation with Educator, Preceptor, and Orientee in Week 2

3-4

LEVEL 2 to LEVEL 3 ASSIGNMENTS

Orientee should be documenting on flowsheet and report sheet with moderate to minimal assistance.

Orientee should be giving report with moderate to minimal assistance

Documentation in MEDITECH is performed with moderate to minimal assistance

Preceptor is encouraged to begin routing calls on Vocera to orientee. Midpoint Evaluation with Educator, Preceptor, and Orientee in Week 4

5-6 Transition to Night Shift

LEVEL 1 to LEVEL 3 ASSIGNMENTS

Orientee should be documenting on flowsheet and report sheet with minimal assistance or independently.

Orientee should be documenting in Meditech with little to no guidance

Orientee should be giving report with minimal assistance or independently.

Orientee should be managing patient care with minimal assistance or independently on more stable assignments.

7-8

LEVEL 1 to LEVEL 2 ASSIGNMENTS

Orientee is transitioning to independence. Should be documenting on flowsheet and MEDITECH independently.

Orientee should be giving and receiving report independently.

Orientee should be managing care of level 1-2 assignments with minimal assistance or independently.

Final Evaluation with Educator, Preceptor, and Orientee in Week 7 or 8. Resource during Week 8.

10

Sample Orientation Timeline for Graduate Nurses/Nurse Residents This timeline is meant to be a guide. Census and acuity in the PICU are dynamic and assignments are never guaranteed. Orientee progress is also dynamic and will affect the timeline of assignments

and evaluations.

Week(s) Graduate Nurse/Nurse Resident Goals

1 - 2

LEVEL 1 ASSIGNMENTS

Orientation to Environment (Bed spaces, supply rooms, etc.)

Introduction to fellow staff members and co-workers o Intensivists and NP’s o Specialists and NP’s o PICU RT’s o PICU Care Partners o PICU Secretaries o PICU Director o PICU Managers o PICU Charge RN’s o Fellow PICU RN’s

Orientation to emergency equipment: o Crash carts o Intubation boxes o Airway Carts o Line/Special Procedures Cart

Introduction to PICU flowsheet and report sheet

Short introduction to MEDITECH

Intro to dayshift/nightshift workflow Evaluation with Educator, Preceptor, and Orientee in Week 2

3-4

LEVEL 1 to LEVEL 2 ASSIGNMENTS

Orientee should be documenting on flowsheet and report sheet with moderate assistance.

Orientee should be giving report with moderate assistance.

Documentation in MEDITECH is performed with moderate assistance.

Orientee should be rounding with moderate assistance.

Preceptor is encouraged to begin routing calls on Vocera to orientee.

5-8

LEVEL 2 to LEVEL 3 ASSIGNMENTS

Orientee should be documenting on flowsheet and report sheet with moderate to minimal assistance.

Orientee should be progressing to document in Meditech with moderate to minimal guidance

Orientee should be progressing to give report with minimal assistance or independently with dayshift/nightshift preceptor.

Orientee should be managing patient care with minimal assistance or independently on more stable assignments.

Orientee should be rounding with minimal assistance. Midpoint Evaluation with Educator, Preceptor, and Orientee in Week 8

8-10 Transition to Night Shift

LEVEL 1 to LEVEL 2 ASSIGNMENTS

Orientee is transitioning to night shift. Orientee is to learn night shift workflow.

Orientee should be giving and receiving report independently with guidance from preceptor.

Orientee should be managing care of level 1-2 assignments with moderate to

11

minimal assistance or independently.

Orientee should be rounding with moderate to minimal assistance.

10-13

LEVEL 2 to LEVEL 3 ASSIGNMENTS

Orientee should be documenting in MEDITECH and flowsheet independently (with minimal guidance).

Orientee should be progressing towards giving and receiving report independently.

Orientee should be able to identify and initiate night shift processes.

Orientee should be rounding with minimal assistance to independently.

14-16

LEVEL 1 to LEVEL 2 ASSIGNMENTS

Orientee should be progressing to independence.

Orientee should be managing care of level 1-2 assignments with minimal assistance or independently.

Final Evaluation with Educator, Preceptor, and Orientee in Week 15 or 16. Resource during Week 16.

12

Orientation Classes and Schedule All PICU orientees (regardless of experience) are required to attend orientation classes. Most of these classes are provided in conjunction with CVICU. These classes are provided throughout the year and may extend beyond the preceptor phase of orientation. For your reference, a list of classes and CHEX groups are provided.

Class CHEX

Day One/ Infection Control/Customer Service / Hemodynamics /Mock Code

Group: PICU New Hire Core Content Curriculum

Respiratory/Ventilator

Group: PICU New Hire Respiratory Content

ECG

Module(s): CHEX – Hemodynamic Monitoring

Pleural Effusion/Topics in Cardiology

Group: PICU New Hire Cardiovascular Content

Neuro

Group: PICU New Hire Neuro Content

Renal/Endo/Mock Code

Group: PICU New Hire Renal / Endocrine Content

Hem/Onc (PICU only)

Group: PICU New Hire Hematology / Oncology Content

Trauma (PICU only)

Group: PICU New Hire Trauma Content

13

Paperwork: Core and Unit-Specific Orientation Competencies What are these? Core competencies and unit-specific competencies are required by policy (HR 410) for all

employees. It is designed to provide “a dynamic evaluation process” and is aligned with Cook Children’s values, mission, and promise to make sure employees are trained to provide a safe environment for patients, families, visitors, and other staff members. Why do we do them? Completing core competencies and unit-specific competencies during orientation is

required in order to meet The Joint Commission standards. It is important to truly evaluate these as a preceptor. Core and unit-specific competencies must be initialed,

dated (with month, day, year), and signed by all parties involved. The orientee will not be able to have a PACE evaluation without completion of these competencies. Who can sign off on competencies in the PICU? The primary preceptor, a charge nurse, resource nurse,

manager, or educator can sign off on competencies. What methods can we use to validate a competency? Ideally, orientees should be signed off after performing

a skill while adhering to CCMC policies. However, competencies can also be reviewed and discussed or reflected upon. Orientees can also perform a return demonstration, or they may be observed during daily tasks. When do orientees have to have competencies completed? Competencies should be completed once the

preceptor-phase of orientation is finished. However, in the instance that this cannot be done, orientees have within six months of their hire date to have all competencies signed off.

Dated (month/day/year) and initialed by individual

checking off.

Signed by orientee and primary preceptor / charge RN / PICU resource RN / PICU Manager /

Educator

14

Paperwork: Weekly Performance Assessment Form What is this? The Weekly Performance Assessment Form is utilized to facilitate goal setting week-by-week

between the preceptor and the orientee. Why do we do it? This form gives the preceptor and orientee an opportunity to discuss goals on a weekly basis

and document them. This form also provides the preceptor an avenue to thoroughly document the orientee’s progress in case any issues occur during orientation. Who can fill it out? The orientee and the preceptor should be discussing the Weekly Performance Assessment

Form together every week since both signatures are required. Can I just put “progressing appropriately” on the Weekly Performance Assessment Form? While

“progressing appropriately” may be true and at times the most appropriate documentation, it does not always illustrate the orientee’s progress in the best way. If possible, try to give as many examples as you can. If anything, attempt to put goals for the next week!

15

Paperwork: Weekly Clinical Performance Evaluation What is this? The Weekly Clinical Performance Evaluation is utilized to describe patient assignments and the

skills the orientee performed for that week. Why do we do it? This form contributes to the picture of the orientee’s progress through their assignments,

skills, and competencies performed. This should support your “Weekly Performance Assessment” form. Again, it is important to be as descriptive as possible. Who can fill it out? The orientee can fill out the top half of the form, but the preceptor should ultimately review

the information and make comments about the orientee’s performance in the “Comments” section if it is not already done on the weekly performance assessment form.

16

Paperwork: Core Orientation Competency Evaluation Grid What is this? The Core Orientation Competency Evaluation Grid gives the preceptor an opportunity to assess

the orientee on their knowledge, skills, and behavior in relation to assessment, environment of care, IV lines, procedures, documentation, equipment, professional responsibility, quality/safety, and medication administration. Why do we do it? This form is completed hospital-wide at Cook Children’s Medical Center for all employees on

orientation. This assessment of competency in these areas promotes safe patient care and a safe environment. Who can fill it out? The primary preceptor should be the only individual to fill this out. However, like all

orientation forms, this form should be discussed with the orientee. Tips on filling out the Core Orientation Competency Evaluation Grid:

Each row in the table should have one of each: K, S, B

You can document “no opportunity to assess,” but comments must be documented explaining why.

If an orientee is determined to be unsafe, this will initiate a conversation between the preceptor, educator or manager, and orientee and an action plan will be formulated.

This is due at two weeks, midway through orientation, and the final weeks of orientation.

Knowledge, skills, and behavior should be circled once per row. Refer to the table below to help guide

you.

17

Paperwork: What do I do with all of it? Paperwork that is not related to evaluation is made available in the orientation binders given to orientee’s during class on PICU Day One. It is their responsibility to give you the forms to sign. This table will help guide both of you to stay on track.

Dayshift Nightshift

Authorization to sign for Controlled Drugs

o Can be given to unit-based pharmacist or faxed. Nurse residents should have already completed this form during the residency.

Medication Agreement | Preceptor/Orientee

Medication Agreement | Preceptor/Orientee | Day Shift Part B

Medication Agreement | Preceptor/Orientee | Night Shift Part B

Preceptor Phase Completion Notification

o This form verifies that the preceptor agrees with the orientee finishing the preceptor-phase of orientation and is now ready to begin work independently. This form must be completed and given to the PICU educator at the final evaluation.

At each evaluation, weekly performance assessment forms and weekly clinical performance evaluations will be collected for the weeks leading up to evaluation. Core competency evaluation grids are required for week two, midpoint, and final evaluations. (Three total grids should be completed by the final evaluation.) When orientees are given their schedule, dates for evaluations will already be determined. Each date will have a checklist of paperwork that will be collected by the educator at that time.

18

PICU Preceptor Resource Map “The one real object of education is to have a man in the condition of continually asking questions.”

Bishop Creighton

Charge Desk: Ca-UTI Talking Points

Camino Binder

Congenital Heart Disease Resource Box

Education Calendar (Daily Planner under “Education” tab)

Float Nurse Resource Binder

LeForte Resource Binder

Life Gift Resource Manual

Meditech Downtime Manual

One Page Lecture Binder

Public Health Event (PHE) Binder

Renal Transplant Handbook

Safety Data Sheet (SDS) Manual

Wound Care Book

B Pod:

Respiratory resources (i.e. ventilator manuals)

Other Resources to review/visit:

PICU Team Site

Get Well Network to assign education to families

Schwarz Library Online Resources on CookNet

A Pod:

Insulin Pump Binder

Trauma Education Resource Manual (assembled by Trauma PNP’s)

Neuro Resource Binder

Neurosurgery Binder

Model of Brain

19

Preceptor Teaching Points Here is a friendly reminder to discuss a few topics of interest during orientation!

What is included in our safety check at each shift? What are our PICU Quality Indicators (QI) and what interventions do we do to prevent each?

1. Ca-UTI 2. CLABSI 3. VAP 4. Skin

Patient/Family Education

Remember to assign patient/family education through Get Well Network! Especially: o Period of Purple Crying o Asthma Education

Documentation

“Recall Values” should never be used!

Steer clear from “Click and Drag” documentation.

Remember to document your invasive procedures!

Don’t forget your “untimed” interventions o Education: PICU o Parent/Caregiver Behavior o Visitors o Emotional Support o Hygiene o Cap Change o Tubing Change o Invasive Line Dressing Change

“Notes” have not gone away. Remember to chart your “Change in Patient Status.”

Remember to document clinician notifications following critical lab values.

Clinician/Interdisciplinary rounds o Don’t forget to bring up if a urinary catheter and/or CVL is still indicated and chart it

(it’s actually a check box)!

Transfers o Remember to do your “hand-off communication” prior to transfer. o Document any road trips as well! o Try to document an IV assessment in Meditech prior to transfer. o Document a focused physical reassessment prior to transfer.

Most importantly, when reviewing your orientee’s documention, don’t forget to chart it!

20

Documenting in the PICU

Who will read this anyway?

Health Care Team - Others from your team are reading what you wrote to get a picture of

what you did over your shift. You need to be as clear and as thorough as possible to reflect

what your care involved in order for other healthcare members to determine what went in to

your patient care for that day.

Document For Yourself! – The statute of limitations for a minor to file a lawsuit is extended

to two years past the “age of majority.” Usually, this number is 20 years old. If you took care

of a 4 year old, will you remember 16 years later what you did that day?

Lawyers and Experts - Lawyers and nurse experts examine this very extensively.

Judges and Juries - Keep things short, but clear. Individuals that don’t know anything about

healthcare can read this information when helping with a case.

Tips on Documentation

When documenting an abnormality, also document the intervention you performed.

Document responses following interventions.

If body system abnormalities are discovered, elaborate on them. (Patient status can

deteriorate over time and having a clear description can provide an accurate clinical picture of

the sequence of events in case unexpected and/or undetected outcomes occur.)

Always document a baseline mental status if it is known.

Don’t confuse your senses! (If you’re looking at a normal breathing pattern, don’t say that the

patient’s bilateral breath sounds were clear and equal.)

Explain when objective and subjective assessments don’t match. (If your patient states that

they are in severe pain, but are sitting up talking and laughing, make sure to elaborate.)

“Drag and Drop” is not your friend. Nothing takes the credibility of your documentation away

faster than stating that your extubated patient has “clear breath sounds” on the “ventilator”

with an “ETT.”

Always assess and document a patient assessment at the time of transfer or discharge.

Document chronologically. It won’t make sense ten years down the line if things are

documented in “blocks” of time rather than when they actually happened.

Unless medical terminology is well known, don’t use it. “When in doubt, spell it out.”

When describing the sizes of things, try to use objects for comparison. (Example: Coin sizes

for wounds, etc.)

Write legibly – even your name!

21

Contact Us Do you have further questions, concerns, or suggestions about PICU nursing orientation, precepting, or PICU education in general? Let us know! Danika Meyer, BSN, RN, CPN Critical Care Education Coordinator Pediatric Intensive Care Unit Cook Children’s Medical Center danika.meyer@cookchildrens.org (682)885-1049 office (682)885-4268 PICU Call on Vocera

Dee Parma MSN, RN Critical Care Education Coordinator Pediatric Intensive Care Unit Cook Children’s Medical Center dee.parma@cookchildrens.org (682)885-7287 office (682)885-4268 PICU Call on Vocera

Mary Bina, BS, RRT Education Coordinator for Respiratory Care Cook Children’s Medical Center Mary.bina@cookchildrens.org (682)885-7567 Call on Vocera

References

Campos, N. (2009, August). The legalities of nursing documentation. Nursing Management, 16-19.

Dusaj, T. (2014). Become a successful preceptor. American Nurse Today, 9(8).

Knowles, M. S. (1977). Adult Learning Processes: Pedagogy and Andragogy. Religious Education,

71(2), 202-211

Wright, D. (2005). The ultimate guide to Competency Assessment in health care. Minneapolis, MN:

Creative Health Care Management, Inc.