< Previous38 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com Feedback Feedback can take many forms. For example, formative feedback allows preceptors to offer ongoing feedback so new nurses can identify what they’re doing well and where they need improvement. Summative feedback, on the other hand, occurs at the conclusion of a learning activity (such as an evaluation com- pleted at the end of orientation). Providing positive feedback is important to help pre- vent and address transition shock, and con- structive feedback is essential for improving performance. Preceptors should provide ongoing feed- back, both informal (for example, when leav- ing a patient room, saying, “You did a great job maintaining sterile technique.”) and for- mal (such as sitting down at the end of each day to collaboratively complete paperwork outlining accomplishments and areas to work on). This feedback helps new nurses grow and improve throughout their orientation. Discussion and assessment Making time to debrief, reflect, and discuss gives new nurses an opportunity to deeply assess their thinking and reasoning. Using these meetings to focus on clinical reasoning can involve discussing case studies (from journals or created by the preceptor) or pa- tients the new nurse is caring for. Meetings at the beginning of a shift to re- view patient information, discuss concerns, and formulate plans to prevent deterioration can help prepare new nurses to successfully provide safe patient care. Meeting later in the day for reflective discussions after an event (for example, an error or complica- tion) can help new nurses learn from what occurred and apply the experience to future situations. New nurses may feel embarrassed and sensitive about their performance, so preceptors should find a private area for these discussions. Questioning Questioning can help new graduate nurses use clinical reasoning. Preceptors should fre- quently ask open-ended questions to encour- age deeper thinking and a wider view of pa- tient situations. Questions that encourage new nurses to consider the effectiveness of current care and other options can prepare them to prevent patient deterioration. “What if…” questions (for example, “What if your patient was also tachycardic? How would that change your assessment of the sit- uation and your plan of care?”) can help new nurses link current situations to their previous patient care experiences and think about fu- ture possible scenarios. These types of ques- tions allow nurses to reason through a variety of situations and preceptors to provide feed- back on the analysis and plan. Orientation probably won’t provide exposure to every possible patient situation; questioning can fill this gap in experiential learning. Think aloud and role play Preceptors can use active teaching-learning strategies, such as thinking aloud and role playing, to help new graduate nurses develop clinical reasoning skills. Clinical reasoning is the ability to think critically and make sound de- cisions during changing clinical situations. To make sound judgments about patient care, nurses must • generate alternatives • weigh them against the evidence • choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. New graduate nurses’ knowledge and ex- perience frequently is limited to books and carefully assigned and monitored patient care, making it difficult for them to clinically reason during changing patient care situations (such as a decline in health status) while also caring for multiple patients, completing full docu- mentation, and working with other healthcare team members. As a re- sult, overwhelmed new nurses may focus on tasks that require follow- ing orders without using clinical reasoning. What is clinical reasoning?MyAmericanNurse.com July 2020 American Nurse Journal 39 Thinking aloud involves talking through analysis, decisions, and actions as they occur. New nurses can talk through their patient as- sessment, priorities, care plan, and the ration- ale for actions they take and care they pro- vide. For example, as a nurse is applying a blood pressure cuff, they can say out loud: “I know the nursing assistant just recorded the blood pressure, but the reading was much different than it was before, so I’m going to recheck it now.” This allows the preceptor to understand the new nurse’s thinking and is an opportunity to provide feedback or ask questions as the situation warrants. Precep- tors can model thinking aloud to help the new nurse feel more comfortable doing it and to enhance learning from hearing the precep- tor’s analysis and rationale. Role playing can help reduce new gradu- ate nurse anxiety and prepare for actual prac- tice. For example, if the new nurse is anxious about caring for a patient who is dying, the preceptor can role play the patient (or family member) to give the nurse an opportunity to practice communication. Role playing in this situation helps the new nurse plan and prac- tice a new component of patient care and re- ceive immediate feedback. Preceptor support Incorporating strategies to encourage clinical reasoning may take additional time and ef- fort, especially at the beginning, but repeated experiences will help nurse preceptors devel- op their new graduate nurse coaching skills. Over time, these strategies will become a rou- tine component of precepting. Managers and educators should support preceptors as they learn and practice their role. Creating easy-to-access resources, such as a checklist or preceptor guide with teach- ing strategy information or tools such as the One-Minute Preceptor, may be helpful. And just like new graduate nurses, preceptors need support, including success recognition and feedback. Promoting success Nurse preceptors are vital for promoting new graduate nurse success during transi- tion to practice. By using support strategies to prevent or alleviate transition shock and enhance new nurses’ clinical reasoning, pre- ceptors can help improve new graduate nurse retention and patient outcomes. AN Visit myamericannurse.com/?p=67023 to access background information about nurse turnover and a list of references. Kelly Powers is an assistant professor at the University of North Car- olina at Charlotte School of Nursing. Julie Pagel is a service line edu- cator at Atrium Health’s Carolinas Medical Center in Charlotte, North Carolina. Elizabeth K. Herron is an assistant professor at the James Madison University School of Nursing in Harrisonburg, Virginia. Cameron* is a new graduate nurse who started on the postsurgical unit 2 weeks ago. He’s working with his assigned preceptor, Tamara. After receiving change-of-shift report, Cameron and Tamara review patient information to create a plan for the day. One patient has a low urine output, and Cameron says that he thinks additional I.V. fluids are needed. Tamara asks him to notify the provider. Cameron suddenly appears nervous and confides that he’s never called a provider before. Tamara uses these strategies to encourage Cameron’s clinical reasoning: • Tamara provides Cameron with formative feedback by stating, “Good job identifying the need for I.V. fluids.” • She discusses the steps for calling a provider and reviews SBAR (sit- uation-background-assessment-recommendation) format. • Cameron says he’s still very nervous, so Tamara provides support by saying she’ll be by his side when he calls. She also provides encour- agement by sharing that she was nervous at first too but became more comfortable after a few experiences. • Tamara asks Cameron to write an outline of his SBAR report and then asks him to practice it with her using role play. • After a successful role play, Tamara provides positive feedback, and Cameron calls the provider. • The call goes well, and Cameron hangs up the phone, expressing re- lief. They continue with their day. • Later, Tamara and Cameron sit down to discuss the day. Tamara uses questioning to enhance Cameron’s clinical reasoning: “What would you have done if the provider chose not to order I.V. fluids when you called about the low urine output?” *Names are fictitious. Precepting in action40 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com Claiming our rights The pandemic has cast a spotlight on human rights. By Leah Curtin, RN, ScD(h), FAAN From Where I Stand A CCORDING to CNN, the night-shift emergency department (ED) nurses at a Detroit hospital reached a tipping point in the COVID-19 pan- demic when they refused to leave the break room until hospital administrators provided more nurses to help care for patients. In a video, one nurse said, “Tonight was the break- ing point because we cannot safely take care of your loved ones with just six, seven nurses and multiple [ventilators] and multiple people on drips. It’s not right. We had two nurses the other day who had 26 patients with 10 [venti- lators].” After 4 hours of deliberation, hospital administrators informed the group they would not be bringing in any more help and the nurses could either return to work or leave the hospital. The concept of human rights comes alive only when it is applied to specific people and specific situations. What are the human rights of the nurses—and the patients—in this situa- tion? A society is a collection of individuals; its value system reflects the values held by its members. And the citizens’ response to per- sonal duties affects the value that the nation places on responsibility. Healthcare profes- sionals freely assume additional duties toward others when they enter their professions. However, they can’t care for an unlimited number of people. They also have a responsi- bility to give reasonably safe care under the circumstances. The circumstances in this ED far exceeded safety and accountability. The staffing was beyond abysmal, placing the very fragile lives of the patients in danger. Can two nurses adequately care (no one is talking here about good or quality) for 26 very ill patients of whom 10 are on ventila- tors, especially in an ED with no idea how many more patients will arrive? What say you, colleagues? Is this possible? Although human rights provide the foun- dation for all relationships, duties provide form for each relationship. And this situa- tion bends that form out of all recognition. It is, indeed, the role-related duty of those who choose to work in healthcare to care for the sick, even if the disease is conta- gious. However, employers have a duty to provide adequate—not good, certainly not quality—staff ing even in these admittedly awful circumstances. If the lives of patients are no incentive, what is? The sad part of this story is that more nurses were available; the next night the hospital hired four agency nurses to supple- ment staffing. The worst part is that hospital functionaries decided to send home what lit- tle staff they had and to bully the day staff into working a 24-hour shift. Apparently, this was a power struggle with nurses and patients as the cannon fodder. Employers have responsibilities, too, in- cluding duties associated with management prerogatives. Fulfilling those responsibilities is the price of leadership. The nurses didn’t abandon their duties, leadership did. Leah Curtin, RN, ScD(h), FAAN Executive Editor, Professional Outreach American Nurse Journal Reference Murphy PP, Young R, Carpenter J. Detroit hospital nurs- es refuse to work without more help, ordered to leave. CNN. April 8, 2020. cnn.com/2020/04/07/us/detroit-nurses- sinai-grace-coronavirus/index.html PRACTICE MATTERS © Copyright 2020. The information contained herein is for general informational purposes only and does not constitute an off er to sell or a solicitation of an off er to buy any product or service. 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