Use these strategies to enhance new nurse clinical reasoning skills.
- The stress associated with the transition from nursing school to clinical practice can lead many new graduates to leave the profession.
- A hospital transition-to-practice program has been identified as a strategy for improving new nurse preparation.
- By offering support and feedback (including positive reinforcement), preceptors can help reduce new nurses’ anxiety and increase their self-confidence so they can become progressively more independent and successfully adjust to their new role.
Transition to practice for new graduate nurses is challenging. The stress associated with learning the full scope of their new role can lead them to leave the profession, and lack of experience can result in errors. A focus on new nurse success is essential to improving retention rates and ensuring patient safety. Enter nurse preceptors, who can help promote new nurse success by providing support and using strategies to enhance clinical reasoning.
The preceptor role
Nurse preceptors play a vital role in promoting new graduate nurse success. By offering support and feedback (including positive reinforcement), preceptors can help reduce new nurses’ anxiety and increase their self-confidence so they can become progressively more independent and successfully adjust to their new role. Preceptors begin providing support by getting to know the new nurses they’re precepting. What are their prior experiences (school, work, life)? What are their goals for orientation and beyond? Each new graduate will come to practice with different experiences and learning needs, so they’ll progress through orientation at different paces.
Next, preceptors should socialize their preceptees to their new role as members of the unit’s intra- and interprofessional teams and connect them with others they can reach out to for additional support and assistance when needed. Because preceptors have an ongoing, close working relationship with their preceptees, they can watch for signs of transition shock (sleeplessness, exhaustion, doubts about their abilities, and fear of failure or disappointing others) and implement additional support strategies in collaboration with unit managers and educators.
Another crucial component of the preceptor role is helping new graduate nurses develop their clinical reasoning skills so they can recognize changes in a patient’s condition and determine the best way to respond. (See What is clinical reasoning?)
Strategies to build clinical reasoning skills
Preceptors can use various strategies to help new graduate nurses develop their clinical reasoning skills and as a result prevent failure-to-rescue events that occur when signs of patient deterioration aren’t recognized or are acted upon too late or not at all. (See Precepting in action.)
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 completed at the end of orientation). Providing positive feedback is important to help prevent and address transition shock, and constructive feedback is essential for improving performance.
Preceptors should provide ongoing feedback, both informal (for example, when leaving a patient room, saying, “You did a great job maintaining sterile technique.”) and formal (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 patients the new nurse is caring for.
Meetings at the beginning of a shift to review 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 complication) 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 can help new graduate nurses use clinical reasoning. Preceptors should frequently ask open-ended questions to encourage deeper thinking and a wider view of patient 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 situation and your plan of care?”) can help new nurses link current situations to their previous patient care experiences and think about future possible scenarios. These types of questions allow nurses to reason through a variety of situations and preceptors to provide feedback 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.
Thinking aloud involves talking through analysis, decisions, and actions as they occur. New nurses can talk through their patient assessment, priorities, care plan, and the rationale for actions they take and care they provide. 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. Preceptors can model thinking aloud to help the new nurse feel more comfortable doing it and to enhance learning from hearing the preceptor’s analysis and rationale.
Role playing can help reduce new graduate nurse anxiety and prepare for actual practice. 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 practice a new component of patient care and receive immediate feedback.
Incorporating strategies to encourage clinical reasoning may take additional time and effort, especially at the beginning, but repeated experiences will help nurse preceptors develop their new graduate nurse coaching skills. Over time, these strategies will become a routine 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 teaching 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.
Nurse preceptors are vital for promoting new graduate nurse success during transition to practice. By using support strategies to prevent or alleviate transition shock and enhance new nurses’ clinical reasoning, preceptors can help improve new graduate nurse retention and patient outcomes.
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Kelly Powers is an assistant professor at the University of North Carolina at Charlotte School of Nursing. Julie Pagel is a service line educator 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.