LIGHTING THE WAY A QUALITY IMPROVEMENT PROJECT TO

LIGHTING THE WAY A QUALITY IMPROVEMENT PROJECT TO INCREASE PUBLIC HEALTH NURSING STAFF EFFECTIVENESS IN PRECEPTING NURSING STUDENTS Patricia M. Schoon, DNP, MPH, PHN, RN Assistant Professor, Metropolitan State University, St. Paul, MN Clinical Instructor, University of Wisconsin Oshkosh, WI Public Health Nursing Students and Education Roundtable: American Public Health Association, 11/1/15

Co-Authors 2 Bonnie Brueshoff, DNP, RN, PHN � Public Health Director � Community Partner for DNP Project Dakota County Public Health Nursing Lead Team � Gina Adasiewicz, MS, PHN, Supervisor � Carol Messler, BSN, PHN, Supervisor � Amy Mimm, MS, PHN, Supervisor � Coral Ripplinger, MS, PHN, Program Coordinator, Supervisor

Acknowledgements 3 Dakota County Public Health Nurses (Family Health and DPC/EP Teams) Teddie Potter, Ph. D, MS, RN � Clinical Associate Professor, School of Nursing, University of Minnesota � Advisor for DNP Project Linda Olson Keller, DNP, RN � Clinical Professor, School of Nursing, University of Minnesota � Former Director, Public Health Nursing, Minnesota Department of Health

OBJECTIVES 4 Identify the quality improvement gaps or barriers to effective PHN precepting of baccalaureate nursing students in a community setting. Design a preceptor staff development program for PHN staff employing both online and face-to-face modules. Describe the benefits of a dual-intervention QI approach of staff development and organizational consultation to create sustainable organizational change.

Background 5 1949 � National Organization for Public Health Nursing identified responsibility for public health nursing to participate in education of nursing students as one of its core functions. Adams, 2004 21 st Century � � � Need for more baccalaureate nurses prepared for public health nursing Fewer public health nurses available for precepting Not all PHNs prepared for population-based practice � Clinical experience in public health agency only clinical setting related to increased student interest in becoming a public health nurse � Gebbie & Hwang, 2000; Keller, Schaffer, Schoon, Brueshoff & Jost. , 2011; Lee & Greenwald, 2009; Moon, Henry, Connelly, & Kirsch, 2005 Zahner, 2013 PHN Workforce is aging – 36% at least 56 years of age – PHN Workforce Study (University of Michigan, 2013)

What is a Preceptor? 6 Preceptorship Experience Preceptor Definition An experienced nursing professional who teaches, supervises, and serves as a role model for a student or graduate nurse for a pre-arranged time in a formalized program. � Usher, Nolan, Reser, Owens, & Tollefson as cited in Biggs & Schriner, 2010, p. 319. Experience is defined as involving an experienced nurse and a novice, either a student or a new hire, working together in a formal relationship for a specific period of time to assist the novice in successfully adjusting to and meeting the expectations of the new role. � Canadian Nurses Association, 1995).

Engagement of The Preceptor Triad 7 Precepting consists of a preceptorship triad – an equal relationship between the nurse preceptor, faculty instructor, and student and also identified four domains of preceptor practice: � Artfully connecting � Creating a culture of respect � Acknowledging contextual realities � Preserving the ideals of ethical, competent, and respectful care Patton, 2010, pp. 143 -145 Preceptor Student Faculty

Precepting as a Bridge Application of Theory to Practice 8 The nurse preceptor is an “essential bridge between the classroom and the real world of human patients and clinical settings. ” Raines, 2012, p. 76

Key Preceptor Roles 9 Role Model � � � Guide � � Unique PHN practice Authentic self Personal stories Navigating the experience Coaching, supporting, and directing Teacher � � � Appling theory Evidence-based practice Skill development

10 Preceptor Practice and Staff Development Literature Preceptor Needs Most studies are hospital-based. Most preceptors do not have formal preparation but want it. Common barriers include time commitment, fitting precepting into daily work, lack of recognition, support, and preparation. Preceptor Staff Development Identified need for faculty to be involved in preceptor preparation and preceptor-student activities. Focus is on preceptor skill building. Content update needed in PHN. Face-to-face, online, self-directed study all have been successful. Follow-up with management recognition & support is necessary. Peer consultation & support is important. Preceptor self-efficacy and satisfaction higher when formal training precedes precepting experiences.

11 Barriers to Precepting Midwestern Public Health Nursing Agency Long-term partnerships with Minnesota Schools of Nursing Provides clinical experiences for baccalaureate nursing students Experienced PHN staff Quality improvement gap in effective precepting

Partnership Barriers 12 The complexity of collaboration with nursing programs and faculty in providing clinical learning experiences for students due to: � Working with multiple diverse nursing programs within each calendar year � Lack of knowledge of individual nursing program curriculums and where the community health course occurs in each of the program curriculums � Lack of knowledge of the community health course sequence in the curriculum, clinical objectives, and expected student outcomes � Lack of student preparation and sometimes interest in the clinical experience � Conflicts between nursing program, students, and public health nursing preceptors schedules and available time

Agency Barriers 13 Availability and ability to provide precepting experiences for students due to: � Time and staff availability limitations � Difficulty integrating student precepting experiences into PHN workday � Lack of clinical tools for teaching-learning � Lack of Preceptor Preparation � A sense of powerlessness among preceptors

PHN Staff Preceptor Needs 14 A need for preceptor staff development and continuing education due to: � Inadequate precepting skill development for PHNs who precept nursing students � Lack of knowledge of current expected entry-level competencies of BSN graduates � Need for preceptors to receive an update on the knowledge and competencies for population-based practice

Precepting Experience 15 Q 31 Precepted Nursing Students Before Q 32 Participated in Preceptor Training Before 5 (19%) Yes 9 (32%) Yes No 22 (81%) N = 27 of 28 19 (68%) N = 28 of 28 No

QI PROJECT: Lighting the Way 16 Quality Improvement Issue � Goal � Precepting nursing students had many barriers that resulted in less effective and efficient PHN precepting practice than desired. Increase the number of staff public health nurses who were confident that they were able to efficiently and effectively integrate precepting into their daily work. QI Intervention Plan PHN Preceptor Staff Development Program � Organizational Consultation �

QI Dual Intervention Approach 17 Public Health Agency Director and Nurse Educator Initiative (HSC Partners) Preceptor Staff Development Program � Blended face-to-face and online tutorials Public Health Director Supervisors, Program Coordinator Organizational Consultation � Collaboration � Communication � Three Levels of Organization 3 PHN Teams PHN Staff Lead Team

Building on Strengths 18 v v Learning organization with ongoing commitment to staff development and staff empowerment Strong history of organization EBP and commitment to QI Ongoing commitment to work in partnership with local Schools of Nursing to prepare PHNs for future Administration willing to make changes based on staff recommendations v Management (supervisors) strong advocacy for PHN staff v Majority of PHN staff motivated to precept nursing students

Self-Efficacy Framework Learner Needs, Curriculum Development, Evaluation 19 Self-Efficacy Theory and Teaching Self-Efficacy Theory Self-efficacy as a judgment about one’s ability to carry out specific activities successfully � Bandura, 1982 Midrange Theory Based on Social Learning Theory Bandura, 1977 Sense of Self-efficacy � � belief that one can influence student behaviors and outcomes Significant research Beliefs of Self-efficacy � � the belief that one can perform certain tasks successfully within a certain context Little research Dellinger, et al. , 2008

Framework: Social Cognitive Learning and Self-Efficacy Theories 20

Needs Assessment Overall Interest Level 21 427 450 N = 27 RR = 90% 400 350 Aggregate results of all questions 300 221 250 220 200 70% Items Agree/Strongly Agree Mean = 2. 9 150 100 50 50 0 1 2 3 4

Priority Target Ranking Top Two of Seven 22 Target 1 (85 -96% Agree) � Q 4 Evidence-based public health nursing practice � Q 18 Demonstrating leadership in working with clients and PHN staff � Q 25 Integrating precepting activities into daily work � Q 26 PHN Interventions Student Self-Audit Tool � Q 28 PHN Scope of Practice Observation/Shadowing Tool � Q 32 What Makes a Good Home Visit/Client Audit Tool Target 2 (78 – 81% Agree) � Q 3 Entry-level public health nursing competencies � Q 7 Applying public health nursing process to communities � Q 21 Communication and feedback � Q 22 Teaching-learning strategies � Q 23 Role modeling public health nursing � Q 27 PHN Population-Based Competency Self-Audit Tool � Q 31 Learner Readiness/Teaching Plan Tool � Q 33 Using PHN Process Self-Audit Tool

Lighting the Way Curriculum 23 Module 1: Precepting Nursing Students and Role Modeling Public Health Nursing Module 2: Public Health Nursing Process and Public Health Nursing Interventions Module 3: Teaching/Learning Strategies for Working with Students and Clients Module 4: Community Needs, Public Health Nursing Ethics and Leadership Module Format: • 6 – 8 Online tutorials followed by face-to-face sessions

Project Deliverables 24 Preceptor Staff Development curriculum (4 blended modules with online tutorials and face-to-face sessions for each) Continuing education eligible units (CEUs) – certificate Resource binders for each participant One copy per team of text, Population-Based Public Health Clinical Menu – The Henry Street Model for Nurses (2 nd ed. ) by Garcia, Schaffer, & Schoon (2014) Ongoing access to online presentations through author’s Voicethread account

Project Evaluation Demonstrate a Outcome One 25 20% increase in confidence to precept nursing students. Category 2 56. 9% 86. 4% = 29. 5% Means Pre-test 2. 65 Posttest 3. 25 Difference. 60

26 Demonstrate a 20% increase in confidence in their ability to help students understand public health nursing practice. Outcome Two Category 2 63. 1% 95. 9% = 32. 8% Means Pre-test 2. 77 Posttest 3. 45 Difference. 68

27 Demonstrate a 20% increase in confidence in their ability to help students develop entrylevel public health nursing competencies. Outcome Three Category 2 62. 7% 88. 0% = 25. 3% Means Pre-test 2. 78 Posttest 3. 31 Difference. 53

28 Demonstrate a 20% increase in confidence in their ability to use clinical teachinglearning strategies to assist nursing students’ practice public health nursing. Outcome Four Category 2: 46. 1% 78. 3% = 32. 2% Means Pre-test 2. 44 Posttest 3. 04 Difference. 60

29 Demonstrate a 20% increase in confidence that they can integrate the demands of precepting nursing students effectively and efficiently into their daily workload. Outcome Five Category 2: 46. 0% 65. 0% = 19. 9% Means Pre-test 2. 36 Posttest 2. 75 Difference. 39

30 Identify specific knowledge, skills, and tools obtained or developed from the Preceptor Staff Development Program that they are likely to use to increase their effectiveness in integrating precepting responsibilities and activities into normal workday. Outcome Six Knowledge Updates and Resources � Application to practice � Skills & Strategies Student- Preceptor Communication � Role Modeling � Assessing Student Learning Styles � Tools Shadowing � Student Self-Audit �

I feel more positive about precepting students now than I did before participating in Lighting the Way. 31 More Positive About Precepting 90 80 70 15 (79%) RR = 19 of 20 (95%) 60 50 40 30 3 (15%) 20 1 (5%) 10 0 Strongly Disagree Agree Strongly Agree

Lighting the Way met my learning needs for more effectively precepting nursing students 32 Met Learning Needs 80 70 60 12 (67%) N = 18 of 20 (90%) 50 40 5 (27%) 30 20 1 (5%) 10 0 Strongly Disagree Agree Strongly Agree

PHN Staff Recommendations 33 Organizational Changes � � Faculty Engagement � � � “from top down” all three levels Both in structure and processes of student clinical experiences Preceptor-clinical faculty Schools of Nursing and PH Agency partnership Student preparation for clinical Integrate Lighting the Way content � � Structure and processes of organization at all three levels Ongoing PHN discussions of how putting content into practice with students Preceptor-Student activities Interactions with clinical faculty

34 Dual Intervention Approach Creating sustainable organizational change through: v Staff development v Organizational consultation

Benefits of Dual-Intervention Approach 35 Staff development paired with organizational consultation facilitates � � � � Collaboration with Lead Team Flexibility in plan and implementation Opportunity for peer consultation and support Follow-up with management Administrative recognition & support Facilitates engagement and empower staff Increases ownerships and commitment Faculty and PH Agency staff working in partnership provide best outcomes for preceptor staff development. Staff provides real life creative ideas

Facilitates Ongoing Engagement and Commitment 36 Faculty and Preceptor Agency – Nursing Program Arrangements Shared Knowledge Role Preparation & Expertise Communication Collaboration Flexibility Accountability Preceptor and Student Preceptor Availability Student Preparation Communication Flexibility Clinical Teaching/Learning Tools Student Accountability