Community Health Nursing

 Module 2: COMMUNICATION AND LEARNING

At the end of this module you will have achieved the following objectives:


  1. Analyze how principles of communication apply to preceptorship.
  2. Apply principles of adult learning to being a preceptor.
  3. Describe how Benner’s “Novice to Expert” theory applies to being a preceptor.
  4. Apply motivation strategies to preceptorship and the learner.
  5. Apply the BON Decision Making Model to Nursing Scope of Practice.

 1. Analyze how principles of communication apply to preceptorship

Principles of Communication

  • Communication is a process involving interaction between at least two people
  • The sender has a responsibility to make the message as clear as possible
  • Whenever possible, use the simplest, most precise words you can. Your words must be understood by the listener.
  • Be open-minded and avoid prejudging the speaker or the message.
  • Nonverbal behavior communicates a message even when words are not used. Note the other person’s body language as well as your own
  • Be aware of your personal values and biases and try to keep them from interfering with your ability to communicate.
  • An active listener shows interest and acceptance
  • Concentrate on the communication happening in the present. Avoid the temptation to daydream or plan ahead what you might say or do next
  • Ask questions to verify your understanding of the message
  • Communication is more effective when it involves talking with and to rather than at the listener.
  • I’ messages (I think, I feel) are more effective than ‘you’ messages; they minimize defensiveness and resistance to further communication. ‘Shoulds’ and ‘Oughts’ hinder communication.

Communication qualities of the effective preceptor

  • Possesses and demonstrates broad knowledge
  • Explains the basis for actions and decisions
  • Answers learner questions clearly and precisely
  • Is open to conflicting ideas and opinions
  • Connects information to broader concepts
  • Communicates clear goals and expectation
  • Captures learners attention
  • Makes learning fun

 2. Apply principles of adult learning to being a preceptor

Principles of Adult Learning

Many students in today’s nursing programs are older and more mature than in previous years. They are adults who very often have families as well as having had previous and current employment experience. Working with adults requires different strategies and it is important that the nurse preceptors be prepared for their role as preceptor using adult learning principles.

Malcolm Knowles identified the following characteristics of adult learners. Recommendations of how instructors can address each of these characteristics are addressed by Stephen Lieb and have been adapted to the clinical setting.

 

Adult Students Are:

Preceptor Actions

Autonomous & self-directed

  • involve student in learning process, serve as a facilitator
  • ask student his/her perspective of what learning is needed
  • have student be responsible for content

Have a foundation of life experiences and knowledge

  • draw out student’s experience and knowledge relevant to the clinical experience
  • recognize the value of student’s past experiences in the learning experience

Are goal-oriented

  • work with student to establish realistic, attainable goals for the clinical experience
  • indicate to the student how the clinical experience will meet their goals

Are relevancy-oriented

  • identify objectives for the student prior to beginning the clinical experience
  • ask students about the need for additional learning experiences that would reflect their interests

Are practical

  • advise the student how activities, skills, actions used in the clinical setting are relevant to his/her role as a nurse

Need to be shown respect

  • acknowledge the wealth of experiences students have had
  • treat student as an equal
  • allow the student to voice opinions
  • be supportive, non-threatening
  • provide immediate, non-judgmental feedback

Lieb, S. (1991)

Other principles of adult learning to keep in mind when working with the nursing student are:

  • Learning is a normal adult activity
  • Adults with a positive self-concept and high self-esteem are more responsive to learning
  • Adults learn best when they possess skills for their own learning
  • Immediate descriptive feedback is necessary is adult learners are expected to modify behavior
  • Success reinforces changes already made and provides a motive for further learning
  • Best to learn with some anxiety, but too much stress can interfere with learning

The adult learner may

  • Have established beliefs and values
  • Be less flexible in thinking and doing
  • Be a rich reservoir of experience
  • Have heterogeneous background
  • Have multiple motives for learning
  • Learn by own and other's experiences
  • Be accustomed to responsibility
  • Be busy with other obligations
  • Fear of inadequacy and failure
  • Be less secure in learning situation
  • May require more time to learn
  • See time perspective as immediate
  • Not see teachers as all-knowing
  • Be problem-orientated learners
  • Be reality-orientated learners

Careful Analysis of the Learner by a Preceptor includes:


  • Accurate assessment of the learner’s knowledge, attitudes, and skills
  • Use of direct observation of the learner
  • Providing effective feedback
  • Performing fair and thoughtful evaluations

Skill in Practice and Teaching


  • Provides effective role modeling
  • Demonstrates skillful interactions with patients
  • Presents information with organization and clarity
  • Generates interest in the subject matter
  • Organizes and controls the learning experience
  • Balances clinical and teaching responsibilities
  • Gives appropriate responsibility to the learner

 3. Describe how Benner’s “Novice to Expert” theory applies to being a preceptor

Patricia Benner, R.N., Ph.D. has analyzed observations of nurses in clinical practice. Aydelotte, as stated in Benner (1984) stated Benner described how nurses new to the profession do things differently than nurses with several years of experience, and how nurses change their way of thinking, use of knowledge, and refocus decision making differently as they gain experience in the profession, that learning is progressive. Using the Dreyfus Model of Acquisition, Benner developed the five levels of proficiency for nursing. The following table indicates these five levels and the implications for the preceptor.

Faculty consider nursing students to be novices in nursing. Students are expected to progress from a novice level student at the beginning of their last semester, to that of a proficient/expert nursing student. The novice to expert concept would be applied at a student level vs. a professional nursing level. This means students would be proficiently achieving at the minimum entry level of competency for the nursing program which they are attending by the end of nursing school. IE: BSN level for those students in the UTEP program and ADN level for those attending EPCC. Please click on the following link to see the competencies on the BON website.

The following link to the BON will take you to the unabridged Differentiated Essential Competencies (DEC) of Graduates of Texas Nursing Programs (PDF). The abbreviated DECs can be found in Module 4 in this program. 


Orientee Characteristics and Preceptor Implications using Benner’s model.

 

STAGE

ORIENTEE CHARACTERISTICS

PRECEPTOR IMPLICATIONS

NOVICE

  • No experience with situations in which they are asked to perform tasks
  • Inability to use discretionary judgment
  • Use of context-free rules to guide actions
  • No rule about which tasks are most relevant in a real-world situation or when an exception to rules is necessary
  • Teach rules to guide actions that can be recognized without situational experience
  • Must be backed up by a competent nurse

ADVANCED BEGINNER

  • Demonstrates marginally acceptable performance
  • Is gaining experience with real situations to note meaningful patterns and attributes (or have them pointed out by preceptor)
  • Can formulate guidelines for actions in terms of patterns and attributes
  • Difficulty identifying important aspects; treats all attributes as equally important
  • Shift from teaching rules to guidelines
  • Help to recognize patterns and their meanings
  • Assist in prioritizing
  • Must be backed up by a competent nurse

COMPETENT

  • Begins to see his/her actions in terms of long-term goals or overall plan
  • Begins to distinguish between relevant and irrelevant attributes
  • Feels the ability to cope and manage the unforeseen events
  • Lacks the speed and flexibility of a proficient nurse
  • Focus on improving decision-making skills and ways to improve coordination of multiple, complicated care needs of patient assignments
  • A good preceptor for a novice nurse

PROFICIENT

  • Can discern situations as wholes rather than single pieces
  • Uses past experiences rather than rules to guide practice
  • Can recognize when the expected normal picture is absent
  • Considers fewer options and hones in on accurate elements of problems
  • Use complex case studies to facilitate learning
  • A good preceptor for a competent nurse

EXPERT

  • Practices holistic rather than fractionated
  • Grasps situation intuitively and correctly identifies solutions without wasting time
  • Extraordinary management of clinical problems
  • Considered an expert by others
  • Often not possible to recapture mental processes
  • Encourage exemplars and descriptions of excellent practice
  • A good preceptor for a competent nurse


Data from Benner, P. (1982)

 

From novice to expert American Journal of Nursing, 82, 402-407 Baltimore, J.J. (2004) It is important to note that most adult learners want to progress and achieve at a very high level to their fullest extent. They want to be perfect. To this end, it is important for preceptors to continually assess the student’s competencies and abilities, and not allow the students to work at a level higher than they are able to practice safely. Even though progression from novice to expert student is the ideal progression, there will be times the student may not be able to achieve at that expert level.

The end result is that the student show progression and ability to practice safe patient care - NOT that he/she is able to provide care for a maximum number of patients within the set preceptorship period.

On the other hand, there may be students who are fearful to take the extra steps needed to progress. IE: They may be so afraid of making mistakes they have difficulty becoming independent and confident. They follow the preceptor closely at all times. This scenario calls for preceptors to be encouraging, motivating, and providing assignments to gradually increase the student’s confidence in decision making and skills.


 4. Apply motivation strategies to preceptorship and the learner

MOTIVATION

“Motivated people have a sense of forward drive as an identifying characteristic, as well as a sense of energy, enthusiasm, and goal-directedness….motivation implies a sense of movement, excitement, and expectancy” (Huber, 2010, p. 481, 482).

Adult learning involves internal motivation - learning because one wants to and not for some external reward such as a grade. Active involvement of the learner is a characteristic of the effective preceptor (Goertzen et al., 1995, Irby, 1994) and is an important method of encouraging the adult style of learning, thereby increasing motivation. The clinical experience may be the first time that a learner has been able to select some of his or her own learning goals and to help direct the methods to best achieve them. This also can be an important step to life-long self directed learning.

Demonstrating enjoyment of patient care and teaching is among the most important characteristics of the effective preceptor (Irby et al, 1991). With the current changes in health care this may be the characteristic that is most under siege. Pressure to see more patients, shrinking reimbursements, and increasing difficulty in fitting teaching into a busy life are making it harder to be positive and enthusiastic. From time to time it is essential to stop, get beyond the pressures and demands of the minute and look back to those qualities of the patient care and teaching that are most important and rewarding to you. Enthusiasm is not something that can be faked; but an honest discussion with the learner of the challenges you face and the values and ideals which keep you going, can be an important boost to your own motivation.

Finally, a supportive relationship with the preceptor is another factor that motivates learners (Goertzen et al., 1995). The effective preceptor shows respect for the learner (Irby, 1995) and by doing so creates a safe environment for professional growth. Just as a growing bone is more fragile, the learner needs a safe environment, characterized by trust and respect in which to build momentum, gain motivation, and achieve the maximum possible growth form the rotation.

Therefore, motivating the nursing student involves:


  • Emphasizing problem solving
  • Translating specific cases into general principles
  • Promoting active involvement of the student
  • Demonstrating enjoyment and enthusiasm for patient care and teaching
  • Developing a supportive relationship with the student

Southern New Hampshire Area Health Education Center (2005)


 5. Apply the BON Decision Making Model to Nursing Scope of Practice

BON Decision-Making Model

 

The Six Step Decision-Making Module for Determining Nursing Scope of Practice was developed by BON staff to assist nurses in making good professional judgment about nursing tasks or procedures in order to ensure safe practice. This six step model references both the Nursing Practice Act and the appropriate BON Rules and Regulations in determining Nursing Scope of Practice. The basic steps consist of the following questions for the nurse to consider along with appropriate action based on the nurse’s response.

  1. Is the activity consistent with the Nursing Practice ACT (NPA), Board Rules, and Board Position Statements and / or Guidelines?
  2. Is the activity appropriately authorized by valid order/protocol and in accordance with established policies and procedures?
  3. Is the act supported by either research reported in nursing and health-related literature or in the scope of practice statements by national nursing organizations?
  4. Do you possess the required knowledge and have you demonstrated the competency required to carry out this activity safely?
  5. Would a reasonably prudent nurse perform this activity in this setting?
  6. Are you prepared to assume accountability for the provision of safe care and the outcome of the care rendered?

A nurse always has a duty to his/her clients/patients to assure that they are safe. One of the most important actions a nurse can take toward that goal is making sure that he/she accepts only those assignments for which the nurse has the education, training, and skill competency. Physical and emotional ability can also impact a nurse’s ability to maintain client safety when accepting an assignment. Click on the Link to review the Six-Step Decision Making Model in Poster format or written document. (BON, 2005)



Link: Six-Step Decision Making Model Document (PDF)

In summary, it is important for nurse preceptors to recognize and value the adult nursing student. Understanding adult learning principles and how to use them to the benefit of learning will enhance the clinical experience for both the student and the preceptor. It is also important to understand and be familiar with the Differentiated Entry Level Competencies of Graduates in order to determine criteria by which to teach and evaluate student progress. Understanding the application of the Six Step Decision Making Model will further enhance the ability to determine safe, effective patient care within the Nursing Scope of Practice.