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Preceptor’s Guide to OrientationUpdated July 20151

“The art of teaching is the art of assisting discovery.” – Mark Van DorenTable of ContentsThank you! . 3Objective . 5Preceptor Definition . 5Expectations of the PICU Preceptor . 5Goal Setting with Your Orientee . 6Questions to ask in your initial meeting: . 6Questions to ask at the beginning of each shift: . 6Questions to ask at the end of each shift: . 6PICU Orientation Schedule for New Nurses . 7Orientation Schedule for Graduate Nurses / Nurse Resident . 7Resourcing for Graduate Nurses / Nurse Residents . 7Orientation Schedule for Experienced Nurses . 7Resourcing for Experienced Nurses . 7Extending Orientation . 7Orientation Assignment List . 8Sample Orientation Timeline for Experienced Nurses . 9Sample Orientation Timeline for Graduate Nurses/Nurse Residents . 10Orientation Classes and Schedule . 12Paperwork: Core and Unit-Specific Orientation Competencies . 13Paperwork: Weekly Performance Assessment Form . 14Paperwork: Weekly Clinical Performance Evaluation . 15Paperwork: Core Orientation Competency Evaluation Grid . 16Paperwork: What do I do with all of it? . 17PICU Preceptor Resource Map . 18Preceptor Teaching Points . 19Documenting in the PICU . 20Contact Us . 212

Thank you!Thank you for agreeing to precept! Preceptorsare a fundamental part of the PICU and are theindividuals that have the largest influence onimproving the culture of our unit and help toensure the maintenance of safe practice.Preceptors are leaders, role models, andmentors.You have been asked to precept because youare skillful, resourceful, and understand thesignificance of developing competent,compassionate nurses to take care of childrenwith critical illnesses.We are so grateful to have you lead and nurturethe next generation of nurses that will beworking in the PICU.There are many benefits to being a preceptor in the PICU! Some of thesebenefits 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 wasdeveloped as a guide for preceptors to facilitate orientation and to support you whileyou do what you do best. Enjoy!“A teacher affects eternity; he can never tell where his influence stops.”- Henry Adams3

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ObjectiveThis workbook provides the PICU preceptor resources and guidelines to help ease theorientation process.Preceptor DefinitionThe preceptor is more than just a teacher. The preceptor equips the newly hired nurse withskills and knowledge in order to provide safe, high quality patient care in the pediatricintensive care unit. The preceptor understands that the orientee is an adult learner whoneeds individualized learning driven by problem solving and meaningfulness of content. Thepreceptor facilitates the transition into a Zero Harm culture through safe learningexperiences. A few characteristics of successful preceptors include those that:1.2.3.4.5.Establish a relationship with their orientee.Set goals on a daily basis.Make their expectations known.Acknowledge and respect the orientee’s previous experiences.Encourage the orientee to identify goals and responsibilities. (For example,performing safety checks at the beginning of each shift, learning their responsibilitiesduring 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 lastingeffects.10. Promote autonomy when it is safe for the orientee.Expectations of the PICU PreceptorAs an informal leader and an individual who is directly impacting the culture of the unit, thereare expectations that the PICU preceptor must abide by. Are you living up to theseexpectations?1. Advocating for assignments appropriate to your orientee’s progress to promotegrowth.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, andthe 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 withthe orientee and educator.5

Goal Setting with Your OrienteeThis section is meant to guide the preceptor in goal setting. Please feel free utilizeor modify as you see fit. Regardless of whether you use these words, it is importantto set goals with your orientee throughout orientation.Questions to ask in your initial meeting:1.2.3.4.5.6.“What are your goals during your time with me?”“What are your strengths and weaknesses?”“What kinds of skills are you most interested in?”“What kinds of skills do you feel like you can improve on?”“What are your biggest fears about working here?”“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 yoursupport for them during orientation. You can always improve being a preceptor, too.6

PICU Orientation Schedule for New NursesOrientation Schedule for Graduate Nurses / Nurse Resident s 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 nightshift.If scheduling allows, graduate nurses and nurse residents will first start on dayshiftfor their first eight weeks and will then transition to night shift for the remaining eightweeks. In some cases, orientees may have to start on night shift. These optionsmay include:o Option A: Day shift 8 weeks, Night shift 8 weekso Option B: Night shift 8 weeks, Day shift 6 weeks. Then, conclude on nightshift 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 stillcontinue 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 toCCMC 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 stillcontinue to provide support for their orientee.Extending OrientationThere is no shame in extending orientation! If it is mutually agreed upon that you wouldbenefit for additional time together, please notify your educator(s) immediately or discuss itin one of your evaluation meetings in order to formulate an action plan.7

Orientation Assignment ListThis 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 intubatedpatientStable Chronic PatientBasic two patient assignment (non-intubated)Stable Surgical/Neurosurgical AdmissionStable Admission / Transfer to floorDischarge to HomeStable patients with tracheostomyStable road trip to MRI/CTLevel 2 Assignments (Acuity level of 5-8)Diabetic Ketoacidosis Admission/MaintenanceVentilated assignmentIntubationStable Cardiac PatientExtubationPeritoneal Dialysis / Manual DialysisStable patient with line placement and/or invasiveproceduresMid to high acuity (5-7) Oncology PatientMore complex admission than level 1Cares for surgical patient pre-op and recoveryManagement of stable patient with extraventricular 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 traumapatientHigh acuity patient (8-10)Admission/management of unstable septicpatientCVVHAdmission/management of unstable OR patientManagement of high risk neuro equipment (Bolt,EVD)Death and dying (includes coordination with LifeGift)Assistance with invasive procedures (lineplacement, chest tube placement, etc.) inunstable patientUnstable road trip to MRI/CT/SurgeryBedside codeHypothermia8

Sample Orientation Timeline for Experienced NursesThis timeline is meant to be a guide. Census and acuity in the PICU are dynamic and assignmentsare never guaranteed. Orientee progress is also dynamic and will affect the timeline of assignmentsand evaluations.Week(s)1-23-45-6Transition toNight Shift7-8Experienced Nurse GoalsLEVEL 1 ASSIGNMENTS Orientation to Environment (Bed spaces, supply rooms, etc.) Introduction to fellow staff members and co-workerso Intensivists and NP’so Specialists and NP’so PICU RT’so PICU Care Partnerso PICU Secretarieso PICU Directoro PICU Managerso PICU Charge RN’so Fellow PICU RN’s Orientation to emergency equipment:o Crash cartso Intubation boxeso Airway Cartso Line/Special Procedures Cart PICU flowsheet and report sheet Short introduction to MEDITECH Intro to dayshift/nightshift workflowEvaluation with Educator, Preceptor, and Orientee in Week 2LEVEL 2 to LEVEL 3 ASSIGNMENTS Orientee should be documenting on flowsheet and report sheet withmoderate to minimal assistance. Orientee should be giving report with moderate to minimal assistance Documentation in MEDITECH is performed with moderate to minimalassistance Preceptor is encouraged to begin routing calls on Vocera to orientee.Midpoint Evaluation with Educator, Preceptor, and Orientee in Week 4LEVEL 1 to LEVEL 3 ASSIGNMENTS Orientee should be documenting on flowsheet and report sheet with minimalassistance 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 orindependently on more stable assignments.LEVEL 1 to LEVEL 2 ASSIGNMENTS Orientee is transitioning to independence. Should be documenting onflowsheet and MEDITECH independently. Orientee should be giving and receiving report independently. Orientee should be managing care of level 1-2 assignments with minimalassistance or independently.Final Evaluation with Educator, Preceptor, and Orientee in Week 7 or 8.Resource during Week 8.9

Sample Orientation Timeline for Graduate Nurses/Nurse ResidentsThis timeline is meant to be a guide. Census and acuity in the PICU are dynamic and assignmentsare never guaranteed. Orientee progress is also dynamic and will affect the timeline of assignmentsand evaluations.Week(s)1-23-45-88-10Transition toNight ShiftGraduate Nurse/Nurse Resident GoalsLEVEL 1 ASSIGNMENTS Orientation to Environment (Bed spaces, supply rooms, etc.) Introduction to fellow staff members and co-workerso Intensivists and NP’so Specialists and NP’so PICU RT’so PICU Care Partnerso PICU Secretarieso PICU Directoro PICU Managerso PICU Charge RN’so Fellow PICU RN’s Orientation to emergency equipment:o Crash cartso Intubation boxeso Airway Cartso Line/Special Procedures Cart Introduction to PICU flowsheet and report sheet Short introduction to MEDITECH Intro to dayshift/nightshift workflowEvaluation with Educator, Preceptor, and Orientee in Week 2LEVEL 1 to LEVEL 2 ASSIGNMENTS Orientee should be documenting on flowsheet and report sheet withmoderate 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.LEVEL 2 to LEVEL 3 ASSIGNMENTS Orientee should be documenting on flowsheet and report sheet withmoderate to minimal assistance. Orientee should be progressing to document in Meditech with moderate tominimal guidance Orientee should be progressing to give report with minimal assistance orindependently with dayshift/nightshift preceptor. Orientee should be managing patient care with minimal assistance orindependently on more stable assignments. Orientee should be rounding with minimal assistance.Midpoint Evaluation with Educator, Preceptor, and Orientee in Week 8LEVEL 1 to LEVEL 2 ASSIGNMENTS Orientee is transitioning to night shift. Orientee is to learn night shiftworkflow. Orientee should be giving and receiving report independently with guidancefrom preceptor. Orientee should be managing care of level 1-2 assignments with moderate to10

10-13 14-16 minimal assistance or independently.Orientee should be rounding with moderate to minimal assistance.LEVEL 2 to LEVEL 3 ASSIGNMENTSOrientee should be documenting in MEDITECH and flowsheet independently(with minimal guidance).Orientee should be progressing towards giving and receiving reportindependently.Orientee should be able to identify and initiate night shift processes.Orientee should be rounding with minimal assistance to independently.LEVEL 1 to LEVEL 2 ASSIGNMENTSOrientee should be progressing to independence.Orientee should be managing care of level 1-2 assignments with minimalassistance or independently.Final Evaluation with Educator, Preceptor, and Orientee in Week 15 or 16.Resource during Week 16.11

Orientation Classes and ScheduleAll PICU orientees (regardless of experience) are required to attend orientation classes. Most ofthese classes are provided in conjunction with CVICU. These classes are provided throughout theyear and may extend beyond the preceptor phase of orientation. For your reference, a list of classesand CHEX groups are provided.ClassCHEXDay One/ Infection Control/CustomerService / Hemodynamics /Mock CodeGroup: PICU New Hire CoreContent CurriculumRespiratory/VentilatorGroup: PICU New HireRespiratory ContentECGModule(s): CHEX –Hemodynamic MonitoringPleural Effusion/Topics in CardiologyGroup: PICU New HireCardiovascular ContentNeuroGroup: PICU New Hire NeuroContentRenal/Endo/Mock CodeGroup: PICU New Hire Renal/ Endocrine ContentHem/Onc (PICU only)Group: PICU New HireHematology / OncologyContentTrauma (PICU only)Group: PICU New HireTrauma Content12

Paperwork: Core and Unit-Specific Orientation CompetenciesWhat are these? Core competencies and unit-specific competencies are required by policy (HR 410) for allemployees. 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 isrequired 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 PACEevaluation 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 performinga skill while adhering to CCMC policies. However, competencies can also be reviewed and discussed orreflected 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 thepreceptor-phase of orientation is finished. However, in the instance that this cannot be done, orientees havewithin six months of their hire date to have all competencies signed off.Dated(month/day/year) andinitialed by individualchecking off.Signed by orientee and primarypreceptor / charge RN / PICUresource RN / PICU Manager /Educator13

Paperwork: Weekly Performance Assessment FormWhat is this? The Weekly Performance Assessment Form is utilized to facilitate goal setting week-by-weekbetween 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 basisand document them. This form also provides the preceptor an avenue to thoroughly document the orientee’sprogress in case any issues occur during orientation.Who can fill it out? The orientee and the preceptor should be discussing the Weekly Performance AssessmentForm 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 alwaysillustrate the orientee’s progress in the best way. If possible, try to give as many examples as you can. Ifanything, attempt to put goals for the next week!14

Paperwork: Weekly Clinical Performance EvaluationWhat is this? The Weekly Clinical Performance Evaluation is utilized to describe patient assignments and theskills 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 reviewthe information and make comments about the orientee’s performance in the “Comments” section if it is notalready done on the weekly performance assessment form.15

Paperwork: Core Orientation Competency Evaluation GridWhat is this? The Core Orientation Competency Evaluation Grid gives the preceptor an opportunity to assessthe 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 onorientation. 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 allorientation 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, BYou 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, andbehavior should be circledonce per row. Refer to thetable below to help guideyou.16

Paperwork: What do I do with all of it?Paperwork that is not related to evaluation is made available in the orientation binders givento orientee’s during class on PICU Day One. It is their responsibility to give you the forms tosign. This table will help guide both of you to stay on track.Dayshift Authorization to sign for ControlledDrugso Can be given to unit-basedpharmacist or faxed. Nurseresidents should have alreadycompleted this form duringthe residency. Medication Agreement Preceptor/Orientee Medication Agreement Preceptor/Orientee Day Shift Part BNightshift Medication Agreement Preceptor/Orientee Night Shift PartB Preceptor Phase CompletionNotificationo This form verifies that thepreceptor agrees with theorientee finishing thepreceptor-phase of orientationand is now ready to beginwork independently. Thisform must be completed andgiven to the PICU educator atthe final evaluation.At each evaluation, weekly performance assessment forms and weekly clinical performanceevaluations will be collected for the weeks leading up to evaluation. Core competencyevaluation grids are required for week two, midpoint, and final evaluations. (Three totalgrids 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 thattime.17

PICU Preceptor Resource Map“The one real object of education is to have a man in the condition of continually asking questions.”Bishop CreightonCharge Desk: B Pod: Respiratoryresources (i.e.ventilator manuals)Ca-UTI Talking PointsCamino BinderCongenital Heart DiseaseResource BoxEducation Calendar (DailyPlanner under “Education” tab)Float Nurse Resource BinderLeForte Resource BinderLife Gift Resource ManualMeditech Downtime ManualOne Page Lecture BinderPublic Health Event (PHE) BinderRenal Transplant HandbookSafety Data Sheet (SDS) ManualWound Care BookA Pod: Insulin Pump Binder Trauma Education Resource Manual(assembled by Trauma PNP’s) Neuro Resource Binder Neurosurgery Binder Model of BrainOther Resources to review/visit: PICU Team Site Get Well Network to assign education to families Schwarz Library Online Resources on CookNet18

Preceptor Teaching PointsHere 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 toprevent each?1.2.3.4.Ca-UTICLABSIVAPSkinPatient/Family Education Remember to assign patient/family education through Get Well Network! Especially:o Period of Purple Cryingo Asthma EducationDocumentation “Recall Values” should never be used!Steer clear from “Click and Drag” documentation.Remember to document your invasive procedures!Don’t forget your “untimed” interventionso Education: PICUo Parent/Caregiver Behavioro Visitorso Emotional Supporto Hygieneo Cap Changeo Tubing Changeo 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 roundso 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)!Transferso 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!19

Documenting in the PICUWho will read this anyway? Health Care Team - Others from your team are reading what you wrote to get a picture ofwhat you did over your shift. You need to be as clear and as thorough as possible to reflectwhat your care involved in order for other healthcare members to determine what went in toyour patient care for that day. Document For Yourself! – The statute of limitations for a minor to file a lawsuit is extendedto two years past the “age of majority.” Usually, this number is 20 years old. If you took careof 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 abouthealthcare 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 candeteriorate over time and having a clear description can provide an accurate clinical picture ofthe 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 thepatient’s bilateral breath sounds were clear and equal.)Explain when objective and subjective assessments don’t match. (If your patient states thatthey 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 awayfaster 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 aredocumented 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 sizesfor wounds, etc.)Write legibly – even your name!20

Contact UsDo you have further questions, concerns, or suggestions about PICU nursing orientation, precepting,or PICU education in general? Let us know!Danika Meyer, BSN, RN, CPNCritical Care Education CoordinatorPediatric Intensive Care UnitCook Children’s Medical Centerdanika.meyer@cookchildrens.org(682)885-1049 office(682)885-4268 PICUCall on VoceraDee Parma MSN, RNCritical Care Education CoordinatorPediatric Intensive Care UnitCook Children’s Medical Centerdee.parma@cookchildrens.org(682)885-7287 office(682)885-4268 PICUCall on VoceraMary Bina, BS, RRTEducation Coordinator for Respiratory CareCook Children’s Medical CenterMary.bina@cookchildrens.org(682)885-7567Call on VoceraReferencesCampos, 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), 202-211Wright, D. (2005). The ultimate guide to Competency Assessment in health care. Minneapolis, MN:Creative Health Care Management, Inc.21

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 evaluation

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