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Implementation of a Certified Nursing Assistant Preceptor ProgramElizabeth HotalingState University of New York Institute of TechnologyNUR 444 Nursing LeadershipAbstractFollowing the success of preceptor programs for Registered Nurses and Licensed Practical Nurses, Certified Nursing Assistant (CNA) preceptor programs are an emerging movement in health care. Due to the high number of CNAs employed in long-term care facilities it is these type of facilities that are developing and implementing CNA preceptor programs. Coordinating with the Staff Development Department of Kingsway Community, a long-term, skilled nursing facility located in Schenectady, NY, the need for such a program was identified. A CNA preceptor program was planned for, developed, implemented, with future evaluation methods put into place at Kingsway Community. All appropriate forms and documentation were developed for continued use at the facility. The preceptor training material was also developed for continuous use as education materials for future preceptors. The initial preceptor training course was instructed by the nursing leadership student, with two Staff Development employees including the Staff Development Coordinator present to enable them to instruct future training classes. Evaluation of preceptors and of the program will be conducted after each preceptor – preceptee relationship. Once the first set of preceptees has completed their preceptorship, the evaluations will be reviewed by the Staff Development Coordinator. The project and program was executed and implemented successfully, with methods of future evaluation in place. Table of ContentsAbstract…………………………………………………………………………….2Introduction………………………………………………………………………..5Background………………………………………………………………………..6Nursing Theory……………………………………………………………………7Figure 1 – Differences in Experience Levels……………………………..8Planning & Development of Preceptor Program………………………………….8Criteria for Preceptor Selection…………………………………………..9Obtaining Interest & the Application Process……………………………9Figure 2 – Informative Poster……………………………………………10Figure 3 – Application Form…………………………………………….11Program Guide Development……………………………………………12Interview Process………………………………………………………………...12Figure 4 – Program Guide………………………………………………..13Figure 5 – Interview Tool………………………………………………..14Training of Preceptors……………………………………………………………15Development of Educational Materials…………………………………..15Communication Skills……………………………………………………16Motivational Skills………………………………………………………..17Teaching Adult Learners………………………………………………….17Figure 6 – Assumptions Regarding Adult Learners……………………….18Evaluations…………………………………………………………………………18Figure 7 – CNA Preceptor Evaluation Form………………………………19Figure 8 – Preceptor Self-Evaluation Form ………………………….……20Conclusion………………………………………………………………………………21References……………………………………………………………………………….22Appendix A – Package of All Developed DocumentationAccording to the Oxford Dictionary, a preceptor can be defined as a teacher or instructor. The term is most commonly used when referring to teaching practical clinical skills in nursing or medicine. Structured preceptor programs have been in place in many nursing facilities to some extent for registered nurses (RNs) for decades and for licensed practical nurses (LPNs) for several years. The implementation of Certified Nursing Assistant (CNA) preceptor programs is an up and coming movement in health care today. Many innovative skilled nursing facilities that employ large numbers of CNAs are looking towards replacing classical orientation programs with formal preceptor programs. Kingsway Community in Schenectady, NY offers multiple nursing services for seniors including a 160 bed skilled long-term nursing facility. Kingsway Community employs over sixty CNAs and offers a CNA six week training program for those interested in becoming CNAs. Working with the Staff Development Coordinator, Phyllis Rosenberger, RN BSN, a CNA preceptor program was developed and implemented within the facility. The goals of the project were developed at the beginning of the process and are as follows:?Upon completion of this project there will be a clearly written program guide for a CNA Preceptor Program for Kingsway Community Nursing Center.?Upon completion of this project, all specifically qualified and selected experienced CNA preceptors will have completed the preceptor training class.?Upon completion of this project, introduction to the preceptor program will become a standard component to the new hire orientation for CNAs. ?Upon completion of this project, evaluation of the preceptor class and each preceptor will be evaluated with self-evaluations and trainee-completed evaluationsBackgroundPrior to the development of the preceptor program, research was conducted into the history of preceptor programs, the emergence of CNA preceptor programs, and critical components to preceptor training programs. According to Myrick & Yonge (2005) the concept of preceptorships in nursing was first used during the time of Florence Nightingale. Myrick and Yonge go on to discuss that due to hospital diploma programs, preceptorships fell to the way-side until the 1960s when nurse practioner programs revitalized the method of teaching and training. Since the 1970s preceptor programs have been growing and gaining popularity. As previously discussed the concept was revitalized by nurse practioners, it then spread to use with RNs. There are multiple benefits to formal preceptor programs. By establishing a specific one on one preceptee-preceptor relationship, a new employee is granted a specific mentor, teacher, role model and long term support system for their entire orientation and professional development. The American Association of Colleges of Nursing (AACN) (2012) has stated that the use of preceptorships and residencies can help to benefit nursing practice by increasing socialization, increasing clinical skill, competence, individual confidence, and reduce long term turnover rates. Due to the physical demands, high stress, extreme responsibility and low compensation rates of CNA positions, there has been a long standing reputation for high turnover rates for CNAs. The opportunity to decrease CNA turnover rates while implementing a program that offers so many other benefits including increasing quality of care is what makes CNA preceptor programs so attractive to skilled nursing organizations. Not only are specific nursing organizations such as Kingsway implementing such programs, some states are offering statewide preceptor training programs. The Iowa Health Care Association along with the National Association of Health Care Assistants (NAHCA) offers an intensive two-day CNA Preceptor Certification Course. This course allows for any health care organization in Iowa to send CNAs for certification. This is an alternate method to developing facility specific programs such as the one developed at Kingsway Community. Nursing TheoryIn 1984 Patricia Benner developed the Novice-to-Expert Model of nursing experience. Hood & Leddy (2006) discuss the five stages of the theory and what experience levels they correlate to; Stage I is a novice nurse which can correlate to student nurses, Stage II is an advanced beginner which can correlate to new graduate nurses, Stage III is the competent stage which correlates to about 2-3 years clinical experience, Stage IV is the proficient stage which correlates to 3-5 years of clinical experience, and lastly is Stage V the expert stage, consisting of several years of experience. This theory was adapted to apply to the levels of experience for CNAs and to stress these different levels during the preceptor training course. The novice level was adapted to brand new CNAs that were starting orientation right after completing the six week CNA training course. The novice level was not applied to individuals still in the training course due to the fact that individuals in the course only experience five clinical days within the six week period. It was determined that five clinical days was not enough to qualify as completing the novice experience level. The advanced beginner level was adapted to correlate with CNAs who were new to the facility, but had some previous clinical experiences. The competent level was adapted to CNAs who had completed their orientation, passed all competencies and were developing their independent clinical experience. The proficient level was adapted to CNAs who had months of experience and were able to excel in all their skills and daily tasks. The expert level was adapted to CNAs who had years of experience and demonstrated clinical excellence. It was stressed to the preceptors during the training course that they were at proficient to expert levels and their main focus as a preceptor had to be encouraging the same clinical excellence in their preceptees. White (2008) discusses the learning differences between novice nurses and advanced beginner nurses. These differences were applied to precepting CNAs and reviewed during the preceptor training course, Figure 1 illustrates these differences.Figure – 1 – Differences in Experience Levelscenter0Precepting new CNAs vs. Experienced CNAs020000Precepting new CNAs vs. Experienced CNAsNew CNAs (Novice)Little or no experience, needs complete guidance and instructionNeeds rules and regulationsRequires constant feedback, suggestions for improvement as well as praise for tasks done correctlyDue to inexperience, new CNAs need a non-judgmental, supportive approach with constant conversation. Never stop talking to a new CNA. Previously experienced CNAs (Advanced Beginner)Functions with directions, needs to learn facility specific policies, procedures, & routinesEncourage questionsMay be focused on remembering rules, think out loud during all skills and tasksMay need support in setting prioritiesNeed to base preceptor actions upon orientee’s level of experiencePlanning and Development of Preceptor ProgramAfter the goals of the project had been established, the background information provided, and the connection to nursing theory obtained, the planning and development stage was initiated. During the planning stage, the qualities of effective preceptors were researched. According to Ohio University Heritage College of Osteopathic Medicine the four major principles of effective preceptors are; communication, careful analysis, skill in teaching and practice, and ability to motivate the preceptee. These concepts were integrated into the development of not only the teaching materials, but also into the criteria developed for preceptor selection. Basic good standing within the organization was also considered while developing these criteria. Criteria for Preceptor SelectionAfter review of the research and determination of good-standing, the official criteria were set for perspective preceptors. It was determined that to be eligible for a preceptor position a CNA employee must have been employed at Kingsway Community for at least six months. This may not appear to be a long enough time, but considering the turnover rates for CNAs it was the recommended length of time by the Staff Development Coordinator. The rest of the criteria is as followed: must have exceptional annual competencies, must demonstrate strong interest and ability in training new employees, must not be under any form of disciplinary action, must possess excellent communication skills, and lastly must have the recommendation of the nurse manager. Obtaining Interest and the Application ProcessOnce the criteria were set, an informative poster was developed to be displayed on each of the nursing units within Kingsway. The main objective of the informational posters was to obtain interest in the program and identify interested CNAs. The posters also provided information on how interested individuals could apply for the preceptor program. Prior to the posters being displayed, the same preceptor criteria were used to develop an application that would be used to review each interested CNA. At the time the posters were displayed on each of the four nursing units, applications forms were left at each nursing station. Figure 2 illustrates the informative poster, displaying the program criteria, benefits, and application process. Figure 2 – Informative PosterThe application was developed using the known qualities of effective preceptors. Application questions were designed to allow applicants the ability to showcase the qualities that would assist them in a preceptor role. Questions were developed to allow individuals to discuss their clinical experience, communication skills, teaching and training experiences, motivational skills, and problem solving abilities. Figure 3 illustrates the application form that was created and used for this step of the project. Figure 3 – CNA Preceptor Application FormProgram Guide DevelopmentWhile the initial documents were being created, the sections of the entire program began to take form. Using the tasks that had been completed and looking forward to the tasks that would need to be completed, a program guide was developed. The purpose of the program guide was to allow for standardization of preceptor training, evaluation, and formalize the process. This would allow for the same steps to be followed during the next preceptor selection, training, and evaluation. It will also allow for standardized review of the process during New York State Department of Health Annual Survey. The Staff Development Coordinator stated that the program would be a standard component for all newly hired CNAs. The program guide was reviewed at the beginning of the preceptor training class to allow for an understanding of how the program was developed and how it will be run. Figure 4 illustrates the main components of the Kingsway Community CNA Preceptor Program Guide. Interview ProcessAll applications that were received by Staff Development were reviewed. Interviews were set according to applicants’ work schedules. The Staff Development Coordinator obtained verbal recommendations from the nursing managers for each of the applicants. Half the interviews were conducted by the Staff Development Coordinator and the other half were conducted by the nursing leadership student. Prior to the interviews an interview tool was developed to assist with the process. The purpose of the tool was to revisit the qualities of effective preceptors that had been used when developing the application and also to offer behavioral questions. As previously discussed, the principles developed by the Ohio University Figure 4 – CNA Preceptor Program GuideHeritage College of Osteopathic Medicine of communication, analysis, skill in teaching, and motivation were re-addressed in the first half of the interview tool. The second half of the interview tool offered behavioral interview questions. McNeil (2012) discusses that behavioral interview questions that allow the candidate the chance to discuss actions he or she took in a previous situation are the best predictor for how that individual will act in a future, similar situation. Behavioral questions were developed to elicit information from the applicants about their previous actions in situations of teaching, training, motivating, communicating, re-directing, and encouraging others. McNeil (2012) also discusses that when listening to the candidates responses to behavioral questions, and good interviewer should listen for three specific components; the situation, the actions taken, and the outcome. McNeil’s suggestions were used as guidelines prior to the interview process. Figure 5 illustrates the interview tool that was developed and used for each of the interviews. Figure 5 – Preceptor Interview ToolTraining of PreceptorsDevelopment of Educational MaterialDue to scheduling constraints, a one hour power point and discussion focused training course was developed to be taught to the selected preceptors. The first points that were discussed during the training session and through the power point were the definition of a preceptor and the goals of the preceptor program. The first goal of the program is to choose the most qualified and experienced CNAs from Kingsway to act as mentors, role models, and teachers to new CNAs. The second goal is to ensure that each new CNA is provided with proper unit socialization and training to increase their hands-on skills, knowledge, competence, and confidence as a CNA. The next element that was covered pertained to characteristics of effective preceptors. According to Kelly-Heidenthal (2004), effective preceptors are clinically experienced, like to teach, and are committed to being good preceptors. Since the element of communication is such an important concept in precepting, ability to be an effective communicator was added to these characteristics. The role of a CNA is a constantly hands-on, clinical role; because of this, the concept of clinical excellence was stressed. The preceptors were instructed that it is their clinical excellence that they need to learn how to pass on to their orientees. The best method for teaching clinical excellence was discussed, the Staff Development Coordinator, Phyllis Rosenberger wanted the concept of “see one, do one” to be emphasized. This concept was used to develop and teach the following steps:Demonstrate a skill or task per the competency checklistHave the orientee demonstrate the task backOffer suggestions or tips for improvement (Effective feedback is important)Sign off orientee for that specific skill/task on the competency checklistUsing information from the Ohio University “The Effective Preceptor” monograph, tips for teaching clinical skills were provided to the preceptors. The tips offered were that preceptors need to;Provide effective role modelingDemonstrate skillful interactions with residentsPresent information to the orientee with organization and clarityGenerate interest in residents’ care and daily activities with enthusiasumGive appropriate responsibilities to the orienteeCommunication SkillsAgain using information obtained from the Ohio University “The Effective Preceptor” monograph, suggestions on communication between preceptor and preceptee were given. During the training course it was pointed out that an effective preceptor should be able to clearly and concisely describe a task prior to and during task demonstration. It was explained that preceptors should be personable and approachable towards their orientees at all times. Preceptors need to be able to listen to their orientees questions, comments and opinions, so that a respectful learner relationship is developed. The importance of constant communication between preceptor and preceptee was also a topic of discussion during preceptor training. Constant communication is vital no matter how much experience the orientee may have, but is most important when precepting CNAs who have just completed the training course. It was recommended that preceptors use a narrative when describing how they complete a task to a preceptee. Motivational SkillsThe ability to provide motivation to a preceptee is an important skill of effective preceptors. The Ohio University “The Effective Preceptor” monograph discusses motivational techniques that preceptors should use. The following is a list of suggested motivational techniques that were offered during preceptor training:Emphasize problem solving and independent thinkingEncourage constant, active involvement of the orientee (needs to always be hands on)Demonstrate enjoyment and enthusiasm for patient care and teachingDevelop a supportive relationship with the orienteeThe importance of maintaining a positive attitude while precepting was also discussed during the preceptor training. According to White (2008), being able to teach with a respectful and positive attitude represents the true art of teaching. Preceptors should treat their orientees as equals and demonstrate care about their success. Teaching Adult LearnersDuring the preceptor training class, education regarding the proper way to interact with adult learners was reviewed. White (2008) lists several assumptions regarding adult learners that can be applied to CNA preceptorships. Figure 6 displays the assumptions about adult learners. Figure 6 – Assumptions Regarding Adult LearnersTips for effectively teaching adults were given during the preceptor training courses. These tips according to White (2008) include the following:Adults should take responsibility in their own learning, preceptors are facilitators of the learning processAn effective preceptor must consider an adult’s previous experiences (work, family, education) during the teaching processLearning needs to “make sense” to adults, provide proper reasoning for tasksDevelop a learning environment by always showing respect to your orienteeEvaluationsEvaluation methods for assessing the competency of the orientees and the effectiveness of the preceptors had to be considered. During the preceptor training course the preceptors were asked to give their opinions and suggestions for improvement to the orientee competency forms. The competency checklists that had been in use at Kingsway for CNA orientation were to be modified using these suggestions by the Staff Development Coordinator. Methods to evaluate the preceptors were considered extremely valuable. Evaluation forms to be completed by the orientees after each orientation were developed. Figure 7 displays the preceptor evaluation form. Figure 7 – CNA Preceptor Evaluation FormFuture feedback from preceptor self-evaluations will provide valuable information. Not only will the feedback allow for individual preceptors to continue improving their skills, but it will also provide a method of evaluating the entire program. A preceptor self-evaluation form was developed following a similar format as the CNA preceptor evaluation. Figure 8 displays the preceptor self-evaluation form. Figure 8 – Preceptor Self-Evaluation FormConclusionWorking under the guidance of the Staff Development Coordinator at Kingsway Community, Phyllis Rosenberger, RN, BSN, a CNA Preceptor Program was developed and implemented within the facility. All necessary forms and documents were developed and approved by the Staff Development Coordinator. The official program guild will allow for future groups of preceptors to receive the same training and for a standardized process to be followed. Through the application and interview process the best qualified CNAs were chosen to act as preceptors within the facility. The chosen preceptors then attended an hour long preceptor training course. Future preceptor training courses will be taught by Staff Development. The Staff Development Coordinator has also established that this program is now a standard component of orientation for all newly hired CNAs. The development of evaluation forms to assess the preceptor will allow for continuing evaluation of individual preceptors as well as the overall effectiveness of the program. All pre-set goals of this project were met successfully. The anticipated success of this program has led the Staff Development Department to plan on applying a similar format in an attempt to renovate the LPN Preceptor Program. ReferencesCNA Certified Preceptor Course. (2012). Iowa Health Care Association. Retrieved from: of Professional Nursing Practice. (2012). American Association of Colleges of Nursing. Retrieved from: , L. & Leddy, S. K. (2006). Conceptual Bases of Professional Nursing. Philadelphia:Lippincott, Williams, & Wilkins. Kelly-Heidenthal, P. (2004). Essentials of Nursing Leadership and Management. Clifton Park,N.Y: Delmar Learning. Mcneil, R. (2012). Better Interviewing, better hires. Long-Term Living: For the Continuing CareProfessional, 61(9), 32-33. Myrick, F., & Yonge, O. (2005). Nursing Preceptorship: Connecting Practice & Education. Philadelphia: Lippincott, Williams, & Wilkins.Preceptor. (n.d.). In The Oxford online Dictionary. Retrieved from: The Effective Preceptor. (n.d.). Hertiage College of Osteopathic Medicine Ohio University. Retrieved from: , D. (2008, March). Novice to Expert: Benner’s Model of Practice. Presented at GraduateNurse Internship for Northeast Health, Troy, NY. White, D. (2008, March). Preceptors Influencing Values, Outcomes, and Transitions: Teachingthe Adult Learner. Presented at Graduate Nurse Internship for Northeast Health, Troy,NY. ................
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