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https://infirmiere-canadienne.com/blogs/ic-contenu/2020/02/03/orientation-en-endoscopie-pour-le-personnel-infirm

Feb 03, 2020, By: Cindy Campbell

“Capturing and addressing knowledge deficits of new staff is essential to support quality practice. Staff unpreparedness or adopting skills not based upon best practices have lasting consequences to the nurse and patient care.” Hanberg & Brown (2006) 

The demand for endoscopic services  has increased dramatically, with services doubling in many centres over the last 5 years (Shenbagaraj et al, 2017). Despite this, formal endoscopy nursing education remains largely overlooked, with no recognized credentialing program in Ontario. Currently, in most hospital and free-standing endoscopy clinics, new hires are oriented by fellow registered nurses (RNs) who may or may not model best practice. This is concerning considering the scope of practice of an endoscopy RN, which includes acute care skills such as sedation administration, pre- and post-anesthesia monitoring, and specialized assisting techniques.

Recognizing this deficit in nursing education, and with the support of a 2018/19 Registered Nurses Association of Ontario (RNAO) Advanced Clinical Practice Fellowship (ACPF), we undertook the development of an orientation education guide for the endoscopy unit of Mount Sinai Hospital in Toronto. The completed 250-page guide followed a competency-based approach and integrated elements of the Competency by Design (CBD) model established by the Royal College of Physicians and Surgeons of Canada (RCPSC) (Gofton, Dudek, Barton, & Bhanji, 2017).

Design and content of the guide

The completed ACPF orientation education guide offers a structured, competency-based approach that emphasizes the diverse skills, knowledge, and abilities unique to endoscopy. This contrasts with the previous, exclusively hands-on orientation, which risked overlooking the spectrum of roles in endoscopy nursing.

The guide underscores relevant organizational policies, professional practice standards, and best practice guidelines in accordance with the Society of Gastroenterology Nurses and Associates and the Canadian Society of Gastroenterology Nurses and Associates. There is also a breakdown of the roles and sources of knowledge that inform the practice of an endoscopy RN, as well as 10 core endoscopy RN competencies (see Figure 1 [PDF, 36.6 KB]) with indicators of achievement.

• Endoscopy RN competencies are highlighted through a series of self-directed activities mapped with hands-on skills modelled by a designated preceptor. These activities are designed to accommodate a range of learning styles and include videos, shadowing support staff, and a toolkit of endoscopy accessories to develop tactile skills.
• There are several learning modules specific to the 10 core endoscopy competencies, such as Health and Safety, which reviews patient assessment, administration and monitoring of conscious sedation, and infection control.
• A technical skills resource guide breaks down each procedure into steps, set-ups, variations in scope, and storage location.
• To organize learning, orientation activities and completed hands-on skills are documented on worksheets stored in a booklet called a “learning passport.”
• A preceptor’s guide serves as a resource to educate preceptors on their role in sharing knowledge and assessment, including the need to coach orienteers with rich, daily feedback. To help focus and direct orientation content, learning activities follow a structured schedule. Learning styles are reviewed, as is Benner’s (2001) theory of Novice to Expert, to focus expectations. Daily learning goals are also included to systematically build learners’ knowledge per Bloom’s taxonomy (Armstrong, 2019).

Development of the orientation education guide

The guide’s development followed a learning plan supported by a team of mentors with expertise across a spectrum of related specialties including nursing education, gastroenterology, anesthesia, endoscopy, and critical care nursing, as well as adult education.

To ensure consistency and quality, the plan followed an evidence-based, systematic approach to determine knowledge gaps and inform tool content. This included a needs assessment, stakeholder analysis, environmental scan, and literature search with findings validated by mentors and stakeholders. Data were then synthesized to create a learning guide based on elements of the CBD model.

RCPSC approach to competency-based medical education

The RCPSC implemented the CBD model in 2017. With CBD, the focus of learning changed from a time-based to an outcomes-based approach. Learning is individualized to capture key abilities unique to each medical specialty through formative and summative assessments blended with feedback. This approach identifies gaps early on and ensures that residents who are struggling get help before progressing to unsupervised practice.

Competency, which largely consists of three components—skills, knowledge, and attitudes (Cox, Whiteside, & Stobinski, 2016)—is continuously assessed with meaningful dialogue from clinical mentors, thus supporting and preparing learners for final assessments of entrustable performance activities (EPAs). EPAs are tasks unique to a specialty area that can be broken down into milestones, or abilities, toward achievement. Assessment of EPAs allows residents to move beyond know-how to “show how” to verify that they have met the criteria (see Figure 2) to work independently (RCPSC, 2017).

Applying the CBD model to endoscopy RN orientation

Applying elements of the CBD model to the ACPF endoscopy orientation guide builds knowledge specific to the scope of practical and professional practice obligations unique to endoscopy over a 4- to 6-week orientation. Ongoing assessment identifies those who are struggling and ensures that they receive additional support.

Alternatively, RNs who complete all learning activities and assessments and can demonstrate safe, competent care before 4 to 6 weeks may qualify for fast-track orientation and progress to the final practical assessment.

Competency assessment measures

Competency assessment establishes expectations of performance and holds new hires to practice standards. This approach confirms they can demonstrate informed, safe care before advancing to independent practice. Assessing competency along the continuum of learning provides measurable data, such as achievement of institutional quality indicators, and identifies gaps that risk becoming entrenched upon advancement to independent practice.

Although the ACPF orientation education guide contains numerous options for competency assessment, the final guide includes a written test, self-reflection, and presentation of a case study. In addition, prior to progressing to independent practice, orienteers perform a final practical assessment, which involves demonstration of a cardinal endoscopic activity (CEA), comparable to an EPA from the RCPSC model.

Competency assessment establishes expectations of performance and holds new hires to practice standards.

Assisting with a hot snare polypectomy was the CEA selected because it captures numerous endoscopy nursing skills. For this final assessment, ideally the preceptor is removed from the process and a clinical nurse specialist or designated senior endoscopy RN evaluates the orienteers’ performance.

Evaluation criteria for new hires

Competency-based evaluation assesses not only what has been learned, but the specific level of performance that students are expected to master (Bandiera, Sherbino, & Frank, 2006). Given the orienteer’s “beginner” status, the final evaluation assessment criteria ask: “Can this RN demonstrate safe care working independently?”

To answer this question, the final practical evaluation follows the “entrustablity” rating scale used in the CBD model (see Figure 3). Along with this scale, both the assessor and the orienteer are given a list of procedural steps of the CEA. These steps allow the assessor and orienteer to see what must be learned in order to meet competency criteria (McGaghie, Miller, Sajid, Telder, & Lipson, 1978). Combined with overall preceptor feedback and the successful completion of learning activities, these methods provide a good picture of the orienteer’s level of competency.

Guide evaluation

Public Health Ontario (2016) cites “evaluating and monitoring” as critical steps in developing robust health policy. Indeed, evaluation is integral to the tenets of nursing education. From the onset of development, the ACPF education guide was positioned as a living document, evolving to capture not only advancements in endoscopy practice and evidence but also orienteers’ and preceptors’ feedback through evaluation measures.

In addition to informal evaluation captured through ongoing daily feedback, formal evaluation included questionnaires provided to both preceptors and orienteers. The questionnaires used a five-option Likert Scale format that included comment sections to enhance qualitative findings.

Owing to the recent introduction of the ACPF guide and low staff turnover to date, evaluation data on outcomes such as improved patient safety, staff satisfaction, and retainment are not yet available. However, user evaluations of preceptors and orienteers examining tool usefulness to date have been chiefly positive. Furthermore, the guide was appraised by nursing peers for innovation in nursing education and was recognized with a 2019 Mount Sinai Hospital nursing practice award.

Conclusion

As endoscopy services continue to expand and patient care complexities increase nationwide, a comprehensive approach to the clinical orientation of endoscopy RNs is essential. The structured, competency-based ACPF orientation tool warrants consideration as an effective means to bolster quality patient care by addressing knowledge gaps through individualized learning, ongoing feedback, and assessment of new staff.

Further evaluation is necessary to measure this tool’s benefit, and successful integration depends on committed preceptors and nurse educators. Meanwhile, the tool offers a unique approach for orienting RNs to acquire specialized knowledge and competencies specific to endoscopy. With modifications, this approach could also be transferable to numerous clinical settings.

References

Armstrong, P. (2019). Bloom’s taxonomy. Center for Teaching, Vanderbilt University.

Bandiera, G., Sherbino, J., & Frank, J. (2006). The CanMEDS assessment tools handbook. An introductory guide to assessment methods for the CanMEDS competencies.

Benner, P. E. (2001). From novice to expert : Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.

Cox, J. A., Whiteside, D., & Stobinski, J. X. (2016). Competency assessment in the operative and invasive procedure setting.

Gofton, W., Dudek, N., Barton, G., & Bhanji, F. (2017). Workplace-based assessment implementation guide: Formative tips for medical teaching practice. Ottawa: Royal College of Physicians and Surgeons of Canada.

Hanberg, A., & Brown, S. C. (2006). Bridging the theory–practice gap with evidence-based practice. Journal of Continuing Education in Nursing, 37(6), 248–249.

McGaghie, W. C., Miller, G. E., Sajid, A. W., Telder, T. V., & Lipson, L. (1978). Competency-based curriculum development in medical education: An introduction. Geneva, Switzerland: World Health Organization.

Ontario Agency for Health Protection and Promotion (Public Health Ontario), Snelling, S, & Meserve, A. (2016). Evaluating health promotion programs: introductory workbook. Toronto, ON: Queen's Printer for Ontario.

Royal College of Physicians and Surgeons of Canada (RCPSC). (2017). Entrustable professional activity (EPA) fast facts.

Shenbagaraj, L., Thomas-Gibson, S., Stebbing, J., et al. (2019). Endoscopy in 2017: a national survey of practice in the UK. Frontline Gastroenterology, 10:7-15.

Cindy Campbell, RN, MScAH, BScN, CGN(c), is a peri-operative RN with 25 years experience. Recognized as a nurse leader and lifelong learner, Cindy seeks to advance quality patient care and the practices of her fellow, front-line RNs through professional practice educational initiatives.