- Email: [email protected]
Air Medical Transport Residency Program for Flight Nurses and Paramedics
Air Medical Journal 36 (2017) 77e80
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Original Research
Air Medical Transport Residency Program for Flight Nurses and Paramedics Jeff Phillips, MEd, MSOL, CFRN, Chad Kuhlman, FP-C, Chris Evanson, FP-C Mayo Clinic Medical Transport, Rochester, MN
What is the initial experience like for new critical care transport providers fresh off of orientation? Is it a positive experience with the providers performing independently full of confidence or is it filled with trepidation, stress, and uncertainty? What are their abilities? At what level are their knowledge and competence? Does an intense 3- to 4-month orientation fully prepare new critical care transport providers to excel in their role and responsibilities? These are questions that arose within our program through feedback from new hires and the struggles they were encountering. Our program's orientation lasts 3 to 4 months. The orientee is expected to build knowledge related to patient care, aviation, and safety in class online; attend clinicals; participate in approximately 30 preceptored flight shifts; learn and test on procedures, skills, and equipment; undergo periodic reviews; complete required certifications; attend cadaver and simulation laboratories; and undergo pre- and postorientation testing. As the end of orientation approaches and the new hire gains a better understanding and perception of the role and responsibility of the critical care transport provider, uncertainty and lack of confidence start to set in. One of our new providers related that coming off of orientation she felt “relief that soon I would be done with a marathon of goals which were achieved. A surreal feeling with a looming thought of yes this is my job, but am I really ready? I am not even close to being at the level my preceptor is and I'm not sure will ever get there.” In addition to personal struggles such as confidence, our new providers were also struggling with their competency and knowledge. For example, 1 new provider was having difficulty with advanced airways that required significant additional training. Another was having difficulty with making critical patient care decisions under stress. A third was unable to perform efficiently at the pace required by their experienced partners. A look at our culture revealed an expectation that once done with orientation they would continue to learn and develop on the job and a sink or swim mentality. We then asked the following question. Sink or swim? Do we seriously take the new hires and put them through a jam-packed 3to 4-month orientation and then kick them out the door and expect them to go save lives? Or do we just hope that they don't cause harm before they get enough experience to be considered an expert? One of our new providers encountered a very challenging E-mail address: [email protected] (J. Phillips). 1067-991X/$36.00 Copyright © 2017 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2017.01.005
case that did not go well soon after completing orientation. The new provider's confidence quickly plummeted, her stress level regarding the job increased, and uncertainty about her competence started to arise. She stated, “I didn't feel like I could express how I was feeling because I was a full flight nurse. People expect me to be able to do the job well like everyone else.” We were left scrambling to provide support and additional training. Yes, I have painted a pretty bleak picture here, and you are probably saying we don't do that with our program or that doesn't happen here. That may be true, but do you have a formalized, intentional, ongoing development and support process for new providers just off orientation? The evidence certainly supports just such an approach.1,2 Do new providers just off orientation worry about asking questions because they feel they are supposed to be experts? Do experienced providers ever hold back from offering feedback or suggestions for fear of insulting new providers because they are no longer orientees? This is not the type of culture you want to have in place during this critical phase of a flight provider's development. Most experienced crewmembers say it takes 2 years to start to feel confident and fully competent. By not providing ongoing development and support after orientation, are we doing what is best for our patients? This was our identified gap. We developed the Mayo One Residency Program, implemented the initial pilot, made improvements, and fully implemented this program over the past 2 years. Our intent was to create a means to ensure we have the right culture in place and to close the gap for new providers just off orientation. Assessment There is no doubt that critical care transport providers work in an intense, stressful environment and must be experts in their field in order to make sound decisions, perform quick interventions, and prioritize care.3 We assessed whether or not new providers just off orientation were fully ready to do so and found they were not. The new providers were found to be struggling in all areas including advanced procedures, critical thinking and decision making, confidence, team integration, and knowledge. The need for ongoing support and development was identified from a variety of sources to include new provider interviews; experienced provider feedback on new providers; procedural success rates; reviews; and, finally, a preresidency survey. In the survey, new providers, experienced providers, leadership, and medical direction were surveyed on a
78
J. Phillips et al. / Air Medical Journal 36 (2017) 77e80
variety of performance areas related to new hires just off orientation. The survey found that experienced providers had a higher perception of competence of the new hire just off orientation than did the new hire. The new providers felt that the experienced providers expected a higher level of competence from them than they actually had. Finally, it was discovered that a new provider's anxiety was much higher when paired with a less experienced provider versus a highly experienced provider. Concept Nursing residency programs have proliferated in the past decade. Traditionally, these programs target new graduate nurses entering the profession for the first time. They are a vehicle to help transition these new nurses into their professional role, develop their knowledge and clinical application, and promote integration in the work environment.4 There is a wealth of available evidence that points to successful outcomes related to nurse residency programs. These include higher rates of retention, decreased vacancy, cost savings, organizational commitment, improved patient safety, and decreased stress to name a few.1,2 Although the needs of the hospital nursing department and new graduates are different than those of a flight program, some of the objectives are the same. Our intent was to take the proven concept of a residency program and apply it toward veteran providers transitioning into a challenging new role. I would argue that the transition into the critical care transport provider role is more challenging and stressful than that of a new graduate nurse, making this type of program all the more important. Purpose and Objectives The purpose of the Mayo One Residency Program is to provide a formalized and ongoing development and support program for new Mayo One Air Operations crewmembers after the completion of orientation through their first year of service. Our objectives include the following: 1) provide ongoing clinical, emotional, and social support for the new providers just off orientation; 2) continue to develop competence, knowledge, and skills after completing orientation; and 3) create a teaching and learning culture for new and experienced crewmembers. This final objective is really the crux of what we are after. The program has a detailed format specifically aimed at the development of the resident, but a change in culture regarding new providers is the most important objective. This residency model enhances human capital and improves quality of care but also contributes toward collaborative learning relationships that support interactive clinical learning and ongoing organizational transformation.5 We are after a culture in which it is alright to be a novice provider beyond the orientation period. It is acceptable for new providers to continue to ask questions, receive feedback, learn, and receive teaching from experienced providers. Pilot Program Format/Plan Adults have a more efficient and effective transfer of knowledge when they construct their own learning and foster their own development.6 Critical care transport providers must be selfdirected, lifelong learners to continue to be competent and knowledgeable in their role. Our goal in designing the program was to place the onus of ongoing development on the learner. This would instill the concept and importance of continuous selfmotivated development into the resident at the beginning stages of his or her flight career. With this goal in mind, we incorporated adult learning theory into the design of the program.7 The pilot program consisted of several learning and development components within 12 monthly modules. Each module has a critical care transport topic. The monthly modules and
their components make up the full residency curriculum. The program is self-directed and facilitated through an online learning management system.8 The learning and development components consist of the following9: 1) formal peer mentorship, 2) flight log, 3) Certified Flight Registered Nurse (CRFN)/Flight Paramedic Certification (FP-C) preparation, 4) 4 formal progress reviews, 5) procedure and equipment testing, 6) critical thinking exercises, 7) expert provider pairing, 8) knowledge building, and 9) the final project. Peer Mentorship The purpose of the mentorship program for the organization is to attract, motivate, develop, and retain profitable talent while increasing competence. The purpose for the resident is to provide a trusted, knowledgeable, and experienced team member as a resource. Successful mentor/mentee relationships contribute toward career success and satisfaction.10 The mentor provides advice, guidance, accountability, and feedback. One of our first mentors elaborated, “It's nice to have the chance to continue to work with newer team members. I feel with my experience I have a lot to offer a new person and the program makes it comfortable to do so. We've had some really great discussions.” Ultimately, the mentor helps new residents to acquire the necessary knowledge, skills, and expertise that will allow them to become effective providers. Both the mentee and mentors are coached on what the expectations are for each of them. Flight Log The resident is required to maintain a detailed flight log. This consists of departure and destination points, partner, patient type, procedures performed, interventions implemented, and outcomes. This is reviewed during the progress reviews. Progress Reviews Four formal progress reviews are conducted every 3 months and at the end of the residency. The review members include the resident, his or her manager, and the program educator. A specific format with documentation is used. The purpose of the progress review is to asses, in partnership with the resident, his or her progress during the first year. It is used to identify areas of strength and weakness, bring any concerns to the forefront, and identify goals moving forward. CFRN/FP-C Preparation New hires are required to take and pass the CRFN or FP-C within a year of completing orientation. These are challenging examinations, and new hires, like everyone else, should receive guidance and assistance in preparing for these examinations. In consultation with the program educator and peers who have successfully passed the examination, they are required to prepare a plan document for prepping and passing the examination. Procedure and Equipment Testing The resident is required to undergo a skills evaluation at the 6and 12-month mark of the program. This consists of a competency evaluation on all procedures and equipment listed in the programs procedural care guidelines. If any areas of weakness are identified, additional training is assigned. Critical thinking, decision making, and prioritization competency are key objectives of our residency program. As a result, critical care transport providers need to have specific expertise to practice effectively and safely.11 These competencies are developed within 3 components of the program: critical thinking assignments, pairing with an experienced provider during duty shifts, and selfdirected learning.
J. Phillips et al. / Air Medical Journal 36 (2017) 77e80
Critical Thinking Assignments To complete the critical thinking assignments, residents are provided with case study scenarios. They are required to create a brief written response to the scenario in the form of a 2- to 3-page paper. In their response, they are required to discuss the care they would provide and answer any questions built into the scenario. They are required to reference team protocols as well as the literature. The completed assignment is reviewed by a subject matter expert who then follows up with the resident through a discussion of the case. Experienced Provider Pairing The bulk of competency development including patient care, safety, and aviation takes place during the duty shift. This means the expert provider the resident is partnered with is a key component to the success of the program. Expert providers were given specific education outlining their role, responsibilities, and expectations. Their role in developing the resident is crucial to the success of the program. They are expected to be constantly asking the what-if questions, challenging the residents, and forcing them to think ahead and to think out loud themselves during care. They should be having discussions and preparing with the residents before patient contact and debriefing with them after. Residents are expected to use the expert provider to the fullest. They are expected to think out loud as they provide independent care, have open discussions when working as a team, and be an active part of the preparation and debriefing process. Knowledge Building In addition to impacting critical thinking, decision making, skills, competency, and assimilation into the work unit, we also want to continue to build knowledge. Although their knowledge is being developed when they are working through case studies or when they are conducting patient care with an expert provider, we wanted to add a more specific didactic piece. For our first iteration of the program, this consisted of assigned reading on critical care transport topics consistent with the topic of each monthly module. Final Project For the final project, the resident is required to create an outline for a future presentation on a transport-related topic. The presentation would be in the form of an article for publishing, a conference presentation, or a poster presentation on a critical care transport related topic. They are expected to consult the clinical nurse specialist, medical directors, and fellow crewmembers when completing their outline. They are required to submit the outline as well as a plan to complete the full presentation at the end of the residency program. Lessons Learned The first iteration of the program was a pilot program consisting of 1 resident who transitioned directly from orientation into the program. This resident was assigned to a base remote from the program administrators. We are at the 1-year completion mark for the pilot program. The program was successful with this resident, but there were many lessons learned. What Went Well Pairing with an expert provider for all flight shifts was 1 of the most important features. Our flight program has extensive patient care guidelines on which providers can rely. However, it is common for critical care transport providers to rely on independent decision making in conjunction with guidelines or protocols.12 The expertise to do so can only be done through experience and ongoing training. Having an experienced provider to be a role model, guide, and
79
teach the new providers helps to bridge the gap to expertise. Managing the program through an online class structure provided an easily accessible platform for all stakeholders to see and interact with the components of the program. Setting the expectation that the new provider would create a specific plan for passing certification produced the desired result. Finally, the mentor provided a key component. It provided a human resource outside of leadership for questions, help assimilating, and as a sounding board. Opportunities for Improvement Although the online learning management system provided the necessary structure, how it was used and interacted with was a significant challenge. Improvements in organization, time lines, and assignment descriptions will have to be made. Workload for the residents was also an issue. They are learning a new job and are expected to perform at a high level, prepare and study for their certification examination, and complete all educational and administrative tasks for the job and the residency. The knowledge building assignments for each module were not educational best practice. Assigned reading was not the ideal way to promote knowledge development and certainly not the most motivating. The final lesson learned was communication between the administrator and the resident. Coordination and streamlining between face-to-face and the various electronic mediums available for communication are needed. Future After the pilot program, several improvements were made, and additional residents entered the program. One of the key improvements was redesigning the modules and assignments. Instructions were made more specific, and more structure and details were added to each module. The resident's response to the case studies was changed from a written response to a discussion with an expert crewmember. Having the resident have a discussion as well as a question and answer session with an expert was more efficient, was less work, and had better learning outcomes for the resident. For the knowledge development component, we eliminated the reading assignments and instead assigned vetted outside resources such as videos, podcasts, and current evidence-based articles. Current evidence supports the use of ongoing training programs for critical care transport providers.1,2,4,13 With the revised program in place and 7 residents currently enrolled, we continue to learn and fine-tune the program. Finally, an evaluation plan is being created to assess outcomes.7 When considering the idea of a residency program that involved transitioning veteran nurses into a higher level of practice, we naturally asked if the outcomes would be similar to those of current residency programs.5 We hope to provide evidence with our evaluation that it does. Conclusion After completing the program, our first resident shared his thoughts on the impact the program has. “Confidence: confidence in how you perform is key to success. It doesn't matter if you are working the scene of a major accident or walking into an ICU [intensive care unit] room you have to be confident. There is a very short time to gain the trust of not only the patient but also the trust of the patient's family and other providers who are present. The residency program allows a new provider to quickly gain this confidence through exposure and support. Exposure: It is likely that your previous experience had some play in you landing a job with critical care transport; however, this experience can sometimes be hard to quantify. What about
80
J. Phillips et al. / Air Medical Journal 36 (2017) 77e80
the high-risk low-frequency situations? A nurse that has worked the ICU for 10 years could certainly entertain balloon pump requests without hesitation, but can they transfer an OB [obstetric] patient with nonreassuring fetal status with the same high level of care and confidence? Because of the exposure with specific specialties via clinical experiences provided in the residency program, you have confidence regardless of the nature of the request. Exposure is not limited to the direct hands on learning, but also the opportunity to expand the learning experience through question and answer that is done on every transport. This includes reviewing charts and researching medical concepts that you're not familiar with.
one in which everyone from the new hire to leadership understood the importance of not leaving the new hire just off orientation to sink or swim, a culture in which the expectations are that a new provider is at a novice level and needs ongoing development. It would be understood that new hires are not expert providers just off orientation and it is alright for them to ask questions and receive direction and feedback. Critical care transport providers have an incredibly steep learning curve and are expected to make critical life and death decisions on a daily basis. As leaders and educators in the field, we need to ensure that we do all we can to make sure they successfully transition into this role.
Support: The support you receive while you are a resident is essential to your success. In my second formal review I specifically remember my manager saying 'we are not going to let you fail, we can't.’ Hearing this I knew that I had every opportunity to be the best and that's just how it was going to be. Every day I came to work there was an obligation between the whole crew to make the most of everything. We capitalized on every opportunity to learn, from the pilot explaining a safe practice around the aircraft to my experienced provider partner explaining why one drug is better than the other.
References
You come into this job knowing it is a whole different experience that will take you out of your established comfort zone and challenge you in ways you could have never imagined. To summarize my personal experiences during the residency program, I can confidently say I am a more capable provider because of it. It has created an excellent base for me to continue to grow and learn.” We have produced a competent knowledgeable team member. More importantly, the program has achieved its true goal, which is creating a teaching and learning culture for new and experienced providers. Any program could implement a program such as this whether it is a detailed one with many components or a simple one with just a few. Whatever was done, it would change the culture to
1. Ulrich B, Krozek C, Early S, Ashlock CH, Africa LM, Carman ML. Improving retention, confidence, and competence of new graduate nurses: results from a 10-year longitudinal database. Nurs Econ. 2010;28:363e375. 2. Bratt MM, Felzer HM. Perceptions of professional practice and work environment of new graduates in a nurse residency program. J Contin Educ Nurs. 2011;42:559e568. 3. Toplye D, Schmelz J, Henkenius-Kirschbaum J, Horvath K. Critical care nursing expertise during air transport. Mil Med. 2003;10:822e826. 4. Bratt MM. Retaining our next generation of nurses: the Wisconsin nurse residency program providing a continuum of support. J Contin Educ Nurs. 2009;40: 416e425. 5. Anderson G, Hair C, Todero C. Nurse residency programs: an evidence-based review of theory, process, and outcomes. J Prof Nurs. 2012;28:203e212. 6. Doolittle P. Complex constructivism: a theoretical model of complexity and cognition. Int J Teach Learn Higher Educ. 2014;26:484e498. 7. Taylor D, Hamdy H. Adult learning theories: implications for learning and teaching in medical education. Med Teach. 2013;35:1561e1572. 8. Yamagata-Lynch L, Do J, Skutnik A, Thompson D, Stephens A, Tays C. Design lessons about participatory self-directed online learning in a graduate-level instructional technology course. Open Learning. 2015;30:178e189. 9. Meyer-Bratt M. Best practices for optimizing organizational success. J Nurses Prof Dev. 2013;29:102e110. 10. Straus SE, Johnson MO, Marquez C, Feldman MD. Characteristics of successful and failed mentoring relationships: a qualitative study across two academic health centers. Acad Med. 2013;88:82e89. 11. Reimer AP, Moore SM. Flight nursing expertise: towards a middle range theory. J Adv Nurs. 2010;66:1183e1192. 12. Byrne-Bader G, Terhorst M, Heilman P, DePalma JA. Characteristics of flight nursing practice. Air Med J. 1995;14:214e218. 13. Mabry RL. MEDEVAC: survival and physiological parameters improved with higher level of flight medic training. Mil Med. 2013;178:529e536.
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Original Research
Air Medical Transport Residency Program for Flight Nurses and Paramedics Jeff Phillips, MEd, MSOL, CFRN, Chad Kuhlman, FP-C, Chris Evanson, FP-C Mayo Clinic Medical Transport, Rochester, MN
What is the initial experience like for new critical care transport providers fresh off of orientation? Is it a positive experience with the providers performing independently full of confidence or is it filled with trepidation, stress, and uncertainty? What are their abilities? At what level are their knowledge and competence? Does an intense 3- to 4-month orientation fully prepare new critical care transport providers to excel in their role and responsibilities? These are questions that arose within our program through feedback from new hires and the struggles they were encountering. Our program's orientation lasts 3 to 4 months. The orientee is expected to build knowledge related to patient care, aviation, and safety in class online; attend clinicals; participate in approximately 30 preceptored flight shifts; learn and test on procedures, skills, and equipment; undergo periodic reviews; complete required certifications; attend cadaver and simulation laboratories; and undergo pre- and postorientation testing. As the end of orientation approaches and the new hire gains a better understanding and perception of the role and responsibility of the critical care transport provider, uncertainty and lack of confidence start to set in. One of our new providers related that coming off of orientation she felt “relief that soon I would be done with a marathon of goals which were achieved. A surreal feeling with a looming thought of yes this is my job, but am I really ready? I am not even close to being at the level my preceptor is and I'm not sure will ever get there.” In addition to personal struggles such as confidence, our new providers were also struggling with their competency and knowledge. For example, 1 new provider was having difficulty with advanced airways that required significant additional training. Another was having difficulty with making critical patient care decisions under stress. A third was unable to perform efficiently at the pace required by their experienced partners. A look at our culture revealed an expectation that once done with orientation they would continue to learn and develop on the job and a sink or swim mentality. We then asked the following question. Sink or swim? Do we seriously take the new hires and put them through a jam-packed 3to 4-month orientation and then kick them out the door and expect them to go save lives? Or do we just hope that they don't cause harm before they get enough experience to be considered an expert? One of our new providers encountered a very challenging E-mail address: [email protected] (J. Phillips). 1067-991X/$36.00 Copyright © 2017 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2017.01.005
case that did not go well soon after completing orientation. The new provider's confidence quickly plummeted, her stress level regarding the job increased, and uncertainty about her competence started to arise. She stated, “I didn't feel like I could express how I was feeling because I was a full flight nurse. People expect me to be able to do the job well like everyone else.” We were left scrambling to provide support and additional training. Yes, I have painted a pretty bleak picture here, and you are probably saying we don't do that with our program or that doesn't happen here. That may be true, but do you have a formalized, intentional, ongoing development and support process for new providers just off orientation? The evidence certainly supports just such an approach.1,2 Do new providers just off orientation worry about asking questions because they feel they are supposed to be experts? Do experienced providers ever hold back from offering feedback or suggestions for fear of insulting new providers because they are no longer orientees? This is not the type of culture you want to have in place during this critical phase of a flight provider's development. Most experienced crewmembers say it takes 2 years to start to feel confident and fully competent. By not providing ongoing development and support after orientation, are we doing what is best for our patients? This was our identified gap. We developed the Mayo One Residency Program, implemented the initial pilot, made improvements, and fully implemented this program over the past 2 years. Our intent was to create a means to ensure we have the right culture in place and to close the gap for new providers just off orientation. Assessment There is no doubt that critical care transport providers work in an intense, stressful environment and must be experts in their field in order to make sound decisions, perform quick interventions, and prioritize care.3 We assessed whether or not new providers just off orientation were fully ready to do so and found they were not. The new providers were found to be struggling in all areas including advanced procedures, critical thinking and decision making, confidence, team integration, and knowledge. The need for ongoing support and development was identified from a variety of sources to include new provider interviews; experienced provider feedback on new providers; procedural success rates; reviews; and, finally, a preresidency survey. In the survey, new providers, experienced providers, leadership, and medical direction were surveyed on a
78
J. Phillips et al. / Air Medical Journal 36 (2017) 77e80
variety of performance areas related to new hires just off orientation. The survey found that experienced providers had a higher perception of competence of the new hire just off orientation than did the new hire. The new providers felt that the experienced providers expected a higher level of competence from them than they actually had. Finally, it was discovered that a new provider's anxiety was much higher when paired with a less experienced provider versus a highly experienced provider. Concept Nursing residency programs have proliferated in the past decade. Traditionally, these programs target new graduate nurses entering the profession for the first time. They are a vehicle to help transition these new nurses into their professional role, develop their knowledge and clinical application, and promote integration in the work environment.4 There is a wealth of available evidence that points to successful outcomes related to nurse residency programs. These include higher rates of retention, decreased vacancy, cost savings, organizational commitment, improved patient safety, and decreased stress to name a few.1,2 Although the needs of the hospital nursing department and new graduates are different than those of a flight program, some of the objectives are the same. Our intent was to take the proven concept of a residency program and apply it toward veteran providers transitioning into a challenging new role. I would argue that the transition into the critical care transport provider role is more challenging and stressful than that of a new graduate nurse, making this type of program all the more important. Purpose and Objectives The purpose of the Mayo One Residency Program is to provide a formalized and ongoing development and support program for new Mayo One Air Operations crewmembers after the completion of orientation through their first year of service. Our objectives include the following: 1) provide ongoing clinical, emotional, and social support for the new providers just off orientation; 2) continue to develop competence, knowledge, and skills after completing orientation; and 3) create a teaching and learning culture for new and experienced crewmembers. This final objective is really the crux of what we are after. The program has a detailed format specifically aimed at the development of the resident, but a change in culture regarding new providers is the most important objective. This residency model enhances human capital and improves quality of care but also contributes toward collaborative learning relationships that support interactive clinical learning and ongoing organizational transformation.5 We are after a culture in which it is alright to be a novice provider beyond the orientation period. It is acceptable for new providers to continue to ask questions, receive feedback, learn, and receive teaching from experienced providers. Pilot Program Format/Plan Adults have a more efficient and effective transfer of knowledge when they construct their own learning and foster their own development.6 Critical care transport providers must be selfdirected, lifelong learners to continue to be competent and knowledgeable in their role. Our goal in designing the program was to place the onus of ongoing development on the learner. This would instill the concept and importance of continuous selfmotivated development into the resident at the beginning stages of his or her flight career. With this goal in mind, we incorporated adult learning theory into the design of the program.7 The pilot program consisted of several learning and development components within 12 monthly modules. Each module has a critical care transport topic. The monthly modules and
their components make up the full residency curriculum. The program is self-directed and facilitated through an online learning management system.8 The learning and development components consist of the following9: 1) formal peer mentorship, 2) flight log, 3) Certified Flight Registered Nurse (CRFN)/Flight Paramedic Certification (FP-C) preparation, 4) 4 formal progress reviews, 5) procedure and equipment testing, 6) critical thinking exercises, 7) expert provider pairing, 8) knowledge building, and 9) the final project. Peer Mentorship The purpose of the mentorship program for the organization is to attract, motivate, develop, and retain profitable talent while increasing competence. The purpose for the resident is to provide a trusted, knowledgeable, and experienced team member as a resource. Successful mentor/mentee relationships contribute toward career success and satisfaction.10 The mentor provides advice, guidance, accountability, and feedback. One of our first mentors elaborated, “It's nice to have the chance to continue to work with newer team members. I feel with my experience I have a lot to offer a new person and the program makes it comfortable to do so. We've had some really great discussions.” Ultimately, the mentor helps new residents to acquire the necessary knowledge, skills, and expertise that will allow them to become effective providers. Both the mentee and mentors are coached on what the expectations are for each of them. Flight Log The resident is required to maintain a detailed flight log. This consists of departure and destination points, partner, patient type, procedures performed, interventions implemented, and outcomes. This is reviewed during the progress reviews. Progress Reviews Four formal progress reviews are conducted every 3 months and at the end of the residency. The review members include the resident, his or her manager, and the program educator. A specific format with documentation is used. The purpose of the progress review is to asses, in partnership with the resident, his or her progress during the first year. It is used to identify areas of strength and weakness, bring any concerns to the forefront, and identify goals moving forward. CFRN/FP-C Preparation New hires are required to take and pass the CRFN or FP-C within a year of completing orientation. These are challenging examinations, and new hires, like everyone else, should receive guidance and assistance in preparing for these examinations. In consultation with the program educator and peers who have successfully passed the examination, they are required to prepare a plan document for prepping and passing the examination. Procedure and Equipment Testing The resident is required to undergo a skills evaluation at the 6and 12-month mark of the program. This consists of a competency evaluation on all procedures and equipment listed in the programs procedural care guidelines. If any areas of weakness are identified, additional training is assigned. Critical thinking, decision making, and prioritization competency are key objectives of our residency program. As a result, critical care transport providers need to have specific expertise to practice effectively and safely.11 These competencies are developed within 3 components of the program: critical thinking assignments, pairing with an experienced provider during duty shifts, and selfdirected learning.
J. Phillips et al. / Air Medical Journal 36 (2017) 77e80
Critical Thinking Assignments To complete the critical thinking assignments, residents are provided with case study scenarios. They are required to create a brief written response to the scenario in the form of a 2- to 3-page paper. In their response, they are required to discuss the care they would provide and answer any questions built into the scenario. They are required to reference team protocols as well as the literature. The completed assignment is reviewed by a subject matter expert who then follows up with the resident through a discussion of the case. Experienced Provider Pairing The bulk of competency development including patient care, safety, and aviation takes place during the duty shift. This means the expert provider the resident is partnered with is a key component to the success of the program. Expert providers were given specific education outlining their role, responsibilities, and expectations. Their role in developing the resident is crucial to the success of the program. They are expected to be constantly asking the what-if questions, challenging the residents, and forcing them to think ahead and to think out loud themselves during care. They should be having discussions and preparing with the residents before patient contact and debriefing with them after. Residents are expected to use the expert provider to the fullest. They are expected to think out loud as they provide independent care, have open discussions when working as a team, and be an active part of the preparation and debriefing process. Knowledge Building In addition to impacting critical thinking, decision making, skills, competency, and assimilation into the work unit, we also want to continue to build knowledge. Although their knowledge is being developed when they are working through case studies or when they are conducting patient care with an expert provider, we wanted to add a more specific didactic piece. For our first iteration of the program, this consisted of assigned reading on critical care transport topics consistent with the topic of each monthly module. Final Project For the final project, the resident is required to create an outline for a future presentation on a transport-related topic. The presentation would be in the form of an article for publishing, a conference presentation, or a poster presentation on a critical care transport related topic. They are expected to consult the clinical nurse specialist, medical directors, and fellow crewmembers when completing their outline. They are required to submit the outline as well as a plan to complete the full presentation at the end of the residency program. Lessons Learned The first iteration of the program was a pilot program consisting of 1 resident who transitioned directly from orientation into the program. This resident was assigned to a base remote from the program administrators. We are at the 1-year completion mark for the pilot program. The program was successful with this resident, but there were many lessons learned. What Went Well Pairing with an expert provider for all flight shifts was 1 of the most important features. Our flight program has extensive patient care guidelines on which providers can rely. However, it is common for critical care transport providers to rely on independent decision making in conjunction with guidelines or protocols.12 The expertise to do so can only be done through experience and ongoing training. Having an experienced provider to be a role model, guide, and
79
teach the new providers helps to bridge the gap to expertise. Managing the program through an online class structure provided an easily accessible platform for all stakeholders to see and interact with the components of the program. Setting the expectation that the new provider would create a specific plan for passing certification produced the desired result. Finally, the mentor provided a key component. It provided a human resource outside of leadership for questions, help assimilating, and as a sounding board. Opportunities for Improvement Although the online learning management system provided the necessary structure, how it was used and interacted with was a significant challenge. Improvements in organization, time lines, and assignment descriptions will have to be made. Workload for the residents was also an issue. They are learning a new job and are expected to perform at a high level, prepare and study for their certification examination, and complete all educational and administrative tasks for the job and the residency. The knowledge building assignments for each module were not educational best practice. Assigned reading was not the ideal way to promote knowledge development and certainly not the most motivating. The final lesson learned was communication between the administrator and the resident. Coordination and streamlining between face-to-face and the various electronic mediums available for communication are needed. Future After the pilot program, several improvements were made, and additional residents entered the program. One of the key improvements was redesigning the modules and assignments. Instructions were made more specific, and more structure and details were added to each module. The resident's response to the case studies was changed from a written response to a discussion with an expert crewmember. Having the resident have a discussion as well as a question and answer session with an expert was more efficient, was less work, and had better learning outcomes for the resident. For the knowledge development component, we eliminated the reading assignments and instead assigned vetted outside resources such as videos, podcasts, and current evidence-based articles. Current evidence supports the use of ongoing training programs for critical care transport providers.1,2,4,13 With the revised program in place and 7 residents currently enrolled, we continue to learn and fine-tune the program. Finally, an evaluation plan is being created to assess outcomes.7 When considering the idea of a residency program that involved transitioning veteran nurses into a higher level of practice, we naturally asked if the outcomes would be similar to those of current residency programs.5 We hope to provide evidence with our evaluation that it does. Conclusion After completing the program, our first resident shared his thoughts on the impact the program has. “Confidence: confidence in how you perform is key to success. It doesn't matter if you are working the scene of a major accident or walking into an ICU [intensive care unit] room you have to be confident. There is a very short time to gain the trust of not only the patient but also the trust of the patient's family and other providers who are present. The residency program allows a new provider to quickly gain this confidence through exposure and support. Exposure: It is likely that your previous experience had some play in you landing a job with critical care transport; however, this experience can sometimes be hard to quantify. What about
80
J. Phillips et al. / Air Medical Journal 36 (2017) 77e80
the high-risk low-frequency situations? A nurse that has worked the ICU for 10 years could certainly entertain balloon pump requests without hesitation, but can they transfer an OB [obstetric] patient with nonreassuring fetal status with the same high level of care and confidence? Because of the exposure with specific specialties via clinical experiences provided in the residency program, you have confidence regardless of the nature of the request. Exposure is not limited to the direct hands on learning, but also the opportunity to expand the learning experience through question and answer that is done on every transport. This includes reviewing charts and researching medical concepts that you're not familiar with.
one in which everyone from the new hire to leadership understood the importance of not leaving the new hire just off orientation to sink or swim, a culture in which the expectations are that a new provider is at a novice level and needs ongoing development. It would be understood that new hires are not expert providers just off orientation and it is alright for them to ask questions and receive direction and feedback. Critical care transport providers have an incredibly steep learning curve and are expected to make critical life and death decisions on a daily basis. As leaders and educators in the field, we need to ensure that we do all we can to make sure they successfully transition into this role.
Support: The support you receive while you are a resident is essential to your success. In my second formal review I specifically remember my manager saying 'we are not going to let you fail, we can't.’ Hearing this I knew that I had every opportunity to be the best and that's just how it was going to be. Every day I came to work there was an obligation between the whole crew to make the most of everything. We capitalized on every opportunity to learn, from the pilot explaining a safe practice around the aircraft to my experienced provider partner explaining why one drug is better than the other.
References
You come into this job knowing it is a whole different experience that will take you out of your established comfort zone and challenge you in ways you could have never imagined. To summarize my personal experiences during the residency program, I can confidently say I am a more capable provider because of it. It has created an excellent base for me to continue to grow and learn.” We have produced a competent knowledgeable team member. More importantly, the program has achieved its true goal, which is creating a teaching and learning culture for new and experienced providers. Any program could implement a program such as this whether it is a detailed one with many components or a simple one with just a few. Whatever was done, it would change the culture to
1. Ulrich B, Krozek C, Early S, Ashlock CH, Africa LM, Carman ML. Improving retention, confidence, and competence of new graduate nurses: results from a 10-year longitudinal database. Nurs Econ. 2010;28:363e375. 2. Bratt MM, Felzer HM. Perceptions of professional practice and work environment of new graduates in a nurse residency program. J Contin Educ Nurs. 2011;42:559e568. 3. Toplye D, Schmelz J, Henkenius-Kirschbaum J, Horvath K. Critical care nursing expertise during air transport. Mil Med. 2003;10:822e826. 4. Bratt MM. Retaining our next generation of nurses: the Wisconsin nurse residency program providing a continuum of support. J Contin Educ Nurs. 2009;40: 416e425. 5. Anderson G, Hair C, Todero C. Nurse residency programs: an evidence-based review of theory, process, and outcomes. J Prof Nurs. 2012;28:203e212. 6. Doolittle P. Complex constructivism: a theoretical model of complexity and cognition. Int J Teach Learn Higher Educ. 2014;26:484e498. 7. Taylor D, Hamdy H. Adult learning theories: implications for learning and teaching in medical education. Med Teach. 2013;35:1561e1572. 8. Yamagata-Lynch L, Do J, Skutnik A, Thompson D, Stephens A, Tays C. Design lessons about participatory self-directed online learning in a graduate-level instructional technology course. Open Learning. 2015;30:178e189. 9. Meyer-Bratt M. Best practices for optimizing organizational success. J Nurses Prof Dev. 2013;29:102e110. 10. Straus SE, Johnson MO, Marquez C, Feldman MD. Characteristics of successful and failed mentoring relationships: a qualitative study across two academic health centers. Acad Med. 2013;88:82e89. 11. Reimer AP, Moore SM. Flight nursing expertise: towards a middle range theory. J Adv Nurs. 2010;66:1183e1192. 12. Byrne-Bader G, Terhorst M, Heilman P, DePalma JA. Characteristics of flight nursing practice. Air Med J. 1995;14:214e218. 13. Mabry RL. MEDEVAC: survival and physiological parameters improved with higher level of flight medic training. Mil Med. 2013;178:529e536.