5 Transformational Part of the Journey

Amy Driscoll

Learning Objectives

  • Discuss professional and personal goals related to nursing
  • Evaluate the components of an action plan and consider how to create one’s own action plan
  • Identifies strategies to support and promote fellow nurses
  • Identifies self-care strategies that can be used in professional and personal practice

The Transformational Journey

Healthcare systems are always evolving to meet the unique health needs of the patient populations they serve. These transformational processes are typically carried out in incremental steps with the goals of better quality and lower costs for healthcare. Because of their role, education, and earned respect in their field, registered nurses are well-positioned to contribute as a major players in bringing about these changes. Nurses must utilize the nursing process to help action plan and assess the factors driving the change, the mandates for practice change, and the competencies that will be needed for implementation (Salmond & Echevarria 2017). These shifts require a new or an enhanced set of knowledge, skills, and attitudes about wellness and population care management, a renewed focus on patient-centered care, and care coordination.

This chapter will review how to properly action plan, whether that is facilitating change at work or developing as a professional to transform healthcare. To promote self-care, it is also important to place a strong emphasis on strategies to support nurses, practice wellness, and recognize burnout.

Action Planning

The process of action planning is an extremely important concept that will have an impact on your clinical practice and professional development. The purpose of action planning is to determine the steps needed to get you from one place or situation to another. The first step in this process is to identify a problem, or the issue you are trying to solve. Once a need is identified, the nurse establishes a goal(s) and then develops strategies to reach the goal. While implementing these strategies, it is important to monitor and, if necessary, modify the plan. Throughout this process, it is important to take time to explore and reflect on what you are doing and why. 

A few months after her preceptor training and after experiencing the gaps in the program, Roxanne joins a small workgroup tasked with improving the unit’s preceptor program.

Roxanne knows that working on a preceptor program is a large undertaking and best done in a group setting with many key stakeholders. She partners with her unit educator and brings the need to the hospital’s Nursing Shared Governance and Nursing Clinical Practice Councils to get assistance in creating a process and educational tools for precepting new staff.

Roxanne learns quickly that goal-setting has impacted her intrinsic motivation to improve the precepting process, as she has buy-in and has experienced firsthand the problems that need to be solved. Another aspect of her participation in this project is that she is more visible within the healthcare setting, which may bring additional opportunities to stand out and participate in committees and educational opportunities to continue her professional journey.

Effective Teamwork Strategies with Action Planning

There are five main principles of effective teamwork when using an evidence-based TeamSTEPPS model, which can be used when working together to achieve a goal within an action plan.

Team Structure  

Identification of a group of individuals who will work together effectively to meet a desired goal or action plan

Communication  

Structured process by which information is clearly and accurately exchanged among the team structure and others involved in the action plan

Leadership  

Each member on the team has a clear role and purpose to maximize the activities and ensure actions are understood, changes in information are shared, and everyone has the necessary resources

Situation Monitoring  

Process of assessing progress to gain information or understanding, or to maintain awareness in supporting a team working through the action plan to meet a goal

Mutual Support  

Ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload. Watch this Video on the Overview of TEAM Steps

 

Communication Technologies to Support Action Planning

The Joint Commission reported that poor communication is a contributing factor in more than 60% of all hospital adverse events they reviewed (Müller et. al., 2018). Despite having a clear action plan, poor communication is found in many different healthcare settings and is especially prominent during patient hand-offs and settings where fast and effective management is indispensable. To overcome communication barriers, communication strategies are encouraged to deliver comprehensive information efficiently, encourage interprofessional collaboration, and limit the probability of error.

SBAR Framework  

The SBAR framework is a technique for communicating critical information that requires immediate attention and action concerning a patient’s condition. SBAR frameworks are widely used throughout healthcare settings to organize critical conversations, such as change-of-shift reports in the clinical setting (Müller et. al., 2018). The SBAR handoff can be shared between any team member from one setting to the next as part of an action plan or transition, which ensures clear communication about the opportunities and next steps (Buljac-Samardzic &  Wijngaarden, 2020). There are additional tools and frameworks when working on improving communication and mitigating risks that can be used as strategies within an action plan to achieve a goal.

“SBAR” stands for: 

  • Situation overview
  • Background of the situation
  • Assessment of the situation
  • Recommendation

Roxanne writes up her observations of the gaps within the current preceptor program and takes them to the Nursing Shared Governance and Nursing Clinical Practice Councils. This allows her to present the information in a concise and professional manner.

Situation: Over the past three weeks, four new hires needed to precept with an agency staff RN, and since there have been many policy and practice changes related to the COVID-19 pandemic, the onboarding and precepting materials are outdated.

Background: Over the past few months, the hospital has dealt with a high turnover rate resulting in increased use of travel agency RNs and not enough preceptors available to onboard new staff appropriately.

Assessment: Preceptors do not currently have updated resources to onboard new team members, and additional staff RNs need to become preceptor-certified to avoid new nurses being placed with a temporary agency team member.

Recommendation: A small group of key stakeholders is needed to evaluate the current program and develop recommendations for the Nursing Shared Governance and Nursing Clinical Practice Councils to approve and move forward with.

Callout Technique

The callout strategy may be used to communicate important or critical information in the moment. The goals of this communication technique include keeping all team members informed and up to date during emergent situations and aiding with anticipated next steps.

Callout Technique Example

Provider: “Airway status?”
Nurse: “Airway clear.”
Provider: “Breath sounds?”
Nurse: “Breath sounds decreased on right.”
Provider: “Blood pressure?”
Nurse: “BP is 96/62.”

Check-Back Communication  

The check-back technique is a closed-loop communication mechanism to ensure that information conveyed by the sender is understood by the receiver as intended.

The steps of checkback communication include the following:  

  1. Sender initiates the message.
  2. Receiver accepts the message and provides feedback.
  3. Sender double-checks to ensure that the message was received.

Check-Back Communication Example

Provider: “Give 25 mg Benadryl IV push.”
Nurse:“25 mg Benadryl IV push.”
Provider: “That’s correct.”

Hand-Off Communication  

Part of the action-planning process is preparing for the next steps in the situation trajectory. This may include providing hand-off communication to another entity.

Communication breakdown is one of the main causes of adverse events in clinical practice, especially during handover situations.

The transfer of information (and possibly authority) and responsibility during transitions in care across the continuum plays a critical role in patient safety and outcomes. Transfer hand-off communication includes an opportunity to ask questions, clarify, and confirm.

Examples of transitions in care include shift changes; transfer of responsibility between and among nursing assistants, nurses, nurse practitioners, physician assistants, and physicians; and patient transfers (Achrekar, et.al, 2016). 

 

 

Painting the picture of your Journey

Personal goals

The first step in creating personal goals is to establish an individual action plan or development plan. Start with a goal description or a statement of what you want to be able to accomplish in the future or do differently as a result of development. To set your personal or development goal, reflect upon what you have learned and consider feedback about your strengths and areas for improvement.

Once the goal or statement is developed, determine the activities or steps that will help assist in reaching the goal. It is important that your goal statement is “SMART”—that is, it is specific, measurable, actionable, realistic, and timely.  

Specific: The purpose of your statement is to be specific about the future state that you want to achieve. Consider answering one or more of the following questions: who, what, when, where, and why.

Measurable: It is also important to clearly define what success looks like to you, including specific accomplishments with measurable outcomes.

Actionable: Identify key actions or steps to be taken that will contribute to the achievement of the goal.

Realistic: This pertains to you having the capacity and capability to accomplish the goal, even if you are not fully competent in that area yet. Also, your goal is realistic if it is feasible one step at a time. Depending on your action or development plan, you may have additional resources or key stakeholders to assist you in taking action on your plan. A mentor or clinical contact can also be a valuable resource to connect you to different areas of needed practice or education depending on your developmental needs.

Timely: Finally, you want to identify some type of tangible target date, such as a date or year.

Individual Development Planning

Roxanne knows that she wants to continue with her career and become a hospital nurse educator.

 By identifying an issue on her unit and using professional communication to bring it forward to the Shared Governance Nursing Council, Roxanne brought more awareness to the fact that her success was personally rewarding. She has had the opportunity to network with key leaders within her hospital and make connections with strong nursing leaders. She also made her leader aware of her future long-term goal, which, in turn, helped her achieve a few short-term contributing goals, such as preceptor certification and participating in a professional council.

Supporting and Promoting Nurses

The (Not So) Great Escape: Why New Nurses Are Leaving the Profession  

For many, nursing is a calling in which college graduates earn the title of a registered nurse to serve and care for people of all ages and health conditions. The question is: why are many nurses leaving the profession within two years of employment? Nurses leaving the profession within the first five years of their career is a significant symptom of the larger challenges in nursing. With alarming rates of up to 33% of new nurses leaving the workforce within the first two years, the (not so) great escape must be addressed overall by the profession (Flinkman et. al., 2013).

Nursing burnout is a widespread event characterized by a reduction in energy through emotional exhaustion, lack of motivation, and feelings of frustration and may lead to reductions in work efficiency (Flinkman et. al., 2013).

Confounding variables that may have an impact on burnout include culture, emotional strain, environment, and work-related injuries. Nursing burnout is a widespread event characterized by a reduction in energy through emotional exhaustion, lack of motivation, and feelings of frustration, and may lead to reductions in work efficiency (Flinkman et. al., 2013).

Self Care

Self-care is not a foreign concept to nurses as it aligns with common concepts used in practice such as self-management, self-monitoring, and self-efficacy. According to the World Health Organization (2021), self-care is defined as what people do for themselves to establish and maintain health and to prevent and deal with illness. Self-care is a skill that nurses should possess and is described as a set of practices and activities nurses should engage in regularly to help decrease stress levels and help nurses live longer, healthier lives (WHO, 2022).

Healthcare professionals need to engage in self-care because as the old adage says, “You can’t pour from an empty cup.” By taking care of yourself, you will be more effective when providing care to the patient and coaching caregivers. Self-care is often neglected because the nursing career can be exhausting (nurses give so much of their physical and emotional being to patients and families). Nurses are notorious for neglecting their self-care needs. According to a cross-sectional study conducted by Sanzone et al. (2020), poor self-care negatively affects quality of care and patient safety. It can lead to unwanted, unhealthy lifestyles (e.g., weight gain, poor nutrition, inadequate rest) and may impact patient outcomes such as higher patient falls, medication errors, and lower quality-of-care scores (Vogus et.al., 2020). Furthermore, stress contributes to chronic disease and potentially other health issues impacting the person professionally and personally, sometimes leading to leaving the nursing profession altogether. Practicing self-care strategies may be a meaningful way to support health and impact patient safety (Salmond & Echevarria, 2017).

Maslow’s hierarchy of needs includes the theoretical basis and conceptual underpinnings that humans have a series of needs, some of which are rudimentary and must be met before a person can turn their attention toward other needs. Meeting one’s basic needs has a significant place in providing a foundation for people to be able to have the desire and motivation to fulfill their higher needs and provide safe care. Concerns over safety and physiological needs are contributing factors to disorders such as anxiety, phobia, depression, and post-traumatic stress syndrome (Esposito, 2021).

Self-care strategies are vital, now more than ever. The stressors related to the healthcare profession have been described as the harmful physical and emotional responses that may occur when the requirements of the job do not match the capabilities, resources, or needs of the healthcare worker. The COVID-19 pandemic in the spring of 2020 presented healthcare workers throughout the United States with the experience of extreme stress due to the sheer volume of hospitalized patients, shortages in resources, and uncertain clinical protocols in treating the virus. Furthermore, job-related stress is commonly associated with gaps in competency related to limited knowledge, emergent cross-training to areas outside of nurses’ clinical ability, increased nurse-to-patient staffing ratios, and strained hospital abilities. All of these factors increase stress, burnout, and depression levels compared with previously reported levels in the literature.

Without adequately tending to one’s own needs, nurses may face compassion fatigue, which is a relevant risk for many healthcare professionals across the continuum of care. Practicing effective self-care strategies such as mindfulness, seeking out mentors, and reflective practices may foster increased resilience among healthcare professionals.

Self Assessment

There are many tactics nurses can use to ensure they are safe and ready to provide safe clinical care during a nursing shift. The IMSAFE checklist is a personal health assessment used to ensure a team member is prepared both mentally and physically for their next shift.

This checklist was originally designed for pilots to self-reflect on their well-being prior to a flight. The acronym IMSAFE stands for “illness, medication, stress, alcohol, fatigue, emotions.” By reviewing these elements of the checklist, the individual can conclude whether they are personally fit to fly in the case of piloting, or in the case of nursing, fit for their shift/job as a nurse. The following video provided by Healthcare Excellence Canada discusses the IMSAFE checklist and illustrates its importance in more detail. It allows nurses to do a pulse check on how they are doing and whether they need to take some time to tend to their own needs. It is also a good tool that you can promote with your team and patients who may be experiencing high levels of stress at their workplace. IM SAFE Video 

Strategies to address for Self-Care 

After self-assessing through the IMSAFE checklist, one can evaluate and examine all areas needing some additional self-care attention and what strategies can help. A tool that may be beneficial to explore is the Emergency Self-Care Worksheet prepared by the University of Buffalo School of Social Work (n.d.). This worksheet helps you determine what activities work best as self-care strategies and creates an outlined care plan to address your needs. It is ideal to complete this tool prior to facing challenges with stress and well-being. Emergency Self Care Worksheet

Mental 

Mental self-care helps nurses intellectually. Taking time to expand or gain knowledge helps the nurse gain insight into things outside of bedside care and can strengthen confidence.

Here are some strategies that can be implemented at work:  

  • Completing a CEU course
  • Engaging in a committee within your team or system
  • Reading a journal article or taking part in a journal club
  • Precepting a new nurse or completing a special training or certification

Here are some strategies that can be implemented at home:  

  • Trying a new hobby independently or with others
  • Engaging in cognitive stimulation (such as completing a puzzle or playing a game)
  • Reading a new book or joining a book club
  • Exploring a nearby museum or nature center and getting fresh air
  • Listening to audiobooks
  • Listening to podcasts (some nurses love to do this on the way to and from work)
  • Starting a journal

Physical  

The CDC recommends 2.5 hours of weekly moderate aerobic activity, such as brisk walking, and 1 hour and 15 minutes of vigorous-intensity aerobic activity, or some combination of the two. You also need two or more days of strength activities that work on all the major muscle groups.

Here are some strategies that can be implemented at work:  

  • Parking far away from the building
  • Using the steps instead of the elevator
  • Standing while you chart
  • Walking the halls during downtime
  • Bringing your own healthy lunch and snacks

Here are some strategies that can be implemented at home:  

  • Meal planning for the week
  • Prioritizing healthy food choices
  • Joining a gym and seeing if your health insurance offers an incentive
  • Going to bed early and waking up at the same time every day (7-9 hours of sleep)
Emotional  

Nursing can be hard on your emotions. While you will often feel the highs of helping patients succeed, there are also the lows of patients with conditions that deteriorate despite efforts.

Here are some strategies that can be implemented at work:

  • Having conversations that bring you joy
  • Recognizing others for their accomplishments
  • Praising yourself and giving yourself grace
  • Writing something in the breakroom to help coworkers smile
  • Being kind to everyone
  • Smiling at everyone you walk past
  • Doing something you enjoy during breaks or going outside to enjoy fresh air

Here are some strategies that can be implemented at home:  

  • Channeling emotions through hobbies
  • Being creative, building something, making something, or writing something
  • Using words of affirmation
  • Giving yourself permission to laugh, cry, and feel emotions
  • Letting yourself sit and complete something to allow you to decompress
  • Creating a playlist that brings you happiness and trying binaural beats
  • Calling a friend
  • Planning an outing with a loved one
  • Daydreaming—plan the perfect vacation, consider new paint colors or furniture for your home, look up the specs on that car you’ve been eyeing

Spiritual  

Spirituality, whether religious in nature or not, may be a key part of supporting self-care and wellness.

Here are some strategies that can be implemented at work:  

  • Try meditation
  • Practicing mindfulness and trying to help patients do the same
  • Respecting and trying to understand others’ beliefs
  • Advocating for patients who would like spiritual support
  • Going outside or at least near a window to appreciate nature on a break

 Here are some strategies that can be implemented at home:  

  • Trying yoga or another physical activity that centers you
  • Keeping a gratitude journal
  • Volunteering for something you are passionate about solo or with others
  • Making “think time” a time for reflection on yourself and your life
  • Joining a religious or spiritual group
  • Trying tapping
  • Deep breathing and being present (it can change your brain)
  • Decluttering your home drawers, computer files, and closets
  • Unplugging from social media, television, and tablets for a day

Social  

Connection and community can be very important to nurses, as they tend to be natural nurturers.

Here are some strategies that can be implemented at work:  

  • Asking coworkers about their day even outside of your department
  • Eating lunch or taking a break with someone
  • Planning potlucks with your coworkers and enjoying meals together
  • Celebrating with coworkers (e.g., work anniversaries, birthdays, life events)

Here are some strategies that can be implemented at home:  

  • Calling a loved one and planning a social event/outing
  • Going out with a friend (e.g., shopping, having coffee, walking)
  • Planning a date night
  • Taking your kids on a road trip

Personal  

Cultivating interests and an identity outside of “nurse” can help you feel more fulfilled and give you some respite from your career.

Here are some strategies:  

  • Participating in a new hobby
  • Adding adventure with a hike, canoeing, or cross-country skiing
  • Setting up a home wellness space
  • Trying essential oils
  • Dividing the housework
  • Only committing to activities and social engagements that you can manage
  • Hiring someone to help you with housework, childcare, or other services
  • Making a manageable daily to-do list of a limited amount of tasks

Professional  

Keeping your professional life organized and on-track can help you reduce stress.

Here are some strategies:  

  • Decluttering your work bag
  • Cleaning your scrubs and ironing them to feel professional and put-together
  • Being a good team member (help others and they will help you)
  • Creating career goals
  • Participating in a work wellness/self-care activity, class, or challenge
  • Arriving at work early and prepared
  • When you’ve clocked out, making sure you are truly clocked out (e.g., avoid calling coworkers or the unit after your shift ends to see what’s happening)

Medical Aspects  

Here are some strategies:  

  • Daily physical activity (working doesn’t count as physical activity)
  • Healthy food and drink choices (pack your food and always drink water)
  • Healthy weight management
  • Routine preventive care
  • Know your health numbers (e.g., Vital Signs, BMI, labs for risk for chronic conditions)
  • Quality sleep
  • Tobacco cessation
  • Quality healthcare services

Technology Applications for Self-Care  

  • Headspace - helps anyone start meditating
  • Talkspace - schedule sessions with an online therapist
  • Shine – helps keep you motivated with positive words
  • Pacifica – track your mood, meditate, and practice cognitive-behavioral therapy
  • ClassPass Go - offers ready-to-play workouts that vary in length and difficulty
  • Managing Stress

Additional Resources  

References

Achrekar, M. S., Murthy, V., Kanan, S., Shetty, R., Nair, M., & Khattry, N. (2016). Introduction of situation, background, assessment, recommendation into nursing practice: A prospective study. Asia-Pacific Journal of Oncology Nursing, 3(1), 45–50. https://doi.org/10.4103/2347-5625.178171

Agency for Healthcare Research and Quality. (2012, September). Fundamentals course: TeamSTEPPS overview (video). https://www.ahrq.gov/teamstepps/instructor/videos/ts_TeamSTEPPS_Overview/TeamSTEPPS_Overview-640-480.html

Agency for Healthcare Research and Quality. (2012, September). The ten steps of action planning. https://www.ahrq.gov/teamstepps/instructor/essentials/implguide1.html

Buljac-Samardzic, M., Doekhie, K. D., & van Wijngaarden, J. (2020). Interventions to improve team effectiveness within health care: A systematic review of the past decade. Human Resources for Health, 18(1), Article 2. https://doi.org/10.1186/s12960-019-0411-3

Esposito, C. L., Contreras Sollazzo, L., & DeGaray, C. (2021). Nurses unions can help reduce stress, burnout, depression, and compassion fatigue during the COVID-19 pandemic, Part 3. Journal of the New York State Nurses Association, 48(1), 30–51.

Flinkman, M., Isopahkala-Bouret, U., & Salanterä, S. (2013). Young registered nurses’ intention to leave the profession and professional turnover in early career: A qualitative case study. ISRN Nursing, 2013, Article 916061. https://doi.org/10.1155/2013/916061
Mudallal, R. H., Othman, W. M., & Al Hassan, N. F. (2017). Nurses’ burnout: The influence of leader empowering behaviors, work conditions, and demographic traits. Inquiry: A Journal of Medical Care Organization, Provision and Financing, 54, 46958017724944. https://doi.org/10.1177/0046958017724944
Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: A systematic review. BMJ Open, 8(8), Article e022202. https://doi.org/10.1136/bmjopen-2018-022202
Salmond, S. W., & Echevarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopedic Nursing, 36(1), 12–25. https://doi.org/10.1097/NOR.0000000000000308
Sanzone, L., Gauthier, M., Antonnacci, R., Pagnotta, A., Jayanetti, S., Liu, Y., & Morenikeji, O. (2020). The significance of nursing self-care practices on resilience and quality of care: A review of current initiatives in critical care settings. Dynamics of Critical Care Conference, September 28–30, 2020, Windsor, Ontario. Canadian Journal of Critical Care Nursing, 31(1), 24–25.
The State of Childhood Obesity. (2021, September). Adult obesity rates. Robert Wood Johnson Foundation.  https://stateofchildhoodobesity.org/adult-obesity/
University of Buffalo School of Social Work (n.d.). Emergency self-care worksheet. Retrieved from https://socialwork.buffalo.edu/resources/self-care-starter-kit/developing-your-self-care-plan.html
Vogus, T. J., Ramanujam, R., Novikov, Z., Venkataramani, V., & Tangirala, S. (2020). Adverse events and burnout: The moderating effects of workgroup identification and safety climate. Medical Care, 58(7), 594–600. https://doi.org/10.1097/MLR.0000000000001341

 

 

 

 

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Opening Doors to Your Future: A Handbook for RN-BSN Students Copyright © 2022 by Nicole Simonson; Jessica Hertig; Jill Saxton; and Amy Driscoll. All Rights Reserved.

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