Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion Navy Nursing Clinical Competencies CDR Nicole

Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion

Navy Nursing Clinical Competencies

CDR Nicole Polinsky, NC, USN

Deputy Lead, Clinical Excellence

CDR Julie Hillery, NC, USN

Maternal-Child Specialty Leader


Objectives

• Participants will be able to:– Discuss the historical perspective of the Navy Nurse Corps’ strategic

goal for Clinical Excellence.

– Discuss development of standardized nursing competencies to achieve specialty-based clinical proficiency in all care environments.

– Recognize accomplishments and challenges experienced during the competency development process.

– Describe Navy Nursing’s standardized core competencies for the professional nurse in Maternal-Child nursing, Neonatal Intensive Care, and Stabilization of the Sick Neonate.

– Apply Navy Nursing’s standardized clinical professional nursing competencies to his or her own work area.

2

Purpose of Today’s Brief: To share the four-year Navy Nursing enterprise initiative for standardizing

clinical professional nursing competencies


Background

Oct 2006 (for FY 2007):•Director, Navy Nurse Corps established Navy Medicine-wide standardization of professional nursing competency as part of Force Structure-21 (FS-21).

•Initiative defined Navy Nursing for the 21st century.

•Readiness and Clinical Proficiency Workgroup tasked with developing process and defining clinical requirements for standardized competencies.

•Five critical mission (“go-to-war” ) competencies identified as priority:

– Medical-Surgical Nursing

– Emergency/Trauma Nursing

– Psychiatric/Mental Health Nursing

– Critical Care (Adult) Nursing

– Operational Nursing3


Background

Oct 2007 (for FY 2008):• Development of “go-to-war” competencies

continued.• Additional nursing specialties were identified

for core competency developmentOct 2008 (for FY 2009):• Six strategic goals were re-defined and

workgroups established for each.• Renamed as “Clinical Excellence” Goal Team

and included 3 sub-groups• Additional specialties identified for

developmentOct 2009 (for FY 2010):• Reduced groups, increased membership,

added initiatives to charter• More competencies identified for development

4


Background: Dashboard View

5


6

Why Standardize?

• Navy Medicine experiences wide variation in specialty nursing competence between units, facilities, and deployed locations– “I like mine better”– “We’re unique”– “We do things different here”– “We’re small, we don’t need to know that here—we never see it”– “We had this incident once…before me…and it’s been on the list

ever since”

• When USNS COMFORT deploys in support of a short-term humanitarian mission, will the intensive care nurses represent one standard, or 36 from the sourcing commands?

One standard of nursing excellence: uniformed, civilian, contractor, volunteer


7

• Why Not Just Use the Specialty?

– Some specialties have zero professional organization competencies, some have several

– Need standard format, rating, methodology

– Need usability [a 50-page tome won’t be used]

Why Create Something “New”?


8


9

First Steps: R&CP Membership

Specialty Leaders

Subject Matter

Experts

People Who Want

to Work

Constituent Representat

ivesJunior Officer

ReservesCivilian

DomainSEATCompetency

Others

Based on competency

Advisor

Chair


10

First Steps: Definition—Competency versus Orientation

Criteria Competency Orientation

Critical Thinking Key Component N/A

Physical location and Process based No Key Component

Unit Specific No Yes

Specialty Specific Yes Maybe

Population Specific Often Maybe

Local “How To” No Yes

Professional Standards based Key Component Inconsistent

• In recent years, many areas performed a “search and replace” on orientation packages, replacing “orientation” with “competency”. There is a difference, however:– Competency measures competence, which is demonstrable – Orientation measures checks in the box on a list – A typical comparison is listed below


First Steps: Definition & Framework

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• Definition of a competency: – The measurement used to define competence in specialty/sub-specialty of

professional nursing. Consists of Critical Thinking/ Clinical Judgment objective with one or more elements of Knowledge, Skills, Abilities, or Attitudes (KSA)

• Each element rated using Benner’s framework (pre/post):– 1 ~ Novice– 2 ~ Advanced beginner– 3 ~ Competent [minimal level for independent practice]– 4 ~ Proficient– 5 ~ Expert

• Overall:– Not a checklist, competencies focus on critical thinking/ reasoning and clinical

judgment– Use Benner’s noviceexpert to rate – Use Bloom’s knowledge/skill/attitude for each trait– “Competent” in this context represents the minimum standard for independent

professional nursing practice within a specialty.– Due to individual experience and personal differences, Benner’s stages are

explicitly not time based. There is not an EXACT timeframe to gain “competence” (i.e. three years in nursing equals competent nurse)


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Framework-Bloom

• Bloom’s (1956)1 taxonomy of competency requires cognitive (knowledge), affective (attitude), and psychomotor (skill/ability) domains. A good summary is available from Clark (2007)2. In this instance in professional nursing within a specialty or domain of practice, Navy Nursing’s initiative will:– Replace and standardize specialty-specific portions of current MTF

orientation manuals– Support unit-specific competencies (high risk, problem prone local

issues) and orientation (process and equipment-specific) required by Joint Commission

– Meet Joint Commission standard 3.10: “competence to perform job responsibilities is assessed, demonstrated, and maintained”3

• Individuals moved from one specialty area to another may be evaluated at a different level in the new specialty, though progress faster than a new nurse– Example: A proficient Emergency/Trauma nurse moved to the Labor

Deck may initially revert to a novice or advanced beginner [in that specialty]

1Bloom B. S. (1956). Taxonomy of Educational Objectives, Handbook I: The Cognitive Domain. New York: David McKay Co Inc 2Clark, D. R. (2007), Learning Domains or Bloom's Taxonomy. Retrieved December 15, 2008 from http://www.nwlink.com/~Donclark/hrd/bloom.html3Joint Commission (2008). Comprehensive Accreditation Manual for Hospitals: The Official Handbook on Accreditation of Healthcare Organizations, Joint Commission Resources. Joint Commission Resources

http://www.nwlink.com/~Donclark/hrd/bloom.html


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Framework-Benner• This program uses Dr. Patricia Benner’s Novice to Expert conceptual

framework as the scale in assessment– Stage 1: Novice - Entry level. Limited critical thinking. Task-based

practice with frequent questions.

– Stage 2: Advanced Beginner - Limited acceptable performance. Often handles the routine fairly easily after performing same skills several times. Still uses mentor for out-of-normal situation.

– Stage 3: Competent - Able to get the job done because of repetitive performance; able to see steps in process of actions with a long term goal or plan of care. Not always clearly recognize overall picture in terms of what is most important.

– Stage 4: Proficient – Able to clearly recognize situations as wholes not parts or simple aspects, ‘big picture’ or long-term goal performance guided by maxims (nuances of a situation, or means to an end reasoning using hypothetical imperatives)

– Stage 5: The Expert - Execute practice with an intuitive grasp of each particular situation rapidly sorting out the exact problem without wasting time contemplating many potential options

•Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley, pp. 13-34.•Nolan, Thomas (2001). Benner's Stages of Clinical Competence http://www.sonoma.edu/users/n/nolan/n312/benner.htm Accessed 22 Jul 2008.•Benner, P. (2007). Personal Communications. E-mail to CDR J. Whitcomb.

http://www.sonoma.edu/users/n/nolan/n312/benner.htm%20Accessed%2022%20Jul%202008


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Method & Process: Competency Development

• Specialty leader/consultant/subject matter expert• Review of literature, professional standard(s), existing

Navy and federal products• Develop draft competencies, synchronize with existing

products• Review and chop with clinical community, facility nursing

leaders• 60+ day pilot test• Approval and publishing to Senior Nurse Executives (SNE)

and staff education communities– Both Active and Reserve Communities

• Annual update for relevancy, reference update, practice change


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Example: Competency Development Schedule

From FY09 Plan


Method & Process: Competency Utilization

• Nurse evaluation– Bi-annual clinical yardstick for clinical appraisal reports in

credentialing– Completed at orientation, pre-deployment, pre-PCS to overseas/

remote command– Completed by CNS or mentor

• Overall assessment– Must have all critical items as “competent” to be overall

“competent”

• Entered in local and electronic training record and credentials– Form has two parts

• Individual assessment [all the details; 8-16 pages landscape]– Goes to the local training record

• Summary assessment [like privilege sheet; just the section headings]

– Goes with the Clinical Appraisal Report to the DNS Credentials 16


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Process: Competency Utilization Trigger•New to specialty•Clinical Appraisal Report due (every 2 years)

•Requesting subspecialty code or AQD

• Nurse issued competency• Preceptor/evaluator

assigned

Nurse performs pre-assessment

Nurse and preceptor review pre-assessment

(needs identification)

(As needed) Skill building to strengthen

nurse’s needs

Nurse and preceptor conduct post-assessment

1-pager (part 2)

attached to CAR or request

Individual assessment (part 1) file in local training

record

Discuss/review/reassess with on periodic basis

• FITREP/Evaluation• Mid-term counseling• Career planning• Personal development

CompletedCompetency

The two part competency is a change in the Dec 2008 edition


Accomplishments

• Competencies:– Nine (9) developed and in use– Three (3) developed, pilot complete, ready for approval– One (1) currently in pilot– Three (3) currently in SNE review– Five (5) Still in development– One (1) adopted for use by other profession (social work)

• Standard Procedure Manual:– Mosby online manual contract purchased for Navy-wide use– Procedures will be standardized at “big” level and trickled down

• Nurse Practice council liaisons– One on East coast, one on West coast– Liaison between individual MTFs and Clinical Excellence

• Partnering strategies initiated

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Challenges

• Military transfers and deployments• Longer than expected process• MTF needs/requests• Maintenance of competencies necessary• Use of competencies at deckplate

– Awareness– Understanding of intended process

• Closing the loop: how to document completion and ensure it “follows” RN to next duty station

• Finding appropriate “fit” for some competencies– Operational– Cross-training—NICU/ER/PICU/PACU to critical care

• Inter-rater reliability• Areas where smaller parts of a core competency are practiced

(i.e.: immunizations)• Research and metrics: how do we know if value added?• In the details: editing, formatting, flow of document required

standardization too19


Lessons Learned

• Generic competencies…putting cart before the horse– Currently in development

• Victims of own success– Workgroups are cross-functional, multi-constituency population

brought together to accomplish defined common goal– Not intended to replace infrastructure or leadership

responsibilities– Specific/targeted accomplishment– Not intended to live forever

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21


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What’s Next? Clinical Excellence Workgroup

InternalStrategic

Partnerships

ExternalStrategic

Partnerships

NsgPro-

cedures

MaintaingenericComps

&Proc-ess

Infra-structureMainte-nance

ofestab

products

“Split the Gem”Clinical Excellence

*Recommended plan; not yet approved


Core Competencies for Maternal-Child Nursing

• Mother-infant– Labor and Delivery– Postpartum and Newborn Care– Primary framework: POEP

• NICU– Framework: NOEP & STABLE

• Neonatal stabilization and pre-transport care– Sick Newborn Care– Developed for MTFs with Level 1 or 2 nursery– Framework: STABLE, NRP, NOEP

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• Challenges:– POEP & NOEP (a blessing & a challenge):

• Strong foundation from which to build• Feedback from the field—necessary skill sets were not apparent in

either program (i.e.: fetal monitoring)• Programs are knowledge and attitude based, lacking 3rd element of

skill/ability• Delayed progress of competency development due to lack of

consensus within 1920/1964 community

– Copyrighted programs• STABLE, NRP, PCEP, POEP, NOEP

– Could not use program itself as competency/KSAs due to copyright– Use as references only

– Navy Nursing training program created around POEP/NOEP • Contract granted for limited amount of time, renewal always an

unknown• Updates to program not included with contract

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• Where are we now?– Released for use in May 2010– Deckplate leaders, educators, CNSs still not aware of document

and how to use– Working to integrate into units and educate on process and

intent of document.– Maintenance of competency (annual review/update)

Here is a preview of the competencies:

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Maternal Infant Nursing Core CompetenciesIndividual Assessment

Name: ____________________________ Orientation Start Date: _________________ Completion Date: _________________Instructions: Pre-Assessment - the nurse will rate each knowledge, skill, or attitude (KSA) from 1 (novice) to 5 (expert) in each box. Following orientation or training, the nurse and preceptor will collaboratively provide a post-assessment.

Self Assessment Evaluation Method Pre-Assessment Page Total: ________ Version 201005191 = Novice (minimal skills, knowledge & judgment. Rigid) D = Demonstration/Observation2 = Advanced Beginner (Basic skills. Limited situational perception, multitasking and prioritization) I = Interactive Class Post-Assessment Page Total: ________3 = Competent (Conscious, deliberate planning, goal setting and multitasking. Min supervision required) T = Test File Individual Assessment in Training Record; Summary in Individual Professional File4 = Proficient (Specialty cert. Prioritizes given evolving circumstances. Uses rules for guidance) V = Verbal Note : Pre-Assessment is the nurses’ self-assessment in the knowledge, skill, or attitude ; post-assessment 5 = Expert (Consultant and super-trainer. Intuitively assesses and acts) is a collaborative result of the nurses ’ status post orientation/assessment

Competency(Knowledge/Skill/Attitude)

AssessmentMethod Comments

References(Appendix A)Pre Post

Foundational/Generic Nursing Competencies (consistent for all RNs) CRITICAL THINKING: Recognizes key symptomology of combat operational stress, PTSD, and traumatic brain injury. Identifies need for referral/evaluation of stress reduction, psychoeducation, and behavioral health interventions for the prevention of and reduction of operational stress disorders for the patient/family system

Traumatic Brain Injury and Operational Stress Awareness

Identifies signs and symptoms of Traumatic Brain Injury. Demonstrates awareness of early cognitive and behavioral changes

Identifies signs and symptoms of Post Traumatic Stress Disorder. Demonstrates awareness of early cognitive and behavioral changes

Critically reviews patient or family past and planned deployment cycle and any change in alcohol use/misuse

Apply operational/occupational stress control concepts to assess patients, peers, and units. Applies Stress First Aid to patients, peers, and units.

Physiologic and Psychosocial Adaptation to Pregnancy

CRITICAL THINKING: Develops an individualized nursing plan of care that is appropriate for pregnancy gestation.

Describe the physiologic changes that occur during pregnancy, including reproductive hormonal changes, cardiovascular, and renal changes

(1) Module I (7) Chapters 5, 6

Describe normal weight gain in pregnancy, including expected metabolic and gastrointestinal changes

Identify changes in laboratory values that occur during pregnancy as a result of normal physiologic adaptation

Identify psychosocial and developmental adaptations to pregnancy, including issues related to mood, anxiety, body image, pregnancy attachment, sexuality and relationships, and expected changes in sleep patterns, appetite, and energy levels

Define common complications of pregnancy: gestational hypertension, gestational diabetes, polyhydramnios, oligohydramnios, intrauterine growth restriction, etc.



References(Appendix A)Pre Post

Describe the process for prenatal care, including the nine visit pathway, common laboratory assessments, and prenatal risk assessment (aneuploidy screening, amniocentesis)

Antepartum AssessmentCRITICAL THINKING: Develops an individualized nursing plan of care that is appropriate for pregnancy gestation.

Describe the key elements of triage assessment and evaluation. List common presenting conditions and categorize appropriately as emergent, urgent, or routine

(4) Module 3(7) Chapter 7

Assist with the collection of vaginal cultures/testing according to unit guidelines and identify rationale for each: nitrazine, ferning, amnisure, fetal fibronectin, group beta strep, chlamydia, gonorrhea, KOH, wet prep

Describe the process and nursing responsibilities for assessment of ruptured membranes

Demonstrate proper technique for cervical examination and identify situations in which cervical exam should only be performed by privileged provider

Assist with amniocentesis and external cephalic version according to facility guidelines

Describe procedure and evaluation criteria for fetal nonstress test, contraction stress test, amniotic fluid index, biophysical profile

The Process of Labor and BirthCRITICAL THINKING: Develops an individualized nursing plan of care that aligns with healthcare provider orders and stage of patient labor process

Identify maternal coping behaviors related to labor and birth (1) Module II(4) Modules 4-7(5)(7) Chapters 9-11



Result Total Post-Assessment Points

(96 items max = 480 points max)

Overall Recommended

Result

96 – 144 Novice

145 – 240 Advanced beginner

241 – 336 Competent

337 – 432 Proficient

444 - 480 Expert

Appendix A: REFERENCES1. 2006 Association of Women’s Health, Obstetric and Neonatal Nurses Perinatal Orientation and Education Program2. 2006 AWHONN Intermediate Fetal Monitoring Course3. 2009 American Academy of Pediatrics/American Heart Association Neonatal Resuscitation Program 4. Martin, E.J. (2002). Intrapartum Management Modules (3rd Ed). Lippincott: Philadelphia.5. Murray, M. & Huelsmann, G. (2008). Labor and Delivery Nursing: Guide to Evidence-Based Practice. Springer: New York.6. RTS Bereavement Services (2008). RTS Bereavement Training Manual. Gunderson-Lutheran: LaCrosse, WI. 7. Simpson, K.R., & Creehan, P.A. (2001). Perinatal Nursing (2nd Ed). Lippincott: Philadelphia.8. Woodke, D. (2010). Telephone Triage Decision Support Tools for Nurses. Ambulatory Innovations: Hot Springs, AR.



Recommended Result

Maternal-Infant Nursing Core Competencies Summary

Comprehensive assessment, planning, implementation and evaluation of care to include:

Develops an individualized nursing plan of care that is appropriate for pregnancy gestation Develops an individualized nursing plan of care that aligns with healthcare provider orders and

stage of patient labor process Develops an individualized nursing plan of care that is appropriate for patient pregnancy

complications to facilitate a positive outcome Develops an individualized nursing plan of care that meets physiologic/psychosocial needs of

mother and newborn Develops an individualized nursing plan of care that fosters and facilitates parents’ knowledge

and skills to provide newborn care at home Develops an individualized nursing plan of care that will enable the nurse to stabilize the

distressed newborn while awaiting for transport to higher level of care Develops an individualized nursing plan of care by utilizing “five rights,” medication

interactions, and potential impact on lactation Develops an individualized nursing plan of care that facilitates and supports family grieving

processes Ensure compliance with local MTF SOP and Policy regarding documentation, communication,

and risk management Treatment Facility: __________________________________ Date Assessed: _________________ Nurse Name: _______________________________________ Current Competency level: _______ Preceptor’s Printed Name: ____________________________ Signature: ____________________ I understand that of all the competencies listed, I will be allowed to perform only those for my skill level/scope of practice and only after I have successfully demonstrated competency. Nurse’s Signature: __________________________________ Date: ________________________ Division Officer’s Signature: __________________________ Date: ________________________

Maternal-Infant Nursing Core CompetenciesSummary


AssessmentMethod Comments References

(Appendix A)Pre Post

Traumatic Brain Injury and Operational Stress Awareness CRITICAL THINKING: Recognizes key symptomology of combat operational stress, PTSD, and traumatic brain injury. Identifies need for referral/evaluation of stress reduction for parents and caregivers, including psychoeducation and behavioral health interventions for the prevention, and reduction, of operational stress disorders for the patient and family system.

Identifies signs and symptoms of Traumatic Brain Injury. Demonstrates awareness of early cognitive and behavioral changes.

Identifies signs and symptoms of Post Traumatic Stress Disorder in mothers, fathers and other primary caregivers. Demonstrates awareness of early cognitive and behavioral changes.

Shaw, R. et al. (2006). Acute stress disorder among parents of infants in the neonatal intensive care nursery. Psychosomatics, 47(3), 206-212. Available from: http://psy.psychiatryonline.org

Critically reviews patient or family past and planned deployment cycle and any change in alcohol use/misuse.

www.birthtraumaassociation.org.uk for the Post Natal Post Traumatic Stress Disorder (PN PTSD) from the Birth Trauma Association

Apply operational/occupational stress control concepts to assess family members/caregivers, peers, and units. Applies Stress First Aid to family members/caregivers, peers, and units.

Transition to Extrauterine Life CRITICAL THINKING: Able to assess and evaluate to develop an individualized nursing plan of care appropriate for the neonate’s gestational age, maternal risk factors and clinical presentation at birth.

Identify intrapartum conditions (i.e. risk factors) that may result in complications for the newborn:a.Maternal disease (e.g. diabetes, lupus, use of tocolytic medications)b.Maternal behavior (smoking, substance abuse, malnutrition)c.Obstetric complications (antepartum bleeding, pre-eclampsia, preterm labor)d.Multiple gestation

Module I – AWHONN Neonatal Orientation and Education Program (NOEP) and associated references (Transition to Extrauterine Life)Stringer, M., Brooks, P., King, K., and Biesecker, B. (2007). New guidelines for maternal and neonatal resuscitation. JOGNN, 36(6), 624-635.

Name: ____________________________ Orientation Start Date: ______________________ Completion Date: ______________________Instructions: Pre-Assessment - the nurse will rate each knowledge, skill, or attitude (KSA) from 1 (novice) to 5 (expert) in each box. Following orientation or training, the nurse and preceptor will collaboratively provide a post-assessment.Note: This competency designed for NICU at NNMC, NMC San Diego, NMC Portsmouth, and USNH Okinawa.

Neonatal Intensive Care Nursing Core CompetenciesIndividual Assessment


http://psy.psychiatryonline.org/

http://www.birthtraumaassociation.org.uk/



References(Appendix A)

Pre Post

Describe physiologic changes that occur during transition to extrauterine life. Askin, D. (2009). Fetal-to-neonatal transition: What is normal and what is not? Part I: The physiology of transition. Part II: Red flags. Neonatal Network, 28(3), e33-e40.

Demonstrate how to use Neonatal Resuscitation Program (NRP) techniques to resuscitate a neonate in the delivery room.

AAP Neonatal Resuscitation Program

Recognize signs and symptoms of common problems during the transition period.a.Respiratory distressb.Hypothermiac.Hypoglycemia

Reynolds, R., Pilcher, J., Ring, A., Johnson, R., & McKinley, P. (2009). The golden hour: Care of the LBW infant during the first hour of life (one unit’s experience). Neonatal Network, 28(4), 211-219.

Describe a systematic head-to-toe approach to examining the neonate. Askin, D. (2007). Physical assessment of the newborn: Part 1 of 2: Preparation through auscultation. Nursing for Women’s Health, 11(3), 293-301.Askin, D. (2007). Physical assessment of the newborn: Part 2 of 2: Inspection through palpation. Nursing for Women’s Health, 11(3), 305-313.

Describe methods of determining gestational age, growth patterns, and maturity.

S.T.A.B.L.E. Program™ Physical Assessment and Gestational Age CD-Rom

Explain the differences between common birth injuries and their implications for practice.

Nicholson, L. (2007). Caput succedaneum and cephalohematoma: The Cs that leave bumps on the head. Neonatal Network, 26(5), 277-281.Reid, J. (2007). Neonatal subgaleal hemorrhage. Neonatal Network, 26(4), 219-227.

Describe thermoregulation instability and management techniques complicated by on-going stabilization.

Knobel, R. & Holditch-Davis, D. (2007). Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilization of extremely low-birthweight infants. JOGNN, 36(3), 280-287.

Neonatal Intensive Care Nursing Core CompetenciesIndividual Assessment


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Result Total Post-Assessment

Points(139 items =

695 points max)

Overall Recommended

Result

139 – 209 Novice 210 – 348 Advanced beginner 349 – 487 Competent 488 – 626 Proficient 627 – 695 Expert

Recommended Result

Appendix A: REFERENCES (Example; entire list is not included here)Neonatal Nursing Associations:•Academy of Neonatal Nurses (ANN):•Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN):•National Association of Neonatal Nurses (NANN):Other references:•AAP (2006). NRP “Cases in Neonatal Resuscitation” DVD•© 2006 Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Neonatal Orientation and Education Program (NOEP)•Acute Care of at-Risk Newborns (ACoRN) case-based education program from the Canadian Neonatal Society: www.acornprogram.net •American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP) Provider 5 th edition textbook with CD-ROM: www.aap.org •Annual Report of the Committee on Infectious Diseases (including Red Book® reference): http://aapredbook.aappublications.org/ •NANN Guidelines for Neonatal Nursing Policies, Procedures, Competencies, and Clinical Pathways: www.nann.org •NANN (2007) – Peripherally Inserted Central Catheters Guideline (2nd edition)•The S.T.A.B.L.E. Program™ (2006): Blood Gas Interpretation Chart, 2nd edition:•The S.T.A.B.L.E. Program™ Physical Assessment and Gestational Age CD-Rom•The S.T.A.B.L.E. Program™ Pre-transport Stabilization Self-Assessment Tool (PSSAT) form for post-stabilization performance review•Verklan, M. & Walden, M. (2010). AWHONN, AACN, NANN: Core curriculum for neonatal intensive care nursing, 4 th edition. St. Louis: Saunders [paperback]. Note: References provided are illustrative and may be substituted for locally held alternates. In the absence of a standardized Nursing Procedural Manual, use your command standard such as the following:•Mosby Nursing Skills [Web Based Procedure Manual by Subscription]. Available at http://www.mosbynursingskills.com•Springhouse Nursing Procedures [Web Based or local cached Procedure Manual by Subscription] Available at http://LWW.com/LNPS•Perry, A. G. & Potter, P.A. (2008) Clinical Nursing Skills & Techniques, 7th ed. Elsevier Mosby, St. Louis.•Springhouse, Lippincott’s Manual of Nursing Practice, 5ht ed. Lippincott Williams & Wilkins

http://www.acornprogram.net/

Neonatal Intensive Care Nursing Core Competencies Summary

Comprehensive assessment, planning, implementation and evaluation of care as the nurse:

Recognizes key symptomology of combat operational stress, PTSD, and traumatic brain injury. Identifies need for referral/evaluation of stress reduction for parents and caregivers, including psychoeducation and behavioral health interventions for the prevention, and reduction, of operational stress disorders for the patient/family system.

Able to assess and evaluate to develop an individualized nursing plan of care appropriate for the neonate’s gestational age, maternal risk factors and clinical presentation at birth.

Able to assess and evaluate to develop an individualized nursing plan of care that maintains and/or improves the neonate’s respiratory function and ventilatory status.

Able to assess and evaluate to develop an individualized nursing plan of care that maintains and/or improves the neonate’s cardiovascular function.

Able to assess and evaluate to develop an individualized nursing plan of care that maintains and/or improves the neonate’s metabolic and nutritional status.

Able to assess and evaluate to develop an individualized nursing plan of care that maintains and/or improves the neonate’s skin integrity and promotes skin care.

Able to assess and evaluate to develop an individualized nursing plan of care that maintains and/or improves the late preterm neonate’s thermoregulation and nutrition.

Able to assess and evaluate to develop an individualized nursing plan of care that maintains and/or improves the neonate’s hematology and immunology status.

Able to assess and evaluate to develop an individualized nursing plan of care that maintains and/or improves the neonate’s neurologic function.

Able to assess and evaluate to develop an individualized nursing plan of care that maintains and/or improves the neonate’s renal and endocrine function.

Able to assess and evaluate to develop an individualized nursing plan of care that improves outcomes for a neonate with a genetic disorder or malformation.

Able to assess and evaluate to develop an individualized nursing plan of care appropriate for the neonate’s developmental stage and to decrease perceived level of pain over time.

Able to assess and evaluate to develop a nursing plan of care for neonate’s undergoing surgery and post-operative care.

Able to assess and identify to formulate a nursing plan of care that includes multi-disciplinary staff to support a neonate’s family facing crisis.

Able to identify and formulate a nursing plan of care that includes care and support of the neonate and family prior to and following neonatal death.

Able to understand operating procedures and troubleshooting techniques for all equipment in the Neonatal Intensive Care Unit.

Treatment Facility: ______________________________ Date Assessed: _____________ Nurse Name: __________________________________ Current Competency level: ____ Preceptor’s Printed Name: _______________________ Signature: _________________ I understand that of all the competencies listed, I will be allowed to perform only those for my skill level/scope of practice and only after I have successfully demonstrated competency. Nurse’s Signature: _____________________________ Date: _____________________ Division Officer’s Signature: ______________________ Date: _____________________

Neonatal Intensive Care Nursing Core CompetenciesSummary

Competency(Knowledge / Skill / Attitude)


Pre Post

Foundational/Generic Nursing Competencies (consistent for all RNs)

CRITICAL THINKING: Recognizes key symptomology of combat operational stress, PTSD, and traumatic brain injury. Identifies need for referral/evaluation of stress reduction, psychoeducation, and behavioral health interventions for the prevention of and/or reduction of operational stress disorders for the patient/family system.

Identify signs and symptoms of Traumatic Brain Injury. Demonstrate awareness of early cognitive and behavioral changes.

Identify signs and symptoms of Post Traumatic Stress Disorder. Demonstrate awareness of early cognitive and behavioral changes.

Shaw, R. et al. (2006). Acute stress disorder among parents of infants in the neonatal intensive care nursery. Psychosomatics, 47(3), 206-212. Available from: http://psy.psychiatryonline.org

Critically reviews patient or family past and planned deployment cycle and any change in alcohol use/misuse.

www.birthtraumaassociation.org.uk for the Post Natal Post Traumatic Stress Disorder (PN PTSD) Birth Trauma Association

Apply operational/occupational stress control concepts to assess patients, peers, and units. Applies Stress First Aid to patients, peers, and units.

Delivery Room Management – Transition to Extrauterine Life

CRITICAL THINKING: Able to assess, evaluate and intervene to initiate spontaneous or assisted ventilation for the neonate immediate following delivery to support a normal extrauterine transition.

Identify intrapartum conditions (risk factors) that may result in complications for the newborn. a. Maternal disease (i.e. diabetes, lupus) b. Maternal behavior (smoking, substance abuse, malnutrition) c. Obstetric complications (antepartum bleeding, pre-eclampsia, preterm labor) d. Multiple gestation

Module I – AWHONN Neonatal and Education Program (NOEP) and associated references (Transition to Extrauterine Life)Stringer, M., Brooks, P., King, K., and Biesecker, B. (2007). New guidelines for maternal and neonatal resuscitation. JOGNN, 36(6), 624-635.

Name: ____________________________ Orientation Start Date: ______________________ Completion Date: ______________________Instructions: Pre-Assessment - the nurse will rate each knowledge, skill, or attitude (KSA) from 1 (novice) to 5 (expert) in each box. Following orientation or training, the nurse and preceptor will collaboratively provide a post-assessment.Note: This competency designed for NICU at NNMC, NMC San Diego, NMC Portsmouth, and USNH Okinawa.

Neonatal Stabilization and Pre-Transport Nursing Core CompetenciesIndividual Assessment


Competency(Knowledge / Skill / Attitude)


Pre Post

Describe physiologic changes that occur during transition to extrauterine life.

Askin, D. (2009). Fetal-to-neonatal transition: What is normal and what is not? Part I: The physiology of transition. Part II: Red flags. Neonatal Network, 28(3), e33-e40.

Demonstrate how to use current AAP Neonatal Resuscitation Program (NRP) algorithm to resuscitate a neonate immediately following delivery.

Lesson 1 – Neonatal Resuscitation Program (NRP) – Overview of Neonatal Resuscitation

Recognize signs and symptoms of common problems during the transition period with a focus on preparation for premature infants.

Delivery room management of the VLBW infant toolkit:http://www.cpqcc.org/quality_improvement/qi_toolkits/delivery_room_management_of_the_very_low_birth_weight_vlbw_infant_toolkit

Describe a systematic head-to-toe approach to examining the neonate.

Askin, D. (2007). Physical assessment of the newborn: Part 1 of 2: Preparation through auscultation. Nursing for Women’s Health, 11(3), 293-301.Askin, D. (2007). Physical assessment of the newborn: Part 2 of 2: Inspection through palpation. Nursing for Women’s Health, 11 (3), 305-313.

Describe methods of determining gestational age, growth patterns, and maturity.

S.T.A.B.L.E. Program™ Physical Assessment and Gestational Age CD-Rom

Explain the differences between common birth injuries and their implications for practice.

Nicholson, L. (2007). Caput succedaneum and cephalohematoma: The Cs that leave bumps on the head. Neonatal Network, 26(5), 277-281.Reid, J. (2007). Neonatal subgaleal hemorrhage. Neonatal Network, 26(4), 219-227.

Define normal neonatal vital signs and monitor.

Neonatal Stabilization and Pre-Transport Nursing Core CompetenciesIndividual Assessment


Neonatal Stabilization & Pre-Transport Core Competencies Summary

Comprehensive assessment, planning, implementation and evaluation of neonatal stabilization and pre-transport nursing care to include:

Recognizes key symptomology of combat operational stress, PTSD, and traumatic brain injury. Identifies need for referral/evaluation of stress reduction, psychoeducation, and behavioral health interventions for the prevention of and/or reduction of operational stress disorders for the patient/family system

Able to assess, evaluate and intervene to initiate spontaneous or assisted ventilation for the neonate immediate following delivery to support a normal extrauterine transition

Able to assess, evaluate to develop an individualized nursing plan of care that will maintain and/or improve neonate’s thermoregulation

Able to assess, evaluate to develop an individualized nursing plan of care that will maintain and/or improve neonate’s respiratory function.

Able to assess, evaluate to develop an individualized nursing plan of care that will maintain and/or improve neonate’s cardiovascular function to maintain adequate perfusion

Able to assess, evaluate to develop an individualized nursing plan of care that will maintain and/or improve neonate’s glucose homeostasis and nutritional support

Able to anticipate laboratory and ancillary diagnostic studies to evaluate the neonate’s physiologic well-being and response to prescribed medical care

Able to understand and incorporate infection control measures to minimize nosocomial infection. Able to understand operating procedures on all equipments in the Neonatal Intensive Care Unit Able to assess, evaluate to develop an individualized nursing plan of care that will promote management of

the dysmorphic neonate diagnosed with a genetic disorder, malformation Able to assess, evaluate to develop an individualized nursing plan of care that will maintain and promote

neonate’s skin integrity. Able to assess, evaluate to develop an individualized nursing plan of care appropriate for neonate’s

experiencing pain Able to assess, identify and formulate nursing plan of care that includes multi-disciplinary staff to support

families facing crisis following the birth of a premature or unstable neonate Able to identify and formulate a nursing plan of care that includes care and support of the neonate and

family prior to and following neonatal death Able to assess, identify and formulate a nursing plan of care that includes care of the late preterm infant and

discharge teaching Use a multi-disciplinary approach to review and critique the stabilization process and identify successes and

areas for improvement Treatment Facility: ___________________________________ Date Assessed: ________________ Nurse Name: _______________________________________ Current Competency level: _______ Preceptor’s Printed Name: ____________________________ Signature: ____________________ I understand that of all the competencies listed, I will be allowed to perform only those for my skill level/scope of practice and only after I have successfully demonstrated competency. Nurse’s Signature: __________________________________ Date: ________________________ Division Officer’s Signature: ___________________________ Date: ________________________

Neonatal Stabilization & Pre-Transport Core CompetenciesSummary


Information

• Core competencies released for use can be found at Navy Knowledge Online (NKO)– https://wwwa.nko.navy.mil/portal/home/

• Interested in documents not yet released ?– Contact:

• CDR Nicole Polinsky

• [email protected]

Or

• CDR Julie Hillery

• [email protected]

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Questions?

Thank you!

Documents

Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion Navy Nursing Clinical Competencies CDR Nicole