Competency and safety in practice are among the major areas of concern for nurse preceptors when precepting nursing students, new nurses and new nurse hires. One reason is that determining which competencies are most critical to teach, as well as how to teach and evaluate those competencies, remains unclear. In order to teach unit specific competencies, the nursing unit must first recognize what are the most critical competencies for nurses on the unit and provide authentic experiences for nurses to increase their competency level and increase their confidence in teaching in a variety of situations. Raising competency and confidence is relevant in the context of preceptorship. Using a systematic approach will help to foster the skills necessary to facilitate a lifelong process full of flexibility and anticipation to ask the right questions to sustain critical thinking. In order to incorporate flexibility, multiple means of engagement must be used in order to enhance the learning experience, such as using visual, hands-on choices, a checklist of learning objectives, and follow-up with a feedback session. Effective learning takes into consideration broadening the learners’ perspectives on different ways of knowing and learning, as this assists learners to become aware of their own strengths and weaknesses in being active participants in their learning. Nurse preceptors are teachers and are pivotal to teaching and evaluating others during clinical training.

Here is an example of a unit specific high-risk competency. The unit is an operating room surgical section. Evaluation and feedback are critical components of the teaching and learning process.

Patient Positioning

Preoperative assessment for positioning needs should be made before transferring the patient to the procedure bed SAT UNSAT
1. Assessment should include but is not limited to: preexisting conditions and/or disease, physical limitations, age, nutritional status, procedure type and position    
2. Communicate with anesthesia and other perioperative personnel
patient needs related to positioning and any changes that may occur during a procedure
Positioning devices should be readily available, clean, and in working
condition before placing the patient on the procedure bed
1. Follow manufacturer’s instruction using equipment ensuring safe operation before use on a patient    
1a. Personnel must be familiar with equipment to prevent patient injury from improper application or use    
1b. Consider; securing devices, table attachments, specialty procedure beds (fracture table) and padding pressure points    
Monitor patient body alignment and tissue integrity during positioning
1. Ask anesthesia provider for permission prior to movement    
2. Explain position to patient (if awake)    
3. Expose site, be cognizant of patient modesty    
4. Ensure adequate number of personnel/equipment is available for safe positioning    
Note safety considerations for each of the following positions
1. Place arm boards less than a 90 degree angle and level to the floor    
2. Assure legs are straight and are not crossed    
3. Pad appropriately areas that may result in pressure to nerves or skin    
4. Considers respiratory condition in the obese and those with diminished vital capacity while laying flat    
5. Considers pillow under knees for long cases and patients with back pain    
1. Preoperatively consider if patient will tolerate ROM at hip (total hip)    
2. Avoids acute flexion of the thigh to prevent nerve damage    
3. Pad all stirrups, assure both are equal height and length    
4.Observe that the buttock does not extend over the bed and is well padded    
5. Raises and lowers legs simultaneously, preventing rapid volume changes    
6. Considers sequential compression hose for laparoscopic cases or extended procedures    
Apply Principles and Rules of Patient Positioning SAT UNSAT
7. Aware of anesthesia needs when positioning also requires trendelenberg and subsequent possible diminished vital capacity    
1. Collaborates with surgeon and anesthesia regarding positioning and movement (requires at least four people)    
2. Prepares chest rolls/pillows to support chest expansion.    
3. Chest rolls extend along lateral chest wall from shoulder to iliac crest to facilitate abdominal movement/respiratory effort and reduce pressure on vena cava    
4. Prepares pillow for under feet to prevent pressure on dorsum of feet and toes    
5. Collaborates with anesthesia to position arms:    
5a. Carefully places patients arms laterally along patients side ensuring they do not touch the side of the bed, padding appropriately.    
5b. Carefully places patients arms over head by moving them slowly toward the floor and bringing them up in an arc, keeping the elbows flexed. Support of the arms at the elbows and shoulders is required to prevent possible shoulder dislocation or nerve injury.    
6. Consults with anesthesia to ensure head/eye/ear position and protection is adequate    
7. Positions the table per surgeon instructions    
8. Applies tape to buttock as directed by surgeon    
9. Checks women’s breast and men’s genitals after final positioning ensuring they are free from pressure    
FEEDBACK: Using this checklist as a source of information, discuss the learner’s performance indicating strengths, weaknesses, suggested improvements, etc. Feedback on students’ performance is a vital component of learning and is highly valued by students because it helps them to ensure they take away from the lesson what was expected of them to learn. Ask students what went well in their performance, what they were particularly pleased about, and what they would like to improve if they were to repeat the learning exercise.

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