Precepting in the Catheterization Laboratory

Orienting new staff to a procedural area can be exciting and challenging. Precepting may be viewed by many as a simple process of instructions and oversight of competency, when in fact it is an intricate cycle of assessing, planning, implementing and re-assessing. At the center of a well-organized orientation stands a preceptor whose role it is not only to be a role model and an educator, but also to integrate the new orientee into the social environment. Socializing, although not always thought of as part of orientation, is actually the first vital component. The simple acts of introduction to the team, invitations to lunch and general concern send a welcoming message to the newcomer. One must keep in mind that the work environment might not be the only assimilation required, e.g., moving to a new city or state, being a new parent or dealing with a difficult separation. All these factors may influence the student’s ability to concentrate on the new job. Any change requires adaptation, and any adaptation progresses in phases. Although time frames and intensity will vary for each individual, the order of phases remains the same. The honeymoon phase encompasses the excitement of meeting new people and learning new skills, intertwined with hopes and expectations, and not much can sway the new orientee from thinking that this is the place he or she wants to be. As skills are learned and expectations are set, the reality phase ensues, and exposes social conflict among staff, organizational obstacles and even personal dilemmas - all of which cause fatigue and frustration. The outcome of this phase may be the deciding factor on whether the orientee stays or goes. Hence, this is a crucial identifier for the preceptor, and it may require collaboration with the cath lab manager, clinical specialist and the orientee to identify obstacles and offer assistance to resolve issues. Ultimately, the orientee needs to decide whether to relinquish the job, or move on to the recovery phase. Working through issues gives a new perspective and leads to the resolution phase. The working environment must have a social structure that is conducive to smooth transitions from one phase to the next, with the preceptor as the key facilitator. Socializing also launches the process in which the preceptor takes on the role of educator. Through conversation, the preceptor asserts past experiences and educational level, and can acquire a sense of the new staff member’s areas of comfort and areas that cause anxiety. Depending on the cardiac catheterization laboratory, new staff may have a wide array of professional backgrounds - from an allied health professional with limited clinical experience, to a well-seasoned procedural area nurse or technologist. The preceptor must discern what the initial learning needs are by determining the orientee’s present knowledge and skills in relation to the job requirements. Current levels of competency must be observed at least once, regardless of whether the orientee states that he/she has done this before. If your lab performs both diagnostic and interventional procedures and the orientee displays competency in scrubbing for diagnostic cases, but has no previous exposure to interventional procedures, the preceptor would identify that knowledge gap as a discrepancy between present skills and required skills. This assessment phase should be repeated multiple times during the course of orientation. An individualized learning plan should be established in collaboration with the orientee. This may involve such activities as attending a class, reading relevant material and/or practicing a particular skill in the lab or classroom. To maximize learning and minimize frustration for the learner, this plan must be designed like an architectural structure: Lay the foundation and then build the walls by adding one brick at a time, i.e., teach basic skills first and then add one new skill at a time. It is tempting to teach the new person every new skill that comes along, however this may overwhelm the orientee and lead to confusion and disappointment. You and your orientee might initially practice pre- and postprocedural skills, and only observe during the procedure. Not only will the orientee be a better learner, he/she will quickly acquire skills that can be performed independently. Unlike physical skills, sharing knowledge should be continual, with the understanding that you might have to explain it again in the context of a similar or different situation. Set realistic and clear goals to be achieved within a reasonable time frame. These expectations may be written or verbalized, and expand from minute to minute, case by case, day by day, or week by week. Sharing these prospective learning experiences with the rest of the team will facilitate other learning opportunities as well. Implementing the learning plan should start with demonstrating the task while verbalizing one’s thought process, then progress by guiding the learner through performing the task until his/her comfort level and competency have been established. It is important to remember that learning a new skill not only requires repetition, it also requires regular exposure. Learning new skills while removed from the reality of the hustle and bustle of one procedure after another generates the physical coordination needed and reduces the tremendous stress a new and inexperienced employee endures. Ultimately, practicing unfamiliar skills in a simulated environment followed by fine-tuning these skills in the actual environment promotes patient safety. Continuous feedback, whether verbal or written, must be objective and include positive and constructive elements. Delegating tasks and progressively allowing the orientee to take charge of self-delegation promotes independence, while strategies such as case studies, role-playing, simulation, and self-evaluation promote critical thinking skills. The preceptor may start out as the instructor, however he/she must gradually adopt the role of facilitator and resource person. Re-assessing the new orientee’s competencies in relation to the job’s required skills completes the circle. With every stage, one must take into account the learner’s knowledge, as well as his/her critical thinking, technical and interpersonal skills. Initially, the preceptor’s focus will be on performing his/her role during a procedure, with limited effort made to guide the orientee, who is still observing. But as the orientee becomes more competent and progressively functional in that role, the focus should shift to promoting increased independence. One of the most difficult aspects of precepting is to refrain from helping the team and solely observe the orientee; however, one must establish that the orientee can be an independent team member prior to that person being considered a member of the team. Assessing, planning, implementing and re-assessing are components of a continuous circle that gradually lead to independency, which is what makes precepting a demanding yet very rewarding job.

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