Home Care Insecurities
I’ve recently been working with a seasoned nurse who is precepting a young nurse new to home care.  The preceptor has expressed concern that she doesn’t know how to help this new nurse gain confidence in her knowledge and skills as a home care nurse:  “She’s doing a fantastic job, but still seems very insecure in her practice.  How do I help her see what I see in her practice?”

Describing the Visit
I suggested that the three of us meet and review a patient care situation that the new nurse had managed well.  We met, and the new nurse described the care she had provided to a man with heart failure.  She described how she read the notes from previous visits and planned for her visit before leaving the office.  She then described the visit.

• She arrived at the house, introduced herself and ensured that the patient was the man she was supposed to be visiting.
• She asked him how he was and reviewed with him what she saw as the purpose of the day’s visit.  She assured him that she’d read through the notes of his regular nurse and knew that his goal was to learn how to avoid high salt foods.  She told him she was going to save time to review his food log with him later in the visit.
• She conducted a cardiac assessment: vital signs, lung sounds, dyspnea assessment, edema and weight check.
• She queried him about his medications and any recent doctors’ visits.
• She went over his Emergency Response plan and asked him for a Teach Back about how he used this tool (click here for the Teach Back tool, and click here for a video showing how it can be used).
• She then gave him a summary of her assessment, and moved on to review his food log. After looking the log over she congratulated him on his many good choices and noted that he appeared to enjoy bologna, and then talked with him about the salt content of bologna and asked if he could think of another cold cut that might be satisfying but less salty.  She and the patient concluded their discussion with the plan that the patient was going to try low sodium turkey breast instead of bologna.
• She documented the visit while still in the home, asking the patient if he had other questions as she entered information in the computer.
• She concluded the visit saying that she anticipated his regular nurse would visit him within in 5-7 days, and that he was managing his illness well.

The Preceptor’s Feedback
I asked the preceptor how she thought the new nurse had done with this visit. She replied, “She was fantastic.  She conducted an excellent visit.  She is just wonderful with patients.  She is an A-plus.”

Feedback on the Feedback (Using S-B-I)
After our meeting, I used the Situation-Behavior-Impact (S-B-I) approach to give the preceptor her feedback.  I started, “In today’s meeting with your preceptee (Situation), I noted that you used a lot of superlatives to describe her as a nurse, but did not identify specific behaviors or elements of her practice that she used in this visit that you considered excellent (Behavior).  This left me wondering if the new nurse knew what she had done well, and if perhaps your general feedback isn’t specific enough to help her build confidence (Impact).”

Then I sat quietly as the preceptor reflected on what I had said.

Get Specific
The preceptor acknowledged that giving feedback was not a skill she was comfortable with, so she gave the new nurse lots of general praise when she did well, and said nothing when her practice was less than stellar.  This opened up an opportunity to talk about giving feedback and how new nurses need specific feedback in order to adopt good solid practice habits, and that confidence comes from knowing you are competent in those habits.  I was able to teach the preceptor about the S-B-I method of giving feedback, and we role played a couple of situations so she could practice giving both specific positive feedback and “need for improvement” feedback using S-B-I.

Adele Pike
Director, Center of Excellence & Education
Visiting Nurse Association of Boston & Affiliates

Note: CHAMP’s new CE hour-conferring course Techniques for Improved Clinical Coaching will help you learn and practice new skills for motivating clinical practice change among clinicians and patients (including the S-B-I approach).