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
Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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.
Purpose of Today’s Brief:
To share the four-year Navy Nursing enterprise initiative for standardizing
clinical professional nursing competencies
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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 Nursing
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
Background
Oct 2007 (for FY 2008):
• Development of “go-to-war” competencies
continued.
• Additional nursing specialties were identified
for core competency development
Oct 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
development
Oct 2009 (for FY 2010):
• Reduced groups, increased membership,
added initiatives to charter
• More competencies identified for
development
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
Background: Dashboard View
5
Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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 shortterm 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
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
Why Create Something “New”?
• 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]
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
First Steps: R&CP Membership
Specialty
Leaders
People
Who Want
to Work
Subject
Matter
Experts
Based on competency
Domain
SEAT
Competency
Others
Constituent
Representat
ives
Junior Officer
Reserves
Civilian
Advisor
Chair
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
First Steps: Definition—
Competency versus Orientation
• 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
Criteria
Competency
Orientation
Key Component
N/A
Physical location and Process based
No
Key Component
Unit Specific
No
Yes
Specialty Specific
Yes
Maybe
Often
Maybe
No
Yes
Key Component
Inconsistent
Critical Thinking
Population Specific
Local “How To”
Professional Standards based
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
First Steps: Definition & Framework
•
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 noviceexpert 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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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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
D. R. (2007), Learning Domains or Bloom's Taxonomy. Retrieved December 15, 2008 from
http://www.nwlink.com/~Donclark/hrd/bloom.html
3Joint Commission (2008). Comprehensive Accreditation Manual for Hospitals: The Official Handbook on Accreditation of Healthcare
Organizations, Joint Commission Resources. Joint Commission Resources
2Clark,
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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.
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
Example: Competency
Development Schedule
From FY09 Plan
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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 and preceptor
review pre-assessment
(needs identification)
(As needed)
Skill building to strengthen
nurse’s needs
Nurse performs
pre-assessment
Nurse and preceptor
conduct post-assessment
Completed
Competency
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
The two part competency is a change in the Dec 2008 edition
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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 19
standardization too
Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
What’s Next?
Clinical Excellence Workgroup
Internal
Strategic
Partnerships
Nsg
Procedures
External
Strategic
Partnerships
Maintain
generic
Comps
&
Process
Infrastructure
Maintenance
of
estab
products
“Split the Gem”
Clinical Excellence
*Recommended plan; not yet approved
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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
Core Competencies for
Maternal-Child Nursing
• 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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Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
Core Competencies for
Maternal-Child Nursing
• 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 Competencies
Individual 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.
Competency
(Knowledge/Skill/Attitude)
Foundational/Generic Nursing Competencies (consistent for all RNs)
Assessment
Pre
Post
Method
References
(Appendix A)
Comments
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.
Self Assessment
Evaluation Method
1 = Novice (minimal skills, knowledge & judgment. Rigid) D = Demonstration/Observation
2 = Advanced Beginner (Basic skills. Limited situational perception, multitasking and prioritization)
3 = Competent (Conscious, deliberate planning, goal setting and multitasking. Min supervision required)
Professional File
4 = Proficient (Specialty cert. Prioritizes given evolving circumstances. Uses rules for guidance)
skill, or attitude ; post-assessment
5 = Expert (Consultant and super-trainer. Intuitively assesses and acts)
Pre-Assessment Page Total: ________
Version 20100519
I = Interactive Class
T = Test
Post-Assessment Page Total: ________
File Individual Assessment in Training Record; Summary in Individual
V = Verbal
Note : Pre-Assessment is the nurses’ self-assessment in the knowledge,
is a collaborative result of the nurses’ status post orientation/assessment
Maternal Infant Nursing Core Competencies
Individual Assessment
Competency
(Knowledge/Skill/Attitude)
Assessment
Method
Pre
References
Comments
(Appendix A)
Post
Describe the process for prenatal care, including the nine visit pathway, common
laboratory assessments, and prenatal risk assessment (aneuploidy screening,
amniocentesis)
CRITICAL THINKING: Develops an individualized nursing plan of care that is appropriate for pregnancy gestation.
Antepartum Assessment
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
CRITICAL THINKING: Develops an individualized nursing plan of care that aligns with healthcare provider orders and stage of patient labor process
The Process of Labor and Birth
Identify maternal coping behaviors related to labor and birth
Self Assessment
Evaluation Method
1 = Novice (minimal skills, knowledge & judgment. Rigid) D = Demonstration/Observation
2 = Advanced Beginner (Basic skills. Limited situational perception, multitasking and prioritization)
3 = Competent (Conscious, deliberate planning, goal setting and multitasking. Min supervision required)
Professional File
4 = Proficient (Specialty cert. Prioritizes given evolving circumstances. Uses rules for guidance)
skill, or attitude ; post-assessment
5 = Expert (Consultant and super-trainer. Intuitively assesses and acts)
(1) Module II
(4) Modules 4-7
(5)
(7) Chapters 9-11
Pre-Assessment Page Total: ________
Version 20100519
I = Interactive Class
T = Test
Post-Assessment Page Total: ________
File Individual Assessment in Training Record; Summary in Individual
V = Verbal
Note : Pre-Assessment is the nurses’ self-assessment in the knowledge,
is a collaborative result of the nurses’ status post orientation/assessment
Maternal Infant Nursing Core Competencies
Individual Assessment
Recommended Result
Result
Total PostAssessment Points
(96 items max =
480 points max)





96 – 144
145 – 240
241 – 336
337 – 432
444 - 480
Overall
Recommended
Result
Novice
Advanced beginner
Competent
Proficient
Expert
Appendix A: REFERENCES
1. 2006 Association of Women’s Health, Obstetric and Neonatal Nurses Perinatal Orientation and Education Program
2. 2006 AWHONN Intermediate Fetal Monitoring Course
3. 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.
Self Assessment
Evaluation Method
1 = Novice (minimal skills, knowledge & judgment. Rigid) D = Demonstration/Observation
2 = Advanced Beginner (Basic skills. Limited situational perception, multitasking and prioritization)
3 = Competent (Conscious, deliberate planning, goal setting and multitasking. Min supervision required)
Professional File
4 = Proficient (Specialty cert. Prioritizes given evolving circumstances. Uses rules for guidance)
skill, or attitude ; post-assessment
5 = Expert (Consultant and super-trainer. Intuitively assesses and acts)
Pre-Assessment Page Total: ________
Version 20100519
I = Interactive Class
T = Test
Post-Assessment Page Total: ________
File Individual Assessment in Training Record; Summary in Individual
V = Verbal
Note : Pre-Assessment is the nurses’ self-assessment in the knowledge,
is a collaborative result of the nurses’ status post orientation/assessment
Summary
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: ________________________
Neonatal Intensive Care Nursing Core Competencies
Individual 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.
Note: This competency designed for NICU at NNMC, NMC San Diego, NMC Portsmouth, and USNH Okinawa.
Competency
(Knowledge/Skill/Attitude)
Traumatic Brain Injury and Operational Stress Awareness
Assessment
Method
Pre
Comments
Post
References
(Appendix A)
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.
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.
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
Self Assessment
Evaluation Method
1 = Novice (minimal skills, knowledge & judgment. Rigid) D = Demonstration/Observation
2 = Advanced Beginner (Basic skills. Limited situational perception, multitasking and prioritization)
3 = Competent (Conscious, deliberate planning, goal setting and multitasking. Min supervision required)
Professional File
4 = Proficient (Specialty cert. Prioritizes given evolving circumstances. Uses rules for guidance)
skill, or attitude ; post-assessment
5 = Expert (Consultant and super-trainer. Intuitively assesses and acts)
Pre-Assessment Page Total: ________
Version 20100519
I = Interactive Class
T = Test
Post-Assessment Page Total: ________
File Individual Assessment in Training Record; Summary in Individual
V = Verbal
Note : Pre-Assessment is the nurses’ self-assessment in the knowledge,
is a collaborative result of the nurses’ status post orientation/assessment
Neonatal Intensive Care Nursing Core Competencies
Individual Assessment
Competency
(Knowledge/Skill/Attitude)
Assessment
Method
Pre
Comments
Post
References
(Appendix A)
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 distress
b.
Hypothermia
c.
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), 219227.
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.
Self Assessment
Evaluation Method
1 = Novice (minimal skills, knowledge & judgment. Rigid) D = Demonstration/Observation
2 = Advanced Beginner (Basic skills. Limited situational perception, multitasking and prioritization)
3 = Competent (Conscious, deliberate planning, goal setting and multitasking. Min supervision required)
Professional File
4 = Proficient (Specialty cert. Prioritizes given evolving circumstances. Uses rules for guidance)
skill, or attitude ; post-assessment
5 = Expert (Consultant and super-trainer. Intuitively assesses and acts)
Pre-Assessment Page Total: ________
Version 20100519
I = Interactive Class
T = Test
Post-Assessment Page Total: ________
File Individual Assessment in Training Record; Summary in Individual
V = Verbal
Note : Pre-Assessment is the nurses’ self-assessment in the knowledge,
is a collaborative result of the nurses’ status post orientation/assessment
Recommended Result
Result
Total PostAssessment
Points
(139 items =
695 points max)





139 – 209
210 – 348
349 – 487
488 – 626
627 – 695
Overall
Recommended
Result
Novice
Advanced beginner
Competent
Proficient
Expert
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 5th 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, 4th 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 32
•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
Neonatal Intensive Care Nursing Core Competencies
Neonatal
Intensive Care
Nursing Core Competencies
Summary
Summary
Comprehensive assessment, planning, implementation and evaluation of care as the nurse:
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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 Stabilization and Pre-Transport Nursing Core Competencies
Individual 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.
Note: This competency designed for NICU at NNMC, NMC San Diego, NMC Portsmouth, and USNH Okinawa.
Competency
(Knowledge / Skill / Attitude)
Foundational/Generic Nursing Competencies (consistent for
all RNs)
Assessment
Method
Pre
Comments
References
Post
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.
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.
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
Self Assessment
Evaluation Method
1 = Novice (minimal skills, knowledge & judgment. Rigid) D = Demonstration/Observation
2 = Advanced Beginner (Basic skills. Limited situational perception, multitasking and prioritization)
3 = Competent (Conscious, deliberate planning, goal setting and multitasking. Min supervision required)
Professional File
4 = Proficient (Specialty cert. Prioritizes given evolving circumstances. Uses rules for guidance)
skill, or attitude ; post-assessment
5 = Expert (Consultant and super-trainer. Intuitively assesses and acts)
Pre-Assessment Page Total: ________
Version 20100519
I = Interactive Class
T = Test
Post-Assessment Page Total: ________
File Individual Assessment in Training Record; Summary in Individual
V = Verbal
Note : Pre-Assessment is the nurses’ self-assessment in the knowledge,
is a collaborative result of the nurses’ status post orientation/assessment
Neonatal Stabilization and Pre-Transport Nursing Core Competencies
Individual Assessment
Competency
(Knowledge / Skill / Attitude)
Assessment
Method
Pre
Comments
References
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_roo
m_management_of_the_very_low_birth_weight_vlbw_infant_toolki
t
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.
Self Assessment
Evaluation Method
1 = Novice (minimal skills, knowledge & judgment. Rigid) D = Demonstration/Observation
2 = Advanced Beginner (Basic skills. Limited situational perception, multitasking and prioritization)
3 = Competent (Conscious, deliberate planning, goal setting and multitasking. Min supervision required)
Professional File
4 = Proficient (Specialty cert. Prioritizes given evolving circumstances. Uses rules for guidance)
skill, or attitude ; post-assessment
5 = Expert (Consultant and super-trainer. Intuitively assesses and acts)
Pre-Assessment Page Total: ________
Version 20100519
I = Interactive Class
T = Test
Post-Assessment Page Total: ________
File Individual Assessment in Training Record; Summary in Individual
V = Verbal
Note : Pre-Assessment is the nurses’ self-assessment in the knowledge,
is a collaborative result of the nurses’ status post orientation/assessment
Neonatal Stabilization & Pre-Transport Core Competencies
Neonatal Stabilization & Summary
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: ________________________
Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
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
• Nicole.polinsky@med.navy.mil
Or
• CDR Julie Hillery
• Julie.hillery@med.navy.mil
37
Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
38
Navy Nursing is a culture of excellence built around a foundation of competence and a tradition of compassion
Questions?
Thank you!