Orientation and Support for Managers

Many PHNs indicated that orientation to the new PA process is necessary. Both groups suggested that new managers would require additional support around the revised tool and facilitating the entire PA process. Managers also expressed that evaluating and contributing to a PA is a timely process of collecting information, providing feedback, and meeting with each nurse. The amount of orientation to the new PA system could vary, since a PHN commented: “As I recently wrote the community health certification exam, I don’t feel this taught me anything new.” Another PHN indicated: “During orientation for a new nurse, new team, introduce the new comprehensive PA tool, so that they know what to expect in your performance.”

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Discussion

The purpose of this qualitative study was to evaluate whether revisions to the PHNs’ PA reflected the self-reported expertise of the PHN in applying the CCHN Standards and the PHCC into practice. Even though thirteen PHNs and six managers participated in this research, representing most of the teams with nurses at the Middlesex-London Health Unit, there was no representation from some teams from Family Health Services, Environmental Health, and Chronic Disease Prevention Services (e.g. immunization), and

Communicable Disease and Sexual Health Services.

There was also limited representation from PHNs with less than three years of nursing experience.

Clinical Implications

Comprehensive PA

PHNs were able to provide excellent examples of how they incorporated the CCHN Standards and the PHCC into daily practice using the comprehensive PA. PHNs also reported that the comprehensive PA was more grounded in nursing practice. The comprehensive PA allowed them to reflect (Jarvis, 1992; Schön, 1983) on how they implemented and articulated their strengths with regard to the CCHN Standards and the PHCC, as well as develop learning plans to guide future practice. PHNs that had

recently completed the community health nursing certification were well versed in the CCHN Standards and the PHCC, which would be consistent with Benner’s views of the expert nurse (1984). A positive finding was that recent graduates were also familiar with the CCHN Standards, thus they were able to adjust to the process and complete the PAs better than anticipated. Nevertheless, this research could benefit from an increased representation of novice PHNs.

The primary limitation of the comprehensive PA was that it was labour intensive. PHNs reported that numerous examples were duplicated in various criteria and it was difficult to identify a direct link to the CCHN Standards and the PHCC. As a result, the original 52 criteria of the CCHN Standards were regrouped into 26 condensed criteria, which highlighted the seven PHCC in the PA. The criteria were collapsed according to the nursing process framework (assessment, planning, implementation, and evaluation) with emphasis on certain criteria that

the standard of promoting health, multiple criteria (understanding the Ottawa Charter, political climate and will, values, culture, social structure, harm reduction and epidemiology) were combined in order to highlight the PHCC (Appendix L). Revisions were made to the other standards to reduce duplication in the examples and to identify direct linkages to the PHCC.

Even though the new tool (with 26 criteria instead of 52) will reduce the labour intensiveness of the document and presumably reduce duplication, the revised comprehensive PA needs to be tested among PHNs to ensure that it continues to solicit examples grounded in practice and allows opportunities for self-reflection and evaluation as required by the College of Nurses of Ontario. Informal feedback from the PHNs on the revised comprehensive PA was very positive, especially with regard to the reduced number of criteria. Nevertheless, this research would benefit from integrating the mapping techniques used by The Community Health Nurses Association of Canada (Innovative Solutions and Health Plus &

Underwood and Associates, 2009), since their process was based on a Delphi Technique (iterative reviews among expert nurses).

This research highlighted a concern with respect to PHNs’ understanding of competency. PHNs and their managers identified that the binary concept of

“competent vs. not competent” did not represent the varying stages of competency for each criterion. A clear definition of the term “competency” is needed.

We recommend the following definition: “knowledge, skills, and experience to complete the criteria with minimal supervision,” which is well aligned with the definition used by the College of Nurses of Ontario and focuses on the PHCC recommendation of minimal supervision. In addition, it was not clear if the term “no opportunity to practise” could be interpreted as either the PHN currently has no opportunity to practise the specified criterion, or the PHN has not taken the opportunity to practise even if the opportunity does exist. An updated Likert scale has been developed that places competency on a continuum, ranging from no knowledge, skills, or experience, to the highest level: the ability to teach either as a mentor or preceptor (Figure 2).

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Figure 2. Proposed Competency Scale

No Knowledge,

Skills, or Expertise Knowledge only Knowledge and Skills (requires

PHNs identified that they did not have an opportunity to practise various criteria among the standards.

Given this finding, it is critical that PHNs and their managers review the competencies specific to functioning in their program, and identify which standards may not be easily measured because of the lack of opportunities to practise (e.g. the lack of opportunity for a PHN to work on a social marketing campaign when working in an immunization clinic).

Health units need to review whether the organization can provide opportunities for PHNs to enhance their skills by working on special assignments. Future research is needed in order to examine the relevancy of the proposed scale for competency.

Abbreviated PA and Barriers and Facilitators to Practise

The advantage of the abbreviated PA was the in-depth analysis of the integration of the CCHN Standards and the PHCC in situations where PHNs faced barriers. Typically, PHNs analyzed situations in which they were implementing a program/providing care to a client with complex needs over time. Typical barriers to practise (communication, collaborative partnerships and inadequate resources) were often resolved directly by role clarification, improving partnerships, and creativity in accessing resources.

Originally, we believed that the experienced PHNs would be able to reflect on their practice in an

require assistance in recording and analyzing their narratives, since this appraisal type requires additional skills in critical analysis, as compared to reporting examples in the comprehensive PA.

Educational and Administrative Implications

In general, one of the main findings of this research was the need to clarify the purpose of the PA. Some managers viewed the PA as an opportunity to reflect only on the positive aspects of the PHNs’

performance, and some were unsure of approaches to exploring areas for development or identifying

opportunities for learning.

We recommend that orientation sessions be conducted to reinforce awareness of the CCHN Standards and the PHCC and to introduce the new comprehensive PA tool to PHNs and managers.

Printed materials that highlight the changes to the PA, as well as highlight examples and guidelines, should also be distributed to PHNs and managers as a part of the orientation process. If the PHN has demonstrated understanding of the CCHN Standards through CCHN certification, orientation sessions could be focused only on the changes to the PA. In addition, it is recommended that the PA process be introduced during the orientation of new employees as a method to emphasize the competencies required for practice for specific teams.

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Study Limitations

This qualitative research focused on PHN’s ability to self-evaluate their implementation of the CCHN Standards and the PHCC. The findings are based on self-report from one public health unit and we are not able to determine whether the PHNs’

examples/narratives represent their “best” practice, as compared to their “total” practice. Even though the PHNs’ managers participated in reviewing the new PA tools, the emphasis of this research was on the PHNs’

self-evaluation, rather than the managers’

perspectives. There were administrative areas that have not been covered in the PA, such as attendance, policy expectations, training and development opportunities within the role of management in highlighting the PHNs’ strengths and areas for development. An increased focus needs to be given to the contextual factors influencing the implementation of this revised PA system in organizations. In

addition, more emphasis needs to be given to understanding managers’ knowledge of the CCHN Standards and the PHCC, especially for non-nursing managers.

Further research is needed to understand the process in which managers developed the PA and understand the supports that are required to facilitate the implementation of the new PA. The impact of a unionized vs. non-unionized environment has not been explored. This study was also limited in terms of the sample, since all of the teams with PHNs were not represented. In addition, representation from new graduates was limited.

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Conclusions

PHNs were able to provide excellent examples of how they incorporated the CCHN Standards and the PHCC into daily practice using the comprehensive PA. PHNs also reported that the comprehensive PA was more grounded in nursing practice. The comprehensive PA allowed them to reflect on how they implemented and articulated their strengths with regard to the CCHN Standards and the PHCC, as well as enabled them to develop learning plans to guide future practice. PHNs that had recently

completed the community health nursing certification were well versed in the CCHN Standards and the PHCC. A positive finding was that recent graduates were also familiar with the CCHN Standards, thus they were able to adjust to the process and complete their PAs better than anticipated. The primary limitation of the comprehensive PA was that the tool was extremely time and labour intensive. As a result, the 52 criteria of the CCHN Standards outlined in the original PA tool were regrouped into 26 condensed criteria, which highlighted the seven PHCC in the revised comprehensive PA tool. Even though the new tool will require less time to complete and

presumably reduce duplication, it needs to be tested among PHNs to ensure that it continues to solicit examples grounded in practice and allows

opportunities for self-reflection and evaluation, as required by the College of Nurses of Ontario. The abbreviated PA offers new opportunities to examine the approaches that PHNs use to integrate the CCHN Standards and the PHCC in public health, especially with regard to barriers and facilitators that affect the implementation of the CCHN Standards and the PHCC. It appears that the abbreviated PA requires PHNs to critically analyse their practice at a higher level than the comprehensive PA; however, additional research is needed to examine this process. PHNs and managers found the dialogue associated with the new PA process helpful or very helpful; however, consensus is needed on identifying the overall

purpose of the PA.

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Recommendations

The recommendations were derived from the qualitative research results, and in discussion with the research team.

Based on the study results, we recommend the following:

Comprehensive PA

• Review the revised comprehensive PA tool with 26 criteria, ensuring consistency with the recently released Public Health Nursing Discipline Specific Competencies Version 1.0 – May 2009 (Community Health Nurses of Canada, 2009).

• Endorse the following definition of competency: “knowledge, skills, and

experience to complete the criteria (College of Nurses of Ontario) with minimal supervision”

(Public Health Agency of Canada).

• Identify expectations for competency for individual service areas/teams.

• Ensure PHNs complete a comprehensive PA prior to an abbreviated PA to promote sufficient grounding in the CCHN Standards and the PHCC.

• Recommend managers and PHNs use a formative approach to performance appraisal during scheduled ongoing meetings to promote dialogue, rather than a summative approach completed once every two years.

Future Research

• Complete further testing on the narrative guidelines and on PHNs’ approaches to the resolution of barriers in implementing the CCHN Standards and the PHCC.

• Complete further work with managers of PHNs and administrators in identifying administrative perspectives of implementing the revised PA, especially with regard to obtaining consensus with regard to the purpose of the PA.

• Develop an orientation package around the comprehensive PA for both PHNs and managers.

• Acquire funding to complete further testing on revised comprehensive PA and

abbreviated PA with a broader study population.

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References

Benner, P., (1984), From novice to expert. Addison Wesley: Sydney, Australia.

Community Health Nurses Association of Canada. (2008). Community health nursing standards of practice (Revised 2008). Community Health Nurses Association of Canada. Toronto: ON.

Community Health Nurses Association of Canada. (2009). Public health nursing discipline specific competencies version 1.0 – May 2009. Community Health Nurses Association of Canada. Toronto: ON.

Innovative Solutions and Health Plus, & Underwood and Associates. (2009). Mapping between the community health nursing standards of practice & the public health core competencies. Public Health Nursing in Canada, March 31, 2009.

Jarvis, P. (1992). Reflective practice and nursing. Nurse Education Today, 12, 174-181.

Longenecker, P.D. (1998). Managing nurse managers. What is the secret? Nursing Management, 29, 35-38.

Mays, N., & Pope, C. (1995). Rigour and qualitative research. British Medical Journal, 311, 109-112.

Morse, J. (1994). Designing funded qualitative research. In N. Denzin & Y. Lincoln (Eds.). Handbook of qualitative research, (pp. 220-235). Thousand Oaks, CA: Sage.

Public Health Agency of Canada. (2007). Core competencies for public health (Release 1.0). Public Health Agency of Canada. Ottawa, ON.

Schön, D. (1983). The reflective practitioner: How professionals think in action. New York: Basic Books Inc.

Spence, D.G., & Wood, E.E. (2007). Registered nurse participation in performance appraisal reviews. Journal of Professional Nursing, 23(1), 55-59.

Teddlie, C., & Yu, F. (2007). Mixed methods sampling. Journal of Mixed Methods Research, 1(1), 77-100.

Whelan, L. (2006). Competency assessment of nursing staff. Orthopaedic Nursing, 25(3), 198-202.

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Appendices

Appendix A: Comparison of Categories: Previous vs. New Performance Appraisal ... 25 Appendix B: Use of Human Subjects – Ethics Approval Notice... 27 Appendix C: Survey Research Letter of Information/Consent Form (PHN) ... 29 Appendix D: Survey Research Letter of Information/Consent Form (Manager)... 33 Appendix E: Public Health Nurse Recruitment Poster... 37 Appendix F: Comprehensive Performance Appraisal (new)... 39 Appendix G: Abbreviated Performance Appraisal... 53 Appendix H: Public Health Nurse/Manager Feedback Form ... 67 Appendix I: Examples: Comprehensive PA Tool – Family Health Services... 71 Appendix J: Examples: Comprehensive PA Tool – Environmental Health and Chronic Disease Prevention Services and Communicable Disease and Sexual Health Services... 83 Appendix K: Narrative Guidelines ... 101 Appendix L: Revised Comprehensive PA Tool... 103

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Appendix A: Comparison of Categories: Previous vs. New Performance Appraisal

Old Performance Appraisal New Performance Appraisal (CCHN Standards)

• Professional Skills/Program Responsibilities (Health Promotion/Disease and Injury Prevention/Health Protection

• Promoting Health

• Communication • Building Individual/Community Capacity

• Leadership/Teamwork • Facilitating Access and Equity

• Accountability • Building Relationships

• Demonstrating Professional Responsibility and Accountability

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Appendix B: Use of Human Subjects – Ethics Approval Notice

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Appendix C: Survey Research Letter of Information/Consent Form (PHN)

Survey Research Letter of Information/Consent Form

Adapting the Performance Appraisal System for Public Health Nurses to Reflect Expertise in Applying the Canadian Community Health Nursing (CCHN) Standards and the Public Health Core

Competencies (PHCC)

Members of the Research Team:

Dr. Pat Sealy Ms. Diane Bewick

Ms. Irene Buckland Foster Ms. Laura Dueck

Introduction

You are invited to take part in a research study. Before agreeing to participate in this study, it is important that you read and understand the following explanation of the proposed study procedures. The following information describes the purpose, procedures, benefits, and risks associated with this study. It also describes your right to refuse to participate or withdraw from the study at any time. It is important that you understand the research study and its risks and benefits before deciding to participate. This understanding is known as the informed consent process. If you have questions about the research or about the informed consent process, please ask a member of the research team for clarification. Also, please ensure that all of your questions have been answered to your satisfaction before signing this document.

Purpose

The purpose of this research is to evaluate whether revisions to the public health nurse’s (PHN) performance appraisal (PA) reflects the self-reported expertise of the PHN in applying the Canadian Community Health Nursing (CCHN) Standards and the Public Health Core Competencies (PHCC).

Procedures

This research requires you to participate in two six-hour workshop sessions, held at the Middlesex-London Health Unit during regular work hours. The first workshop will outline the research objectives. As a part of this session, you will be given the opportunity to complete the comprehensive and abbreviated

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of eight to ten nurses, in which you will have the opportunity to discuss the practice examples and narratives in reference to the CCHN Standards and PHCC. The focus group sessions will be facilitated by two Research Associates. The focus group sessions will be audio-taped and a co-moderator will take field notes to identify key ideas/themes. You will then meet with your manager and review this

information to assess your actual performance for this appraisal period, and complete the PHN/Manager Feedback Form on the PA process.

After, participating PHNs will be invited to a second workshop to review and validate the findings of the qualitative analysis to-date. Each PHN will be asked to document a second narrative, this time focusing on a situation in which they faced barriers to practice and document the facilitators that addressed the situation.

Risks

There are few risks associated with your participation in this research. Thoughts on sensitive professional issues may be discussed, which may cause some emotional discomfort. A risk to

confidentiality does exist, since participants will be openly discussing topics and issues, and individuals may be identified by specific project or event.

Benefits

Participants will benefit from the opportunity to contribute to the identification of barriers and facilitators in implementing CCHN Standards and PHCC, as well as the development of a meaningful PA system;

however, you may not benefit personally from your participation.

Confidentiality

All information obtained during the study will be held in strict confidence. Each PHN will be given a code number, which will be stored in a separate locked area from the coded PAs and transcripts. No names or identifying information will be used in any publication or presentation. The focus group sessions will be audio-taped, in which participants will be identified only by a code number; no names or identifying information will be included on the transcripts. Direct quotes from the sessions may be used in the

reports, but will not be accompanied by identifying information. The researchers will receive a copy of the comprehensive and abbreviated PA, as well as the PHN/Manager Feedback Form, using code numbers and demographics (education, years of experience, years at the Middlesex-London Health Unit, and

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Compensation

Refreshments will be provided during both workshops.

Results

Results will be made available to all participants after analysis.

Questions

If you have any questions about the study or your involvement, please contact a member of the research team:

Dr. Pat Sealy

Nurse Researcher/Educator REED Services

50 King Street

London, ON N6A 5L7

Tel: 519-663-5317 Ext. 2369 Email: [email protected] Ms. Diane Bewick

Director

Family Health Services 50 King Street

London, ON N6A 5L7

Tel: 519-663-5317 Ext. 2425 Email: [email protected] Ms. Irene Buckland Foster

Tel: 519-663-5317 Ext. 2425 Email: [email protected] Ms. Irene Buckland Foster

In document Middlesex-London Health Unit (Page 24-79)