Guest post: Patience required for onboarding and mentoring new CDI staff

By Sonja Racke, RN, BSBM, CPC, CRCR for the ACDIS CDI Blog

How many of you remember the nursing days of “see one, do one, teach one?” Of having Nurse Wretched (not Ratchet) hanging over your shoulder while inserting your first Foley catheter in a female grumbling “just look for the blinking eye” and then yanking it out of your hand and saying, “I’ll do it” in her most demeaning voice ever?

How many remember your first unit orientation as a trial by fire process commandeered by a gray-haired nurse in her cap, tight hose, and white nursing dress that was usually three sizes too small?

Whether your first experience as a floor nurse was five or fifteen years ago, I think every nurse has a horror story or two to tell about their first nursing job. Lots of nightmares were created over a new graduate’s first floor experience.

Many of us come to CDI as experienced nurses, years of tasks, situations, and conversations under our belts and ready to charge full force into CDI. We are perfectionists, we are impatient because we have learned patience can be detrimental to our patients, we are head strong and can be demanding, both of our careers and our co-workers.

Coming into CDI straight from the units or floors is like turning the new associate’s world sideways on its axis. Nothing about learning this role relates to learning patient care. It is a mentally intense process, not a physically intense process and requires a completely different approach than seeing, processing, and intervening as we did on a unit. The stakes, although very different, remain high, but not with the same potential outcomes from unsuccessful interventions. My favorite idiom with my team is, “No one dies from a CDI specialist’s mistake.”

Where nursing experience and maturity are significant attributes for a new CDI specialist, consideration needs to be taken as their entire approach to nursing shifts when moving to CDI. The critical thinking skills are now used assessing and analyzing a patient they never see. They are relying on the physician to paint that picture, no longer able to walk into a room and realize the patient is a train wreck. They must be able to perceive that from the chart—and know how to get the physician to portray that if the chart doesn’t. Their communication skills are challenged as they are questioning what a physician writes, in the form of a query.

Intimidation and insecurity roll back through their minds as what was once old is suddenly brand new again and different. Remember that 2 a.m. phone call you had to make asking the surgeon if he really wanted you to give 50mg of morphine IV push (instead of meperidine)? How did that work out for you? Remember transitioning to EHRs from paper charts? Did that happen in 2-3 months? Or were most of you still struggling with the nuances 6-7 months into it? The technology and the approaches are all new, and quickly bring insecurity to even the most steadfast nurse.

When I tell potential candidates in an interview that in CDI our team has at least a one-year ramp up before they are held accountable for full productivity, you can see the confusion on their faces. After all, this is just about reading a chart and helping coding, right? When I tell new hires to ASK, always ASK, it is clear this is in direct contradiction to their former work processes.

Onboarding new CDI specialists from a hospital environment requires a slow, methodical, coaching, and transformative approach. This approach, in most cases is a change for a new CDI specialist, and simply going through the onboarding process is culture shock. As a mentor and leader, we need to be nurturing, motivational, and encouraging.

The learning curve with CDI is a huge one for a nurse. Most come to CDI not even understanding what a DRG means, never realizing their former nursing notes are read! When a candidate indicates they are looking for a Monday through Friday desk job and can no longer handle shift work and patient care, I recommend they pursue teaching or accounting. They are easier. I have never used my “nurse brain” with this intensity before coming to CDI. The only thing desk jobs and CDI have in common is the desk.

Managing and mentoring a new CDI specialist requires kid gloves, patience, repetition, and perseverance, and an understanding that your reward of seeing that light come on in your mentee’s eyes may take a long while. CDI is a teach-a-man-to-fish career. Doing the tasks for them or fixing their mistakes for them is a practice for failure. A new CDI specialist learns nothing by having their mentor go behind and make their queries compliant or adjust their physician response categories and impacts. A CDI specialist becomes successful and proficient by being taught how to fish, not by being handed the fish for a short-term solution.

A CDI specialist needs to understand not just the “why” behind the actions, but the how and even the when. Onboarding a new CDI specialist is a testament to the department’s educators and to the onboarding process. Here are a few lessons learned and best practices in no certain order (you may have several others on your list and that is great!):

  1. Have a structured calendar of “events” and a pre-defined timeline for onboarding. It must also be flexible enough to assure the new CDI specialist is not bored awaiting the next thing or left behind because of needing additional assistance on an area.
  2. Be patient and flexible with the pace (both mentor and mentee) and constantly seek and give feedback.
  3. Have an objective checklist that is task-based for both the CDI specialist and educator/mentor to use.
  4. Have a structured yet flexible, consistent process for assuring all CDI specialists receive all the necessary tools, resources, and education so there is no inconsistency between new hire A and new hire B.
  5. Be patient and flexible with the pace (both mentor and mentee) and constantly seek and give feedback.
  6. Use a variety of subject matter experts to instruct the new CDI specialist. Different viewpoints create an environment where a CDI specialist can tailor their own approach to their workload and assure all are consistent in policy and procedures.
  7. Have a team of educators that is dedicated or focused on new hires; and train them appropriately.
  8. Be patient and flexible with the pace (both mentor and mentee) and constantly seek and give feedback.
  9. Have their desk/equipment and access ready on day one.
  10. Approach onboarding with the style of educating that works best for the new associate as often as possible.
  11. Be patient and flexible with the pace (both mentor and mentee) and constantly seek and give feedback.
  12. Reduce or eliminate productivity requirements for the associate mentoring the new hire.

Yes, there is a reason one of those appears four times in this list. It has that much importance. I doubt that you will ever see patience on an onboarding list of best practices; however, I firmly believe that as nurses, it is a trait we need to reestablish in ourselves after years of demanding immediate results both in our communications and our actions. Patience was certainly not something a physician understood as you were taking your time to draw up epinephrine when the patient’s heart rate was 16.

Remembering the difficulty in transition you and/or others may have gone through when moving to CDI certainly pads the experience for a new associate, as well as recognizing the education and introductive approaches need to be significantly different for CDI than ICU. CDI is not a “do one, see one, teach one” field. It is most definitely a teach-a-man-to-fish career..

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