Download Neonatal Competency (Word 2003)

RN Competency Form: Newborn
Competence Verification & Learning Guide: Facility
Name (learner)
Date Initiated
Unit
☐RN  ☐LPN  ☐Recent Graduate  ☐Experienced Nurse  ☐New to Specialty  ☐Traveling Nurse 
Note: for LPN practice guidelines, see state nursing statutes & regulations
The preceptor will initial each competency when he/she, as preceptor and colleague, feels safe in allowing the learner to deliver this aspect of
care without direct supervision.
Self-Assessment: 1 – Identified Limitation (little or no experience); 2 – Capable (familiar but may need assistance); 3 – Independent - can
perform these tasks safely; 4 – Proficient - extensive experience *For further information, see instruction sheet at end of this form.
References
IA. The learner will incorporate relevant assessment & intervention (A&I) skills in delivery of care to include the following:
Prepare for birth of newborn per policy
ensure 2 NRP providers present for birth
Learning Guide #
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Preceptor initials
Verification method
& facility specific requirements
Learner initials
Required Competencies
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Date all met
Self-assessment
Learning Guide follows competency pages and contains items for each competency that need to be reviewed based on learner’s experience and unit
need, they include reminders of important teaching points that may otherwise be missed.
IA 1
Facilitate safe birth
assist provider with delivery
perform APGAR scoring
IA 2
Stabilize newborn at birth
perform suctioning, positioning to maintain clear
airway
provide continuous respiratory monitoring
perform thermal stabilization
institute glucose monitoring protocol
provide close monitoring through transition period
Conduct initial newborn assessment (RN only)
determine gestational age
complete all documentation
identify primary needs
recognize abnormals
perform hearing screening
Use newborn equipment safely per manufacturer and
hospital guidelines
IA 3
Administer the following to newborns per policy:
ophthalmic ointment, aquamephyton, hepatitis B
vaccine, hepatitis B immune globin (all IV meds--RN
only)
IA 6
IA 4
IA 5
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 1
References
Learning Guide #
Preceptor initials
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Learner initials
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Verification method
& facility specific requirements
Date all met
Self-assessment
RN Competency Form: Newborn
Required Competencies
Implement emergency measures per guidelines
IA 7
Apply fluid management principles in the care of the
newborn per policy (IV RN only)
IA 8
Provide newborn care per policy
initiate bilirubin protocol
care for umbilical cord
institute newborn safety policies
care for circumcision site
promote parent bonding with infant
Feed infant per protocol
position newborn safely
ensure proper placement for tube feeding
breast pump
IA 9
Uses guidelines to set up for and assist with procedures
on the newborn
assess pain with newborn pain scale
provide medication and comfort measures based on
newborn need (IV meds—RN only)
Complete discharge of newborn per guidelines
IA 11
Prepare high risk newborn for transport
IA 13
Admit to Special Care/NICU
IA 14
IA 10
IA 12
Comments/alternative learning plans:
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 2
RN Competency Form: Newborn
All preceptors are to sign & initial below. Ideally new graduates should have only one to two preceptors for the entire orientation.
Preceptor Signature
Initials
Preceptor Signature
Initials
Signatures at completion of preceptorship/orientation:
Preceptee/orientee
Date
Primary Preceptor
Date
Manager
Date
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 3
RN Competency Form: Newborn
LEARNER GUIDE: Reference the items in the right-hand column that need review.
IA. The learner will incorporate relevant assessment & intervention (A&I) skills in delivery of care to include the following:
IA 1
Prepare for birth of newborn per policy
Review room set up: emergency equipment, warmer, suction, emergency
- ensure 2 NRP providers present for birth
medication sheet, etc.
Orient to crash cart checks
IA 2
Facilitate safe birth
Review contents and use of equipment in newborn crash cart
- assist provider with delivery
Review maternal history to determine risk factors
- perform APGAR scoring
Group Beta Strep (GBS)
IA 3
Stabilize newborn at birth
Review procedure for newborn stabilization & guidelines used, critical
- perform suctioning, positioning to maintain clear airway
observations, use of O2, etc.
- provide continuous respiratory monitoring
Review thermoregulation devices (overhead warmers, isolettes, heel warmer,
- perform thermal stabilization
blanket warmer, bundling/hats, Kangaroo care)
- institute glucose monitoring protocol
Review hypoglycemia protocol
- provide close monitoring through transition period
Review transition protocols
Review Neonatal Abstinence Syndrome (NAS)
IA 4
Conduct initial newborn assessment (RN only)
Review gestational age scoring and significance, normal findings for newborn
- determine gestational age
and guidelines for action following and abnormal findings (including
- complete all documentation
meconium staining).
- identify primary needs
- recognize abnormals
- perform hearing screening
IA 5
Use newborn equipment safely per manufacturer and
Review equipment manuals and practice on the following as needed: bilibed,
hospital guidelines
biliblanket, bili lights, bili meter, isolette, transcutaneous bilimeter, infant and
diaper scales, glucose monitor, Ohio Care center, cardiac monitor, pulse
oximeter, auto syringe, neo puff
IA 6
Administer the following to newborns per policy:
Review medication protocols, pharmacist’s role, parent teaching, parent
ophthalmic ointment, aquamephyton, hepatitis B
declination policy
vaccine, hepatitis B immune globin (all IV meds--RN
only)
IA 7
Implement emergency measures per guidelines
Review emergency response per NRP guidelines
Review administration of fluids to newborn including types of fluid commonly
IA 8 Apply fluid management principles in the care of the
newborn per policy (IV RN only)
used, calculating mL/kg for day 0 to day 5, documentation
IA 9
Provide newborn care per policy
Review hyperbilirubinemia protocol, provider notification and documentation
- initiate bilirubin protocol
(competency)
- care for umbilical cord
Review cord care guidelines/teaching
- institute newborn safety policies
Review identification and abduction prevention policies
- care for circumcision site
Review parent teaching re: cares and newborn activity expectations and how to
- promote parent bonding with infant
assess bonding
IA 10 Feed infant per protocol
Review feeding policies for breast, bottle and tube feeding, teaching parents,
- position newborn safely
I&O measurement
- ensure proper placement for tube feeding
Review procedure for tube feeding in neonates & dietician’s role
- breast pump
IA 11 Uses guidelines to set up for and assist with procedures
Review guidelines for the following: circumcision, septic workup including LP,
on the newborn
UA/UV/IO/IV placement, mechanical ventilation
- assess pain with newborn pain scale
Review protocol for newborn pain management (Sweetese, medications, pain
- provide medication and comfort measures based on
scale)
newborn need (IV meds—RN only)
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 4
RN Competency Form: Newborn
LEARNER GUIDE: Reference the items in the right-hand column that need review.
IA 12 Complete discharge of newborn per guidelines
Review immunization requirements, state required testing and parent
declination policy, hearing screening (6080.066), newborn metabolic
screening, referrals for high risk family/infant
Review parent teaching re: infant care and follow up, car seat, water and air
temperature, “back to sleep”, milk storage, etc.
Infant Relinquishment
Outpatient weight checks: policy, scheduling
IA 13 Prepare high risk newborn for transport
Review protocol
S.T.A.B.L.E.guidelines
IA 14 Admit to Special Care/NICU per guidelines
Review protocol
Other facility specific items to cover:
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 5
RN Competency Form: Newborn
REQUIREMENTS: All nurses will complete these competencies upon hire. Some competencies may be reviewed annually. This form
follows the Competency Outcomes and Performance Assessment (COPA) model.
PRECEPTEE/LEARNER INSTRUCTIONS:
Complete self-assessment: Rate your skill in each area to identify the areas where you need additional experience, access to
teaching resources, and/or lab practice. Discuss your results with your preceptor to help establish a plan and goals for your learning
experience and to aid in choosing patient assignments. Scoring per instructions at the top of page 1.
PRECEPTOR INSTRUCTIONS:
A. Review self-assessment with preceptee/learner to establish plan.
B. Required Competencies: The specialty area competency forms are required for independent practice on this unit. This column
represents the Alaska Statewide required competencies per ACE-HC and should not be altered. The preceptor will sign each one off
when he/she, as preceptor and colleague, feels safe in allowing the preceptee/learner to deliver this aspect of care without
direct supervision.
C. Verification Method & Agency Specific. Document comments/check marks for the competency and any agency specific
requirements. Verification methods include:
1. Demonstration – Preceptor watches learner perform task/procedure in safe, capable manner in a simulated lab or computer
setting or as part of direct care performance. The expectation for new graduates is that they demonstrate as many of the
competencies as possible.
2. Test – Learner passes a test provided by the facility to measure competence for this skill. (Minimum passing grade indicated.
Initial only after test passed.)
3. Module –Learner has completed a training tool (computerized or written module, class, video, etc.) provided by the facility to
measure competence for this skill.
4. Verbalization - Learner explains to the preceptor the process and/or planning that evidences safe, reliable knowledge base.
This may include case scenarios, discussion, and/or description of plan.
NOTE: some competencies may have the verification method specified per facility guidelines (e.g. “test only”)
Record N/A and initials only for items that never apply to this learner’s role or performance.
D. Sign-off: Sign and date when all elements of the competency are met. If unable to sign off an area due to patient population issues
or learner needs more time, document a plan in the comments section at the end of the form. Discuss alternative ways of meeting
the requirement(s) as well as any additional time needed with the nurse manager and/or nurse educator. All preceptors assisting in
orientation of a new staff member/intern must sign and initial in the signature chart at the end of this document.
E. References: Competencies should be met in accordance with these. Add your facility approved references here.
F. Learning Guide: These are memory ticklers. The amount of time spent on each of them depends on the learner’s experience. New
graduates will likely need time on almost all of the areas listed.
REFERENCES COLUMN: List foundational documents to support the learning experience and to use as the official measure by which
the competencies are assessed. The ACE-HC group recognizes the following as sources for evidence based practice that can be
included in the reference list along with local policies, procedures and forms: Perry & Potter, Elsevier/Mosby, Lippincott, Kozier & Erb,
ANA, nationally recognized hospital related regulatory organizations (CLIA, CDC, CMS, JC, etc.), and specialty nursing organizations’
scope, standards and core curricula. This column’s content may be changed to be facility specific.
NOTE: ACE-HC competency forms are intended to be used between facilities within Alaska.
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 6