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When Deborah “Deb” Spencer, RN, joined UVA Health Children’s Neonatal Intensive Care Unit (NICU) 22 years ago, she immediately felt at home. “I knew when I walked in the door, I would stay there until I retired, and that proved true,” she recalls.

For Spencer, who now works in the Intermediate Care Nursery, UVA Health has been more than a place of work. It's been a place of happiness, job satisfaction — and heartbreak. Her son, Daniel, was diagnosed as an infant with cystic fibrosis.

Throughout Daniel’s life, Spencer found comfort in the quality of care he received from UVA Health. Daniel’s health declined in recent years, and he passed away in August 2024 at the age of 43. “The staff took very good care of Daniel in his final days, and I will be forever grateful to them,” shares Spencer, who later nominated one of Daniel's nurses, Morgan Stewart, RN, for a DAISY Award, and supported Stewart as she was surprised with the award.

TSAM® A New Approach to Learning in the NICU

Passionate about investing in new nurses, Spencer says being Daniel’s mom shaped the way she precepts. “I love imparting things I’ve learned throughout my nursing career and as a mom, grandmother, and parent of a sick child,” she says.

This year, she and Taylor Mackrell, BSN, RN, became two of the early adopters of the Tiered Skills Acquisition Model (TSAM®), a new model of orientation being piloted in the NICU. TSAM® uses a phased orientation — moving nurses from observation to hands-on practice and, eventually, to full independence.

“Deb and Taylor exemplified the best of how this new approach supports competency development,” describes Kathleen Rea, DNP, APRN, ACNS-BC, PCCN, CNL, Adult Acute and Progressive Care Clinical Nurse Specialist, who has supported the pilot from behind the scenes.

The TSAM® model will be supported by Kahuna, a digital competency platform that helps track an orienting nurse’s progress. “I’m going to be honest, when I first got the Kahuna training email, I thought it was a scam,” Spencer says with a laugh. As she started learning about it, though, she saw how TSAM® is layered into the tool — which makes it feel less like checking boxes and more like building skills in a clear order. “This model really has a flow to it,” Spencer explains.

Spencer and Mackrell: A Perfect Match

The phased structure of TSAM® helped Spencer when she began precepting Mackrell, a new graduate nurse who joined UVA Health in March 2025 after completing a NICU summer externship. Mackrell had always known she wanted to work with children — a calling shaped in part by a relative's journey with hypoplastic left heart syndrome.

That interest deepened during a clinical experience with UVA Health Continuum Home Health, where Mackrell spent the day caring for a young patient with cerebral palsy. “By the end of the day, there was nothing else I wanted to do,” she remembers. A year later, Mackrell witnessed a team prepare a premature baby for transport to UVA Health. "I remember watching the team put the lines in before the helicopter came,” she describes. “I thought it was the coolest thing I had ever seen in my life and knew that was exactly what I wanted to do.”

When Mackrell started her job in the Intermediate Care Nursery at UVA Health, Spencer became her first preceptor. They immediately clicked. “I saw a level of maturity in Taylor,” recalls Spencer. “I saw brightness and love, and she just exuded all the qualities that I find important in a nurse.”

Mackrell felt positive about the fit, too. The unit's learning curve is steep, with babies on CPAP, 24-week preemies, and post-operative patients all requiring different levels of care. “There was never a time where Deb made me feel dumb for not knowing something,” Mackrell explains. “Even when things are chaotic and babies are screaming, she is the nurse who says, 'We’ll get through it!’ She is a calming presence.”

Building Skills, Step by Step

As Mackrell’s orientation progressed, TSAM® helped her build skills step by step. She started by observing, then slowly took on more tasks until she was able to care for patients more independently.

Recently, Mackrell began orienting in the NICU. “I had ICU experience from my externship, but it’s a whole different scene when you’re the nurse now, versus the student,” she says. Even with the higher acuity, Mackrell feels supported by the nurses guiding her, including Kathleen Battle, RN; Jessica "Jess" Y. Morris, RN; and Heather Santiago, RN. “I hit the jackpot with preceptors!” she declares.

For Spencer, helping nurses like Mackrell grow is a meaningful way to spend the final years of her career. “I like to see people come into nursing because they have a desire to learn, a passion for helping people and families, and a commitment to alleviating some of the suffering in the community,” she says. “I enjoy bringing up this new generation of nurses and nurturing their passion for nursing.”

Spencer advises all nurses to embrace their “why” like she and Mackrell do: “A lot of people have their own personal stories of why they chose nursing,” she says. “I think it's important that we stay connected to that, because it keeps us grounded and keeps our humanity and compassion in what we do.”