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Authors

  1. Bullock, Lynn Marie DNP, RN, NE-BC
  2. Groff Paris, Lisa DNP, RNC-OB, C-EFM
  3. Terhaar, Mary DNSc, RN

Abstract

A new outcome-focused orientation model was developed in response to poor preceptor satisfaction and a high nurse graduate turnover. Progression through the program was determined by the orientee's accomplishment of the target or strategic outcomes across seven progressive phases-not by time and budget. At the conclusion of the first year, decreased turnover, increased preceptor satisfaction, and substantial financial savings were documented.

 

Article Content

One fourth to two thirds of new graduates will choose to leave their first position within a year of hire (Block, Claffey, Korow, & McCaffrey, 2005; Godinez, Schweiger, Gruver, & Ryan, 1999; Olsen, Nelson, & Stuart, 2001). Literature supports that the primary reason nurses leave their job within the first year of hire is poor orientation (Newhouse, Hoffman, Suflita, & Hairston, 2007). This departure denies them the opportunity to become comfortable, capable clinicians organized and effective in their work. Early departure creates a sense of disappointment among all who invest in the beginnings of new careers and places a financial burden on institutions that hire and then lose this new talent. Graduates who leave at 1 year may return to practice in new settings with new challenges, rules, patients, and colleagues only to begin again at the entry level.

 

Organizations strive to develop systems that will support satisfying, long-term career development (Schoessler & Waldo, 2006). Support systems can be effective only if the needs of the current new graduates are met in the context of their views of work, expectations for work-life balance, and focus on personal achievement (Lancaster & Stillman, 2002). Well-designed programs will be sustainable if able to improve experiences and outcomes for patients, preceptors, managers, and new graduates alike.

 

This article has two purposes: to introduce a program of support for new graduates based on feedback from focus groups regarding nursing orientation and to describe outcomes at the close of its first year.

 

BACKGROUND

New graduates are knowledgeable about the science that supports practice, are comfortable using technology, and are capable of gathering information to help patients and families understand conditions, medications, and plans of care (The Advisory Board, Nursing Executive Center, 2008). Although motivated to do their best for patients, new graduates require support to establish therapeutic relationships with patients and families and effectively manage conflict and time. They need to learn to prioritize complex competing demands and to recognize situations requiring additional support or resources for safe, effective care (Olsen et al., 2001).

 

Experienced nurses work alongside new graduates every day, sharing responsibilities and relying on them as colleagues. They understand that new graduates need guidance, support, constructive feedback, acceptance, and inspiration. Experienced nurses need these less experienced colleagues to succeed and become proficient partners with whom to provide care.

 

Nursing administrators and executives need to support the integration of new graduates as competent staff members every year yet consider the new graduates far from prepared for the work place (The Advisory Board, Nursing Executive Center, 2008). They know that during the first year, new graduates will require education, direction, support, and evaluation to ensure safe practice while they develop as professionals. Resources must be allocated to accomplish these objectives in the context of tremendous pressure to hold down cost. Finally, to retain new, bright talent, nurse leaders must plan for a stable work force, grow the next generation of leaders, and realize the full benefit of investment in orientation (Jones, 2004; Pine & Tart, 2007).

 

Edwin Locke's Goal-Setting Theory states that retention of new graduates can be maximized not through monetary incentives or time limits but through development of clear, easily defined goals combined with accurate feedback. Such goals can assist the new graduate by promoting a sense of security and accomplishment in their performance (Beeman, Jernigan, & Hensley, 1999; Locke, 1968).

 

The shortage of bedside nurses appears to have abated as forces in the economy have delayed retirements, brought nonpracticing nurses back into care, and required part-time nurses to bring home full-time pay. This relief will be temporary because the workforce continues to age, baby boomers continue to leave practice to themselves become healthcare consumers, and other careers call would-be nurses away from the bedside to more attractive careers with less risk (Buerhaus, Auerbach, & Staiger, 2009). Although the shortage appears less acute, the number of new graduates entering the workforce fails to keep pace with the rate of expansion in the healthcare industry that is expected to require more than 587,000 new registered nurse positions be filled by 2016 (U.S. Bureau of Health Statistics, 2009). The result will be a 40% shortage by the year 2025 (Buerhaus et al., 2009). The apparent relief is temporary, and effective responses must be sustainable in the context of this fluctuating environment.

 

During the month of February 2009, 27,000 new registered nurse positions were created in the health sector even as 681,000 jobs were eliminated in other segments of the economy (U.S. Bureau of Labor Statistics, 2009). At the same time, new graduates found competition fierce (American Association of Critical-Care Nurses, 2009). This year's new graduates cannot expect to find positions in the specialties, facilities, and communities of their choice as recent graduates could.

 

THE PROBLEM

The challenge is to integrate large numbers of new graduate nurses in ways that promote retention beyond the first expensive year of practice, without compromising care, working the experienced staff members to the point of burnout, or incurring prohibitive expense that inflates healthcare costs. Successful retention will enable hospitals, and the professionals who practice in them, to benefit from the investments made in developing safe, competent nursing colleagues.

 

RESEARCH QUESTION

"Can turnover at the end of the first year be reduced for new graduate nurses by implementing an orientation program designed more precisely to meet new graduate needs?"

 

METHODS

A 5-year program was begun at this community hospital to increase the effectiveness of nursing orientation for new graduates, to establish this facility and its leaders as partners with whom new graduates will choose to develop nursing careers, and to build a capable, committed future workforce for the community.

 

Design

A pretest/posttest quasi-experimental design was used to investigate the effect of the new orientation program on retention of new graduates. Our institutional review board does not require approval for quality improvement projects, and therefore, this study was deemed exempt.

 

Intervention

Focus groups were conducted with new graduates, preceptors, managers, and staff to identify components of orientation considered effective or ineffective and then to identify strategies to increase retention. Content analysis identified five themes that informed orientation redesign. Staff nurses, managers, directors, preceptors, and recent new graduates took part in the redesign. The new program was implemented and repeated, and focus groups evaluated the outcomes.

 

BASELINE DATA

Baseline data were collected to describe opportunities to improve orientation and determine factors that contribute to the loss of new graduates.

 

Quantitative Data

Turnover, vacancy rates, and orientation expenses were all used to establish the need and the targets for performance improvement (see Table 1).

  
Table 1 - Click to enlarge in new windowTABLE 1 Workforce Data for New Graduates per Year From 2007 to 2009

Qualitative Data

Focus groups were conducted with individuals who had a legitimate stake in the orientation process, including educators, preceptors, managers, experienced nurses, and new graduates who had recently completed orientation.

 

BASELINE RESULTS

Five themes were identified in the data, including hopelessness, impropriety, regret, overwhelming responsibility, and failure.

 

Hopelessness: "What's the use?" All participants believed that they were working hard, committed to the new graduates' success, yet losing new graduates anyway. Managers would hire new graduates into vacant positions and then feel frustrated when new graduates left at the end of the first year. Many believed new graduates had no appreciation for the investment made in their careers and preferred to find more mature nurses to hire.

 

Impropriety: "Something isn't right." Preceptors reported they were invested in the success of the new graduates. They advocated on their behalf and worked to manage everything that could encroach on good learning. Preceptors believed managers were asking too much too soon. Staff nurses acknowledged they too pushed new graduates too fast. Preceptors could see the problem developing but felt helpless to stop it.

 

Regret: "I'm sorry!" Preceptors felt burdened with regret. They felt a need to apologize often and to many people. "I apologize to my peers when I cannot run charge and precept at the same time; carry the code beeper and precept at the same time; or carry additional patients and precept at the same time." Preceptors apologized to patients and families when new graduates needed extra time to learn. They apologized to oncoming staff when new graduates needed time to catch up at the end of a shift. They apologized to other disciplines when new graduates needed explanations. Preceptors apologized to new graduates when pressured colleagues were impatient and did not respect their need and right to learn.

 

Overwhelming Responsibility: "It's too much." Preceptors were motivated to serve. They were considered capable caregivers, effective communicators, and good problem solvers who understood both the demands of patient care and the challenges facing the managers on their units. As a group, they shared an informed yet practical view of day-to-day operations. They appreciated the pressures on managers to run units well, deliver quality care, avoid use of agency staff, and contain cost. New graduates voiced frustration regarding the expectations placed upon both them and their preceptor to meet the needs of the unit. They felt rushed and unsupported by current staff of the unit and the manager.

 

Discontinuity: "These younger nurses are different." Preceptors and experienced staff nurses expressed frustration because the nurses entering the workforce are different. They identified that some new graduates expected praise and promotion quickly yet do not reciprocate with commitment to investments made in their careers. The new graduates perceived that nobody was willing to take the time to understand their thoughts and needs.

 

Failure: "It is so frustrating." Despite everyone's best efforts, preceptors, managers, educators, and staff still encountered many new graduates who simply could not practice independently when the allotted time for orientation was completed.

 

 

DEVELOPING THE INTERVENTION: REDESIGNING ORIENTATION

A leadership team conducted a review of the literature and queried peer institutions to identify innovations. Edwin Locke's Goal-Setting Theory was selected as the framework in redesigning the orientation model. The literature supports that employees are motivated by clear goals and appropriate feedback. Performance and motivation are improved by working toward clear, obtainable objectives (Beeman et al., 1999; Locke, 1968). Seventy-five preceptors, recent new graduates, managers, and stakeholders participated in a daylong program where they brainstormed, developed strategies, and drafted tools to be used in developing a goal-driven orientation.

 

The goals for the first year were to establish orientation of new graduates as the collective responsibility of preceptors, managers, and the entire nursing staff; eliminate significant frustrations whenever possible; develop resources to assist preceptors; engage preceptors in ongoing reform; and provide meaningful support and development for this key group of leaders.

 

REDESIGNED ORIENTATION STRUCTURE

The structure, teaching strategies, and resources for orientation were changed. The new structure consists of seven phases, each focused on a set of outcomes that move the learner toward effective professional practice. Meetings including orientee, preceptor, manager, and nursing professional development staff were held to evaluate the attainment of objectives in each phase to determine progression through the phases and track progress toward safe independent practice. The time frames for each phase in the model are not prescriptive but rather estimation based on past experience to assist managers in the budgeting process (see Figure 1). Unit-specific checklists outlining activities that meet orientation goals were developed by the nursing professional development staff to individualize every phase of the new orientation model. To further assist the new graduate and the preceptor in their roles, nursing professional development staff created a resource guide for each phase-based checklist containing supporting evidence that spanned from the simplest pictorial guides for various procedures to complex articles and critical-thinking exercises.

  
Figure 1 - Click to enlarge in new windowFIGURE 1. New orientation structure.

Phase 1, Preparation, begins at hire and involves individualized communication. Hiring managers contact each new graduate and provide the details of his or her first few weeks of work including schedule, contact information, and the name of the preceptor. Preceptors make contact using e-mail, which is a mode of communication familiar and comfortable for most new graduates. The goal is to create a sense of belonging and provide information the new graduate needs to plan life and work.

 

Phase 2, Welcome, Engagement, and Assessment, begins the centralized nursing orientation and involves establishing connections between preceptor and new graduate. They meet off the unit in a setting that provides a relaxed atmosphere to discuss any concerns about orientation and professional goals. This enables the preceptor to evaluate learning style, identify individual learning needs, and plan activities that support each new graduate's success. Because new graduates are often focused on mastering technical skills, skills days are offered during this phase.

 

Phase 3, Intense Support, focuses on providing comprehensive care to a limited set of patients with basic needs commonly admitted to the home unit. Policies, procedures, and protocols are reviewed and used to guide safe patient care. New graduates review medications commonly administered on the unit, identifying side effects, interactions, and implications for care. They also review the most common diagnoses and discuss best practices for these patients.

 

During this phase, preceptor and orientee work four 10-hour shifts, either Monday through Thursday or Tuesday through Friday. They provide direct patient care for 8 hours. The remaining 2 hours is set aside for debriefing, critical thinking, skill development, documentation, or other identified needs. All preceptors and orientees are scheduled to work on Wednesdays, allowing for peer support and professional development. This time can be used for unit-based educators to evaluate performance, complete documentation, refine critical thinking, discuss priorities, practice specific skills, review pathophysiology and pharmacology, and further acculturate new graduates.

 

During Phase 4, Increasing Independence, the preceptor increases the challenge. Preceptors introduce patient acuity by calling attention to potential risks and complications and help the new graduate plan for the unexpected.

 

During Phase 5, Increasing Patient Load, the preceptor increases the challenge by increasing the patient load. Preceptors coach new graduates as they learn organization and prioritization for a larger volume of patients as they plan, organize, prioritize, and independently perform skills.

 

Phase 6, Increasing Acuity, is focused on providing care for patients with complications and complex conditions or treatments. The size of the assignments is reduced so the new graduate can be exposed to caring for patients who encounter the most frequent or highest risk complications seen on the unit. They learn about the importance of surveillance, rescue, resources, teamwork, and judgment.

 

Phase 7, Independent With Feedback, focuses on each new graduate becoming autonomous with coaching from the preceptor. This is the opportunity to put it all together, to receive supportive feedback, and to build confidence. Everything focuses on the development of time management, prioritizing, and critical-thinking skills. Preceptors are encouraged to allow the graduate to experience the feeling of getting behind without allowing risk for patients. Experiencing the consequences of poor time management can be a powerful teacher and motivator.

 

The next step is resourced practice. Graduates have completed orientation but have access to resource nurses available on all shifts to assist with critical thinking, skill mastery, moral support, and celebrations. Unit-based educators were made available during the day, and mentors were hired for the night shift and weekends. These mentors were not counted in staffing numbers. Their focus was to make rounds and provide support to new graduates whose orientation was complete.

 

IMPLEMENTATION OF NEW TEACHING AND LEARNING STRATEGIES

New strategies were developed for all aspects of the orientation process. Attention was focused on improving communication, collaboration between nursing recruitment and unit management, preparation for arrival of the new graduates, and development of phased activities, structures, and supports based on specific learning objectives; building resources for use by preceptors and new graduates; promoting self-directed learning; and introducing new graduates to the many units, departments, disciplines, and teams critical to providing quality care. Together, these strategies formed the base for the refined orientation program.

 

Nursing professional development staff designed a toolkit to assist the preceptors. New graduates are accustomed to preparing for clinical, and the new program for orientation used that strategy to increase knowledge and comfort in the new setting. Pharmacy records were analyzed, and lists of the most frequently administered medications on each unit were developed so graduates could prepare for safe, informed medication administration. Lists of the most common admitting diagnoses for each unit were developed to enable the graduates to prepare for effective practice.

 

The most commonly used policies for each unit were identified and included in the preceptor toolkit to ensure safe patient care. Additional policies were introduced and reviewed with new graduates as they progressed throughout the phases of their orientation.

 

Because, sometimes, conditions on the unit do not match the new graduate's learning needs, a set of field trips was planned. New graduates visited units to which patients were referred and from which patients were received. Learning objectives and resource people were identified so new graduates would make connections and develop an understanding of and value for the work on these collaborating units.

 

New graduates were hired in cohorts so each had a peer group they knew well in the first few years at the bedside. Cohorts were assembled weekly for 3 weeks, then biweekly twice more, and again in 6 months for networking, coaching, and support.

 

RESULTS

Qualitative Findings

Focus groups were repeated and the following themes emerged:

 

"This is actually working better" (formerly hopelessness: "What's the use?"). Preceptors remained hardworking and committed to the new graduates, the managers, the units, and the quality of care. Hopelessness was not relevant in the follow-up focus groups.

 

"This feels better" (formerly impropriety: "Something isn't right"). The theme of impropriety did not persist. Some units faced operational challenges resulting in the need for some adaptations to the original plan, but managers and preceptors reported higher satisfaction with their work to support the new graduates.

 

"We are working on this" (formerly regret: "I'm sorry!"). The burden of regret was not expressed in the follow-up groups. Instead, they spoke with pride about encounters with new graduates.

 

"It's fine" (formerly overwhelming responsibility: "It's too much"). Preceptors identified that the tools, the phases, and the shared accountability made the orientation more manageable. They voiced excitement that they "finally had time to teach." New graduates did not feel rushed or overwhelmed by the patient assignments. Preceptors and managers were confronted with challenges during implementation but spoke about being able to resolve them within the framework of the new orientation.

 

"Younger nurses are different, but this seems to help" (formerly discontinuity: "These younger nurses are different"). The generational differences were more understood and accepted. The preceptors stated that the time provided to review learning needs and to plan the orientation helped them develop a trusting relationship.

 

"Success" (formerly failure: "It is so frustrating"). The theme of failure did not persist. Preceptors, managers, and educators no longer voiced frustration at the loss of new orientees.

 

 

Quantitative Findings

Annual new hires decreased by 51% over the study years from 253 in 2007 to 128 in 2009. During the same period, new graduates decreased in actual numbers from 45 to 38 but increased as a percentage of total new hires from 18% in 2007 to 30% in 2009 (see Table 1). The total vacancy rate declined between 2007 and 2009 from 8.3% to 0.7%, and total nurse turnover declined as well from 19% to 11.6% (see Table 1).

 

New graduate turnover has decreased each year after the implementation of the revised orientation program. During the first year (2008), new graduate turnover decreased by 50%, from n = 14 to n = 7. The same improvement was found the following year (2009), when new graduate turnover decreased to a rate of zero (see Table 1).

 

The return on investment realized through the implementation of this program was calculated using the cost of turnover and the cost of the previous orientation program compared with the new model. Orientation using the new model increased cost per new graduate by $1,220. Nonetheless, this overall expense of orienting new graduates was fully recovered in the savings accomplished through retention at the end of the first year.

 

The cost of new graduate turnover is estimated at 1.5-2 times their annual salary (Block et al., 2005). The new graduate turnover rate within the first year of hire was 6% in 2007 but decreased to 1% in 2008 (see Table 1). The cost of new graduate turnover was $1,053,000 in 2007. Ninety- seven new graduates were hired during the study period under the new model, increasing the cost of orientation by $118,340. However, this expense is well below the cost of new graduate turnover.

 

DISCUSSION

There was clear agreement that orientation for new graduates had not been effective, and comprehensive redesign was required. One strength of this project was the extensive attention paid to perceptions and concerns of recent new graduates, preceptors, leaders, and staff. The qualitative approach was used to assure meaningful engagement and participation of these key stakeholders in an important change process.

 

Ten-hour shifts were found to work well as an instructional strategy. Scheduling 4 days in succession allowed consistency in assignments and opportunity for coaching, feedback, and remediation. New graduates were able to observe progression of patients throughout the hospital stay, and preceptors were able to observe critical thinking over time. This staffing pattern introduced challenges for managers and added expense.

 

The new orientation model required both a shift in the way patient assignments were made and providing time away from direct patient care for debriefing and critical-thinking exercises. Although clearly preferred by nursing professional development staff, implementing 10-hour shifts proved difficult for preceptors and managers alike. The in-house float pool was intended to cover the 2-hour gap, but the solution was imperfect as few people wanted to cover such a short time. As a result, it was used strategically during the orientation program when teaching and coaching were important. Twelve-hour days were used when organization, time management, and collaboration were emphasized. Some preceptors modified the plan, accomplishing the goals and requirements of the new orientation model in a variety of ways. For example, some preceptors conducted their debriefing and/or critical-thinking exercises at the beginning of the shift to better accommodate the unit's patient flow. Others maintained 12-hour shifts and conducted their debriefing and/or critical-thinking exercises for 4 hours on a separate day. Preceptors believed these modifications enhanced the orientee's organization and time management skills.

 

CONCLUSIONS

This work was conducted in the context of a significant recession, and market conditions could not be controlled. As a result, it is impossible to establish a clear causal relationship between the orientation program and reported outcomes. Market conditions may have caused new graduates to stay in their first position until the market softens. Regardless, improved retention rates among new graduates are impressive and data support the success of the program.

 

Even though the cost to the institution of this new orientation model was just over $100,000, turnover savings exceeded $1,000,000. Certainly, the methods bear replicating. When the market recovers, the nursing shortage can be expected to resurge. Every nursing service will be wise to prepare to effectively welcome, orient, and retain bright, talented new graduates. This program is one strategy that may prove helpful.

 

ACKNOWLEDGMENT

The authors thank Jody Porter, DNP, RN, vice president of Patient Care Services and chief nursing officer, for reviewing and editing this manuscript.

 

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