Authors

  1. Rogers, Amber MSN, RN
  2. Burke, Cindy MSN, RN, CMSRN, NPD-BC

Abstract

Nurse educators play an important role in implementing changes within hospital orientation, supporting a learner-focused orientation. Utilizing different learning styles and delivery methods, an orientation can promote an environment where registered nurses are active participants and guide the learning. This article discusses the process of incorporating multiple learning styles and modalities into an experienced registered nurse orientation program, creating a learner-centered environment promoting engagement, increased satisfaction, and retention of experienced staff.

 

Article Content

Effective nursing orientation enhances retention of crucial knowledge for practice. However, recent evidence from review of the literature suggests there is a gap in the evidence base for experienced registered nurse (RN) orientation, which may impact learning outcomes as well as nurse retention and job satisfaction (Peltokoski et al., 2016). The system clinical educator (SCE) also reviewed literature related to hospital orientation programs, adult learning theories, and engagement. The literature review was used to modify an experienced RN orientation program for a five-hospital system in the midwestern United States. The Experienced RN Orientation Program (ERNOP) was redesigned to increase participant engagement through integration of multiple learning modalities, with consideration for individual learning styles. The goal of this project was to create a meaningful orientation program that actively engaged experienced RNs to enhance application and retention of critical onboarding information. The revised program was built on an interactive seminar framework that included simulation, personal response devices (PRDs), case studies, learning boards, games, and role-play. Participant performance and feedback were used to evaluate the success of the program redesign.

 

BACKGROUND

A five-hospital system in the midwestern United States offered a lecture-based experienced RN orientation monthly. An experienced RN is defined as a nurse who has worked 6 months in the acute care setting. The system-wide ERNOP was offered at the largest facility site, followed with unit-specific education at the employment site. Orientation consisted of 1 week of lecture-based learning, followed by electronic medical record training on the second week. The orientation program was facilitated by two SCEs and subject matter experts (SMEs).

 

The hospital system made a decision to increase the frequency of orientation from monthly to biweekly to provide more frequent onboarding and more flexibility with start dates. Because of this change, the SCE recognized the inability to continue with the previous schedule, which was 2 weeks of orientation. Modifications were needed, and the SCE began to look at different formats and delivery methods to utilize during ERNOP.

 

The SCE analyzed evaluation data from anonymous web-based evaluations by participants that consisted of four questions, using a 5-point Likert scale (see results in Table 1) and three open-ended questions. The survey data had 56 responses over the course of 6 months. Survey completion was not mandated, and not all participants filled it out. In reviewing participant survey data (see Table 1) the SCE noted an opportunity to improve the ERNOP and make it more beneficial and engaging to the participant while ensuring key information was delivered. This data analysis and findings from the literature enabled the SCE to restructure the orientation process based on the adult learning theory. Approximately 16 hours of lecture-based content delivered by SMEs was modified with the integration of the adult learning theory and learners' experience using real-life scenarios. The revised ERNOP consisted of a12-hour interactive seminar, simulation, PRDs, case studies, learning boards, group games, and role-playing with immediate evaluation by learners and facilitators.

  
Table 1 - Click to enlarge in new windowTABLE 1 Survey Results of Base Orientation Program

LITERATURE REVIEW

The adult learning theory is helpful for the education of nurses with the goals to develop the knowledge and skills required for success. Malcolm Knowles' adult learning theory recognizes that adult learners bring their life experience, are problem-focused learners, are internally motivated, and want to understand why they are doing a task or process (Malik, 2016). In this theory, knowledge is not solely with the instructor, but the learner's experience is also a source of knowledge. The concept of using the learner's experience as knowledge was an important consideration for the redesign of the ERNOP (Stoica, 2019). In order to draw from the adult learner's experience, the learner needs to be engaged in behavioral, emotional, and cognitive aspects (Padgett et al., 2019). Behavioral engagement can include class participation, cognitive engagement is described as critical thinking by the learner, and emotional engagement is the enjoyment of the learning (Padgett et al., 2019).

 

Learning styles were also taken into consideration. Learners may prefer visual, auditory, reading/writing, or a kinesthetic approach to learning, and educators are wise to use all these modalities to reach a variety of learning styles (Alharbi et al., 2017; Stirling, 2017). Use of a variety of learning methods also helps the learner to perceive that education is personalized, which may help in the retention of information and learned skills (Kanadali, 2016).

 

INTERACTIVE ORIENTATION

In creating the new ERNOP, the SCE worked closely with the SME presenters. SMEs assisted the SCEs in building content with current evidence with talking points for the SCE to use during the orientation. Second, electronic preseminar work was also created and assigned to be completed prior to class to facilitate learning and student success. This design of class and laboratory activity or a blended classroom method was chosen because research has demonstrated blended models engage students and help customize the learning pace (Shang & Liu, 2018).

 

On the second day of orientation, the Concept Application Class explores content introduced in computer-based prework, which includes system-specific policies and care protocols. Instructional design was used to design content efficient and appealing to the learner (Mercadal, 2019).

 

Games were designed to teach risk management, pain and pharmacy topics, and infection prevention practices, because games have been shown to increase engagement, learning enjoyment, and retention (Gallegos et al., 2017). Games also allow participants to establish teamwork and comradery. Use of PRDs was built into the revised program to allow the SCE to anonymously assess the learner's knowledge and then tailor the education to their needs. For example, if the participants all correctly respond to an item, then little or no dialogue is needed, whereas incorrect responses require discussion led by the SCE. Gaming and PRD were well received by participants per post class evaluations.

 

RN participants were provided the opportunity to critique role-playing by the SCEs by providing examples of what was done well and what could be improved. The ability to critique falls under evaluation in Bloom's Taxonomy, which is a high-level objective (Armstrong, 2019), and the participant who successfully critiques understands the information. Although role-play can be also done by students, the SCE chose to do the role-play themselves, so participants did not feel "put on the spot" as the activity occurs early in the orientation process. Role-play also worked well as an icebreaker, building relationships between the facilitators and students (Herrman, 2016).

 

The revised ERNOP includes an opportunity for participants to present a topic congruent with learning objectives in the afternoon session of the Concept Application Class when participants are more familiar with each other. In this topic, presentation posters are set up around the room, replicating a poster walk common in nursing conferences, with the class divided into small groups and each group is assigned a poster. Each small group presents their board to the class for discussion. The SCE supplements any content that may be missed by the small groups. Learner-led presentations encourage a more active role of the learner and moves them from passive learning to active (Herrman, 2016).

 

The Simulation/Skills Class on the final day of orientation focuses on skills needed for safe patient care. A basic rhythm interpretation examination is provided, followed by a hands-on skill session that allows the SCE to provide feedback as well as verifies that the RNs can conduct assigned skills independently and safely.

 

The learners also participate in a 4-hour high-fidelity simulation session with focus on patient care scenarios common to all areas of nursing practice. Each scenario explores the complex events in the acute care setting. For example, one scenario includes patient education and teach-back but ends up in a cardiac arrest. The scenarios include two mock codes, a stroke scenario, and a respiratory distress scenario. Crash cart and defibrillator practice is provided. Also included are "breakout"-style games where participants are provided clues while working through simulation scenarios as a participant or as an observer. When simulation scenarios are complete, the SCE guides the debriefing with open-ended questions. This debriefing is crucial as it allows for reflection, analysis, understanding, and synthesis of the simulation and what occurred (Verkuyl et al., 2018).

 

RESULTS

Quantitative and qualitative data were collected via an anonymous electronic survey after the new ERNOP was implemented to determine if the blended, interactive format was more effective, compared to the previous lecture-based orientation format. Following human subjects' review approval, retrospective analysis compared the RN evaluation of strongly agree responses to the four questions. The results for 161 participants (see Figure 1) demonstrated a significant increase in the percentage of strongly agree responses to each of the four questions (p < .0001).

  
Figure 1 - Click to enlarge in new windowFIGURE 1. Comparison of responses after orientation changes implemented. This graph provides a comparison of the responses to four questions asked during base orientation and after the changes. Only "strongly agree" responses were used for comparison. The base results are in blue, and the orange results show responses after the changes. The graph shows that, after revision, all metrics improved significantly. This figure is available in color online (

Qualitative data were also obtained through open-ended questions. One hundred thirty-six participants responded to the question, "What was your biggest take-away from nursing orientation classes?" Five major themes emerged from the data (see Table 2).

  
Table 2 - Click to enlarge in new windowTABLE 2 Emerging Themes

The next questions asked were "What did we do exceptionally well?" and "How can we improve general nursing orientation to be more effective?" One hundred forty-seven participants answered these questions. Overall responses were very positive, and 80% of responses include one of the following key elements:

 

* the use of different learning formats;

 

* engaging, interactive, involvement with games;

 

* instructors are fun, approachable, positive, pleasant;

 

* "best orientation" I have been to.

 

 

Though the other 20% of responses did not mention one of the above key words, most reflected positive responses to the orientation. Examples of these comments are "stayed on track of time, enjoyed the movement instead of constant PowerPoints," "you made the orientees feel a reduction of stress, in essence a safe place to learn with the lightheartedness, confidence, and expertise that you exhibited in orientation," "kept attention well," "the orientation was great," and "you did an awesome job, keep up the good work."

 

LIMITATIONS

Although this was a thorough study, there are some limitations noted. Ongoing evaluation and research are planned to help eliminate these limitations in any future studies. The previous survey data were from a small sample size. This smaller sample size may have been impacted by the closure of a hospital within the system that resulted in a hiring freeze. In addition, participants were not required to complete the survey in the previous orientation program and often did not. The SCE have recently incorporated the evaluation into the end of ERNOP, and it is accessed by a QR code. This has increased participation in the survey and ensures the responses are done immediately after the orientation.

 

Studies on performance and retention are ongoing. Surveys were completed to evaluate the RNs' ability to perform safely post ERNOP. These surveys are given to the unit educators of the new hires for completion based on the new hires' preparedness to work within the hospital system. Early data are promising, but evaluation is ongoing. Data on retention are ongoing and have been challenging to obtain because of various factors including, but not limited to, movement of employees within the system, promotions, the closure of a facility, and furloughs because of the COVID-19 pandemic. The preliminary data are very positive, and the SCE hopes to share this information in the future.

 

CONCLUSION

The revised ERNOP remains as an engaging and interactive environment that allows the experienced nurses to be the center of the learning in orientation. It is important to design nursing orientation programs so that experienced nurses find the program worthwhile, meaningful, and appropriate for practice. The use of various teaching methods other than lecture, such as simulation, PRD, and case studies, can improve the engagement of participants. Interactive modalities can also help gauge the level of understanding and critical thinking processes of RNs. Positive feedback from attendees illustrates they gained benefits from being actively involved in their learning. It is also important that instructors have good facilitation skills to engage learners but also possess skills such as being positive, approachable, and pleasant. All these factors noted can lead to a positive orientation, which supports retention and increases satisfaction. Hospitals and educators should use evidence and "think outside the box" when designing nursing orientation programs. Continuous evaluation of participant feedback can help guarantee success.

 

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