2003 - ARNNL · · 2017-05-29clinical nursing supports negatively affect employers’ ability to provide comprehensive ... identifies factors that contribute to a quality professional

ORIENTATION PROGRAMS FOR REGISTERED NURSES: BEST PRACTICE GUIDELINES

2003

This Position Statement was

approved by ARNNL Council in

2003.

Orientation Programs For Registered Nurses: Best Practice Guidelines

55 Military Road | St. John’s | NL | Canada | A1C2C5 | Tel: (709) 753-6040 | 1 (800) 563-3200 | Fax: (709) 753-4940 | [email protected] ARNNL.CA

Acknowledgements

The ARNNL wishes to acknowledge the registered nurses who participated in the consultative process leading to

the development of this document.

These include:

Nurses from many regions of this province who participated in the invitational forum “Nursing Practice and

Education: Enhancing the Partnership” sponsored by the Joint Program Evaluation Committee of the BN

Collaborative Program

Individual nurses and key stakeholder group representatives for their feedback on the consultation

document

Participants in the ARNNL teleconference session with the project consultant1 and ARNNL Nursing

Education Consultant

Clinical nurse educators and nurse managers from across Canada and in the United States who provided

consultation and documentation on their respective orientation programs

An extensive literature review and a cross-country scan of orientation programs throughout Canada and

in selected US organizations were completed and are available at the ARNNL upon request.

1 Project Consultant: Janet Murphy Goodridge, RN MN IBCLC

ARNNL.CA 55 Military Road | St. John’s | NL | Canada | A1C2C5 | Tel: (709) 753-6040 | 1 (800) 563-3200 | Fax: (709) 753-4940 | [email protected]

Association of Registered Nurses of Newfoundland and Labrador

Table of Contents Preamble ............................................................................................................................ 1 Background and Literature Review ..................................................................................... 1 Key Elements ...................................................................................................................... 3 Summary and Conclusion ................................................................................................... 7 References .......................................................................................................................... 8 Definitions ........................................................................................................................ 12

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Preamble The vision of the Association of Registered Nurses of Newfoundland and Labrador (ARNNL) is “Healthy People in Newfoundland and Labrador.” It is our goal to ensure that there is excellence in nursing, public protection, quality health care and healthy public policy. When new nurses begin employment and experienced nurses move into new clinical areas of practice, access to high-quality orientation programs is fundamental to the provision of safe, quality nursing care and to the integration and retention of new nurses. At both national and provincial levels, it is recognized that trends such as staff shortages, heavy nursing workloads, frozen education budgets, and lack of clinical nursing supports negatively affect employers’ ability to provide comprehensive orientation programs and continuing education to meet the ongoing learning needs of registered nurses. As a means of ensuring quality nursing care is provided to clients, ARNNL has developed “Orientation Programs for Registered Nurses: Best Practice Guidelines.” These guidelines aim to provide direction to employers and registered nurses about the key elements of relevant and comprehensive orientation programs. The guidelines will also serve as a tool for promoting evidenced-based nursing practice. These guidelines are not minimum practice standards, but should be viewed as best practice guidelines that organizations must strive to achieve. This will ensure that all registered nurses receive a quality orientation program.

Background and Literature Review These guidelines were developed by the ARNNL in response to a number of issues related to nursing education and practice, specifically, the preparedness of new graduate nurses for entry-level practice. The Canadian Nurses Association (CNA), the ARNNL, and other provincial nursing associations have documented both the importance of employers recognizing the need for orientation and support programs for new graduates, as well as the need for employers to have realistic expectations of the competencies of nurses entering practice (ARNNL, 2001, 2002; CNA, 1998; College of Registered Nurses of Nova Scotia (CRNNS), 1997; Saskatchewan Registered Nurses Association (SRNA), 2001; RNABC, 2000, 2002). Experienced nurses moving to new clinical areas of practice also require orientation programs that are sensitive to their unique learning needs.

The significance of a supportive professional practice environment for registered nurses cannot be understated. In its 2001 Position Statement on Quality Professional Practice Environments, the CNA identifies factors that contribute to a quality professional practice environment for registered nurses. The implementation of nursing orientation programs and access to ongoing supports to meet individual learning needs, are included as key elements that enable nurses to deliver quality care. However, there are a number of relevant issues within our current health care environment that impact on the nursing practice environment and, in turn, on nursing orientation programs. Major nursing shortages in times of increased patient acuity, rapid technological changes and environments with limited funding resources, including limited funds for continuing education, are all concerns facing nurses in this province. Health care restructuring across Canada since the early 1990s has resulted in more part-time and casual nursing positions and the elimination of many nursing management positions (Baumann, O’Brien-Pallas et al., 2001). The loss of nurse managers translates into a loss of clinical leadership and expertise at the practice level, all valuable supports to new nurses. While data suggests that Newfoundland and Labrador has a low percentage of casual nurse positions, many new graduates still enter the workplace in casual positions (Canadian Institute for Health Information, 2002). In many health care settings, financial pressures have resulted in a limited investment of resources in professional development opportunities. Increasingly, there is refusal of time off for continuing education, and nurses are often moved to areas outside their specialization (Koehoorn, Lowe, Rondeau, Schellenberg & Wagar, 2002).

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Given the reality of today’s work environment, there is significant pressure from within the system for new nurses to quickly integrate into the organization. The nursing work force is aging. Older, more experienced nurses are often faced with having to preceptor or mentor nursing students and new graduates in already stressed practice environments. In environments where there is heavy reliance on casual nurses, there is even more pressure on full-time staff to take on greater workloads, thus limiting new nurses’ access to experienced full-time staff. There is substantial evidence that the transition from student to graduate nurse is characterized as a period of intense stress (Amos, 2001; Bick, 2000; Janes, Beck & Denny, 2002; Maben & Macleod Clark, 1998; Oermann & Garvin, 2002; Ross & Clifford, 2002; Whitehead, 2001). New graduates often feel overwhelmed and under prepared for their roles within the health care system (Kells & Koerner, 2000; Oermann, Moffitt-Wolf, 1997; Staab, Granneman & Page-Reahr, 1996; Ross & Clifford, 2002; Whitehead, 2001). The stress is often translated into feelings of a lack of confidence and competence and the conflict of a work environment that does not reflect their perceptions of nursing practice. Registered nurses who change practice areas experience similar feelings (Blythe, Baumann & Giovanetti, 2001; Murray, 1998). The importance of providing a comprehensive orientation program for new graduate nurses is well documented (Godinez et al., 1999; Hernandez, 2001; Kells & Koerner, 2000; Proehl, 2002; Remus, Smith & Schissel, 2001; Revis, Thompson, William, Bezanson & Cook, 1996; Williamson, 2001; Winter-Collins & McDaniel, 2000). Orientation programs that encourage new nurses to feel welcome, safe, valued and nurtured eases transition and enhances their overall satisfaction. Several authors have recognized the importance of a supportive practice environment for new graduates (Beeman, Jernigan & Hensley, 1999; Lavoie-Tremblay et al., 2002; Winter-Collins & Mc Daniel, 2000). An orientation program that addresses the new graduate’s need for belonging and security by placing socialization as the first organizational goal, contributes positively to role adjustment (Beeman et al., 1999). In addition to a comprehensive orientation program, other key supports recommended to ease transition and encourage nurse retention include: access to continuing education opportunities, formal preceptoring and mentoring relationships, strong nursing leadership, adequate nurse:client ratios and support for evidence-based practice (RNABC, 2002). Orientation program time frames for new and experienced nurses vary widely in the literature; typical periods suggested are three to four months for a new graduate in an acute care setting, six months or more for specialty areas, and six weeks for an experienced nurse in transition (Beeman et al., 1999; Fey and Miltner, 2000; Wolgin 1998). Generally, nurses recommend longer orientation periods than they are currently receiving in the workplace (Noseworthy & Harnett, 2002; Nursing, 1999; Remus, Smith & Schissel, 2000; Tar Heel Nurse, 1998). It is noteworthy that a Newfoundland and Labrador study also reported that the adjustment period for new graduates to feel comfortable in taking on full responsibility is up to six to seven months (Janes et al. 2002); thus supporting the need for longer orientation programs. Preceptor models are a valuable and effective method of orientation for new graduate nurses (Balcain, Lendrum, Bowler, Doucette & Maskell, 1997; Diehl-Oplinger & Kaminski, 2000; Drogas, 1995; Hardyman & Hickey, 2000; Kells & Koerner, 2000; Revis et al., 1996; Wright, 2002). In addition to extending excellent clinical experiences for new graduates, preceptor programs can help decrease stress during their transition period (Bain, 1996; Brasler, 1993; Duff & Kirsivali-Famer, 1994). More importantly, preceptor programs can encourage the development of collegial relationships with peers and other staff nurses (Oermann & Moffit-Wolf, 1997), significant in supporting beginning practice. In recent years, preceptor programs have gained increasing popularity and are now considered fundamental to most nursing orientations (Fey & Miltner, 2000; Proehl, 2002).

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Long-term mentoring relationships are also valuable in promoting the growth and development of new nurses and in supporting career advancement issues. There are numerous examples in the nursing literature highlighting the value of mentoring programs, especially in moving from novice to expert practice settings where nurses function in diverse, often independent roles (Smith, McAllister & Crawford, 2001). The literature supports the use of a competency-based assessment frame-work as the guiding paradigm for the development and implementation of orientation programs (Biancuzzo, 1994; Fey & Miltner, 2000; Harper, 2002; Proehl, 2002; Mikos &Schild,1999; Revis et al. 1996). As a means of easing transition and increasing recruitment and retention rates for new graduates, there is a trend in many areas to move towards intensive internship or fellowship programs (Beecroft et al., 2001; De Simone, 1999; Evans, 2001; Fey & Miltner, 2000; McKane & Scumacher, 1997; Penprase, 2000). These diverse programs vary in length from twelve weeks to two years. The majority includes a competency-based assessment framework with a clinical preceptorship as the key clinical support of the program. The literature provides examples of innovative orientation program strategies designed to facilitate learning. These include computer-assisted learning, clinical skills training opportunities, case studies, and on-unit learning and support groups (Lavoie-Tremblay et al., 2002; Wong, 2002). Many of the approaches emphasize the value of integrating strategies that encourage critical thinking about clinical situations. Critical thinking enables the nurse to consider several possibilities in a clinical situation by analyzing the information and deciding on appropriate actions (Oermann, Truesdell & Ziolkowski, 2000). Examples of collaborative approaches to orientation using shared resources between a university and hospital were also noted (De Simone, 1999; Frame, Ballantyne, Haussler, McLaughlin, Kudzma, Murphy & Munro, 2002; Penprase, 2000). Establishing collaborative relationships benefits both education and practice by (1) promoting the straightforward dissemination of current research to support evidenced-based practice; and (2) ensuring that there is congruence between education and practice expectations. In summary, it is an opportune time for the ARNNL to provide guidance to employers on the long-term value of effective orientation programs and other key supports in the registered nurse practice environment. An investment in a comprehensive orientation program will enable nurses to practice safely and competently thus ensuring quality client care and will support a more positive transition to beginning practice. In addition, studies have shown that access to professional development opportunities such as orientation and continuing education programs, has a significant positive impact on staff satisfaction (Gustin et al., 1998). Moreover, from the employer’s perspective, offering high quali-ty staff education can be an effective way to attract, motivate and retain top nurses (Tanner, 2002).

Key Elements In the absence of recognized standards for orientation programs, an extensive literature review, cross-country scan and provincial consultation process were completed to determine the key elements that need to be in place to ensure that registered nurses receive a quality orientation to the practice environment. Nine key elements emerged as essential components in creating a comprehensive orientation program. Included under each element are descriptors that provide additional direction and interpretation.

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Key Elements 1. Supportive practice environments that nurture and value new nurses help reduce stress, ease

transition, increase competence and ensure safe quality care.

Descriptors a. Innovative strategies are implemented within organizations to strengthen the collegial relationship between

new staff and more experienced staff: e.g., focused unit meetings, journal clubs, social gatherings and on-unit learning and support groups.

b. Strategies are developed within organizations to educate experienced nurses about the supports needed by new nurses in easing their transition: e.g., the important role of mentoring, role modeling, communication, providing feedback and acting as a resource.

c. Experienced nurses are encouraged to model the desired change in the practice environment and challenge the status quo.

d. Workplace environments foster open communication, whereby nurses are supported and encouraged to ask questions and obtain guidance without fear of criticism or ridicule.

e. New nurses are supported and encouraged to have a voice on unit or program decision-making. f. New nurses are given an opportunity to work on comfortable assignments with less complex client

situations before moving to more challenging situations. During the first year of employment, a “no-float” and “no in-charge” policy is maintained for new graduates. Appropriate nurse-client ratios are the norm.

g. A formal evaluation mechanism is established to ensure that new nurses receive continuous, constructive feed-back from their preceptors, nurse managers, clinical educators and/or designated experienced nurses.

h. Support for a multidisciplinary team approach is evident in the practice environment. 2. High quality orientation programs require substantial investment in human, material and financial resources.

Descriptors a. Stable funding for orientation programs, mentorship pro-grams and continuing education for nurses is

essential. b. Clinical nurse specialists, nurse educators, nurse practitioners, preceptors, mentors, nurse managers and

human resources staff are essential learning supports to an orientation program. c. To facilitate the orientation process and support evidenced-based practice, employers must ensure easy

access in the clinical area to material resources such as computers (with internet access), reference texts and literature, policies, procedures, protocols, and guidelines.

d. Collaborative relationships utilizing both education and practice are beneficial in the development and implementation of orientation programs.

e. Nursing and interdisciplinary provincial and national groups/individuals are useful as an external resource for identifying competencies required beyond entry-level practice e.g. “novice to expert” for specialty areas.

3. All new graduate nurses and experienced nurses in transition require a comprehensive nursing

orientation with clearly defined time frames, goals and expectations.

Descriptors a. Orientation time frames and the goals, expectations and content of the program are clearly defined in writing

to avoid ambiguity between nurses and employers about the nature and extent of the orientation period. Suggested minimum time frames are eight to twelve weeks for new graduates, six weeks for nurses entering a new practice area, and six months for nurses employed in specialty areas.

b. New nurses collaborate with nurse managers, clinical educators and other relevant clinical supports to design a relevant orientation program.



c. New nurses are provided with a “protected period” considered supernumerary staff for a significant time during the orientation period. This recognizes the important role of orientation as an educational experience and ensures that new nurses are not viewed simply as “extra help.”

d. Experienced nurses moving to a new clinical area require an orientation program tailored to meet their unique needs.

e. Float or resource pool nurses require a comprehensive orientation with sufficient time in each of the assigned clinical areas.

f. A multi-phased orientation program, using Benner’s “novice to expert” framework, may be an effective approach to achieve more advanced level competencies. For example, orientation content may be extended over a one-year period with an initial orientation followed by clinical experience and a later return to more advanced theoretical content. This approach may work well in a specialty area, and gives nurses an opportunity to strengthen their skills and knowledge with more routine client situations before moving to the more complex.

4. Orientation programs are grounded in a competency-based assessment model and linked with

ongoing continuing education programs.

Descriptors A competency-based orientation includes: a. Assessment of entry-level competencies (i.e., critical thinking and problem solving skills, interpersonal skills

and technical skills). b. Programs tailored to individual needs based on competency assessment and building on previous

knowledge. c. A process for developing relevant unit or program specific competencies with performance indicators/criteria

and appropriate evaluation tools. d. Evaluation of expected competencies at the end of orientation and at defined periods in the first year: e.g.,

end of the probationary period. e. A process for ensuring that competence is maintained when there are changes in practice or policy. f. Establishing long-term goals with new nurses in achieving advanced competencies. 5. Orientation programs are dynamic and maintain a degree of flexibility to allow for extending or shortening the orientation period as needed.

Descriptors a. Orientation programs require evaluation on a regular basis. b. Orientation periods may need to be extended if goals are not met within expected time frames. This could

be related to any number of factors, such as a limited variety of client situations available, the introduction of new technology; limited availability of clinical supports (preceptors, educators); emergency situations on unit or within a community health setting that take time away from orientation; slower progress in achieving clinical competencies; and new nurses with language or cultural challenges.

c. Orientation program time frames may be shortened if the new nurse achieves competencies before the expected date and is at ease in the new work environment. In situations where the new nurse completes a student preceptorship on the unit or agency of hire, the orientation program may be shortened or adapted to meet the nurse’s needs.

d. Critical pathways are effective methods to improve structure, clinical experiences, consistency and documentation within a unit or program orientation.

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6. The foundation of an effective orientation program is a quality clinical preceptorship followed by a mentorship program that supports the registered nurse beyond the formal orientation.

Descriptors a. Criteria for the selection of preceptors and mentors are clearly articulated in writing. b. Preceptors and mentors are given support and guidance through education sessions designed to address

issues such as roles and responsibilities, reality shock, adult education principles, communication, socialization, conflict resolution, critical thinking and judgment skills, evaluation, documentation and teaching/ learning approaches.

c. Preceptor-friendly assignments are encouraged to benefit the new nurse and preceptor: e.g., shared client assignment, lower nurse-client ratios, time for review and evaluation of progress.

d. New graduates’ skills in leadership, coordinating care and teamwork are reinforced through time spent with team leaders/charge nurses later in the orientation period (if possible).

e. Innovative ways to recognize preceptor contributions are developed; these include continuing education credits, peer recognition events, financial rewards, clinical ladder programs.

f. Organizations with a limited pool of experienced nurses to act as preceptors should explore alternate ways to ensure that new nurses are linked formally with experienced nurses. In some situations, it may require more than one experienced nurse working with each new nurse and/or linking by teleconference or telephone if the nurse works in a rural community.

g. Opportunities are developed to support long-term mentorships extending beyond the defined formal orientation period. Mentors may assist with professional development issues and career planning.

7. Orientation programs are developed and implemented using adult education principles.

Descriptors

a. Diverse teaching/learning approaches are used, such as clinical skills training, self-learning packages, computer-assisted learning, internet access, Web CT sites, case studies, scenarios, problem-based learning, narratives and on-unit/program learning groups.

b. Adhering to adult education principles ensures that the orientation process builds on new nurses’ previous life and work experiences.

c. Content, timing, sequencing and teaching/ learning approaches are all based on learner’s needs. 8. Opportunities are presented throughout the orientation period to strengthen new nurses’ critical

thinking, clinical judgment and organizational management skills.

Descriptors a. Build on processes already in place in the clinical setting, such as nursing rounds, clinical conferences and

“teachable moments.” b. To assess thought processes, design learning experiences in orientation sessions to develop the above

skills through scenarios, case studies, small group work and open-ended questions. c. Provide client assignments focusing on high volume client populations in the initial orientation period.

9. New graduates and experienced nurses in transition seek opportunities for professional growth and

learning to enhance competency in the new setting.

Descriptors

a. Take initiative in seeking information about policies and protocols. b. Collaborate as a member of the multidisciplinary team. c. Accept responsibility for learning, demonstrate account-ability, recognize limitations and seek consultation

as needed, especially in situations that go beyond the nurse’s knowledge and experience. d. Identify current knowledge and skill gaps and knows how to access resources to attain knowledge and

skills. e. Seek information independently through a variety of resources: e.g., reads professional journals, attends

in-service sessions, and integrates research findings in nursing and related fields to build evidence-based practice.



Summary and Conclusion

The ARNNL supports the development of comprehensive orientation programs for registered nurses reflecting the nine Key Elements identified above. The responsibility for ensuring that orientation programs are available and accessible in the diverse practice settings throughout Newfoundland and Labrador is a shared responsibility of employers, professional associations, educational institutions, government, individual nurses and unions. Collaboration between these key stakeholders is fundamental to ensure orientation programs are of sound quality and reflective of nurses’ needs and the need for safe, competent nursing care.

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Definitions New graduate/new nurse: An entry-level practitioner…“the beginning registered nurse at the point of registration or licensure following graduation from a nursing education program” (ARNNL, 2000). Experienced nurse in transition: A registered nurse with significant clinical experience in one area of practice, who is moving to a new clinical practice setting. Continuing education: Any program or course or conference beyond the level of education that is required for entry into the profession of nursing. It consists of experiences undertaken by nurses to enhance competencies (knowledge, skills, attitudes and judgments related to specific areas of practice) (Canadian Nurses Association, 2000). Preceptor: “Preceptors are experienced and competent staff members who serve as clinical role models and resource persons for new employees. They orient new staff to their roles and responsibilities and introduce them to the formal and informal rules, customs, culture, and norms of their co-workers and the workplace” (Schoenly, 1998).When the purpose and objectives of the experience are achieved the preceptorship ends (Stevens-Barnum, 1997). Orientation: A program of activities designed to ensure safe, quality client care by familiarizing new nursing staff with the work environment, including expectations and policies. The goal is to ease the adjustment of new graduate nurses and experienced nurses moving to a new clinical setting by fostering their social integration into the organization and providing decision support for their specific level of nursing practice: e.g., novice, advanced beginner (adapted from Registered Nurses Association of British Columbia, 2000). Competencies are assessed and validated during the orientation. Mentorship: An informal, voluntary, long-term relationship that develops between an experienced practitioner and an inexperienced nurse; the junior person receives guidance and instruction from the senior nurse on relevant issues relating to professional development (Stevens- Barnum, 1997). Mentor: An experienced, senior nurse who instructs and guides a less experienced nurse over a sustained period (Stevens- Barnum, 1997).

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St. John's

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A1C 2C5

Tel (709) 753-6040

1 (800) 563-3200 (NL only)

Fax (709) 753-4940

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arnnl.ca

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2003 - ARNNL · · 2017-05-29clinical nursing supports negatively affect employers’ ability to provide comprehensive ... identifies factors that contribute to a quality professional