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Bridget Everhart is a nurse practitioner and is the inpatient diabetes educator at University of Colorado Hospital, Denver, CO. She was the nurse educator in the surgical intensive care unit during implementation of the staged orientation program.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
Corresponding author: Barb Maule Chesnutt, 639 East End Ave, Pittsburgh, PA 15221 (e-mail: barb.chesnutt{at}gmail.com).
Although graduate nurses have limited experience when they enter nursing practice, they are typically expected to be responsible for a standard patient assignment shortly after they complete orientation. Even if a graduate nurse is not required immediately to care for a severely ill patient, the nurse must at least have the skills to solve urgent and emergent situations that occur unexpectedly in critical care. Thus, it is imperative that graduate nurses receive a clinical orientation that meets their needs as new nurses and gives them a strong basic foundation in critical care.
At the University of Colorado Hospital (UCH) in Denver, we assessed the critical care clinical orientation in the surgical intensive care unit (SICU) to determine if we were meeting the orientation needs of graduate nurses and adequately preparing the nurses to care for SICU patients. We found that our traditional orientation needed improvement, and we subsequently developed a detailed unit-specific staged orientation program to better prepare graduate nurses for critical care practice.
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Background |
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 Top Background Traditional SICU Orientation...Improvement Plan for SICU...SICU Staged Orientation ProgramResultsDiscussionConclusionReferences |
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Clarke and Aiken4 noted that adequate surveillance and appropriate actions are necessary to rescue patients from preventable complications. Anticipating possible complications is important, and opportunities to identify complications are sometimes lost. Clarke and Aiken also noted that while a novice nurse is honing skills in caring for patients, an experienced nurse serves as a "safety check" to the novice. Ashcroft5 reported that early recognition and intervention are essential to patients’ survival, that variables predictive of cardiac arrest are elusive, and that nursing expertise matters.
Because of the advanced beginner skills of graduate nurses and the increasing complexity of caring for patients, UCH implemented a hospital-wide graduate nurse residency program in 2002 tailored to meet the needs of graduate nurses and help them develop into competent first-line caregivers. The residency program is part of the University HealthSystem Consortium and the American Association of Colleges of Nursing Postbaccalaureate Nurse Residency Program Demonstration Project.6 The goals of the project are to reduce the turnover of new graduates, enhance job satisfaction and autonomy, increase critical thinking skills, improve support of new graduates, and protect patients’ safety while the nurses obtain the additional competencies needed to function as staff nurses.
The residency program provides a 1-year orientation for baccalaureate-prepared graduate nurses and includes a structured series of classroom courses and facilitated support sessions. Content includes topics such as pain management, patients’ safety, and evidence-based practice. All UCH graduate nurses (medical-surgical and critical care) are part of the graduate nurse residency program and are required to attend all classes and participate in the program. The residency program is separate from and in addition to the 5-day general hospital and nursing orientation that every RN receives when the nurse begins employment in the hospital.
Unlike the structured hospital-wide graduate nurse residency program, the SICU clinical orientation was relatively unchanged for graduate nurses. The inconsistency between the structured residency program and the less structured SICU clinical orientation soon became apparent. Graduate nurses were attending courses through the residency program that were tailored to the nurses’ level of experience, and content was presented in increments from basic to advanced. Time was also allotted during residency courses for the nurses to share written personal exemplars (nursing experiences).
In contrast, the orientation experiences of graduate nurses in the SICU were quite varied. The nurses did not consistently receive assignments tailored to match their skill levels, learning was not always incremental from basic to advanced, and scheduled times for discussion or knowledge confirmation were not routine. Variations in the SICU clinical orientation did occur to meet the needs of some individual graduate nurses, but the general SICU orientation went relatively unchanged from the years when most nurses attending orientation in the SICU had experience in critical care.
In 2003, the SICU clinical orientation was assessed, and a new program was implemented to meet the clinical orientation needs of SICU graduate nurses at UCH. In this article, we outline the assessment of the traditional method of clinical orientation and describe the development and implementation of the SICU staged orientation program.
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Traditional SICU Orientation Program |
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TopBackgroundTraditional SICU Orientation...Improvement Plan for SICU...SICU Staged Orientation ProgramResultsDiscussionConclusionReferences |
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Preceptors
RNs who acted as preceptors in the SICU had attended the 4-hour preceptor course and successfully completed preceptor competencies. The preceptors also had more than 2 years of experience in the SICU.
The SICU educator assigned 2 primary preceptors to each graduate nurse in the beginning of clinical orientation. Each preceptor worked with the graduate nurse approximately 50% of the time. The graduate nurse followed the preceptors’ schedules for the entire orientation period. At times, because of vacations or illness, a third backup preceptor was assigned.
Preceptors and graduate nurses were matched as closely as possible on the basis of personality and learning styles. The educator was familiar with each preceptor’s teaching style. Informal discussions with the graduate nurses about the nurses’ learning styles helped guide the educator in making the best possible matches between preceptors and graduate nurses. For example, some graduate nurses preferred preceptors to accompany them during nearly every interaction with patients in the beginning of orientation, whereas others preferred to perform some care by themselves and have the preceptor follow up to discuss and confirm findings. Generally, this approach to matching preceptors and graduate nurses worked well. Occasionally the preceptor assignment needed to be changed.
Patient Assignments
In general, the charge nurse from the previous shift made the patient assignments for each graduate nurse and preceptor on the upcoming shift. In the day-to-day function of the unit, the charge nurse determined each patient’s acuity on the basis of the stability of the patient’s condition, equipment use, and discussion with the nurse caring for the patient. However, the charge nurses had no specific guidelines for making orientation assignments, and they usually did not know the graduate nurses’ specific needs.
The charge nurse assigned patients on the basis of what he or she knew of the orientees’ skills from observation during bedside rounds and discussions with preceptors and whether a patient seemed like a good experience for a new nurse. As a result, patient assignments did not always match a graduate nurse’s skill or knowledge level.
At times a nurse was assigned a high-acuity patient before the nurse had demonstrated competency with basic critical care skills. For example, in early stages of orientation, a graduate nurse was assigned a patient receiving multiple vasoactive agents even though the nurse had not demonstrated competency in managing arterial catheters or an understanding of hemodynamic concepts necessary to adjust the dosages of these medications.
In addition to inconsistency in patient assignments during orientation, the highest acuity patients were often assigned in the last month of a graduate nurse’s orientation. Caring for this type of patient at the end of orientation seemed logical because the graduate nurses should be best prepared for high-acuity patients during the last month of orientation. However, in the immediate period after orientation, graduate nurses are typically assigned pairs of patients with lower acuity in order to provide the nurses time to acclimate to fully managing a patient assignment without preceptor backup. Because the graduate nurses were accustomed to providing care to only 1 high-acuity patient in the last month of orientation, the nurses were out of practice in organizing care for 2 patients, a situation that caused difficulty with time management immediately after orientation.
Another unintended consequence of ending orientation with high-acuity patients was the false sense of failure graduate nurses felt when the nurses did not get assigned this type of patient after orientation. The nurses mistakenly thought that the number of high-acuity patients assigned after orientation was a measure of a nurse’s success in the SICU. Some charge nurses occasionally did assign a single high-acuity patient to a graduate nurse who had just completed orientation, whereas others assigned pairs of patients with lower acuity. This practice led to graduate nurses’ "keeping score" of who was assigned a single high-acuity patient and created a competitive nature among some graduate nurses when the nurses compared assignments. Also, some graduate nurses reported feelings of failure and decreased self-confidence if they did not receive the types of assignments that their peers did.
Didactic Education
As part of the graduate nurse residency program, all graduate nurses were required to attend a 40-hour didactic basic course in critical care in the second month of orientation. UCH clinical nurse specialists, educators, and other expert clinicians taught the course. Content was based on the American Association of Critical-Care Nurses Core Curriculum for Critical Care Nursing7 and included assessment and monitoring techniques associated with major body systems as well as therapeutic techniques and nursing interventions. Case studies also facilitated application of knowledge. In 2006, UCH replaced the critical care course with Internet-based Essentials of Critical Care Orientation (ECCO) sessions.8 For the purposes of this article, the critical care course is referenced because the new staged orientation program was implemented during the time that course was held.
The Basic Knowledge Assessment Test (BKAT),9 a standardized test with established validity and reliability used to measure basic knowledge in critical care nursing, was administered to all critical care graduate nurses before the critical care course and again after 6 months of clinical orientation.
Graduate nurses were encouraged to discuss the content of the course with preceptors on the unit, and preceptors were directed to assist the nurses in applying critical care concepts at the bedside. However, no formally scheduled sessions existed to discuss application of critical care class content to patients in the SICU.
The degree to which preceptors explained concepts varied, and aside from the Critical Care Clinical Orientation Competencies checklist, the preceptors did not have written or structured guidance about which concepts to focus on and the depth of explanations required. Some graduate nurses reported that the preceptors taught practical applications of advanced critical care concepts at the bedside; other graduate nurses reported minimal teaching of advanced concepts by preceptors, but rather a "sticking to the basics" approach. Graduate nurses reported that even when taught advanced concepts, they often could not focus on the teaching because too many distractions occurred when they were trying to balance this didactic component with patient care. Some graduate nurses reported feeling particularly stressed if they had one preceptor who emphasized didactic teaching at the bedside and the other preceptor focused on completing tasks.
Preceptors reported that early in orientation, graduate nurses were often overly focused on completing tasks. Preceptors also reported that some graduate nurses continued to be focused on tasks throughout orientation and could not concentrate on information being taught about concepts. On the other hand, some graduate nurses reported feeling pressured by their preceptors to complete tasks and felt that they did not have any time to ask the preceptors conceptual questions. Additionally, some of the graduate nurses were fearful of making mistakes and worried that if they focused on the preceptors’ teachings they would fall behind on tasks and make a mistake when hurriedly trying to catch up.
Preceptors put different amounts of emphasis on self-directed learning for the graduate nurses. Some preceptors assigned homework and expected the graduate nurse to study outside the clinical setting while other preceptors did not. Preceptors who assigned a graduate nurse homework typically allotted time during a subsequent shift to review the nurse’s knowledge of the homework topic. Expectations for self-study of SICU clinical issues were not clear for the graduate nurses or the preceptors. Hence, assigning homework was preceptor-specific and caused tension on several occasions when one preceptor of a graduate nurse required homework and the other preceptor did not.
Verifying Clinical Competency
All new critical care nurses are required to complete the Critical Care Clinical Orientation Competencies checklist with their preceptors during orientation. In order to ensure that all critical care RNs have achieved a documented level of safe critical care practice with the listed skills, the checklist is the same for all critical care areas. Each orientee completes the self-evaluation side of the checklist, identifying his or her knowledge and experience with each skill (Figure 1
). The preceptors are required to teach and verify that each skill competency has been met by signing their initials by each skill.
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Preceptors and graduate nurses are told at the beginning of orientation that the checklist is to be reviewed each shift and that completed skills are to be signed off as applicable. However, in reality the checklist was not addressed every shift; it was reviewed and completed intermittently during orientation and then was fully completed at the end of orientation. Preceptors and graduate nurses reported several reasons for the inconsistent completion of the checklist, including that they were too busy caring for patients to complete it, they had to sort through the whole list (about 10 pages) to find the skills they had completed that day, and that it lacked relevance to day-to-day care of SICU patients.
Because a graduate nurse’s partnered preceptors were not formally required to meet with each other regularly about the progress of the nurse, the competencies checklist served as a communication tool between the preceptors about the nurse’s skill acquisition. If the checklist was inconsistently completed, one preceptor could not see what the other preceptor had taught. The result was that some content was discussed repeatedly and other content was only briefly addressed.
Along with the preceptors, the SICU educator was responsible for ensuring that each graduate nurse was safe and competent for practice. The educator made bedside rounds every week and met with graduate nurses and preceptors on an informal basis. Each graduate nurse and the nurse’s preceptors completed a weekly evaluation form and gave it to the educator, who reviewed it, followed up with any concerns, and placed the form in the graduate nurse’s employee file. The weekly evaluation form described patient assignments, weekly goals, strengths, and areas for improvement.
The educator completed performance appraisals for each graduate nurse at the midpoint and end of the 6-month SICU orientation. The performance appraisals were based on input from preceptors and on the weekly evaluation tools. A shortcoming with this method of performance appraisal was that the educator had to rely heavily on preceptors’ feedback to assess a graduate nurse’s performance. Sometimes the preceptors’ feedback varied greatly in terms of the nurse’s strengths, weaknesses, and clinical competency. On several occasions, concerns about the competency of a graduate nurse were not voiced until several weeks into orientation, so opportunities to intervene early were lost, sometimes resulting in extension of orientation time. Additionally, informal meetings with the educator during a graduate nurse’s shift were not always useful in receiving feedback from the nurse or in getting a sense of the nurse’s performance, because the graduate nurses often felt disrupted and concerned that they would get behind on task completion.
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Improvement Plan for SICU Clinical Orientation |
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TopBackgroundTraditional SICU Orientation...Improvement Plan for SICU...SICU Staged Orientation ProgramResultsDiscussionConclusionReferences |
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summarizes our improvement plan. We (B.M.C. and B.E.) developed the staged orientation program to improve SICU orientation. The following is a description of the program.
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SICU Staged Orientation Program |
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TopBackgroundTraditional SICU Orientation...Improvement Plan for SICU...SICU Staged Orientation ProgramResultsDiscussionConclusionReferences |
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One of the authors (B.M.C.) had many years of experience in critical care and as a preceptor and had worked with graduate nurses both as a preceptor and as a charge nurse after the nurses’ orientation. She was interested in coordinating this new program and was willing to commit extra time and effort to the endeavor. The staged program structure and goals were formally presented to the SICU administration, and approval was given to pay for her time spent on graduate nurses’ orientation, mainly shifting paid time from the administrative duties of a charge nurse to overseeing the staged orientation program. Her role as the SICU graduate nurse resident facilitator is reviewed throughout this article.
Time Frames and Checklist
In the SICU staged orientation program, the 6-month clinical orientation is divided into 5 defined segments or stages (Table 2). This division provides structure and permits better tracking of where each graduate nurse is in the orientation process (eg, stage 3 or stage 4). More importantly, it defines 5 specific times to evaluate each graduate nurse’s progress; the traditional orientation included only 2 specific times, 1 at the midpoint and 1 at the end of orientation. Each stage except stage 1 is 6 weeks long. Stage 1 is 1 week long because of the nature of its introductory content.
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All 5 checklists contain 2 pages of focused content, a format that is more efficient for a preceptor to complete at the end of a busy shift. Also, defined checklists for each stage provide a clear guide for preceptors about content to teach at a particular time. This practice improves consistency between preceptors and in turn provides more structure for the graduate nurses.
Stage Assignments
In each stage, a specific type of patient is assigned to each graduate nurse and the nurse’s preceptors. The patient’s acuity and the specific checklist match the nurse’s skill and knowledge level. The complexity of assignments progresses incrementally from lower acuity patients to higher acuity patients. This progression allows the graduate nurse to be challenged, yet gain an opportunity to develop a time management routine without becoming overwhelmed. According to Seago and Barr,10 progressive responsibility for graduate nurses is key for a successful orientation. The acuity of the patients cared for peaks in stage 4; in stage 5, assignment returns to a lower acuity patient assignment. We thought it was important that graduate nurses end orientation with the same types of assignments they would experience after orientation.
Clinical Competency Verification for Stage Advancement
For each stage, the graduate nurse and the nurse’s current preceptor complete the checklist together. The preceptor reviews the checklist component with the graduate nurse and then initials the item. The initials indicate that the preceptor has reviewed the component and that the graduate nurse has performed a return-demonstration or has verbalized understanding of the concept. Because the graduate nurses critical care course at the beginning of orientation is based on the Core Curriculum for Critical Care Nursing,7 copies of this book are available in the SICU for preceptors to use as a primary reference as they teach critical care concepts.
By the last week of each stage, the checklist is fully completed, and the resident facilitator or the educator schedules a 2-hour meeting with the graduate nurse. The primary purpose of the meeting is for the graduate nurse to demonstrate comprehension and retention of stage content. Successful completion of this process (clinical competency verification) is required before the graduate nurse can advance to the next stage.
During the clinical competency verification with the educator or facilitator, the graduate nurse demonstrates his or her performance capability and understanding of each component on the stage checklist just completed with the nurse’s preceptor. Whereas each graduate nurse’s daily interaction with his or her preceptor is to gain knowledge and skill, the purpose of this meeting is to confirm the nurse’s understanding and retention of the stage components. If the component is a skill, the nurse actually performs the skill; if the component is knowledge-based, the nurse verbalizes understanding of the concept and answers questions asked by the educator or facilitator. Stage advancement is based on the quality of the performance in terms of meeting unit standards of practice and UCH policy and procedure. The educator and the facilitator measure each graduate nurse’s knowledge of critical care concepts on the basis of the Core Curriculum for Critical Care Nursing,7 which is consistent with the reference material used by the preceptors.
Having the educator or facilitator rather than a preceptor perform the clinical competency verification has several advantages. It gives the educator a more direct method of measuring each graduate nurse’s progress than the informal bedside rounds in the traditional orientation. Preceptors prefer the collaborative team-work involved in the evaluation of graduate nurses and like having the educator make the final determination for stage advancement.
The facilitator and educator divide the task of competency verifications for stage advancement, because these sessions can be time consuming when more than a single graduate nurse needs to demonstrate competency at the same time. Typically, the educator verifies competency for stages 3 and 5 because mid and final performance appraisals coincide with those time frames.
If a graduate nurse demonstrates competency, he or she passes to the next stage. If a nurse does not demonstrate competency, he or she does not pass, and a short period (usually 1 week) is granted for the nurse to prepare and reattempt stage advancement. In this period, the nurse remains in the same stage, continuing with previously scheduled shifts. If the nurse passes on the second attempt, he or she progresses to the next stage. If the nurse does not pass on the second attempt, the educator institutes a detailed development plan with specific requirements and associated time frames. The nurse remains in the same stage until goals of the development plan are met. Graduate nurses who do not meet the goals of the development plan are subject to the usual process that occurs when a staff member is not deemed clinically competent in the ICU (transfer to another unit if appropriate, self-termination, or termination), all of which is directed by nursing management.
Specifics of the Stages
Stage 1 consists of three to four 12-hour shifts and emphasizes documentation, ICU guidelines and applicable policies, use of computer systems and equipment, and beginning development of organizational skills (Figure 2). Some of the content in stage 1 (eg, restraint documentation) is a repeat of elements discussed in the hospital orientation of any RN. This repetition is intentional because graduate nurses are inundated with so much material that repeating some of these important concepts provides reinforcement. In addition, the graduate nurses need to learn how these global orientation elements are carried out in the SICU.
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Stage 2 lasts 6 weeks and emphasizes basic critical care knowledge and organizational skills. The patient assignment is 1 ICU patient paired with 1 non-ICU or intermediate (step-down) patient or 2 patients of whom 1 will soon be downgraded to non-ICU status. Monitoring of central venous pressure, beginning ventilation concepts, and discussion of arrhythmias are examples of concepts learned in stage 2. An 8-hour rotation with respiratory therapy and a 4-hour rotation with a unit secretary are completed during this stage. Each of these rotations has a separate short checklist that is completed during the rotation. The rotation checklists were developed to give clear direction about what should be taught during those experiences. An example of a component on the respiratory checklist is to explain the difference between peak and plateau pressures.
Stage 3 lasts 6 weeks and emphasizes pathophysiology. The patient assignment is 2 ICU patients, including patients who have pulmonary artery catheters or pacemakers or are receiving vasoactive agents (Figure 3). Stage 3 is a pivotal point for most of the graduate nurses. The higher acuity patients increase the demands on the nurses’ critical thinking, advanced skills, and organizational abilities. This point in the traditional SICU orientation was the place where the window for establishing a well-rounded critical care foundation was sometimes lost because learning to balance the constant requirements of "thinking" (understanding concepts) and "doing" (completing tasks) can be overwhelming and sometimes led to an overemphasis on one or the other.
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Throughout stage 3 and for the remainder of orientation, each graduate nurse learns and practices delegation. Delegation is an important skill to practice because failure to identify tasks to delegate can lead to inefficient time management and prioritization. Delegation is not stressed in the first 2 stages of orientation because the graduate nurses need to practice performing basic nursing tasks in the critical care setting, such as providing mouth care, repositioning patients, and monitoring blood glucose levels.
Stage 4 lasts 6 weeks and emphasizes critical thinking. Each graduate nurse and the nurse’s preceptors are assigned a single high-acuity patient. Graduate nurses are typically oriented to the night shift during stage 4 to optimize exposure to this particular patient assignment, especially if there are not enough assignments of 1 patient per graduate nurse to support several graduate nurses in this stage of orientation.
Stage 5 is 6 weeks long and emphasizes time management and delegation again. The patient assignment is a "busy" pair of patients (multiple interventions required), similar to a graduate nurse’s typical assignment in the immediate period after orientation. It is critical that assignments in this final stage of orientation allow the graduate nurse to practice time management and prioritization but do not overwhelm the nurse. We have learned that unrealistic assignments (assignments that are too busy) in this stage can shatter a graduate nurse’s confidence. The ideal patient assignment is a pair of ICU patients in which 1 of the patients requires frequent collection of samples for laboratory tests or has diagnostic tests (eg, computed tomography, echocardiography) scheduled during the shift. This assignment allows the graduate nurse to practice delegation and manage interruptions.
Delegation is difficult to teach. We have noticed that our graduate nurses tend to underdelegate, probably because as advanced beginners, they are more focused on tasks and get satisfaction from completing tasks. Delegation, as defined by the Colorado State Board of Nursing,11 is handing over a particular job to another team member who is competent to perform the task. The person delegating is responsible for ensuring that the job is completed and documented appropriately. Because the traditional SICU orientation included no details on when or how to teach delegation, this skill was inconsistently taught and practiced. Putting delegation skills into the checklists has helped the graduate nurses practice these skills, and the checklists are a reminder to preceptors of the need to model and teach the skills.
Graduate nurses generally do not master time management and prioritization in the 6-month clinical residency. However, we think that the more they practice these skills during orientation with mentoring from preceptors, the greater the chance the nurses will become proficient and avoid becoming overwhelmed after orientation. New nurses need assistance and advice in balancing the plan for the day with what they sometimes perceive as "interruptions," such as frequent telephone calls and unanticipated procedures. Preceptors in stage 5 help the graduate nurses see these events not as interruptions but as a usual part of complex care in the ICU that should be anticipated and incorporated into the plan of care.
Also during stage 5, the graduate nurses spend a shift in each of the 4 ICUs in the hospital. Each nurse is paired with an experienced preceptor from that ICU to observe and assist with patients’ care. The orientation includes learning the unit layout and location of supplies and provides an introduction to the unit’s population of patients in preparation for any future "float" shifts to the 4 units. These ICU shifts are helpful for instances in the future when the graduate nurse is assigned temporarily to these other units to support staffing needs. At UCH, all critical care nurses, including new nurses, who are temporarily assigned to another unit are carefully matched with patients so that the nurses provide care only in those areas in which the nurses have demonstrated competency (eg, general medical or surgical critical care patients rather than a patient requiring specialized skills such as management of an intra-aortic balloon pump).
Didactic Modules
Four didactic modules were specifically developed as classroom adjuncts to the SICU staged orientation program. Each module is 4 hours long. The modules are held during the last 2 months of orientation and are mandatory for completion of the program. The SICU educator and/or resident facilitator facilitates the modules in a scheduled time separate from clinical shifts. The classes focus on physiology review and reinforcement of critical thinking via case studies.
Each module (cardiac, pulmonary, renal, and hepatology/neurosurgery; Table 3) has a written list of content. Each graduate nurse receives the list in advance and is expected to study the content and be prepared to participate in discussion. During the class, the material is reviewed in a question-and-answer format, and actual SICU case studies are used to help the graduate nurses connect critical care concepts to patients’ care. In many instances, graduate nurses share their own experiences with patients and discuss the decision-making process involved in treatment choices.
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Graduate nurses are encouraged to ask questions and clarify their understanding of concepts and patient scenarios. We want to ensure that graduate nurses not only know what to do but also know why they are doing it. In addition, the facilitator asks the nurses questions to analyze their thinking. According to Rowles and Brigham,12 this type of questioning "promotes active thinking about conclusions to be drawn; promotes discussion from multiple points of view; allows students to discuss concepts from their own experience; promotes higher-level problem-solving skills; and learning is transferred from classroom to clinical environment."
Our graduate nurses have reported that the opportunity to ask questions and review actual patients that they have cared for in the low-stress environment makes them feel more confident in their knowledge. These modules are a follow-up to the basic critical care course offered in the second month of orientation. Because the Essentials of Critical Care Orientation sessions have replaced the critical care course, the didactic modules have been modified and now focus on case studies that augment the online sessions.
Implementation
Before implementation of the staged orientation program, the preceptors and other charge nurses had to agree to use the new process. The unit manager and educator agreed to try the new program. Discussions with the preceptors and charge nurses revealed that they noted deficits in the knowledge and skill of some graduate nurses during and after orientation and thought that a new orientation process was probably warranted. However, some of the preceptors were concerned that the staged program would generate more paperwork. Despite this concern, the preceptors agreed to try the program.
In preparation for implementing the SICU staged orientation program, the preceptors attended a 2-hour training session on the program taught by the resident facilitator. The 5 stages were reviewed in detail, including the philosophy, checklist content with associated patient assignments, and required clinical evaluation sessions. The staged program did add more paperwork to the orientation process because the Critical Care Clinical Orientation Competencies checklist still had to be completed, in addition to the stage checklists.
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Results |
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TopBackgroundTraditional SICU Orientation...Improvement Plan for SICU...SICU Staged Orientation ProgramResultsDiscussionConclusionReferences |
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Compared with graduate nurses who completed the traditional orientation, most graduate nurses who have been through the staged orientation program seem to have an easier transition to the typical assignments of patient pairs after orientation. This difference is attributed to the use of pairs of patients in stage 5, which matches the typical assignments immediately after orientation. However, a few graduate nurses have become overwhelmed with their assignments after orientation and have required additional tailored patient assignments.
Unlike graduate nurses who completed the traditional orientation, graduate nurses who completed the staged program have not voiced disappointment when they do not get assigned a single high-acuity patient immediately after orientation, probably because we clarify assignments after orientation from the beginning of the staged orientation, and the nurses do not expect to be assigned a high-acuity patient immediately after orientation. With these clear guidelines for assigning patients, comparison and tracking of assignments between graduate nurses are no longer an issue.
As part of the staged orientation, we tell graduate nurses that they will not be assigned immediate postoperative heart surgery, lung transplant, or heart transplant patients immediately after orientation. Graduate nurses are assigned to these types of patients only after the nurses have 1 full year of experience after orientation and additional training. This year of clinical practice after orientation allows the graduate nurses time to build skills and confidence and also is congruent with the UCH graduate nurse residency program, which lasts 1 year. Casey et al13 found that graduate nurses had feelings of inadequacy with their clinical knowledge throughout the first year of practice. Our graduate nurses reported similar feelings, supporting our plan to allow 1 year of practice before orientation to this high-acuity population of patients. Most of our graduate nurses who completed the staged orientation program tell us that they were relieved that they were not going to be assigned high-acuity patients immediately after orientation.
One year after orientation, each graduate nurse is required to attend a postoperative heart recovery class and a lung and heart transplant class. After attending these classes, the graduate nurse completes two 12-hour orientation shifts with a preceptor in which the nurse cares for heart surgery and lung and heart transplant patients in the immediate postoperative period. An associated checklist is completed. The graduate nurses have reported that they value the time to develop organizational skills and hone critical care knowledge for a year before assuming responsibility for this type of high-acuity patient.
Preceptors’ Evaluation of the Stages
During the 6-month trial period of the staged program, we closely followed the progress of graduate nurses and obtained feedback from preceptors, charge nurses, and graduate nurses. At the completion of the trial, the preceptors had uniformly positive reviews of the staged orientation program and agreed to continue to use it.
With the implementation of the SICU staged orientation program, more was expected of preceptors in the SICU. Because clinical evaluations for stage advancement occurred every 6 weeks, the preceptors needed to complete the stage checklists on a routine basis. With the staged program, preceptors seem to have an improved understanding of the need to provide documentation as teaching occurs. This understanding of the need for timely documentation has improved preceptor-partnering efforts in training the graduate nurses. The reviews of the checklists clearly indicate what material still needs to be covered, maximizing clinical education efforts. The preceptors like the format of the stage checklists, and the lists are easy to use. Because the content to be taught in each stage is clear and patient assignments match learning needs, preceptors feel more confident that they are teaching the right material at the right time.
Preceptors like the incremental patient assignments and the organization of the components on the checklist. In addition, preceptors report that they are proud when a graduate nurse successfully passes the clinical evaluation and advances to the next stage. Preceptors also state that they feel an increased level of responsibility and personal investment in the graduate nurses’ success. Because the outcomes of the graduate nurses’ orientation have been successful on so many fronts, the preceptors propose that all newly hired RNs complete the staged orientation program.
Preceptors’ Education
In order to address the learning needs of the preceptors, classes were developed on clinical applications in the care of critically ill patients. Nine different 4-hour classes were held throughout the year on the following topics: liver transplantation, cardiovascular conditions, lung transplantation, cardiac surgery, general surgery, neurosurgery, renal conditions, hemodynamics, and pulmonary conditions. Physicians and staff nurses taught the classes. The SICU educator (B.E.) mentored the staff nurse instructors and was the class facilitator. The graduate nurse facilitator (B.M.C.) chose the course content, enlisted instructors, and provided continuing education credits. In the classes, the instructors reviewed critical care concepts, critiqued case studies, and discussed evidence-based research. Each class had a presentation on the content, but time was allotted for questions and discussion. The classes were not mandatory for preceptors, but many of our graduate nurse preceptors chose to attend.
Precepting entails added duties and responsibilities, so we provided breaks from precepting when possible. As noted by Everhart and Slate,14 breaks allow preceptors to avoid burnout, which can adversely affect a graduate nurse’s success. Once the preceptors were assigned to a graduate nurse, they guided the nurse through all 5 stages (6 months) of orientation. We kept track of the amount of time each preceptor spent orienting graduate nurses and ensured that breaks were given as needed. Some preceptors preferred to orient graduate nurses and did not desire a break.
We thought that it was important for the preceptors to have regularly scheduled meetings. The preceptor council, facilitated by the SICU educator, was organized and meets every other month. This time is devoted to discussing the progress of the graduate nurses in the staged orientation program, orientation strategies, and reviewing stage content to verify that preceptors are teaching consistently. All preceptors were invited to participate, even if they were not orienting a graduate nurse.
Verification of Clinical Competency
Direct verification of clinical competency between stages has been beneficial and places primary accountability for stage advancement on the individual graduate nurse. Occasionally, a graduate nurse was not prepared or was having difficulty with the stage content. This situation was atypical, because most graduate nurses look forward to stage 4. Of 14 graduate nurses who completed the SICU staged programs, 3 did not pass the stage 3 verification on the first attempt. Of these 3, 2 were able to pass on the second try after additional self-study. The third graduate nurse chose to transfer to a non-ICU setting. We anticipated that knowledge verification for stage 3 would be challenging for the graduate nurses because they have to verbalize advanced concepts, such as the effects of vasoactive agents on hemodynamics. Because we had 3 graduate nurses who did not pass stage 3 on the first attempt, we reviewed the content. We decided that the content is important and should remain unchanged, especially because knowledge of these concepts is imperative to care for the stage 4 assignment.
To provide consistency in determining stage advancement, we were the only ones who performed the clinical competency verifications. We reviewed each component on all of the stage checklists before the verifications to clarify what defined successful completion. This review was an important part of the process to ensure that expectations of each graduate nurse’s performance were consistent. Having the same 2 people perform the verifications provided consistency, but scheduling the verifications was occasionally challenging. Each graduate nurse has a limited period for completing the 2-hour competency verification, and commonly, multiple graduate nurses are attempting stage advancement in the same week.
Graduate nurses have stated that the requirement to demonstrate knowledge and skill between stages makes them feel more confident in their clinical practice, even though some state that they get nervous.
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Discussion |
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Although it is ideal for preceptors to have 2 years of ICU experience, the shortage of nurses has limited the number of experienced preceptors. The stages can be beneficial in these instances because the clearly defined checklists, defined patient assignments, and competency verification of each graduate nurse’s performance by a clinical expert offer additional structure and support for less experienced preceptors.
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Conclusion |
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