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To learn more about critical care education and training, read "Early Socialization of New Critical Care Nurses" by
Deanna L. Reising in the American Journal of Critical Care, 2002;11(1):19–26
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit http://ccn.aacnjournals.org and click "Respond to This Article" in either the full-text or PDF view of the article.
None reported.
Corresponding author: Donna M. Proulx, RN, MS, CCRN, Catholic Medical Center, 100 McGregor St, Manchester, NH 03102 (e-mail: dproulx{at}cmc-nh.org).
Review of Literature
Casey et al1 used a survey to evaluate the stresses and challenges experienced by new graduates in 6 acute care hospitals during a 1-year period. Several overall themes were apparent in the new graduates’ reports of what was most difficult in their transition from student to nurse:
For many graduates, having other new graduate peers available to talk to and share clinical experiences was helpful. Graduates with less than 6 months of experience indicated that lack of organizational skills was a barrier to optimal performance in their new role. The graduates also reported having difficulty in developing a routine and prioritizing tasks.
In another survey of newly graduated nurses, Thomka2 received feedback from several graduate nurses that expectations during this transitional period were unclear. In that study, responses from graduates included that they expected less "in-the-fire" experience and would have preferred several weeks of 1-on-1 mentoring. A nurse mentor working with these graduates voiced the need for new nurses to carry a smaller patient load so mentors can focus on meeting the learning needs of the nurses. One graduate nurse in a phenomenological study by Delaney3 voiced concern that having multiple preceptors (6) was frustrating and confusing, because the preceptors each had their own routine and way of doing things.
The 5-stage model of skill acquisition as described by Dreyfus and Dreyfus4(p37) and the application of this model to nursing by Benner5(p21) enhances the understanding of the learning process with graduates. Benner’s model explains how a nurse develops from a novice to an expert. In the novice stage, lacking experience or contextual meaning, graduates are given rules to guide performance. The nurses first gain situational experience by making objective measurements, such as obtaining a patient’s blood pressure, daily weight, or urinary output. The nurses start to apply these basic patient findings within the rules or guidelines they have been told are normal. This process becomes the foundation for contextual knowledge as the nurses progress to the expert level.
Unit Preceptor Team
Our unit’s preceptor team consists of a critical care educator, a chairperson, and several experienced preceptors from all 3 shifts. Our nurse preceptors are divided into 2 categories: primary and clinical resource. The primary preceptor group consists of nurses who work mostly full-time and are consistently coassigned to train nurses who are new to our unit. The preceptors are familiar with the orientation process and are competent to evaluate and document the progress of new nurses. Primary preceptors are also invited to participate in our unit-based annual preceptor appreciation day. This day is dedicated to recognizing the efforts of preceptors and to increasing the preceptors’ own knowledge. Activities in the past have included interactive group discussions and guest speakers on different learning styles and generational differences. Each year, 1 primary preceptor is selected as preceptor of the year in recognition of his or her work, and the winner is awarded a 1-year membership to the American Association of Critical-Care Nurses. The role of clinical resource preceptor is reserved for critical care nurses who are entry-level preceptors and are assigned occasionally to work with new employees in the absence of the primary preceptor.
Problems With Current New Graduate Orientation
In years past, our new graduates began their clinical orientation with a 1-patient assignment for 2 weeks, before a second patient was added for the remaining 10 weeks. A new graduate nurse was coassigned with a preceptor to care for 1 patient, and the preceptor often had an additional patient of his or her own. This situation often became frustrating to the preceptor when time had to be split between the needs of an additional patient and the learning needs of a new graduate nurse. This approach was not designed to be goal-directed learning, other than to care for the assigned patient together. This orientation format was developed to accommodate our normal staffing pattern, a ratio of 2 patients to 1 nurse. The orientation schedule for a new nurse was not formally organized by an educator but was simply assigned by the clinical leader (shift leader). The preceptors were chosen at random from staff available on each shift, and the unit did not have a core group of nurses trained as preceptors. As a result, a single orientee could potentially be assigned to work with multiple preceptors during a 1-week period. In addition, new graduate nurses were being given different information about basic critical care concepts by each daily preceptor, consistent with the beliefs of that preceptor. Assigning a different preceptor to a new graduate nurse also made it hard to track the progress or educational needs of the new nurse.
Orientation Program Redesign Goals
The goal of our redesign was to help graduate nurses first become fluent with hands-on technology and skills, so their thought process could be dedicated to higher level thinking when they were later assigned to work with the unit preceptors. The new program also had to provide structure to the learning process in a normally unstructured patient care environment. We also wanted a process in place to ensure that each graduate was given the same information about basic care concepts, so that the autonomy that critical care offers does not confuse the graduate nurses before they have developed their own critical-thinking skills. During the program redesign, we took steps to avoid repeating concepts that did not work in the past. One past mistake was assigning 2 patients to a new graduate nurse too early in the orientation process. Historically, this situation led to frustration for both the graduate nurse and the preceptor, because the graduate was not always ready to care safely for 2 acutely ill patients.
Program Redesign
After we had reviewed the stages of skill acquisition that a graduate nurse must move through before becoming competent, we wanted to develop an orientation program that could be designed to best meet the needs of the learners, with a primary goal of fostering critical thinking skills sooner. Understanding that graduate nurses need to develop technical proficiency early in their training, we redesigned the graduate orientation program to include 3 phases (see Figure
).
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Day One
The first day in the intensive care unit, the graduate nurses are assigned to work with our critical care educator and do not have a patient assignment. This day is used to provide an orientation to the physical unit and to introduce each graduate nurse to staff members and unit policies and references. Equipment used is presented, with time for hands-on return demonstration. A digital photograph of each new employee with his or her primary preceptor is taken and is posted in the staff lounge to welcome the new employees and introduce them to current staff. An overview of the orientation template is explained to the graduates (see Figure
and Table 1), including the timeline of all 3 phases and the critical care classroom schedule. The graduates are also given a list of questions to ponder; these questions are to be reviewed daily after the graduate nurse has assumed care of a patient.
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An individualized orientation schedule of classroom and clinical hours (Table 2) is developed for each graduate nurse by the unit educator, and a copy is posted on the preceptor assignment board. Two calendar weeks are considered a single clinical week on the unit because of the 2-day-a-week classroom schedule. The last day of the critical care course is dedicated to critical-thinking scenarios; mannequins and monitor simulators are used to challenge the graduates with common clinical situations.
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Phase 1 involves having 2 graduate nurses assume care of the same patient (under the direction of our educator). The responsibility of care for 1 patient was divided into 2 nurse positions: primary and secondary roles (Table 1). These labels were chosen to identify specific duties; neither position ranks higher, because all tasks listed are expected of a nurse. This itemized list of duties developed by our unit educator highlights specific tasks required when providing basic care to a patient in the critical care unit. Our hypothesis was that if the graduate nurses could dedicate their attention to learning half of the patient’s needs at once, they would not become overwhelmed with all of the demands required of a nurse. This predetermined list of duties helps provide structure to the delivery of care and also helps ensure that the expectations of the graduate nurses and the nurse educator are the same.
Initially the graduate nurses are coupled in pairs and assigned to care for the same patient for 2 consecutive days (under the direction of our educator). This way each graduate nurse can perform both roles (primary and secondary) in 2 days and see the total care required for that patient. Although 2 graduates are caring for the same patient simultaneously, each nurse has different duties. The educator is ultimately responsible for the 2 patients. Both graduates are responsible for listening to intershift report; reading physicians’ progress notes from the past 24 hours, nurses’ notes, patients’ medical history, and findings on physical examination; and reviewing providers’ orders. The well-defined expectations of the primary and secondary roles help provide direction and bridge the gap to reality in this task-oriented phase of nursing.
After 2 weeks of working with the educator, each graduate is ready to combine both learned roles and assume care of 1 critically ill patient under supervision of a preceptor. Although some may view this decrease in duties from 100% to 50% as atypical in learning to care for a critical care patient, the concept was developed to provide structure to the learning environment and to allow graduate nurses time for attention to detail. We hoped that fostering this attention to detail in new nurses would promote a more prudent practice later when the nurses were challenged with multiple tasks at hand.
Phase 2
In phase 2, each new graduate is coassigned with either a unit preceptor or the educator to care for 1 patient. The preceptors are added at this point to assist the educator, so the supervision responsibility does not exceed more than 2 patients per nurse. With this approach, the preceptors are used in a more efficient manner; 1 preceptor is assigned to 2 patients (similar to our normal staffing pattern). Patients the graduate nurses are qualified to care for are chosen each evening before the scheduled day by the educator or assigned preceptor. The idea is to select patients whose clinical status is stable who do not have orders for procedures. Admissions, bedside procedures, and transfers are introduced later into assignments when the graduates have gained confidence with a regular routine.
The goal of this stage is to provide supervised independence for the graduate nurses. They start to make individual decisions about patient care, while still being supervised closely by their preceptors. This phase provides an opportunity for the graduate nurses to perform procedures they have previously practiced with a preceptor, for example, preparing and administering an intravenous medication without the step-by-step direction of the preceptor. Although the preceptor monitors the preparation and delivery, the graduate nurse is allowed to approach the process independently. If the graduate nurse has a question, the preceptor encourages the new nurse to verbally explore all options and rationale before making a final decision, instead of the preceptor just giving the graduate nurse an immediate answer. An effort is also made to assign the preceptors and graduates patients who are close to each other, so that the 2 teams can assist each other with unscheduled procedures, patient care, or lunch coverage. The graduates also learn to be comfortable with communication skills such as hand-off report, communication, and delegation.
One struggle for the preceptors during this phase is the conscious effort to stay focused on the graduate nurses and not become distracted by other acute issues taking place with other patients. This focus also becomes difficult at times for noninvolved staff members, who may view the preceptor as doing nothing, but in actuality the preceptor is listening to report with the graduate nurse.
Phase 3
In phase 3 of the orientation, each new graduate nurse is assigned to care for 2 patients under the supervision of 1 preceptor. By week 9, the new nurses begin working their assigned evening or night shift (with a preceptor). The graduates are not scheduled to work the night before a class day.
Matching patients’ acuity to the skill level of graduate nurses became a challenge. Most days, all 4 graduates were assigned to the unit on the same day because they attended classroom lectures twice a week. This arrangement required preceptors and charge nurses to find 8 patients on a single shift that would match the skill level of new graduate nurses. Typically, the preceptor or educator would request an assignment the day before, and the charge nurse would adjust the assignment if the assigned patient’s condition changed.
Between weeks 9 and 10, each new graduate is assigned a time to complete the basic dysrhythmia examination. This time frame allows the graduate nurses the opportunity to gain clinical experience with rhythm identification and treatment while caring for patients with the preceptors. If a passing score of 85% is not obtained on the examination, the unit educator provides individual remediation in identified areas of weakness.
The target date for a graduate nurse to be ready to complete orientation is about week 12. For each graduate nurse, the specific date of completion is discussed with the unit director, educator, primary preceptor, and the graduate nurse at a final summation meeting. This meeting is scheduled by the unit educator and is used to summarize the progress and experiences of the graduate nurse. The graduate nurses are asked to self-evaluate their progress and address their comfort level with completing orientation. If it is decided that orientation will extend beyond the 12-week mark, specific goals are identified and agreed upon by the group. Once orientation is completed, a graduate nurse is expected to be able to care for 2 critical care patients receiving mechanical ventilation.
Results
The first year this template was used, the plan met the original goals of the redesign and had some unexpected benefits. The information provided was standardized, because all of the graduates initially worked with our critical care educator. Also learners’ attention to detail improved. One graduate nurse noticed that an intravenous tubing sticker listed an incorrectly calculated date of expiration. Another graduate noted that the respiratory therapist had recessed the inline suction catheter too far back after suctioning, so the closed-sheath system was leaking oxygen.
At the end of orientation, we met informally with the new graduates and requested feedback on the program. Feedback on the changed approach was positive. The graduates stated that they felt secure in having sufficient time to master the technical skills required (hands-on equipment) in the first phase of the program. One new graduate stated that this system of being coassigned with another new graduate to care for the same patient helped the first nurse foster a peer relationship with a new coworker. Another graduate suggested that we specifically add that the primary and secondary nurses share information gathered during patient care before giving intershift report. Although doing so seemed common sense, it had not been included in the written plan and therefore was not consistently done by each graduate nurse. This additional instruction would potentially prevent a fragmented report to the oncoming nurse. One graduate stated that although she had a high anxiety level initially when starting each phase, after a few days she was able to calm her fears because she knew that she was able to meet the expectations of more responsibility.
The preceptors found the new design surprisingly rewarding. Overseeing 2 graduate nurses with 1 patient each was less stressful than being assigned 1 graduate nurse and a patient of the preceptor’s own (as in the past). The preceptors recognized the strength that the new graduates had gained in the first 2 phases, as compared with new graduates in previous years. The graduates were no longer hesitant to do suctioning or turn patients. We think that this difference is directly linked with the specific time allotted to learn technical skills in phase 1. This comfort with hands-on tasks allowed the graduate nurses to focus on time-management skills, which is often difficult when advancing to a 2-patient assignment. The nurses also seemed to improve in prioritizing tasks, for example, when one patient needs a dressing change and another patient needs to have a blood sample obtained for laboratory tests at the same time. One preceptor also noted healthy competition; one of the new graduate nurses would say, "I got to start an IV," and the other graduate nurse would then seek that opportunity.
Time-management and critical-thinking skills also seemed to improve with this model. One graduate commented that he had just changed a patient’s dressing 2 hours before, then wondered why it was resaturating so quickly. He reassessed the drainage and reviewed the patient’s laboratory values, activity, and fluid/volume status to determine an appropriate course of action. Instead of focusing on the dressing change technique or how late the hour was getting, he was wondering, Why did this soak through so quickly? This example reflects just the desired level of critical thinking that we were hoping the graduates would achieve.
Our time frame for having a graduate nurse complete orientation to critical care has not changed; it remains at 12 weeks. These changes to our orientation format are not only cost-effective but also have improved our utilization of resources. The previous method of assigning 4 graduate nurses to 4 preceptors with each pair caring for 1 patient reduced our staffing capacity by half, because each preceptor was assigned 1 patient instead of 2. In phase 1, using the educator (who is normally out of staffing) to care for patients makes the preceptors available for a full assignment. This step also saves about $10 000 in nursing salary over this 2-week period (320 preceptor hours were not needed: 2 weeks with 4 preceptors). In phase 2, an additional $7500 was saved in nursing salaries, because the educator was again used in addition to a preceptor to work with the graduates. (A total of 240 preceptor hours were not needed: 3 weeks with 2 preceptors.) Our unit director commented that she was able to approve more summer vacation requests by staff because this template allowed preceptors to be used more efficiently.
Remaining Challenges
One challenge that remains is how to obtain the same benefits of this model when an odd number of graduates are hired. If a graduate nurse did not successfully pass the licensing examination and had to forfeit his or her hired position, a graduate nurse would not be paired. This model might not be a success if the educator and preceptors do not work as a team, communicate, and plan ahead of time. Also, we must trust that the clinical leaders and relief charge nurses will strive to keep the predetermined assignments and nurse-to-patient ratios and not alter the model to fit the immediate needs of the unit.
Conclusion
The working environment in which a nurse acquires skills has changed drastically. In years past, a nurse was not considered for a position in critical care unless he or she had prior experience. This requirement provided a clinical work environment heavily populated with experienced personnel. Today, not only are graduate nurses accepted directly into critical care but their working environment is weighted with less-experienced nurses. The impact of this lesser experienced working environment on nurses moving from novice to expert has yet to be determined.
PRIME POINTS
References
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