Impact of disease-specific orientation on new graduate nurse satisfaction and knowledge retention.
Transition from student to novice nurse can be especially challenging, and a weak orientation can further complicate this difficult time for new graduate nurses. The neuroscience field is complex, and orientation can cause new nurses to lack a comprehensive understanding of their specialty, resulting in a task-focused approach to bedside care. Using a convenience sample and both qualitative and quantitative data, this study implements a disease-specific orientation track for new graduate nurses to spotlight the most common neurological diagnoses and disorders while concentrating on building an understanding of how to provide the best care possible to these patients. This article reports the outcomes achieved from the first phase of the study including improved clinical competence, readiness and retention of knowledge, overall satisfaction with orientation, and increased comfort level in caring for the neurological patient. In addition, the feedback and information gathered have provided a foundation for the project to be tailored and continued to further improve these results with future new graduate nurses on the neuroscience unit.
Transitioning from student to new graduate nurse is very challenging, especially on a fast-paced, high-acuity neuroscience unit. This transition offers learning experiences beyond those acquired in school. Many of the concepts learned can only be internalized through personal experience (Santucci, 2004). New graduate nurses have just graduated from an accredited nursing program and do not have any nursing experience other than clinical time. New graduate nurses must be provided with an effective orientation program that will ensure that they receive the necessary information to be successful.
Review of the Literature
Little research has been conducted on orientation outcomes or the identification of what elements may be critical to a successful new graduate transition (Krugman et al., 2006). Current literature reports that as many as 80%-90% of new graduate nurses will leave their job within the first year of employment (Orsini, 2005). If orientation is inadequate and developmental support is not sufficient, turnover will increase. The reality shock for a nurse moving from student to staff nurse is very stressful and influences turnover, retention, and job satisfaction (Hickey, 2009).
The cost to orient a new nurse to the unit can range up to $92,000 (Ward, 2009, p. 87). Financial considerations include the cost of lost productivity related to the new vacancy, added responsibility while a position is vacant that results in lost productivity of the remaining employees, and paying per diem nurses higher wages to fill in during the vacancy and the expense of orienting a new employee for replacement (Ward, 2009).
In 2002, the National Council of State boards conducted a survey of chief nursing officers who reported perceptions that new nurses in their hospitals were inadequately prepared to recognize abnormal symptoms. Transition from student to nurse is a significant issue that needs to be addressed by targeted programs that provide best practices in developmental support (Krugman et al., 2006). Tailored orientation programs remain cost effective for the organization and allow inexperienced nurses to develop safe, competent practice (Santucci, 2004). A structured environment will reduce RN turnover (Orsini, 2005), increase orientation satisfaction, and improve orientee confidence and overall quality of care for the patients.
The neuroscience field is very complex and can be intimidating to new graduate nurses. Many nursing programs offer a semester that includes classroom education related to neurology and neurosurgical nursing; however, many students do not experience the neurosciences as a clinical rotation because not all facilities have a neuroscience unit. With the traditional method, the new graduate orientation on the acute neuroscience unit progressed weekly by adding patients to the orientee's team. During the first week on the acute neuroscience unit at the bedside, the new graduate nurse started with two patients, and each week, one patient was added to the assignment. Most new nurses are hired to night shift, so this process continued up to six patients, which is the potential full team. This process was used to ease the transition from student to nurse and aid in developing time management and prioritization skills. The types of patients varied in the teams throughout orientation, as assigned. In addition, the preceptor would attempt to ensure that the orientee had the opportunity to care for a wide variety of patient populations, but there was not a particular disease-specific focus. This traditional method has been somewhat successful, yet resulted in a task-focused approach to patient care.
After evaluating the current research, a new orientation plan was developed to improve the new graduate nurse's clinical competence when completing orientation and to provide a solid foundation on which to start his or her neuroscience nursing career. A disease-specific approach was developed. Full review and approval by the institutional review board were obtained. As with the traditional method, the unit provides an on-unit clinical educator, management, charge nurses, preceptors, and innovative technology that are available to the orientees throughout the process. The trial/pilot method introduces the addition of several American Association of Neuroscience Nurses (AANN) resources made available during orientation. Finally, this trial method is believed to benefit patients, families, and other staff because the new nurses will exhibit increased proficiency in the neuroscience specialty.
A convenience study was used to measure the knowledge retention and orientation satisfaction of new graduate nurses hired by the acute neuroscience unit in 2009. Evaluation of the disease-specific orientation included both qualitative and quantitative measures. The outcomes of interest included the new graduate nurse orientee's clinical competence, readiness and retention of knowledge after orientation, overall satisfaction with orientation, and comfort levels in caring for the neurological patient population.
The participants who consented to participate in this study included all new graduate nurses hired to the acute neuroscience unit for the period of 1 year. No incentives were provided to the participants, and it was explained that they did not have to participate in the study. No one opted out. The new nurses were informed about the orientation process and then given the option to consent for participation in the research study. If the nurse would choose not to participate, he or she would still complete the same orientation process but would not be tested; therefore, no information about the participant would be used in the study. Preceptors were chosen by the clinical educator. Compatibility issues between new orientee and preceptor were addressed during the weekly meeting with the managers and educator. All encouraged the orientees to express concerns timely so changes could be made as necessary to ensure a successful orientation process. Resources were readily available as all orientees worked with a preceptor, and their progresses were followed by the clinical educator.
Eighteen new graduate nurses participated in this study. One nurse did not complete orientation and was lost to any follow-up related to resignation of her position. Of the 17 nurses remaining in the study, 13 graduated with a Bachelor's Degree in Nursing, three graduated with an Associate's Degree in Nursing, and one graduated with a Diploma in Nursing. One nurse had an additional Bachelor's in Exercise Physiology. All were women aged 22-45 years.
The preceptors had 2-30 years of experience. Each preceptor completes a 12-week online, threaded discussion preceptor class lead by clinical educators. They were not provided with any extra incentive; however, we have a professional development program at our facility, and the preceptors could use precepting to earn points toward meeting their desired level in the program.
The study took place on a 37-bed acute neuroscience unit, part of the Illinois Neurological Institute at the OSF Saint Francis Medical Center in Peoria, IL. The OSF Saint Francis Medical Center is a 540-bed academic medical center and is affiliated with the University of Illinois in Peoria. The unit is composed of 28 general neurology beds and nine intermediate level beds. Diagnoses widely vary within the neuroscience field, with a large majority of the volume being surgical patients.
Patient admissions were evaluated for types of common diagnoses seen on the unit, and eight were chosen as specific focus areas for orientation. Three orientation tracks were developed for the orientees to follow based on those common diagnoses identified (see Figure 1). Providing three tracks allowed for multiple orientees at one time. Each orientee followed one of the tracks. These assigned tracks were posted at the nurse's station so that the charge nurses could work to correctly assign patients to each particular new graduate nurse.
Before the start of orientation, the preceptors and the orientees were provided with education related to the expectations for the disease-specific orientation process. Each preceptor and orientee was given objectives and assignments for each week. The preceptors were provided with guidelines for topics to review weekly with the orientee while caring for patients (see Figure 2). The orientee section included information to use as a study guide for the week, which focused on crucial "need-to-know" information related to the care of each particular diagnosis. These guides also ended with summarized questions for each week and included the minimal expectations for takeaway knowledge related to that diagnosis.
FIGURE 2 Guidelines for Topics to Review Weekly With Orientees Seizures Objectives:  Orientee is comfortable discussing different types of seizures.  Orientee is confident in care needs for patient having a seizure.  Orientee has reviewed unit and hospital specific material related to care of the patient with seizures. Orientee:  Should care for patient with seizures if possible.  Review the following protocols: Seizure Management, Video EEG  Locate and review standing orders for Adult Video EEG.  Verbalizes different types of seizures: absence, simple and complex partial, generalized tonic-clonic, myoclonic.  Discusses care for patient in status epilepticus.  Read and review AANN Reference Series/power point on Healthstream entitled OSF Neuro Care of the Pt. with seizures.  Review seizure medications and restrictions for use on general units. (Use "Guide for Medication Use" to find this information). Preceptor:  Actively seek assignments including seizure patients for orientee.  Carefully review expectations of orientee this week and complete education necessary for their success and understanding of the care for a patient with seizures.  Review WADA procedure (sodium amobarbitol in anglo) - Link on 35 portal  Assist orientee in finding standing orders and protocols online to aid in study for this week.  Communicate timely and effectively with Cindy regarding progress and needs of orientee.  Complete competency tool related to diagnosis with orientee.  Complete weekly orientee evaluation. Questions for this Week: 1. What are some different types of seizures? (generalized tonic clonic, absence, simple or complex partial) 2. What is an emergent complication seen in patient's with seizures. (status epilepticus) 3. What is the maximum dose of Fosphenytoin that can be given IV on a general unit? (300mg)
The general neuroscience nursing orientation lasted for 9 weeks. The first week of orientation consisted of new employee orientation, a requirement of all hospital staff, and professional orientation, which is mandatory for all registered nurses. During the second week of orientation, the orientee began patient care on the acute neuroscience unit. As in previous orientations, one patient was added to the orientee's team weekly to allow for development of time management and prioritization skills. The difference with disease-specific orientation is that orientees are assigned at least one patient from their designated track. Depending on which week of the track was being followed, the orientees were encouraged to study about the particular diagnosis focusing on this particular disease process, signs and symptoms, treatments, possible complications, protocols, and cares. The AANN's "Foundations of Neuronursing" PowerPoint presentations and the AANN Clinical Practice Guidelines were provided as study materials. In addition, we offered a unit web portal, which included links to other pertinent web sites and educational resources.
FIGURE 3 New Orientee Survey New Orientee Survey Please rate the following questions/statements with a 1-5 scale: 1 - disagree 2 - slightly disagree 3 - neutral; need more practice 4 - slightly agree 5 - completely agree 1.--I feel comfortable caring for a patient who has experienced an ischemic stroke. 2.--I am fairly comfortable with medications related to ischemic strokes (tpa, reopro, heparin, blood pressure medication, antilipids, blood glucose management, etc.) 3.--I know the difference between an ischemic stroke and a hemorrhagic stroke and how the treatment differs. I am comfortable caring for a patient who has suffered from a hemorrhagic stroke. 4.--I understand and am fairly comfortable with medications and treatment related to the hemorrhagic stroke (blood pressure control, Nimodipine, pain medication and when to use, smoking cessation, etc.) 5.--I am knowledgeable in caring for the surgical patient and can differentiate surgical procedures and understand their comprehension. 6.--I am familiar with common post op order sets and can anticipate what will be ordered for my patient. 7.--I am comfortable assessing for pain, sensation, and other complications that can occur post operatively. 8.--I am comfortable caring for the post craniotomy patients and am able to understand why my patient underwent a craniotomy and the treatment given to them since surgery. 9.--I am comfortable with most diagnoses related to craniotomies or am able to find information easily if I am unfamiliar with the particular diagnosis. 10.--I am able to correlate different injuries associated with the spine to the manifestations that the patient experiences post trauma. 11.--I have a general knowledge of what the patient has been through before being transferred to the acute neurology unit (reduction/traction, vasopressors, surgery, steroids, etc.).
The clinical educator, patient care manager, and assistant patient care manager alternately met with each orientee and preceptor weekly to ensure that the orientation was progressing as planned and all educational needs were being met. Any concerns were addressed at that time and as needed during the orientation process. Literature suggests that the inclusion of regularly scheduled meetings to assess orientation progress can positively benefit the difficult role transition of the new graduate nurse (Goodwin-Esola, Deely, & Powell, 2009). These interviews consisted of evaluating the goals and objectives for the current week, addressing any questions, assessing for barriers, and preparing for the following week. A template was designed for the weekly interviews, which included objectives and expectations for both the new graduate nurse and his or her preceptor, and was completed after each meeting.
Knowledge retention was quantitatively measured with pretests and posttests, which specifically related to the orientation plan goals and objectives. The test included information specific to the neurological disorders encountered on the acute neuroscience unit for an overall understanding of the orientation material. The format of the pretest and posttest included matching, multiple choice, true or false, and open-ended questions related to diagnosis, diagnostic testing, medications, care, and anatomy. The posttest was repeated again at 3 and 6 months to compare scores and assess knowledge retention.
Satisfaction levels of new graduate nurses were evaluated by a survey (see Figure 3) after orientation, which measured comfort levels associated with caring for patients with neurological diagnoses as outlined by the orientation plan. Furthermore, these satisfaction and comfort levels were qualitatively explored during the mentioned weekly interviews. The unit integration tool used was adapted from a research project conducted by Santucci (2004). This tool was used to evaluate the effectiveness of training and support provided to the orientee by the preceptor. A Likert scale based on frequency was used to identify how often the preceptor displayed the actions in question.
As stated, each orientee was tested for knowledge retention. A pretest was given to provide baseline data for each nurse. The same test was then given at 3 and 6 months after orientation. Pretest scores ranged from 50% to 84%, with a mean score of 63.27%. Three-month test scores ranged from 61% to 97% with a mean score of 76.48%. One nurse was not tested at 3 months because of scheduling conflicts. Six-month test scores ranged from 71% to 98% with a mean score of 84% (See Figure 4). One nurse did not complete the 6-month test due to resignation.
Each nurse was evaluated after orientation for unit integration with the tool mentioned. Questions asked in this survey focused on the orientee's perception of his or her preceptor(s) and how well they felt that the preceptor(s) facilitated identification of the orientee's strengths and weaknesses, assisted the orientee to set goals, identified opportunities to practice skills, and provided constructive feedback. The Likert scale used response options of most of the time, some of the time, rarely, and unable to evaluate. For the most part, respondents answered positively with the exception of two questions. The questions included the following: "Has your preceptor helped you formulate your own learning goals?" and "Has your preceptor selected patient assignments based on your developmental level in the program?"
Finally, we evaluated orientees for overall satisfaction with the orientation process via a 5-point agreement scale, with 1 = disagree (with the statement provided) and 5 = completely agree (see Figure 5). This survey focused on satisfaction and comfort levels in caring for the neuroscience patient. In addition, the survey included statements relating to general knowledge of the unit, navigation of the electronic resources, and medication knowledge related to these specific diagnoses. Most of the responses were positive with the exception of four areas. The patient population was limited; therefore, it was not surprising that nurses felt less comfortable with spinal cord injuries and differentiating various spine surgeries. Being novice nurses, difficulty with anticipating treatment and after-operation orders and understanding less common neurological disorders is to be expected (Benner, 2001).
The first group of orientees included 17 new graduate nurses. The large group of orientees was excellent for data collection but, at the same time, created challenges when trying to follow the tracks. It was difficult to ensure that the orientee had a patient assigned to his or her team with the specific disease process for that week because the patient population is often limited and unpredictable. Often, it was difficult to assign certain diagnoses because of the unavailability of patients. The preceptors and the orientees were instructed to review this diagnosis information regardless of whether it was possible to provide direct care to this population of patients. While we continue this study, we will be using our sister unit for help with this issue by having the orientee spend the day in the neuroscience critical care unit if there is a patient with the diagnosis needed.
With such a large group of orientees, preceptors were limited. Staff members willing and able to precept were utilized to ensure that the orientees were given the best opportunity for success. Furthermore, because the number of preceptors was so limited and schedule constraints existed, some orientees had multiple preceptors. With a group this large, it was unavoidable, but hopefully in the future, this can be avoided.
Other challenges that were experienced included the addition of a new nurse residency program, critical care and EKG classes required for intermediate care (considered critical care), and the time needed to prepare for those classes and sessions. The obstacle was balancing schedules to include all of these expectations in addition to what was required for orientation. Some of the new graduates handled this well, whereas others felt overwhelmed with information.
Implications for Nursing Practice
New graduate nurses often start their first position having only classroom learning experiences related to neuroscience nursing. This orientation program is significant to nursing because it not only prepares the new graduate nurses to provide basic nursing care but also increases their knowledge and builds their confidence in caring for a variety of complex neuroscience patients. The new graduate nurse is prepared and therefore is able to provide a higher quality of care to the neuroscience patients.
Suggestions for Future Research
In the future, the neuroscience examination should be evaluated for validity and reliability in assessing knowledge retention given that it included several different types of questions, some of which could be interpreted subjectively. A formal resource will be used to complete this test development process (McDonald, 2007). In addition, the surveys for orientee satisfaction and unit integration were not anonymous in this first year. Our focus was mainly on gathering the information necessary to complete our project, but we will do anonymous surveys in the second phase to see if our results were more favorable than the first year, in relation to the initial surveys being not anonymous.
A thorough orientation process is critical to ensure that nurses are well prepared and educated to care for the neuroscience patient. Continued research in this area to identify the vital pieces will help reduce nurse turnover, improve job satisfaction, and ensure high-quality patient care. Although the initial results of this project were positive, we are continuing this study for another year to obtain more data and compare the results from each year. We will continue to strive for an orientation process that provides for a successful transition from a new graduate nurse to a competent neuroscience nurse.
Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, N J: Prentice Hall Health.
Goodwin-Esola, M., Deely, M., & Powell, N. (2009). Progress meetings: Facilitating role transition of the new graduate. Journal of Continuing Education in Nursing, 40(9), 411-415.
Hickey, M. (2009). Preceptor perceptions of new graduate nurse readiness for practice. Journal for Nurses in Staff Development, 25(1 ), 35-41.
Krugman, M., Bretschneider, J., Horn, P., Krsek, C., Moutafis, R., & Smith, M. (2006). The national post-baccalaureate graduate nurse program. Journal ,for Nurses in Staff Development, 22(4), 196-205.
McDonald, M. (2007). The nurse educator's guide to assess learning outcomes. Sudbury, MA: Jones and Bartlett Publishing.
Orsini, C. (2005). A nurse transition program for orthopaedics. Orthopaedic Nursing, 24(4), 240-248.
Santucci, J. (2004). Facilitating the transition into nursing practice. Journal for Nurses in Staff Development, 20(6), 274-284.
Ward, C. (2009). Enhancing orientation and retention: One unit's success story. Journal of Continuing Education in Nursing, 40(2), 87-90.
Julie Ballard, RN BS CNRN, is a nursing patient care manager at Illinois Neurological Institute, OSF Saint Francis Medical Center, Peoria, IL.
Cindy Mead, RN BSN CNRN, is a clinical educator at Illinois Neurological Institute, OSF Saint Francis Medical Center, Peoria, IL.
Deborah Richardson, RN MSN NEA-BC, is the Vice-President and COO at Illinois Neurological Institute, OSF Saint Francis Medical Center, Peoria, IL.
Questions or comments about this article may be directed to Abby Lotz, RN BSN CNRN, at email@example.com. She is a nursing patient care manager at the Illinois Neurological Institute, OSF Saint Francis Medical Center, Peoria, IL.
The authors declare no conflicts of interest.
FIGURE 1 Orientation Tracks Based on the Common Diagnoses Tracks include: Track 1 Week 2- 2 patients Lumbar/Cervical spine post-op Week 3- 3 patients Craniotomy/Brian tumor Week 4- 4 patients Trauma Week 5- 4 patients Spinal cord injury Week 6- 5 patients Seizure Week 7- 5 patients Neurological disorders Week 8- 6 patients Ischemic Stroke Week 9- 6 patients Hemorrhagic stroke Track 2 Week 2- 2 patients Seizures Week 3- 3 patients Neurological disorders Week 4- 4 patients Ischemic stroke Week 5- 4 patients Hemorrhagic stroke Week 6- 5 patients Lumbar/Cervical Post op Week 7- 5 patients Craniotomy/ Brain Tumors Week 8- 6 patients Trauma Week 9- 6 patients Spinal cord injury Track 3 Week 2- 2 patients Ischemic stroke Week 3- 3 patients Hemorrhagic stroke Week 4- 4 patients Lumbar/Cervical Post op Week 5- 4 patients Craniotomy/brain tumor Week 6- 5 patients Trauma Week 7- 5 patients Spinal cord injury Week 8- 6 patients Seizure Week 9- 6 patients Neurological Disorders FIGURE 4 Mean Scores From the Neuroscience Exam Given at the Beginning of the Orientation, 3 Months After the Orientation, and 6 Months After the Orientation Baseline 63.27% 3 Month 76.48% 6 Month 84% Note: Table made from bar graph. FIGURE 5 Results From Question 24 on the Orientation Satisfaction Survey Reading, "I Feel That My Overall Orientation Experience Was Positive. I Feel That I Have Received All of the Tools Necessary to Be Successful on the Acute Neuroscience Unit." Completely Agree 11 Slightly Agree 4 Slightly Disagree 1 Note: Table made from pie chart.
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|Author:||Ballard, Julie; Mead, Cindy; Richardson, Deborah; Lotz, Abby|
|Publication:||Journal of Neuroscience Nursing|
|Date:||May 31, 2012|
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