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Transitional orientation: a cost-effective alternative to traditional RN residency.

SIGNIFICANT CHALLENGES FOR health care leaders include an aging nursing workforce with subsequent retirement, consistent turnover for new RN graduates of 35%-61%, reported job dissatisfaction, and anticipated RN shortages of 36% by 2020 (Baggot, Hensinger, Parry, Valdes, & Zaim, 2005; Beecroft, Kunzman, & Krozek, 2001; Fink, Krugman, Casey, & Goode, 2008; Siela, Twibell, & Keller, 2008). Recruitment, orientation, and development costs, particularly for inexperienced RNs, additionally challenge hospitals to find cost-effective methods to assure patients receive competent nursing care. Nurse leaders at the Lee Memorial Health System (LMHS) recognized the need to initiate proactive strategies to respond to the challenges described.

LMHS, located in Southwest Florida, is the fifth largest public health system in the United States with four campuses that include four acute care hospitals and two specialty hospitals, with a total of 1,423 patient beds. Since 2002, LMHS has used the Performance Based Development System (PBDS; Performance Management Services, Inc. [PMSI]) to assess and validate nurses' competence. The PBDS assessment provides hospital clients with an evaluation profile that describes the individual's ability to meet expectations for critical thinking and interpersonal skills. Multiple publications describe the validity, reliability, and various uses for the assessment process (del Bueno, 1990; 1994; 2005). Aggregate assessment results are also shared each year with participating clients as benchmarks to use for comparison purposes. PMSI data currently indicate only 35% of inexperienced RNs meet entry-level performance expectations. Sixty-five percent of these new graduates, however, improve post orientation to an acceptable competence level.

In the years from 2002-2006, all inexperienced RNs entering LMHS were enrolled in a standardized internship program that included, regardless of initial competence assessment results, a series of traditional didactic classes based on body systems and an arbitrary number of weeks for clinical orientation. In 2006, it was noted positive reassessment results for inexperienced RNs post orientation had decreased to an alarming 38%. Immediate response to this statistic was a redesign of the internship class content from a body system didactic focus to use of a patient-centered critical thinking methodology designed by Dorothy del Bueno. This methodology includes video simulations and pathophysiological concepts (see Table 1). Used as group development, an impressive improvement from 38% to 55% in interns' reassessment results occurred after this change.

Transitional Orientation Program

Although a welcomed improvement, the increase was still lower than the PMSI benchmark of 65%. More importantly, nonproductive orientation costs remained the same. Root cause analysis, performed to determine why orientation costs had not changed, revealed initial competence assessment results and recommendations were not being used to individualize the interns' development or orientation.

Initial assessment results, which range from does not meet expectations to meets with exceptions, are intended to determine the time needed for orientation and the type and intensity of clinical resources required to achieve a competence level (see Table 2). Therefore, in 2008/2009, LMHS initiated a multifaceted development methodology called the Transitional Orientation Program, designed to develop and retain competent RNs. In addition to the previously described change in internship education, orientation time, clinical precepting, and development strategies for every inexperienced RN were modified to reflect the initial competence assessment conclusion.

This individualized approach resulted in an increase in acceptable competence reassessment results from 55% to 67%, which equaled the PMSI benchmark for that year. Analysis of orientation time revealed individualization of orientation with the change in learning strategies decreased orientation for all clinical specialties by an average of 1 week with a subsequent savings of $177,000 in nonproductive costs. Again, although these results were gratifying, LMHS believed there was an even greater opportunity for improvement in competence results and cost savings.

In 2010, LMHS initiated a third phase of the Transitional Orientation Program to respond to anticipated workforce challenges including commitment to hire at least 200 inexperienced RNs each year. Also initiated was a change in the previous practice of hiring large groups of RN graduates twice a year, a process that proved stressful for orientees, clinical preceptors, and system educators. RN graduates were given access to eight possible entry points offered during the course of the year. Additionally, a medical-surgical patient care unit at two different campuses was designated as a transitional unit for every new RN who had an initial assessment result of does not meet expectations. Assignment to this unit provided intensive individualized development for those interns unable to identify patient problems accurately or manage their complications effectively. The director and clinical staff on the transitional units received training in the use of nontraditional development strategies. Also, day shift RNs were designated as clinical coaches and were provided with specific evaluation tools to document interns' progress. To facilitate the required intensive clinical development, patient/ nurse ratios on these units were limited to 4:1, with the intern and clinical coach jointly responsible for patients' care from the first day of the assignment.

Although the clinical coaches had been prepared as described, LMHS believed it was critical to provide additional support for them for this new role. Support was also needed to assist in the intensive development needs required by the transitional unit interns and for other inexperienced RNs assigned initially to their unit of hire. Therefore, LMHS established two new clinical educator positions called intern development specialists (IDS).

The IDS Role

The IDS is a registered nurse with graduate preparation and previous clinical education experience. The IDS accountability for inexperienced RNs assigned to the transitional units includes:

* Reviewing the initial competence assessment findings with the orientee.

* Developing a specific orientation plan while in the transitional unit based on the initial assessment findings.

* Planning and scheduling development activities to be completed while in the transitional unit.

* Monitoring documentation of ability to meet competence expectations (see Table 3).

* Making decisions based on actual performance and clinical coach feedback of the orientees' readiness to transition to their unit of hire for continued development.

The IDS' secondary responsibilities include the following:

* Monitoring the documentation of ability to meet competence expectations for the inexperienced RNs assigned directly to their unit of hire.

* Inclusion of these orientees in development activities planned for the transitional unit RNs (see Table 4).

* Periodic oversight of professional development for 2 years post hire for all inexperienced RNs.

Data Analysis--Findings

Analysis of data in 2010 showed positive reassessment results increased to 72% for all inexperienced RNs. Further analysis of data, however, revealed the inexperienced RNs assigned to a facility with an IDS achieved an 83% acceptable assessment result as compared to only 63% for inexperienced RNs assigned to facilities without an 1DS. This successful outcome was especially significant as only 21% of new RNs received initial positive assessment results.

A total of 146 inexperienced RNs were hired at LMHS in 2010. Sixty-four were hired for the two facilities with an IDS, with the other 82 assigned to non-IDS facilities. Forty-six of the 64 IDS interns spent on average 3 weeks in transitional units. In spite of the additional intensive development resources provided for those 46 interns, total orientation time decreased by 69 weeks, resulting in a $54,000 savings in nonproductive costs. In comparison, orientation time increased by 26 weeks for the non-IDS interns with an increase in nonproductive costs of $20,000 (see Table 5). Retention rates for all inexperienced RNs hired since 2010 at LMHS increased dramatically from 69% in previous years to 90% 18 months post hire.

Through September 2011, 102 inexperienced RNs hired for the two facilities with an IDS had an acceptable competence reassessment result of 81%. Nonproductive costs decreased by $91,000. Alternately, nonproductive orientation costs for the two facilities without IDS support increased more than $41,000 (see Table 5).

Based on the successful outcomes achieved in 2010 with the introduction of the IDS role, two additional educators were hired for the other non-IDS facilities. Within 3 months acceptable competence reassessment results improved from 63% to 85%.

Factors Critical to Success

Descriptions of residency and internship programs with transitional units initiated by other organizations have been reported in the literature (Anderson, Linden, Allen, & Gibbs, 2009; Goode, Lynn, Krsek, & Bednash, 2009; Herdrich & Lindsay, 2006; Pine & Tart, 2007). Although improved job satisfaction and retention rates are described by these organizations, valid and reliable competence evaluation and orientation costs generally are not reported.

LMHS believes three critical factors are responsible for the reduced orientation costs and improved competence ability. Placement of the most limited interns in a transitional unit is a valuable element that provides intensive development with a designated clinical coach. The data indicate, however, placement in a transitional unit is not as critical as the presence of an IDS, who is devoted to individual followup, oversight, and development of those inexperienced RNs with the greatest limitations. The second critical element required for success is the use of assessment data to identify definitive individual development and learning needs accurately before any orientation is initiated.

The third critical element was the change from content-focused teaching to interactive patient-centered learning strategies. As indicated, however, although improvement was achieved in competence ability and orientation costs from this change, it is the continued accountability vested in the IDS, who consistently monitors and evaluates competence improvement with judicious use of nonproductive time, that is the critical link to success of the Transitional Orientation Program at LMHS.

Future Plans

LMHS will continue to provide a transitional unit in one facility with backup, if needed, for inexperienced RNs with an initial competence assessment result of does not meet expectations. Additionally, LMHS will continue to evaluate the cost effectiveness of both the use of the IDS role and of any education strategies used for competence development. The IDSs will continue to collaborate with directors and clinical coaches to determine interns' placement and progress, and will participate in the implementation of a modified version of the transitional orientation program for experienced nurses new to LMHS. They are also collaboratively developing an inventory of interactive patient-focused learning strategies and prototype schedules to address individual and collective development needs identified by initial assessments for all RNs new to LMHS. Finally, the success and positive outcome achieved by the transitional orientation program could not have been realized without the continuous vision and support from nursing administration, finance, and human resources.


Anderson, T., Linden, L., Allen, M., & Gibbs, E. (2009). New graduate RN work satisfaction after completing an interactive nurse residency. JONA, 39(4), 165-169.

Baggot, D.M., Hensinger, B., Parry, J., Valdes, M.S., & Zaim, S. (2005). The new hire/preceptor experience. JONA, 35(3), 138-145.

Beecroft, P.C., Kunzman, L., & Krozek, C. (2001). RN internship: Outcomes of a one-year pilot program. JONA, 31(12), 575-582.

del Bueno, D.J. (1990). Experience, education and nurses ability to make clinical judgments. Nursing and Health Care, 11(6), 290-294.

del Bueno, D.J. (1994). Why can't new grads think like nurses? Nurse Educator, 19(4), 9-11.

del Bueno, D.J. (2005). A crisis in critical thinking. Nursing Education Perspectives, 26(5), 278-282.

Fink, R., Krugman, M., Casey, K., & Goode, C. (2008). The graduate nurse experience: Qualitative residency program outcomes. JONA, 38(7/8), 341-348.

Goode, C.J., Lynn, M.R., Krsek, C., & Bednash, G.D. (2009). Nurse residency programs: An essential requirement for nursing. Nursing EconomicS, 27(3), 142-147.

Herdrich, B., & Lindsay, A. (2006). Nurse residency programs: Redesigning the transition into practice. Journal for Nurses in Staff Development, 22(2), 55-62.

Pine, R., & Tart, K. (2007). Return on investment: Benefits and challenges of a baccalaureate nurse residency program. Nursing Economic$, 25(1), 13-18.

Siela, D., Twibell, K.R., & Keller, V. (2008). The shortage of nurses and nursing faculty. AACN Advanced Critical Care, 19(1), 66-77.

KIMBERLY GUTHRIE, PhD, RN, is a Clinical Education Specialist, Lee Memorial Health System, Ft. Myers, FL.

JAIME TYRNA, MS, BSN, RN, BC, is System Director of Clinical Learning, Lee Memorial Health System, Ft. Myers, FL.

DONNA GIANNUZZI, MBA, RN, NEA-BC, is Chief Patient Care Officer, Lee Memorial Health System, Ft. Myers, FL.
Table 1.
Transitional Orientation Program Overview

Phase I:     * Change traditional course content to a focus on
2007           critical thinking development using low-fidelity

Phase II:    * Orientation time and development strategies determined
2008-2009      by initial competence assessment conclusion (savings of
               $177,000 in nonproductive time).

Phase III:   * Commitment to hire 200 new RN graduates per year.
2010         * Initiate eight entry points for inexperienced RN hires.
             * Establish transitional units.
             * Nurse/patient ratio limited to 1:4 on transitional
             * 1:1 clinical coach on the transitional unit.
             * Orientee and coach responsible for patient assignment.
             * Two intern development specialists hired.

Phase IV:    * Two additional intern development specialists (IDS)
2011           hired.
             * Coordinated planning by the IDS for competence
               development of all inexperienced RNs.

Phase V:     * Extend a modified transitional orientation program for
2012           experienced RN development.

Table 2.
PBDS Assessment Conclusions

                                 Does Not Meet
 Summary                          for Problem          Limited--
 Finding     Does Not Meet        Management         Does Not Meet

Definition   The individual    The individual      The individual was
             was not able to   was able to         able to recognize
             focus on or       focus on/identify   and manage
             safely manage     patient             patient
             patient           complications       complications but
             complications     accurately but      with limitations
             accurately.       unable to manage    that could be
                               the problems        unsafe.
                               presented safely.

                 Limited but
 Summary       Acceptable/Entry            Meets with
 Finding          as New RN                Exceptions

Definition   The individual was     The individual was able
             able to accurately     to accurately identify
             identify and safely    and effectively manage
             manage patient         patient complications.
             complications but      Should need minimal
             needs further          orientation to hospital/
             development.           unit norms and

Table 3.
Sample of Competence Expectations Documented
On the Clinical Unit

Technical Proficiency   Performs priority procedures safely,
                        effectively, legally.

Differentiation of      Establishes and/or revises priority for
Urgency                 patients based on acuity of need, resource
                        availability, and patient request.

Risk Management         In response to data indicating potential or
                        actual risk to patients, initiates action to
                        correct, reduce, or prevent the risk.

Table 4.
Sample of Competence Development Strategies

* Video patients (PBDS) case studies
* Critical Thinking Development Series (PBDS)
* High-fidelity simulation--computer driven mannequin
* On-line computer content programs
* Reflective learning
* Technical skills labs

Table 5.
Transitional Orientation Program Outcome Data

                                        IDS            Non IDS

2010                                    83%              63%
% Acceptable reassessment results   Savings of    ($20,000) Increase
  Nonproductive orientation cost     $54,000

2011-9/2011                             81%              63%
% Acceptable reassessment results   Savings of    ($41,000) Increase
  Nonproductive orientation cost     $91,000
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Title Annotation:registered nurse
Author:Guthrie, Kimberly; Tyrna, Jaime; Giannuzzi, Donna
Publication:Nursing Economics
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2013
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