Is it important to have consistent orientation/ residency training outcomes?  How can you begin to improve consistency in the clinical performance of new staff at the end of your orientation /residency programs?

One answer is to consider the variability factors that are inherent in all unit-based nursing orientation programs. There is variability in the new hire nurses in terms of education and experience when the precepting process begins. There is variability in the attitudes, skills, and behaviors of the preceptors who work with the new hire nurse. There is variability in the patients’ number, acuity and diagnoses occurring on each shift and so on. The list is long.

According to the original creators (i.e. Joseph M. Juran, W. Edwards Deming, Kaoru Ishikawa, Walter A. Shewhart, et.al.) of process/quality management, eliminating or controlling sources of unwanted variability is critical to consistently producing desired outcomes.

Deming wrote that the variability could be attributed to both “common causes” and “special causes”. Common causes contributed in ways that were not under the control of the individuals involved and thus generally the responsibility of management whereas special causes related to differences in knowledge, skills, and performance of the individuals which is largely their responsibility. Dr. Shewhart, another pioneer in this field, split the causes of variability into assignable causes (which can be addressed) and chance causes (which cannot). Another guiding principle is that a few causes typically account for a large part of the problems in outcome consistency – known as the “vital few”.

All of these historical thinkers also had concepts of 1) planning the process, which included setting it up, 2) operating the process, 3) measuring the process operation and working with the outcome and related process measures to identify causes of inconsistency in desired outcomes and 4) modifying the process to improve it – a cycle that never ends. ‎Deming called this cycle the Shewhart cycle after his mentor but it is commonly known as: Plan, Do, Check, and Act (PDCA) or PDSA (Plan, Do, Study, Act).

Part of the first step, planning the process, is to clearly define what is the desired outcome or result and how can the result be measured. What is the desired outcome of the precepting process? (i.e. end product of the process that is acceptable for use and meets the intended needs)

A key “result” or “outcome” of the precepting process is the set of attitudes, knowledge, skills and the strength of the staff relationships of the new-hire nurse at the completion of the unit-based precepting process. Another result may be an assessment of the preceptor(s) changes in their attitudes, knowledge, skills, and relationships.

The most common operational definition of the desired outcome or result is that the preceptor signs off on a set of knowledge, skill and attitude items organized into checklists. These items are those deemed required for the new-hire nurse to safely work on the specific nursing unit. Is this adequate? Is there any better way to assess the outcome of the unit-based nurse orientation (precepting) process? We’ll discuss this in the next blog posting in this series.

Associated measures of performance of most processes include the elapsed time to produce the intended outcome, the cost (efficiency) of producing the outcome and in some cases the robustness of the process to changes in the environment (number of new hires on the unit, patient loads, etc.) that are not directly controllable.

Another part of planning the process includes documenting the steps, methods, decision points etc. so that appropriate measurements can be established. This level of process definition/description is more detailed than currently exists in many hospitals.

This is the first in a series of posts that will address first some options for defining and measuring the outcome of the precepting process for new-hire nurses, second documenting the process to establish measurement opportunities and third how to use the data from the measurements to identify key causes of inconsistency.

If you have thoughts on what you think might be one or more of the vital few causes of inconsistency in the outcome of the unit-based new hire nurse orientation (precepting) process or any other thought about improving the process, please post a comment.

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