Why is realizing consistent outcomes from the precepting process so hard?

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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Can hospitals measure the performance of nursing new-hire orientation programs?

In an earlier post, I discussed the idea that the nursing new-hire orientation activity can be viewed as a process. A process has been defined as a set of activities and tasks that, once completed, will accomplish an organizational goal. The orientation of new hire nurses surely fits this definition.

Processes have one or more inputs and produce a well-defined output or outcome. To measure the performance of a process, organizations usually collect data on:

1) cycle time (length of the orientation process)

2) efficiency (cost of the resources used per new-hire going through the process)

3) effectiveness (outcome or result of the process)

Some would add adaptability (variability of the other measures under different loads such having one new hire in orientation on a unit versus having three new hires in orientation).

Ideally, any process improvement actions would reduce the cycle time, lower cost, increase the effectiveness and improve the adaptability – all at the same time.

Each of these basic performance measures presents challenges today as no existing hospital information system will provide this information.

Cycle Time

To measure cycle time, we must have agreement on when the process starts and when it is complete.  For our purposes, does the time start on the first day of employment (encompassing general hospital orientation, general nursing orientation, and unit-based orientation) or the day/time of the first shift on the assigned unit for the new hire to begin their unit-based orientation with a preceptor(s).  We have similar issues for knowing when the new hire nursing orientation is complete.  This information is important because it starts and stops the consumption of resources discussed next.


Efficiency is about the resources (people, materials, facility, capital, etc.) used per completed output from a process. The total resources can be normalized by converting all the resources used to a dollar amount. However, this information is not readily available generally.

Consider just the value of the people resources. For example, it is difficult to separate the resources needed to provide patient care (via the preceptor/preceptee team during unit-based part of the new hire orientation) from the resources actually used for the orientation process (orienting/training the new nurse). Few systems can pull this out of the overall patient care costs in an ongoing way.

In most hospitals, the best approximation available is the cost of the new hire (preceptee’s) time for the shifts worked during orientation) and possibly some part of the cost of the preceptor’s time for the shifts worked during orientation.  Likewise, the unit educator time used for a particular new hire or the allocated cost of the orientation program coordinator or nursing unit manager’s time is not readily available and can only be approximated.


Effectiveness of the process is also somewhat difficult to know with today’s hospital data systems. Measuring effectiveness requires knowing the outcome of applying resources during the process to change the value of the input (in this case the new hire nurse’s knowledge, skills and attitudes) compared to the value of the output (the knowledge, skills and attitudes of a new hire nurse who completes the nursing orientation). Also, an effective process should consistently create the desired value. Thus, the variance of the outcome should be measured as well.

Measuring pre and post-orientation levels of the desired knowledge, skills and attitudes of a newly hired nurse is difficult for hospitals.  Doing job performance level measurement is even more difficult. Also, there are other results of the new-hire orientation process such as the level of confidence of the new hire after orientation and their attitudes toward staying with the hospital as a result of the orientation experience that could be considered.


Considering the above, I believe the answer to our original question of whether hospitals can measure the performance of nursing new-hire orientation is – not yet.  However, given the cost of this process and importance of consistent, high-level outcomes to patient safety, it is worth the effort to capture and use as much performance data as possible.

Also, hospitals can certainly do periodic projects to test and evaluate potential improvements to the nursing new-hire orientation process.  In designing these special projects, all the dimensions of process performance certainly should be considered.

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Can nursing orientation costs be managed? Should they be?

Orientation for new-hire RNs in hospitals is costly. In an article in the journal of nursing economics, the average (16 weeks) unit-based orientation cost was estimated at $41, 624 – and this was published back in 2007.

Let’s update this a little using more recent salary related costs; according to KPMG’s 2011 U.S. Hospital Nursing Labor Costs Study, the total cost of a full-time RN averages $98,000 per year (or $1885 per week).  Thus, the average cost for the preceptee’s time would be a little over $30,000 (16 weeks at $1885 per week).  Adding another $30,000 for staffing the vacancy during the orientation the total cost reaches over $60,000.  So far, we haven’t included all of the cost factors yet. 

Factors impacting the costs include but are not limited to: 

  • Hospital policy on staffing the preceptor/preceptee patient load
  • Length and design of the classroom and unit-based orientation 
  • Salary for those involved in nursing orientation including the preceptor(s), preceptee, unit educator, orientation classroom trainer, orientation program manager, etc.
  • Salary for those brought in to cover the patient load for the vacant position while the orientation is underway
  • Payroll related costs such as social security and 401K contributions, unemployment and workers compensation insurance, health care and other benefits 
  • Orientation program support costs such as materials, maintaining the program due to equipment upgrades, regulatory or accreditation changes, and other changes in hospital policies and systems.
  •  The way the hospital allocates other general hospital overhead costs to the program.

 Can this cost be managed? 

Some of these costs could be managed by nursing management. For example, the policy on staffing load assigned to the preceptor(s) and preceptee determines a significant part of the salary costs.  The length and design of both the classroom and unit-based orientation components is also largely under the control of the nursing organization. Other cost factors cannot be managed directly such as the hospital benefits program.

How can cost be managed?

A classic process management approach would be to measure and take actions to improve:

  • Cycle time (length of the preceptorship),
  • Efficiency (cost of the resources used per preceptorship),
  • Effectiveness (outcome of the preceptorship); and some would add
  • Adaptability (variability of the other measures under different loads such having one new hire in orientation on a unit verses having three new hires in orientation).

 Can the high cost of nursing orientation be managed? Yes.  Should it be done? Yes; but only if you are able to lower costs while maintaining or improving effectiveness at the same time.  It can and has been accomplished for many other processes in a wide variety of organizations.  

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