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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The Relaxation Response

The relaxation response is a physiological state of deep rest. It is the opposite of fight-or-flight. The relaxation response is associated with decreased heart rate, blood pressure, and muscle tension, and increased energy and self-control. Regular practice of the relaxation response reduces anxiety and repetitive worry patterns, increases resistance to stress, and reduces symptoms of many medical conditions.

Nurses, especially new nurses, can benefit from practicing the relaxation response to help manage their stress. Some days can be incredibly overwhelming, and you can use this technique, or share it with others.


By adopting a daily practice, people can:

  • Develop a sense of purpose and wisdom. By turning down the outside noise of pictures, words, and sounds, we become more attuned to the silence within, and our own intuition. We can listen more deeply.
  • Create a space between stimulus and response. By increasing concentration, awareness, and centeredness, we become more able to listen, to hear, to reflect, and to respond out of choice. This is especially important during stressful days at work.
  • Align behaviors with life purpose and meaning. By transcending our self-defeating attitudes, beliefs, and assumptions that act as filters for the way we perceive, we are more able to override our conditioned response and behave in new ways.
  • Health and Renewal. Quieting the bodymind through relaxation helps to reduce pain and anxiety, promote deep rest and sleep, reduce muscle tension, increase blood flow and reduce blood pressure, improve immune function, improve overall sense of well-being.

Methods to Elicit Relaxation Response

Basic Components of Relaxation Response

  • Mental focusing, such as your focusing on the breath; repeating a word, phrase, prayer, or sound; or using repetitive muscular activity.
  • Passive disregard toward distracting thoughts, sounds, or intrusions.

Try it!

  1. Find a comfortable position.
  2. Take several deep breaths.
  3. Begin to relax muscles and quiet the mind by being still.
  4. Find and maintain a mental focus for 10 – 20 minutes.
  5. Let go of distracting thoughts and judging attitude.


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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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What does the evidence say about nursing orientations?

Recently we conducted a review of current published articles (2015-2017) to evaluate evidence and recommendations for Transition into Practice programs including orientation and residency models. The evidence is clear in a number of areas:


  • New graduate RN retention in the first year of employment is a challenge for hospitals, ranging from a low of 25% to a high of 64% or greater. Furthermore, the decision to leave nursing is frequently related to dissatisfaction with orientation and begins within the first few months of hire. The most frequently mentioned barriers to a smooth transition included: Lack of consistent preceptor communication, Short staffing, high patient acuity, having to make critical decisions without help, little personnel support, lack of skills and knowledge, high variability in the orientation process in different institutions, and emotional stress of “reality shock”.


  • Implementation of residency/ internship models with multiple units and preceptors has been well documented to reduce turnover and increase retention of new graduates, increase nursing and unit satisfaction, provide significant cost savings for the hospital, and increase actual recruitment and desire for employment. The key factors contributing to success of residency programs can be incorporated into less formal orientation structures.


  • Investment in preceptor development through training and feedback is critical to their effectiveness. Specific learning needs include development of affirmative coaching, dealing with difficult communication, creating civility in the workplace, specific teaching strategies and learning styles, the role of emotional intelligence in learning and how to effectively manage change.


  • Effective preceptor coaching can significantly improve development of clinical reasoning and critical thinking.


  • Preceptors need structured support and consistency of feedback based on shared data. They also need time to precept, role clarification, and some formal reward or recognition system for the critical importance of their work to safe practice and patient care.


  • A few studies have begun to address the crucial need to support development of wellbeing and resilience skills of newly hired nurses. Transition stress has been documented for many years, and a strong preceptor relationship can help with this stress. There are other strategies that can be easily taught to new nurses and it is important to recognize the impact of supporting wellbeing on learning, competency development, and integration into the culture. Orientees can learn to manage their wellbeing and emotional/ physical stress; preceptors can help with this by tracking and coaching.


Research to improve efficiency and outcomes of transition into practice is increasing. While there is a need for ongoing correlational research the body of current evidence demands integration into our transition structures.  One of the most comprehensive sites we have to support evidence based transition is the Vermont Nurses in Partnership (VNIP).  Their website provides numerous resources, literature and concrete suggestions to improve transition process and outcomes.  For more information visit their website or take a look at their Clinical Transition Framework Evidence Base.

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The importance of well-being in nursing practice

Why is well-being important?

Reality shock for nurses is a problem that shows no signs of going away. Self-care is so vital for new hire nurses, but it is also important that hospitals support reflective learning practices that support well-being. Because around 25% of new nurses leave nursing during their first year of practice, hospitals can build strong programs with less turnover by focusing on well-being during nursing orientation.

How to focus on well-being

Neuroscience evidence suggests mental training and learning skills in four key areas can make a difference in improving well-being and even rewire areas of the brain.

  • Sustaining positive emotion. Prolonging positive emotion has been shown to improve psychological well-being.
  • Rebounding from negative emotion. The second component of well-being is a person’s response to negative emotion. Science in this area suggests resilience, or how quickly a person recovers from adversity, can result in a person experiencing less negative emotion overall and may even have protective properties against mental health disorders.
  • Mindfulness and mind-wandering. Mindfulness-based practices of all types have now entered the mainstream. Data show that when people are really focused on what they’re doing, and their minds are not wandering, they actually feel better about themselves, perform better, and experience less negative emotion.
  • Caring for others. Prosocial behaviors such as empathy, compassion, and gratitude comprise another component of well-being. There’s substantial evidence to suggest that engaging in acts of generosity is a very effective strategy to increase well-being.

The first two points regarding staying positive and coping with negativity can be difficult for new nurses. This post from allnurses.com shows how quickly new hires can become overwhelmed and start questioning if they made the right career choice. Providing resources for both Preceptors and Preceptees to effectively give positive and negative feedback is one way to make this easier. Open lines of communication with their Preceptor will help new nurses feel supported, and if Preceptors are mindful about pointing out when their Preceptees are doing something well, staying positive about their experiences as a new nurse in a new hospital won’t seem so impossible.

Building self-care into nursing orientation

Encouraging new hire nurses to engage in reflective learning activities as a part of their orientation is a great way to help them manage their well-being and resiliency. The American Holistic Nurses Association provides a number of resources for nurses, including Holistic Self-Care information and exercises and Stress Management tips.

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A better nursing orientation: Transition to practice

The National Council of State Boards of Nursing’s study of the transition of new graduate nurses confirmed what many hospitals already knew: There is a disconnect between education and real life experience in a hospital.

The Problem The Impact
New nurses care for sicker patients in increasingly complex health settings. New nurses report more negative safety practices and errors than experienced nurses.
New nurses feel increased stress levels. Stress is a risk factor for patient safety and practice errors.
Approximately 25% of new nurses leave a position within their first year of practice. Increased turnover negatively influences patient safety and health care outcomes.
From the National Council of State Boards of Nursing

The NCSBN concluded that, “There is a need for best practices of training new nurses that can be replicated across the country to ensure consistent quality of care, and drop the alarming turnover rates of new nurses”. They also provided TTP training courses that both new graduate nurses and preceptors can take:

Transition to practice program For new nurses 2

How can a Transition to Practice model be integrated into your nursing orientation training?

As we know, new hire nurses can get overwhelmed by trying to learn everything about their new hospital, caring for patients, and dealing with possible reality shock. Pairing novice nurses with preceptors who can help guide them through their orientation helps combat this, but implementing a system that supports preceptors as well as preceptees can benefit your program immensely.

While nursing boards require certain documentation to be compliant, your preceptorship program should include all of the following to support new hire orientation:

  • Convenient skills tracking. Both preceptees and preceptors should have an easy way to track their training so there are no gaps in competency.
  • Weekly meetings. Preceptees should be meeting with their preceptors regularly, and tracking and recording weekly meetings will give preceptees important feedback, and allows preceptors to clearly communicate goals and expectations.
  • An emphasis on well-being. New nurses are encouraged to keep a journal to that they can reflect on their learning and remain aware of their mental state. Incorporating self-reflection into your orientation process will emphasis this vital element of transitioning to practice.


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The Preceptorship Support Platform Explained

The Preceptorship Support Platform is an online tool built to support nursing orientation programs by providing a paperless solution for documentation and process management. Each feature of the program has a specific purpose, and the platform was built in collaboration with nurses to incorporate best practices (like those laid out in this article from American Nurse Today) because we wanted to make nurses’ lives easier.

What are the features?


Hospitals can add their custom clinical and policy checklists to the platform so new hires and their preceptors can keep track of their progress online. Because this tool is completely customizable, hospitals can add documents, images, or links to other sources in their unit and hospital-wide checklists.

Patient Log

Like with the checklist feature, orientees can record their patient experiences to be approved by their preceptors online. This section also includes a visual tool that allows both orientees and preceptors to see what diagnoses and skills preceptees have had a chance to observe or assist with.


With this tool, preceptees can see what they need experience with and precepetors and coordinators can make sure that new hires are on track with their orientation.


While preceptors and preceptees should be meeting regularly to set goals and give feedback, we know how difficult this can be to arrange and keep up with. Having structured meeting templates with built-in goal setting and feedback can help nurses find time to have these essential meetings and make sure that they are effective. Hospitals can customize the structure and frequency of these meetings to fit their program.


Self-care is an important, but often overlooked, piece of a successful preceptorship. Keeping a journal is one way that new nurses can reflect on what they have learned, the challenges they’ve faced, and the successes they’ve had. Including journaling in a program that helps to manage the rest of their orientation will encourage them to engage in reflective learning activities in addition to their regular clinical training.

Well-being Tracker

As a part of the journal feature, preceptees are asked a series of questions meant to assess their overall well-being. Preceptees can see how their answers vary over time so they will know when to ask for help, and preceptors and managers can see an overall well-being score so they can intervene if someone is struggling.

Preceptee View

Shared Notes

Because some new hires have multiple preceptees, coordinators, and managers involved in their orientations, the shared notes section is available to make it easier for everyone to stay in the loop. The ability to access these notes, checklists, and other documentation is one of the main benefits of transitioning to an online program that saves time and paper.


  • New hires are responsible for driving their progress. They can work through the checklists at their own pace, and they are responsible for submitting completed lists and patient logs to their preceptors.
  • There is built in feedback for preceptees. Studies show that consistent feedback is necessary for new nurses to succeed, so the platform is built so preceptors have the opportunity to submit feedback as preceptees work through their checklists and log patient experiences, in addition to discussing performance during meetings.
  • All of the documentation, including preceptors signing off on each skill or checklist, is automatically recorded, so orientation coordinators can easy compile reports.
We’d love to talk with you about how the Preceptorship Support Platform can benefit you.
Schedule a live demo.

The 6 elements of a successful preceptorship

Preceptorships are a vital part of the nursing orientation process. While preceptees should always take responsibility for their own learning, there are a few things preceptors can do to help their new nurses succeed.

  1. Building a relationship

Because the success of nursing preceptorships relies on the successful partnership of preceptors and preceptees, establishing a trusting relationship is one of the most important responsibilities for preceptors. Make it clear that both parties are partners working towards a common goal of expanding clinical knowledge. In the first meeting, clear goals and responsibilities should be established so that both preceptor and preceptee know what is expected of them, and that they can count on each other to fulfill them.

Throughout the nursing orientation period, encouraging preceptees to manage their own learning, while providing guidance and feedback, will prepare new hire nurses to smoothly transition out of the preceptorship.

  1. Communication and conflict management

Developing competence in communication is a critical skill for novice nurses. Lack of clear communication can also be a source of stress or conflict encountered during the orientation/ residency program. Provide specific expectations of preceptee responsibilities and tasks each day; check on progress at midday and at the end of the shift have a quick review of key accomplishments; provide positive feedback and feedback and clarify any issues.

  1. Giving feedback

A preceptor can initiate a feedback-friendly environment by demonstrating a sincere interest in their preceptee’s development as a nurse:

  • What is his/her background?
  • What are his/her career goals?

Knowing this, preceptors can show the connections between current skills and eventual requirements and expectations. Be sure preceptees can witness veteran nurses giving and receiving feedback from coworkers, physicians, and patients. Involve other co-workers: Ask others to let preceptors know about a preceptee’s positive performance so they can be included in evaluations. Ask them to give positive comments to preceptees as they observe them “doing the right thing or doing something right.” Also, ask co-workers to refer negative criticism directly to preceptors, not to others on the unit, so that preceptors can speak with the preceptee directly. This builds trust with the preceptee.

  1. Holding effective meetings

Having a consistent meeting scheduled each week is extremely helpful to the preceptorship success. The predictability reduces anxiety and provides the structure needed for your preceptee to effectively prepare and participate in planning goals and evaluating their own performance.

  1. Keep VARK in mind

VARK is a leaning inventory developed by Neil Fleming that classifies learning styles in four easy to remember categories: (V)isual learning, (A)uditory learning, (R)ead/Write learning & (K)inesthetic learning. Establishing effective teaching strategies for each type of learner will increase the success of every part of the preceptorship.

  1. Developing well-being and resilience.

Retention rates for new nurses is almost always a concern for hospitals. Focusing on reflection and self-care during nursing orientation is one way to use preceptorships to improve retention. Preceptors should encourage their preceptees to take time to reflect on their experiences and take note of how they are feeling so they can avoid getting overwhelmed. There are many resources available on the web for learning mindfulness and relaxation techniques, including this guide from the University of Maryland, to share with preceptees.

Keeping detailed records of each area of training for preceptees will guarantee that there are no gaps in competency and will help reduce turnover for new nurses.

Did you know there is a new online tool to support a better nursing orientation that can help you manage all of these elements? The Preceptorship Support Platform provides a customizable tool to hospitals looking to improve their preceptorship outcomes.

Schedule a live demo.