nursing study – The Preceptorship Support Platform

Orientation, Preceptorship Support Platform, Tips for Preceptors

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.

Orientation, Preceptorship Support Platform, Studies

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.

Orientation, Preceptorship Support Platform, Studies, Tips for Preceptors

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.

Orientation, Preceptorship Support Platform, Studies

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:

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.