Clinical Evidence Review A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.
PRECEPTOR-BASED ORIENTATION PROGRAMS: EFFECTIVE FOR NURSES AND ORGANIZATIONS? By Kristin E. Sandau, RN, PhD, and Margo A. Halm, RN, PhD, CNS-BC
ursing orientation for acute or critical care nurses typically occurs in 3 stages: general hospital orientation (1 day), general nursing orientation (3-5 days), and a 6- to 12-week (or longer) precepted clinical experience whereby new nurses are paired with experienced nurses to learn directly on the unit of hire.1 Preceptors assist orientees to acquire basic nursing/unit-specific skills and become familiar with patients, protocols, care providers, and the unit’s culture. By the end of orientation, orientees are expected to demonstrate competence in basic unit-specific skills. Casey et al2 surveyed a cross-section of new graduate nurses (NGNs) from different hospital areas and found high stress and difficulty transitioning from student to professional roles. Root causes included lack of confidence in skill performance, deficits in critical thinking/clinical knowledge, relationships with peers and preceptors, struggles with dependence on others, frustrations related to the work environment (eg, nurse-to-patient ratios), organization/priority setting, and communication with physicians. As Casey et al2 acknowledged, preceptors are integral to role modeling of professional behaviors and facilitating nurses’ adjustments to their role. Thus, preceptors have immense responsibilities. This review was conducted to discover what impact preceptored orientation programs have on clinical knowledge and skills of nurse orientees as well as organizational and financial outcomes.
N
Results Twelve research or program evaluation reports from the United States were retrieved (Table 1). Samples included NGNs and experienced nurses, and ranged in size from 18 to 197. Interventions included both classroom and preceptor-based learning. Program types included structured orientation (7 weeks-1 year), internship (8 weeks-1 year), and residency programs (1 year). Length of clinical preceptorships varied by specialty, experience, and learning needs. Some interventions incorporated structured cohort/roundtable sessions; regular meetings
About the Authors
CINAHL was the primary search engine. Key words included nurse orientees, preceptors, critical
Kristin Sandau is an associate professor of nursing at Bethel University in St Paul, Minnesota. She was a coauthor and cofacilitator of the Allina Hospitals/Minnesota Nurses Association preceptor education curriculum. Margo A. Halm is a clinical nurse specialist and director of nursing quality and research at the Salem Hospital in Salem, Oregon, where she leads and mentors staff in the principles of clinical research and evidence-based practice.
©2010 American Association of Critical-Care Nurses doi: 10.4037/ajcc2010436
Corresponding author: Margo A. Halm, RN, PhD, CNS-BC, Salem Hospital, Salem, OR 97301 (e-mail: margo.halm@ salemhospital.org).
Methods
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thinking, competency, socialization, retention, and job satisfaction. Only reports of educational programs in acute/critical care settings with a preceptor component from the past decade were reviewed. Reported outcomes focus exclusively on orientees. Thus, evaluations of preceptor education were not included.3-6 Various types of evidence were considered, but small investigations (N < 10) and qualitative analyses were excluded.
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Table 1 Results matrix of educational interventions with preceptors Outcomesa,b
Reference Morris et al7
Design; intervention (length) Quasi-experimental; orientation (NGNs: 7 weeks; ICU RNs, experienced or not: variable)
N/ population 197/NGNs and RNs with variable experience
Competency/ autonomy
Job satisfaction/ organizational commitment
Program satisfaction
Retention/ vacancy
Turnover/cost avoidance
Simulation 94% retention 8.8% (baseline) experience at 18 months vs 6.3% (1 year) and pocket (2 cohorts), Program cost guides rated 59%-83% at additional high 3 years (5 $24 810 but Satisfaction: cohorts) offset by orientees, Vacancy 14.3% improved 83%; precep(baseline) vs recruitment/ tors, 73%; 4.8% (3 years) retention managers, 77%
Autonomy: readiness to manage patient care at completion (perceptions of manager, preceptor, educator): • 80%-90% experienced ICU nurses • 53%-75% inexperienced ICU nurses • 54%-70% NGNs
Pine and Tart8 Program evaluation; 48/BSNprepared residency (1 year) NGNs
Desired more spontaneous, team-based learning activities
50% (baseline) vs 13% (1 year) $823 680 savings from retention even with program cost
Halfer9
Program evaluation; 1 pediatric hospital/ orientation NGNs (1 year with 4- to 9-month specialtybased preceptorship)
Newhouse et al10
Quasi-experimental (posttest); internship (1 year)
7 clinical depts vs control/ NGNs
Lower antecedent sense of belonging for interns at 6 months (vs baseline and 12 months) Organizational commitment, NS
Retention of internship RNs higher at 12 months (also at 18 and 24 months but NS)
Altier and Krsek11
Prospective (pretest/posttest); residency (1 year with variable length preceptorship)
111 (6 health centers)/ NGNs
High satisfaction with praise and professional opportunities at 1 year
87% at 1 year
Shermont and Krepcio12
Experimental (pretest/posttest); orientation (variable)
100 new hires (3 surgical inpatient units)
7.2% reduction 29.5% (baseline) in vacancy vs 12.3% aver(first 3 years) age each class Annual cost avoidance: $707 608
High satisfaction with communication loop, coaching and collaboration to promote critical thinking, partnerships/sense of belonging
Baseline RNs more likely to consider leaving than at 6 months
Turnover decreased from 54% (baseline) to 0-4% (over 3 years)
Continued
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Table 1 Continued Outcomesa,b
Reference
Design; intervention (length)
N/ population
Krugman et al13
Descriptive comparative; residency (1 year)
Marcum and West14
Program evaluation; 20 (medorientation ical (13 weeks) unit)/ NGNs
Blanzola et al15
Quasi-experimental (posttest); internship (16 weeks) vs 6-week orientation
Almada et al16
Program evaluation 40/NGNs (posttest); orien(150-bed tation (11 weeks) hospital)
Beecroft et al17
Quasi-experimental (pretest/posttest); internship (6 months)
Competency/ autonomy
Job satisfaction/ organizational commitment
6 sites/BSN- Competency: prior- Moderate prepared satisfaction itizing outcomes NGNs with interimproved at 6 actions at and 12 months baseline, Autonomy: fairly increasing high at outset, at 6 and 12 dipped at 6 months months with con(except 1 tinued satisfacsite) tion at 1 year (except 1 site)
18/NGNs
78/NGNs (interns vs control group)
Owens et al18 Program evaluation; 75/NGNs internship (8 (5 hospiweeks) tals)
Program satisfaction
Retention/ vacancy
Perceived stress high at baseline, decreasing at 6, 12, and 24 months Program satisfaction generally positive Program perceived strongly effective at 6 months
Turnover/cost avoidance 8%
89% at 18 months (vs 29%-40% baseline)
$330 481 return on investment
Competency: Self/peer evaluation significantly improved for interns (vs controls) High satisfac- High overall tion with choice of employment
Retention increased from 66% to 89% (NGN improved from 25% to 93%) Vacancy decreased by 9.5%
Intern group Comparable Competency: conmaintained organizatinuous increase more realistic tional comin confidence for view of mitment both groups; professional scores for intern selfnurse role both groups evaluation at 6 and 12 trended toward months improvement at 2 months and end of program but NS Autonomy: NS Competency: No difference in NGN/ preceptor/director perceptions, except directors scored NGN significantly lower for “asks questions to increase practice knowledge”
Control group had highest possibility of quitting at 6 months but not 12 months Turnover 36% (control) vs 14% (intern) $543 011 net program benefit Years 1 and 2: 73%-74% retention with additional 14%15% staying within system Vacancy decrease from 7.3% to 6%
Abbreviations: ICU, intensive care unit; NGN, new graduate nurse; NS, not significant. a Competency/autonomy were assessed with an investigator-developed tool, the Skills Competency Self-Confidence Survey, the Slater Nursing Competencies Scale, the Organizing/Prioritizing Outcome, the Gerber Control Over Practice Scale, and the Scutzenhofer Professional Nursing Autonomy Scale; job satisfaction/ organizational commitment were assessed with the Modified Hagerty-Patusky Instrument, the McCloskey-Mueller Satisfaction Survey, the American Society Training Development Evaluation, and the Organizational Commitment Questionnaire; program satisfaction was assessed with the Orientation Satisfaction Scale, the Self-Reported Stresses, and Corwins Nursing Role Conception Scale; and turnover/cost avoidance were assessed with the Anticipated Turnover Scale. b Critical thinking was assessed in only 1 study.14 Assessment was done by using the Performance Based Development System and the Professional Judgment Rating Form. The authors reported improvement in critical thinking at 8 weeks and that 83% showed very strong critical thinking skills at 1 year.
Table 2 Evidence grading Class
between orientees, preceptors, and managers; and professional role development sessions. Orientee outcomes that were evaluated included knowledge/ skills (critical thinking, competency, autonomy), organizational (sense of belonging, job satisfation, organizational commitment, program satisfaction), and financial (retention/turnover, cost avoidance). Various measurement approaches were used. Knowledge/Skill Outcomes Critical thinking increased in the 1 program that evaluated this outcome.14 In 2 reports,15,17 self/peer ratings of competency trended toward improvement or improved significantly by program completion, with a continuous increase in confidence. Prioritization of outcomes was also enhanced by 6 and 12 months.13 Findings were mixed with regard to autonomy. Perceived fairly high at the beginning of 1 program, nurses’ autonomy dipped at 6 months but had recovered by year end.13 In another report,7 readiness to manage patient care at program completion was rated higher for experienced nurses than for NGNs. Autonomy was unaffected in another program.17 Organizational Outcomes In 1 evaluation, internship nurses at 6 months had a lower sense of belonging than at baseline or 12 months.10 Overall, satisfaction was high for choice of employment,16 as well as for praise, professional opportunities, and interactions at 12 months.11 Orientees also reported high satisfaction with their educational programs—even NGNs with high stress levels. Internship nurses maintained more realistic views of the professional nursing role.17 Nurses were satisfied with communication, coaching, and collaboration, as well as with spontaneous and simulation learning. Among all resources, preceptors were perceived to be most supportive during orientation. Financial Outcomes On the whole, evaluations were favorable for retention, vacancy, and turnover. Despite program overhead, good returns on investment were demonstrated, with cost avoidance associated with reduced turnover and employee replacement expenses.7-9,14,17
Recommendations Overall, studies reviewed represent class IIa evidence in support of preceptor-based orientation to increase program satisfaction and retention and to reduce turnover and cost (Table 2). Although
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Criteria
Class I Supported by excellent Definitely evidence, with at least 1 recommended prospective randomized controlled trial
Definition Interventions always acceptable, safe, and effective; considered definitive standard of care
Class IIa Acceptable and useful
Supported by good to very Interventions acceptable, good evidence; weight of safe, and useful; considevidence and expert opinered intervention of ion strongly in favor choice by most experts
Class IIb Acceptable and useful
Supported by fair to good Interventions also acceptable, evidence; weight of evisafe, and useful; considdence and expert opinion ered optional or alternanot strongly in favor tive by most experts
Indeterminate Promising, evidence lacking, premature
Preliminary research stage; evidence shows no harm but no benefit; evidence insufficient to support final class decision
Class III Not acceptable or useful; May be harm- may be harmful ful; no benefit documented
Treatment of promise but limited evidence
Interventions with no evidence of any benefit; often some evidence of harm
Adapted from “Part 1: Introduction to the International Guidelines 2000 for CPR and ECC,”19 with permission.
institutions may initially look to education as a source for budget cuts, leaders should consider thorough, structured orientation programs with adequately prepared preceptors. Education to prepare preceptors for this critical role ranges from 1- to 3-day workshops. Further study is needed regarding appropriate ongoing education and support for preceptors. Preceptor-based orientation programs may ultimately lead to a return on investment at 1 year, as studies reported cost savings of $24 810 to $823 680 despite program costs. Although class IIa evidence also supported the effect of preceptors on orientees’ competency, this outcome has been less consistently and robustly measured. Other researchers could consider adding standardized competency rating scales. It is worth noting that no studies evaluated outcomes related to cultural competency, an expected competency from the Joint Commission. Critical thinking was measured in only 1 study.14 Other authors have documented interventions to improve critical thinking that rely on methods that are not based on preceptors. Studies reviewed showed that stress continued for new nurses, even with solid orientation programs. Additionally, increased autonomy did not occur until the first full year after orientation. Thus, plans must be in place for continued support of NGNs after initial orientation. NGNs perceive that it takes at least 12 months to
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feel comfortable and confident in their practice2,13 and to feel that they belong. This time frame extends far beyond the typical several week orientation provided by hospitals. Thus, resources such as orientation facilitators and mentors should be used to provide ongoing support for NGNs throughout their first year. Deliberate and evidence-based interventions that use preceptors are pivotal in orientation of nurses in the complex and dynamic world of acute health care. Consequently, preceptors are key to the orientation of both NGNs and experienced nurses, and the contribution of preceptors to successful outcomes of orientees and organizations should not be underestimated. FINANCIAL DISCLOSURES None reported.
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a new model of critical care orientation. Am J Crit Care. 2009; 18(3):252-259. Pine R, Tart K. Return on investment: benefits and challenges of a baccalaureate nurse residency program. Nurs Econ. 2007;25(1):13-18,39. Halfer D. A magnetic strategy for new graduate nurses. Nurs Econ. 2007;25(1):6-11. Newhouse R, Hoffman H, Suflita J, et al. Evaluating an innovative program to improve new nurse graduate socialization into the acute healthcare setting. Nurs Adm Q. 2007; 31(1):50-60. Altier M, Krsek C. Effects of a 1-year residency program on job satisfaction and retention of new graduate nurses. J Nurses Staff Dev. 2006;22(2):70-77. Shermont H, Krepcio D. The impact of culture change on nurse retention. J Nurs Adm. 2006;36(9):407-415. Krugman M, Bretschneider J, Horn PB, Krsek CA, Moutafis RA, Smith MO. The national post-baccalaureate graduate nurse residency program. J Nurses Staff Dev. 2006;22(4): 196-205. Marcum E, West R. Structured orientation for new graduates: a retention strategy. J Nurses Staff Dev. 2004;20(3):118-124. Blanzola C, Linderman R, King M. Nurse internship pathway to clinical comfort, confidence, and competency. J Nurses Staff Dev. 2004;20(1):27-37. Almada P, Carafoli K, Flattery J, et al. Improving the retention rate of newly graduated nurses. J Nurses Staff Dev. 2004; 20(6):268-273. Beecroft P, Kunzman L, Krozek C. RN internship: outcomes of a one-year pilot program. J Nurs Adm. 2001;31(12):575-582. Owens D, Turjanica M, Scanion M, et al. New graduate RN internship program: a collaborative approach for systemwide integration. J Nurses Staff Dev. 2001;17(3):144-150. Classes of recommendations 2000. Part 1: Introduction to the international guidelines 2000 for CPR and ECC. Circulation. 2000;102:I-1.
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