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Optimizing Transition to Practice Through Orientation: A Quality Improvement Initiative
Clinical Simulation in Nursing (2017) 13, 583-590
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Featured Article
Optimizing Transition to Practice Through Orientation: A Quality Improvement Initiative Lara J. Murphy, EdD, DPM*, Lisa Janisse, RN, BScN, MScN London Health Sciences Centre, London, Ontario N6A 5A5, Canada KEYWORDS experiential learning; simulation; nursing orientation; transition to practice; adult learning theory; competency-based testing
Abstract Background: With dwindling nursing student placements in acute care facilities, increased pressure and responsibility have been placed on students to facilitate their transition to practice. Through the strategy of simulation-based orientation programs, the preparation to practice gap can be reduced. Methods: In 2013, London Health Sciences Centre embarked on a quality improvement initiative to revise their Central Nursing Orientation through the use of simulation and experiential learning. Results: Five hundred twenty-one new nurse hires participated in the revised orientation program and were compared with 749 who participated in the original program. New nursing hires commented on improved confidence and preparation for the unit. Summative assessments resulted in 23.4% of new hires unsuccessful in their first attempt, 6% in their second attempt, and 0.5% in their third. Conclusions: The successful development of a simulation-based orientation program provided our new nursing hires with a standardized approach for a successful transition to practice. Through this process, we also identified the continued learning needs during transition and the opportunity to engage with our academic institutions to better prepare our future nurses. Cite this article: Murphy, L. J., & Janisse, L. (2017, November). Optimizing transition to practice through orientation: A quality improvement initiative. Clinical Simulation in Nursing, 13(11), 583-590. http://dx.doi.org/ 10.1016/j.ecns.2017.07.007. Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Increasing demand and decreasing resources within health care has had a rippling effect on new nursing graduates. There is increased pressure on new nursing graduates to have the knowledge and experience within an acute care setting prior to graduation to facilitate their transition to practice (Teoh, Pua, & Chan, 2013). With dwindling placements and increased demand on staff,
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author: [email protected] (L. J. Murphy).
facilitation of these experiences are limited. Identified by the nurses themselves, transition to practice struggles include ‘‘striving for a new professional self’’ and having the ‘‘know how’’ in regards to competencies and boundaries (Arrowsmith, Lau-Walker, Norman, & Maben, 2016). Duchscher (2009) relates to transition shock and the process of adjustment that is developmental, intellectual, sociocultural, and physical in nature. Benner, Sutphen, Leonard, and Day (2010) agree, acknowledging that new graduate nurses often present to the workforce with a defined practiceeeducation gap. In a study performed by Berkow, Virkstis, Stewart, and Conway (2009),
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http://dx.doi.org/10.1016/j.ecns.2017.07.007
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it was identified that even with variation in educational demographics of new hires, there was noted constancy in the greatest improvement needs to narrow the preparationepractice gap. These included complex skills, critical thinking, prioritization, and decision making (Berkow et al., 2009; Hommes, 2014). With the increased Key Points complexity and needs of Through the strategy our patients, it is crucial of simulation and we discover a way to bridge experiential learning, this gap between what stuwe were able develop dents learn in the classroom an orientation program and how they apply it to that provided our new their clinical practice hires with the appro(Olejniczak, Schmidt, & priate resources and Brown, 2010; Yuan, support for a successWilliams, & Fang, 2011). ful transition, closing Both academic and health the gap through a stancare institutions are respondardized process. sible for developing nursing Utilizing an orientastudent’s clinical competion program applying tencies for entry into pracexperiential learning tice with schools focusing on methods can improve curricula and health care the competence and institutions focusing on confidence of new orientation and preceptor hires during their tranprograms (Berkow et al., sition to practice. 2009; Liaw, Palham, Chan, Integration of Wong, & Lim, 2014; Teoh competency-based aset al., 2013). New nursing sessments for all new orientation is central for hires can help identify new graduates to have a sucand correct entrycessful transition to nursing level practice gaps to practice (Phillips, Kenny, provide safe and qualEsterman, & Smith, 2014). ity patient care and Inadequate orientation proreduce potential risks grams can directly affect on patient care during attrition rates, confidence, transition to practice. and satisfaction in new hires (Hommes, 2014). It can further impact the workload on experienced nurses and patient safety (Hommes, 2014; Lamers, Janisse, Brown, Butler, & Watson, 2013; Zigmont et al., 2015). Yet, significant gaps in orientation have been identified including facilitators not accounting for the transition piece in the content of the orientation or the continued concern of new hires about being placed in clinical situations beyond their cognitive or experiential comfort level (Duchscher, 2009). Duchscher (2009) suggests addressing this gap through orientation programs focused on knowledge and practice related to transition. Yuan et al. (2011) identified the major focus of clinical education is facilitating the development of knowledge application, accurate clinical judgment, and skill development. Zigmont et al. (2015) proposed the primary goals for orientation include assessment of competency, incorporation of policy and safety
guidelines, and integration of new hires into the environment and culture while limiting the interruption of safe provision of quality patient care. Simulation is a strategy defined as the interactions and transactions between learners, educators, leaders, environments, processes, and culture with the aim to improve and standardize patient-centered care. Simulation is an established crucial learning strategy in health care education for the development of clinical competency (Liaw et al., 2014). Jeffries and Rogers (2007) identified four major outcomes from simulation: gained knowledge, increased skill competence, increased learner satisfaction, and improved critical thinking. An integrative review of literature was performed by Olejniczak et al. (2010) on the use of simulation in graduate nurse orientation with three emerging themes identified: socialization to the professional role, competence and confidence in self-performance, and learning in a safe and supportive environment. Yuan et al. (2011) underwent a review of studies involving high-fidelity simulation and identified qualitatively a positive impact on confidence, development of critical skills, and overall better preparation for clinical practice. Hommes (2014) implemented a simulation curriculum within their nursing orientation process identifying an increased perceived confidence and competence level from all participants following the simulated activities. Through the integration of experiential learning theory with the use of simulation in new hire orientation, Zigmont et al. (2015) was able to show enhancement in preparation of new RN staff and improved communication among administrators, staff, and orientees. Impacts included reduction in orientation length and gross financial savings. Further identification of inappropriate hires through their ‘‘red light’’ system demonstrated both financial and safety benefits to the unit and organization. Zigmont et al. (2015) agreed further research was needed on this competency based process to show validity and reliability. Simulation-based education, through the ability to provide hands-on training, promotes community while increasing competence, autonomy, and motivation to learn (Zigmont, Kappus, & Sudikoff, 2011). Facilitation of the education is provided through educators and specialists within simulation. Learning cannot be forced, instead supported and explanations provided on the importance and relevance to practice (Zigmont et al., 2011). The potential impact of simulation-based education on care providers with continued learning needs has been identified and yet still requires further evaluation on the outcome of competency and transition to practice (Clark & Yoder-Wise, 2015; Liaw et al., 2014; Zigmont et al., 2015).
Background London Health Sciences Centre is one of Canada’s largest acute care teaching hospitals. It is a multisite facility supported by over 3,500 nurses. On average, the institution
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hires approximately 300 nurses externally a year. It is a requirement that each new hire participate in a corporate and central nursing orientation prior to working on the clinical unit. Historically, central nursing orientation consisted of four days of didactic training and one day of computer training. Dependent on the unit, each new hire was then given a select number of mentored shifts and unit orientation days. In 2013, a quality improvement initiative was designed to address identified gaps in the transition to practice for our new nursing staff. Specifically, the primary goal was to create an orientation built on experiential learning principles and evaluate the efficacy of simulation as a training methodology through competency testing, participant evaluations, and turnover. The primary objectives of the program were to: 1) Evaluate and revise the current orientation process utilizing experiential learning methods to improve the competence and confidence of new hires during their transition to practice. 2) Integrate competency-based assessments for all new hires for identification and correction of entry-level practice to provide safe and quality patient care and reduce the impact on patient care during transition to practice.
Theoretical Framework To provide effective adult education through the use of simulation, Zigmont et al. (2011) agree there is a need and requirement for a ‘‘sound understanding of both adult learning theory and experiential learning’’ (p. 47). Malcom S. Knowles was one of the first to describe adult learners as learners demonstrating specific characteristics in comparison to children. These characteristics included adults are autonomous and self-directed, goal and relevancy oriented, practical, have previous knowledge and experience and the need to connect learning to these, and need to be shown respect (Conner, 2012). As self-regulated learners, adults require a student-centered approach versus the traditional teacher-centered approach for children (Zigmont et al., 2011). Objectives are geared toward relevancy and the learner versus instructor and institution determined. The learning environment is focused on the student and makes the educator a facilitator for their learning (Fidishun, 2012). Educators in health care are unable to force practitioners to learn, instead they must demonstrate relevance of the learning and help the learner decide themselves about how, why, and when to learn (Zigmont et al., 2011). Defined by Kolb (2015), experiential learning is a theory that helps explain ‘‘how experience is transformed in learning and reliable knowledge’’ (p. xxi). He goes on further to describe that truth is not obtained from experience but is ‘‘inferred by a process of learning that questions preconceptions of direct experience, tempers the vividness and emotion of
experience with critical reflection, and extracts the correct lessons from the consequences of action’’ (p. xxi). David Kolb’s learning style model and cycle were created based on the premise that each learner has a specific preference in engaging in learning. These included concrete experience or abstract conceptualization and active experimentation or reflective observation (Kolb, 1984). Simulations adhere to the guiding principles of experiential learning and the adult learning theory in which it allows for hands-on experience in a safe environment and guided reflection allowing each learner to engage in learning associated best with their style and preference (Zigmont et al., 2011).
Materials and Methods This study was reviewed by the Office of Research Ethics at Western University in London, Ontario and deemed exempt from the ethics review board. The quality improvement study was a comparison study based on data obtained from the traditional central nursing orientation program spanning January 2013 to December 2014 and the revised program from January 2015 to December 2016. The study participants included newly graduate and more seasoned registered nurses and registered practical nurses hired externally to Organization A during the defined dates. Exclusions included internal transfers between clinical departments. From January 2013 to December 2014, 749 nurses were included in the study and compared with 521 nurses who participated in the new program from January 2015 to December 2016.
Program Development Historically, central nursing orientation consisted of one day of corporate orientation, attended by all new nursing staff of the organization, one day of computer training, and four days of didactic driven nursing orientation. Evaluation of the current program was completed through the collaborative work of Professional Practice and the hospital-based simulation centre. Methods of evaluation included review of all course content including objectives, PowerpointÓ presentations, and handouts in relevance to current practice and the policies and procedures put forth from the organization and Accreditation Canada and regulatory standards of practice; attendance of all days of current program by the Simulation Specialist; review of all course evaluations from participants; creation of multiple focus groups including instructors and educators of the current program; and gap analysis and content duplication with units specific orientations. Additionally, current resources including space allocation, human resources, and consumables were evaluated. Findings are summarized in Table 1. In total, it took approximately 18 months from initiation to implementation. The new program consisted of one day of corporate orientation, one day of computer training, and three days of experiential learning. Over 40 Clinical
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Educators, Professional Practice Consultants and staff, as well as expertise from the simulation centre were required for this initiative. Experiential learning methods included skill-based stations, high-fidelity simulations, hands-on case study application, and a competency-based head-to-toe assessment. Each station was built on the application of skills, requirements of the organization, and entry to practice competencies from The College of Nurses of Ontario. Day three, four, and five consisted of small group rotations within a defined number of stations per day. At maximum, each group consisted of 10 learners, and each station was an hour in length. All stations were designed to be able to accommodate hands-on learning and demonstration of skills from all learners within the group. This included the demonstration of a sterile Peripherally Inserted Central Catheter line dressing, blood sampling, Personal Protective Equipment donning and doffing, as well as management of an unwitnessed fall, patient admission process, blood transfusion, and wound care management, etc. It was decided that pain management, patient safety, and Trillium Organ Donation would remain lectured based and be provided by subject matter experts. All other stations were designed and managed by working groups made up of Clinical Educators. Each Clinical Educator attended a professional development workshop throughout the year to acquire the necessary skills to develop learning objectives, content, assessment tools, and to provide in the moment feedback when necessary. Clinical Educators were assigned stations that aligned with their specialties and expertise. Table 1
Assessment Assessments of the learners consisted of self-reflection, observation, summative, and formative methods. Each new hire was initially asked to fill out a learning style survey to better understand their ways of learning. This information was also given to their specific Clinical Educator for future use. New hires were also asked to complete a personal reflection similar to the professional quality assurance requirements. During each station, the Clinical Educator facilitating the station was asked to observe and comment on the individual’s performance. If there were any ‘‘red flags,’’ it was asked that they bring this information forward to the program director immediately for further evaluation. A ‘‘red flag’’ was considered someone who was not meeting the minimal requirements of a station, demonstrating purposeful neglect or disrespect or not meeting the standards of safe patient care. Areas of improvement were to be addressed in the moment with feedback as well as provided to their individualized educator for follow-up during their unit orientation. On the final day of orientation, each new hire participated in a summative head-to-toe assessment of a patient. The London Health Sciences Centre Physical Assessment Tool was designed based on the entry to practice competencies of nurses put forth by the College of Nurses of Ontario (see Appendix 1). Standards listed on the tool were either defined as mandatory or noncompulsory. One missed mandatory item was an automatic failure. Each participant was presented with the same patient, provided 10 minutes to complete their
Previous Central Nursing Orientation Evaluation Summaries
Individual Groups
Central Nursing Orientation 2014-2015 Comments
Participants
‘‘More interactive sessions to engage different types of learners.’’ ‘‘Perhaps utilize some different teaching methods/learning styles, as opposed to 8 hours of PowerpointÓ presentations.’’ ‘‘Make it more interactive’’ (stated on every month). ‘‘May be more useful to have group actually practice proper body mechanics.’’ ‘‘Need hands on for restraints.’’ ‘‘Learning setting not effective.’’ ‘‘The room does not meet learning needs.’’ ‘‘More small groups for interactive learning that allows hands on and personal experiences.’’ ‘‘Engage the class in hands on and interactive learning so that all types of learning are targeted.’’ ‘‘It was very difficult to stay awake and alert for the whole day.’’ ‘‘Make the modules more interactive, testing maybe? Would make me pay more attention and make the content more applicable to processes and critical thinking rather than reviewing theories we learned in school.’’ ‘‘Involve more interactive lectures: props, case studies, clicker questions, worksheet.’’ Would show up and be teaching content they were not comfortable with. Would not have the appropriate resources to provide any form of hands on training with the new hires. Would sometimes have to teach in a hotel based on the size of the class. Would have over 60 new hires trying to see one crash cart. Sometimes the audiovisual equipment would work and sometimes it would not. Then would then have to improvise. ‘‘I literally had one new hire fall asleep next to me.’’ The content was geared to topics the new hires should have already known in school rather than application specifically at the hospital. The facilities were not learner friendly or a good representation of London Health Sciences Centre and what we had to offer.
Facilitators
Observers
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assessment and 5 minutes to present their findings. The rubric included the mechanics of performing a head-to-toe assessment as well as demonstration of critical thinking and prioritization of care based on abnormal findings. If unsuccessful with the first attempt, the new hire was provided the opportunity to perform the head-to-toe assessment in two further separate occasions. The same tool was used for each assessment. A high-fidelity manikin was used for the first two assessments, and an actual patient from the medicine service was used if a third assessment was required. Unsuccessful participants were provided supplementary education and training between assessments and written feedback to promote reflection and learning. It was required that each participant have at least four mentored shifts prior to attempting their second test, and they were not scheduled to work independently until deemed successful. If their second attempt was unsuccessful, a formal meeting was held that included human resources, clinical leadership, Professional Practice, and union representation prior to their final attempt. If the final attempt was deemed unsuccessful, it was at the discretion of the clinical leaders and human resources regarding potential ramifications on the employment relationship.
Implementation In January 2015, the first cohort of new hires participated in the revised Central Nursing Orientation. Collaboration between senior leadership of Professional Practice and the simulation centre was integral for the successful implementation. Space allocation, station setup, consumables, and rotation were the responsibility of the simulation centre staff. The accountability of staffing and scheduling for the new program was with the group of Clinical Educators assigned to each teaching station. Administration was responsible for communication, organization, and day-to-day requirements of the orientation. Professional Practice consultants and simulation experts were present for quality assurance of programming. The program was overseen by the Director of Professional Practice. All Clinical Educators were provided training on experiential learning methods. Clinical Educators designated as evaluators for the head-to-toe assessment station were provided specific training and follow-up throughout the implementation process to maintain consistency and reliability of results.
analysis was performed on all data sources received from the orientation occurring January 2013 to December 2014 to orientation from January 2015 to December 2016.
Results Seven hundred forty-nine new external hires participated in central nursing orientation during January 2013 to December 2014 comparative to 521 new external hires in January 2015 to December 2016. Qualitative data included course evaluations, facilitator, Professional Practice Consultant, and Simulation Specialist feedback. Quantitative data comparison included employment terminations that occurred within the probationary period for each allocated time frame, overall orientation length, and summative assessment results.
Quantitative Overall nursing probationary terminations were comparative with 10.68% turnover rate for 2013/2014 and 12.28% for 2015/2016. This included all voluntary and involuntary exits from the organization. Summative assessments resulted in 23.4% of new hires unsuccessful in their first attempt, 6% of the total new hires were unsuccessful in their second attempt, and 0.5% in their third (Table 2). Overall, the orientation length was shortened by one 8hour day with the potential savings of $156,000 in the two-year period based on entry-level nursing wages.
Qualitative Qualitative data were reviewed for program content, execution of the program, objectives being met, overall satisfaction, competency, and confidence in new hires, and any implications on unit orientation or transition to practice. In comparison with the previous orientation, positive comments included enjoyment of the hands-on practice and instruction, asking questions in a nonjudgmental environment, and increased confidence and preparation for clinical practice (Table 3). New hires commented on the ability to self-reflect and identify areas of development to be able to continue their transition while providing safe patient care. Areas of continued improvement for the program included adapting the remaining lecture-based stations into more of an experiential learning method, limiting the number of new hires
Program Evaluation Evaluation of the program included qualitative assessment of each station and the program as a whole, by the new hires, Clinical Educators, Professional Practice Consultants, and simulation experts. This was compared with the qualitative information obtained from the previous two years of the old version of the orientation process. Quantitative data sources included human resources and summative assessment de-identified data. Comparative
Table 2
Percentages of Unsuccessful Competency Testing
Head-to-Toe Assessment First attempt Second attempt Third attempt
Percentage of Total New Hires Unsuccessful
Percentage of New Hires Unsuccessful per Attempt
23.42 6.34 0.53
23.42 27.07 8.33
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per group, and having more time at each station. Facilitators of the stations and Professional Practice Consultants also felt the overall changes were positive and impactful: ‘‘It is wonderful!! Not worrying about equipment, set up and having adequate support from the simulation centre is amazing. I literally can walk in and teach!!’’; ‘‘It is no longer perceived as a chore. It has now become the best part of my job!!’’; ‘‘Participating in the redesign of the new orientation program aligns well with our organization’s vision of ‘Exceptional Experiences, Extraordinary People and Engaging Partnerships’.’’
Discussion On review of our quality improvement initiative, it is believed by the authors that both objectives were met. Defined by the participants comments and staggering improvements in the competency-based testing rates, new hires demonstrated improved entry-level competencies and confidence through experiential learning. It was also identified that 23.42% of new hires were unprepared to meet the expectation for nursing practice at London Health Sciences Centre. Without early identification of these gaps, potential adverse patient safety events and increased financial burden on the institution could have ensued. Interestingly, only
Table 3 Current Central Nursing Orientation Evaluation Summaries Central Nursing Orientation 2015-2016 Participants Comments ‘‘I enjoyed having the opportunity to have hands-on practice and instruction.’’ ‘‘Being able to ask questions in a safe environmental without judgment was valuable to me during orientation.’’ ‘‘Thought it was great to through a crash cart then a mock code blue, I felt more prepared.’’ ‘‘Most valuable was practicing head-to-toe even though I was nervous I was happy for immediate feedback.’’ ‘‘Glad to get familiar with hospital guidelines and expectations.’’ ‘‘Great refresher training of content.’’ ‘‘Being able to participate and observe in activities to compare practice was most valuable.’’ ‘‘Multiple experts and real clinical knowledge available.’’ ‘‘I enjoyed the different stations. They were very informative and helpful.’’ ‘‘Has definitely increased my confidence.’’ ‘‘Head to toe physical assessment was very helpful and useful. It really prepares me for working on the floor.’’ ‘‘Catered to all learning styles, great!’’ ‘‘I liked how much we got to participate today and learning in different methods. Makes me feel more confident.’’ ‘‘I appreciate knowing what is expected of me when I start working on the floor.’’ ‘‘Patient admission station was very helpful as we could work through real-life situations, use critical thinking.’’
0.53% of the new hires were determined to be at risk and unable to meet entry to level competencies following educational support. This demonstrates the abilities of new hires to transition to practice successfully with defined education and support. This may correlate with the lack of significant improvement in staff turnover during these comparative time periods. In the end, the significance was in the transition to practice in a safe and effective manner not their potential inabilities to meet the standard. A positive impact was also identified by the Clinical Educators who facilitated the development and monthly execution of the program. Although staff turnover in this field was not evaluated, qualitative comments demonstrate increased job satisfaction and vision alignment with the organization. Critically reviewing the previous orientation content enabled the development of an orientation program that was shorter in length. This allowed for a potential cost savings, impacting the organization as a whole and the specific departments where the nurses were from. Each department chose whether to use this extra day as an additional unit specific orientation day, mentored shift, or assume the cost savings.
Conclusions Through the strategy of simulation and experiential learning, we were able to develop an orientation program that provided our new hires with the appropriate resources and support for a successful transition to practice and help close the preparation to practice gap through a standardized process. Our educational program met the needs of the learners including: knowledge application, clinical judgment and reasoning, and skill development (Zigmont et al., 2015). Through this process, we also identified the continued learning needs in the transition to practice and the potential opportunities to engage with our academic partners to better prepare our future nurses. Currently this program continues to run monthly at our institution through the continued partnership between Professional Practice and the simulation centre. Continuous quality improvements include peer to peer feedback, maintenance of up-to-date resources and content at all stations, and additional pediatric focused content. Modifications to the current assessment tool and interrater reliability testing to validate the London Health Sciences Centre Physical Assessment Tool are currently in progress. Continued analysis is being performed in attempt to quantify the impact of our competency-based testing on patient safety and patient satisfaction. Other areas of consideration include length of unit specific orientation and number of mentored shifts needed prior to completion of the orientation process. Discussions are also being held with academic institutions on collaborative approaches to the transition of new nursing hires and successful integration into practice.
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Acknowledgments The authors would like to thank and acknowledge all the Clinical Educators at London Health Sciences Centre and the simulation centre staff whose hard work, dedication, and expertise made the development and execution of this new orientation possible. It is also because of these individuals that this program continues to be a successful and impactful orientation program within the organization today.
References Arrowsmith, V., Lau-Walker, M., Norman, I., & Maben, J. (2016). Nurses’ perceptions and experiences of work role transitions: A mixed methods systematic review of the literature. Journal of Advanced Nursing, 72(8), 1735-1750. http://dx.doi.org/10.1111/jan.12912. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Berkow, S., Virkstis, K., Stewart, J., & Conway, L. (2009). Assessing new graduate nurse performance. Nurse Educator, 34(1), 17-22. Clark, T. J., & Yoder-Wise, P. S. (2015). Enhancing trifocal leadership practices using simulation in a pediatric charge nurse orientation program. The Journal of Continuing Education in Nursing, 46(7), 311317. http://dx.doi.org/10.3928/00220124-20150619-02. Conner, M. (2012). Adult learning theory. In Encyclopedia of the Sciences of Learning. New York, NY: Springer. (pp. 141-143). Duchscher, J. E. B. (2009). Transition shock: The initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing, 65(5), 1103-1113. http://dx.doi.org/10.1111/j.1365-2648.2008. 04898.x. Fidishun, D. (2012). Adult learning/Andragogy. In Encyclopedia of the Sciences of Learning. New York, NY: Springer. (pp. 143-145).
Hommes, T. (2014). Implementation of simulation to improve staff nurse education. Journal for Nurses in Professional Development, 30(2), 6669. http://dx.doi.org/10.1097/01.NND.0000433144.66804.4c. Jeffries, P. R., & Rogers, K. J. (2007). Theoretical framework for simulation design. In Jeffries, P. R. (Ed.), Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League of Nursing. (pp. 21-33). Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall, Inc. Kolb, D. (2015). Experiential learning: Experience as the source of learning and development (2nd ed.). Upper Saddle River, NJ: Pearson Education Inc. Lamers, K., Janisse, L., Brown, G., Butler, C., & Watson, B. (2013). Collaborative hospital orientation: Simulation as a teaching strategy. Nursing Leadership, 26, 61-69. Liaw, S. Y., Palham, S., Chan, W., Wong, L. F., & Lim, F. P. (2014). Using simulation learning through academic-practice partnership to promote transition to clinical practice: A qualitative evaluation. Journal of Advanced Nursing, 71(5), 1044-1054. http://dx.doi.org/10.1111/jan.12585. Olejniczak, E. A., Schmidt, N. A., & Brown, J. M. (2010). Simulation as an orientation strategy for new nurse graduates: An integrative review of the evidence. Simulation in Healthcare, 5(1), 52-57. http: //dx.doi.org/10.1097/SIH.0b013e3181ba1f61. Phillips, C., Kenny, A., Esterman, A., & Smith, C. (2014). A secondary data analysis examining the needs of graduate nurses in their transition to a new role. Nurse Education in Practice, 14, 106-111. Teoh, Y. T. E., Pua, L. H., & Chan, M. F. (2013). Lost in transitiondA review of qualitative literature of newly qualified registered nurses’ experiences in their transition to practice journey. Nurse Education Today, 33, 143-147. Yuan, H. B., Williams, B. A., & Fang, J. B. (2011). The contribution of high-fidelity simulation to nursing students’ confidence and competence: A systematic review. International Nursing Reviews, 59, 26-33. Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). Theoretical foundations of learning through simulation. Seminars in Perinatology, 35(2), 47-51. http://dx.doi.org/10.1053/j.semperi.2011.01.002. Zigmont, J. J., Wade, A., Edwards, T., Hayes, K., Mitchell, J., & Oocumma, N. (2015). Utilization of experiential learning, and the learning outcomes model reduces RN orientation time by more than 35%. Clinical Simulation in Nursing, 11(2), 79-94.
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Appendix
Appendix 1
London Health Sciences Centre Physical Assessment Tool Guideline for Learners Component
Introduction
Pain Assessment Airway/Breathing
Circulation
Neuro
Vital Signs Abdominal: GU/GI
Extremity/Skin/Back assessment SBAR Summation
Yes/No
Hand Hygiene*** Did participant introduce him/herself and ask pt. for permission to complete assessment? Did participant explain plan? Did participant identify pt.? Did participant consider PPE? OPQRSTU Pneumonic used*** Airway patent? (snoring, stridor, talking) Did participant note breathing spontaneously? Swallowing secretions? Chest symmetry No retractions/stridor/tug Work of breathing (e.g. speaking full sentences without difficulty) Desired position Auscultated breath sounds*** Inspected & palpated neck, chest Skin color, temp., moisture Palpated pulse (central & peripheral) Capillary refill*** Auscultated heart sounds Level of consciousness*** Oriented to person, place & time*** Pupil size and reactivity to light T, HR, BP, RR, SpO2*** Inspected abdomen Auscultate Bowel Sounds*** Lightly palpate abdomen Inquired date of last BM*** Inquired when last voided*** Inquired date of last menstrual period (if applicable) Inspected & palpated arms/legs and back for crepitus, deformities, bruising or wounds*** Assessed CSM of extremities Be able to identify the significance of the abnormal findings in SBAR reporting format*** Summarize the abnormal findings and prioritize the plan of care***
Components with an *** are mandatory.
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Featured Article
Optimizing Transition to Practice Through Orientation: A Quality Improvement Initiative Lara J. Murphy, EdD, DPM*, Lisa Janisse, RN, BScN, MScN London Health Sciences Centre, London, Ontario N6A 5A5, Canada KEYWORDS experiential learning; simulation; nursing orientation; transition to practice; adult learning theory; competency-based testing
Abstract Background: With dwindling nursing student placements in acute care facilities, increased pressure and responsibility have been placed on students to facilitate their transition to practice. Through the strategy of simulation-based orientation programs, the preparation to practice gap can be reduced. Methods: In 2013, London Health Sciences Centre embarked on a quality improvement initiative to revise their Central Nursing Orientation through the use of simulation and experiential learning. Results: Five hundred twenty-one new nurse hires participated in the revised orientation program and were compared with 749 who participated in the original program. New nursing hires commented on improved confidence and preparation for the unit. Summative assessments resulted in 23.4% of new hires unsuccessful in their first attempt, 6% in their second attempt, and 0.5% in their third. Conclusions: The successful development of a simulation-based orientation program provided our new nursing hires with a standardized approach for a successful transition to practice. Through this process, we also identified the continued learning needs during transition and the opportunity to engage with our academic institutions to better prepare our future nurses. Cite this article: Murphy, L. J., & Janisse, L. (2017, November). Optimizing transition to practice through orientation: A quality improvement initiative. Clinical Simulation in Nursing, 13(11), 583-590. http://dx.doi.org/ 10.1016/j.ecns.2017.07.007. Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Increasing demand and decreasing resources within health care has had a rippling effect on new nursing graduates. There is increased pressure on new nursing graduates to have the knowledge and experience within an acute care setting prior to graduation to facilitate their transition to practice (Teoh, Pua, & Chan, 2013). With dwindling placements and increased demand on staff,
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author: [email protected] (L. J. Murphy).
facilitation of these experiences are limited. Identified by the nurses themselves, transition to practice struggles include ‘‘striving for a new professional self’’ and having the ‘‘know how’’ in regards to competencies and boundaries (Arrowsmith, Lau-Walker, Norman, & Maben, 2016). Duchscher (2009) relates to transition shock and the process of adjustment that is developmental, intellectual, sociocultural, and physical in nature. Benner, Sutphen, Leonard, and Day (2010) agree, acknowledging that new graduate nurses often present to the workforce with a defined practiceeeducation gap. In a study performed by Berkow, Virkstis, Stewart, and Conway (2009),
1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.07.007
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it was identified that even with variation in educational demographics of new hires, there was noted constancy in the greatest improvement needs to narrow the preparationepractice gap. These included complex skills, critical thinking, prioritization, and decision making (Berkow et al., 2009; Hommes, 2014). With the increased Key Points complexity and needs of Through the strategy our patients, it is crucial of simulation and we discover a way to bridge experiential learning, this gap between what stuwe were able develop dents learn in the classroom an orientation program and how they apply it to that provided our new their clinical practice hires with the appro(Olejniczak, Schmidt, & priate resources and Brown, 2010; Yuan, support for a successWilliams, & Fang, 2011). ful transition, closing Both academic and health the gap through a stancare institutions are respondardized process. sible for developing nursing Utilizing an orientastudent’s clinical competion program applying tencies for entry into pracexperiential learning tice with schools focusing on methods can improve curricula and health care the competence and institutions focusing on confidence of new orientation and preceptor hires during their tranprograms (Berkow et al., sition to practice. 2009; Liaw, Palham, Chan, Integration of Wong, & Lim, 2014; Teoh competency-based aset al., 2013). New nursing sessments for all new orientation is central for hires can help identify new graduates to have a sucand correct entrycessful transition to nursing level practice gaps to practice (Phillips, Kenny, provide safe and qualEsterman, & Smith, 2014). ity patient care and Inadequate orientation proreduce potential risks grams can directly affect on patient care during attrition rates, confidence, transition to practice. and satisfaction in new hires (Hommes, 2014). It can further impact the workload on experienced nurses and patient safety (Hommes, 2014; Lamers, Janisse, Brown, Butler, & Watson, 2013; Zigmont et al., 2015). Yet, significant gaps in orientation have been identified including facilitators not accounting for the transition piece in the content of the orientation or the continued concern of new hires about being placed in clinical situations beyond their cognitive or experiential comfort level (Duchscher, 2009). Duchscher (2009) suggests addressing this gap through orientation programs focused on knowledge and practice related to transition. Yuan et al. (2011) identified the major focus of clinical education is facilitating the development of knowledge application, accurate clinical judgment, and skill development. Zigmont et al. (2015) proposed the primary goals for orientation include assessment of competency, incorporation of policy and safety
guidelines, and integration of new hires into the environment and culture while limiting the interruption of safe provision of quality patient care. Simulation is a strategy defined as the interactions and transactions between learners, educators, leaders, environments, processes, and culture with the aim to improve and standardize patient-centered care. Simulation is an established crucial learning strategy in health care education for the development of clinical competency (Liaw et al., 2014). Jeffries and Rogers (2007) identified four major outcomes from simulation: gained knowledge, increased skill competence, increased learner satisfaction, and improved critical thinking. An integrative review of literature was performed by Olejniczak et al. (2010) on the use of simulation in graduate nurse orientation with three emerging themes identified: socialization to the professional role, competence and confidence in self-performance, and learning in a safe and supportive environment. Yuan et al. (2011) underwent a review of studies involving high-fidelity simulation and identified qualitatively a positive impact on confidence, development of critical skills, and overall better preparation for clinical practice. Hommes (2014) implemented a simulation curriculum within their nursing orientation process identifying an increased perceived confidence and competence level from all participants following the simulated activities. Through the integration of experiential learning theory with the use of simulation in new hire orientation, Zigmont et al. (2015) was able to show enhancement in preparation of new RN staff and improved communication among administrators, staff, and orientees. Impacts included reduction in orientation length and gross financial savings. Further identification of inappropriate hires through their ‘‘red light’’ system demonstrated both financial and safety benefits to the unit and organization. Zigmont et al. (2015) agreed further research was needed on this competency based process to show validity and reliability. Simulation-based education, through the ability to provide hands-on training, promotes community while increasing competence, autonomy, and motivation to learn (Zigmont, Kappus, & Sudikoff, 2011). Facilitation of the education is provided through educators and specialists within simulation. Learning cannot be forced, instead supported and explanations provided on the importance and relevance to practice (Zigmont et al., 2011). The potential impact of simulation-based education on care providers with continued learning needs has been identified and yet still requires further evaluation on the outcome of competency and transition to practice (Clark & Yoder-Wise, 2015; Liaw et al., 2014; Zigmont et al., 2015).
Background London Health Sciences Centre is one of Canada’s largest acute care teaching hospitals. It is a multisite facility supported by over 3,500 nurses. On average, the institution
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hires approximately 300 nurses externally a year. It is a requirement that each new hire participate in a corporate and central nursing orientation prior to working on the clinical unit. Historically, central nursing orientation consisted of four days of didactic training and one day of computer training. Dependent on the unit, each new hire was then given a select number of mentored shifts and unit orientation days. In 2013, a quality improvement initiative was designed to address identified gaps in the transition to practice for our new nursing staff. Specifically, the primary goal was to create an orientation built on experiential learning principles and evaluate the efficacy of simulation as a training methodology through competency testing, participant evaluations, and turnover. The primary objectives of the program were to: 1) Evaluate and revise the current orientation process utilizing experiential learning methods to improve the competence and confidence of new hires during their transition to practice. 2) Integrate competency-based assessments for all new hires for identification and correction of entry-level practice to provide safe and quality patient care and reduce the impact on patient care during transition to practice.
Theoretical Framework To provide effective adult education through the use of simulation, Zigmont et al. (2011) agree there is a need and requirement for a ‘‘sound understanding of both adult learning theory and experiential learning’’ (p. 47). Malcom S. Knowles was one of the first to describe adult learners as learners demonstrating specific characteristics in comparison to children. These characteristics included adults are autonomous and self-directed, goal and relevancy oriented, practical, have previous knowledge and experience and the need to connect learning to these, and need to be shown respect (Conner, 2012). As self-regulated learners, adults require a student-centered approach versus the traditional teacher-centered approach for children (Zigmont et al., 2011). Objectives are geared toward relevancy and the learner versus instructor and institution determined. The learning environment is focused on the student and makes the educator a facilitator for their learning (Fidishun, 2012). Educators in health care are unable to force practitioners to learn, instead they must demonstrate relevance of the learning and help the learner decide themselves about how, why, and when to learn (Zigmont et al., 2011). Defined by Kolb (2015), experiential learning is a theory that helps explain ‘‘how experience is transformed in learning and reliable knowledge’’ (p. xxi). He goes on further to describe that truth is not obtained from experience but is ‘‘inferred by a process of learning that questions preconceptions of direct experience, tempers the vividness and emotion of
experience with critical reflection, and extracts the correct lessons from the consequences of action’’ (p. xxi). David Kolb’s learning style model and cycle were created based on the premise that each learner has a specific preference in engaging in learning. These included concrete experience or abstract conceptualization and active experimentation or reflective observation (Kolb, 1984). Simulations adhere to the guiding principles of experiential learning and the adult learning theory in which it allows for hands-on experience in a safe environment and guided reflection allowing each learner to engage in learning associated best with their style and preference (Zigmont et al., 2011).
Materials and Methods This study was reviewed by the Office of Research Ethics at Western University in London, Ontario and deemed exempt from the ethics review board. The quality improvement study was a comparison study based on data obtained from the traditional central nursing orientation program spanning January 2013 to December 2014 and the revised program from January 2015 to December 2016. The study participants included newly graduate and more seasoned registered nurses and registered practical nurses hired externally to Organization A during the defined dates. Exclusions included internal transfers between clinical departments. From January 2013 to December 2014, 749 nurses were included in the study and compared with 521 nurses who participated in the new program from January 2015 to December 2016.
Program Development Historically, central nursing orientation consisted of one day of corporate orientation, attended by all new nursing staff of the organization, one day of computer training, and four days of didactic driven nursing orientation. Evaluation of the current program was completed through the collaborative work of Professional Practice and the hospital-based simulation centre. Methods of evaluation included review of all course content including objectives, PowerpointÓ presentations, and handouts in relevance to current practice and the policies and procedures put forth from the organization and Accreditation Canada and regulatory standards of practice; attendance of all days of current program by the Simulation Specialist; review of all course evaluations from participants; creation of multiple focus groups including instructors and educators of the current program; and gap analysis and content duplication with units specific orientations. Additionally, current resources including space allocation, human resources, and consumables were evaluated. Findings are summarized in Table 1. In total, it took approximately 18 months from initiation to implementation. The new program consisted of one day of corporate orientation, one day of computer training, and three days of experiential learning. Over 40 Clinical
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Educators, Professional Practice Consultants and staff, as well as expertise from the simulation centre were required for this initiative. Experiential learning methods included skill-based stations, high-fidelity simulations, hands-on case study application, and a competency-based head-to-toe assessment. Each station was built on the application of skills, requirements of the organization, and entry to practice competencies from The College of Nurses of Ontario. Day three, four, and five consisted of small group rotations within a defined number of stations per day. At maximum, each group consisted of 10 learners, and each station was an hour in length. All stations were designed to be able to accommodate hands-on learning and demonstration of skills from all learners within the group. This included the demonstration of a sterile Peripherally Inserted Central Catheter line dressing, blood sampling, Personal Protective Equipment donning and doffing, as well as management of an unwitnessed fall, patient admission process, blood transfusion, and wound care management, etc. It was decided that pain management, patient safety, and Trillium Organ Donation would remain lectured based and be provided by subject matter experts. All other stations were designed and managed by working groups made up of Clinical Educators. Each Clinical Educator attended a professional development workshop throughout the year to acquire the necessary skills to develop learning objectives, content, assessment tools, and to provide in the moment feedback when necessary. Clinical Educators were assigned stations that aligned with their specialties and expertise. Table 1
Assessment Assessments of the learners consisted of self-reflection, observation, summative, and formative methods. Each new hire was initially asked to fill out a learning style survey to better understand their ways of learning. This information was also given to their specific Clinical Educator for future use. New hires were also asked to complete a personal reflection similar to the professional quality assurance requirements. During each station, the Clinical Educator facilitating the station was asked to observe and comment on the individual’s performance. If there were any ‘‘red flags,’’ it was asked that they bring this information forward to the program director immediately for further evaluation. A ‘‘red flag’’ was considered someone who was not meeting the minimal requirements of a station, demonstrating purposeful neglect or disrespect or not meeting the standards of safe patient care. Areas of improvement were to be addressed in the moment with feedback as well as provided to their individualized educator for follow-up during their unit orientation. On the final day of orientation, each new hire participated in a summative head-to-toe assessment of a patient. The London Health Sciences Centre Physical Assessment Tool was designed based on the entry to practice competencies of nurses put forth by the College of Nurses of Ontario (see Appendix 1). Standards listed on the tool were either defined as mandatory or noncompulsory. One missed mandatory item was an automatic failure. Each participant was presented with the same patient, provided 10 minutes to complete their
Previous Central Nursing Orientation Evaluation Summaries
Individual Groups
Central Nursing Orientation 2014-2015 Comments
Participants
‘‘More interactive sessions to engage different types of learners.’’ ‘‘Perhaps utilize some different teaching methods/learning styles, as opposed to 8 hours of PowerpointÓ presentations.’’ ‘‘Make it more interactive’’ (stated on every month). ‘‘May be more useful to have group actually practice proper body mechanics.’’ ‘‘Need hands on for restraints.’’ ‘‘Learning setting not effective.’’ ‘‘The room does not meet learning needs.’’ ‘‘More small groups for interactive learning that allows hands on and personal experiences.’’ ‘‘Engage the class in hands on and interactive learning so that all types of learning are targeted.’’ ‘‘It was very difficult to stay awake and alert for the whole day.’’ ‘‘Make the modules more interactive, testing maybe? Would make me pay more attention and make the content more applicable to processes and critical thinking rather than reviewing theories we learned in school.’’ ‘‘Involve more interactive lectures: props, case studies, clicker questions, worksheet.’’ Would show up and be teaching content they were not comfortable with. Would not have the appropriate resources to provide any form of hands on training with the new hires. Would sometimes have to teach in a hotel based on the size of the class. Would have over 60 new hires trying to see one crash cart. Sometimes the audiovisual equipment would work and sometimes it would not. Then would then have to improvise. ‘‘I literally had one new hire fall asleep next to me.’’ The content was geared to topics the new hires should have already known in school rather than application specifically at the hospital. The facilities were not learner friendly or a good representation of London Health Sciences Centre and what we had to offer.
Facilitators
Observers
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assessment and 5 minutes to present their findings. The rubric included the mechanics of performing a head-to-toe assessment as well as demonstration of critical thinking and prioritization of care based on abnormal findings. If unsuccessful with the first attempt, the new hire was provided the opportunity to perform the head-to-toe assessment in two further separate occasions. The same tool was used for each assessment. A high-fidelity manikin was used for the first two assessments, and an actual patient from the medicine service was used if a third assessment was required. Unsuccessful participants were provided supplementary education and training between assessments and written feedback to promote reflection and learning. It was required that each participant have at least four mentored shifts prior to attempting their second test, and they were not scheduled to work independently until deemed successful. If their second attempt was unsuccessful, a formal meeting was held that included human resources, clinical leadership, Professional Practice, and union representation prior to their final attempt. If the final attempt was deemed unsuccessful, it was at the discretion of the clinical leaders and human resources regarding potential ramifications on the employment relationship.
Implementation In January 2015, the first cohort of new hires participated in the revised Central Nursing Orientation. Collaboration between senior leadership of Professional Practice and the simulation centre was integral for the successful implementation. Space allocation, station setup, consumables, and rotation were the responsibility of the simulation centre staff. The accountability of staffing and scheduling for the new program was with the group of Clinical Educators assigned to each teaching station. Administration was responsible for communication, organization, and day-to-day requirements of the orientation. Professional Practice consultants and simulation experts were present for quality assurance of programming. The program was overseen by the Director of Professional Practice. All Clinical Educators were provided training on experiential learning methods. Clinical Educators designated as evaluators for the head-to-toe assessment station were provided specific training and follow-up throughout the implementation process to maintain consistency and reliability of results.
analysis was performed on all data sources received from the orientation occurring January 2013 to December 2014 to orientation from January 2015 to December 2016.
Results Seven hundred forty-nine new external hires participated in central nursing orientation during January 2013 to December 2014 comparative to 521 new external hires in January 2015 to December 2016. Qualitative data included course evaluations, facilitator, Professional Practice Consultant, and Simulation Specialist feedback. Quantitative data comparison included employment terminations that occurred within the probationary period for each allocated time frame, overall orientation length, and summative assessment results.
Quantitative Overall nursing probationary terminations were comparative with 10.68% turnover rate for 2013/2014 and 12.28% for 2015/2016. This included all voluntary and involuntary exits from the organization. Summative assessments resulted in 23.4% of new hires unsuccessful in their first attempt, 6% of the total new hires were unsuccessful in their second attempt, and 0.5% in their third (Table 2). Overall, the orientation length was shortened by one 8hour day with the potential savings of $156,000 in the two-year period based on entry-level nursing wages.
Qualitative Qualitative data were reviewed for program content, execution of the program, objectives being met, overall satisfaction, competency, and confidence in new hires, and any implications on unit orientation or transition to practice. In comparison with the previous orientation, positive comments included enjoyment of the hands-on practice and instruction, asking questions in a nonjudgmental environment, and increased confidence and preparation for clinical practice (Table 3). New hires commented on the ability to self-reflect and identify areas of development to be able to continue their transition while providing safe patient care. Areas of continued improvement for the program included adapting the remaining lecture-based stations into more of an experiential learning method, limiting the number of new hires
Program Evaluation Evaluation of the program included qualitative assessment of each station and the program as a whole, by the new hires, Clinical Educators, Professional Practice Consultants, and simulation experts. This was compared with the qualitative information obtained from the previous two years of the old version of the orientation process. Quantitative data sources included human resources and summative assessment de-identified data. Comparative
Table 2
Percentages of Unsuccessful Competency Testing
Head-to-Toe Assessment First attempt Second attempt Third attempt
Percentage of Total New Hires Unsuccessful
Percentage of New Hires Unsuccessful per Attempt
23.42 6.34 0.53
23.42 27.07 8.33
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per group, and having more time at each station. Facilitators of the stations and Professional Practice Consultants also felt the overall changes were positive and impactful: ‘‘It is wonderful!! Not worrying about equipment, set up and having adequate support from the simulation centre is amazing. I literally can walk in and teach!!’’; ‘‘It is no longer perceived as a chore. It has now become the best part of my job!!’’; ‘‘Participating in the redesign of the new orientation program aligns well with our organization’s vision of ‘Exceptional Experiences, Extraordinary People and Engaging Partnerships’.’’
Discussion On review of our quality improvement initiative, it is believed by the authors that both objectives were met. Defined by the participants comments and staggering improvements in the competency-based testing rates, new hires demonstrated improved entry-level competencies and confidence through experiential learning. It was also identified that 23.42% of new hires were unprepared to meet the expectation for nursing practice at London Health Sciences Centre. Without early identification of these gaps, potential adverse patient safety events and increased financial burden on the institution could have ensued. Interestingly, only
Table 3 Current Central Nursing Orientation Evaluation Summaries Central Nursing Orientation 2015-2016 Participants Comments ‘‘I enjoyed having the opportunity to have hands-on practice and instruction.’’ ‘‘Being able to ask questions in a safe environmental without judgment was valuable to me during orientation.’’ ‘‘Thought it was great to through a crash cart then a mock code blue, I felt more prepared.’’ ‘‘Most valuable was practicing head-to-toe even though I was nervous I was happy for immediate feedback.’’ ‘‘Glad to get familiar with hospital guidelines and expectations.’’ ‘‘Great refresher training of content.’’ ‘‘Being able to participate and observe in activities to compare practice was most valuable.’’ ‘‘Multiple experts and real clinical knowledge available.’’ ‘‘I enjoyed the different stations. They were very informative and helpful.’’ ‘‘Has definitely increased my confidence.’’ ‘‘Head to toe physical assessment was very helpful and useful. It really prepares me for working on the floor.’’ ‘‘Catered to all learning styles, great!’’ ‘‘I liked how much we got to participate today and learning in different methods. Makes me feel more confident.’’ ‘‘I appreciate knowing what is expected of me when I start working on the floor.’’ ‘‘Patient admission station was very helpful as we could work through real-life situations, use critical thinking.’’
0.53% of the new hires were determined to be at risk and unable to meet entry to level competencies following educational support. This demonstrates the abilities of new hires to transition to practice successfully with defined education and support. This may correlate with the lack of significant improvement in staff turnover during these comparative time periods. In the end, the significance was in the transition to practice in a safe and effective manner not their potential inabilities to meet the standard. A positive impact was also identified by the Clinical Educators who facilitated the development and monthly execution of the program. Although staff turnover in this field was not evaluated, qualitative comments demonstrate increased job satisfaction and vision alignment with the organization. Critically reviewing the previous orientation content enabled the development of an orientation program that was shorter in length. This allowed for a potential cost savings, impacting the organization as a whole and the specific departments where the nurses were from. Each department chose whether to use this extra day as an additional unit specific orientation day, mentored shift, or assume the cost savings.
Conclusions Through the strategy of simulation and experiential learning, we were able to develop an orientation program that provided our new hires with the appropriate resources and support for a successful transition to practice and help close the preparation to practice gap through a standardized process. Our educational program met the needs of the learners including: knowledge application, clinical judgment and reasoning, and skill development (Zigmont et al., 2015). Through this process, we also identified the continued learning needs in the transition to practice and the potential opportunities to engage with our academic partners to better prepare our future nurses. Currently this program continues to run monthly at our institution through the continued partnership between Professional Practice and the simulation centre. Continuous quality improvements include peer to peer feedback, maintenance of up-to-date resources and content at all stations, and additional pediatric focused content. Modifications to the current assessment tool and interrater reliability testing to validate the London Health Sciences Centre Physical Assessment Tool are currently in progress. Continued analysis is being performed in attempt to quantify the impact of our competency-based testing on patient safety and patient satisfaction. Other areas of consideration include length of unit specific orientation and number of mentored shifts needed prior to completion of the orientation process. Discussions are also being held with academic institutions on collaborative approaches to the transition of new nursing hires and successful integration into practice.
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Acknowledgments The authors would like to thank and acknowledge all the Clinical Educators at London Health Sciences Centre and the simulation centre staff whose hard work, dedication, and expertise made the development and execution of this new orientation possible. It is also because of these individuals that this program continues to be a successful and impactful orientation program within the organization today.
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Hommes, T. (2014). Implementation of simulation to improve staff nurse education. Journal for Nurses in Professional Development, 30(2), 6669. http://dx.doi.org/10.1097/01.NND.0000433144.66804.4c. Jeffries, P. R., & Rogers, K. J. (2007). Theoretical framework for simulation design. In Jeffries, P. R. (Ed.), Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League of Nursing. (pp. 21-33). Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall, Inc. Kolb, D. (2015). Experiential learning: Experience as the source of learning and development (2nd ed.). Upper Saddle River, NJ: Pearson Education Inc. Lamers, K., Janisse, L., Brown, G., Butler, C., & Watson, B. (2013). Collaborative hospital orientation: Simulation as a teaching strategy. Nursing Leadership, 26, 61-69. Liaw, S. Y., Palham, S., Chan, W., Wong, L. F., & Lim, F. P. (2014). Using simulation learning through academic-practice partnership to promote transition to clinical practice: A qualitative evaluation. Journal of Advanced Nursing, 71(5), 1044-1054. http://dx.doi.org/10.1111/jan.12585. Olejniczak, E. A., Schmidt, N. A., & Brown, J. M. (2010). Simulation as an orientation strategy for new nurse graduates: An integrative review of the evidence. Simulation in Healthcare, 5(1), 52-57. http: //dx.doi.org/10.1097/SIH.0b013e3181ba1f61. Phillips, C., Kenny, A., Esterman, A., & Smith, C. (2014). A secondary data analysis examining the needs of graduate nurses in their transition to a new role. Nurse Education in Practice, 14, 106-111. Teoh, Y. T. E., Pua, L. H., & Chan, M. F. (2013). Lost in transitiondA review of qualitative literature of newly qualified registered nurses’ experiences in their transition to practice journey. Nurse Education Today, 33, 143-147. Yuan, H. B., Williams, B. A., & Fang, J. B. (2011). The contribution of high-fidelity simulation to nursing students’ confidence and competence: A systematic review. International Nursing Reviews, 59, 26-33. Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). Theoretical foundations of learning through simulation. Seminars in Perinatology, 35(2), 47-51. http://dx.doi.org/10.1053/j.semperi.2011.01.002. Zigmont, J. J., Wade, A., Edwards, T., Hayes, K., Mitchell, J., & Oocumma, N. (2015). Utilization of experiential learning, and the learning outcomes model reduces RN orientation time by more than 35%. Clinical Simulation in Nursing, 11(2), 79-94.
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Appendix
Appendix 1
London Health Sciences Centre Physical Assessment Tool Guideline for Learners Component
Introduction
Pain Assessment Airway/Breathing
Circulation
Neuro
Vital Signs Abdominal: GU/GI
Extremity/Skin/Back assessment SBAR Summation
Yes/No
Hand Hygiene*** Did participant introduce him/herself and ask pt. for permission to complete assessment? Did participant explain plan? Did participant identify pt.? Did participant consider PPE? OPQRSTU Pneumonic used*** Airway patent? (snoring, stridor, talking) Did participant note breathing spontaneously? Swallowing secretions? Chest symmetry No retractions/stridor/tug Work of breathing (e.g. speaking full sentences without difficulty) Desired position Auscultated breath sounds*** Inspected & palpated neck, chest Skin color, temp., moisture Palpated pulse (central & peripheral) Capillary refill*** Auscultated heart sounds Level of consciousness*** Oriented to person, place & time*** Pupil size and reactivity to light T, HR, BP, RR, SpO2*** Inspected abdomen Auscultate Bowel Sounds*** Lightly palpate abdomen Inquired date of last BM*** Inquired when last voided*** Inquired date of last menstrual period (if applicable) Inspected & palpated arms/legs and back for crepitus, deformities, bruising or wounds*** Assessed CSM of extremities Be able to identify the significance of the abnormal findings in SBAR reporting format*** Summarize the abnormal findings and prioritize the plan of care***
Components with an *** are mandatory.
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