As the nursing shortage continues to challenge hospital systems across the nation, nursing professional development (NPD) practitioners are repeatedly asked to “get creative” with their orientation process to expedite it without compromising competency and patient safety. The situation can pose challenges for NPD practitioners as they strive to both innovate and meet the needs of the organization simultaneously. As an advocate for the NPD specialty, I developed a novel idea to compress orientation, rather than simply lessen it. Using concepts in brain-based learning theory (Shukla, 2023), it was hypothesized that if the frequency that an orientee is working is increased, the orientee will experience less knowledge loss between shifts and be able to improve their learning capacity on existing knowledge from their last shifts. This would enable the orientee to achieve knowledge retention and competency in a shorter amount of time.

There was some literature that provided evidence of support for nurses benefiting from more shifts per week during orientation (Caruso, 2014; Pena, et al. 2022; Thompson, 2019). There also was much stakeholder support from colleagues, including management and senior leadership to trial a compressed nursing orientation concept.  This trial was conducted with one cohort of new graduate nurses for the duration of their acute care orientation on the resource team. Orientees would work four rather than three days a week. Weeks would consist of two eight and two 12-hour shifts rather than the usual three 12s of a traditional inpatient nursing schedule. The number of shifts in the original orientation pathway would not change, but by adding an extra shift to each week, the orientee would end orientation two weeks sooner without compromising the number of patient experiences they had nor their ability to document competence. Though financial considerations did not drive this orientation modification, with more shifts being eight rather than 12 hours long, there would also be savings on orientation costs as a bonus. This model was trialed through the duration of the cohort’s precepted orientation.

After the first implementation of this model, several opportunities for improvement were identified, including the following described below:

1. Preceptor Buy-In: It was important to communicate these shift obligations to the orientees during the interview process. The expectation to work a four-day, 40-hour work week was clearly agreed upon and accepted by all candidates who were hired. However, a key stakeholder in this orientation pilot was not stressed enough—the preceptor.  The preceptors of the orientees in this trial received an email about the model and guidelines for the eight-hour shifts.  Improvements could have been made to better explain the science behind this model. This modification was rooted in trying to increase an orientee’s learning capacity, not trying to unnecessarily speed the process which was a common misconception among preceptors. We did not anticipate the overwhelming response from the preceptors who felt it was a huge ask to have orientees work four days a week.  The preceptors’ strong feelings were acknowledged during rounds and it was brought to an upcoming collaborative council meeting, which consisted of bedside RN leaders, for additional feedback and discussion.  However, by that time the sentiment had influenced the orientees’ perception. Suddenly, orientees were expressing concern with work life balance and challenging to find time for personal errands outside of work.

2. Handoff Report: With the orientees leaving in the middle of the shift half of the time, preceptors expressed concern that the orientees wouldn’t know how to give a good report.  Expectations were reestablished with the preceptors and orientees during staff rounding that the orientee should still be practicing giving reports to the preceptor on the days they left early. However, due to demands of the patient assignment at that specific time, this was much more difficult to operationalize. It was a valid preceptor concern that was acknowledged, and while the orientee was slower to acquire this skill, it was still achieved by the end of the compressed orientation.

3. Maximizing Patient Experiences: To acknowledge concerns regarding work-life balance, a modification was made in the middle of the trial and the orientee was given autonomy to decide which shifts would be eight vs. 12 hours each week —with the caveat that this decision would be based on that shift’s assignment. If valuable learning opportunities were available in the later hours on their short days and the orientee wanted to stay for that experience, they could make that their 12-hour shift instead. This did not consistently work and unfortunately, some of those opportunities occurred later in the week when the orientee had already satisfied their two 12-hour shifts and needed to clock out regardless to avoid overtime. In addition, some of the nursing workflow norms, such as when assessments and other documentation needed to be completed led to some expectation challenges. After lunch during the eight-hour shifts, preceptors occasionally noted that orientees were “checked out” for the final hour of their shift and coasting until it was time to leave, or the orientee would avoid taking a lunch break to clock out 30 minutes early. This led to a resetting of expectations that the orientees be engaged and present for the entirety of their eight hour shifts as well; empowering them to “be the nurse” until it was time to clock out.

4. Preceptor Consistency: When the orientee was working more shifts than the preceptor, it was more difficult to provide preceptor consistency.  Primary preceptor schedules often overlapped or didn’t align with the orientees’ class schedules which led to four to five preceptors needed to meet the four day requirement in a six week schedule period. Because of this inconsistency in schedules, there needed to be different preceptors who would consequently spend half of the shift assessing the orientee’s abilities and getting to know them before feeling comfortable challenging them. This may have stunted the preceptors’ opportunity to build on the orientees’ existing knowledge and skills.  

Adhering to this model through the cohort’s precepted orientation presented several challenges, however 100% of the orientees (N=3) were able to provide safe, competent care and had verbally expressed the same level of confidence at their final check in in a shorter amount of time compared to subsequent cohorts. When following up with the orientees a few weeks post precepted orientation, a few expressed the process wasn’t as bad as they thought when looking back and were glad to be off precepted orientation earlier to continue building their practice independently.  They were happy to be in charge of their schedules, found increased confidence in their practice working on their own and felt supported by the resources available on nightshift.

In summary, the biggest takeaway during this pilot was the importance of engaging the preceptors as key stakeholders in the orientation process change. Preceptors are essential to facilitating transitions in nursing practice. Their roles and responsibilities, according to the Ulrich Precepting Model, makes them a strong ally to the NPD practitioner and it is important to ensure they have a voice in the orientation process (Ulrich, 2018). Their partnership is integral to the success of our new nursing workforce. As the compressed orientation model continues to be evaluated, our goal is to increase collaboration with the preceptors and evaluate further how this impacts the orientee’s abilities to successfully complete orientation. A long-term goal would be to evaluate how this compressed orientation affects new nurse retention rate.

References

Caruso, C. C. (2014). Negative impacts of shiftwork and long work hours. Rehabilitation

Nursing, 39(1), 16–25. 10.1002/rnj.107

Pena, Heathe; Kester, Kelly; Cadavero, Allen; O’Brien, Stacey. (2023). Implementation of an

Evidence-Based Onboarding Program to Optimize Efficiency and Care Delivery in an Intensive Care Unit. Journal for Nurses in Professional Development 39(6),p E190-E195. DOI: 10.1097/NND.0000000000000915.  

Shukla, Aditya.  (2023). Brain-Based Learning: Theory, Strategies, And Concepts. Cognition

Today. https://cognitiontoday.com/brain-based-learning-theory-strategies-and-concepts/#Brain-Based_Learning_Strategies

Thompson, B. J. (2019). Does work-induced fatigue accumulate across three compressed 12

hour shifts in hospital nurses and aides? PLOS ONE, 14(2), e0211715. 10.1371/journal.pone.0211715

Ulrich, Beth. (2018). Mastering Precepting: A Nurses Handbook for Success. Second Edition. 

Sigma Publishing.   

Weiss, Ruth Palombo. (2000). Brain Based Learning. Training & Development, 54(7), no. 7, 21.