Opinion: How to Improve the Orientation Program for Newly Hired Nurses

May 15, 2023

By: Erica DeMoss, Director of Clinical Education at Avant Healthcare Professionals

When you offer a position to a nurse, and they accept, it is a time of celebration and hope. As a leader, you celebrate filling an open position and shoring up your staffing. You also hope they will succeed and want to stay long-term. The new nurse is celebrating a new job and hoping to find a place where they can practice the art of nursing, a place where they make an impact on people's lives, and an opportunity to learn and grow.

The first couple of months after a nurse starts on your unit are crucial. This is when the new nurse learns what your unit is about, how to be a nurse on your unit, and whether they want to be there long-term. Onboarding and orientation are crucial to integrating any new staff member. Even knowing this time's importance, many managers inadvertently set their new nurses up for failure during orientation.

In my experience as a preceptor, manager, and educator, several key recommendations tend to lend themselves to a successful orientation: planning, choosing the proper preceptor, consistency with preceptors, use of the Married-State Preceptor Model, timely feedback, and clear expectations. Each of these plays an essential role in a successful orientation program. If even one of them is ignored, the result could be an ill-prepared or disengaged nurse who wants to leave your department. This could impact the safety and well-being of your patients.

Planning

The first step in a successful orientation program is planning. When I speak of planning, I do not just mean to say, "All orientees will orient for X number of weeks, and they will be good to go," and then throw them on the schedule. Orientation should not be cookie-cutter; it has more nuance and strategy. You should have a set of milestones or accomplishments that your new nurse must reach before advancing to the next phase in their orientation. For example, I have worked in several Emergency Departments throughout my career. The best orientation I was involved in had nurses starting in the lower acuity areas and working their way up to the higher acuity areas. Each area adds to the nurse's knowledge base and prepares them for the next area. It typically progressed over 8-12 weeks but could be adjusted.

Another strategy that is helpful with planning is developing and utilizing orientation pathways. These also include milestones or accomplishments the new nurse should meet before moving forward. Pathways can have suggested skills, procedures, or activities that should be completed, as well as a goal for the number of patients the nurse can manage with minimal assistance from their preceptor. Pathways also provide a plan for the orient and the preceptor to refer to help guide discussions and teaching moments.

The Right Preceptor

The wrong preceptor can torpedo the orientation success of a new nurse on your unit. I have seen many managers and educators choose a preceptor based solely on how long they have been a nurse on the unit. While the nurse who has been on the unit for 10+ years may know all the ins and outs of the unit along with policy and procedure, it may not mean that they are a good teacher or even have any desire to teach a "newcomer." It is never a good idea to throw someone into orienting a new staff member. Instead, identify those highly capable nurses who appear to have a passion for sharing their knowledge or are enthusiastic about their work. In my experience, these nurses make the best preceptors.

Once you have identified your ideal preceptors, you should discuss with them and find out their feelings about training new hires in your unit. Once you have established that they are willing to precept new hires, educating them about precepting is a good idea. This instruction should include information on adult learning principles, expectations of orientation, providing feedback, and the different roles a preceptor performs (role model &mentor, socializer, teacher, and resource).

Consistency with Preceptors

Once your preceptors have been chosen, it is important to ensure that your new hires have consistency with their preceptors. Ideally, your new nurse should have one preceptor throughout orientation, with possibly a second due to scheduling conflicts, time off, or illness. Some feel it is suitable for their new hires to experience different viewpoints and teaching styles. Still, this leads to clarity and satisfaction with the orientation process. When a new nurse on your unit has a different preceptor daily, they have to adjust to a new learning style and constantly inform their new preceptor of what they have already seen, done, and experienced. Other drawbacks to using multiple preceptors include the likelihood of missing subtle signs of the new nurse struggling or experiencing culture and reality shock. 

Another thing to remember is that while there is a fair amount of standardization of how things are done throughout a facility, people may approach or complete things differently. This puts the orientee in the wrong spot and can cause the preceptor to question the ability of the new nurse.

Married-State Preceptor Model

Once orientation starts, I recommend using the Married-State Preceptor Model (MSM), especially with newly licensed nurses, international nurses, or nurses new to a specialty. With this model, the orientee and preceptor are joined at the hip. Initially, the preceptor provides most of the care with the orientee shadowing. As orientation progresses, the orientee gains confidence and starts assuming more and more of the patient care until they can, and feel comfortable, taking the entire workload on their own. With this model, the preceptor is always present to oversee the care and act as a reference. Adding patients during this process can take away from the learning opportunities of the orientee. Their preceptor may need to be more readily available due to the heavy workload of patients given.

Timely Feedback

The importance of timely, appropriate feedback must be balanced. More times than I can count, I have heard preceptors complaining about how poorly their orienteers are performing, but when I have spoken with them, they have never received feedback on areas they are lacking. This disconnect is detrimental to the success of the newly hired nurse. For there to be continuous improvement throughout orientation, a newly hired nurse needs to receive frequent feedback that is timely and appropriate.

Regarding timely feedback, I am referring to feedback that occurs either in the moment or as close as possible to the situation prompting the feedback. With the situation still fresh in the minds of both the person giving feedback and the person receiving it, it is easier for everyone involved to connect the feedback to the situation. Failure to provide timely constructive feedback can reinforce negative behaviors or poor practices because the oriented is unaware of a problem. Positive feedback should also be delivered promptly to help strengthen good practices and to communicate that the orientee is performing or progressing well.

In addition to the feedback being timely, it should also be appropriate. Appropriate feedback is specific and objective, and this is important so that there is no confusion or gray area about what is communicated. Relevant feedback should also include concrete suggestions or ways that the orienteer can improve their performance. The goal of feedback should always be improvement and growth, so with this in mind, you also want to ensure that the feedback is encouraging but honest. In an ideal world, all orienteers actively seek feedback regularly by asking, "What did I do well today?" or "What do I need to work on or improve for next time?" but we do not practice in an ideal world. Because of this, preceptors need to be comfortable providing regular feedback.

Clear Expectations

Once your new nurse starts their orientation, it is crucial that everyone, even those not actively involved in precepting, be on the same page regarding orientation. Expectations are set with all staff regarding orientation periods, and that time is to be respected as a learning opportunity for your new staff member. This also means that assignments and preceptors should not change unless unavoidable.

Your new nurse should be aware of the expectations from orientation. Please provide them with all paperwork, checklists, pathways, etc., that they must reference or complete during orientation. They must also be informed and understand the milestones or accomplishments they must complete to advance through orientation.

The Bottom Line

Bringing a new staff member on is an exciting time but can also be a precarious time. The success or failure of a newly hired nurse can hinge on their orientation. So many are focused on getting their new nurses off orientation and practicing independently, but there is often room for improving how this is accomplished. Proper planning, choosing the right preceptor, consistency, using the Married-State Preceptor Model, timely feedback, and clear expectations are simple ways to improve the orientation experience for newly hired nurses. I challenge healthcare leaders to look at their orientation programs and find ways to incorporate these recommendations. It is a commitment on their part to do what is best for the new nurses and the patients.