Adequacy of orientation

[Photofosterrn]

I have concerns that the orientation period I am currently in is missing something vital to my success as an RN once off orientation.

I am a new graduate nurse and I started my first job as an RN (no prior experience other than my senior preceptorship at another hospital) 6 weeks ago on a medical/surgical unit. The first week and a half, of my 12 week orientation, was spent in a classroom environment that did not include simulation. I spent one shift observing a preceptor's shift during a hectic night, and the next shift I passed medication. From then on, I was given a full patient load (5-6 patients) and told to ask my preceptor if I have any question. My preceptor has since spent her nights with me checking that my documentation in computer is complete and fielding any questions I may have.

I anticipated a more gradual transition from student to novice nurse.

If you could share with me how your institution handles the orientation process of RNs to the unit, tips on how to navigate this period, share your perspective what an adequate orientation should include, I would be extremely grateful! Thank you!

[TheCommuter, BSN, RN]

Our new grads are oriented via the 'baptism by fire' process: different preceptors, no organization, and the acquired ability to stay above water.

While we'd like a more streamlined new grad orientation process, our staffing needs are immediate and pressing, which may negatively impact the new nurse's experience. In essence, if the preceptor assigned to the new grad has called in sick, the new grad will be placed with someone else. If the unit is understaffed on a shift that the new grad is orienting, the new grad might have to take a load of patients and provide primary care.

It is far from optimal, but it is what it is. The area where I live is flooded with more new grads than can be absorbed into the local job market, so most of our new nurses deal with it and make their experience work until they obtain a year or two of experience. If they quit, the likelihood of finding another job is low due to their inexperience.

We currently have a new nurse who is threatening to quit because he feels his orientation has been substandard. He commutes 50+ miles to our workplace because he could not find a job closer to home. He had no other employment lined up. He was educated out of state, which further reduces the likelihood that local hospital systems will hire him, because HR managers in this area prefer students who completed clinical rotations at local facilities.

I was a new grad in 2006 who received the worst-of-the-worst baptism by fire orientation: one 8-hour shift of training before getting cut loose to work on my own. As unsafe and suboptimal as the situation may have been, I was new to the state and had to make it work out because no one else was going to pay my way in the world other than me.

Good luck to you.

[Emergent, RN]

Welcome to nursing. Many, if not most of us had to fly by the seats of our pants orienting. It's the same way when you change departments or specialties.

It is what it is.

[Libby1987]

I'm not in acute care so I don't know how much this applies, but our new nurses would benefit from some outside learning on their part, which they don't appear to do.

There seems to be an expectation that it's all on the employer's part to provide all necessary information to be able to function independently. That would take more than 3 mos considering that they come armed with nearly nothing to do the job. We have to teach patient procedures, reimbursement criteria, regulations, documentation required by the state and CMS, appropriate nursing action, appropriate communication, all of the basic requirements such as HIPAA and infection precautions off the top of my head.

It's amazing how nurses don't at least do some self study when they go home after they get an idea of what they will need to know, for example it amazes me that I need to suggest that they get familiar with our assessment forms (CMS assessments not specific to our company) instead of taking that initiative. Should it be on company time? Sure and it is, just please come prepared because time with a preceptor is limited and it's not necessary for me to be over the shoulder of a new nurse for some of these things. I'm there to explain and assist with understanding, not read it to you for the first time. And these things needs to be reviewed as they become more relevant with clinical orientation anyway. the one time cram in the first week won't be enough.

Also, come prepared to perform procedures, the preceptor shouldn't have to teach basic procedures. I want to know that you know what to do and just have me for support. I have had to teach/reinforce such basic things as sterile tech. I'm absolutely fine with someone wanting to review or verbalize each step as they go just to be correct but come prepared and be familiar.

We have hired a variety of personalities and experience, one nurse in 6 years came prepared each day to optimize learning. Though they all have been eager to learn, they tend to put most of the responsibility on their preceptor.

[Photofosterrn]

I appreciate everyone's response thus far. It seems like this topic brings up considerable frustration on the part of the preceptor and the orientee. There clearly is a disconnect between expectation of what the role of the preceptor is for the orientee and the role of the orientee for the preceptor.

I wonder if there is a way to bridge that gap and lesson some of the frustration.

[dishes, BSN, RN]

The only expectations you can change are your own. What steps have you taken to ease your transition?

[NurseOnAMotorcycle, ASN, RN]

I was cringing to read The Commuter's experience, and I really hope that it is the exception and not the rule for new grads at their first job.

I am orienting another floor nurse to the emergency dept and am gradually increasing the pt load/new skills/critical care info over the entire 12 weeks. I can't even imagine exposing patients to a nurse who hadn't been properly monitored and trained to care for them!

[Photofosterrn]

I have requested meetings with my clinical coordinator to gain a better understanding of their timeline for training to determine what particular milestones I am expected to hit and by what point in the orientation I am expected to achieve those milestones, something my preceptor was unable to answer for me.

I have asked my clinical preceptor to provide feedback on my time management and asked for ways to improve.

I have researched different methodologies of this orientation process to gain a better understanding of this tumultuous period and to gain a fuller understanding of some of the best and worst aspects of the new graduate transition.

One thing I have not been able to find is a research based article discussing evidence based practices for the orientation process and transitioning from student nurse to staff nurse.

If someone knows of any research out there, could you point me in the right direction as to where I could find it? Searching on the web has not provided quality researched based articles stating some of the best practice principles that provide a supportive work environment and a quality workplace orientation, two critical aspects that facilitate smooth transition. I believe that by gaining a better understanding this process, I would be able to understand what I should be and should not be expecting of the organization during this process.

Thank you all again for your feedback!

[dishes, BSN, RN]

I am not sure if this will point you in the right direction but you might want to check some of these resources;

American Nurses Association, Mentoring programs and projects

Canadian Nurses Association, A Guide to Preceptorship and Mentoring (2004)

Benner, Patricia, From Novice to Expert (1982)

Cardillo, Donna, Your First Year as a Nurse- Making the Transition from Total Novice to Successful Professional (2010)

[Nonyvole, BSN, RN]

Was pretty much forced to jump in the deep end, then was pulled off orientation early and dumped in the deep end - again. The first shift I was shown where everything was, the next shift I had a couple patients, and then it was off to the races. It was up to me to look up what I didn't know and ask for help; they weren't going to spoon-feed it to me. About a month being an extra nurse and then I was on my own. A few shifts off of orientation and I was handed my first critical patient with minimal backup.

Granted, this isn't usual, and I know that I was darn lucky to have kept my head above water and to have gotten over the initial learning curve so quickly.

OP, it looks like you're being proactive, which is good.

[Jules A, MSN]

I agree it does sound like you are being proactive and are contentious which are huge pluses. I would accept what they are offering and just do your best. I also went through orientation when it was two shifts and then a whole patient load. Somehow I managed and wouldn't have dared to ask or expect any more although it sure would have been nice.

[CamillusRN, BSN]

Our new grads are oriented via the 'baptism by fire' process: different preceptors, no organization, and the acquired ability to stay above water.

Same here. I was hired on the same day my license came through, and in two weeks I was assessing my own ER patients, shipping out my own critical patients, and taking my own med-surg / ICU patient loads while the more experienced nurses were available for questions as they took care of their own patients. The nurses I worked with were all apologetic about not having enough staff for a more thorough orientation, but also made it clear that they had had as short (or shorter) an orientation as myself when they had started out. As Emergent said, it is what it is.