Orientation for a new grad

[CapeCodMermaid, RN]

We have been having many discussions at my facility about the orientation process for new graduate nurses...RNs and LPNs. I think we're missing something. I, when a new grad, had 3 days of orientation and was expected to perform adequately. Of course I went to a hospital based school of nursing and had hundreds of hours in a clinical setting....meds to an entire unit, running a floor as charge...

So, for the new grads out there: how long is long enough? Two weeks, 3? 6? I do not run a nursing school. I expect you come with a basic skill level but I am constantly surprised at how little new grads actually know and how little they had to do in school.

I love hiring new people and want to keep them once I've hired them.

I ask them every day how they are doing and what I can do to help. I get a big smile and an "I'm fine thanks" only to hear 2 weeks later they are still overwhelmed and frustrated that no one has helped them.

Kids, I am very smart and have been doing this forever, but even I cannot read your mind.

Sorry for the rant. It's been a long day and I'm trying to get to the bottom of what most new grads need to be successful.

[justmeRNtoBSN]

I think for new grads 3 weeks of intense training ensuring that all units covered on all shifts. Being new to LTC I feel somethings I should know so I get embarrassed if I don't but I frequently go to my more seasoned LPNs. Also I think they just want to exude some confidence maybe take them for a sit down to openly discuss issues or educational opportunities. I am at the point were I am ready to leave my position but it's more for the lines I don't believe i am at the level to be a building supervisor with a unit as well to myself. I hope that this gives you some help.

[LadyFree28, BSN, LPN, RN]

I understand.

I am precepting a new grad that has no experience, and we have some complex pts; granted I went to this particular school and find it appalling that they had placed limitations, while I had more in depth clinical rotations.

It's frustrating as well as sad that this is going on in the profession right now.

[KJoRN81, RN]

I started at a LTC/rehab facility 2 months ago. I was expected to be on the floor, alone, after 2 shifts of training on each "hall"....I have only recently begun to feel very comfortable and happy in my position. A lot is expected of us and it's incredibly frustrating because, as a new grad, I DID know nothing! All I can say is, at least a month or more of training, and perhaps a more formal sit-down where they can come to you with issues that they're having, or things that they're pleased about. A simple "how are you doing?" probably isn't going to get results like a planned-out office visit.

'The purpose of life is to discover your gift. The meaning of life is to give your gift away.'

[bluegeegoo2, LPN]

I only had 3 days of orientation as a brand new nurse. What helped me the most through the first year was having amazing support from a couple of seasoned nurses who I knew I could go to with any question at any time and get helpful answers and tips without attitude. They are the reason I stayed. Yes I was overwhelmed and cried at home (and sometimes in the bathroom) but their patience and support made all of the difference in the world. In summary, my personal experience is that the support, or lack thereof, in a facility is what will make or break a new nurse's experience and desire to stay or run for the hills.

[JBMmom, MSN, NP]

I had a great orientation, 10 shifts before I was on my own. However, I think it's really a quality over quantity sort of thing. Some aspects are just going to take time. Whether you've had 3 med pass orientation shifts or 10, it's still going to be slow when you're on your own. The key is getting the other experiences that go along with running a floor. If the orienting nurse looks at an orientation shift as a "shift off" to relax while the med pass is taken care of by the orientee, they are doing a real disservice to that new nurse coming in. Capecodmermaid, I think from your many posts that you are the sort of person that so many nurses would LOVE to work for. It sounds to me like you really do your very best for the staff, and I'm sure that comes through to them clearly. For that reason, I know that if you asked me how I was doing, no matter how close to drowning I felt, I probably wouldn't admit it because I'd be concerned about either letting you down, or coming off like I was throwing my preceptor(s) under the bus. Knowing that you are able to run an LTC with the care that you do, sometimes makes it frustrating to hear about the other end of the spectrum, if only your passion and caring could be the norm rather than an exception.

[LTCRN4LIFE]

Exactly! I too could have written that post. Same experience. For new C.N.A.'s I find when I see they are ready to advance in their orientation I start given them half an assignment. If they can handle that for a week I move it up to 3/4 and soon they are able to do a full assignment.

For Nurses that are new even if they are going to be on 1 unit the majority of the time I float to all 3 units for their orientation and I don't start them on the unit they are going to end up on. I meet with them regularly finding out their strengths and weaknesses and getting them more experience on their weaknesses. When I see them relaxing and not looking "like a deer in the headlights" I move them to their unit and do another week instructing the person they are orienting with to be their "guide" their "fly on the wall"

Usually after this week they are ready and I tell them.....you never work alone.....ask another Nurse on one of the units that you oriented on. They are your resources. I also always have a Nurse on call....myself included and I tell them to call me if they need to. So usually 2-3 weeks orientation for the Nurse that is new. 1 - 1 1/2 week for an experienced Nurse.

[chrisrn24]

I had approx 6 weeks of full time training before I was on my own. I was a new grad.

[PsychNurseWannaBe, BSN, RN]

When I started as a GN, I was given 3 weeks. Now that nursing home was owned by a hospital and bigger organization. When they sold, they only gave 3 days, which I think is a joke. You can't learn and apply what may come up. They need a solid foundation. Years later I started at a different place and was still given 1 week of class room time with the Nurse Educator and then a week on the floor. Put the time in them now and save yourself the headache of having a high turnover rate which only increases your labor dollars, among other things.

[benegesserit]

I had 6 shifts of orientation as a new grad in LTC, plus one night shift where I was sort of oriented for a half shift or so. 5 of the 6 shifts were not on the hall where I ended up working most often. Now my facility seems to be doing more orienting - 6 shifts is common for experienced nurses, and new grads are getting longer if needed. I also got more orientation than that when I started a new job at a different facility, despite not being a new grad (I think I got 6 shifts on days and 2 on nights).

I don't really think my orientation as a new grad was adequate, but I survived (and so did my patients). It definitely helped that the nurse I oriented with was very willing to help out in subsequent weeks/months.

"Long enough" has to be individual, because there are so many factors involved. How well did their nursing program prepare them? Do they have previous relevant work experience (as a CNA or something)? How quickly do they learn? Is their preceptor too hands-off, too hand-holdey, or just right?

I think you have to remember that your new grad nurses are probably terrified of not being up to the job, terrified of you as the person who can fire them, and therefore terrified of giving you any impression that they can't handle it. So they smile and say everything is fine until they reach the point where they can't fake it anymore.

It might help to make it clear to them that you know that real-life nursing is not the same as school, that the hospital environment they were probably trained in is very different from LTC, that you fully expect them to struggle and make mistakes, and that you'll be much more concerned if they don't come to you or another more experienced nurse with at least a few difficulties. People who can admit their limitations and mistakes are much safer than those who can't!

I assume you're asking their preceptor about this already. You could also follow up with the nurses who work with and after them - they'll probably be able to give you an idea of where they're struggling and what is getting neglected.

Things I have seen being frequent problems:

Time management. Especially not recognizing that sometimes it's easier for the oncoming nurse if they just pass things on to the next shift rather than holding off on report to try to get everything done.

Muddling through things (incorrectly, with resulting harm) because they don't realize they could or should ask for help.

Lack of clear expectations leading to a blind-leading-the-blind situation. One nurse orients a new nurse with bad info, and that new nurse in turn passes it on to the person they eventually orient.

[NurseMellie]

I have assisted with training new grads after noticing that they were way undertrained by the nurses who were supposed to show them the ropes. We developed a LN Packet that has the protocols that the LNs are going to use the most. They received computer training for our system, at least 1 day (could have been more depending on what they needed). Then they would spend at least a day with me and I focused on where items were in the facility, where to look for information on policy, went over the LN packet in detail, more computer training with processing actual orders and documentation, labs, etc. Then they usually had roughly 5 shifts of orientation on the floor they were hired for or if they were oncall, they received multiple training days on each unit. I also tell them, you will make mistakes and that's ok, everyone does. Learn from your mistakes and keep moving forward to become more efficient. I'm always asked how long it should take to be come efficient? That's up to the individual person and how they learn and process. It can take at least a yr before a LN feels like they know and feel comfortable in their role.

Even after their orientation period, I check in with them to see how they were doing. A lot of the time I got "Oh, I'm doing fine." or they would have simple questions but later it would turn out they were struggling. I can only do so much and if they deny help or don't ask questions, I can't help.

I had a very different experience. I was an aid at my facility, so I knew most of the ropes, then a NT, then a LPN and now a RN. I also worked in those roles as I went to school. To me that is the best experience that I received. Nursing school doesn't prepare you for practical application most of the time. They try to teach you to critically think, that's why you have all the careplans and what not. But actually applying what you've learned? Not so much. We have some great instructors who bring their students to my facility so any time I am working a unit, they want students with me. I don't mind. I show them what I do and what I've learned for my particular setting. I've also had former students look me up for questions that they didn't trust to anyone else.