Trends in Onboarding and Orientation - Solutions to Make it Safe and Efficient

This blog is taken from a recent HealthStream webinar entitled “Trends in Onboarding and Orientation – Solutions to Make It Safe and Efficient.”  The webinar was moderated by HealthStream’s Beth Pfeifer and featured Julie Miller, BSN, RN, CCRN-K, Clinical Practice Specialist for the American Association of Critical Care Nurses (AACN).

While the experience-complexity gap is nothing new to nurse leaders, it has been greatly exacerbated by the pandemic. Recruitment and retention issues have served to further broaden the gap leaving relatively inexperienced nurses to precept novice nurses as experienced nurses continued to leave the bedside. These recruitment and retention challenges have created a more urgent need to have strategies to help make onboarding and orientation safer and more efficient for everyone involved. Miller shared tactics that will allow healthcare organizations to match employee needs more precisely to the right content.

Trends and Challenges in Onboarding and Orientation

Miller began by discussing the results of a recent AACN study that looked at the top three challenges as reported by nursing managers, directors, and Chief Nursing Officers (CNOs).

• Retention was the top concern which is perhaps not terribly surprising given that the national turnover rate for nurses is 27% and most hospitals are reporting a vacancy rate around 15%.
• The emotional health and well-being of their staff was second on the list. Miller shared that the pandemic combined with retention and vacancy rate issues have created a challenge in this area. It has also meant that job seekers are more interested in a good work-life balance and whether an organization’s culture supports emotional well-being.
• Nurse leaders also reported that an increasing number of travelers and a growing contingent workforce has meant even greater challenges to the safety and efficiency of onboarding and orientation.

In addition, the study looked at trends among nurses including student nurses. This cohort also reported nursing shortages as a significant concern. This trend appeared slightly worse in the Western region and appears to be exacerbated by accelerated retirements and significant numbers of hospital-based nurses under the age of 35 leaving the workforce. 

Miller shared that the study results also identified some meaningful shifts in hiring patterns. While the majority of nurses still begin their careers by spending about two years in an acute care hospital, about 6% of them expressed a desire to work part-time.

Slower hiring processes are also becoming more of the norm with a trend towards hiring nurses over time as opposed to having multiple start dates with large groups of nurses starting at the same time. 

Quiet quitting was also mentioned by nurses and student nurses. Often seen as a byproduct of a lack of engagement or a desire to maintain work-life balance, it has manifested itself in nurses not wishing to work overtime, and no longer wishing to serve on committees and professional and governance councils.

The Experience-Complexity Gap – Education Considerations

As experienced nurses leave the profession or retire early, the experience-complexity gap widens even as the complexity of the patients being cared for remains high. “The Advisory Board recommends that healthcare organizations who wish to bridge this gap should teach novice nurses more effectively. Further, they recommend re-designing the processes for onboarding and training to accelerate the transition from novice to competency,” said Miller. Miller recommends beginning with an assessment of your current orientation plan and then compare that to what your organization’s nurses need to know right now. This strategy helps avoid cognitive overload. “When nurses reach cognitive overload, they’re no longer learning and they’re actually retaining less of what we are trying to teach them,” said Miller. She also shared that AACN provides a free assessment on their website that will help leaders evaluate and think through how to improve orientation and onboarding in their organizations.

Matching Learner Needs to Content – Safer More Efficient Onboarding and Orientation

AACN found that 52% of student nurses were seeking a career in some form of critical care nursing. AACN’s Essentials of Critical Care Orientation (ECCO) can help leaders match content to the specific needs of the learner. ECCO has both an Intensive Care Unit (ICU) and a Progressive Care Unit (PCU) track. The ICU track includes 18 modules and 72 assignments and the PCU track includes 17 modules and 68 assignments. Continuing education (CE) credits are offered at the assignment level making assignments flexible and customizable for learners and the organization. 

Miller shared that ECCO is based on an instructional design principal known as “try then learn.” The technique mimics the healthcare environment where nurses will need to assess their patients and begin making judgements about how to best care for the patient.

Miller went on to recommend that ECCO is best implemented as part of a blended learning strategy and encouraged users to blend its content with activities designed to reinforce and apply concepts learned in the modules.

ECCO also includes a Preceptor Tool that helps preceptors thoroughly cover information and recommends the skills to demonstrate. Each module covers the information that the nurse will need at the bedside including information about the hospital’s protocols and procedures. In addition, there are tips on how to facilitate the nurse’s performance on that particular clinical skill.