key: cord-0854804-18cngq54 authors: Winslow, Susan A.; Britt, Cherika P.; Dorrell, Jolene J.; Gentry, Deborah J.; Gillis, Debra D.; Hochmiller, Kathy L.; Smith, Catherine V.; McGee, Genemarie W.; Wilkerson, Julie S. title: Building on Early Coronavirus (COVID-19) Pandemic Orientation Modifications to Improve Competency Validation for Newly Hired New-to-Practice and Experienced Nurses date: 2022-02-03 journal: J Nurses Prof Dev DOI: 10.1097/nnd.0000000000000859 sha: 190974655cff1371eb4e6da59dab6dc5e94ffbd2 doc_id: 854804 cord_uid: 18cngq54 Nursing professional development and human resource leaders revised general nursing orientation content and structure based on changes because of COVID-19 in length, focus, and platforms from the early stages of the pandemic. The aim of this quality improvement project was to incorporate best of pandemic modifications with key stakeholders and new-to-practice and experienced nursing hire needs emerging from COVID-19 realities on the workforce. The benefit for nursing professional development practitioners is relatability of general nursing orientation revisions for sustainability of clinical excellence and safety. T he emergence of the coronavirus disease 2019 (COVID-19) pandemic provided opportunities for all nursing professional development (NPD) practitioners to rapidly modify existing educational structures, formats, content, and processes for general nursing orientation (GNO) program delivery. The first waves of COVID-19 populations necessitated immediate educational implications. Clinical care, social distancing, preparation for predictive surge modeling, personal protective equipment (PPE) accessibility and reuse, and restrictions on nursing student clinical rotations were affected. The imposed challenges required NPD practitioners to instantly flip to predominately virtual formats for most synchronous and asynchronous educational offerings for routine onboarding, knowledge competency validations, and instructor-led classes. Simultaneously, most NPD practitioners were faced with creating just-in-time learning for redeployment or reassignment of ambulatory and nonacute care nursing and support staff to supplement inpatient units and departments anticipating or experiencing COVID-19 surges. As the early weeks of COVID-19 turned into months of changing realities, regulations regarding social distancing, masking, and shielding; group setting capacity limitations; and PPE availability presented unique challenges, particularly for the provision of nursing orientation and initial competency validation. PROBLEM COVID-19-induced nursing orientation challenges were not limited to pandemic-related changes such as social distancing, limited group setting capacities, and PPE requirements. The situation was further complicated by a rapidly changing healthcare landscape. Hiring freezes reduced workforce resources in many areas of the country as elective and other discretionary patient care temporarily diminished in most major healthcare settings. A completely unforeseen phenomenon of new-to-practice graduates with reduced live clinical patient experience because of restrictions during transition senior practicum and capstone experiences entering the workforce emerged. Nursing orientees and existing staff demonstrated symptoms of emotional and physical fatigue as social distancing began to manifest a lack of workplace human connection. Ongoing patient visitation limits placed additional stressors on patients, families, and healthcare workers. The just-in-time orientation launched during the early phase of COVID-19 was no longer sufficient to prepare nursing orientees for the ongoing emerging healthcare setting reality. The initial phase of the COVID-19 pandemic crisis required significant changes in existing GNO models to accommodate rapid onboarding, synchronous and asynchronous virtual training platforms, PPE limitations, and social distancing while still providing hands-on-based skill validation and practice. Introduction of new clinical care components, such as proning, predicted increased use of mechanical ventilation, and new pharmacological medications had to be incorporated. Reverting to the historic, pre-COVID-19 GNO onboarding model was not perceived by NPD leaders to position nursing orientees for success at this health system setting. The need to identify and retain the best innovative elements from the COVID-19 crisis orientation and deliver a redesigned GNO to continue positive effects on nursing workforce employee preparation and the onboarding experience was evident. A review of the literature identified best practices for GNO programs. Well-documented educational strategies include simulation-based training and inclusion of nursing bedside informatics to create critical thinking, problem solving, and time management skills (Kennedy et al., 2012) . Successful nurse orientation programs shown to improve turnover and satisfaction utilize an educational theory to plan and select teaching strategies to meet the needs of orientees (Kiel, 2020) . Critical elements of orientation redesign include socialization, employee support, clear expectations, and effective coaching (Kozub et al., 2015; Joswiak, 2018; Rivera et al., 2015) . Ideal models include real-time documentation and team communication in a blending of skills and policy (Green, 2016) . Efficacious orientation programs have wellestablished goals using proven learning materials with support systems such as preceptorship, simulation, mentorship, and appropriate learning methodologies. These tenets connect education to real situations and validated evaluation tools to measure retention, turnover, and job satisfaction (Pertiwi & Hariyati, 2019) . The pandemic forced a need to examine traditional paradigms of GNO programs in response to modifications made to address challenges brought on by the COVID-19 situation. Early adaptation of alterations in instructor-led education and onboarding needed to be assessed for longer term sustainability models (Weiss et al., 2020) . An interdisciplinary team composed of NPD practitioners, executive leaders of system patient engagement, human resources, system leadership institute, clinical education, and nursing at this Mid-Atlantic health system undertook a quality improvement project to merge the best of modified COVID-19 GNO just-in-time training with the historic GNO model. The aim was to provide a new system model of efficient and effective general nursing onboarding to support validation of strategic nursing core skill and knowledge confirmations in the unfolding pandemic situation. The interdisciplinary orientation team made up of human resource and NPD practitioners sets goals to include rapid assessment of key stakeholder feedback for revision of orientation and onboarding amid the ongoing crisis supporting needs of nursing hires because of the pandemic. Key stakeholders included those accountable for onboarding nursing personnel and those receiving the nursing hires. Paradigms accepted by the team included alignment with Benner's (1984) theoretical model of novice-to-expert progression of nursing expertise, knowledge test out challenges for experienced hires, and sequencing of skills from simple to complex. Confirmation of strategic imperatives, critical thinking, patient experience, and mentorship aspects through debriefing were also confirmed as key concepts requiring enhanced focus. Specific attention on the instructor-led components of onboarding required new prioritization to support team members' sense of safety and engagement. Structured interviews were held with key stakeholders, including hiring managers, NPD staff, and new-to-practice and experienced nurse hires. The goal was to ascertain (a) opportunities gleaned from educational innovation forced by early phases of COVID-19, (b) feedback on historic aspects of the system GNO model, and (c) orientee satisfaction feedback on general orientation. Organizational development experts from the health system created a survey outline of open-ended questions whereby the interdisciplinary team scheduled and conducted phone interviews with the key stakeholders aware of modifications to GNO since COVID-19. Patient experience and patient-sensitive measure outcome lead cross-walked GNO content to align with emerging needs of usual and novel patient populations. Timing of introduction and testing of the new GNO model was a critical element given the unfolding pandemic situation. The just-in-time model of modified GNO introduced in the early phase of the pandemic was not a long-term viable strategy. The modified GNO was intended to rapidly prepare nursing orientees to provide care for patients predominately on COVID-19 units and support redeployment. A sustainable GNO model was needed for the foreseeable future in an ongoing situation of social distancing (Centers for Disease Control and Prevention, 2020). Following key stakeholder feedback and review of recent satisfaction data, the interdisciplinary team began to crosswalk historic, just-in-time, and emerging clinical content to outline priority skill and knowledge elements of GNO. The team intentionally focused on identifying opportunities for synchronous and asynchronous virtual instructor-led experiences and in-person simulation given social distancing requirements. Orientation group sizes for nursing orientees varied, so the ability to safely socially distance was paramount. Historic, live, instructor-led nursing onboarding classes that had converted to alternate modalities were evaluated for long-term sustainability using virtual platforms. Likewise, new nursing personnel challenge test-out options for the health system were evaluated to prioritize in-person opportunities. Paper competency validation instruments were converted to electronic formats to minimize human touch. The new model of GNO, depicted in Figure 1 , went live in early fall 2020, 3 months after the modified just-in-time GNO first launched (see Figure 1 ). Despite being a health system composed of approximately 8,000 nurses with an average of 50-100 nursing orientee hires a week, the nursing orientees' first day was converted from a computerbased module to a live instructor-led synchronous virtual welcome from the human resources department working in collaboration with nursing. This replaced a previous day of extensive computer-based tutorials (CBTs) with little or no interactive classroom engagement that historically had low satisfaction. This new interactive format provided all nursing orientees a sense of connectedness and safety in the current situation. Nursing orientees are provided challenge test options on Day 2 for the electronic medical record and basic arrhythmia knowledge. CBTs were now staggered to focus FIGURE 1. New model of general nursing orientation. www.jnpdonline.com on core content up front and pace the remainder over the orientation period. The testing options and revised CBT content allowed for classroom time to be used for simulation and experiential learning opportunities. Nursing orientees attend group skill validations on Days 3 and 4, focusing on emerging patient clinical care needs; real-time documentation; and patient experience dimensions of huddles, bedside report, and rounding. The nurse participants in the group skills validation sessions practice social distancing and proper PPE usage. Nursing orientees are divided into groups of 10 or less, following current capacity group size restrictions in this region. Masks and eye protection were provided and used in all skill validations where 6-feet social distancing could not be maintained, such as close observation during urinary catheter insertion requiring two clinicians. Nursing orientees are provided the opportunity to apply patient care policies and procedures using low-fidelity simulation with hospital equipment in a safe learning environment. A newly designed general nurse competency validation completes the new onboarding process; benchmarks for each domain of nursing competence are validated using a myriad of validation strategies (see Figure 2 ). The new tool was developed based on the Nurse Development Resources benchmarks, which is a standardized, evidencebased tool for competency assessment, and literature of current nursing competency theorists (Martin & LaVigne, 2016) . The tool reflects revised orientation concepts and content and bridges from Day 1 across the first week of blended learning to preceptor-led unit orientation. Under the redesigned GNO model, new-to-practice nursing orientees return to a physical training location at approximately 1 month for clinical simulation scenario experiences to work on complex team dynamics, communication, critical thinking, and additional application of tactile skills and documentation. Success of the revised GNO model was evaluated through satisfaction surveys of the nursing orientees using a Kirkpatrick Level 1 evaluation: using a Likert score based on a 1-5 scale of participant satisfaction on meaningfulness, sense of safety, quality of instructors, and observations of differences observed in practice once out on units. Simple survey methodology was utilized at key junctures of the new model; end of Day 1, conclusion of skills validation experiences, and simulation scenarios. Results were analyzed using quantitative and qualitative aggregate data methodology. Surveys were collected on 247 nursing orientees under the revised model over a 3-month period. Because of the urgency of the situation, reliability and validity testing was not conducted on the survey instruments. demonstrates improved satisfaction from newly hired novice and experienced nurse participants. Data from Day 1 confirm positive response with an average satisfaction rating of 4.7 on a 5.0 Likert scale. After the in-person skills validation days, nursing orientees indicate 100% agree or strongly agree response with obtaining essential skills to begin unit clinical orientation, use of appropriate teaching methodologies, sense of engagement, safety of the learning environment, knowledgeable instructors, and benefit of the information. After performing care for complex patient scenarios, new-to-practice nursing orientees overwhelmingly agree that the simulation scenarios at 1-month post hire helped advance their critical thinking skills, allowing safe reinforcement of current knowledge they obtained from school and through their GNO orientation. New-to-practice nurses unanimously agree or strongly agree that the simulations were found to be beneficial and were able to assimilate new knowledge into their practice. The COVID-19 pandemic presented an opportunity to enhance/improve long-standing GNO processes. Building on innovative and adaptable just-in-time nursing interven-tions to improve overall orientation and onboarding was a time-sensitive challenge demonstrated by early success. The progression from the historic model of GNO through early COVID-19 to an improved model was realized (see Table 1 ). This collaborative, outcome-focused professional development team readily recognized the positive impact strategizing for lasting improvement. Gathering participant feedback, reviewing satisfaction results, and partnering with human resources and NPD leaders were key to the NPD team's success. The collaboration ensured a cohesive and streamlined welcome and nurse orientee onboarding experience to the health system. Subject matter experts in patient care measures, patient experience, team member experience, NPD, and simulation all collaborated in providing an innovative approach to GNO for nursing orientees. The GNO satisfaction survey demonstrates a positive response from nursing participants to the implementation of a blended approach to learning. This quality improvement project had limitations pertaining to methodology. The authors acknowledged the presence of potential bias in the survey instrument and key stakeholder results. The authors created the key stakeholder structured interview group questions and orientee satisfaction surveys for the purposes of this project and did not conduct reliability or validity testing on the tools. The GNO satisfaction survey results from orientees were obtained via selfreported survey findings. No incentives for survey participation were provided. Ethical concerns were considered throughout the project, and nurse orientees were given the option to not participate in surveying. As this was not an interventional study, institutional review board consideration was not pursued. The COVID-19 pandemic has challenged all healthcare providers in a myriad of ways previously unimagined. The NPD practitioners were strategically positioned to bring innovative problem solving to the situation. Extraordinary creativity emerged in the early phase of the pandemic and continues to challenge long-standing norms for classroom and virtual education. Emerging models of onboarding, competency validations and nursing continuing professional development are just beginning to arise as an outcome of this current situation. The future for GNO includes the impetus for nursing orientees to complete a satisfaction survey at key junctures to provide a more robust survey sample size for ongoing sustainment. Reliability and validity testing of the satisfaction tools is underway. Future studies could include specific correlation with orientation and patient safety measures. Specific impact of orientation on new-to-practice and ongoing nursing retention is of strategic interest and is being tracked and trended. The pioneering of new methods for providing GNO instruction prompts innovative strategies for the future. From novice to expert: Excellence and power in clinical nursing practice Coronavirus (COVID-19 ENGAGE: A different new nurse orientation program Transforming orientation through a tiered skills acquisition model Nursing department orientation: Are we missing the mark? An analysis of restructuring orientation to enhance nurse retention. The Health Care Manager Redesigning orientation in an intensive care unit using 2 theoretical models Benchmarks: An evidence-based approach to creating high performing nurses Effective orientation programs for new graduate nurses: A systematic review Improving orientation outcomes: Implementation of phased orientation process in an intermediate special care nursery Nursing professional development specialist's role in adapting education, onboarding, and just-in-time education during the COVID-19 pandemic