UBC Graduate Research

Unit Specific Nursing Orientation Santucci, Julia Apr 18, 2017

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Unit Specific Nursing Orientation   By  Julia Santucci, RN Bachelor of Science in Nursing, University of Victoria, 2006   SCHOLARLY PRACTICE ADVANCEMENT RESEARCH PROJECT SUBMITTED IN PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF       MASTER OF SCIENCE IN NURSING       In   THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (School of Nursing)  THE UNIVERSITY OF BRITISH COLUMBIA  Vancouver      April, 2017  Julia Santucci, 2017                                                                              UNIT SPECIFIC NURSING ORIENTATION      2 Table of Contents  Abstract……………………………………………………………………..……………..………4  Acknowledgements………………………………………………………..………………………5  CHAPTER 1: EXPLORING THE LITERATURE ON UNIT SPECIFIC NURSING ORIENTATION…………………………………………………………………………….….....6  Introduction…………………………………………………………………….……..…..6  Research Question……………………………………………………………………..….8  Significance…………………………………………………………………………….…9  Theoretical Perspective……………………………………………………………….…...9 . Methodology………………………………………………………………………..……11  Search Strategy……………………………………………………………………..……12  Limitations…………………………………………...…………………………….…….13  Table of Selected Articles………………………………...………………………….…..14  CHAPTER 2: FINDINGS FROM INTEGRATIVE LITERATURE REVIEW………….…..…18  Conducting an Investigatory Survey…………………………….………………….……19  A Nursing University Program………………………………………………….….……20  Orientation Specific to Experienced New Nursing Hires..…...…………….………...….22 . Transition Support……………………………………………………………………….25  A Fellowship…………………………………………………………………………….31  Staged or Phased Orientation……………………………………………………………33    A Unit Specific Orientation Class………………………………………………….……37  Summary…………………………………………………………………………………39  CHAPTER 3: DISCUSSION OF FINDINGS…………………………………………….……..40                                                                             UNIT SPECIFIC NURSING ORIENTATION      3 CHAPTER 4: CONCLUSION AND RECOMMENDATIONS………………….……………..48  Suggestions for Education and Organizations….………………………..……...……….50  Limitations of the Review………………………….………….……….…...……………51  Conclusion……………………………………………………………………… ………52  REFERENCES…………………………………………………..………………………………53                                                                                                                UNIT SPECIFIC NURSING ORIENTATION      4 Abstract  Purpose:  The purpose of this paper is to critically review the current literature (1-8 years) related to unit specific nursing orientation of newly hired nurses to uncover criteria for effective orientation using learner-centered approaches. Methods:  An integrative literature review will be used to review, evaluate and integrate the selected literature collected on my research topic of unit specific new hire orientation of newly hired nurses by means of a systematic search strategy. Findings:  The research reports several newly designed orientation interventions and programs, which were implemented in acute care settings to identify challenges and to address identified challenges in the orientation process.  Interventions which support a well-organized unit specific orientation for newly hired nurses may not only lead to a better prepared newly hired nurse, but also the retention of newly hired nurses. Research limitations and implications:  A major limitation was the limited amount of available appropriate studies for this integrated literature review.  Nursing research is relatively new on the topic of unit specific nursing orientation.  Still, because of the ever-increasing concern with nursing turnover it is imperative that this research continues.   Keywords:  employee, orientation, nurse, new graduate, novice, learner-centered, new hire, newly hired nurses.                                                                                     UNIT SPECIFIC NURSING ORIENTATION      5 Acknowledgements  I would like to express my deepest appreciation to my advisor and supervisor Dr. Geertje Boschma, PhD, if it not for your continuous encouragement and guidance, I would not have been able to see the finish line, never-mind crossing it.  Your knowledge and support is truly what got me to this end goal. I would also like to thank my co-supervisor, Marion Clauson, MSN, RN, for providing indispensable information and advice.  Your support and patience were essential to the completion of my paper.   Finally, I would like to thank my incredibly loving and supportive Husband, Aaron and my Mother, Francesca, Father, Vince and my family and friends.  Without their undying patience and humour, it would have been an incredibly long and lonely road.                                                                                               UNIT SPECIFIC NURSING ORIENTATION      6 CHAPTER 1: EXPLORING THE LITERATURE ON UNIT SPECIFIC NURSING ORIENTATION    Introduction  Unit specific orientation for newly hired registered nurses, which follows a general nursing orientation for new employees at a typical urban health authority in British Columbia (BC) usually consist of at least a week of mostly didactic instruction that allows for minimal learner engagement and, depending on the size of the institution’s newly hired group, it may be difficult to get all generic questions of the newly hired nurses answered.  This format typically puts unnecessary stress upon the unit specific orientation, which usually comes on the heels of the general nursing orientation.  This next phase of orientation is stressful because all unanswered questions of a generic nature that have not been addressed, still need to be answered for the newly hired nurses to successfully start their work on a particular unit.  Often, the remaining, unanswered generic questions are more administrative in nature, such as: how do I get my ID badge, which then leads to, where do I pick up my ID badge, where and when can I get my uniform?  These questions should have been answered in New Employee Orientation.  Having to find answers to these questions lessens the already short amount of time one has to facilitate all the new unit specific clinical information, which the newly hired nurse will require to receive prior to starting their career on the specific unit.   An initial search of the literature revealed that this ineffective approach to orientation is not uncommon.  For example, Culley, Babbie, Clancey, and Clouse (2012) describe traditional orientation as an introduction to the institution’s policies, procedures, information systems, and reviews of skills and tasks.  This process can take place over three to five days and is a source of “information overload” (p. 46).  It seemed a more systematic review of recent evidence in the                                                                           UNIT SPECIFIC NURSING ORIENTATION      7 literature would be useful to explore whether a more effective approach to orientation could be identified. The purpose of this Scholarly Practice Advancement Project is to explore by means of a systematic study of the literature how unit specific orientation can be enhanced to maximize newly hired nurses’ confidence and knowledge base at the start of their new position.  The project seeks to explore how the organization and educational format of such an orientation experience can be enhanced from a pedagogical point of view. In this project, I would like to explore whether ways to improve orientation practices on acute medical units could be identified in the literature.  This is a topic of significance, because the risk of an ineffective orientation of newly hired nurses to a specific department may lead to a belief of an unsupportive environment, failure to cope and decreased retention (Culley, et al, 2012, Sullins, 1989).  “In the past, [newly hired nurses] honed their technical, critical thinking, and time management skills by [first] working on general medical-surgical units” but as the acuity of patients on these units increased, even newly hired nurse on a general acute medical-surgical unit will need to enter the workforce “highly skilled”, including having good organizational skills (Gomes, et al, 2009, p. 575).  The general medical-surgical units are still perceived as ‘entry to practice’ even though the acuity of patients has increased.  The pressure of higher acuity on acute general medical-surgical units is forcing newly hired nurses to be highly skilled from the start.  Limited time for reflection and discussion during general nursing orientation are two reasons why careful attention must be paid to the nature and quality of unit specific nursing orientation that follows the general orientation.  A purposeful exploration of the findings and recommendations arising from recent studies on such unit specific orientation processes would provide useful knowledge for clinical nursing practice.  Unit specific orientation                                                                           UNIT SPECIFIC NURSING ORIENTATION      8 needs to be innovative and capture what is required to give newly hired nurses the best platform for success. In an initial review of the literature on the orientation process for newly hired nurses, a relationship between support and success has been identified.  Support comes in different forms and from different individuals (Culley, et al, 2012, Sullins, 1989, Gomes, et al, 2009).  These supportive individuals often include the following roles: Clinical Nurse Educators, Clinical Nurse Leaders (Charge Nurses), a Buddy Nurse (during orientation shifts), Peers, and Patient Care Managers.  Several scholars also acknowledged the importance of progress reports throughout the orientation process and suggested that orientation should include: verbal, visual and tactile experiences (Culley, et al, 2012, Gomes, et al, 2009, Olmstead, et al, 2013).  However, we do not have a clear view from the literature of the current state of the art about the most effective and pedagogically sound unit specific nursing orientation processes.  Therefore, the goal of this SPAR project is to explore what the current nursing education literature suggests in terms of effective teaching and learning strategies and how best to incorporate effective, learner-centered strategies into unit specific nursing orientation.  The purpose is to critically review the current literature (1-8 years) related to unit specific nursing orientation to uncover criteria and recommendation for effective orientation using learner-centered approaches.  Research Question Which pedagogical strategies can be drawn from current nursing education literature that will support effective unit specific orientation to enhance newly hired registered nurses’ success and retention at the bedside on an acute general medicine unit?                                                                            UNIT SPECIFIC NURSING ORIENTATION      9 Significance Retention rates are decreasing amongst newly hired, recently graduated registered nurses (RN) who are finding the “transition from student to qualified nurse stressful and intimidating” (Edwards, Hawker, Carrier & Rees, 2015, p. 1255).  They may either leave the unit where they have started their career for another unit or leave the nursing profession altogether.  A well-designed, more pedagogically sound unit orientation promotes confidence and competence thereby potentially increasing retention rates for new RN graduates [and possibly new RN hires]. Providing structured support throughout this transition period seems essential.  Such structured support best starts with a strong, well-designed learner-centered orientation (Edwards, et al, 2015; Park, 2010).  Theoretical Perspective What are adequate pedagogical strategies for enhancing orientation processes from a conceptual point of view?  Would a learner-centered pedagogical focus strengthen the orientation process?   There are multiple learner-centered pedagogies used in nursing education, which are based on the viewpoint most famously expressed by Paolo Freire in 1970, that “education is a vehicle for social change” (Weimer, 2013, p. 18).  Furthering his theoretical perspective, Freire found that “when students were trusted [to make decisions about their own learning], their motivation to learn increased dramatically” (Weimer, p. 19).  A learner-centered approach has the teacher “promot[ing] the learning by facilitating the acquisition of knowledge” and empowering the student to be more responsible for their own learning (p.11).  Such approaches could also be applied in newly hired nursing orientation sessions to place them on a sound                                                                           UNIT SPECIFIC NURSING ORIENTATION      10 pedagogical footing and potentially enhance newly hired nurses’ engagement with their new work environment. Weimer (2013) has outlined the “key ingredients” of the learner-centered approach, as follows: 1. It is teaching that engages students in the hard, messy work of learning.  2. It is teaching that motivates and empowers students by giving them some control over   learning processes.  3. It is teaching that encourages collaboration, acknowledging the classroom (be it virtual or real) as a community where everyone shares the learning agenda.  4. It is teaching that promotes students’ reflection about what they are learning and how they are learning it.  5. It is teaching that includes explicit learning skills instruction. (p. 15).  Weimer (2013) explained that the goal of a learner-centered approach is to “maximize the learning potential inherently a part of any experience where students produce a product, perform a skill, or demonstrate their knowledge” (p. 11).  Although nurses on a medical unit work as a team, a nurse is autonomous in their critical thinking, which is needed when caring for their patient.  A nurse who can evaluate their own learning when given the tools can then evaluate the care plan they have initiated for their patients.  Autonomy in nursing requires confidence and competence which start with a strong foundation.  A well-designed unit specific orientation has the potential to be the start of that strong foundation.  In this project, I will further explore whether it is deemed beneficial to the newly hired nurses’ orientation to incorporate such learner-centered approaches as part of the orientation process and whether recommendations could be drawn from the newest evidence on new hire orientation practices.                                                                               UNIT SPECIFIC NURSING ORIENTATION      11 Methodology An integrative literature review has been used to review, evaluate and integrate the selected literature collected on my research topic of unit specific new hire orientation.  The integrative review includes a systematic search strategy of the literature.  Although work place orientation is not a new concept in the nursing world, it is useful to review the recent and relevant literature on the topic to incorporate the most up-to-date recommendation from recent scholarship in the orientation process.  An integrative literature review is an appropriate method to address this relatively new nursing topic of including a learner-centered approach to a unit specific orientation.  In this integrative review, I look at established new hire orientation models drawn from business-related scholarship as well as new literature on unit specific nursing orientation and to then understand what worked and what did not (Torraco, 2005).  The initial plan for this review stems from a need to understand how a learner-centered approach to unit specific orientation may promote a newly graduated nurse and a newly hired nurse to be a more competent, confident and contented front line nurse, which in turn may lead to retention of nurses on these specific medical units.  Integrative literature review is important for the potential of providing evidence-based nursing practice, as this type of review allows broader understanding of nursing practice phenomena, such as the importance of unit specific nursing orientation and the benefits pertaining to retention of staff.  Integrative literature reviews permit the inclusion of experimental and non-experimental research to enhance a comprehensive understanding of the relevant insights on the topic (Whittemore & Knafl, 2005).  Inclusion of non-experimental research may lead to potential limitations.                                                                           UNIT SPECIFIC NURSING ORIENTATION      12 Some of the potential limitations of this approach are: not considering the importance of primary sources while searching for literature, a secondary source may misinterpret the primary source data, and data-analysis of a primary source may be incomplete in the secondary source and therefore can lead to lack of rigour and inaccuracy in data collection.  This approach of using already published work may also promote selection bias which can be influenced by whomever is conducting the research, as they may interpret the data to suit their own agenda (Whittemore & Knafl, 2005).   Still, relevant literature found on the topic of unit specific nursing orientation will be used in this review and I have attempted to increase rigour and decrease bias by following the steps laid out by Whittemore et al (2005).  Whittemore and Knafl (2005), suggests mitigating these limitations by following these stages: problem identification, literature search, data evaluation, data analysis and presentation.  These steps are being followed throughout this SPAR paper.  Search Strategy I have used the following key search terms: employee*, orient*, employee* AND orientation*, nurse* AND (“new graduate” OR “novice OR “recent graduate”), pedagog*, learner-centered, learner-centered approach, new hire.  The following subject headings were used: DE “EMPLOYEE orientation” OR DE “EMPLOYEE orientation materials”, MH “Employee orientation”, MH “Novice Nurses”, MH “New Nursing Graduates”, MH “Personnel Retention” OR MH “Personnel Turnover”.  The following search engines were used: Business Source Complete, CINAHL, Web of Science, Academic Search Complete and Education Source.  The search was limited to literature from 2006 and afterwards.  I used few limiters other than timeline, such as, English articles and peer-reviewed.  These search terms produced numerous                                                                           UNIT SPECIFIC NURSING ORIENTATION      13 articles but after careful evaluation and selection of the focus only 10 articles met the inclusion and exclusion criteria, which included the following criteria: Registered Nurse, hospital unit specific orientation, nurse retention, peer reviewed, English language, publication years 2006-2016.  Exclusion criteria: nursing students and non-hospital settings.  One study report has been included in the review which focused on new nurses and physicians’ orientation but it was apparent that ¾ of the population sample (N=195) in the study were RNs (N=145).  Therefore, the findings were relevant for this review.  Two articles discussed data on orientation processes closely related to unit orientation processes: One Finnish integrative literature review on nurses’ hospital orientation and one systematic review on interventions to help new graduates transition to newly qualified nurse.  I have included these two articles in my discussion in the discussion chapter.  I initially also looked at business models of new hire orientation and did not include these in the review as I wanted to only include studies relevant to newly hired nurses.  I have summarized the literature that is included in this review in Table 1.  Limitations A limitation in this SPAR project is that there were a limited number of articles relevant to unit specific orientation on a general medicine unit, many of studies targeted unit specific orientation for specialized areas, such as critical care.  The only integrative literature review I could find was published this year, 2016 and it too was for unit specific nursing orientation on specialized units.  This lack of research studies around unit specific nursing orientation for general medical units supports the need for future research.  The limited numbers of studies that have been reported, however, provide relevant insights that will be examined in the following discussion chapter.                                                                            UNIT SPECIFIC NURSING ORIENTATION      14 Table 1.  Summary of studies included for the review  Reference Purpose of Study and Intervention Design Data Collection & Analysis Sample Characteristics Key Findings Brakovich & Bonham (2012) USA To investigate what the perception by Newly Licensed Registered Nurses (NLRN) of the orientation process  Intervention: Graduate Nurse Experience Survey at 3rd month of employment A qualitative descriptive Questionnaire developed by Casey & Fink (2004)  A random sampling of Newly Licensed Registered Nurses N=157 Challenges identified by the participants of this study when starting as a NLRN: stress, job performance, deficits in clinical skills and knowledge, lack of confidence and feelings of inadequate preparation  Culley et al (2012) USA To determine the effect of a newly implemented approach to nursing orientation for a newly hired nurse vs the previous traditional nursing orientation  Intervention: Nursing University Program  An experimental Performance reviews (from nurse managers) Comparison data: medication errors, documentation errors, lab errors and retention N=103 The control group (those oriented by traditional method) N=60 The experimental group (those oriented with the Nursing University Program) N=43 Data showed a decrease in errors and a 20% improvement in new staff turnover after 6 months of employment (with those who participated in Nursing University). Dellasega et al (2009) USA To describe a unit specific orientation process for newly hired diabetes case managers at a large teaching hospital  Intervention: Orientation specific to new RN hires with experience A qualitative pilot study Nurses daily professional journal Focus group interview Thematic Analysis  Experienced Registered Nurses N=3 Tailor orientation to meet the needs of an experienced nurse and find out prior to orientation what those needs may be  Dyess & Parker (2012) USA To describe and evaluate a collaborative program that A quantitative Pre-post evaluation Questionnaire (Nursing A convenience sample N=109 (all nurses who Transition support is valuable: improved retention and transition.                                                                           UNIT SPECIFIC NURSING ORIENTATION      15 supports newly registered nurses  Intervention: A collaborative academic-practice partnership that provides active support within a 10-month focused program Evaluation Competency Assessment) Questionnaire (Student Leadership Practices Inventory) Student’s paired t-test  participated in the Novice Nurse Leadership Institute programme during 2006-2009) Friedman et al (2013) USA To determine the effect of a specialized Pediatric Nurse Fellowship program (PNFP) on new graduate RN retention and the cost of such a program  Intervention:  Pediatric Nurse Fellowship Program A retrospective descriptive comparative Questionnaire, nominal data Pearson chi-square test Two sample t-test New Graduate RNs hired by the Cohen’s Children’s Medical Center pre-and post-initiation of the program N=77 There was a significant difference in retention rate between Standard Orientation (82%) vs post commencement of the PNFP (94%).  Also, a significant estimated savings from a decreased turnover  Gomes et al (2009) USA To help an orientee progress from novice or advanced beginner to a competent nurse in any acute care setting  Intervention: Innovative staged orientation program  A descriptive comparative Descriptive statistics Evaluations Project is ongoing: N=15, 3 Experienced RNs (100% success) 6 New Graduate RNs (50% success) 6 RNs in progress when article published Principles of survival and caring provide foundation for a successful orientation program.  There are multiple individuals necessary to implement and support a successful orientation program: Unit Educator, Unit Manager, Preceptor, Staff Mentor  Kozub et al (2015) USA To describe a revised unit specific orientation program (Critical Care) that is based on a blend of Benner’s Novice to Expert Framework and Maslow’s Hierarchy of needs, to decrease turnover A descriptive comparative Various statistical analysis  Change in Basic Knowledge Assessment Test (BKAT) scores N=42 nurses went through the revised orientation program during 2011 to 2013.  Experienced non-ICU RNs (27) Revised unit orientation program increased nurse retention (1 & 2 years) and decreased turnover.  Critical Care knowledge improved after orientation for both pre & post intervention groups                                                                           UNIT SPECIFIC NURSING ORIENTATION      16 and increase retention  Intervention: Phased unit orientation model New Graduate RNs (6) Experienced ICU RNs (9) Peltokoski et al (2015) Finland  To examine newly hired nurses’ and physicians’ perceptions of their orientation process, to explore correlations between background variables and the comprehensive orientation process.  Intervention: Comprehensive orientation process A cross-sectional pilot study descriptive Questionnaire (developed by the researchers) Orientation Process Evaluation (OPE) Statistical Package for Social Sciences (SPSS) Non-parametric tests Convenience sample of RNs (N=145) and Physicians (N=37) working in two Finnish hospitals It was concluded that the orientation process was not properly implemented and the result was that at least 25% of the respondents stated there was no assessment of competence pre, during and post orientation and over 50% stated that the orientation was not evaluated in their annual performance discussion. A significant finding was the critical role of an appointed preceptor and that a longer orientation period had a more favorable outcome Rush et al (2015) Canada To examine the relationships between selected components of formal new graduate transition programs and new graduate transition experiences.  Intervention: Formal New RN Graduate Transition Programme (NGTP) A quantitative study which is part of a larger mixed methods study across seven hospitals in British Columbia Online survey Casey-Fink Graduate Nurse Experience Survey Descriptive statistics Statistical analysis N=245 New RN Graduate New RN graduates who participated in a NGTP had significantly higher transition scores vs those RNs who went through standard orientation (SO).  Ward (2009) USA To examine an implementation of a unit specific orientation class and Descriptive Evaluation questionnaires (developed by the researcher) Data collected during 2004-2006 2004 N=9 Participants scored 26% higher on the post BKA after unit specific orientation, than on the                                                                           UNIT SPECIFIC NURSING ORIENTATION      17 the effect on better preparation to work on unit, job satisfaction and retention.  Intervention: Formal unit specific orientation class  2005 Basic Knowledge assessment (BKA) was added (developed by Clinical Nurse Specialist on unit): pre-and post-unit orientation  2005 N=7 2006 N=6 pre-test.  The retention rate of the unit increased from 44% in 2004 to 84% in 2006.                                                                                            UNIT SPECIFIC NURSING ORIENTATION      18 CHAPTER 2: FINDINGS FROM INTEGRATIVE LITERATURE REVIEW This chapter will focus on the analysis and findings of the ten studies selected for this review that are related to unit specific nursing orientation.  Each study will be discussed separately and the main findings reported.  Orientation was not clearly defined within the selected studies but there was a shared belief, as Gomes, Higgins, Butler, and Farzaneh (2009) suggest, that the orientation programs of the past must be “replaced with innovative designs that support orientees and their mentors while ensuring patient safety in challenging environments” (p. 575).  The studies reported varying concepts and strategies for the orientation process and one study investigated the needs of newly hired nurses to help implement an orientation that may encourage nursing retention (Dellasega, Gabbay, Durdock, & Martinez-King, 2009).  Common orientation concepts evident in the studies were the importance of preceptor involvement; orientation followed by a transition period and continued evaluation (pre-and post-initiative interventions).   The studies also reported several newly designed orientation interventions and programs, which were implemented in acute care settings to identify challenges and to address identified challenges in the orientation process.  These interventions were: an investigatory survey (Brakovich & Bonham, 2012), a Nursing University Program (Culley et al, 2012), orientation specific to experienced new nursing hires (Dellasega et al, 2009), transition support (Dyess & Parker, 2012, Peltokoski et al, 2015, Rush et al, 2015), a Fellowship Program (Friedman et al, 2013), staged or phased orientation (Gomes et al, 2009, Kozub et al, 2015), and a unit specific orientation class (Ward, 2009).  The following sections describe the seven interventions, drawing from the findings from the above-mentioned studies.  These interventions, which seem to support a well-organized unit specific orientation for newly hired nurses may not only lead to a better                                                                           UNIT SPECIFIC NURSING ORIENTATION      19 prepared newly hired nurse, but also enhance the retention of the newly hired nurses.  An underlying common thread of the studies was the notion that a strong orientation may lead to nurse retention.  In the summary at the end of this chapter I will synthesize these common threads which will then be discussed further in the discussion chapter.  Conducting an Investigatory Survey The qualitative, descriptive study by Brakovich and Bonham (20112) took place in an integrated, five-hospital healthcare system located in the United States of America.  The researchers developed a questionnaire which measured the newly licensed registered nurses (NLRNs) “experience upon entry into the profession and during transition into the role of advanced beginner” (Brakovich & Bonham, 2012, p. 51).  The survey was distributed to NLRNs who were in their third month of employment in various clinical areas.  The researchers sent out 169 surveys to NLRNs who went through the orientation process between May 2010 through May 2011 and 157 NLRNs participated.  The survey findings included responses about the use of preceptors during the orientation process. Orientation and number of preceptors varied by clinical unit and the areas were named but no numbers of orientation length, number of preceptors, or nature of each orientation was outlined for each clinical area.  The length of orientation varied between 3-6 weeks and more than 24 weeks and the number of preceptors each NLRN had during orientation, per respondents, was none to three. The survey consisted of 24 statements related to the NLRNs perception of their level of confidence and comfort as a newly hired registered nurse.  There were four themes identified by the NLRNs in their transition during orientation which they described as difficult: lack of                                                                           UNIT SPECIFIC NURSING ORIENTATION      20 confidence in skill performance and critical thinking skills, time management skills, increased role responsibility, and communication with peers and physicians.  Brakovich & Bonham (2012) discussed some of the potential implications of the survey findings for designing a comprehensive orientation process, such as, increased retention, improved patient safety, opportunity for employee engagement and decreased cost to healthcare.  They continue by suggesting that a dedicated education unit may bridge a gap between nursing school and working as an NLRN.  Such a gap was highlighted as a concern in the NLRN survey responses.  The staff who worked on a dedicated education unit would be trained as preceptors and therefore have the knowledge to facilitate a learner centered orientation, allowing for newly hired nurses to acclimatize confidently to a new area of work.  Although there was no evidence of validity or reliability in this study, the researchers found that having “highly developed” preceptors was a benefit to the organization (p. 61).  Providing a well-developed and consistent unit specific orientation is a pedagogical strategy that may have the potential for a newly hired nurse’s success on their new unit.  A Nursing University Program Culley, Babbie, Clancey and Clouse (2012), examined the difference between traditional new hire orientation and a new approach to new hire orientation, which was developed by the authors.  They called it the Nursing University program.  According to Culley et al, traditional orientation consists of three to five days of “information overload”, where new nursing hires spend “many hours over several days watching videos and reviewing [hospital] policies” (p. 46).  This type of orientation is not the way many people learn and no one can retain massive amounts                                                                           UNIT SPECIFIC NURSING ORIENTATION      21 of new information.  The authors argued that orientation should adapt to how people learn, as there are varying learning styles.   The Nursing University Program comprises of formal delivery of information through classroom work as well as tactile experiences conducted in a simulation lab.  The information is given by lecture and then orientees perform the skill with the hope that they will have a better understanding for the rationale of the policy regarding the skill.  The program runs over two semesters and the classes are as follows: I.V. therapy essentials and central line care, blue alert (Cardiac code), aspects of documentation, excellent service, and essentials of pain management, national patient safety goals, laboratory interpretation and blood sampling, and competency review.  A time schedule of these classes was not provided.  Culley, Babbie, Clancey and Clouse explain that this program is a learner-centered approach with diverse learning modalities that adjust to the varied learning styles of newly hired nurses. Culley et al, recognized that there were areas in traditional orientation that needed enhancement to improve nursing practice and avoid unfavourable operational outcomes, such as, practice errors and decreasing nurse turnover.  In the first six months of employment, the researchers closely monitored the orientees to identify trends in the types of nursing practice errors.  The study used information provided by nurse managers on orientee performance in the first six months of employment in their clinical area.   The researchers analyzed the performance of 103 orientees: 60 were oriented prior to the implementation of the new program (group A) and 43 were oriented using the Nursing University program (group B).  The authors compared data regarding medication errors, documentation errors and retention between the two groups of orientees.  Retention was defined as “being employed on the same unit where the nurse was hired six months after completion of                                                                           UNIT SPECIFIC NURSING ORIENTATION      22 orientation” (p. 47).  Group A’s retention rate was 69% and group B’s retention rate was 82%, a 20% increase in retention within the group who completed the Nursing University program, although the researchers did not state if this was statistically significant but it was an important improvement.  The article did not include the comparative data on medication and documentation errors.   There was no evidence of validity or reliability in this study and the researchers would like to continue measuring the efficiency of this new orientation program and for future study, compare their program with a nurse residency orientation model.  The Nursing University Program approaches new hire nursing orientation holistically, providing a learner-centered approach by offering alternatives to didactic only orientation.  This program allows newly hired nurses to practice in a simulation lab, which is giving the newly hired nurses the opportunity to put into practice and understand the rationale behind the institution’s nursing practice standards.  The observed practice of the newly hired nurses by the staff educator in a controlled environment aides the evaluation of any knowledge gaps, which then enables the educator to provide feedback and develop, with the newly hired nurse, learning goals for ongoing nursing practice.  Providing multiple pedagogical modalities that follow an individual nurse’s learning style can potentially enhance newly hired nurses’ success and increase nurse retention.  Orientation Specific to Experienced New Nursing Hires A qualitative pilot study by Dellasega, Gabbay, Durdock, and Martinez-King (2009), examined the orientation needs of newly hired nurses, both Registered Nurses and Licensed Practical Nurses, who already had previous experience when they started new on the unit.  Dellasega et al (2009) identified few differences between orientation needs of a newly licensed                                                                           UNIT SPECIFIC NURSING ORIENTATION      23 nurse and a newly hired nurse with experience.  An assumption with regard to the novice licensed nurse and the experienced nurse hired to a new position is that experienced nurses are capable of “adopt[ing] varied methods of learning as they identify [their own] deficits” (p. 311). The researchers assess that most orientation programs focus on mentoring the newly licensed registered nurse but they found that even an experienced newly hired registered nurse requires mentorship to navigate their new position and perhaps tailoring parts of the orientation process to “meet the specific emotional needs of nurses…transitioning in their orientation rather than starting from scratch may improve retention” (p. 311). In this qualitative pilot study, Dellasega et al (2009) monitored three experienced registered nurses during their six-month orientation period.  The orientation consisted of three months of classroom orientation and followed by three months of clinical orientation and supervision.  The nurses were hired to a new position as diabetes case managers at a large academic medical center.  All three nurses had diverse previous experience but it was not noted in the study how many years of prior nursing practice they had.  Throughout the three-month orientation period the nurses kept a daily professional journal, recording their responses they believed relevant to the educational period of the orientation process and any specific supports they thought were needed.  At the end of the three-month period an experienced researcher and focus group facilitator, facilitated a focus group to “further explore the concept of transitioning into a new position” (Dellasega et al, 2009, p. 313).  The facilitator and the newly hired nurses’ clinical supervisor decided on the following prompts to stimulate conversation: What was it like to begin this new job; how did you feel about the educational content and presentation; what needs did you have during the orientation process that were and were not met?                                                                           UNIT SPECIFIC NURSING ORIENTATION      24 An iterative process was used to review the focus group transcript, by using selected journal entries to “confirm or contradict themes” (p. 313).  Data that enriched the recorded patterns was taken from other statements in the focus group and journals.  Once consensus among coders was reached, Dellasega et al, created a model to tailor the educational needs of experienced new hired nurses: the experienced nurse transition process.  The process works through three phases: assessing expectations, realistic appraisal and adjusting.   Data from phase one, assessing expectations, revealed that, not unlike newly licensed registered nurses, a nurse, although experienced, when at the start of a new position, with all the new material to learn in a short amount of time, had feelings of uncertainty and often questioned their decision to accept the new position (Dellasega et al).  In Phase two of the process, using realistic appraisal, the experienced nurses were quickly able to identify their knowledge gaps and their ability to handle the deficits.  The nurses could draw on past experiences of success to keep moving forward during their orientation.  During the adjusting phase, phase three of the process, the experienced nurses recognized their abilities to practice in their new position as soon as they started meeting with patients and putting their new knowledge into practice.  The researchers found that during the focus group session, the nurses discussed that a deficit of the orientation process was that there was no opportunity to speak with a peer clinician.   The researchers of this qualitative study noted that this was a small sample size, N=3, of experienced nurses entering a specialized role, which seemed a limitation.  These nurses were given quite a bit of time to thoroughly document in their journals and then discuss their experiences.  Dellasega et al (2009) found that new hire orientation ought to be tailored to the new hire when it comes to hiring an experienced nurse.  The researchers found that experienced newly hired nurses felt trepidation at the beginning of their orientation to a new position, not                                                                           UNIT SPECIFIC NURSING ORIENTATION      25 unlike a novice newly hired nurse.  Unlike a novice newly hired nurse, the experienced newly hired nurse could recognize what they did not know earlier than a novice newly hired nurse and had an easier time seeking out resources they needed to facilitate their ongoing learning.  The newly hired nurse is not always a novice or newly graduated nurse and this study shows that even an experienced newly hired nurse requires a strong orientation.  Understanding that not every newly hired nurse has the same teaching needs is important for an effective and successful unit specific orientation. Transition Support Several of the selected articles in this review have mentioned the importance of a transition process for newly hired nurses to an acute care setting which is a continuation of a well-supported orientation process and may enhance nurse retention (Dyess & Parker, 2012, Peltokoski et al, 2015, Rush et al, 2015).  Dyess and Parker, described and evaluated a community collaborative project, Novice Nurse Leadership Institute (NNLI) and development of a transition program that involves 13 healthcare organizations that provided support for 109 newly licensed registered nurses (NLRNs).  The program uses diverse pedagogical methods, such as lectures, online classes and experiential learning, to support NLRNs in strengthening competencies in clinical skills, coping skills, and introducing the concept of leadership.  The participants in the program had 12 months or less of work experience and were selected by their organization.  The program begins every September and ends in June of the next year (10 months) and consists of 20 8-hour sessions that takes place on the campus within the University College of Nursing.   Dyess and Parker (2012) collaborated with the partnering organizations within the NNLI to produce an evaluation plan for the program.  To evaluate the impact of the program, a mixed                                                                           UNIT SPECIFIC NURSING ORIENTATION      26 methods approach was used with a pre-and post-evaluation design.  The study evaluation question was: “what was the newly hired Registered Nurse and organizational related outcomes as a result of participation in the NNLI program?” (p. 618).  The specific evaluated outcomes included: skills and competency, leadership development, and retention rates in the participating organization and in the profession. This was a quantitative study with a convenience sample of N=109.  The sample included all NNLI program participants from 2006-2009.  Data was collected at the beginning of the NNLI program and during session 19 using the same survey instrument which measured skill set acquisition and leadership development.  The instrument used to measure clinical psychosocial and technical skills was the 52 question self-report tool, the Nursing Evaluation Competency Assessment (NECA).  The items on the NECA were scored on a four-point Likert scale and measures five dimensions of practice: planning and evaluation, patient care, communication, member of the discipline and leading care.  The leadership competencies were measured with the Student Leadership Practices Inventory (SLPI), which is a 30 question self-report instrument that assesses five elements of leadership.  The SLPI was scored on a 5-point Likert-type scale. The pre- and post NNLIs program scores were compared and analyzed using a Student’s paired t-test.  The final sample was N=89 as not all surveys were fully completed.  The score relevant to my research question was the impact of this program on acquisition of clinical skills.  The researchers found that there was a statistically significant difference in clinical skill acquisition during the first year.  The newly hired nurse orientation program was a learner centered multimodal transition program consisting of on-line, in-class and hands-on instruction.  The newly hired nurses were asked to select their own mentor; a mentor was an experienced                                                                           UNIT SPECIFIC NURSING ORIENTATION      27 Registered Nurse who would be the newly hired nurses’ ‘go to’ resource person throughout the transition period.  There was no significant difference with the communication subscale.  There was also a significant association with retention and the NNLI program.  All 109 nurses who participated in the NNLI program inception (2006) were still practicing in 2010, when this study ended and 80% of those nurses remained with their original employer.  Dyess and Parker (2012) state that this study cannot be generalized as only the nurses selected by their organizations were admitted to the NNLI program and not all nurses had the opportunity to participate.  A self-repot survey may skew results as it is one’s own view of one’s competencies.  Still, the study employed a learner-centered model, promoting a unit orientation which continued into a transition period to better support newly hired nurses in their new position in hopes of increasing retention of nurses.  This seemed an effective strategy. The second study that reported relevant findings about transition support was a cross-sectional pilot study which examined newly hired nurses’ and physicians’ perceptions of a comprehensive health care orientation process in two Finnish acute care hospitals with each using a similar orientation process (Peltokoski, Vehvilainen-Julkunen & Miettinen, 2015).  The researchers used a convenience sample of RNs (N=145) and Physicians (N=37).  Peltokoski et al (2015) outline four important aspects of a comprehensive health care orientation process: goals and responsibilities, standardized content, implementation and evaluation.  The above-mentioned aspects of this study are relevant to my research question about a learner-centered pedagogical focus.  In this study success of the orientation process is a shared responsibility between managers, educators, preceptors and the orientee.  The orientees’ needs and goals guide their learning which then should be supported by the preceptor to maintain a learner-centered focus.  In addition, leadership and progress must be evaluated on a continuous basis.                                                                           UNIT SPECIFIC NURSING ORIENTATION      28 Peltokoski et al (2015) report that between May 2009 and June 2010, all RNs and physicians who were employed in May 2009 or later and were still employed at least three months were mailed a 55-item questionnaire.  Of the 401 questionnaires mailed out, 182 were returned.  A newly developed instrument was used to evaluate the orientation process: the orientation process evaluation (OPE).  Prior to start of this study a pre-test was performed, which was not used in the study, with a convenience sample from both study hospitals, RNs (N=16) and physicians (N=2).  In collaboration with the expert group and the results of the pre-test, the questionnaire was shortened to 54 items with following 4 sub-scales: goals and responsibilities, standardized content, implementation and evaluation.  The response choices were on a five-point Likert scale.  The reliability of the scale was considered good with the Cronbach’s alpha value of 0.87 (p. 616).  As the OPE instrument is relatively new further research is needed to validate this instrument. The RNs and physicians were asked to report the length of their orientations in days and these ranged was between less than 4 days to 25 days.  Satisfaction was measured on a scale of 4 to 10 (4 the worst and 10 the best) and was moderately low.  None of the 4 sub-scales achieved a target level score of 4 or more, the highest score was goals and responsibilities at 3.45 and the lowest score was evaluation at 2.64.  This is significant as 27% of respondents reported that at no time before, during or after the orientation process was their competence level assessed and 51% of respondents reported that the only feedback they received was from preceptors and peers.  A significant finding was the critical role an appointed preceptor had on a favourable orientation outcome and another that a longer orientation period correlated positively with a comprehensive orientation process.                                                                            UNIT SPECIFIC NURSING ORIENTATION      29 The third study addressing transition support, by Rush, Adamack, Gordon, Janke, and Ghemet (2015), is a Canadian quantitative study which is a part of a larger mixed methods study across seven hospitals in British Columbia.  This study compared new RN graduates who participated in a new graduate transition program (NGTP) versus RNs who went through standard orientation (SO).  Internationally, transitional programs have been developed to facilitate and support the integration of newly licensed RNs into the workplace.  In the United States, transitional programs have been “recommended as standard practice to facilitate new graduate transition” (p. 144).  An implication for nursing management reported in the study that stood out for me was the idea that nurse managers should specifically train preceptors instead of choosing random RNs to place with newly hired RN graduates.  This strategy helps the new RN grad get the support they need while the preceptor receives the specific training they require. The researchers define orientation as “a period to familiarize staff with a new work environment, related expectations, and policies and included clinical support through a supernumerary period” and define a transition program as “a program that occurred in addition to a general and/or specific unit orientation and was designed specifically to assist new nurse graduates with their transition to practice” (p. 145).  Rush et al (2015) describe a transition program as a phase which follows the initial general nursing orientation and unit specific orientation, providing continued non-evaluative support from a mentor.   Rush et at (2015), sent the new RN graduates (n=1008) who were working in an acute care setting an on-line survey that consisted of five sections: demographics, orientation to the employer/nursing unit, general transition, specific new graduate nurse transition program and the Casey-Fink Graduate Nurse Experience Survey.  The survey was sent out via e-mail from mid-June to mid-July 2011.  Of the 1008 surveys e-mailed out, n=245 RNs’ surveys were retained for                                                                           UNIT SPECIFIC NURSING ORIENTATION      30 statistical analysis.  Slightly less than half of the respondents had been working for more than a year as a new graduate RN, 39.2% had worked six months to a year and 12.7% had worked for less than six months. The research reported that 174 respondents had received a unit specific orientation and of these respondents, 44.8% reported an orientation that was two weeks or less, 27.6% reported an orientation that lasted more than two weeks but less than four weeks and 27.6% reported an orientation that lasted longer than four weeks.  Over half of these new graduate RNs had more than 75% preceptored shifts.  Post-hoc comparisons not only revealed that nurses who attended an orientation of four weeks or longer had significantly higher transition scores, 6.30 points higher, than RNs whose orientation were 2 weeks or less but also significantly outperformed other nurses on the communication/leadership scores (P=0.0152), the support scores (P<0.0001) and the professional satisfaction scores (P=0.004) (Rush et al, 2015, p. 148).   This was a surprising finding; a one-way analysis of variance showed no statistically significant relationship between the amount of preceptored shifts and transition score.  There was however a statistically significant difference in transition scores between new graduates who participated in a formal NGTP and those RNs who did not.  In addition, those RNs who completed an NGTP scored higher than those that did not, in organising/prioritising, communication/leadership, support, and professional satisfaction.  Rush et al, discovered that the more hours a new RN graduate works (>49 hours) in a two-week period, the more comprehensive their transition.  Over a third of the respondents worked as casuals, thereby working short notice call relief, which is not regular work hours, limiting their number of work hours and “threatens their integration and transition to the workplace” (p. 153).                                                                             UNIT SPECIFIC NURSING ORIENTATION      31 A common theme and conclusion that threaded its way through these three studies was the need for an experienced preceptor to mentor and guide the newly hired nurse throughout the orientation and transition process.  Also, that the length of the well-designed orientation and transition period is long enough to facilitate a learner-centered approach for the newly hired nurse, promoting a successful beginning to a nursing career.    A Fellowship A retrospective descriptive comparative study by Friedman, Delaney, Schmidt, Quinn and Macyk (2013), described strategies for nursing retention and financial impact on a pediatric critical care unit and a critical care unit.  The purpose of this study was to determine the retention and cost associated with the hiring of new graduate RNs before and after the implementation of a specialized nurse fellowship program.  The goal of the Pediatric Nurse Fellowship Program (PNFP) which was implemented at the Cohen Children’s Medical Center (CCMC) in United States was to appropriately educate and mentor pediatric critical care, emergency department, and hematology and oncology nurses.  Historically, new graduate RNs were not hired immediately into these high acuity units but since experienced RNs were not applying for the positions the fellowship program was implemented to educate, mentor and support newly hired and newly hired graduates to facilitate an increase in retention and decrease turnover. The RN retention rate at CCMC from 2005 through 2007 (prior to the implementation of the PNFP) was 65% for one year and 50% for two years.  Prior to the implementation of the PNFP at CCMC, the cost associated with orientation was more than $250,000.  This program was in place to bridge the gap between new graduate or novice nurses to pediatric critical care                                                                           UNIT SPECIFIC NURSING ORIENTATION      32 and the high acuity unit by providing educational tools, professional mentoring, and support mechanisms.   The PNFP design is three semesters long (52 weeks).  This program used a mix of learning modalities to educate the newly hired pediatric nurses.  Allowing each newly hired pediatric nurse, whether they were a novice nurse or an experienced nurse, to adjust the program template that best suited their educational needs.  Semester 1 (weeks 1-10) provides: simulation, Essential of Critical Care Orientation (ECCO), pediatric ECCO, or Association of Pediatric Hematology Oncology Nurses (APHON) and Bone Marrow transplant (BMT) core curriculum, professional seminars, assignments with master fellow and RN mentorship.  Semester 2 (weeks 11-27) provides: preceptorship with a specially educated associate fellow (share patient assignment and work schedule), meetings and educational sessions with master fellow, 2 bring back days (focus groups), and completion of clinical pathway.  Semester 3 (weeks 27-52) provides: independent patient assignments with resource person (senior associate fellow), individual work schedule, bring back day, and graduation (Friedman et al, 2013, p. 163).   Friedman et al (2013), used a retrospective descriptive evaluation design for this study.  Retention between a group of RNs who went through the standard orientation (SO) and RNs who went through the PNFP were evaluated.  A non-probability convenience sample was used consisting of new grad RNs starting orientation (SO) during March 2005 to August 2007, prior to the implementation of the PNFP and September 2007 to March 2010, after PNFP implementation.  SO was 18 weeks long and consisted of two weeks of classroom work with take-home self-learning modules and post-test.  The RN then worked with an assigned preceptor on the unit for two to six months.                                                                           UNIT SPECIFIC NURSING ORIENTATION      33 Retention was measured from data collected at four points, 3, 6, 9, and 12 months, from CCMC’s department of human resources, after commencement of their programs.  The research question was: What is the difference in retention for new graduate RNs pre-and post-initiation of the PNF orientation program?  The sample was a non-probability convenience sample and consisted of 77 new graduate RNs; SO RNs (n=28), PNFP RNs (n=49).  The four-point chi-square test for retention yielded a statistically significant difference of retention at nine months: retention of SO RNs was 82% and retention on PNFP RNs was 94%.  An independent sample t-test was conducted in the difference of length of employment between the SO and PNFP RN groups and the length of employment were significantly higher in the PNFP group. The implementation of the PFNP resulted in a comprehensive orientation process for the new graduate RN that included: a preceptor, educator, and regular leadership meetings for evaluation and assessment of knowledge.  Although fiscally, a 52-week orientation program may not be appropriate for an entry-to-practice nursing position, the pedagogical strategy of learner focused orientation appears to tie in with a successful orientation of a newly hired bedside nurse.   Staged or Phased Orientation The following two studies by Gomes, Higgins, Butler, and Farzaneh (2009) and Kozub, Hibanada-Laserna, Harget, and Ecoff (2015) respectively, report that a staged or phased orientation process is integral to promoting a favourable outcome for both newly hired nurses and the organization’s leadership; newly hired RNs gain confidence in their nursing competencies by gradually being introduced (over a period of time) to higher acuity and more complex patients while being supported by peer mentors and nursing managers may be able to reduce nursing turnover.                                                                           UNIT SPECIFIC NURSING ORIENTATION      34 Gomes et al (2009), argue that an increase in nursing turnover adversely impacts patient care, as it can create inconsistencies in care by decreasing continuity of care.  The Department of Nursing Education and Research, in which Dr. Melissa Gomes was the former Director, recognized that the quality of an orientation influences nursing turnover and it has developed and implemented an “innovative staged orientation program…[which has] received recognition for exemplifying best practice, and promises to become the gold standard for orientation within the local (urban Virginia) hospital system” (p. 575).   Gomes et al (2009) introduced this staged orientation’s structure and processes and evaluated the results in this descriptive comparative study. The researcher believes that “a supportive environment is conducive to success and retention; thus, principles of survival and caring provide the foundation of the orientation program” p. 575).  In this orientation process, there are four key individuals that provided the needed support to make this program work: unit educator, unit manager, and a preceptor and staff mentor.  Each of these individuals meet with the orientee on a weekly basis (there is no mention in this study if the team meets individually or as a group) to supportively assess the orientees progress, as this process can help recognize issues early and a learning plan can be implemented.  The researchers stated that the preceptor is at the center of this program and should not only be trained and equipped with the appropriate tools as a preceptor but should also receive support from the other stakeholders.   A staged program is based on a Maslow’s type hierarchy, where the orientee can build upon their skills in patient care complexity, workload organization and critical thinking.   Between each stage is when assessment and evaluation is needed.  At the apex of this program is a “specialty based, on-line curriculum that is supplemented by didactic classroom sessions, simulations, and clinical rotations” (p. 576).  Although this program was implemented in the                                                                           UNIT SPECIFIC NURSING ORIENTATION      35 Emergency Department of a Virginia Hospital, at the time of publication of this study there was no data yet available on retention. Kozub et al (2015), described the implementation of a phased unit orientation model in United States critical care unit.  The model is based on a blend of Benner’s Novice to Expert Framework and Maslow’s Hierarchy of needs theory.  Kozub et al (2015), stated that this orientation model was selected to decrease turnover and increase retention.  In the original orientation model in this critical care unit a preceptor used competency completion without first evaluating an orientees’ skill level, at times leading to inappropriate patient assignments during the orientation period.  The original orientation model was assessed and with the blend of Benner and Maslow, a new orientation model was designed and organized into three phases which “created objective benchmarks to evaluate the orientee’s progression” (p. 206).  Phase one is 2-3 weeks in length, phase 2 is 4 weeks, and phase 3 lasts 4-6 weeks. The original orientation program matched the orientee with a preceptor using the Gregorc Style Delineator (a tool used to identify individual learning styles) and the orientee would be matched with two preceptors.  Preceptors attend an initial class before becoming a preceptor and a refresher class every 5 years (p. 207).  The first day of orientation entailed a one-on-one session with a staff development-advanced clinician (SD-AC) who gave an overview of the hospital, unit environment and routines.  The orientee then completed an ECG rhythm exam and took the ICU Basic Knowledge Assessment Test to assist the preceptor to focus on the needs of the orientee.  The orientation was a mix of didactic sessions and clinical practice.  The clinical practice was a learner-centered approach as the orientees were not only matched with preceptors but preceptors who had “similar styles for processing of information or were made aware of style differences”, enabling the preceptor to tailor the orientation to the orientee’s learning style (p.                                                                           UNIT SPECIFIC NURSING ORIENTATION      36 206).  The preceptor would assess competency throughout the orientation.  Regular meetings would be held with the SD-AC, the orientee and the preceptor to evaluate the orientation process.  If competencies were not met by the end of the orientation period a professional growth plan would be created with the SD-AC.  The phased unit orientation model came into being after the Clinical Nurse Specialist in the ICU assessed the original orientation model and concluded that although the process was comprehensive it needed structure, organization and refinement.  The preceptors gave feedback concerning the inconsistency in the progression of the competencies.  The new phased unit orientation retained elements of the old orientation model, such as, the preceptor matching, first day orientation, critical care curriculum and classes, the new hire conference worksheet, baseline BKAT, ESO testing, and bi-weekly orientation meetings.  But new elements that were added included a 3-phase orientation: basic ICU skills and safety practices, intermediate skills and time management, and complex patient conditions.  Kozub et al. noted that the “phased approach allows for building from basic to complex concepts and incremental learning” (p. 207).  The phased orientation program was implemented in May 2011 and a total of 42 RNs completed the new program through 2013.  Most newly hired nurses who attended this phase orientation program were experienced nurses, non-ICU nurses (n=27), then new graduates (n=6) and experienced ICU nurses (n=9).  During the pre-intervention period of 2009 to 2011, 41 of 43 newly hired nurses completed the orientation process and during the post-intervention period of 2011 to 2013, 42 of 43 nurses completed the orientation process.  The 1-year nurse retention rate increased from 82.9% to 87.8% post-intervention and the 2-year retention rate increased from 58.5% to 78.5% post-intervention.  The turnover rate from 2009 to 2011, went from 8% to 11%                                                                           UNIT SPECIFIC NURSING ORIENTATION      37 and after implementation of the orientation process the turnover rate went from 8% to 5% from 2012 to 2013.   The lessons learned from the implementation of this program were to “create buy-in from seasoned preceptors and collect pre-data before project implementation” (p. 213).  The sample size was small thus making statistical significance difficult.  These two studies introduced the notion that a successful orientation is well-defined, structured and consistent.  Included, the learning style of the newly hired nurse.  The inclusion and success of a learner-centered approach supports my research question.  A Unit Specific Orientation Class Particularly relevant to my research question was Ward’s (2009) study on a unit specific orientation class.  Ward examined an implementation of a unit specific orientation class and the effect of better preparation to working on a surgical unit.  Ward also measured job satisfaction and retention.  As stated by Ward (2009) an orientation program is successful if the orientee remains employed on the unit they were hired to for at least one year.  There are many reasons why a new graduate nurse leaves a workplace, including: inadequate training, lack of support, feelings of not belonging and incivility.  Preceptors are also included in this study as being an important part of a successful orientation process, as a preceptor assists with socialization and clinical practice.  The education council of the inpatient acute care surgical unit identified the need for a unit specific orientation with a preceptor along with the hospital’s general nursing orientation.  The purpose of this informal class was to “familiarize orientees with the unit’s patient population and frequently performed procedures and allow for easy discussion and active participation” (p. 88).                                                                             UNIT SPECIFIC NURSING ORIENTATION      38 The unit-specific orientation class was provided to all new nursing hires, new graduates and experienced nurses.  The education council included the input of the interdisciplinary team to put together an outline of the class and help facilitate the orientation.  The class was held over two days and along with discussing the general unit functions, orientees were taken on a tour of the unit and hospital.  There was a review of pertinent procedures performed on the unit and comprised of didactic and hands on training.  The class was designed to be informal as to illicit easy discussion and participation in a comfortable and non-judgemental environment.   Orientees completed an evaluation questionnaire at the end of the two-day class.  The study was conducted from 2004 to 2005 and in 2005 a 25-question basic knowledge assessment, which was formulated by the unit clinical nurse specialist, was added to the curriculum.  The pre-test was given at the beginning of the first day and the post-test was given at the end of the second day.  Topics included: blood transfusion, ostomy care, central lines, chest tubes, patient-controlled analgesia, total parenteral nutrition, trach care and venipuncture.  Thirteen orientees took the tests with both the pre- and post-test completed by eight orientees.  The pre-test average score was 60.5% and post-test average score was 86.5%.  A total of 22 orientees participated in the class from 2004 to 2006 and the 1-year retention rate was 59%.  The retention rate increased from 44% in 2004 to 84% in 2006 and in 2006 the class expanded to include the whole acute care division, as there was an increase in the number of new graduate nurses hired.  Based on the success of this research study, it seems reasonable to conclude that unit specific orientation is a significant pedagogical strategy in the success of a newly hired nurse.                                                                              UNIT SPECIFIC NURSING ORIENTATION      39 Summary These studies identified the different types and durations of orientation and the importance of implementing formal, learner-centered, longer, preceptor guided orientation for the newly hired registered nurse, with an increase in nursing retention as the goal.  The next chapter will discuss the findings from these studies and further analyze the implementation of a unit-specific orientation and the impact on the success of a newly hired registered nurse.                                                                                            UNIT SPECIFIC NURSING ORIENTATION      40 CHAPTER 3:  DISCUSSION OF FINDINGS The literature review identified an important relationship between effective initial and transitional support and the likely success of a newly hired registered nurse, which may then lead to a higher retention rate.  The findings from the literature review showed the importance of a well-defined and consistent nursing orientation process, one which includes a transition process (Dyess & Parker, 2012, Peltokoski et al, 2015, Rush et al, 2015).  Some of the suggestions for a successful orientation process for a newly hired Registered Nurse across the ten studies reviewed included: the use of peers as orientation preceptors, a longer duration for orientation which includes a transition period, and specific courses for newly hired nurses.  In relation to the use of peers as orientation preceptors, the related studies confirmed that although peer preceptors are an important part of the orientation process, it is imperative that preceptors are given the opportunity to be educated for the role of preceptor.  Another common suggestion that will be discussed is the idea of implementing a longer orientation process that includes a transition period.  Specific new hire courses were discussed in some of the studies with the aim of identifying and addressing common struggles of new hired nurses to better support them during their orientation phase. In this discussion chapter, the afore mentioned suggestions for a successful orientation process will be discussed. In the studies reviewed in this integrative literature review, support was recognized as being delivered by the following: Clinical Nurse Educators, Clinical Nurse Leaders, Orientation Nurse, Peer as Preceptor and Patient Care Manager (Culley et al, 2012, Sullins, 1989, Gomes et al, 2009).  Although all the individuals mentioned here play an important supportive role with the newly hired registered nurse, the one role mentioned in seven out of the ten reviewed studies, as critical, is that of the Preceptor.                                                                             UNIT SPECIFIC NURSING ORIENTATION      41 According to Jeffery and Jarvis (2014), the preceptor, usually chosen by the Clinical Nurse Educator, is the person who will mentor and evaluate the newly hired registered nurse throughout unit specific orientation.  The responsibilities of the preceptor during orientation is vast and includes not only continued clinical assessment with constructive and positive feedback but also, provides unit specific learning opportunities.  Unit specific learning opportunities pertain to common practices, clinical tasks, documentation, paperwork and cultural norms associated with each specific clinical unit.   The preceptor is a peer from the unit in which the newly hired registered nurse has been hired to and carries a major “influence on the comprehensive orientation process” (Peltokoski et al, 2015, p. 619).  The researchers of the studies which involved preceptors mentioned that dedicated preceptorship shifts are valuable to the orientation process and selection of preceptors must be done carefully, to be able to match learning styles of the orientee with an appropriate preceptor (Gomes et al, 2009, Peltokoski et al, Rush et al, 2015, & Ward, 2009).  This is no easy task but by developing a preceptors’ teaching and clinical skills through formal preceptor education and continued preceptor competencies, there is a greater possibility of success and retention of a newly hired registered nurse.  The continued education of a preceptor will also support the preceptor in understanding the learner-centered approach to learning, particularly when the orientee has a differing learning style than the preceptor (Ward, 2009). Sorensen and Yankech (2008) state that there is a correlation between improvement of an orientees’ critical thinking skills and a preceptor who has been specifically trained to be a preceptor, which can then lead to a more profound orientation experience on hospital units, units which are becoming more acute and fast paced (Baggot, Hensinger, Perry, Valdes & Zaim, 2005).  Sandau & Helm (2011) and Sandau, Cheng, Pan, Gaillard & Hamme (2011), found that                                                                           UNIT SPECIFIC NURSING ORIENTATION      42 developing a strong preceptor education workshop can lead to an increase in retention of the newly hired registered nurse, thusly reducing unit attrition costs.  While many of the research studies surveyed newly hired nurses, who were also newly graduated registered nurses, one study by Dellasega et al (2009), followed three experienced registered nurses, hired to a new position, during their six-month orientation period.  The researchers noted that when these experienced nurses came together in a focus group to discuss their orientation experience, all three experienced registered nurses mentioned that they believe they would have benefited from support from a peer clinician.  Although these were experienced nurses who could identify and verbalize their own knowledge gaps, they felt a peer clinician, which arguably could be considered very similar to a preceptor, would have been a welcome support and resource.  It is interesting to note that even though these three newly hired nurses were experienced nurses, the orientation period stretched over six months. The researchers in many of the research studies included in this literature review, recognized that there may be a relationship with orientation satisfaction and duration of the orientation.  Salonen, Kaunonen, Meretoja & Tarkka (2007), found that newly hired nurses were “significantly more satisfied with the duration” of orientation when a preceptor was provided (p. 797). Although my research question is directed at unit specific orientation, I included this finding because it has relevance for enhancing unit specific orientation.  These researchers’ observation that an effective transition process, which is longer than an orientation period, is an effective pedagogical strategy that supports newly hired nurses is relevant for unit specific orientation.  I would argue that an effective unit orientation should include a strong transition process.  Newly hired registered nurses on general acute care units are faced with a hectic environment that includes patients with higher acuity, demand for faster discharges and constant                                                                           UNIT SPECIFIC NURSING ORIENTATION      43 evaluations of patient care quality and safety. (Dyess & Parker, 2012, Peltokoski et al, 2015, Rush et al, 2015). Orientation for a newly hired registered nurse commonly consists of a week-long general nursing orientation, hosted by the hiring institution.  This general nursing orientation is not specific to any institution department, as there are newly hired nurses from all departments in attendance.  Unit specific orientation follows general nursing orientation and it is up to the individual departments as to how unit specific orientation is conducted, including length of time, and it is a period where the newly hired nurse works in a supernumerary capacity with support, learning the culture, daily norms, expectations of the unit (Rush et al).  There is a significant discrepancy among the studies included in this integrative review, as to duration of orientation, ranging from zero days of orientation to 10 months of orientation making direct comparisons difficult (Dellasega et al, 2009, Peltokoski et al).  In the large urban hospital in which I work, unit specific orientation is two days long and is followed by four guided bedside shifts where the newly hired nurse is supernumerary and is partnered with one preceptor, who will support the newly hired nurse throughout the four guided bedside shifts.   From the review, it appears that a transition period follows unit specific orientation, which is an extension of the orientation period and includes support for the newly hired nurse but they are no longer supernumerary (Rush et al).  Rush et al, state that support during the transition period varies and typically engages the newly hired nurse in education sessions specific to nurses new to the unit and mentoring from an impartial person who provides “non-clinical and non-evaluative support” (p. 144).  Rush et al, suggests that a formal transition period needs to be implemented in consideration of newly hired nurse being largely hired in a casual capacity prior to acquiring full time work.  This can greatly impede the continuity required to become a                                                                           UNIT SPECIFIC NURSING ORIENTATION      44 confident and competent nurse when the newly hired nurse is not always working with the same patients or the same nursing and interdisciplinary team.   While Dellasega et al (2009) did not mention the term transition in their research, the newly hired nurses included in this study had an orientation period which lasted six months, much longer than orientation periods mentioned in other research studies regarding orientation.  As mentioned in Chapter 2, there were three phases to this study: assessing expectations, realistic appraisal and adjusting.  The newly hired nurses were given more orientation time to understand and recognize their knowledge gaps in phase two of orientation, realistic appraisal.  The nurses were included in their own learning process by identifying gaps and managing these gaps, indicating a learner-centered approach that enhances nurse engagement in their learning during orientation, thus enhancing success and retention of these newly hired registered nurses. Regardless of the terminology used in the research studies, orientation or transition period, a common theme was the length of time and how the orientation or transition period ought to be at least four weeks in length (Rush et al, 2015).  A longer orientation or transition period allows adequate time for the newly hired registered nurse to practice any new skills needed for the unit in which they were hire and for their orientor or preceptor to understand what their learning needs are and properly orient them with the goal of competent and safer patient care and building the foundation to a successful nursing career (Peltokoski, Vehvilainen-Julkunen & Miettinen, 2016). In several of the studies, the researchers implemented a formally structured orientation program which commenced with the basic general nursing orientation and then transitioned into a structured program consisting of specific courses (Culley et al, 2012, Friedman et al, 2013, & Kozub et al, 2015).  The orientation programs differed in length: three, five, and six months.  All                                                                           UNIT SPECIFIC NURSING ORIENTATION      45 the orientation programs for newly hired registered nurses provided a detailed curriculum to be followed over a specified period.   Two of the studies included in this integrative literature review pertained to registered nurses newly hired in a specialized unit, critical care (Friedman et al, 2015, Kozub et al, 2015).  The purpose of these two studies was to improve an existing orientation program and to increase retention.  Included in these programs and an important component, was ensuring that each new nurse hired was partnered with an experienced preceptor.  Each newly hired nurse attended courses specific to critical care and because both models were based in a learner-centered approach, experienced registered nurses were given the opportunity to progress at a more rapid rate.  The curriculum in Kozub et al’s study was presented in three phases, although there was a target orientation time of eleven to twelve weeks, newly hired ICU experienced nurses could finish the program in six to eight weeks and newly graduated nurses could extend their learning to eighteen weeks.   An important part of the orientation process is for the orientee to be objectively evaluated.  Providing well-defined program criteria gives the orientee a clear understanding of what their learning goals and program expectations are throughout the orientation and removes the potential of preceptor evaluation subjectivity (Kozub et al, 2015).   Although literature on unit specific orientation was not abundant, in the studies I selected, the research was conducted on specialized hospital units.  The study conducted by Culley et al (2012), evaluated a pilot project which introduced a new approach to a general nursing orientation for newly hired nurses, novice and experienced.  As with all the studies included in this integrative literature review, the purpose of Culley et al.’s study was to improve nurse retention by starting with evaluating the original orientation process and implementing a change                                                                           UNIT SPECIFIC NURSING ORIENTATION      46 that focused on reducing errors and improving nurse retention.  The researcher found that not all nurses have the same learning styles and providing a learner-centered approach to orientation may help better the learning experience.   Delivering the mass amount of required orientation information to the newly hired nurse in diverse learning modalities and over an extended amount of time increases the chance that there is a leaning style that meets the preference of the learner.  The formal curriculum for general nursing orientation, which Culley et al. implemented, is conducted over a two-day period, unlike the formal curriculum for a specialized unit.  The specific classes needed were identified from closely monitoring newly hired nurses over a six-month period and ascertaining trends in types of errors and causes for attrition (Culley et al).  The structured classes follow a learner centered approach by using different styles of teaching, didactic and hands-on simulation, allowing the learner to be evaluated in a controlled supportive environment.  The study authors would like to continue their research and compare the orientation curriculum model with that of a “nurse-residency model” which would extend the program six to twelve months and pair a newly hired nurse with a preceptor who would incrementally evaluate the orientee’s progress. The large urban hospital in which I work as a clinical nurse educator offers a one year New Grad program for newly hired registered nurses.  The varied course topics provide new nurses with support and guidance in areas that have been addressed as areas where new grads commonly struggle with in their first year of work, such as, Code Blues, Lab Results, and Death & Dying.  Though the courses are readily available multiple times throughout the year and the new hire is paid to attend, it is not mandatory to attend these courses.  I have found that because newly hired nurses are usually hired in a casual capacity, it is difficult to say no to a twelve-hour work shift in order to attend a four-hour class.  I believe making these classes mandatory would                                                                           UNIT SPECIFIC NURSING ORIENTATION      47 benefit the orientation process by providing the support needed to increase orientation satisfaction and increase nurse retention.  The main suggestions for a successful orientation process for a newly hired Registered Nurse across the ten studies reviewed included: the use of peers as orientation preceptors, a longer duration for orientation which includes a transition period, and specific courses for newly hired nurses.  A directing notion for the implementation of these suggestions to be successful is the concept of orientation to be guided by a learner-centered approach.  It is the newly hired nurse who will know how they best learn and retain knowledge and successfully start or continue their nursing career journey.                                                                                           UNIT SPECIFIC NURSING ORIENTATION      48 CHAPTER 4: CONCLUSION AND RECOMMENDATIONS  The purpose of this integrative literature review was to examine studies that explore how unit specific orientation can be enhanced to maximize newly hired nurses’ confidence and knowledge base at the start of their new position with the goal of increased nurse retention.  The search garnered ten studies in which orientation was analyzed, evaluated and new approaches implemented.  The ten studies included: two qualitative studies, one with a mail out questionnaire and the other used journaling, focus groups and interviews, an experimental study using performance reviews with a control (traditional orientation) and experimental (formal curriculum orientation) group, two quantitative studies, one using pre-post evaluation questionnaires and the other using an on-line survey (which was part of a larger mixed methods study), a retrospective descriptive comparative study which used a questionnaire to compare new nurses who went attended the standard orientation versus those who attended a fellowship orientation program, two descriptive comparative studies, both using statistical evaluation of new hired nurses who went through traditional orientation compared to those attending a phased or staged orientation program, a cross-sectional descriptive pilot study using a questionnaire to survey nurses and physicians to evaluate the orientation process and a descriptive study using evaluation questionnaires post an implementation of a formal unit specific orientation class.  Common themes which emerged from the ten studies were discussed and the findings support that a successful orientation uses peers as preceptors during orientation, also prepares the preceptors, and has a longer duration which includes a transition period and specific courses for newly hired nurse.  Success was measured by an increase in retention rates and decrease in clinical errors which seemed effective criteria for success.  Although research on the topic of                                                                           UNIT SPECIFIC NURSING ORIENTATION      49 unit-specific orientation is new, the research question can be answered because effective, learner-centered unit orientation does enhance newly hired registered nurses’ success and retention. Peers as orientation preceptors was identified in the literature as a necessity for a successful new hire nursing orientation (Dyess & Parker, 2012, Friedman et al, 2013, Gomes et al, 2009, Kozub et al, 2015, Peltokoski et al, 2013, Rush et al, 2015, Ward, 2009).  The preceptors should be appropriately educated as preceptors, which includes knowledge of differing learning styles, and following a learner-centered approach to teaching.  Also, preceptors should be oriented to the goals and content of an orientation program and the goals of the newly hired nurse (Dyess et al, Friedman et al, Gomes et al, Rush et al).  The literature also suggests that providing a newly hired nurse with a trained preceptor has increased orientation satisfaction and new hire retention.  A trained preceptor has the capability to understand the learning style preferences of a newly hired nurse, even though it may not align with their own learning style, and provide appropriate learning opportunities. A longer orientation or transition period was also a common theme that threaded its way through the literature (Dyess et al, 2012, Gomes et al, 2009, Peltokoski et al, 2015, Rush et al, 2015).  The findings suggest a correlation between an increased length of orientation and an improvement in new hired nurses’ confidence as they build relationships with patients, peers and the interdisciplinary team.  Additionally, the study outcomes of nurses who had a longer orientation showed that these nurses were more satisfied with their work, increasing nurse retention. Some pedagogical strategies which came from the literature was the implementation of a formally structured new hire curriculum, which includes a longer transition period (Culley et al, 2012, Friedman et al, 2013, Kozub et al, 2015).  A structured curriculum enhances development                                                                           UNIT SPECIFIC NURSING ORIENTATION      50 for the newly hired nurse by introducing mixed modalities of education, such as on-line classes, lectures, and simulation.  Combined with the mixed modality of education is a partnership with peer preceptors, educators, and management.  This dedicated curriculum and support has the potential to increase the newly hired nurses’ knowledge, confidence and competence, leading to increased retention and job satisfaction.  Suggestions for Education and Organizations According to a 2008 study conducted by O’Brien-Pallas et al (2010), nurse turnover rate in Canadian hospitals is approximately 20% each year.  With the increasing need for nurses and the decrease in retention, continued research is needed to attempt to lessen the turnover rate.  The findings from the literature review have highlighted the necessity to decrease the nurse attrition rate, and starting with the implementation of effective orientation processes seems an essential first step for every new nurse’s introduction to their work place.   It is recommended that a successful orientation include a preceptor, a preceptor who is trained for the role.  On the entry-to-practice acute medical unit of which I am a Clinical Nurse Educator, the only requirement for an orientor is to have been working on the unit for at least a year.  No formal preceptor education is required.  I would like to see mandatory preceptor education provided and continued preceptor education for nurses who would like to mentor and learn how to teach in a learner-centered approach.   It is suggested that mixed modalities of teaching be implemented for orientation, ensuring that all learning styles are covered.  Organizations should offer not only didactic lectures to cover the policies and standards of the workplace but also include on-line modules and simulation so                                                                           UNIT SPECIFIC NURSING ORIENTATION      51 newly hired nurses can practice clinical skills and can learn from errors for better patient safety and quality of care. A key finding related to successful orientation is the need for longer durations of orientation.  Length of orientation would rely on the experience of the newly hired nurse, as not all newly hired nurses are novices but saying that, an experienced nurse may have experience in one branch of nursing and may require as much orientation as a novice nurse (Dellasega et al, 2009).  A proposal would be to evaluate the clinical expertise and learning style of the newly hired nurse prior to orientation and tailor the orientation specifically to the new nurse hire. A learner-centered approach, which is the core notion in my research question, is recommended for unit specific orientation.  A learner-centered approach has the potential of closing any knowledge gap a newly hired nurse may have that may impede confidence and competence as they move along in their nursing career.  Thusly, potentially increasing nurse retention.  Limitations of the Review Several limitations to this integrative literature review have been recognized.  Nursing research is relatively new on the topic of unit specific nursing orientation and only a few studies were available and within these few studies, only one pertained to a general medical unit, the two other studies related to specialized units.  Newer studies were easier to find when nursing retention was used in conjunction with orientation when searching the literature.   Another limitation was the quality of the studies.  Sample sizes were relatively small and some studies used convenience samples making generalizability and assessing statistical significance difficult.                                                                             UNIT SPECIFIC NURSING ORIENTATION      52 Conclusion Acuity on general entry-to-practice hospital units has increased and nurse retention has decreased.  According to the findings in this integrative literature review a well-designed unit orientation with a mixed modality of education, promotes confidence and competence thereby potentially increasing nurse retention rates by providing structured support throughout an extended transition period.  A strong supportive orientation incorporates a learner-centered approach (Edwards, et al, 2015; Park, 2010).  Nursing research is relatively new on the topic of unit specific nursing orientation and because of the ever-increasing concern with nursing turnover it is imperative that this research continues.                                                                                         UNIT SPECIFIC NURSING ORIENTATION      53 References Baggot, D. M., Hensinger, B., Parry, J., Valdes, M. S., & Zaim, S. (2005). The new         hire/preceptor experience: cost-benefit analysis of one retention strategy. Journal of         Nursing Administration, 35(3), 138-145.  Retrieved from         http://ovidsp.tx.ovid.com.ezproxy.library.ubc.ca Brakovich, B., & Bonham, E. (2012). Solving the retention puzzle: let's begin with nursing           orientation. Nurse leader, 10(5), 50-61.  doi:10.1016/j.mnl.2012.03.010  Culley, T., Babbie, A., Clancey, J., & Clouse, K. (2012). Nursing U a new concept for nursing         orientation. Nursing management, 43(3), 45-47.           doi:10.1097/01.NURSE.0000406194.73311.8f  Dellasega, C., Gabbay, R., Durdock, K., & Martinez-King, N. (2009). An exploratory study of          the orientation needs of experienced nurses. Journal of Continuing Education in Nursing,          40(7), 311-316 316p. doi:10.3928/00220124-20090623-04 Dyess, S., & Parker, C. G. (2012). Transition support for the newly licensed nurse: a programme          that made a difference. Journal of Nursing Management, 20(5), 615-623.          doi:10.1111/j.1365-2834.2012.01330.x Edwards, D., Hawker, C., Carrier, J., & Rees, C. (2015). A systematic review of the          effectiveness of strategies and interventions to improve the transition from student to newly           qualified nurse. 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Indianapolis, Indiana: Sigma Theta Tau International. Kozub, E., Hibanada-Laserna, M., Harget, G., & Ecoff, L. (2015). Redesigning orientation in an          intensive care unit using 2 theoretical models. AACN advanced critical care, 26(3), 204-         214.  doi: 10.1097/NCI.0000000000000088  O’Brien-Pallas, L., Murphy, G.T., Shamian, J., Li, X. & Hayes, L.J. (2010). Impact and            determinants of nurse turnover: a pan-Canadian study. Journal of Nursing Management,           18, 1073-1086.  doi: 10.1111/j.1365-2834.2010.01167.x  Olmstead, J., Hoskins, R., MacCartney, V, & Little, J. (2013). World’s best orientation progess           grading sheet: Handling employees demonstrating failure to progress through orientation.           Journal of Emergency Nursing, 39(1), 82-85.  Retrieved from          http://doi.org.ezproxy.library.ubc.ca/10.1016/j.jen.2012.10.005 Peltokoski, J., Vehvilainen-Julkunen, K., & Miettinen, M. (2016). Nurses’ hospital orientation          and future challenges: an integrative review. International Nursing Review, 63, 92-103.          doi: 10.1111/inr.12226                                                                            UNIT SPECIFIC NURSING ORIENTATION      55 Peltokoski, J., Vehvilainen-Julkunen, K., & Miettinen, M. (2015). Newly hired nurses' and          physicians' perceptions of the comprehensive health care orientation process: a pilot study.          Journal of Nursing Management, 23(5), 613-622. doi:10.1111/jonm.12187 Rush, K. L., Adamack, M., Gordon, J., Janke, R., & Ghement, I. R. (2015). Orientation and          transition programme component predictors of new graduate workplace integration. Journal          of Nursing Management, 23(2), 143-155. doi:10.1111/jonm.12106 Salonen, A. H., Kaunonen, M., Meretoja, R. & Tarkka, M.-T. (2007). Competence profiles of         recently registered nurses working in intensive and emergency settings. 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The orientation process. Strategies to ensure success. AORN journal,           49(2), 536.  Retrieved from https://doi.org/10.1016/S0001-2092(07)66676-9                                                                             UNIT SPECIFIC NURSING ORIENTATION      56 Torraco, R. J. (2005). Writing integrative literature reviews: Guidelines and examples. Human           Resources Development Review, 4(3), 356-367.  Retrieved from           http://search.proquest.com.ezproxy.library.ubc.ca/docview/221810269?accountid=14656 Ward, C. W. (2009). Enhancing orientation and retention: one unit's success story. Journal of         Continuing Education in Nursing, 40(2), 87-90. doi:10.3928/00220124-20090201-11k Weimer, M. (2013). Learner-centered teaching: Five key changes to practice (2nd ed.). San           Francisco, CA: Jossey-Bass. Whittemore, R. and Knafl, K. (2005). The integrative review: Updated methodology. Journal of          Advanced Nursing, 52, 546-553.  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