@prefix vivo: . @prefix edm: . @prefix ns0: . @prefix dcterms: . @prefix skos: . vivo:departmentOrSchool "Applied Science, Faculty of"@en, "Nursing, School of"@en ; edm:dataProvider "DSpace"@en ; ns0:degreeCampus "UBCV"@en ; dcterms:creator "Mok, Keilee"@en ; dcterms:issued "2017-01-04T17:21:01Z"@en, "2016-12"@en ; dcterms:description "Background/Purpose: As private hospitals become more popular in Hong Kong, the quality of nursing care has become the focus of executive teams within the private sectors. With recent high nursing turnover rate and low work morale, Hospital S (a private hospital in Hong Kong), has created a new standardized two-day nursing orientation program to address this nursing shortage. The overall objectives of this orientation program are: to strengthen nursing professional identity, to standardize nursing competency, and to build a confident and competent nursing team to provide safe care. The purpose of this paper is to discuss the creation of this quality improvement project, the Strength-Weakness-Opportunity-Threats (SWOT) analysis framework, and the application of leadership strategies along the implementation process. Method: Through a two-day interactive, structured program, new nurses have gained evidence based knowledge and practice, professional standards, and practical skills that were aimed for better clinical transition. Through case studies, practicum, and group discussion, key concepts such as patient safety, organizational values, and professional standards were reinforced. Leaders applied strategies, such as structural and psychological empowerment and staff engagement, throughout the program to ensure an increased level of nursing commitment, nurse satisfaction, and self-confidence. Results: A high level of satisfaction toward this program was reported by 18 new nurses with an increased level of professional confidence and competency. Also, this program was perceived as highly useful for clinical practice by the nurses who participated. Further, there was a high pass rate for both pre-orientation and post-orientation written test among the new nurses. These two tests were used to evaluate new nurses’ understanding of pre-reading material and orientation material. In addition, there was a 100% compliance with completed competency checklists. Conclusion: The findings indicated that this program has empowered new nurses to be confident in their clinical practice through providing structured education, professional supports, and organizational resources. Both successes and lessons learned from this program will hopefully act as a blueprint for nurse leaders when they undertake their quality improvement projects."@en ; edm:aggregatedCHO "https://circle.library.ubc.ca/rest/handle/2429/60162?expand=metadata"@en ; skos:note " A STANDARDIZED TWO DAY NURSING ORIENTATION PROGRAM: A QUALITY IMPROVEMENT PROJECT AT A PRIVATE HOSPITAL IN HONG KONG by Keilee Mok Bachelor of Science in Nursing, University of Northern British Columbia, 2005 A SPAR PROJECT SUBMITTED IN PARTIAL FULFILMENT 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 December 2016 © Keilee Mok, 2016 STANDARDIZED NURSING ORIENTATION Keilee Mok ii Abstract Background/Purpose: As private hospitals become more popular in Hong Kong, the quality of nursing care has become the focus of executive teams within the private sectors. With recent high nursing turnover rate and low work morale, Hospital S (a private hospital in Hong Kong), has created a new standardized two-day nursing orientation program to address this nursing shortage. The overall objectives of this orientation program are: to strengthen nursing professional identity, to standardize nursing competency, and to build a confident and competent nursing team to provide safe care. The purpose of this paper is to discuss the creation of this quality improvement project, the Strength-Weakness-Opportunity-Threats (SWOT) analysis framework, and the application of leadership strategies along the implementation process. Method: Through a two-day interactive, structured program, new nurses have gained evidence based knowledge and practice, professional standards, and practical skills that were aimed for better clinical transition. Through case studies, practicum, and group discussion, key concepts such as patient safety, organizational values, and professional standards were reinforced. Leaders applied strategies, such as structural and psychological empowerment and staff engagement, throughout the program to ensure an increased level of nursing commitment, nurse satisfaction, and self-confidence. Results: A high level of satisfaction toward this program was reported by 18 new nurses with an increased level of professional confidence and competency. Also, this program was perceived as highly useful for clinical practice by the nurses who participated. Further, there was a high pass rate for both pre-orientation and post-orientation written test among the new nurses. These two tests were used to evaluate new nurses’ understanding of pre-reading material and orientation material. In addition, there was a 100% compliance with completed competency checklists. Conclusion: The findings indicated that this program has empowered new nurses to be confident in their clinical practice through providing structured education, professional STANDARDIZED NURSING ORIENTATION Keilee Mok iii supports, and organizational resources. Both successes and lessons learned from this program will hopefully act as a blueprint for nurse leaders when they undertake their quality improvement projects. Keywords: nursing competency, nursing empowerment, nursing leadership, nursing orientation, nurse retention, patient safety, professional identity, program evaluation, quality of nursing, standardization in health care, SWOT analysis, quality improvement STANDARDIZED NURSING ORIENTATION Keilee Mok iv List of Tables Table 3.1 Objectives for Standardized Two Day Nursing Orientation Program…………….15 STANDARDIZED NURSING ORIENTATION Keilee Mok v Table of Contents Abstract………………………………………………………………………………………ii List of Tables………………………………………………………………………………...iii Table of Contents……………………………………………………………………………iv Acknowledgements………………………………………………………………………......v Dedication……………………………………………………………………………………vi Chapter 1: Introduction……………………………………………………………………..1 1.1 The Purpose of this Quality Improvement Project……………………………..........2 1.2 The Hospital S’s Two-Day Nursing Orientation Program…………………………...3 1.3 Theoretical Framework……………………………………………………................4 1.4 Summary……………………………………………………………………………..5 Chapter 2: Literature Review…………………………………………………….................6 2.1 Search Engines …………………………….…………………..................................6 2.2 Building Professional Identity at Nursing Orientation……………………………...6 2.3 Staff Empowerment via Quality Improvement Projects……………………………9 2.4 Apply Standardization in Nursing Orientation…………………………….............11 2.5 Summary………………………………………………………………...................13 Chapter 3: Method…………………………………………………………………….........15 3.1 The Design of a New Two-Day Orientation Program………………………...........15 3.1.1 The Overall Process. ………………………………………………………..16 3.1.2 Program structure.…………………………………………………………...16 3.2 SWOT Analysis……………………………………………………………………18 3.2.1 The relationships among strengths, weaknesses, opportunities, and threats...18 3.2.2 Nursing leadership: empowerment and engagement………………………..19 3.2.3 Standardization: SPO framework, nurse competencies, orientation policies.22 STANDARDIZED NURSING ORIENTATION Keilee Mok vi 3.3 Summary……………………………………………………………………………23 Chapter 4: Findings………………………………………………………………………...24 4.1 Standardized Evaluation Tools……………………………………………………...24 4.2 Key Findings………………………………………………………………………..25 4.2.1 Staff Satisfaction ……………………………………………………............25 4.2.2 Program practicality.………………………………………………………...26 4.2.3 Staff competency…………………………………………………………….27 4.3 Summary…………………………………………………………………………....28 Chapter 5: Discussion……………………………………………………………………....29 5.1 Increased Staff Satisfaction and Professional Identity……………………………...29 5.2 A High Level of Program Practicality and Staff Empowerment…………………...30 5.3 Staff Competency and Standardization…………………………………………......31 5.4 Lessons Learned………………………………………………………………….....32 5.4.1 A rushed needs assessment…………………………………………….........33 5.4.2 Inconsistent leadership participation………………………………………...34 5.4.3 Non-comprehensive evaluation process…………………..………………....34 5.5 Implications on Nursing…………………………………………………….............35 5.4 Conclusion…………………………………………………………………………..36 References …………………………………………………………………………………..38 Appendices…………………………………………………………………………………..42 Appendix A……………………………………………………………………………..42 Appendix B……………………………………………………………………………..49 Appendix C……………………………………………………………………………..52 Appendix D……………………………………………………………………………..53 Appendix E………………………………………………………………………….…..54 STANDARDIZED NURSING ORIENTATION Keilee Mok vii Acknowledgements I would like to thank the following people for giving me support and encouragement throughout my journey with this quality improvement project. I owe my deepest gratitude to my grandmother, my mother, my aunt, and my sister who gave me the wisdom, health, freedom, and support to pursue my path in life. My grandmother is my drive to become a better person. Also, thank you to my dad, Lyall, who have been pushing me to enrich my intellectual capacity and to ponder about the true meaning of life. I would like to extend my sincere appreciation and gratitude to Dr. Maura MacPhee, my supervisor. This thesis would not have been possible without her constant encouragement, empowerment, and patience. Her wisdom, her leadership, and her sense of humor have grown on me intellectually, professionally, and personally. Maura has become my mentor and my dear friend. Maura has given me a new path toward making my dream come true- to build a brand new hospital. Thank you Maura. I would also like to thank Dr. Patricia Rodney, my project committee member, for her dedication to this long journey despite her other professional commitments and my long-distance study. I appreciated very much that she accepted my request without a question and has been extremely supportive and encouraging during the whole process. Paddy has guided me into the world of nursing politics prior to this project and it has changed my life since. Thank you Paddy. At last, I am very grateful to have the following people in my life who have been giving me unconditional love, encouragement, and happiness throughout this Masters in Nursing program: Karen L., Tina, Katie, Karen C., Melissa, Zoe, Juliana, Candy, Derek, Peter, Eric, Leigh, Tom, and Sing. Thank you to all of you. STANDARDIZED NURSING ORIENTATION Keilee Mok 1 Chapter 1: Introduction Similar to most developed countries with a two-tier health care system, Hong Kong’s public healthcare system is struggling to provide quality, safe healthcare for its growing and aging population. (Food & Health Bureau, the Government of HKSAR, 2015). Private hospitals are becoming increasingly utilized by the public. In Hong Kong, currently there are a total of 11 private hospitals and 42 public hospitals, and private hospitals comprise 10.4% of acute hospital bed capacity (Information Services Department of HKSAR, 2016). Meanwhile, the Department of Health (2016) reported that the demands on the private system have been increasing since 2013. In 2013, the total health expenditure in Hong Kong was 5.4% of its gross domestic product (GDP) and the private expenditure on health was 52.4% of the total health expenditure. This means people were pursuing private health services more than public health care that year and this situation continues today. The reasons for this growth are related to private hospitals’ record of decreased wait times and higher quality of services (Nurse A, personal communication, January 2016). Given the increasing demands for private care, these private hospitals are, not surprisingly, starting to compete with each other and seeking ways to excel in the health care “market”. The Hospital Authority in Hong Kong and many international accreditation companies evaluate hospital success based on key performance indicators, such as pressure ulcer rates and fall incidents (Food & Health Bureau, the Government of HKSAR, 2015). Many of these indicators are nurse sensitive or based on the quality of nursing care delivery. Many Hong Kong private hospital executive teams are therefore investing in nurse orientation and in-hospital education as strategies for developing and maintaining quality, safe nursing care delivery (Nurse B, personal communication, February, 2016). 1.1 The Purpose of this Quality Improvement Project In this paper, I will discuss the creation of a two-day nursing orientation program as a STANDARDIZED NURSING ORIENTATION Keilee Mok 2 quality improvement project in a small scale private hospital in Hong Kong, the Hospital S. This nursing orientation program was developed to address the high turnover rate and the low job satisfaction among Hospital S nurses. According to the Human Resources Department of Hospital S, the turnover rate among nurses is up to 32%, the highest in history for its nursing department. A high turnover rate has direct adverse effect on staff morale and productivity (Hayes et al., 2006). Through the new orientation discussed in this paper, the hospital executive team hopes to improve the quality of nursing care and to retain and recruit nurses. The means to achieve these objectives are through strengthening nurses’ professional identity, standardizing nursing knowledge and skills, and building a competent nursing team (Nurse C, personal communication, January 31, 2016). In this paper I will describe the overall creation of this orientation and some leadership strategies that were used. The aim of this paper is to use this quality improvement project as a blueprint for other health care organizations and their executive leadership. 1.2 The Hospital S’s Two-Day Nursing Orientation Program As I have indicated above, the development of a two-day nursing orientation has been a continuous quality improvement project to improve overall nursing quality and nursing practice at Hospital S. In addition, the development process helped to establish a strong professional identity among direct care nurses and their leadership, and it promoted the establishment of explicit scopes of nursing practice. Nursing orientation and building professional identity are critical to the success of nurses’ clinical adaptation and their professional role development (Burkhardt et al., 2015; Caricati et al., 2014; Deppoliti, 2008; Elias 2006; Keefe, 2007; Pine & Tart, 2007; Ulrich et al., 2010). In Hong Kong, working in a private sector is very different from working in a public sector. Public hospitals have well-developed policies and standards through the collaboration between the Hospital Authority and the Department of Health (Food & Health Bureau, the STANDARDIZED NURSING ORIENTATION Keilee Mok 3 Government of HKSAR, 2015), and these policies and standards are tightly regulated. Although private hospitals are also regulated by the Department of Health, there are less restrictions and less detailed policies in place at private hospitals. One rationale for more flexibility and less regulation of the private sector is adaptability to public demands for different types of services (Nurse A, personal communication, December 2015). Hospital S is a well-known private hospital servicing expatriates and the upper-class population in Hong Kong. Hospital S, therefore, has opportunities to enhance its nursing services in innovative ways, including the executive leadership’s decision to create a standardized orientation program for its nursing staff. Hospital S requires its healthcare providers to achieve high quality, safe standards associated with magnet-like health care environments. The “American Nurse Credential Centre Magnet recognition is considered as the most prestigious credential a hospital can obtain that signifies the achievement of highest nursing quality and patient outcomes” (Lyle-Edrosolo & Waxman, 2016, p .70). In Hong Kong culture, nurses expect to have clear directives, and many nurses who have worked in the public sector are used to strict policies and standards. Magnet-like qualities, such as autonomy over practice and shared decision-making (Lyle-Edrosolo & Waxman, 2016), has created discomfort among Hospital S nurses (Nurse B, personal communication, January 2016), necessitating more education and professional support starting with orientation. Another factor influencing job satisfaction and potential retention in the private sector is the use of skill mix staffing models. Skill-mix models involve registered nurses (RNs) and enrolled nurses (ENs). ENs are similar to licensed practical nurses in North America. Although the education for RNs and ENs and their scope of practice are different, at Hospital S, these two classifications of nurses are currently performing similar duties. Policies and procedures are determined for the hospital’s unique populations. The blurred scope of practice boundaries at Hospital S is causing frustration among nurses and poor patient care STANDARDIZED NURSING ORIENTATION Keilee Mok 4 coordination (Nurse C, personal communication, 2016; Schluter et al., 2011). In this case, an orientation program, therefore, can be used to establish professional nursing role and identity and to nurture teamwork between RNs and ENs (Beyea et al., 2007; Pine & Tart, 2007). In addition, using education methods such as patient simulation and clinical skills training during orientation will help to promote effective communication skills, critical thinking (Beyea et al., 2007), and to develop professional autonomy that enable nurses to voice their practice concern around patient safety (Pine & Tart, 2007). Further details related to program planning and program structure incorporating the above education strategies will be discussed in Chapter 3. 1.3 Theoretical Framework For this paper, I used a Strength-Weakness-Opportunity-Threat analysis template to look into the internal strengths and weaknesses, and the external opportunities and threats with respect to nursing development for Hospital S orientation program as described in Appendix A (i.e. how nursing leadership and organizational structure would affect the development of this orientation program). I used my SWOT analysis to guide my discussion of factors that were critical to planning and development of the new two-day orientation program for Hospital S nurses. A SWOT analysis is usually used by management and leadership teams within health care organizations to seek strategies on current challenges and to match resources with opportunities (Unrenfeldt et al., 2014). The strength of SWOT analysis is it can quickly identify influencing factors that promote success in an organization, and it is a simple tool to use (Camden et al., 2009; Unrenfeldt et al., 2014). Use of this SWOT approach helped me systematically analyze contextual factors (e.g. political, social) within the Hospital S and outside the hospital within the Hong Kong community. In addition, I used Avedis Donabedian’s Structure-Process-Outcome(SPO) framework (2003) to lay out the overall process for creating this standard two-day nursing orientation (see Appendix B). STANDARDIZED NURSING ORIENTATION Keilee Mok 5 Donabedian (2003) developed the SPO framework to clearly explicate the causal relationships between structures, processes and outcomes of an organization. I used this quality improvement project framework to create a blueprint for a two-day nursing orientation program at Hospital S (i.e., necessary structures, processes and expected outcomes). 1.4 Chapter Summary The main purpose of this quality improvement project was to improve overall nursing quality and to ensure patient safety within a small private hospital in Hong Kong. Projecting from a leadership perspective and based on a theoretical framework (SWOT analysis), the creation of a standardized two-day nursing orientation program was aimed to achieve the following objectives: strengthen nurses’ professional identity, standardize nursing knowledge and skill, and build a confident and competent nursing team. The Nursing Administration team of Hospital S believed these objectives would directly address the nursing shortage from high turnover rate and low job satisfaction. STANDARDIZED NURSING ORIENTATION Keilee Mok 6 Chapter 2: Literature Review Two primary leadership goals for the standardized two-day nursing orientation program for Hospital S were to improve nursing quality and to retain nursing staff. As I have noted in the previous chapter, the Hospital Executive and Nursing Administration believed that strengthening the professional identity of nurses and standardizing knowledge and skills during orientation would cultivate a sense of belonging and a professional nursing culture within HKAS (Nurse C, personal communication, January 2016). Thus, this program would lead to further positive outcomes, such as better clinical transition, higher job satisfaction among nurses, and better patient outcomes. However, quality improvement initiatives (such as this new orientation program) within an organization require more than just project implementation and strategies (Cluster, 2010; Ulrich et al., 2010; Moffitt & Butler, 2009). I conducted a comprehensive literature review to examine key points of interest to me based on my previous experience with quality improvement initiatives, nursing education, and professional development. My major points of interest were: the importance of building professional identity through nursing orientation, staff empowerment via quality improvement initiatives, and the advantages of applying standardization within nursing orientation. This literature review consolidated my understanding in the importance of building an evidence based orientation program which emphasizes on professional development, staff empowerment, and program standardization in relation to patient safety and nursing retention. 2.1 Search Engines for the Literature Review Several major health science databases were examined: PubMed, Medline, CINAHL, and PsycINFO. Key words and subject terms, such as “orientation”, “staff retention”, “empowerment”, “professional identity”, “turnover”, “knowledge transfer”, “standardization”, and “quality improvement”, were used to search for peer reviewed, STANDARDIZED NURSING ORIENTATION Keilee Mok 7 scholarly papers that explore the above concepts. 2.2 Building Professional Identity at Nursing Orientation Here I explored the importance of building professional identity at nursing orientation and how professional identity and commitment relate to staff retention. Nursing orientation has been identified as a platform for nurses to build their professional identity (Burkhardt et al., 2015; Deppoliti, 2008; Elias, 2006; Pine & Tart, 2007). Many researchers believe that helping nurses to build a strong professional identity is a means to empower nurses to perform their job and to retain them in an organization (Deppoliti, 2008; Friedman et al, 2013; Hoeve et al., 2013; Ulrich et al., 2010;). Hoeve et al. (2013) confirmed that other than just social image of nursing, education, work environment and work values are some key factors that would influence nurses’ self-concept, professional identity, and work performance (p. 299). Hoeve et al. (2013) published a discussion paper with 18 studies to explore the factors that influence the development of nurses’ self-concept and professional identity and the importance of this identity development. If a nurse’s professional identity is being perceived as negative by her or himself, then job performance would be affected. In the same study, the authors also recommended nurses should “pursuing higher education…broaden their knowledge and skills…becoming more visible on a macro level…gaining more professional autonomy… contribute to the development to their self-concept and identity as a nurse” (p. 306) to build a strong professional identity in this society and to be more committed to their profession. Furthermore, Deppoliti (2008) conducted a qualitative study exploring the experience of 16 hospital nurses when they established their professional identity during 1 to 3 year post-graduation. During this study, Deppolitii (2008) identified orientation as one of the essential passage points while nurses transition into their profession successfully. Other passage points included: finding a niche; having the conflict of caring; taking the licensure examination; STANDARDIZED NURSING ORIENTATION Keilee Mok 8 becoming a charge nurse; and moving on in their profession. Finding a work environment that matches personal values and skills and having an orientation with a ‘good’ preceptor became an important part in “developing a sense of being a nurse” (p.258) for new nurses at the early stage of their career. In this study, the authors also mentioned another important point: building a professional identity is a continuous journey which requires continuing education, learning from others, perfection with practice and knowledge, and fulfilling responsibility to patients. Asking and answering questions from peers, role modelling, and learning to use technical equipment were identified by nurses as part of their professional development (Deppoliti, 2008, p. 260). Successful transitions throughout these passage points required a good balance between managing challenges and finding supports. However, the study also identified that “when orientation processes were not successfully negotiated, voluntary or involuntary termination and feelings of anger and failure resulted” (Deppoliti, 2008, p. 258). This theory indicates that a good orientation program would require organizational support to create a passage for new nurses at Hospital S to build their professional identity. Further, Latham et al. (2011) claimed that building professionalism among frontline nurses would help to sustain a healthy workplace and directly enhance staff retention. In their quasi-experimental, non-control group design study, they used pre-and Post-orientation tests over 3 years with 89 RNs mentors and 109 mentees at two major medical settings. Latham et al. (2011) discovered that trained mentors who attended a comprehensive mentoring leadership education would help to enhance professionalization of frontline nurses and yet build a supportive, healthy work environment. This comprehensive mentoring leadership education includes shared governance, conflict resolution, team building, and overviews of health system regulation. Latham et al. (2011) stressed that the professionalism developed by the frontline RNs “helps to create a unit culture of support, professional teamwork … and STANDARDIZED NURSING ORIENTATION Keilee Mok 9 improved nurse retention and vacancy rates” (p. 352). To conclude, building professional identity in nurses through education not only helps them to grow personally; it also builds the environment or community that they are working in. (Burhardt et al., 2015; Deppoliti, 2008; Latham et al.). At the same time, professional commitment has a high impact on one nurse’s decision to stay in an organization or not (Caricati et al., 2014; Elias, 2006). All the above literatures support that building a strong professional identity will contribute to higher professional commitment and organizational commitment. Thus, this plays an important role in creating a healthy work environment and staff retention. Nursing orientation is a crucial stage in constructing a professional identity. As a result, if nursing orientation is well constructed to build a healthy professional identity, it will decrease staff’s intention to leave (Deppoliti, 2008; Ulrich et al., 2010). 2.3 Staff Empowerment Via Quality Improvement Projects A large body of nursing research has established connections between nurse empowerment and better nurse and patient outcomes. (Cummings et al., 2010; Custer, 2010; Dahinten et al., 2014; Greco et al., 2006; Laschinger et al., 2009; Wong and Cummings, 2007). For example, Custer (2010) performed a quality improvement project on the effectiveness of introducing standardized insulin orders for diabetic patients versus the use of non-standardized orders on a critical care unit. After a three-month data collection period with 331 individual glucose samples from 16 eligible patients, standardized insulin order use was claimed to be successful in bringing the mean glucose level down for these patients versus non-standardized orders. Besides the success within the standardized insulin order itself, Custer (2010) emphasized the importance of leadership support, staff empowerment, and staff education among nursing during this nurse led project. He claimed that these elements made the project successful and were very effective in sustaining systematic changes. Nurses interpreted the nursing initiated interventions (the standardized insulin STANDARDIZED NURSING ORIENTATION Keilee Mok 10 orders) as part of empowerment as they had more autonomy to make decisions on patient care. Through knowledge transfer, resource allocation, communication, interdisciplinary team collaboration, and shared governance, this project could improve patient glucose outcomes. At the same time, nurses were more empowered to perform patient care and quality improvement projects (Custer, 2010). The attributes of Custer (2010)’s success, such as information and resources, shared governance and autonomy in decision making, are well recognized by many researchers as forms of structural and psychological empowerment (Dahinten et al., 2014; Greco et al., 2006; Laschinger et al., 2009; Ulrich et al., 2010). These forms of empowerment are known to have direct and indirect relationships with greater staff organizational commitment (Dahinten et al., 2014; Greco et al., 2006; Laschinger et al., 2009) and in preventing staff burnout (Greco et al., 2006; Hayes et al., 2005). Staff organization commitment is a predictor of staff turnover (Dahinten et al., 2014; Hayes et al., 2006); therefore, many nurse leaders have use different empowerment strategies to better engage nurses and to retain staff (Dahinten et al., 2014; Greco et al., 2006). With respect to quality improvement initiatives, some researchers believe that staff empowerment is essential toward staff engagement and the sustainment of change initiatives (Custer, 2010; Moffitt & Butler, 2009). Moffitt and Butler (2009) performed a project on improving patient care using staff led initiatives while merging two in patient units in a small community. They discovered that nurses ran into many psychological and physical challenges when merging two units with constant changes in practice. As a result, they used psychological empowerment strategies such as shared decision making, shared governance, and decentralized power to facilitate nurse-led patient care initiatives. They found that nurses were more engaged in identifying practice challenges and more committed to being part of the solution for better patient care. In this study, nurses led many new standardized patient STANDARDIZED NURSING ORIENTATION Keilee Mok 11 care initiatives, such as nursing rounds and allocating staffing the unit, that resulted in an increase in satisfaction rate for patients, physicians, and nurses. Furthermore, these new initiatives were sustained on the unit as daily nursing practice (Moffitt & Butler, 2009). Additionally, Custer (2010) agreed that quality improvement projects should be driven by nurses who know how the work process best. In his study, Custer (2010) stressed the importance of collaborative communication and democratic decision-making processes. Some researchers have contended that quality improvement should be a corporate responsibility, driven from the top down. Glickman et al. (2007) raised the dilemma that organizations often face; the conflict between using central control or local authority for quality improvement projects. Glickman et al. (2007) and Moffitt and Butler (2009) both concluded that both are needed: higher level leadership is needed to create a vision of an organizational culture of empowerment; local (i.e., unit level) leadership and staff engagement are necessary to implement innovation at the local level. To conclude, the above studies support that nursing empowerment is important for patient care and organization commitment. Yet quality improvement projects require higher level leadership to empower nurses to achieve success and to sustain changes (Glickman et al., 2007; Moffitt & Bulter, 2009). Nurses often gain satisfaction and feel empowered from nurse led quality improvement projects (Custer, 2010). As a direct consequence, they are more committed to their job and to their patients: thus, leading to better staff retention and positive patient outcomes (Custer, 2010; Greco et al., 2009; Moffitt & Bulter, 2009). 2.4 Applying Standardization in Nursing Orientation Applying standardization in health care has been proven to increase reliability and quality assurance in organizations (Custer, 2010; Frankel et al., 2009). Standardization has typically been used in health care processes to ensure the right service is being delivered from the right people at the right time through a right process (Custer, 2010); for example, through STANDARDIZED NURSING ORIENTATION Keilee Mok 12 hospital policies and patient care guidelines. However, during this part of literature review, I would like to focus on the benefits of applying standardization in nursing processes, especially during nursing orientation, to achieve better staff outcomes in terms of competency and job satisfaction. Ulrich et al. (2010) performed a longitudinal study of an 18-week structured Registered Nurse residency program at the Children’s Hospital in Los Angeles and its effects on staff retention and empowerment. Based on 10 years of data collected, this residency program was proven to lower turnover intent and indicated that it empowered new graduates to be more competent when transiting into a professional role at clinical settings. Ulrich et al. (2010) identified that program structure and standardization are the top key characteristics among 13 characteristics of a successful residency program. Standardized elements included program structure, processes, evaluation tools and process, and competency assessment. Other key characteristics included evidence based content and practices, active stakeholder engagement and organization-wide commitment, transparency and accountability, and rigorous evaluations etc. (p. 374). All these elements had contributed to the increase in nurse job satisfaction, nursing competency and confidence, and organizational commitment from the nurse residency program (Ulrich et al., 2010). In addition, Beyea et al. (2007) performed a study of a new graduates registered nurse residency program at an academic medical center. With the realization that fewer new graduates were ready for clinical practice and there were fewer competent critical care nurses available due to rising retirement rates, this residency program focused on human patient simulation and skill based training to cultivate critical thinking and competent clinical skills. This program contained a standardized 12-week training period, standardized simulated scenarios, and standardized debriefing sessions with a situational briefing model. Through a standardized evaluation method, Beyea et al. (2007) concluded that this residency program STANDARDIZED NURSING ORIENTATION Keilee Mok 13 increased clinical productivity and supported transitions from novice to competent nursing practice. Also, nurses who participated in this program felt less anxious and more confident in their practice after simulation training. Furthermore, to bring standardization closer to patient care and nursing practice, Moffitt and Butler (2009) applied standardization on nursing process to enhance patient and nursing outcomes when merging a medical unit with an oncology unit together in a small community hospital. During the implementation of a relationship based, patient care model, standardized engagement processes were used by nurses; for example, standardized methods and guidelines for walking rounds and a standard formula for calculating adequate nursing staffing ratio. These standardized nursing processes showed positive impacts on both patient and staff satisfactions at the end of the study. Nurses felt more empowered with these standardized tools with higher autonomy in decision making and practice (p. 190). To sum up, all these studies support that standardization is needed in nursing training programs in relation to planning, program structure, and implementation process (Beyea et al., 2007; Custer, 2010; Pine & Tart, 2007; Ulrich et al., 2010). Herdrich & Lindsay (2006) added that a nurse orientation program also needs standardization in terminology, materials, and processes to control other variances that might limit the potentials of the program (p. 62). Furthermore, applying standardization in nursing care is a strategy which ensures staff competency (Moffitt & Butler, 2009), empowers staff (Beyea et al., 2007), and enhances positive outcomes on patient care (Custer, 2010) and staff retention (Ulrich et al., 2010). 2.5 Summary The benefits of building a strong professional identity through nursing orientation toward nurses as individuals and toward health care settings as a whole are apparent. The benefits include increased professional commitment, increased job and organizational commitment, better patient outcomes, lower turnover intent, and a healthier workplace. With leaders’ STANDARDIZED NURSING ORIENTATION Keilee Mok 14 empowerment strategies (such as shared decision making, information sharing, and promotion of autonomy), nurses will have more autonomy and be more engaged to lead quality improvement projects that matter to them and benefit their patients. Furthermore, standardization plays an essential role in ensuring nurses are competent and confident to lead organizational changes. By giving nurses standardized tools, standardized education, and standardized processes, they will feel empowered and confident to facilitate best care and to apply critical thinking and knowledge in problem solving. STANDARDIZED NURSING ORIENTATION Keilee Mok 15 Chapter 3: Method Historically, the Hospital S work culture focused on convenience—slotting in new nurses as needed. New nurses used to receive a three-hour hospital orientation and a six- hour nursing orientation at dates set by management. Because orientation dates were at set times, some new nurses were not able to attend their nursing orientation for three to six months after starting their work rotations. New nurses only received a six-shift clinical orientation with a randomly assigned mentor on their designated unit. Hospital S has 11 inpatient units, and previously each unit had its own clinical orientation program and standards. In addition, there was a floating system within the hospital; after three months on a unit, new nurses were required to work in other units as needed. In these instances, no additional orientation to other units was provided. Further, the new nurses did not receive regular, systematic performance feedback and there were no individualized learning plans to guide and support them or their mentors. Some nurses expressed that they did not know about their performance until their Nursing Officer called them into the office or when they received a patient complaint. Most importantly, orientation did not include a discussion of professional nursing standards, including ethical practice. 3.1 The Design of a New Two-Day Orientation Program The new two-day nursing orientation program at Hospital S has become a required orientation program with classroom education and a standard practicum. This program’s content, delivery processes, and competency assessment tools were standardized to better ensure a consistent approach to new nurse orientation. In addition, management standardized key nursing practice policies to support competent, safe nursing practice throughout the hospital. The project team include a Senior Nursing Officer, five Nursing Officers, two Nursing Quality Improvement Coordinators, five Senior Registered Nurses, a Staff Education STANDARDIZED NURSING ORIENTATION Keilee Mok 16 Coordinator, a Human Resources Manager, five frontline nurses, and a Senior Pharmacist. 3.1.1 The overall process. The creation of this new quality improvement program was based on Donabedian’s Structure-Process-Outcome (SPO) framework (2003) (Appendix B) with the aim to ensure a safe, successful clinical transition for new nurses and to achieve patient safety. The SPO table (Table B1) explains different stages of this program. The far-left hand column of the SPO table contains all the Structure (program) created for this two-day nursing orientation program; the middle column involves all the Processes (interventions) that the project team used to create the program; the far-right column lists out all the direct and indirect Outcomes from this program. For example, a needs assessment (Structure) was generated through informal meetings (Processes) between nursing leaders and staff, and data about current practice gaps and challenges were gathered. The Outcomes of this needs assessment were identified learning needs from the direct care nurse perspective to better cultivate a sense of ownership among staff. Table B1 (Appendix B) illustrates the intersections of Structures-Processes-Outcomes. For example, during the needs assessment, leadership engaged in practice gap identification and learning needs. Similarly, during program evaluation, staff were involved in providing feedback. Many structures, therefore, (e.g., needs assessment, program evaluation) were thoughtfully designed to optimize staff engagement, and to create a culture of continuous improvement where staff reflectively appreciate the importance of ongoing assessment of new nurse needs. They also actively contributed to processes that support new nurses and evaluate their performance against professional nursing standards. Another hope is that staff engagement throughout the program development, implementation and evaluation will reinforce a culture of new nurse support versus bullying. 3.1.2 Program structure. To meet the Hospital S goals of enhanced nurse recruitment and retention and improved nursing practice, the project team developed a set of concrete, STANDARDIZED NURSING ORIENTATION Keilee Mok 17 specific objectives based on the needs assessment (see Table 3.1). Table 3.1 Objectives for Standardized Two Day Nursing Orientation Program Objectives 1 To strengthen nurses’ professional and organizational commitment through aligning personal, professional values with organizational values 2 To empower nurses to be competent and confident in their professional selves through transferring up-to-date health knowledge and nurturing critical thought process 3 To ensure patient safety by maintaining professional practice standards 4 To build a cohesive, supportive nursing team through open communication, group activities, and providing leadership support at an early stage 5 To ensure a safe, successful clinical transition for new nurses through interactive classroom teaching, practicum, and clinical orientation To achieve the above objectives, the project team received approval to extend the original half-day session to two days. The new program is outlined in Table C1 (Appendix C). At the far-right column, the intended objectives are listed along with the particular program content. On Day 1, the program focuses on organizational priorities, professional values and behaviors, and international patient safety goals. The foundation on nursing process and critical thinking are built through interactive teaching methods such as case studies, simulation, and group discussions. Frankel et al. (2006) believed that a highly reliable health care organization requires interactive teamwork classes that emphasize on communication and critical thinking to cultivate a culture of safety among staff (p. 1692). Two key priorities for the organization and individual nurses are patient safety and nursing professionalism. On Day 2, the orientation curriculum includes skills lab, team building, and assimilation into practice. The main objectives threaded through both days are patient safety and standardization in practice. The education materials, tests, and competency checklists presented in this orientation program are standardized in order to maintain practice standards and to ensure nursing quality with Hospital S (Ulrich et al., 2010). As mentioned earlier, the needs assessment revealed that effective use of nursing process was considered foundational to nurse leaders and nurses. Orientation, therefore, focuses on STANDARDIZED NURSING ORIENTATION Keilee Mok 18 applications of nursing process: how to systematically assess, diagnose, plan, implement and evaluate quality, safe nursing care (Ulrich et al., 2010). Clinical reasoning is reinforced during group discussion and case scenarios in orientation (Pine & Tart, 2007). 3.2 SWOT Analysis A SWOT analysis is used to analyze the strengths, weaknesses, opportunities, and threats to Hospital S with respect to introducing a new orientation program. Usually a SWOT analysis is performed prior to and after implementation of a quality improvement intervention. This approach helps to evaluate a program’s effectiveness and to search for further improvement opportunities in an organization (Bradhma et al., 2011; Camden et al., 2009). Some researchers suggest that the limitations of SWOT analysis are its time-dependent outcomes (Bradham et al., 2011; Camden et al., 2009). This means that SWOT analysis can only analyze a snapshot of an organization at a given time; in this case, the project team used SWOT to evaluate the current situation within Hospital S at the time of the new orientation program. This was done in order to get a sense, in real-time, of internal and external facilitators and barriers to program implementation. 3.2.1 The relationships among strengths, weaknesses, opportunities, and threats. Appendix A shows the SWOT analysis for Hospital S at the time of new program implementation. The Strengths are categorized as: organizational structure, leadership, standardization, program material, program outcomes, and organizational resources (Table A1). From my engagement in the project team, the two dominant strengths are leadership and standardization: they have been most critical to orientation program implementation and sustainability. The details of how they are interrelated will be discussed in the next section. Weaknesses are grouped into four categories: organization culture, leadership, work culture, and orientation program (Table A2). Interestingly, leadership is one of the main weaknesses, along with organizational culture. At the time of new program implementation, Hospital S STANDARDIZED NURSING ORIENTATION Keilee Mok 19 was still plagued with high nurse turnover rates and low morale due to previous leadership that was authoritarian and unsupportive of nursing. Although culture change is underway and new leadership is in place, the holdovers from a dysfunctional culture represent internal weaknesses. Ongoing culture shifts will be dependent on continued leadership support for nursing and allocation of appropriate resources that demonstrate support for nurses—particularly nursing professional development. Most of the Opportunities listed in Table A3 are due to Strengths, such as leadership and standardization. For example, nurse leaders from other organizations will learn from Hospital S successes and hopefully engage their staff in similar quality improvement projects. Opportunities also include building a better social reputation and enhanced recruitment of nursing staff due to the new orientation program. Threats are potential problems that Hospital S will need to minimize over time (Table A4). For example, professionalizing nursing within Hospital S depends on the image and attitudes towards nursing in the Hong Kong Health Authority. One hospital making changes could be threatened by prevailing negative attitudes towards nursing. 3.2.2 Nursing leadership: empowerment and engagement. Nursing leadership has become the major strength of the Hospital S new orientation program. True engagement depends on nurse leaders who create a shared meaning and purpose with employees. This shared vision needs to inspire hospital nurses and create a sense of ownership among them (Scott, 2015). The new nursing orientation program serves as an entry point to align nurses’ vision of themselves (e.g., professional identity) with the hospital’s vision and mission (Table B1). As mentioned by Gliskman et al. (2007), leadership is the driver in quality improvement projects; quality improvement requires all stakeholders, particularly the leadership and staff, to engage with each other towards a common purpose, such as quality, safe, patient-centered care. From Donabedian’s (2003) SPO Framework for the new orientation program (Table STANDARDIZED NURSING ORIENTATION Keilee Mok 20 B1), strong nursing leadership ensures all levels of involvement within Hospital S. The nurse leaders of Hospital S were responsible for the following: getting Executive Board’s approval on the resources and project proposal; providing release time and supports for frontline staff involvement in program development, including the needs assessment and program evaluation; active leadership involvement in the project team; constant reinforcement of the ‘new’ vision of the organization, particularly the value of professional nursing; and development of policies and standards to promote professional nursing. All these engagement processes have created a sense of staff ownership in new nurse orientation, and establishment of a cohesive team culture among all levels of nursing leadership and staff within Hospital S. Meaningful and sustainable change within an organization requires a shared vision and all levels of organizational involvement (Custer, 2010; Scott, 2015). Quality improvement is more sustainable and staff are more committed if leadership supports and empowers nurses to do the changes themselves (Caricati et al., 2014; Moffitt & Butler; 2009). Staff empowerment is the mediator for staff engagement (Dahinten et al., 2014; Greco et al., 2006; Laschinger et al., 2009; Ulrich et al., 2010). Empowerment is the perception of a nurse in relation to the level of support he or she gets from an environment or from others. (Dahinten et al., 2014; Greco et al., 2006). Meanwhile, engagement is how committed a nurse is toward his/her working environment (Greco et al., 2006; Laschinger et al., 2009). Dahinten et al. (2014) and Greco et al. (2006) discovered that structural empowerment such as resources and information enhance the positive outcomes of staff commitment, job satisfaction, and staff competency. During the nursing orientation, there were many examples of structural empowerment to achieve these positive outcomes (Appendix B). For example, there were evidence-based reading packages and orientation materials; standardized skills competency checklists for new nurses as practice guideline; and current information on organizational priorities and up to date knowledge on international health standards for new STANDARDIZED NURSING ORIENTATION Keilee Mok 21 nurses and staff. These types of empowerment strategies enable nurses to be more competent when performing their duties and more committed in achieving better outcomes for both patients and the work environment (Custer, 2010; Moffitt & Butler, 2009). Allocating organizational resources to this orientation program also counted as structural empowerment, which leads to higher job commitment and better patient outcomes (Custer, 2010). Meanwhile, psychological empowerment, such as through shared governance, fosters autonomy (Laschinger et al., 2009). And expressing confidence in high performance (Ulrich et al., 2010) will increase staff’s confidence in performing their job, increase organizational commitment, and lower staff’s turnover intention (Greco et al., 2006; Laschinger et al., 2009; Ulrich et al., 2010). During the planning and implementation stage of this new orientation program, the project team used different psychological empowerment strategies to engage frontline staff. Psychological empowerment strategies included validating staff’s hard work; getting their feedback on current practice during needs assessments; and identifying solutions for practice—all of which are believed to achieve higher job commitment and lower turnover intent (Greco et al., 2006; Laschinger et al., 2009). Another example from this project was when the Nursing Administration encouraged frontline staff to be involved with needs assessment prior to the creation of the new orientation program (Appendix B). Staff were engaged and felt that they were ‘being valued’ (Nurse B, personal communication, January 2016). Researchers agree that when nurse leaders apply both psychological and structural empowerment, the outcomes of staff engagement will be most optimal (Dahinten et al., 2014; Greco et al., 2006; Laschinger et al., 2009; Ulrich et al., 2010). During quality improvement projects, staff empowerment and engagement are two key concepts that are known to be essential in increasing satisfaction in staff and in sustaining changes within organizations (Avolio et al., 2004; Camden, 2009; Custer, 2010; Moffitt & Butler, 2009; Ulrich et al., STANDARDIZED NURSING ORIENTATION Keilee Mok 22 2010). These two concepts also contributed to the success of this new nursing orientation program in respect to increasing staff’s confidence and competency, satisfaction, and a sense of belonging toward Hospital S. 3.2.3 Standardization: SPO framework, nurse competencies, orientation policies. Standardization is another strength identified in the SWOT analysis, which has contributed to the success of the new orientation program. As discussed earlier, Ulrich et al. (2010)’s longitudinal study on a residency program showed that building a structure for an orientation program and applying standardization within are key to success in terms of increasing staff confidence and ensuring professional competency. Applying standardization in nursing training and hospital policies has been proven to enable nurses to practice in a consistent, competent, safe manner (Beyea et al, 2007; Moffitt & Butler, 2009; Ulrich et al., 2010). Thus, nurses practicing consistently according to professional standards create a highly reliable organization (Frankel et al., 2006) and a better working environment that ensures patient safety and retains nurses (Frankel et al., 2006; Pine & Tart, 2007). Standardization ensures quality and safety especially in highly skilled fields, e.g. aviation and health care (Frankel el at. 2006). Standardization in this project has been applied in three main areas: the SPO framework for the orientation program as a standardized approach to initiation of all new nurse employees; foundational competencies; and policies that reinforce the importance of orientation and nurse professional development. The SPO framework in Appendix B contains all the processes and outcomes of theses standardization. As leaders at Hospital S, making sure the involved processes within Table B1 are repeatable with desirable outcomes is important to sustain this program especially when there are limited resources. The detailed evaluation process and evaluation tools will be presented in Chapter 4. STANDARDIZED NURSING ORIENTATION Keilee Mok 23 Standardized orientation policies and protocols were created to emphasize the importance of mandatory nursing orientation prior to clinical practice and the assignment of designated clinical mentors. These policies formalize the importance and valuing of nurses within the organization. Rather than the previous haphazard approach to new nurse hiring and assimilation into the work environment, the use of a standardized SPO framework and accompanying orientation policies reflects the new vision of professional nursing. 3.4 Summary This new two-day nursing orientation program is a classroom based yet interactive, intuitive, and practical educational program for new nurses. Through a nurse leader perspective, this program was planned with dedicated objectives, programmed with evidence-based teaching strategies and material, and assessed with a SWOT analysis of Hospital S. Interestingly, leadership is an internal strength yet it is also a weakness of this hospital. However, during the planning of this nursing orientation, leadership’s strengths have become more apparent. These leadership strengths include empowerment, engagement, and standardization application. Staff empowerment enhances staff engagement to achieve higher job satisfaction and better patient outcomes. In addition, standardization adds value to the SPO framework for the program, nursing competencies, and orientation policies. STANDARDIZED NURSING ORIENTATION Keilee Mok 24 Chapter 4: Findings In Chapter 3, I have discussed the program design, program structure, and some detailed descriptions of the key components of this new orientation program, i.e. SWOT analysis, staff empowerment, and standardization. In this chapter, I will discuss the key findings from the evaluation of this orientation program. It is important to note, however, that this program evaluation is only based on the perspectives of new nurses, the results from the standardized evaluation tools, and the results from all the tests involved. 4.1 Standardized Evaluation Tools Standardized evaluation tools are critical to the maintenance and the sustainment of quality improvement projects, especially with pilot nursing education program (Beyea et al., 2007; Ulrich et al., 2010). Prior to this project, Hospital S did not evaluate any nursing education program, such as its former nurse orientation. Consequently, an important deliverable from this project was the development of quantitative and qualitative tools to evaluate the new standard two-day nursing orientation. These tools were developed by the Nursing Quality Improvement Coordinators (NQICs) based on literature review. The Hospital S Nursing Orientation Program Evaluation-Individual Session (Appendix D) was a quantitative tool with 16 questions scored on 5-point Likert scale (ranging from strongly agree to strong disagree; strongly dissatisfied to strongly satisfied). This evaluation was filled in by new nurses after each orientation session. In addition, the Feedback on Nursing Orientation (Appendix E) --a qualitative tool with six open ended questions-- was conducted through one on one interviews by NQICs with each new nurse approximately four weeks into individual clinical mentorship. The interview times varied based on each individual nurse’s work schedule. The mean score of the Pre-orientation test and Post-orientation test were used to evaluate the effectiveness of test content, orientation material, and teaching style. All data related to program evaluation were analyzed by NQICs and presented to the STANDARDIZED NURSING ORIENTATION Keilee Mok 25 Nursing Administration and the Hospital Executive team. Data that were relevant to frontline nurses and related to the success of this new orientation, such as satisfaction rate toward the new program and some positive comments on program’s practicality, were presented in the hospital Nursing Newsletters and distributed to frontline nursing staff. Nursing Administration wanted to share success with the team and to empower them to drive for better practice. Giving up-to-date information and sharing success are structural empowerment strategies which are crucial in increasing staff commitment, decreasing staff burnout and staff turnover intent (Greco et al., 2007; Laschinger et al., 2009) 4.2 Key Findings Although the number of new nurses who participated in this pilot orientation program was small (n=18), it was considered the largest group of intake at Hospital S to start nursing orientation at once. The data collected was considered as ‘pilot’ data as this was a pilot program and there was no other comparable data. The key findings were categorized into three main areas of interest: staff satisfaction, program practicality, and staff competency. 4.2.1 Staff satisfaction. Most new nurses were highly satisfied with this new orientation program and felt more confident in themselves after attending this program. Based on the evaluation, 16 nurses out of the 18 new nurses who attended the pilot 2-day nursing orientation program rated ‘Highly Satisfied’ with the orientation program, and two rated ‘Satisfied’. Program topics such as International Patient Safety Goals (IPSG), Code Blue Response, Professional Standard Behaviors, and Nursing Documentation were rated as the top four sessions, with mean ratings over 4 out of 5 (Good) among all other sessions within the program (see Appendix C). One new nurse wrote a comment, “I have learned so much about international standards and Hospital S nursing practice through this program and I feel more like a health care professional now” (Anonymous, personal communication, June 2016); meanwhile another new nurse stated “I feel more confident in my nursing practice as I STANDARDIZED NURSING ORIENTATION Keilee Mok 26 am now up to date with the Code Blue practice and I know what my roles are during a code” (C. Chew, personal communication, June 2016). Further positive outcomes derived from the program content can be referred to the SPO framework in Appendix B. 4.2.2. Program practicality. Besides the overall satisfaction rate, both qualitative and quantitative data showed that nurses considered this program’s content as highly practical and relevant; they felt empowered and equipped for their clinical practice after attending the orientation. From the quantitative data collected after each orientation sessions, it showed that 16 out of 18 new nurses rated “Strongly Agree” and 2 rated “Agree” that this orientation program would facilitate their transition to clinical practice. Furthermore, from the interviews conducted by Nursing Quality Improvement Coordinators with individual nurses 4 weeks into clinical mentorship, it showed that all 18 new nurses agreed this new orientation program helped them adapt to Hospital S’s nursing practice and work culture. One nurse with over 20 years of nursing experience stated, “I have never experienced this kind of interactive, practical orientation program in my nursing career. From this program, I learned to use theories to support my practice and critical thinking; I enjoyed the content related to communication skills and case management” (Nurse D, personal communication, June 2016). Similarly, results showed that new nurses appreciated dedicated classroom time prior to clinical mentorship. From the Feedback on Nursing Orientation form (see Appendix E), all 18 new nurses agreed on Question 2 that it would be more practical and suitable for new employees to participate in this orientation prior to actual clinical days. A new graduated nurse commented, “with all the knowledge and practice that I have gained from this nursing orientation, I feel more ready to work in clinical settings, I was anxious to work at a private hospital before this program” (Nurse E, personal communication, June 2016). Another highlight of classroom orientation that were identified by new nurses included: briefings by STANDARDIZED NURSING ORIENTATION Keilee Mok 27 leadership about: Hospital S values and mission; organizational culture and standards; and practices and policies related to nursing practice. A nurse with three years of private nursing experience stated, “the knowledge related to Hospital S policy and nursing practice was very useful to me as private hospitals’ policies are very different from each other’s” (Nurse F, personal communication, July 2016). Likewise, a new graduated nurse stated, “it was nice meeting the director of nursing and felt being supported” (Nurse E, personal communication, June 2016). Visible leadership involvement is important to achieve high reliability within a health care organization (Frankel et al., 2006) and in staff engagement (Laschinger et al., 2009). 4.2.3 Staff competency. In addition to new nurses’ satisfaction toward the program’s practicality for clinical transition and its overall outcomes on individual development of professional identity and skills consolidation, a standardized level of staff competency is also a key finding of this orientation program. To standardize staff competency and practice was one of the main goals of this orientation program. Besides the standardized program structure and curriculum, a set of standardized competency tools such as Pre-orientation test, Post-orientation test, and Skills Competency Checklists were created by Nursing Administration to accomplish this goal (see Appendix B). Standardized competency checklists are often used to evaluate staff competency in an objective manner (Beyea et al., 2007; Herdrich & Lindsay, 2006; Ulrich et al., 2010). In this evaluation, there were some objective program outcomes which supported that a standardized level of staff competency had been achieved: a high mean score of Pre-orientation test (88.4%) and Post-orientation test (81.6%), a 100% pass rate for examination during the practicum session, and 100% compliance with new nurses returning their sets of completed competency checklists within a month post orientation. Furthermore, a new graduated nurse stated, “I felt more competent and confident in after I completed the competency checklists with my mentor; I know I am using best practice in my STANDARDIZED NURSING ORIENTATION Keilee Mok 28 nursing care” (Nurse F, personal communication, July 2016). 4.3 Summary In summary, it was difficult to evaluate sustainable outcomes, such as quality of service delivery and job satisfaction, from one pilot program. However, the findings from this pilot session showed that new nurses assigned high satisfaction scores for program content and practicality or usability. These initial results suggest that the new orientation program at HKAS will enhance new nurses’ transition to clinical practice and the development of professional identity. Additionally, objective outcomes showed that a standardized level of nursing competency have been achieved through this new orientation program. Standardization of curricular content and a classroom component may prove to be an important means of recruiting and retaining new nurses, and replacing traditional approaches to care with evidence-informed practices. STANDARDIZED NURSING ORIENTATION Keilee Mok 29 Chapter 5: Discussion The findings of this new two-day nursing orientation program support its advantages for new nurses and the evidence collected indicates that this program has achieved its overall program objectives. The program objectives included strengthening nurses’ professional identity, building a competent and confident nursing team, and standardizing nursing knowledge and skills. In this chapter the key findings will be linked to three key main concepts for discussion: increased staff satisfaction and professional identity; a high level of program practicality and staff empowerment; and increased staff competency and standardization. Further, lessons learned from this new standardized two –day nursing orientation program will be shared from a leadership perspective. In closing, I will conclude this paper with the program’s implications to nursing profession. 5.1 Increased Staff Satisfaction and Professional Identity One of the main program objectives, strengthening nurses’ professional identity, has been considered as achieved. From our findings, most nurses were highly satisfied with the new orientation program and spoke of an increased level of confidence in their professional practice. The common theme derived from new nurses’ feedback was an increased sense of professional identity and an increased awareness of nurses’ professional role within the Hospital S. Ultimately, nurses strengthen their professional identity and develop their self-confidence through having a structured nursing education and learning a higher level of nursing knowledge (Hoeve et al., 2013; Pine & Tart, 2009; Ulrich et al, 2010). In this case, new nurses have gained more professional knowledge from international and local practice standards through this orientation program (see Appendix C). When a nurse training program is evidence-based, standardized, focuses on professional role development and competency training, nurses will feel more confident in own self and own profession (Beyea et al., 2007; Herdrich & Lindsay, 2007; Pine & Tart, 2007; Ulrich et al., 2010). As a result, this increase STANDARDIZED NURSING ORIENTATION Keilee Mok 30 in the level of professional confidence will directly lead to higher job satisfaction, increased organizational commitment and better patient outcomes (Beyea et al., 2007; Herdrich & Lindsay, 2007; Pine & Tart, 2007; Ulrich et al., 2010). Laschinger et al. (2009) also believed that “when nurses have the tools they need to practice professionally, they experience greater vigor or energy as they engage with their patients, are more likely to be enthusiastic and proud of the care they are able to provide and to report greater absorption with their interactions with patients and co-workers” (p. 644). 5.2 A High Level of Program Practicality and Staff Empowerment In addition to developing professional identity, this program also empowered nurses to be more confident in transitioning to clinical settings. Overall data showed most nurses agreed that this program was highly practical and relevant to nursing practice. For instance, as described in chapter 4, a seasoned nurse stated that she gained both theories and practical skills that support her clinical practice from this orientation program. Meanwhile, a new nurse graduate reinforced that this program lowered her anxiety level toward clinical practice yet increased her readiness to practice. Laschinger et al. (2009) performed a study on the relationship among empowerment, engagement, and work effectiveness, also explored the effect of nursing experience (new graduates and experienced nurses) on the relationship among these three concepts. The sample size was over 500 nurses with years of experience ranging from 2 years to over 41 years. Interestingly, Laschinger et al. (2009) found that empowerment had statistically significant effects on both engagement and work effectiveness, and that empowerment and engagement had statistically significant effects on work effectiveness in both groups. However, there was less strong engagement and work effectiveness relationship in the new graduates’ group (p. 643). These findings indicate that empowerment and engagement are crucial for new nurses and experienced nurses, as these are important attributes in creating a high efficient, committed work environment. At the STANDARDIZED NURSING ORIENTATION Keilee Mok 31 same time, new graduates might take a longer time to get used to new work environment to be effective at their job. Furthermore, nurses felt empowered and more confident with the knowledge, skills, and hospital policies that they learned about and gained skill in from this nursing orientation. Structural empowerment such as knowledge transfer, hospital policies, and organizational support often empower nurses to perform their job in a more confident and competent manner as they know where to access resources (Greco et al., 2006; Ulrich et al., 2010). Likewise, psychological empowerment is equally important in engaging staff when they are facing new working environment (Moffitt & Butler, 2009), especially with new nurse graduates who may have fewer personal resources and structural supporting systems (Laschinger et al., 2009). For example, nursing leadership’s active involvement in this program empowered nurses to be more committed to this orientation program and to Hospital S (see Appendix B) and this was evidenced by program findings in Chapter 4. In summary, when nurses feel empowered; they are more committed to their job and their organization, and less likely to leave the organization (Dahinten et al., 2014; Greco et al., 2006; Laschinger et al., 2009; Ulrich et al., 2010). 5.3 Staff Competency and Standardization Applying standardization within this orientation program has achieved a consistent level of staff competency through the use of standardized tools and staff empowerment. Ulrich et al. (2010) believed confidence is a precursor of competence, as nurses require a sense of confidence before they could become competent in practice. Our early findings also showed empowerment could promote confidence. This project indicates that nurses require some sort of empowerment--structural (standardized tools and knowledge) and/or psychological (fostering autonomy and shared decision making), before becoming competent. The results listed in Chapter 4, for instance, showed a high mean score in the Pre-orientation STANDARDIZED NURSING ORIENTATION Keilee Mok 32 test (88.35%) and Post-orientation test (81.56%), indicating that new nurses gained a similar level of knowledge from the Pre-reading package and the program material. Similarly, the 100% pass rate for examination during the practicum meant new nurses were practicing according to guidelines. Finally, 100% compliance with returning a full set of completed competency checklists within a month post orientation indicated that all new nurses had the same opportunities to practice standardized skills and competencies within clinical settings. Overall, the project results indicate that competency standardization has been achieved on a small scale: from nursing orientation to clinical settings through new nurses. The literature indicates that standardization in frontline nursing care and orientation programs have been proven to improve patient outcomes (Custer, 2010; Moffitt & Butler, 2009) and nurse job satisfaction (Custer, 2010; Ulrich et al., 2010). The effect of standardization on nurse’s perception on self-competency level is evident, for example, through a nurse’s comment in Chapter 4, when she stated that she felt more competent in her practice with the use of standardized competency checklist (Nurse F, personal communication, July 2016). The next step for nurse leaders at Hospital S is to apply standardization further into patient care. Applying standardization in patient care processes with team training would allow a health care organization to achieve high reliability and create a safe culture (Frankel et al., 2006). In summary, the findings indicate that all the program objectives have been met. Professional identity development, staff empowerment, and standardization were key attributes for program success, and generated results of increased staff satisfaction, an increased level of staff confidence in clinical transition, and a standardized level of competency among new nurses. New nurses are now more confident and competent in their nursing practice with the knowledge and support that they gained from the new orientation program. This results in higher job satisfaction, increased organizational commitment, and better patient outcomes within Hospital S. STANDARDIZED NURSING ORIENTATION Keilee Mok 33 5.2 Lessons Learned Although this new two-day orientation program is considered successful with respect to the program objectives, there are some lessons can be learned for further quality improvement projects within Hospital S and other health care agencies. As Walshe (2007) mentioned, quality projects are “complex social interventions” and “the multiple outcomes are a complex co-product of the context, content and application variables” (p. 57). In this case, the outcomes of this new nursing orientation are highly dependent on Hospital S’s internal strengths and weaknesses, orientation program’s content, and program application processes. As nurse leaders at Hospital S, it is important to explore the internal weaknesses before adopting new innovation (Frankel el et., 2006). From my perspective, according to the SWOT analysis in Appendix A, there are some key internal weaknesses that have limited the potentials of this new nursing orientation. These limitations include a rushed needs assessment, inconsistent leadership participation, and a non-comprehensive evaluation process. These internal weaknesses of Hospital S were all related to a lack of time for planning and implementation. 5.4.1 A rushed needs assessment. During the planning phase of the program, as a Quality Improvement Coordinator, I could not conduct a proper needs assessment due to a lack of time to engage key stakeholders in assessing organizational readiness for change. Glickman et al. (2007) emphasize that it is very important for health care leaders to make accurate assessments of organizational culture before and after implementing quality improvement programs (p. 342). Furthermore, having a broader range of stakeholders on the planning committee is necessary to capture different aspects of a quality improvement project (Burharkt et al., 2015). In this program, we only involved a few frontline senior nurses and the Nursing Administration team. Overall, the processes for project planning and staff engagement were rushed and unstructured. This made it difficult to disseminate information STANDARDIZED NURSING ORIENTATION Keilee Mok 34 and to have a broader perspective of current new nurse practice needs. Unfortunately, there were only a few opportunities to engage direct care nurses (i.e., potential mentors for new nurses) in the planning process. “Leaders must be aware of performance gaps before they can commit to adoption of any innovation” (Frankel et al., 2006, p. 1706). Without knowing the true practice gaps of Hospital S prior to the implementation of this new nursing orientation, it was more difficult to evaluate the outcomes of the program. 5.4.2. Inconsistent leadership participation. During the implementation phase, another weakness was inconsistent leader participation during the orientation program. In current high demanding and time constrained health care settings, there are more work demands on managers to engage and to empower nurses (Greco et al., 2006). As listed in the SWOT analysis in Appendix A, some nurse leaders were late and absent during the orientation program, as they had to perform daily operations. Yet in implementing a quality improvement program such as a nurse training program, active stakeholder engagement and organizational wide commitment are key to success (Custer, 2010; Glickman et al., 2007; Ulrich et al., 2010). 5.4.3 Non-comprehensive evaluation process. Furthermore, due to limited time to properly plan an orientation program evaluation strategy, we lacked standardized evaluation tools to assess successful completion of orientation program objectives. Instead, we developed our own survey tool with basic satisfaction questions (Included in Appendix D & E). Our evaluation outcomes, therefore, have limitations due to the nature of the questions posed, and possible limitations related to concern for confidentiality. A structured, evidenced based training program would require a vigorous standardized evaluation process with a variety of evaluation tools (Beyea et al., 2007; Moffitt & Butler, 2009; Ulrich et al., 2010). For instance, Herdrich & Lindsay (2006)’s study used different standardized evaluation tools and processes tailor made for different specialty nursing residency programs; this was STANDARDIZED NURSING ORIENTATION Keilee Mok 35 because they believed different specialty nurses learn in different ways as communities and there are many variables that could change the outcomes of the program. With this new two-day nursing orientation program, more evaluation tools might be beneficial for further development of the program. These include, for example, pre and post evaluation on self-confidence, self-assessment on competency, and staff turnover intent. 5.3 Implications for Nursing From a leadership perspective, the Hospital S Culture (and Hong Kong culture) is based on a power hierarchy of ‘see, copy, and do’; critical thinking is not seen as essential due to ‘hierarchal’ control from senior nurses and physicians. Nonetheless, this project had successes, including: a) an SPO Orientation Program Framework to guide ongoing implementation and evaluation; b) a standardized, 2-day program with positive initial feedback from new nurses; c) a SWOT analysis to promote program strengths and address potential and actual challenges; and d) awareness of a needed culture shift. I consider this project successful because I do believe there is a greater executive leader awareness, and a sense of urgency, to enhance nurse professionalism within Hospital S. The urgency is due, in part, to increased healthcare privatization, more competition among private hospitals, and savvy consumers with increased expectations for higher quality, safe care delivery. The Executive Board and the Nursing Administration, therefore, is beginning to recognize the merits of nurse orientation, and the need for continued organizational supports that promote greater nurse professionalism (Appendix B). Leadership styles, however, typically influence cultural shifts (Dahinten et al., 2013; Greco et al., 2006; Moffitt & Butler, 2009), and it may take a while for authoritative, directive leadership to be replaced with more transformational styles of leadership. The new orientation program has been created as a portal for new nurses to be more competent and confident in their own practice and profession. This program, therefore, may STANDARDIZED NURSING ORIENTATION Keilee Mok 36 provide the impetus to ensure that new nurses are exposed to key concepts, competencies, professional nursing and standards of care, that will raise the ‘bar’ for nursing within Hospital S. We are in the first stages of cultural change, but eventually, the orientation program for new nurses will result in professional development planning for all nursing staff and inter-professional teams. Orientation programs often put emphasis on junior, recent nurse graduates. A common misconception is that knowledge deficits only happen with junior nurses. In our pilot orientation program, there were some seasoned nurses hired on as new staff. Despite their years of experience, they had never participated in a standardized nursing orientation program, and they greatly appreciated the opportunity and the program content. Dellasega et al. (2009) did an exploratory study on experienced nurses going through orientation in a new job. These nurses reported high levels of fear, stress, and anxiety due to unfamiliarity with a new practice context and expectations on them to perform at a high-level right away. The conflict between the expectation of ‘should know everything with years of experience’ and the reality of ‘being treated as a novice nurse’ created a high level of stress and anxiety for them, especially when they wanted to ask questions about new practices. Dellasega et al. (2009) emphasized that new nurses, whether junior or senior, benefit from mentorship, ongoing education and peer networking and empowerment opportunities. Empowerment opportunities include organizational support, information and knowledge, and psychological support from peers. 5.4 Conclusion A question for current nurse leaders to ponder is whether professional nursing can advance without thoughtful, planning orientation programs and regular knowledge and practice updates. This SPAR project has revealed that tools, such as the SPO Framework and the SWOT analysis, can effectively guide development, implementation and evaluation of a STANDARDIZED NURSING ORIENTATION Keilee Mok 37 new nurse orientation program for one hospital in Hong Kong. Hopefully, this project will serve as a ‘template’ for other nurse educators in Hong Kong and beyond, as they strive to advance nurse professionalism within their organizations. STANDARDIZED NURSING ORIENTATION Keilee Mok 38 References Beyea, S. 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International Journal for Quality in Health Care: 19(2): 57-59 STANDARDIZED NURSING ORIENTATION Keilee Mok 42 Appendices Appendix A SWOT Analysis of Hospital S Table A1.SWOT Analysis of Hospital S Strengths Categories Examples Organization structure: Close-ties Smaller hospital with close ties • Easier to engage and to collaborate with multidisciplinary leaders for nursing orientation • Easier to disseminate information to necessary units & personnel Leadership: Engaged Broad Members Dedicated Hospital Administration and DON toward quality improvement • Administration team is aligned to focus on improving nursing quality as top organizational priority • Resources has been allocated for Nursing Administration to execute quality improvement programs such as Nursing Orientation • DON has a session within nursing orientation program to align team vision and to drive for patient safety and quality nursing • DON is dedicated to improve the nursing service and to support nursing staff • DON has created new leadership positions, SNO & NQIC, to promote nursing-quality Leadership: Transformational & empowering leaders A shift to transformational leadership: build trust to increase job satisfaction • SNO & NQIC are dedicated to provide structural & psychological empowerment through engaging staff in decision making and in leading quality improvement programs • Transformational leadership makes it feasible to build trust with staff and empower staff to express practice needs • Easier to gather data to form a need assessment for the orientation program in a timely manner • Able to create a sense of ownership and a higher job satisfaction rate Leadership: Staff empowerment Create a sense of ownership through empowerment: • When new nurses are being engaged in the evaluation process, they feel being valued and gain a sense of empowerment & ownership toward the orientation program • Nursing Administration celebrate success with staff through newsletters to create a sense of ownership, psychological empowerment, and higher job satisfaction Leadership: Staff empowerment Empowerment through shared decision making • Incorporate frontline staff and their perspective into program planning with needs assessment, solutions identification, and evaluation process • Staff gain trust toward the nursing department when they see practice gaps that are identified and improved through the nursing orientation • These processes empower staff to continue to make decisions for their own practice and to improve their work environment Leadership: Staff empowerment Empower staff through knowledge transfer • Actively involve nursing staff into the Nursing Assessment process can cultivate an evidence based practice and a continuous improvement mentality • Share evaluation results and improvement progress with staff to close the loop and to nurture a sense of ownership STANDARDIZED NURSING ORIENTATION Keilee Mok 43 Table A1.SWOT Analysis of Hospital S Strengths Categories Examples • These knowledge and information empower staff to practice in a confident and competent manner Leadership: Staff engagement Engagement through an interactive learning environment • Introduce interactive teaching methods such as case studies, role play, simulations, and practicum have been introduced in the new orientation program to create an engaging learning environment for new nurses and to trigger critical thinking Leadership: Team building Enhance multidisciplinary collaboration, build capability for teamwork • Involve other disciplines into nursing orientation as speakers to enhance mutual understanding and collaboration among different disciplines around patient care • Give exposure to new nurses to work with others at early orientation stage for better adaptation at clinical settings • Build a more cohesive, supportive team learning environment Leadership: Team building Team building • Team building exercises, group activities, and pairing up during practicum promote a supportive team learning environment • Clinical tour to designated wards allow new nurses to get familiar with clinical environment and future teammates • Building a cohesive team to increase job satisfaction and work morale Standardization: Program materials & process Standardization for quality and program sustainability • Standardized class materials create a mutual knowledge platform for all new nurses • Standardized competency checklists act as guidelines for new nurses and as objective assessment tools to maintain nursing standards • These standardized tools enhance individual learning and promote standardized nursing practice • The orientation program is sustainable and repeatable as the processes involved are standardized and captured as a Standardized Operation Procedure Standardization: Program evaluation Program evaluation performed with standardized tools in a timely fashion • 100% participation in the evaluation process: all 18 participants filled in standardized evaluation forms and participated in the post orientation interview • Evaluation data was captured at the end of each session for the most accurate data • Evaluation reports reflect current learning needs and gaps for program improvement • Standardized evaluation tools and evaluation process are applicable on another nursing orientation as they are standardized • Data and evaluation reports are used for continuous improvement for further development of this nursing orientation Organizational Resources: Synergy Synergy among new staff • NQICs are new change leaders that bring quality improvement experience to create and implement this standard 2-day nursing orientation • New nurses bring in various experience and knowledge from all sort of clinical background • Empowering staff to be involved in decision making creates synergy effect in improving patient care and nursing practice at Hospital S STANDARDIZED NURSING ORIENTATION Keilee Mok 44 Table A1.SWOT Analysis of Hospital S Strengths Categories Examples Orientation material: Professional autonomy Promote professional autonomy & identity • Orientation material promotes nursing profession, professional autonomy, and critical thinking; this creates a culture shift within nursing department • New nurses feel empowered and more confident in own competencies and own profession Program Outcomes: Confidence & Competency Positive outcomes from the new nursing orientation • A high passing rate for the Pre-orientation test, Post-orientation test, and Practicum proves new nurses retain knowledge from reading material and class participation • Positive feedback from new nurses: individual learning needs are met • New nurses feel supported by leadership team • New nurses feel more prepared toward clinical environment post nursing orientation, gained a sense of belonging, and feeling more professional as a nurse Note: DON= Director of Nursing, HR= Human Resources, NOs= Nursing Officers, NQIC= Nurses Quality Improvement Coordinator, SNO= Senior Nursing Officer Table A2. SWOT Analysis of Hospital S Weaknesses Categories Examples Organization culture: Competitive priorities Compétitive organizational priorities • Other priorities within Hospital S are competing for limited resources with this nursing orientation program especially when this program requires a longer period to show its success, i.e. staff’s job satisfaction and staff retention • Executive Board might allocate resources on other quality improvement programs that produces short term results • There is no solid sustainment plan for the orientation program Organization culture: High turnover rate High turnover rate & low work morale • Current turnover rate is 23% among nursing department, the highest of all time over the last 50 years. • Recent staff survey shows low job satisfaction and low work morale within nursing department • Staff expressed frustration toward heavier workload with mentoring inexperienced staff and short of staff Organization culture: Lack of communication Lack of two-way communication in the organization • Frontline staff are often not being involved in decision making with organization changes • There is no venue for staff to give feedback on new initiative, current practice, or express their concerns • Staff feel being devalued and detached from the organization, which led to low job satisfaction and low work morale • Directly affect nursing practice, patient safety, and work environment Organization culture: Uncompetitive employee package An uncompetitive employee package for nurses • Hospital S offers a lower salary range for nurses with very few professional development opportunities • Staff has expressed their concerns in this area especially when there are other new hospitals offer more attractive employee packages STANDARDIZED NURSING ORIENTATION Keilee Mok 45 Table A2. SWOT Analysis of Hospital S Weaknesses Categories Examples Leadership: Medical profession dominant hierarchy Medical profession dominant hierarchy • Historically the nursing department has been led by a physician and the medical team often has priority over the nursing team especially during resources allocation • There is minimal professional autonomy within nursing leadership due to physician control over decision • Some nurse leaders expressed frustration and intention to resign Leadership: Authoritative leadership Authoritative leadership culture • Authoritative “power over” culture has been existing in Hospital S for many years, especially within the nursing department • This type of leadership extends from the director level to the team level • Some leaders view “power” as holding on to information • Staff has expressed that often no explanation behind new initiatives and just “ordered” by their managers • Staff is less engaged with authoritative leadership and unable to exercise own professional autonomy; leads to low work morale and low job satisfaction Leadership: Inconsistent Leadership Inconsistent leadership • This new orientation program will not be able to sustain without consistent leadership • Some NOs were late and absent for nursing orientation: this shows no accountability to own performance and staff’s learning success • SNO & NOs are often busy with hospital operations and have limited time to engage with staff; sometimes misses appointments with staff; if they meet with staff, it will be very brief and multitasking • Staff have expressed this as “they are too busy for us” Leadership: A lack of accountability Lack of accountability for staff competency and quality improvement • There is no yearly performance review and objective evaluation tools on nursing competency for staff and frontline leaders • Frontline leaders such as NOs & SRNs have no accountability on staff’s competency • There is no clinical educator for nursing staff education or mentoring • Staff expressed there is no resources for professional development and do not aware of own competency Leadership: Staff mix model Staff mix (RN & EN) • Mixing the skill sets of RNs & ENs for patient care • RN pay scale is more than EN • No clear guideline for nurses to understand the difference in RNs & ENs practice within Hospital S • Staff feel unsafe and cannot rely on each other • This creates a divided team dynamic within Hospital S Leadership: Staff fatigue & burnout Fatigue and burnout from organizational changes • Staff expressed burnout from too many organizational changes that do not have a sustainment plan • No explanations were given behind most program implementations and they are ‘being told’ to implement • Staff feel disempowered and hopeless in improving current situation Work culture: Increased workload Increased workload • A higher patient acuity with a big practice gap among nurses at Hospital S make it more difficult for nurses to provide safe patient care STANDARDIZED NURSING ORIENTATION Keilee Mok 46 Table A2. SWOT Analysis of Hospital S Weaknesses Categories Examples • Senior nurses expressed their concerns and stress on increased workload with higher patient acuity and more responsibilities in mentoring junior nurses Work culture: Practice gap A gap in nursing experience among nurses • Most senior nurses at Hospital S have15 years or above nursing experience; most junior nurses have 3-year clinical experience or less • There are very few nurses have nursing experience between 5-15 years • This gap in nursing experience creates a huge variance in practice • The differences in age and training background among nurses creates communication gaps and makes it difficult to pass on knowledge through mentorship • Inadequate communication widens the practice gap, directly affect nursing quality and patient safety Orientation Program: Structure Orientation is too compact with too much material • Orientation timetable is too condensed with too much diverse materials, difficult to focus on the quality of learning • New nurses expressed stress related to too much information to obtain within 2 days • New nurses feel overwhelmed by the expectations from Hospital S Orientation Program: Insufficient evaluation process & tools Insufficient evaluation process and tools • A lack of time to properly plan the evaluation process and tools • Limitations lie within evaluation tools • Evaluation tools did not capture subjective self-perception of new nurses pre and post orientation program • Data collected from the evaluation were not analyzed thoroughly due to a lack of time • Evaluation did not reflect program's weakness and current challenges with orientation • Evaluation tools did not incorporate program objectives such as the effect on staff retention and job satisfaction: all these objectives require a longer period to evaluate and to monitor • There is no formal, written feedback from the presenters and existing staff, instead informal verbal feedback STANDARDIZED NURSING ORIENTATION Keilee Mok 47 Table A3. SWOT Analysis of Hospital S Opportunities Categories Examples Social Reputation Build a better hospital reputation among the Private and Public Sectors • Improving nursing practice through nursing orientation can improve patient care and build a better reputation for Hospital S within the private hospital industry Leadership: Professional role model Be a role model: advocate for nursing autonomy • Nursing Administration teams from other hospitals will reflect and learn from Hospital S’s success, such as leadership engagement, frontline empowerment, competency & process standardization, and quality improvement outcomes from the new nursing orientation program • Nurse leaders will learn from the processes involved in this orientation: gather evidence to advocate for more resources and professional autonomy within own hospital to improve nursing quality with training • Hospital S’s nursing team become the role model for other nurses Leadership: Professional role model This 2-day nursing orientation becomes the blueprint for quality improvement projects • The strategies that were used in this orientation program will become the blueprint for future quality improvement projects, especially for within nursing field • Strategies such as: applying standardization in healthcare and in education, staff empowerment with quality improvement Standardization: Professionalism Promotes professionalism, creates a unified culture, be a benchmark for other health professionals • Standardized HR policies makes nursing orientation formal and professional, this formality enhances nursing professionalism • New Policies, such as standardized orientation date and clinical mentorship, create a unified, professional orientation environment for new nurses • These strategies can be a benchmark for other health disciplines in the private sector to build their own orientation program Staff Recruitment Potential nursing staff recruitment • This standard 2-day nursing orientation program may attract other nurses to join HIKAS Hospital because of its positive outcomes • Internal staff may also promote its success to other nurses for further recruitment STANDARDIZED NURSING ORIENTATION Keilee Mok 48 Table A4. SWOT Analysis of Hospital S Threats Categories Examples Global shortage Global nursing shortage • A higher demand for nurses but with a limited supply of nursing students from limited universities in Hong Kong • A higher retirement rate among the seasoned nurses (baby boomer generation) • More private hospitals and medical businesses are being built in Hong Kong and internationally to attract new graduates and public nurses for a wide range of job opportunities Global competition Competitive global quality improvement initiatives • There are many different global quality improvement initiatives out that the Executive Board might want to pilot at Hospital S to be a leading hospital in Hong Kong • This new nursing orientation must show success to fight for resources to sustain and maintain its quality External competition Competitive private hospital industry • Competitive HR packages are being offered by other private hospitals to recruit senior nursing staff from HOSPITAL S • Competitors might have better quality improvement programs to build a better repetition to attract more customers • There are a few new private hospitals being built in HK that are offering attractive employee packages to new graduates Divided nursing profession A wide spread use of staff mix: RNs & ENs • A divided nursing team and tension due to unclear scope of practice & imbalanced benefits • More nursing staff that work in the private sectors feel unfair when ENs & RNs both performing same patient care but RNs are being paid more • RNs feel unsafe with ENs' individual practice without RNs’ supervision • ENs & RNs becoming against each other and develop mistrust among these two nursing professionals Legality of staff mix Potential legality issue • Patients and family might challenge the Staff-mix nursing model as some ENs might breech their scope of practice with high acuity patients and unsupervised, delegated task • Lack of adequate knowledge and skills competency in nurses directly affect patient safety STANDARDIZED NURSING ORIENTATION Keilee Mok 49 Appendix B SPO Framework: The Two-Day Nursing Orientation Program Table B1. SPO Framework: The Two-Day Nursing Orientation Program at Hospital S Structure Process Outcome Needs Assessment • Nurse leaders acknowledged current high nursing turnover rate • Nurse leaders engaged & empowered staff through informal meetings • Gathered data from nursing staff • Nurse leaders Assessed current nursing practice gaps & challenges • Formulated a preliminary needs assessment • Pinpointed improvement opportunities from frontline perspective • Created an awareness of nursing quality & patient safety • Created a sense of ownership through staff participation in identifying challenges & solutions • Staff felt being valued and more engaged Proposal for a new two day nursing orientation program • Evidence based, quality improvement plan based on the needs assessment • PowerPoint presentation and sharing • Key stakeholders engagement • Project timeline for planning & implementation stage • Support from Hospital & Nursing Administration • Approval for resource & funding • Improving nursing practice becomes high priority within Hospital S • Proposal includes staff’s input & suggestions Timetable for nursing orientation • Eextended from a 3-hour to a 16-hour (2 day) pilot program • SNO & NQICs were responsible for this program • A timetable was planned around limited resources based on needs assessment • Arranged resources for manpower for nursing orientation • Projected education materials and venue for this program • Positive feedback on the length of extended orientation program from new nurses and staff • New nurses gained more knowledge toward hospital culture & policies • New nurses felt more prepared for new clinical environment Program structure & format • Interactive learning atmosphere • Nursing Administration involvement • Multidisciplinary approach • Revised program structure from former orientation program • Performed literature reviews on effective nursing orientation • Arranged new nurses sitting in a circle for better interaction • Involved Power-point presentation, case studies, group discussion, role play, and practicum • Engaged DON, SON, & NOs as presenters and some Allied health leaders as guest speakers • Positive feedback from new nurses on learning environment • New nurses felt supported by Nursing Administration and more confident toward clinical practice • New nurses gained a sense of belonging and better understanding toward multidisciplinary collaboration and work • Built a cohesive team prior clinical practice Standardization of knowledge & competency • Clinical practicum with Competency checklist • Pre-orientation test & Post-orientation test • New nurses written a Pre-orientation test prior orientation to standardize understanding for pre-reading • A Post-orientation test was to standardize new nurses’ understanding toward the orientation program • NQIC & NOs demonstrated common nursing skills at practicum • New nurses felt more equipped for clinical • A high mean score for Pre-orientation test, Post-orientation test, & Practicum • New nurses gained good understanding of the main principles from the Orientation program STANDARDIZED NURSING ORIENTATION Keilee Mok 50 Table B1. SPO Framework: The Two-Day Nursing Orientation Program at Hospital S Structure Process Outcome with standardized skill competency checklists • New nurses provided return demonstration in pairs and be tested on the competency checklists • All nurses were required to pass all the above prior independent practice on ward • Individual learning objectives were being evaluated based on standardized tools • Created a set of standardized guidelines for mentors to evaluate New nurses’ competency • Set a platform for standardized knowledge and nursing competency among new nurses Education material • Orientation package: a Welcome Letter, a self-reflection exercise, In-class presentation, & a Pre-orientation test (multiple choices) • Evidence based material based on current standards of nursing practice • New material on patient safety, professional autonomy, & critical thinking • Orientation package was given by NQICs to all new nurse two-week prior orientation • The Welcome letter was addressed from the DON to support new nurses’ learning journey • Education material from former orientation program was revised to ensure relevancy, quality, and accuracy • New education material added to reinforce standards of nursing practice, patient safety, and expectations of Hospital S • NQICs empowered new nurses through valuing their current expertise in knowledge • NQIC reinforced nurses’ professional roles and responsibilities based on Hong Kong Nursing Council’s Professional Practice Code • NQICs and presenters used open-ended questions and case studies to encourage problem solving & critical thinking • Cultivate evidence based practice and practice according to professional guidelines • New nurses appreciated the Orientation package, more engaged during orientation • New nurses reflected own expectations toward the program and learning needs prior to orientation • New nurses felt being welcomed and gained a sense of belonging • New nurses gained knowledge on current nursing standards and made aware that patient safety is Hospital S’s top priority • New nurses felt more confident and more aware of own social responsibility as a profession • New nurses demonstrated critical thinking and case management through case studies & simulations. • New nurses felt supported by nurse leaders and felt more equipped for clinical practice Organizational Resource • Manpower plan • Teaching Materials: - Conference room & Computers - PowerPoint presentation - Disposable equipment for practicum - Printed material for Orientation package - Meals &Incentives for Q&A • Organized all the needed resource 3 weeks prior to orientation • A checklist of equipment to be delivered 2 weeks prior to orientation for practicum session • NQIC coordinated with all involved personnel for a rehearsal a week prior to actual orientation date • Rehearsal involved using all IT equipment and timing each session for unpredictable events • Debriefing was held after rehearsal related to feedback on presenting style, timing, and backup plan • A reminder was sent to all involved personnel a day prior to orientation & on actual date • All presenters were present for rehearsal and arrived on time for orientation • Most presenters were able to deliver their material within scheduled time • Orientation materials were funded by Nursing Administration and prepared by NQICs • All orientation materials were available during orientation program • New nurses were satisfied and engaged in this supportive environment • New nurses appreciated free lunch, incentives from Q&A sessions, and learning materials for practicum. STANDARDIZED NURSING ORIENTATION Keilee Mok 51 Table B1. SPO Framework: The Two-Day Nursing Orientation Program at Hospital S Structure Process Outcome Program Evaluation • Hospital S Nursing Orientation Program Evaluation (Individual Session) (Quantitative) • Feedback on Nursing Orientation (Qualitative) • Revised In-Service Program Questionnaire (Overall program quantitative evaluation) • Observations and verbal feedback • SNO & NQIC created evaluation tools to capture qualitative and quantitative data • Data being collected at the end of each session for more accurate outcome • The Revised In-service Program Questionnaire was given to new nurses at the end of each orientation day for overall program performance by the Staff Education Department • Presenters provided verbal feedback on orientation program to NQICs after each session • NQIC had 1 on 1 interview with new nurses 2 weeks post clinical orientation and new nurses fill in the qualitative feedback form • NQICs collected all data, compiled evaluation reports, presented improvement plan to SNO and DON • There were no missing data • New nurses felt being valued by Nursing Administration and gained a sense of ownership with program evaluation • Evaluation report reflected current learning needs of new nurses and gaps for program improvement • Data size was large enough to generalize the needs of new nurses • Evaluation tools captured useful data for continuous improvement opportunities • A culture of continuous improvement was cultivated New Policy Formulation • Standard hiring process: mandatory nursing orientation & standard start date • Pre-orientation 1:1 meeting with NQIC • Mentorship program with a designated mentor • SNO & NQICs formulated a new hiring policy with Human Resources department • Nursing orientation was standardized to be mandatory prior to clinical start date • Clinical start date was standardized for all new nurse across all wards • Mentorship program with a designated mentor was introduced and organized by Nursing Administration • NQIC met with new nurses through informal meeting prior orientation: give out orientation package & explain program expectation • Reinforced Hospital S’s vision that quality in nursing is a priority • The nursing orientation program was standardized and had a formality • New hires felt engaged and being supported throughout both orientation and mentorship program Note: DON= Director of Nursing, NOs= Nursing Officers, NQIC= Nurses Quality Improvement Coordinator, SNO= Senior Nursing Officer STANDARDIZED NURSING ORIENTATION Keilee Mok 52 Appendix C The Program Structure of Standardized Two-Day Nursing Orientation The program structure of a standard 2-day nursing orientation is listed in Table C1 with aligned program objectives. There are five main objectives: 1. To strengthen nurses’ professional and organizational commitment through aligning personal, professional values with organizational values 2. To empower nurses to be competent and confident in their professional selves through transferring up-to date health knowledge and nurturing critical thought process 3. To ensure patient safety by maintaining professional practice standards 4. To build a cohesive, supportive nursing team through open communication, group activities, and providing leadership support at early stage 5. To ensure a safe, successful clinical transition for new nurses through interactive classroom teaching, practicum, and clinical orientation Table C1. The Program Structure of Standard Two Day Nursing Orientation Day 1 Objective Program Content Teaching Format Presenters 1,4 Team Building Group activities NQIC 1, 3, 4 Organization Vision & Mission Slideshow 1, 2, 3, 4, 5 HKAS Professional Behavior & Patient Experience Model Case studies, slideshow SNO 1, 2, 3, 5 International Patient Safety Goals Case studies, slideshow, Q&A NQIC 1, 2, 3 ,4, 5 Medication Administration Case studies, slideshow, Q&A NQIC 1, 2, 3, 4, 5 Enhance Nursing Quality & Customer Services Case studies, group activities, practical session NO 2, 3, 4, 5 Clinical Pharmacy Slideshow Pharmacist 2, 3, 5 Code Blue Response Case studies, slideshows, Q&A SEC 1, 2, 3, 4, 5 Case Management Approach Case studies, group activities, slideshow NQIC 1, 2, 3, 5 Infection Control Slideshow, practical session NO Day 2 2, 3, 5 IT Access Electronic devices, practical session NO 1, 2, 3, 4, 5 Nursing Documentation Case studies, group activities & presentation, Q&A NQIC 1, 2, 3, 4, 5 Medication Routes & Patient Education Case studies, slideshow, Q&A NQIC 2, 3, 4, 5 Common Equipment Operation Demonstration, practical session NOs 1, 2, 3 ,4, 5 Ward Visit Group activities, practical session, NOs 2, 3, 4, 5 Practicum (Medication Administration) Demonstration, practical session, Pairing up, Examination NQIC 2, 3, 5 Post Test Individual NQIC,NOs Note: DON=Director of Nursing, NQIC= Nursing Quality Improvement Coordinator, Nursing Officer= NO, SEC= Staff Education Coordinator, SNO= Senior Nursing Officer STANDARDIZED NURSING ORIENTATION Keilee Mok 53 Appendix D Feedback on Nursing Orientation Date: _________________ Staff name: _______________________ Staff Number: _____________ Unit: __________ Date of Nursing Orientation: ________ Date of Clinical Orientation: ________________ New Employee □ Former HKAH Hospital Employee: □ Year of Nursing Experience: _____ Interviewed by: ___________________ Name of Mentor: __________________________ Questions: 1) Do you think having this Nursing Orientation prior to your actual start date could assist/ help you to adapt to your clinical settings? If so, in what way? 2) When do you think it will be more practical/ suitable for new employees to participate in this orientation? (please tick the appropriate box) a. Prior to actual clinical days □ or after you have been working for a period of time □ And Why? b. If so, how long into your clinical days? 1 month □ 3 months □ 6 months □ c. Do you find learning materials about other units’ practice are relevant to you/ your practice? If so, how? If not, could you explain why? 4) Through this Nursing Orientation, do you find you have gained knowledge in our HKAH work culture & our nursing practice? If so, do you mind give us some examples? 5) Overall, please give us some of your constructive feedback on our Nursing Orientation? Thank you very much for your contribution. STANDARDIZED NURSING ORIENTATION Keilee Mok 54 Appendix E HKAS NURSING ORIENTATION PROGRAM EVALUATION (Individual session) In order to make continue improvement of our nursing orientation program, please complete the following evaluation questions. We appreciate your input. Thank you! Participant: RN EN Department: Working in U200, U300,U500 Working in specialty areas Date and Time: Topic/ Session: Presenter (s): Please circle the most appropriate answer The Presenter Very Poor Poor Neutral Good Very Good i. Knowledge of subject matter 1 2 3 4 5 ii. Presentation skill 1 2 3 4 5 iii. Encouraged audience to participate 1 2 3 4 5 iv. Responded well to questions 1 2 3 4 5 v. Time management skill 1 2 3 4 5 vi. Overall 1 2 3 4 5 Content / Teaching materials Strongly Disagree Disagree Neutral Agree Strongly Agree i. Well Organized 1 2 3 4 5 ii. Easy to understand 1 2 3 4 5 iii. Course content met your needs 1 2 3 4 5 iv. Relevant to your daily work 1 2 3 4 5 v. The amount of content is appropriate 1 2 3 4 5 vi. The duration of session is appropriate 1 2 3 4 5 vii. Others (please specify): 1 2 3 4 5 Comments: Overall Strongly Disagree Disagree Neutral Agree Strongly Agree i. This session meets my expectation 1 2 3 4 5 ii. This session help me to adapt HKAH’s working culture/ nursing practice 1 2 3 4 5 Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied Overall Satisfaction 1 2 3 4 5 THANK YOU "@en ; edm:hasType "Graduating Project"@en ; edm:isShownAt "10.14288/1.0340511"@en ; dcterms:language "eng"@en ; ns0:peerReviewStatus "Unreviewed"@en ; edm:provider "Vancouver : University of British Columbia Library"@en ; dcterms:rights "Attribution-NonCommercial-NoDerivatives 4.0 International"@* ; ns0:rightsURI "http://creativecommons.org/licenses/by-nc-nd/4.0/"@* ; ns0:scholarLevel "Graduate"@en ; dcterms:isPartOf "University of British Columbia. NURS 595"@en ; dcterms:subject "Nursing leadership"@en, "Professional identity"@en, "Standardization in health care"@en, "Nursing orientation program"@en, "Nursing competency"@en, "Nursing empowerment"@en, "Quality improvement"@en, "Nurse retention"@en, "Inservice training"@en, "Program evaluation"@en, "Quality of nursing"@en ; dcterms:title "A standardized two day nursing orientation program : a quality improvement project at a private hospital in Hong Kong"@en ; dcterms:type "Text"@en ; ns0:identifierURI "http://hdl.handle.net/2429/60162"@en .