Designing a Comprehensive Model for Critical Care Orientation

Abstract

One of the greatest challenges in clinical nursing education is providing an orientation program that meets the needs of critical care nurses with various backgrounds and levels of experience within a relevant and stimulating format. Since the 1990s, a major shift has occurred within the culture of intensive care units (ICUs) to employ, orient, and mentor new graduate nurses. Formerly, after graduation, the standard progression for all critical care nurses was at least 1 year of medical-surgical experience in a general care area. The gradual transition from medical-surgical nursing into the critical care environment that once existed has changed in response to the dwindling supply of nurses in the workforce. Concurrently, the population of patients in ICUs has increased, the severity of illness has increased, and the length of stay has decreased. Critical care educators are challenged to accommodate graduate nurses into ICUs while maintaining competence and ensuring the highest quality of care. In this article, we describe how we faced that challenge and exceeded all expectations.The previous program of orientation for critical care nurses at Northwestern Memorial Hospital, Chicago, Illinois, consisted of 2 primary methods: classroom education and clinical instruction with a preceptor. Nurses were hired into any of our 5 ICUs: medical, surgical, cardiothoracic, neurosciences, and coronary care. The length of orientation ranged from 8 to 12 weeks, depending on the nurse’s number of years in nursing and level of experience.Each new nurse was enrolled in the Critical Care Course, a 3½ day course that included lectures covering a basic review of cardiac dysrhythmias, pulmonary disorders, renal failure, interpretation of blood gas analyses, and monitoring hemodynamic parameters. Before implementation of our new critical care orientation program, most ICUs did not accept new graduates. All new nurses, regardless of experience, were required to either attend the classes offered every 2 months or test out of the classes via written examination. Task competency was validated at the bedside by a preceptor, who used a standardized checklist. Select units also provided classes that focused on the units’ specific population of patients. Written materials were made available to the orientees, but no designated time outside of the orientees’ assigned orientation hours for patients’ care was given to review and discuss these materials.Because of numerous concerns about content and consistency of classes as well as the need to promote critical-thinking skills in the orientees, the managers and staff educators requested support from Northwestern Memorial Academy, the training and development section of the human resources department. The academy, in turn, asked the clinical nurse specialist (CNS) for the department of respiratory care, who held dual certification as a critical care CNS and in continuing education and staff development, to assess the program and recommend revisions.In our traditional approach, when a new nurse was hired, the manager of the ICU was disconnected from the educational part of the orientation and focused on the departmental orientation from a human resource perspective. The staff educator took on the bulk of the role of determining compliance with the mandatory hospital-wide educational programs, the unit-based classes, online learning modules, scheduling of orientation, and follow-up. The preceptor’s role was to “shepherd” the orientee though the critical care orientation and ensure completion of the orientee’s competency-based skills lists.A comprehensive assessment of the critical care orientation was performed during the last quarter of 2003 and into the first quarter of 2004. The CNS identified 3 primary areas of inconsistencies in our previous orientation program: instructional reliability, teaching materials, and scheduling. We defined instructional reliability as the ability of 2 different instructors to teach an identical session with equal results. In other words, participants who attended identical sessions taught by different instructors should have the same understanding or grasp of the material. However, we found that equal results were not the case. Teaching materials consisted primarily of standardized PowerPoint presentations, and sometimes outdated written materials were used. Occasionally, instructors (usually the staff educators) were not available to teach scheduled classes because of unit staffing needs and classes had to be canceled. Because classes were offered bimonthly, they did not always coincide with the start of orientation sessions; therefore, new nurses were inconsistently scheduled for these classes.In addition to inspecting the teaching materials used in the critical care classes, the CNS evaluated each instructor’s teaching skills and the methods used to elicit class participation. She assessed each instructor’s ability to present the information, noting whether he or she simply read from notes or had a more active role in interacting with the participants. The CNS also taught sessions of the Critical Care Course, which allowed her to evaluate the teaching materials from the instructor’s perspective. Next, the CNS developed 4 separate assessment tools, one each for new orientees, preceptors, the unit-based staff educators, and the nurse managers. These assessment tools were based on her experience with the development and evaluation of previous orientation programs. The tools consisted primarily of open-ended questions and were distributed to each of the 4 groups.The staff educators, managers, and preceptors were asked about their perceptions regarding the amount of time spent preparing to orient new staff, new nurses’ level of motivation to learn, barriers to the effectiveness of preceptors, resources to improve function of preceptors, preceptors’ satisfaction, helpfulness of the current critical care orientation classes in introducing critical care concepts, level of satisfaction with the critical care orientation program itself, and suggestions for improvement. In addition, recent orientees were asked about how much time they spent in classroom education, in clinical orientation with a preceptor, and in self-directed activities. They were also asked about how their learning needs were assessed, whether they met regularly with the staff educators to discuss goals, the orientees’ preferred learning methods, and whether the orientees accomplished their goals of orientation. Tables 1 through 4Table 2Table 3Table 4 list the specific questions asked of each group. Many of these questions were duplicated throughout the groups to provide a comprehensive picture of the current state of the orientation process.To identify repetitive themes, the CNS analyzed the results of these questionnaires and the course evaluations of the previous year’s critical care orientation program. A proposal was submitted in early 2004 with recommendations for improvement. The areas to be addressed included the previously discussed inconsistencies in teaching methods, scheduling, and education.Results from the staff educators indicated inconsistencies in the way the program was implemented from ICU to ICU. In some units, orientees were allowed to test out of classes if they had critical care experience; in other units, they were required to attend all classes regardless of their experience level. In addition, the criteria for competence varied from unit to unit. For example, in one unit, competence was assumed once an orientee had achieved an acceptable score on the posttest, whereas in other units, skills checklists were used, but not consistently.Staff educators were also concerned that orientees sometimes completed their orientation period needing more time to apply the information in the clinical setting. In addition, no was available to to in an ICU CNS also to assess the critical-thinking skills of the orientees and in the way content was classroom instructors how to on a to ensure that the was instructors were to from the preceptors’ These included or inconsistencies in the skills of the preceptors and perceptions of the were on the of did on the of which was the most was also based on years of on the unit, and previous experience as a teaching skills to be The a course that is but not mandatory for preceptors, of sessions offered in a The classes assessment and critical new and the the of instructional not all preceptors attended these some preceptors had more information on teaching a of support for the orientation a that to nurses to as culture a of staff available to as preceptors and a of staff to in this In addition, preceptors because of the also identified areas of with the orientation These areas included scheduling skills preceptors, and the concerns of classes scheduled at the of orientation was a of because did not with clinical in a of critical-thinking skills on each preceptor’s skills and the preceptor’s motivation to with patients were not available within the assigned orientation The of and to in an because no time was outside of hours for care to the assessment of the program provided the for a major of the critical care orientation program, in the of a new for orientation. The primary of the new program is to provide each new nurse the skills to function and in the ICU. We out to a program that provide preceptors the resources and materials to ensure implementation of a quality orientation program from unit to unit and a program that of competence and assessment of critical-thinking teaching materials that were and that current had to be to the inconsistencies and concerns with the previous program: in teaching materials, scheduling, instructional reliability, of assessment of critical-thinking outdated materials, and the areas of the preceptors and also had to the learning needs of nurses with different levels of new of critical care orientation was that on to has 5 levels of and this are 3 of that we used to the critical care orientation and nurses to their role in the new ICU nurses to a of and competence in nursing the program time for resources in critical care concepts, and in or These new ICU nurses the to The of our program for nurses the ICU regardless of their previous or level. In the of our program, we provided preceptors with the resources and materials to ensure that a quality orientation program is implemented from unit to new on the a of learning methods, to and self-directed learning as an when These methods and the 3 of nurses to to a level of clinical new of critical care orientation was developed first has an that the of a to orientation from unit to unit. primary of critical the program as changed from one of traditional to as a the new on a a of learning to and self-directed learning as an when for assessment and evaluation of a ability to apply the in and challenge has to provide stimulating learning for 3 critical care nurses, care nurses, and graduate nurses. learning were to a of our the traditional learning methods of classes in with to a have with a of learning on each nurse’s experience, learning needs are identified in different the section of the A of learning methods are used, depending on the results of these The primary learning methods used in the new online a human and clinical time with a preceptor. The staff educator and other learning methods are for each These other methods classroom lectures the orientation classes for the nurses in the from critical care and our new most of the traditional classroom lectures have with the learning of Critical Care and is a comprehensive learning program developed by the of Nurses and of 8 and a basic review of and or and specific relevant to that A of are used in and The program also in which are to the of the staff, the number of on and all of orientees’ in completion of the was to provide a educational program on monitoring hemodynamic and pulmonary was developed in with the of the of the of the of the the and the of and the of Critical Care are into 2 levels of each concepts, interpretation of and of monitoring hemodynamic parameters. of on hemodynamic in and hemodynamic as failure, and a nurse and he or she hours of continuing education learning provide current content in a that be at scheduled or at the of the one of our instructional we also a to assess how each orientee this information to specific We assess of the by and of experience with the human which are methods for critical-thinking of assessment is when the competence of any new a assessment an and with a the by or her concerns about and with the of a The a staff educator or an the to a in the but the more information the the of the the to evaluate the way the for the and participants to in a were developed by critical care nurses and staff educators at Northwestern Memorial to the learning needs of orientees at levels of in to challenge nurses at all levels of was developed to specific teaching 5 is an of a that be used by an orientee and is a that be used by a with an orientee The that the the orientee the The orientee is evaluated on or her ability to discuss the care within the of these of the are in a learning evaluation of critical by the orientees in a more learning environment through the of a human is by the department of and has an in the education of who are to patients with a of orientees to learn, and the evaluate the orientees’ response to in a The be to an an or a were developed by critical care nurses and staff educators that an orientee to numerous that in the ICU. a in a new an of to and of a with with and of a from and and to a from with is because the be used to the critical-thinking skills in a environment and educators in as motivation and to as well as The of critical is of critical is in or in methods also support 3 of of and other learning tools from to These the orientees’ that each of a care is not about but about the as a with A from a to by with a clinical and information for new for assessment and evaluation of an orientee’s ability to apply the in and 2 the 3 separate orientation for critical care nurses with different experience critical care nurses, nurses critical care experience, and graduate nurses. All nurses a general nursing orientation during their first information on the content given to all nurses during the first of the start of orientation, each critical care nurse is by the The is a comprehensive test that a of critical care monitoring and for the was provided through with previous of the and by a of who for and current as indicated by the was for The and we have found that the critical care nurse to the critical care staff educator that an acceptable score on the is the nurse or on all the nurse to orientation and no is the score is on any the educator the to the orientee’s identified learning with the orientee’s preceptor, the educator the orientee’s to completion of these the of orientation, competence is validated when the orientee has a score of at least on the assigned who have experience in a care unit with and to a in the and and monitoring of patients. time is by clinical time with the nurses’ preceptors, unit with the and sessions on clinical on the of the content that in educators with the preceptors to a that time for these the of orientation, competence for this is also validated when the orientee has a score of at least on all and of of our ICU areas the units’ managers to graduate nurses, that had at this These managers the Northwestern Memorial to a program to support these with the managers, and staff educators from the an program the Critical Care was to the and of graduate nurses into the critical care of this program are to ensure basic nursing and to support the preceptors in providing critical care information that the graduate nurses are to function when in a critical care of the is in in a of modules, each with a on a The modules, based on the found in and are in the program to the of that as in patients. on the and skills in the previous the is a of all that a with The of the is to a graduate nurse into a within the first 2 of the is the of program: 5 of general nursing orientation for all graduate nurses to general of care. The of program all of the graduate nurses to review and the general skills in nursing orientation the of a clinical who is either one of the staff educators or an staff instructors and review skills in a environment during the In the they a of graduate nurses out to various care of the content in the unit are in to provide to of have that graduate nurses who have through this clinical and skills to start the this and continuing for the 8 weeks, the graduate nurses in the ICU to critical care nursing with the and A is in the new nurses attend at least 1 session focused on of the critical care information in the is also with when the orientees are in the unit with the are developed by the and the staff educators that each graduate nurse’s time is unit-based completion of assigned online modules, clinical and time in the unit with the the clinical critical care in the respiratory a with an are by a of methods, with nurses, and teaching in any critical care unit. the content in the a new nurse graduate is scheduled to in a unit, of and skills in the critical care sessions is by the nurse’s preceptor, who that with the is to from the previous that the orientee to the ICU environment through with the preceptor, and patients. the graduate nurse of and are and with which to provide care for program has that Northwestern Memorial has to provide resources to the program to any nurses with care experience who from in the as identified by the staff educators and the of each graduate nurse has completed all but to in the unit with a preceptor. experience the graduate nurse into the critical care nursing role while the of a preceptor. the completion of the graduate nurse is an in critical care nursing and be allowed to provide care for patients in the the orientation the of each orientee is evaluated by the program and the unit educators to ensure completion of each part of the orientation. These evaluations of and checklists completed by preceptors and nurses also each and with a score of or is the program with all to a of for the orientee to the program and within a graduate nurses, nurses who are new to critical care, and critical care nurses are evaluated nurses within these identified groups are evaluated all 5 We have specific evaluation criteria for each and criteria are used all more evaluation of orientees’ ability to function in the The staff of the have primary for ensuring and this the and preceptors’ on whether or not a nurse is for an that one of the of this new orientation program on the amount of support that be provided to the ICU Before the start of the new orientation, each was given the to review all the learning Many materials were also developed to preceptors and orientees, a a a a and a of critical care staff educators and the managers are for the orientation each and graduate is given a of the that when the preceptor’s graduate nurse is in at the or in the unit. nurses are also given checklists the for each session that they need to in the unit with their is the of each graduate nurse to with or her to review the is by the program manager during the nurse’s of the the graduate nurses, and the to the managers. is when a graduate nurse is assigned to more a is an of a graduate nurse’s checklist. and educators in the of program were allowed to their to the required for implementation of the the of an orientation program is to a critical care the ICU nurse managers also and human resource graduate nurses be from orientation to the orientees a unit accommodate at one this intensive new program be the learning needs of current staff who were a different ICU nurse manager that graduate nurses in the ICU have a learning and not critical and assessment skills after they have out of orientation for months to 1 their in the unit, the graduate nurses have developed clinical competence but are not in their The manager has the year of new graduate nurses’ ICU their the time during which they in the same their and the staff in the nurses’ clinical and to managers in each ICU the implementation of the program by the for learning in the unit, and more clinical teaching time for the educators outside the unit. 12 the of the new of critical care orientation. these are they be the of the managers that a primary in an orientation program based on competency was a of preceptors who are to as indicated in the preceptors’ have skills and at least 2 years of care experience with one of years in critical care clinical experience in the preceptor’s current unit. were to these skills to the preceptors to evaluate and orientees’ more nurses to preceptors, one nurse manager a new the new critical care orientation program with a of preceptors because of their skills to staff that the orientation had of graduate nurse who to the ICU and culture is be in this program, graduate nurse be and have managers a with the graduate nurses and the preceptors to early in the orientation. of this program some of the nurse managers to and unit culture with previously with the orientation program. For example, one manager that in unit, nurses did not that graduate nurses had a in the and the was a the new critical care orientation program the managers the that the graduate nurses be to did the culture to results the program for graduate nurses. that used a were developed for preceptors, staff educators, and nurse managers. is an evaluation of the program to be completed by the is an evaluation to be completed by the were asked about the of the program, the effectiveness of the and and They with nurses who completed the previous orientation program, the new graduate nurses did the the first nurses had completed the new critical care orientation program: graduate nurses, care nurses, and critical care nurses. The staff educators and preceptors that the new critical care orientation program was intensive the previous program because they did not have to time preparing and teaching critical care the of the classes were by content and Because and written materials were orientees, preceptors, and staff educators had questions about and nurses that educational materials were provided in written and that they were to more time on of care on critical care as or interpretation of from of this new orientation a we to the orientation program, we had implemented the new orientation allowed a to The were that groups did the addition, we that with the of the graduate nurses had clinical and assessment skills after orientation. with our previous orientees, nurses in the critical-thinking in their and more managers are to the as the orientation program for graduate this new was well some were during the early period after These be as found that the graduate nurses were to in the new program and their motivation to and improve their clinical they in the amount of information and they the of the The that were with the graduate nurses during the time or time with their preceptors some of the nurses’ when clinical were ICU nurses found the new orientation program a for their current However, the nurses the the learning and the clinical experience because these nurses were not included in the provide a more orientation educators and managers the preceptors to the same of orientation for the nurses as that used for new graduate when clinical were not always For example, at the unit a with a or that with the of that new critical care nurses for this same clinical experience, the included for the needs and while the clinical learning experience for the new nurses. The review of and was not as well as other were we to coincide with the their need to information to graduate nurses. We found to with the preceptors that the graduate nurses are to the units with more critical care information, and the preceptors should as role for graduate nurses to to a The preceptors that they need to provide information, but the has from critical care to the of of the program was the most of this program because of the of the program and the number of as as 2 or as as new every 4 weeks, the educators found orientees and preceptors a because of the in with the the available have to the program to nurses with backgrounds into sessions with the graduate nurses. We that this have an on resource to be of the on ICU resources as we accommodate the number of participants. the we that a to that of the graduate nurses the experience for new new of critical care orientation allowed to some of the challenges critical care educators in nurses with a of experience levels into the critical care setting. The new program has in a more orientation experience for all orientees and for preceptors as We the and for new nurses to function and in the and for the preceptors to have the resources and materials to ensure implementation of the orientation of the is also in areas of the other the education of graduate is as a for major to the way orientation is provided in other nursing this new educational as a we have of our ICUs from to The of the new orientation program be to any learning and nurses at any level. The have as we to and the with the implementation we to the program and as in the and the to all the in this program and nursing for their support of the proposal and the to of the Northwestern Memorial for their in development and during implementation of the program, and the staff of the for their in and implementation of the we the support of all the critical care preceptors and staff of the ICUs at Northwestern Memorial Hospital, during the of has a in which we all