Best Practices in Orientation:

Development, Dissemination and Uptake for Nursing Practice in Long-Term Care
by Anitta Robertson, Irmajean Bajnok

This second article in the series addressing knowledge development, management and use will focus on the development and implementation of an orientation program that was established to promote evidence-based nursing practice in longterm care. This program is one of the multiple initiatives of the Registered Nurses Association of Ontario (RNAO) to support nurses as knowledge professionals, through establishment of innovative programs, promotion of knowledge uptake, and development and dissemination of policy initiatives. The RNAO is Ontario’s professional nursing association with the mandate of speaking out for health care and speaking out for nursing.

Professional Development and Orientation

Professional development is an important component of a quality work environment for nurses and is linked to the quality of care provided to clients. Nurses are attracted to organizations that provide supports to help them learn about their role in the system in an active, dynamic, comprehensive and supportive way. Evidence suggests that nurses, who have been involved in a supportive comprehensive and informative introduction to the organization and the expectations of their role, do not leave within the first year of employment (Carey and Campbell, 1994). Research in this area indicates that nurses who experience role clarity reported a greater sense of accomplishment in their work (Maas, et. al., 1994).

Within the Centre for Professional Nursing Excellence at RNAO, professional development is seen as a dynamic interaction between the professional nurse and knowledge, resources, and information networks that results in confident nurses, nursing excellence, and quality care. (See Figure1). Professional development incorporates the development and dissemination of relevant, meaningful learning resources, which promote the acquisition of knowledge and knowledge transfer for nurses to function effectively in their practice. In the practice setting professional development includes orientation and ongoing education opportunities, which enable nurses to grow their knowledge and skills to meet the current and emerging needs of the population served.

Orientation is a particularly important aspect of professional development. This importance has been reinforced of late as the relationship between orientation and recruitment and retention becomes more evident (Maas et.al.,1994; Meyer and Meyer, 2000; Redus, 1994).

It is estimated that 35-60% of new graduate nurses change their place of employment within their first year ( Owens, 2001) and the critical impact of orientation on a new employee’s success in the first months of employment is evidenced in the literature ( Connelly, 1998). A successful orientation program promotes self-confidence and job satisfaction (Redus, 1994), while inadequate orientation contributes to a high turnover rate in a given practice setting (Mathews& Nunley, 1992). As the professional practice of the nurse evolves, the need for relevant and meaningful educational opportunities to develop knowledge and expertise becomes a critical aspect of both confidence and satisfaction in the role.

According to Crawford and Kiger (1996) orientation is a vital professional development activity for novice nurses, which occurs in the adaptation stage of professional development. The other three stages of professional development were conceptualized by Crawford and Kiger as foundation, consolidation and stabilization. With each stage, the knowledge professional builds nursing knowledge and expertise to form a greater understanding of both the context of practice and the specialty content of practice, culminating with contributing back to the professional knowledge base through expert practice, research, teaching, and mentorship.

As depicted in the Stages of Professional Development Model, (Figure 2), each phase of professional development occurs during each of the levels of professional maturity- novice nurse, mid-career nurse or mature nurse. In applying this model to orientation, it becomes clear that while orientation is necessary with each change in position or employment setting, the specific requirements may vary markedly depending on the level of professional maturity.

Nursing Practice in Long-Term Care and Care of Older Persons

LTC is an ideal setting for nursing practice to realize its independence and potential (Sears, 1996). A primary role of the registered nurse in LTC is coordinating the interdisciplinary team as well as directly contributing to all aspects of the care and service provided to residents (Ontario Long Term Care Association, 2001 b).

The care of older persons is a recognized specialty requiring unique knowledge, skills and competencies. The care requirements of older persons are evolving with increasing client acuity resulting in greater needs for nursing interventions. The rapidly changing work environment has necessitated the need for nurses to develop advanced clinical skills to care for residents with multiple physical, cognitive and behavioural health problems (Ontario Association of Non-Profit Homes and Services for Seniors, 1998). This has resulted in an array of learning needs that must be addressed and supported through both orientation and ongoing education.

Orientation and ongoing education, key components of organizational professional development, are necessary for quality care, and in addition are increasingly being recognized as indicators of healthy work environments (Baumann et al, 2001). In the Healthy Work Environment Best Practice Guideline Project led by RNAO in partnership with Health Canada, and funded by the Ontario Ministry of Health and Long Term Care, this element of a quality work environment will be addressed in the guideline focused on The Professional Practice of Nursing.

Orientation Program for Nurses in Long-Term Care Project

In 2001, the RNAO received funding from the Ontario Ministry of Health and Long Term Care to develop an orientation program for nurses in long term care. The goal was to raise the profile of this sector among nurses, and contribute to ease of recruitment and retention, while at the same time influencing the quality of care for long-term care clients. The RNAO embarked on an approach to program development using an Advisory Committee to oversee the process, and an Expert Content Panel led by a project manager. The program development process was guided by evidence from a comprehensive literature review and input from key stakeholders in long term care. The workbook and elearning formats of the program provide comprehensive information for the orientee as well as for educators and preceptors who support orientation activities.

The seven step process used to guide the program development included:

The Assessment Phase

The various levels of consultation undertaken in the assessment phase of the project validated the need for improvements in existing processes and approaches to orientation and professional development in LTC facilities. These included: the need to provide a more organized and standardized approach to practice expectations; an expanded nature and clearer focus of content; increased length of time for orientation; and use of formal preceptorship supports. The feedback overwhelmingly indicated that the content should focus on the comprehensive specialty knowledge and skills necessary to function in roles of providing and coordinating care in LTC facilities.

Literature Review

The results of the literature review indicated that LTC facilities face difficulties in mounting programs that support learning needs of employees and that current education programs in LTC facilities do not match the evolving expectations of professional and non regulated staff based on the changes in resident health care requirements. There was evidence that approaches to professional development in LTC facilities are primarily informal in nature and depend on the self-directed initiative of professionals as a vehicle to achieve goals within a fiscally constrained environment (Ross, 2001).

Program Development and Design

Program development activities reflected a participatory approach, use of principles of self directed learning, evidence-based content, and collaboration with diverse partners. To achieve optimal outcomes while fostering individual applications, the program was developed to assess each learner’s proficiency level and the expectations embodied in the new position. The division of content into learning modules and adoption of a guided selfdirected learning approach were chosen as strategies for achieving the goal of realistic, sound educational programming for adult learners. This format offers flexibility and independence in the learning process. Another significant consideration in the design of the program was the need for interactivity and a method to assess progress and successful knowledge transfer. For this reason, specific activities and exercises were developed throughout the program to validate learning and knowledge acquisition.

An attempt was also made to incorporate activities to address facility specific information and long term care specialty content. The program was developed in two delivery modes (hard copy workbook and an e-based learning strategy) to accommodate individual needs and enhance flexibility of delivery. The incorporation of the e-based format was seen as providing significant benefits to learners in being accessible and readily available, self-paced, motivating, engaging, and facilitating learning any time.

Content Development

The content of the program is organized into four key areas or domains including: professional, organizational, role and clinical. The content of the Professional Domain addresses the professional role of the nurse in long term care, including leadership functions, regulations, as well contributions of the care team. This domain serves to promote a positive image of nurses in LTC. The Organizational Domain contains information on the organization, its mission, vision and values and the role(s) of nurses within the structure and culture of the LTC setting. The Role Domain contains information on specific position expectations and reporting relationships. The Clinical Domain contains speciality clinical content outlining knowledge and practice requirements in LTC settings. Within each of the 4 domains content is organized in modules.

In addition to these content areas, a methodology section was incorporated into the program to assist users understand the various components of the program and aid them in navigating and accessing these aspects. This section also provides resources and information for various types of users in the form of flow charts and written guidelines. The diagram below (Figure 3) demonstrates a schematic representation of how the program could be used by nurses interested in working in the long-term care sector.

A standard curricular format was used for the content presented in each module including:

Each content area or topic contains various levels of activities, and quizzes to facilitate learning and engage the learner.

Prior to pilot testing, feedback from a broad stakeholder review reinforced the following program strengths: assists to prepare nurses better for their roles and responsibilities; provides information that all employees need to know to excel in their positions; well organized; comprehensive and concise; will increase the level of care provided. Pilot Testing and Considerations for Implementation

Pilot testing of the program provided further opportunities for review and assessment of the program. Through two different pilot testing sessions, the program was used as the means of orientation for 31 newly hired RNs and RPNs in 6 different facility sites. During these pilot tests the program was also used by 24 nurses functioning in preceptor/mentor roles and 11 nurses who were employed in administrative capacities. Evidence from these pilot tests validated the relevance and applicability of the program as a resource for orientation Positive aspects of the program noted in the results of the pilot tests included: comprehensiveness; currency and relevancy; ability to accommodate different learning styles and individual needs of learners; interactivity; ability to test knowledge and learning; and easy to use and access. The resource was seen as equally useful to orientees, educators and preceptors. The participants involved with the pilot testing felt that the program would have a positive impact on the quality of care, nurse satisfaction and recruitment and retention. In addition, the program was identified as being a valuable tool for continuing education for longer term employees.

Based on the entire program development process including the two pilot testing phases, specific policy recommendations were identified which focused on the need for:

Conclusion

The focus on orientation and preparation of new staff in LTC through the use of a comprehensive, consistent, and evidence based program has set clear expectations for the quality of care in this setting. The program itself represents a benchmark of the nature and type of knowledge new and continuing staff require in long term care settings, and provides guidelines related to how this content should be delivered.

The LTC orientation project is another pillar in the comprehensive approach RNAO has embarked upon to influence both the elder care agenda and the quality of elder care. Other pillars include a focus on best practice guidelines in such areas as continence, falls prevention, wound care, and delirium, dementia and depression; creating forums for dialogue, debate and knowledge exchange through international conferences; and elder care think tanks bringing together professionals, policy makers, government and seniors.