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Orientation of the Registered Nurse to the Perinatal Setting

  • Association of Women’s Health, Obstetric and Neonatal Nurses
Published:January 04, 2022DOI:https://doi.org/10.1016/j.jogn.2021.11.003

      Position

      The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) recommends that nurse orientation is customized to meet the needs of the individual orientee based on baseline knowledge and preferred learning method, such as hands on skills, discussion, case scenarios, and simulation. Learning outcomes should be focused on the nursing process and should incorporate specific information required by each facility, including key safety content. The duration of orientation is based on the individual nurse and experience; specialized areas of practice such as perinatal care may require more than a standardized 12-week process.

      Background

      Whether they are new to the profession, the unit, or the organization, new nurses may be the most vulnerable during orientation when they are exposed to new information, teaching styles, and behavioral and environmental factors that affect their practice (
      • Perregrini M.
      Creating a safe orientation environment.
      ). It is expected that all members of the perinatal care team promote a culture of safety and use effective communication strategies that facilitate and support safe patient outcomes. Continuous support of the nurse orientee during the onboarding period can promote successful transition into perinatal practice (
      • Friedman M.I.
      • Delaney M.M.
      • Schmidt K.
      • Quinn C.
      • Macyk I.
      Specialized new graduate RN pediatric orientation: A strategy for nursing retention and its financial impact.
      ); improve retention (
      • Friedman M.I.
      • Delaney M.M.
      • Schmidt K.
      • Quinn C.
      • Macyk I.
      Specialized new graduate RN pediatric orientation: A strategy for nursing retention and its financial impact.
      ;
      • Guerrero S.
      • Chênevert D.
      • Kilroy S.
      New graduate nurses’ professional commitment: Antecedents and outcomes.
      ); reduce feelings of failure, insecurity, and self-doubt; and prevent high levels of burnout (
      • Hatzenbuhler N.J.
      • Klein J.E.
      Educational preparation for clinical practice: Reflections of newly graduated RNs.
      ). Support of the nurse orientee includes the following:
      An orientation period of at least 12 weeks for those entering any area of practice has been recommended (
      • Lesher B.B.
      • Witt J.M.
      • Woodard R.M.
      • Haberyan A.B.
      New graduate RN perinatal internship.
      ). However time-based orientation is not the only factor to consider. It is important to provide additional, focused training on the complexity of patient care and the demand in multiple clinical areas such as triage, antepartum care, support for physiological birth and labor, perioperative care, postpartum care, newborn transition, and newborn care.
      Extended orientation timelines provide nurse orientees with the opportunity to integrate into the social structure of the clinical setting, apply skills during formal education, and learn new skills within the demands of the environment (
      • Baumann A.
      • Crea-Arsenio M.
      • Hunsberger M.
      • Fleming-Carroll B.
      • Keatings M.
      Work readiness, transition, and integration: The challenge of specialty practice.
      ;
      • Lesher B.B.
      • Witt J.M.
      • Woodard R.M.
      • Haberyan A.B.
      New graduate RN perinatal internship.
      ). Organizations are encouraged to incorporate up-to-date, interactive, evidence-based education into orientation plans (;
      Association of periOperative Registered Nurses
      AORN position statement of orientation of the registered nurse and surgical technologist to the perioperative setting.
      ; ). In addition, a continual process of knowledge acquisition, skills refinement, and risk recognition is essential. Because of the number and complexities of competencies associated with successful orientation, many professional organizations consider these factors rather than designating a finite period in which they are achieved (; ).
      Competence is defined, measured, and evaluated using various methods or tools that focus on specific knowledge, technical skills, and the ability to deliver safe, high-quality care. Competence is assessed and evaluated by the nurse orientee, nurse peers, nurse supervisors, mentors, and/or preceptors (

      American Nurses Association. (2021). Nursing scope and standards of practice (4th ed.) Author.

      ). The orientation process and required competencies focus on the patient population, procedures, conditions or diseases, and equipment. Competence is demonstrated when registered nurses can integrate knowledge, skills, and personal attributes consistently in daily practice to meet established standards of performance. Competencies ensure quality of care; provide structure for the orientation; and are used to communicate role expectations, guide feedback, and ensure that accreditation requirements are met. Registered nurses demonstrate professional competence throughout their careers; however, employers are responsible to provide an environment conducive to competent practice (

      American Nurses Association. (2021). Nursing scope and standards of practice (4th ed.) Author.

      ). The
      National Council of State Boards of Nursing
      Transition to practice: Why transition to practice (TTP)?.
      supports best practices for training nurse orientees to ensure consistent quality of care.
      It is highly recommended that clinical educators use a framework or a pathway to guide the development, implementation, and evaluation of the orientation process (
      • Lesher B.B.
      • Witt J.M.
      • Woodard R.M.
      • Haberyan A.B.
      New graduate RN perinatal internship.
      ). Using a professional practice model to guide the orientation pathway can help to identify relationships between learned concepts and promotes organization in daily practice, which results in the provision of high-quality care (
      • Kaya A.
      • Boz İ.
      The development of the professional values model in nursing.
      ). Professional practice models serve as theoretical, practical, and visual representations of an organization's culture (
      • Keleekai-Brapoh N.
      • Toresco D.
      Anchoring a professional practice model: Success through collaboration.
      ) and guide nursing practice, professional behaviors, and clinical leadership (
      • Reilly J.
      • Krause K.
      • Vande Zande C.
      • Knutzen B.
      Implementing relationship-based care as a professional practice model: Promoting nurses’ understanding and confidence to apply in practice.
      ). Professional practice models provide nurse orientees with a clear understanding of what is expected of them regarding clinical skills, knowledge, and professionalism (
      • Ortiz M.R.
      Professional practice models: A way to guide the leading-following process.
      ). The
      Association of Nursing Professional Development
      About ANPD.
      and the support defining and promoting the discipline of nursing through grounded core principles and constant improvement.
      In addition to a professional practice model to guide the orientation pathway, use of the Quality and Safety Education for Nurses (QSEN) competencies can ensure that orientees have the knowledge, skills, and attitudes necessary to improve quality of care and safety within the health care system. The QSEN competencies help nurse orientees to identify and gaps between what is happening and what should be happening and allow them to focus on their work from a quality and safety perspective ().

      Role of the Nurse

      Adult learning is the practice of a mature mind gathering information and using that information to guide and direct decisions and actions. Adult learning requires the learner to assume the responsibility of gathering and applying knowledge. An adult learner must be an active participant, have the capability to assimilate knowledge with past experiences, and understand the connections among these factors. All preceptors and educators should implement adult learning principles into the orientation process. When nurses transition to various areas of practice, orientation programs should account for patient acuity: providing care for patients at lower to higher risk helps orientees bridge gaps in knowledge (
      • Schmitt C.A.
      • Schiffman R.
      Perceived needs and coping resources of newly hired nurses. SAGE Open Medicine, 7.
      ). As each milestone in practice approaches, the adult learner can complete a self-assessment then demonstrate competency with the identified skill.
      Preceptor development is essential to the success of the orientation process (
      • Barba M.
      • Valdez-Delgado K.
      • VanFosson C.A.
      • Caldwell N.W.
      • Boyer S.
      • Robbins J.
      • Mann-Salinas E.A.
      An evidence-based approach to precepting new nurses.
      ;
      • Lindfors K.
      • Meretoja R.
      • Kaunonen M.
      • Paavilainen E.
      Preceptors’ perceptions of the elements of a successful and an unsuccessful orientation period for newly graduated nurses.
      ). Nurse preceptors are role models and transitioning nurse orientees should set their own professional growth goals based on those models. During transition to practice, the preceptor ensures the orientee’s successful transition from novice to competent practitioner. The number of preceptors used during orientation can vary; however, a small number of preceptors who communicate with each other is often preferred to offer the orientee varying perspectives (
      • Schmitt C.A.
      • Schiffman R.
      Perceived needs and coping resources of newly hired nurses. SAGE Open Medicine, 7.
      ). The preceptor-orientee relationship affects the nurse orientee’s professional track throughout the entire career trajectory.
      The preceptor trains the orientee in nursing practice, provides opportunities to perfect communication and psychomotor skills, verifies the ability to navigate equipment and documentation system in real time, directs the creation and management of care plans, and helps the orientee assimilate to the team (
      • Powers K.
      • Herron E.K.
      • Pagel J.
      Nurse preceptor role in new graduate nurses’ transition to practice.
      ). To provide this level of education and support, the preceptor may employ strategies such as feedback, questioning, thinking out loud, role play, and discussion of assessment (
      • Powers K.
      • Herron E.K.
      • Pagel J.
      Nurse preceptors and new graduate success.
      ). Use of these strategies during orientation protects patients and helps the orientee develop clinical reasoning.
      Clinical reasoning develops over time and with experience. The fast-paced changes of complex perinatal care do not allow much time for the novice nurse to assess and think about possible consequences or risk reduction. Therefore, the primary role of the preceptor is to ensure patient safety and nurture the orientee’s clinical reasoning skills.
      Clinical educators are committed to developing and growing the skills of nurses and are integral to the development of a healthy workforce. Clinical educators collaborate with the preceptor and orientee to identify areas of opportunity and establish weekly performance improvement goals. As the preceptor and nurse orientee work together to ensure a successful transition to practice, the clinical educator helps the preceptor obtain proficiency in training and answers the orientee’s questions about clinical practice.

      Recommendations

      Nurse orientees identified leadership as critical to their personal success (
      • Schmitt C.A.
      • Schiffman R.
      Perceived needs and coping resources of newly hired nurses. SAGE Open Medicine, 7.
      ), and many facets of leadership can support and improve orientation processes for novice nurses.
      • Nurse managers should provide structure; set expectations for the unit; and are responsible for managing human and financial resources, ensuring patient and staff satisfaction, maintaining a safe environment, ensuring standards and quality of care, and aligning unit goals with hospital strategic plans (
        Agency for Healthcare Research and Quality
        The role of the nurse manager.
        ).
      • Nurse preceptors, educators, and clinical nurse specialists should facilitate integration into the team by acknowledging that the nurse orientee has theoretical knowledge and some practical experience but is not an expert and is not expected to perform at the expert level (
        • Charette M.
        • Goudreau J.
        • Bourbonnais A.
        Factors influencing the practice of new graduate nurses: A focused ethnography of acute care settings.
        ).
      • Hospital administrators, nurse managers, and other nurse leaders such as preceptors, educators, and clinical nurse specialists should develop training programs to enhance the orientee’s self-efficacy in diversity, inclusion, and equity to enhance the delivery of quality care to diverse patients, families, and communities (
        • Piggott D.A.
        • Cariaga-Lo L.
        Promoting inclusion, diversity, access, and equity through enhanced institutional culture and climate.
        ;
        • Zappas M.
        • Walton-Moss B.
        • Sanchez C.
        • Hildebrand J.A.
        • Kirkland T.
        The decolonization of nursing education.
        ). The exchange of ideas and open communication is encouraged and supported in the presence of differences in race, gender, sexual orientation, religion, age, social class, or disability (
        • Piggott D.A.
        • Cariaga-Lo L.
        Promoting inclusion, diversity, access, and equity through enhanced institutional culture and climate.
        ).
      • Hospital administrators should provide adequate funding and resources to promote safe staffing ratios that support the needs of the orientation process.
      • National nursing organizations should provide support through statements and resources to support the orientation needs of their members.
      • Regulatory bodies such as The Joint Commission focus on compliance with evidence-based practice, standards of practice, and regulatory requirements. The Joint Commission identifies the minimal standards required for the provision of care, treatment, and services. These minimal standards relate to patient safety, fire safety, and emergency codes (HR.01.04.01,
        The Joint Commission
        Competency assessment vs orientation. The human resource (HR) chapter of the accreditation manuals include requirements for ‘orientation’ and ‘competency’ assessment’. How do these activities really differ from each other?.
        ). The

        American Nurses Association. (2021). Nursing scope and standards of practice (4th ed.) Author.

        supports the definition of minimal standards for the regulation of practice by regulatory agencies (2021).

      Acknowledgment

      AWHONN gratefully acknowledges members who contributed to this position statement: Susan Hale, DNP, RNC-OB, C-EFM, EBP (CH); Heretha Hankins MSN-Ed, RNC; and Marin Skariah, MSN, FNP-BC, RNC-MNN, C-EFM.

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