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’...