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New Graduate Orientation Evaluation: Are There Any Best Practices Out There?

A Scoping Review

Laflamme, Jennifer MSN, RN-BC, CHFN; Hyrkas, Kristiina PhD, LicNSc, MNSc, RN

Author Information
Journal for Nurses in Professional Development: 7/8 2020 - Volume 36 - Issue 4 - p 199-212
doi: 10.1097/NND.0000000000000642

Abstract

When is a new graduate nurse ready to transition from orientation to independent practice? What criteria should be used to guide this decision? These are frequently asked questions among clinical educators, and there is no easy, inexpensive, or agreed upon way to evaluate the right timing. Moreover, anecdotal comments are often voiced by preceptors and nurse leaders, revealing varying expectations and perceptions regarding orientees’ progression and readiness for practice. This article was inspired by the question: How can the literature guide the evaluation of the orientation of the new graduate nurse, setting them up for success while protecting the safety of our patients? The purpose of this scoping review was to describe, based on the literature, current evidence to inform best practices to guide objective orientation evaluation, including progression and completion.

Current State and Scope of the Problem

In the midst of a nursing shortage, a common strategy is to hire new graduate nurses who are often enrolled into a transition-to-practice program and also offered orientation, which may be weeks to months in duration (Edwards et al., 2015; Jones et al., 2017). The orientation part of the employment process needs to be organized in a timely manner, but also so that it includes the most efficient, cost-effective, and safe means to be successful (Jones et al., 2017). There is much to be gained and lost in evaluating the progression of the new graduate during and at the end of orientation.

Concerns described in the literature include retention of the newly hired nurses and the delivery of quality, evidence-based patient care (McNamara et al., 2016). A study completed by Biegen et al. (2017) has shown that Magnet hospitals, rural hospitals with new graduate transition programs, and small urban hospitals (likely with a specialty focus) maintained higher retention rates than smaller hospitals in rural areas. However, in terms of retention, Biegen et al. (2017) have reported that estimates of turnover vary, and actual numbers are hard to determine. Furthermore, the authors have addressed that this important metric requires clarification and specification: Did a new graduate nurse intend to leave or actually left their position? In addition, age, education, experience, and work environment have been shown to play into decisions to leave (Biegen et al., 2017).

The new graduates’ orientation experiences, including the length of the process, have been described in the literature (Scott et al., 2008; Spiva et al., 2013). In their qualitative study, Spiva et al. (2013) interviewed 21 new nurses at a large acute care hospital. Four patterns emerged from the collected data. First, preceptors were described as satisfactory or not, fostering or slowing the new graduate’s progress during orientation. Second, growth and confidence were gained with experience. Third, nurturing was necessary at the unit, program, peer, and preceptor levels. Lastly, the orientation experience was identified in need of change. The recommended changes included preceptor development, standards for learning institutional policies, and creation of a mentor program. In addition, it was found that there was a demand among the new graduates for consistent feedback on performance. For example, one interviewee cited: “Performance goals were never clear to me. I do not know what I am being judged on” (Spiva et al., 2013, p. 30). In terms of satisfaction with the length of the orientation process, Rush et al. (2019) have noted in their recent integrative review that, although unit orientation programs varied (time frames ranging from 6.5 days through 6 months), the longer the orientation was (>4 months), the more satisfied the new graduates were, and this also resulted in better transition and retention. This integrative review addressed, as well, that orientation length averaged almost 2 weeks less for new nurses who turned over as compared to those who did not.

Goals of orientation can often be unclear to new graduate nurses, and along the same lines, there can be ambiguity among healthcare leaders regarding expectations, the objectives of orientation, and how to evaluate them (Martin & Lavigne, 2016; Spiva et al., 2013). Moreover, new graduate nurses may also feel unprepared for their new role, yet they have a sense of overwhelming responsibility for tasks and duties that are unfamiliar to them (Odland et al., 2014). Although it is neither possible nor realistic to identify all the challenges and situations a new graduate may experience, because unpreparedness is an existential phenomenon and part of professional life, employers are recommended to provide support and develop programs that ease transition into their professional role (Odland et al., 2014). Today, there are indeed a few transition-to-practice models to meet this need, and in the literature, one of the most often recognized is the nurse residency program (Jones et al., 2017; Maguire, 2013; Silvestre et al., 2017). These models have, however, a broad focus on transitioning to practice, and they do not currently provide tools for orientation to evaluate new graduates’ readiness to practice on their own (Martin and LaVigne, 2016; Nielsen et al., 2016; Spiva et al., 2013).

Secured fiscal resources have been found to be necessary for a new graduate’s transition to independent practice, and therefore, nursing administration needs to be aware of orientation evaluation best practices so that these are fully encouraged and supported (Jones et al., 2017; Martin & LaVigne, 2016). Orientation evaluation may be a critical retention strategy. The literature shows that postorientation turnover rates have remained high for new nurses, up to 27.7% according to National Health Care Retention and RN Staffing Report by NSI Nursing Solutions (2019; Spiva et al., 2013). Turnover has also been linked to higher rates of hospital-acquired safety issues, such as infection, falls, and medication errors, adding to the cost of having to replace and train nurses (Spiva et al., 2013). Safety issues and, more specifically, competencies have been addressed in orientation. For example, James et al. (2017) tested incorporation of Quality and Safety Education for Nurses (QSEN) competencies into a 5-day RN orientation program. The authors concluded, however, that quality improvement metrics were difficult to attain without commitment and support from administration for initial resources for orientation and also to residency and ongoing professional development programs.

Discussions regarding goals and expectations during orientation (Martin & Lavigne, 2016; Spiva et al., 2013), varying and predetermined time frames (Martin & Lavigne, 2016) often associated to satisfaction and retention (Biegen et al., 2017; Odland et al., 2014; Spiva et al., 2013), the need for fiscal resources (Jones et al., 2017), transition-to-practice models (Silvestre et al., 2017), and their relation to orientation (Jones et al., 2017; Maguire, 2013) have been prevalent foci of interest in the current literature. However, progression through orientation and best practices to evaluate new graduate nurses is yet to be recognized as an important topic for nurse educators, administrators, and researchers. The contemporary perspectives, practices, and aspects available on orientation evaluation were the starting point of this scoping review. The goal of this review article was to summarize findings and recent evidence from the literature and make recommendations to nurses directly or indirectly involved in new graduate nurse orientation.

METHODS

This scoping review was conducted to compile an answer to the question regarding evaluation of new graduate orientation. The method, scoping review, has been described as a type of literature review that discusses available evidence about a broad topic utilizing any applicable study design (Arksey & O’Malley, 2005). It can reveal main sources and types of evidence available and/or map key concepts found (Arksey & O’Malley, 2005). Peters et al. (2015) have also added that this method can be used to synthesize and map available literature by its “nature, features, and volume” (p. 141). Systematic reviews, in comparison, have a narrow focus with a specific research question and study designs decided prior to the review (Arksey & O’Malley, 2005). There can be varied reasons to perform a scoping study. The review consists of five stages: (a) identifying research question; (b) finding relevant studies; (c) selecting studies; (d) charting the data; and (e) collating, summarizing, and reporting results (Arksey & O’Malley, 2005).

Specifically, a scoping review has been considered useful when a body of literature has not been extensively reviewed or if narrowing the focus for a systematic review has not been possible (Peters et al., 2015). In this review, the research question was: What are currently identified evidence-based and best practices available to guide orientation evaluation of the new graduate nurse? The review focused on answering the following, more specific questions: What is the goal of orientation? What theoretical aspects have been described to guide orientation? What methods have been described for initial and ongoing evaluation, including competencies? What tools have been used for monitoring progress?

The literature searches for the scoping review were conducted in CINAHL, PubMed, Cochrane Database of Systematic Reviews, MEDLINE, Nursing and Allied Health Collection, and Ovid Nursing Database in November 2018. Only articles published within the last 5 years were included (see Figure 1). Websites included in the search and review of prominent healthcare organizations were the American Association of Colleges of Nursing (AACN, 2019), the American Association of Critical Care Nurses (AACCN, 2019), the American Nurses Association (ANA, 2009), Institute of Medicine (IOM, 2003), the National Council of State Boards of Nursing (2019), and the World Health Organization (2010) (see Table 1). The key words for the literature searches included the following: clinical competence, competency, employee orientation, employee performance appraisal, evaluation, inservice training, nurse, nursing, orientation, performance appraisal, staff development, and transitional programs (see Table 2).

FIGURE 1
FIGURE 1:
Search results.
TABLE 1
TABLE 1:
Professional Organizations and Essential Core Competencies
TABLE 2
TABLE 2:
Search Terms

Inclusion criteria for the reviewed materials were as follows: empirical articles (qualitative and quantitative), written in English with the focus on innovations with orientation evaluation (i.e., initial, ongoing, and completion), expectations of a nurse ready to transition to practice, the new graduate experience, new graduate retention, and methods of knowing. The exclusion criteria of the found materials were studies not pertaining to inclusion criteria and non-English language. Altogether 4,912 articles published within 5 years and in English were found. There were 2,262 full-text articles, and these were evaluated and screened against the inclusion and exclusion criteria. After removing duplicate articles, 14 articles and 7 websites that were referenced to in the selected articles, were included in this scoping review, mostly published in the United States (86%), Norway (7%), and Australia (7%; see Figure 1 and Tables 1 and 3).

TABLE 3
TABLE 3:
Data Summary of the Included Articles and Links to the Review

FINDINGS

Goal of Orientation

In the literature, at the end of orientation, the new graduate nurse was likely to be described as practicing within the advanced beginner stage of Benner’s novice-to-expert model (Benner, 2001). What did competency mean or entail at each stage on orientation? The word competency referred to organization or specialty-specific skills and thus needed to be defined by each organization in order to determine what the learning process, including evaluation, encompassed for that particular practice site (Martin & LaVigne, 2016). When considering then competencies and goals of orientation, Benner’s model described expectations and the stage that most new graduates were. More specifically, it elucidated an unreasonable expectation that an advanced beginner would be able to use their experience to perceive the importance of a situation similarly as a proficient nurse could do, but that it was more reasonable to expect a new graduate could identify individual factors that make up a commonly seen situation (Benner, 2001).

Many existing orientation practices and traditions have been described in the literature, and several of them had standard orientation time frames from weeks to months (McNamara et al., 2016). However, evidence was lacking in support of time frames. In addition, an important observation was that safe and competent practices were still not necessarily existing even though an orientation competency tool was “checked off” (Martin & LaVigne, 2016). Often, orientation progression and completion were constructed on checklists, based on variable, subjective preceptor feedback, and educated guesses (Martin & LaVigne, 2016).

There was no one method described in the literature that had shown to be able to merge the goals and various specialty priorities into a single evaluation tool (Lasater et al., 2015; Maguire, 2013). Furthermore, clear criteria for orientation progression were needed as well (Martin & LaVigne, 2016). An important foundation, essential core competencies for healthcare providers have been, however, available for some time, and these have been agreed upon by national professional healthcare organizations, including ANA and IOM (see Table 1). Interestingly, what has not been agreed upon is how these competencies are evaluated, and this is an opportunity to be embraced (Martin & LaVigne, 2016).

Theoretical Aspects

Patricia Benner’s (2001) classic theory “From Novice to Expert” has described five stages of nursing skill attainment based on the Dreyfus model of skill acquisition. According to the theory, the learner was described to utilize increasingly more experience in practice decisions and less on abstract principles as they moved through each stage. Every consecutive stage was characterized by less focus on individual pieces of information and more of an understanding of the whole situation, including the ability to identify what information was relevant (Benner, 2001). Overall, the five stages of Benner’s theory described a trajectory from novice to advanced beginner, competent, proficient, and expert. Considering the attributes of each stage of skill attainment, the foci of orientation evaluation criteria for novice and advanced beginners were and should be expected to be different from each other in order to be appropriate (Spiva et al., 2013). Furthermore, an important aspect for consideration was the new graduates’ clinical experiences during their academic courses and how they may have been completely new to a practice area (novice) or come into their new role with some (advanced beginner) experience (Benner, 2001).

Initial and Ongoing Evaluation

In the literature, evaluation of orientation was commonly described as starting during hospital orientation and continuing to the unit, with preceptors and unit leaders (Nielsen et al., 2016). Tests, meetings, and preceptor evaluation were three methods used to determine completion of orientation and identified often as innovations (Jones et al., 2017; Martin & LaVigne, 2016).

QSEN’s competencies (i.e., quality improvement, safety, patient-centered care, teamwork and collaboration, and evidence-based practice) were incorporated into many academic curriculums in nursing schools, especially baccalaureate programs, around 2008–2010 (James et al., 2017). More recently, there have also been initiatives applying these competencies for hospital orientation. For example, one study described a hospital in the Southeastern United States who revised their nursing orientation using the QSEN competencies as the framework (James et al., 2017). Each day of hospital orientation included competency topics, over the course of 4 days. Debriefing was included as a technique to determine and evaluate outcomes of orientation and therefore QSEN competencies (James et al., 2017).

In addition to debriefing, participating nurse orientees’ (i.e., new graduates and experienced nurses) knowledge related to the competencies were evaluated and measured, giving a pretest on the second day of hospital orientation and a posttest 4 weeks later (James et al., 2017). Although results showed little improvement in posttest scores, there were advantages and opportunities identified due to the change of using QSEN competencies as the orientation framework. A benefit was that competency language was familiar to new nurses, as this was well incorporated in academic courses. Results from the posttests revealed overall improved test scores from pretests, but the changes were not statistically significant. Pretest scores showed, however, that knowledge of quality improvement and evidence-based practice were lacking in new hires, which was considered to be an opportunity for academic institutions and practice sites for increased attention to the need to provide more than one occasion to teach these essential competencies (James et al., 2017; Martin & LaVigne, 2016).

Ongoing new hire orientation evaluation, including educator and nurse manager feedback, has been reported in the literature. Green (2016) described a hospital orientation program at the University of North Carolina Hospitals in Chapel Hill, North Carolina, in which engagement and active participation of new nursing orientees was enhanced. ENGAGE, the name of the program, reflected the foci of its core elements: Essential Nursing Guidance and Growth Experience. Evaluation of orientee achievement included role-play, use of audience response systems, hands-on practice, question review, and feedback throughout activities. In addition to evaluating the orientees’ learning, the orientee also evaluated the ENGAGE program, generally giving educators feedback on the process, as well. Moreover, managers were surveyed after the first year anniversary of the program. Interestingly, the trajectory of results ranged from seeing no change in the quality of care delivered at the bedside to noting that new graduates were quicker to seek help and were more knowledgeable about relevant policies (Green, 2016).

In addition to examples of orientation evaluation efforts in hospitals, the literature referred also to websites that described constructs intended to determine and support evaluation regarding competencies and related outcomes. The AACCN (2000) and QSEN (2019) provided frameworks that address the essential core competencies. For example, the AACCN, more specifically, the AACN Synergy Model for Patient Care, was based on assumptions that when patient characteristics (i.e., resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision-making, and predictability) and the competencies of the nurse (i.e., clinical judgment, advocacy and moral agency, caring practices, collaboration, systems thinking, response to diversity, facilitation of learning, and clinical inquiry) synergized, optimal patient outcomes were possible to be achieved (AACCN, 2000). The model presented expectations for patient care delivery, depending on nurses’ competency levels ranging from competent to expert.

Competency Evaluation

Competency needed to be assessed on more than one occasion of observing a nurse performing a task and crossing this off on a checklist (Wright, 2015). According to the literature, desired practices, consistent with predetermined competency parameters, required a few observations to be considered competent (Wright, 2015). Furthermore, the suggestion was that each organization define competency. With these recommendations in mind, the newly hired nurses’ performance could be evaluated on each domain of skill ability (i.e., technical, interpersonal, and critical thinking). However, Wright (2015) and Martin and LaVigne (2016) emphasized the importance to select an evaluation method that best provided information regarding the competency in question. Some of the suggested methods included tests, return demonstrations, self-assessments, and peer reviews (Martin & LaVigne, 2016; Wright, 2015). For example, to determine if a nurse was able to safely insert a Foley catheter, a written test may not have been the best way, but a return demonstration with discussion of key points might have been.

Achieving competency and transitioning successfully to independent practice required evaluation that was also characterized by a partnership between organizations and orientees. Olmstead et al. (2013) addressed the orientee’s responsibility to engage in active learning. In other words, orientees coming into their new role were expected to show a strong foundation in basic nursing skills, with an understanding that specialty skills would be taught in the department. They were also anticipated to demonstrate ability to perform patient care, exhibit a positive attitude, show initiative, and adapt into workflow expectations. The authors proposed to evaluate the required behaviors through regular assessments regarding the orientees’ progress toward expected performance using a grading sheet. This approach took into consideration that some orientees advanced quickly and others had needs for learning (i.e., knowledge, patient care skills, attitude, comfort level, and initiative), support, and encouragement to be addressed in order to progress (Olmstead et al., 2013). The authors also offered two examples to demonstrate the usefulness of such an evaluation process. The first described a successful completion of orientation after addressing attitudinal problems several weeks into practice, and the second illustrated a timely transition of the orientee to another open, more suitable position within the same organization (Olmstead et al., 2013).

Tools for Monitoring Progression

Although sparse, there were some articles available in the reviewed literature describing how to evaluate progress. Lasater et al. (2015) recognized the importance of a process to evaluate clinical judgment, using the Lasater Clinical Judgment Rubric (LCJR), within the context to which the newly hired nurses were employed. More specifically, the focus of interest was to evaluate nurses’ ability to make quality clinical judgments that would maximize patient safety while utilizing their own previous experiences, knowing the patient, identifying reasoning patterns used, and reflecting on the time of care and after the fact. The Tanner model, as a framework for the LCJR, incorporated assumptions of the complex environment of care, the nurse’s own background and experiences, the context of the situation, and the relationship to the patient. With these assumptions in mind, the four dimensions of clinical judgment in nursing were assessed: noticing, interpreting, responding, and reflecting. The LCJR integrated development levels for each aspect of clinical judgment and presented an opportunity for assessment of both novice and experienced nurses (Lasater et al., 2015). In their article, Lasater et al. (2015) described the use of the LCJR as a tool to monitor progression by asking each newly hired nurse to complete three unit-specific case studies that were scored by nurse educators based on evidence-based clinical practice guidelines used in the hospital. Lower scores than the expected accomplished or exemplary levels (on a 4-point scale: exemplary = 4, accomplished = 3, developing = 2, beginner = 1) in any dimension of the LCJR signaled the unit manager and educator to create an orientation plan focused on any identified clinical judgment deficits or lack of exposure to types of situations presented. Throughout the orientation, the preceptor, unit educator, or manager and the newly hired nurse met on a regular basis for ongoing assessment until there was mutual agreement that orientation was complete. The dimensions of the scoring tool were used as guidelines for this process. Continued documentation of ongoing assessments and development were recorded in the employee file. Interestingly, the clinical judgment assumptions of the Tanner model and LCJR’s development levels also reflected aspects of the essential core competencies presented by the major healthcare organizations (AACCN, AACN, ANA, IOM, National Council of State Boards of Nursing, QSEN, and World Health Organization; see Table 1) and thus representing the core competencies of readiness to provide quality patient care (James et al., 2017; Martin & Lavigne, 2016; McNamara et al., 2016).

In addition to evaluation of newly hired nurses’ clinical judgment, the LCJR was also identified as a tool that could potentially be used prior to employment, as a guide to determine appropriateness for a position or the necessity for clinical judgment development. Lasater et al. (2015) described, based on their observations, that the tool helped to identify potential experienced nurse employees’ goodness of fit and specify new nurse hires’ needs for tailored orientation supporting development (Lasater et al., 2015).

Another example of use of the LCJR, described by Nielsen et al. (2016), incorporated a modified version of the LCJR for initial evaluation of the clinical judgment of all newly hired nurses. Preceptors at this large, urban medical center strongly supported use of the Tanner model and adapted LCJR as a framework for their orientation of new graduate nurses. It was considered “effective and efficient” in supporting preceptors in evaluating new graduate clinical judgment, in addition to giving feedback and prioritizing. In addition, the authors (Nielsen et al., 2016) reported that the framework was valuable for performance evaluation. On the basis of the described experiences, use of the LCJR framework was also regarded as necessary because preceptors fulfilled the teaching role while often managed a full patient assignment (Nielsen et al., 2016, p. 89).

DISCUSSION AND IMPLICATIONS FOR FURTHER RESEARCH

Transition of new graduate nurses to independent practice has recently been a few educators’ and researchers’ focus of interest who have investigated, for example, interventions and support that may inform effective strategies and best practices related to competency attainment, recruitment, and retention (Brook et al., 2019; Calleja et al., 2019; Edwards et al., 2015; Innes & Calleja, 2018; Rush et al., 2019). Our scoping review focused on orientation evaluation and the findings that emerged from the reviewed literature are providing some new information, thus adding insights on the topic.

There were five focuses of interest (i.e., goals of orientation, theoretical aspects, initial and ongoing evaluation, competency evaluation, and tools for monitoring progression) that initiated also new questions indicating that continued efforts are needed to contribute to the evidence. Core competencies, as part of goals of orientation, were agreed upon among leading healthcare organizations, but how they should be evaluated was not, leaving an opportunity to be embraced (Brook et al., 2019). There are benefits, according to Benner’s theory, to recognizing the developmental level that each new graduate practices at. This theory provides opportunities to form realistic expectations for novice nurses and insights on how to individualize orientation to role-specific competencies integrated with learning needs (Innes & Calleja, 2018). In a very recent article, Murray et al. (2019) address that the focus of interest should not be only acquisition of skills as described by Benner, but also the different stages of transition as described in Duchscher’s theory. On the basis of Kramer’s 1974 seminal work, Duchscher’s transition shock model considers initial stressors (i.e., weight of responsibility, being afraid to question, and the knowledge–practice gap that challenges clinical reasoning and critical thinking), aspects, and theories that impact transition to practice, such as reality shock, transition theory, role adaptation, and growth of new graduate nurses (Murray et al., 2019). Stages of transitioning (i.e., doing, being, and knowing) are yet to be urgently addressed and studied from the point of view of orientation, especially orientation evaluation, mentoring, targeted education, and setting realistic expectations of competence in the first year of clinical practice.

An identified and surprising benefit of using frameworks and tools (e.g., observed clinical competency assessment model based on observed structured clinical examination originating from medical education, LCJR built on Tanner’s model, Progressive Orientation Level Evaluation Tool leaning on Benner’s theory and Maslow’s hierarchy of needs, Appraisal of Nursing Practice tool derived from the ANA’s definition of competency and the QSEN competencies, and the clinical transition framework) is that these can provide an evidence-based, standardized, while still allowing an individualized, approach that support learning, competency validation, and development of critical thinking and integrate high-end apprenticeships for developing specialty knowledge, including skilled know-how and ethical comportment (Acuna et al., 2017; Becker et al., 2018; Boyer et al., 2018; Franklin, & Melville, 2015; Miraglia & Asselin, 2015). The prospect of linking the use of a model (e.g., AACN synergy model) or a framework (e.g., QSEN competencies) as a method of ongoing evaluation to patient outcomes is one to be explored. Furthermore, outcomes of using grading sheets to regularly evaluate orientation in the moment or to counsel nurses in another direction is for consideration and to recommend as a best practice.

A few research studies have addressed the importance and influence of mentorship and preceptorship to retention of nurses in clinical practice (Brook et al., 2019). Preceptors with nurturing relationships with the new graduate can assist in navigating the workplace culture and socialization with coworkers, thus positively affecting a constructive practice environment and retention (Brook et al., 2019; Innes & Calleja, 2018). The crucial characteristics, identified in the literature, describe a preceptor as a resource who provides support, knowledge, guidance, teaching, and feedback (Innes & Calleja, 2018). Preceptor development is essential, in particular, to implement findings from this scoping review and, especially, how to give feedback and foster clinical judgment while juggling a patient assignment. Today, this role is certainly in need of formal training (Innes & Calleja, 2018).

Benefits noted in the literature regarding orientations within a transition program included increases in retention, job satisfaction, transition, and comfort with skills (Rush et al., 2019). Graduate nurse orientation programs tended to be shorter in duration than nurse residency programs (1–20 weeks) and included some of the same characteristics such as educational content and clinical support (Edwards et al., 2015). Specific information on what works in these programs was not found, which is another opportunity for future research (James et al., 2017; Lasater et al., 2015). Studies with a focus on residency programs, orientation tools relating to preceptor development, methods to teach critical thinking, and transition to practice programs were found in the literature but are beyond the focus of interest of this article.

Regardless of the wide variability of program outcome criteria, noteworthy cost saving has been reported in the literature due to retention and decreased turnover within the initial 1–3 years of hire. Providing an adequate orientation for a new graduate nurse can be challenging for hospital organizations due to training costs, decreased productivity, and quality care delivery, yet inadequately executed this can lead to decreased retention in the first year and create increased financial strain (Acuna et al., 2017; Peltokoski et al., 2016). The average cost to replace a new graduate nurse can be as much as $88,000 and, according to Acuna et al. (2017), adding an expense to the already high cost of orientation (Peltokoski et al., 2016). A recent recommendation has proposed to focus on the transition to practice by providing safe, helpful environments in which the crux is to increase competencies, satisfaction, engagement, and retention of the new graduate (Acuna et al., 2017). Moreover, some evidence is available that longer orientations can lead to a decrease in turnover rates (Rush et al., 2019) and that including both mentorship and preceptorship as an intervention for new graduate nurses may contribute an average decrease in turnover of 20% (Brook et al., 2019). In terms of the costs, this aspect requires more attention and research, for example, to determine the most cost-effective strategies and continued evaluation of the expenses and salary levels.

Limitations

Limitations to this scoping review are noted. Peters et al. (2015) pointed out that a scoping review should include at least two reviewers. In this study, the original review was completed with one investigator (J. L.), with the second investigator (K. H.) reviewing a selection of articles during the analysis and writing process, seeking clarification as needed. Second, only articles published in English and within the past 5 years (2013–2018) were included. There may have been relevant articles published in other languages and before or after the included time frame that might have added or contributed to the results. Third, it is possible that conceptualization and definitions in use for the core concept were not refined enough and therefore not all relevant studies were found or were accidently excluded from this scoping review. Lastly, a challenge was to find literature with a focus on orientation and specifically on orientation evaluation of new graduate nurses. This limitation may have impacted the reported findings, because a few articles combined and blended orientation evaluation with transition to practice programs often based on a framework or model supporting nurse residency programs.

CONCLUSION

Many research opportunities exist to create evidence to support orientation evaluation improvements. Empirical studies are needed to increase and strengthen current evidence, and especially larger sample sizes are required. Research regarding the efficacy of organization-specific orientation tools with a focus on core competencies versus those available in public would be helpful, as this question was not found within the current literature.

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