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Department: Performance Potential

The tiered skills acquisition model

Orientees' perceptions of confidence

Kjelland, Kimberly MSN, APRN, PPCNP-BC; Allen, Marlena BSN, RN; Holder, Kimberly BSN, RN; Jenny, Amanda BSN, RN; Roe, Christy BSN, RN, RNC-NIC; Troutman, Heather BSN, RN, RNC-NIC; Nieves, Holly DNP, APRN, PPCNP-BC; Voils, Traci ADN, RN, RNC-NIC; Monroe, Martha PhD, RN

Author Information
Nursing Management (Springhouse): September 2021 - Volume 52 - Issue 9 - p 51-53
doi: 10.1097/01.NUMA.0000771756.09339.e2
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The tiered skills acquisition model (TSAM) can assist newly licensed RNs to move from academia to a practice setting.1 This model was designed to improve the process of orienting newly licensed nurses. Although the TSAM is geared toward new graduates, this approach has been successful in orienting experienced nurses to a new role.2 To determine orientees' perceptions of their confidence to function independently after completing a TSAM-based orientation, a study of newly hired nurses with differing levels of previous nursing experience was conducted on a 32-bed, Level III neonatal ICU (NICU) at a 434-bed Magnet® redesignated hospital.

Tiered learning

Using Benner's novice to expert model as a foundation, the TSAM includes developing tiers of skills ranging from basic nursing practice to complex interventions.1 (See Table 1.) Nurses demonstrate competency in the skills of one tier before moving to the next. The TSAM differs from the traditional incremental productivity model in which orientees begin their experience caring for one patient and build toward a full patient assignment over a fixed orientation timeframe. In the TSAM, orientee-preceptor pairs care for a full patient assignment from the beginning. By taking a full patient assignment for the entirety of the orientation period, new nurses are exposed to a variety of patient situations and opportunities for learning. This approach may also reduce the cost of orientation, eliminating the need for additional staff.

Table 1: - The NICU TSAM
Tier Skills
Tier 1
  • Observation and shadowing only

  • Orientee is expected to take notes during observation of preceptor for discussion

  • Familiarization with hospital policy and procedure manual

  • Unit-specific “Develop You” modules

Tier 2
  • Assess and document vital signs on a full patient load

  • Physical assessment and documentation

  • Assessment and documentation of intake and output

Tier 3
  • Administer patient feeding (oral or gastric), as well as management and assessment of enteral feeding methods

  • Administer medication and document medication administration

  • Management of I.V. fluid and medication

  • Ventilator management

  • Drawing labs

Tier 4
  • Communication with physicians/providers

  • Giving and receiving report

  • Patient discharge

  • Discharge teaching

  • Documentation of care plan

  • I.V. fluid changes

Tier 5
  • Patient admission

  • Assist with placement of a peripherally inserted central catheter

  • Assist with intubation

Tier 6
  • Special procedures, such as chest tubes, blood transfusion, and lumbar puncture

  • Managing specialty I.V. medications (dopamine, dobutamine, alprostadil)

  • Palliative care

Tier 7
  • Orientee functions with only oversight by preceptor

Preceptors are trained to guide orientees through the skills of each tier. Orientation is individualized so new nurses move through the tiers at a rate dependent on demonstrated competence, which can shorten the length of orientation. In addition, this model includes structured resource time away from patient care duties for the orientee to learn from the preceptor in areas of need. Resource time is scheduled and can be as long or short as needed.

Method and design

The tiered orientation team developed the process for orienting new nurses to the NICU using the TSAM. Current clinical orientation standards were incorporated into the process to maintain consistency in the orientation experience. Members of the orientation team with adequate clinical experience attended the preceptor class and oriented new employees, including describing the TSAM. During this study, there was variability in the number of preceptors: two of the orientees worked with two preceptors during the orientation period, two other orientees worked with three preceptors, and the remaining four orientees worked with four preceptors. Orientees anonymously completed the Baptist Health Lexington Preceptor Performance and Proficiency Assessment (BHLPPPA) 1 month after completing orientation.3

Investigators identified the BHLPPPA as an instrument that reflects the components of the TSAM and measures orientee confidence in their precepting experience as it prepares them for independent nursing practice. The BHLPPPA is a 28-item instrument with a total score ranging from 28 to 112. Each item asks participants to indicate strength of agreement, with options including “strongly disagree” (1 point), “disagree” (2 points), “agree” (3 points), and “strongly agree” (4 points). One additional item was added to the BHLPPPA asking orientees to rate agreement with the statement, “My preceptor and I could have benefitted from additional support from the educators during my orientation.” This item was reverse scored, with “strongly disagree” worth 4 points and “strongly agree” worth 1 point. With the addition of this item, total scores ranged from 32 to 113. Participants were also asked to write comments, as well as suggestions for improving the orientation.


This Institutional Review Board-approved study used a sample of only eight newly hired NICU nurses due to the hospital's and unit's high nurse retention rate. See Table 2 for a description of the sample. Of the 28 items on the BHLPPPA, 24 responses were rated “strongly agree” or “agree.” Of the remaining items, four participants indicated “disagree.” See Table 3 for a description of items rated “disagree.”

Table 2: - Study sample
Range Mean
Age (years) 22 to 38 29
Orientation length (weeks) 4 to 16 12.25
BHLPPPA score 93 to 113 109

Table 3: - Items rated “disagree”
During my orientation, my preceptor “thought out loud” to teach problem-solving.
During my orientation, my preceptor ensured that I was proficient in early identification of the deteriorating patient.
During my orientation, my preceptor ensured that I was proficient in managing the deteriorating patient.
During my orientation, my preceptor ensured that I was proficient in critically analyzing issues related to the complex patient.

Participants' comments included:

  • “[I} would like to see [an] educator during my shift after [I'm] off orientation when on my own.”
  • “Ensure that preceptors understand the tier system. It was brand new when I started so this could be resolved already.”
  • “[I] liked the ability to individualize my orientation [because] I have NICU experience.”
  • “[Hold] neonatal resuscitation program and NICU classes earlier. I didn't care for enough ‘sick’ babies during orientation.”
  • “[Hold] classes earlier.”


Participants indicated that the TSAM prepared them for independent practice in their nursing role. Given the TSAM's focus on moving from simple to complex skills, this method may be an effective orientation model in multiple healthcare settings.

For example, on a unit such as labor and delivery, the TSAM could effectively support the learning necessary for new nurses to become competent in delivering care. The skill set required to care for birthing mothers can be easily taught using a progressive mastery model. Orientees could begin by mastering I.V. catheter insertion on a full patient load, followed in order by application of the fetal monitor, basic fetal monitoring evaluation, and cervical checks. Competency in skill development occurs as orientees continue to perform learned skills while addressing the next, more complicated group of skills. An alternative application of the TSAM on the labor and delivery unit could require an orientee to perform one skill per 12-hour shift for every patient on the unit. This approach would allow the orientee to focus on increasingly complicated skills related to critical thinking in caring for the birthing mother.

Similarly, a tiered skills approach to nursing orientation could be used across hospital units, as well as in other healthcare settings. A plan would need to be developed to identify the skills needed in a specific setting, along with the complexity and difficulty of each skill. This plan could form the basis of a new orientation structure and provide a clear method for confirming competency as new hires learn to care for their patients. Repetition of skills is an important strategy incorporated within the TSAM and, in general, a positive approach to learning a skill.4 The TSAM uses repetition focused on one skill at a time, ensuring competency before moving to more complex activities. Based on this study's evaluation of the TSAM, investigating this orientation model across hospital units is recommended.


This study was conducted at a four-time Magnet redesignated hospital; therefore, results may not be generalizable. The NICU where this study was conducted has an annual nurse retention rate of 97.75% to 98%. Due to the high retention rate of this facility and nursing unit, the sample consisted of the eight nurses hired during the study period. In addition, variability in the number of preceptors may have influenced results.

Nursing management implications

Adopting the TSAM for orientation can assist nurse leaders to efficiently manage the onboarding of new hires. Potential benefits include cost savings, increased orientee confidence, and reduced orientation length. Nurse retention may also result from an effective orientation experience.5 Although the present study didn't examine cost savings, Beamer and colleagues found that implementation of the TSAM for orientation led to a savings of $5,300 per new graduate nurse and $2,050 per experienced nurse.2

Participants in this study indicated a high level of confidence in their orientation experience. Similarly, Joswiak, the developer of the TSAM concept, found that use of the model resulted in higher confidence among orientees and a reduction in orientation length.1 Given that previous research has shown well-designed orientation programs are effective in assisting nurses with transitioning from educational programs to practice, this study's results support the continuing implementation of the TSAM.6


1. Joswiak ME. Transforming orientation through a tiered skills acquisition model. J Nurses Prof Dev. 2018;34(3):118–122.
2. Beamer JC, Kromer RS, Jeffery AD. Imagining an orientation built on trust. J Nurses Prof Dev. 2020;36(1):2–6.
3. Bradley H, Cantrell D, Dollahan K, et al. Evaluating preceptors: a methodological study. J Nurses Prof Dev. 2015;31(3):164–169.
4. Bosse HM, Mohr J, Buss B, et al. The benefit of repetitive skills training and frequency of expert feedback in the early acquisition of procedural skills. BMC Med Educ. 2015;15:22.
5. Pennington G, Driscoll A. Improving retention of home health nurses. Home Healthcare Now. 2019;37(5):256–264.
6. Pertiwi RI, Hariyati RTS. Effective orientation programs for new graduate nurses: a systematic review. Enferm Clin. 2019;29(Suppl 2):612–618.
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