Rethinking Critical Care Orientation

By Julie Miller, BSN, RN, CCRN-K Oct 19, 2021

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“How long should critical care orientation last for a newly graduated nurse?” is a frequently asked question on the AACN eLearning community discussion board (and others)

“How long should critical care orientation last for a newly graduated nurse?” is a frequently asked question on the AACN Nurses in Professional Development Community Discussion Board (and others). Answers typically range from as few as eight weeks to as many as 16 weeks. When I see this question I also see the accompanying concerns that the length of time isn’t sufficient to acclimate the new nurse to critical care, that budgets and staffing needs drive these decisions, and that what the nurse new to critical care practice needs isn’t really considered. Why? Because that is the way we’ve always done it?

A unique approach to orientation

I recently watched a video describing a novel approach to critical care training that goes against the traditional 12-16 weeks of critical care orientation. In “Critical Care Nurse Residency Program Enhances Nursing Recruitment and Retention,” Cindy Malinowski, MN, RN, CCRN, and Monica Brower, MSN, RN, CCRN, from Saint Alphonsus Health System in Boise, Idaho, created a 24-week orientation for nurses new to the ICU.

Why did they choose a new approach?

Their critical care staffing was in crisis with high turnover, lack of experienced nurses to fill vacancies, a growing number of inexperienced nurse applicants, high census and high patient acuity, and a widening experience-complexity gap. Does this situation sound familiar?

I can already hear you saying, “Well, no one is going to approve a 24-week orientation here.” Before you stop reading, I ask you to consider their approach, to consider something different. Their outcomes show not only is it possible, but it can make a huge difference in recruitment and retention. The program also demonstrated a positive impact on the perceived readiness of the nurses to care for critically ill patients. At the end of 24 weeks, the nurses in this program were capable of caring for the sickest critical care patients and were competent in CRRT, Impella and intra-aortic balloon pumps. Their critical care leadership team noted these early-tenure nurses were more engaged and sought opportunities for continued professional growth. The other important note here is they were able to sustain the program during COVID surges, and after orientation, nurses were better prepared to help with staffing challenges.

How did they overcome nonproductive staffing orientation costs?

To overcome the often-heard concern regarding unit “nonproductive costs” for nursing orientation, the educators were creative about their approach. Collaboration with their nurse leaders was essential to find unique approaches to common barriers. Working with their chief nursing officer, they created a separate cost center for the program that eliminated nonproductive staffing costs in the ICU cost centers. This simple change to orientation budgeting eliminated costs for nonproductive time that many nurse leaders face when overseeing a unit budget. Additionally, grants may be available to help support programs like this from your state department of labor. The educators here were successful in obtaining state department of labor funding for an initiation grant to launch the program as a registered apprenticeship.

What is in the 24-week orientation plan?

The 24-week program has weekly goals and a blended approach of eLearning modules using AACN Essentials of Critical Care Orientation (ECCO). It includes a preceptor toolkit and preceptored clinical time of two or three-12 hour shifts per week and mandatory classroom time with five case-based class days to reinforce ECCO content. Over the 24 weeks, they also include specialized education on topics such as ECG rhythms, ACLS, hemodynamic monitoring, CRRT and others.

Their preceptor toolkit includes:

  • Mandatory preceptor workshop with letter of commitment
  • Weekly goal sheets for weeks one-24
  • Standardized clinical judgment questions
  • AACN ECCO preceptor tools
  • SBAR provider notification tools to guide interdisciplinary communication

How does the 24-week orientation schedule break down?

The first six-week period focuses on assessment and basic critical care monitoring skills as well as quality metrics. A quote from one of their preceptors states, “I’ve never had new hires so prepared on their first day!” Weeks seven-24 focus on advanced skills and concepts. The orientees take a typical patient load, and preceptors advocate for patient assignments that align with their education. During the first 20 weeks, they are on day shift providing opportunities to participate in bedside and off-unit procedures, increased collaboration with the interprofessional team and more frequent access to managers, unit supervisors and educators. During weeks 21-24, they move to nights and stay with a preceptor to ensure they are supported to learn the routines on night shift.

How did they have enough preceptors to cover 20 weeks on dayshift?

All nurses in all four ICUs are trained as preceptors once they have two years of experience. Each orientee is assigned a primary preceptor with the intent they work that nurse’s schedule. They are also assigned two backup preceptors. The goal is to have no more than three orientees working on the same day, so there are enough nurses available to precept. Preceptors at their hospital also receive a premium $1/hour when they precept as well as points on their professional development ladder. The educators support and provide whatever resources are needed, including bedside education.

Why consider a change to orientation?

  • Many nurse graduates report not feeling confident or prepared to practice. Many nurses in their first year report feeling ill prepared at the end of their orientations to care for critically ill patients. New nurses who lack confidence and who do not feel supported in their orientation are often dissatisfied with their workplaces, and first-year turnover rates continue to be as high as 24%. Financial and resource constraints contribute to reductions in orientation time, which results in less-prepared critical care nurses.
  • Cognitive overload is overwhelming during orientation. Orientations that attempt to front-load everything a nurse needs to know to manage critically ill patients are likely doomed to fail. A more successful approach provides the novice nurse with the essential knowledge and skills, and provides guidance on how to develop and learn concepts, over time, that are more complex.
  • In addition, the widening experience-complexity gap creates opportunities to ensure nurses new to practice have everything they need to be prepared.
  • The Advisory Board suggests redefining the value proposition for your staff, learning what is most meaningful to them and identifying things that will differentiate you in the market. The “2023 NSI National Health Care Retention & RN Staffing Report” suggests “operational considerations must address how employment decisions are made and include programs that build relationships, commitment and confidence early in the employment cycle.”

What other approaches have hospitals utilized to improve orientation?

How to Balance Staffing Needs and Beat Learner Fatigue” describes two other health system approaches to adjusting orientation schedules to reduce cognitive load. These approaches also offered nurses new to critical care practice more opportunities for reinforcement of critical care content. They also provided the nurses with more context to apply concepts they were learning during orientation.

Changing an orientation program can be a daunting task. Consider what works in your current orientation plans and what elements might benefit from a new approach.

Please share with us your ideas for rethinking your critical care or progressive care nursing orientation.