Graduate nurses have many learning needs as they enter into the nursing workforce and they must continue to improve on their basic learning skills and competencies while attempting to learn new complex nursing skills (Phillips, Kenny, Esterman, & Smith, 2014). All areas of nursing present many challenges, therefore orientation to the area requires a tailored and holistic approach for new graduate nurses (Dyess & Sherman, 2009). This paper will focus on enhancing orientation for graduate nurses. This paper will provide the readers with an analytical discussion of relevant literature as well as a clear rationale for the need to change and improve orientation for graduate nurses. A thorough detailed change management plan will be implemented using Lippitt’s seven steps of change. Furthermore, strategies for assessing outcomes will be discussed, outlining the success rate post implementation. Lastly, this paper will summarise and highlight the main issues for this change.
Graduate nurses entering the nursing workforce are required to possess a wide variety of skills and up to date competencies in order to function as beginning professionals (MacDonald, 2014). The learning curve does not stop once a student has completed their Bachelor of Nursing Degree, in fact, it is just the start for graduate nurses with several issues that they need to face (MacDonald, 2014). These include nursing shortages, advancements in technology and an aging population with increased health care needs (MacDonald, 2014). The development of formal orientation programs in health care is critical in the recruitment and retention of nursing staff (Robitaille, 2013). Recent literature demonstrates that a comprehensive, well thought out program can reduce adjustment periods for novice nurses, minimise turnover and establish a solid foundation for a productive and lengthy career (Charleston, 2014). According to Charleston (2004), the main reason for orientation during the Graduate Nurse Program are to enhance skills and knowledge in the new graduate, to facilitate the addition of theory and practice and to ease the new graduates’ transition from university life to the clinical setting (Charleston, 2014).
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According to Chestnutt and Everhart (2007), graduate nurses entering a clinical area must receive appropriate orientation that meets their required needs, provides exceptional support and communication with all health professionals (Chestnutt & Everhart, 2007). Structural empowerment, being able to manage workload, fairness, organisational values and leadership are significantly related to job satisfaction, therefore making a graduate nurse more likely to not leave the nursing profession (Junttila, 2014). Orientation to a hospital or ward add to graduate nurses’ ability to perform duties, increase confidence, competence and job satisfaction. It also lowers the turnover rate and enhances the quality of nursing care, for example; decreasing medication errors (Junttila, 2014).
Travele (2007) states, “An inexperienced nurse’s knowledge is theory based because he or she lacks the wisdom that defines an experienced nurse. Targeted education needs to be progressive to engage this computer-savvy generation in learning”. A useful way to simplify orientation and capitalise on educator resources, is to offer online courses. Therefore, this paper will provide a change management plan to implement a wiki (website) to improve orientation to new graduate nurses. This will allow graduate nurses to communicate and share information with other graduate nurses, as well as be able to access visual aids such as links on clinical procedures. This will enhance their knowledge, clinical skills and be able to socialise with others, which in turn, will make for an easier transition from university to the clinical setting.
The reason for the initial promoting of change to improve orientation for all graduate nurses was feedback from current and previous graduate nurses from Holmesglen Hospital on their experience of when they were orientated to the hospital and their specific ward.
A graduate nurse, reflecting back on her transition process during orientation provided a simple but powerful statement representative of her experience:
“I thought, I’m an RN now, so I have to know the answers. I can’t say I’m a student anymore. I worry about not knowing enough, not knowing what to do. Should I do this, or should I do that? Did I miss anything? I feel like I’m walking a fine line.” (Rush, Adamack, Gordon, Lilly, & Janke, 2013)
Other statements from previous nurses included:
“One day during orientation, I came onto the floor like I normally do. It was on my schedule to be on this floor with this person. So I go in there, and I take report on all my patients, and they call back and tell me you are going to the fifth floor tonight. It was four o’clock when I was told I had to switch floors and preceptors. I thought to myself, what are they doing? You are confusing me and screwing me up. It was very frustrating.” (Rush et al., 2013; St Clair, 2013)
“The first few months were the hardest and the most stressful time for me, I was overwhelmed with so many resources during orientation, I didn’t know where to start.” (Phillips et al., 2014)
To address these challenges, it is vital that graduate nurses are provided with a transition framework that facilitates their growth and the achievement of their potential. These studies described graduate nurses’ transition experiences as they were walking the fine line between student and nurse (Romyn et al., 2009).
Change Management Plan
To enable sustainable change, nurses need to take the lead in managing it (Davies, 2014). Lippitt’s phases can be used in nursing practice especially with the advancement in technology, the nature of healthcare organizations, and professional standards. Although we experience change every day, nurses have a difficult time embracing “planned” change.
As presented in the discussion, the use of a wiki (website) can provide nurses with educational material, links to relevant websites on practical skills and procedures and it can provide a place to communicate with other nurses, preceptors, other graduate nurses, and the rest of the graduate team. The change management theory that will guide the implementation of the proposed project of improving orientation for graduate nurses will be outlined using Lippitt’s seven steps of change.
1. Diagnoses of the problem.
According to Lippitt et al. (2014), this stage involves a change agent that may notice that an intervention or change would benefit the system or person and offers assistance (Swansburg, 2014). A change agent is someone who acts as a catalyst for change (Swansburg, 2014). During this phase, there was formal and informal feedback from past and current graduate nurses about their experiences during orientation which prompted a need for change.
The goals of the project would be a) enhance graduate nurses’ orientation to a clinical setting, b) support the new graduate nurses while improving their education and c) improving professional communication through information technology. This first stage of change would involve speaking to the Holmesglen educators and nurse managers to discuss how this change could be implemented into the orientation of new graduate nurses. Providing awareness, having adequate support and outlining the benefits that this project could offer to new graduates and staff would be the main focus of this phase. After the support and contribution of the key stakeholders, then the second stage of the change process can be established.
2. Assessing the motivation and capacity for the change
Phase two will involve the change agent gaining the trust of the key stakeholders as well as anyone who will be involved within the nursing workforce in order to proceed with the project. If trust is not shown, then it becomes hard to influence any motivation for anything to change (Belcher & Jones, 2009). An important part of this phase is to see how the group perceives the change agent and the motivation to the possible change.
During this phase, it is important to approach it a sensitive and appropriate manner due to the fact that new graduate nurses will be excited to start their graduate nurse program but as well be scared about their career (Dyess & Sherman, 2009; St Clair, 2013). The recipients of this project which are the graduate nurses, will hopefully want to gain the best possible orientation into their nursing workforce and take advantage of the resources that will be provided.
However, there also can be a barrier because at this stage the graduate nurses will have potential overload of information that they have been giving in relation to their new nursing career. Therefore, it will be important to introduce the wiki (website) to their education and practice at a specific time.
3. Assessing the resources and motivation of the change agent
Information must be collected regarding the situation in the workplace and why the project would benefit staff. One way to collect this information it to talk to other past and current graduate nurses on their experiences. If the motivation of new graduate nurses is there and they are willing to change the way in which orientations are run, then it makes it a lot easier for the change agent.
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A meeting to discuss what staff would like to present and offer within the website would be beneficial so that they feel that they are involved in the process of change. If a meeting were to be compulsory then, a presentation about “Wikis and website programs” and what they involve needs to be implemented. At some point during the presentation, it would be useful to provide the rationale behind the change and to state the benefits of its use. The one off meeting would be targeted towards new graduates but all staff can be present as they may want to access the website at some point in their career as well.
All graduate nurses and other nurses all displayed an expression of interest in the meeting on the use of a website through formal and informal feedback.
4. Defining the progressive stages of change
The fourth stage of planned change involves specifying the objectives of the change, charting out exactly how the change will be achieved, and the length of time you anticipate the plan will take (Daly, 2014). A pilot or trial period of the project also may be helpful at this point to allow for evaluation of the change, and to modify the plan if necessary (Daly, 2014).
During this phase, the group will begin to formulate their ideas about the change. According to Lippitt et al. (2014), problems may arise in relation to motivation when the group starts to express intentions and actions towards the planned change (Swansburg, 2014). These problems can occur due to anxiety about the change or fear of failing the change (Daly, 2014).
A trial procedure was offered involving the change which may help to alleviate symptoms such as anxiety and fear, therefore accepting the idea for change. In the development of a wiki (website), this will hopefully enhance orientation to graduate nurses. Once all staff members are aware of how the website can improve their practice and increase their knowledge, then hopefully they will be more willing to accept the change.
5. Ensuring the roles and responsibilities of the change agents are clear and understood
Phase five involves choosing the appropriate role of the change agent. The role of the change agent during the change process is critical to the success of the plan (Davies, 2014). Failure to define the role of the change agent can result in confusion and a breakdown in communications (Davies, 2014). The change agent will ensure that all staff feel that they are well supported and encouraged to work towards actual efforts based on their intentions. The first step would be the actual creation of the website, followed by an active demonstration to the group that could be performed on the site. An example of a demonstration and activity that could be presented could be a link to a website where answers to clinical practice questions are found. This part would be very brief but most importantly informative in order to display simplicity to the work environment.
Throughout the wiki, there could be links to clinical skills and techniques as well as up to date evidence based articles that will provide the best practice guidelines. Visual aids such as videos of procedures would also be very helpful for graduate nurses who may not get to experience assisting with a specific procedure during their orientation. These videos give the graduate nurses a visual aid so that when they are faced with this in their practice they at least have background knowledge and are able to visually recall what took place during the procedure even though they have not performed it on a patient.
6. Maintaining the change through feedback, and group coordination
The key to maintaining the change is keeping the lines of communication open (Davies, 2014). Frequent, ongoing discussions by staff regarding the change will need to continue as each step in the plan is implemented, evaluated, and revised as necessary. During the implementation of the project, the focus will be to target new graduate nurses entering the nursing profession to improve their orientation. If the project is well received, then the inclusion of the website into the orientation will be not only useful for graduate nurses but can also be beneficial for other employees entering the nursing profession with no prior experience/graduate program. It can also aid as a review system for existing staff that may want to access the visual aids or articles to review some procedures that they may not come across day to day.
There will also be ongoing debriefs, where anonymous feedback forms will be distributed to all participants to ensure confidentiality. New graduates will also be informed of the change and will be asked to give feedback on the quality of the new change and the use of the website. According to Lippitt et all. (2014), “One critical factor in the stabilization of change is the spread or non-spread of change to neighbouring systems” (Swansburg, 2014). If the use of a website i in Holmesglen Hospital spreads from the target group of graduate nurses to other staff members, this would show that stabilisation of the intervention is occurring.
7. Gradually removing the change agents the relationship
Phase seven involves termination by the change agent, leaving the system or the organization to maintain the change (Davies, 2014). All graduate nurse will be able to have ongoing involvement with the group and staff members as well as the other key stakeholders; nurse educators and nurse managers on the wiki. However, the goal of the wiki is that it becomes a way to contribute to discussions and share knowledge with the group. With ongoing use of the website, graduate nurses will become more comfortable using the website and will be more likely to interact and use it. Therefore, nurses will be able to contribute their knowledge and participate more readily to discussions.
Strategies for measuring outcomes
The reason why to measure change, is to monitor progress, identify the next steps, learn from the process for practice, monitor implementation and to identify whether the desired goals have been achieved (Bond, 2013).
Some ways to measure this change will include using questionnaires and surveys which are quick and easy to gather data from people in a non-threatening way as well as observation by gathering accurate information about how the change is processing (Bond, 2013). Another strategy will include having monthly check-ins with the supervisors, nurse managers, and leaders to capture successes and challenges (Bond, 2013). Furthermore, using direct observation from an outsider to see if the change has been implemented correctly with a positive change (Bond, 2013).
During this change, there should be a comparison of the new graduate nurses before using the website and after they finished their orientation, this will identify participant’s motivation, support and behaviour during and after the change. Interviewing the graduate nurses’ one on one as they will be able to provide feedback about the new change and insight of what needs to be changed.
Once all of the feedback and data on how the change went, data analysis should be completed. This would be performed using a software on the computer. It would be able to determine any improvement since starting the change to the end of the change, and then, be able to improve for the new graduate nurses that will be coming through next year and the year after. Lastly, when measuring change, one must communicate, engage and reflect to ensure the change process is acceptable and sustainable (Bond, 2013).
Summary and Conclusion
Within this paper, a discussion was addressed to encourage staff involvement in the process and offer opportunities to enhance learning during the challenging time of orientation for new graduate nurses. Additionally, a rationale for why the change needs to be implemented was identified. Furthermore, Lippitt’s seven stages was used to implement the change. Lippitt’s seven stages of change closely aligns with the nursing process and is appropriate for a variety of settings to implement change. Being aware of the needs of staff members as well as the barriers to change that may be met is vital for moving this initiative change forward. With the implementation of this change, it may be a valuable learning opportunity for new graduate nurses that could improve and enhance their orientation experience and promote a smoother transition into the nursing profession.
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