It was my first day in the emergency department (ED) as a new graduate nurse. While I had completed my final clinical rotation in the pediatric section of this very ED, I was still anxious about what to expect. This community hospital had massive volume, housed a level 1 trauma center, and had multiple specialty areas, including a women’s emergency suite, chest pain center, behavioral health unit, and 24-hour observation.
I had 12-16 weeks to orient myself to each of these areas along with the main department, fast track, and triage. It was a daunting task, and I was incredibly worried that I wouldn’t cut it. All of this dissipated almost immediately when I met my preceptor, Becky. She was an experienced emergency and flight nurse and had been working in this department for over a decade.
However, even more important than the knowledge she brought, she had an impeccable ability to share it all in a way that was conducive to the student in front of her. Her secrets were simple and can be easily emulated for any nurse onboarding program.
3 Tactics for a Successful Onboarding Experience
1 Assess each nurse individually.
Becky regularly onboarded new nurses to the department. However, she never treated any of them the same. While she was likely the most capable and experienced nurse around, she never assumed that her way was the only way. In my first week with Becky, she was constantly assessing me.
- Assessing my knowledge of skills
- Assessing my comfort level with various types of emergency patients
- Assessing my preferred method of learning
- Assessing my ability to critically think
Once Becky had a good understanding of what I needed to know and how I would be best suited to learn it, then and only then did she start putting together my individualized plan.
2 Walk the line between autonomy and safety.
Becky knew that I learned best by getting out there and doing the job. I needed to experience the onboarding program through kinesthetic learning. However, it would be unwise of any preceptor to just leave new graduate nurses completely to their own devices.
Therefore, Becky used the same steps for every preceptee. If you knew how to do a procedure or skill, she would ask you to tell her the steps. If you could do this without difficulty, she would then watch you closely until she felt assured that you could manage autonomously. Then she let you go and do these things alone.
However, if you had never done something before or if you were unable to articulate competence, you would watch first, repeat the steps second, and then perform with supervision. These steps allowed someone who was more tentative time to feel comfortable or someone surer to know exactly what they needed to do to get to the final steps and complete this part of their onboarding.
3 Provide quick and constructive feedback.
It would be naive to think that any new nurse or transitioning nurse would make no mistakes during their onboarding process. I still remember one of my first mistakes as a registered nurse. It was during those first several months onboarding in the emergency department. I misread a vial of medication and gave a patient more than I intended. While there was no poor outcome, it was a learning experience that stuck with me forever.
Becky handled it beautifully. She acknowledged that I had made a mistake and needed to remedy it immediately. While she did not beat me up over it, she did appropriately let me know that not taking every precaution when administering medications is a serious error that can cause patient harm. She had me tell the doctor, tell the patient, and write up an incident report. However, after it was all done, she shared her own experiences with making mistakes and reminded me that I, too, would learn from it and never do it again.
The art of onboarding can be incredibly difficult in nursing. The profession brings in people of all skill levels, background, experiences, and personalities. However, successful onboarding doesn’t follow a script much different than being an effective manager in any work setting or industry.
Nurses must be assessed for what they individually bring to the table.
- How do they learn?
- What do they know?
- What is most important for them to learn or experience by the end of their onboarding?
- What is their individualized plan to get them there?
Further, it is imperative for preceptors to always ensure safety to the highest degree. Even nurses who prefer a lot of autonomy, like myself, need to prove we are competent and know the basics. Finally, feedback should be quick, often, and constructive. Mistakes can and will happen, and it is how a nurse learns to respond to them which is of the upmost importance to get the prepared for a successful career.
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