A simple checklist helps guide the transition from classroom to clinical unit.

Hospital nurse educators at the University Medical Center in Paterson/Wayne, NJ, members of St. Joseph’s Health, know their primary role: Efficiently transition new graduate nurses and promote safe practice from classroom orientation to clinical units. Onboarding new nurses via recently trained preceptors can prove a daunting task for nurse educators. St. Joseph’s Health developed the Phases of Orientation Checklist to help educators set practical clinical goals and assign tasks, skills, and competencies for new nurses. The checklist takes a progressive tiered approach, divided into three phases of clinical orientation and moving from low-level to high-level skills and goals. Written in simple language, the checklist helps to ease new nurse graduates into practice and also provides new preceptors with clear orientation goals and objectives.

Uncovering a challenging

The Association for Nursing Professional Development’s Scope & Standards of Practice identifies hospital nurse educators as responsible for implementing a new nurse’s individualized orientation plan. St. Joseph’s Health expects nurse educators to coordinate clinical orientation using skills preceptors, develop orientation calendars, and schedule progress meetings and unit-specific classes for newly hired RNs. St. Joseph’s influx of new graduate nurses and recently trained preceptors prompted a discussion that led to the development of the Phases of Orientation Checklist.

Before rolling out the checklist, a survey conducted among St. Joseph’s nurse educators (nine responded) found that 57% didn’t use a checklist or tool for assigning skills and competencies during orientation; 43% did use a checklist. The survey showed that educators used various evidence-based tools to coordinate and structure orientation meetings. However, working in these educational silos produced disjointed outcomes. At the end of orientation, some new nurses weren’t equipped to function independently, which extended onboarding and increased time and costs for clinical units.

Other than Joswiak, Beamer and colleagues, and Cantrell and colleagues, little research exists about assigning task-layered tiered skills to transition new nurses through orientation. However, the results of the survey led St. Joseph’s educators to discuss developing a process that new nurses and preceptors could understand, including clear orientation language and gradually achieved goals.

With support from nursing leadership, the educators collectively approved adoption of the Phases of Orientation Checklist. They agreed that the checklist would help meet the needs of the increasing numbers of nurses coming out of orientation onto the clinical units. They also felt that a uniform checklist would produce and maintain a cohesive orientation process.

Following the checklist

Based on Benner’s novice-to-expert model and Bloom’s taxonomy, the Phases of Orientation checklist helps ensure the effective and progressive orientation of goals and skills. In Bloom’s taxonomy, nurses move from lower-level thinking skills (knowledge and comprehension) through mid-level skills (application and analysis) to higher-level thinking skills (synthesis and evaluation). Similarly, Benner’s novice-to-expert model acknowledges that nurses evolve over time as they gain experience and acquire expertise.

Phase I

In the first phase of the checklist (within Bloom’s taxonomy of knowledge and comprehension), the preceptor and nurse educator guide the new nurse in building skills related to medication administration, patient documentation, and hand-off communication. The critical thinking questions involve the new nurse asking about the reasoning behind a clinical step or procedure. For example, the nurse might ask, “How did you know to initiate the hypoglycemic protocol for the patient with diabetes?”

Phase II

During the second phase (which falls within Bloom’s taxonomy of application and analysis), the new nurse learns about and takes part in care plans, admissions and discharges, and provider and interprofessional phone calls. They also gain experience at delegation and time management.

Critical thinking questions in this phase aim to trigger higher-level thinking. For example, the preceptor might ask, “Our patient with diabetes is exhibiting signs of hypoglycemia. What steps should we take to manage the situation?”

Phase III

During this final phase of orientation (aligned with Bloom’s taxonomy of synthesis and evaluation), the new nurse might be listed as the primary nurse on the patient board, offer report in an interprofessional meeting, spend time at the desk with a unit associate, have an opportunity to shadow a patient care associate, and complete I.V. insertions. In addition, the preceptor and nurse educator will ask the new nurse to participate in continuing education, such as online modules and specialty classes.

In an effort to prompt ever more nuanced critical thinking, the preceptor and nurse educator ask the new nurse to present solutions to questions. For example, they might ask, “How would you educate the patient with diabetes about managing their diet and medication adherence? Also, how would the patient know when to seek immediate medical attention at home?”

Checklist benefits

New nurses spend months on clinical orientation. Periodic scheduled orientation meetings with the new nurse, preceptor, educator, and unit manager can prove difficult to organize in an acute care clinical setting. The practical progressive checklist establishes the expectation that each meeting will focus on the new nurse’s current clinical skill set and the next goal on the checklist. All participants have access to the checklist, and it remains visible for reference throughout each meeting. This visibility allows the anxious new nurse and preceptor to understand what’s guiding the educator’s questions about performance and helps move the nurse through orientation

Formalizing the orientation process for the hospital nurse educator provides validity to these meetings. In addition, it helps managers, preceptors, and new nurses clearly and easily understand this tiered approach to achieve goals and measure progress. The educator uses the checklist to drive the orientation meetings objectively, and the new nurse uses it to reflect on the skills, tasks, and competencies they’ve mastered or found challenging. When the new nurse recognizes where they’re struggling, the educator can plan additional opportunities to help them reach their clinical goals.

All St. Joseph’s educators use the checklist; they mirror each other, which provides a uniform process in which assigned educators may change but the educational process remains consistent. The educators have found that the checklist clarifies expectations for the new nurse on orientation and their assigned preceptor. In addition, the tool’s simple language proves less overwhelming for the new nurse.

With competing priorities on the clinical units, limited time exists to meet, evaluate, and execute a new nurse’s individualized orientation plan. The checklist keeps the process simple and concise, so the new nurse, preceptors, and managers need not take much time away from direct patient care. Having a tool to start the meeting can help avoid subjective pitfalls that can occur when the nurse educator starts by asking, “How are you doing?” Benner’s model emphasizes that nurses frequently don’t know what they don’t know, which leaves them struggling to answer that first question.

Bridging the gap

According to the Association of Nursing Professional Development standards, nurse educators can advocate for themselves and new nurses by communicating with leaders about new clinical orientation processes that promote staff retention. In addition, a checklist supports a partnership among the manager, preceptor, and new nurse. The nurse educators’ goal, bridging the preparation–practice gap, as described by Hickerson and colleagues, creates an environment that supports new nurses as they transition to clinical units.

The Center for Education Department at St. Joseph’s Health uses the Phases of Orientation checklist for all nursing division clinical units on both hospital campuses (St. Joseph’s University Medical Center Paterson and St. Joseph’s Wayne Medical Center). The department set new nurse retention rates and preceptor evaluations as benchmarks for analysis of the checklist. Currently, the department is conducting data analysis to determine checklist success. Anecdotal data indicates adaptability of the Phases of Orientation checklist to our specialty units as easier than we initially expected. The obstetrics and intensive care educators noted that orienting new graduate nurses to specialty units can prove daunting and intricate but that breaking down the phases of orientation allows for objective and measurable goals. The checklist also aids nurse, educator, and preceptor conversations about progress.

Maureen Mulligan is a clinical education specialist and NICHE coordinator at St. Joseph’s University Medical Center in Paterson, New Jersey.

American Nurse Journal. 2024; 19(12). Doi: 10.51256/ANJ122438

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Key words: nurse educators, new nurse orientation