Historically, outpatient oncology settings have not hired new graduate RNs (NG-RNs). However, with staffing shortages, outpatient oncology clinics have hired NG-RNs who required orientation from formal onboarding programs. Using a mix of didactic instruction, hands-on rotation experiences, and nursing leadership support, an NG-RN orientation program was developed to attract, support, and professionally train NG-RNs in the outpatient setting. Based on this program’s results, NG-RNs improved their competence and confidence within their first year of practice in the outpatient oncology setting.
Earn free contact hours: Click here to connect to the evaluation. Certified nurses can claim no more than 1 total ILNA point for this program. Up to 1 ILNA point may be applied to Nursing Practice OR Oncology Nursing Practice OR Professional Practice/Performance OR Roles of the APRN. See www.oncc.org for complete details on certification.
The U.S. Department of Labor (2023) reported that the employment of RNs will grow 6% over the next 10 years, with 193,100 openings projected each year for the next decade. This gap is multifocal: the inability of nursing schools to meet the training demand for graduate nurses to enter the profession, an aging population that increases healthcare demand, and the retirement of nurses. In addition, the nursing profession has an experience–complexity gap, resulting in an increase of experienced nurses leaving organizations and an influx of novice nurses to backfill the open positions (Nursing Executive Center, 2019). These issues have forced the profession to reconsider traditional workforce requirements and training opportunities.
Historically, new graduate RNs (NG-RNs) were guided to seek employment for their first nursing position on inpatient units to gain experience, build a solid foundation of skills, understand the patient experience, and receive mentorship from experienced nurses (Mota et al., 2007). Contrarily, outpatient settings hired nurses with inpatient experience. As healthcare treatments and procedures transition into outpatient settings and the U.S. nursing shortage continues, the need for more nurses in these settings has increased and outpaces the number of experienced nurses seeking outpatient employment (Nursing Executive Center, 2019). From 2005 to 2015, U.S. inpatient stays decreased by 6.6%, and visits to outpatient areas increased by 14% (Abrams et al., 2018). The increased visits, gross outpatient revenue per visit, and increased capital investments in outpatient facilities demonstrate the shift from in-hospital services to outpatient care delivery (Abrams et al., 2018). This trend has been particularly apparent in oncology where many complex or highly-reactive infusions and procedures have shifted to the outpatient setting, therefore increasing outpatient volumes (Aljurf et al., 2021).
To meet demand, the Nursing Executive Center (2019) has recommended hiring NG-RNs into outpatient settings and providing outpatient-specific training and onboarding to orient them to this clinical practice setting. Therefore, the Duke University Health System’s National Cancer Institute–designated cancer center developed an outpatient orientation program to support NG-RNs hired into outpatient oncology settings. The purpose of this article is to describe the development and implementation of an outpatient oncology NG-RN orientation program.
To hire and train NG-RNs to the oncology outpatient clinics within the Duke University Health System’s cancer center, a team was formed consisting of oncology educators, clinical leadership, and clinical nurse specialists. A literature search returned 36 studies fitting criteria specific to new graduate nursing. The majority of studies discussed internship, fellowship, and mentorship programs to guide NG-RNs’ transition to practice. Eight studies were specific to NG-RNs in outpatient care settings. Six studies focused on programs developed to help NG-RNs transition to practice in outpatient care environments, four of which focused specifically on the oncology setting. Although no studies specifically described a program for preparing NG-RNs, there was consensus that preceptors must be adequately prepared to work with and train NG-RNs, orientation must be structured and focused to ensure effective onboarding, and institutions should collaborate with nursing schools to bridge the transition gap (Kidd et al., 2020).
The team benchmarked the program planning with two National Cancer Institute–designated cancer centers. Internal to the Duke University Health System, the non-oncology hospital–based outpatient clinics had recently implemented an NG-RN orientation program; results and lessons learned were foundational for the development and implementation of the oncology-specific program. In addition, the team audited existing oncology nurse orientation curriculum resources within the organization and nurse residency session topics for gaps in the curriculum. Several oncology-specific education topics were identified as a critical need for the NG-RN to learn earlier in orientation.
Oncology-specific orientation: During the second week of orientation, didactic presentations and hands-on skills training sessions were provided. Lectures included oncology basics and how to perform a detailed assessment on patients with cancer. Hands-on skills training focused on using lift equipment, accessing and deaccessing implanted ports, inserting and maintaining peripheral IVs, and performing safe handling of hazardous drugs and safe injection practices. Orientation sessions also included opportunities to introduce NG-RNs to oncology leadership to establish a sense of belonging, as well as a campus tour to orient NG-RNs to the community.
Oncology pearls microlearning sessions:These 30-minute virtual sessions promoted early introduction to oncology content relevant to all clinical rotations. Topics included laboratory review, well-being, extravasation, and genetics and genomics. Sessions were recorded so that participants could review the content later.
Online orientation portal: An online orientation portal was created for NG-RNs and preceptors to use as a central repository for all orientation materials. With easy access to the orientation materials, NG-RNs and preceptors coordinated their week-to-week advancement, despite working in new locations with new preceptors. In addition, the platform permitted NG-RNs and preceptors to provide self-introductions and photos as a means of getting to know each other.
Structured program feedback: Each week, the NG-RN cohort gathered with program leadership to discuss their experiences and challenges. The goal was to address concerns or gaps in skill acquisition in real time for a better orientation experience. The meetings also provided a space for peer support and bonding among the NG-RNs while they transitioned to practice.
Because orienting NG-RNs in outpatient clinics was an unfamiliar process for established preceptors, a gap analysis was performed on existing preceptor training to develop enhanced training specific to NG-RN needs (Kidd et al., 2020). Subsequently, specialized training was provided to clinic nurse preceptors. Content included a program overview, a tutorial on access to and use of the online portal, and tips for providing constructive feedback and fostering critical thinking. Because of the anticipated culture shift of NG-RNs in outpatient oncology, preceptor sessions allowed future preceptors to voice concerns and hesitations.
Using a pre-/post-test design, this program was implemented within the outpatient clinics of Duke University Health System in North Carolina. The Magnet®- and National Cancer Institute–designated comprehensive cancer center is an academic health system facility that is comprised of a large academic-based hospital and two community hospitals, with six interprofessional outpatient clinic locations, six infusion centers, and five radiation oncology clinics.
Retention: Retention rates were measured for continued employment in the outpatient oncology permanent unit and continued employment within another oncology unit. Retention was measured at 3, 6, and 12 months.
Program evaluation: The Casey-Fink Graduate Nurse Experience Survey (CFGNES) (Fink et al., 2008) was used to evaluate the program. CFGNES uses multiple item formats to examine perceptions of an NG-RN’s transition to practice during their first year in the following five factors: (a) support, (b) organization and prioritization of care, (c) stress, (d) communication and leadership, and (e) professional satisfaction. This survey has an internal reliability of Cronbach’s alpha = 0.86 (Casey et al., 2021). For the outpatient oncology NG-RN program, three items were identified as indicators of program outcomes: (a) improvement in skills or procedures that the NG-RN feels uncomfortable performing independently, (b) satisfaction with chosen nursing specialty, and (c) preceptor support. Survey responses were rated using a four-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree). Surveys were distributed electronically to all NG-RN cohorts. Cohorts 1 and 2 were resurveyed at six months, and cohort 3 was resurveyed at three months. Survey participation was encouraged but was voluntary and anonymous.
In addition to the CFGNES, the program team developed an eight-question electronic survey to obtain NG-RN knowledge acquisition from the oncology pearls microlearning sessions. The survey also assessed NG-RN responses about the convenience and ease of attending orientation and their preferred learning methods. Responses to survey items were “yes” or “no” or on a four-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree). The survey link was sent to all NG-RNs from cohorts 1–3. Descriptive statistics were performed on aggregate data.
The first outpatient oncology NG-RN program was implemented in June 2021. Since then, a total of 25 NG-RNs have completed the program across six cohorts. Across the six cohorts, the average retention rate at one year was 71.6%. Among the six cohorts of NG-RNs who left their permanent outpatient unit, three transferred within the organization to inpatient oncology units and four left the organization but stayed in the oncology practice.
NG-RNs indicated on the CFGNES that the greatest discomfort with clinical skills included IV insertions, bladder catheter insertion, tracheostomy care, and emergency management (see Table 1). Eighteen respondents reported a lack of confidence with communication, delegation, knowledge, and critical thinking in their transition to becoming a practicing RN. At baseline, 23 respondents reported satisfaction with their chosen specialty; likewise, 12 respondents continued to report satisfaction with their chosen specialty at six months. In addition, 23 respondents reported that they agreed or strongly agreed that their preceptor provided encouragement, gave feedback, and facilitated developing confidence.
Nurses who participated in the oncology pearls microlearning sessions (N = 9) reported an increase in knowledge ranging from 66.7% to 100% over the five NG-RN sessions. Staff who participated were asked how each oncology pearls microlearning session increased knowledge on the topic presented and whether the activity resulted in “no to little increase in knowledge” or “increase in knowledge.” In addition, staff were asked whether the content presented was relevant to their practice. All respondents reported that the orientation content was relevant to their practice. However, three participants reported that the sessions were difficult to attend because of scheduling conflicts, and two recommended a prerecorded webinar that NG-RNs could view at their own pace and schedule.
Overall, the orientation program for NG-RNs in the outpatient oncology setting allowed for new graduate candidates to be hired, trained, and retained; this program has significant positive implications for reducing the outpatient staffing crisis. Continuous program assessment and adaptability to meet NG-RN and outpatient needs contributed significantly to the program’s effectiveness.
According to Nursing Solutions, Inc. (2021), nearly a third of all newly hired nurses leave their institution within a year of hire, with first-year turnover accounting for almost a quarter of all RN departures. Nurse retention rates for this program are on track with the national first-year turnover average. With the recruitment of NG-RNs to the program, vacancies have been filled across the organization’s multiple outpatient oncology sites. Since the start of the orientation program, 10 nurses have been placed in infusion, 3 in radiation oncology, and 10 in interprofessional medical-surgical clinics. After two NG-RNs completed their rotations, they were transferred to inpatient units based on their professional goals. With this program, the organization filled 23 open positions, which helped increase clinical nurse staffing for the growing outpatient oncology environment. Of the NG-RNs who left the hiring institution, all stayed within an oncology setting. NG-RNs’ satisfaction with preceptor support, confidence, and encouragement illustrates how vital preceptor contributions are for retaining new staff. A dedicated position was approved by the organization to oversee the program’s continued development.
Anticipated learning needs of NG-RNs were consistent with survey feedback, and survey responses facilitated real-time program changes. Examples of real-time changes include moving the rotation timeline, modifying rotation duration and content of hands-on skills training, revising the oncology pearls microlearning sessions, and adding guest speakers to weekly check-in sessions to provide information on palliative care and wound ostomy management.
Limitations of this onboarding program included the small number of new hires who completed the program and the cohort size variance. These issues limit generalizability to other outpatient areas, yet reflect essential adaptability to meet NG-RN needs. There was variability in the timing and distribution of CFGNES among the six cohorts, making interpretation of data difficult. However, the program is highly adaptable for easy implementation. In the future, similar programs should track return on investment in addition to retention.
Based on results from this outpatient oncology NG-RN orientation program, NG-RNs can be hired and trained to work in the outpatient setting. Strong preceptor training, compassionate support from leadership and clinic staff, and a structured curriculum establish an environment for learning and can improve long-term retention rates for a new graduate workforce.
The authors gratefully acknowledge the vision and leadership of Mary Ann Plambeck, MSN, RN, OCN®, NEA-BC, during program development and implementation, Deborah “Hutch” Allen, PhD, RN, CNS, FNP-BC, AOCNP®, for her assistance with manuscript edits, and Jennifer Frith, DNP, RN, OCN®, NE-BC, for continued program leadership and support.
Karla Lambson, MSN, RN, OCN®, is an ambulatory oncology nursing program manager at the Duke Cancer Institute in Durham, NC; and Kerri A. Dalton, DNP, RN, AOCNS®, is a clinical nurse specialist, Cindy Bohlin, MSN, RN, PCCN-K, is a clinical nurse educator for oncology services, and Meg Helsley, MSN, APRN, AOCNS®, is a clinical nurse specialist, all at Duke University Health System in Durham, NC. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Lambson can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org.
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