Preceptors can improve retention of new nurses

Individualized programs create better results

A new job can be overwhelming no matter what industry you may choose, but when the new job is in home care, saying that the job is overwhelming may be an understatement. Traditional orientation programs don't always take into account the myriad details that a home care nurse needs to know to both succeed in the job and to be happy with it; so two agencies are handling new employee orientation with preceptors.

Since her agency started the preceptor program four years ago, new nurse retention has been higher and employee satisfaction has increased as well, says Suzanne Van Loon, RNC, BSN, MPH, director of clinical services at VNA of Somerset Hills in Bernardsville, NJ. "Our new hires have been split 50/50, with half of the nurses having home health experience and half of the nurses not having home health experience," she says. "Our three-month orientation program gives all new nurses a chance to adjust both to our agency and to home health if this is a new field for them."

The preceptor's responsibilities are to introduce the new employee to the different protocols and processes of the agency, assess the new employee's learning needs through discussion and observation, and plan the new employee's learning experience, says Van Loon. "Because the preceptor spends so much time with the new employee during the first four weeks, her case load is reduced," she says.

At first, the new employee will make visits with the preceptor, but she also will spend time with other agency employees, Van Loon points out. "New employees spend days with our clinical director, our quality improvement director, rehab employees, OASIS coordinator, intake employees, our respite department manager, and our nursing secretary," she explains. "This gives each new employee a real understanding of all of the agency's activities and introduces key people that she will need to know," she adds.

Even though the preceptor and the new employee are not together every day once the orientation period begins, they have regular progress meetings, along with the new employee's supervisor, to review what has been learned and to identify areas that may need to be enhanced, such as computer skills or OASIS training, explains Van Loon. The training is designed to meet the individual's needs, not a time frame, she adds.

"It is a very positive relationship that develops," she says. "It is nonthreatening and it makes it easy for the new employee to ask questions without worrying that admitting a lack of knowledge may result in a poor review," she adds. While the orientation period is defined as three months, the preceptor relationship can be informally extended as needed, she says.

"We select case managers to serve as preceptors," says Vikki Prochaska, RN, MSN, CNAA, director of home care at Kenosha (WI) Visiting Nurse Association. The first week of training, the new nurse spends time learning the computer system and OASIS entry, she says. "The next two weeks, the new nurse works with her preceptor, visiting patients, completing documentation, and talking about agency operations," she says. After two weeks with her preceptor, the new nurse will spend the next few weeks visiting patients with a variety of other nurses, she says.

"We like for a new nurse to see how a variety of nurses handle patient visits and paperwork because everyone develops their own way to do the job and you can learn something different from each nurse," she explains. The new employee does stay in contact with her preceptor and the preceptor reviews the new employee's progress.

Prochaska's program is 90 days and comprises orientation and evaluation, but it is very individualized, with different nurses progressing at different paces, she says. "It is important to tailor the training to the nurse's experience and ability so that the job doesn't overwhelm and frustrate the new employee," she explains.

Selecting the right employee to serve as a preceptor is just as important as selecting the right nurse to hire as a home health nurse. "We require that our preceptors have a minimum of two years' nursing experience and at least one year of home health experience," says Van Loon. "We also want someone who loves being in the field and is very organized with a natural talent for teaching," she adds.

"I look for preceptors who consistently do their job the right way, without taking a lot of shortcuts," says Prochaska. "While everyone develops shortcuts as they learn their job, it is important for a new nurse to learn every step of the process the correct way so that mistakes can be easily found and fixed," she explains. "Preceptors also have to be ready to become the new nurse's best friend during a trying period of her life.

"We also encourage our preceptors and our new employees to let us know if personality conflicts do arise," says Prochaska. While she tries to match preceptors and new employees on the basis of personality as well as skills, there may be times that the new employee needs to move to a different preceptor, she says. A move from one preceptor to another does not reflect the skills or ability of either the preceptor or the new employee; it is strictly a personality issue, she emphasizes.

"A preceptor who is very confident may seem intimidating to a nurse who is less assertive, so the new nurse will feel free to ask questions of, and learn more from, another preceptor with a different personality," she explains.

A reduced workload for preceptors does mean an increased workload for other nurses, but every one in the agency appreciates the value of a preceptor-based orientation, says Van Loon. While the individual training and orientation may seem costly as first, the real savings are seen in the retention of new employees, instead of a revolving door of nurses who stay fewer than three months, she adds.

Not only does this approach to orientation solve retention problems, but it also is a recruiting plus, Van Loon points out. "Nurses who are new to home health are relieved to find out that that they will have one person, other than a supervisor or manager, to whom they can go with their questions," she says. "This removes a lot of their anxiety about working in a new field and makes them look forward to learning a new job," she adds.

A preceptor-based orientation also addresses the fact that home health care cannot be learned in a classroom, says Van Loon. "The only way to learn home health is to do it. This approach gives new nurses a chance to do home care in a safe, supervised environment."