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NCPD Article

Bridging the Gap: Standardizing Orientation to Improve Vacancy and Turnover Rates of Ambulatory Oncology Nurses

Christina M. Matousek

orientation, oncology nursing, clinics, ambulatory, standardization, onboarding
CJON 2024, 28(3), 323-328. DOI: 10.1188/24.CJON.323-328

This article describes standardizing ambulatory oncology nursing orientation within an academic comprehensive cancer center to reduce turnover rates. The nursing professional development specialist created a standardized orientation using templates to ensure consistency and disease-specific experiences because this center is organized into 17 interprofessional disease teams.

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    The care of patients with cancer, which has historically been provided in the acute care setting, shifted to ambulatory care beginning in the 1990s because of technological innovations, financial incentives, and patient preference (Abrams et al., 2018). The demand for ambulatory oncology nurses has since increased, with 80% of all cancer care being provided in the outpatient setting (Hubbard & DeMeyer, 2022). Within ambulatory care, the nursing roles are multifaceted and require collaboration with the interprofessional team and independent critical thought (American Academy of Ambulatory Care Nursing, n.d.). Nursing roles in ambulatory settings can be ambiguous and, without proper role clarification, may make the transition from acute to ambulatory care a challenging experience.

    Although most nurses entering ambulatory settings have experience, ambulatory care requires a unique set of attributes that some experienced nurses may find difficult to attain. The American Academy of Ambulatory Care Nursing (n.d.) states that the scope of ambulatory nursing includes care coordination, transition management, and telehealth. Ambulatory nurses need to have strong critical thinking skills, sound clinical judgment, and the ability to implement the nursing process in patients who may not be under their direct care. Proper ambulatory nursing training ensures that nurses can provide the same level of care that was historically delivered in the acute setting (Pirschel, 2019).

    Evidence highlights that the development of ambulatory nursing orientation is a key component to ensuring competent care (Andronico et al., 2019; Fischer, 2022; Hampton et al., 2020; Kiel, 2020; Lambson & Dalton, 2022; Page, 2022; Vadivelu, 2020; Ward et al., 2022). Hampton et al. (2020), Page (2022), and Vadivelu (2020) reported on how poor onboarding can negatively affect retention and turnover. Feedback from staff revealed a lack of consistency with preceptors and the orientation to their roles, leading to decreased confidence in their practices (Page, 2022).

    Research suggests that using a standardized orientation can positively affect retention and turnover rates, particularly in ambulatory settings (Andronico et al., 2019; Fischer, 2022; Hampton et al., 2020; Kiel, 2020; Lambson & Dalton, 2022; Page, 2022; Vadivelu, 2020; Ward et al., 2022). Creating a standardized orientation, including weekly progress meetings and oncology-specific competencies, improves retention, staff engagement, and nursing confidence (Page, 2022). Standardized nursing orientation increases nurses’ knowledge and skills (Monforto et al., 2020) and creates a smooth transition to practice, which allows the nursing professional development specialist (NPDS) to incorporate the needs of the trainee when formulating learning strategies (Kiel, 2020).

    At Smilow Cancer Hospital, a large comprehensive cancer center in New Haven, Connecticut, ambulatory oncology is divided into 17 disease teams, including endocrine, gastrointestinal, genitourinary, head and neck, melanoma, neurosciences, neuro–spine, ophthalmology, pain, palliative care, sarcoma, and thoracic, with some being additionally divided into surgical or medical oncology. Each team uses two nursing roles, the RN coordinator and the practice nurse, to help support patients with cancer. The nurse coordinator is responsible for facilitating appointments and gathering data for new patients. The practice nurse is responsible for assisting the clinic team with follow-up visits, telephone call triage, paperwork, and other duties.

    Purpose

    The purpose of this initiative was twofold. Initially, the goal was to evaluate the competency and needs of nurses related to the onboarding process. Following the assessment, the NPDS developed a standardized orientation plan within the ambulatory setting, with the goal of improving vacancy and turnover rates.

    Methods

    The leadership team began a quality improvement project to understand the previous orientation structure for nurses and improve it for future hires. The NPDS performed a baseline assessment to understand the two roles within each team by shadowing. This experience served to understand what new hires would need to learn to become competent before completing orientation. The assessments showed that the functions of the nurse coordinator and practice nurse were fundamentally the same across the interprofessional clinic. Although disease-specific tasks differed between clinics, the nurse coordinators were responsible for new patient consultations, practice nurses, and return visits.

    The NPDS conducted a gap analysis to understand the previous orientation process and where knowledge gaps existed. During the assessment, the NPDS obtained feedback from the nurses on each team about what experiences or education would be beneficial for new hires. Preimplementation, the orientation of nurses consisted primarily of a one-on-one preceptorship; however, there were many instances when the clinics had a complete turnover of staff, causing a lack of preceptors to support orientation. The NPDS found that new hires were assigned to teams without any formal training, causing them to learn their roles independently. In addition, managerial or educational meetings were not embedded into the orientation plan. The areas where improvements and educational opportunities were needed included disease-specific aspects that were unique to each team, such as disease processes, procedures, patient education, and anticancer treatment modalities.

    Implementation Plan

    Following the assessment and gap analysis, the NPDS developed an orientation template to ensure that each new hire is onboarded consistently. This template outlined the experiences to be included, contact information to help facilitate communication, and directions to different sites. This allowed for ease of scheduling and building orientation calendars for the NPDS while ensuring consistency for future trainees (see Table 1).

    TABLE1

    Each new hire was allotted a minimum of 8 weeks of orientation, with a maximum of 12 weeks. The onboarding plan included one-on-one preceptorship and shadow experiences to bridge the knowledge gaps identified in the gap analysis. For example, in the thoracic surgery clinic, the new hires were asked to identify a new patient who would be undergoing an esophagectomy. The trainee would shadow the surgeon during the initial consultation to learn about the disease process and surgical procedure. Next, the trainee would observe this patient’s surgery, followed by a shadow experience in the surgical intensive care unit to understand postoperative patient care. During the patient’s follow-up visit, the trainee would shadow the physician to have a true understanding of the entire patient experience, from consultation to recovery.

    Additional shadow experiences included infusion, medical or surgical oncology counterparts, radiation, advanced practice providers, clinical trials team, and unlicensed assistive personnel. Didactic learning included three oncology fundamentals classes in which learners reviewed basic oncology and ambulatory education, depending on experience in oncology and/or ambulatory. The NPDS also added weekly progress evaluations, which included the trainee, NPDS, and management team to discuss the trainees’ progress, answer questions, voice any concerns, and establish a plan for the following week (see Figure 1). The leadership team implemented the standardized orientation plan from July 2021 to July 2022. The NPDS distributed a postimplementation survey to all roles in the ambulatory service line and also compared retention and turnover rates from July 2020 to July 2022.

    FIGURE1

    Results

    The NPDS distributed a postimplementation survey to determine staff satisfaction with the standardization of nursing orientation. Questions prompted feedback on the orientation process, preceptors, and their shadow experiences (see Figure 2). Although this survey was distributed to all staff, the results attained from the practice nurses and nurse coordinators were the focus of this analysis. Nursing leadership distributed this survey to 31 staff members, 28 of whom returned surveys. Of the 28 respondents, 16 were practice nurses or coordinators.

    FIGURE2

    In general, the respondents gave positive feedback on the standardization of orientation, stating that they felt supported as a preceptor and/or trainee; however, there were common themes identified for improvement. Staff felt that the shadow experiences could have been more specific and frequent to help improve knowledge. Staff also felt that the structure of each orientation plan could be improved. In addition, staff reported that increased time spent shadowing the surgical or medical oncology counterparts would be beneficial.

    Nursing leadership compared vacancy and turnover rates from May 2020 to July 2022. In May 2020, the nurse vacancy rate was 8.49%, compared to July 2022 when it was 8.76% (see Figure 3). In May 2020, the turnover rate was 17.39%, compared to July 2022 when it was 4.17%. Although the vacancy rate increased slightly by 0.27%, the turnover rate decreased by 13.22%.

    FIGURE3

    Discussion

    With the increased need for ambulatory nurses, it is necessary to bridge the knowledge gap for those transitioning to the ambulatory care setting. Despite the improvements in turnover rates, there was virtually no change to vacancy rates. These results suggest that a lack of standardization of nursing orientation may have a negative impact on nursing turnover and vacancy rates in the ambulatory setting.

    Since 2020, studies have shown that 24% of newly hired nurses leave their positions within one year and 20% of healthcare workers have left their position (Fischer, 2022; Galvin, 2021; NSI Nursing Solutions, 2024; Ortega et al., 2022). Although standardizing orientation appears to have positively affected turnover, the NPDS and nursing leadership identified opportunities for improvement, such as staffing ratios, managerial support, and work environments (Fischer, 2022). Other confounding factors that may have contributed to high turnover rates include staff burnout, the COVID-19 pandemic, poor work–life balance, and pay inequality.

    The results were consistent with evidence that proper onboarding can positively affect turnover and vacancy rates. Hampton et al. (2020) highlighted the importance of improving the transition-to-practice experience and the benefits it can have on retention and job satisfaction. Vadivelu (2020) demonstrated how ambulatory orientation improved the knowledge and skills of staff. Kiel (2020) found that after restructuring multiple orientation programs, one facility saw a reduction in turnover rates from 64% to 34% in one year, whereas another saw a reduction from 22% to 10%. Both facilities used a standardized organizational approach to the orientations and credit the standardized onboarding as a key component of their success (Kiel, 2020).

    Limitations

    Limitations of this work included staffing and space challenges during the COVID-19 pandemic. Although the NPDS established a standardized onboarding plan, the lack of preceptors made this approach challenging to maintain, while social distancing within the clinic made side-by-side preceptorship difficult. In addition, given the small sample size, the clinician satisfaction survey data lacked descriptive and parametric statistics, so generalizability of results may be limited. Additional research in this area may also allow for one to understand the impact that standardized orientation may have on patient outcomes and nursing competence, which was not examined in this project.

    Implications for Nursing

    This project and similar studies continue to support the need for a standardized orientation to enhance nursing practice in the ambulatory care setting to improve turnover and vacancy rates (Andronico et al., 2019; Fischer, 2022; Hampton et al., 2020; Kiel, 2020; Lambson & Dalton, 2022; Page, 2022; Vadivelu, 2020; Ward et al., 2022). The U.S. Department of Labor (2022) projected that more than 275,000 additional nurses will be needed between 2020 and 2030; therefore, retention of staff is key to maintaining a stable workforce. Because of the impact that turnover can have on burnout rates of nurses, organizations can implement strategies such as a standardized orientation to help retain staff.

    Conclusion

    Improving the onboarding experience in ambulatory oncology can positively affect patients, staff, and leaders. Creating a standard orientation plan allows for efficiency for the NPDS and provides new hires with the knowledge and skills to provide safe patient care. Additional work is needed on strategies to improve the new hire experience because the effects to vacancy and turnover are often multifactorial.

    About the Authors

    Christina M. Matousek, MSN, RN, OCN®, is a nursing professional development specialist at Smilow Cancer Hospital at Yale New Haven Health in Connecticut. The author takes full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Matousek can be reached at christina.matousek@ynhh.org, with copy to CJONEditor@ons.org.

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