The orientation of new staff nurses toa health services agency needs to include innovative approaches which encourage both analytical thinking and the synthesis of new ideas. These highly trained professionals are coming to their new setting with a wealth of knowledge and skills. The agency's role in the orientation process should be to help them build on these valuable resources and apply them in new and different situations.
For too many years, orientation has meant lectures given by individuals from various departments of the agency on relationships, procedures, and expectations. This format with its lack of learner participation has resulted in sensory overload and boredom. The amount and kind of learning that takes place is overly dependent upon the time, the piace, and the individual presentor. This method removes most of the responsibility for learning from the learner.
Mediated instruction, the use of audiovisual materials, on the other hand, can offer a great improvement over these more traditional orientation methods. With mediated instruction, pictures, color, and sound guide the learner to find the answer in her/himself. When this mode of delivery is coupled with programmed instruction, immediate feedback is provided through self-correction, and reinforcement of correct behaviors takes place.
At the University of Rochester Medical Center, several factors led us to develop a mediated instruction learning module to orient our new staff nurses to community health concepts. One of these factors was the variety of educational tracks from which our new nurses are coming: licensed practical nurse, diploma, associate degree, and baccalaureate level. Furthermore, the varying combinations of education, experience, and geography (in our mobile society) produce an enormous variety of backgrounds. Because of this diversity, very careful orientation is greatly needed in order to provide a baseline level of our expectations regarding community health concepts.
A second impelling factor was the "unification model" in operation at our School of Nursing, whereby education, practice, and research are combined, and each faculty member has the responsibility to maintain expertise in practice, broaden expertise through research, and transmit expertise through teaching. Because of these responsibilities, the community health faculty sought ways to improve practice within the hospital setting and discovered this real need to develop orienta tion improvements.1
Still another impetus toward developing our learning module was the fact that orientation for new staff nurses at the medical center takes place every three weeks, thus making it difficult for one particular community health nurse clinician to be available on a regular basis; of ten, it was simply whoever was available who taught the orientation for that time. On the other hand, when a particular community health nurse could be designated as responsible for orientation, spontaneity suffered after several repetitious classes. Moreover, since class size varied from 5-40 members, there were often great differences in the presentation of the material from class to class.
We have, therefore, developed a learning module (Figure 1) which includes a slidetape presentation to orient staff nurses to community health concepts, which includes time for them to complete an actual public health referral form utilizing the concepts iust presented. Our module deals with the problems of identifying patients who need continuing support at the time of their discharge, and the actual completion of the form which initiates the follow-up process when such need is indicated. The materials of this learning package are:
* slide-tape program
* screen (or plain wall)
* handout of class outline and objectives
* evaluation form
* sample Kardex and face sheet of patient record
* blank referral form
* scrap paper for noting incomplete data
* pen or pencil
* resource person for a few minutes at the completion of the learning package
The learning process begins for the new staff nurses as they enter the room for orientation. At this time a staff development person hands out the class objectives and class outline, a case study Kardex, a chart front sheet with case study data, a blank referral form, and an évalua tion form. The staff development instructor explains how the slide-tape program will function. The content of the learning package is summarized in the objectives and class outline each participant received (Figure 2). In this manner, an organizing framework assists the learners to acquire knowledge. As information is amplified, minimal notes can be made on the outline without the distraction of copious note taking; therefore, maximum attention can be forced on the presentation.
The key concepts indicated in this module are the processand con tent of referring patients to the community. Definitions which clarify the process include: discharge planning, the activities in moving the patient to the proper level of care" and continuity of care - a series of connected patient care events over time and across several different settings, including health care institutions, agencies and the home. It is noteable that both processes require a multi-disciplinary approach as well as patient and family participation. The ultimate goal in patient planning is promoting continuity of care functions into the routine nursing care of every patient.
The referral process is broken down in five steps: 1. identifying patients who need referral; 2. utilizing resources in collecting all pertinent data; 3. consulting with the patient and his family regarding the plan after discharge; 4. completing the public health referral form where applicable; and 5. following through on the post-hospital plan.
Critical areas' that require nursing assessment are set forth in question format:
Is the patient able to act independently? The patient's past andlor present ability to manage health problems will help to answer this question.
How is the patienl s physical condition? The presence or absent of pathological signs and symptoms, as well as his general condition, give clues to his/her need for intervention after discharge.
How congruent are the patient's feelings and affect? The patient's general mood and the consistency among affect, behavior, and conversation may demonstrate whether there is a need fur follow-up care.
What interpersonal abilities does the patient have? How the patient interacts wilh staff and his ability to be interdependent with his family can assist in determining the answer.
What verbal abilities does the patient have? If the patient is able to talk about himself, his concerns, his successes and failures, he g ives a n indication of his need.
Can the patient meet his role expectations' The ability of the patient to meet his role expectations - e.g., parenting, wage earning - and the feelings regarding this, help to dispel questions
How congruent is the patient'* lifestyle? Whether the patient's lifestyle is consistent with his culture or has critical factors that might upset his lifestyle, such as in eviction, has n bearing on how much need there is for follow-up care.
Are the patient's fu tu re pians appropriate? The determination need=, to bt made »bout the patient's intentions in terms of future heallh and other plans.
How much intellectual ability does the patient have? Involved m this area is the patient's vocabulary, apparent general intelligence, coherence, and ability to solve problems and make decisions.
It is pointed out that these questions act as guidelines in identifying patients who need referral. There could be instances when all questions are answered affirmatively, but the patient stül requires assistance after hospital discharge. On the other hand, some patients could show deficiencies in an area and not need followup care. The nurse's judgment is the try.
After the nurse identifies patients who may require referral, the second step in the referral process involves utilizing resources in collecting all pertinent data. The data base should utilize:
A- The patient, his family, and significant others
B. The chart
C. Staff members
D. The physician
E. The social worker
F. Others, such as the dietician and physiotherapist
The third step in the referral process requires consultation with the patient and his family regarding continuity of care. With the input from a variety of sources, tentative ideas and possible plans could be shared with the patient to formulate a definite comprehensive plan for continuity of care. The cooperation of the patient and his family are paramount to the success of any plan.
Completion of Form
The fourth step in the referral process constitutes the completion of the public health referral form where applicable. It is pointed out that there is a possibility that when all data a re compiled and ideas shared with the patient and his family, apian could be formulated that would not require a public health referral. Consultation with colleagues is stressed.
The fifth step in the referral process involves the post-hospital foilow-through. Feedback concerning patient's post-hospital care could assist nurses in their future plans with other patients.
The key concept regarding t he con ten t of the referral is reviewed so that complete, accurate, and detailed information can be available to community health nurses in the field. The kind of information requested and its source is presented as follows:
A. Full identifying data. This information can be found on the front sheet in the patient's chart.
B. Pertinent physician. This is on the chart or the Kardex.
C. History. The chart, the Kardex, and the patient are sources of information for this area.
D. Medications, diet orders, and/or treatment plans. The Kardex and medication book should have this information.
E. Functional evaluation. The use of the Kardex with staff consultation and patient evaluation, should answer any questions.
F. Nursing evaluation. Sources that could prove helpful a re t he chart, t he Kardex, the staff, t he pa tient, and the physician. The nurse who cares for the patient is the primary source of information.
G. Social/Economic factors. In addition to the previous sources mentioned in the nursing evaluation, the social worker is a valuable resource for this area.
H. Prognosis. This information is found in the chart and perhaps the Kardex, The physician may be consulted to clarify the information.
I. Therapeutic goals. This can be determined from a combina t ion of physician, staff, and written records.
During the program, it is pointed out that the nurse whocares for the patient has most of the necessary information already, since a complete data base is essential for giving intelligent nursing care. The transfer of that da ta base to a formal document is a task requiring 15-30 minutes.
About 20 minutes into the slide presentation, time is allotted for completion of a public health referral form using the case study data provided initially. When a total of 35 minutes has passed, a correctly completed referral form is flashed on the screen in four parts so that each participant can correct his/her own completed referral. This is the conclusion of the slide-tape presentation. Acommunity health clinician is available to answer questions and respond to comments. Once the anonymous evaluations are completed, the orientee has fulfilled the class objectives. This concludes the orientation program.
We have used this module for one and a half years, critiquing it to eliminate irrelevant or inconsistent material, but actually having to make only minor changes.
This learning package was pilot-tested, before money was spent on the preparation of slides, audio, music background, cartoons, art, and photography. From a simple lesson plan which included the objectives and outline of the class, a script was written and a few overhead transparencies developed. Utilizing, the evaluation form de vised for this orientation class, data regarding relevance, interest, organization, and learning were collée ted from the learners during the pilot phase Adjustments in the lesson plan and script were made as a result of this ongoing feedback. After most of the suggestions oí new staff nurses had been incorporated into the script over several months, the actual development of the slide sequence, music, art, and photography was begun.
Several advantages have been evident from the use of the module. Utilizing a learning module which incorporated a slide-tape presentation freed the community health nurse clinician for other responsibilities, requiring only 5-10 minutes of a clinician's time every three weeks to answer questions from the group. This results in a savings to the School of Nursing of approximately $200/year in faculty salary due to the decrea se in faculty time needed in orientation from 45 minutes to 10 minutes. The module has the additional advantage of increasing standardization of material presented, and thereby its effectiveness.
Monotony in any presentation decreases listener/viewer motivation and interest. A different mode - use of audio-visuals and an opportunity to participate in the learning increases learner interest. Effectiveness is also increased in that those nurses who require more time to assimilate information can repeat the learning module through private viewing as many times as they desire. A still further advantage is that refresher classes can occur on all shifts of duty with a minimum of disruption of services to patients. The learning module uses equipment that is portable, selfcontained and uncomplicated to operate.
The method of the learning module was chosen for orienting nurses for several reasons. In any learning situation the nature of the learner, the nature of the material to be covered, and the theories of learning need to be taken into account for planning strategies in the teaching-learning situation.
Since the staff nurses who attend these orientation classes have completed their basic education, they fall into the class of adult learners. It has been shown that this particular group of learners, especially, need to feel that material is relevant in order for them to become motivated to learn. In addition, new learning should relate to previous learning to increase comprehension and retention.
Learning theorists such as Cagne, have postulated some effective learning techniques. He himself discusses verbal association or Type 4 lea mingas the use of visual images mediating verbal material. The slide-tape presentation combines the image with the words through title sudes, photographic slides, and cartoons while the audio port ion communicates throughout the presentation.
Skinner's stimulus-response learning was viewed by Gagne as Type 3 learning." This type of learning involves reinforcement of an immediate nature which results in learning that is rapid and difficult to extinguish. Immediate reinforcement of correct behaviors occurs when the participant corrects her or his own referral form by comparing it with a correctly completed referral form which is on the screen long enough to permit note-taking.
The learning module combines many of the suggested learning propositions of Bevis." These include: a learner need for knowledge, cues for problems-solving, movement from familiar to unfamiliar material through active participation, reinforcement of desired behaviors, repetition with feedback, varied opportunities for application, and realistic self-assessment. The lesson plan itself as it is translated into the script, as well as the placement and use of the various pictures and colors promulgate the learning propositions of Bevis.
The self-assessment recommended by Bevis can be found as a part of the evaluation requested at the completion of the learning module. The evaluation form (Figure 3) serves to aid the creator of the module as well as the learner.
As educators we must be ever cognizant of our necessary role as innova tors in order to achieve the goal of ioy in learning; we need to synthesize and develop materials to meet this goal, keeping in mind the words of Galileo: "You cannot teach a man anything; you can only help him to find it within himself."
- 1. Sullivan J, Walgren D. Seigel H, et al: A new multi-agency model for continuity at care unpublished, based on a presentation at the 1977 American Public Health Association Convention, Washington, DC.