Nurses new to Labor & Delivery (L&D) sometimes have trouble adjusting because of the high level of specialization – they need to be prepared to support a wide range of patients, from low intervention natural births to high-risk labors that may involve the operating room.
“Everything that you could do as a nurse, we do in L&D,” says Michelle Swanson, RN. “We have an inpatient unit, we have an outpatient unit, we have low risk patients, we have really critically ill ICU patients. And because our patients are really two patients in one, it can really crank up the acuity.”
Recognizing that after 12 weeks of orientation, some new nurses were not as confident as they could be with some areas of care, Swanson, together with fellow L&D nurses Christy McKinney, RN, and Katie Leidecker, RN, created a supplemental curriculum they call New Nurses Orientation Class (NNOC).
Before they created NNOC (pronounced “knock”), a new nurse would work one-on-one with a preceptor, learning about one patient each shift. Preceptors tried to make sure that orientees had experiences with the full range of patient encounters, but the unpredictability of the patient population was an obstacle.
“It was kind of a ‘learn as you go’ approach,” says McKinney, “and this made it hard to provide a comprehensive experience. For example, a new nurse might go through 12 weeks of orientation without ever seeing a patient that has twins.”
After a period in 2015 that saw a higher than average number of new nurses transitioning to L&D, Swanson, McKinney and Leidecker began to recognize the need for a class that could offer comprehensive information about what new nurses should expect on the floor, hands-on activities to help them build confidence in their decision-making, and provide them with the opportunity to ask questions about specific scenarios.
It took almost six months from the first night the class was conceived by Swanson, Leidecker and McKinney during a shift on 4 Women’s until the first classes were held. The trio had to get buy-in from leadership, devise a structure for the course, design activities and ensure that the class materials were as comprehensive as they needed to be. Swanson, who has been a nurse for 25 years, recalls her surprise by how much information they had to compile.
“When we first started to put together the information for the class I thought, ‘This will be a breeze. We’ll be able to knock it out in a couple of hours.’ But once we got rolling I couldn’t believe how much goes into L&D once you put it all down on paper,” she says.
“Once we got rolling I couldn’t believe how much goes into L&D once you put it all down on paper.”
It wasn’t just the volume of information that was challenging. The three also worked hard to present the information in the most effective way possible for a range of learning styles, says Leidecker.
“A lot of time was spent trying to craft these classes so that it really fit for a variety of learners, a variety of backgrounds,” she says. “It’s kind of like our baby. We spent a lot of time bringing it into the world.”
When NNOC is in session, new nurses meet with instructors in four-hour blocks once a week for three to four weeks. Though the classes involve some lecturing, Swanson, Leidecker and McKinney have tried to incorporate as much hands-on learning as possible. This includes a training manikin named ELSA that lets new nurses run through emergency situations like the baby getting stuck on the way out or the mother requiring chest compressions.
NNOC also incorporates games that help new nurses sharpen their reaction times and acclimate to themselves to the floor. In each room in L&D, there are emergency medications; finding these drugs and administering them correctly requires quick and accurate decision-making when a life-threatening emergency develops. During NNOC, new nurses play a matching game that requires them to race against one another to find these drugs and match them with why they would be given, how to administer them, and in what dose.
“It’s important to have this hands-on learning,” says McKinney, “because it can be very scary when they’re learning how to do this in real life. We want our orientees to learn these skills. The benefit of the simulation is that they can stop and ask questions.”
Recent NNOC graduate Allison Joseph, RN, was grateful to have a forum to ask the questions that there might not be time to ask during a busy shift.
“It was great to be able to ask questions and get into really specific scenarios. There are things you want to talk about and there are things you want to go over with experienced nurses that you might not really have time to get into during your orientation,” says Joseph.
The collaborative, hands-on experience offered by the class also helps new nurses cohere as a team, both with one another and as part of the larger community of UNC L&D nurses.
“It’s important to have this hands-on learning,” says McKinney, “because it can be very scary when they’re learning how to do this in real life. We want our orientees to learn these skills. The benefit of the simulation is that they can stop and ask questions.”
“I think it helps that, during the class they can see each other’s weaknesses and strengths,” says McKinney. “This is the only time as new nurses when they can talk to each other and ask questions. It’s helping our unit and these nurses invest in one another because as soon as they finish orientation they are our peers. We depend on them and they have to depend on us for every emergency and everything that happens, so we want to make sure they have the best training possible.”
NNOC has trained more than a dozen new nurses in the past year, and as more new nurses are hired the NNOC alumni list continues to grow. Swanson says that, though she, Leidecker and McKinney weren’t looking for accolades, they were happy for the opportunity to improve upon the training process, a change that ultimately improves patient experience.
“L&D is a great unit, a great place to work and we affect a lot of lives in a really significant way,” says Swanson. “But there are just so many things that go into being an L&D nurse, and it was exciting that we were able to recognize a need in our orientation process and make a change that gives our new nurses more confidence and a better sense of their place on the team.”