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Induction, the first phase of indoctrination, takes place after the employee has
been selected but before performing the job role. The induction process includes all
activities that educate the new employee about the organization and employment
and personnel policies and procedures.
Induction activities are often performed during the placement and pre-
employment functions of staffing or may be included with orientation activities.
However, induction and orientation are often separate entities, and new employees
suffer if content from either program is omitted. The most important factor is to
provide the employee with adequate information.
Employee handbooks, an important part of induction, are usually developed
by the personnel department. Managers, however, should know what information the
employee handbooks contain and should have input into their development. Most
employee handbooks contain a form that must be signed by the employee, verifying
that he or she has received and read it. The signed form is then placed in the
employees personnel file.
The handbook is important because employees cannot simmilate all the
induction information at one time, so they need a reference for later. However,
providing an employee with a personnel handbook is not sufficient for real
understanding. The information must be followed with discussion by various people
during the employee process, such as the personnel manager and staff development
personnel during orientation. The most important link in promoting real
understanding of personnel policies is the first-level manager.
Induction provides the employees with general information about the
organization; whereas orientation activities are more specific for the position.
Organization may use a wide variety of orientation programs. For example, a first-
day orientation could be conducted by the hospitals personnel department, which
could include a tour of the hospital. The next phase of the orientation program could
take place in the staff development department, whereas aspects of concern to all
employees, such as fire safety, accident prevention, and health promotion, would be
represented. The third phase would be the individual orientation for each
department. At this point, specific departments, such as dietary, pharmacy, and
nursing, would each responsible for developing their own programs.
Because induction and orientation involve many different people from a
variety of departments, they must be carefully coordinated and planned to achieve
preset goals. The overall goals of induction and orientation include helping
employees by providing them with information that will smooth their transition into the
new work setting. The purpose of the orientation process is to make the employee
feel a part of the team. This will reduce burnout and help new employees more
quickly become independent in their new roles.
It is important to look at productivity and retention as the orientation program
is planned, structured, and evaluated. Organizations should periodically assess their
induction and orientation program in light of organizational goals; programs that are
not meeting organizational goals should be restructured. For example, if employees
consistently have questions about the benefit program, this part of the induction
process should be evaluated.
Too often, various people having partial responsibility for induction and
orientation pass the buck regarding failure of weakness in the program. It is the
joint responsibility of the personnel department, the staff development department
and each nursing service unit to work together to provide an indoctrination program
that meets the needs of employees and the organization.
For some time, managers in healthcare organizations, especially hospitals,
did not fulfil their proper role in the orientation of new employees. Managers
assumed that between the personnel and staff development or in-service
departments, the new employee would become completely oriented. This often
frustrated new employees because although they received an overview of the
organization, they received little orientation to the specific unit. Because each unit
has many idiosyncrasies, the new employee was left feeling inadequate and
incompetent. The latest trend in orientation is for the nursing unit to take a greater
responsibility for individualizing orientation.
The unit manager must play a key role in the orientation of the new
employee. An adequate orientation program minimizes the likehood of rule
violations, grievances, and misunderstanding; fosters feelings of belonging and
acceptance; and promotes enthusiasm and morale.

Sample two-week orientation schedule for experienced Nurses
Week one

Day 1, Monday
8:00 AM- 10:00 AM
Welcome by personnel department ;
employee handbooks distributed and
10:00AM- 10:30 AM Coffee and fruit served; welcome by
staff development department
10:30Am- 12:00 PM General orientation by staff
12:00PM-12:30PM Tour of the organization
12:30-1:30PM Lunch
1:30-3;00PM Fire and safety films; body mechanics
3:00-4:00 PM Afternoon tea and introduction to
each unit supervisor
DAY 2 , Tuesday

8:00 AM- 10:00 AM Report to individual units
Time with unit supervisors;
introduction to assigned preceptor
10:00AM- 10:30 AM Coffee with preceptor
10:30-12:00 PM General orientation of policies and
12:00PM-12:30PM Lunch
12:30- 4:30 Pm CPR recertification
Day 3, Wednesday Assigned all day to unit with preceptor
Day 4, Thursday Assigned all day to unit with preceptor
Day 5, Friday Morning with preceptor , afternoon
with supervisor and staff development
for wrap-up

Monday to Wednesday Work with preceptor on shift and unit
assigned , gradually assuming greater
Thursday Assign 80% of normal assignment
with assistance and supervision from
Friday Carry normal workload. Have at least
30 minute meeting with immediate
supervisor to discuss progress.

It is difficult to pick up a nursing journal today that does not have at least one
article that speaks to the relationship between nursing care hours, staffing mix, and
quality of care. This has occurred in response to the restructuring and
reengineering boom that occurred in many acute care hospitals in the 1990s.
Restructuring and reengineering was done to reduce costs, increase efficiency,
decrease waste and duplication, and reshape the way care was delivered.
Given that health care is labor intensive, cost cutting under restructure and
reengineering often included staffing models that reduced RN representation in the
staffing mix and increased the use of unlicensed assistive personnel ( UAP). This
fairly rapid and dramatic shift in both registered nurse care ours and staffing mix
provided fertile ground for comparative studies that examined the relationship
between nursing care hours, staffing mix, and patient outcomes.
Although early research on nursing care hours, staffing mix, and patient
outcomes lacked standardization in terms of tools used and measures examined,
nationwide attention shifted to this issue and a plethora of better funded and more
rigorous scientific study followed. A current review of literature consistently and
overwhelmingly demonstrates that as RN hours decrease in NCHPPD, adverse
patient outcomes increase, including increased medication errors and patient falls
and decreased patient satisfaction with pain management.
Unit managers must understand the effect that major restructuring and
redesign have on their staffing and scheduling policies as well. As new practice
models are introduce, there must be a simultaneous examination of the existing staff
mix and patient care assessments to ensure that appropriate changes are made in
staffing and scheduling policies.
For example, decreasing licensed staff, increasing numbers of unlicensed
assistive staff, and developing new practice models have a tremendous impact on
patient care assignment methods. Past practices of relying on part-time staff,
responding to staff references for work, and providing a variety of shift lengths and
shift rotations may no longer be enough. Administrative practices also have saved
money in the past by sending people home when there was low census; they also
have floated them to other areas to cover other unit needs, not scheduled staff for
consecutive shifts because of staff preferences, and had scheduling policies that
were often made without attention to patient continuity and assigned by numbers
rather than workload. Some of these past practices have benefited staff, and have
been for the benefit of the organization, but few of them have benefited the patient
.Indeed, assigning a different nurse to care for a patient each day of an already
reduced length of stay may contribute to negative patient outcomes.
Therefore, there must be an honest appraisal of current staffing, scheduling,
and assignments policies simultaneously as organizations are restructured and new
practice models are engineered. Changing these policies often has far-reaching
consequences, but in order for new models of care to be successfully implemented
this must be done. For example, if primary nursing is effective, then nurses must
work a number of successive days with a client to ensure there is time to formulate
and evaluate a plan of care. In this example, floating policies and requests for days
off may need to be changed or modified to fit the philosophy of primary nursing care
Shullanberger state that having an adequate number of knowledgeable,
trained nurses is imperative to attaining desired patient outcomes. Ascertaining an
appropriate skill mix depends on the patient care setting acuity of patients, and other
factors. There is no national standard to determine whether staffing decisions are
suitable for given setting. Additionally, many of the tools and methods used to
determine staffing have been unreliable and invalid, either in their development or
their application. However, some formulas developed recently allow for adjustment
for variations in the skill mix of staff. These formulas are still relatively new but may
be a better tool to use when making staffing decisions. In addition, Manthey
describes several factors that will drive additional new staffing plans in the coming
decade. These factors , which she calls Work Force 2000 include the increased
importation of foreign nurses who must be safely incorporated into the care delivery
system, on-going fiscal restraints that result in the need for lean staffing, and
plentiful, attractive career options for nurses outside the hospital.
Full-time staff may be hired to meet the average staffing needs of an
institution. The most common adjustment for an increased workload is to transfer
staff from a less busy area to the overloaded area. This is economical for the agency
but disrupts the unity of work groups, causes the transferred nurse to feel insecure,
and contributes to job dissatisfaction and turnover. Some units require specialized
knowledge and skill that not every nurse has cross training is helpful.
In the companion floor system, two units relieve each other. Staff nurse are
oriented to the second unit and know that if they are transferred, it will be to the
companion unit. Thus, staff aggravation is minimized, flexibility is possible, and
quality care is maintained.
At best, a complementary, or float, staff is composed of full-time staff nurses
who are oriented to many areas and like challenge of different types of patient and
settings. Unfortunately, most nurses prefer stability. Consequently, the float staffs
are likely to be part-time staff or new personnel waiting for a permanent assignment.
Having full time staff work double shifts and overtime is another option. The
nurse is already oriented to the area, and the continuity of care is facilitated. There
are disadvantages, however. Institutional cost increase. The nurse may become
tired, errors likely to increase with fatigue, and overtime may interfere with the
nurses personal lives.
Flexible working hours can be an incentive for inactive nurses to start part-
time employment and thus can reduce staffing shortages. Most nurses are women
who have to combine their nursing ole with many other roles, such as wife, mother,
and homemaker. A part-time job can broaden the womans horizons beyond her
home, increase her income, give her ego satisfaction, and help her maintain her
nursing skills. It is not uncommon for nurses to want to work part-time while
continuing their education. Part time nurses tend to work more than their share of
unpopular hours, and some prefer evening and night duty exclusively. When part
time nurses other responsibility decrease, they are likely candidates for fulltime
work. It is sometimes possible for two people to share a job.
There are, of course, disadvantages to the use of part-time nurses.
Educational and administrative expenses are higher proportionately for part-time
than for full-time help. For example, it is likely to cost as much to orient a part-time
nurse as a full-time nurse, thus costing more per hour worked. Maintaining continuity
of care is complicated, because two or more part-time people fill budgeted full time
There are also disadvantages for the employee. The part time nurse may not
receive benefits such as paid sick, or vacation days, and is not likely to be
considered for promotion. Sometimes benefits are prorated for part-time workers.
There are many variables to consider when planning staffing schedule s. the more
accurately those variables are assessed, the better one is able to contain costs while
providing high quality care.
Managers have several relatively undesirable options for handling a called in
absence or otherwise uncovered shift. They can consider the following:
Using a float, per diem, or agency nurse.
Asking a nurse to work for the sick person and cancelling a shift for that
person later in the week.
Asking a part-time person to work for an extra shift. Substituting one type of
classification for another, such as an LPN for an RN.
Asking one staff member to work a few hours of overtime and another to
come in a few hours early.
Doing without a substitute.
Covering the shift themselves.
Requiring staff to stay on duty after their scheduled shift ends. Some
managers believe that a tired nurse is better than no nurse at all. The American
nurses Association and other professional organizations oppose mandatory
overtime. There is fear that tired, overworked nurses may have compromised
decision-making abilities and be more prone to making mistakes. Nurses fear
litigation and risk of losing their nursing licenses. Mandatory overtime is a political
issue and is often a negotiating point for unionized nurses. Some states have
adopted legislations prohibiting mandatory overtime. Organizations often have
policies about their mandate overtime. Some specify that refusing to work required
overtime constitutes patient abandonment and is punishable. Some states have
clarified that refusing mandatory overtime is not patient abandonment.
Periodic shortages of nurses have always occurred, whether nationally,
regionally, or locally. It has been difficult for the profession as a whole to accurately
predict exactly when and where there will be short supply of professional nurses. But
all nurse- managers will at some time face a short supply of staff, both registered
nurses and others.
Healthcare organizations have used many solutions to combat this problem.
Such things as advanced planning and recruitment have already been discussed.
Another long-term solution to a shortage of staff is cross-training. Cross training
involves giving personnel with varying educational backgrounds and expertise the
skill necessary to take on tasks normally outside their scope of work and to move
between units and functions knowledgeably. These are all good solutions for long
term problem solving and show vision on the part of the leader-manager.
However, staffing shortages frequently occur on a day-to-day basis. These
occur because of an increase in staff absenteeism or illness. Healthcare
organizations have used many methods to deal with an unexpected short supply of
staff. Chief among the solutions are closed-unit staffing, using a central pool of
nurses from which to draw additional staff, requesting volunteers to work extra duty,
and mandatory overtime.
Closed-unit staffing occurs when the staff members on a unit make a
commitment to cover all absences and needed extra help themselves in return for
not being pulled from the unit in times of low census. In mandatory overtime,
employees are forced to work additional shifts, often under threat of patients
abandonment, should they refuse to do so. Some hospitals routinely use mandatory
overtime in an effort to keep fewer people on the payroll.
Mee argues that mandatory overtime must be eliminated or the nursing
shortage will worsen and the quality of patient care will be further erode. She also
suggest that mandatory overtime threatens RNs licences as working in an
exhausted state may represent a risk to public health and patient safety. Calarco
goes on to suggest that while mandatory overtime is neither efficient or effective In
the long term, it has been even more devastating short-term I pact in terms of staff
perceptions of a lack of control and its subsequent impact on mood, motivation, and
productivity. Vernarec concurs, stating that nurses who are forced to work overtime
do so under stress of competing duties- to their job, their families, their own health
and their patients safety. Clearly, mandatory overtime should be a last resort and
not standard operating procedure because an institution does not have enough staff.
Regardless of how the manager chooses ti deal with an adequate number of
staff, certain criteria must be met:
Decisions made must meet state and federal labor laws and organizational
policies. Staff must not be demoralized or excessively fatigued by frequent or
extended overtime requests.
Long term as well as short term solutions must be sought.
Patient care must not be jeopardized.
The acquisition of qualified people in any agency is critical for the establishment,
maintenance, and growth of the organization. Therefore active recruitment is
important, and the attraction of qualified applicants is the first step in selection of
personnel. Each institution should have someone who is responsible for recruitment.
Recruiters should know nursing qualifications and the needs of the institution with
candour and enthusiasm. Referrals from employees should be sought and in-house
applicants encouraged; however favouritism should not be shown. To aid in the
selection of the best candidate for the job, an adequate budget should be provided
for necessary advertisements, and these advertisements should depict an institution
that cares about employees and patients.
Recruiting, selecting, and training employees, the decreased quality of care while
orienting new workers, and the emotional turnover on continuing employees, serious
attention should be given to retention efforts. Exit interview, particularly anonymous
questionnaires, can help identify the reasons people resign. Post-termination
questions mailed to employees 1 or 2 months after their resignation may obtain more
accurate information than does the exit interview. After a period time has elapsed, a
person may be less emotional and more objective with some distance from the job
and may feel more anonymous with less fear of addition, attitude
surveys can be used with current employees to identify sources of dissatisfaction
and concern. Focus groups can be used to identify and solve problems. Once
stressors are identified, strategies to reduce them can be planned. It is important to
meet personnels psychological needs for advancement, responsibility, achievement,
and recognition. Nurses want input into decision making and control their own lives.