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P28 - Have You Heard of Skills Stacking? How It Can Impact Graduate Nurse On-Boarding

Background: In a very busy, high-acuity, and high-intensity general medicine unit, Magnet-designated teaching hospital, graduate nurses find it very challenging to manage, prioritize, and hardwire competing tasks and skills in the increasingly complex hospital environment and complex patient populations. Some graduate nurses caught in the pandemic were not able to get adequate clinical exposure to help prepare them transition to professional nursing practice. The hurdle of effective time management can be particularly distressing for newly licensed registered nurses (Pellico, Brewer, Kovner, 2009;57, Unruh, Zang, 2013;50). The top reasons for leaving include perceptions of excessive workload, stress, and inability to do quality work (Unruh, Zang, 2014; 30).

Historically, the model we used in onboarding graduate nurses was focused on their ability to manage multiple patients, from one patient up to five patients in a span of 12 weeks, which also included 6 days of internship classes and week one as general hospital and nursing orientation. 34 interns completed post-orientation survey. We recognized then the need to standardize nursing orientation to support both novice and tenured clinical coaches.

• Conducted a literature review on skills stacking and cognitive framework.
•    Developed an orientation plan that includes skills stacking and routinization to guide both the intern and the clinical coach. Skills stacking is a workflow management process which enables the graduate nurse to organize, prioritize, and manage their time. Routinization is developing habits or practices that are repeated in routine situations. Improving stacking skills decreases stress among newly licensed registered nurses and helps promote a healthier work environment, supporting safety and quality in health care (Ebright, 2010).
•    Provided clinical coach POW wows.
•    Reviewed concept of skills stacking and routinization, discussed expectations and implications of the new model and required paperwork documentation.
•    Conducted bi-weekly check-ins with the intern, educator, clinical coach, and a member of the unit leadership team as able.
•    Discussed what is going well, areas of improvements, skills stacking progression, concerns, and goals for the next two weeks.
•    Discussed clinical coach concerns as applicable.
•    Performed just-in-time mentoring to clinical coaches as needed.

Results: Completed post-orientation survey showed favorable results. 18 of the 19 interns felt that skills stacking helped prepare them develop a routine and master basic concepts and skills of assessment, documentation, and medication administration. Clinical coaches are in favor of the skills stacking model versus the increasing number of patient progression model. Qualitative data revealed great guide for the interns by knowing what to expect and focus on and great guide for the coaches especially when handing off the intern to a new coach or a secondary coach.

Length of orientation decreased from 12 weeks to 10 weeks.

Five other nursing units adopted the skills stacking model. The center for nursing education and research department plans to adopt this model throughout the facility.


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Katriza Lardizabal
9/30/21 5:44 pm

Hi Ms. Tess, I'm just wondering if you can send me a copy of the template that you guys use for the Skills Stacking? my email address is katrizaantonio@yahoo.com. I would like to use this model for when I am precepting and I also think this would be beneficial to my unit. Thank you in advance.