In 2008/2009, the Orientation: Transition to Public Health Nursing Toolkit was developed to enhance the integration of new hires into public health nursing practice in Ontario and to increase retention of these hires. The changing landscape of public health in Canada, such as the introduction of new standards and competencies, presents challenges to leaders orienting staff to public health nursing. The toolkit was designed to provide a standardized general orientation, involving a broad range of public health knowledge and issues. Through the use of technology, a virtual network of public health nurses, educators, managers, senior nurse leaders and nursing professors from various areas of Ontario designed, implemented and evaluated the toolkit. Three modules were developed: foundations of practice (e.g., core competencies, national and provincial standards, public health legislation), the role of the public health nurse, and developing partnerships and relationships. Evaluations demonstrated that the toolkit was useful to new hires adjusting to public health nursing. It has had significant uptake within Canada and is well accepted by public health nursing leaders for use in Ontario's health units.

Introduction

The relationship between job satisfaction and retention of public health nurses (PHNs) has been explored in two Canadian studies (Armstrong-Stassen and Cameron 2005; Best and Thurston 2006). Work environments that provide access to information, resources, support and the opportunity to learn create more satisfied employees (Kanter, as cited in Haugh and Spence Laschinger 2007). Job dissatisfaction is related to job stress and intent to leave a job (Armstrong and Cameron; Kluska et al. 2004). Few new hires make a smooth transition to fully functional new graduates without significant orientation requirements (Regan et al. 2009). Preparing new hires not only for their current job but also for other positions within their workplace assists in retention (Saxe-Braithwaite et al. 2009). Articles pertaining to orientation of public health nurses in Canada were not identified in the literature scan for the project. However, policy makers and manager groups have noted in a pan-Canadian consultation about public health nursing services the need for strong orientation programs for new staff and for organizations to invest in orientation to strengthen public health nursing (Meagher-Stewart et al. 2009).

In 2009, the Orientation: Transition to Public Health Nursing Toolkit (Algoma Public Health 2008) was developed to increase retention of new hires in Ontario's 36 public health units. The toolkit was designed to provide a broad range of public health knowledge beyond each health unit's program-specific orientation and to offer elements of social support. The project was funded by the Nursing Secretariat of Ontario's Ministry of Health and Long-Term Care. Its main objectives were successful integration of new hires into practice and promotion and assessment of clinical competence. For the purpose of the project, new hires included both new graduates and experienced registered nurses from other healthcare sectors. A virtual network of mid-to-late career PHNs, educators, managers, senior nurse leaders (SNLs) and nursing professors from various geographical areas of the province was formed. This virtual network selected and developed the orientation content by teleconference. An advisory group composed of representatives from national and provincial nursing associations and agencies guided the network's progress. This article outlines the development, implementation, evaluation, dissemination and uptake of the toolkit and suggests avenues for future development.

Project Conception and Initial Planning

At the 2007 annual general meeting of ANDSOOHA (Public Health Nursing Management in Ontario), educators, managers, supervisors and directors spoke about orienting new staff. The changing landscape of public health – for example, the introduction of the Canadian Community Health Nursing Standards (CCHN standards) (Community Health Nurses Association of Canada 2008) to the Core Competencies for Public Health: Release 1.0 (core competencies) (Public Health Agency of Canada 2006) – posed challenges for orientation to the role of PHN. New hires required information about health promotion approaches and new agencies dedicated to the promotion and protection of health and the prevention of disease. ANDSOOHA sought funding to develop a common general orientation for use in all health units across Ontario to address the current environment of public health.

Algoma Public Health and ANDSOOHA obtained funding in January 2008 from the Nursing Secretariat of Ontario's Ministry of Health and Long-Term Care to develop, implement and evaluate the toolkit. Three nurse leaders became the administrative team: a project lead, the Algoma lead and an ANDSOOHA association lead. Partnerships were an essential part of the project. Partners included the Community Health Nurses of Canada (CHNC); Canadian Association of Schools of Nursing (CASN); Registered Nurses Association of Ontario through its Community Health Nurses Initiatives Group (CHNIG); Ottawa Public Health; the Leeds, Grenville and Lanark District Health Unit; and Niagara Public Health. Nursing professors from St. Lawrence College and the universities of Ottawa, McMaster, York and Brock also became members of the project. Partners supported the funding proposal, shared their perspectives and advised the Algoma and ANDSOOHA administrative team.

Key informant interviews were held with nurse leaders in other provinces to collect their experiences in developing orientation packages geared to public health. A literature scan was undertaken to identify promising practices. It suggested that orientation should be based on competencies, that orientation is a stressful time for new hires and that planned orientation is key to successful integration. Two models of orientation influenced project planning. Connelly and Hoffart (1998) described a two-foci orientation: an effective element of welcoming newcomers and the assessment of clinical competency. Schoessler and Waldo's (2006) developmental process model highlighted skill acquisition, adapting to life changes and experiential learning styles as essential. These models became early influencers on the tone, format and content of the toolkit.

A survey of nurse leaders indicated that they required a product to assist them in implementing the core competencies and CCHN standards. They supported development of a standardized general orientation for PHNs in Ontario. As one leader noted, "the learning curve is longer for a PHN; this orientation will help."

A designated support person from the from the Nursing Secretariat of Ontario's Ministry of Health and Long-Term Care provided advice to the administrative team, shared other demonstration project teams' experiences and reviewed financial reports. An evaluation consultant hired by the MOHLTC established parameters for evaluation and directed evaluation processes.

Upon receiving notification of funding from the Nursing Secretariat, the administrative team distributed a letter of understanding to SNLs in health units, seeking partners at the health unit level. Commitment to evidence-based practice was an expectation. The administrative team requested that 0.15 FTE (full-time equivalent) of a PHN educator be designated for coordinating the project at the health unit level.

Five health units were selected by blind review to receive funding ($10,000 each) to become a pilot site. One health unit was not funded through the project but found internal funding to participate in the design and development stage. Other health units not among the five formally participating attended meetings and workshops and reviewed minutes.

In total, over 20 public health nursing professionals recruited from within the five funded units and the internally funded unit participated in the working group (the "developers"). They were linked by the project lead to a 10-member advisory group composed of representatives from national and provincial nursing associations, agencies and universities.

Content Development

The advisory group determined that developers would use a modular approach to presenting the orientation information. A self-learning module is a self-contained unit or package of study materials used by an individual (DeYoung 2008). This format is adaptable for migration to an electronic platform for online learning, a future plan for the toolkit. At a meeting in March 2008, developers presented their health unit's current orientation practices and ideas for improvement. Common elements included the following:

• Online learning represents challenges in many health units.
• Content must appeal to learners of diverse ages and backgrounds.
• Learning should take place over an extended timeline, respecting new hires' adjustment within the organization.
• Learning should be prioritized to what is most critical for a new hire.

It was agreed that each module would include:

• A common theme and format
• An adult-learning perspective, including integration exercises such as case studies and scenarios, role playing, personal reflection and inclusion of advance organizers
• Strategies to address diverse learning styles
• Online resources available at the "click" of a mouse
• A list of references

Developers were encouraged to access their university links to understand the current curriculum and determine the gaps that needed to be filled for new hires in transition to public health nursing.

Developers noted that an individual was needed at each pilot site to "drive the information from the pages of the toolkit to its application in the real world of nursing practice." This individual would become an interpreter of the organization and its practices, recognizing that the toolkit's information would need customization to each health unit. The title of "guide" was selected as most appropriate to the transition "journey" of each new hire.

The developers identified 21 topics relevant to new hires. From these, they prioritized the following three for module development:

• Foundations of practice (e.g., core competencies, CCHN standards, professional standards, public health legislation)
• The role of the PHN
• Developing partnerships and relationships

The budget for the project was based on teleconferences as the main vehicle for module development. However, developers preferred a combination of teleconferences and face-to-face meetings. To decrease the costs of meeting face-to-face, they decided to split along geographical lines. A western team or "hub" took responsibility for developing the foundations-of-practice module, the central hub developed the partnerships/relationships topic and an eastern hub developed the role-of-the-PHN module.

File sharing between and within hubs was problematic. Some members of the working group were unable to open large documents. This problem was particularly acute in the rural health units and satellite offices. Version control was also difficult due to the problems in accessing the documents.

The modules were developed between April and September 2008. Although content was quickly identified, developers experienced difficulty developing integration exercises and learning activities. The objective of addressing different learning styles by providing a variety of learning activities for each topic proved challenging. Developers indicated that their educator skills were challenged by developing adjunct learning opportunities to help new hires integrate the content. Developers found capturing and cataloguing references from evidence-based articles time-consuming as they worked to meet project deadlines.

"Next steps" for new hires were highlighted in the final pages of the toolkit. The toolkit identified the Canadian Nurses Association certification program for community health nurses and the Public Health Agency of Canada's skills enhancement program for public health providers as vehicles for continuing professional development to further enhance public health nursing knowledge.

Revisions and Initial Evaluation

Developers shared module content with experienced PHNs in their own health units. Developers in the other hubs then reviewed modules, and revisions were completed (see Figure 1). After learning objectives and activities and online resources were added, educators at two large urban health units reviewed the modules.

Two processes were used to evaluate and improve the toolkit before dissemination. One involved a product review: in September 2008, fourteen new hires, including new graduates and RNs from other health sectors, reviewed the modules during their orientation period and provided feedback. Final revisions were based on the new hires' feedback. The analysis of the survey from new hires assured toolkit developers that "they got it right." The second process involved group interviews with module developers to determine their experiences (discussed below).

Dissemination and Further Evaluation

Hard copies of the final version, entitled Orientation: Transition to Public Health Nursing Toolkit (Algoma Public Health 2008), were circulated in January 2009 to SNLs in Ontario's public health units. Two more sections were added to the toolkit at this time to "broker" it into public health units. A section on implementation information presented strategies for managers, such as tools to assess an organization's readiness to support orientation and its learning climate, as well as to communicate the change. This section outlined reasons for adopting the toolkit, including improved retention of new hires, meeting accreditation standards and easing transition to public health nursing practice. A checklist was included to help managers select guides for the new hires. An information for guides section was created from the experiences of module developers in implementing the toolkit in September and October 2008 within their health units. This section outlined communication requirements, learning strategies, technological assistance to be provided and an estimation of time spent with new hires. Guides were expected to be advocates for new hires during the orientation period.

The process evaluation, which involved group interviews with developers, explored issues such as knowledge transfer, partnership development and project challenges and successes. Most hubs identified their university links as sources of support for developing content. One developer noted that "universities gave a critical academic perspective when reviewing the module." Developers commented that they had exchanged knowledge and information with other hubs, often for the first time. One member noted that the teleconferences "enhanced knowledge transfer across the hubs." Developers reported that the geographical proximity within a hub enhanced module development: "hubs were a success to develop the modules."

Time was the most significant challenge for participants. Developers and managers negotiated time on the project, resulting in a reorganization of their existing responsibilities. In larger health units, four or five staff participated in module development and continued as guides for new hires, although smaller health units could not assign this number. Module development was a greater challenge for smaller units than for large ones. Both smaller and larger units provided significant in-kind contributions of staff time and resources.

A second round of funding was sought from and awarded by HealthForceOntario through the Nursing Secretariat in 2009 to determine SNLs' intent to implement the toolkit. It was hoped that the extensive development and review process involving many PHNs, educators and managers would increase adoption. Thirty-one of 36 SNLs (86%) returned a self-administered survey. Findings indicated that sending a hard copy was effective in getting the toolkit on SNLs' desks in all but one of the 31 responding health units. Within six to seven weeks of receiving a hard copy, most SNLs had discussed the orientation toolkit with others in their health units and at various meetings throughout the province. A considerable number (64%) were discussing implementation in their units, while another 25% were in the process of implementation. Most respondents noted that the section on implementation information for managers was very helpful. One respondent identified that having a standardized general orientation curriculum across Ontario was the real strength of this project. Another noted that the toolkit went beyond its original intent and was useful in defining job descriptions and job interview questions.

New hires to public health nursing were the targets of this educational innovation; however, experienced nurses and managers also examined the modules. As one PHN stated:

I have been working in public health for almost nine years and this would have been an excellent package for orientation. I am learning a lot by reading the supporting documents. The learning activities help get me thinking about how the CCHN standards and core competencies are used in daily practice.

Currently, the orientation toolkit is posted on the Ontario Public Health Association, Community Health Nurses of Alberta and ANDSOOHA websites. Presentations were given at three national conferences in 2009: CASN, CHNC and the Canadian Public Health Association. As interactive workshops have a positive effect on uptake of innovations (Dobbins et al. 2002), a workshop was provided at the Ontario Public Health Association conference in November 2009. Community health associations in other provinces and territories have expressed interest in the toolkit.

Direction for Future Work

Feedback from SNLs indicated that modules addressing specific issues common to all health units should be developed centrally, for example, basics of case management for infectious diseases and position descriptions and performance management based on the orientation. From an evaluation perspective, future surveys could determine why some health units did not adopt the toolkit. The effect of the orientation on retention remains to be measured. The toolkit will be reviewed according to ANDSOOHA's work plan, and PHNs, educators and managers will be called on to refresh the content.

Conclusion

There has been much interest in the toolkit from public health practitioners, agencies, associations and organizations across Canada. This project was an unprecedented opportunity for mid-to-late career PHNs to assist new hires transition to public health nursing throughout Ontario. The developers and reviewers enjoyed the experience of shaping public health nursing practice at a time when the educational background and/or experience of new PHNs may not sufficiently prepare them for practice. As Thorne (2009: 52 ) notes, "it is the patient care setting that is the authority on artful practice, clinical imagination and learning synthesis." The commitment and energy demonstrated by project participants were critical to the development of the toolkit, as was the support given by SNLs in their health units.

In a recent publication about building public health nursing capacity, Meagher-Stewart et al. (2009) noted that focus groups of PHNs stressed the importance of learning opportunities for effective practice and the need for structures to facilitate knowledge exchange. The Orientation: Transition to Public Health Nursing Toolkit (Algoma Public Health 2008) provides an essential learning opportunity for new hires to public health nursing, providing a structure for knowledge exchange. ANDSOOHA's undertaking to develop a general orientation for new hires to public health in Ontario has been an innovative development in the nursing community.

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