Enculturation is the process used by newcomers to adopt an organization's behavioral roles, norms, and values.1-4 Successful enculturation is essential to organizations because it correlates with engagement, belonging, and personal and team performance.1,5 Socialization activities facilitate engagement and enculturation by establishing personal connections, reducing stress, and increasing a sense of belonging.6,7 The culture of a healthcare organization is highly influential and can affect patient outcomes. For example, a study from the Veterans Administration hospital system found a significant association between large-scale adverse events in hospitals and lower scores on measures of organizational culture.8 The consequences of low engagement are dire for patient outcomes, including increased falls, medication errors, infections, and mortality.9-11 Nationally, 30% of nurses are disengaged,12 and each disengaged nurse may cost an organization $22 000 annually.13 Disengaged nurses are most at risk of quitting, costing an estimated $52 350 per nurse.14 Together, enculturation, engagement, and socialization are crucial to successful onboarding, increasing satisfaction, and nurse retention.3,13,15

Shanafelt and Noseworthy16 modeled the drivers of engagement and burnout, which have been reinterpreted by these authors into a conceptual model that makes a clearer delineation between those of the individual and the institution (Figure 1). The individual drivers were once essential aspects of a comprehensive 2-day orientation and onboarding at a large southwestern tertiary healthcare center, which included the founders' story, mission, vision, and values. One driver of engagement, meaning, was manifested by joining an organization uniquely focused on patients' health. A 2nd driver, culture and values, was realized by learning the organization's origin story, history, and norms. New staff experienced the 3rd driver of engagement, socialization, during several days of orientation and subsequent work unit integration. During the pandemic, elements of history, culture, and socialization were trimmed or cut entirely from the orientation process. Orientation was delivered virtually, diminishing the in-person connection between new nurses and their new colleagues. The gap extended to the unit orientation because many preceptors were also hired during the pandemic and were not formally enculturated themselves. A multiyear expansion of the campus began to accelerate hiring, which also threatened to destabilize the organization's culture.5 Together, the pandemic-related orientation changes and accelerated hiring defined a critical gap for enculturation.

Figure 1: Concept model for drivers of engagement. This model is adapted from another model of engagement from Shanafelt and Noseworthy.16 In this model, Organizational culture, sense of community, and meaning in work comprise approximately half of the dimensions of engagement and those most malleable at the individual level. The other dimensions are subject to more rigid organizational structures: efficiency and resources, workload demands, lack of control, and work-life integration. From: Shanafelt TD & Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146; used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.Background

For purposes of this project, the 3 stages of enculturation are: 1) anticipation of the new role; 2) early adjustment when everything is new and stressful; and 3) final adjustment when the newcomer transitions to becoming an “insider.”5,17Early enculturation during the 2nd stage is important because it predicts long-term retention.5 Notably, even established insiders must continue the enculturation journey because organizational culture changes due to external factors and group composition.4,5,18

Enculturation is an impact multiplier because it is the most direct way to increase staff engagement, which is the vigor, dedication, and absorption that staff feel about their work.16Organizational culture, sense of community, and meaning in work (Figure 1) comprise approximately half of the dimensions of engagement, and those most malleable at the individual level.16 The other dimensions are subject to more rigid organizational structures: efficiency and resources, workload demands, lack of control, and work-life integration.16 Magnet Recognition Program® designation addresses these organizational structures and specifically requires enculturation in item SE9.19 Magnet® hospitals report a 3-fold lower turnover rate, averaging 8% in the 1st year versus 24% for non-Magnet hospitals.20

Social connections developed during onboarding help new nurses interpret the organization's culture3 and develop a sense of belonging.15 Discussion prompts and other reflective practice activities help nurses assimilate into their roles, engage in shared governance, and optimize individual development.7,19-25 Repetition of enculturation activities and involvement of leaders helps new staff to perceive and understand the culture, improving their ability to align with the unit and organization.3,18

Toolkits can be used to organize content such as role-playing scenarios, clinical skills training, and coaching discussions22,26; yet few publications have evaluated the implementation of toolkits. One relevant study described an onboarding toolkit that yielded a 17% increase in nurse leaders feeling prepared for a new role.27 This project assembled an Enculturation Toolkit and piloted it in the progressive care unit (PCU) at a large southwestern tertiary hospital with the goal of increasing enculturation and engagement.

Project Aims Aim 1

Increase or sustain engagement for preceptors and new nurses participating in Enculturation Toolkit activities during onboarding as measured by the Meaning and Joy in Work Questionnaire (MJWQ).28

Aim 2

Increase or sustain enculturation for preceptors and new nurses participating in Enculturation Toolkit activities as measured by the History and Values Survey (MCHV).

Aim 3

The preceptors and new nurses will participate in activities from the Enculturation Toolkit for 80% of potential opportunities.

Project Methods Design

The project used a pre-post design and a survey before and after the implementation of the evidence-based practice (EBP) innovation, the Enculturation Toolkit. EBP implementation followed the Clinical Scholar Model for EBP, which is the model used by the organization.29 The model starts with a question or problem statement, and then existing evidence is used to assess the situation and determine whether a practice change is warranted. The change is then evaluated, and the results are disseminated.

Setting and Population

The setting was an integrated specialty practice in the Southwest that recently achieved Magnet redesignation. The pilot took place in the PCU, a hospital-based medical-surgical and cardiology unit. The PCU had approximately 180 allied health staff who reported to 2 supervisors, 1 nurse manager, and 1 nurse administrator. The innovation targeted preceptors and new experienced nurses. Nurse residents and new-graduate nurses were excluded as they have their own yearlong program.

Innovation

The toolkit was assembled based on 3 themes of focus: socialization and connection; values and heritage; and meaning and purpose.16 The content was selected from resources available through the institution (short videos, internally produced movies, presentations, readings, and other content), the learning management system (>7000 topics), and a documentary about the organization.30 Toolkit activities addressed multiple Bloom's Learning Domains, including Affective and both low and high levels of the Cognitive domain (Supplemental Digital Content 1, https://links.lww.com/JONA/B136).31 Toolkit materials were endorsed by unit leadership and operationalized by linking the resources in a Microsoft OneDrive (Microsoft Corp, Redmond, Washington) folder (Supplemental Digital Content 2, https://links.lww.com/JONA/B137).

Implementation

The pilot implementation of the toolkit took place during 2 types of interactions: 1) a small group meeting with the new nurse, their preceptor, and unit leaders; and 2) a larger group meeting with other new nurses. During onboarding check-in meetings, the supervisor led a 5- to 10-minute values-based reflective discussion (VBRD) from the toolkit, centered on the organization's values. For example, “In the past 2 weeks… What situations sparked concern, frustration, or joy?” The discussion was tied to the values with a prompt (eg, “How were our values reflected in that situation?”). The larger group meeting was a bimonthly gathering, called Culture Club, which included other toolkit activities (Supplemental Digital Content 2, https://links.lww.com/JONA/B137). The 1st part of the meeting was a time to socialize and build community using an icebreaker, and the remaining time centered on activities to promote socialization and connection, values and heritage, and meaning and purpose. The logistics of implementation is shown in Table 1.

Table 1:

Enculturation Implementation Plan

Measures

Engagement has been described as a sense of meaning and joy32-34 and was measured for this project using MJWQ, a validated instrument used with permission.28 This validated instrument has been used to measure engagement and intent to leave.35,36 The MJWQ used a Likert scale for 17 questions in 3 domains: meaning, value/connection, and caring.28 The questions relating to each of the 3 subscales were presented in random order as suggested by the creator of the survey.37

The MCHV survey included author-composed knowledge questions and behavioral scenario questions adapted from the organization's learning management system. Although it has not been evaluated for reliability or validity, the facts and concepts are expected knowledge and behaviors for all employees. The MJWQ and MCHV surveys were sent to the new nurses and preceptors during the 1st week of employment for the nurse. After a new nurse attended both Culture Club and the final check-in meeting, they were sent the 2nd survey. The final survey was sent after 8 to 12 weeks of employment (Table 1).

Diversity, Equity, and Inclusion Impact Statement

The Enculturation Toolkit activities were designed to increase enculturation, the process of socializing into an environment while maintaining one's own identity.38,39 The reflective practice that occurred during the enculturation discussions was the ideal time to engage each new nurse to understand whether the goals of equity and inclusion were being fulfilled.3,5,18 When diverse staff members are allowed to retain their identity, live out the values of the organization, and feel safe doing so, then they will feel empowered to do their best work and advance the mission of the organization.

Data Collection, Statistics, and Analysis

REDCap (Research Electronic Data Capture; Vanderbilt University, Nashville, Tennessee) was used to administer surveys, which were sent at week 1, months 2 to 3, and months 4 to 5 (Table 1). Automatic daily reminders were sent until survey completion or for 18 days. Responses were anonymous and tracked by a participant-created code. Demographic attributes were collected. Participant feedback for the project was solicited in the 2nd and 3rd surveys and summarized with descriptive statistics (2 Likert questions) and qualitative content analysis (open-ended questions). Table 2 shows the alignment of the aims, measures, and assessments, along with the analysis method.

Table 2 - New Nurse Enculturation Project: Alignment of Aims, Measures, and Assessments Project Aims Measure Assessment Data Analysis Engagement will increase for preceptors and new nurses who participate in Enculturation Toolkit activities during the onboarding process. (Outcome) MJWQa A 17-item survey of Likert questions in 3 subscales of value/connections, meaning, and caring Likert data were summed at each time point and evaluated with RM-ANOVA Enculturation will increase for preceptors and new nurses who participate in Enculturation Toolkit activities during the onboarding process. (Outcome) MCHV A 12-item survey of Likert and multiple-choice questions to assess knowledge of the history, values, and expected behaviors The Likert data were evaluated at 3 time points using RM-ANOVA. The multiple-choice data were analyzed using percent correct for all items (0%-100%), comparing the mean percent improved, and analyzed by the McNemar test The preceptors and new nurses will participate in activities from the Enculturation Toolkit for 80% of potential opportunities. (Process/fidelity) Final survey attestation The final survey included a question to document which meetings were attended Percent compliance as compared with the 80% goal. Feedback questions were summarized with descriptive statistics (2 Likert questions) and qualitative content analysis (1 open-ended question)

Abbreviation: RM-ANOVA, repeated-measures analysis of variance.

aThe MJWQ has content and construct validity, internal consistency, and an overall Cronbach's α of 0.94.

Protected Health Information Privacy, Data Storage, and Confidentiality

All participants were employees. No protected health information was collected, nor was any employee information collected (eg, name, ID number, etc). The REDCap data were stored on a secure, password-protected share drive. Participant responses were anonymous. The organization's institutional review board determined that this project did not require review.

Results Response Rate

From November 2022 to February 2023, a total of 18 new nurses and 34 preceptors were invited to participate in each of the 3 surveys, 83% of which were completed. Only 64% of the participants who completed all 3 surveys were analyzed (13 new nurses and 19 preceptors). The demographics of the participants are summarized (Supplemental Digital Content 3, https://links.lww.com/JONA/B138).

Fidelity

All new nurses attended the VBRD midpoint check-in, final VBRD check-in, and Culture Club. For preceptors, 68% attended the midpoint check-in, and 47% attended the final check-in (average, 57.5% for any check-in). Preceptors were not invited to Culture Club. Overall, for both preceptors and new nurses, participants took part in 79% of the opportunities presented.

Engagement

Engagement, as measured by MJWQ, was high and sustained throughout the period. Figure 2 shows the MJWQ responses for preceptors and new nurses at each of the 3 time points. The high baseline value resulted in a “ceiling effect,” whereby there was no statistically higher value to achieve at the 2nd and 3rd time points.40

Figure 2:

Engagement and enculturation survey results. MJWQ responses for preceptors (A) and new nurses (B) demonstrated high initial and sustained scores throughout. Although knowledge increased for the organizational logo (C) and mission statement (D), the changes were not significant (P values generated by McNemar test from baseline to 1 month posttraining). Knowledge of the organization's primary value (E) and the 8 values (F) were initially high and stayed high.

Enculturation

All participants had a trend of increasing knowledge of the organization's mission and logo meaning (Figure 2), although the results were not statistically significant by the McNemar test.41 The other measures relating to the values of the organization had high scores at baseline and were sustained throughout. In response to questions that probe a sense of belonging, preceptors and new nurses both scored high (Supplemental Digital Content 4, https://links.lww.com/JONA/B139). Both preceptors and new nurses scored high on the scenario-based behavior questions, and there was no statistically significant change in scores over time.

Final Qualitative Feedback

New nurses scored the VBRD check-in meetings as a 4.5 and Culture Club as a 4.6 out of 5. Preceptors rated the VBRD check-in meetings an average of 4.0 out of 5, and when combined with new nurse responses, the average rating for VBRD meetings was 4.3. Open comments allowed participants to share their feedback on the toolkit activities in their own words. The comments relating to enculturation activities were categorized as either positive (n = 19) or negative (n = 0), relating to the Enculturation Toolkit activities. Some comments were:

It was helpful to hear other people's perspective of what the culture means to them and how they utilize it in their workday.

I believe this program helped integrate the true meaning behind the organization and what it means to be a part of this unit.

Discussion

The literature emphasizes the importance of reinforcement of enculturation activities.3,18 Existing resources allowed for the creation of a well-equipped toolkit, and participant feedback on the toolkit activities was positive. The pilot implementation demonstrated that reinforcement correlated with sustained engagement. The high level of initial engagement (according to the MJWQ) was maintained throughout the entire 3- to 4-month posthire period. The values-based behavior questions indicated that the preceptors and new nurses had decision-making behavior that was consistent with the organization's values.

New-hire nurse turnover is consistently high in the 1st year, reflecting the importance of successful onboarding and enculturation.12,14 The setting for implementation was a telemetry/step-down PCU unit, where the turnover rate in a hospital setting is often highest.14 Because new nurse satisfaction has been shown to decrease 4 to 6 months after hire, sometimes continuing for up to 1 to 2 years,42 the authors anticipated that the outcome of this project might have displayed limited enculturation and decreased engagement at the final survey measurement. Instead, the survey results were positive, showing sustained high engagement for several months after hire and an upward trend in measures of enculturation.

Strengths, Limitations, and Future Directions

One limitation of the pilot project was that the implementation was only a partial use of the Enculturation Toolkit. Two other limitations relate to the timeline. The 1st is that the time from the baseline survey to the submitted response varied and was generally 1 to 10 days (mean, 6.4 days). The participants may have encountered additional enculturation-related materials during this time that were not part of this project, which may have contributed to the ceiling effect.40 The other is that the follow-up was only 4 months, whereas it would be helpful to look at the impact after 6 months and at 1 year. Trends in the enculturation measures suggest that if there were more participants or a longer innovation period, the knowledge increases may have become statistically significant. Considering that the average response rate to an email survey invitation is 30%,43 a strength of this project was the high rate of responses, with 64% of participants (n = 32) completing all 3 surveys. The scores for engagement were high and sustained, the knowledge and behavior were high and improved in some measures, and narrative feedback was positive. After this successful pilot implementation, the next step is to consider implementing it in other units, test other parts of the toolkit, and observe the follow-up over a longer time to measure the impact on retention. One way to get a better measurement of the impact would be to have the baseline measurement occur prior to orientation.

Conclusion

Using existing materials, this project team constructed an Enculturation Toolkit that was piloted for new-hire nurses in an inpatient PCU. New nurses and preceptors both rated the activities favorably with objective and subjective feedback. Measures of enculturation that were not high initially showed increases for both new nurses and preceptors. The literature emphasizes the importance of reinforcing enculturation activities and the pilot implementation demonstrated that reinforcement correlated with sustained engagement. Potentially, these toolkit activities could be used throughout the 1st year and beyond to sustain engagement and enculturation for the long term. The Enculturation Toolkit may have application for new-graduate nurses and should also be piloted in this population.

Acknowledgments

The authors acknowledge the work of the PCU staff. In addition to the challenges of moving to a new, larger unit, the preceptors acclimated to the role of training new colleagues. The authors thank the PCU leadership team for coordinating extra logistics, including Jenifer L. Wueste, MSN, RN, PCCN, Amanda L. Stumpf, MSN, RN, PCCN, and Lindsay D. Fix, MSN, RN, PCCN. The authors also thank Doralyn Costello, MSN, RN, OCN, for sharing the scavenger hunt activity she created. They thank Julie A. Thompson, PhD, Duke University, for the data and statistical analysis review and the copyediting support provided by the Scientific Publications staff at Mayo Clinic.

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