Impacts & Innovations Kim Maryniak Tim Markantes Colleen Murphy Enhancing the New Nurse Experience: Creation of a New Employee Training Unit EXECUTIVE SUMMARY New graduate nurses require support to effectively develop competency, as well as promote retention. Nursing leaders noted decreased retention of new nurses, unmet patient satisfaction, and nursing practice issues. A New Employee Training Unit program was developed to focus on education and mentoring of new graduate nurses. The program showed success at the 1-year evaluation in retention and patient satisfaction. THE SETTING is a 561-bed acute care nonprofit hospital, serving a suburban community in Arizona, and is part of a large health system. Nursing leaders within the medical-surgical service line at the facility identified trends of decreasing nurse retention, particularly with nurses employed at the hospital for 3 years or less. The Kim Maryniak human resources department monitored turnover and retention rates monthly. By December 2015, the turnover for registered nurses (RNs) within 3 years of employment was greater than 19%. Additionally, the turnover rate of nurses within their first year of experience was 28.9%. The medicalsurgical service line had a turnover rate of 39.9% for RNs within their first year of employment. Reasons for employer-related turnover were voiced by staff and included communication, workload, recognition, and onboarding. This information was based on employee satisfaction surveys and exit interview data. Average cost for turnover of a clinical RN ranges from $37,700 to $58,400 (Nursing Solutions Inc., 2016). Targets for Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions about RN communication were also not being met. The category for nurse communication within the medical-surgical service line was 76.7% in December 2015. This was below the facility goal of KIM MARYNIAK, PhD(c), MSN, RNC-NIC, is a Clinical Education Specialist, Yuma Regional Medical Center, Yuma, AZ. TIM MARKANTES, MS, MBA, RN, PMHCNS-BC, PMHNP-BC, is Nurse Practitioner, Dignity Health, Phoenix, AZ. COLLEEN MURPHY, BSN, RN, is Senior Manager, Banner Thunderbird Medical Center, Glendale, AZ. 77.1%. Feedback from HCAHPS surveys, as well as that gathered from followup phone calls with patients, identified themes. Many responses indicated patients felt nurses were rushed, and patients and families did not understand teaching. Another common theme was patients did not feel their pain was managed adequately. In addition, peer review processes revealed themes of common issues in nursing practice. Nursing peer review included determination of factors leading to nursing care issues, using a process that did not involve blame. Frequently, elements identified were related to lack of critical thinking, poor communication (either with patients or healthcare team members), assessment, and diabetes management. A planning and development group was formed, led by nursing leaders from the service line and the professional practice department. This group sought to create a program to provide a standardized process, improve efficiencies related to onboarding and, and increase retention of new nurses. On average, 165-170 new graduate nurses joined the facility annually, with approximately 36-40 per year in the medical-surgical service line. With the number of new graduate nurses joining the service line, the primary focus of the group was to address the needs of this population by creating a New Employee Training Unit (NETU) program. Literature Review Literature was reviewed to determine best practices for integrating practice and education, preceptor development, and identify needs of new nurses. Databases included EBSCOHost, ProQuest, and Ovid, using search terms of new graduate nurses, new nurses, new grads, nurse and learning needs, new nurse and learning needs, new graduate nurse and learning needs, and nurse and preceptor. According to Benner (2000), clinical competence in nursing is developed along a continuum. A new graduate nurse in the early stages of the continuum may be at the novice or advanced beginner level. The novice nurse pursues experiences that serve to establish a basis upon which to guide practice. It is expected he or she will provide safe care with supervision and guidance from experienced RNs. The nurse s practice is primarily guided by referencing policies, procedures, and standards (Benner, 2000). In the 2010 Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health, nursing practice and education must be transformed to support nurses along the continuum of 322
nursing, including the transitioning of new graduate nurses. Recommendations include strategies such as didactic education, use of simulation, and dedicated preceptors, as well as a planned program for the transition to practice of new nurses. Phillips, Kenny, Esterman, and Smith (2014) examined needs of graduate nurses who were transitioning into the RN role by a secondary analysis of qualitative data. Recommendations from this study include initial placement in a clinical setting with less complex decision making, matching patient assignments to skill level, socialization and positive feedback with new nurses, and a comprehensive process (Phillips et al., 2014). Ulrich and colleagues (2010) performed a long-term evaluation of a nursing residency program. The structured experience, including a one-on-one preceptor, clinical experiences, classroom and hands-on training, demonstrated improvement in retention, competency, and development of confidence. Adams and coauthors (2014) noted successful new graduate residency programs in critical care included classroom content as well as a hands-on clinical component. Individuali - zation of the program, use of consistent preceptors, discussions about professional topics and issues, and continual feedback throughout these programs were Components System Didactic classes Hands on experiences Dedicated preceptor Table 1. Program Components Details Simulation experiences Online learning Diabetes management Critical thinking Assessment Pain management Communication Wound care Intravenous starts Assigned preceptor Table 2. Goals and Measures of Success also recommendations identified by focus groups in these programs. Blegen and associates (2015) assessed preceptorships of newly licensed RNs and the effects on competency and retention. Areas evaluated included time, continuity, support, patient assignment, feedback, communication, using errors for learning opportunities, development of clinical reasoning, and use of technology. Dedicated preceptors and appropriate patient assignments were associated with increased comfort, confidence, and retention. Bengtsson and Carlson (2015) performed a qualitative study on developmental needs identified by preceptors. Themes identified included knowledge about activities, clinical teaching and learning strategies (such as use of concrete tools, adult learning principles, principles for assessment), knowledge and skills about reflective and critical reasoning (such as reflection in clinical practice and self-assessment), and knowledge and skills about communication models (including communication skills, principles for communication, and constructive criticism) (Bengtsson & Carlson, 2015). NETU Program Components and Measurement The NETU planning team determined program components, goals, and measures of success (see Tables 1 & 2). The initial design integrated a 30-bed medical-surgical inpatient unit with designated preceptors, supplemental learning experiences, and was guided by a competency tool. The program allowed for new graduate nurses to spend 5 weeks in the NETU before moving to the home unit, and manage at least four patients upon completion of the program. New nurses in the system participate in simulation experiences and online learning. As part of the NETU program, new RNs additionally completed two didactic classes which included diabetes management, critical thinking, assessment, pain management, and communication. In addition, new graduate nurses had experiences with intravenous starts (in either endoscopy of preoperative areas) and wound care. The goals for the new RN participants in the NETU Goals Developing confidence with assessment skills and creating the patient s plan of care Practicing foundational intervention and psychomotor skills Establishing safe practice behaviors to reduce patient and employee harm Providing familiarity with facility policies and procedures Assisting with organization and prioritization skills Applying knowledge and skill into practice Measures of Success 2% improvement in retention from the previous year within the medical-surgical service line 0.5% increase in RN communication HCAHPS scores from the previous year within the medical-surgical service line 323
Figure 1. New Graduate Weekly Experiences Week 0 New employee/ hospital Nursing Computer training Online learning Week 1 IV experience Wound experience Tour and unit Diabetes class Clinical day 1 and 2 Week 2 Clinical day 3 Clinical day 4 Clinical day 5 Assessment, critical thinking, communi cation, pain class Week 3 Clinical day 6 Clinical day 7 Simulation day 1 Simulation day 2 Week 4 Clinical day 8 Clinical day 9 Clinical day 10 Week 5 Clinical day 11 Clinical day 12 Clinical day 13 Figure 2. Preceptor Weekly Expectations Week 0 Meet new hire and review plan during online training time, invite to lunch. Review expectations of bedside report, rounding, teach back. Week 1 Model accuracy, safety, documentation of procedures and skills. Verify location of applicable protocols and procedures. Set goals to meet identified needs., direct, and support as needed. Coordinator for review and progress. Week 2 Validate accuracy and safety of procedures and skills performed. regarding admission process, computer skills, assuming care, giving and receiving report, direct and support as needed. Coordinator for review and progess. Week 3 Continue to validate the accuracy of skills. Foster independence from preceptor. performance. Week 4 Validate accuracy of skills performed. Direct care to be performed in a timely manner. performance and patient plan of care. Focus on progress; communicate concerns to NETU Devise a joint plan to address identified needs. Week 5 Validate the accuracy of skills performed. performance. Focus on progress; communicate concerns to NETU Devise a joint plan to address identified needs during transfer to home clinical unit. program included: (a) developing confidence with assessment skills and creating the patient s plan of care, (b) practicing foundational intervention and psychomotor skills, (c) establishing safe practice behaviors to reduce patient and employee harm, (d) providing familiarity with facility policies and procedures, (e) assisting with organization and prioritization skills, and (f) applying knowledge and skill into practice. The expectations of the new nurses and preceptors were captured on an pathway, which was used throughout the program (see Figures 1 & 2). The first week was noted as week 0, as it was strictly system. Week 1 began the NETU program. Monitoring progress of the NETU participant included regular check-ins with nursing leadership, as well as online followup evaluations at 30, 60, and 90 days. Comments from the followup evaluations included I can say without a doubt that I felt wel- 324
comed from the start and supported; All of the preceptors I had were amazing and I cannot thank them enough for their time, patience, and guidance; and I learned to effectively communicate and delegate certain tasks for patient care. Also, I learned to assess patients in an easy and efficient manner. Additionally, feedback was obtained with each class evaluation. Class evaluations included rating effectiveness and knowledge of presenters along with how well each objective was met for each presentation. Participants rated these factors on a Likert-type scale from 1 (strongly disagree) to 4 (strongly agree); 95% of ratings for classes within the first year were rated 4 for each component. Open-ended questions also asked what the participants would change in their practice and general comments. Written comments included I have a better understanding of my personality, learning style, and communication style, and I think that will help me in dealing with other staff members, patients, family members; I felt all of the material was very informative; I will be sure to be much more thorough in my daily assessments even if it takes a bit longer, it will make a great difference; and I felt like I learned a lot especially since she used examples to relate it to the topic. There were two measures of success. The first measurement was focused on retention, with a target of 2% improvement in retention from the previous year within the medical-surgical service line. The second measurement was focused on patient satisfaction, with a target of 0.5% increase in RN communication HCAHPS scores from the previous year within the medical-surgical service line. Preceptor Development With the dedicated medical-surgical unit used as the NETU, the intention was that all RNs on that unit would be qualified preceptors over time. Nursing leadership began intentional recruitment of eligible candidates to help fulfill this vision, as well as promoted professional development of current RNs. Criteria for preceptors on the NETU included a minimum of 2 years experience, a bachelor of science in nursing degree, and no disciplinary action. Additional instruction of qualified preceptors is another vital component of the NETU program. This supplementary training included a didactic class for preceptors, covering topics of patient experience, personal influences on learning, adult learning theory, learning needs and planning, critical thinking, evaluation and feedback, and conflict management. The preceptors were also re - quired to attend the didactic sessions the NETU new graduate nurses attended, so that, as preceptors, the content could be reinforced in practice. Evolving the Program Within the first year of the program, other potential opportunities were identified based on trending nursing issues and feedback. The NETU program began expanding outside of the medical-surgical service line to include new graduate nurses starting in observation areas and in the float pool. An additional didactic class was created for medication considerations and heparin. Other hands-on experiences in the laboratory and cardiac monitoring room were also added. Nurses identified as needing remediation from other nursing units also came to the NETU for a limited time. These individuals were identified from observations and feedback of preceptors, educators, and nurse leaders. Another additive to the NETU program was creation of a NETU Coordinator, who helped coordinate experiences and assist with the regular check-ins. Current Status The NETU program began in December 2015. The 1-year evaluation demonstrated significant success. Direct costs throughout the year associated with the program (not including salaries of the new graduate nurses and preceptors) were $34,000 for the NETU Coordinator (implemented mid-way during the year), $4,142 for preceptor education, and $200 for printing costs. At the time of the 1-year evaluation, 39 new graduate nurses participated in the program. Conservative estimate of cost savings for retaining these new graduate nurses is $2,262,000. Six nurses were also successfully remediated through the NETU from other nursing departments, which is an estimated savings of $330,000. The total cost savings related to retention for 1 year of this program was $2,592,000. Additional savings included a reduction in time over shift, with an approximated value of $3,700. The retention rate target of 79.9% was exceeded at 88.8% overall for the medical-surgical service line. Of the nurses hired within the medical-surgical service line who went through the NETU program, retention was 100%. The HCAHPS score target for RN communication for the medical-surgical service line, set at 77.1%, was also exceeded at 77.3%. Future Growth The NETU program has expanded to a second medical-surgical nursing unit. This will allow for more availability of preceptors, which can increase program capacity. Nursing leadership would like to bring all new graduate nurses through the NETU as the funnel for all nursing units. Future plans also include growing the program to add of new nursing assistants. Conclusion New graduate nurses require support to effectively develop competency and promote retention. Unique strategies can provide necessary components to build and maintain the support for these nurses. The New Employee Training Unit is a strategy which 325
has demonstrated success within the first year of implementation. This program is continually evolving, based on identified needs and feedback. The continued development of the NETU program assists in reinforcing professional practice. Future research studies and evidence-based projects could build upon the NETU concept. Organizations would benefit from utilizing this program for all healthcare groups and identified specialties. $ REFERENCES Adams, J.M., Alexander, G.A., Chisari, R.G., Banister, G., McAuley, M.E., Whitney, K.B., & Erickson, J.I. (2014). Strengthening new graduate nurse residency programs in critical care: Recommendations from nurse residents and organizational stakeholders. The Journal of Continuing Education in Nursing, 46(1), 41-48. Bengtsson, M., & Carlson, E. (2015). Knowledge and skills needed to improve as preceptor: Development of a continuous professional development course a qualitative study part I. BMC Nursing, 14(51), 1-7. Benner, P. (2000). From novice to expert: Excellence and power in clinical nursing practice (commemorative ed.). Menlo Park, CA: Prentice Hall. Blegen, M.A., Spector, N., Ulrich, B.T., Lynn, M.R., Barnsteiner, J., & Silvestre, J. (2015). Preceptor support in hospital transition to practice programs. The Journal of Nursing Admini - stration, 45(12), 641-648. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Nursing Solutions, Inc. (2016). 2016 national healthcare retention & RN staffing report. Retrieved from http://www.nsinursingsolutions.com/files/assets/library/retention-institute/ NationalHealthcareRNRetentionReport2016.pdf Phillips, C., Kenny, A., Esterman, A., & Smith, C. (2014). A secondary data analysis examining the needs of graduate nurses in their transition to a new role. Nurse Education in Practice, 14(2), 106-111. Ulrich, B., Krozek, C., Early, S., Hipps Ashlock, C., Marquez Africa, L., & Carman, M.L. (2010). Improving retention, confidence, and competence of new graduate nurses: Results from a 10-year longitudinal database. Nursing Economic$, 28(6), 363-375. 326