Sie sind auf Seite 1von 5

Kim Maryniak

Tim Markantes
Impacts & Innovations Colleen Murphy

Enhancing the New Nurse Experience: Creation of a New


Employee Training Unit
77.1%. Feedback from HCAHPS surveys, as well as
EXECUTIVE SUMMARY that gathered from followup phone calls with
New graduate nurses require support to effectively
patients, identified themes. Many responses indicat-
develop competency, as well as promote retention. ed patients felt nurses were rushed, and patients and
Nursing leaders noted decreased retention of new
families did not understand teaching. Another com-
nurses, unmet patient satisfaction, and nursing prac-
mon theme was patients did not feel their pain was
tice issues. managed adequately.
A New Employee Training Unit program was devel-
In addition, peer review processes revealed themes
oped to focus on education and mentoring of new
of common issues in nursing practice. Nursing peer
graduate nurses. review included determination of factors leading to
The program showed success at the 1-year evalua-
nursing care issues, using a process that did not
tion in retention and patient satisfaction.
involve blame. Frequently, elements identified were
related to lack of critical thinking, poor communication
(either with patients or healthcare team members),

T
HE SETTING is a 561-bed assessment, and diabetes management.
acute care nonprofit hos- A planning and development group was formed,
pital, serving a suburban led by nursing leaders from the service line and the
community in Arizona, professional practice department. This group sought
and is part of a large health sys- to create a program to provide a standardized orienta-
tem. Nursing leaders within the tion process, improve efficiencies related to onboard-
medical-surgical service line at ing and orientation, and increase retention of new
the facility identified trends of nurses. On average, 165-170 new graduate nurses
decreasing nurse retention, partic- joined the facility annually, with approximately 36-40
ularly with nurses employed at
Kim Maryniak
per year in the medical-surgical service line. With the
the hospital for 3 years or less. The number of new graduate nurses joining the service
human resources department line, the primary focus of the group was to address the
monitored turnover and retention rates monthly. By needs of this population by creating a New Employee
December 2015, the turnover for registered nurses Training Unit (NETU) program.
(RNs) within 3 years of employment was greater than
19%. Additionally, the turnover rate of nurses within Literature Review
their first year of experience was 28.9%. The medical- Literature was reviewed to determine best prac-
surgical service line had a turnover rate of 39.9% for tices for integrating practice and education, preceptor
RNs within their first year of employment. Reasons for development, and identify needs of new nurses.
employer-related turnover were voiced by staff and Databases included EBSCOHost, ProQuest, and Ovid,
included communication, workload, recognition, and using search terms of “new graduate nurses,” “new
onboarding. This information was based on employee nurses,” “new grads,” “nurse and learning needs,”
satisfaction surveys and exit interview data. Average “new nurse and learning needs,” “new graduate nurse
cost for turnover of a clinical RN ranges from $37,700 and learning needs,” and “nurse and preceptor.”
to $58,400 (Nursing Solutions Inc., 2016). According to Benner (2000), clinical competence in
Targets for Hospital Consumer Assessment of nursing is developed along a continuum. A new grad-
Healthcare Providers and Systems (HCAHPS) ques- uate nurse in the early stages of the continuum may
tions about RN communication were also not being be at the novice or advanced beginner level. The
met. The category for nurse communication within novice nurse pursues experiences that serve to estab-
the medical-surgical service line was 76.7% in lish a basis upon which to guide practice. It is expect-
December 2015. This was below the facility goal of ed he or she will provide safe care with supervision
KIM MARYNIAK, PhD(c), MSN, RNC-NIC, is a Clinical Education
and guidance from experienced RNs. The nurse’s
Specialist, Yuma Regional Medical Center, Yuma, AZ. practice is primarily guided by referencing policies,
procedures, and standards (Benner, 2000).
TIM MARKANTES, MS, MBA, RN, PMHCNS-BC, PMHNP-BC, is In the 2010 Institute of Medicine (IOM) report
Nurse Practitioner, Dignity Health, Phoenix, AZ.
The Future of Nursing: Leading Change, Advancing
COLLEEN MURPHY, BSN, RN, is Senior Manager, Banner Health, nursing practice and education must be trans-
Thunderbird Medical Center, Glendale, AZ. formed to support nurses along the continuum of

322 NURSING ECONOMIC$/November-December 2017/Vol. 35/No. 6


nursing, including the transitioning of new graduate also recommendations identified by focus groups in
nurses. Recommendations include strategies such as these programs.
didactic education, use of simulation, and dedicated Blegen and associates (2015) assessed preceptor-
preceptors, as well as a planned program for the tran- ships of newly licensed RNs and the effects on compe-
sition to practice of new nurses. tency and retention. Areas evaluated included time,
Phillips, Kenny, Esterman, and Smith (2014) continuity, support, patient assignment, feedback,
examined needs of graduate nurses who were transi- communication, using errors for learning opportuni-
tioning into the RN role by a secondary analysis of ties, development of clinical reasoning, and use of
qualitative data. Recommendations from this study technology. Dedicated preceptors and appropriate
include initial placement in a clinical setting with patient assignments were associated with increased
less complex decision making, matching patient comfort, confidence, and retention. Bengtsson and
assignments to skill level, socialization and positive Carlson (2015) performed a qualitative study on devel-
feedback with new nurses, and a comprehensive ori- opmental needs identified by preceptors. Themes
entation process (Phillips et al., 2014). Ulrich and col- identified included knowledge about activities, clini-
leagues (2010) performed a long-term evaluation of a cal teaching and learning strategies (such as use of
nursing residency program. The structured experi- concrete tools, adult learning principles, principles for
ence, including a one-on-one preceptor, clinical expe- assessment), knowledge and skills about reflective and
riences, classroom and hands-on training, demon- critical reasoning (such as reflection in clinical prac-
strated improvement in retention, competency, and tice and self-assessment), and knowledge and skills
development of confidence. Adams and coauthors about communication models (including communica-
(2014) noted successful new graduate residency pro- tion skills, principles for communication, and con-
grams in critical care included classroom content as structive criticism) (Bengtsson & Carlson, 2015).
well as a hands-on clinical component. Individuali-
zation of the program, use of consistent preceptors, NETU Program Components and Measurement
discussions about professional topics and issues, and The NETU planning team determined program

Table 1.
continual feedback throughout these programs were components, goals, and measures of success (see
Tables 1 & 2). The initial design integrated a 30-bed
Program Components
medical-surgical inpatient unit with designated pre-
ceptors, supplemental learning experiences, and was
Components Details guided by a competency tool. The program allowed
System orientation Simulation experiences
for new graduate nurses to spend 5 weeks in the
Online learning
NETU before moving to the home unit, and manage at

Didactic classes Diabetes management


least four patients upon completion of the program.

Critical thinking
New nurses in the system participate in simulation

Assessment
experiences and online learning. As part of the NETU

Pain management
program, new RNs additionally completed two didac-

Communication
tic classes which included diabetes management, crit-

Hands on experiences Wound care


ical thinking, assessment, pain management, and

Intravenous starts
communication. In addition, new graduate nurses
had experiences with intravenous starts (in either
Dedicated preceptor Assigned preceptor
endoscopy of preoperative areas) and wound care.
The goals for the new RN participants in the NETU
Table 2.
Goals and Measures of Success

Goals Measures of Success


Developing confidence with assessment skills and creating 2% improvement in retention from the previous year within
the patient’s plan of care the medical-surgical service line

Practicing foundational intervention and psychomotor skills 0.5% increase in RN communication HCAHPS scores from
the previous year within the medical-surgical service line
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

NURSING ECONOMIC$/November-December 2017/Vol. 35/No. 6 323


Figure 1.
New Graduate Weekly Experiences

Week 0 Week 1 Week 2 Week 3 Week 4 Week 5


• New employee/ • IV experience • Clinical day 3 • Clinical day 6 • Clinical day 8 • Clinical day 11
hospital • Wound • Clinical day 4 • Clinical day 7 • Clinical day 9 • Clinical day 12
orientation experience • Clinical day 5 • Simulation • Clinical day 10 • Clinical day 13
• Nursing • Tour and unit • Assessment, day 1
orientation orientation critical thinking, • Simulation
• Computer • Diabetes class communication, day 2
training • Clinical day pain class
• Online learning 1 and 2

Figure 2.
Preceptor Weekly Expectations

Week 0 Week 1 Week 2 Week 3 Week 4 Week 5


• Meet new hire • Model accuracy, • Validate accuracy • Continue to • Validate • Validate the
and review safety, and safety of validate the accuracy of skills accuracy of skills
orientation plan documentation of procedures and accuracy of skills. performed. performed.
during online procedures and skills performed. • Foster • Direct care to be • Provide feedback
training time, skills. • Provide feedback independence performed in a about clinical
invite to lunch. • Verify location of regarding from preceptor. timely manner. performance.
• Review applicable admission • Provide feedback • Provide feedback • Assist in setting
expectations of protocols and process, about clinical about clinical goals for the next
bedside report, procedures. computer skills, performance. performance and shift.
rounding, teach • Set goals to meet assuming care, • Assist in setting patient plan of • Review and sign
back. identified needs. giving and goals for the next care. off any applicable
• Provide feedback, receiving report, shift. • Assist in setting competencies.
direct, and direct and • Review and sign goals for the next • Focus on
support as support as off any applicable shift. progress;
needed. needed. competencies. • Review and sign communicate
• Meet with NETU • Review and sign • Meet with NETU off any applicable concerns to NETU
Coordinator for off any applicable Coordinator. competencies. Coordinator.
review and competencies. • Focus on • Devise a joint
progress. • Meet with NETU progress; plan to address
• Review and sign Coordinator for communicate identified needs
off any applicable review and concerns to NETU during transfer to
competencies. progess. Coordinator. home clinical
• Devise a joint unit.
plan to address
identified needs.

program included: (a) developing confidence with captured on an orientation pathway, which was used
assessment skills and creating the patient’s plan of throughout the program (see Figures 1 & 2). The first
care, (b) practicing foundational intervention and psy- week was noted as week 0, as it was strictly system ori-
chomotor skills, (c) establishing safe practice behaviors entation. Week 1 began the NETU program.
to reduce patient and employee harm, (d) providing Monitoring progress of the NETU participant
familiarity with facility policies and procedures, (e) included regular check-ins with nursing leadership,
assisting with organization and prioritization skills, as well as online followup evaluations at 30, 60, and
and (f) applying knowledge and skill into practice. The 90 days. Comments from the followup evaluations
expectations of the new nurses and preceptors were included “I can say without a doubt that I felt wel-

324 NURSING ECONOMIC$/November-December 2017/Vol. 35/No. 6


comed from the start and supported;” “All of the pre- nursing issues and feedback. The NETU program
ceptors I had were amazing and I cannot thank them began expanding outside of the medical-surgical serv-
enough for their time, patience, and guidance;” and “I ice line to include new graduate nurses starting in
learned to effectively communicate and delegate cer- observation areas and in the float pool. An additional
tain tasks for patient care. Also, I learned to assess didactic class was created for medication considera-
patients in an easy and efficient manner.” tions and heparin. Other hands-on experiences in the
Additionally, feedback was obtained with each laboratory and cardiac monitoring room were also
class evaluation. Class evaluations included rating added. Nurses identified as needing remediation from
effectiveness and knowledge of presenters along with other nursing units also came to the NETU for a lim-
how well each objective was met for each presenta- ited time. These individuals were identified from
tion. Participants rated these factors on a Likert-type observations and feedback of preceptors, educators,
scale from 1 (strongly disagree) to 4 (strongly agree); and nurse leaders. Another additive to the NETU pro-
95% of ratings for classes within the first year were gram was creation of a NETU Coordinator, who
rated 4 for each component. Open-ended questions helped coordinate experiences and assist with the
also asked what the participants would change in regular check-ins.
their practice and general comments. Written com-
ments included “I have a better understanding of my Current Status
personality, learning style, and communication style, The NETU program began in December 2015. The
and I think that will help me in dealing with other 1-year evaluation demonstrated significant success.
staff members, patients, family members;” “I felt all of Direct costs throughout the year associated with the
the material was very informative;” “I will be sure to program (not including salaries of the new graduate
be much more thorough in my daily assessments even nurses and preceptors) were $34,000 for the NETU
if it takes a bit longer, it will make a great difference;” Coordinator (implemented mid-way during the year),
and “I felt like I learned a lot especially since she used $4,142 for preceptor education, and $200 for printing
examples to relate it to the topic.” costs. At the time of the 1-year evaluation, 39 new
There were two measures of success. The first graduate nurses participated in the program.
measurement was focused on retention, with a target Conservative estimate of cost savings for retaining
of 2% improvement in retention from the previous these new graduate nurses is $2,262,000. Six nurses
year within the medical-surgical service line. The sec- were also successfully remediated through the NETU
ond measurement was focused on patient satisfac- from other nursing departments, which is an estimat-
tion, with a target of 0.5% increase in RN communi- ed savings of $330,000. The total cost savings related
cation HCAHPS scores from the previous year within to retention for 1 year of this program was $2,592,000.
the medical-surgical service line. Additional savings included a reduction in time over
shift, with an approximated value of $3,700.
Preceptor Development The retention rate target of 79.9% was exceeded
With the dedicated medical-surgical unit used as at 88.8% overall for the medical-surgical service line.
the NETU, the intention was that all RNs on that unit Of the nurses hired within the medical-surgical serv-
would be qualified preceptors over time. Nursing lead- ice line who went through the NETU program, reten-
ership began intentional recruitment of eligible candi- tion was 100%. The HCAHPS score target for RN
dates to help fulfill this vision, as well as promoted communication for the medical-surgical service line,
professional development of current RNs. Criteria for set at 77.1%, was also exceeded at 77.3%.
preceptors on the NETU included a minimum of 2
years’ experience, a bachelor of science in nursing Future Growth
degree, and no disciplinary action. Additional instruc- The NETU program has expanded to a second
tion of qualified preceptors is another vital component medical-surgical nursing unit. This will allow for
of the NETU program. This supplementary training more availability of preceptors, which can increase
included a didactic class for preceptors, covering top- program capacity. Nursing leadership would like to
ics of patient experience, personal influences on learn- bring all new graduate nurses through the NETU as
ing, adult learning theory, learning needs and plan- the funnel for all nursing units. Future plans also
ning, critical thinking, evaluation and feedback, and include growing the program to add orientation of
conflict management. The preceptors were also re- new nursing assistants.
quired to attend the didactic sessions the NETU new
graduate nurses attended, so that, as preceptors, the Conclusion
content could be reinforced in practice. New graduate nurses require support to effective-
ly develop competency and promote retention.
Evolving the Program Unique strategies can provide necessary components
Within the first year of the program, other poten- to build and maintain the support for these nurses.
tial opportunities were identified based on trending The New Employee Training Unit is a strategy which

NURSING ECONOMIC$/November-December 2017/Vol. 35/No. 6 325


has demonstrated success within the first year of Benner, P. (2000). From novice to expert: Excellence and power in
implementation. This program is continually evolv- clinical nursing practice (commemorative ed.). Menlo Park,
CA: Prentice Hall.
ing, based on identified needs and feedback. The con- Blegen, M.A., Spector, N., Ulrich, B.T., Lynn, M.R., Barnsteiner, J.,
tinued development of the NETU program assists in & Silvestre, J. (2015). Preceptor support in hospital transition
reinforcing professional practice. Future research to practice programs. The Journal of Nursing Admini-
studies and evidence-based projects could build upon stration, 45(12), 641-648.
Institute of Medicine. (2010). The future of nursing: Leading
the NETU concept. Organizations would benefit from change, advancing health. Washington, DC: National
utilizing this program for all healthcare groups and Academies Press.
identified specialties. $ Nursing Solutions, Inc. (2016). 2016 national healthcare retention
& RN staffing report. Retrieved from http://www.nsinursing-
REFERENCES solutions.com/Files/assets/library/retention-institute/
Adams, J.M., Alexander, G.A., Chisari, R.G., Banister, G., NationalHealthcareRNRetentionReport2016.pdf
McAuley, M.E., Whitney, K.B., & Erickson, J.I. (2014). Phillips, C., Kenny, A., Esterman, A., & Smith, C. (2014). A sec-
Strengthening new graduate nurse residency programs in ondary data analysis examining the needs of graduate nurses
critical care: Recommendations from nurse residents and in their transition to a new role. Nurse Education in Practice,
organizational stakeholders. The Journal of Continuing 14(2), 106-111.
Education in Nursing, 46(1), 41-48. Ulrich, B., Krozek, C., Early, S., Hipps Ashlock, C., Marquez
Bengtsson, M., & Carlson, E. (2015). Knowledge and skills needed Africa, L., & Carman, M.L. (2010). Improving retention, con-
to improve as preceptor: Development of a continuous pro- fidence, and competence of new graduate nurses: Results
fessional development course – a qualitative study part I. from a 10-year longitudinal database. Nursing Economic$,
BMC Nursing, 14(51), 1-7. 28(6), 363-375.

326 NURSING ECONOMIC$/November-December 2017/Vol. 35/No. 6

Das könnte Ihnen auch gefallen