CNE Objectives and Evaluation Form appear on page 12.

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Diana Halfer

A Magnetic Strategy for New Graduate Nurses

Executive Summary
Childrens Memorial Hospital in Chicago reduced the turnover among new grads from 29.5% to 12.3% through the implementation of a multi-faceted orientation program. The program includes classroom learning, mentoring, precepting, clinical exchanges, and support for professional transitions and code debriefing. The classroom component includes 80 hours of general content, 32 to 72 hours of specialty-specific content, PALS certification, and, in some cases additional specialty courses. Preceptors, trained in coaching and educational techniques, are assigned to support clinical skill development and socialization for new grads. New grads select a clinical mentor who is not working on the same unit to provide additional confidential and objective support. Professional Transitioning Sessions involve participation in a facilitated peer support group with an emphasis on emotional issues and coping strategies. Debriefing sessions are conducted with new grads after stressful events such as emergency resuscitations, a program that is now available to all nurses.

national nursing shortage that will become severe over the next decade, nursing leaders are looking for approaches that will attract and retain the newest generation of nurses. These newcomers are searching for employers that will provide the financial and professional support needed to launch them on successful professional careers. The transition from student to professional nurse is a critical change of roles that encompasses a variety of career milestones in the first post-graduate year. These milestones include becoming licensed as a registered nurse, selecting ones first employer and areas of practice specialization, establishing oneself as a health care team member, acclimating to a new job and organization, and becoming confident in ones clinical skills. In addition, some new graduate nurses will face moving away from home for the first time, learning to manage their own finances, and finding their way around a new city and making new friends. The following case study describes how one urban, Magnetdesignated pediatric academic medical center introduced an RN internship program to nurture new graduates in building their pediatric careers. The business impact of developing a magnetic strategy to attract and retain new graduate nurses will also be discussed.

ITH A FORECASTED

Background
In 2002, the medical centers nursing recruitment and retention committee analyzed nursing turnover and found it was highest (29.5%) for new graduate nurses in their first year of employment. These nursing drop-outs have financial costs for health care organizations and it ultimately impacts the health care teams delivery of quality care. The actual cost of turnover approximates a nurses annual salary when hiring and orientation costs are calculated (see Table 1). Turnover also disrupts the work of health care teams as dissatisfied nurses leave organizations. To better understand the factors contributing to young nurses exodus from their first job, the medical centers nursing recruitment and retention committee reviewed the job satisfaction of new graduate nurses during the first 18 months of their employment. The findings revealed that career adjustment extended well beyond mastering clinical skills. Mentoring and professional development opportuni-

DIANA HALFER, MSN, RN, is Administrator of Clinical and Organizational Development, Childrens Memorial Hospital, Chicago, IL. NOTE: The author reported no actual or potential conflict of interest in relation to this continuing nursing education article.

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Table 1. Turnover Cost Calculation Cost Factors Cost of new graduate salary for 4 months (average orientation time) 25% of nursing preceptor time for 4 months Replacement labor premium pay costs for 4 months (the incremental cost of premium pay for overtime or temporary labor) Fixed costs of $200 per hire Cost per new graduate hire = $41,624

Table 2. Precepted Orientation Length Practice Area Medical-Surgical inpatient units Resource team Intensive care units Emergency department Operating room Length 4 months 5 months 6 months 6 months 9 months

ties were very important factors for their job satisfaction. As a result, the committee decided to benchmark how other organizations were addressing the on-boarding of novice nurses. At a National Association for Childrens Hospitals and Related Institutions conference, a year-long RN residency model was presented by a California childrens hospital that reduced RN turnover in the first year of employment (Beecroft, Kunzman, & Krozek, 2001). Based on this report, medical center leaders decided to redesign nursing orientation to support both competency development and role transition of new graduate nurses. A design team comprising nursing leaders, educators, advanced practice nurses, nursing preceptors, and social workers developed a new approach for supporting recent graduate nurses in their first year of employment.

classes were held in the first few weeks of employment. Nursing preceptors individualized the orientation for new nurses with a jobspecific orientation. The preceptor taught clinical skills and tasks that were documented in an orientation checklist. This approach put more emphasis on learning specific skills rather than on becoming competent in caring for patients and families with different acuity levels. Depending on the nurses experience and specialty area, nursing orientation averaged 6 weeks to 4 months. The operating room was an outlier to this average lasting 9 months. Orientation was offered twice a month throughout the year and was coordinated by area-based clinical nurse educators. These instructors coordinated the classes, made preceptor assignments, and monitored the new nurses progression through orientation.

and to prepare novice nurses to utilize critical thinking skills in the management of acutely ill pediatric patients. The programs theoretical underpinnings are based on Benners novice-to-expert research (1984), Knowles adult-learning principles (1970), and Marlene Kramers classic research on reality shock (1974). The resulting program begun in 2003 was partially funded by a 3-year Health Resources and Services Administration Nursing Practice, Education and Retention Grant. The year-long orientation supports the competency and professional development of novice nurses in medical-surgical inpatient areas, critical care areas, the operating room, emergency department, and resource team (in-house registry program). The length of the precepted orientation increased in all areas except the operating room (see Table 2). This internship program is offered quarterly, in March, July, September, and November. The program components include classroom learning and skills labs, a precepted orientation, professional transitioning sessions, clinical learning exchanges, clinical mentors, and a CODE debriefing program.

Classroom Learning
The RN Internship Program classroom instruction focuses on the development of clinical competence to support the delivery of family-centered care in a tertiary care setting. The goal is to advance the RN interns clinical practice experience and build on the knowledge obtained from the undergraduate nursing program. The core curriculum is approximately 80 hours of classroom content and includes topics such as family-centered care, patient/family education, pediatric physical assessment, patient safety, pain management, sedation management, child abuse and neglect, cultural diversity, and car seat safety. The courses are taught by advanced practice nurses, expert clinical nurses, and

Before the RN Internship

Before the internship program was designed, novice and experienced nurses attended the same nursing orientation classes. These

RN Internship
The internship program was designed as a transitioning program to bridge the gap between the academic and the service settings

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other members of the allied health team (social workers, chaplains, nutritionists, and respiratory therapists) as well as parent members of the family advisory board. These class days are scheduled during the first couple weeks of orientation, at intervals of 1 month, 2 months, 6 months, and 1 year. In addition to the core curriculum, specialty curriculums for the inpatient units and critical care areas provide population-specific education, varying in length from 32 to 72 hours. Interns have the flexibility of completing pediatric courses such as age-specific care through an online educational Web-based subscription program. Emergency management skills are developed as well. RN interns are required to attend Pediatric Advance Life Support classes within their first year of employment. Depending on the nurses pediatric subspecialty area other courses are required, such as the Neonatal Resuscitation Program; Sugar, Temperature, Artificial Breathing, Lab, Emotional Support; National Child Assessment Satellite Training; and Emergency Nursing Pediatric Course. tors. The coordinator provides the RN interns with a list of mentors described by areas of expertise; from this list the RN intern selects a mentor. Mentors do not work on the new RNs unit, which increases the confidentiality and objectivity of the relationship. At their first meeting the new nurse and her or his mentor become acquainted with each other and establish ground rules for their relationship. Subsequent meetings occur in several different venues, such as meeting for lunch or for coffee, exchanging e-mails, talking on the phone, and sharing off-site social activities. The coordinator of the mentor program oversees and supports the development of each relationship through consultation support, education, and resources that include a handbook for the mentor and mentee. Some of the issues of concern to new graduate nurses and addressed by their mentors include adjusting to shift work, living on ones own for the first time, commuting to work, fear of making mistakes or not doing well, wanting to fit in on the unit, and learning to live in a new city. Mentees often describe the mentor as someone who made a difference and is available to celebrate their good experiences and help them through the bad days. One mentee reflected that her mentor helped to provide a mirror for me and reflected when my socks matched and when they did not match. Some mentees identified the access to having a mentor as the difference in being able to view their adjustment to clinical experiences as a learning opportunity rather than an adjustment marked by failures. Many lessons were learned as the mentoring program developed. In the initial RN intern classes the coordinator matched the interns with a mentor. But some RN interns viewed the assigned match as forcing a relationship that did not interest them. Based on this feedback the program was modified to guide RN interns in selecting a mentor and establishing positive relationships as an important career skill. This change enabled the mentees and mentors to build more successful relationships. Having an objective mentor who does not work on the same unit as the new nurse was critical in retaining some RN interns. One drawback, however, is that the lack of geographic proximity decreases the casual and spontaneous meeting opportunities between new and experienced nurses. Being unable to find time to meet has often been a common factor for some relationships not succeeding.

Professional Transitioning Sessions

Led by professionals, the transition group discussions allow the RN intern a safe, confidential environment in which to share various experiences. By meeting with peers in small groups, the new intern learns coping skills in adjusting to her or his new professional role. These sessions also enable the interns to share concerns and talk about how they feel when they make a mistake. They can exchange and compare their feelings with other interns and discover that their feelings are normal. Offering valuable information and supportive comments to each other, group members often develop close-knit bonds and establish friendships during the course of the year. These 90-minute transition sessions are scheduled six times a year during the nurses first year and are linked to orientation class days. Each transition session is led by a nurse and a social worker, child life therapist, or chaplain. The facilitators attend a workshop familiarizing them with the new graduate nurse experience and receive a manual with topics that can be used to begin a discussion. The facilitators can comfortably guide sensitive discussions such as how to keep ones personal feelings and beliefs out of the patient/family decision-making process. Crea-

Clinical Mentor
Guiding these young nurses through their orientation are experienced RNs who are committed to the development of the RN intern. Through a mentor program, the RN interns become integrated into their first professional nursing position. Mentors provide a listening ear, an objective voice, and valuable insights for balancing work/life priorities. Novice nurses are introduced to this clinical mentoring program during their first week of orientation. The mentoring coordinator defines the process, outlines guidelines for a mentoring relationship, and supplies concrete examples of how a mentor can assist with career development. The mentoring coordinator recruits nursing mentors from experienced staff nurses, advanced practice nurses, administrative leaders, and educa-

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tive strategies used by the facilitators include meditation music to reduce anxiety levels and art therapy to encourage expression of feelings. One facilitator provided art supplies for mask-making. The participants talked about their public face when they present themselves to families and their personal feelings behind the mask they created. The success of the groups is linked to the experience of the facilitators and the activities preferred by the interns. Most interns find the groups beneficial. One intern commented, You are given the opportunity to voice feelings and concerns, and are given positive feedback and reassurance. It helps you to realize that you are not alone and that others are feeling the same as you. However, group discussions are not helpful to all participants, as evidenced by the reaction of one intern: The transition group is good for girls who want to vent. opportunity to actually see what the patients and families experience during their inpatient stay or outpatient visit. The clinical exchanges are coordinated and arranged by the area-based nursing clinical educators. tor regarding the orientation experience. If a novice-preceptor match is unsuccessful, the clinical educator will intervene and assign a new preceptor. Nurse interns often begin their precepted orientation on the night shift; this provides the advantage of allowing interns to get acclimated to a shift that is part of a rotation schedule and allows for a less hectic learning environment.

Individualized Preceptor Orientation

RN interns are assisted by the unit-based nursing preceptor in learning clinical skills and developing team relationships. Guiding the new nurse in gaining proficiency in nursing skills and responsibilities, preceptors also play an important role in the socialization of the RN intern by introducing them to team members and unit routines. The preceptor is seen as a unit-based mentor who helps interns develop their confidence and competence. New nurses prefer to work with one preceptor initially, but, as their confidence grows, they often enjoy having exposure to the experience and insights of other nursing preceptors. Some units may have multiple RN interns at one time, producing an increased preceptor workload. To prevent preceptor fatigue, a phased preceptor model was introduced. With this model the interns are initially grouped with the clinical educator who orients the entire intern group to unit procedures, equipment, and documentation. Then the RN interns are paired with a preceptor who may be less experienced but can mentor the intern on providing safe care. Once the RN intern has successfully met the basic competencies, she or he works with an experienced preceptor who teaches the novice how to develop clinical judgment skills while caring for complex patients. The area-based nursing clinical educators then match the RN interns with a preceptor, monitor the RN interns competency development, and serve as resources for both the preceptor and the intern. Verbal and written feedback from both parties are provided to the clinical educa-

Preceptor Support
Nursing preceptors need support to make this program successful. They receive education, mentoring by the clinical educators, and recognition for their role. Preparation for preceptors is provided by a blended learning approach. Web-based education instructs preceptors about their roles and responsibilities, adulteducation principles, and the exchange of constructive criticism. Following the self-study Webbased courses, the preceptors attend a 4-hour workshop in which they learn about generational differences and participate in group discussions about learning styles, coaching, and giving and receiving feedback. The clinical educators mentor the nursing preceptors and are available for consultation when concerns arise with the progression of the RN interns. Preceptors play a critical role in the on-boarding of new nurses and are recognized during preceptor month and the annual exemplar nursing program. In addition, preceptors receive a 5% hourly pay differential when precepting new nurses. This is the same pay differential provided to relief charge nurses. This similar reward system indicates that equal value is given to the staff nurses for assuming either additional educational or leadership responsibilities.

Clinical Learning Exchange

The clinical learning exchange gives the RN intern the opportunity to develop a holistic approach to pediatric nursing care. As the RN interns rotate through multiple patient-care areas specific to their patient population, they learn about patient/family experiences firsthand. The clinical exchange also builds working relationships throughout the hospital for future encounters between the intern and other staff in various departments. After these experiences, the RN intern can visualize the person behind a telephone conversation and understand the care delivery needs that are generating a request. One example is the experience of an RN intern who works with pediatric cardiovascular surgery inpatients. The nurse attended an outpatient cardiac catheterization procedure, followed a patient through open-heart surgery, and stayed with the patient and family during the immediate postoperative period in the pediatric intensive care unit. Novice nurses view these clinical exchanges as an important

Code Debriefing
Critical incidents, such as a patient emergency resuscitation code event, may be disruptive to a nurses adaptive response to situa-

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tional stressors. When the event is over, a nurse may experience strong emotional or physical reactions, either immediately or sometime later. These stress reactions can occur at home or at work, especially if the nurse is placed in a similar situation as that of the critical incident. To support nurses with these experiences a codedebriefing team was organized and is led by the resuscitation nursing education coordinator whose team includes clinical educators who meet with those involved in a code. The clinical educators help RN interns discuss their experiences, put them in perspective, and learn individual stress-management techniques. This beneficial codedebriefing program is based on Mitchell and Everlys (2001) critical incident stress management model. Because of the infrequency of codes, many new nurses do not experience a code situation during their internship. At the 1-year class and graduation celebration, re-education occurs on the code-debriefing program which is now available to all medical center nurses.
Table 3. Internship Staffing Resources Position/Role Nursing orientation coordinator (full-time) Resuscitation education coordinator (half-time) Administrative assistant (full-time) Clinical mentor coordinator Professional transition group facilitators Nursing preceptors Nursing clinical educators In-patient medical surgical units (4 full-time) Pediatric intensive care (2 full-time) Neonatal intensive care (2 full-time) Emergency department (1 full-time) Operating room (1 full-time) Resource team (1 half-time)

Internship Funding and Staffing

The internship program has been partially funded by a Health Resources and Services Administration (HRSA) Nursing Practice, Education and Retention Grant of $639,000 for 3 years. The HRSA grant supports two full-time positions, consultation for a culturaldiversity curriculum, and development of three pediatric Web-based courses, as well as classroom supplies, audiovisual equipment, and medical equipment and mannequins for simulating acute medical interventions. A $50,000 grant from The Walden W. and Jean Young Shaw Foundation, which has generously supported nursing research at the medical center, was used to purchase additional medical equipment for practicing in the skills lab. The hospital provides two classrooms, a computer lab, and a clinical skills lab. Multiple individuals within the department

support the internship program. The fixed staffing includes a fulltime internship coordinator, a halftime resuscitation education coordinator, and full-time administrative support. Administrative assistants schedule classes and instructors, register RN interns for classes, prepare class materials, and order class supplies and equipment. Area nursing clinical educators may spend 30% to 50% of their time teaching classes and coordinating the specialty curriculum, individualized preceptor-led orientation, and clinical exchanges. The nursing clinical educators monitor and document the competency development of the RN interns. The critical care areas have two clinical educators with one designated to support RN intern competency-development on the night shift. The coordinator of the mentor program, clinical mentors, and transition group facilitators contribute their time to the program. The preceptors are supported through the nursing-unit operational budgets, and patient-care assignments are adjusted to incorporate the additional teaching responsibilities (see Table 3).

Recruitment Impact
Nursing recruitment and retention have increased since the

inception of this internship program. Brochures market the program to the 500 undergraduate nursing students who have clinical experiences at the medical center each year as well as to the 200 nursing students and faculty who attend the medical centers annual nursing student conference. A description of the RN internship on the medical center Web page also generates interest in the program. In 2005 there were multiple applications for every one intern hired into the program, allowing nursing directors to select the most highly qualified candidates who completed the NCLEX exam, best fit the medical centers culture, and often came with relevant nursing assistant experience. The number of new graduate nurses recruited increased by 28% the first year after the program was implemented (see Table 4). In 2004, the ability to recruit more new nurses supported the expansion of the 28-bed pediatric intensive care unit to a 42-bed unit. The ratio of novice to experienced nurses hired has remained stable and they compose 52% to 55% of all nurses hired. For the fiscal year 2005 the nursing vacancy rate was a negative 2.1%, reflecting a successful proactive hiring strategy and 7.1% reduction in nursing vacancy rate since fiscal

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Table 4. New Graduate Nurses Hired Fiscal Year 2001 2002 2003 * 2004 2005 Number Hired 70 84 84 117 95 % of RNs Hired 52% 52% 54% 55% 52%

Editorial
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* Internship program implemented

year 2002. The proactive hiring strategy is based on turnover trends in patient care units and length of orientation for newly employed nurses. The magnetic attraction of the internship program has allowed the medical center to offer starting salaries at the median of the market range and avoid the cost of sign-on bonuses and expensive advertising.

Retention Impact
In 2002 the nursing turnover (voluntary and involuntary) was 29.5% in the first year of employment. With the introduction of the internship program turnover has averaged 12.3% per class which has resulted in significant cost savings. The average cost per new graduate nurse hire is calculated at $41,624 (see Table 1). Since the inception of the internship program, there has been an average of 17 more nurses staying at the medical center each year, yielding a cost savings of about $707,608 annually. The internship program also contributed to increasing nursing satisfaction. Every 18 months the medical center conducts an employee opinion survey for all its employees; the nursing satisfaction results have improved steadily and far exceed the national norms.

and by increasing their job satisfaction, enabling them to overcome initial barriers and stick with the organization. Intangible benefits occur at the organizational, community, and individual levels. By minimizing disruptive turnover, there is improved health care team satisfaction, higher morale, and greater productivity. The organizations reputation is advanced in the professional community with internships that support career development for new graduate nurses. For the individual nurse, the program launches her or him on a positive career trajectory in her or his chosen profession. RN interns who have completed the program report that they have a stronger understanding of nursing and say they can hit the ground running as they begin to build their careers in pediatric nursing.$
REFERENCES Beecroft, P., Kunzman, L., & Krozek, C. (2001). RN internship: Outcomes of a one-year pilot program. Journal of Nursing Administration, 31(12), 575582. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing Company. Knowles, M.S. (1970). The modern practice of adult education: Andragogy vs. pedagogy. New York: Association Press. Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: C.V. Mosby Company. Mitchell, J.T., & Everly, G.S. Jr. (2001). Critical incident stress debriefing: An operations manual for CISD, defusing and other group crisis intervention services (3rd ed.). Ellicott City, MD: Chevron Publishing Corporation.

with each potential partner. Can the cultures of your organizations really work together? Are your values and goals compatible? After identifying a preferred partner, it is essential to negotiate the terms of the agreement. It is imperative to address governance issues early in the process: who will sit on the board, hire the staff, control the money, etc? Establish management processes, accountabilities, and performance evaluations. Define the metrics for success and a process for resolving difficulties. Importantly, also define an exit strategy; how and when will the alliance end? Finally, develop a portfolio of alliances. Complex organizations often have an alliance office model to help embed this capability throughout the organization. In selecting different partners for different dances, you might create the next award-winning Astaire/Rogers partnership.$ NOTE: Nursing Economic$ invites you to explore and share your professional partnerships at a special Nurse Faculty/Nurse Executive Summit in Scottsdale, AZ, November 29-December 1, 2007. Watch the journal for more details or visit www.nursingeconomics.net.

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Summary
A well-designed and implemented internship program can have a magnetic business impact by reducing recruitment and retention costs for new graduate nurses

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