Nursing retention is an outcome which impacts quality of care and organizational expenditure. Effective transition-to-practice (TTP) programs produce and retain safe, competent and confident clinicians. In Critical Care, staff retention post-TTP is particularly crucial: national data indicates that up to 50% of new graduate RNs leave their first job within two years, however better ICU nursing retention rates have been correlated with better patient outcomes. Since 2005, Northwell Health hospitals, including Long Island Jewish Medical Center (LIJMC), have hired non-experienced Critical Care RNs through the Critical Care Nurse Fellowship Program (CCNFP). System-wide, implementation of CCNFP has increased ICU RN retention for at least one year from date of hire. At LIJMC, CCNFP is the transition-to-practice model for Critical Care RNs hired for high-acuity areas: Surgical ICU, Cardiothoracic ICU, Medical ICU, Cardiac Care Unit, and Post-Anesthesia Care Unit.
Problem:
At LIJMC, CCNFP had a total duration of 22 weeks: 10 weeks of Phase 1, focused on clinical knowledge, and 12 weeks of Phase 2, focused on clinical skills. This model required considerable expenditure, including: financial resources, leadership time and resources, and orientee time and resources. Of orientees accepted as Critical Care Nurse Fellows (CCNFs) July through October 2016, 75% successfully completed the orientation process in 22 weeks or less. 44% were retained in critical care for at least one year from date of hire. These metrics did not demonstrate desirable return on investment.
Objective:
CCNFP LIJMC leaders aimed to enhance program efficiency and effectiveness. Their objective was to utilize development and design to improve CCNFP’s quality outcomes: decrease length of TTP, increase rate of RNs successfully completing ICU TTP within 22 weeks, and increase rate of RNs retained in LIJMC ICUs for at least one year from date of hire.
Interventions
CCNFP LIJMC program leadership facilitated 360° team engagement using interviews, focus groups, and structured evaluations with program directors, managers, assistant managers, educators, staff, current and recent orientees. Feedback was collected, discussed, analyzed and utilized to drive development and design of site-based CCNFP processes, incorporating: program leadership, organizational enculturation, practice-based learning, and nursing professional development support. Changes made included: enhanced stakeholder representation, including staff RNs, in panel interviews of CCNFP candidates, reduction of orientee hours spent in didactic, enhancement of orientee hours spent in practice-based learning, professional development of ICU staff as program leaders, earlier transition from 7.5 hour shifts to 11.5 hour shifts, and reduction and individualization of total length of orientation, with consideration of prior experience in med-surg or telemetry.
Results and Implications
Average hours for a new graduate RN to complete CCNFP at LIJMC were reduced from 823.5 hours in 2016 to 748.5 hours in 2017, demonstrating a 9% reduction. Simultaneously, rate of completion of CCNFP objectives in 22 weeks or less increased from 75% in 2016 to 85% in 2017, and rate of retention at least 1 year from date of hire increased from 44% in 2016 to 94% in 2017. Non-measurable outcomes included engagement of team members to respond to quality outcomes by participating in program development and design, engagement of team members in professional development activity, and organizational enculturation of new team members to the LIJMC culture of structural empowerment.
The outcomes suggest that transition-to-practice programs can be improved by engaging and empowering program leadership at all levels in development and design, professional development activity, and organizational enculturation of new team members.
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