In July 2017, my director kept asking me to find out how other organizations were dealing with the high percentage of newly licensed nurses (NLNs) on the acute care units. The hiring data collected from our health system revealed a much higher percentage of NLNs hired than experienced nurses. This percentage has steadily increased over recent years to a concerning level. At one of our acute care facilities, 70% of all nurses hired for 2017 were new graduates. Nursing professional development (NPD) practitioners were being over taxed with orientating their NLNs, and some were expressing concern about the ratio of new graduates.
There were not enough expert nurses on the units to assist the NLNs after they completed their orientation and when they were practicing independently. We had implemented a transitional support system, the resident development specialist role, years previously. However, we needed more information on how other organizations were meeting the acute, daily, operational needs of the NLNs, as they cared for patients at the bedside. Later that month, I ran into a colleague who had worked as an Associate Chief Nursing Officer (ACNO) for a healthcare system, Dr. Lori Lupe. Dr. Lupe had successfully implemented a new model to meet those acute needs of the NLNs on units that had minimal expert nurses to assist at the bedside. Dr. Lupe had worked as an ACNO and shared her story of how her organization met the needs of the high ratio of NLNs on acute care units.
THE PROBLEM
NPD practitioners in a large, academic, medical center in southern Florida, with approximately 500 beds, approached Dr. Lupe with concerns about the nursing residents. The concerns were rooted in a high vacancy rate and high turnover of NLNs. The organization had also reached a point where the preceptors for the new novice nurses only had 6 months experience and were struggling with prioritization and organization themselves. This was a source of frustration and dissatisfaction for the nurse preceptors and the new nurses. The turnover rate for registered nurses in this organization ranged between 12% and 14%, but the organization was growing and adding more service lines and nursing units, which further exacerbated the RN vacancies. It was recognized that focus needed to shift to retention efforts to stop the revolving door of orienting new graduates and their departure to other organizations. The organization's nursing leadership and NPD practitioners began to meet with the recent graduates to discuss retention strategies and how to implement support for their professional development while maintaining costs.
The focus groups of recently hired new graduates indicated they wanted clinical support and they needed more experienced nurses, particularly on the night shifts. Themes reported by the groups included feeling overwhelmed by admissions, discharges, and transfers with the urgent high demand for bed turnover. These NLNs needed support and someone they could call to assist with new skills to perform and how to prioritize and manage the workload demands. They also needed support from experienced nurses to deal with patient changes in health status and patient deaths. The challenge for nursing leadership and NPD practitioners was to create the resources to support the NLNs while remaining within an established budget.
UNIT SELECTION FOR A PILOT
The nursing leadership team, which consisted of the ACNO, service line directors, and NPD practitioners, reviewed the workload activity related to admissions, discharges, and transfers and how the following items had increased over the last 3 years: the hours per patient day on each unit, the budgeted resources, turnover on each patient care unit, and the number of recent graduates and their assigned shifts. Two of the medical-surgical units with the lowest budgeted hours per patient day had the highest turnover rates with the greatest number of new graduates on the night shift. One of the units had recently experienced leadership turnover, which further destabilized the environment for patient care staff. This unit had a population that had high care needs that were both physical and emotional. The implementation team reviewed the distribution of new nurses on each shift and resources available. Over 70% of the nurses with less than 2 years of experience were assigned to the night shift, so the team focused on how to develop resources for their support. The day shift had the resources available on the unit. The team decided to have a trial of a new model on this patient care floor, which was composed of two medical-surgical units: one was 32 beds and the other 30 beds.
THE MODEL: IMPLEMENTATION OF AN NLN CLINICAL RESOURCE NURSE
There was one nurse manager on each of these two units; both managers had extensive medical/surgical experience and were excellent clinicians. Each unit also had a day shift charge nurse who had extensive experience in patient care. The manager of the units and the service line director felt they could manage patient flow on the night shift with only one charge nurse over both units to free up the second charge nurse to float as a clinical resource nurse among the two units with no patient assignment. The managers were also responsible for working some night shift hours each month to evaluate the impact of the new delivery model.
The ACNO reanalyzed the numbers and minimized the number of meetings required for the managers, so they would be available on their units. The service line director would assist the managers in the identification of the most appropriate charge nurse to serve as the resource nurse on the night shift who would assist with skill development, prioritization, and emotional support of the newer nurses. The new resource nurse role and the new charge nurse role expectations were implemented. The night shift resource nurse was an experienced nurse and was also identified by the newer nurses as approachable and helpful. The nurses on the night shift readily called the resource nurse. Initially, they tracked how many calls and what type of calls the resource nurse was receiving to ensure the calls were appropriate and the staff understood how to use this new resource available to them. They were called for skills such as inserting nasogastric tubes (NG), starting IVs, and accessing central lines. The implementation team also wanted them to provide some oversight for quality of care and adherence to standards of care. The trial was a success in providing support to the newer nurses, in their development, as it related to skills, quality, and standards of care. The patient care nurses expressed relief that they now had someone to call on when they felt overwhelmed or uncertain.
The team reviewed the activity logs of the resource nurse, interviewed the patient care staff for feedback, interviewed the night shift supervisors for input, and interviewed patients on the unit regarding their care. The Resource Nurse Model provided support and improved quality of care without adding cost, but the team also recognized that the person selected for that role had specific mentoring and teaching skills, which may not be universal to all nurses. The team wanted to identify those skills, so they could spread the concept beyond the one nurse who was working four 10-hour nights. Finding additional nurses with the same attributes, who were interested in such a role, was not an easy task. The NPD practitioners in the Organizational Learning Department assisted in writing the job description and in the selection process.
The leadership team had other obstacles to address, which included how to manage when there were call-ins and there were insufficient numbers of nurses in the hospital to allow the resource nurse to remain free of a patient assignment. The team recognized the resource nurse could not have an assignment and also needed to be free to readily assist when needed. The team also explored how much help the charge nurse could provide the new nurses, but again there were times when staffing was such that the charge nurses needed to take a patient assignment too. One night, the resource nurse was ill and not available to the team, so backup plans needed to be developed to determine how this void would be filled in a consistent manner. The leadership team wanted to spread this model to other units.
Overall, the pilot trial was a success, and the two units involved had not experienced any further resignations. The nurses indicated they felt more secure and safer with the resource nurse available to assist with new experiences and skills. The patient care staff indicated moral had increased. The resource nurse enjoyed her new role in helping newer staff to develop. The night supervisor reported fewer calls to the pilot units for assistance with IVs, NG insertions, patient complaints, and conflict resolution. The Hospital Consumer Assessment of Healthcare Providers and Systems scores on the pilot units increased, but it was too soon to draw that final conclusion from the data. It was also too soon to evaluate the impact on code blues, airway emergencies, and rapid responses, but the impact was being evaluated. These are outcomes the team would continue to evaluate and track with savings from decreased numbers of orientations needed due to increased retention.
In conclusion, after talking to Dr. Lupe and hearing about her success with the Resource Nurse Model, my organization is investigating on possibly implementing a similar model as we try to address the issue of the high percentage of NLNs on acute care units. These NLNs, once oriented and on their own, still need an expert, experienced nurse, readily available on all shifts, to step in and provide critical, clinical support at the bedside. NPD practitioners are key in the identification of the root causes for the turnover and how to address those issues to slow the revolving door of NLNs. This was one example of how the unique clinical resource nurse supported the needs of the NLN nurse. Further evaluation might support this model as a method to also impact patient outcomes, patient and NLN satisfaction, NLN retention, and intent to stay.