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Specialized new graduate RN pediatric orientation: a strategy for nursing retention and its financial impact.

THE PEDIATRIC NURSE Fellowship Program (PNFP) at Cohen Children's Medical Center (CCMC) is designed to address the need for properly educated and mentored pediatric critical care, emergency department (ED), and hematology/oncology nurses. CCMC is the children's hospital for the North Shore-LIJ Health System (NSLIJ). In the calendar years 2005 through 2007, CCMC was struggling with a 1-year RN retention rate of 65% and a 50% 2-year retention rate in the pediatric intensive care unit. Additionally, the pediatric ED was struggling with a high RN vacancy rate. Similarly, Children's Hospital Los Angeles was experiencing a 1-year retention rate of 64% for new graduate RNs when an RN residency program was developed (Ulrich, Krozek, Early, Hipps Ashlock, & Marquez Africa, 2010). As nursing positions were posted for these high-acuity units, CCMC found no experienced applicants. The available pool of RNs consisted only of newly graduated RNs who historically were not hired into high-acuity units immediately following graduation. Prior to the initiation of the fellowship program, the cost associated with orientation at the CCMC was in excess of $250,000 annually. Research by Aiken and Cheung (2008) support the financial significance of nursing turnover rates for hospitals in the United States.

The goal of the PNFP is to welcome new graduates or to transition experienced nurses from their current settings into pediatric critical care, emergency, or hematology/oncology units. This specialized orientation program is designed to bridge the gap between the novice nurse and the new high-acuity pediatric specialty, while providing the new graduate RN with support mechanisms (Keefe, 2011), educational tools, and professional mentoring (Reinsvold, 2008). It also serves to transition the new graduate RN from school to practice (Kovner et al., 2007). The PNFP is designed to provide nurse fellows with the education needed to deliver safe and effective nursing care to the health system's pediatric patients.

The concept of nursing fellowship programs in the NSLIJ Health System began in adult critical care at North Shore University Hospital and Long Island Jewish Medical Center in 2005. Nursing leadership at both tertiary facilities collaborated with the Patient Safety Institute, which is the medical simulation center for the NSLIJ Health System, to develop and implement a specialized orientation program that would fulfill the need for qualified critical care registered nurses of any nursing specialty. The Nurse Fellowship Programs were designed as year-long programs to address an identified need to prolong the learning experiences of new graduate nurses (Blaufuss, Maynard, & Schollars, 1992). The Pediatric Nurse Fellowship (PNF) uses a blended learning program to educate nurses. The components of the PNF programs are: (a) nurse leaders as mentors; (b) Essentials of Critical Care Orientation (ECCO), both adult and pediatric versions: American Association of Critical Care Nurses' web-based critical care curriculum, or Association of Pediatric Hematology Oncology Nurses (APHON) core curriculum and Bone Marrow Transplant (BMT) core curriculum; (c) professional seminars; (d) associate fellows (experienced pediatric nurses educated in the art of preceptorship of new graduate nurse fellows); (e) master fellows (master's-prepared educators providing education and guidance to the nurse fellows during the length of the fellowship program); and (f) simulation as a learning strategy. The PNF's program design is illustrated in Figure 1. Each pediatric nurse fellowship specialty adjusts the fellowship template to best achieve the educational goals for that particular program.

As a result of the Nurse Fellowship Program's success in the adult critical care areas and the impact that a fellowship program had on retention of adult critical care nurses as well as positive financial impact on the hospitals (Friedman, Cooper, Click, & Fitzpatrick, 2011), nursing leadership and nursing education at CCMC made the commitment to implement the PNFP in the pediatric intensive care unit, the pediatric ED, and the pediatric hematology/oncology unit.

Background

Being a new graduate nurse is very difficult in any critical care environment, and in particular pediatrics. New graduate nurses are known to experience feelings of failure and shame when mistakes are made (Dracup & Bryan-Brown, 2004). Specialized pediatric orientation programs, which focused on new graduates, and supported their education, were able to reduce turnover as much as 17%, provide substantial cost savings to the institution, and improve nursing satisfaction (Beecroft, Kunzman, & Krozek, 2001; Halfer, 2007). In addition, orientation programs that include intensive one-to-one preceptorship (Dracup & Bryan-Brown, 2004; Friedman et al., 2011; Proulx & Bourcier, 2008), such as the nurse fellowship programs of the NSLIJ Health System, are effective for integrating and supporting future pediatric nurses in the aforementioned specialties.

Banner's "Novice to Expert" theoretical framework was instrumental in the development and implementation of the nurse fellowship programs as initiated by the health system. In Benner's nursing theory (1984), the advanced beginner, a nurse with less than 2 years of experience, is described as a nurse who requires the support and guidance of a competent-level nurse. The elements of Benner's nursing theory are further supported by Ellerton and Gregor (2003). Ellerton and Gregor concluded that at 3 months, new graduates are very apprehensive about work and approach patient care in a largely procedural manner and are dependant on guidance from senior experienced nurses. Ellerton and Gregor describe a form of new graduate nursing practice at the 3-month juncture equivalent to Benner's advanced beginner. Using Benner's model as a framework, Friedman and colleagues (2011), and Morris and associates (2007) created critical care orientation models; Pine and Tart (2007) created a graduate nurse residency model; Rosenfeld, Smith, Iervolino, and Bowar-Ferres (2004) translated Benner's model to an emergency department critical care residency model; and Valdez (2008) described how Benner's model is implemented in the emergency setting. A common theme in these studies speaks to enhancing new graduate nurses' transition from student to critically thinking practitioner. The application of Benner's model to interactive patient care simulation, which is an integral part of the PNFR was recommended by Larew, Lessans, Spunt, Foster, and Covington (2005). Success in reducing pediatric turnover rates for new graduate RNs from 35% to 6% at 12 months, compared to the new graduate RN control group hired prior to the implementation of their specialized orientation program, was demonstrated by Versant (2010). Other research suggests residency programs support the transition of new graduates into clinical practice (Goode, Lynn, Kresk, & Bednash, 2009; Krozek, 2008).

In December 2006, the Institute for Healthcare Improvement (IHI) announced the "5 Million Lives Campaign" with the goal of protecting five million patients from occurrences of medical harm. Health education has been identified by the IHI as paramount in the success of the "5 Million Lives Campaign" (IHI, 2006). The primary goal of the Nurse Fellowship Programs of the NSLIJ Health System is to educate new graduate nurses by means of a blended learning approach. This blended learning program design is depicted in Figure 1. The expectation is this blended learning educational approach will address the IHI's intensive care intervention strategies by improving the educational foundation of new graduate nurses. Included in this approach is simulation. Simulation has been identified as a way of validating mistake-proof designs and creating a culture of safety. New graduate nurse education that utilizes simulation as a learning strategy, as provided through the Nurse Fellowship Programs, adds to the body of literature supporting innovative orientation strategies and improved nurse retention.

The Institute of Medicine (IOM) report, To Err is Human, identified preventable medical errors as a major area for improvement in health care (Kohn, Corrigan, & Donaldson, 2000). Staff shortages, combined with the high-stress environment of a critical care or emergency setting, adversely impact patient safety (Lin & Liang, 2007). Improved graduate nurse retention is expected to enhance the critical care work environment and potentially increase health care safety.

In October 2010, the IOM and the Robert Wood Johnson Foundation published The Future of Nursing: Leading Change, Advancing Health. Included in the groups' recommendations is a call for transforming the health care system in the United States through the use of nurse residency (fellowship) programs. The report opines that state boards of nursing, Centers for Medicare and Medicaid Services, Health Resources and Services Administration (HRSA), the Joint Commission, hospitals, health care systems, and foundations have a responsibility to develop, sponsor, support, and evaluate nurse residency programs to transition new graduate RNs to practice into new clinical areas.

On average hospitals spend 11.7% of their nursing budgets on temporary nursing staff to close the gap in their staffing patterns (Healthcare Association of New York State [HANYS], 2005). Using temporary nursing staff has become a permanent solution for many hospitals, and provides an average of 5% of their nursing staff (PricewaterhouseCoopers, 2007). HRSA predicts the United States will need 90% more new graduate RNs to address the nation's shortage of nurses, which is expected to intensify by 2020 (HANYS, 2007). Filling the nursing gap with temporary nurses has burdened the overstressed budgets of the nation's hospitals, as temporary nursing services are costly (Sandhausen, Rusynko, & Wethington, 2004).

Documenting cost-benefit analyses of increased retention in the intensive care unit (ICU) is essential to support the costs of a protracted, intensive orientation process. Reductions in nursing turnover have been estimated to have a cost savings of 1.5 to 2 times a nurse's salary (Atencio, Cohen, & Gorenberg, 2003; The Advisory Board Company, 2005). Taking into account the average cost of replacing just one nurse, decreasing nursing turnover can yield a significant return on the educational investment (American Academy of Nursing, 2010). Every percentage point increase in nursing turnover costs a hospital on average $300,000 annually (PricewaterhouseCoopers, 2007). The financial impact on health care is astronomical. In the current health care economy, the importance of the fiscal impact of new graduate RN retention cannot be underestimated.

The purpose of this study was to determine the effect of a specialized pediatric orientation program (PNFP) on retention of new graduate RNs and the net cost of this orientation program. The research questions for this study were: (1) What is the difference in retention for new graduate RNs pre and post-initiation of the PNFP orientation program? (2) What is the net cost savings that results from retaining critical care, ED, and hematology/oncology nurses post-initiation of the PNFP?

Methods

A retrospective descriptive evaluative design was used. Retention between two groups of graduate RNs in the critical care units of CCMC before and after the initiation of the PNFP was evaluated.

Sample. A nonprobability convenience sample was used. The sample in this study consists of all new graduate RNs hired to begin nursing orientation during March 2005 to August 2007, prior to the initiation of the PNFP, and September 2007 to March 2010, after the initiation of PNFP. One group of new graduate RNs hired prior to September 2007 received standard orientation (SO). New graduate RN is defined as a registered nurse having passed his/her NCLEX exam within 1 year of hire. No exclusions have been identified.

Standard orientation in 20052006 consisted of 2 weeks of classroom training on basic patient care equipment and didactics on pediatric assessment, pain management, mechanical ventilation, and dysrhythmia recognition. The teaching methodology was take-home self-learning modules with a return post test.

The RN worked with an assigned preceptor(s) on the unit for 2 to 6 months. Preceptors utilized a competency checklist and met with the unit manager and educator to track the orientee's progress towards skills mastery. RN orientees were sent to the unit to work with preceptors before they had a chance to prime IVs, administer medications, suction, or perform other basic nursing functions in a patient care environment. The preceptors performed all the hands-on training and teaching.

In mid 2006 the orientation was expanded to include ICU content and skills in a leveled approach. Level I was caring for an acutely ill pediatric patient. The orientees spent 2 weeks with an educator working on the unit. The orientees had PowerPoint lectures, discussions, and hands-on practice with mannequins for the skills needed for basic pediatric patient care. This phase was followed by transition, with the preceptor, to the pediatric ICU (PICU) to care for stable patients. After 2 weeks in the PICU, they returned to the classroom for level 2 orientation. Level 2 orientation included 1 week of basic critical care orientation-PowerPoint lectures and skills, and 2-3 months of work with a preceptor. Level 3 orientation focused on the most acutely ill patients. Many RNs were on standard orientation for 2 months or longer before it was determined they could not safely care for the patients independently (see Figure 2).

CCMC nursing leadership realized the current orientation process was not producing clinically proficient and critically thinking critical care nurses. A nursing satisfaction survey and internally developed perceived self-efficacy tool were administered to the nursing staff after implementation of the staged level orientation. The results of that survey indicated a high level of nursing satisfaction but there was a continued concern on the part of the new nurses to believe they were ready to work independently in the critical care environment. This, coupled with the known low retention and high turnover rates and knowledge of the success of the adult critical care nurse fellowship program, prompted CCMC's leadership to aggressively pursue adopting the fellowship model for the pediatric program.

The second group of new graduate RNs, hired between September 2007 and March 2010, received the PNFP (see Figure 1). All new graduate RNs were included in the study. The sample size of new graduate RNs hired March 2005 to August 2007 was 28, and the sample size from September 2007 to March 2010 was 49.

Measures. The retention of both groups was measured using data retrieved from a report generated by the CCMC's Department of Human Resources Information Technology (HRIT). Retention was measured longitudinally at four points, 3, 6, 9, and 12 months after commencement of their respective programs.

Setting. To protect the identity of the subjects, the HRIT reports were requested without names or employee identifiers. The report was generated electronically once by accessing the People Soft[TM] personnel data base system and included all four time points. The report was password protected; however, it contained the date of termination which may be a possible means of identifying an employee. The specific termination date, therefore, was not recorded on the data analysis tool. Only a "yes" or "no" response to the term of employment by 3, 6, 9, or 12 months was indicated. In addition, any paperwork related to the study was maintained in a locked cabinet. No consent was obtained as this was a retrospective study and the research posed no more than minimal risk of harm to the subjects and involved no procedure where consent would normally be required (Burns & Groves, 2005). Data were inputted into SPSS 19[R] for statistical analyses.

Financial impact was measured by comparing traveler/agency nurse cost, turnover rates, and retention rates among the new graduate RNs hired between March 2005 and August 2007 and the new graduate RNs hired between September 2007 and March 2010. The financial data were obtained from the human resource department, the office of the nurse executive of CCMC, and the office of the chief nurse executive. The cost of the PNFP was taken into account when calculating the financial impact between both orientation programs.

Method/Instrument. The instrument used was a data collection tool developed specifically for this study. The tool's layout consisted of multiple columns labeled for various demographic variables as well as four columns designated for retention at 3, 6, 9, and 12 months. The type of data collected was nominal. The data for the demographic variables was given a numerical value and the retention scores were coded as either zero for no retention or one for continued retention.

Preliminary statistical analyses including basic descriptive statistics using measure of central tendency and dispersion were calculated to answer Research Question 1: What is the difference in retention for new graduate RNs pre and post-initiation of the PNF orientation program? These descriptive techniques provided information about the sample distribution. The Pearson chi-square test was used to compare the proportion of employment retention between the two groups separately at each of the time points, 3, 6, 9, and 12 months for the SO group and for the PNFP group. The data for the demographic variables were assigned a numerical value, and the retention scores were coded as either 0 for no retention or 1 for continued retention. The length of employment was compared across these two groups utilizing the two-sample t test. The retention of both groups was measured using de-identified data retrieved from the HRIT. Research Question 2: What is the net cost savings retaining pediatric specialty care nurses post-initiation of the PNF orientation program? was measured by comparing traveler/agency nurse cost, turnover, and retention for new graduate RNs hired pre and post-fellowship initiation. The financial data used to calculate the cost of the PNFP were obtained from the office of the nurse executive. The additional cost of the PNFP was taken into account when calculating the financial impact between orientation programs.

Traveler/agency nurse cost for CCMC was provided by the office of the nurse executive. Nursing turnover was defined as all employee separations and included employees who left voluntarily, left involuntarily, retired, transferred to other locations, died, or were separated due to disability, multiplied by 100 and divided by the total number of full-time equivalent employees (transfers within the same location were not included) (American Society for Healthcare Human Resources Administration [ASHHRA], 2008). The pediatric nursing turnover data were provided by the office of the chief nurse executive. Retention was measured using ASHHRA's definition as the total number of employees on staff for a period of time compared to the total number from that specific group remaining on staff after a period of time. Therefore, the total number of new graduate RNs hired into the PICU, ED, and hematology/oncology units at CCMC prior to the PNFP (March 2005 to August 2007) as compared to the new graduate RNs hired post PNFP (between September 2007 and March 2010) were reported as a percentage. The data for calculating retention were generated by the HRIT department.

Differences among samples were examined with regards to demographic variables using Pearson chi-square for categorical variables, such as gender, race, etc. Following preliminary data analysis, statistical tests of the study questions were performed. Continuous variables, such as age, length of employment, and turnover were compared using the two-sample t test.

Results

The sample consisted of 77 new graduate RNs hired by CCMC pre and post initiation of the fellowship program. The range of ages of the total sample was 23 to 50 years with a mean of 30.1 (SD=6.9). Ages averaged 33.2 years for SO and 28.4 years for the PNFP. The results of the demographic characteristics by orientation program are presented in Table 1. Chi-square analysis of demographic data revealed there was no significant difference in gender, ethnicity, or nursing degree by orientation program.

Research question 1. The normality of the variables of age, length of employment, and turnover was assessed using measures of central tendency, including means, standard deviation, skewness, and kurtosis. The results of four chi-square tests to evaluate retention (yes vs. no) by orientation program indicated statistically significant differences in retention at 9 months. The chi-square values are presented in Table 2. The retention rate of pediatric new graduate nurses before initiation of the Pediatric Nurse Fellowship Program was 82% (28/5). The retention rate of new graduate nurses since the inception of the PNFP was 94% (49/3). The PICU retention rate increased from 69.4% to 86.7%, and ED retention increased from 86.6% to 96.5%. The hematology/oncology unit had a sample size of four and, therefore, was not a representative sample.

To test if there was a significant difference in length of employment by orientation program (SO vs. PNFP), an independent samples t test was conducted. The difference between groups was significant: p=0.05, t (-1.97), df (75). Length of employment for the PNFP (M=353.78, SD=-51.62) was significantly higher than length of employment for the SO (M=322.57, SD=-87.83). To test if there was a significant difference in age by orientation program (SO vs. PNFP), an independent samples t test was conducted. The difference between groups was significant: p=0.002, t (3.25), df (75). Age for the PNFP (M=28.37, SD=5.40) was significantly different than age for the SO (M=33.21, SD=8.09).

Research question 2. Traveler/agency nurse expenditures were $1,259,113 pre fellowship and $594,535 post fellowship. Reduction of traveler/agency nurse expenditures resulted in a cost savings of $664,578 after initiation of the PNFP for the PICU, ED, and hematology/oncology unit. Cost for administrating the PNFP was $66,800. Included in the cost of the fellowship was pediatric ECCO for the fellows and the associate fellows as well as a percentage of the salary for the RN administrator at the Patient Safety Institute. The cost of the master fellow and associate fellows is considered financially neutral since they were also used in the tradition orientation model. No consistent higher-acuity type functioning was identified in the new nurse at the 2-month time period in the leveled orientation model. Thus the RNs off orientation were given less acute assignments for about 1 year; this was a non-quantifiable factor. The fellowship orientation model assured CCMC the RN fellow would be completely functional at 6 months, capable of taking a level three assignment. CCMC felt the soft gain on "return of investment" was the quality of the RN caregiver at 6 months in the fellowship model. Therefore, PNFP expenditures yielded a net cost savings of $597,778.

Additional analyses were conducted to determine savings based on turnover rates. Annual percent of turnover was calculated pre and post fellowship. PICU turnover was 1.61% pre fellowship and 0.66% post fellowship. ED turnover was 0.66% pre fellowship and 0.38% post fellowship. An independent sample t test on turnover between pre and post fellowship was conducted. The results of the tests indicate a significant difference in turnover in the PICU [t = -2.79, p = 0.007, df (51)]; however, the ED test results were not statistically significant [t = -1.94, p = 0.059, df (46)]. The hematology/oncology unit had a very small sample size and, therefore, was not a representative sample. The results revealed decreased nursing turnover yielded significant cost savings. The change in turnover pre to post fellowship resulted in the retention of 17.3 nurses in the PICU and 3.5 nurses in the ED. This decreased turnover yielded a potential savings estimate of $1,816,500 for the PICU and $367,500 for the ED (a total cost savings of $2,184,000). Savings were calculated using a conservative estimate of nursing turnover of 1.5 times a nurse's salary (Atencio et al., 2003; Beecroft et al., 2001; Friedman et al., 2011).

Discussion

Research question 1. The NSLIJ Health System's model of nurse fellowship programs supports the existing literature that the fellowship program improved retention of new graduate nurses in critical care areas such as the PICU and the pediatric ED. The fellowship program also enabled CCMC to recruit new graduate nurses into the ED to fill vacancies in that high-volume critical care area. The use of simulation as part of the PNFP enabled novice and advanced beginner nurses to make mistakes in a safe environment and practice critical thinking during simulated critical patient events. The overall goal of the PNFP was to improve health care safety by providing the pediatric nurse fellows with a solid orientation program that increased employee retention and employee satisfaction, resulting in a positive impact on patient satisfaction and patient safety. In addition, the annual retention in the current study improved retention of new graduate RNs from 84% to 94%.

Implementation of the PNFP resulted in an enhanced development plan for the newly graduated nurse transitioning to a pediatric critical care environment. The blended learning process is complemented by a partnership of new nurse, preceptor, educator, as well as regular leadership meetings to assess comprehensive knowledge acquisition, skills mastery, and critical thinking of the new graduate nurse. Focus groups in the form of "bring back days" further reinforced the transparency of development.

The use of an e-learning curriculum, combined with instructor-led discussion, simulation-based integration of skills, and expert mentorship through a precepted experience (associate fellows), strengthened the confidence of the new graduate nurse at critical junctures in her or his employment. Upon conclusion of semester two, there was clearer understanding of the psychomotor, cognitive, and communicative abilities of the nurse who is then able to emerge into independent practice with a solid foundation, and a firm desire to continue employment in that unit; particularly, the retention of the nurse at the 9-month point of hire, where the rate has proven statistically significant. In the traditional orientation model, the nurses were leaving by 6 months. This may explain why no significant findings were found at 12 months, the time interval usually reported in the literature.

Recognizing an advanced beginner nurse requires the guidance of a competent-level nurse (Benner, 1984; Ellerton & Gregor, 2003), the PNFP expanded the associate fellow model of semester two to include a senior associate fellow as a dedicated resource to the newly graduated nurse in semester three. This position was added during the design of the PNF because in the previous orientation model nurses were leaving within 6 months of hire. Nursing administration believed the addition of the senior associate fellow provided a safety net to the fellows during the transition to independent care. Then, as the new nurse was assuming an independent patient care assignment, the senior associate fellow was rounding daily with her or him to ensure all questions were addressed and key elements of care were attended to properly. This dedicated and supporting resource provides an increasing level of confidence in the new nurse in the knowledge an experienced person, committed to helping her or him through the critical thinking and crucial interventions of uncertain situations, is readily available. Moreover, the concept of hiring a cohort of nurses into the program provides a sense of community among the fellows and adds a level of peer support that seems to further their growth and development. This facilitates maturation in their role and acclamation to the work environment. As new cohorts of fellows are hired, the new culture's values are strengthened and a cultural tipping point is reached. A culture change evolves and the new culture is entrenched.

An independent samples t test was conducted on age and the results were significant (p=0.002). Age averaged 33.2 for the pre-fellowship group and 28.4 for the PNFP group. This may be impacted by the fact that prior to the institution of the PNFP, a nurse needed medical-surgical experience to be considered for appointment in a critical care area. The PNFP has admitted 85% of new graduate nurses into their program.

Research question 2. Comparison of traveler/agency nurse expenditures was calculated based on data generated from the CCMC Office of the Nurse Executive. After expenditures to implement the fellowship were calculated, the PNFP yielded a net cost savings of $597,778. PICU retention rates increased from 69.4% to 86.7%, and ED retention rates increased from 86.6% to 96.5%. The change in turnover pre to post fellowship resulted in the retention of 17.3 nurses in the PICU and 3.5 nurses in the ED. This decreased turnover rate yielded a potential savings estimate of $1,816,500 for the PICU and $367,500 for the ED (total cost savings of $2,184,000). Savings were calculated using a conservative estimate of nursing turnover of 1.5 times a nurse's salary (Atencio et al., 2003; Beecroft et al., 2001; Friedman et al., 2011). Nurse turnover has been estimated at $300,000 per percentage point of turnover (Price Waterhouse Coopers, 2007).

Calculating actual return on investment is complicated because many of the PNFP's benefits are difficult to quantify and are considered avoided costs. Avoided costs are described as quality of care, reduced turnover, patient and physician satisfaction, positive effects of increased nurse-patient ratios on quality of care, and nurse burnout, which would be indirect measures of cost (Jones, 2004; The Advisory Board Company, 2005). Halfer, Graf, and Sullivan (2008) and Friedman and associates (2011) suggest nurse fellowships and residency programs are financially beneficial but it takes time and administration support to reap the financial benefits. Halfer and colleagues and Friedman and associates successfully decreased staff turnover and demonstrated that costs related to recruitment, orientation, and temporary labor costs associated with RN vacancies can be mitigated significantly. Currently, there is no standardized way of measuring cost-benefit analysis of nurse retention and no uniformity in measurement that would allow for more substantial comparison among studies (Jones, 2004, 2005). Reliance on temporary, agency, or traveler nurses to fill vacant positions as a result of staff turnover can be a detriment to organizations and patients (Ulrich et al., 2010}. Adverse patient outcomes, decreased continuity of care, and loss of staff productivity have been attributed to high nurse turnover (Duffield, Roche, O'Brien-Pallas, & Catling-Paull, 2009). Therefore, fellowship programs are effective in decreasing turnover rates and increasing retention rates in new graduate RNs (Friedman et al., 2011).

Limitations

Limitations of this study include the use of the retrospective comparative descriptive design and the use of a convenience sample which limits the generalizability of the study findings. The existence of other intervening variables, which were not identified in the present study and may influence new graduate nurse retention, is a limitation.

Suggestions for Future Research

There is a need for replication of this study using larger sample sizes in varied critical care specialties. Using samples of new graduated RNs from other geographic areas around the country, and possibly internationally, should be examined. There is also a need for longitudinal studies following new graduate RNs in fellowship programs, monitoring the impact of fellowships on retention and health care finances.

Conclusion

Specialized pediatric orientation programs that support new graduate RNs have documented increased retention and decreased turnover. Further, health care finances are impacted positively by specialized orientation programs. Although, the current downturn in the economy has ameliorated the nursing shortage by delaying nurses retiring, this is only a temporary condition. As the economy improves, the baby boomer nurses will begin to retire, leaving a hole in the experienced critical care workforce. Hence, this is the opportune time for nurse leaders to monitor existing specialized orientation programs such as the PNFP or institute a similar specialized orientation program as described in this study.

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M. ISABEL FRIEDMAN, DNP, MPA, RN, BC, CCRN, CNN, is Program Director, Nursing Fellowship Programs, Center for Learning and Innovation, Lake Success, NY.

MARGARET M. DELANEY,, DNP, RN, CEN, BC, CHSE, is Nurse Educator, Emergency Department, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, NY

KATHLEEN SCHMIDT, MSN, PNP, CCRN, is Pediatric Critical Care Educator, Steven and Alexander Cohen Children's Medical Center of New York, New Hyde Park, NY.

CAROLYN QUINN, MSN, RN, NE-BC, is Associate Executive Director, Patient Care Services, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, NY.

IRENE MACYK, MSN, RN, PCNS-BC, is former Director, Nursing Education, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, NY; and is currently Director, Patient Care Services/Medicine, North Shore University Hospital,

Table 1.
Demographic Characteristics by Orientation Program (SO vs. PNFP)

                            Orientation Program

                      Standard       PNFP      Total
Gender
  Male                1 (25.0)     3 (75.0)       4
  Female             27 (37.9)    46 (62.1)      73
Degree in nursing
  MSN                 1 (16.6)     5 (83.4)       6
  BSN                21 (33.9)    41 (66.1)      62
  AS                  5 (71.4)     2 (28.6)       7
  Missing             1 (50.0)     1 (50.0)       2
Ethnicity
  White              19 (30.6)    43 (69.4)      62
  Other               9 (56.0)     6 (34.0)      15

Table 2.
Pearson Chi-Square Values on Retention at 3, 6, 9,
and 12 Months by Orientation Program (SO vs. CCNFP)

Retention              [chi square]    df       p

Retention 3 Months         0.58         1    0.447
Retention 6 Months         2.58         1    0.108
Retention 9 Months         4.09         1    0.043 *
Retention 12 Months        5.95         1    0.105

* p < 0.05

Figure 1.
Pediatric Nurse Fellowship Program Design

                Semester 1          Semester 2          Semester 3
                Weeks 1-10          Weeks 11-27         Weeks 27-52

Pediatric    * Simulation        * Preceptorship     * Independent
Nurse        * ECCO, pediatric     with a              patient
Fellowship     ECCO, or APHON      specially           assignments
Program        and BMT core        educated            with resource
               curriculum          associate           person (senior
             * Professional        fellow (share       associate
               seminars            patient             fellow)
             * Assignments         assignment and    * Individual work
               with master         work schedule)      schedule
               fellow            * Meetings and      * Bring Back day
             * RN mentorship       educational       * Graduation
                                   sessions with
                                   master fellow
                                 * 2 Bring Back
                                   days
                                 * Completion of
                                   clinical
                                   pathway

Figure 2.
Standard Orientation Program Design

                 Week 1              Week 2

2005             System             Hospital
              orientation         orientation

                Nursing      Unit orientation using
              orientation    self-learning modules
                                 and posttests

Standard RN
Orientation

2006             System       Didactic skills with
              orientation     unit educator using
                                PowerPoint, and
                Nursing        skills practice on
              orientation        task trainers

                       Week 3-8                    Week 9-24

2005
                  Classroom training        Preceptor guided using
                   on basic patient          competency checklists
                    care equipment              and manager and
                                               educator meetings

Standard RN           Weeks 3 & 4                Weeks 6 & 17
Orientation

2006             Preceptor-guided PICU           Work in PICU
                 experience on stable           with preceptor
                       patients

                        Weeks 5                    Weeks 18

              Level 2 basic critical care     Level 3 orientation
                  didactic education        of acutely ill patients
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Title Annotation:CNE SERIES
Author:Friedman, M. Isabel; Delaney, Margaret M.; Schmidt, Kathleen; Quinn, Carolyn; Macyk, Irene
Publication:Nursing Economics
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2013
Words:6429
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