A Path to Better Staffing: Meeting the Needs of Novice Nurses (Part 1)

“I look around my unit sometimes, and it’s like all my co-workers are new nurses. What happened?” I heard this comment from an experienced nurse attending AACN’s National Teaching Institute & Critical Care Exposition. The 2022 National Nursing Workforce Survey by NCSBN provides data that such impressions are common. The survey found that the median age of RNs was 46, a significant change from NCSBN’s 2020 study when the median age was 52. The report notes that the decline in median age was associated with over 200,000 experienced RNs leaving the workforce. Such dramatic changes are daunting. How can we ensure safe and effective care while working with mostly new nurses?

We hear repeatedly how newly licensed nurses struggle with their readiness to practice. Frequently, there are more orientees than preceptors, and many preceptors are new to their role, having recently completed orientation themselves. Nursing professional development practitioners (NPDPs) may struggle to keep up with the influx of newly licensed nurses (NLNs), and preceptor burnout is a major issue. These orientation challenges may also affect turnover and retention, and become a barrier to appropriate staffing. Additionally, NPDPs must simultaneously address the professional development needs of more experienced nurses.

The issues and comments regarding NLN orientation and preceptor burnout in a recent post in AACN Clinical Practice Community led me to consider some unique ways to approach orientation and staffing when onboarding NLNs to critical and progressive care. Here are some tips from healthcare workers facing the same challenge and how they handled it.

Start Early!

Exposing nursing students to specialty-focused nursing roles such as acute care, medical-surgical, telemetry, progressive care and critical care is one way to engage them early and give them an opportunity to develop up-to-date knowledge and skills for patient care. Health system and nursing school partnerships provide opportunities to improve practice readiness for specialty areas. At one university, nursing students volunteered to participate in a senior capstone project that used the Essentials of Critical Care Orientation program as self-study and paired them with a nurse preceptor for 108 hours of hands-on direct care experience. After the program, students self-reported:

• Increased critical care knowledge and higher self-confidence
• Improvements in their ability to recognize and intervene for a change in a patient’s condition and to advocate on behalf of the patient

Nursing school curriculum redesign is another area to consider. One nursing school used a senior elective in the last semester and redesigned the curriculum to use critical and progressive care elearning instead of a textbook to better engage students. This nursing school implemented a progressive and critical care elearning program coupled with simulation to expose the student nurses to clinical judgment scenarios in a realistic critical care environment.

Results of the the school’s project include the following:

• The majority of students ranked their knowledge of critical care and confidence in their ability to apply that knowledge as high or very high.
• Eighty percent of students had high or very high confidence in their ability to recognize a change in a patient’s stability and advocate on behalf of the patient.
• Fifty-three percent indicated they were very highly or highly confident in their ability to intervene appropriately for a change in a patient’s stability.
• Seventy-six percent of students thought this critical care course was extremely to very influential in their decision to pursue a critical care specialty after graduation.
• Anecdotally, one extern student reported that nurses where the student worked said the student’s knowledge of critical care and hemodynamics exceeded the nurses’ expectations. This student also reported that their participation in the critical care curriculum influenced the hospital’s decision to hire them.

As the article notes, these types of partnerships and curriculum redesigns provide early exposure to specialty clinical content, contribute to better-prepared NLNs and create a potential to reimagine the NLN orientation timeline. Such outcomes also may have financial benefits for the hiring institution.

Novel Orientation

Nursing schools aren’t the only ones trying novel approaches to fill the specialty nursing recruitment/retention gap. Some hospitals are taking a hard look at their orientation practices and revising them to create more engagement, build clinical judgment skills and improve the socialization of NLNs. NLNs who are more comfortable in their units following orientation are less likely to leave. Decreasing turnover improves staffing and reduces nursing turnover costs.

Here are some ideas for trying a different approach to orientation:

• One hospital decided to rethink critical care orientation and came up with solutions that gave NLNs more time for acclimation and development of competence, and shifted the financial burden of orientation to a cost center dedicated to orientation costs. The benefits to the organization included better-prepared nurses who demonstrated confidence in their practice, as well as a decrease in first-year turnover.
• Another hospital brought back their transition to practice residency and a structured orientation approach that included becoming independent on progressive care units before transitioning to critical care orientation. This structured approach reduced the staffing burden for preceptors in ICUs and reduced the cognitive burden for NLNs, giving them an opportunity to develop their competence at a slower pace.
• Balancing when to provide didactic critical care education using “Essentials of Critical Care Orientation” (ECCO) or homegrown critical care classes is frequently discussed among NPDPs. How to Balance Staffing Needs and Beat Learner Fatigue offers suggestions to reduce the amount of education NLNs are expected to assimilate in their first few months of orientation.
• Another hospital redesigned their orientation processes in response to the great resignation. Their day-shift staff members were overburdened due to staffing shortages and also struggling to precept all the NLNs during orientation. Realizing their night shift nurses had experience and could serve as preceptors, the educators redesigned the orientation to include a midpoint two- to four-week rotation to the night shift. They included the requirement of a successful midpoint evaluation before moving the NLNs to the night shift. Satisfaction among both shifts, preceptors and orientees was high, and unexpected benefits occurred, such as improved between-shift communication and a positive impact on the health of the work environment.

Improving Orientation Satisfaction, Ensuring Nurse Competence

“What do you mean they aren’t ready to come off orientation? I thought their checklist was complete!” Have you ever been in this situation regarding your new orientees to ICU or PCU? The skills checklist is complete, but the orientee is still not ready to practice independently. Assessing nurse competence goes beyond the knowledge, skills and abilities checklist. “AACN Competence Framework for Progressive and Critical Care: Initial Competency 2022” provides a method for validating the overall competence of nurses new to the ICU or PCU practice setting. Using the eight Synergy Nurse Competencies (SNCs) and the performance outcomes, the AACN Competence Framework defines the core elements necessary for competent nursing practice. A beta test of the framework and available toolkit includes the following outcomes:

• Orientees rated the program very effective in preparing them to practice with minimal supervision.
• Orientees, preceptors, educators and nurse leaders reported increased confidence in the orientees’ ability to recognize and intervene for a change in a patient’s condition, advocate for the patient and practice safely.
• The majority of nurse leaders, educators and preceptors were satisfied with the AACN Competence Framework and toolkit orientation program.
• One year later, the majority of orientees (86%) were still employed in the unit where they started.

Using the SNCs and performance outcomes is beneficial for the orientee, as they have specific outcomes to achieve. The performance outcomes also provide a way for the preceptor to speak objectively about the orientee’s progress. Novice preceptors have reported the performance outcomes provided them with the words to give actionable feedback. Improving NLNs’ competence and readiness to practice improves their confidence, which may lead to reductions in first-year turnover and improved staffing.

Tips for Planning Orientation

If you need ideas to plan orientation, create engagement and help nurses who are struggling with orientation, read these AACN blogs. They include some great ideas to build confidence, engage NLNs and improve learning with a flipped classroom. NLNs may struggle with communication and feedback during change-of-shift report. Consider incorporating a feedback loop during the change-of-shift report. This action contributed to improvements in confidence, satisfaction and communication among graduate nurses in orientation who struggled with how feedback was being delivered during the end-of-shift report.

In part 2 of this blog, learn about additional strategies to help NLNs by supporting preceptors or offering resources after orientation. Comment below to share your ideas for addressing the unique needs of NLNs.