Effect of Formal Transitions on Registered Nurse Retention Rates

Planned Change Theory

Problem Definition and Background

For the behavioral health nurse at St. Mary Hospital does the use of a formal, comprehensive transition to practice program specialized to behavioral health impact full time registered nurse (RN) retention rate compared to the current informal preceptor program in place?

The average hospital is estimated to lose about $328,400 per year for each percentage increase in annual nurse turnover (Nursing Solutions, Inc. [NSI], 2019).  The national average RN turnover rate is 17.2% in 2019, the highest rate in a decade, furthermore the turnover rate on inpatient behavioral health units is even higher at 23.1% in 2018, the highest of any nursing specialty (NSI, 2019, p. 8). What are the ramifications of high nurse turnover rates on an inpatient behavioral health unit?  The main factor outside of economics is patient and staff safety.  As reported by Kelly et al (2016) a national survey conducted by the U.S. Department of Justice noted the average annual rate of nonfatal workplace violence between 2005 and 2009 as 5.1 incidents per 1,000 employees across occupational categories, whereas mental health workers experienced a rate of 20.5 incidents per 1,000 employees.  Managing psychiatric nurse retention should be a strategic imperative, particularly given the high cost of turnover, the ongoing nursing staffing crisis, and the increased risk for violence to patients and staff.

System Level Change

The 12^th floor of St Mary Medical Center poses a unique challenge for nursing retention and recruitment.  This is a split unit that serves both the geriatric and medical-surgical behavioral health population, requiring nurses to not only possess specialized behavioral health skills, but also skills unique to the geriatric and medical-surgical population.  This unit has experienced extreme levels of nursing turnover, as of August of 2017 to present approximately 57% of nurses that have been working for at least a year have either reduced hours to part-time or less, transferred off unit, or quit within the first 16 months of service.  In addition, this unit has also seen a 30% reduction in more senior staff that either reduced hours to part-time or have transferred off the unit.  In addition to the unique skills an RN must possess to work on this unit, St Marys is a safety net medical center.  Safety net medical systems offer services expected by local communities and are required by state and local governments, regardless of the revenue to support the services (VanDeusen et al., 2015, p. 1).  This increases patient acuity, as safety net systems tend to see a higher acuity of patients that do not regularly access preventative or primary care.  Furthermore, a safety net medical system tends to experience lower profit margins, and thus decreased resources than a traditional medical system (Dobson, DaVanzo, & Haught, 2017).

Currently the 12^th floor at St Mary Medical Center has an informal preceptor program lasting anywhere from 2-4 weeks.  Preceptors are assigned on a voluntary basis or more frequently, by availability typically on a new orientee’s first day on the unit.  There is no formalized orientation education, instruction, or contracts that the preceptor or preceptee can refer except for a generalized behavioral health competency packet.  Hospital policy encourages preceptors to complete a preceptor’s workshop prior to precepting, though dates of this workshop are inconsistent and many nurses are unaware of this policy or program on the unit.  This informal preceptorship while providing autonomy to nurses working on the unit, provides a fragmented, inconsistent preceptorship that reduces competence and job satisfaction while increasing stress and turnover.  (Benner et al., 2010)

The proposed change for the 12^th floor is to implement a formal, structured, comprehensive preceptor program lasting six months specialized to the unique needs of medical-surgical, geriatric behavioral health unit to increase nurse satisfaction, patient safety, and increase new-hire retention rates.  According to Luhanga et al (2010, p 1), preceptors lack specific techniques in feedback, critical questioning, and supporting orientees in goal-setting, which jeopardizes confidence in clinical skills, and transitions to independent practice.

Change Theory

For this planned change, Dr. Kotter’s eight step process for leading change was chosen for its simple yet comprehensive approach to change management of a complex organization.  Kotter’s change theory advocates not for top-down hierarchical change, but change that is produced by building a coalition of organization members at all levels that are committed to change (Kotter, 2018).  This theory aligns with the development of a structured preceptor program because without the buy-in of more experienced nurses the planned change will fail.

Kotter’s Theory

Kotter’s eight step process includes creating a sense of urgency, building a guiding coalition, forming a strategic plan and initiatives, enlisting a volunteer army, enabling action by removing barriers, generating short-term wins, sustaining acceleration, and institutional change. (Kotter, 2018) A key feature of Kotter’s theory is the notion that each step need not occur in a chronological fashion, but all processes should be occurring simultaneously.

A sense of urgency is already present on the 12^th floor as five-year employee satisfaction surveys have consistently decreased in almost all domains.  An assessment of the current preceptor program asked the recently precepted and current staff what precepting issues might contribute to staff turn-over and what weaknesses were present in the current unit preceptor model providing additional feedback for change planning.

St Mary Medical Center utilizes a shared governance model, which consists of clinical nurses at the unit level who assist coordinating council representatives in decision-making and coordinating councils which consists of clinical nurses from each service line who coordinate and provide direction to unit councils.  The shared governance model practiced at St Mary is uniquely situated for the application of Kotter’s theory of building a coalition and enlisting a volunteer army.

According to Kotter (2018), “change can only occur when very significant numbers of employees amass under a common opportunity and drive in the same direction (p. 15).”  One of the councils at St Mary Medical Center is the professional development council where nurses from all units discuss the policies and protocols for the development of the nurse across their career including precepting and role transitions.  In addition, the RN level 2 council is comprised of tenured nurses that meet monthly to create and improve leadership opportunities for floor nurses.  Both of these councils will be key forces in building a volunteer army and developing a guiding coalition.

Strategic initiatives are specific measurable goals that support the desired change (Kotter, 2018). Through a thorough literature review, continued staff assessment, and critical appraisal of best practices a formal, comprehensive transition to practice program specialized to behavioral health along with a preceptor development workshop will be created to achieve these strategic initiatives.

Barriers

One of the steps in Kotter’s theory is to enable staff by removing barriers to adoption.  An important question to ask is how has the current preceptor program failed?  Have other programs been tried, but abandoned?  Or has the unit always “done it this way.”  Understanding an organization’s explicit and implicit barriers to adoption is crucial to a planned change.  Planning change on a unit that is already burnt out and under staffed due to high turn-over rate and high acuity patient population is a unique challenge that must be addressed for success to occur.  Further assessment of staff attitudes and opinions concerning precepting will be important in planning change. Assessments concerning where precepting has failed is not enough, but attitudes and opinions on the adoption of a formalized preceptor program will be important in identifying apathy and complacency in adopting change.

Legal Issues

As hospital margins continue to shrink and regulatory agencies put greater emphasis on quality and safety nurses are called to meet the demands of a complex and ever-changing healthcare landscape.  A strong preceptor program will reduce the likelihood of malpractice by actively engaging both preceptors and preceptees in unit culture, uniformly educating preceptees on current standards of care and reengage preceptors on current standards of care.  This will educate nurses on how to safely and appropriately care for behavioral health patients with special needs.

Ethical Issues

The role of a nurse preceptor in setting the tone of a unit culture cannot be underestimated or undervalued.  According to Muller (2018) the four principles of bioethical decision making are autonomy, beneficence, nonmaleficence, and justice.  These are all critical concepts to keep at the forefront of planning a formalized, structured preceptor program.  Adequate preceptor training will not only allow the preceptor autonomy in practice but will encourage a sense of beneficence by providing time, support, and education to the floor nurse willing to invest energy in precepting new orientees.

The formalized program provides a uniform training that enhances the unique skills needed to safely care for a complex behavioral health population supporting the ethical principle of non-maleficence.  Finally, the principle of justice is embodied in a program that sets the bar high for both preceptor and preceptee.  Providing support to both, lays a foundation where each patient is cared for by nurses that were trained equitably and are invested in supporting one another.

References

• Benner, P., Sutphen, M., Leonard, V., Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
• Dobson, A., DaVanzo, J., & Haught, R. (2017, June 28). The Financial Impact of the American Health Care Act’s Medicaid Provisions on Safety-Net Hospitals. Retrieved from https://www.commonwealthfund.org/publications/fund-reports/2017/jun/financial-impact-american-health-care-acts-medicaid-provisions
• Kelly, E. L., Fenwick, K., Brekke, J. S., & Novaco, R. W. (2016). Well-Being and Safety Among Inpatient Psychiatric Staff: The Impact of Conflict, Assault, and Stress Reactivity. Administration and policy in mental health, 43(5), 703–716. doi:10.1007/s10488-015-0683-4
• Kotter, J. (2018). 8 Steps to Accelerate Change in Your Organization. doi: https://www.kotterinc.com/wp-content/uploads/2019/04/8-Steps-eBook-Kotter-2018.pdf
• Luhanga F. L., Dickieson P., Mossey S. D. (2010). Preceptor preparation: An investment in the future generation of nurses. International Journal of Nursing Education Scholarship, 7(1), 1-18.
• Muller, L. S. (2018). Legal and ethical issues. In D. L. Huber (Ed.) Leadership and nursing care management. (6th ed., pp. 85-101). St Louis: Elsevier.
• NSI Nursing Solutions, Inc. (2019). National Health Care Retention & RN Staffing Report. Retrieved from http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/2019%20National%20Health%20Care%20Retention%20Report.pdf
• Spector, N., Blegen, M. A., Silvestre, J., Barnsteiner, J., Lynn, M. R., Ulrich, B., . . . Alexander, M. (2015). Transition to practice study in hospital settings. Journal of Nursing Regulation, 5(4), 25-38. Retrieved from www.ncsbn.org/Spector_Transition_to_Practice_Study_in_Hospital_Settings.pdf
• VanDeusen Lukas C, Holmes SK, Koppelman E, et al. System Redesign Responses to Challenges in Safety-Net Systems: Summary of Field Study Research. Rockville, MD: Agency for Healthcare Research and Quality; 2015. AHRQ Pub. No. 15-0053-EF.