Evidence-based Practice

Overview and Significance of the Practice Issue

Several baby boomer-aged nurses retiring and other nurses transferring to less acute units have caused a shortage of critical care nurses at Southwest General Hospital (SWGH). Statistics reflect that the nursing shortage will continue due to these factors resulting in the demand for acute care nurses outpacing the supply of qualified individuals. The current turnover rate of critical care nurses averages 18.7%, with organizational costs of replacing one nurse nearing $40,000 (NSI Nursing Solutions, Inc. [NSI], 2021).

The current recruitment practices at SWGH do not include hiring new graduate nurses (NGN) directly to the intensive care unit (ICU) due to inexperience, lack of available staff resources, or inadequate NGN orientation programs. Recruitment and retention of NGNs to critical care environments is complex. It requires efforts to bridge a practice readiness gap or risk nearly 24% of NGNs leaving positions within their first year of employment (Baudoin et al., 2022; NSI, 2021). Baudoin et al. (2022) recommended that hospitals enable NGN hires into acute care environments, provided programs exist to provide adequate learning to ensure successful transitions to practice.

PICOT Statement
Will implementing a new graduate nurse NGN (P) critical-care internship and residency program (I) at SWGH help integrate NGNs to improve ICU recruitment and retention rates (O) compared to no critical-care nurse internship and residency program (C) during a 12-to-16-week timeframe (T)?

P- Population and Problem: SWGH does not consider NGNs for ICU employment. The ICU has poor critical-care nurse recruitment and long-term retention of nurses.

I – Intervention: Introduction of a multi-faceted NGN critical care internship and residency program utilizing unit-specific orientation, supportive mentors, detailed preceptor/preceptee roles, and regular feedback. A focus group of key SWGH stakeholders representing clinical educators, internship program directors, experienced ICU nurse leaders as preceptors, and nurse managers to plan, implement and perform regular evaluations (Bakon et al., 2018).

C – Comparison: SWGH does not have a residency program that supports the transition of NGN to the ICU. Bakon et al. (2018) emphasized lack of proper NGN orientations leads to more staff turnover, increased hospital costs, preceptor burnout, and poor unit morale.

O – Outcome: SWGH’s successful integration, recruitment, and retention of NGNs in the ICU as indicated by NGN retention rates greater than 90%. According to a literature review by Asber (2019), NGN residency programs improved NGN retention rates, accounting for first-year retention rates ranging from 74% to 100%.

T – Timeframe: A 12 to 16-week intensive internship with an ICU nurse mentor is planned with a proposed follow-up residency period to provide ongoing support. In a Canadian study by Rush et al. (2014, as cited in Bakon et al., 2018), NGNs reported needing the most help transitioning during the first three months after graduation.

Proposed Intervention and Expected Outcome
To improve the recruitment and retention of new graduate nurses to SWGH’s ICU, I recommend implementing a multi-faceted NGN critical care nurse internship and residency program. A focus group of clinical educators, experienced nurses, and associated nursing program faculty is needed to design, plan and implement an intense NGN ICU internship. The program would include a combination of organizational and unit-specific orientations, experienced nurse preceptors and mentors guiding safe clinical skills development, and scheduled evaluations and feedback opportunities over 12 to 16 weeks. There is significant evidence that nurse residency and internship programs improve an NGN’s clinical skills, confidence, and professional development to support a successful transition to practice (Bakon et al., 2018).
Outcomes of the successful integration of an NGN ICU internship program will be measured by greater than 90% of NGN retention rates beyond the first year of hire. Asber (2019) indicated in a literature review that NGN residency programs improved first-year retention rates by74% to 100%.

Synthesis of Evidence to Support the Proposed Intervention

There are countless research studies examining measures to mitigate factors that compound the nursing shortage issue related to nurses retiring and high turnover rates of NGNs. The evidence supports that using nurse residency and internship programs is vital for ensuring the successful transition of NGNs and sustaining the workforce. The predominant factor obtained from scholarly literature sources highlighted the utilization of nurse preceptors and mentors are crucial for NGNs to develop the knowledge, skills, and attitudes necessary to become competent nurses. Study findings by Degrande (2018), Özkaya Sağlam et al. (2021), and Van Patten and Bartone (2019) confirmed the use of preceptors and mentors enables NGNs to have a positive experience while successfully transitioning to professional practice. Degrande and Özkaya Sağlam et al. found that guidance and collaboration offered by preceptors and mentors reduced stress and helped NGNs overcome fears related to working with acutely ill patients, allowing improved confidence and critical skills development. Likewise, Van Patten and Bartone reported that the combination of preceptorship and debriefing processes reduced stress, enabling a more positive and productive learning experience. The common themes of the research provided reinforced how providing adequate supportive, educational resources and personnel with well-structured programs are vital for enhancing the NGN’s experience influencing a positive practice transition. Quantitative findings by Yao et al. (2021) supported evidence that enhancing student nurses’ professional identity and self-efficacy improve competencies by 48% and 52%, respectively. The study’s findings can be translated to support the inclusion of internship strategies targeting self-efficacy and professional development. Additional research by Zhang et al. (2019) provided quantifiable evidence that extensive use of one-on-one mentorships in NGN internships improved first, second and third-year turnover rates at 3.77%, 3.48%, and 8.11% compared to no mentorship turnover rates of 14.07%, 9.36%, and 14.19%.

It is prudent to acknowledge several limitations presented by the scholarly research provided. Degrande et al. (2018), Özkaya Sağlam et al. (2021), and Zhang et al. (2019) all expressed that the use of small participant sample sizes or single-site studies minimized the transferability and generalization of findings. Research by Van Patten and Bartone (2019) noted that the data obtained from a single point in time using a pre-designed Versant RN Residency curriculum impaired the transferability of findings to other facilities that use different residency programs. Similarly, Yao et al. (2021) emphasized caution against over-generalizing the results of their study because the requirements and structures of nursing internship and residency programs vary in every country.

Stakeholder Implications

The existing shortage and poor recruitment and retention of ICU nurses at SWGH impact several stakeholders at the organization’s micro, meso, and macro levels. Hospital directors and financial officers at the macro-level are burdened by the costs of high nursing attrition rates, which can average $5 million annually (NSI, 2021). The proposed evidence-based intervention may help increase nurse recruitment and retention rates, allowing financial resources for additional investments and healthcare improvement projects.
Meso-level stakeholders affected by poor ICU nurse recruitment and retention include nurse managers, clinical educators, and human resource directors. Nursing management is tasked with ensuring the ICU is appropriately staffed with adequately trained nurses that support quality, safe patient care. At the same time, human resource directors are challenged with developing innovative ways to recruit new staff or, in many cases, offer sign-on bonuses that add to the expense of hiring. Adding an NGN critical care internship for hire and residency program may be a more effective and less costly ICU nurse recruitment strategy.
Frontline nurses, physicians, families, and patients at the micro-level are most notably impacted by inadequate staffing in the ICU related to poor nurse recruitment and retention. In a cross-sectional survey, Ball et al. (2018) noted that every additional patient assigned to a nurse increases a patient’s chance of dying by 7% within 30 days of admission. Increased patient-to-nurse ratios in the ICU are associated with poor patient outcomes associated with missed nursing care and emotionally and physically exhausted nursing staff (Ball et al., 2018; Guo et al., 2017). High turnover rates also stress nurse preceptors and mentors who become tired of frequently training new unit nurses. Maintaining the objective of increased retention and recruitment of NGN nurses directly to the ICU will alleviate the stressors and costs associated with inadequate staffing ratios and high nurse attrition rates.

Asber, S. R. (2019). Retention outcomes of new graduate nurse residency programs. JONA: The Journal of Nursing Administration, 49(9), 430–435. https://doi.org/10.1097/nna.0000000000000780
Bakon, S., Craft, J., Wirihana, L., Christensen, M., Barr, J., & Tsai, L. (2018). An integrative review of graduate transition programmes: Developmental considerations for nursing management. Nurse Education in Practice, 28, 80–85. https://doi.org/10.1016/j.nepr.2017.10.009
Ball, J. E., Bruyneel, L., Aiken, L. H., Sermeus, W., Sloane, D. M., Rafferty, A., Lindqvist, R., Tishelman, C., & Griffiths, P. (2018). Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study. International Journal of Nursing Studies, 78, 10–15. https://doi.org/10.1016/j.ijnurstu.2017.08.004
Baudoin, C. D., McCauley, A., & Davis, A. H. (2022). New graduate nurses in the intensive care setting. Critical Care Nursing Clinics of North America, 34(1), 91–101. https://doi.org/10.1016/j.cnc.2021.11.007
DeGrande, H., Liu, F., Greene, P., & Stankus, J.-A. (2018). The experiences of new graduate nurses hired and retained in adult intensive care units. Intensive and Critical Care Nursing, 49, 72–78. https://doi.org/10.1016/j.iccn.2018.08.005
Guo, Y., Luo, Y., Lam, L., Cross, W., Plummer, V., & Zhang, J. (2017). Burnout and its association with resilience in nurses: A cross-sectional study. Journal of Clinical Nursing, 27(1-2), 441–449. https://doi.org/10.1111/jocn.13952
NSI Nursing Solutions, Inc. (2021). 2021 NSI national health care retention & RN staffing report. NSI Nursing Solutions Inc. Retrieved April 14, 2022, from https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf
Özkaya Sağlam, B., Sözeri Eser, İ., Ayvaz, S., Çağı, N., Mert, H., & Küçükgüçlü, Ö. (2021). Intensive care experiences of intern nurse students: A qualitative study. Nurse Education Today, 107, 105098. https://doi.org/10.1016/j.nedt.2021.105098
Van Patten, R. R., & Bartone, A. S. (2019). The impact of mentorship, preceptors, and debriefing on the quality of program experiences. Nurse Education in Practice, 35, 63–68. https://doi.org/10.1016/j.nepr.2019.01.007
Yao, X., Yu, L., Shen, Y., Kang, Z., & Wang, X. (2021). The role of self-efficacy in mediating between professional identity and self-reported competence among nursing students in the internship period: A quantitative study. Nurse Education in Practice, 57, 103252. https://doi.org/10.1016/j.nepr.2021.103252
Zhang, Y., Huang, X., Xu, S., Xu, C., Feng, X., & Jin, J. (2019). Can a one-on-one mentorship program reduce the turnover rate of new graduate nurses in china? A longitudinal study. Nurse Education in Practice, 40, 102616. https://doi.org/10.1016/j.nepr.2019.08.010

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