EBP 2.0: Promoting Nurse Retention Through Career Development Planning

Abstract

This is the second article in a new series about evidence-based practice (EBP) that builds on AJN’s award-winning previous series—Evidence-Based Practice, Step by Step—published between 2009 and 2011 (to access the series, go to https://links.lww.com/AJN/A133). This follow-up series will feature exemplars illustrating the various strategies that can be used to implement EBP changes—one of the most challenging steps in the EBP process.

In Brief

This second article in a new series on implementing evidence-based practice changes discusses the implementation of a program to reduce first-year nurse turnover rates at an urban Chicago hospital.

Figure: Photo © Istock/spxChrome.

The implementation of evidence-based practice (EBP) can be a daunting process. Projects can be derailed by poor planning and ineffective mitigation of barriers. In this article, Manisa Baker and Beth A. Vottero from Purdue University Northwest's College of Nursing describe how they used knowledge translation tools to guide the implementation of a nursing professional development program at an urban Chicago hospital. After they tell their story, we comment on their approach to making this a sustainable change.—Sharon J. Tucker and Lynn Gallagher-Ford

THE IMPLEMENTATION STEP: THE PROFESSIONAL DEVELOPMENT AND CAREER PLANNING PROGRAM

Our story is about the creation and implementation of an evidence-based quality improvement (QI) initiative at a level 1 trauma hospital. The aim of the Professional Development and Career Planning Program was to reduce first-year nurse turnover rates on two telemetry units that had high rates of turnover.

The implementation of this program began with a pilot project that targeted all new nurses hired on these units from November 2017 to June 2018. A total of eight nurses participated in the program. The pilot project was initiated by the first-year nurse turnover team, which consisted of representatives from human resources, nursing administration, and operations improvement. This team adapted a standardized professional development and career planning tool based on the milestone pathway tool described by Cooper and colleagues.¹ The newly hired nurses were introduced to the program during orientation and started it at the end of their 90-day probationary period. Four to six months after each nurse's hire date, the program coordinator (one of us, MB) met with each nurse for their follow-up session, during which she reviewed information about the program and discussed professional development opportunities and socialization on the unit with the newly hired nurse.

Background. Our desire to reduce first-year nurse turnover rates led us to rethink how we supported new nurses through their orientation at our facility. Our goal was to create a program that would help new nurses during orientation and increase their career satisfaction at our hospital. We created the Professional Development and Career Planning Program based on findings from a search of the literature on best practices for the orientation of new nurses, as well as input from unit leaders and practicing nurses. We believed it was important that our program collect data and track a nurse's professional work history, progress toward practice expectations, and long- and short-term professional goals. With this in mind, we included in our program career planning, such as mandatory and elective practice expectations, and a list of classes that were required or available to nurses at our facility for professional development. We introduced the program to all new hires during orientation. We collaboratively worked with new nurses to identify opportunities for development and a timeline for the completion of a career plan, which was then shared with the unit manager and leadership.

The work of White and colleagues guided our understanding of the context of the project.² Understanding the context is key to the success of both implementing and sustaining a practice change. Context provides information about the unit's readiness for change and potential barriers to implementation. We defined context as the environment and culture of the two telemetry units with high first-year nurse turnover rates. To better understand the perceptions of the units’ staff regarding the culture and readiness for change, we used the Alberta Context Tool, which measures organizational context.³ The Alberta Context Tool assesses a person's perception of the context and can be collated to provide unit or facility data. The tool includes a series of questions that address various domains and concepts related to organizational context: leadership, culture, evaluation, social capital, informal interactions, formal interactions, structural and electronic resources, and organizational slack (staffing, space, and time).³

Findings from the Alberta Context Tool provided our project team with information about unit strengths and perceived barriers to change. Strengths included leadership, culture, and formal interaction patterns. Opportunities for improvement included social capital (that is, the interactions and connections among members of a care team), informal interaction patterns, and structural and electronic resources. Regarding the identified need for more social and informal interactions, we noted that nurses’ opportunities to converse with other team members were dependent on the shift they worked—those working the night shift have fewer chances to interact with members of the care team.

Implementation. We completed a literature review using several databases and focusing specifically on systematic reviews of implementation strategies. We appraised and assessed the quality of the evidence related to implementation strategies by using AMSTAR (A Measurement Tool to Assess Systematic Reviews).⁴ We also compared the context of each article to the context of our project, allowing us to choose strategies that have been studied in a hospital setting. In addition, we evaluated each article using the Joanna Briggs Institute levels of evidence.⁵ We chose implementation strategies using the Expert Recommendations for Implementing Change (ERIC), which provides recommendations for effective strategies that can be used with a QI project.⁶ In addition to our strategy of assessing barriers and facilitators, we used the following ERIC strategies to implement our program: audit and feedback, educational detailing and printed educational materials, and leveraging local opinion leaders.

We next selected two models to guide the delivery of the program. First, we utilized the Ottawa Model of Research Use, a knowledge translation model, to guide implementation of our program. This model consists of three processes: assessing, monitoring, and evaluating.⁷ Regarding the assessment process, the data from the Alberta Context Tool guided the identification of barriers to adoption: namely, staffing and inconsistencies with informal communication. For the monitoring process, we developed an adoption plan, using both e-mail and face-to-face meetings to overcome any communication barriers. In addition, we met with unit leaders to provide education on the program and to answer any questions.

Box: Pre- and Postassessment Questions

To determine if the intervention had been altered from our original intention, we systematically evaluated the effectiveness of our program using the plan–do–study–act model.⁷ This was the second model we used to guide the delivery of the program. It helped us to assess the impact of our intervention and implementation strategies. This QI methodology takes a comprehensive look at local influences on the intervention, enabling us to adapt the process in an iterative way to promote change at the local level.⁸ We assessed the effectiveness of the program through the use of pre- and postassessment questions and focus groups. The preassessment questions were sent by e-mail to each program participant before the follow-up meeting; the postassessment questions were sent by e-mail after the follow-up meeting (see Pre- and Postassessment Questions). The program coordinator subsequently held separate focus groups with the new nurses and their managers. We compiled the data from both the e-mail responses and the focus groups, and examined the findings to make small changes, as needed. These improvement cycles assisted us in organizing the monitoring phase described in the Ottawa model.

We developed educational materials and PowerPoint presentations that provided managers, staff, and new nurses with details about the purpose and goals of the program. This assured a baseline understanding among the staff nurses, their managers, and the first-year nurse turnover team of the purpose of the program, which proved to be a successful implementation strategy. Data collected during pre- and postassessment provided the most useful feedback. Organizing focus groups was also helpful, because this technique helped to engage the participating nurses. One noted that the most useful aspect of the program was “the professional opportunities available that I can use to advance my knowledge.” Another commented, “It's great that you want to know what our goals are and that you are helping us reach our goals.”

Evaluation. In 2017, a total of 23 first-year nurses left our hospital, three from the telemetry units. Between January and May of 2018—during the time of our pilot project—five first-year nurses left, only one from the telemetry units. This demonstrated the success of our program to retain new nurses during the pilot period.

Table 1: Pre- and Postassessment Results

We asked nurses the same questions during the pre- and postassessments (except for the question asking nurse to rate the benefit of the program, which was only asked in postassessment). Table 1 details our findings. We solicited managers’ feedback through the focus groups. They believed the program was beneficial because it gave staff the opportunity to share goals they may not have otherwise felt comfortable sharing with their managers. Although the project team wasn't able to address all the barriers identified in the context assessment, constant communication between the program coordinator and unit managers, in the form of face-to-face meetings (formal and informal) and e-mails, helped to reduce most barriers. In the follow-up meetings, we reinforced leadership's support for the new nurse's career goals and transition plans. In addition, the program coordinator shared a summary of the information she'd discussed with the newly hired nurses—regarding professional development goals, concerns, and planned activities—with each nurse's manager. This enabled our managers to work with the nursing staff to meet their goals (if they wish to transition to a different specialty or shift, for instance).

Lessons learned. Nurse turnover can be affected by factors that aren't related to the nurse's work environment (personal stressors or desire for a better work–life balance, for example). A healthy work environment has been cited as a characteristic of units with low turnover rates.⁹ Factors that can affect the nurse's perception and experience of the work environment include staffing, teamwork, leadership support, and workload. Nursing leaders can strive to manipulate factors that are within their control to promote healthy work environments and professional growth and satisfaction. Because positive work environments are built through collaboration and teamwork, nurse managers can, for instance, provide support to staff nurses through open communication. It is also important that they assess the context of their unit to better understand the nursing staff's perceptions.

As noted, several factors, including staffing and workload, were outside the scope of this project and have been identified in the literature as increasing turnover rates.¹⁰ Additional limitations included the small number of nurses hired during the span of the pilot project. In addition, it was difficult to arrange meetings between the project team and the night-shift nurses because of the difference in sleep schedules and the timing of work tasks. We recommend further evaluation of resources provided to night-shift team members. Such resources might include options to take classes at alternative times that align with their sleep and work schedules or online training that can be completed at their convenience. Finally, the results of the context assessment may not be representative of the unit, since the sample was small.

Implications and future directions. During the pilot project, the context assessment was not administered to all staff. In hindsight, the completion of the context assessment by a majority of the staff would have provided additional insight into the strengths and perceived barriers to change throughout the organization.

In describing our experience, we've provided a glimpse into the initial results of this program. Reevaluation after a year will provide deeper insight into the success of this change. Plans to expand this program to other units are currently in discussion.

We learned from this experience the need to optimize the strengths of key members of the team who were identified as early adopters and champions. Team members who are enthusiastic about a change or who are viewed by others as leaders should be engaged early to promote acceptance of the change. Developing a robust plan to incorporate and utilize champions can directly impact the sustainability of the program. We've also learned that the use of knowledge translation and QI models can be helpful in implementing such programs. There is no silver bullet to implementation; therefore, utilization of small tests of change and evaluation are key to the success of a project.

COMMENTARY

In this article, Baker and Vottero describe their experience with an EBP project, detailing the implementation strategies they used to improve the uptake and success of the Professional Development and Career Planning Program. Strengths of their project include the use of published models to guide implementation. They used the Ottawa Model of Research Use, the plan–do–study–act QI model, and a list of published implementation strategies (ERIC, for example) to improve the successful implementation of their professional development program. They applied the Alberta Context Tool assessment to first identify barriers and facilitators, which is a highly important and recommended first step.¹¹

These authors reviewed the literature for the most effective strategies and selected those that could help promote successful uptake of the program. Another strength of their project was the solid evaluation plan, which included hard data on retention rates and data from managers and nurses regarding the experience. Moreover, Baker and Vottero were able to articulate the strengths and limitations of the project along with future directions.

Clearly, successful uptake of EBP must include recognition that change itself is a journey, and that with the right tools and knowledge, the road traveled can lead to sustainable change. As identified by Baker and Vottero, approaching practice change from an iterative perspective allows for small tests of change that use evaluation data to continue to improve implementation of an EBP change in health care. The use of knowledge translation models, context assessments, and ERIC strategies provided a road map to making a sustainable change at this medical center.