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PRECEPTOR PREPARATION IMPROVES RETENTION RATES

PRECEPTOR PREPARATION IMPROVES RETENTION RATES

INTRODUCTIONThere is no question that a nationwide nursing shortage exists. Recruitment and retention of new nurses is a continu-ing and significant problem for healthcare organizations. RN turnover in the first year of hire can be significant in terms of cost and employee morale, and can have potential effects on patient safety and quality of care. The use of a clinical coach or preceptor for a new nurse leads to improved orientation and onboarding outcomes. Preceptor selec-tion, preparation, and ongoing follow-up and support contribute to the development and maintenance of preceptor competence. Improved nurse satisfaction with a competent preceptor reduces turnover rate. The purpose of this white paper is to summarize the scope of the problem, discuss contributing issues, and introduce strategies that lead to best-in-class preceptor preparation.

SECTION I. SCOPE AND SIGNIFICANCE OF THE PROBLEMThe Nursing Shortage: RNs comprise the largest group of healthcare employees, holding 2.5 million jobs, 59% of which are in hospitals. Employment of RNs is expected to grow 23% from 2006 to 2016 as up to 587,000 new jobs are created.1 Increasing medical knowledge and technological advances, which enable more complex procedures and treatment of more patients, and the aging population contribute to the need for more nurses, which in turn continues the nursing shortfall. In turn, the mean age of nurses is rising, leading to a loss of nurses through retirement. The Health Resources and Services Administrations (HRSA) Bureau of Health Professions projects a 12% nursing short-age by 2010 and 20% by 2015, figures based on an increase in demand for but a stable supply of nurses.2 HRSA projects that without aggressive intervention, the supply of nurses in America will fall to 36% below requirements by the year 2020.3 It is estimated that from 2006 to 2016 the healthcare system will require more than 1 million new nurses to meet this growing demand and to replace retiring RNs.4

The American Association of Colleges of Nursing (AACN) in their Nursing Shortage Fact Sheet cites evidence that insufficient staffing raises the stress level of nurses, affecting job satisfaction and driving many nurses to leave the profession.5 Recruitment and retention of new nurses continues to be a priority for healthcare organizations, which can expect to hire many new and experienced nurses in future years. Competent, well-prepared preceptors can be an important facet of successfully onboarding new nurses.

Nursing Vacancy Rates and Turnover: Hospitals invest many resources in recruitment and retention strategies for RNs. One strategy is the Magnet Recognition Program, which started in 1983 as an effort to research and identify hospital variables that attract and retain well-qualified nurses to provide quality care. Magnet hospitals consistently have lower RN vacancy and turnover rates, which may be attributable to widespread use among these hospitals of new-hire intern, residency, and unit-based orientation programs led by preceptors.

Although investment in retention programs has successfully lowered overall turnover, evidence shows less success with turnover within the first year. Among all occupations, turnover of first-year new hires accounts for more than one-third of turnover among all employees; the 2007 median rate of turnover was 17.1% for first-year employees compared with 13.6% for all employees.6

Reducing RN turnover saves money. According to White Plains Hospital Centers CEO Jon Schandler, improved nurse retention, an effect of pursuing Magnet designation and other initiatives, positively affected the hospitals bottom line: In 2008, we reduced RN turnover by 3% for $1.4 million in savings.7

The Advisory Board Company estimates the replacement cost for an RN to be $62,100 to $67,100.6 Dr. Christine Kovner and colleagues found that 13% of newly licensed RNs had changed principal jobs after one year, and 37% reported that they felt ready to change jobs.8

The National Council of State Boards of Nursing (NCSBN), in their mission of public protection through safe nursing practice, recently conducted research to study transition into practice. The goals of the study were to describe the transition experience of new RNs, identify influencing factors, and examine how the transition experience affects

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PRECEPTOR PREPARATION IMPROVES RETENTION RATES

clinical competence and safe practice issues of new RNs. NCSBN reported a turnover rate for new RNs within the first year of practice to range from 35% to 50%.9 According to the NCSBN, the transition process is a period when new RNs become increasingly independent, and preceptors are vital to that process.

Growing evidence suggests that the intense workload resulting from constant onboarding demands is exacerbating turnover rates. Preceptors and other staff tire of constantly orienting staff who do not stay on the job or who stay on the job but cannot do the job. The issue of clinical quality is significant and cannot be overlooked. New hires, many without clinical expertise, pose safety concerns and potential for financial losses from the Centers for Medicaid & Medicare Services (CMS) and other payers. It is this preparedness gap that fuels the nursing shortage; novice nurses are not prepared for the clinical realities of complex work requirements. Organizations must have strategies in place to reduce nursing turnover. Adequately trained and supported preceptors enhance the onboarding process for new nurses.

Preceptor Programs Increase New Nurse Job Satisfaction and Reduce Turnover: There are many variables that influence turnover for newly licensed nurses. Pellico and co-authors discuss several qualitative and quantitative studies that examined this transition phase of the new nurse.10 Lack of social support is positively linked with turnover intentions, whereas work group cohesion is negatively linked with turnover intentions. The preceptor plays an integral role in both of these aspects of onboarding new nurses.

Preceptor or clinical coach models have been used in nursing for many years. Effective preceptor programs skillfully transition the novice nurse (new to nursing or new to a specialty or setting) to the work setting. There is no dispute that effective preceptor programs increase new nurse job satisfaction and reduce RN turnover. In its report, The Impact of Transition Experience on Practice of Newly Licensed Registered Nurses, the NCSBN stated that during the first three months of practice, new RNs who had a primary preceptor practiced at higher competency levels whereas those who were without the guidance of preceptors practiced at less competent levels during the first three to six months of practice.9

Preceptor Selection Linked with Successful Orientation Outcomes: The goal of precepting is to ensure that new staff are competent to fulfill the responsibilities and functions of their assigned positions and to seek prompt assistance from the manager and educator when the orientation is not positively progressing. Table 1 summarizes the responsi-bilities of nurse preceptors.

TABLE 1. RESPONSIBILITIES OF NURSE PRECEPTORS

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Assess learning needs

Develop and implement a learning plan

Teach how to manage patients on a particular unit and shift

Evaluate clinical competence

Teach critical thinking

Document learning and clinical progress

Facilitate social interaction and foster acclimatization to the organizations and units culture

Role-model interpersonal skills for interdisciplinary collaboration and patient satisfaction

Collaborate with manager and educator to promote positive orientation outcomes

PRECEPTOR PREPARATION IMPROVES RETENTION RATES

The success of a preceptor program begins with the nurses chosen to be preceptors. Although preceptors need to be knowledgeable about the specialty, they also need teaching, learning, and interpersonal skills (Table 2). Nursing has long known that clinical competence is not the only skill needed to become a successful nurse manager. The same goes for being a successful educator or preceptor. The most important selection criterion is that the nurse wants to take on this expanded role. Preceptor selection (Table 2) should not be based on convenience, such as schedule or implied knowledge that comes with longevity.

Potential preceptors need to be clinically competent. They should demonstrate advanced knowledge of pathophysiol-ogy, treatment modalities, nursing skills, equipment, and population-specific and culturally competent care related to patients commonly cared for on a particular unit. Potential preceptors utilize current hospital policies, procedures, and clinical guidelines in rendering care. They demonstrate use of the nursing process, critical-thinking skills, and principles of delegation and time management. Nurses chosen to be preceptors guiding new staff should problem-solve and prioritize effectively by evaluating a situation objectively and, if appropriate, referring it in a timely fashion. They must be able to collaborate effectively with the interdisciplinary team. Managers and educators select nurses to be preceptors who implement appropriate interventions so that positive patient outcomes and timely discharges are achieved. Potential preceptors are staff who regularly and appropriately inform the nurse manager and educator about team members performance, unu