Sunday September 23rd 2018

Stepping into a culture of safety

Onboarding programs help retain nurses, strengthen patient care

newly hired nursesRetaining newly hired, competent nurses — whether new graduates or experienced RNs — is good is for everyone: employers, staff, patients and the new employees, themselves. What are vital to their tenure, however, may be how they are transitioned into the workplace and whether the organization is committed to a culture of safety.

“Orientation is the first step in retaining nurses,” said Dennis Sherrod, EdD, RN, professor and Forsyth Medical Center Endowed Chair of Recruitment and Retention at Winston-Salem State University and a member and past-president of the North Carolina Nurses Association. “Although it’s difficult when working with a large group of new employees, it’s important that the orientation be nurse-centered, meaning individualized as much as possible to their needs, that there is a mentorship piece in place and that newly hired nurses are introduced to the culture of the workplace early on.”

Nurse turnover is an ongoing issue — with some health care facilities faring better than others. According to the 2016 National Healthcare Retention & RN Staffing Report by NSI Nursing Solutions, Inc., the turnover rate for bedside RNs rose to 17.2 percent in 2015, an increase from 16.4 percent in 2014.

According to a 2014 article in Policy, Politics, & Nursing Practice, New York University College of Nursing Professor and researcher Christine T. Kovner, PhD, RN, FAAN, and colleagues reported that about 17.5 percent of new nurses leave their initial job within the first year.

Beyond the upheaval on units, nurse turnover is costly. The NSI Nursing Solutions, Inc., report noted “the average cost of a turnover for a bedside nurse ranges from $37,700 to $58,400, resulting in the average hospital losing $6.6 million. (Some reports place turnover costs even higher.)

Offering smoother and safer transitions

An overarching goal of Southeastern Health’s orientation program is promoting a culture of safety in newly hired employees – both new grads and experienced nurses, according to Cynthia McArthur-Kearney, DHA, MSN, RN, NE-BC, manager of Education Services at the North Carolina hospital system and NCNA member. This is accomplished, in part, by using concepts outlined in TeamSTEPPS.

TeamSTEPPS is a system aimed at assisting health care professionals to provide higher quality, safer patient care by strengthening their skills around teamwork, communication, conflict resolution and eliminating barriers to ensuring the best clinical outcomes for patients.

All RNs going through the nursing services orientation are exposed to the program’s concepts, and all preceptors receive specialized TeamSTEPPS training so they can reinforce important concepts specifically to new grads during orientation and in their residency program.

“We don’t need to train new grads on how to insert catheters or change dressings,” McArthur-Kearney said. “Although the tasks are important, we want to teach them critical thinking. And the focus needs to be on safety. We need to make sure new grads – and all our nurses – understand what a culture of safety looks like and why it’s important.”

For example, preceptors working with new grads emphasize the importance of teamwork to achieving positive patient outcomes, understanding the roles of each team member, and how to communicate effectively with team members, including patients and their families. Role playing is often employed, such as learning how to have an effective conversation with a team member who may want to do a clinical task in an outdated way, explained McArthur-Kearney.

“To have a culture of safety, nurses also need to be aware of their environment, what’s going around them,” McArthur-Kearney said. “So we emphasize that if a nurse sees a team member who is not filling a role during a code or who appears overloaded with an influx of patients, for example, that nurse must step up to ensure the best patient outcomes.” They also are taught how to identify when a situation may be getting out of control, as well as de-escalation strategies.

Another important component of on-boarding at Southeastern Health is orienting all newly hired staff on concepts outlined in the hospital’s strategic pillars. These concepts focus on embracing a language of caring, being fully present when interacting with colleagues, patients and family members, and showing kindness, including through non-verbal cues.

Added McArthur-Kearney, these strategies not only help to create and maintain a culture of safety, but also help with staff retention.

Another approach to quality and safety

The University of Alabama at Birmingham Medical Center changed the way it conducted its orientation and residency programs for new hires about four years ago, according to David James, DNP, RN, CCRN, CCNS, who previously served as the advanced practice nurse coordinator for Clinical Nursing Excellence at UABMC and is an Alabama State Nurses Association member.

“Orientation used to be more of an inservice-type model with a lot of content and a ‘parade of stars,’ where staff from various departments were given a few minutes to discuss their roles,” James said. “Now we’ve moved to a different model, taking the Quality & Safety Education for Nurses competencies used at the UAB School of Nursing and using them for our orientation schema.”

Developed by nurse leaders involved in the QSEN initiative, the competencies address quality and safety education around patient-centered care; teamwork and collaboration; evidence-based practice; quality improvement; safety; and informatics. (Please see the QSEN Institute website at

Each day of the UABMC orientation is linked to one of those core competencies, James said. And although having everyone understand that patient safety is essential, it’s extremely important that nurses know what systems are in place to support patient safety – whether it’s evidence-based practice or the use of technology.

In terms of structure, all newly licensed RNs attend the five-day orientation, which also addresses UABMC workplace culture, and then participate in a yearlong residency program to help ease their transition into practice and hardwire key competencies, according to Connie White-Williams, PhD, RN, NE-BC, FAAN, the director of UABMC’s Center for Nursing Excellence and an American Nurses Association member.

“Our onboarding process for experienced nurses beyond the orientation is unit-based and individualized to their needs,” she said. For example, a nurse who has 15 years in cardiac care and is hired onto a neuro unit should not be expected to take a full workload as quickly as someone who was hired onto a unit they have vast experience in.

Further, White-Williams added that about a month after their employment, she and Chief Nursing Officer Terri Poe, DNP, RN, NE-BC, meet with these experienced nurse hires to get their input about what went well, where improvements can be made and whether they feel welcomed.  And experienced nurses, like new grads, are assigned preceptors who serve as an ongoing resource.

But to ensure a culture of safety and to retain staff takes more.

“We have probably 900 new nurses this year who we are trying to successfully orient and onboard,” White-Williams said. “We’re no different than anyone else in terms of trying to retain folks. It really does take a village to do this successfully, and it takes a lot of resources.”

A journey toward safety

“We say let’s hire for attitude and train for skill,” said Clyde A. Bristow III, MSN, RN, CENP, chief nursing officer at Wake Forest Baptist Health Lexington Medical Center and director of Clinical Education. “We can teach nurses how to insert an IV, but what we’re looking for are things like how does the nurse engage and communicate with patients, do they make them feel safe.”

Safety is an ongoing theme at WFBH. All newly hired staff must attend a four-hour program called Safety Starts Here within their first 90 days of employment, according to Bristow.

“We start early by weaving in culture of safety principles – those based on high reliability and best practices – throughout our [orientation and new grad residency] programs, and all newly hired nurses must integrate them into their care,” Bristow said. Those principles range from engaging in daily safety huddles to maintaining  patient privacy to working collaboratively with all disciplines, and they are constantly reinforced.

All new hires also must commit to WFBH’s “patient and family promise,” according to Phyllis Knight-Brown, MSN, RN, WFBH clinical education manager and a member of the Association of Nursing Professional Development, an organizational affiliate of the American Nurses Association. That promise speaks to staff pledging to patients that they will keep them safe, care for them, involve them and their families in care, and respect them and their time.

“We also try to empower all our nurses to feel they can say, ‘I have a concern’ or ‘I need help,’ especially new nurses so they are not struggling alone,” she said.

Looking specifically at newly hired, newly licensed RNs, WFBH provides them with a yearlong, residency-type program called Journeys. It consists of a general and a unit-based orientation; a structured preceptorship; quarterly workshops, which include simulated practice and didactic sessions; and the opportunity to network and gain support from their co-hort. Workshop content is specific to new nurses’ units, however, the eight-hour sessions also cover issues such as stress management and self care, cultural competence and diversity, safety terminology and resources, patient instability, and shared governance.

“We have some flexibility in the program so we can tailor it more to the needs of our new nurses,”
Bristow said. “We don’t want to find out on the 89th day that they don’t get along with their preceptor or haven’t learned how to do x, y or z. So preceptors and nurse managers meet often to determine where someone might need training. Then that nurse is placed in a situation where he or she can learn, which really benefits them as new nurses.”

WFBH also has a network of resource nurses, including preceptors, who can continue to provide guidance and information after the orientation and residency is complete.

Final comments

There is no secret recipe to creating a good orientation and onboarding program to retain competent and safety-focused nurses, according to Sherrod. However, it needs to be competency-based, nurse managers and staff need to celebrate and welcome new hires, and everyone should have a mentor.

Beyond orientation and residencies, retention also is dependent on factors such as workload, effective collaboration, strong professional practice roles and a healthy work environment.

“Having this retention culture is a way to help prevent a revolving door of new hires and strengthen an organization’s culture of safety and retention by providing nurse-centered orientations and work policies,” Sherrod said. “And retention is everyone’s responsibility.”

— Susan Trossman is a writer-editor for the American Nurses Association.

Correction: A previous version of this story incorrectly stated that the QSEN initiative was led by the American Association of Colleges of Nursing. QSEN is led by the QSEN Institute, which was originated by a small group of nursing leaders and originally housed at the University of North Carolina School of Nursing, then transitioned to Case Western Reserve University School of Nursing. AACN participated in Phase II and III of the project. Learn more at

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