Resurrecting an NLN to ICU Program – Filling the Void

With the severe nursing shortages in recent years, nursing has been making fundamental shifts in how it hires and orients RNs – especially newly licensed nurses (NLNs). Historically, many hospitals have imposed restrictions that limit NLNs from practicing in an intensive care unit (ICU) setting, but these positions are becoming difficult to fill with experienced RNs, and in many cases they remain unfilled, creating staffing shortages that make bedside staff and nursing leaders equally exasperated. At Brigham and Women’s Hospital in Boston, our historical NLN to ICU Program ran from 2004 to 2009, when shortages were few and far between. During the first two years of my nursing career, I was “flexed” off many shifts – neither my unit, nor others to which we regularly floated, needed me in staffing. Those were the days!

Prior to 2020, we saw a large cohort of the baby boomer generation retire, but the subsequent COVID-19 global pandemic not only wreaked havoc in waves, it made us witnesses to a massive exodus of experienced staff and continuing increases in patient acuity, resulting in an experience-complexity gap. The cycle of increased acuity, unavailable inpatient beds, lack of experienced staff, and multiple closures at nursing homes and long-term acute care facilities have caused a vicious number of challenges. These circumstances eventually led us to reevaluate the resurrection of our NLN to ICU Program. Specifically, we focused on two ICUs, the cardiac surgery and neuroscience units, both of which had multiple unfilled positions requiring nurses with experience, yet many NLN applicants.

When we huddled together to start planning, we began with a literature review and identified various themes among existing NLN to ICU programs at other facilities:

• Majority of programs were a minimum of six months, with some extended to 12 months
• Hiring metrics (work as a nurse’s aide, strong practicum experience and GPA)
• Consistency of preceptor development
• Socialization and teamwork

We then brainstormed qualities to seek in these candidates, and we came up with the following:

• 3.5 GPA or higher
• Previous work as a nursing assistant
• Senior-year practicum in an ICU setting, preferably a teaching hospital
• Strong references from practicum preceptor or clinical instructor faculty
• Open to constructive criticism or seeks feedback
• Flexible and open to change

After determining these starting points, we proceeded to the design phase, pulling together criteria from successful NLN to ICU programs through our research efforts. Vanderspank-Wright, et al. identified that NLNs “are at a higher risk for turnover within the profession as compared to their more experienced colleagues.” With the high amount of burnout in our critical care areas after three years of an ongoing pandemic and increasingly sicker patients, we decided that an onboarding program focused solely on the ICU would be too great a burden on these preceptors. Feedback received from our Nurse Executive Board during the 2004-2009 iteration of the program stated that “the path to competent, proficient, then expert is always marked by a progressive increase in clinical knowledge and critical thinking,” and “development as a nurse is a gradual process.” For this reason, we created a structured orientation, as follows:

• Three-month orientation to intermediate care
• Three months productive as staff on intermediate care
• Three-month orientation to intensive care

Just as Innes and Calleja (2018) noted that socialization “was found to positively influence confidence and competence during new graduate transition,” we made sure to cohort these six orientees together in all necessary classes, to create the framework necessary to facilitate camaraderie and connection. Classes include a basic dysrhythmia workshop and trach education, as well as their protected year-long monthly session of the Nora McDonough Nurse Residency Program. As they are on a different trajectory than the traditional intermediate care NLN, we sought to maintain the cohort to increase their connection and, hopefully, success. We were careful to choose primary preceptors and, when needed, secondaries to maintain as much consistency as possible. We are fortunate to report that all six orientees have completed their initial intermediate care orientation and are now productive staff members.

The next three months will continue to be crucial to the formation of their nursing skills, as well as growth and development of critical thinking. At the start of 2024, they will move to their hired ICU areas for 12 weeks of critical care orientation. Supplemented by the Essentials of Critical Care Orientation (ECCO) modules, they will receive the complete range of resources we have to offer. Additional classes will include two eight-hour days of our home-grown Critical Care Nurse Intern (CCNI) program – covering topics such as respiratory/ventilators, hemodynamics and procedural sedation. Additionally, we have scheduled protected time for debriefing and discussions between these NLN to ICU candidates and our critical care professional development managers. After this nine-month period, these NLN to ICU candidates will become fully productive in the two ICUs that were determined to need them most. We discovered other hospitals are also experiencing these challenges and adjusting their orientation time frames. We hope to compile and share our experience and findings in a comprehensive review, similar to Adams et al.

In addition to ECCO, AACN offers the following resources to support the orientation of nurses new to intensive and progressive care:

• AACN Competence Framework for Progressive and Critical Care: Initial Competency 2022
• Essentials of ECG and Dysrhythmia Monitoring
• Coming soon: AACN Knowledge Assessment Tool for nurses new to ICU and PCU
• Preceptor Training: Fundamental Skills for Preceptors
• Blog posts supporting orientation of new nurses
• Pediatrics and Neonatal:
• Essentials of Pediatric Critical Care Orientation 6.0
• Essentials of Neonatal Critical Care Orientation 4.0
• Nursing Communities
• Future and New Nurse Community
• Nurses in Professional Development

AACN also offers the following resources to support the development of continuing competence:

• Acute and Critical Care Pharmacology
• Webinars (e.g. Vasopressors and Pressure Injury in the Critically Ill Patient)
• AACN Core Curriculum for Progressive and Critical Care
• AACN Procedure Manual for High Acuity Progressive and Critical Care, 8th Ed.
• Community
• AACN Clinical Practice Community

Are you considering the NLN to ICU program journey to fill a staffing crisis? How successful have NLN to ICU programs been at your facility, if you have maintained them in past or current times? We owe it to ourselves and our future nursing workforce to share our experiences to create solutions that match the shifts we have seen and continue to experience in our workforce.