As part of its onboarding process for new graduate nurses, Inova Health System developed a clinical mentor extender program to bridge the transition between orientation and working on the unit. This is a critical time when many new grads may be struggling with rea, and support is still needed.
AACN clinical practice specialist Sarah Delgado spoke with two of the program's nurse leaders, Priscilla Trewartha and Maureen DeSena, to learn about its impact.
Sarah Delgado:
Please explain the Clinical Mentor Extender program and what it aims to do.
Priscilla Trewartha:
The goal of the Clinical Mentor Extender program is to support our new graduate nurses after orientation and through their first year of practice. It is done in collaboration with the hospital's professional practice and leadership teams. The extenders meet the grads on their units at the bedside, and they're providing support in both clinical and nonclinical areas. The goal is to have that opportunity for the grads to seek advice, share their triumphs, talk about their challenges, and for the mentors to provide mentorship to the grads in their environment during their transition to practice in that first year.
Sarah:
What prompted you to create the clinical mentor extender role? And can you talk a little bit about the challenges you faced with new-nurse retention?
Maureen DeSena:
The clinical mentor extender role was created to provide additional support to new graduate RNs throughout their entire first year of transition to practice. We also recognized during their first year that turnover was a concern, and we planned to hire larger numbers of new grads than ever before. We were also aware of weaknesses with their programming in school and access to our facilities for clinical experience due to the pandemic. We hoped that the additional support would make them more successful and that we would retain them. We were experiencing a significant shortage of nurses. We had over 700 vacancies. There was a 25% overall nurse turnover rate, and a 19.8% new graduate first-year turnover rate, which is better than the national turnover rate, but we wanted to improve.
A proposal was submitted to the executive cabinet to increase hiring by 100% from the prior year. And this would've equated to 1,200 nurses hired throughout 2022. Knowing that the market was new grads, we set a lofty goal of hiring 1,000 new grads and 200 international nurses. That's how the 1,200 came to be. The goal was to reduce the turnover rate of the new grads and improve retention.
Sarah:
What are the clinical mentor extender's specific goals when they're working with one of the new nurses?
Priscilla:
Our goal is simple, which is to support them. And when we encounter that new grad, if they have a clinical question or they are looking for clinical advice, we support them. Or maybe they're looking for strategies on how to prepare for a night shift or how to work their first holiday when their family's at home. Every interaction is different because we're following that nurse's lead in what kind of support they need at that moment. I think that this speaks to us meeting them in their environment and kind of molding and being flexible to make that encounter meaningful for that nurse.
Sarah:
Can you talk about how the program has been successful in meeting the identified challenges so far?
Maureen:
We feel like we have been very successful. Our first mentor extender team began rounding in March 2022. From March to December 2022, the clinical mentor extender team performed 12,600 rounds throughout all five hospitals in Inova Health System. We can drill down in our data on the areas of focus on where they needed support. We developed what's called a “referral algorithm,” which has been key to the clinical mentor team as well as Priscilla and myself because we get alerted with any nurse that has been identified as a risk for leaving the organization. Our goal of this program is to reduce turnover, and we need to know when we're at risk of losing a nurse.
Our program results in an automatic communication to Priscilla and me. From July 2022, when we went live with the electronic database, through December, we had a total of 24 new grads that were identified as a risk for leaving the organization. And as of today, 21 of them are still here. We wondered, "What does that equate to?" and we went to the NSI 2022 data; their range of cost of turnover was recently updated and increased to $46,000. So, that equates to over a million dollars in cost avoidance for retaining our nurses.
Priscilla:
I think one of the unintended outcomes that we had was actually the satisfaction in the extenders themselves. Nursing had just gone through a pandemic. They were burned out, especially our experienced nurses. It was a very trying time where you show up to work and every day, something's changing, and you're adapting. And so with our extenders, a lot of them were at the point where they were saying, "I don't want to leave Inova, but I don't want to work full-time." Or sometimes they're saying, "I want to get back into something, but I don't want to work full-time. And I want to be able to give back." Giving back to the new grads was always the theme. When we ask them how much they enjoy the role, they go on and on, and rave about it.
We hear comments such as, "I have gotten so much professional growth and satisfaction with this role and being able to give back post-pandemic, and being able to be there to support those new grads because I know how hard it was. And I wish that I had this program when I was a new grad." Other nurses who see us rounding say things like, "I wish you were here for me when I was a new grad." Because they see the value, and they can feel it. The other outcome we are looking for is the new grad's perception of support, and we survey them as well. Our survey shows that 87% of the new nurse grads report they feel very supported by the program, which is exactly what we were looking for.
Sarah:
I know an important feature of this program is that the mentor extenders come from the system level. Can you talk a little bit about the benefits of that?
Maureen:
It is very beneficial because the clinical mentor extenders are a neutral party. They create a psychologically safe space, as all conversations are kept confidential. They establish that safe space with each encounter. In all transparency, one of the biggest challenges has been that unit leadership was not used to team members from the system level in their space speaking to their employees. So, we had a lot of communication to explain the role and gain buy-in. We've developed and strengthened those relationships. Many unit leaders now see the value and reach out proactively for assistance with our new nurses.
Sarah:
Priscilla, I know when you were working to build the clinical mentor extender role, one of the important features was distinguishing it from the role of the nurse educator, which was already in place. Can you talk a little bit about the differences or similarities between clinical mentor extenders and nurse educators?
Priscilla:
Every nurse is an educator in some facet, but the roles of the extender and the formal nurse educator are very different. When we were looking to hire the clinical mentor extender team, we required preceptor experience. The extender is providing education at the bedside during their rounds if something comes up versus at Inova, where nurse educators focus on education for all nurses, not just new graduates. Nurse educators have a lot of other responsibilities, such as annual competencies, new education initiatives, recognizing that there's been a couple of safety events. or that the staff are asking all the same questions, and then preparing customized education for that unit. We partner closely with nurse educators, because while we provide education in the moment, sometimes a follow-up is required by the unit educator. Then I do reach out to that nurse educator for that unit to give them a brief synopsis. So, it's all about partnership, but they are very different roles. The nurse educator at Inova also requires an MSN. whereas our clinical mentor extenders require a BSN.
Sarah:
If you were talking to another nurse leader who wanted to develop a program like this, where would you recommend they begin?
Maureen:
I think they need to, first, determine where their opportunities are in their organization to address them. Factoring in if they have enough support to give the new nurses the support they need for the entire year is important. Asking what are the current resources that they could, perhaps, use to expand that support to ensure first-year success. What is their turnover rate? They need to look at the cost of their turnover rate, and if it would balance out and save on retention.
Priscilla:
A key lesson for me was about never underestimating the importance of in-person communication. It is so easy with today's technology to rely on emails, meeting report-outs via Zoom, not only during that implementation, but more importantly with all of the following program iterations and continuing to build those relationships in person with as many unit leaders as possible. And that, to me, really has been the key to pushing the program forward. Over the past year, I rounded at every hospital in our system. Maureen and I even called it the Clinical Mentor Extender tour. And some of the most valuable improvements have come from that tour. Now, we're working toward having standing check-ins and rounds so we can continue to build that partnership.
Sarah:
Priscilla, I know the launch of this program also coincided with your shifting roles and new education. Do you want to talk a little bit about that alignment?
Priscilla:
I was in my DNP program and looking to graduate in 2021. I've been with Inova since I was a new grad. So, I'm part of the fan club. I believe that Inova has such great values that really mimic my own. and it was really important for me to stay at Inova while looking for that next step. I reached out to Maureen and knew that she was a part of professional practice. And that's when you just start putting your feelers out there, and I said, "I'm going to graduate soon. And if you have anything coming down the line, I'm interested."
The stars aligned a little bit. I was able to transfer in January 2022. That's where Maureen and I started with a piece of paper and a pen and said, "What is this going to look like?" And it has been just an amazing journey, so much personal growth and professional growth.
Sarah:
That's so important with nursing. Our careers are a journey, and finding new paths along the way is so exciting. Maureen, do you have other thoughts on that alignment, on bringing Priscilla into the program and how things came together?
Maureen:
It is important to put the Clinical Mentor Extender program in context; that it was one of several initiatives that professional practice has offered to our new grads for their transitions, especially those coming out of COVID. Besides the Clinical Mentor Extender program, we run a new-grad boot camp, and that came out of COVID. It's the only time that all of our nurses come together face-to-face for training. The topics have changed since the pandemic, but they still come together. We talk about prioritization, delegation and communication. Priscilla coordinates that. And then she also coordinates system nursing essentials, bringing all of the nurses, experienced as well as new graduates, to a Zoom session, to go over all of Inova's initiatives with onboarding. And so having standardization has been wonderful because all of our nurses are hearing the same content.
Sarah:
Can you talk about the electronic documentation system that you developed for the program?
Priscilla:
Yes. Documenting electronically really was a big game changer for us. When we first started, we were capturing everything on paper, and there were major gaps. We partnered with our patient experience team and were given the opportunity to build a custom template in the electronic database. We were able to make it what we needed, and because we'd been rounding with pen and paper for so long, we had that vision pretty clear. Now, the extenders are able to see each other's notes. They're able to easily follow up from prior encounters. And we're able to capture a lot of the data showing the number of rounds and, most importantly, the areas of focus.
That data is then being turned into usable reports that guide the care site teams on where to focus with the new nurses. And it's also important to mention that psychological safety is key here. We keep that template private among our Clinical Mentor Extender team and ensure that information or trends shared with unit leaders and executive teams do not include identifying information.
Sarah:
I do want to highlight your having the chance to design the template. I think the engagement of the people doing the work and designing the documentation of the work is an essential piece across all that nurses do.
Priscilla:
It really was. I was able to query a couple of the extenders and ask, "What changes do you need? What's good? What's bad? What should we add?"
Maureen:
I remember the person who helped us with designing the documents said, "Finally, nursing is coming to the table to utilize this technology that we have." She was thrilled to work with us, and she has since developed a template specifically for our operating room nurses.
Sarah:
Can you talk about the backgrounds and experience of the clinical mentor extenders?
Maureen:
When we originally started this program, we thought we would hire our retired nurses. So, we looked to bring recently retired nurses from our organization back to the bedside to help with that experience complexity gap in bringing in all of their knowledge of their years of nursing. But we were not successful. We didn't get any retired nurses that wanted to come back to the bedside. We had to cast a larger net to figure out how we were going to fulfill the role. We have academic partnerships with a lot of our local nursing schools, so we sent a flyer to them. And we actually got quite a few responses.
Priscilla:
Yes, 43% of the team has a formal academic education background in nursing, as an instructor or clinical faculty, 23% have a BSN, 51% have an MSN and 26% have a DNP or a PhD. The added benefit is that they're bridging that gap between the hospitals and the nursing schools. And some of them are then taking it back to their full-time educator jobs and building things into test questions, because they're seeing what the new nurses are struggling with and are then better able to prepare that next cohort of new grads coming in. So, having that partnership of them doing the clinical mentor extender role, there's a benefit to the current students that we really didn't expect.
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