Healthcare systems are experiencing unpresented workforce shortages and worker burnout. Past nursing shortages have been focused, impacting designated segments of the hospital, whereas the current shortage is impacting all areas of the healthcare workforce from entry-level positions to providers.1 The traditional interviewing and onboarding model involves the interested nurse applying to a specific position based on the nurse's perceived desire for the position or department and assumes the nurse wishes to remain in that position on that unit for their entire work life cycle. The traditional model has a complicated application and onboarding process, involves multiple silos, and results in process delays and dissatisfaction.2 Once the nurse is hired, the Human Resources department typically has no proactive contact with the nurse to ensure a personal and professional fit for the hired role and future professional goals of the nurse. The current system may lead to dissatisfaction and stagnation in careers, which results in nurse disengagement, burnout, turnover, and vacancies.
Our nurse managers experienced these same frustrations, becoming overwhelmed with the processes of hiring, onboarding, and ongoing nurse development. Despite the nurse managers' best efforts, there can be delays and missed opportunities, resulting in dissatisfaction for all involved.3 The nurse managers expressed frustration that much of their time was spent performing clerical functions related to onboarding instead of focusing on establishing a personal connection with the nurse.
Most nurses currently entering the workforce are part of a generation known to maintain loyalty to their personal professional development versus loyalty to the organization. When millennial and Generation X workers become frustrated with the complicated system, they walk away rather than tolerate the system.4 They demand a seamless application process, instant feedback, and opportunities to continue career progression.4,5 Once the nurse is hired, the nurse manager must turn their focus to retention. In 2021, Marufu and colleagues conducted a meta-analysis reviewing factors influencing nurse retention.6 The authors identified several factors related to retention; high on the list was lack of career advancement opportunities (lacking the ability to advance and learn new skills). Nurse managers expressed concerns about not having time or resources to respond to the continued professional development needs of the nursing workforce.
Our solution: The PPDC
After reviewing challenges with hiring, onboarding, and continual development of the nursing workforce at our healthcare facility, our leadership team began to develop a new vision for the future. This vision led to establishing a Professional Practice Development Center (PPDC). The leadership team couldn't identify any similar centers in healthcare. Instead, they turned to outside industries, such as government career centers, and personal experience with academic career advisers to create the PPDC. The PPDC allows a focused team to centralize and streamline the entire work life cycle of the nurse, from interviewing and onboarding to ongoing professional development.
This article will describe the PPDC model and explore the goals of the center, interview processes, professional advising, lessons learned, and outcomes in an acute care hospital setting. Of note, this article focuses on the nurse, but other nursing positions such as patient-care associates and technicians use the same processes.
PPDC framework
The PPDC was newly created to support workforce continuity from interviewing, onboarding, and career development. The PPDC is led by a nursing director who supports the professional advisers, onboarding coordinators, and clinical educators. Professional advisers, who have prior leadership or career advising experience, are the foundation of the department. Advisers work closely with the nursing units to understand their culture and needs as they relate to current and future open positions. The advisers schedule periodic meetings with the nurse managers to provide a consistent flow of information. The other position in the department is an onboarding coordinator, who's responsible for all activities after the nurse has accepted a position. The coordinator communicates regularly with the nurse, schedules all orientation activities, and completes all requests for access to the electronic health record (EHR), doors, the automated dispensing cabinet (ADC), and more (see Table 1).
Goals of the center
Acknowledging evidence-based practices and recognizing the workforce challenges, the goals of the PPDC are to:
* reduce hiring time,
* increase satisfaction with the hiring process for both the nurse and nurse manager,
* reduce administrative burden for the nurse manager,
* ensure every nurse finds the best fit within the organization matching the nurse's skills and competencies to the unit needs, and
* provide guidance for the nurse's ongoing professional goals.
Every day a nurse position remains open results in a financial and quality burden to the hospital. Reducing the time positions remain open and ensuring nurses are hired in the right position initially are elements of success for all involved.7
The traditional hiring and onboarding model is time-intensive and can result in significant workload burden on the hiring manager, who spends critical time completing interviews, establishing nurse access, and making sure all required paperwork is completed. Much of this time isn't value-added for the nurse manager and results in minimal time for the nurse manager to work with the team on critical elements for nurse retention, such as culture and system improvement. Relying on the nurse manager to contact new nurses and conduct initial interviews can lead to delays, which can jeopardize the hiring process if the nurse applicant perceives the delay as unresponsiveness on the part of the nurse manager or if another organization reaches the nurse sooner. Reducing time to initial contact with the applicant improves the likelihood of securing the nurse and greater nurse satisfaction.7,8
Recognizing a shorter hiring process is a best practice, the PPDC established a reduced timeline for hiring nurses as a performance metric. When a nurse applies for a position, an adviser reaches out to the nurse within 1 day. The adviser then conducts the screening interview and establishes next steps with the applicant based on their interest. By centralizing the initial contact, the adviser can reach the applicant in more a timely manner than the nurse manager who has competing priorities. The PPDC advisers have reduced the time to initial contact with the nurse applicant by over 48 hours or longer for some units, which has contributed to improved hiring success.
After the nurse has accepted a position, the PPDC continues to guide the nurse through the onboarding process. The PPDC onboarding coordinator primarily completes these tasks, including all necessary documentation and access requests for the nurse based on the nurse's hiring unit. Having one person responsible eliminates errors and delays that previously occurred. Prior to hiring nurses, the onboarding coordinator meets with the nurse manager to determine standard work to ensure no access needs are missed before the nurse's start date. By completing these administrative steps, it's estimated that the PPDC saves the nurse manager more than 3 hours of time per new nurse. Another benefit of having an onboarding coordinator is the personalized connection for the new nurse. The onboarding coordinator contacts the nurse several times prior to their start date to verify they have all the necessary information, such as required personal documentation for new hire paperwork and their orientation schedule.
Finding the right fit
There are two different "fits" for a nurse to consider for optimal personal and professional growth: where to practice and desired work status. A new graduate nurse may not understand the variety of departments and career pathways available for both short- and long-term development.8 Experienced nurses may know where they wish to practice based on their professional experience but may not be aware of the variety and flexibility of work status options or unique opportunities available within the organization.8,9
Department placement
During the adviser's initial conversation with the new or experienced nurse, understanding the nurse's short- and long-term personal and professional goals is critical to success. New graduate nurses traditionally are attracted to areas such as critical care, ED, labor and delivery, or neonatal departments, and historically these departments have a lower demand for new graduates.9 Experienced nurses may face a similar challenge if they want to work in a specialty area of nursing but are unclear about how to establish a path to that area. In the traditional hiring model, the specialty nurse manager may "reject" the nurse in the system because of a lack of immediate need and fail to discuss with the applicant other opportunities in the organization or alternative ways to attain their goal.9 At this point, the nurse may move on to seek employment opportunities at other facilities.
Dyrbye and colleagues surveyed more than 6,900 nurses about their career choices. Of the respondents, 15% indicated that they had career choice regret, and those nurses experienced a higher degree of burnout.8 To prevent career choice regret, the authors recommend career advising as a strategy to ensure the nurse is hired to the right position and has a professional development plan to support their goals. The PPDC works with each nurse to either secure a position on their desired unit or develop a path to that area. Finding the right placement and establishing a clear career pathway can reduce the likelihood of career-related regrets.8
After the nurse has secured a position, the adviser continues the relationship with the nurse, which can benefit both the nurse and the nurse manager. Despite the best intentions, there are situations where, even after proper planning and discussions and rigorous interviews, the nurse is placed on a unit that isn't the best fit. Improper fit can be related to the unit culture, communication challenges, or patient population. Most nurse managers have experienced a new nurse arriving on the unit excited for the opportunity only to find that the unit doesn't fit the nurse's competency, personality, or professional goals. In some cases, the nurse will resign from the facility, and in extreme cases, the negative experience can cause the nurse to leave the profession altogether.
In the traditional model, the nurse manager may work with the nurse to determine the appropriate location for transfer or leave it to the nurse to determine their next steps. In the PPDC model, the nurse manager refers the nurse back to the PPDC adviser for further exploration of a different location that meets the cultural and competency fit of the nurse. This process helps retain the nurse in the system and in a placement that allows professional fulfillment for the nurse and a positive outcome for all involved.
In addition to proper placement, nurse managers can benefit from understanding a nurse's desired career path. The adviser becomes a resource for the nurse to have honest career discussions to help them reach their personal and professional goals. Based on our conversations with nurses, they said they didn't feel comfortable having these discussions with the nurse manager because they didn't want to be disloyal or let the nurse manager down if they wouldn't be staying long-term on the unit.
For those nurses who've had successful placement and have an established career pathway, the initial hiring nurse manager has clear expectations about how long the nurse will remain on the unit before moving to the next phase of their career journey. The initial nurse manager can then proactively plan for the vacancy and hire a replacement in advance so there's no gap in coverage. The next nurse manager on the pathway will know when to expect the nurse on the unit and can determine an appropriate orientation plan for this nurse. The orientation for this experienced nurse often requires less time and fewer resources because of the organizational knowledge gained in their previous position.
Work status
The current nursing workforce desires options beyond full-time employment. 6,10 Flexibility in scheduling is the new normal for the nursing workforce and organizations offer various programs to meet this demand. Factors that drive the need for flexibility include family, a desire for higher education, and an aging workforce.4,9-11 Like others, we've found that offering flexibility in work status has improved the ability to hire nurses.6,10 The challenge is making sure nurses understand the flexible work options available to them throughout the organization.
Most online application portals can be daunting, and the nurse may choose the first status/position they see that seems to match their desired position without taking time to explore all the available options. Once the application is received, the PPDC adviser discusses with the nurse their needs and expectations, including work time commitment, benefits, and future career goals. The adviser recommends the appropriate status for the nurse (full time, part time, p.r.n., or a variety of flexible staffing options). The recommended status may be outside of what the nurse initially applied for but will lead to greater satisfaction by meeting the nurses' personal and professional goals.
Professional advising
Past generations have demonstrated long tenure at organizations working in the same role or linear career progression in roles (clinical nurse, nurse manager, director, and so on). The new workforce generations have drifted away from this model.4 Millennial and Generation Z nurses are less interested in linear career progression and more interested in obtaining new skills and experiences that fulfill their wish to serve people.12 If organizations don't recognize and support this path, the nurse will create their own path out of the organization. Experienced or tenured nurses may be stagnant but not know how to develop their skills.
The PPDC adviser is unbiased; the adviser's goal is to do what's best for the nurse's development with a focus on retention. In surveys of nurses served by the PPDC, they've commented that it's a benefit to talk through career possibilities with someone in a neutral office environment rather than talking to the nurse manager who's advocating for a single unit or specialty.
My Vision Plan
Career advising and career pathways aren't new to nurses. Most colleges have a career pathway to guide students through the necessary academic activities to achieve their degree, and many organizations continue the concept through a variety of professional development plans.6,13 The PPDC adviser plays a key role in establishing the pathway called My Vision Plan (MVP), which directs the nurse through activities, competencies, or cross-training to help them achieve their career goals. One of the many lessons learned during the COVID-19 pandemic was the successful cross-training of nurses among departments to meet the labor needs within specialty areas such as critical care. Continuing cross-training postpandemic has resulted in greater flexibility of teams, increased nurse competencies to meet the patient demands, and opportunities for nurses to develop new skills for career progression.14
The pathway provides a roadmap for a nurse to achieve their career goals. For example, if the nurse has a desire to become a certified registered nurse anesthetist (CRNA) and a current critical care position is unavailable or the nurse isn't ready for critical care, the nurse may be placed on a surgical floor. The nurse will be given competencies to obtain in preparation to transfer to the CCU when the next position is available. These competencies may include obtaining advanced cardiac life support; cross-training between units; or shadowing shifts in the OR, ED, or CCU. The plan establishes a projected transfer date, which allows the nurse manager to proactively plan for future staffing needs.
Lessons learned and outcomes
Healthcare leaders have learned many lessons from COVID-19, and one of the greatest is that changes are needed to achieve success. Implementation of the PPDC model required leaders throughout the hospital to reconsider many traditional practices. The structure of the PPDC has been instrumental to its success. Providing support to our nurse leadership team has increased the overall efficiency of the hiring process, encouraged neutral dialogue between the applicant and the advisers on unit selection, and fostered professional growth within the organization.
Nurse managers were protective of their team, proclaiming they knew what was best for them and focusing on retention of team members at all costs. Nurse managers had to learn to trust PPDC advisers to guide nurses according to the best interests of both the nurse and the organization. Developing trust is a slow process, but the nurse managers and advisers have established relationships and achieved this trust. The nurse managers now understand that they must place the needs of the nurse and organization before the needs of the unit.
The organization and nurse managers have had to endorse a new policy regarding transfer flexibility and turnover data. Transfers must be fluid across the organization to allow flexibility, proper fit, and career development. A former organizational policy had required nurses to serve on a unit for 1 year before they could transfer to a new unit. This policy had to change to allow immediate transfers within the organization to ensure the right fit for a nurse and the unit. Organizations that aren't flexible risk losing nurses to opportunities at other organizations.
Second, organizations have emphasized unit-based retention of team members. Although retention is critical for units, turnover and retention must be expanded to an organization-based metric, given nurses' desires for cultural fit and their career progression goals. Changing the retention metric to organizational-based versus unit-based to gain nurse manager support has been critical to the success of the PPDC model. Nurse managers now understand how important placing nurses in the right role is to the organization's overall success.
The PPDC routinely surveys the nurse managers and nurse candidates they serve to measure overall satisfaction and identify opportunities for improvement. Nurse managers report being extremely satisfied more than 84% of the time, with the remainder reporting that they're somewhat satisfied. The nurse managers find the PPDC team easy to work with, organized, collaborative, and understanding of the unit needs. They've reported professional growth based on advisers' insights regarding new and existing nurses and their ideal roles in the organization. The nurses indicate an overall satisfaction with the program, reporting that the PPDC gave them a clear expectation of the role they were hired for and the information they needed for successful onboarding. Feedback gained from surveys of both the nurse and the nurse manager are used to continually improve the processes within the PPDC.
Continuous learning
Continuous learning has been a theme of the journey to implement the PPDC. This model has successfully removed the administrative burden of hiring, placed nurses in the right employment status and position, and improved ongoing professional development to achieve the nurse's personal and professional goals. As the organization continues to address the workforce challenges in healthcare, the PPDC will provide the pathway to workforce sustainability.
INSTRUCTIONS What's my next step? Navigating nursing career progression
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