The first time a nurse new to a hospital or practice interacts with a nursing professional development (NPD) practitioner is during orientation and onboarding. At Peace Hospital, Kentucky’s largest psychiatric hospital, the NPD team, including Mandi Walker and LaeLonni Williams, lived out the role of Change Agent as outlined in The Nursing Professional Development Scope and Standards of Practice (Harper & Maloney, 2022). They shared at their 2024 ANPD Aspire Convention podium presentation titled "Redesigning a Psychiatric Department” their process, journey, and implementation of a new orientation and onboarding process that not only improved the experience for staff but saved the hospital money. As true change agents, they successfully calculated and presented their return on investment (ROI) to the entire executive team (commonly coined c-suite), earning buy-in and paving the way for a successful change.

Background

As the largest psychiatric facility in Kentucky, Peace Hospital boasts 800 staff members, including 200 nurses, serving patients in both inpatient and outpatient settings as part of the greater U of L Health System.

In December 2019, UofL Health was formed as a consolidation of multiple facilities in the region and started a journey of combining and streamlining practices across the new system. UofL Health’s multi-site NPD leader collaborated with nursing leaders at every facility within the system. Through this process, the multi-site leader became aware of issues and concerns regarding onboarding and education within Peace Hospital. There was a high turnover rate — 32% — and quality metrics such as physical holds, seclusion and restraint reflected that. The existing NPD team consisted of three central staff members who were responsible for onboarding and annual competencies for every discipline in the hospital; this process had not changed for more than a decade. At the time, new hire onboarding consisted of a nine-day universal training course, regardless of discipline (e.g., nursing, therapy, etc.). This included three days of de-escalation and safe physical management training, electronic medical record training, and general psychiatric education. The high use of seclusion and restraints, as well as hands-on physical patient management, indicated cause for concern that the de-escalation training was not sufficient or meeting the learner’s needs.

Environmental Scanning

Over the course of three months, the NPD team leaders conducted thorough environmental scanning to get to the heart of these challenges. Their process included:

• Reviewing quality metrics
• Meeting with new hires and preceptors to hear their pros/cons of current systems
• Meeting with system NPD director and instructional designer to conduct a gap analysis
• Reviewing unit onboarding documentation, class content, and competency processes

Through this, they discovered there was no streamlined preceptor training and everyone was doing their own process. There was also no nurse residency program in place to support new graduate nurses. Additionally, they identified gaps in the onboarding process, discussed pain points, and determined areas of needed improvement. After their environmental scan, the NPD team formulated a proposal for re-designing the NPD department and onboarding processes, which they presented to the Peace Hospital c- suite: the chief nurse office, chief operating officer, chief executive officer, and finance director. Conservative projections of the financial implications of NPD recommended changes showed savings in the millions of dollars over three years for the hospital, and a high projected return on investment — numbers the leadership team initially didn’t believe and asked to rerun.

The Recommendations

The recommendations the NPD leaders presented to the c-suite included:

• Restructuring the NPD department
• Developing efficient and effective onboarding process, e.g., creating standardization for preceptor processes
• Developing a transition to practice program
• Implementing a de-escalation and safe physical management program that focused further on de-escalation

They calculated that these improvements would have a major ROI. The original de-escalation program alone cost half a million to run annually, and overall training costs were around $1.5 million over three years, without achieving the desired outcomes. They calculated that if they switched to the programs used at other sites within the hospital system, they would bring down the cost, saving $1 million over three years for de-escalation education alone.

The NPD team continued their argument for improvement by saying they would take the $1 million the changes would save and use this to restructure the NPD department, adding four additional positions, including an NPD manager. The target outcome of re-designing the department and onboarding was a reduction in turnover, which cost the hospital $13.4 million a year. Their proposal included a goal of reducing this by 3% a year, with a total of 10% over three years, which would save $8.2 million in total turnover costs in the first two years. All of this would result in an ROI of 377%. After double-checking these calculations, the c-suite approved their recommendations.

Implementing the Approved Changes

After implementing the proposed changes, the NPD team at Peace now consists of an NPD manager, three “NPD 2s” and four “NPD 1s”, including a PRN NPD. The NPD 1s require two years as an RN — their role consists of unit specific orientation, point of care, and just in time education. They follow up with new employees up to 12 weeks after they start, conduct ongoing assessment of unit specific needs, and drive improvements for the unit for continuing education and role development. The NPD 2s require three years of RN experience as well as a master’s degree in leadership or education. NPD certification is preferred. Their role is to lead the first two days of new employee orientation, facilitate clinical placements for nursing students, create education in the learning management system, facilitate preceptor training, operationalize a new nurse residency program, support nursing shared governance, and drive improvements on the facility level.

The NPD team restructured orientation with a few goals in mind — namely to improve the experience of all staff and to reduce the high injury rate that resulted from going “hands-on” frequently with patients. First, they condensed orientation from nine days to five days. This included one day of organizational onboarding, three days of facility onboarding, and two days of non-violence crisis intervention (NVCI) (originally one day, raised to two in 2024, making orientation now six days). After the initial onboarding, new staff follow up with an NPD for the first six to twelve weeks, spreading orientation and onboarding across a few weeks.

The team chose a national standardized de-escalation and safe physical management program to reduce restraint and implement a patient-centered approach which aligned with the health system’s values. A key purpose of this training is to emphasize paying attention to a patient so that intervention can happen sooner, versus waiting and needing to go hands-on. Once they implemented this initial requirement and how it applied to the role, they had to develop ongoing annual training requirements. The program kick-off consisted of refreshments, games, prizes, and NVCI instructors present to answer questions and address concerns with staff. This was followed by the NPD team conducting six months of education, training a total of over 700 staff members. The initial blitz included one class a day for six weeks.

Key Initiatives and Outcomes

Aside from re-designing the onboarding and de-escalation processes, the NPD team has had several key successes since 2021.

• Redesigning unit-specific onboarding pathways and checklists, whereas the prior ones had been the same for all units and patient populations
• Launched a nurse residency program, with three cohorts having successfully completed
• Initiated preceptor training
• Updated student clinical placement processes that have resulted in an improvement in student evaluations and in hiring of new graduate nurses
• Promotion of professional nursing certification, including reimbursement for preparation materials and no out-of-pocket options for testing, resulting an increase in certified nurses from 6% to 11%
• Increased participation in the system’s Nursing Professional Development Program (NPDP) and Nurse Leader Professional Development Program (NL-PDP) in which nurses demonstrate their commitment to nursing excellence through clinical practice, quality, and patient safety
• Rewriting the electronic health record (EHR) education to be psychiatric specific. The previous class was more geared to the medical patient and was not as helpful.

The NPD team’s financial outcomes aligned very well with their initial predictions. They ended up training more instructors for the de-escalation program than initially planned; however, their two-year total for de-escalation ended $239,000 under budget. Overall, salary, de-escalation, and onboarding costs came to $1.7 million, which was $26,000 over budget.

This was offset, however, by a rapid reduction in turnover costs. Turnover dropped from 32% to 24% within the first year of the departmental and onboarding redesign. Turnover at the end of year two was 23%. Progress continues towards the three-year goal of 22%, which will be determined at the end of fiscal year 2024. The retention savings amounted to $20.5 million in the first two years, for a 1084% return on investment, far exceeding initial projections.

Currently, the system’s goal is to get down to 18% nursing turnover. And although NVCI is going well, the system had a few severe staff injuries that were outside the realm of normality which bumped up workman’s compensation. However, the patient injury rate has gone down, just not in a statistically significant way yet.

Looking Ahead

The project to re-design an entire NPD department while concurrently changing how education and onboarding was delivered at Peace Hospital was an overall success. The senior leaders of Peace Hospital are continually appreciative of the efforts of the NPD team and have embraced the changes implemented. The CEO mentions every time she meets with the multi-site NPD leader how much improvement she has seen in the quality of care and the standard of nurses within the organization. The NPD team will finalize all project data at the end of three years and will seek to publish.