1 Accreditation of a Nurse Residency Program Jennifer Belt, RN, BSN Mark and Robyn Jones College of Nursing, Montana State University NRSG 575: Professional Paper Dr. Galloway and Dr. Wines May 5, 2024 2 Chapter 1 The American Nurses Credentialing Center (ANCC) defines nurse residency programs (NRP) as “planned, comprehensive periods programs in which registered nurses (RNs) obtain the knowledge and skills to deliver safe, quality care in their specialty area of practice” (Cosme et al., 2023, p. v). Nurse residency programs are endorsed by the Institute of Medicine and National Council of State Boards of Nursing (NCSBN) and provide support for the newly licensed nurse (NLN) transitioning from the academic to the clinical setting (Institute of Medicine, 2011; Spector & Echternacht, 2010). Throughout this paper, the term NLN will refer to a nurse with 0-12 months of clinical experience post-licensure. The need for NRPs was most succinctly described by Lelin Townsend, in the 1930s, when she identified a need to bridge “the gap between the doctor’s lecture and the actual nursing problem” (Townsend, 1931, p. 1183). Today, 50% of United States hospitals support a NRP, one direct benefit of which is a higher return on investment in NLNs (Sutor & Painter, 2020; Asber, 2019; Silvestre et al, 2017). Other benefits reported by NLNs include increased job satisfaction, improved quality of nursing performance, and improved clinical decision-making skills (Bratt & Felzer, 2011). There is no clear beginning to NRPs but the concept gained momentum following the publication of Reality Shock: Why Nurses Leave Nursing in 1974 and Novice to Expert in 1984 (Kramer, 1974; Benner 1984). Historically, the benefits of NRPs are well documented; however, inconsistencies in program length, evidence-based curriculum, operating standards, and preceptor standards make programs difficult to compare (Goode et al., 2016). To address the gap in the standardization of NRPs, the ANCC established the Practice Transition Accreditation Program (PTAP) which provides a structured framework through which nursing leaders and nurse professional development (NPD) practitioners implement NRPs. Nurse 3 professional development practitioners “support nurses in evidence-based practice and quality improvement through professional development” (Walters Kluwer, 2017, para. 1). Accreditation is “a process by which a voluntary, non-governmental agency appraises and grants accredited status to institutions and/or programs or services which meet predetermined structure, process, and outcome criteria” (American Nurses Credentialing Center, 2023b, About Accreditation section). The ANCC PTAP is inclusive of single and multisite organizations with baccalaureate and associate-prepared registered nurses. The ANCC PTAP Conceptual Model is based on Patricia Benner’s novice-to-expert nursing theory (Figure 1). The model consists of 5 domains including program leadership, program goals and outcome measures, organizational enculturation, development and design, and practice-based learning (Cosme et al., 2023). Nurse residency programs awarded ANCC PTAP accreditation have completed a program self-study and peer review appraisal demonstrating a commitment to excellence in nursing education and skill-based competency programming (Cosme et al.; Goudreau & Smokenski, 2023). Aftershocks of the COVID-19 pandemic include a mass exodus of nurses from the nursing profession. Today, 41% of the nursing workforce has fewer than 10 years of experience and research indicates a measurable decline in the practice proficiency of the NLN (NCSBN Nursing Regulation Department, 2023). Research indicates that by 2027, 20% of the nursing workforce has the intention to leave the profession of which a quarter are considered to be “early career” (NCSBN Nursing Regulation Department, 2023). Combined with the recent acknowledgment that NLNs are not prepared for the complexity of today’s healthcare system or the increasing healthcare needs of the patient population, nursing leaders have an ethical duty to bridge the identified gap in competence of the NLN by promoting and maintaining “optimal standards in education and practice” (Kavanagh & Szweda, 2017; American Nurses Association, 4 2015, p.28). Healthcare organizations need to embrace the standardization of NRPs to improve nurse retention and ensure patient safety (Suto & Painter, 2020). This paper will explore the benefits of ANCC PTAP accreditation of the NRP at a rural hospital in Montana. Background Healthcare organizations use quality improvement efforts at the microsystem level to develop processes, structures, and outcomes that ensure high-quality and safe patient care (Harris et al., 2022; Donabedian, 2005). Quality improvement “is the systematic formal approach to the analysis of practice performance and efforts to improve performance” (American Academy of Family Physicians, 2023, para. 1). A clinical microsystem is a front-line unit of patient care comprised of a group of people working together to serve a specific patient subpopulation (Thomas, 2022). Nurses assess the patient care environment and the clinical microsystem for obstacles hindering patient care (Grace & Uveges, 2023; Harris et al.). When a clinical problem is identified, nurses take the necessary actions needed to correct the problem and create sustainable change (Harris et al.). The 5 P’s framework and the strengths, weaknesses, opportunities, and threats (SWOT) analysis are two tools used to evaluate the clinical microsystem. These tools will be utilized to map the current state of the NRP at Facility Y. Five P’s Framework The 5 P’s framework provides a comprehensive overview of the department’s purpose, patient population, professionals, processes, and patterns (Harris et al., 2022). Purpose The Professional Development Department (PDD) at Facility Y, a 99-bed not-for-profit acute care hospital that serves 97,000 residences in 5 counties providing inpatient and outpatient services, launched the NRP in 2020 with the intent of improving the onboarding experience of 5 NLNs within the organization (St. Peter’s Health, 2024). The mission, vision, and values of the PDD mirror that of the organization. The mission is to “improve the health, wellness, and quality of life of the people and communities we serve” (St. Peter’s Health, 2024, Mission section). The vision is to “be the gold standard of healthcare in Montana” (St. Peter’s Health, 2024, Vision section). The values are to “treat everyone with dignity, respect, and loving-kindness”, to “keep colleagues safe, in every sense of the word”, to “empower and invest in our people to help them grow and thrive”, to “inspire collaboration to cultivate joy, pride, and a sense of belonging, to “drive excellence through learning, innovation, and continuous improvement”, and to “steward our resources wisely so we can fulfill our mission” (St. Peter’s Health, 2024, Values section ). Facility Y is accredited by Det Norske Veritas (DNV) Healthcare and carries an ISO- 9001:2015 certification demonstrating the organization's commitment to the delivery of safe, high-quality care focused on continuous improvement (St. Peter’s Health, 2021). The PDD serves all hospital employees and focuses largely on continuing nursing education. The NRP is intended to build community and support for the NLNs as they transition into practice and to provide them with values, policies, and procedures specific to Facility Y. Patients All NLNs employed by Facility Y are invited to participate in the NRP and are paid for their time in the program. Invitees include inpatient and outpatient NLNs who are baccalaureate or associate degree-prepared. Typically, participants have less than 12 months of nursing experience, and individuals disinterested in the program are not required to participate. Since the program’s inception, 36 NLNs have been invited to participate. Of those contacted, 19 have completed the program, which is a 52% completion rate. There are a variety of reasons for poor retention; six participants either never showed up or withdrew before starting, seven participants 6 withdrew after starting, 1 participant left on FMLA and chose not to complete the program upon return, and three participants left the organization and moved out of town. Two nurses who did not finish the program voluntarily cited childcare as the reason for stopping. An estimated five participants changed departments during their first year of practice at Facility Y. While the program is not denied to any nurse, some nurse leaders do not initiate program participation for their NLNs citing untimely content. Participants learn about the program at recruiting fairs, from Facility Y’s website, and from the nursing leadership team (NLT). There are two local accredited nursing schools from which many NLNs graduate and seek employment at Facility Y. Several senior-year nursing students from out of town or out of state utilize phone numbers and email addresses listed on the organization's website to contact the lead instructors to learn about the program. To date, limited data has been collected regarding participant demographics. Professionals A program director (PD) oversees the PDD and the NRP. The PD is a master’s prepared nurse with an unencumbered nursing license. The NRP is facilitated by two baccalaureate- prepared NPD practitioners with unencumbered nursing licenses who develop content and provide instruction for the program. The program is vetted by the chief nursing officer (CNO) and NLT. The NPD practitioners and the PD participate in an annual conference put on by the Montana Nurses Association regarding continuing education credits. The conference serves as an exclusive opportunity for NPD practitioners to obtain education and knowledge on adult learning principles. Processes The 9-month NRP schedule and supplemental content are available to all participants through an online platform. The current schedule includes two 4-hour skills days, three 2-hour 7 in-classroom sessions, five 3-hour in-classroom sessions, and a graduation. Participants meet monthly or bimonthly and participate in nurse-led discussions, didactic training, and skills competencies. The current curriculum was created using content from Sutor and Painter's (2020) Critical Care Nurse Residency Structured Competency Plan. Content topics include Patricia Benner’s transition to practice model, team structure, legalities of documentation and charting, communication, patient-focused care, patient safety, delegation, advanced directives, oxygen modalities, rapid response, code blue, time management, patient falls, employee safety, DVT prophylaxis, evidence-based practice, safety and design in healthcare, wound and ostomy care, diabetes management, clinical reasoning, head to toe assessments, renal perfusion and impairment, health literacy, palliative and end of life care, ethics, controlled substances, professional development, and wellness. In addition, all participants engage in the Nurse Experience Project’s Transition to Practice video modules which correlate with monthly content (Practicing Excellence, 2023). To graduate from the program participants are expected to attend 70% of the program activities and complete an evidence-based practice project with a quality improvement idea. The majority of program participants self-schedule and are encouraged to account for the NRP when planning and submitting their department schedule requests. Make-up sessions are offered to program participants reliant on interest and participation. The two most frequently reported reasons for missing class are conflict with work schedule and employee illness. Patterns The NRP kicks off approximately twice per year. Timing depends on the demand for the program. The NPD practitioners meet monthly to discuss the program status, collaborate to complete job tasks, and ensure program quality. Invitations to join the program are extended 8 from the NPD practitioners after a nurse is hired onto a unit and identified by their nurse leader as a candidate. Content for the program is reviewed after each cohort and modified per participant and instructor feedback. NPD practitioner-driven changes to the program are reviewed with the NLT on an as-needed basis. In addition to the NRP, Facility Y supports NLNs with a six to ten week in-unit orientation. During the in-unit orientation, NLNs are paired with a preceptor and complete a department competency checklist. The NRP and in-unit orientation run concurrently but are not integrated. Recently, the NRP implemented the Casey-Fink Survey to collect participant feedback. More information about the Casey-Fink survey can be found in the Evaluation Tool and Outcome Measures section of Chapter 3. Prior feedback was collected verbally during the program graduation and at individual sessions. The number one cited benefit of the program by program graduates has been induction into the hospital community and the opportunity to talk to other new graduate nurses. The second most cited benefit of the program has been the skills days during which participants have the opportunity to train with hospital-specific equipment and supplies. While nurse retention is a goal of the program, no data has been collected to evaluate nurse retention at the 1-year mark for those who completed the program compared to those who did not complete the program. Strengths, Weaknesses, Opportunities, and Threats The strengths, weaknesses, opportunities, and threats (SWOT) analysis allows one to compare their internal business to the business of competitors. Completing the SWOT analysis provides an introspective look into the business at hand and allows team members to make strategic business decisions relative to the business market (Business Professor, 2021). A SWOT analysis for the NRP at Facility Y highlights program strengths, weaknesses, opportunities, and 9 threats (Table 1). The strengths of the program are linked to people and motivation. Weaknesses of the program are linked to program design, metrics, and enculturation. Opportunities for the program are realized by the potential applicant pool, and threats to the program are lack of accreditation and competing programs. Problem The NRP at Facility Y has not undergone the ANCC PTAP accreditation process which demands quality improvement of the structures, processes, and outcomes of the NRP. Hospitals across the country, including Facility Y, have experienced a high rate of turnover among nursing staff following the COVID-19 pandemic (NCSBN Nursing Regulation Department, 2023). Not providing an accredited NRP program leaves Facility Y more vulnerable to the nursing shortage and hinders the organization's ability to practice excellence in nursing. Significance Stress experienced from the COVID-19 virus has caused a mass exodus of nurses from the healthcare industry which is not projected to stop in the immediate future. Staffing shortages or crises have impacted hospitals nationwide and NLNs are found to have a decrease in practice proficiency compared to pre-pandemic times (NCSBN Nursing Regulation Department, 2023). To thwart the nursing shortage and to increase the practice proficiency of the NLN, Facility Y needs to plan for ANCC PTAP accreditation of the NRP. American Nurses Credentialing Center’s PTAP accredited NRPs are shown to improve cost savings realized through a more opportune workforce pipeline, increased staff retention, accelerated clinical roles, reduced healthcare errors and improved quality indicators, and a reduced need for travel staff (Stiesmeyer, 2022). Additionally, facilities that maintain accreditation may be eligible for reimbursement from the Center for Medicare and Medicaid (Stiesmeyer). Supporting an 10 accredited NRP fits well with the Quadruple Aim in Healthcare which calls for measures to create healthier populations, reduce per capita healthcare costs, improve patient satisfaction, and improved work life of healthcare providers (Harris et al., 2022). Stress and reduced satisfaction in the healthcare work life have contributed substantially to the current healthcare crisis (NCSBN Nursing Regulation Department). Ultimately, provider burnout and high turnover rates threaten patient-centered care. The hospital needs to develop cost-effective solutions like the implementation of a standardized or accredited NRP to prevent staff turnover and burnout (Harris et al.). Purpose/Aim The purpose of this project is to propose a quality improvement plan that will prepare Facility Y for ANCC PTAP accreditation of the NRP. This project aims to collect support from the CNO, PD, and NLT for the implementation of quality improvement cycles directed at creating a state of readiness for ANCC PTAP accreditation. 11 Chapter Two American Nurses Credentialing Centers Practice Transition Accredited Programs (ANCC PTAP) have organizational value described in the literature. The ANCC PTAP framework uses the Donabedian model for quality improvement to help organizations develop standardized, evidence-based nurse resideny programs (NRPs) that are accreditation-ready (Graebe & Cosme, 2022). The model encourages leaders to examine the structures, processes, and outcomes of the NRP at their organization, to identify areas needing improvement, and to initiate improvement efforts (Graebe & Cosme, 2022). Four common themes revealed in the literature will be explored as they relate to standardized NRPs with the majority focus on ANCC PTAP accredited NRPs. The themes identified include the benefits of standardized, evidence-based programs, newly licensed nurse (NLN) turnover rates, barriers to accreditation readiness, and organizational impacts of accreditation. Search Strategy Databases searched included the Web of Science, the Cumulative Index of Allied Nurse and Health Literature (CINAHL), and the Montana State University Library Catalogue (CatSearch). Key search terms included a combination of “Nurse Residency” AND “Accreditation” AND “American Nurses Credentialing Center” and “Transition to Practice” AND “Accreditation” AND “American Nurses Credentialing Center”. Articles with the term “accreditation” in the title and a focus on NRPs were included in the review. The initial search on the Web of Science, limited to the last five years, did not include the search term “American Nurse Credential Center” and rendered 44 and 139 articles of which 2 articles were included in the literature review. Subsequent database searches were expanded to include articles published between 2014 and 2023 to reflect the total time the ANCC PTAP has been in existence. A 12 CatSearch yielded 32 search results which were later reduced to 26 by limiting the search to peer-reviewed articles. Of those, 5 were included in the review. An identical search in CINAHL generated 6 results and yielded 2 new articles. One article did not meet inclusion criteria and was included in the review because it compared the outcomes of a standardized, evidence-based onboarding program to a limited onboarding program for NLNs. In total, 8 articles were selected for review, including 1 randomized and multisite comparison study, 1 content analysis, 1 retrospective content analysis, and 5 case reports (Spector et al., 2015, Church et al., 2019; White et. al., 2021; Trepanier et al., 2023; Tyo et al., 2018; Franquiz & Seckman, 2016; Fuselier et al., 2019; Halfer & Benedetto, 2020). Conceptual Framework The conceptual framework utilized by the ANCC for the accreditation of NRP programs is the Donabedian model for quality improvement which will be utilized in this project proposal (Graebe & Cosme, 2022). Donabedian, a medical doctor by trade, studied and advocated for quality patient outcomes. Donabedian felt that outcomes, which are central to quality, should not be the sole measure of quality. In his argument, he cited a scenario in which a similar outcome for two different people resulted in a different quality of life experienced by each person. Instead, Donabedian expanded his studies on quality to focus on the processes, structures, and outcomes of care provided in the hospital setting. In a quote from his publication, Donabedian believed that providers should ask the question, “What goes on here?” which Donabedian thought put equal weight on the study of structures, processes, and outcomes (Donabedian, 2005, p. 721). In contrast, Donabedian felt the questions “What is wrong, and how can it be made better?” put an overemphasis on individual values which would inherently threaten the objectivity of the researcher (Donabedian, p. 721). 13 Utilizing the Donabedian model for quality improvement requires a thorough review of the processes, structures, and outcomes of an organization’s NRP. The model aligns well with the ANCC PTAP accreditation criteria requiring organizations to implement standardized program content, create and define program processes, and track predetermined program outcome measures (Cosme et al., 2023). In the context of NRPs, processes are defined as the quality of education and program planning and evaluation. Structures are defined by the presence of adequate facility equipment, administrative processes, and funding (Donabedian, 2005). Outcomes are defined by the impact the program has on nursing professional practice and patient and system outcomes (Huseman-Maratea et al., 2022). In this project proposal, the Donabedian model for quality improvement will be used to ensure a detailed evaluation of the current and future states of the NRP. Search Results A review of the literature revealed several themes or concepts related to the accreditation of NRP programs. The themes included the benefits of standardized, evidence-based programming, decreased NLN nurse turnover rates, organizational impacts of accreditation, and barriers to accreditation readiness. Benefits of Standardized and Evidence-Based Programming Hospitals that incorporate standardized, evidence-based NRPs benefit from the optimization of patient care which can lead to improved quality of care and patient safety (Brown Tyo et al., 2018; Spector et al., 2015). NLNs who participate in standardized, evidence- based NRPs reported fewer errors, fewer negative safety practices, higher competence, less stress, and more job satisfaction compared to NLNs who participated in a limited onboarding program (Spector et al.). Additionally, nursing departments whose NLNs participated in a 14 standardized, evidence-based NRP appreciated a 2-week reduction in the NLN time to independent practice attributed to a reduction in lecture time, the use of simulation, and the development of clinical pathways inherent to standardized, evidence-based NRPs (Halfer and Benedetto, 2020). Accreditation Decreases NLN Nurse Turnover The most commonly reported benefit from ANCC PTAP accreditation was a decrease in nurse turnover (Trepanier et al., 2023, Brown Tyo, 2018; Halfer & Benedetto, 2020). Following the achievement of ANCC PTAP accreditation, one healthcare system reported a reduction in 1- year nurse turnover rates from 43% to 9% and 50% to 9% at two hospitals, and another hospital reported a decrease in the 1-year nurse turnover rate from 29.5% to 12.3% (Brown Tyo; Halfer & Benedetto, 2020). One large healthcare organization appreciated a 10.36% reduction in first-year turnover which translated into an annual cost savings of $14,671,911 and took into account a loss of $72,000 per year per nurse (Trepanier et al.). Nurse leaders should take the financial benefits appreciated from a reduction in the 1-year NLN turnover rates into account when considering the risks and benefits of implementing an ANCC PTAP accredited NPR. Barriers to Accreditation Readiness All organizations considering moving forward with the application process for ANCC PTAP will need to identify and resolve gaps or barriers in their existing program before applying. In preparation for accreditation, organizations have the option to create their own accreditation readiness survey or use the ANCC gap analysis tool (Franquiz & Seckman, 2016; Brown Tyo, 2018). Foundational to accreditation success is a supportive and engaged leadership team and a program with the capacity to meet accreditation standards (Franquiz & Seckman). Trepanier et al. (2023) identified several capacity issues related to accreditation including 15 reduced nurse turnover making it difficult to hire NLNs, difficulty hiring NLNs into specialty units, difficulty securing dedicated time for NLNs to complete the program, difficulty securing NPD practitioners to implement the program, and difficulty providing an adequate quantity of prepared preceptors to support the NLNs clinical practice. Additionally, organizations applying for accreditation have to provide documentation to support their program’s success in each domain of the ANCC PTAP Conceptual Model (Fuselier et al., 2019). Fuselier et al. encounter barriers in the ability to produce adequate documentation. The barriers included a lack of policy regarding program content updates, inconsistent storage procedures for program content making the content difficult to retrieve and update, and a lack of preexisting methods to measure student competency and outcomes. Once gaps in practice have been identified, quality improvement plans need to be created and implemented to close the gaps. One suggested strategy to support the accreditation readiness process is to implement biweekly meetings during which an action plan can be developed to meet the needs of the program and solve problems (Franquiz & Seckman; 2016). The ANCC PTAP accreditation process requires organizations to thoughtfully and purposefully evaluate their existing program to make changes based on ANCC PTAP accreditation standards (American Nurse Credentialing Center, 2020). Organizational Impacts of Accreditation American Nurses Credentialing Center’s PTAP accreditation positively impacted organizations (Church et al.,2019; White et al., 2021). Many impact areas have been identified and some will be discussed in detail. Most impacts discussed in the literature were positive and few were neutral. Areas of impact included leadership support, stakeholder interest, national/state recognition, credibility, collaboration with other facilities, funding, internal recognition, recruitment, organizational improvements, and professional dissemination (Church 16 et al., 2019; White et al., 2021). Increased funding was realized through grants, Center for Medicare and Medicaid Services reimbursement, additions to the annual budget, and funds from the hospital foundation (Church et al., White et al.). Internal recognition took the form of internal demand for ANCC PTAP accreditation. Positive impacts on recruitment included an increase in the number, diversity, and qualification of applicants. Organizational improvements included a transformation of nursing professional practice, an increase in professional accountability for organizational and program processes, and more quality improvement initiatives (White et al). Impacts of accreditation were appreciated system-wide and elevated the excellence in nursing practice at ANCC PTAP accredited organizations (White et al.). Summary The benefits of ANCC PTAP accreditation have been identified, and hospitals can demonstrate excellence by offering ANCC PTAP accredited NRPs. The time to ensure public safety by improving nurse retention rates and quality of care is now (Spector et al., 2010; NCSBN Nursing Regulation Department; 2023). The quality improvement project proposed in this paper will aid Facility Y in the development of an ANCC PTAP accreditation-ready NRP. To achieve organizational readiness for accreditation, all structures, processes, and outcomes described by the Donabedian Model for quality improvement will need to be evaluated for barriers, and plans for gap closure will need to be implemented (Graebe & Cosme, 2022). 17 Chapter 3 This project proposes a plan to key stakeholders at Facility Y to transform the nurse residency program (NRP) into an evidence-based and peer-reviewed onboarding program eligible for American Nurses Credentialing Center’s Practice Transition Accredited Program (ANCC PTAP) accreditation. The NRP outlined in this chapter will better enculture the newly licensed nurse (NLN) into the organization by providing peer and organizational support, practice-based learning, leadership engagement, and tools to empower excellent nursing practice (Cosme et al., 2023). Nationally, ANCC PTAP accredited NRPs appreciate increased funding, improved nurse retention, community recognition, and nurse-driven organizational improvements (Brown Tyo, 2018; Halfer & Benedetto, 2020; Church et al., 2019; White et al., 2021). Nurses who are better supported through the onboarding process report fewer errors, less stress, and improved job satisfaction (Spector et al., 2015). The project recommends Facility Y review the existing NRP using the ANCC PTAP gap analysis tool and a stakeholder evaluation survey. Once gaps in ANCC PTAP accreditation readiness are identified, a NRP steering committee will meet monthly to ensure gap closure. The goals of this project are to improve the practice proficiency and retention of the NLN at Facility Y. Design of the Quality Improvement Initiative This is an educational quality improvement project. Newly licensed nurses at Facility Y are the target population. A detailed description of NLNs at Facility Y is provided in the Patients section of the 5 P’s Assessment in Chapter 1. Stakeholders of the project include members of the nursing leadership team (NLT) composed of the chief nursing officer (CNO), department directors, and unit managers. Other stakeholders are the NRP program director (PD) and nursing professional development (NPD) practitioners, for whom additional information can be found in 18 the Professionals section of the 5 P’s Assessment in Chapter 1. This project introduces new stakeholders to the NRP including nurse preceptors who provide 6-10 weeks of in-unit training and nurse mentors who will provide additional onboarding support. Planning the Project Intervention Following the Donabedian model, the transformation of the NRP into an ANCC PTAP accreditation-ready state will require the appraisal of the program’s existing structures, processes, and outcomes. The PD will lead all change efforts supported and guided by the CNO. Using Facility Y’s employee travel request form and situation, background, assessment, and recommendation (SBAR) structured communication, the PD will request for self and 1 NPD practitioner to attend an ANCC PTAP introductory workshop. The request will need approval from the CNO and People Development department. Workshop attendance is highly recommended to all hospitals considering ANCC PTAP accreditation. Workshops provide the opportunity for hospitals to best understand the accreditation process and to collaborate with other hospitals through idea-sharing (American Nurses Credentialing Center, 2024). Following workshop attendance, the PD in collaboration with NPD practitioners will complete the ANCC PTAP Gap Analysis Tool to evaluate the current NPD and draft ideas for program updates. Additionally, to discover nurse competence and stakeholder satisfaction in the current program, the PD will distribute the Nurse Residency Program Stakeholder Evaluation Survey to those involved in the onboarding of NLNs. Then, to garner leadership support and stakeholder involvement in the change process, the PD will create the NRP steering committee. Additional tools found in the ANCC Cost Estimator Resource Guide will be used to estimate the cost of accreditation. ANCC PTAP Gap Analysis Tool 19 The ANCC provides the ANCC PTAP Gap Analysis Tool used to audit and revise existing NRPs following ANCC PTAP accreditation standards (American Nurse Credentialing Center, 2020). The tool outlines 25 required fields for ANCC PTAP accreditation and directs the user to identify, yes- a gap exists, or, no- a gap does not exist, in the current program for each required field. When a gap in program structures, processes, or outcomes is identified, the tool instructs the user to evaluate the program's current state and proposes an improvement plan to close the gap. Utilization of the tool requires reference to the 2024 Application Manual: Practice Transition Accredited Program (Cosme et al., 2023). Stakeholder Evaluation Survey An internal stakeholder or customer evaluation survey will be used to inform the NRP program stakeholders of needed improvements to the existing NRP development and design (Joseph et al., 2021, Cosme et al., 2023). Initially, the survey will be used to collect baseline quantitative data from stakeholders. Over time, the survey will be used to set benchmarks and monitor progress toward desired outcomes (Joseph et al., 2021). The survey utilized in this quality improvement project will be the Nurse Residency Program Stakeholder Evaluation Survey provided by Failla et al. (2021). The 43-question survey is valid and reliable and evaluates nurse competence in five domains including evidence-based practice, patient-centered care, teamwork and collaboration, quality improvement and safety, and informatics (Failla et al., 2021). Additional information regarding each competency can be found on the Quality and Safety Education for Nurses (QSEN) website (Quality and Safety for Nurses, 2022). The survey will be distributed to the CNO, NLT, charge nurses, and formal nursing preceptors. Nurse Residency Program Steering Committee 20 A NRP steering committee will be created to evaluate and inform revisions made to the NRP. Proposed revisions will be identified from the gap analysis tool and stakeholder evaluation survey. Additionally, the committee will provide structure to the NRP that will help to enculture the program into the organization. Program and participant enculturation into the organization is a requirement of ANCC PTAP accreditation (Rocha-Lona, 2017; Cosme et al., 2023). Key stakeholders will ensure the program aligns with the strategic goals of the organization and that cost-effective, sustainable methods of improvement are utilized to accreditation-ready state (Rocha-Lona, 2017). In addition, key stakeholders will ensure the NRP program is outfitted with the appropriate resources like nurse preceptors, NPD practitioners, and a PD for program implementation and management (Rocha-Lona, 2017; American Nurse Credentialing Center, 2020). The PD will chair the NRP Steering Committee and invitations to join will be extended to the CNO, interested NLT members, two nursing preceptors, two NPD practitioners, and one former NRP graduate. Including committee representation from multiple hierarchical levels within the organization will foster the communication, leadership, teamwork, idea-sharing, and commitment necessary for program success (Rocha-Lona, 2017). Barriers Identified Several barriers to the implementation of an accredited nurse residency program have been identified. Accredited ANCC PTAP programs are 6-12 months in length: however, at Facility Y, participation typically wanes around months four and five resulting in participant dropout or the provision of several make-up sessions. Nursing leaders can mitigate the loss of program participation by establishing dedicated time for NLNs to participate in the program and setting the expectation that participation is required. Another barrier to program implementation is the number of formal preceptors available to teach each new cohort. Many preceptors at 21 Facility Y have completed a formal preceptor training; however, to support an accredited NRP program, preceptor participation in continued learning will need to be ongoing and an evaluation process will need to be planned (American Nurses Association, 2023). Another challenge identified is overtime expense and nurse burnout. Participants attend NRP sessions above their regular full-time equivalent (FTE) which limits sessions to 4 hours in length to avoid overtime expense. Asking participants to complete the program outside of their FTE may contribute to nurse burnout. Also, through the ANCC PTAP accreditation planning process, Facility Y may discover barriers to accreditation related to its capacity to offer the program in multiple practice settings (Cosme et al., 2023). Proposed Implementation Procedures Pre-Planning The ANCC PTAP application requires organizations to prove that at least one nurse has graduated from the ANCC PTAP accreditation-ready program; therefore, the timeline to accreditation relies on Facility Y’s ability to implement and sustain an ANCC PTAP accreditation-ready program (Cosme et al., 2023). In month one, Facility Y will send the PD and one NPD to an ANCC PTAP accreditation workshop (American Nurses Credentialing Center, 2024). Following the workshop, the PD and NPD practitioners will complete the PTAP Gap Analysis Tool, and the PD will send the stakeholder evaluation survey to all stakeholders with an invitation to join the NRP steering committee. Initially, the committee will meet monthly to discuss quality improvement plans and ensure viability. Once planned changes are confidently underway, which is estimated to take about five months, the committee will move to quarterly meetings. The committee will use the ANCC PTAP Gap Analysis Tool and the Nurse Residency Stakeholder Evaluation Survey results to guide recommendations and changes. All identified 22 gaps and progress toward gap closure will be tracked using Smartsheet software. All anticipated gaps to accreditation with proposed program updates are listed in Table 1. Changes to the program’s structures include more leadership involvement, role clarity, an updated preceptor program, the implementation of a mentorship program, and material updates. Changes to the program’s processes include revised onboarding, revised competency-based curriculum, the development of a NLN onboarding pathway, additional NPD practitioner continued education, and the development of a policy entailing program content review and updates. Changes to outcomes include the creation of five specific, measurable, attainable, relevant, time-bound (SMART) goals. A full project timeline is found in Table 2. Leadership Involvement Program leadership is one of the 5 domains of the ANCC PTAP practice model (Cosme, 2023). Currently, there is limited communication between NRP leaders and nursing department leaders. Creating the NRP Steering Committee will ensure NLT and executive leadership involvement in the program. Involvement of key stakeholders in the program will aid in the program’s enculturation into the organization. In the current state, the NLT has limited NRP involvement. The committee will review survey results and outcome measures to identify and close gaps using the plan, do, study, act model. Role Clarity Clarifying roles will help the program grow. To date, the program has experienced many missed opportunities due to a lack of ownership in program processes. The PD will be responsible for financials, communicating with the executive leadership team, aligning the program with the organization's strategic plan, orienting all stakeholders, chairing the NRP Steering Committee, directing NPD practitioners, and succession planning. The NPD 23 practitioners will plan and deliver educational content and logistics related to program delivery including rounding with NLNs, preceptors, and unit managers. Unit managers will provide support and ensure NLNs can attend all required activities. Preceptor Program Updates Currently, nursing staff apply to attend the preceptor program which is a 1 time 4-hour class. To meet accreditation standards, Facility Y will need to evaluate preceptor performance and provide continued preceptor education. To better meet this standard, Facility Y will incorporate the Evaluation of Preceptor Experience tool (Table 8) into the in-unit orientation process (Blegen et al., 2015). The tool consists of 23 items and is valid and reliable. It uses a 5- point response scale in which a 1 means agree and a 5 means disagree (Blegen et al., 2015). Preceptors and NLNs will electronically complete this tool through Microsoft forms at weeks two and six and at the end of the NLN’s in-unit orientation. Results from the tool will be used to develop annual and as-needed preceptor education. The Microsoft form will be created, shared, and tracked by NPD practitioners. Preceptor survey results will be reviewed at quarterly NPD practitioner meetings. A preceptor program update will be a standing agenda item at the NRP steering committee meetings. Mentorship Program Facility Y will implement the Medical-Surgical Nurse Mentorship program which will be coordinated by the NPD practitioners (Academy of Medical-Surgical Nurses, 2012). The inclusion of a mentorship program is a requirement of ANCC PTAP accreditation (American Nurses Association, 2023). It will take an estimated four months to implement the program in three steps. The NPD practitioners will complete the preprogram checklist in month one, recruit mentors in month two, and facilitate completion of the mentorship checklist and education in 24 months three and program launch in month four. Continued mentorship program maintenance will be shared between NPD practitioners. A mentorship program update will be a standing agenda item at NRP steering committee meetings. Materials Updated material for the NRP program will include more supplies allowing for the gamification of activities. Gamification allows for active learning and improved knowledge acquisition (Garrison et al., 2021). Games, like escape boxes, will be used to better evaluate and document nurse competence during learning activities. Revised Onboarding Potential NRP program candidates will apply for a new graduate RN position on the company website. All NRP applications will be made available to inpatient nursing leaders. This new onboarding process should bolster NRP program retention by creating the expectation that the program is required for all NLNs. Units that choose to not participate in the program will still be eligible to hire NLNs through other job postings on the company’s career webpage. The PD will coordinate this new job posting and process with the CNO and People Operations team. The change is expected to take six weeks. Competency-based NLN Onboarding Pathway ANCC-PTAP accreditation requires a competency plan and evaluation for every NLN (American Nurses Credentialing Center, n.d.b.). In many instances, NLNs will be evaluated by their clinical preceptors for competence (Shinners & Deasy, 2021). NPD practitioners will develop a revised competency plan using existing department competency checklists and new- hire orientation competencies. Gaps in existing competencies will be identified and closed. Additionally, a competency evaluation will be added to each NRP learning session. The NPD 25 practitioners will develop a learning plan or onboarding pathway for each NLN which will be shared with preceptors. The learning plan or booklet will be modeled after an onboarding booklet shared by the University of Utah (2021). The booklet will include weekly reflective journaling and encourage meetings between the NLN and preceptor used to identify competency areas needing remediation. All program surveys will be accessible via QR code in the onboarding booklet. Nurse professional development practitioners will meet weekly for three months to develop the NLN competency-based onboarding plan. Once finalized, the onboarding plans will be sent to the graphics department for printing. The cost of the books is material and accounted for in Table 5. Nurse Professional Development Practitioners Continuing Education Facility Y will require the PD and NPD practitioners complete six hours of training on adult learning principles of their choice on an annual basis. The PD and NPD practitioner will track training hours in an internal log audited by the PD. Previous training on adult learning principles occurred during a Montana Nurses Association Provider Unit conference. The new process will enable the NPD practitioners to guide their learning and introduce relevant new activities to the NRP program. Starting in July 2024 three hours will be required for the remainder of the year on a prorated basis. Then, in 2025, six hours will be required between January and December. Policy for Content Updates The current NRP does not have a policy or formal process for reviewing and updating program content which must be consistent across cohorts (American Nurses Credentialing Center, 2020). The PD will develop a policy describing a plan for the NPD practitioners to 26 review and update content to best practice standards annually during the first quarter. This policy will take 2 weeks to create and will be approved during a NRP steering committee meeting. Program Financial Cost Enhancing the NRP program with ANCC PTAP accreditation does not come without cost. The ANCC provides the Cost Estimator Resource Guide to help hospitals develop a financial plan for accreditation. The guide includes several Excel spreadsheets used to calculate program cost associated with the planning and development (Table 3), personnel maintenance (Table 4), material maintenance (Table 5), accreditation costs (Table 6), and total costs (Table 7) of the program (American Nurses Credentialing Center, n.d.a). The total annual cost to maintain an ANCC PTAP accredited program at Facility Y is projected to be $78,258, and the total planning cost is projected to be $10,134. The average turnover rate for a nurse living in a north- central state is 20.7% (Nursing Solutions, Inc., 2023). According to Kari Koehler, CNO, the average nurse turnover cost at Facility Y is $74,890 (personal communication. February 26, 2024). If the NRP runs twice a year with 6 participants in each cohort, then 12 participants will complete the program each year. Assuming a turnover rate of 20.7%, the hospital expects to lose 2.48 NLNs per year which will cost $185,727. If ANCC accreditation reduces the nurse turnover rate to 10.35% or by half, then the hospital will only lose 1.2 nurses per year which will cost $89, 868 and save $95,859. The cost-to-benefit ratio is calculated by dividing the total benefit of the program by the total cost. In this scenario, the annual cost-to-benefit ratio is 1.2, calculated by dividing $95,859 by $78,258. This scenario does not account for any cost savings attributable to value-based care payments which possibly could improve with the introduction of an accredited onboarding program for NLNs. Evaluation Tool and Outcome Measures 27 The ANCC PTAP accreditation requires NRPs to create clear objectives and track five measurable goals using the SMART goal format in five categories including nursing professional development, self-reported, stakeholder evaluation, learner competency, and financial (Cosme et al, 2023). Nursing Professional Development For the nursing professional development category PD and NPD practitioners at Facility Y will complete six hours of training on adult learning principles of their choice on an annual basis. The NPD practitioner will track training hours in an internal log that is audited by the PD. The outcome goal for this measure is that 100% of NPD practitioners and the PD complete 100% of the required training annually. To be accredited, Facility Y the PD will need to prove education in adult learning principles and describe how adult learning principles are integrated into the program (Cosme et al., 2023). Ensuring that the PD and NPD practitioners receive continued learning in adult learning principles will help the NRP create and identify content appropriate for the NLN. Self-Reported For the self-reported goal, the NRP program will continue to administer the Casey-Fink New Graduate Nurse Experience Survey © 2023 at the beginning, middle, and end of the NRP program using Microsoft forms (Casey& Fink, n.d.). The valid and reliable tool contains three elements. One, it asks NLN to self-evaluate in 8 factors including role confidence, manage patient care, support, role satisfaction, stress and burnout, resilience, organizational commitment, and preceptorship. Two, it is used to assess the NLN’s confidence in performing nursing skills. Three, it can be used to collect demographic data (Casey & Fink, n.d.). Results from the survey are reported on a Likert scale in which a 1 means strongly agree and a 4 means strongly disagree 28 and will be mapped on a run chart (Casey& Fink, n.d.). NPD practitioners will aggregate survey results in each category and track results over time to assess the NLN's readiness for practice and areas needing additional training. The outcome goal for this measure will be that NLN will have a 25% increase in readiness for practice in each Casey-Fink New Graduate Nurse Experience Survey © 2023 category comparing results from the beginning of the program to the end of the program. Additionally, results from cohort to cohort will be compared and tracked over time. The rationale for this outcome measure is to track nurses' perceived confidence in practice and to identify areas where the NRP can contribute added support and training. Stakeholder Evaluation For the Stakeholder evaluation category, Facility Y will ask NRP stakeholders, who are defined in the Stakeholder Evaluation Survey section of this paper, to complete the Nurse Residency Program Stakeholder Evaluation Survey annually. Results from the survey are reported on a Likert scale in which a 1 means strongly agree and a 4 means strongly disagree (Failla et al., 2021). Results will be mapped on a run chart. The initial outcome goal for this measure will be for the stakeholder satisfaction in each competency category to increase 10% annually. The rationale for this outcome measure is to evaluate stakeholder satisfaction with the NRP. Satisfaction is defined by a stakeholder’s perception of NLN competence in each category. Using the survey, the PD and NPD practitioners will identify competency areas of weakness and action plans to address those competencies will be developed with the guidance of the NRP steering committee. Nurse Competence For the nurse competency category, the outcome goal will be to observe a 10% annual decrease in event reporting for medication errors in each department where NLNs work. Facility 29 Y will begin tracking reported medication errors 12 months before accreditation and will continue to track reported medication errors each month. This measure requires collaboration with the Quality Department to track and trend total medication errors reported monthly through the event reporting system. The number of reported errors will be tracked using a run chart. The rationale for this outcome is to better determine nurse competence at the bedside. Facility Y would expect to see a decrease in the number of reported medication errors by NLNs at the organization over time as a result of program participation. Financial The financial goal for this project will be to see a 50% reduction in the NLN turnover rate by comparing data 1 year before accreditation to 1 year after accreditation. The NLN turnover rate is calculated by dividing the number of NLNs who left the organization within 12 months of hire by the total number of NLNs hired. This number can be reported on an annual basis and should reflect only NLNs who participated in the program. It will be tracked and calculated by the PD for each NRP cohort. The rationale for this outcome measure is to evaluate whether the program generates improved nurse retention. Improved retention will help leaders at the organization assess the value of the program. Summary Aligning the NRP with the ANCC PTAP accreditation standards will require a dedicated PD and committed nursing leadership team (American Nurses Credentialing Center, 2023). The gap analysis tool and stakeholder evaluation survey will be used to collect data about the existing program and inform change. The NRP steering committee will act as the change agent by informing change and ensuring progress toward program goals. Five SMART goals will be established to measure success of the of the revised NRP. 30 Chapter 4 The Great Resignation of 2021 prompted by the COVID-19 pandemic left hospitals with reduced staffing secondary to high nurse turnover (Fuller & Kerr, 2022; Boston-Fleischhauer, 2022). At the same time, the practice proficiency of the newly licensed nurse (NLN) declined due to nontraditional education methods used during the pandemic such as virtual learning (NCSBN Nursing Regulation Department, 2023). To be successful in today’s post-pandemic market, healthcare organizations need to focus on talent acquisition and retention (Maurer, 2022). Nurse residency programs (NRPs) are the recommended strategy hospitals utilize to transition NLNs into practice. (Institute of Medicine, 2011). Nurse residency program accreditation is one strategy hospitals use to ensure and showcase practice excellence in the onboarding of NLNs (Cosme et al., 2023). The American Nurses Credentialing Center (ANCC) accredits nurse residency programs that complete a transition to practice program self-study and peer review demonstrating excellence in each of the 5 domains found in the ANCC PTAP Conceptual Model (Figure 1) (Cosme et al., 2023). The NRP at Facility Y is not currently accredited by the ANCC. Achieving ANCC Practice Transition Accredited Program (PTAP) accreditation will ensure the NRP at Facility Y is standardized and evidence based (Cosme et al., 2023). Hospitals with accredited NRPs report an increase in the perceived competency of the NLN and a reduction in 1-year nurse turnover (Trepanier et al., 2023). The purpose of this quality improvement project was to propose a plan to rebuild the NRP at Facility Y into an ANCC PTAP accreditation-ready program. This chapter summarizes the changes Facility Y expects to implement as a result of this project, compares expected project implementation and findings to the literature, explores the project's impact on nursing practice, and concludes by addressing the role of the clinical nurse leader (CNL) in this quality improvement effort. 31 Quality Improvement Project Summary The purpose of this quality improvement proposal (QIP) was to improve the NRP at Facility Y through the identification and facilitation of changes needed for the NRP to qualify for ANCC PTAP accreditation. American Nurses Credentialing Center’s PTAP accreditation requires hospitals to evaluate quality improvement initiatives using the Donabedian Model for Quality Improvement (Graebe & Cosme, 2022). Donabedian asked, “What goes on here?” referring to the structures, processes, and outcomes of healthcare programs (Donabedian, 2005, p. 721). Utilization of the model ensures organizations examine and improve internal structures, processes, and outcomes without bias (Donabedian , 2005). Specific to ANCC PTAP achievement, hospitals aiming to apply for accreditation examine their NRPs in five domains including organizational enculturation, practice-based learning, development and design, program leadership, and quality outcomes (Cosme et al., 2022). Consistent with the literature, leadership support is essential to ANCC PTAP accreditation success. This QIP sought the creation of a NRP steering committee to ensure leadership engagement and support (Franquiz & Seckman, 2016). The steering committee is expected to thwart anticipated barriers to accreditation by allowing designated time for NLNs to attend NRP sessions, maintaining Nursing Professional Development (NPD) practitioners, and supporting the development of prepared preceptors (Trepanier et al., 2023). Additionally, NRP’s are expensive and leadership support is essential for program funding (Stiesmeyer, 2022). Next, this QIP sought to utilize the ANCC PTAP Gap Analysis Tool and the Stakeholder Evaluation Survey as methods to evaluate the current state of the program before initiating any changes (Brown Tyo, 2018; Joseph et al., 2021). Other NRP surveys have been identified in the literature (Franquiz & Seckman, 2016). The ANCC provides the ANCC PTAP Gap Analysis 32 Tool to help hospitals plan for accreditation (Cosme et al., 2023). The Stakeholder Evaluation Survey focuses on nationally accepted nurse competencies and will be used to identify and close current gaps in competence among NLN nurses at the organization (Joseph et al., 2021). The NRP steering committee is expected to implement several additional changes to the NRP based on results from the Stakeholder Survey and Gap Analysis Tool. A list of all program updates can be found in Table 1. Several gaps in accreditation-readiness have been identified in the literature and are expected to impact the QIP at Facility Y. Gaps identified by Fuselier et al. (2019) are a lack of policy describing a timeline for program content updates and insufficient documentation to support quality outcomes for each required domain. To address these issues, the Program Director (PD) will develop a policy detailing program content updates, and NPD practitioners will meet weekly to create a competency plan that will address and measure nurse competence in each required domain throughout the program. Several benefits of ANCC PTAP accreditation found in the literature are expected to be appreciated at Facility Y following the implementation of this QIP. First and foremost, Facility Y will see a reduction in 1-year nurse turnover rates, which will translate into cost savings (Trepanier et al., 2023, Brown Tyo, 2018, Halfer & Benedetto, 2020). Next, nursing leadership will report a larger, more qualified, and more diverse applicant pool (Church et al., 2019, White et al., 2021). Leaders will also notice a transformation in professional nursing practice and see an increase in nurse accountability (White et al., 2021). Employees of the new standardized and evidence-based program will report improved job satisfaction, increased competence, fewer reported errors, and fewer negative safety practices (Spector et al., 2015). Overall, the implementation of this QIP will positively impact Facility Y. Discussion 33 The American Nurse’s Credentialing Center’s PTAP program remains fairly new. Additionally, the literature exploring the impact of accreditation outside of nurse turnover and nursing satisfaction is limited. Church et al (2019) and White et al. (2021) provide several positive impacts of accreditation; however, both studies utilize results from the same survey provided by the ANCC. More study is needed to further evaluate the worth of accrediting a NRP compared to simply implementing an evidence based and standardized NRP without accreditation. The NRP changes outlined in this QIP are based on evidence found in the literature and nursing best practices. Using the Donabedian Model for Quality Improvement, all NRP changes focused on the structures, processes, and outcomes of the program. Some opportunities for improvement identified, like creating a more streamlined pathway for NLNs to join the program, may not translate directly into ANCC PTAP accreditation, but it will help to spread the NRP by establishing the expectation that those hired into the program will participate. Ogrinc et al. (2018) defined spread as, “the process by which new ideas are communicated over time through a social system, with the intended outcome being the adoption of the new idea” (p. 130). The enhanced preceptor program and mentorship program will also help to spread the NRP by providing deliberate and structured support to those helping to onboard NLNs. Literature correlating nurse residency programs to patient outcomes is lacking, largely due to hospitals not publicly reporting adverse events. Zaitoun et al. (2023) correlated nurse competence with a nurse’s ability to engage in a culture of safety, inherently reducing risk to the patient. I believe that by creating a more competent workforce through NRP program enhancements, Facility Y will experience improved patient outcomes. Implications and Recommendations 34 Transforming the NRP into an ANCC PTAP accreditation-ready state will positively impact Facility Y by creating a more knowledgeable and competent workforce that is encultured into the hospital and more likely to stay at the organization. Frögéli et al. (2023) described the importance of providing new employees with adequate socialization achieved through structured and early experiences at the organization. Employee socialization and enculturation are fundamental to NRPs and are required for ANCC PTAP accreditation (Cosme et al., 2022; Kramer et al., 2013). Matousek (2023) wrote that onboarding pathways and employee feedback are instrumental to the reduction of employee turnover. This QIP accounts for the development of onboarding pathways and introduces several opportunities for employee feedback through self and preceptor evaluations. Using the ANCC PTAP Conceptual Model and framework, Facility Y will standardize the NRP and begin to track measurable outcomes that speak to the program’s value (Casey & Cosme, 2022). Valuable programs are more likely to receive funding and leadership support which are essential components of program sustainability (Stiesmeyer, 2022). Sustaining the changes made to the NRP will require program integration into hospital policy and practice (Ogrinc, 2018). One suggested opportunity to sustain change is to develop a monthly NRP newsletter to share program results, content, and achievements with stakeholders. Organizations with NRPs that are accredited or that meet state licensing requirements are eligible for federal reimbursement by way of pass-through funding via Nursing and Allied Health Education Program Payments (White et al., 2021; Code of Federal Regulations, 2023). According to Missy Poortenga, the Executive Officer of the Montana State Board of Nursing, the Administrative Rules of Montana do not address nurse residency or transition to practice programs (personal communication. November 14, 2023). Currently, there are 15 hospitals and 27 critical access hospitals in Montana, of which, only 3 are ANCC PTAP accredited (Montana 35 Performance Improvement Network, 2023; American Hospital Directory, 2023; American Nurses Credentialing Center, 2023). The lack of accreditation and federal funding for NRPs in the State is concerning for the overall health and sustainability of the nursing workforce. Nursing leaders in New Jersey and members of the New Jersey Collaborative Center for Nursing utilized money from Growth Apprenticeship and Nontraditional Sector grants to support the standardization of NRPs throughout the State (New Jersey Collaborating Center for Nursing, 2024). Similarly, nurse leaders and NPD practitioners in the state of Montana can work together to advocate for the establishment of more standardized and evidence-based NRP in Montana which may qualify for federal reimbursement in the future. Conclusion This project provides a pathway to ANCC-PTAP accreditation readiness for a rural hospital in Montana aiming to improve the onboarding process of NLNs. Hospitals that provide an evidence-based and peer-reviewed NRP that meets ANCC PTAP accreditation criteria demonstrate a commitment to nursing excellence and realize the benefits of program accreditation (Cosme et al., 2023; White et al, 2021; Spector et al., 2015). Crook et al. (2011) wrote that companies aiming for high performance need to invest in human capital through programs that recruit the best talent and nurture employees to keep them from leaving the company. Applied to this QIP, the investment in human capital would have positive impacts on operational performance measures (Crook et al., 2011). Supportive of this idea, ANCC PTAP accredited programs appreciate a decrease in 1-year nurse turnover rates, better talent acquisition, increased nurse satisfaction, improved professional nursing practice, and more nursing professional accountability (Trepanier et al., 2023, Brown Tyo, 2018, Halfer & 36 Benedetto, 2020; White et al., 2021; Spector et al., 2015). Hospital leaders can use the methods and change ideas outlined in this QIP to ready their own hospital’s NRP for accreditation. Clinical nurse leaders identify problems, implement solutions, and track outcomes in the clinical microsystem using cost-effective and evidence-based methods (Wienand et al., 2015). The American Association of Colleges of Nursing (2013) provides CNLs with clinical competencies and practice expectations. This QIP typifies the CNL’s ability to operate as an organizational and system leader, defined by CNL competencies 2.1-2.8 (The American Association of Colleges of Nursing). 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(2015). Implementing the clinical nurse leader Role: A care model centered on innovation, efficiency, and excellence. Nurse Leader, 13(4), 78–85. https://doi.org/10.1016/j.mnl.2014.11.011 Zaitoun, R. A., Said, N. B., & de Tantillo, L. (2023). Clinical nurse competence and its effect on patient safety culture: a systematic review. BMC Nursing, 22(1), 173–173. https://doi.org/10.1186/s12912-023-01305-w https://www.wolterskluwer.com/en/expert-insights/the-value-of-nursing-professional-development https://www.wolterskluwer.com/en/expert-insights/the-value-of-nursing-professional-development https://doi.org/10.3928/00220124-20211008-08 https://doi.org/10.1016/j.mnl.2014.11.011 https://doi.org/10.1186/s12912-023-01305-w 46 Figure 1 ANCC PTAP Conceptual Model Note. From “2024 Application Manual: Practice Transition Accreditation Program,” S. Cosme, L. Cartwright-Stroupe, D. Cato, M Cooling, K. Evans, M. Le, C. Lee, W. Lerch, G. Luchen, H. Meissen, K. Spencer, A. Thomassen, M. White, C. Young, C, 2023, American Nurses Credentialing Center, p. 1 (https://www.nursingworld.org/organizational- programs/accreditation/ptap/download-ptap-manual/). Copyright by the American Nurses Credentialing Center. https://www.nursingworld.org/organizational-programs/accreditation/ptap/download-ptap-manual/ https://www.nursingworld.org/organizational-programs/accreditation/ptap/download-ptap-manual/ 47 Table 1 SWOT Analysis: NRP Program at Facility Y Strength • Engaged nursing leadership team • Engaged participants • Interdisciplinary involvement • In-person and online platform • Gamification Weakness • No clear objectives • No clear metrics • Unable to benchmark • Poor hiring track into the program • Limited program knowledge available at recruiting fairs • Limited enculturation/preceptor program collaboration • Inconsistent program start-dates • Not required for staff to attend Opportunities • 2 accredited nursing schools in the area • Responsive public relations team • Motivated nurse recruiter Threats • Not accredited • Multiple programs in the State • Funding Note. 48 Table 2 ANCC-PTAP Accreditation-Ready NRP Changes: Structures, Processes, Outcomes Structures Current State Future State Leadership No steering committee The steering committee meets monthly to effect change. Then, quarterly to evaluate outcomes and ensure stakeholder engagement. Role Clarity Poorly defined roles PD: financials, chairs NRP steering committee, aligns NRP with strategic goals, orients stakeholders, directs NPD’s, succession planning NPD: plan and deliver educational content, round with NLNs and preceptors, communicate with unit managers Unit managers provide support and scheduling Equipment Simulation lab equipment; Padlet platform as a program manual New gamification supplies (escape room supplies); spiral bound book for NLN onboarding manual Preceptor Program Not formally integrated with NRP program; One time 4-hour class Integrated with NRP program; NPDs meet to discuss quarterly; Evaluate preceptors using the Preceptor Experience Tool, Annual and need- based continued education Mentorship Program No mentorship program Implement Medical-Surgical Nurses Mentorship Program Processes Current State Future State Onboarding NLN invited to join NLN applies for Nurse Residency job through Facility Y career page Competency- Based Onboarding Pathway Not integrated with new employee orientation; Not all learning activities with competency. Pathway created for NLN reflective of the entire onboarding experience. Learner competency evaluation included with all activities. Opportunity for learner and preceptor to develop competency plan and remediation. NPD Practitioner Training Annual MNA Provider Unit conference Annual MNA Provider Unit conference plus six hours of learner-driven content annually Content Review No formal timeline for content review Policy outlining content review on an annual basis 49 Outcomes Current State Future State SMART Goals No SMART Goals 5 SMART goals, one in each category: nursing professional development, self- reported, stakeholder evaluation, learner competency, and financial Note. Program Director (PD); Nurse professional development practitioner (NPD); Specific, Measurable, Attainable, Relevant, and Time-bound (SMART), Montana Nurses Association (MNA) 50 Figure 2 Timeline Note. Colors represent different tasks and milestones identified for accreditation readiness; Program Director (PD), Nursing Professional Development practitioner (NPD), Nurse Residency Program (NRP) 51 Table 3 Planning and Development Costs 52 Note. PD spends 8 hours at ANCC PTAP workshop, 5 hours working on policy, 18 hours planning for and running the steering committee, 4 hours working on and evaluating the stakeholder survey, 2 hours initiating gap analysis tool. NPDs will spend 60 hours planning and developing a program to include the ANCC PTAP workshop for one, 2 hours initiating the gap analysis tool, 8 hours on preceptor program enhancement, 8 hours on the mentorship program implementation, and 48 hours on the learner competency plan and onboarding booklet. Gamification materials at $150. From “Cost Estimator Resources Guide,” by American Nurses Credentialing Center, n.d., p. 4 (https://www.nursingworld.org/~49f122/globalassets/docs/ancc/ptap-cost-estimator-resource- guide.pdf). Copyright 2023 by the American Nurses Credentialing Center. Reprinted with permission by the American Nurses Credentialing Center. https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf 53 Table 4 Personnel Maintenance Costs Note. Program includes 52 hours of instruction. Two NPD practitioners spend 52 hours of instruction and 2 hours each of program maintenance per week for a total of 260 hours. From “Cost Estimator Resources Guide,” by American Nurses Credentialing Center, n.d., pp. 9-11 (https://www.nursingworld.org/~49f122/globalassets/docs/ancc/ptap-cost-estimator-resource- guide.pdf). Copyright by the American Nurses Credentialing Center. Reprinted with permission by the American Nurses Credentialing Center. https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf 54 Table 5 Material Maintenance Costs Note. Average cost per cohort: $15 per person including printed book and graduate pen. Food costs $250 for graduation plus $50 introductory session. Equipment cost covers maintenance for manikins and equipment not expired needed to run simulations. From “Cost Estimator Resources Guide,” by American Nurses Credentialing Center, n.d., p. 13 (https://www.nursingworld.org/~49f122/globalassets/docs/ancc/ptap-cost-estimator-resource- guide.pdf). Copyright by the American Nurses Credentialing Center. Reprinted with permission by the American Nurses Credentialing Center. https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf 55 Table 6 Accreditation Costs Note. From “Cost Estimator Resources Guide,” by American Nurses Credentialing Center, n.d., p. 14-15 (https://www.nursingworld.org/~49f122/globalassets/docs/ancc/ptap-cost- estimator-resource-guide.pdf). Copyright by the American Nurses Credentialing Center. Reprinted with permission by the American Nurses Credentialing Center. https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf 56 Table 7 Total Cost Note. From “Cost Estimator Resources Guide,” by American Nurses Credentialing Center, n.d., p.16 (https://www.nursingworld.org/~49f122/globalassets/docs/ancc/ptap-cost-estimator- resource-guide.pdf). Copyright by the American Nurses Credentialing Center. Reprinted with permission by the American Nurses Credentialing Center. https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf https://www.nursingworld.org/%7E49f122/globalassets/docs/ancc/ptap-cost-estimator-resource-guide.pdf 57 Table 8 Evaluation of Preceptor Experience Tool Note. From “Preceptor Support in Hospital Transition to Practice Programs,” M.A. Blegen, N. Spector, B.T. Ulrich, M.R. Lynn, J. Barnsteiner, & J. Silvestre, (2015), The Journal of Nursing Administration, 45(12), p. 645. (https://doi.org/10.1097/NNA.0000000000000278). Copyright 2015 by Kulters Kluwer Health, Inc. https://doi.org/10.1097/NNA.0000000000000278