EBP 2.

0:
IMPLEMENTING AND SUSTAINING CHANGE

Promoting Nurse Retention Through

Career Development Planning
Knowledge translation tools help guide the implementation
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of a nursing professional development program.

This is the second article in a new series about evidence-based practice (EBP) that builds on AJN’s award-
winning previous series—Evidence-Based Practice, Step by Step—published between 2009 and 2011 (to
access the series, go to http://links.lww.com/AJN/A133). This follow-up series will feature exemplars illus-
trating the various strategies that can be used to implement EBP changes—one of the most challenging
steps in the EBP process.

T
he implementation of evidence-based practice
(EBP) can be a daunting process. Projects can
be derailed by poor planning and ineffective
mitigation of barriers. In this article, Manisa Baker
and Beth A. Vottero from Purdue University North-
west’s College of Nursing describe how they used
knowledge translation tools to guide the implemen-
tation of a nursing professional development pro-
gram at an urban Chicago hospital. After they tell
their story, we comment on their approach to mak-
ing this a sustainable change.—Sharon J. Tucker and
Lynn Gallagher-Ford
THE IMPLEMENTATION STEP: THE PROFESSIONAL
DEVELOPMENT AND CAREER PLANNING PROGRAM
Our story is about the creation and implementation
of an evidence-based quality improvement (QI) initia-
tive at a level 1 trauma hospital. The aim of the Pro-
fessional Development and Career Planning Program
was to reduce first-year nurse turnover rates on two
telemetry units that had high rates of turnover.
The implementation of this program began with
a pilot project that targeted all new nurses hired on
these units from November 2017 to June 2018. A to-
tal of eight nurses participated in the program. The
pilot project was initiated by the first-year nurse turn-
over team, which consisted of representatives from
human resources, nursing administration, and opera-
tions improvement. This team adapted a standard-
ized professional development and career planning
tool based on the milestone pathway tool described
by Cooper and colleagues.1 The newly hired nurses
were introduced to the program during orientation
and started it at the end of their 90-day probationary
period. Four to six months after each nurse’s hire
date, the program coordinator (one of us, MB) met
with each nurse for their follow-up session, during
which she reviewed information about the program
and discussed professional development opportuni-
ties and socialization on the unit with the newly hired
nurse.
Background. Our desire to reduce first-year nurse
turnover rates led us to rethink how we supported
new nurses through their orientation at our facility.
Our goal was to create a program that would help
new nurses during orientation and increase their ca-
reer satisfaction at our hospital. We created the Pro-
fessional Development and Career Planning Program
based on findings from a search of the literature on
best practices for the orientation of new nurses, as
well as input from unit leaders and practicing nurses.
We believed it was important that our program collect
data and track a nurse’s professional work history,
progress toward practice expectations, and long- and
short-term professional goals. With this in mind, we
included in our program career planning, such as
mandatory and elective practice expectations, and a
list of classes that were required or available to nurses
at our facility for professional development. We in-
troduced the program to all new hires during orienta-
tion. We collaboratively worked with new nurses to
identify opportunities for development and a time-
line for the completion of a career plan, which was
then shared with the unit manager and leadership.

62 AJN ▼ June 2019 ▼ Vol. 119, No. 6 ajnonline.com

 By Sharon J. Tucker, PhD, RN, APRN-CNS, F-NAP, FAAN, Lynn Gallagher-Ford, PhD, RN, NE-BC, DPFNAP, FAAN,
Manisa Baker, DNP, RN, APRN, CCNS, CCRN-K, and Beth A. Vottero, PhD, RN, CNE
The work of White and colleagues guided our
understanding of the context of the project.2 Under-
standing the context is key to the success of both im-
plementing and sustaining a practice change. Context
provides information about the unit’s readiness for
change and potential barriers to implementation. We
defined context as the environment and culture of the
two telemetry units with high first-year nurse turn-
over rates. To better understand the perceptions of
the units’ staff regarding the culture and readiness for
change, we used the Alberta Context Tool, which
measures organizational context.3 The Alberta Con-
text Tool assesses a person’s perception of the context
and can be collated to provide unit or facility data.
The tool includes a series of questions that address
various domains and concepts related to organiza-
tional context: leadership, culture, evaluation, social
capital, informal interactions, formal interactions,
structural and electronic resources, and organiza-
tional slack (staffing, space, and time).3
Findings from the Alberta Context Tool pro-
vided our project team with information about unit
strengths and perceived barriers to change. Strengths
included leadership, culture, and formal interaction
patterns. Opportunities for improvement included so-
cial capital (that is, the interactions and connections
among members of a care team), informal interaction
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Photo © Istock / spxChrome.
patterns, and structural and electronic resources. Re-
garding the identified need for more social and infor-
mal interactions, we noted that nurses’ opportunities
to converse with other team members were dependent
on the shift they worked—those working the night
shift have fewer chances to interact with members of
the care team.
Implementation. We completed a literature review
using several databases and focusing specifically on
systematic reviews of implementation strategies. We
appraised and assessed the quality of the evidence re-
lated to implementation strategies by using AMSTAR
(A Measurement Tool to Assess Systematic Reviews).4
We also compared the context of each article to the
context of our project, allowing us to choose strate-
gies that have been studied in a hospital setting. In
addition, we evaluated each article using the Joanna
Briggs Institute levels of evidence.5 We chose imple-
mentation strategies using the Expert Recommen-
dations for Implementing Change (ERIC), which
provides recommendations for effective strategies
that can be used with a QI project.6 In addition to
our strategy of assessing barriers and facilitators, we
used the following ERIC strategies to implement our
program: audit and feedback, educational detailing
and printed educational materials, and leveraging lo-
cal opinion leaders.
AJN ▼ June 2019 ▼ Vol. 119, No. 6 63
 EBP 2.0:
IMPLEMENTING AND SUSTAINING CHANGE
We next selected two models to guide the delivery
of the program. First, we utilized the Ottawa Model of
Research Use, a knowledge translation model, to guide
implementation of our program. This model consists
of three processes: assessing, monitoring, and evaluat-
ing.7 Regarding the assessment process, the data from
the Alberta Context Tool guided the identification of
barriers to adoption: namely, staffing and inconsisten-
cies with informal communication. For the monitoring
process, we developed an adoption plan, using both
e-mail and face-to-face meetings to overcome any
communication barriers. In addition, we met with
unit leaders to provide education on the program
and to answer any questions.
There is no silver bullet to implementation;
therefore, utilization of small tests of
change and evaluation are key to the
success of a project.
To determine if the intervention had been altered
from our original intention, we systematically evalu-
ated the effectiveness of our program using the plan–
do–study–act model.7 This was the second model we
used to guide the delivery of the program. It helped
us to assess the impact of our intervention and imple-
mentation strategies. This QI methodology takes a
comprehensive look at local influences on the inter-
vention, enabling us to adapt the process in an iterative
Pre- and Postassessment Questions
All questions, except for the fourth, were answered using a five-point
Likert scale, ranging from 1 = least favorable to 5 = most favorable.
1. How would you rate the last three work days?
2. How supported do you feel on your unit?
3. How would you rate your work–life balance?
4. What does work–life balance mean to you?
5. How would you rate the availability of resources on your unit?
6. Overall, how would you rate your work environment?
7. How beneficial is the Professional Development and Career
Planning Program? (postassessment only)
64 AJN ▼ June 2019 ▼ Vol. 119, No. 6 ajnonline.com
way to promote change at the local level.8 We assessed
the effectiveness of the program through the use of
pre- and postassessment questions and focus groups.
The preassessment questions were sent by e-mail to
each program participant before the follow-up meet-
ing; the postassessment questions were sent by e-mail
after the follow-up meeting (see Pre- and Postassess-
ment Questions). The program coordinator subse-
quently held separate focus groups with the new
nurses and their managers. We compiled the data
from both the e-mail responses and the focus groups,
and examined the findings to make small changes,
as needed. These improvement cycles assisted us in
organizing the monitoring phase described in the Ot-
tawa model.
We developed educational materials and Power-
Point presentations that provided managers, staff, and
new nurses with details about the purpose and goals
of the program. This assured a baseline understanding
among the staff nurses, their managers, and the first-
year nurse turnover team of the purpose of the pro-
gram, which proved to be a successful implementation
strategy. Data collected during pre- and postassess-
ment provided the most useful feedback. Organizing
focus groups was also helpful, because this technique
helped to engage the participating nurses. One noted
that the most useful aspect of the program was “the
professional opportunities available that I can use to
advance my knowledge.” Another commented, “It’s
great that you want to know what our goals are and
that you are helping us reach our goals.”
Evaluation. In 2017, a total of 23 first-year nurses
left our hospital, three from the telemetry units. Be-
tween January and May of 2018—during the time
of our pilot project—five first-year nurses left, only
one from the telemetry units. This demonstrated the
success of our program to retain new nurses during
the pilot period.
We asked nurses the same questions during the
pre- and postassessments (except for the question ask-
ing nurse to rate the benefit of the program, which
was only asked in postassessment). Table 1 details
our findings. We solicited managers’ feedback through
the focus groups. They believed the program was ben-
eficial because it gave staff the opportunity to share
goals they may not have otherwise felt comfortable
sharing with their managers. Although the project
team wasn’t able to address all the barriers identified
in the context assessment, constant communication
between the program coordinator and unit managers,
in the form of face-to-face meetings (formal and in-
formal) and e-mails, helped to reduce most barriers.
In the follow-up meetings, we reinforced leadership’s
support for the new nurse’s career goals and transition
plans. In addition, the program coordinator shared a
summary of the information she’d discussed with the
newly hired nurses—regarding professional develop-
ment goals, concerns, and planned activities—with
each nurse’s manager. This enabled our managers to
work with the nursing staff to meet their goals (if they
wish to transition to a different specialty or shift, for
instance).
Lessons learned. Nurse turnover can be affected
by factors that aren’t related to the nurse’s work en-
vironment (personal stressors or desire for a better
work–life balance, for example). A healthy work envi-
ronment has been cited as a characteristic of units with
low turnover rates.9 Factors that can affect the nurse’s
perception and experience of the work environment
include staffing, teamwork, leadership support, and
workload. Nursing leaders can strive to manipulate
factors that are within their control to promote healthy
work environments and professional growth and satis-
faction. Because positive work environments are built
through collaboration and teamwork, nurse manag-
ers can, for instance, provide support to staff nurses
through open communication. It is also important that
they assess the context of their unit to better under-
stand the nursing staff’s perceptions.
As noted, several factors, including staffing and
workload, were outside the scope of this project and
have been identified in the literature as increasing
turnover rates.10 Additional limitations included the
small number of nurses hired during the span of the
pilot project. In addition, it was difficult to arrange
meetings between the project team and the night-shift
nurses because of the difference in sleep schedules and
the timing of work tasks. We recommend further eval-
uation of resources provided to night-shift team mem-
bers. Such resources might include options to take
classes at alternative times that align with their sleep
and work schedules or online training that can be
completed at their convenience. Finally, the results
of the context assessment may not be representative
of the unit, since the sample was small.
Implications and future directions. During the
pilot project, the context assessment was not admin-
istered to all staff. In hindsight, the completion of the
context assessment by a majority of the staff would
have provided additional insight into the strengths
and perceived barriers to change throughout the or-
ganization.
In describing our experience, we’ve provided a
glimpse into the initial results of this program. Re-
evaluation after a year will provide deeper insight
into the success of this change. Plans to expand this
program to other units are currently in discussion.
We learned from this experience the need to opti-
mize the strengths of key members of the team who
were identified as early adopters and champions.
ajn@wolterskluwer.com
Table 1. Pre- and Postassessment Results
Preassessment Postassessment
Rating of last three work days 3.5 4
Perceived support on unit 4.83 4.75
Rating of work–life balance 4 3.25
Rating of availability of 4.5 4.63
resources on unit
Rating of work environment 4.5 4.75
Perceived benefit of the pro- N/A 4.25
gram
Note: Scores were based on a 5-point Likert scale, ranging from 1 = least favorable to 5 = most
favorable.
Team members who are enthusiastic about a change or
who are viewed by others as leaders should be engaged
early to promote acceptance of the change. Develop-
ing a robust plan to incorporate and utilize champions
can directly impact the sustainability of the program.
We’ve also learned that the use of knowledge transla-
tion and QI models can be helpful in implementing
such programs. There is no silver bullet to implemen-
tation; therefore, utilization of small tests of change
and evaluation are key to the success of a project.
COMMENTARY
In this article, Baker and Vottero describe their expe-
rience with an EBP project, detailing the implemen-
tation strategies they used to improve the uptake and
success of the Professional Development and Career
Planning Program. Strengths of their project include
the use of published models to guide implementa-
tion. They used the Ottawa Model of Research Use,
the plan–do–study–act QI model, and a list of pub-
lished implementation strategies (ERIC, for example)
to improve the successful implementation of their
professional development program. They applied
the Alberta Context Tool assessment to first iden-
tify barriers and facilitators, which is a highly im-
portant and recommended first step.11
These authors reviewed the literature for the most
effective strategies and selected those that could help
promote successful uptake of the program. Another
strength of their project was the solid evaluation plan,
which included hard data on retention rates and data
from managers and nurses regarding the experience.
Moreover, Baker and Vottero were able to articulate
the strengths and limitations of the project along with
future directions.
Clearly, successful uptake of EBP must include rec-
ognition that change itself is a journey, and that with
AJN ▼ June 2019 ▼ Vol. 119, No. 6 65
EBP 2.0:
IMPLEMENTING AND SUSTAINING CHANGE
the right tools and knowledge, the road traveled can
lead to sustainable change. As identified by Baker
and Vottero, approaching practice change from an
iterative perspective allows for small tests of change
that use evaluation data to continue to improve im-
plementation of an EBP change in health care. The
use of knowledge translation models, context assess-
ments, and ERIC strategies provided a road map to
making a sustainable change at this medical center. ▼
Sharon J. Tucker is the Grayce Sills Endowed Professor of
Psychiatric-Mental Health Nursing and director, Translational/
Implementation Research Core, and Lynn Gallagher-Ford is se-
nior director, both at the Helene Fuld Health Trust National In-
stitute for Evidence-Based Practice in Nursing and Healthcare
at the Ohio State University College of Nursing in Columbus.
Manisa Baker is a visiting assistant professor, and Beth A. Vottero
is an associate professor, both at Purdue University Northwest’s
College of Nursing in Hammond, IN. Contact author: Sharon J.
Tucker, tucker.701@osu.edu. The authors have disclosed no po-
tential conflicts of interest, financial or otherwise.
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