Effect of Tiered Acquisition Model on Nurse Retention
A tiered skills acquisition model (TSAM) during orientation significantly improves nurse retention and should be implemented as the standard approach for onboarding new nurses. 1
Evidence for TSAM Effectiveness
The most direct evidence comes from a 2018 study implementing TSAM with 188 newly licensed registered nurses at a teaching hospital, which demonstrated:
- Improved retention rates among newly licensed nurses using the tiered progression approach 1
- Increased nurse confidence and role satisfaction, both critical factors linked to retention 1
- 18% reduction in overall orientation length, making the process more efficient while maintaining effectiveness 1
- 45% increase in patient care experiences during orientation, providing more robust clinical exposure 1
How TSAM Works
The tiered model structures orientation by having orientees gradually assume increased responsibilities through progressive tiers of skills from simple to complex 1. This aligns with evidence-based principles:
- Competency-based progression where nurses advance through defined skill levels rather than arbitrary time periods 2
- Stepwise approach beginning with shadowing experienced staff and progressively increasing independence and patient acuity 2
- Clear role definition and expectations at each tier, which facilitates integration and reduces role ambiguity 2
Why TSAM Improves Retention
The mechanism by which TSAM enhances retention relates to addressing key factors that drive nurse turnover:
- Structured training facilitates role transition and increases job satisfaction, both directly linked to retention 2
- Professional mentoring throughout the tiered progression positively affects role transition, job satisfaction, and retention 2
- Competency-based advancement provides ongoing feedback and facilitates professional growth, contributing to retention 2
- Recognition of skill development through tier advancement addresses the need for acknowledgment, a key retention factor 3
Implementation Requirements
To maximize retention benefits, TSAM should include:
- Duration of 3-6 months for structured orientation programs, allowing adequate time for skill progression 2
- Competency evaluation mechanisms at each tier with ongoing feedback to facilitate professional growth 2
- Professional mentoring relationships established throughout the orientation period 2
- Clear reporting structure understood by all team members to support the orientee 2
- Long-term professional development planning integrated into the orientation framework 2
Supporting Educational Strategies
Enhance TSAM effectiveness by incorporating:
- Didactic content delivered through multiple modalities including lectures, case studies, and journal clubs 2
- Simulation training with structured debriefing for complex clinical scenarios 4
- Orientation manual as reference including framework, timeline, protocols, and learning resources 2
- Interactive training sessions rather than passive learning alone 4
Broader Context on Orientation and Retention
The evidence strongly supports that orientation structure directly impacts retention:
- Nurse residency programs lasting one year show increased satisfaction and retention compared to traditional orientations 5
- Restructured orientation programs consistently demonstrate positive effects on reducing nurse turnover 6
- Multisite implementation of TSAM has been successfully replicated across different healthcare settings 7
Common Pitfalls to Avoid
- Avoid rigid time-based progression instead of competency-based advancement, which undermines the model's effectiveness 2
- Do not skip mentoring components, as mentoring is essential for retention outcomes 2
- Ensure adequate evaluation mechanisms at each tier rather than waiting until orientation completion 2
- Prevent role ambiguity by clearly defining expectations at each tier level 2
Additional Retention Strategies Beyond Orientation
While TSAM addresses the critical orientation period, ongoing retention requires: