How a Nonlinear Path Is Improving High Acuity Nurse Education

When Kelley Cotter stepped into her nurse educator role at University Children’s Health Center for Clinical Excellence, the organization was facing challenges with nurse turnover and orientees transferring from intensive care units to lower-acuity units due to readiness gaps.

So Cotter’s team set out to update the hospital’s nurse orientation model for pediatric intensive care (PICU) and pediatric congenital cardiac (PCCU) units. They used the Children’s Hospital Association’s Pediatric Learning Solutions (PLS) courses and the Tiered Skills Acquisition Model (TSAM) to create a flexible tiered orientation model designed to set new hires up for success.

“This work directly addressed the challenges new nurses face when entering pediatric critical care, especially the high levels of overwhelm that often led them to transfer to lower‑acuity areas,” said Cotter, MSN, RN, CPN, NPD-BC. “By implementing the TSAM process, we created a more structured and supportive transition that has helped new graduates feel more confident and capable at the bedside.”

The transition from a stringent, checklist-based model which left little space for adapting to individualized learning needs was, like the new model itself, nonlinear.

Collaborating to lay the foundation

Cotter’s team learned about Cook Children’s Medical Center’s tiered orientation model at an industry conference, which inspired them to explore a similar model on their own units. As the educators refined their skills acquisition model, they connected with a peer at Seattle Children’s for guidance in the redesign.

“This orientation update was shaped by research, collaboration with other organizations, and ongoing trial and error,” Cotter said. “It has significantly strengthened the transition of new graduate pediatric ICU RNs into the units.”

Once the team had developed its three-tiered orientation plan, Cotter said a critical step was preparing preceptors well in advance of implementation, as well as securing leadership support early. This allowed for greater flexibility for learners and educators within the newly established model.

“Updating the model has strengthened and improved support for both preceptors and new nurses,” Cotter said. “For organizations considering a less linear approach, I’d share that while this model is different from the traditional orientation I had 13 years ago, it truly works when you invest time in preparing and supporting your preceptors.”

Individualized paths

Under the new model, applicable PLS courses are assigned to new hires at the start of orientation with staggered due dates that align with their onboarding timeline and allow for progressive learning as they transition into their roles. This builds in checkpoints for new staff who may need assistance in certain areas, while also providing opportunities for accelerated progress.

“It allows experienced nurses to move through the tiers at a pace that reflects their background with guidance from me and their preceptor,” Cotter said. “Those with more experience spend more time in the later tiers until they’re ready to practice independently.”

This level of flexibility also allows educators to adapt learning experiences to evolving unit and patient needs.

“We use PLS modules with new hires, annually based on unit needs, and whenever we need to refresh or learn new content,” Cotter said. “The PICU rarely cares for patients with pacemakers, but we had a liver transplant patient who required one due to persistent bradycardia. To prepare the team, I assigned the pacemaker module to all staff and created a bedside tipsheet using some of the PLS content so everyone had the knowledge needed to safely care for the patient.”

Beyond the courses

While PLS courses and in-person training make up the core of the new educational model, Cotter’s team is working to increase the use of other PLS resources as well, including:

• Requiring new staff to download the PLS app
• Encouraging both learners and educators to explore PLS job aids and tip sheets
• Suggesting staff take advantage of CHA discussion boards to connect with peers and share knowledge
• Tracking staff continuing education credits earned within PLS courses

“I hope that new educators entering the role will recognize the value of CHA resources, particularly discussion boards and courses,” Cotter said.

By combining expertise from peer hospitals, PLS and CHA resources, and individualized attention from the education team, University Children’s Health was able to retain four out of five recently hired new nurse graduates. While the team is still collecting data to quantify outcomes, qualitative feedback and results from the first cohort to complete the program have been encouraging.