Title : Nurse-led restructuring of unlicensed assistive personnel roles improves retention, engagement, and behavioral safety outcomes in pediatric care
Abstract:
Workforce instability and high turnover among unlicensed assistive personnel (UAPs) present significant challenges to maintaining a healthy work environment and ensuring safe care for high-risk behavioral pediatric patients. Contributing factors include inadequate role preparation, unclear expectations, and limited opportunities for professional development and engagement. This nurse-led quality improvement initiative evaluated the impact of a structured onboarding, mentorship, and role alignment program on UAP retention, engagement, and behavioral safety outcomes across emergency and acute care pediatric settings on a single campus within a large pediatric academic medical center. This initiative focused on strengthening workforce development and creating a supportive practice environment through a targeted redesign of the UAP role. Key interventions included implementation of a structured, mental health-focused onboarding program; a mentorship model pairing UAPs with Psychiatric Resource Nurses to promote skill development, engagement, and role integration; and realignment of UAPs under psychiatric services to enhance role clarity, support, and accountability. Hiring practices were revised to prioritize behavioral health experience and clearly communicate role expectations. Orientation enhancements emphasized experiential learning through inpatient psychiatric unit shifts to build confidence and competency. A pre–post evaluation compared 2024 (pre-implementation) and 2025 (post-implementation) outcomes, including retention, engagement, and safety metrics. Following implementation, UAP turnover decreased by 26.8%, demonstrating improved retention and workforce stability. Employee engagement scores improved across multiple domains, including overall engagement (4.36 to 4.44), clarity of role expectations (4.40 to 4.88), perceived supervisor support (4.50 to 4.81), and encouragement of professional development (4.30 to 4.81), reflecting a strengthened work environment. Behavioral safety outcomes also improved, with restraint events decreasing by 39.3% and Behavioral Emergency Response Team (BERT) activations declining. Concurrently, use of a Collaborative Approach to Preventing Escalation (CAPE) increased, indicating greater staff confidence in early intervention and proactive de-escalation. This nurse-led model demonstrates that investing in structured onboarding, mentorship, and role clarity for UAPs improves retention, enhances engagement, and strengthens the work environment while also advancing patient safety outcomes. The initiative supports Magnet principles of structural empowerment and exemplary professional practice and offers a scalable framework for workforce development within pediatric academic medical centers to promote sustainable staffing and high-quality care delivery for behavioral health populations.
