Perceptions of a Nurse Residency Program

1. Perceptions of a Nurse Residency Program Nancy Fink, MSN, BSN, RN, CCRC Karen Lutter, MSN, BSN, RN, NE-BC

2. Objectives • Describe the purpose of the nurse residency pilot program at IH-DM. • Identify historical background behind typical nursing orientation. • Review the next steps for developing a nurse residency program. • Describe the outcomes from building a nurse residency program and the implications for retention.

3. Background • Survival of the hospital RN • Decreased supply of RNs and increased burnout • Dissatisfaction with job leads to early departure • National Turnover and Vacancy Rates in Acute Care Hospitals • 21.3% average turnover rates • 8.9% to 16.4% average vacancy rates

4. Background • Stress among new RNs in new position • Transition issues • 30%-60% of new RNs leave within one year • Cost of orientation • 100% of annual salary

5. Background • Inconsistent at Iowa Health Des Moines • Hospital orientation • Preceptor training • Length of unit orientation • Gap between academics and frontline nurse • Turnover and Vacancy at Iowa Health Des Moines • 11.36% Turnover (2008); 8.33% (2010) • 2.31% Vacancy (2009); 1.74% (2010) • Historically RNs left within 1-5 years of their employment; current trend in 2010 within 5-24 months

6. Introduction • Issues to retain newly licensed nurses • Provide job satisfaction • Consistent orientation plan with enhanced preceptor development • Increased confidence and competence

7. Purpose • Find the perceptions expressed by newly hired graduates regarding their confidence and competence after six months of attending a residency program and examining their transition into the acute care setting.

8. Legal and Ethical • IRB approval obtained at Iowa Health Des Moines and Clarkson College. • Data analyst sent the SurveyMonkey link to the participants at midpoint. • New RNs accessed the survey through their protected electronic email system. • Confidentiality maintained by the data collection system • Implied consent was given if participant answered the survey.

9. Literature Review • Not another lecture (Poynton, Madden, Bowers, Keefe & Peery, 2007) • New RNs do not want to sit in a classroom • Need to direct more hands on learning • Material to be more relevant to their nursing specialty or interest • Develop Curriculum (Bonnel, 2009). • Built to enhance the academic curriculum • Residency Support (Altier & Krsek, 2006) • Enriched learning experience of newly licensed nurses • Includes didactic and clinical orientation • Successful transition into nursing practice

10. Literature Review • Nursing Executive Center (NEC, 2008) • Identified need for preparing RN for new role after graduation • Nurse leaders identified that new RNs need to go beyond academic preparation to retain and build confidence of new RN • Used a dual-survey method for academic and frontline nursing leaders • Purpose of survey to isolate specific nursing competencies • Thirty-six competencies isolated that drive nursing preparation-practice gap • University HealthSystem Consortium (UHC) and American Association of Colleges of Nursing (AACN) • Curriculum for residency program and guidelines to enhance the confidence and competence of the new RN (Poynton, Madden, Bowers, Keefe & Peery, 2007)

11. Theoretical Framework • Utilization of Patricia Benner’s Theory (1984) • Novice to Expert • Development of extended orientation with newly licensed nurses • Growth with extended orientation from novice to advanced beginner • Curriculum constructed with foundation of academic degree

12. Methodology • Nurse manager assisted in identifying newly licensed nurses to participate in residency program. • Once the managers agreed for the newly licensed nurse (RN) to participate in the residency program, the new RNs were approached. • Final selection was determined by the research investigators.

13. Methodology • Invited newly licensed RNs within last six months and graduated from an accredited nursing program. • Participants reviewed the class schedule and the class objectives and given the opportunity to ask questions. • It was explained to the participants that at any point they can withdraw from the class and the research. • Six participants currently enrolled in the residency program.

14. Curriculum Foci • Leadership skills/Evidence Based Practice • Critical Thinking • Delegation & Resource Management • Prioritization & Healthcare Delivery • Communication (Physician, peers) • Review Core Measures (CNS & Quality) • Model of PDSA • Ethics, Advance Care Planning • Diversity in Healthcare/Customer Service • Role Change (Shadow another healthcare role during this week) • Conflict Resolution/Change Theory • Career Development/Celebration

15. Average Score from Survey Questions 1-5Graph 1 of 2

16. Average Score from Survey Questions 6-10Graph 2 of 2

17. Projected Expenses • Residency program will be developed and implemented by the Clinical Professional Development staff at no additional cost to the organization • Extended education time for the graduate nurse • 12 sessions; 4 hours in length; 48 hours • Graduate nurse starting wage $20.77/hr • Additional cost $996.96/nurse • Six graduate nurses in pilot • Total cost $5,981.76

18. Projected Expenses

19. Limitations • Need for a strong preceptor program • Challenges in orientation module tool • Challenges in prioritization in patient assignments • Resources for faculty and finances • Educator needs at least 7 hours prep work for one hour of class time (Beecroft, Kunzman, & Krozek; 2001) • Resource considered as in-kind support as responsibility of clinical professional development department within IHDM • Benchmarking • Difficult at this point as residency program pilots for RNs is new • Program for IHDM • Number of participants small • Survey tool not tested for validity

20. Recommendations • Continue the RN Residency program augmenting the existing nursing orientation at Iowa Health Des Moines (IHDM) in 2011 and 2012. • Start within six months of licensure • Enhance preceptor program • Add simulation to the course material to increase hands on skills • Develop tool kit for nurse leaders • Collaborate with Human Resources with application process

21. Recommendations • Institute of Medicine (IOM, 2010) • The Institute of Medicine and Robert Wood Johnson Foundation included implementing a residency program as a targeted recommendation at the local, state, and national level. • Time Line for Implementation • First pilot, 6 residents participated, April 2010 – September 2010 • Second pilot, goal for 20 residents to participate, August 2011 - February 2012 • Third pilot, goal for 20 residents to participate, February 2012 - August 2012 • Full implementation August 2012

22. Conclusion

23. References • Altier, M.E. & Kresek, C.A. (2006). Effects of a 1-year residency program on job satisfaction and retention of new graduate nurses. Journal for Nurses in Staff Development, 22(2), 70-77. • Beecroft, P.G., Kunzman, L., & Krozek, C. (2001). RN internship: Outcomes of a one-year pilot program. JONA, 31(12), 575-582. • Benner, P. (1984). Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley. • Bonnel, W. (2009). Clinical performance evaluation. In D.M. Billings & J.A. Halstead (Ed.) Teaching in Nursing: A Guide for Faculty (3rd Ed.) (pp. 449-458); St. Louis, MO: Saunders Elsevier.

24. References • Nursing Executive Center. (2008). Bridging the preparation-practice gap: Volume I: Quantifying new graduate nurse improvement needs. The Advisory Board , ix-71. • Poynton, M.R., Madden, C., Bowers, R., Keefe, M., & Peery, L.H., (2007). Nurse residency program implementation: The Utah experience. Journal of Healthcare Management, 52(6), 385-397. • Reinsvold, S. (2008). Nursing Residency: Reversing the cycle of new graduate RN turnover. Nurse Leader, 46-49.

25. Questions