Nurse Residency Program

Chester Wheeler, Allison Ledsome and Tracey Cornille

College of Central Florida

 

 

 

Abstract

Being a nurse is both a very humbling and honoring job.  Becoming a nurse is a very time consuming, life altering task.  Newly licensed registered nurses (NLRNs) are faced with a harrowing transition as they move from being a student to becoming employed as a new nurse.  They must adjust to life outside of school work.  They are no longer being guided by their professors on how to best take care of a patient or which nursing diagnosis is best to choose.   NLRNs are forced to take responsibility personally and professionally while also learning how to independently work as a nurse.  To help with this transition, Nurse Residency Programs (NRPs) have begun to take their place in many hospitals throughout the country.  These programs provide NLRNs the opportunity to learn and gain confidence while taking on their new job title and responsibility as a registered nurse.  Thorough research has shown these programs to be effective for not only helping new graduates to gain confidence but they have positively affected patient outcomes and the retention rate of new nurses.

Nurse Residency Program

With the aging of the population in the United States now, appropriate nursing staff is of great need and importance in health care institutions.  Newly licensed registered nurses (NLRNs) are entering the work force after graduation with nervousness and uncertainty (Olson-Sitki, K., Wendler, M., Forbes, G., 2012, p. 156).  It is of utmost importance to equip them with the tools they need to practice in a safe, professional and competent way.  Putting a nurse residency program (NRP) in place for NLRNs will prepare them for the expectations of the job and will also offer them support and confidence in the profession, institution, and themselves. 

Purpose of Project

The purpose of this evidence based project (EBP) is to implement a NRP for NLRNs entering employment at J.B. Williams Memorial Hospital.  The program will serve to give more thorough training, education, and practical clinical experience with staff support and mentorship.  By providing extensive training opportunities including seminars, simulation experiences, and one-on-one mentorship, the NLRNs will receive more exposure to clinical situations and opportunities to be involved in their new professional role.  The NLRNs will be involved in EBPs including conducting literature reviews and researching best practice-patient outcomes with newly implemented evidence based interventions.  The participants will also be involved in shadowing experienced nurses for enhanced nursing role involvement.  The NLRNs will learn to work with the health care team to provide excellent care while still working under the wing of their mentor and close supervision of their nurse leaders.  Participants will also have opportunities to participate in leadership roles and to begin to develop leadership skills.  The NLRNs will be able to meet in groups with each other to participate in group learning while sharing their experiences, both positive and negative, in a safe environment.  This project will be monitored with retention and satisfaction statistics and surveys will be gathered at the six month and 12 month time points.    

Background

 Graduating from nursing school can be a very exciting and terrifying time all at once.  Entering a new job as a NLRN with the very limited orientation that is traditionally offered by large health care institutions, can cause more stress and anxiety than a new nurse can handle.  This increased strain and demand coupled with the crisis of a nursing shortage can lead to poor patient outcomes, poor job satisfaction with subsequent resigning of the new nurses’ position.  A literature review completed by Olson-Sitki, Wendler, and Forbes (2012) showed “the most difficult role adjustment period for new nurses is between 6 and 12 months after hire, as they practice through their first year-an idea supported by Benner” (p. 156).  Little, Ditmer and Bashaw (2013) stated “complexity of hospital systems make the transition from college to new RN increasingly challenging, often resulting in stress and dissatisfaction” (p. 361).  Implementing a more extensive training and transition opportunity in the form of a Nurse Residency Program (NRP) has been shown in studies to not only increase nurse retention rates but also, it improves patient outcomes and decreases institution expenditures.  NRPs can also increase the NLRN’s professional confidence and overall professional satisfaction.  Little et al. (2013) shared that “the Institute of Medicine strongly recommends the development and implementation of nurse residency programs to improve retention of nurses, expand existing competencies, leading to improved patient outcomes” (p. 361).  In a study by Rosenfeld, Glassman and Capobianco (2015), the authors reported “in 2002, the University HealthSystem Consortium/American Association of Colleges of Nursing (UHC/AACN) advanced a standardized curriculum for Nurse Residency Programs (NRPs).  By 2014, the UHC/AACN model has been adopted by more than 130 hospitals nationwide” (p. 332).  Linus, Reeder, Bradley and Polis (2014) reported that “nurse residency programs are designed to increase retention, and provide essential tools to assist new or recent GNs in this transition…the UHC reported that 94.6% of new graduates completing a nurse residency program were retained after 1 year” (p. 116).  Little, et.al. (2013) continued “nurse residency programs have been developed to provide emotional support, establish clinical competence, and retain new graduates who are making the transition into practice, supporting the future of nursing practice” (p. 362).    Offering a more extensive training program for NLRNs entering this complicated field can help them realize they are not alone in the sometimes painful journey of novice to more experienced nurse.  Incorporating different educational activities and experiences to cover all aspects and styles of learning are important to help the NLRNs further develop the concepts they have already learned in traditional nursing school programs while also helping them to apply this knowledge they have retained.  In the article by Rosenfeld, Glassman, and Capobianco (2015), many of the learning experiences NLRNs can be involved with include: “seminars, evidence-based practice projects, shadowing experienced RNs, unit senior staff support, and group activities with other members of the residency program” (p. 336).  With the opportunity of good support accompanied with appropriate education and exposure, NLRNs have the capacity to make a positive impact on the lives of the patients they care for, the nurses they work with and organizations they are employed by.  Olson-Sitki, et al. (2012) stated, “a standardized residency program…has been proposed as essential for all new GNs, similar to training provided to physicians, pharmacists, and pastoral care residents…to guide the growth and development of these newest nurses in the workforce to facilitate transitions between educational programs and professional practice” (p. 161).

 

 

Proposed Change

The current and continuing nursing shortage is straining the nursing profession to provide quality of care with less staff, less resources, and more stringent criteria to uphold quality of care. With the shortage of nurses, job retention is even more crucial to providing quality care. With the introduction of NRPs, it will help to fill the gap and introduce well-rounded comfortable nurses into the profession (Altier, 2006). Currently many health care facilities struggle with nurse job retention, job satisfaction and financial stability. Research reveals that between 35% and 65% of nurses change jobs in the first year of employment and that nurse turnover is a major cost driver in hospitals. Healthcare leaders believe the resulting lack of confidence and stress contributes to rising new nurse turnover (Pittman, 2013). Residency programs for NLRNs have been strongly advocated by the Institute of Medicine, American Organization of Nurse Executives, and other professional organizations. Their cost-effectiveness as well as their impact on NLRN retention, job and practice satisfaction, improved performance, and reduction in environmental reality shock has been demonstrated (Kramer, 2012). The process will follow the Evidenced-Based Advancing Research and Clinical Practice through Close Collaboration (ARCC) Model (Melnyk & Fineout-Overholt, 2015).  Currently at J.B. Williams Memorial Hospital, there is no NLRN residency program in place. Many new nurses are only given six weeks of training and orientation before they are expected to care for patients on their own. This so called ‘orientation period’ does not provide NLRNs with the tools they need to prosper as nurses, let alone bolster reported patient satisfaction surveys. To ensure better nurse retention rates, nurse-reported job satisfaction, patient-reported satisfaction, and increased positive patient health outcomes, it is imperative that our hospital adopts with enthusiasm a NRP that embraces evidenced based practices and innovation in order to properly acclimate and assimilate NLRNs into our facility’s culture for the betterment of the future of the nursing profession, the reputation of our hospital and the welfare of our patients alike.

The NRP will last 12 months and the effectiveness of the program will be evaluated at both six and 12 month increments to determine the performance of the program in order to judge the established outcomes for area of improvement.

Initially, the NRP will consist of ten selected NLRNs applying at the facility.  The NLRNs will be paired with ten nurse mentors who work on the participants’ respective nursing units. Throughout this program, NLRNs will be guided through a 12-month program to help them adjust to the various facets and demands of the nursing profession. Throughout this time, the NLRNs will be provided with the confidence and skills needed to feel comfortable in the profession independently. Having confidence and knowing how to handle situations will help the nurses better cope with the stressors and fatigue of being a professional nurse while increasing nurse retention. With the current nursing shortage and aging population of nurses, retention is more important than ever. Having reliable and strong nurses in the field will increase the overall outlook of the profession, reported nurse job satisfaction, reported patient satisfaction with the healthcare services received, and increased positive patient healthcare outcomes.

EBP Process Model

With the aging population of nurses and shortage of nurses, newly graduated nurses are being thrown into the profession without a gradual introduction. Often times, NLRNs are overcome with fear and anxiety regarding their new responsibilities and requirements, feeling alone in the acclimation process (Olson-Sitki, Wendler, & Forbes, 2012).   Retention of NLRNs is becoming a great concern for the profession as the population of patients is becoming older and more acutely as well as chronically ill. The model being used to implement the nurse residency program is the Evidenced-Based Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model.

The purpose of the Evidenced-Based Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model is used to provide health care institutions and clinical settings with an organized conceptual framework that can guide system-wide implementation and sustainability of EBP to achieve quality outcomes (Melnyk & Fineout-Overholt, 2015). Since evidenced-based clinicians are essential in cultivating an entire system culture that implements EBP as standard of care, the ARCC model encompasses key strategies for individual and organizational change to and sustainability of best practice (p. 289).  To implement the NRP for NLRNs, the question “Are new graduate nurses who participate in nurse residency programs vs. traditional unit/floor orientations more likely to retain employment after 6 and 12 months?” must being considered and maintained throughout the EBP process. When conducting EBP, barriers that may arise within the team must be examined; (a) inadequate EBP knowledge and skills, (b) lack of administrative support, (c) lack of an EBP mentors, (d) lack of belief that EBP improves patient care and outcomes, (e) perceived lack of authority to change patient care procedures, and (f) nurse leader/manager resistance (p. 290).  To execute the introduction of a NRP for NLRNs, an organized team willing to participate and educate participants on their role within the process must be formed. By addressing these barriers and educating the team involved, there will be a higher level of participation and less resistance. With these barriers addressed, there will be higher and more positive outcomes for the NRP.  The goal of the program is to give the NLRNs a sense of unity with a team and allow them to venture out on their own, but with the guidance of an experienced nurse with them. The experienced nurse that they are paired with will be their mentor for the next 12 months. The nurses involved are explained that they will have a “shadow” for the next 12 months and are to help introduce them and ease them into the profession.

Clinician Involvement

Implementing a NRP requires our organizational stakeholders to be fully involved across all levels of nursing, including nursing leadership, nursing education, nursing professional development, human resources, and staff nurses. Frontline nurse managers are integral in this program development, implementation, and outcome evaluations. Recruitment of NLRN participants will begin with nurse managers during the interview process.  The nurse managers will then recommend them to the residency coordinator for consideration. Engendering a clinical culture of acceptance and understanding that generates excitement over a NRP involves the support of the facility’s administrators, educators, and both official and unofficial nurse leaders advertising the benefits of the program. The future of nursing depends on the efforts of today’s nurses.

Overseeing the implementation of the NRP will require a planning team and residency coordinator. The planning team will compromise administrators, nurse leaders, nurse educators, nurse managers and a new appointed/hired residency program coordinator. The planning team should have a clear vision and a strong belief in the NRP for not only the benefit of the new nurses and hospital but the patients as well. This team will meet weekly during the inception of the program and monthly thereafter while being established, then transitioning to quarterly meetings after a year of successful outcomes. The residency coordinator will be responsible for the NLRNs’ transition from student nurses to professional nurses, equipping them with not only the coping skills to deal with the stressors of being an independent nurse, but also the education and training to transition from a novice to a competent nurse that embraces evidence based practice, exudes confidence in their roles, and that are equipped to become nursing leaders. Nursing educators will provide guidance and assistance as required, but the bulk of the responsibility of will be assigned to the residency coordinator. 

Supplemental education and expert knowledge will be incorporated into the curriculum in the form of guest speakers, educators and clinical experts as relevant course work is presented. Drawing first from the existing facility personnel, known leaders and experts in the areas of wound care, dialysis, critical care, surgery, obstetrics, pediatrics, and cardiac care will be recruited to share their knowledge and expertise with participants. Depending on the available funding or willingness to volunteer their time and knowledge, outside experts will be recruited for guest lectures.

Each program participant will be assigned to a nursing mentor that will be recruited from the staff nurses currently working the nursing units that each participant is assigned. These mentors will have a demonstrated history of excellence in nursing, leadership whether formal or informal, and an enthusiasm to promote evidence based practice and nurture fledgling nurses in order to create a new generation of nurses equipped with the skills to prosper in the field. Nurse residency participants will be assigned to the same shifts as their mentors, shadowing will occur three out of five shifts per week to promote skill building and independence at the same time- meaning participants will work in conjunction with their mentors for three days and two days independently for the twelve months of the program. Weekly, a dedicated group meeting between all mentors and participants will be scheduled in order for all participants to interact, debrief their experiences, and reflect on their growth, creating a shared perspective on the experience of being a new nurse in a complex health system and the tools necessary to succeed.

                                                                         

Outcomes

The inception of an NRP into our facility will not only provide for evidence based practice to be the foundation of clinical practice in the new generation of nurses that are the future leaders of our facility but also, it is to battle the high rates of NLRN attrition after one year or less being nearly 60% as reported by human resources in 2014. This has historically equated to for every 100 NLRNs that are hired in the fiscal year, 60 of them leave their position within the first year. J.B. Williams Memorial Hospital has failed at providing new nurses with the support, education, mentorship, and guidance to cope and prosper in this diversely complex and stressful field. New nurses are friends not food; our facility must invest in retaining them as long term employees. According to Human Resources at J.B. Williams Memorial Hospital (2015), 75% of the current nursing staff is due to retire in the next 5-10 years. This means that if we do not provide an environment to nurture and retain new nurses that J.B. Williams Memorial will be in a dire situation to provide the even the most basic of care to the community.  Through the NRP, the facility hopes to achieve four primary outcomes: 1) to reduce NLRN attrition rates from 60% to less than 20% in their first year of employment; 2) increase nurse-reported job satisfaction by 25% in the first year of the program; 3) increase patient-reported quality of care or satisfaction by HCAHPs scored per assigned unit by at least 5-10% from baseline scores; and 4) decrease the expenditure of new nurse hiring and orientation by 25% by increasing retention of NRP participants. These outcomes are bare minimum predictions as the NRP is new to the facility and we hope to meet if not surpass these predicted outcome achievements.

 

 

 

Activity

Month 1-3

Month 4-6

Month 7-9

Month 10-12

Month 13-15

Research into Most Relevant Literature

x

Obtain Approval for NRP from Admin

x

Hire a NRP Coordinator and establish a NRP committee

x

Establish Curriculum/Guest Lecturers

x

Recruit Mentors

x

Educate/Support Mentors (ongoing throughout program)

x

x

x

x

Recruit NLRNs, interview and select

x

Initiate NRP with clear established outcomes presented to NLRNs and Mentors @ month 3

x

Evaluate six month mark outcomes measures

x

Initiate satisfaction survey for NLRNs, mentors, staff and leaders @ month 9

x

Data analysis since 6 month survey

x

Satisfaction survey for NLRNs, mentors, staff and leaders @ month 15 (1 yr. since initiation of program

x

Evaluate 12 month outcome measures

x

Dissemination of data analysis, survey results

x

 

Budget

The NRP will be funded through the facility’s operational budget with an annual budget of $7,000 per year for supply costs, equipment, and printing of course materials. The residency coordinator salary should also be considered in the budget reflective of his or her experience, education, and job fulfillment. The budget cost of each participant shall be covered by their designated unit assignment, thus reinforcing the unit manger’s participation in recruiting, recommending, and promoting the program. Guest lectures and speakers shall be compensated for their time according to their hourly rate if in-house and a flat rate of $100-$250 determined by the residency coordinator for external lectures.

Nurse attrition rates has had a significant impact on our facility both in the quality of care delivered as demonstrated by substandard HCAHPs scores and the financial burden of hiring new nurses. Human Resources (2014) estimates that our hospital spends approximately $300,000 yearly for every 1% increase in nurse turnover. This amount has no consideration to the funds spent on advertising, recruiting, cost of agency hires, overtime expenses, orientation training, and productivity losses. Considering the cost that is required to hire new nurses throughout the year, the cost jumps to nearly $9 million dollars per year. This money that is being lost to hiring then losing new nurses and paying for agency or temp help is unacceptable. The yearly cost of the NRP is estimated to be $256,500 (see table below).

Residency Coordinators:	One full time + one part time	$108,000
NLRN Participant salary	10 participants x $ 21.25/hr x 560 program hours	$$119,000
NLRN incentive completion bonus	10 participants x $ 2,000 bonus	$ $20,000
Supplies/Equipment/Printing	Annual Budget	$7,000
Guest Lecturers	10 lecturers x $250	$2500
		TTotal: $256,500

: =

 

 

 

 

Equipment and Supplies

Supplies: Pens, Pencils, Notebooks/Binders, Tape, Staples, Paper Clips, Mentor Pins, NRP Pins	$1000.00
Printing: Course Materials, Welcome Packets, Mentor Packets, Guest Lecturer Lessons, Newsletter	$2000.00
Equipment: Projector/Mock Handhelds	$2000.00
Clinical Supplies: Gauze, Needles/Syringes, Wound Vac Supplies, Urinary Catheter/Trach/ Central Line/ NG Tube Kits, EKG Electrodes	$2000.00
Simulation Mannequin	Available through Nursing Education Depart.
Access to EBP Journals	Available through Hospital Existing Subscription to EBSCO, CINAHL, Up to date

 

 

 

Conclusion

Fiedler, Hicks, Read, Jegier and Lane (2014) stated “studies examining the short-term outcomes of nurse residency programs have shown that these programs improve retention rates and strengthen a variety of skills, as well as deepen clinical reasoning and judgment among participants” (p. 417). When NLRNs enter the workforce, it is important to equip them with the exposure, education and support they need to continue to succeed. They have finally survived nursing school and proved they can pass their state boards, now it is critical to continue to guide them into their new profession. With the availability of a nurse residency program, they can be provided with the tools they need to become a more experienced nurse. They can also grow personally gaining confidence and a broader knowledge base. Giving them the confidence to do the job while offering knowledge to know how, can increase their desire to stay with the job which can ultimately help lessen the nursing shortage while also positively effecting patient outcomes. In conclusion, Wierzbinski-Cross, Ward, Baumann stated “Nurse Residency programs have the potential to improve new graduate nurse confidence, skill, satisfaction and retention rates. In turn, improved retention and competence result in improvements in quality and patient safety” (p.20).

 

 

                   

 

 

References

Altier, M. & Krsek, C. (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.

Fiedler, R., Hicks, F., Read, E., Jegier, B., Lane, K. (2014). Long-term outcomes of a postbaccalaureate nurse residency program: A pilot study. The Journal of Nursing Administration, 44(7), 417-422.

Goode, C., Bednash, G., Lynn, M., Murray, B., McElroy, D. (2013). Lessons learned from 10 years of research on a Post-Baccalaureate nurse residency program. The Journal of Nursing Administration, 43(2), 73-79.

Goode, C., Lynn, M., Krsek, C., Bednash, G.  (2009). Nurse residency programs: an essential requirement for nursing. Nursing Economic$, 27(3), 142-159.

Kramer, M., Maguire, P., Halfer, D., Budin, W., Hall, D., Goodloe, L., Lemke, J.  (2012).  The organizational transforamative power of nurse residency programs.  Nursing Administration Quarterly, 36(2), 155-168.

Linus, R., Reeder, S., Bradley, P., Polis, N.  (2014).  Nurse leaders’ perceptions of the value of a nurse residency program.  Journal for Nurses in Professional Development, 30(3), 117-121.

Little, J., Ditmer, D., Bashaw, M.  (2013).  New graduate nurse residency:  A network approach.  The Journal of Nursing Administration, 43(6), 361-366.

Manzano, W., Rivera, R., Sullivan, R.  (2013). What We Have Learned from a Model Nurse Residency Program: Ideas for Linking Service and Education. Nursing Education Perspectives, 34(6), 371. doi:10.5480/1536-5026-34.6.371

Melnyk, Bernadette M., and Fineout-Overholt, E.  (2015) Evidence-based practice in nursing and healthcare:  A guide to best practice (3rd ed.)  Philadelphia, PA:  Wolters Kluwer Health.

Olson-Sitki, K., Wendler, C., Forbes, G.  (2012).  Evaluating the impact of a nurse residency program for newly graduated registered nurses.  Journal for Nurses in Staff Development, 28(4), 156-162. 

Pittman, P., Herrera, C., Bass, E., & Thompson, P.  (2013).  Residency programs for new nurse graduates.  The Journal of Nursing Administration, 43(11), 597-602.

Rosenfeld, P., Glassman, K., Capobianco, E.  (2015).  Evaluating the short- and long-term outcomes of a post-BSN residency program:  findings of a retrospective study of nurse residents, 2005-2012.  The Journal of Nursing Administration, 45(6), 331-338.

Wierzbinski-Cross, H., Ward, K., Baumann, P.  (2015).  Nurses’ perceptions of nurse residency:  identifying barriers to implementation.  Journal for Nurses in Professional Development, 31(1), 15-20.