Nurse Residency Programs and the Benefits for New Graduate Nurses.
The concept of "reality shock" experienced by a new graduate starting his or her career was first described by Kramer in 1974 with a discussion about the widening gap between a new graduate nurse's comfort level, confidence, skills, and ability to deliver safe and adequate care (Kramer, 1974). Kramer (1974) discussed the seven major challenges that befall a new nurse in trying to work through this transition, including challenges with delegation, prioritization, decision-making, collaboration, conflict resolution, and the ability to give and accept constructive feedback (Kramer, 1974). In addition, there is often a disconnect between a new graduate's expectations of his or her role and the organizational or leadership expectations, which can contribute to a feeling of incompetence and increased stress in navigating this new professional reality (Villanueva, Taylor, Dickson, & Foster, 2015). The major arching themes within these challenges are the need to address communication with the multidisciplinary team, patients, and families; organization of patient care de mands with prioritization; critical thinking skills; and stress management, particularly in the hectic environment of health care (Theisen & Sandau, 2013; Villanueva et al., 2015).Background
In conjunction with the lack of adequate support for new graduate nurses in the early 2000s, the field of nursing was also entering a time of increased healthcare demands with a critical shortage of registered nurses made worse by decreasing retention rates, particularly retention of new nurses. To combat this high turnover rate and tackle the challenge of increasing this support for new graduate nurses, The Joint Commission recommended the growth of residency programs with a planned period of time in the beginning of one's career in which new graduates could obtain more knowledge and build up their foundational skills to deliver the safest care (Institute of Medicine [IOM], 2010). This recommendation is one strategy included in the Future of Nursing 2010 guidelines to address the reality shock experienced by new graduates, decrease new staff burnout, and improve nursing retention (IOM, 2010).
The first nurse residency programs were started in 2004 and led by the American Association of Colleges of Nursing (AACN) in the ICU setting (Barnett, Minnick, & Norman, 2014). Nurse residency programs have found much success in improving job satisfaction for new graduates and nursing retention for hospital systems, prompting continued growth through the ICU, acute care, and pediatric settings with tailored programs to fit the clinical context. In a 2016 study in 316 pediatric hospitals throughout the country, including free-standing pediatric hospitals and community hospitals with pediatric units, 70% offered a nurse residency program tailored to the pediatric population (Smith, Robinson, Echtenkamp, Brostoff, & McCarthy, 2016).
Within the growth of nurse residency programs, there has been a variety of different structures and timelines used to orient new graduate nurses, creating many options for new graduates to pick the program that focuses on and fits the identified needs with communication, organization, critical thinking, and/or stress management. As covered in The Future of Nursing (IOM, 2010), residency programs should be at least one year, with a focus on a specific population or clinical area of specialization for a new graduate to achieve a full transition to independent practice (Goode, Reid Ponte, & Sullivan Havens, 2016). Forty percent of the current nurse residency programs in the United States last for approximately one year, although there is much variety ranging between several weeks to the year-long program (Barnett et al., 2014). Although the year-long program requires a substantial commitment from nurse residents and has financial implications for the hospital system, the program allows adequate time to transition nurse residents into their new position, learning through didactic sessions and/or simulations, and for building upon clinical experiences to increase their confidence and voice in influencing the plan of care.
Although each residency program has unique features, the three structures used most commonly in residency programs are didactic-based, simulation-based, and clinical preceptorships. Each program has unique benefits, but all have the purpose to build upon the new nurse's foundation in communication, organization, critical thinking, and stress management.
Structures of Residency Programs
Didactic-Based
To ease the transition from mostly classroom learning to increasing knowledge for a specific clinical context, many nurse residency programs use a didactic portion of the orientation process. The strengths of this type of program lie in focusing on contextual clinical knowledge; communication skills; organization through discussions about prioritization, delegation, and professional growth; and critical thinking through debriefings and case studies. Not only do education sessions help new graduate nurses learn about important contextual information, such sessions also allow them to learn from their past clinical experience and current experiences on their new unit in a familiar setting of a classroom. A didactic-based residency program can also use classroom time to discuss topics, such as communication; difficult conversations with fellow team members, patients, or families; prioritization; and delegation. Nurse residents can learn from the experiences of their peers and talk through these challenges in an unbiased, non-threatening environment, helping create a comradery among nurse residents as a cohort, much like nursing school (Klingbeil et al., 2016).
This environment of open communication can also help with the challenge of stress management as a new nurse, drawing support from those who understand and can give advice. Pediatric nurses suffer greatly from compassion fatigue, contributing to high rates of burnout, especially when caring for children with complex, chronic, and/or terminal conditions (Berger, Polivka, Smoot, & Owens, 2015). For this reason, discussion about compassion fatigue and interventions to provide self-care can be a useful topic to incorporate into didactic sessions for pediatric nurses. This open communication about compassion fatigue can be used to strengthen the comradery among nurse residents and provide a communication outlet for them during the beginning years of their careers.
Didactic-style residency programs can be particularly important with new graduate pediatric nurses due to important differences in the medical and developmental care for a child versus an adult, communication and shared decision-making with parents and/or legal caregivers, and care of the adolescent patient with preparation for transition to adult care (Darcy Mahoney, Hancock, Iorianni-Cimbak, & Curley, 2012; Villanueva et al., 2015). With the lack of pediatric-specific undergraduate nursing programs available for students and difficulty finding pediatric clinical placements, a number of new graduate nurses begin their career with little pediatric-specific education or experience. To address this gap in knowledge, as well as provide a foundation for new graduates, the didactic-based programming for pediatric nurse residency programs is especially helpful. One example of a didactic-based program in a free-standing pediatric hospital included an initial week-long organizational orientation that discussed important clinical topics within the context of hospital-specific policies and procedures. In addition, throughout the nurse resident's first year of practice, there were three scheduled education sessions with both clinical and professional content, focusing on ethics in pediatric healthcare, death and dying, boundaries of care, and professional growth (Klingbeil et al., 2016). When didactic sessions include situational learning, debriefings, or case studies, a discussion can allow the new nurses to think about how they responded to a situation or would respond, also improving their critical decision-making skills when those difficult situations arise in clinical practice (Theisen & Sandau, 2013).
The AACN, credited for developing the first nurse residency programs, sponsors a curriculum in collaboration with Vizient, Inc., to try and standardize this didactic experience (Greene, Warren, & Perkins, 2016). Although there is a cost for hospitals to implement this curriculum, the program is a step to create some consistency of content across programs, particularly in the ICU setting. With the purpose to "help transition new nurse residents into their clinical roles and build their confidence" (Vizient, Inc., 2018), the Vizient, Inc./AACN curriculum includes lessons and activities centered around improving nurse residents' skills of evidence-based decision-making, professional development, investment in clinical outcomes, and completion of evidencebased or quality improvement project (Vizient, Inc., 2018). The curriculum can be adjusted to apply to any setting and is used in a variety of pediatric hospitals throughout the country.
This requirement to complete a clinical project, either through quality improvement or research to answer a clinical question, is a unique aspect of some didactic-based programs (Barnett et al., 2014; Vizient, Inc., 2018). Only 40% of nurse residency programs currently require a project to be completed with the purpose to aid in the socialization to the unit and improve communication skills through discussion with identified stakeholders in volved in the project (Hillman & Foster, 2011). While there are many benefits for nurse residents in completing the project in striving for professional growth early in their career, there has also been a positive link between socialization into unit culture and increased nursing retention (Hillman & Foster, 2011; Kramer, Maguire, Halfer, Brewer, & Schmalenberg, 2013).
One example of a project completed by pediatric nurse residents addressed the concern with identifying peripheral IV infiltrations, a common difficulty with IV site assessments, especially in young children who are unable to communicate localized pain (Lim, Wong, Kek, Suhairi, & Yip, 2018). Their project identified one possible solution by using more transparent, but equally secure, dressings over IV sites, finding that by improving the visibility of the site, earlier detection of IV site complications improved (Lim et al., 2018). For nurse residents interested in quality improvement or research work, an addition of this component in the nurse residency program can open the door to future opportunities and help in selecting a residency program tailored to their interests. With these benefits, a strong didactic curriculum can help establish a strong foundation in which nurse residents can build upon during the entirety of their nursing career.
Simulation-Based
Much like didactic programs focus on contextual knowledge, communication, and organization, the strength of simulation-based programs lies in the focus on critical thinking skills and communication skills in a simulated high-pressure situation. The use of simulation is an education technique that involves immersive learning with new technology in a lowstress environment, allowing nurse residents to practice clinical skills and communication without pressure (Conner-Warren, Hillman, & Murphy, 2014; Edwards, Hawker, Carrier, & Rees, 2015; Hillman & Foster, 2010; Meyer Bratt, 2013; Theisen & Sandau, 2013). In simulating a critical patient situation or one that requires communication with several different specialties, the practice working through the situation allows the nurse resident to develop their critical thinking and work on their communication style interactively (Theisen & Sandau, 2013). Debriefing following a simulation uses reflective learning techniques to discuss what went well and areas that require growth (Theisen & Sandau, 2013). Using a simulation lab also allows the opportunity to practice clinical skills with the use of hospital technology and equipment in the form of IV pumps, ventilator equipment, IV placement kits, or urinary catheter insertion. To allow for the use of simulation in the residency program, an available simulation space in the hospital, mostly found in teaching facilities, or a partnership with a local college of nursing is required (Conner-Warren et al., 2014).
Scenarios used in simulations are often chosen due to their need for excellent communication and leadership skills. In terms of the education of pediatric nurses, these scenarios can also highlight the unique qualities of the care of young patient, which require differing responses and management. Some scenarios can include the need to provide developmentally appropriate care based on the child's actual or developmental age and mental capacity, the vulnerability of children and differences with adult physiology, and involvement of parents and/or caregivers (Darcy Mahoney et al., 2012). Darcy Mahoney and colleagues (2012) studied the use of highfidelity pediatric simulators in undergraduate nursing education and its impact on the confidence of students after participating in four different scenarios. Each scenario required the nursing students to incorporate a developmentally appropriate focused physical examination based on the situation, clear and concise communication with the multidisciplinary team, parent and family education, and weight-based dosing of medications, a vital difference in the care of children versus adults (Darcy Mahoney et al., 2012). Both quantitative and qualitative data demonstrated positive results following involvement in simulations with increased self-reports of confidence in decision-making, prioritization, and communication (Darcy Mahoney et al., 2012). Many nursing schools currently use simulation throughout a nursing student's education, so the integration of simulation in the residency program is a useful transition tool from the classroom to clinical practice.
Practicing skills such as these in the simulated environment for pediatric nurse residents, particularly hands-on learners, further builds upon the foundation with experiences in critical thinking in high-stress clinical situations, communication with the provider and families, and organization of priorities. In practicing one's response and role in these scenarios, the challenge of stress management is addressed, allowing the new graduates to feel empowered and prepared when these scenarios arise in future clinical practice. Debriefings are also used to address this stress, and facilitators can use this time to provide advice and techniques for management in the future. Simulation-based residency programs allow "improvement in confidence, competence, readiness of practice... and has been shown to be more effective than other types of programs offered in developing knowledge and skills" (Edwards et al., 2015, p. 1263).
Clinical Preceptorship And Mentorship
The use of clinical preceptors with hands-on and progressive learning is another aspect of most residency programs, as well as a common part of the traditional orientation to a new unit. Learning from an established nurse on the unit allows the new nurse to orient in the clinical setting under their guidance. This orientation period with a preceptor is the most crucial aspect of a successful transition to independent practice because it is truly "on the job" learning with the need for adequate communication and critical thinking to care for their patients. With a preceptor's guidance, this time of orientation also allows the new graduate to work on establishing adequate organizational and prioritization skills when caring for specific patient populations on the unit, with someone available to discuss plans and delegate (Theisen & Sandau, 2013). One difficult part of transitioning to independent practice is learning how to effectively care for an increased number of patients, each with differing needs and acuities. Under the guidance of an established nurse preceptor who has learned to manage this patient load, new graduates can become socialized to the culture of the unit and learn strategies to help them master the important nursing skill of prioritization and team work (Dwyer & Hunter Revell, 2016).
The clinical preceptorship model addresses new graduate skills of communication and organization through role modeling, as well as aiding with stress management through the strengthening of a support network. A clinical preceptor is a built-in mentor, one who has experienced the transition and orientation process, and therefore, can be a support to aid with stress management (Fink, Krugman, Casey, & Goode, 2008). A mentoring relationship between new pediatric nurse graduates and their preceptors can improve their sense of belonging, competence, and security, while also developing their leadership skills and platform for professional growth (Weese, Jakubik, Eliades, & Huth, 2013). A preceptor who acts as a mentor can help new graduates achieve these benefits through teaching them the role, welcoming them to the unit, supporting them in their difficult and often overwhelming transition, and providing protection and guidance when difficult patient scenarios arise (Weese et al., 2013). A strong and knowledgeable preceptor is vital to form this relationship, also indicating the need for the support of professional development and comprehensive training of new and existing preceptors. With increased knowledge about a new graduate's transition, preparation, and goals, a preceptor can be well-equipped to be the support and security welcomed by the new graduate in a time of uncertainty. In addition, introduction of orientation checklists to be jointly completed by both the preceptor and new graduate can aid in identifying patient diagnoses, skills, and experiences during orientation, thus taking advantage of the preceptor's experience and guidance.
Job Satisfaction and Nursing Retention
Growth in the four foundational skills of communication, organization, critical thinking, and stress management through nurse residency programs helps build the confidence and self-reported competency of new graduates. Regardless of the structure, completion of any type of residency program has been shown through qualitative studies and surveying to be associated with increased levels of confidence, competency, and job satisfaction, with a reduction in stress and anxiety of the new graduate (Edwards et al., 2015). Not only does the use of didactic work and simulation assist with transitioning a new graduate's thought process toward clinical practice, involvement in a program with other nurse residents forms a support system with other new graduates experiencing the same transition (Fiedler, Read, Lane, Hicks, & Jeiger, 2014; Kramer et al., 2013). "Group cohesion [is] effective in moderating the negative effects of current stress exposure and PTS symptoms on negative nurse outcomes, specifically on increased compassion fatigue and burnout" (Li, Early, Mahrer, Klaristenfeld, & Gold, 2014, p. 89). Positive effects on new graduate experiences were universal throughout the various structures of nurse residency programs, with no difference statistically between the type of program (Edwards et al., 2015). Acknowledgement of the difficult transition and extra support systems created through a residency program is a critical aspect that assists in increasing this satisfaction among nurse residents.
Related to job satisfaction is the improvement in retention rates in new graduate nurses. According to an article published in Policy, Politics, & Nursing Practice in 2014, 1 in 5 new graduate nurses leave their initial place of employment within the first year of their career, with 1 in 3 leaving within two years (Kovner, Brewer, Fatehi, & Jun, 2014). With the implementation of nurse residency programs, healthcare organizations are benefiting with improved retention of competent, adequately trained, and confident nurses, which can have implications in quality of care and patient satisfaction. One example of the effect of nurse residency programs on nursing retention was seen with the implementation of the Statewide Maryland Nurse Residency Collaborative in 2014 (Warren, Perkins, & Greene, 2018). The state saw a 6% to 10% decrease in voluntary turnover, and retention rate increased from 91% in 2014 to 96% in 2016 (Warren et al., 2018). In a study completed over a four-year period in a hospital system with a nurse residency program, 182 of the 251 nurse residents who completed the program were still employed with the organization, with a calculated savings of 4 million dollars per the office of recruitment (Hillman & Foster, 2011).
In addition, the increase in nursing retention also decreases costs for hospital systems by decreasing the reliance on contracted workers to fill staffing holes. A cost-benefit analysis published in Nursing Economic$ found an overall decrease in contract labor costs from $19,099 to $5,490 per average daily census, as well as a savings of approximately $10 to $50 per day per new staff member with utilization of a residency program versus a traditional orientation method (Trepanier, Early, Ulrich, & Cherry, 2012). Through the investment in seeking to improve the transition and experience of new graduates, nurse residency programs help foster a commitment to the organization that improves retention and decreases voluntary turnover, with fewer graduated residents leaving the organization completely (Hillman & Foster, 2011). The option of a residency program also creates a supportive and dedicated work community that many new graduates seek out in their first place of employment. Improvement in nursing retention is not only beneficial for nurse residents, but it also decreases the cost of recruitment and orientation in the long term and can be considered a smart investment for hospital systems. In terms of policy implications, due to the benefits for the new graduate nurses, the nursing department, and the institution as a whole, nurse residency programs should not only be encouraged at all pediatric institutions, it could also become a condition of Magnet[R] designation or a requirement for accreditation for hospital systems in the future.
Recommendations For New Graduates
As nursing students are graduating and looking to begin their job search where they will start their career, it is important to realize the option of applying to a residency program and the proven benefits in the research. There is often a strong attraction to work in a well-respected hospital system following graduation to position oneself for success in one's career. Most hospitals that offer nurse residency programs are likely to be associated with urban academic medical centers with respected teaching environments, as well as be Magnet-designated, which is a highly respected work environment for a nurse (Warren et al., 2018). In addition, hospitals with nurse residency programs highly value professional development of nurses, with an increased number of resources available to join membership organizations, support for certifications and advancing one's education, and progressing up the clinical ladder (Fiedler et al., 2014). The attraction of new graduates to nurse residency programs is due to the extensive orientation, focusing on skill improvement, professional development, and role transition. In deciding upon a nurse residency program, the new nurse graduate should assess his or her strengths and weaknesses, particularly in their communication, organization, critical thinking, and stress management skills, and choose a program designed to grow one, some, or all skills.
Not all new graduates, however, choose to work in the acute or critical care clinical setting following graduation. Although there is a wide variety of clinical settings one can practice in that may not offer the option of a nurse residency program, it is still crucial to find a position that offers a comprehensive orientation period with aspects that speak to personal goals of the new graduate. Although the acuity of care may be different in outpatient or primary care settings, new graduates still need to work through the transition to independent practice and encounter different, yet equally important, challenges. No matter the setting, it is important for new graduate pediatric nurses to know their options in exploring opportunities following graduation, particularly the beneficial opportunity to participate in a nurse residency program with a didacticbased, simulation-based, preceptorbased, or combined structure. In a time characterized by much uncertainty and transition, the involvement in a nurse residency program tackles the identified nursing challenges of communication, organization, critical thinking, and stress management to aid in a new graduate's development to become a collaborative, independent, and competent healthcare provider at the bedside.
References
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Allison L. Walsh
Allison L. Walsh, MSN, CPNP-AC, is a recent graduate of the Univeristy of Pennsylvania College of Nursing, Philadelphia, PA.
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| Author: | Walsh, Allison L. |
|---|---|
| Publication: | Pediatric Nursing |
| Article Type: | Report |
| Geographic Code: | 1USA |
| Date: | Nov 1, 2018 |
| Words: | 4574 |
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