UHC/AACN Nurse Residency Program University HealthSystem Consortium UHC/AACN Nurse Residency Program THE POWER OF COLLABORATION

Setting the Stage: 1990 Nursing Clinics of North America: Sept. ‘90 Special issue devoted to the nursing shortage Prominent nurse leaders outlined issues estimated by year 2000 the nursing shortage would range from 100,000 to 1,000,000 Strategies proposed included: move nursing to community, scholarships, magnet initiatives, recruitment of teenagers, other All authors stressed the need for a coordinated, nationwide effort

Fast Forward: 2001 Shortage of nurses developed as predicted in 1990 Nursing expanded into many settings, especially community, yet in 2001 over 60% of patients are in acute care facilities AONE preliminary data from survey of 693 hospitals shows average national RN vacancy rate = 10% Critical Care = 14.6%, Med- Surg = 14.1% Initiatives to address anticipated shortage over previous 10 years active but not united nationally

UHC/AACN Collaboration Idea for collaboration between UHC and AACN generated from UHC Chief Nursing Officer Council/Schools of Nursing Deans joint meeting on nursing workforce issues in April 1999 UHC and AACN selected representatives to work on a task force: To support collaboration To initiate action plans to address the shortage of nurses, particularly BSN: standardized nurse residency program and strategies to increase schools of nursing capacity

Why Residency Programs? Transition into practice documented as challenging to graduate nurses gap between student status and practice widely reported (Kramer, Oermann, Basler) Estimates report 35% to 60% of new grads change employment the first year (Godinez, 1996) Tradewell (1996) and others note it takes one year to master transition into practice

2001 CNO Survey Results 85% report an extended program to prepare new graduates to be competent practitioners Programs range from 4 weeks to 2 years Classroom time ranges from 13 to 376 hours Percentage of technical content ranged from 0% to 90% with a mean of 32% Critical thinking content ranged from 20% to 100% with a mean of 65% Most respondents could not quantify the cost of their programs

Residency Task Force Work Groups Current residency programs: Made recommendations on criteria for admission, program goals, expectations of residents, conceptual framework (Benner “Novice to Expert”), core competencies, format guidelines, and process evaluation Outcomes measures: Made recommendations on structural measures (recruitment, retention, promotion, continued education, program cost), and process measures (critical thinking, nurse satisfaction, control over practice, collaboration, teamwork, and clinical competency) (Continued)

Residency Task Force Work Groups Preceptor curriculum: Made recommendations on definition of preceptor, selection of the preceptor, role components, curriculum content, standardized forms, and preceptor recognition Senior integrated practicum: Provided summation of common content categories, common clinical objectives, clinical emphasis, teaching/learning methods and referred the group to the AACN Essentials of Baccalaureate Education for Nursing (1998) Curriculum Design team: Faculty members and nurse educators met twice for two days to design the curriculum

Theoretical Framework Dreyfus’ Model of Skill Acquisition, Benner’s From Novice to Expert in Clinical Nursing Practice The new graduate transitions from advanced beginner to competent practitioner: Improved organizational ability and technical skills Focus on managing the patient condition as opposed to accomplishing “tasks” Identify significant clinical signs and symptoms Moving toward involvement and responsibility

Residency Curriculum Objectives At the conclusion of Residency, the graduate nurse will: Transition from advanced beginner toward competent professional nurse in the clinical environment Develop effective decision-making skills related to clinical judgment and performance Provide clinical nursing leadership at the point of care Incorporate research - based evidence linked to outcomes into practice Strengthen commitment to nursing as a professional career choice Formulate an Individual Development Plan as related to their new clinical role

Curriculum Content Areas Leadership - focus on managing the resources, including staff, supplies and services for optimal patient care Resource Management Communication Organization of Data/Shift Report Managing the Delivery of Care Patient Outcomes - focus on topic areas that have been found to be influenced by nursing care or are largely the responsibility of nurses Nurse Sensitive Patient Outcome: Managing the Changing Patient Condition Patient Teaching Patient Pain Management Nurse Sensitive Patient Outcome: Evidence-based Skin Care Practice Nurse Sensitive Patient Outcome: Fall Prevention Patient Safety: Medication Administration Infection Control (Continued)

Curriculum Content Areas Professional Role - focus on the growth and development of the nurse both professionally and personally End-of-life Care Ethics Diversity in the Nursing Care Environment Stress Management, Self-care, and Situational Stress Evidence-based Practice Professional development

Key Threads Critical thinking Patient safety - minimizing risk Leadership Communication Research based practice Professional development

Monthly Resident Seminar Cohorts Days for 1 Year Resident Facilitators Successful transition to practice! Resident Facilitators

Small groups of 6 - 10 residents Group by specialty Cohorts Small groups of 6 - 10 residents Group by specialty Consistent groups for the entire year Support group Develop trust

Characteristics Resident Facilitators Advanced practitioners: a clinical nurse specialist, educator, senior clinical nurse, manager, or school of nursing clinical faculty Good working relationships Established credibility Excellent facilitation skills

Role Resident Facilitators Facilitates monthly round table discussions on “Tales from the Bedside” and case studies May also meet with residents on regularly scheduled basis to facilitate continuous learning, development, and critical thinking Assists resident to formulate an individual professional development plan (Continued)

Once a month for 4 or more hours Monthly Seminar Days for 1 Year Once a month for 4 or more hours Begin with “Tales from the Bedside” Facilitated discussion driven by the residents Share questions, concerns, fears, successes What happens in the seminar, stays in the seminar EXCEPT (Continued)

Content Portion Monthly Seminar Days for 1 Year Don’t lecture! Learn from faculty what is covered in school - focus on application of concepts Interaction is crucial! Be creative!

Clinical Narrative Discussion Monthly Seminar Days for 1 Year Clinical Narrative Discussion Content portion followed by case study and clinical narrative discussion Resident facilitators lead the discussions, may add a clinical expert on the topic to the group Key to the development of critical thinking

Pulling it All Together – Evidence-based Project Focus on seeing the big picture and making a difference Identify an area for improvement – “Tales from the Bedside” is a good source of ideas Focus can be on work environment or patient safety or patient outcomes Report on project: poster, power point, etc.

Final Project Helps the residents learn: The chain of command The process for changing policies and procedures The performance improvement process That they can make a difference! “If not me, who?”

Outcomes Turnover rate at 11.7% compared to upwards of 35 – 60% reported in the literature for new graduates

Evaluation Research Framework Resident Job Satisfaction McCloskey Mueller Satisfaction Scale (MMSS, 1992)* Autonomy over Practice Gerber Control Over Nursing Practice Scale (CONPS, 1990)* Evaluating Graduate Nurse Experience Casey-Fink Graduate Nurse Experience Survey (2000) Demographic Characteristics of Resident, Hospital Residency Demographic Database Program Evaluation Residency Program Evaluation Form *Discontinued use as of September 2006

Gerber Control over Nursing Practice: Total Average* *Gerber tool: 21 item, 7 point Likert scale. Cronbach’s alpha = .96 Time 1 = hire date Time 2 = 6 months Time 3 = 12 months

McCloskey Mueller Satisfaction Scale: Total* Score at time three higher than MMSS scores reported in the literature *MMSS tool: 31 item, 5 point Likert scale. Cronbach’s alpha = .87

Casey-Fink Total (no stress items)* *Casey-Fink tool: Demographics, self-rating of skill competency, and self reporting of confidence and comfort using a Likert format. Also multiple choice questions on stress and skills. Cronbach’s alpha = .89

Casey-Fink Stress

Casey-Fink Organize and Prioritize

Casey-Fink Communication and Leadership

Casey-Fink Professional Satisfaction

Representative Resident Comments “I have been very happy with the residency program. It has relieved the great anxiety of coming from a theory based BSN program.” “I am a better nurse because of the residency program. I love my job and contribute that in part to this program.” “I feel this position would have been overwhelming had I not had the residency program to help me.” “I really enjoy hearing from fellow RNs so I know others share my stresses, fears, frustrations.”

Representative Resident Comments Room for improvement: “Residents need more time to talk about concerns as a group.” “The residency program should focus more on building relationships and supporting each other rather than spending time on things that we have already learned in school.” “The lectures do not always apply to our day-to-day nursing care.” “There is not enough socialization in the residency program. Becoming a new nurse in a new environment is difficult.”

What’s Next Nurse residency program accreditation standards have been out for public review and comment Goal is approval at the CCNE Spring board meeting Residency program will be available to organizations outside of UHC

For more information, contact Cathy Krsek at: krsek@uhc.edu or 630/954-4799

Any transition serious enough to alter your definition of self will require not just small adjustments in your way of living and thinking but a full-on metamorphosis. Martha Beck