Article Content
Nurse residency program (NRP) refers to a support program designed to facilitate the newly licensed nurse's initial transition into professional practice (Krugman et al., 2006), although "nurse residency" can refer to programs across the spectrum of experience (Institute of Medicine, 2010). Spector and Echternacht (2011) observed diverse vernacular for nursing transition programs. Nomenclature for individual(s) administering these programs varies greatly as well, including program-specific personnel titles like nurse residency director, manager, coordinator, or facilitator (Krugman et al., 2006). Other more general titles include clinical nurse specialist, education coordinator, and nursing professional development specialist (Anderson, Hair, & Todero, 2012; Park & Jones, 2010; Ready, Fater, Conley, Rebello, & Cordeira, 2012). Program reporting structures also differ such as to a manager versus to a vice president. Variety among assigned divisions exists with nursing professional development (NPD) departments, human resources, or an organization-wide education branch housing the NRP.
Ideally, a hierarchy of personnel should exist (Anderson, Hair, & Todero, 2012; Krugman et al., 2006); however, in the authors' experience, the NRP leader may be a part- or full-time nurse educator solely responsible for program development, implementation, and evaluation, while also participating in individual nurse recruitment, orientation, and retention. Furthermore, this educator may hold additional roles such as nursing school liaison, staff educator, or quality improvement nurse, resulting in role confusion and strain. Despite nursing leadership input and support, this individual often struggles to manage the program with volunteer facilitators, preceptors, and mentors while attempting to ensure positive program outcomes and stakeholder satisfaction and striving for quality improvement.
All these factors contribute to role ambiguity for the leader, residents, and nurse colleagues. Because of the observed lack of uniformity, the authors chose the general title NRP leader to refer to the person(s) primarily responsible for program oversight including the educational and administrative functions. The term nurse resident will refer to any nurse within the NRP leader's sphere of influence.
NRP Leader as an Emerging NPD Role
To be an NPD specialist, one must be a registered nurse with expertise in nursing education. This individual "influences professional role competence and professional growth of nurses in a variety of settings; supports lifelong learning of nurses[horizontal ellipsis] and fosters an appropriate climate for[horizontal ellipsis]the adult learning process" (National Nursing Staff Development Organization [NNSDO] & American Nurses Association [ANA], 2010, p. 44). The NRP leader works with nurse residents to ensure role competence and supports their professional growth, including facilitating lifelong learning using adult learning principles and a supportive climate. Thus, an NRP leader is clearly an NPD specialist.
However, the NRP leader role goes beyond the NPD specialist description, such as influencing the organization's culture, collaborating with human resources for hiring and orientation, and being a performance coach for nurse residents. It involves acting as a public relations officer, marketing representative, retention specialist, program manager, advocate, and counselor. The authors perceive the multifaceted NRP leader as a unique role emerging within NPD-a transition specialist. Key elements of this role include power equalization, organizational connectedness, transition management, and co-creating a relationship with the nurse resident. In contrast to the current situation where organizational needs, budget, and executive expectations often influence performance, the authors believe that the NRP leader role and responsibilities need to be clearly defined and based on theory, current literature, and nursing professional practice standards with consideration of contextual factors.
REVIEW OF LITERATURE
Role Transition Within Nursing Practice
By nature of the role, the NRP leader works predominately with adults in transition; thus, a broad theoretical understanding of the role transition process, its effect on nursing practice, and basic transition management skills are essential. Transition comprises the internal physical, psychological, emotional, and spiritual adaptive processes involved with an external change event, such as assuming a new nursing role (Rich, 2010). An individual may undergo 10-20 transitions over a lifetime (Williams, 1999); transition categories include developmental, situational, health-illness related, and/or organizational (Anderson, Goodman, & Schlossberg, 2012; Meleis, 2010). Any role change is a significant life event and often produces stress leading to anxiety, ineffective coping, and even clinical depression (Duchscher, 2008; Meleis, 2010; Williams, 1999). Thus, a nurse's impaired transition could pose immediate concerns regarding the quality of care and patient safety.
Although the actual change event may occur quickly, transition involves three phases with critical points experienced usually over 8 months or longer. The initial stage, or "doing" involves letting go of former identity and is marked by an initial elation that masks an underlying grief process (Bridges, 2009; Duchscher, 2008; Williams, 1999). The middle crisis stage is challenging as the person seeks to cognitively adapt to the change, or "being" the nurse. This stage often involves a crisis of confidence or defining moment, where the person decides to continue forward or to return to the former state (Duchscher, 2008; Williams, 1999). The final "knowing" stage ideally results in skill mastery and integration of the new nurse identity (Duchscher, 2008; Meleis, 2010). Complications can occur with multiple simultaneous or sequential transitions within a short time (Bridges, 2009; Duchscher, 2008; Meleis, 2010; Williams, 1999).
Transition Management
An NRP leader naturally acts as a transition manager, formally or informally providing an essential stabilizing presence and beneficial interventions for the nurse resident to help bridge the expectation-reality gap. The nurse resident can evaluate transition assets and liabilities encompassing economic, emotional, physical health, transition skills, supportive work environment, and transition support factors (Anderson, Goodman, & Schlossberg, 2012; Williams, 1999). The NRP leader can assist a nurse resident to positively change these factors through educating, building on individual strengths, providing support, and encouraging healthy coping strategies during the transition process.
Other transition-related nursing interventions include assessment of readiness that may involve a trial transition, debriefing, and role supplementation (Schumacher & Meleis, 1994). To help identify actual or potential role insufficiency, the NRP leader may provide role supplementation by heightening awareness of nursing behaviors, sentiments, sensations, and goals related to the new role. The NRP leader provides support for nurses experiencing all categories of transition, as well as their families taken unaware by transition's ripple effect that forces reciprocal changes among significant others (Bridges, 2009; Meleis, 2010; Williams, 1999). Beyond transition management, the NRP leader role involves a range of educational and administrative responsibilities.
Description of Residency Leader Role and Responsibilities
Other Disciplines
A sample of literature from other disciplines including medicine, pharmacy, academic libraries, and chaplaincy offered interesting perspectives on the residency leader role and responsibilities. Whereas most authors focused on the educational and administrative aspects of the role, a few specifically addressed the person(s) responsible for the program, their preparation for the role, and related aspects of the role (Gaiser & Troxell, 2011; O'Sullivan, Heard, Petty, Mercado, & Hicks, 2006; Otterstad, 2003; Webber, Mullins, Chen, & Meltzer, 2012). O'Sullivan et al. summarized the subroles inherent to residency leadership with the acronym EASE: educator, administrator, scholar, and evaluator.
The authors found less variation in residency program leadership nomenclature in other disciplines; predominant titles were program dean/director and assistant/associate program director (Boiselle et al., 2007; Marr, Billings, & Weissman, 2007; O'Sullivan et al., 2006; Webber et al., 2012; Winegardner, Davis, Szandzik, & Kalus, 2010). Regarding reporting structures, a hierarchy of leadership existed (Webber et al., 2012). Residency leaders predominately worked within academia-potential employer cooperatives with postgraduate residents (Brewer & Winston, 2001; Derrickson & VanHise, 2010).
The authors found many commonalities in the residency program leaders' responsibilities across the various disciplines (see Table 1). These responsibilities included organizational involvement, recruitment, quality improvement, professional development, program evaluation, and career guidance. They aligned with the authors' experiences as NRP leaders and the limited available nursing literature.
Article Content
Within Nursing
Some authors explored nurse educator involvement during situational transitions, such as job change triggered by education and levels of practice; however, they primarily focused on specific aspects such as the experience, mentoring, transition education, learning environment, use of debriefing, and program implementation and evaluation (Delaney & Piscopo, 2007; Hansen, 2011; Keller, Meekins, & Summers, 2006; Wieland, Altmiller, Dorr, & Wolf, 2007; Winfield, Melo, & Myrick, 2009). Typically assigned to associate degree or baccalaureate nurses, NRP leaders are employed by the hiring organization and may or may not work collaboratively with an academic institution (Holland & Moddeman, 2012). In accredited NRP programs, leaders are involved in resident certification and research participation (Krugman et al., 2006). Existing literature addressing the person(s) responsible for working with nurses in new roles usually addressed responsibilities including orientation, monitoring clinical progress, and didactic presentation; authors also mentioned nurse advocacy, psychosocial support, and career guidance (Keahey, 2008; Krugman et al., 2006; Ready et al., 2012; Varner & Leeds, 2012).
Challenges and Benefits of the NRP Leader Role
Role strain was a prevalent theme in the literature, because of the breadth of responsibilities. Challenges included addressing immediate program demands and resident tracking, along with adhering to an education schedule (Otterstad, 2003). O'Sullivan et al. (2006) cited the heightened expectation for program leaders to participate in scholarly activities, such as presentations, writing for publication, and research. Varying degrees of organizational support, financial considerations like budget and payroll, and a need for professional development also added to role stress (Boiselle et al., 2007; Brewer & Winston, 2001; Derrickson & VanHise, 2010; Webber et al., 2012; Winegardner et al., 2010). The current multigenerational workforce presents unique difficulties for leaders seeking to juggle administrative and educational tasks while attempting to engender organizational commitment (Carver & Candela, 2008).
Given the challenges associated with the role, Gaiser and Troxell (2011) and Kane (2010) eloquently addressed the rationale for becoming a residency program leader-the unique relationship afforded to the leader in the lives of the residents. The residency program leader is often the first person to congratulate or extend sympathy to a resident on personal life events, recognize professional achievements, and debrief after a crisis such as a first code or medication error. "The relationship between a resident and a program director is unique[horizontal ellipsis](he) cares for the residents beyond their education" (Gaiser & Troxell, 2011, p. 173). The essence of the residency leader role is making a difference in someone's life; the NRP leader provides care to nurses in transition.
NRP LEADER AND NPD
NPD Domains
Once conceptualized as overlapping domains, NPD involves professional development, continuing education, and academic education (NNSDO & ANA, 2010). Perhaps, more than any other NPD specialist, the NRP leader role serves as a living connection among these domains (see Figure 1). The NRP leader may promote lifelong learning as a continuing education provider, by pursuing additional education and serving as mentor for nurse residents and experienced nurses pursuing academic degrees. From recruiting at local schools of nursing to orientation within an acute care setting and providing online learning, community-based initiatives, and research, the NRP leader must be versatile within all NPD practice domains and realms of responsibilities. As an NPD specialist, the NRP leader should adhere to the scope and standards of practice (NNSDO & ANA, 2010) while functioning within these domains.
Article Content
Scope of Practice
As an NPD specialist, the NRP leader must function effectively within two environments: clinical practice and learning. Currently, the most common practice environment is the inpatient acute care setting; the learning environment may be the physical classroom, bedside, and simulation laboratory settings as well as the independent self-directed learning and virtual environments. The practice environments include the social and cultural setting and are subject to government regulations and initiatives and trends within health care and the nursing profession. Meeting the needs of the practice setting, the NPD specialist's scope of responsibility is broad and demanding (NNSDO & ANA, 2010).
Standards of Practice and Professional Performance
The NRP leader's educational and administrative responsibilities should reflect the standards of practice and professional performance (Table 2; NNSDO & ANA, 2010). Mirroring the nursing process, the NRP leader assesses educational needs, identifies issues and trends among the organization and learners, and then, works with all stakeholders to ascertain desired outcomes. After program planning and development, the NRP leader coordinates activities and resources while managing the learning environments to ensure effective program implementation. Evaluating the program and learner outcomes enables the NRP leader to ensure the program remains cost effective, efficient, and relevant.
Article Content
Regarding the NPD Standards of Professional Performance, the NRP leader engages in quality improvement, ensuring professional competence through lifelong learning; adopts reflective practices; and solicits professional feedback via collegiality and collaboration. Professional ethics drive performance, particularly in the areas of advocacy, research, and resource utilization within the NRP leader's role fulfillment. Leadership is inherent to the role, whether by facilitating professional growth in others through guidance and sharing knowledge or by seeking to advance NPD specifically or the nursing profession as a whole.
Operationalization of the NRP Leader Role Within NPD
Experts described an NPD specialist role as involving intertwining elements of professional development in nursing practice: educator, facilitator, academic liaison, communicator, researcher, consultant, collaborator, advisor, mentor, change agent, and team member (NNSDO & ANA, 2010). A number of factors influence the operationalization of the NRP leader role, including the type of healthcare setting, organization's mission, vision, and strategic plans. Other factors are the organizational structure including the size of the health system, the need to move between facilities, size of the staff education department, and available resources.
Educator and/or Facilitator
The NRP leader develops and implements an educational program aimed at successful transition through professional development. Whether in class or during clinical rounds, the NRP leader is often simultaneously assessing learning needs and validating clinical competence and program outcomes, while fostering a positive learning climate (NNSDO & ANA, 2010). Whether providing the education using effective teaching methods or facilitating learning through a subject-matter expert, the NRP leader uses available resources and adapts to the organization's setting. Ideally, the organizational structure will remain flexible for quality improvement changes and to ensure a positive return on expectations, including nurse resident satisfaction, professional development, patient outcomes, and organizational return on investment (Hansen, 2011).
Educator and/or Academic Liaison
Within the educator/academic liaison elements, the NRP leader mentors nurse residents and may serve as a preceptor for colleagues pursuing graduate degrees. As a visionary leader, this individual may chair the program's curriculum committee and participate in academic forums. The NRP leader role extends beyond the organization to include managing positive relationship with local nursing schools and actively participating in professional organizations. Both a resource and a provider, the NRP leader supports educational opportunities in the organization and beyond.
Change Agent and/or Team Member
The NRP leader is a natural change agent within the organization, with the potential to influence the community, state, national, and international arenas. Awareness of the current healthcare issues, educational trends, and organizational factors prompts the NRP leader regarding the need for change within the program and enables the leader to devise solutions to program challenges. The leader supports organizational changes such as a new electronic health information system implementation along with breaking down interprofessional and intraprofessional silos by inviting the representatives from other departments to participate in residency class sessions. "Administrative leaders need to recognize that NRPs are a way to change the organizational culture by emphasizing relationship building and collaborative practice" (Anderson, Hair, & Todero, 2012, p. 209).
Researcher and/or Consultant
Evidence-based practice and practice-based evidence are at the heart of NPD (NNSDO & ANA, 2010). As an NPD specialist, the NRP leader integrates theory, current research evidence, and national standards (National Council of State Boards of Nursing, 2012), along with educational and clinical expertise to develop an evidence-based educational transition support program congruent with stakeholder values. At the same time, the leader must use practice-based evidence to maintain a relevant program (Varner & Leeds, 2012). The leader must also determine the most effective research-based educational methods within the particular learning environment among the resident-learner population, aimed at achieving desired program outcomes (Anderson, Hair, & Todero, 2012). Opportunities may arise for the leader to participate with research projects, such as evaluation tool validation. The NRP leader directly influences research utilization and attitudes toward research among nurse residents. Accurate data collection to monitor resident progress influences residency program evaluation (Otterstad, 2003).
Leader and/or Communicator
With administrative support, the NRP leader aligns the program with the organization's mission, vision, and values. The NRP leader strives to ensure that residency program objectives are met as well as organizational goals are achieved. With a vision for the program, this individual uses problem-solving, diplomacy, and communication skills to ensure human and material resource allocation. Often responsible for overall program outcomes, including cost efficacy, the residency program leader role has a unique managerial facet compared with other professional development roles (Otterstad, 2003). The NRP leader promotes NPD as a specialty in various ways, such as by attaining new credentials and maintaining ethical principles.
Collaborator, Advisor, and/or Mentor
The NRP leader serves as the organization's representative with local academic institutions and collaborates with professional organizations to support lifelong learning and to influence legislative support for nurse residents. Anderson, Hair, and Todero (2012) indicated the importance of intraprofessional socialization; the NRP leader is an essential mentor sharing personal strategies related to professional nursing role adaptation. A model of professionalism, the NRP leader advises nurse residents as they develop a career development plan and then mentors them during its execution.
IMPLICATIONS FOR PRACTICE
Essential NRP Leader Competencies
Career Development
As a mentor, the NRP leader needs to participate and promote involvement in professional organizations. The NRP leader must be knowledgeable of professional development resources within and outside of the organization and be willing to link nurse residents and preceptors with these resources. The NRP leader must have effective oral and written communication skills and model critical thinking. Because of the unique challenges associated with facilitating transition, the NRP leader must provide compassionate yet balanced guidance. As an evolving specialist role, the NRP leader must accept personal responsibility for his or her career development by seeking advanced education, in addition to attending annual professional conferences and workshops throughout the year.
Education
The NRP leader needs to create and maintain a positive learning environment, be able to assess learner characteristics, and be competent in a variety of teaching methods and learning validation while incorporating technology. The NRP leader must embrace innovative educational methods to successfully develop a quality program (NNSDO & ANA, 2010). The NRP leader needs to be competent in program design and curriculum development and have a strong theoretical base related to transition management and adult learning within both classroom and clinical environments. The NRP leader will need strong interpersonal skills, cultural sensitivity, and the ability to develop a multigenerational program. Specific educational competency statements for the NRP leader include the following:
* Facilitates learning by integrating a variety of teaching methods, including technology, into the NRP.
* Provides clinical preceptor development by teaching critical reasoning strategies for nurse resident interaction.
* Uses current evaluation methods involving patient narratives to determine learner-centered program outcomes.
Leadership
The NRP leader competencies include adherence to nursing regulations and standards of ethical decision making. The NRP leader must remain abreast of current trends, research, and evidence-based practice to ensure the program remains relevant. The NRP leader enacts change in light of organizational, regional, national, and international contextual factors. Organizational skills, financial planning, and effective resource utilization for the program are essential for residency leaders (Otterstad, 2003). Thus, a competency statement might be, "the NRP leader maximizes human and fiscal resources for optimum program outcomes and organizational benefit." While advocating for the program, the NRP leader communicates successes with the executive and nursing leadership teams and shares, challenges, and facilitates problem solving while maintaining confidentiality.
Program and Project Management
Program and project management competency are essential for the NRP leader as the individual primarily responsible for the program. The NRP leader needs to market the program effectively, such as recruiting at local schools of nursing and maintaining a Web site. Naturally, the NRP leader needs to participate in the financial planning process to ensure adequate resource allocation. The person must be able to execute projects and the overall program, while balancing efficiency, cost effectiveness, innovation, and creativity.
Practical Role Implementation Considerations
NRP Leader Preparation
The appropriate preparation and selection of the NRP leader is essential to achieve optimal program outcomes. As an NPD specialist, the NRP leader must be a licensed registered nurse with a graduate degree in nursing; national certification is strongly recommended (NNSDO & ANA, 2010). Experience in business administration, academia, and professional development helps ensure program outcomes (O'Sullivan et al., 2006). Given the level of academic preparation coupled with established NPD competencies, the NRP leader should be an advanced practice nurse educator specialized in transition management. However, issues related to advanced practice role clarity, professional identity, and intraprofessional implications exist internationally (Lowe, Plummer, O'Brien, & Boyd, 2012).
Candidate Characteristics
Personal and professional attributes are relevant to both leader selection and program success. Brewer (1997) indicated outstanding program coordinators as "providing a broad perspective of the organization, providing moral support, creating learning opportunities, and providing feedback" (p. 533). Former residents identified important attributes as strong mentoring skills, availability, and provision of constructive feedback, along with familiarity with staff and organization. Anderson, Goodman, and Schlossberg (2012) highlighted the importance of the "core conditions" of empathy, genuineness, and unconditional positive respect to relationship-building with adults in transition. Furthermore, the individual needs to be flexible and open to working a range of hours with varied responsibilities each week, often within a system challenged by finite human and material resources.
Networking
Otterstad (2003) and O'Sullivan et al. (2006) mentioned medical residency program leader associations and annual meetings for professional development and education. Although such support exists within NPD and among proprietary NRPs, collaboration among all types of NRP programs would greatly enhance the development of high-quality programs, allow for superb networking opportunities, and provide essential support for this specialty subgroup.
Other Considerations
Workload expectations must be balanced and reasonable for the NRP leader to function optimally. The organization needs to allow flexible scheduling to fulfill professional responsibilities, including research, publication, community involvement, and program administration (NNSDO & ANA, 2010). Organizational structure and job title for the NRP leader are extremely important considerations, as they affect essential collegial relationships inherent in program implementation. An NPD leader needs physical workspace conducive to educational planning, and an adequate program budget is essential.
Research Potential
More research needs to be done regarding the effect of the leader-resident relationship as a factor in program outcomes (Rich, 2010) as well as specialized leader development (O'Sullivan et al., 2006). Satisfaction and longevity in medical residency leadership is a significant concern with annual turnover ranging from 10% to 20% with a mean tenure of 3-5 years (Boiselle et al., 2007; Sanford, 2010; Webber et al., 2012). Similar figures in NRP leadership would affect NRP program quality and succession planning. Furthermore, research is needed regarding strategies to promote healthy personal and professional transitions for nurses, including readiness assessment and use of role supplementation within the NRP leader-resident nurse relationship (Meleis, 2010).
CONCLUSION
In light of the NRP evolution, increasing support by national agencies, and a growing body of research, the NRP leader role needs to be clearly defined. Emerging within the context of NPD, the NRP leader is a specialist working with nurses in transition by bridging the gap between academia, continuing education, the community, and professional development. Informed by theory and current literature while adhering to professional practice standards, the NRP leader is uniquely poised to affect the future of nursing.
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