1. Kram, Stacey L. DNP, RN-BC, CCRN, PCCN
  2. Wilson, Janet MSN, RN

Article Content

In 2011, the Robert Wood Johnson Foundation and Institute of Medicine collaborative report, The Future of Nursing: Leading Change, Advancing Health, made eight recommendations about how nurses can meet the present and future needs of the public. One recommendation for transforming nursing education is the creation of nurse residency programs to help both novice nurses and nurses new to a clinical practice area transition into practice. Benefits of a nurse residency program include increased job satisfaction, self-confidence, and socialization and decreased nurse turnover.


Although the call for nurse residency programs is relatively new, the concept isn't. This article describes the nurse residency program at University of Maryland Shore Regional Health (SRH) and the results that it's achieved.


Orientation needs

University of Maryland SRH is a rural healthcare system that consists of three acute care hospitals and a freestanding ED, with about 210 beds altogether. Two of the three hospitals are Magnet(R) recognized. Critical Care University (CCU) and Graduate University (GU) are comprehensive orientation programs providing mentorship, education, and supervised hands-on clinical experience to novice nurses at SRH. They guide the delivery of safe and best-practice nursing care to yield positive outcomes for patients.


CCU prepares novice nurses for direct care in the ICU, telemetry, and emergency services. GU is a program for novices entering medical-surgical units, surgical services, neurology, and women's and children's services.


CCU and GU began as a comprehensive educational strategy for attracting and retaining qualified nurses to address the 24% vacancy rate of noncritical care nursing staff and 60% vacancy rate of critical care nursing staff. Because of these high vacancy rates, contract labor in the critical care areas was costing the organization $6.8 million annually.


The nitty gritty

Nurses eligible for the residency program include both RNs who are newly licensed and experienced RNs who don't have acute care experience. Applicants are required to submit an essay that discusses current trends in healthcare along with at least two faculty or employer references. Program and unit nurse managers interview the selected candidates.


The Future of Nursing report also called for an increase in the proportion of nurses with a bachelor's of science in nursing (BSN) degree to 80% by 2020. In response, CCU and GU strive to attract BSN-prepared nurses from nearby universities. Associate degree-prepared novices are hired with an agreement that gives them 5 years to complete a BSN degree with organizational financial assistance. Regardless of education level, all novice nurses are expected to become consumers of nursing research and participate in a journal club, as well as complete an evidence-based practice project that they identify as a need within the organization.


Benner's novice to expert theoretical framework is used to assist with the transitioning of new nurses into clinical practice. Both comprehensive orientation tracks are specifically designed with a learner-centered approach to transition novice nurses into independent practice in either the medical-surgical or critical care clinical setting at all SRH facilities.


Initially, all novices attend class 40 hours per week and receive full pay and benefits. Classes typically begin each July, with the program's length depending on the new position. The GU program lasts 5 months, whereas the CCU program takes 7 months.


Theory and practice

Novice nurses selected for the program receive theoretical didactic instruction and participate in a clinical practicum. Because adult learners gain and retain knowledge when they perform tasks and demonstrate skills that are relevant to their immediate learning goals, simulation exercises accompany classroom learning experiences.


The novice nurse can implement nursing interventions in a safe and monitored learning environment. Real-time feedback given to novice nurses reinforces their simulated experience. Developmental feedback strengthens their skills, ability to perform tasks, and critical thinking. Feedback provides positive reinforcement of critical skills and behaviors, and also highlights areas that require improvement.


Simulation provides a safe learning environment for the novices, where they perform advanced physical assessment skills, administer and monitor moderate sedation and analgesia, participate in resuscitation exercises, respond to neurologic emergencies, and prepare for the American Heart Association Advanced Cardiovascular Life Support course.


The didactic component includes not only a review of pathophysiology and disease processes, but it also incorporates a comprehensive multidisciplinary orientation to the organization and the nursing department. The novices receive extensive education on therapeutic communication with peers, families, and patients.


Making the transition

After completing the first 5 weeks, the novices begin assimilating into their destination units, with classroom instruction on specified days for the next 10 to 20 weeks to reflect on their clinical experiences.


Each novice nurse is paired with an experienced unit-based nurse preceptor to foster socialization to the new role of clinical nurse and help him or her become familiar with the unit's unique workflow.


Reflection through formal debriefings and informal conversations provides a safe environment for novices to ask questions and explore their actions. Novices who'll be working night shifts transition into their new schedule approximately 6 weeks before the end of their clinical experience.


Faculty roles

The program has one full-time manager responsible for curricular content; education delivery; scheduling; and coordinating the novices' experiences, payroll, and issues regarding performance or progression that may need to be addressed. One full-time faculty member assists with educational delivery and mentors the novice nurses.


To meet the novices' needs, content experts from all disciplines participate in the classroom component. Unit-based preceptors step in once the novice nurses begin their clinical experiences throughout the organization. Observational experiences in associated areas are scheduled to allow further socialization into the healthcare environment.


Continuous evolution

Healthcare continues to change dramatically. The Affordable Care Act strongly influences the way in which care is now delivered to the community. In addition, healthcare delivery in Maryland poses challenges due to the state's unique all-payer rate-setting system. Under the Total Patient Revenue system, the healthcare organization receives one fixed global budget despite fluctuations in the volume of services rendered. This can lead to limited money and allocation of resources to nonproductive time, such as orientation and education. Decreased lengths of stay and increased patient acuity levels also pose challenges to newly graduated nurses entering the workforce.


The program's curriculum is updated annually to capture changes and ensure that novice nurses understand the implications of healthcare policy, such as quality-based reimbursement, population health, and the best and most cost-effective delivery of safe care.


Staying power

Since 2002, a total of 334 novice nurses have entered the organization through CCU and GU. The overall 1-year posthire retention rate of all novices is 95%. Turnover rates reported in the literature for newly graduated nurses at 1-year posthire range from 13% to 75%. Estimates of the costs to replace these novice nurses range from $49,000 to $92,000 per nurse, or a total cost to organizations estimated at $856 million. CCU and GU continue to be cost-effective solutions for attracting, training, and retaining high-quality nurses at SRH.




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