ADVANCE for Nurses serving nurse graduates & senior students
Landing a Nurse Residency
Bridge the transition from nursing school and gain a solid start in your career
When it's time to leave the protected environment of nursing school and provide direct care to patients in the acute care setting, a very real sense of excitement combines with a good deal of anxiety. Wise new grads seek out a nurse residency program to help bridge that transition and gain a solid start on the road from novice to expert practitioner.
Locating a Program
For many new grads, the first question is: How do I find the best residency program to meet my needs? Toni Rowin, MSN, RN, director of nursing education and professional development, Seton Family of Hospitals, Austin, TX, advised grads to expand on that question. "It's more than just the right residency it's the right residency and the right healthcare system," she said. "Start with an Internet search for nurse residency programs, and then look for measures of high-quality standards for nursing, such as Magnet status, shared governance, excellent patient outcomes, strong nursing leadership, and practices and equipment to protect nurses from workplace injury and infection."
Ann Marie Yodh, MS, MSN, RN, who directs the nurse residency program at Middlesex Hospital, a Magnet facility in Middletown, CT, echoed Rowin's message. "The best approach is to view each hospital's Web page initially," she said. "Talk with other nurses who have gone through the program. Also, visit the hospital to tour the facility and speak with various staff members to get a feel for the organization."
Take a close look at medical centers with Magnet status (see www.nursecredentialing.org/magnet/searchmagnet.cfm for listing), recommended Kathy Motacki, MSN, RN-BC, referral liaison, Children's Specialized Hospital, Mountainside, NJ. "[These] are top choices, since part of their requirements to reach Magnet status is an excellent education program for newly hired nurses," she said.
Networking with other students can provide an insider's perspective, recommended Glenn Prescott, BSN, RN, professional liaison, Shepherd Center, Atlanta. "Word of mouth from one student to the next is vastly important," he said.
Evaluating a Program
Once you've identified some possibilities, consider the nine goals of exemplary nurse residency programs established by The Advisory Board Company's Nurse Executive Center in their 2006 report, Transitioning New Graduates to Hospital Practice Profiles of Nurse Residency Program Exemplars (www.advisoryboardcompany.com/content/clinical/nursing.html). Consider each program in terms of the goals:
- bridge gaps in residents' clinical skill set;
- connect "book knowledge" to real-life clinical challenges;
- ensure ongoing support from leadership and peers;
- foster espirit de corps among resident class;
- broaden residents' understanding of healthcare delivery;
- empower residents to contribute to practice improvement;
- demonstrate residency program value; and
- facilitate partnerships with area nursing schools.
Seton hospitals chose the nationally renowned Versant residency program in part because it meets all nine goals. "These include looping, a term coined by Versant to describe the nurse's rotation to clinical units and hospital departments relevant to the home clinical area," said Rowin. "Relationships are an important part of nurse residencies. There are mentors, the cohort of other new graduates, the looping experience, and the use of three preceptors as opposed to one." (See The Gold Standard: Versant Residency Programs)
Yodh advised looking at all components of the residency program. "For example, the length of time in the program is extremely important," she said. "Another significant factor is the preceptor relationship. Do the preceptors receive education on how to precept? Does the program have classes built into the work schedule that will enhance skills in critical thinking, assessment and clinical decision-making? Is there a support group for all new RNs that meets routinely throughout the program? And finally, are there various specialty tracks available in the program?"
Mimi Alvarez, MSN, RN, APRN-BC, coordinator, University Hospital Consortium Nurse Residency Program, University of North Carolina Health Care, Chapel Hill, agreed the length of the program is crucial. "The literature shows it takes a while to transition to bedside nursing, that there's a natural developmental curve for new nurses," she said. "I would say it takes a year to 18 months, if not longer, to fully acclimate and socialize within nursing."
Although new grads may not be assigned to a preceptor for that amount of time, they do need support in the form of regular meetings with other nurse residents, continuing education programs and mentoring from experienced nurses after their preceptorship is completed. "It's important that they work within a framework of 'There are no mistakes it's all a learning curve', so we're not continuing to eat our young," Alvarez explained.
Prescott urged students to prepare in advance for their residency interview. "Applicants should have done their homework prior to the actual appointment by reading up on the hospital, asking questions of their peers and having specific questions ready for the recruiter or nurse manager," he said. He also recommended asking about vacancy and turnover rates for RNs on the unit and hospital-wide.
Positioning Yourself for Success
Many nurse residency programs are extremely competitive, with slots awarded far in advance. What's the best way to land a coveted residency? "Start early, do your research, plan to take your state boards before the residency, and make sure you're aware of application deadlines because they might be earlier than you expect," Rowin said. "Be flexible, plan to stay and be sure your application is complete. If the application gives you an opportunity to discuss your career goals and aspirations, that's a great place to really set yourself apart."
Alvarez described steps nursing students can take to position themselves for their desired residency program. "Having some kind of experience within a healthcare system is critical," she emphasized. "First of all, it provides them with people skills, such as customer service, and introduces them to the culture. A combination of precepted experience and a nurse externship will definitely give you a jump start on obtaining a nurse residency slot."
Prescott agreed students improve their chances if they have made a positive impression on nursing staff. "One could look at the clinical rotation or externship as a huge job interview," he explained. "The applicant gets the chance to try on a specific unit or a hospital, and the staff, in turn, gets the chance to pose the question: 'Is this a nurse I would want to work with or that I would want caring for myself or my family member?' Staff feedback is always taken into consideration during the hiring process and can make or break a candidate's chance at employment."
Bonita Hulin, BA, RN, director of emergency services, Exeter in New Hampshire Hospital, hires nursing students as techs and sometimes allows them to shadow an RN. "This hasÊallowed me to see their work ethic, and has determined how quickly they really understand what they are seeing and doing," she said.
Students can increase their value to the organization by selecting direct care roles as patient care techs. "These help to prepare the student for the reality of the practice environment [and] develop technical, organizational and communication skills, which are more marketable," Yodh concluded.
Pam Wells, MSN, RN, vice president patient care services and chief nursing officer, Lucile Packard Children's Hospital (LPCH), Palo Alto, CA, acknowledged, "It has gotten more difficult to get into these programs. At Packard, the retention rate has improved, so we have been able to reduce our class size." Wells is looking for motivated nurses who can articulate why they've chosen LCPH and who have a variety of healthcare experiences through preceptorships and/or paid work in their chosen clinical area.
Wells also cited some other characteristics that will position new grads well for a nurse residency: "Nurses who aren't afraid of hard work and enjoy challengesÉnurses who believe in continual learning and are attracted to that environmentÉnurses who want to become highly competent," she enumerated. "[We're looking for] nurses who have taken steps in nursing school to go above and beyond to develop their critical thinking skills and knowledge base."
Sandy Keefe is a frequent contributor to ADVANCE.
The Gold Standard: Versant Residency Programs
Informally known as the gold standard for nurse residency programs, the Versant RN residency is a program staffed by experienced nurse executives, researchers, educators, statisticians and Web technology experts. Hospitals partnering with Versant have access to experts such as Charlie Krozek, MN, RN, president and managing director, Versant residency program, Los Angeles.
Feedback Is Crucial
For many years, new graduate nurses have expressed a need for more feedback during their transition into practice. "The Versant Residency is evidence-based in two ways," Krozek explained. "Not only do we look for evidence that the program works, but we also provide new grads with constant evidence of how they are doing within the program. It's our goal to transition newly graduated RNs in a comprehensive, supportive environment so they can become confident in their practice and to ensure their ability to provide safe and competent care to their patients."
Versant nurse residents receive regular electronic feedback about how they're doing compared with other nurse residents. "The nurse managers also sit down and keep the dialogue going based on that evidence," said Krozek. "This process benefits not only the superstars who receive confirmation they're doing well, but also provides an opportunity for extra help for nurses who are struggling to bring themselves up to a certain level of competency. If the nurse resident isn't a good fit for a particular unit, the evidence makes that clear so there can be discussion of a reassignment."
Preceptors Along the Continuum
The idea of having a preceptor team for each nurse resident came about when Versant leaders identified difficulties scheduling a resident 1-to-1 with a single preceptor for 18 weeks. "We use technology to track the competencies and progression of each nurse resident, making it possible to assign two or three different preceptors," said Krozek. "Hospitals also use the technology to differentiate their current preceptors into three categories within Benner's model: competent, proficient and expert."
"The goal is to have the new grad start out with a competent nurse who probably has about 2 years of experience," Krozek continued. "The competent nurses' work is strongly based on procedures, and they can remember what it's like to be a novice and teach accordingly. Toward the end of the transition program, the resident is paired with an expert nurse who operates experientially."
Krozek emphasized the importance of protected time for novice practitioners within a nurse residency program. "If they're thrown into independent practice too early, that defeats the residency's goal of allowing them to develop confidence in themselves," he said. "Our research shows that nurse residents at the end of 18 weeks of protected time have the same confidence level as a control group of new grads have at the end of 13 months."