Laying the foundation to prepare first-year nurses for the rigors of patient care
The residency concept was not new but the development of a standardized model would make a difference. UHC reached out the American Association of Colleges of Nursing (AACN) because they are the voice of baccalaureate and higher-degree nursing. In 2002, a demonstration nurse residency program launched at six sites. Today, the UHC/AACN residency operates at almost 200 healthcare organizations. Over 57,000 BSN-prepared nurses have gone through the program.
Support From the Start
Reaction from organizations that have implemented the program is overwhelmingly positive. At this point, more than half the nursing staff at some hospitals have experienced the residency. Deb McElroy, MPH, BSN, RN, associate vice president, nursing programs, at UHC explained, “The support it provides and the specific role modeling from the facilitators allows them to process what they learn in the clinical environment.” First-year nursing can be overwhelming and the residency lays the foundation for novice nurses to evaluate different challenges and ultimately become better practitioners.
Brenda Vermillion, DNP, RN, director of nursing education, The Ohio State University Wexner Medical Center said, “Our institution became involved to best prepare new grad nurses for their upcoming career,” a sentiment echoed by nurse leaders everywhere. She continued, “If you have a bad first experience, it affects your entire career.” Extensive on-boarding support is crucial to the retention of first-year nurses, especially because the national turnover average, according to McElroy, is between 20% and 27%.
At Wexner Medical Center and its affiliated hospitals, Vermillion directs the program and a residency coordinator handles much of the day-to-day operations. Each month, a cohort of residents meets with the coordinator to discuss issues and challenges in an area of practice. Some of the topics include nursing quality and patient safety; pain management and end-of-life care; ethical decision-making; professional goal-setting; conflict resolution and dealing with difficult people; and code blue and failure to rescue. “We try to hit topics that new nurses worry about,” said Vermillion. “What will I do if my patient’s condition changes abruptly? What do you do the first time you have a patient who codes?”
Mikayla Polacsek, BSN, works on the acute coronary unit in the Richard M. Ross Heart Hospital at Ohio State. She is in her final month of the one-year residency program. After graduating from OSU, she knew she wanted to work there. The residency was a welcome bonus.
Mentoring is an important aspect of the residency. New nurses learn the value in asking questions. Polacsek said, “A lot of my mentors are nurses on the floor. I got lucky, my unit has a whole spectrum of ages.
They’re really willing to step in and say, ‘Can I help you?'”
She continued, “When I first came to the unit, I wanted to do everything myself. Knowing when to ask for help is something I learned from mentors.” It’s difficult for a nurse of any level to juggle too many things, but especially one in her first year. The residency offers them a safe space to admit when they don’t understand something and seek advice from more seasoned nurses. At round-table discussions at the residents’ meetings, first-year nurses share troublesome issues and what they learned from patient experiences with each other.
“It’s directly impacted my patient care because I know what I can do to benefit my patients,” Polacsek said. During one of the monthly educational sessions, the new nurses learned about diabetes education. Polacsek learned how to advocate for patients with high blood sugar to get a diabetes consultation, because she learned the evidence behind the decision.
“When I first became a nurse, I was so nervous about getting my tasks done,” she recalled. “Now I see the balance and communicate with patients. Who are they are as a person? What do they need?” Open communication lets nurses consider issues like are patients struggling at home? Are there underlying issues contributing to their health?
Creating Critical Thinkers
Guiding nurses to make better clinical decision-making skills is one of the hallmarks of the residency program. “It’s really about engaging our staff and helping them become critical thinkers,” noted Vermillion. A major component is the residents honing their evidence-based practice skills. That helps the nurse transition from a school mind-set to a patient care mind-set.
According to Kathy McGuinn, MSN, RN, CPHQ, director of special projects, AACN, 93% of program participants are involved in an evidence-based practice project. “We really love that. Nurse residents will take a problem, look at the evidence and offer potential solutions to address a healthcare need,” she said. At an annual meeting each year, they have the opportunity to present what they learned.
Vermillion remarked, “We hear these terms ‘evidence-based practice’ all the time.” Working on those projects teaches the novice nurses to verbalize to others why they are making certain decisions. “It’s the why that makes the difference,” she said. “We can tell patients, we’re doing this because it makes a difference in this outcome.” Nurses think about what occurred before and after interventions and assess what resources they should provide.
Polacsek’s evidence-based practice project looked at whether diabetes consults correlated to re-admission rates, something that has not been well-researched. This project was more in-depth then anything she did in school. She looked at charts of 30 patients who received consults and 30 patients who did not and examined why certain patients were ordered the diabetes consultation. Polacsek conducted literature reviews and talked to the clinicians, sometimes nurses, sometimes nurse practitioners, and sometimes physicians, who ordered the diabetes consults. “It seemed there was a correlation between better outcomes with patients who received the consult.” To conclude her residency, she presented her findings in December 2015.
McGuinn admitted, “It is expensive to keep people in residency programs, but it’s so worth it. If you’re a CNO trying to make a business case in the board room, you look at the retention rates.” While there is a cost associated with starting and maintaining a nurse residency, the programs enjoy a high return on investment in terms of staff retention and employee morale. According to McGuinn, if a new hire leaves after one year, it can cost the institution almost $88,000 to replace her, between advertising for the job, human resources costs, training a replacement, and, of course, the nurse’s salary.
“We’ve seen improvements in all kinds of metrics: Lower stress, improved organizing skills, improved communication,” explained McElroy. Nurses who go through the program are more committed to their organization. “The signature outcome has been improved retention.” For a resident nurse, the mean 10-year retention rate is 93.4%. “There’s really no downside,” said McGuinn.
The AACN cites surveys saying 80% of nurse residents would recommend the program. Both Polacsek and the nurse administration at the OSU Wexner Medical Center are among them. The member organizations can reach out to their peers to find out how things are done at different facilities. Monthly calls, a listserv, and a residency curriculum accessible online are all benefits on the administrative level.
Supporting New Staff
“We know there is much to be gained by hiring new nurses, especially at an academic medical center,” noted Vermillion. The hospital took a close look at the residency program and pulled together stakeholders from all over, including staff nurses who were former residents, clinical nurse specialists, assistant nurse managers, nurse managers, and even the CNO to determine if they are giving the nurses what they need. “We wanted to give new staff the support they needed to foster their practice and reduce stress,” Vermillion noted.
The residency has taught Polacsek to use teamwork, ask questions and not be shy about patient advocacy. She has become more skilled on her unit and feels once the program ends, she will still apply it to her practice. “I’m continuing to improve as a nurse.” Such forward progression is at the heart of nurse residency programs.