- Email: [email protected]
Win for Nurses, Hospitals, and Patients
The New Graduate RN Residency: Win/Win/Win for Nurses, Hospitals, and Patients Charles Krozek, MN, RN
W
hen asked why he was successful in the ring, American boxer Muhammad Ali replied, “I run on the road long before I dance under the lights.” For new nurses, today’s health care workplace can feel a lot like a boxing ring. The right transition program is the preparatory run before the participatory dance.
HEALTH CARE: NO EASY PLACE TO BE Nurses always have faced the challenge of providing the highest quality of care, despite conditions and environments disposed to thwart it. For Florence Nightingale, the challenges were overcrowding, defective sewers, and no ventilation at Scutari. For today’s onboarding nurse, the problems are understaffing, rising acuity, and fear of failure. October 2008
According to a report released in March 2008, the shortage of RNs in the United States could reach as high as 500,000 by 2025, with demand growing by as much as 3% each year.1 The causes are well known: • Aging nurses: Labor forecasts and population trends indicated that the nursing population would increasingly age with the rapid retirement of baby boomer nurses and decreasing numbers of enrolling nursing students. In 1996, the average age of a nurse was 44.2 In 2006, it was almost 47.3 The cost-cutting practice used by many hospitals of not replacing nurses that retired or resigned has made the problem worse. • Aging patients: The population of 65 and older Americans will double between 2000 and 2030, while the number of women between 25 and 54—the traditional nursing pool—will stay the same.4
Nurse Leader 41
such coexisting conditions as diabetes, hypertension, heart disease, and kidney failure. This paradoxical chronic critical illness requires treatment with more powerful medications that require more intense and experienced vigilance and monitoring. Nurse confidence also plays a role in patient safety. Because they provide continuous care during a patient’s hospitalization and typically are the first to assess the need for medical intervention, nurses discover potentially lifethreatening errors or oversights by doctors, pharmacists, and other nurses within the hospital. Less experienced nurses may be reluctant to address these FLOODS OF ENTERING NOVICES, WAVES issues with the more experienced clinicians. OF EXITING EXPERTS: NURSING’S 3. Retaining them: Graduate nurses have indicated it PERFECT STORM takes them at least 1 year to feel confident and comAs an increasing number of graduate nurses enter the petent performing their duties. Their experiences durworkforce, employers face three major challenges: ing this first year are crucial, as studies indicate that 1. Recruiting them: In a highly 30% to 65% of new nurses leave by competitive market, hospitals their second year.8 Why do they leave? The primary reason cited is must stand out to attract new To fill vacancies, HCOs use concern about patient care.8 It is a graduate nurses. In addition, concern that will deepen with the some nurses pursue jobs outside costly traveling nurses or increasing acuity of an aging poputhe hospital as staff shortages require existing personnel to lation. The resultant stress-related and organizational vacancies turnover has a domino effect—secmake it easier to work for insurwork overtime, driving up ondary turnover as patient loads ance companies, surgical centers, rise as a result of the first wave of and urgent care facilities. Other costs, burning out staff, and turnover, putting the nurses who renurses leave to pursue nurse main under even greater pressures. practitioner master’s degrees that jeopardizing patient care. This second wave of turnover is can remove them from the workdoubly crippling to health care orforce for 2 to 5 years. Many ganizations because it washes out senior nurses as never return to direct bedside nursing. well, reducing the number of experienced frontline In a frenzy to acquire nurses, hospitals try to outdo nurses to teach and mentor. An influx of novices coueach other with lucrative incentives, from big sign-on pled with an efflux of mentors can put quality care bonuses to new cars and new home down payments. and patient safety at risk. Some hospitals even assist students with tuition in exchange for job commitments. Not only do these activiWhen nurses leave, hospitals take a major hit to the ties incur greater expenses for HCOs, they also bottom line. This is especially true with new nursing alienate existing nurses who have been working for graduates. According to a JCAHO report, the cost for years without such incentives. advertising, training, and loss in productivity associated 2. Developing them: Nurses provide approximately 95% with recruiting a new nurse averages $50,000 per nurse of direct patient care in hospitals.6 However, new and can add as much as 5% to a hospital’s annual budget.9 To fill vacancies, HCOs use costly traveling nurses or nurses typically struggle to adjust to their new roles and gain confidence in their clinical skills. A big require existing personnel to work overtime, driving up source of frustration and fear: the “preparedness gap.” costs, burning out staff, and jeopardizing patient care. At best, without an effective approach to new nurse Over time, the cost of care increases dramatically and development—or on-boarding—HCOs risk losing their labor expenses, already the largest line item for most investment. At worst, they risk losing quality patient hospitals, keep growing. care. Understandably, novice nurses are at a disadAs HCOs struggle to meet the challenges of recruiting, vantage in light of increasing patient acuity. As new developing, and retaining new graduate nurses, competiillnesses and threats to the public’s health continue tion for them grows. The result: A flood of novices alto emerge, new drugs and technologies extend life most universally unprepared to enter patient settings and longer than ever before. In a recent study, nurses contribute immediately to quality patient care. What is an confirmed that people admitted to their units are HCO to do to ensure a steady flow of graduate RNs with sicker than ever before.7 Patients that would never the competence and confidence to perform their roles have made it to the hospital a few years ago now and the commitment to continue their careers? For most live longer after major surgery and often suffer from HCOs, the answer rests in RN transition programs.
Nursing schools have responded to this shortage. From building new schools to increasing the number of slots, they are expanding their capacity to educate greater numbers of new nurses. The result: Nursing programs are bursting at the seams. According to the American Association of Colleges of Nursing, there has been a 7-year upswing in enrollment at nursing programs on the baccalaureate level with a 5.9% increase in 2007.5 All these new nurses are good news. The bad news? Health care organizations (HCOs) are struggling to get them, train them, and keep them.
42 Nurse Leader
October 2008
RN TRANSITION PROGRAMS: WHAT WORKS Over the years, hospitals have used preceptorships, mentor programs and didactic content but these efforts were fragmented, at best. Very few are able to integrate these parts into a cohesive whole. What new nurses need instead is an integrated, interconnected program hardwired throughout the organization—a systematic approach to nurse on-boarding. Characteristics of a systematic RN transition program include: • Standardization: Variability in practice means inconsistency in care. A well-prepared nurse who can think critically and perform to best-practice standards is more likely to deliver consistently safe patient care. No matter what their specialty, residents should complete the same core training. By attending classes together, they receive the same type of clinical experiences. Standardization reduces inconsistencies in practice that lead to errors and compromise patient safety. When the entire nursing staff can deliver consistently accepted standards of care, there are fewer such negative outcomes as infiltration of IVs, patient falls, central line issues, and care coordination issues. • Practical application of knowledge: Traditional programs—nearly 80% of which are 12 weeks or less— lack adequate clinical immersion and inadequately prepare new nurses to assume the complex role of RNs.10 The lack of clinical immersion affords few chances for new RNs to hone patient care skills and understand hospital protocols. A systematic transition program gives RNs the right information in the right sequence. This knowledge must link to real world clinical labs that allow residents to transfer their knowledge into practice, building skills and confidence in those skills. • Support systems: Traditionally, experienced or senior nurses were assigned the tasks of being preceptors or coaches with little training or consideration for interpersonal skills. Often their roles were unclear, and they felt burdened by the responsibility. This type of arrangement does not foster the sense of trust and emotional support that new RNs need. A comprehensive support structure establishes a network of senior nurses who act as preceptors, mentors, and confidants. This system heightens residents’ confidence in their abilities, their satisfaction with their new employer, and their sense of commitment to the profession. By design, this support structure increases the positive experiences of the novice RN and reduces turnover. • Rigorous evaluation: A systematically administered transition program lends itself to rigorous evaluation. The systematic approach creates expected outcomes. Expected outcomes are measurable. Rigorous evaluation of residents’ performance is valuable to the residents as well as their preceptors and mentors. Evaluation of every aspect of the transition program gives both educators and residents useful feedback tools. October 2008
• Continuous improvement: Rigorous evaluation combined with comprehensive support gives administrators the ability to enhance the transition program on a continual basis. Tools such as web-based learning management give educators and administrators overviews of individual residents’ performance as well as that of entire cohorts. Critical data in a manageable format allows administrators to make informed decisions and implement decisions strategically and effectively. A systematic RN transition program is an outcomesbased on-boarding approach that can develop new graduates’ clinical and analytical skills, promote their interest in practice improvement and career advancement, and provide emotional support. Easing the transition from the classroom to the bedside, systematic RN transition programs enable HCOs to give new nurses the experience they need to become safe, confident, competent professionals. So doesn’t every hospital have one?
MAKING THE CASE FOR AN RN TRANSITION PROGRAM Few would argue the potential return on investment of a systematic RN transition program. However, few HCOs can afford the potentially costly and time-consuming process of building an internal program. External transition program development is an emerging industry that will facilitate— and accelerate—organizations’ implementation of outcomesbased, systemized transition solutions. Rather than taking months or years to develop an evidenced-based systematic program, an organization can partner with an RN transition program provider to implement a sustainable transition with proven results in as little as 12 weeks. Before selecting any strategy, it is wise to perform a cost/benefit analysis comparing the cost to develop a program against the cost of engaging outside assistance. Whichever you choose, make sure there are outcome measures and that they align with the organization’s strategic goals (eg, efficient use of financial resources, increased patient safety, role satisfaction, and physician satisfaction). When selecting an RN transition program provider, it is important to select one with a proven record of accomplishment of recruiting, developing, and retaining the finest new graduate nurses. A proven solution should: • Enhance recruitment and retention: An effective program can create an attractive and competitive recruitment proposition for HCOs trying to secure the best of a limited field of candidates, while documenting positive outcomes retaining them. • Enhance patient care and safety: A systematic RN transition program accelerates the competency of new RNs, enabling them to acquire the skills they need to succeed. By ensuring all new RN hires practice with standardized, evidence-based procedures and protocols, RN transition programs eliminate the practice variability that leads to care inconsistency. • Simplify residency management: The best programs offer adapt to the unique needs of many HCO environ-
Nurse Leader 43
ments and provide such tools as web-based applications that completely manage program implementation, clinical monitoring, and residency evaluation. • Improve profitability: Reducing turnover leverages an organization’s recruiting investment and minimizes its reliance on costly agency nurses and expensive overtime. In addition, an effective packaged program eliminates the need to invest in a costly internal program, saving money and eliminating months or even years from the start-up process. • Improve workplace satisfaction. Stopping the revolving door minimizes the financial and emotional drains associated with a never-ending turnover cycle. Providing a structured way for staff to work together improves teamwork and group cohesion. Teaching activities that take place in different parts of the hospital improve interdepartmental and interdisciplinary communication. • Provide actionable competence ratings. Effective transition programs include mechanisms to measure new RNs’ clinical competence and safe practice behaviors. A common methodology, which some regulatory agencies employ, measures competency by surveying the new graduates and their preceptors. A more effective technique is the Slater Observation strategy. In this methodology, trained observers rate nurse-patient interactions against 76 criteria within a specified timeframe. These specially trained observers have demonstrated interrater reliability actually to observe the new graduate in action. While this approach takes more time and resources, it is necessary to guarantee residents’ competence.
CONFIDENCE COUNTS: THE REAL VALUE OF AN RN TRANSITION PROGRAM Human resources experts in the health care field agree that one of the chief components of turnover in new graduate nurses is an absence of confidence in the tasks that they perform for patients on a daily basis. An extensive study of 63 new graduate RN residency cohorts from 14 adult-care hospitals across the United States compared residents that had completed an RN transition program from a leading provider to a control group of nurses who did not complete a transition program but had an average tenure of slightly more than 17 months.11 The results: Residents who had recently completed an 18week transition program post-nursing-school demonstrated at least equal and often higher levels of both competence and confidence than the more experienced control group of nurses. In other words, the self-confidence of residents at the end of a systematic 18-week transition program equals that of nurses with more than a year of additional job experience. And when it comes to caring for patients in today’s challengingly dynamic health care environment, competence and confidence count. When hospitals simply hire wave after wave of new graduate nurses in an endless and unsatisfying staffing cycle, everybody loses. When they opt instead for a struc44 Nurse Leader
tured, systematic RN transition program that can accelerate development of both compentency and confidence, it’s a win/win/win for nurses, hospitals, and the most important constituent of all—the patient. References 1. Buerhaus P, Staiger D, Auerbach D. The Future of the Nursing Workforce in the United States: Data, Trends and Implications. Sudbury, MA: Jones & Bartlett; 2008. 2. U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. National Sample Survey of Registered Nurses. 2000. Available at: ftp://ftp.hrsa.gov/bhpr/rnsurvey2000/rnsurvey 00.pdf. Accessed May 27, 2008. 3. Robert Wood Johnson Foundation. 2006 Annual Report. Available at:http://www.rwjf.org/files/publications/annual/2006/yir/ nursing.html. Accessed May 27, 2008. 4. U.S. General Accounting Office. (2001) Nursing Workforce: Multiple Factors Create Nurse Recruitment and Retention Prob lems. GAO-01-912T. Available at: http://www.gao.gov/new.items/ d01912t.pdf. Accessed May 27, 2008. 5. American Association of Colleges of Nursing. (2005). Faculty shortages in baccalaureate and graduate nursing programs: Scope of the problem and strategies for expanding the supply. Available at: http://www.aacn.nche.edu/Publications/White Papers/FacultyShortages.htm. Accessed May 27, 2008. 6. Gordon and Betty Moore Foundation. Betty Irene Moore Nursing Initiative. Available at: http://www.moore.org/bimni-strate gies.aspx. Accessed May 27, 2008. 7. American Association of Critical-Care Nurses and AACN Certification. Safeguarding the patient and the profession: the value of critical care nurse certification. Am J Crit Care.2003;12(2):15464. Available at http://ajcc.aacnjournals.org/cgi/content/full/ 12/2/154?ijkey=36dea692d3f83809cd37d99a67308fa1fbcae6 39#R3. Accessed May 24, 2008. 8. Halfer D, Graf E. Graduate Nurse Perceptions of Work Experience. Nurse Economist. 2006:150-155. Available at: http://www. medscape.com/viewarticle/541778. Accessed May 20, 2008. 9. Joint Commission. Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Oakbrook Terrace,IL: JCAHO; 2002. 10. Suling, L. The Impact of Transition Experience on Practice of Newly Licensed Registered Nurses. NCSBN. Available at https://www.ncsbn.org/Suling.ppt. Accessed May 28, 2008. 11. Versant. Quantifying the Nursing Residency Advantage: The Fast-Track to Nursing Competence & Confidence. White paper. Los Angeles, CA: Versant Corp: 2008.
Charles Krozek, MN, RN, is the president and managing director for Versant in Los Angeles, Calif. He can be reached at [email protected]. 1541-4612/2008/ $ See front matter Copyright 2008 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2008.07.011
October 2008
W
hen asked why he was successful in the ring, American boxer Muhammad Ali replied, “I run on the road long before I dance under the lights.” For new nurses, today’s health care workplace can feel a lot like a boxing ring. The right transition program is the preparatory run before the participatory dance.
HEALTH CARE: NO EASY PLACE TO BE Nurses always have faced the challenge of providing the highest quality of care, despite conditions and environments disposed to thwart it. For Florence Nightingale, the challenges were overcrowding, defective sewers, and no ventilation at Scutari. For today’s onboarding nurse, the problems are understaffing, rising acuity, and fear of failure. October 2008
According to a report released in March 2008, the shortage of RNs in the United States could reach as high as 500,000 by 2025, with demand growing by as much as 3% each year.1 The causes are well known: • Aging nurses: Labor forecasts and population trends indicated that the nursing population would increasingly age with the rapid retirement of baby boomer nurses and decreasing numbers of enrolling nursing students. In 1996, the average age of a nurse was 44.2 In 2006, it was almost 47.3 The cost-cutting practice used by many hospitals of not replacing nurses that retired or resigned has made the problem worse. • Aging patients: The population of 65 and older Americans will double between 2000 and 2030, while the number of women between 25 and 54—the traditional nursing pool—will stay the same.4
Nurse Leader 41
such coexisting conditions as diabetes, hypertension, heart disease, and kidney failure. This paradoxical chronic critical illness requires treatment with more powerful medications that require more intense and experienced vigilance and monitoring. Nurse confidence also plays a role in patient safety. Because they provide continuous care during a patient’s hospitalization and typically are the first to assess the need for medical intervention, nurses discover potentially lifethreatening errors or oversights by doctors, pharmacists, and other nurses within the hospital. Less experienced nurses may be reluctant to address these FLOODS OF ENTERING NOVICES, WAVES issues with the more experienced clinicians. OF EXITING EXPERTS: NURSING’S 3. Retaining them: Graduate nurses have indicated it PERFECT STORM takes them at least 1 year to feel confident and comAs an increasing number of graduate nurses enter the petent performing their duties. Their experiences durworkforce, employers face three major challenges: ing this first year are crucial, as studies indicate that 1. Recruiting them: In a highly 30% to 65% of new nurses leave by competitive market, hospitals their second year.8 Why do they leave? The primary reason cited is must stand out to attract new To fill vacancies, HCOs use concern about patient care.8 It is a graduate nurses. In addition, concern that will deepen with the some nurses pursue jobs outside costly traveling nurses or increasing acuity of an aging poputhe hospital as staff shortages require existing personnel to lation. The resultant stress-related and organizational vacancies turnover has a domino effect—secmake it easier to work for insurwork overtime, driving up ondary turnover as patient loads ance companies, surgical centers, rise as a result of the first wave of and urgent care facilities. Other costs, burning out staff, and turnover, putting the nurses who renurses leave to pursue nurse main under even greater pressures. practitioner master’s degrees that jeopardizing patient care. This second wave of turnover is can remove them from the workdoubly crippling to health care orforce for 2 to 5 years. Many ganizations because it washes out senior nurses as never return to direct bedside nursing. well, reducing the number of experienced frontline In a frenzy to acquire nurses, hospitals try to outdo nurses to teach and mentor. An influx of novices coueach other with lucrative incentives, from big sign-on pled with an efflux of mentors can put quality care bonuses to new cars and new home down payments. and patient safety at risk. Some hospitals even assist students with tuition in exchange for job commitments. Not only do these activiWhen nurses leave, hospitals take a major hit to the ties incur greater expenses for HCOs, they also bottom line. This is especially true with new nursing alienate existing nurses who have been working for graduates. According to a JCAHO report, the cost for years without such incentives. advertising, training, and loss in productivity associated 2. Developing them: Nurses provide approximately 95% with recruiting a new nurse averages $50,000 per nurse of direct patient care in hospitals.6 However, new and can add as much as 5% to a hospital’s annual budget.9 To fill vacancies, HCOs use costly traveling nurses or nurses typically struggle to adjust to their new roles and gain confidence in their clinical skills. A big require existing personnel to work overtime, driving up source of frustration and fear: the “preparedness gap.” costs, burning out staff, and jeopardizing patient care. At best, without an effective approach to new nurse Over time, the cost of care increases dramatically and development—or on-boarding—HCOs risk losing their labor expenses, already the largest line item for most investment. At worst, they risk losing quality patient hospitals, keep growing. care. Understandably, novice nurses are at a disadAs HCOs struggle to meet the challenges of recruiting, vantage in light of increasing patient acuity. As new developing, and retaining new graduate nurses, competiillnesses and threats to the public’s health continue tion for them grows. The result: A flood of novices alto emerge, new drugs and technologies extend life most universally unprepared to enter patient settings and longer than ever before. In a recent study, nurses contribute immediately to quality patient care. What is an confirmed that people admitted to their units are HCO to do to ensure a steady flow of graduate RNs with sicker than ever before.7 Patients that would never the competence and confidence to perform their roles have made it to the hospital a few years ago now and the commitment to continue their careers? For most live longer after major surgery and often suffer from HCOs, the answer rests in RN transition programs.
Nursing schools have responded to this shortage. From building new schools to increasing the number of slots, they are expanding their capacity to educate greater numbers of new nurses. The result: Nursing programs are bursting at the seams. According to the American Association of Colleges of Nursing, there has been a 7-year upswing in enrollment at nursing programs on the baccalaureate level with a 5.9% increase in 2007.5 All these new nurses are good news. The bad news? Health care organizations (HCOs) are struggling to get them, train them, and keep them.
42 Nurse Leader
October 2008
RN TRANSITION PROGRAMS: WHAT WORKS Over the years, hospitals have used preceptorships, mentor programs and didactic content but these efforts were fragmented, at best. Very few are able to integrate these parts into a cohesive whole. What new nurses need instead is an integrated, interconnected program hardwired throughout the organization—a systematic approach to nurse on-boarding. Characteristics of a systematic RN transition program include: • Standardization: Variability in practice means inconsistency in care. A well-prepared nurse who can think critically and perform to best-practice standards is more likely to deliver consistently safe patient care. No matter what their specialty, residents should complete the same core training. By attending classes together, they receive the same type of clinical experiences. Standardization reduces inconsistencies in practice that lead to errors and compromise patient safety. When the entire nursing staff can deliver consistently accepted standards of care, there are fewer such negative outcomes as infiltration of IVs, patient falls, central line issues, and care coordination issues. • Practical application of knowledge: Traditional programs—nearly 80% of which are 12 weeks or less— lack adequate clinical immersion and inadequately prepare new nurses to assume the complex role of RNs.10 The lack of clinical immersion affords few chances for new RNs to hone patient care skills and understand hospital protocols. A systematic transition program gives RNs the right information in the right sequence. This knowledge must link to real world clinical labs that allow residents to transfer their knowledge into practice, building skills and confidence in those skills. • Support systems: Traditionally, experienced or senior nurses were assigned the tasks of being preceptors or coaches with little training or consideration for interpersonal skills. Often their roles were unclear, and they felt burdened by the responsibility. This type of arrangement does not foster the sense of trust and emotional support that new RNs need. A comprehensive support structure establishes a network of senior nurses who act as preceptors, mentors, and confidants. This system heightens residents’ confidence in their abilities, their satisfaction with their new employer, and their sense of commitment to the profession. By design, this support structure increases the positive experiences of the novice RN and reduces turnover. • Rigorous evaluation: A systematically administered transition program lends itself to rigorous evaluation. The systematic approach creates expected outcomes. Expected outcomes are measurable. Rigorous evaluation of residents’ performance is valuable to the residents as well as their preceptors and mentors. Evaluation of every aspect of the transition program gives both educators and residents useful feedback tools. October 2008
• Continuous improvement: Rigorous evaluation combined with comprehensive support gives administrators the ability to enhance the transition program on a continual basis. Tools such as web-based learning management give educators and administrators overviews of individual residents’ performance as well as that of entire cohorts. Critical data in a manageable format allows administrators to make informed decisions and implement decisions strategically and effectively. A systematic RN transition program is an outcomesbased on-boarding approach that can develop new graduates’ clinical and analytical skills, promote their interest in practice improvement and career advancement, and provide emotional support. Easing the transition from the classroom to the bedside, systematic RN transition programs enable HCOs to give new nurses the experience they need to become safe, confident, competent professionals. So doesn’t every hospital have one?
MAKING THE CASE FOR AN RN TRANSITION PROGRAM Few would argue the potential return on investment of a systematic RN transition program. However, few HCOs can afford the potentially costly and time-consuming process of building an internal program. External transition program development is an emerging industry that will facilitate— and accelerate—organizations’ implementation of outcomesbased, systemized transition solutions. Rather than taking months or years to develop an evidenced-based systematic program, an organization can partner with an RN transition program provider to implement a sustainable transition with proven results in as little as 12 weeks. Before selecting any strategy, it is wise to perform a cost/benefit analysis comparing the cost to develop a program against the cost of engaging outside assistance. Whichever you choose, make sure there are outcome measures and that they align with the organization’s strategic goals (eg, efficient use of financial resources, increased patient safety, role satisfaction, and physician satisfaction). When selecting an RN transition program provider, it is important to select one with a proven record of accomplishment of recruiting, developing, and retaining the finest new graduate nurses. A proven solution should: • Enhance recruitment and retention: An effective program can create an attractive and competitive recruitment proposition for HCOs trying to secure the best of a limited field of candidates, while documenting positive outcomes retaining them. • Enhance patient care and safety: A systematic RN transition program accelerates the competency of new RNs, enabling them to acquire the skills they need to succeed. By ensuring all new RN hires practice with standardized, evidence-based procedures and protocols, RN transition programs eliminate the practice variability that leads to care inconsistency. • Simplify residency management: The best programs offer adapt to the unique needs of many HCO environ-
Nurse Leader 43
ments and provide such tools as web-based applications that completely manage program implementation, clinical monitoring, and residency evaluation. • Improve profitability: Reducing turnover leverages an organization’s recruiting investment and minimizes its reliance on costly agency nurses and expensive overtime. In addition, an effective packaged program eliminates the need to invest in a costly internal program, saving money and eliminating months or even years from the start-up process. • Improve workplace satisfaction. Stopping the revolving door minimizes the financial and emotional drains associated with a never-ending turnover cycle. Providing a structured way for staff to work together improves teamwork and group cohesion. Teaching activities that take place in different parts of the hospital improve interdepartmental and interdisciplinary communication. • Provide actionable competence ratings. Effective transition programs include mechanisms to measure new RNs’ clinical competence and safe practice behaviors. A common methodology, which some regulatory agencies employ, measures competency by surveying the new graduates and their preceptors. A more effective technique is the Slater Observation strategy. In this methodology, trained observers rate nurse-patient interactions against 76 criteria within a specified timeframe. These specially trained observers have demonstrated interrater reliability actually to observe the new graduate in action. While this approach takes more time and resources, it is necessary to guarantee residents’ competence.
CONFIDENCE COUNTS: THE REAL VALUE OF AN RN TRANSITION PROGRAM Human resources experts in the health care field agree that one of the chief components of turnover in new graduate nurses is an absence of confidence in the tasks that they perform for patients on a daily basis. An extensive study of 63 new graduate RN residency cohorts from 14 adult-care hospitals across the United States compared residents that had completed an RN transition program from a leading provider to a control group of nurses who did not complete a transition program but had an average tenure of slightly more than 17 months.11 The results: Residents who had recently completed an 18week transition program post-nursing-school demonstrated at least equal and often higher levels of both competence and confidence than the more experienced control group of nurses. In other words, the self-confidence of residents at the end of a systematic 18-week transition program equals that of nurses with more than a year of additional job experience. And when it comes to caring for patients in today’s challengingly dynamic health care environment, competence and confidence count. When hospitals simply hire wave after wave of new graduate nurses in an endless and unsatisfying staffing cycle, everybody loses. When they opt instead for a struc44 Nurse Leader
tured, systematic RN transition program that can accelerate development of both compentency and confidence, it’s a win/win/win for nurses, hospitals, and the most important constituent of all—the patient. References 1. Buerhaus P, Staiger D, Auerbach D. The Future of the Nursing Workforce in the United States: Data, Trends and Implications. Sudbury, MA: Jones & Bartlett; 2008. 2. U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. National Sample Survey of Registered Nurses. 2000. Available at: ftp://ftp.hrsa.gov/bhpr/rnsurvey2000/rnsurvey 00.pdf. Accessed May 27, 2008. 3. Robert Wood Johnson Foundation. 2006 Annual Report. Available at:http://www.rwjf.org/files/publications/annual/2006/yir/ nursing.html. Accessed May 27, 2008. 4. U.S. General Accounting Office. (2001) Nursing Workforce: Multiple Factors Create Nurse Recruitment and Retention Prob lems. GAO-01-912T. Available at: http://www.gao.gov/new.items/ d01912t.pdf. Accessed May 27, 2008. 5. American Association of Colleges of Nursing. (2005). Faculty shortages in baccalaureate and graduate nursing programs: Scope of the problem and strategies for expanding the supply. Available at: http://www.aacn.nche.edu/Publications/White Papers/FacultyShortages.htm. Accessed May 27, 2008. 6. Gordon and Betty Moore Foundation. Betty Irene Moore Nursing Initiative. Available at: http://www.moore.org/bimni-strate gies.aspx. Accessed May 27, 2008. 7. American Association of Critical-Care Nurses and AACN Certification. Safeguarding the patient and the profession: the value of critical care nurse certification. Am J Crit Care.2003;12(2):15464. Available at http://ajcc.aacnjournals.org/cgi/content/full/ 12/2/154?ijkey=36dea692d3f83809cd37d99a67308fa1fbcae6 39#R3. Accessed May 24, 2008. 8. Halfer D, Graf E. Graduate Nurse Perceptions of Work Experience. Nurse Economist. 2006:150-155. Available at: http://www. medscape.com/viewarticle/541778. Accessed May 20, 2008. 9. Joint Commission. Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Oakbrook Terrace,IL: JCAHO; 2002. 10. Suling, L. The Impact of Transition Experience on Practice of Newly Licensed Registered Nurses. NCSBN. Available at https://www.ncsbn.org/Suling.ppt. Accessed May 28, 2008. 11. Versant. Quantifying the Nursing Residency Advantage: The Fast-Track to Nursing Competence & Confidence. White paper. Los Angeles, CA: Versant Corp: 2008.
Charles Krozek, MN, RN, is the president and managing director for Versant in Los Angeles, Calif. He can be reached at [email protected]. 1541-4612/2008/ $ See front matter Copyright 2008 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2008.07.011
October 2008