The new registered nurse (RN) faces the stress of finding a job and moving from nursing student to professional RN. During this transition period, it’s critical that these nurses develop the confidence and competence they need to deliver quality patient care in a supportive practice environment.
A nurse residency program can ease that transition by providing a supportive environment and promoting nurse engagement, a crucial factor in healthcare delivery. For example, in 2005 Gallup identified the top predictor for prevention of medical errors as nurse engagement, with number of nurses/total per day and percentage of overtime hours per year close behind. Engagement doesn’t focus solely on the nurse in the residency program; it must also include the organization and staff.
This article provides strategies to create that supportive environment and engage nurses at every level who are touched by a nurse residency program.
The residency program
The National Council of State Boards of Nursing, leading educators, the Institute of Medicine, and the Robert Wood Johnson Foundation have declared the need for a nurse residency program that supports new graduate nurses during their transition from novice to competent practitioner.
Residency programs are based on the assumptions that there is a recognized preparation gap between nursing education and clinical practice, that experienced nurses must value new graduate nurses as the ones who will replace them in the future, and that a positive organizational culture must be present within the clinical environment as well as within the organization as a whole.
The findings of a 10-year study by Ulrich and colleagues reported in 2010 identified 13 characteristics of a successful residency program, and “active stakeholder engagement and organization-wide commitment” are identified as key. With this in mind, it’s helpful to identify the strategies that an organization can implement to welcome new RNs and help them with a positive transition experience.
The chief nursing officer (CNO) has been called the “organization keeper,” and it’s the CNO’s responsibility to create a culture of engagement throughout the facility that champions the residency program. It’s important for the CNO to meet new graduates and provide a warm welcome to the organization. This introduction demonstrates the CNO’s communication style and reflects the organization’s culture. It presents a first impression to new graduates about how open communication works at the organization. There are several strategies the CNO can use during the initial meeting and throughout the residency to communicate commitment to the RN residents:
- Discuss the organization’s mission and vision and the role the nurse plays in meeting organizational goals. Share the practice model that is used and how it aligns with the mission and vision. These discussions help to set the expectations, responsibilities, and accountabilities of the RN while providing patient care in a challenging, multidisciplinary environment.
- For facilities on the Magnet journey or following Magnet principles for nurse engagement, introduce these principles and discuss how they are operationalized at the point of care.
- Participate in rounding during the residency. This engages residents and staff while offering support and sends a message that the CNO fully supports the residency and is interested in what is happening at the unit level.
- Introduce the new graduate to Quality Improvement (QI) projects, including how they correlate with organizational values that support positive patient outcomes. One organization offers a 4-hour introduction to the Joint Commission’s National Patient Safety Goals and how its QI projects align with these goals. Residents then participate in mock survey experiences in which they learn tracer methodology and how their daily practices (such as hand washing and medication administration) impact quality. Having the new graduate become part of a QI project early in his or her career provides a larger scope for practice and brings realization of how QI projects impact patient safety and outcomes.
Supervisors and charge nurses are in leadership roles that also impact the new graduate’s transition. These leaders have the responsibility for making sure staffing is appropriate as to number and skill mix; assignments are appropriate for the preceptor-resident skill level; and that learning-identified opportunities are available and are in alignment with the resident’s learning goals.
Much like the CNO sets the culture for the organization, the nurse manager does so for the patient-care unit. Nurse managers who use peer interviewing for resident selection report that it’s a powerful way to engage staff with the hiring process. With the recent change in job availability for new graduates, there’s now competition for select residency positions. Some hospitals report over 200 applicants for limited residency seats. Having unit staff involved in the process has demonstrated an “increased investment in the success of the new hires they help to select.” Who better than former residents to evaluate candidates for “work group compatibility” within the culture of a given unit?
The residency manager, or educator, is responsible for the administration of the residency program. The residency manager coordinates and correlates all aspects of the program, ensuring the resident is provided the experiences needed for success. Ideas for engagement at the unit level include:
- competency validation with peer verification. In a move away from the annual skills fair to a meaningful competency validation model that puts unit staff “at the center for the verification process,” peer verification uses a “collaborative approach among key stakeholders” to manage unit-based competencies. (For more information, see Figueroa et al, 2011, and Wright, 2005.)
- nursing narratives. These narratives are either written or verbal accounts of a personal story that reflect a clinical situation that was in some way meaningful for the teller. They allow others to hear of a significant experience through the eyes of the nurse. Sharing these stories enriches the person and the profession of nursing while engaging others. (For more information, see Jacobs, 2011.)
- journal clubs and unit-based continuing education offerings. Providing unit-specific educational offerings in a variety of delivery methods (journal articles, patient presentation and case studies, simulation, and debriefing sessions) by unit staff demonstrates a commitment to evidence-based practice and lifelong learning. One unit that uses this approach reports its staff members feel “more supported—better about their work experience” and demonstrate improved unit commitment and better retention. (For more information, see Daley & Dautrich, 2011).
The preceptor plays the most critical role for the new graduate in ensuring a successful transition. It’s this relationship that determines the success of the program itself. Preceptors provide guidance as well as effective feedback to the resident. Strategies for success include:
- preceptor education, including communication strategies and effective feedback techniques. From the resident perspective, a preceptor who is able to clearly communicate expectations; provide specific feedback in a positive, nonthreatening manner; and actively encourage the resident creates the framework for a successful relationship. (For more information, see Sato & Shamash, 2011.)
- preceptor forum. Having a well-educated, stable preceptor group directly impacts the program. An ongoing forum to “gather, network, and share best practices” offers opportunities for preceptors to reflect and plan on what’s working, what’s not, and what new methods could be employed. According to preceptors who have attended these forums, they believe that constant contact with each other while “brainstorming” has led to “an improved quality of care and safety” during the residency. (For more information, see Irizarry & Chua, 2011.)
Effective communication—still the best strategy
Long hours and financial dollars are vested in the development and implementation of a successful residency program. The best program, however, won’t be successful without an engaged workforce with strong communications skills. As in all relationships, the ability to communicate openly and effectively with all members of the healthcare team is crucial.
Healthy communication strategies include both nonverbal and active listening in which the parties involved are present in the moment and truly engaged with each other. When there are shift differences, it may mean scheduling a meeting when the night shift nurse is not too tired or the day shift nurse not too busy. In hectic patient-care units, this may mean moving to a quieter place with fewer distractions. It means turning off or ignoring phone calls, pagers, and other disruptions and giving full attention to the conversation at hand.
During these crucial conversations, all those involved want to feel that they are being listened to and understood. There needs to be encouragement to appropriately express ideas or concerns (for example, “I see…,” “You’ve got it…,” or, “Tell me more…”), clarify messages (for example, “In other words…” or “If I understand you correctly…”), and summarize the conversation (for example, “What I hear you saying is…” or “If I understand you correctly…”).
The goals of any transition program are to improve the new graduate’s transition experience and increase confidence and competence as well as organizational commitment and retention. When done well, a transition program affects not only the nurse resident but all healthcare professionals the graduate comes in contact with. A well-run residency program engages the work force at every level and results in an increase in organizational change and commitment.
Jean Shinners is the Education and Curriculum Manager, Versant, in Ithaca, New York.
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