Nurse Residency Project

Question

Nurse Residency Project

The problem addressed in the evidence-based practice (EBP) is the need to retain new nursing graduates in the organization and decrease turnover rates by implementing a nurse residency program. Registered nurse (RN) turnover in the organization is costly in terms of the quality of patient care and sustaining the professional organization. It cost a hospital approximately 300,000 dollars annually, and over 80,000 dollars to train one nurse. Replacing new graduates is costly to the hospital due to the onboarding and additional resources needed to train new graduates. The facility where I am doing my practicum currently has a retention rate of less than 30 percent in the first year.

Most nurse graduates are leaving the organization after one year. Nurse graduates are experiencing stressful work environments, low satisfaction, and high turnover intention. The question is whether the nurse residency program will help the organization retain nurses and decrease turnover rates within the hospital by 75% in the first year and 90% by the second year. A pre-and post-evaluation is to be completed by all the new graduates before starting the program and every three months up to the one year of employment at which time they will have completed their nurse residency program.

The evaluation will be to address if the nurse residency program gave them support, confidence, and the development of clinical skills needed to transition from novice to professional nurse. The conclusion is that the nurse residency program provides retention of new graduates, is cost-effective to the organization, and most of all improves the quality of care for patients.

Keywords: evidence-based practice, nurse residency program, registered nurse, nurse graduates

Acknowledgments

Special thanks to Peninsula Regional Medical Center, Salisbury, Maryland for supporting and participating in my project. This project was dedicated to supporting and educating new nurses at the beginning of their careers, and to helping them transition from the school setting to practice. With the completion of this project better guidelines for orientation and supporting new graduates transition to professional nurses. In addition, a special thanks to my preceptor Cynthia Hurley, MSN, RN who spent long hours helping and supporting me through this research project.

Nurse Residency Program for Nurse Graduates

In the past decade, health care research has studied and predicted the nursing shortage in health care across the United States. According to the American Association of College of Nursing Schools, (2014) as the baby boomers retire the need for nurses is going to rise it is predicted that the RN workforce is expected to grow from 2.71 million in 2012 to 3.24 million in 2022. Nursing schools across America are feeling the need to produce more graduates from nursing schools. The supply vs. demand will not be enough to sustain the shortage. Organizations will have to invest and look for creative ways to retain nurses.

According to Kavanaugh et al., (2012) nurses make up the largest employees in healthcare. The research has shown that adverse events and mortality are highly dependent on nurse staffing levels and skill mix. Nursing-sensitive value-based purchasing (NSVBP) has the potential for improving the quality of nursing care by financially motivating organizations to have an optimal nurse practice environment. The new nurse graduate gets an eight-week orientation and then is expected to take care of patients on their own they are left with little support, lack of confidence, and are not clinically competent in all the skills needed to take care of patients with multiple chronic health conditions.

According to Duffield et al., (2014), the research conducted focused on the need for policymakers to provide a greater focus on nurse retention. It also shows that organizations with high turnover rates need to focus on implementing changes to keep nurses in their organizations. Studies have shown that most focus on the cost to the organization when a nurse leaves and the cost to replace that nurse. With these facts present, organizations must invest in new graduates by implementing a nursing residency program to reduce the turnover rates and retain nurses in their organization.

Evidence-based practices support the implementation of nurse residency programs to give new graduates the support, confidence, and competence to transition from beginner to competent through the continuum of learning experiences through a preceptor/mentor and coach.

This chapter introduces a practicum experience project on the implementation of a nurse residency program for new graduates. Evidenced-based nurse residency programs are effective when it comes to retaining new graduates. This chapter addresses the statement of the problem, the importance of the project, the project goal, and the criteria for evaluation. Discussions are specifically included about key stakeholders, barriers, facilitators, and models for change.

Statement of the Problem

There is no surprise that the nursing shortage affects every aspect of health care delivery. According to Zinn et al. (2012), as baby boomers are retiring, the nursing shortage will follow. It is pivotal for organizations to attract nurses to their organization as well as retain them. Nursing residency programs are investments in supporting the new graduate. Some individuals are discouraged from entering the nursing profession and leave the profession due to difficult work environments. The literature suggests that by 2020 the supply of nurses will not meet the demand for nurses. Organizations need to look at what we can do now to retain nurses.

According to Duffield et al., (2014), nurse turnover is a critical issue in the United States due to the costs to both human and financial, which influences negatively hospital budgets. The big impact may be on patient outcomes as well as staff. If we cannot find ways to help new graduates transition to practice safely then we are not doing our jobs as an organization to commit to quality safe patient care. According to Turkel (2016), the novice nurse with little experience has difficulty managing critical events and may lack the knowledge and skill to anticipate actual or potential complications. This is a time when new nurses are developing a skill set and critical thinking skills that is why the need for the residency program is so important.

Importance of the Project

New graduates starting their career experience many challenges to include work environment, learning needs, critical thinking skills, and developing a skill set needed to care for patients with multiple chronic disease conditions. This project is important to meet the demands of novice nurse and to help educate them, build confidence, and give them the time needed to succeed in an ever-changing health care environment. In addition, the project is important also to provide safe, quality patient care, and improve outcomes for patients. With educating new nurses and supporting them through the transition of the program, the goal is to retain nurses through the program and allow them to blossom into professional nurses.

The findings in this report will call for immediate and drastic changes in the health care organization. Developing and implementing a program for a nurse residency will have to have buy-in from the organization, stakeholders, preceptors, mentors, leadership, staff and new graduates coming into the organization. The organization and stakeholders will have to be involved to ensure that the process of change is implemented and successful.

Organization Changes Needed

Implementing an organizational change is not without challenges. The goal of implementing the change is to improve patient outcomes and help new nurses develop safe practices. To implement the nurse residency program is for leaders, educators, preceptors, and mentors to have established guidelines and develop a curriculum that enhances the education of new nurses to their new role. The organization and stakeholders will have to be willing to invest in the nurse residency program for the development and retention of new graduates to the organization.

"Nursing residency programs are expensive to implement, but organizations and healthcare leaders should view nursing residency programs as a return on their investment. NRP's not only producing higher job satisfaction, but they also reduce turnover rates among nurse graduates"(Blevins, 2016). One way to improve retention is to have an NRP that is developed to teach new nurses, critical thinking, new skills, communication, and leadership. Preceptors and Mentors will be pivotal in supporting the new graduate throughout their residency program.

Who Should Be Involved in the Change Process?

When developing a change project that affects the entire organization change can be effective if the organization sees it as a benefit to the organization. The change process will include stakeholders, the chief nursing officer, human resources, clinical nurse specialists, nurse preceptors, nurse mentors, and the entire leadership team. The nurse preceptors will be involved in precepting the new graduates for their eight-week orientation and the nurse mentors will serve as the support system over the next year. The leadership in each unit will serve as direct contact with each new graduate on their unit to address all concerns and useful remediation to help the new nurse be successful.

During the process, the most important people will be the new graduate on the unit. Educators such as the clinical nurse specialist along with human resources will be responsible for the formulation of policies and guidelines to develop and implement the change. The experienced nurses on the units hiring new graduates will focus on mentoring the new nurse graduate and providing an environment that promotes learning, and transparency. The stakeholders will give input along with leadership during the process for the project to be successful.

Significant Barriers to Change

Change is never easy whether implementing new technology, changing policies and procedures to meet best practices, or implementing a nurse residency program. The barrier to implementing the change is having the organization invest in the change and be committed to the change process. According to Cappel et al., (2013), for the nurse residency program to be successful, the organization will have an academic partnership with an academic nursing program. Preceptors will volunteer to train new nurses and will have the experience to train new graduates in the residency program. The barrier to selecting preceptors is although they may be skilled in the nursing tasks they are unable to integrate evidence-based practice into care delivery.

Facilitators to Change

Change is a process that needs buy-in from the stakeholders from the chief nursing officer to the entire leadership team in the organization. Facilitators of change may include stakeholders and the entire leadership team within the organization. Interested parties in the change are nursing staff, mentors, educators, clinical managers, clinical supervisors, and clinical nurse specialists in my organization. The above team will support and help with the entire nurse residency program's educational and orientation guidelines. Organizations that support the nurse residency program will facilitate the change process, and implement the change process in timely to meet the nursing shortage in our hospital and support our future new graduates. In doing this, new nurses will feel part of a team with the needed support, confidence, and skills needed to improve patient outcomes.

Kotter's Eight Steps for Change Initiative and Implementation

There are several models for change that have been evaluated through literature to be successful. In this project, I will use Kotter's Eight Stage Process to manage the organizational change of implementing a nurse residency program for new graduates. According to Kotter International, (2016), the eight-step process is the most widely used to implement change within an organization. Kotter's eight-stage process organizations must excite people regarding the change. Work to assemble a team of people to collaboratively work on the change effort, and develop initiatives to achieve the change within the organization. Select groups ready and able to drive change, and remove barriers to change, consistently track and evaluate accomplishments, always hire and develop employees who can motivate change within the organization.

No matter what change management project one would need to incorporate the important factors that make change successful. According to Parry et al., (2014), they conducted a study to look at what indicators in change management make it successful. The following are important leadership skills of direct supervisors in managing performance, employee morale, and comment to the organization in which employees feel part of the team recognized and rewarded. Communication from leadership to the employees from top-down, people in the team must feel the passion and drive for the project.

This is particularly why I feel transformational leadership is key in managing change. Transformational leaders empower people to be successful and think outside the box. They trust their team and direct them to do the best they can and realize the value of employees' input is important. For this project, we need the entire team for input to make this project a success.

Project Purpose

In the past decade, the nursing shortage and turnover rates have left staff nurses frustrated, feeling overwhelmed, and eventually leading to burnout. This has a twofold effect on experienced staff as well as new graduates entering the workforce. If nurses spend their time training nurses, we should invest in keeping them. When turnover rates happen in a hospital such as mass exits, this leaves the current staff picking up the pieces, and this is when patient care suffers the most. According to Letourneau & Fater, (2015), new graduates are not prepared to take care of patients that are high acuity level in the practice setting. New graduates lack the level of competence required to assume responsibility for patient safety.

The challenge associated with implementing the nurse residency program is having all the necessary tools developed and an educational structure designed to meet the challenges new graduates face during their residency. This project will include extensive education and real-life cases to review and make critical decisions that they will have to make on their own without the preceptor. The implementation of the nurse residency program is needed and a way of preparing new graduates to be competent and successful in their new careers.

Criteria for Evaluation

Each new graduate will fill out a checklist that has core competencies listed. The core competencies checklist will be reviewed daily with the new graduate over the next eight weeks to make sure that the competencies checklist is completed and that the new graduate understands the policies and procedures surrounding the competencies, and how to perform the skills successfully. Implementation of the nurse residency program will be evaluated by direct feedback from the nurses in the residency program, in eight weeks they will answer a questionnaire related directly to support, they received during orientation and what changes they think would help future new nurses. The education will focus on clinical competencies and real situations with patients.

The information gathered from the program will be to evaluate the student's success such as meeting with the mentor weekly during orientation and then two times a month over the next year. The information gathered by the new graduates, preceptors, and mentors will be used to make necessary changes to the program if needed. I will also collaborate with stakeholders to collect the information and share findings to improve the program. I will also be responsible for increasing the retention rates of new graduates in the organization. This data will be collected over time.

The evaluation will also seek to improve the new graduate's knowledge of complex patients, teach critical thinking skills, and support them through team support not only in their respective unit but through leadership. The Evaluation will address the immediate needs of the new nurse and in eight weeks re-evaluate the successes made during that time. The evaluation will also include the needs of the nurse before taking patients on her own and having someone to talk to such as the mentor to help with difficult situations. (see Appendix A). The information will be shared with the leadership team and nurses to make necessary changes to meet the needs of the new graduate.

Conclusion

In conclusion, the nursing shortage is a real problem, and in our organization turnover, rates are making a significant impact on patient care, as well as the staff left behind. If health care organizations see the benefit through evidence-based practice to develop and implement a nurse residency program I believe we as an organization and team will make a difference in retaining qualified nurses, and improving the health and outcomes of the patients, we care for every day. In the next chapter, the paper will focus on best practices and complete a literature review to show that this project is needed in our organization.

Literature Review

Nursing makes up the largest workforce in healthcare. With retiring baby boomers and the need for nurses due to the projected shortage in 2020, organizations will have to create an environment that not only supports new nurses but invests in their career starting. The effects of nurses entering the workforce without clinical sound judgment, competencies, and obtaining a multi-faceted approach to teaching them the skills needed to make improve patient outcomes, and take care of patients with multiple chronic disease conditions the care for patients is at stake. Research has shown that nurse residency programs implemented throughout organizations can give new nurses the support, confidence, and skills needed to provide quality patient care and in turn, improve patient outcomes.

New graduates need a twelve-month residency program in which they learn new skills, develop as a nurse, and have support while transitioning from school to practice. To provide care to patients with complex disease conditions, the new graduate needs time to adjust to a fast-paced environment that includes learning technology such as the EMR, developing skill sets, handling emergencies, knowing when a patient is deteriorating, interpreting lab and diagnostic results, and when to notify the physician. They also need to understand the policies and procedures, along with being able to explain to patients why they are receiving a particular medication, and addressing the pain needs of patients. The only way we can be successful is by educating new nurses and giving them the support to transition to practice.

Body of Evidence

The literature review was conducted utilizing Ebscohost through the Kaplan online library. A search was conducted using keywords (new graduates, nurse residency, turnover, nursing shortage, and supporting new graduates) to focus on studies that showed best practices for the retention of new graduates and ways to improve the organization's overall retention rate. Databases searched include:

1. Medline Complete.
2. Cochrane Library.
3. Allied health Literature (CINAHL).
4. Ovid Nursing database.

Many of the articles described the need for the implementation of a nurse residency program to retain new nurses. Most of the articles also discussed other factors that contribute to nurses leaving the profession such as incivility, disruptive work environment, low job satisfaction, and not feeling supported. In most articles, the literature supports nurse residency programs and suggests that it provides the new nurse the support, confidence, and skill set to be successful and feel successful in their career.

Need for Nurse Residency

Recruitment and retention of new nursing graduates are critical to sustaining the workforce. New nurses are in demand now and will be in the future to offset the nursing shortage due to aged nurses retiring. It is our goal to help retain nurses and is cost-effective to implement a nursing residency program for new graduates.

A systematic review conducted from 338 studies initially identified; eleven studies were included in the review that focused on newly graduated nurses enrolled in a transition program. According to Missen et al., (2014) these studies used a variety of study designs including quasi-experimental and pre-and post-testing. The systematic review showed that transition programs are necessary for creating safe and supportive work environments that support nurses in the clinical environment. The positive effect on transition programs is that they retain new nurses and decrease turnover rates.

A cost-benefit analysis was conducted by Trepanier et al,. (2012) to assess the economic outcomes of a new graduate RN residency program utilizing turnover rate and contract labor usage data from a multi-site health organization. Secondary data of newly graduated RN's (n=524) from fifteen different hospitals. The cost analysis findings indicated that a new graduate residency program was associated with a decrease in the twelve-month turnover rate from 36.08% to 6.41% (p<0.5) and a reduction in contract labor usage from 19,099 to 5,490 per average daily census. These cost-benefit analyses suggest net savings between 10-50 dollars per patient day when compared to traditional methods of orientation. A nursing residency program is an investment (Trepanier et al., 2012).

In supporting the same view of retention, Welding (2011) explains that residences for new graduate nurses improve the level of job retention among nurses while at the same time equipping new graduate nurses with the relevant tools to succeed in the practice. Welding (2011) refers to the findings by The University Health Consortium (UHC) and the American Association of Colleges of Nurses (AACN) where it was established that 95.6% of the retention of new graduates emanated from the existence of the residency programs. Without a residency program for new nurses, the rate of turnover was 30% according to Welding (2011).

The best approach to ensuring that the high levels of turnover are alleviated is to come up with a residency program that allows these nurses to feel part of the practice. The retention levels are brought about by the fact that emotional hardships and stressors among new graduates are handled effectively with residencies for the nurses. They get the opportunity to access needed advice from senior nurses or their colleagues hence working under proper conditions as opposed to a situation when they are forced to live away from their workplaces. Welding (2011) recommends the need to adopt residences for new nurses as the best way to increase retention and combat turnover among new nurses.

A longitudinal study by Bratt et al., (2014) sampled 382 urban and 86 rural newly licensed hospital nurses during a twelve-month residency program. The data was collected at the start of the program, and again at six months, and then at the end of the program. In the article, Bratt et al., (2014) showed that rural nurses had low job stress and higher job satisfaction than urban nurses. The authors of the study included measures of nurse residents' characteristics using a questionnaire. The total scale and subscales used were decision making, job satisfaction, which included enjoyment, quality of care, and time of care. Job stress included competencies, physical environment, staffing, and team respect, nursing performance, and organizational commitment.

The results of the study showed that providing a nurse residency program in rural as well as urban hospitals is a useful recruitment and retention strategy for new graduates. McDonald and Ward-Smith (2012) also utilized research literature to present the factors that support the existence of nursing residences for new nurses coming into the practice. The study utilized research materials from both PubMed and Ovid because they relied on leading to the understanding of the significance of new residences for new nurses coming into the practice. Based on the literature search, McDonald and Ward-Smith, (2012) seem to challenge the fact that nursing residences result in automatic job satisfaction and elimination of stresses among the individuals joining the practice.

In essence, McDonald and Ward-Smith, (2012) cite evidence from the literature that some new nursing graduates complain of high levels of stress within the nursing units despite the support from their managers. As much as there is support from the management, there tends to be challenges when it comes to listening to their concerns and problems in nursing residences.

In this regard, both Bratt et.al (2014) and McDonald and Ward-Smith, (2012) state that it is necessary to have nursing residences to reduce the stress that the new graduates undergo for retention purposes. Nevertheless, McDonald and Ward-Smith, (2012) are more emphatic with the point that the management needs to be more careful in the manner in handles the new graduates to boost their adaptability to the new environments. Otherwise, it is always a challenge to cope with the nursing units leading to untold stressors.

Riegel (2013) also studied the process of orienting new nurses especially in regard to the millennial new graduates. A descriptive study that utilized email and the online platform for data collection was applied to the collection of information from 17 participants born between 1980 and 1989 (Riegel 2013). The focus of the study was to establish the significance of nursing residency in terms of promoting the effective orientation of new graduate nurses to work in complex environments efficiently to attain desirable patient outcomes.

In the results, Riegel (2013) established that new graduates seek structure and individualized orientation as they transition into practice. They also added that they needed to be assimilated into the work culture in the best way possible as they get into the practice. The provision of residency is necessary to the new graduates to ensure that they have the opportunity to be oriented into the practice in a structured manner that also introduces them to the cultural aspects of the nursing practice. The Institute of Medicine’s Future on Nursing endorsed the need to offer residency services to new graduates. According to Riegel (2013), the need for residency for new nurses is justified by the fact that it offers the new graduates structure and emotional support as they prepare to work in challenging and complex environments.

Barriers to Implementation

As much as residences for new graduates are perceived as advantageous and supportive of the growth of new graduates into the field, there are barriers that face the implementation of the nursing residency program. The regulatory practice for transitioning the nurses into the field is desirable but faces challenges hence slowing the program. While investigating the barriers to the implementation of the program, Spector and Echternacht (2011) revealed that cost is one of the key barriers to the implementation of the program. They affirmed that the residency program for new graduates comes with many positive elements but it is affected by high costs of implementation.

For instance, Spector and Echternacht (2011) assert that most hospitals and institutions of nurses fear that they would earn a lower return on their incomes (ROI) because of the implementation of the program. The costs reported to be an impediment to the implementation include those involved in the construction of these residences and subsequent maintenance. Given that the nurses do not pay rents and rates for these residences, there is always a feeling that they would result in losses.

At the same time, Spector and Echternacht (2011) counter the possibility of costs being a barrier by citing the Mississippi Nurse Residency Program that saved at over $4 million as a result of the implementation of the program. Thus, there is still a debate on whether costs are generally a barrier because there are also costs saved in terms of travel for these nurses and hiring new nurses as a result of increased turnover.

Delack, et.al (2015) also investigated the barriers that have been inhibiting the successful implementation of the residency programs for new nurses. As much as the residences for new nurses are important and motivating to them, there is a barrier to implementation that emanates from their own perceptions and transition difficulties. The residences could be available, but the willingness of the new graduate nurses to successfully transition into the field by occupying the residences remains a big challenge. The new nurses tend to resist being included in the nursing residences and this makes it more difficult to move to continue with its implementation for their benefit.

The barrier exists in the challenges that the new nurses face in terms of balancing their expectations with the reality of the situations they find themselves in at the field. In some instances, there is a challenge of the work-life balance in cases where they decide to live in the residences that are offered to them at the end of their courses. Living within the nursing residences brings the perception that there has been no change in the environment of practice hence negating the work experiences of these nurses. It is vital to note that the successful implementation of the nursing residences for new nurses is motivated by the positivity of new nurses toward them.

Otherwise, it is always quite challenging to come up with residences against the willingness of the new graduate nurses. The negative perceptions of some of the new graduate nurses negate the focus on the program leading to a slowed approach to its implementation. In terms of dealing with this barrier Delack et.al (2015) affirm that it would be necessary to educate them on the significance of these residences in boosting their own personal growth as nurses. Information that this gives them the perfect opportunity to grow as nurses would be critical in changing their perspectives toward the adoption of the program.

The State of Science

Consistencies from Evidence

The articles reviewed have identified the nurse residency program as a significant project to increase the retention rates of new graduates while also improving their orientation into the practice. For instance, Welding (2011) asserts from the literature search that there has been a 95.6% retention in the new nurse graduates living within the nursing residents. This is motivated by the fact that they are encouraged and prepared for the field in the course of their living at the residences. The same idea is also shared by Trepanier et al,. (2012) who affirms that with the implementation of the nursing residency program for the new graduates, there was a decrease in the rate of turnover from 36.08% to 6.41% because of the successful implementation of the program.

This leads to the general appreciation of the view that the nurse residence program in terms of ensuring that these individuals stay in their jobs over a long period. It is vital to continue building a strong team of nursing and the presence of nursing residences for new graduates helps promote this vision by enabling them to stay on the job rather than look for other options elsewhere. Both Welding (2011) and Trepanier et.al (2012) affirm that the promotion of the program is in fact saving to hospitals since they will not need to incur other costs of hiring nurses.

Riegel (2013) added to the evidence with the interview on 17 nurses and revealed that the residences for new graduate nurses go beyond retention and facilitate the acquisition of skills to deal with the challenging environment that they get into. This is facilitated by the ability of the new graduates to consult their seniors and ask questions about the nature of the practice. Trepanier et.al (2012) justifies the significant role that the residences play in improving the orientation of the nurses as evidenced by the saving of between 10 and 50 dollars per patient day as a result of the skills gained in line with the nursing resident program.

They always have more room to improve and better their skills by interacting with each other and observing what is done by other senior nurses. The focus on the job is also higher hence promoting the level of orientation as opposed to a situation when they have to utilize traditional forms of orientation where they live far away from the patients. Effective training is needed to boost the level of adaptability among the nurses hence realizing the best possible outcomes in the course of service delivery at the hospitals.

Inconsistencies from the Evidence

The literature used for this study showed differences in the role that the nursing residences for new graduates play in ensuring that they are stress-free and motivated in the course of their introduction into their careers. While Bratt et al., (2014) tended to point to the idea that there is automatic attainment in terms of the physical environment, team respect, performance, and organizational performance leading to the reduction of stress among nurses, McDonald and Ward-Smith, (2012) stated that these factors might not be attained automatically.

Based on the findings by McDonald and Ward-Smith, (2012) the new graduate nurses also tend to suffer from stress while trying to adapt to the nursing units that they are not used to. This is worsened in instances where their leaders or managers fail to give them an appropriate opportunity to express themselves and their interests appropriately. The two articles differ in the view that the availability of residences is an automatic solution to the stresses that the new graduate nurses undergo. In light of this difference, it is vital to gain an in-depth understanding of how the new graduates can be successfully transitioned into the practice. The residences should be used to make sense to them as acceptable individuals to fit into the practice smoothly.

Possible Explanations for Inconsistencies

Research has been instrumental in justifying the need for better orientation and accommodation of new graduate nurses into the practice using the nursing residency program. Accordingly, research has also been instrumental in explaining how the new nurses feel when they are brought into the practice and their perspectives on how to fit into it. Nevertheless, the inconsistencies emanate from the fact that the studies have not been conclusive in terms of understanding how the new graduates want in their residences as they get into the practice.

There have been no conclusions on whether the new nurses are affected by their nearness to the hospital or their preference to live in other nursing residence projects away from the hospital. The nursing residence project is vital, but the location could also be a matter of concern that the research needs to have investigated before reaching the relevant conclusions. Thus, little is known about how the location of the nursing residences affects the adaptability of the new graduates hence eliminating any opportunity for stress and ultimate resignation from the job.

Evidence to Support the Change

The need to adapt nursing residency programs in healthcare institutions is embedded in the ability of these programs to transform newly licensed nurses into developed professionals subsequently improving the healthcare quality and patient outcome. Hofler and Thomas (2016) demonstrated the effectiveness of a residency program utilizing the case study of North Carolina, as one of the best places where the program has been successfully implemented. Hofler and Thomas (2016) point out that it is vital to support the change because the residence program is instrumental in accounting for a reduction in the rate of turnover among nurses by ensuring more than a 75% retention rate. Based on their research within the health organization, Hofler and Thomas (2016) established that it has experienced a retention rate of over 85% as a result of offering a nurse residency program.

To further promote the structured transition of the nurses into the practice, it is vital to ensure that they have frequent access to guidance and directions from the seniors. This is made more possible when the managers are able to listen to their issues hence bestow confidence and increased competence among the new set of nurses getting into the practice. There is also a need to change in terms of reaching out to new graduates and emphasizing the need for them to stay at nursing residences for professional growth.

This would lead to the alleviation of stressors and a better transition of the new graduates into their new role as professional nurses. Accordingly, nurse residency programs are essential in facilitating the improvement of a new nurse’s work experience, enable successful retention, and allow a financial return for those healthcare organizations investing in them. Ultimately, this results in patients and caregivers being provided with the highest possible level of clinical service.

Summary

In summary, the need for nurse residency programs is vital to the success of new graduates. The literature shows that nurse residency programs along with an extensive orientation to new graduates allow them to transition from school to practice. While offering new graduates the nurse residency program alleviates stress for the new graduate and allows them time to become familiar with providing safe care to patients. This is a time when graduates need to have support and confidence during this transition. Health care is a rapidly changing environment and stakeholders need to invest in new nurses for the benefits are two-fold this is one way to keep new nurses in the organization and help retain them for the future.

Implementation

It is essential to keep new nursing graduates in the healthcare system for them to be able to provide care and overcome the current nursing shortage problem, which is experienced in healthcare. The findings of Bratt (2013) indicate that the lack of experience contributes significantly to nursing graduates not being hired. Further, the associated cost involved in the training of new nurses also affects their employability. In response to this, the nurse residency program is the most appropriate for fostering the transition of new nursing graduates and thus helping them gain the necessary skills, confidence, and experience required for entering the workforce and helping healthcare organizations to have a sufficient number of nurses. Therefore, the implementation process of the discussed nurse residence program for new graduates will be discussed in this chapter.

The implementation of the nursing residency program will include structures and processes of evidence that will be based on nursing strategies. According to Pizzingrilli and Christensen (2015), this will be necessary in order to ensure there will be an effective integration of knowledge, skill development, and retention of new graduates in the healthcare system. In order to accomplish this, the following will be carried out.

First, about the effective integration of knowledge, a significant amount of emphasis will be placed on reflective practice. This practice will be realized in the form of journaling as well as the use of roundtable discussions. This will be beneficial for fostering learning and an increased feeling of empowerment among the new graduates. With regard to skill development, this will be accomplished through the use of ongoing educational meetings. These meetings will be used to provide the necessary framework for the expansion of curriculum that will be effective in overseeing the bridging of the existing gap between the nursing school and professional nursing practice. The retention of these nurses will be enabled by the expansion of looping rotations that will foster inter-professional collaboration; therefore enhancing patient care as asserted by Gaesawahong (2014).

Consequently, the successful implementation of this nursing program will be useful in granting new nurses the necessary knowledge, skills, and abilities that will foster a successful transition to professional practice facilitating the delivery of quality patient care. Further, the implementation of this program will also play a significant role in facilitating the retention of new nurses in the profession while overseeing the engagement of competencies that can be shifted to acute and outpatient care settings. Finally, the implementation of this nursing residency program will be important for enhancing the employability of new nurses who usually find it quite difficult to secure nursing positions given their lack of experience.

It is also essential to discuss the eligibility of those who can participate in the nurse residency program that will be implemented in the view of Adams et al. (2015). Thus, those who can be considered eligible include graduates of the school of nursing who have been certified. This can also include those nurses who have received a Bachelor’s or Master’s degree. Eligible nurses must also include those who are currently unemployed. It is also essential to note that the nurse residency program for these new graduates will be characterized by a 12-week session that will include a total of 240 clinical hours.

As previously mentioned in this study, the implementation of this nurse residency program is a kind of change. As a result, the Kotter’s eight steps process that had been earlier suggested will be the change initiative that will be used to guide the implementation of this program. Further, the implementation of the program will be conducted in a timely manner allowing the new graduates to quickly feel like part of the team boosting their confidence and improving patient outcomes in the healthcare organization.

Procedures and Methods

Kotter’s eight steps change initiative will be used to facilitate the implementation of the nurse residency program for new graduates as explained below.

1. The first step will begin with the establishment of a sense of urgency. According to Adams et al. (2015), this is the most critical step to be taken. By creating awareness of the need and urgency of the program, it will be much easier to gain support from the concerned stakeholders. When it comes to the nurse residency program, the urgency is embedded in the fact that there is a shortage of nurses and nurses’ turnover is quite high. This is a great threat to the process of healthcare provision as fewer professionals are available to care for patients, which subsequently affects the quality of health and patient outcome. Therefore, the message concerning the implementation of the program will need to be open and honest being carried out through a convincing dialogue. This will not only serve to convince the staff of the program’s significance but also motivate them for action.
2. The second step in the implementation process as facilitated by Kotter’s eight steps will entail the development of a guiding coalition. Pizzingrilli and Christensen (2015) explicate that this step encompasses the establishment of a team that will oversee the efforts made in the implementation of the nurse residency program. This team can encompass key stakeholders that are considered people of influence who are fully committed to the adaptation of the program and are also in an excellent position to promote and support the program’s implementation. In building this coalition, it is critical to ensure that the team that forms it consists of the employees and stakeholders from different jobs and positions. This is beneficial for allowing different staff to fully identify with the team and support it.
3. The above step in the implementation process of the program will then be followed by the third step that will encompass the creation of a vision for change. The formulation of a clear vision for the nursing program is vital for helping people gain an understanding of what is to be achieved once the program is in place. This will thus be useful for making the program much more effective according to Gaesawahong (2014).

Therefore, in relation to the suggested nurse residency program, the vision can encompass the development of a healthcare system and process that will be adequately supported by competent and confident nursing staff. This is a vision that can be grasped quite easily and is also very memorable to people. Thus, the vision that has been created will serve to assist everyone to understand what the nurse residency program is all about and what they can do to help.

4. Communicating the established vision is the next step to be taken in the program implementation process according to Kotter’s eight steps change initiative. Discussing the vision of the nurse residency program is essential for ensuring acceptance of its implementation by the stakeholders. Thus, it is vital to discuss the program using every chance that is available as advised by Bratt (2013). In addition, using the vision on a daily basis in terms of making decisions and solving problems will also be important for creating awareness about it. The message communicated about the vision should also be included in the actions directed towards the program implementation.
5. The next step to be taken in the implementation process of the program is the removal of obstacles. This will work further to ensure that the program is much more successful. Pizzingrilli and Christensen (2015) consider that this is because the removal of any present obstacles could to a large extent undermine the vision of the program. One of the obstacles that are most likely to be experienced during this time is related to resistance given that the nurse residence program will introduce a new way of doing things in the organization. There are people who will not be pleased with its implementation.
6. The sixth step in the implementation process of the nurse residency program is the creation of short term wins. This step is critical because of the role that it plays in the maintenance of momentum. According to Pizzingrilli and Christensen (2015), in order to do this, it is vital to first consider the strategy that can best be used to deliver success following the utilization of the program on a daily basis. This short term wins will, therefore, be useful in showing employees what the program’s contribution to the organization is. This will be further useful for enhancing motivation among the employees and expanding the program since the wins will be an indicator of the organization’s changing course.
7. The seventh step to be taken in the implementation process is the consolidation of improvements made. Gaesawahong (2014) affirms that this is critical for allowing the recognition of early and stable success. As a result, this action will be useful for providing encouragement and therefore enabling increased innovation and change. In this regard, the stakeholders will be more positive about the program if they are able to see the benefits that it has brought about. It is essential to note that during the consolidation of the improvements, the victory should not be declared early. This is because otherwise, this can easily lead to failure.
8. The final step that will be taken in the implementation of the nurse residency program is integrating the program into the corporate culture of the organization. This is done with the intent of making the use of this program continue for it to become part of the organization’s vision. Increased efforts should be directed towards ensuring that the changes made can be witnessed in every aspect of the organization’s performance.

According to Gaesawahong (2014), the significance of this action consists in providing the program a more solid place within the culture of the organization. It is also critical to ensure that all employees and stakeholders that are new to the organization are able to integrate into the program and support its utilization in the organization.

Results

Following the implementation of the nurse residency program for new graduates in the organization, a number of significant improvements were witnessed. This can be best evidenced by the fact that there was a rise in graduate success and productivity which is essential when it comes to the improvement of the quality of care provided to patients and thus their outcome. There was also an increase in the retention of nurses after the implementation of the nurse residency program. This is evidenced by the fact that there was 80% retention among residents that were engaged in the nurse residency program.

This to a large extent can be taken as a monumental success in comparison with various published reports that assert that there is a turnover rate of 30% within the initial year of employment as reiterated by Adams et al. (2015). The decrease in nurse turnover has further been brought about by the aspects of the nursing residency program that include encouragement of critical thinking development as well as nursing research. Further, the use of the program to encourage job satisfaction has also been a plus which has further enhanced the loyalty of the nurses contributing to their retention.

At the same time, it is also vital to mention that the implementation of the nurse residency program has successfully served the role of developing clinical competency among the nurses. This competency was tested using a basic knowledge assessment test following the completion of the nurse program by the graduates. It is also essential to note that at the end of the program, many of the nurses that participated in it exhibited increased confidence and mastery of the nursing process ensuring quality care of patients. The positive testimonies that were given by patients and their families confirm this. The nurses’ supervisors also confirmed this change in the nurse graduates which was an indicator of the fact that they had gone far ahead. They were now empowered through the knowledge that was embedded in the nursing residency program.

The results also showed that making proper intervention plans entails the establishment of what nursing graduates are the most disadvantaged as they leave school. Therefore, it is absolutely necessary to carry out an early and regular assessment of the graduates as they graduate and attempt to make a transition from students to professionals as postulated by Burr and Malagon-Maldonado (2014). Therefore, by doing so, it will be much easier to detect those students who are having a difficult time in their transition and therefore recruit them for the nurse residency program.

In addition, it is essential to note that integrating this kind of graduates into the program and the organization will be more effective in reducing the high nurse turnover that has been experienced for a long time. At the same time, this will also be essential in cutting costs for the organization in the long run since the price of replacing a single nurse is very high. It is also essential to mention that the nursing staff found the nurse residency program to be very sound. This is evidenced by the approval that the program received from the nurses.

Artifacts

The patient evaluation was carried out for both the pre-nurse residency program and post-nurse residency program. A number of similar questions were thus prepared and asked before and after the program’s implementation regarding nursing care, nurse confidence, competency, and general performance. The nurses were also given a pre-program and post-program survey. They were also asked the same questions as the patients before and after the implementation of the nurse residency program.

Conclusion

The results that were obtained from this project indicated that there was a positive response in relation to compliance with the nurse residency program. The implementation of the given nurse residency program for new graduates was conducted in stages as evidenced by the number of steps that were needed to be taken. Doing so was therefore essential for enhancing the chances for success once the program had been integrated into the culture of the organization. However, it is vital to note that the entire process was not completely smooth as a number of problems were witnessed. The leading problem in this regard was a significant amount of resistance.

For instance, management initially resisted the program’s implementation given that they found the cost of the program to be high, but after realizing its long term benefits to the organization they readily accepted it. The patients were also very cooperative with the program and they readily accepted to be cared for by nurses who were part of the program despite being fresh graduates of nursing school with minimal experience.

They also supported their learning process by allowing the nurses to receive instructions from their supervisors and to be creative in their skills and methods of care. The nursing staff also played their role in the program by consenting to assist the graduates who were participating in the program. Therefore, in the end, the cases of high nurse turnover reduced considerably. This was an indicator of better trained, more confident, and competent nurses who were better positioned to provide the best quality of care to patients.

Evaluation

The evaluation of the nurse residency program is a way of establishing its level of effectiveness in relation to reducing the high nurse turnover that is experienced and the accompanying poor level of skills and lack of confidence in newly licensed nurses. It is essential to conduct this evaluation. Burr and Malagon-Maldonado (2014) assert that this is because the information that is gathered during this process is valuable in terms of cost efficiency and can also provide the impetus required for continued backing and support of the leadership. This information is also critical when it comes to the process of resource allocation necessary for supporting the program.

Thus, the evaluation process will be useful in overseeing the provision of tangible evidence that is related to the achievement of program goals and outcomes. This will subsequently compel ongoing improvements in the program. In facilitating the evaluation process, it is vital that the associated plans not only entail program outcomes but also are best placed to have a long term impact on the practice. In addition, it is also necessary that the evaluation process involves stakeholders in the process and this process should be connected to another organizational outcome assessment.

In the current evaluation of the implemented nurse residency program for the new graduates, the Kirkpatrick’s four-step evaluation model will be applied. According to Pizzingrilli and Christensen (2015), this framework encompasses the assessment of the learner’s reaction or satisfaction with the program which is simply referred to as reaction. It also includes what has changed in the learner’s knowledge, attitudes, and skills which are referred to as learning. Further, this framework also includes the changes in job behavior or performance as a result of the program which is also known as behavior. Finally, this framework also includes the ultimate outcomes that took place while participating in the program being simply referred to as results.

Reaction

The reaction of the nurse residents was measured using questionnaires that contained forced and open-ended responses. These questionnaires were administered at the end of each learning session that nurse residents underwent and also at the end of the entire program. This was significant as it allowed for formative and summative evaluation of the nurse residency program.

Learning

With regard to the evaluation of learning, the changes in the knowledge, attitudes, and skills of the nurse residents were measured using an instrument that was generated by the program’s coordinating team. In particular, these aspects were measured using a number of activities that included role-playing, qualitative analysis of the nurses’ journaling, and pre-post program changes that were related to the nurse residents’ perception of job satisfaction and stress.

Behavior

The changes in the behavior of the nurse residents were also measured as part of the evaluation process. This was done through the process of measuring the pre and post-performance appraisals that used the standardized competency assessment tools. Therefore, due to the ability to note the indicators of nursing residents’ professional goals, a survey of managers, and peers using the standardized instruments, it was possible to determine the nurses’ level of performance.

Results

This is the final step in the evaluation process and is perceived as the most challenging. It entails evaluating the improvements that have been made in relation to nurses’ retention rate. This is vital given the financial implications that the retention rate has on the organization. Therefore, to be able to capture retention data, it is vital to enlist the assistance of the HR department. This will make it easy to earmark new graduates within the employee database and facilitate tracking of their movement within the organization. Further, data should also be collected in relation to pre-program new graduate retention rates which should then be compared to post-program retention rates.

Discussion of the Results

For a long time, the high nurse turnover and the lack of faith in the abilities and competency of newly licensed nurses were points of concern for many nurses. The results provided by the evaluation of the nurse residency program are positive and indicate a number of significant improvements in the nurses and overall healthcare provision within the organization. Therefore, the nurse residency program for new graduates has proven to be a superior method in overcoming the problem of nurse shortage not only in the organization but also in the healthcare system in general.

Thus, the results of the evaluation of learners’ reactions indicate the following. The data collected from the questionnaires signaled a positive reaction by the nurse residents. Many of the nurse residents were able to record some kind of satisfaction with the program and asserted that it helped significantly in the transition process as they aimed to become accomplished professionals within the healthcare system.

The results related to the evaluation of the nurses’ knowledge, attitude, and skills revealed the following. There is an improvement in the knowledge of the nurses in relation to their job requirements. That is, after the implementation of the nurse residency program, the nurses were more knowledgeable about the practical nature of their profession. Further, this was also an indicator of the fact that they had improved job skills and became more competent in delivering care to the patients in comparison with the time when they started out and before the implementation of the program. The results of these evaluation criteria also indicated a much more positive attitude of the nurses. This can be attributed to the increased confidence that many of them recorded which helped them become confident in their competency and abilities.

With regard to the results related to behavior, a significant amount of behavior change was observed in the job, and overall performance of the nurse residents. That is the results of both pre and post-appraisals that were conducted have shown a positive change in the job behavior of the nurse residents since the implementation of the residency program. This was further accompanied by the outstanding performance in many of the tasks that these nurse residents undertook. An appraisal from the patients they cared for was positive in many cases. This was an indicator of the fact that the nurse residency program was positive and was therefore successfully helping the nurse graduates to turn into excellent and outstanding nurse professionals.

Finally, when it comes to the evaluation of the final outcomes of the participation in the nurse residency program for new graduates, the results that were obtained included the following. There was an improvement in the retention capacity of the organization after the program’s implementation.

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