Effectiveness of the New Graduate Residency Program Elizabeth

Effectiveness of the New Graduate Residency Program Elizabeth Davis, DNP, CNL RNC-MNN Katherine Weibel, MBA RN

Nurse Residency Programs �Created to ease role transition from student to nurse �Focus on clinical competence �Provide emotional support and confidence �Provide ongoing institutional support �Enhance traditional orientation �Bridge the preparation to practice gap �Supported by Joint Commission, the Institute of Medicine and accrediting bodies in academia Olson-Sitki, Wendler & Forbes, 2012 Spector & Echternacht, 2010

Adventist Midwest Health �Not-for profit hospitals and out patient based health care facilities �Focus on “whole-person” approach to wellness �Mission “Extend the Healing Ministry of Christ” �Focus on “Transforming Care…Transforming Lives” �Vision to provide “unsurpassed value…using the most up to date evidence” �New Graduate Residency Program began in 2009 �Supported transition of 163 NGN (http: //keepingyouwell. com)

Aim for Improvement In 2009, AMHS developed their NRP based on Versant’s model addressing the needs of NGN as they transitioned into practice. However, program outcomes do not demonstrate effectiveness, curriculum changes have not been made to align with theoretical frameworks and program evaluation tools are not in alignment with the current curriculum. Mission: Provide a comprehensive program evaluation of the NRP, collate and disseminate data related to programs outcomes, implement curriculum changes within the NRP program to facilitate NGN transition into practice and demonstrate measureable outcomes.

Literature Support o There has been a documented need for effective transition to practice programs for over 70 years (Spector & Echternacht, 2010). o While development of clinical skills is necessary, research validates need to focus on promoting leadership, team building, conflict management, psychological aspects of change and systems thinking in a complex work environment (Keller, Meekins & Summer, 2006). o Organization socialization imperative as new nurses are less able to cope with job related stress. Nurses who lack confidence may commit errors (Boswell, Lowry & Wilhoit, 2003). o Program focus to support transition from novice to advanced beginner. Developing clinical leadership, strengthening commitment to professional choice, develop effective decision making skills (Pine & Tart, 2007) o Program outcomes should be clearly described while content selected for teaching and evaluation measurement tools should based on theory (Anderson, Hair & Todero, 2012).

Timeframe Development: November 2013 Implementation: January-November 2014 • Analyze Casey-Fink Data results • Meeting with Regional Educator • Demonstrate Need/Evidence • Pilot self-confidence/self-care content • Redesign curriculum with QSEN framework • Develop content/topics for NRP cohort mtgs • Review manager New Graduate Nurse Survey results • Form NRP task force • Create NGN resource tools for manager/clinical coaches Evaluation: October 2014 -ongoing • Analyze Casey-Fink 6 month survey results • Make adjustments as needed based on survey results • Continue to evaluate NRP cohort throughout first year

Residency Program Outcomes Casey-Fink Graduate Nurse Experience Survey AMHS 2012 Prior to Intervention Comfortable delegating tasks to Nursing Assistants o No significant change noted • Feel overwhelmed by patient care responsibilities and workload o More NGN agreed they were overwhelmed after one year • Satisfied with chosen nursing specialty o More disagree at 6 months yet improves slightly after one year • Manager provides encouragement and feedback about my work o Increase in NGN who disagree at end of one year • Experiencing stress in personal life o NGN indicated an increase at one year

Residency Program Outcomes � What difficulties are you having with transition from “student” role to “RN” role? Workload was identified by 46% of NGN � What could be done to help you feel more supported or integrated into the unit? o Improved work environment was identified by 54% of NGN � What aspects of your work environment are most satisfying? o 77% of NGN list patients/families � What aspects of your work environment are least satisfying? o Nursing work environment was noted by 77% of NGN o

Target Outcomes � Decrease number of NGN feeling overwhelmed by 0. 5 on the Casey-Fink Likert Scale � Maintain satisfaction with work and chosen profession � Increase percentage of NGN who feel comfortable delegating tasks to the nursing assistant by 20% compared to no change � Decrease percentage of NGN dissatisfied with work environment (77%) by 47% to reach target of 30% � Increase feedback provided by managers by 0. 5 � Decrease percentage of NGN (54%) who feel an improved work environment would help them feel more supported or integrated in the unit by 40% to reach target of less than 15%

Implementation Process �Adopted the organization theoretical framework of Quality, Safety and Education in Nursing (QSEN) as NRP curriculum to incorporate transition difficulties �Aligned with the National Council of State Boards of Nursing (NCSBN) �Developed curriculum content to align with Casey-Fink surveys �Incorporated areas of need evidenced by 2012 Casey-Fink survey results: o Communicating with physicians o Comfortable delegating tasks o Overwhelmed by responsibilities and workload o Satisfied with chosen nursing specialty o Self-confidence and stress management �Continued with ongoing and consistent program evaluation using the Casey-Fink Graduate Nurse Experience Survey �Met with NGN Focus Groups (IRB Approval)

Process Approach �Collected and collated data from “Preparing Nursing’s Next Generation: Survey for Nurse Leaders” after approval from Advisory Board Company �Presented DNP project work at Patient Care Meeting house wide �Provided and taught additional content for those participating in Preceptor Development course New Graduate Nurse Preceptors Managers

Manager Evaluation Of the 15 “Preparing Nursing’s Next Generation: Survey for Nurse Leaders” sent to AMHS manager of new graduate within the last two years, nine surveys were completed and returned. Likert survey questions from Advisory Board focused on: � Clinical knowledge � Technical skills � Critical thinking � Communication � Professionalism � Management of responsibilities � Overall satisfaction of new graduate nurses

Focus Groups �Six focus groups were scheduled with the new graduate nurse (NGN) identified from within the last two years � 47 invited to participate with 18 NGN attended �Several initially on the list had left the organization and a few noted they could not attend but would provide information at a later time �Format used World Café encompassing eight questions: o What about your work inspires you? o What opportunities exist to improvement your work environment? o Does you work environment provide support you need to be successful? o Types of challenges or rewards in your daily work?

Focus Groups World Cafe Questions: o Do you believe there is balance between the effort you put forth at work and reward for good work? o What would give you reason to pause about your current position? o What would encourage you to remain within the organization?

Cohort Activities QSEN Competencies Addressed • Safety: Focused on self-confidence, conflict resolution and stress management. Power posing, reflecting on “why” one chose nursing and Draw a Person in the Rain activity • Teamwork and Collaboration: Communication simulation using dominoes, SBAR simulation using bedside report

Activities • Informatics: SBAR simulation, documentation scavenger hunt • Quality Improvement and Evidence Based Practice: Develop a unit specific QI project • Patient-Centered Care: Fear in a Hat reflection…”harming a patient because of my lack of knowledge”, Journaling and Self-Reflection

Group Activities

NGN Evaluation Measures Casey-Fink Graduate Nurse Experience Survey Findings Compared � Confident communicating with physicians 2012 18% were more comfortable after one year 2013 38% were more comfortable after one year 2014 94% were more comfortable after one year � Comfortable delegating tasks to Nursing Assistants 2012 No significant change noted 2013 end of one year 13% were more comfortable 2014 100 % were more comfortable

Evaluation Measures � Feel overwhelmed by patient care responsibilities and workload 2012 2% felt more overwhelmed after one year 2013 30% felt less overwhelmed after one year 2014 67% felt less overwhelmed after one year � Satisfied with my chosen nursing specialty 2012 More disagree at 6 months yet improves slightly after one year 2013 Consistent with 2012 survey 2014 Consistent at 86% to 89% at both six months and one year… no decrease noted! � Manager provides encouragement and feedback about my work 2012 Increase in NGN who disagree at end of one year 2013 Significant increase in NGN who disagree at one year by 25% 2014 Increase in NGN who agree still getting feedback

Evaluation of Practice Transition � Difficulties with transition from “student” role to “RN” role? 2012 Workload was identified by 46% of NGN 2013 100% initially identified workload as a difficulty and 50% at one year 2014 68% identified workload at 6 months and 62. 5 % at one year 50% identified self-confidence at 6 months which decreased to 18% at one year! � � What could be done to help feel support and integration into the unit? 2012 33% initial focus was on improved work environment with 54% identifying work environment at one year 2013 66% selected work environment initially and 50% at one year 2014 60 % focused on work environment at 6 months and increased to 81. 3% at one year Aspects of work environment most satisfying? All NGN cohort groups initially identified the patients/families, peers. and positive work environment. However, after one year a positive work environment was not mentioned as most satisfying.

Recommendations � Continue implementing QSEN competencies in NRP curriculum � Continually update/revise curriculum to meet the needs of changing healthcare environment � Focus on collaboration with senior leadership and management to improve work environment concerns � Solidify plans for NRP Task Force � Re-survey nurse leaders at the completion of the new cohort program � Move forward with Mentoring Program � Work with academia to form partnerships which support the new graduates transition into practice and workload � “Pay it forward”: Create a book from previous NGN cohorts for next group

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References Halfer, D. (2007). A magnetic strategy for new graduate nurses. Nursing Economic$, 25(1), 6 - 11. Keller, J. , Meekins, K. , & Summers, B. (2006). Pearls and pitfalls of a new graduate academic residency program. Journal of Nursing Administration, 36 (12), 589 -598. Olson-Sitki, K. , Wendler, M. , & Forbes, G. (2012). Evaluating the impact of a nurse residency program for newly graduated registered nurses. Journal for Nurses in Staff Development, 28(4), 156 -162. Spector, N. , & Echternacht, M. (2010). A regulatory model for transitioning newly licensed nurses to practice. Journal of Nursing Regulation, 1(2), 18 -25. Ulrich, B. , Krozek, C. , Early, S. , Ashlock, . C. , Africa, L. , & Carman, M. (2010). Improving retention, confidence, and competence of new graduate nurses: results from a 10 year longitudinal database. Nursing Economics$, 28(6), 363 -375.

References Varner, K. & Leeds, R. (2012). Transition within a graduate nurse residency program. Journal of Continuing Education in Nursing, 43(11), 491 -499. Welding, N. (2011). Creating a nursing residency: decrease turnover and increase clinical competence. Med. Surg Nursing, 20(1), 37 -40.