Shock Absorbers
Hospital residency programs smooth the bumps for new nurses
The minute Nancy Keller begins her shift as a cardiac nurse at St. John Hospital and Medical Center in Detroit, she’s swept up in a whirlwind. “When you hit the door, everything starts happening,” she says. “People are handing you phones, pagers and giving you reports—there is no easing into the workday.” That’s a far cry from nursing school, when “an instructor would lead a group [of students] slowly and quietly up to the patient floor,” says Keller, who first took on a full patient load in February 2006.
The initial jolt that Keller felt is so common among nurses just starting out that nurse executives have dubbed it “reality shock”
To help buffer the shock—and keep new nurses from running for the exits—hospital executives are looking beyond the traditional orientation process to the same types of support provided for doctors and other professionals starting their hospital careers.
“No one else is being asked to walk out of the classroom, walk up to the bedside and begin work,” says Aliina Hirschoff of the Advisory Board in Washington, D.C. She points out that the federal government funds training for pharmacists and pastoral care ministers before they work in a hospital.
“It’s the same with doctors,” says Cathy Krsek, R.N., director of a nurse residency program that is co-sponsored by the University HealthSystem Consortium and the American Association of Colleges of Nursing. “They have had clinical rotations in medical school, but nobody questions the fact that they need residencies after they complete their schooling.”
Nurse residency programs are part classroom teaching and part support group, and last longer than the usual hospital orientation. And while they can be costly—at least one hospital spends nearly $22,000 per nurse—nurse executives say the results more than justify the expense: reduced turnover, more proficient nurses, enhanced critical thinking.
“If we don’t support these nurses, we’ll have staggering turnover rates,” warns Jo Ann DelMonte, R.N., coordinator of the graduate nurse residency program at University of Colorado Hospitals, Denver. Although turnover rates for recent nursing school graduates are not compiled on a national level, sample rates at individual hospitals range from 36 percent to 75 percent in the first year, according to a December 2006 report from the Advisory Board’s Nursing Executive Center. That range is much higher than the 10 percent to 20 percent for RNs in general.
Replacing nurses is expensive—the Advisory Board report shows that hospitals spend between $22,420 to $77,200 per nurse, including temporary nurses, additional orientation costs and lost productivity.
Hirschoff, an author of the report, says that hospitals will become more dependent on recent nursing school graduates as baby boom RNs retire and the pool of recent graduates increases.
‘Knowledge Seekers’
That isn’t to say that hospitals have been ignoring nurse graduates. A 2001 survey of UHC chief nursing executives showed that 85 percent of responding hospitals had a program to prepare new graduates to be competent practitioners. “These programs were all over the map,” says Krsek, noting that they ranged from four weeks to two years and their content varied substantially. UHC and partner AACN wanted to standardize the curriculum, format and evaluation of the programs.
The resulting year-long residency program, aimed at nurses with bachelor’s degrees, is intended to be used in conjunction with—and continue past—a hospital’s orientation, which can last six months.
Groups of six to 10 nurses are gathered by specialty and meet monthly for a four-hour session in which they share “tales from the bedside,” facilitated by an expert nurse. “It helps them solve problems they are experiencing out on the unit,” Krsek says. The nurses remain with the same group throughout the year, so they develop trust and become a support group.
From six pilot sites in 2002, the program now has 37 sites and more than 6,500 nurse resident graduates. So far, the turnover rate in the first year for nurse residents is 9.3 percent.
The programs go beyond reinforcing clinical skills; they teach novices how to be a hospital nurse. Residents learn a concise way to give patient reports to doctors and how to delegate tasks. They also improve their critical thinking. For example, at St. John Hospital and Medical Center in Detroit, the nurses see video vignettes of complex cases and then decipher the causes of patient conditions. In one scenario, nurses have to determine why a patient has no urinary output. Judging from symptoms and lab tests, they must determine if the condition is dehydration or is caused by kidney or bladder problems.
“They become better at asking the right question, pulling together needed data and realizing what fits and what doesn’t, and where to find the resources they need,” says Mary Sullivan, R.N., coordinator of the St. John program. “We expect them to be knowledge seekers. That’s all a learning process.”
For nurses, the residency classes are a relief after nursing school and its tests. “It was a relaxed learning environment that provided hands-on practice,” says Keller of the St. John program. “The instructors weren’t there to grade you, they were there to help you.”
Time and Money
As with most things in health care, the biggest consideration for hospitals wanting to start a residency program is resources—both human and capital. There’s a hefty amount of staff time involved, which can impact payroll as well as patient care because of the nurses required to cover shifts during training sessions.
“You need people to teach, mentor and track the resident nurses,” says Donna Brackley, R.N., senior vice president of patient care services at the Concord, Calif., campus of John Muir Medical Center. The program at her 254-bed hospital has staff serve as educators, facilitators, mentors and preceptors. The John Muir program incorporates a clinical orientation into the residency and lasts nearly six months.
Hirschoff says calculating the cost of a residency can be complex. She advises hospitals to count the pay for staff, such as facilitators and educators; classroom space; the pay for nurse residents during course time; and the pay for nurses to backfill shifts. Some organizations figure catering, educational materials, high-tech patient simulators and medical supplies into the cost. Many hospitals have resources that can be donated in-kind, such as classroom space, while others have to pay for them. In addition, some hospitals have received grants from foundations or the Health Resources and Services Administration to fund the programs.
For all of these reasons, costs vary widely; Middlesex Hospital in Middletown, Conn., prices out its program at $22,000 a nurse, which includes a cost for the nurse not being fully productive while he or she is in the unit orientation portion of the residency program. St. John in Detroit puts the number at $1,700 for each nurse resident, splitting the cost between its nursing education department and individual units.
“If the hospital doesn’t want to make a big investment, it could take pieces of a program and improve its environment,” Hirschoff says. For instance if education is out of reach, the hospital could facilitate a support group for new nurses.
Build It or Buy It?
Some hospitals, such as St. John, devise their own programs. John Muir and 34 other hospitals chose to buy a program from Versant Advantage Inc., a subsidiary of Childrens Hospital Los Angeles. The product is based on the residency programs that Childrens first used in 1999.
Hospitals pay for start-up and for each nurse entering the residency program; in return, they receive the Versant curriculum, the blueprint for the infrastructure to support the program, and ongoing hospital-specific program monitoring and evaluation. For the average hospital, the start-up cost, which includes 10 residents, reaches $40,000 to $50,000 and payments for each nurse entering the program range between $3,000 to $5,000, depending on volume, says Patricia Cornett, R.N., a Versant senior vice president. Like other residency programs, Versant has enviable retention statistics, showing 6 percent turnover at 12 months and 11 percent at the two-year mark for nearly 2,500 nurses.
John Muir’s Brackley says the residency programs don’t just keep nurses in the hospital, they attract them. “I’ve spent the last 20 months with nurses seeking their first RN jobs,” she says. “What they are looking for is an environment where they can really focus on learning and have a higher level of comfort that they will be successful.” John Muir has 300 applications to fill the 30 to 40 new graduate positions the system will have this fall.
“Hospitals are all competing for a finite number of nurses, and this allows us to be very selective,” Brackley says.
Another impressive statistic: All of John Muir’s 56 nurses who have gone through the program at the Concord campus since July 2005 are still working at the medical center.
Moreover, nurses are better equipped to start assignments in the emergency department and critical care immediately after their residency program, rather than start on a medical-surgical unit and work their way into more complex care. Post-residency nurses are also active in John Muir’s unit-based councils and quality efforts, and a quarter of them are helping with the nurse residency program as preceptors.
But everyone involved in residency programs say the social bonding is as important to a successful nurse transition as the content covered. “Before or after group meetings, we had the opportunity to share our feelings and experiences,” says Keller of St. John Hospital and Medical Center. “Most of us were stressed, but when we told our stories, we laughed and you could feel the tension going out of the room. It helps you realize you are not alone.”