SE11b

 

Transition to Practice SE11

 

Provide one example, with supporting evidence, that demonstrates the effectiveness of the transition to practice program for new graduate nurse(s).

  • Narrative must include a description of the five domains of the transition to practice program that facilitates effective transition.
  • Evidence must include quality outcomes that demonstrate the effectiveness of the transition to practice program.

 

Note: The five domains of the transition to practice program must include

  • Program Leadership
  • Organization enculturation
  • Development and design
  • Practice-based learning and
  • Quality outcomes

 

 

Example b: Transition to Practice Program for New Graduate Nurses – Registered Nurse Residency Program

Program Leadership
The Catholic Health Initiatives (CHI) St. Vincent Hot Springs (SVHS) Registered Nurse Residency Program (RNRP) is a yearlong transition to practice program for new nurse graduates. CHI SVHS is dedicated to preparing new graduates for entry into practice through a program built on a firm foundation. CHI SVHS provides high-quality nursing care by maintaining a high level of knowledge and skills among all those who serve the patients. The RNRP is coordinated by Stephanie Reynolds, MSN, RN, Resident Coordinator, who is responsible for the RNRP’s ongoing development, implementation, daily coordination, and evaluation of quality outcomes.

 

Reynolds works with unit managers to interview applicants and provide feedback into the selection of new graduate nurse residents. Reynolds is responsible for monitoring residents’ job performance throughout the yearlong program. Reynolds conducts training and education while providing oversight for all RNRP activities. She plans, implements, assesses, and evaluates RNRP residents’ nursing care in accord with established standards, policies, and procedures.

 

Organizational Enculturation

All residents attend CHI SVHS General Hospital Orientation (GHO) on their first day. St. Vincent’s deep history is shared with the residents to enculturate them to the organization during this orientation. Doug Ross, MD, FACEP, SVHS President and SV Market Chief Medical Officer, presents “Heritage Connection: Understanding Our Mission, Vision, and Values” to all new residents. The mission states that as CommonSpirit Health, the overarching organization of CHI SVHS, we make the healing presence of God known in our world by improving the health of the people we serve, especially those who are vulnerable, while we advance social justice for all. The CHI SVHS organization is presented during GHO as a great place to work, practice medicine, and deliver excellent and compassionate care. Hospital administration and staff present this rich and authentic mission with positivity and enthusiasm for the SVHS organizational culture.

 

In the first week of orientation, Reynolds presents to the residents the CHI SVHS Professional Practice Model (PPM) as the foundation for its nursing care. In addition, Reynolds also presents the Care Delivery Model (CDM) to the residents to further introduce them to the foundational elements of CHI SVHS care delivery. The CDM for CHI SVHS is shift primary nursing, in which the nurse maintains overall responsibility for the patient during their shift as the primary caregiver but is assisted by others in providing direct care. The patient is the center of everything CHI SVHS does, as depicted in the PPM. The patient is surrounded by the people who care for them, with every group pointing to the patient as the center of their collaborative care efforts.

 

Residents are further enculturated through the matching process/ceremony and orientation on their unit. Residents are hired into a specialty track, either Medical/Surgical (MS), Labor Delivery Recovery Postpartum (LDRP), Emergency Department (ED), Operating Room (OR), or Critical Care (CC). Residents spend time on every unit and shift in that specialty. They are matched to a unit and shift, taking into consideration feedback from them and their preceptors; the residents learn which unit they are matched during a matching ceremony. Nurses from their unit congratulate the residents, and everyone celebrates with noisemakers and signs welcoming residents to the unit. The matching ceremony is a celebration that is significant to the residents’ enculturation to the SVHS organization, as they are celebrated for their accomplishments in the program to that point.

 

The residents are then oriented on their matched unit with a preceptor for at least six weeks, depending on the unit. Preceptors assimilate the resident into the unit’s culture and teach the values of the practice setting. The preceptor’s role is to prepare the residents with the tools needed to succeed at both the clinical and social levels as a new nurse on the unit. The orientation process with the clinical preceptor is the final piece of the new resident’s gradual assimilation into the organization’s overall culture. Hospital orientation, the RNRP matching ceremony, and the preceptor orientation are significant parts of preparing new residents for embracing them in the CHI SVHS organizational culture.

 

Development and Design

Infrastructure/Processes
After GHO, residents participate in General Clinical Nurse Orientation (GCNO), which lasts for the rest of the first week of the RNRP. Reynolds and the Education Department coordinate the training, and the classes are taught by content specialists who use lecture, demonstration, and simulation to teach residents the processes and procedures used at CHI SVHS. Topics include computer training, professional practice, nursing quality, infection prevention, emergency response, and safe patient handling. Simulation stations are set up, with the residents rotated in groups to practice nursing skills.

 

The RNRP is built on an evidence-based practice curriculum developed by experts from academic medical centers and nursing schools across the country. This extensive one-year program features a series of learning and hands-on work experiences that help new nurses develop the clinical leadership skills needed to become successful members of the healthcare team.

 

Essential Components of the RNRP
Nursing Leadership Commitment and Support:

  • Interaction with nurse leaders at multiple points throughout the RNRP
  • Leadership engagement in Welcome Day
  • Structured guidelines to ensure consistent processes throughout the RNRP
  • Established policy that residents and those with less than six months of experience will only begin their employment in acute care at CHI SVHS through the RNRP

 

RNRP Participant’s Commitment:

  • Participation in all learning activities and assignments of the RNRP
  • Active engagement in self-learning
  • Adherence to the core values of CHI SVHS

 

Peer Group Support:

  • Reflective learning to assist with interpreting challenges and accomplishments in the context of developmental stages in nursing
  • Activities to promote teamwork and peer support among residents

 

Curriculum:

  • Based on national recommendations of the Commission of Collegiate Nursing Education and the National Council of State Boards of Nursing
  • Focused on the principles of adult learning
  • Staged over several months to meet learners’ readiness
  • Interprofessional collaboration with patient care partners
  • Structured Competency Based Orientation tool to guide clinical experiences

 

Curriculum Content Objectives:

  • Leadership:
    • Patient care delivery, resource management, and delegation
    • Conflict resolution
    • Interprofessional communication
    • Patient care coordination
  • Quality Outcomes
    • Management of the changing patient condition
    • Patient and family education
    • Pain management
    • Skin integrity and wound management
    • Patient falls prevention
    • Medication safety
    • Infection prevention and control
  • Professional Role
    • Ethical decision making
    • End-of-life care
    • Cultural competence in the nursing care environment
    • Stress management and self-care
    • Evidence-based practice
    • Professional development

 

Program Support Staff:

  • RNRP resident coordinator
  • Clinical educators
  • Content specialists
  • Leadership
  • In each department, assigned preceptors who have received training through the structured Clinical Coach Class and Mosby’s 3.0 Preceptor Modules
  • Real-time feedback from the preceptor to the resident each day
  • Resident evaluation of each preceptor
  • Residents assigned a consistent preceptor on their permanently matched unit throughout unit orientation
  • Rounding on the units to resolve issues as they arise

 

Continued mentoring and learning occurs through monthly learning activities and professional development days.

 

The RNRP provides a formal, consistent, and structured paid orientation for new graduate nurses. The RNRP uses a multi-faceted, competency-based approach to developing critical thinking and technical skills. Classroom instruction, simulations, case studies, skills lab, observational experiences, and clinical experiences contribute to effective learning in this program. All residents participate in monthly education experiences and are assigned a preceptor who guides their hands-on clinical experience on their units.

 

Goals
The goals of the RNRP include preparing residents to:

  • Care for patients with increasing levels of acuity and complexity in the hospital setting
  • Develop clinical nursing leadership at the point of care
  • Improve patient safety and quality of care
  • Foster critical thinking skills
  • Bring evidence-based practice to the bedside
  • Strengthen their commitment to the profession of nursing and develop individual career goals
  • Facilitate the clinical and leadership skills needed to be a successful member of the healthcare team

 

Timeline
The SVHS RNRP adheres to the following timeline:
Week 1: General Hospital Orientation/Clinical Nurse Orientation

  • Objectives: This week, residents will understand many of the components of CHI SVHS’ faith-based organization, including the Mission and Core Values. Residents will obtain the basic information needed about employment with CHI SVHS and how to get started in their new role. Residents will also validate basic nursing skills competencies. By the end of the week, residents will feel welcomed into the CHI SVHS community.

Week 2: Clinical Bootcamp

  • Objectives: This week, residents are put through intensive training regarding clinical skills, such as IV insertions, Foley catheter care, wound care, and more skills check offs. Residents will be introduced to equipment that is regularly used. There are Relias assessments and testing performed, as well as extensive EPIC training.

Weeks 3-8:

  • These weeks, the residents rotate within the appropriate track on different floors and units on day shift (three weeks) and night shift (three weeks). This schedule is slightly modified for some tracks based on the unit’s hours of operation and/or the operations on the unit that it is important for the resident to experience. The preceptor assigned to the resident completes an evaluation each shift using the Rate Your Resident tool on the RNRP intranet page. These scores are then sent to Reynolds and tallied at the end of the six weeks. Scores from the Rate Your Resident tool are used to evaluate the residents’ progress and help them match to the residents preferred unit.
  • Objectives: residents will develop clinical nursing skills and care for patients on the units. These weeks, residents will understand the basic infrastructure of each unit and how it is run. Residents will learn from preceptors and develop critical thinking skills and evidence-based practices while providing nursing care to patients. Residents will determine which unit they fit best based on unit culture and patient population.

Week 8:

  • Residents rotate through different ancillary units/departments specific to their track.
  • Objective: residents will obtain information needed to learn the ancillary units in the hospital and how it will pertain to clinical practice in their track.

Last Day of Week 8:

  • The Matching Ceremony is the last day of the final week. One week prior to matching, residents fill out a preference form stating their preferred unit and shift, along with which preference is more important to them (shift or unit). RNRP resident coordinator and administration members then meet to match residents with open positions. The residents are matched in the order of their ranking based on the Rate Your Resident scores submitted by preceptors.
  • Objective: residents will feel honored and welcomed into the matched SVHS unit community.

Weeks 9-1 Year:

  • After matching, the residents continue additional orientation with a preceptor on their matched unit for at least six weeks. They are considered a resident for the length of the program, which is one year. During the year, the residents attend monthly professional development and classes, in addition to working on their newly chosen nursing unit.
  • Objective: residents will continue to meet all program goals and requirements. Residents will complete the Competency Based Orientation (CBO) Tool with their preceptor. Residents will stay on track with monthly classes related to the RNRP for continuing education. Residents will describe unit practices on matched units as taught from preceptors.

 

Program Support and Staff Roles
Residents are continually supported by the RNRP resident coordinator, the content specialist providing education, nurse leaders on nursing units and experienced preceptors working individually with the residents. All these individuals working hands-on with the residents are available to help them meet program goals throughout their journey. Residents are encouraged to lean on the nursing managers on their assigned units for guidance and to confide in for questions. Preceptors assigned to teach residents provide continuous support to help them meet objectives, program requirements, and individual nursing goals.

 

Competency Requirements
Validation of residents’ competency is integrated throughout the RNRP. Basic nursing skill competencies and CHI SVHS expected behaviors are validated through skill check-offs in weeks 1 and 2 of Clinical Nurse Orientation and Clinical Bootcamp and through skills check-offs or return demonstration in the continuing required classes. Residents demonstrate general nursing and unit-specific competency to their preceptors to complete their competency-based orientation (CBO) tool within the first 6-12 weeks of being matched to their permanent unit. When an individual or group in the RNRP is identified as needing additional skill competency validation, this is accomplished through, either 1:1 time with a clinical educator or an electronic learning module assignment with either a test or graded checklist component.

 

Practice-based Learning

Simulated Skills
During the first week of training, when the residents are completing the general Clinical Nurse Orientation, Reynolds uses simulation to teach and validate skills such as Foley catheter insertion and IV pump management. Reynolds is equipped with a simulation manikin that can run scenarios and with a mock patient room, equipment, and supplies/products to enable her to run any simulations needed for training.

 

Practiced-based Learning on the Unit
Practice-based learning is facilitated through hands-on learning working with a preceptor on the hospital units. Residents are assigned a preceptor to follow them as they rotate through the appropriate units. Preceptors are experienced nurses who teach residents and help them assimilate to the unit’s nursing practice setting. Preceptors use the Rate Your Resident feedback tool to evaluate the resident at the end of each shift, assessing:

  • Clinical Skill
  • Resourcefulness
  • Teamwork
  • Attitude
  • Dependability (Integrity)
  • Critical Thinking

 

Residents are scored using the following scale:

  • 1 = Requires continual or frequent supervision and instruction
  • 2 = Functions at expected level for this point in residency
  • 3 = Functions as a competent entry level nurse requiring minimal coaching

 

Preceptors can provide further explanation for each area being evaluated. Residents use a similar feedback tool, Rate Your Preceptor, to provide objective feedback that is used to help preceptors be more effective.

 

Reynolds meets with each resident every two weeks for them to share their experience in rotating units providing patient care. Reynolds evaluates residents’ overall progress in the program during these meetings, in which they are also encouraged to share what is going well and not well and areas for improvement. For example, if a resident wants more practice with IV starts, Reynolds arranges to get the resident in the Outpatient Surgery department to practice starting IVs or in the skills lab to practice on manikins. Reynolds has an open-door policy for the residents, and she shares her phone numbers, encouraging them to contact her whenever they need.

 

Practice-based learning continues after residents complete rotations and are matched to their new permanent home unit at CHI SVHS. Throughout their unit orientation, residents have a preceptor who has received training through a preceptor class in which they learn to use knowledge, skills, and evidence-based strategies for residents’ success in the CBO program at CHI SVHS. Preceptors help to mold new residents into a good fit on the unit and prepare them for the various aspects of patient care they will face in nursing practice.

 

The CBO tool is used to guide the RNRP residents' clinical experience on their matched units. Orientation pathways for preceptors are available on the CHI Insider webpage. Preceptors provide general guidance and support for working on the matched unit while teaching the resident professional skills and holistic nursing practice. Residents and preceptors’ time together consists of hands-on, practice-based learning.

 

Quality Outcomes

The goals of the RNRP are met by preparing new graduates to care for hospital patients with increasing levels of acuity and complexity and to improve patient safety and quality of care. With preceptors’ guidance, they are developed into competent nurses who provide safe bedside care while enacting the CHI SVHS Core Values. This competent and safe nursing care meets the program goals and directly impacts the patient experience.

 

Nurse managers and preceptors help develop residents’ leadership and critical thinking skills to enhance their decision-making in caring for patients. Bringing evidence-based practice to the bedside is taught on all nursing units throughout the organization as clinical nurses and nursing leaders develop and improve patient care practices. The resources available to the RNRP support evidence-based nursing practice.

 

The Casey Fink survey was instituted as one of the quality outcomes for the RNRP starting with the June-July cohort. This survey is a self-report instrument used to measure new nurses' perceptions of role transition issues experienced at entry into practice and through the first 12 months of professional practice. This survey is given to the CHI SVHS RNRP residents at three, six, and 12 months. The Casey Fink survey for this cohort showed significant improvement in multiple areas, including recognizing significant changes in patients’ conditions, feeling comfortable knowing what to do with a dying patient, taking action to solve problems, and having confidence in identifying actual or potential safety risks to patients. (Evidence SE11b-1, Quality Outcomes – Casey Fink Survey)

 

Retention of the nurses in the RNRP cohorts are also tracked and trended. For example, 32 nurses started the RNRP in July 2021, which was the second largest cohort since the inception of the program. In July 2022 (12 months) 24 nurses (75%) remained employed at SVHS. The largest cohort of nurses (41) started the RNRP in June 2022. In June 2023 (12 months), 29 nurses (70%) remained employed at SVHS.

 

Reynolds continues to examine evidence-based practices to improve the program to ensure SVHS always provides the best experience possible for new graduate nurses. This will ensure the organization can attract and retain as many nurses as possible. CHI SVHS has been successful with its RNRP for new graduate nurses for several years and will continue to provide it.