Moreno, Kathryn C. MSN, RN, OCN; Semko, Adriana BA
The nursing shortage is well publicized in the media, yet because economic recessions tend to have a positive impact on the number of nurses in the field, areas ripe with healthcare organizations, such as Jacksonville, Fla., can present a challenge for new graduate nurses to start their careers. It can also be difficult for healthcare institutions with a limited number of new graduate openings to choose the candidates most likely to succeed in a high-acuity, high-stress work environment.
With the nursing shortage expected to reach its peak in 2020, it's anticipated that there will be a 50% turnover in the field related to retirement.1 The most plentiful resource for replacing the aging population is with new graduate nurses. These new graduates will be entering a high-stress field and expected to function with the same specialty knowledge and skill as their experienced counterparts. It's imperative that healthcare organizations select the best candidates and then provide those candidates with the proper tools and support.
In 2010, the Institute of Medicine released the Future of Nursing report, which included nine recommendations for the nursing profession to meet the healthcare needs of the country.2 The third recommendation was for healthcare organizations to implement nurse residency programs (NRPs). At a major healthcare organization in the Southeastern United States, there has been some form of NRP since 2008. With the release of this report, along with the published literature on NRPs, this healthcare organization revised its program to meet the evidence standards.
Casting the line
In addition to revising the structure and content of the program, the departments of nursing and human resources revised their partnership, working together on advertising the program, candidate screening, interviewing, and the selection process. The goal of the program is to build leaders at the bedside. Although some of this can be accomplished through a nursing program, a large portion of developing nurse leaders at the bedside depends on hiring the right people.
There has long been an argument for increasing the entry level of nurses to the baccalaureate level. Historically, diploma and associate degrees of nursing have been the standard minimum degree in nursing; however, recent literature has demonstrated statistical significance of higher patient safety related to the nurse's degree of preparation. One recommendation of the Future of Nursing report is to increase the proportion of bachelor's of science in nursing (BSN) degree-prepared nurses at the bedside to 80% by 2020.3 Human resources revised the application process to give BSN-prepared students a point advantage. This, partnered with recruitment sourcing efforts, has increased the number of BSN-prepared nurses who are interviewing for open positions and are a part of the NRP.
Healthcare organizations commonly focus on NRPs as a method to increase retention rates in new graduate nurses.4 It can cost an institution between $82,000 and $88,000 to replace a nurse who leaves.5 New nurses are generally at risk for turnover; 30% to 60% of novice nurses reported an employment change within the first year of employment.6 Many aren't equipped with the needed skills or prepared for the stress level of the workplace. The combination of selecting individuals who are the right fit for an institution and providing them with a safe, structured outlet to express feelings while they develop their skills creates a structure of success.
Sink or swim
Our NRP takes approximately 4 to 6 weeks from the time the position is posted, to the time the interviews are conducted. Before posting a position, the number of openings is confirmed with nurse managers, a nurse administrator, and the CNO. A nurse manager liaison is identified and collaborates with the staffing specialist to coordinate the interviews and assist in distributing information, such as identifying internal candidates and optimal dates for panel interviews. All of the nurse managers with position openings on their units are required to attend every candidate interview. The staffing specialist also works with a clinical nurse educator, or the nurse manager liaison, to review the job posting, making sure it accurately reflects the role, responsibilities, and career progression. Deadlines are included in the posting for licensure requirements and application inclusions. The position is posted for 1 work week and applicants who fail to submit applications during this time period aren't considered. Incomplete applications are also not considered.
All completed applications are initially considered. If, during the time of initial review, any of the required documents are missing, the applicant is no longer considered. Candidates can call the staffing specialist to confirm that all of their documents were received. Candidates must submit the following documentation: a letter of intent, transcripts, a letter of recommendation, and a résumé. Each document is measured and assigned a point value.
After all of the documents have been reviewed (all by the same person for accuracy and consistency), the top candidates are selected and scheduled for a five-question phone screen. The phone screen occurs over 15 minutes and involves five questions related to career goals, experience, and differentiating factors. The candidate has an opportunity to ask the staffing specialist any questions, and the staffing specialist has an opportunity to describe the program and provide a realistic job preview. After all of the phone screens have been conducted (all by the same person for accuracy and consistency), the staffing specialist will choose the candidates who are best suited for the next step: the panel interview.
This panel consists of one nurse manager from each unit that's hiring, one clinical nurse educator, and one staffing specialist. An average interview panel consists of 10 members. The panel conducts all of the interviews together over the course of 3 to 4 days. This is an enormous commitment and exemplifies the importance of the NRP to the organization. In addition, it provides consistency and ensures that each potential hire experiences the same process. Typically, verbal offers are made at the end of the interview week and electronic written offers are received within 2 business days. All unsuccessful candidates are notified either via e-mail or a phone call. After the candidate accepts the offer, the standard hiring process begins with new employee orientation, nursing orientation, and preceptored experience on the unit of hire.
Got a bite!
In addition to this standard practice, the new employee also begins nurse residency classes, which are part of our NRP. The goal of the program is to build leaders at the bedside by assisting new graduate nurses through the year of transition from student to competent and skilled clinical nurse. Classes consist of some didactic material, but mostly group discussion and sharing of experiences. The residents also have the opportunity to lead a class.
Program objectives focus on the advancement of skills in 13 individual topics as they relate to three major sections of development: leadership, patient safety, and professional development. The overall program objective is that by the end of the program, the novice nurses will transition to safe and competent advanced-beginners, according to Benner's Novice to Expert theory.7 This is done through increasing communication, assessment, teamwork, and critical thinking skills, as well as skill and knowledge development in various areas related to the employee's practice.
The 1-year timeframe was chosen because new graduates tend to be optimistic and hopeful at the beginning of their employment. Generally, new nurses' negative self-perceptions about skill levels and abilities begin to set in between 3 and 6 months, and the group starts to see itself in a negative light. However, by the end of the first year, confidence starts to rebuild and skill levels grow. It's imperative to see these new graduates through their period of disenchantment and how they manage to regain confidence.
All acute care nurses with less than a year of experience participate in the NRP. The Casey-Fink Graduate Nurse Experience Survey, a validated tool for self-perception of readiness to practice, is administered electronically three times during the first year of practice (baseline, midpoint, and 1-year mark). Participation in the study is voluntary and anonymous. The Casey-Fink tool has an overall Cronbach's score of 0.89. Data are collected in a deidentified manner. Aggregate data are analyzed at the institutional level only, with the focus on development and progression throughout the first year of practice, comparing results based on degree of preparation. Participants also complete a program evaluation. Revisions to the NRP are made based on this feedback to guarantee constant improvement. For example, when the program first started, it met less often but for longer periods of time. Based on resident feedback, classes were changed from every 5 months for 4 hours to every 3 months for 2 hours.
Catch of the day
Since restructuring the NRP in 2010 and developing a strong partnership between the departments of nursing and human resources, the turnover of nurse residents in the first year of practice has dropped to 3.4%. Comparatively, national turnover rates of nurses in the first year of practice are between 18% and 50%.8 Some of the well-documented benefits of low turnover rates include increased patient safety and quality of care, high rates of both patient and staff satisfaction, and high levels of nurse safety.9,10 At the conclusion of the program, these nurses aren't only competent and safe in practice, but also feel well supported in a practice environment where they're valued.
Members of nursing leadership are deeply invested in this program and strive to ensure that optimal candidates are being selected during the onboarding process and those candidates are being supported and developed in their first year of practice. This dedication can be observed through nurse managers blocking their schedules for multiple days to uniformly interview and select candidates as a group. It's also observed through the presence of the CNO, nurse supervisors, and nurse managers at the graduation of each nurse residency class. And, finally, it can be observed through the first few cohorts of nurse residents who are now 2 to 3 years into practice and becoming nurse mentors to give back and help grow the new nurse residents.
Selecting optimal candidates to hire and immerse into the organizational culture allows new graduate nurses to change the climate of nursing at their institution as they enter the field well supported, with fresh energy, and interested in becoming leaders at the bedside to provide the best possible care for their patients.
1. Goode CJ, Lynn MR, Krsek C, Bednash GD. Nurse residency programs: an essential requirement for nursing. Nurs Econ. 2009; 27:(3):142–148.
2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2010.
3. National Research Council. A Summary of the February 2010 Forum on the Future of Nursing: Education. Washington, DC: National Academies Press; 2010.
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7. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984.
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9. Jones CB, Gates M. The costs and benefits of nurse turnover: a business case for nurse retention. OJIN. 2007; 12:(3):4.
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