RN residency programs for newly licensed nurses (NLNs) have become firmly established as a best practice to create a safe and supportive environment for nurses transitioning roles from student to professional. Particularly useful in specialty nursing practice, an RN residency program for NLNs can be a beneficial and cost-effective strategy to meet urgent staffing needs. However, evidence has increasingly demonstrated that a balance in nursing staff skill mix is crucial to ensure patient safety and optimal outcomes. Hickey, Gauvreau, Curley, and Connor (2013) studied factors contributing to patient mortality in pediatric cardiac surgery patients and found a positive correlation between percentage of nurses with less than 2 years of experience and in-hospital patient mortality; they identified as a cut point that units in which more than 20% of the workforce is composed of these newer nurses have a statistically significant increase in patient morality. Furthermore, Hickey et al. (2016) identified that units with a higher proportion of nurses with greater than 2 years of experience had lower mortality rates.
Although these studies are limited to a specific patient population, nursing professional development (NPD) practitioners must consider the broader implications of the effect of newer nurses in the workforce and work with nurse leaders to balance the hiring of NLNs with experienced nurses. However, in many highly specialized areas, this can prove to be problematic, as the specific experience needed for a seasoned nurse to seamlessly transition into a new setting may create severe limitations in the number of viable applicants. How, then, can NPD practitioners and nurse leaders navigate the hiring of experienced nurses transitioning from one area of specialty to another? The purpose of this article is to discuss the components of a successful Transition RN Fellowship program, program outcome measurement, and implications for NPD practitioners.
As an organization with a robust vendor-supplied RN Residency program accredited with distinction by the American Nurse Credentialing Center (ANCC) Practice Transition Accreditation Program, we found ourselves with a robust pipeline of NLNs but were lacking in our pool of experienced nurse applicants with appropriate pediatric experience. Our organization routinely received a large number of applications and interest from experienced nurses working in a variety of nonpediatric specialties, but nurse managers found it challenging to successfully train and transition these nurses to pediatrics. In our previous state, newly hired experienced nurses received a maximum of 6–8 weeks of orientation and inconsistent specialty-specific training based on manager discretion. In the isolated occurrences in which nurses with limited pediatric experience were hired, they were often unsuccessful in acquiring the necessary knowledge and skills in the time allotted, leaving managers frustrated and forced to either spend additional funds to extend orientation or terminate employment after a sizeable investment in training. We found that managers were increasingly relying on the RN Residency to meet their staffing needs, leading to an increase in the overall percentage of NLNs within our nursing workforce.
We believed that our RN Residency for NLNs may hold the key to solving this problem; using the residency as a framework, we crafted a new program dedicated to training experienced nurses with limited pediatric experience, with the goal of supporting nurses to successfully transition into pediatrics from another area of specialty. It was clear that the new program would need to include a strong didactic curriculum as well as an extended clinical orientation to ensure proper acquisition of skills and knowledge. Furthermore, we anticipated that creating an avenue for a longer orientation and training program would empower nurse managers to make hiring decisions based on values and fit with organization and department culture rather than focusing on previous pediatric experience. Our vision for this program was to provide a unique group of experienced nurses with the support and opportunities needed to develop and succeed in a new role.
The Transition RN Fellowship was launched in August 2015 and is offered twice per year, in February and August. Participation in the program is limited to nurses with at least 1 year of nursing experience, and new hires are included in the program at the collaborative discretion of the hiring manager and program manager. The program is 6 months in length with a 12- to 16-week immersion period, depending on the unit to which the fellow is hired. The immersion period is typically 12 weeks for general pediatric units and 16 weeks for intensive care units. The salaries for orientation of these nurses were included in the RN Residency program’s budget, thereby eliminating a sense of urgency felt within unit-level leadership to speed up or shorten the orientation process. During the immersion period, fellows attend classes as well as precepted clinical time on their home unit. In addition, fellows participate in looping, which is an opportunity to spend a shift in an area or department other than their home unit, either for the purpose of enhancing their understanding of that area or for learning more about a specific skill set, such as tracheostomy care, peripheral intravenous insertion, or wound and ostomy care.
The didactic portion of the program includes a competency-based core curriculum, which is a general pediatric curriculum designed to meet the needs of every fellow, regardless of specialty. Specialty-specific curriculum is offered for certain areas and is designed by subject matter experts (SMEs) to build on the foundation provided in the core curriculum. Skills labs are integrated into both the core and specialty-specific curriculum to help the fellows become familiar with equipment and organizational practices. As we worked to design the core curriculum, we recognized the need to focus on the differences between other areas of practice and pediatrics and to hone our curriculum to meet the specific needs of our fellows while taking their existing knowledge and skill into consideration. We anticipated that, although the fellows would need a broad range of content to appropriately prepare them for pediatric practice, a balance was needed to ensure that they were not treated as NLNs.
Interprofessional SMEs were recruited from across the organization to develop and deliver classroom content. SMEs come from a variety of professions, including nursing, respiratory therapy, social work, medicine, spiritual care, child life, and physical and occupational therapy, among many others. The inclusion of these colleagues in provision of the program curriculum helps our fellows develop a deeper understanding of where they fit within the interprofessional team.
To ensure that fellows have the support they need during what can be a challenging transition, the program also includes scheduled mentorship and debriefing. Both mentor and debriefing meetings are conducted in group settings; however, each has its own purpose. The goal of mentorship is to promote career and professional development. Each mentor circle is composed of approximately five or six fellows and two mentors. Nurses and nurse managers with at least 3 years of experience are eligible to serve as mentors. Fellows attend one mentor meeting during immersion and one postimmersion. Each meeting has a topic and an agenda to ensure that consistent professional development information is shared with the fellows.
The purpose of debriefing is to provide the fellows with the tools to engage in self-care and to allow them to discuss issues and concerns, with the ultimate goal of preventing moral distress and burnout. Debriefing takes place in a confidential setting in which fellows can freely discuss their experiences and challenges in the fellowship program on both a professional and personal level. Groups are comprised of approximately 6–10 fellows and two debriefers. In addition to nurse managers, social workers and chaplains are utilized as debriefers to ensure that fellows are surrounded by individuals who are trained in counseling and can assist them in navigating crisis situations. Fellows meet in their debriefing groups twice during the immersion period and once postimmersion.
Evidence-Based Practice Projects
We have worked in the past several years to develop a culture of evidence-based practice (EBP) in our organization and have found great success through EBP projects with our NLN RN residents. In designing the Transition RN Fellowship program, one of our priorities was to find a way to offer this crucial experiential learning opportunity in a shorter format. We developed a standardized EBP project design for fellows that includes development of a practice question, search for and appraisal of a minimum of three pieces of evidence, evidence synthesis and recommendation, and a 5-minute presentation on their topic at the end of the program. In addition to unit-based advisors for each project, fellows also receive mentorship and support from DNP- and PhD-prepared nurses from across the organization, as well as our Health Sciences Librarian. Curricular components of this project include an introduction to EBP, a lecture on evidence search strategies, and a presentation about critical appraisal and synthesis of evidence, followed by 6 hours of dedicated project work time with mentors available to assist. The purpose of these projects is to introduce EBP concepts and provide fellows with an understanding of the resources available to them within our organization when clinical questions arise. In surveys conducted at the end of each cohort, 88.3% of fellows have reported that they are interested in participating in EBP projects in the future.
In addition to the curriculum and supportive components provided throughout the program immersion, all fellows participate in a mandatory Postimmersion Education and Support Day. The goal of this supplemental class day is to provide transition fellows with valuable support to assist in their clinical and professional growth. This class day is purposefully timed approximately 3 months after their transition to independent practice, as we recognize the immediate weeks postimmersion are focused on clinical competence and growth. Topics for this class day include hospital throughput, precepting, coping and resiliency, collaborative governance, and guided preparation for their annual performance evaluations. Also embedded within these days are mentor and debriefing meetings. The inclusion of these components allows us to continue providing guidance and support to our fellows, while also helping them navigate their own professional development.
The Transition RN Fellowship team consistently strives to improve the overall experience for those participating in the program. This continuous improvement process has led to the development of several program goals:
- 100% of Transition RN Fellows will have 100% of all immersion competencies validated by the end of the immersion period.
- At the end of each cohort, evaluations of the core curriculum classes will have a weighted mean of least 3 out of 4, with at least 51% of Transition RN Fellows rating each class as excellent.
- Transition RN Fellow turnover will be less than 10% at 1 year.
- At the end of each cohort, at least 90% of Transition RN Fellows will agree or strongly agree that the Transition RN Fellowship curriculum provided them with valuable information to help with their career transition.
- All aggregate Incivility Scale measures will be less than 2.1 on a 5-point scale.
Each of these goals is aligned to a specific outcome, which is measured to identify whether program goals are being met. Table 1 demonstrates our performance in outcome measures as they align with program goals.
Having already achieved accreditation for our NLN RN Residency, it was important to us to validate the quality of this new program as compared to national standards. For this reason, we underwent the rigorous journey to ANCC Practice Transition Accreditation Program accreditation. In December 2018, the Transition RN Fellowship program was awarded Accreditation with Distinction, the highest level of recognition awarded by the ANCC for transition to practice programs.
More impactful for the organization, however, is the effect the program has had on staffing and skill mix. Since the program was introduced, a total of 155 fellows have completed the program, with an aggregate retention of approximately 88%. Managers have reported a high level of satisfaction with the quality of candidates they are able to hire, and we find that fellows are able to reach a level of competence and proficiency faster than NLNs who have a longer transition as they work to become fully competent. This has allowed for a rebalancing of skill mix throughout our units to ensure that we are able to safely absorb NLNs into the workforce while surrounding them with experienced nurses to support their development. In addition, we have found that the fellowship program is meeting the needs of ambulatory areas that do not currently utilize the NLN RN Residency.
Many NPD practitioners are tasked with creating and sustaining innovative and outcomes-driven programs to ensure safe and supportive transition to practice and that serve the unique needs of their organization. Although much of the focus in recent years has been on NLNs, practitioners must also consider the balance of skill mix and the needs of other transitioning nurses. The inclusion of a Transition RN Fellowship program in an organization’s transition-to-practice offerings helps to create additional capacity for recruitment, training, and support for nurses who may otherwise be overlooked. In addition, programs geared toward experienced nurses allow NPD practitioners and nurse leaders to carefully manage the balance of experienced and new nurses within any care setting, in the ultimate pursuit of optimal patient outcomes.
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