Nursing services company The Ensign Group Inc. announced it acquired two skilled nursing facilities in Idaho and one in Utah for an undisclosed price. Ensign said it bought the Emmett Care & Rehabilitation Center, located in Emmett, ID, and the Park View Rehabilitation and Care Center, which is based in Burley, ID. It also acquired the Paramount Health & Rehabilitation Center of Salt Lake City, which it had leased about a year ago.
Orientation is an overwhelming time for new nursing employees, who are faced with learning many systems, processes, and people as quickly as possible. The situation is even more difficult for new graduate nurses, who must overcome the transition from school to practice.
New grads have a tricky balancing act to perform involving learning new skills, committing policies and procedures to memory, prioritizing patients' needs, and even remembering where the supply closet is. Wouldn't it be nice if they had a safe environment in which to practice those skills before being thrust onto the unit and dealing with real patients?
That's the idea behind Phoenix-based Banner Health System's new simulation center. The organization is hoping that simulation holds the key to successfully onboarding new nurses and helping them transition swiftly to become competent, confident nurses.
Waste not, want not
Banner Health opened its first simulation center in 2006 at Banner Good Samaritan Medical Center in Phoenix. The facility proved so popular with the nine Banner facilities in the state that it soon became too small.
Around this time, Banner's Mesa Hospital was moving into a new facility, leaving the organization wondering what to do with an empty medical center. It decided to turn the building into a state-of-the-art simulation training center to be used by all of Banner's facilities in Arizona.
The center was extensively renovated to house the largest simulation center in the country, which passes for a real-life hospital. It includes a 20-bed ED, an 18-bed med-surg unit, a 14-bed ICU, and two ORs. It is filled with a variety of high- and low-fidelity simulation modalities and offers some virtual training. It also hopes to develop virtual avatars to facilitate behavioral health training.
Standardizing training
Carol Cheney, MS, director of simulation and innovation at Banner Health, says the organization decided to create a standardized onboarding program for all nursing staff in the Arizona region, which would involve time at the new simulated medical center.
Previously, each facility had its own orientation and precepting structures. "We did an audit and [found that] all units trained in different ways," says Cheney. "We wondered, who produces the better nurse? And no one had an answer."
Cheney spearheaded a project to create a standardized orientation for all new nursing employees and ushered everyone through the program at the simulated medical center.
She brought teams together to examine what needed to be part of orientation, what was required by regulation, as well as problem areas that could be identified as common across Banner facilities.
"We created a comprehensive curricula surrounding these topics," says Cheney. "We double-checked all policies and procedure guidelines against [Agency for Healthcare Research and Policy and Institute for Healthcare Improvement], so we could bring forward the best evidence-based practice standards."
Skills and scenario-based training
All new hires, whether experienced nurses or new graduates, first go to their own facilities to receive facility-specific orientation. Afterward, they go to the simulation medical center, where they participate in skills training and scenario-based training.
The experienced nurses are guided through short scenarios, but the new nurses must experience four-hour scenarios that are set in the department in which they will work. For example, if they will be working in the ICU, new nurses have a one-to-two patient ratio just like they will have in reality.
The four-hour scenarios involve all aspects of unit life that new nurses will experience. For example, they:
Learn how to perform patient handoffs
Practice patient assessments
Distribute medications
Contact physicians or ancillary services for items their patients need or for patient orders
Enter their documentation in the electronic medical record
"We have a facilitator on the floor to help them," says Cheney. "The real goal is to immerse them in that environment, on a somewhat simplistic level—we're not trying to scare them—to show them the reality of the unit they will be on." After the scenario is complete, the new nurses are debriefed and encouraged to talk through the scenario and what happened. Because the facilitators know exactly what occurred, they can provide coaching and guidance specific to each nurse.
"We do it in a nonpunitive way," notes Cheney. "We don't say, 'Susie, you didn't do this.' What we'll do is talk about the patients and what was happening with the patients."
In essence, the scenarios allow new nurses to practice patient care, critical-thinking skills, documentation, and all of their new responsibilities in a safe environment. "And the beauty is that their [fictional] patients are essentially plastic," laughs Cheney.
Measuring outcomes
Before the program began, Banner surveyed preceptors to identify common problems they were seeing among new graduates. The facility turned these common issues into scenarios for new grads to practice at the simulation center.
Cheney says Banner doesn't want new nurses' time with preceptors to be spent on learning tasks such as how to hook up an IV pump, which can be done in the simulation lab.
Banner wants time spent with the preceptor to be an opportunity for new nurses to develop critical thinking and focus on learning clinically advanced knowledge. The new simulation training center also allows Banner to create a report on each new graduate and his or her particular skills and competence.
"Orientation used to be really arbitrary," Cheney says. "Now we're saying, 'Let's not look at time; let's look at competence.' "
Report summaries based on a series of measurements help identify new nurses' competence level. The reports are provided to each learner and his or her manager, preceptor, and educators, which allows units to individualize training.
The simulation medical center identifies new nurses who are ready to take on a greater patient load, as well as those who struggled with suctioning or tracheotomy care so the unit can help them in that area.
Cheney is also collecting data to refine the training for the long term. "We're able to see, where do people make their errors? Are they procedural errors or are they decision-making errors?" she says.
Cheney plans to examine the data Banner is collecting to identify what really needs attention and what does not. This will allow the organization to refine the program over time and continually work to ensure that new nurses receive the best orientation possible.
Editor's note: This is the second article in a two-part series about nurse residency programs. Part one, which discussed the benefits provided by residency programs, appeared in the November 17 edition of the NurseLeaders weekly e-newsletter.
Benner (1984) told us that upon becoming a nurse, individuals develop in stages based on gaining experience. It is important to note that Benner describes experience not as longevity with the passage of time, but rather as the refinement of knowledge through encounters with many practical situations. Nurses are typically exposed to a variety of patients and care situations along the path to becoming competent. A well-structured nurse residency program can guide the new graduate nurse through exposure to many circumstances, thereby increasing experience, which in turn supports quicker development of competence.
Structuring a program
A nurse residency must be more than an extended orientation. New graduate nurses are not just transitioning to a new job environment, they are transitioning to a new role. This role development includes not only developing clinical skills, but learning to apply critical thinking and becoming acquainted with leadership skills. Residents are no longer nursing students; the focus of a nurse residency should be guidance for application of their knowledge.
Most organizations accept nurse resident applicants as a cohort, which helps manage the program efficiently. Participants also gain an informal support system in their resident peers.
Many programs struggle with how to integrate a didactic component into a nurse residency. Keeping didactics within the cohort can be beneficial, but as residents are working in various clinical specialties, topics must have a general focus. Although clinical exposure is the foundation of a nurse residency, didactics that enhance the experience of the specialty need to be incorporated. In addition, leadership skills should be touched upon during a nurse residency.
The desired outcome of a nurse residency is new graduate nurses who quickly develop into competent, efficient, and confident staff members. Offering flexibility within the clinical structure to consider the nuances of various nursing specialties is crucial to the success of a program.
A successful program also requires preceptors and mentors who are committed to facilitating the growth of nurse residents.
Strong preceptors support the clinical component and guide residents gradually from shadowing to independent practice while ensuring exposure to different situations that lead to competence. Strong mentors support the didactic component by posing various challenges to residents that facilitate their assimilation of knowledge and clinical exposure into competent nursing practice.
Sometimes, the roles of preceptor and mentor may be fulfilled by the same individual. Other times, depending on the scheduling needs for residents or the unit, multiple preceptors may be used. Communication among all those involved with residents is crucial to monitor progress and must extend to the unit's nursing leadership and the nurse residency program coordinator. This can be a formal or informal process but should be defined as part of the program.
Benefits of a nurse residency group
In developing or updating a nurse residency program, the initial considerations should look at activities to support the cohort. A nursing core orientation usually offers an in-depth overview to organizational nursing practice for newly hired nurses. Offering a separate core orientation for the resident cohort may better meet the new nurse graduates' needs.
Bringing the cohort together at defined intervals for education provides the opportunity not only to review various topics relevant across the practice spectrum, but also allows the individuals to build stronger relationships with other nurse residents.
Socialization is an important consideration in job satisfaction, and each nurse resident will integrate with his or her unit's team. But the shared experience of entering the nursing profession together makes the residents true peers who can support each others' development as nurses. And as the cohort successfully completes its journey through the residency, a recognition celebration for the group is in order.
Curriculum and activities
Developing unit-based activities for the nurse residency requires flexibility in guiding the structure of the program. Flexibility allows for program adaptation at the unit level, ensuring that it meets the needs of residents and the unit. Nurse residents typically should not “count in the staffing numbers” for an extended period, so a variety of learning opportunities can fit into scheduled shifts. By having residents and preceptors teamed for patient assignments, there is flexibility for residents to be guided for clinical opportunities or be relieved for didactic components.
Consideration should be given to developing tools or strategies that will help assess and monitor progress. A tracking tool that notes residents' exposure to skills and processes can offer insight. Creating a unit-specific tool can outline various assessment skills, equipment, procedures, specific medications, or documentation standards needed within the unit's specialty. It could be formatted for daily or ongoing use and it can note opportunities to observe or perform. Whatever tools are developed should be simple to use and have the purpose of guiding the resident-preceptor teams in structuring the clinical experience for variety and challenge.
The didactic component of a nurse residency should guide and support residents as adult learners and be addressed at the unit level and for the cohort. Mentors can facilitate residents' incorporation of clinical experiences and knowledge. It is this incorporation that leads to competency and efficiency and gives new nurses confidence in their practice.
Routine meeting time between residents and mentors away from the clinical setting can be used for discussion and review. This time may include going over new clinical experiences, knowledge that is important to the specialty area, or case studies, all avenues to reinforce learning.
Additional education can be accomplished through granting self-study or guided time. Residents can complete assignments that will benefit integrating specifics into their practice. This might include review of unit-based competencies or unit-based policies and procedures or specific classes such as ACLS. Residents may be assigned to visit alternative sites that give insight into the continuum of care for the patient. For example, a resident on a cardiac care unit might visit the cath lab, or a resident on a postsurgical unit might visit the operating room.
Residents should also have exposure to understanding nursing leadership. Mentors should take responsibility for introducing residents to issues such as resource utilization, peer review, and quality improvement. Shadowing a nurse leader at the organizational or unit level can give residents perspective on the demanding challenges of a nurse leader.
Length
Organizations offer various timelines for their programs, but be flexible with the prescribed program length to accommodate the needs of each specialty practice. Whatever the required length of time, participant evaluation is needed to monitor progress. Input for the evaluation should come from the preceptors, mentors, and unit nurse leaders and be shared with the resident program coordinator. Self-evaluation should be offered to residents, and peer evaluations from other nurses could be considered. In addition, nurse residents should have the opportunity to evaluate their preceptors and mentors.
When developing or updating a nurse resident program, start by setting objectives for participants to accomplish. There may be objectives for the cohort, with additional objectives for the resident's unit. The program's main goal is always competent nurses, regardless of the outlined objectives. By combining the structure of a nurse resident cohort with flexibility at the unit level, this goal will be accomplished.
Reference
Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley.
Vicky Goeddeke, RN, MS, CEN, CPEN, is the ANCC Magnet Recognition Program® and nursing excellence manager at Northwest Community Hospital in Arlington Heights, IL.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Two nurse anesthetists from Minnesota sacrificed their careers to pursue lawsuits against Allina Health Care, which ended with a settlement and changes to Medicare rules that helped save the profession, the Minneapolis Star Tribune reports. But despite the victory they helped bring about, Ladonna Schweer and Gayle McKay had to sue their own organization, the Minnesota Association of Nurse Anesthetists, in order to make the group honor its long-standing vow to compensate them for putting their ideals ahead of their jobs, the Star-Tribune reports.
Nurses often try to find ways to do more for the profession that they love. In many facilities, nurses make note of how they can help and lend a hand to those in need.
One nurse who is lending a hand to others is psychiatric nurse, Trisha Pearce. Pearce witnessed firsthand what the war can do to returning soldiers and their families when her brothers returned from Vietnam and the Gulf War.
Pearce, with more than three decades worth of experience in mental health and chemical dependency, did not want to see returning soldiers suffer without help, so she founded the Soldiers Project Northwest in 2007.
The project reaches out to veterans of the wars in Iraq and Afghanistan, along with active-duty personnel and military families. The project provides free, confidential, therapeutic counseling, and aims to educate communities on the psychological effects of the war. Volunteers also benefit from the project, and are able to receive training to better aid these soldiers and their families.
There are currently 57 volunteers involved with the project that is now an affiliate of the Los Angeles-based national Soldiers Project. Pearce volunteers more than 20 hours a week to ensure military families can receive the support they need. Named the Outstanding Female Non-Veteran of the Year by the Washington state Department of Veterans Affairs, Pearce rode in the Auburn Veterans Day parade alongside groups of veterans.
Another nurse who has been practicing for more than three decades is also leaving her mark and helping those hospitals in third-world countries.
After her first medical mission trip to the Amazon in South America, Mary McMahon, a nurse from Georgia, returned home and founded the nonprofit organization, Nurses for the Nations. The organization is gearing up for an 11-day trip to Liberia in January, where nurses will test for malaria, provide mosquito nets, and teach sanitation and proper use of the nets in six remote villages.
The philosophy of Nurses for Nations is to focus on one small region of the world at a time, which McMahon believes can inspire long-term change. McMahon plans to turn the organization's focus on another medically desperate part of the world during the next three to five years.
In March 2008, a task force was formed to review and revise the American Nurses Association's (ANA) Professional Development Scope and Standards of Practice. This document establishes the range of practice and the principles by which nursing staff development professionals conduct our professional lives.
It is no easy task to revise such an important document. Why undertake such a critical venture? To begin with, says task force member Dora Bradley, PhD, RN-BC, vice president of nursing professional development at Baylor Health Care System in Dallas, "it has been 10 years since the last version was created. There have been so many changes in healthcare as well as our profession, so we must look at the Scope and Standards in terms of how our roles have evolved." Bradley notes that, for example, technology was not even addressed in the most recent Scope and Standards.
"The new version of the Scope and Standards must also consider the fact that the continuing education target audience is now worldwide," she says. "We must think in terms of a globalization concept and how education needs can be assessed across the world. Simulation and virtual reality must also be incorporated as these teaching modalities grow in scope and importance. I remember someone saying that 98% of the change in the world has occurred in the last 100 years, and 90% of that change has occurred in the last 10."
The task force started by conducting an intensive literature review of training and continuing education in and out of the healthcare arena. The ANA mandated that the group create something "that would represent not only current practice, but a future trajectory to guide practice for the next five years," says Bradley. "We must create a 30,000-ft. view because our specialty has so many different arms where we practice, our roles, and practice setting, etc."
The task force identified specific future trends to be addressed. These include (Bradley et al., 2009):
Increased use of technology
Global target audience
Teaching/learning modalities
Evidence-based practice
Increased accountability
Increased interdisciplinary involvement
Fiscal management
Need for complex implementation expertise
Professional development metrics
Decreasing time to achieve competency
Generational differences, including the emerging adult (Tanner, Arnett, and Leis, 2009)
Escalating competing priorities
Knowledge management and succession planning
Increased need for clinical affiliations and academic partnerships
Move toward learning as an investment in human capital
Cost avoidance versus expenditure
Focus on transition into practice
Bradley says the "influence of the work environment became very apparent, which was not addressed in previous editions. Learning and practice environments have tremendous influence on how much of this role [as identified in the Scope and Standards] can be operationalized by the individual specialist. For example, a one-person staff development department can't do orientation, continuing education, research, etc., not when there is only one person doing everything. We must be respectful of the practitioner's practice environment."
There was a significant struggle as the task force altered the practice model. The former model was a triangle with three intersecting circles (continuing education, staff development, and academic education), which appeared to reflect the professional development aspects of the nurse.
The proposed new model is a systems model focusing on the practice of nursing professional development (NPD). The system includes inputs (environment, learner, NPD specialist), system throughputs (evidence-based practice, practice-based evidence, orientation, competency program, inservice education, continuing education, career development, research-systematic inquiry, scholarship, academic partnerships, pole of NPD specialist), and system outputs (outcomes, change, learning, professional role competence and growth). Note that academic education is now addressed via partnerships. Nurses in academia have their own set of competencies and a certification model separate from the Professional Development Scope and Standards. The proposed model is also more fluid, documenting inputs, throughputs, and outputs (Bradley et al., 2009).
The suggested changes were posted on various professional association Web sites, including the ANA and the National Nursing Staff Development Organization (NNSDO), for public comment. Education requirements generated the most buzz: The task force proposed that educational preparation for NPD specialists be a master's degree in nursing. This is controversial because many NPD specialists have a master's degree in education. Due to public comment, the proposal has been changed to a master's degree in nursing or appropriate related discipline such as education.
However, if the master's degree is in such a related discipline, the NPD specialist must hold a baccalaureate in nursing. Additionally, the task force recommends that executive leaders for NPD be RNs prepared at the doctoral level in nursing or education. At a minimum, department administrators are strongly encouraged to have a master's degree in nursing or related field.
When will the revisions be published? At presstime, the task force was working to approve the final revisions and submit them to the ANA. The ANA must guide the proposed document through its approval process, and hopefully, the new version of the Scope and Standards will be ready to print in the first quarter of 2010.
Bradley points out that the task force received about 30 pages of public comment pertaining to the proposed document. She notes that this is comparable to feedback received from other specialties, which have more practitioners, when their Scope and Standards undergo revision. Professional development specialists are obviously deeply committed to their specialty and the way they practice.
Those of us involved in this specialty would be wise to incorporate the future trends identified by the task force into our practice settings. The effect and the rapidity of change greatly influence how we incorporate these trends. The new Professional Development Scope and Standards should be used to enhance our professional growth and development as well as our practice initiatives.
References
Bradley, D., et al. (2009). "The Past, Present, and Future: The Evolution of the ANA Nursing Professional Development Scope and Standards." General session at the 2009 NNSDO convention, Philadelphia.
Tanner, J.L., Arnett, J.J., and Leis, J.A. (2009). "Emerging Adulthood: Learning and Development During the First Stage of Adulthood." In M. C. Smith & N. Defrates-Densch (Eds.), Handbook of Research on Adult Learning and Development, 34–67. New York: Routledge.
This article was adapted from one that originally appeared in the December issue of The Staff Educator, an HCPro publication.