LTC Nurse Residency Results in 86% Retention Rate

Post-acute care has become an essential component of value-based care. By preparing new nurses through a long-term care residency program, facilities can improve nurse retention, confidence, and competency.

Accountable care organizations, value-based care, and new reimbursement models are changing the healthcare landscape, and with that the role of the post-acute care nurse is evolving as well.

"It's important that [patients] don't go back to the hospital. So these nurses have to have a different skill level than, maybe, what people perceived long-term care as previously," says Edna Cadmus, PhD, RN, NEA-BC, FAAN, clinical professor at Rutgers University School of Nursing.

There are few structured programs, however, to help newly licensed RNs develop the expertise needed to successfully transition to practice in post-acute care.

To address this issue, the New Jersey Action Coalition, is focused on implementing the Institute of Medicine's (now the National Academy of Medicine) Future of Nursing recommendations. It is one of 51 groups doing this work across the country.

Cadmus is co-lead of the coalition, which falls under the umbrella of Campaign for Action partnership between the Robert Wood Johnson Foundation and the AARP.

"We felt there were acute care nurse residency programs in many hospitals, but for post-acute settings and, specifically, long-term care, there had been no evidence of any residency programs out there," she says.

"And we knew that there was a high turnover rate of nurses in long-term care facilities."

Turnover among RNs in long-term care facilities nationally was 50% and retention was almost 67%.  After the New Jersey LTC residency program, the retention rate of participants was 86%.

Long-Term Care Competencies

The program launched in 2013 with funding from the Centers for Medicare & Medicaid Services and continued until 2016 with additional funding from the New Jersey Department of Health.

Though it wasn't a walk in the park, the coalition recruited thirty-six facilities to participate in the program.

"Knowing the financial situation of how long-term care is reimbursed, it really was a challenge for us to recruit, but once we explained the return on investment, that helped," Cadmus says.

The participating organizations sent 39 preceptors and 37 new nurses through the program.

Preceptors took five days away from their facilities for training to learn new skills to help them mentor new nurse residents. The new nurse residents were away from the facilities once a week to learn key competencies in geriatric care such as:

• Fall prevention
• Nutrition
• Hydration
• Managing pain
• Pressure injuries

They also covered components of the Massachusetts Nurse of the Future Nursing Core Competencies like:

• Communication
• How to use technology to leverage care
• Leadership development
• Patient-centered care concepts
• Quality improvement

Both residents and preceptors obtained dementia care certification and all residents did a quality improvement project for their organization. "They were giving back but also contributing as a new nurse leader into the organization as a new nurse," Cadmus says.

The Residency Blueprint

The improvement in turnover was an obvious bonus. "If you have such a high turnover and you can [start to] keep people you're obviously saving money," Cadmus says.

But the residency had other benefits as well.

"We surveyed the nurses and found that their confidence as well as their competence increased," she says.

"Usually somewhere around six months is when a new grad is looking to leave their first level of employment. We felt we got them over that hurdle to really kind of get them stable for that first year."

Still there are challenges in developing residencies in post-acute care. Unlike acute care organizations which can hire a group of new nurses to go through a residency as a cohort, post-acute care organizations usually hire just one or two nurses at a time.

And the setting does not always have a robust career ladder for nurses to climb.

"When you're in a hospital situation there's a lot of opportunities to move up, to go into a clinical ladder, to try different departments to work in. It's not the same environment in long-term care," Cadmus says.

"So when you think about the new graduate, especially this new generation, they're looking to be able to not only make a difference, but also to have opportunities to change into different roles or to be promoted into different things. If you don't have those opportunities they're out the door."

Cadmus and her co-authors share their experience with developing and implementing the residency program in the book Developing a Residency in Post-Acute Care. They hope it can serve as a blueprint for others wishing to launch their own residency programs.

"We've gotten a lot of calls from people asking about how you do it. We're giving you everything you need to know about how to make this work," she says. "That was why we felt it was important to document how to do this. There's no reason why anybody should have to reinvent the wheel."