After four years of nursing school, do nurses need this additional training? To answer this question, it is prudent to examine the traditional four year baccalaureate nursing curriculum. In general, the first two years of study are dedicated to the fulfillment of general education courses such as English, history, statistics and any other non-nursing courses mandated to meet graduation requirements. Other courses while non-nursing in scope are necessary to build a strong foundation toward nursing theory. Such courses include nutrition, chemistry, organic chemistry, microbiology, anatomy and physiology I and II and sometime physics and pathophysiology. It is not until the last two years of the curriculum that students immerse themselves in the core nursing theory and clinical practice.
What happens in the last two years? In the United States nurses are trained as generalist nurses, this means that the student is not required to focus on specialization. Therefore, the student nurse is rotated through one rotation or semester of pediatrics, obstetrics, psychiatric, and community. The emphasis is placed on adult and older adult which together may consist of two clinical rotations. The last clinical rotation is the preceptorship where students are paired one-to-one with a professional registered nurse and work more independent of clinical faculty.
It is not until the senior preceptor-preceptee training period that students have a more "real world" feel for the autonomy of nursing practice. Clinical rotations in nursing school do not mimic the full responsibilities of a professional registered nurse. Yes, during earlier rotations students are exposed to bits and pieces of various aspects of the field to learn the why and how things are done, but with clinical faculty to student ratio set at 1:10 the clinical rotation experience is limited.
What happens then during a semester rotation? If there are 12 patients on a floor and there are only 2 RN's and one technician. Ideally, the student group would be divided evenly among the two nurses so that each nurse would provide report to five students. This is not always the case as some nurses do not want to mentor students, patients refuse to have student nurses, or the patient census decreases.
For each rotation there is a new unit or hospital; the learning process in interrupted. Students must acclimate to new surroundings become familiar with the nursing staff, type of equipment; learn the layout of the unit, and everyday routines of the unit. In addition, students need to familiarize themselves with the "regulars" identified as physicians and other healthcare providers who work on the unit daily, as well as learn with charting systems and communication networks on how to contact providers and hospital departments.
Nursing and ancillary staff tend to be reserved in their interactions uncertain of student nurse scope of practice, and skill level. Clinical becomes focused on setting the patient up for the day and a how to list such as how to read and understand daily orders, how to administer medication, how to document in the electronic record, and how to work the smart pump. Students become more focused on "task", but the nurses' role exceeds far beyond the few items on a check list to accomplish during the day. It is not until the graduate nurse starts their first job that they are immersed in an overwhelming world of responsibility.
What about new nurse orientation process? Yes, each time a nurse is hired whether a newly graduated nurse or a seasoned nurse with years of experience there is the same orientation process. The orientation process is developed to familiarize nurses to the hospital and routines of the department. New hires are evaluated on their ability to function as an autonomous nurse. It is understood that a nurse with years of experience would need less time being mentored than a new graduate nurse.
The new graduate nurse needs more then what the generic orientation process offers, unlike nurses with years of practice, new graduate nurses experience high levels of anxiety, fear, and frustration related to meeting the needs of the individual patient and the needs of the setting (Kramer, 1974), learning and practicing new invasive procedural skills, delegating to ancillary staff, collaborating with and reporting to physicians on a frequent basis. For even the most experienced RN the hospital environment is considered at times very stressful, demanding, and not conducive to providing safe patient care with increasing responsibilities, more technology, high nurse-to-patient ratios, and higher acuity patients. Nurses have taken a greater role doing more invasive procedures from phlebotomy, urinary catheter insertion, nasogastric tube insertion, bladder irrigation, insertion peripheral intravenous catheter, wound and chest tube management, to name a few. Today, patients admitted to a medical/surgical floor are patients who in the past would have been admitted to the intensive care unit. The current orientation process plays a limited role to the socialization of new graduate nurse.
What's the problem? The turnover rate among newly graduated RNs is extremely high. Turnover is defined as the number of new graduate RNs that leave a position before 12 months (Trepanier, Early, Ulrich, & Cherry, 2012). In a survey conducted by Bowles and Candela (2005), perceptions of first job experience nurses new to the profession, 30% left their job within the first year of employment and 57% left their first job within two years of employment. Twenty-six percent of survey respondents cited the most common reason for leaving was stress caring for high acuity patients, feeling patient care was unsafe, and unacceptable nurse-to-patient ratios (Bowles & Candela, 2005). Similar comments were discussed by Beecroft, Kunzman, and Krozek (2001) who reported new graduate nurse turnover rates of 35% to 60% within the first year of employment. In addition to concerns about new graduate nurse turnover the loss financially is approximately $40,000 in employer hiring and orientation expenses (Halfer & Graf, 2006), but even a conservative estimate of $10,000 per RN results in a substantial financial loss (The HSM Group, Ltd, 2002). Reality shock is proposed to contribute to a majority of new graduate RN turnover.
What can we learn from medicine? What are the benefits of residency? The residency experience for medicine is now a common expectation not only from medical graduates but those who hire physicians. Dr. William Osler, a British Canadian who arrived in 1888, known as one of the four founding physicians of Johns Hopkins Medicine is best known for the establishment of the medical residency program (The Johns Hopkins University, n.d.). The success of the program is credited to the developed pyramidal structure consistent of medical students, interns, fewer assistant residents, and a single chief resident (The Johns Hopkins University, n.d.). The pyramidal hierarchy is an excellent example of well-planned socialization. Training is developed to immerse individuals and gradually increase responsibility and accountability. This gradual immersion into the profession with its built-in support system allows individuals to develop a greater sense of control and decrease level of stress.
Kramer (1974) identified that new nurse graduates experienced increase anxiety, and increase fear in the first 12 months of clinical practice. This is not to say that the nursing profession should adopt an intricate system, but at the informal level it is easy to identify a similar hierarchy in the nursing field with student nurses, new graduate nurses, nurses, and veteran nurses. The Institute of Medicine's (2011) Future of Nursing recommendations support the development of nurse residency programs for both the RN and APRN level. New graduate nurse transition programs have been documented to increase retention rates in organizations (Chappell, 2014; Mennick, 2007), greater satisfaction with mastery of work organization and clinical task (Halfer & Graf, 2006). Recently, the findings from a new graduate nurse residency program reported a decrease in the 12-month turnover rate from 36% to 6% (Trepanier et al., 2012).
What are some components to nursing residency? In addition to the normal orientation process, transition programs should be at least one-year in length, include peer-to-peer interaction, debriefing, self-reflection, mentor support programs, (Chappell, 2014) and skills development. Trepanier et al (2012) described components to nursing residency that consisted of five categories didactic direct instruction, clinical immersion and competency validation, looping, mentoring, and supportive debriefing. A brief description of each follows. The didactic direct instruction and case study takes 15-20% of RN residency incorporating core concepts and multispecialty classes such as 12 lead ECG. Clinical immersion and competency validation process promotes the application of content. At this phase, the new graduate is not primarily responsible for direct patient care, but works under close supervision of the preceptor. Looping is a term used to describe the floating of new graduates to floors outside their dedicated learning unit where patients may have been transferred or admitted to the dedicated learning unit. For example, if the dedicated learning unit is the intensive care unit then time may be spent in the emergency department and the operating room. Supportive mentoring includes assigned mentor circle groups that are facilitated by experienced RNs and includes special topics such as career development. Supportive debriefing allows new graduates to discuss their experiences and voice their feelings (Trepanier et al., 2012).
This article has highlighted many of the limitations to the training of student nurses in nursing school and the inadequacies of hospital orientation for the new graduate nurse. New graduate RN residency programs are a human capital project that assists not only nurses, but also improves patient outcomes. Kelly (2014) reported shorter patient length of stay (LOS) when RNs worked on the same unit for at least one year. Nurse residency programs are a worthwhile investment that requires more resource, funding and further consideration by nurse leadership and hospital organizations.
References
Beecroft, P., Kunzman, L., & Krozek, C. (2001). RN internship: Outcomes of a one-year pilot program. Journal of Nursing Administration, 31(12), 575-582.
Bowles, C., & Candela, L. (2005). First job experiences of recent RN graduates. JONA, 35(3), 130-137.
Chappell, K. (2014). The value of RN residency and fellowship programs for Magnet Hospitals. JONA, 44(6), 313-314.
Halfer, D., & Graf, E. (2006). Graduate nurse perceptions of the work experience. Nurse Economics, 24(3), 150-155.
The HSM Group, Ltd. (2002) Acute care hospital survey of RN vacancy and turnover rates in 2000. JONA, 32(9), 437-439.
The Johns Hopkins University. (n.d.). The four founding physicians. Johns Hopkins Medicine. Retrived on June 18, 2014 from https://www.hopkinsmedicine.org/about/history/history5.html
Kelly, J.C. (2014). Nurse tenure, education linked to shorter hospital stays. American Economic Journal: Applied Economics, 6, 231-259.
Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: Mosby.
Mennick, F. (2007). Keeping new RNs in their jobs. American Journal of Nursing, 107(12), 21.
Trepanier,S., Early, S., Ulrich, B., & Cherry, B. (2012). New graduate nurse residency program. Nurse Economics, 30(4), 207-214.
