Residencies: doctors have it figured out

[Amistad]

After chatting with a fourth year med student today at clinical, it occurred to me how vastly different the physician career-path is from our own. Fourth year medical students are undergoing the process of being matched to a residency in the specialty of their choosing. They apply to prospective hospitals and hope to be matched to their top choice, awaiting the chance to learn from their experienced superiors. Then, after gaining some experience, they apply for a fellowship or are recruited to a hospital.

Meanwhile, new graduate nurses face roadblock after roadblock to becoming an experienced nurse. As nursing students approach graduation, they frantically begin the Job Search, only to encounter "__ years experience required" on almost every job posting. If nursing school is not adequate preparation to be recruited to a nursing position, is our education failing us? How are we to become experienced professionals if hospitals are unwilling to let us grow to this capacity?

I believe the answer to this problem is nurse residency programs. Like medical residencies, these programs assume and even require that the applicant be a relatively-inexperienced new graduate. I feel that like medical residencies, nurse residencies should become a traditional and required portion of nursing training. I envision this to be far off in the future, but maybe someday every teaching hospital will have "nurse residents" and every nursing student will go through a residency as part of their training, not just the lucky few who are accepted to these programs today.

[bebbercorn]

I cannot agree enough, midwives seem to be the only one that have apprenticeships in the nursing field and it just seems ridiculous to me that we haven't figured out a better way.

[Esme12, ASN, BSN, RN]

Nursing schools may be trying to flood the market, but most new grads aren't eligible to apply to open positions so the system is failing us. If new grads did a 12-18 month residency in the field they are enthusiastic about, then they would be eligible to fill open positions in teaching hospitals, rural hospitals, community hospitals, or wherever there is a need.

And I would disagree that new grads aren't willing to work for dirt cheap wages and be on call for that year... There are many new grads who can't get a job whatsoever, and many who are working in fields they aren't interested in just because that's the only option. When my mom graduated from nursing school, she went straight into the ICU and had a year-long training program. That was common at the time. This year there are probably about 50 new grads being trained for the ICU in the entire US, and they will likely stay at those hospitals. What about small community hospitals who need nurses in their specialized fields, but no one is willing to transfer because they'll lose their seniority? This would be a win-win for everyone in the end, and the so-called "nursing shortage" might be alleviated.

While the new grads direct hired in specialties I disagree that is only about 50 nurses nation wide.

It used to be called graduate nurse orientation when I graduated for general med-surg it was a minimal 3 months with direct guidance, almost like nursing school where we learned how to start IV's, learn policies and procedures, get CPR etc. We followed a secretary and learned all about orders and what to do with them(remember we didn't have computers yet). We went to all departments and learned their responsibilities. The specialty units got and addition classroom time..... an additional 3 months were spent acclimating the new grads to their floors and to all shifts.

I think it made us better nurses......but the average starting pay was $4.25/hr.

New grads jumped ship....ALL THE TIME...the minute they were finished with the orientation they had "experience" and would get hired at their "facility of choice" their "dream job". This is expensive for the facilities and the orientations got shorter and shorter....until today ....where they barely exist.

Sadly.....we are not considered a commodity right now (if we ever were) with the surplus of nurses in the market. As little as 6 years ago hospitals were still offering to pay your school loans,under their loan forgiveness programs, just to get nurses in the door......see what a little marking does and a bad economy causing hundreds of unemployed college grads to flock to the career that guarantee of a job does to the job market and benefits?

Will hospital ever really get residency programs? Probably not......nurses do not bring in revenue and our services are not billable....even though that is the best was to have qualified nurses.

[bebbercorn]

"... And I would disagree that new grads aren't willing to work for dirt cheap wages and be on call for that year... There are many new grads who can't get a job whatsoever, and many who are working in fields they aren't interested in just because that's the only option. "

4:31 pm by bebbercorn

I would have, I was working at Old Navy for $7 an hour when I graduated with no benefits. When my first job said $20.60 for the first three months I was ecstatic... then a RAISE at the end of orientation??? Whhhaaaat? Boo-ya!!!

[Amistad, RN]

As others have pointed out ... physicians' residencies are funded by the federal government. "Nurse residency" programs are simply extended orientations of six months or longer ... but the nurse is still an employee of the hospital.

I'm curious about this part of your post:

Are you meaning to say that you believe 50 new graduate nurses start working in ICUs annually, in the entire United States? My hospital alone typically hires at least that many in any given calendar year, just for the ICUs.

Competition for employment in nursing, and all other fields, varies drastically from region to region.

Maybe nurse residencies could be federally funded? Not saying they should be, but it's an idea.

Also, I don't believe there are only 50 new grads working in the ICUs annually. I was just exhaggerating and should not have put a number to it, but I have to say it doesn't seem like the norm for new grads to get hired there. I'm glad to hear that your hospital is able to hire that many and provide adequate training.

[applewhitern, BSN, RN]

Not all doctors work their residencies for "dirt cheap wages." The resident doctors at my university teaching hospital are paid more than I make now, plus they only work 4 days per week. They have generous amounts of time off, and they can work in emergency rooms for extra money if they want to. They don't always get the residency of their choice, either. Some end up taking whatever they can get. Besides, medical and nursing are two different fields.

[nursel56]

Nursing schools may be trying to flood the market, but most new grads aren't eligible to apply to open positions so the system is failing us. If new grads did a 12-18 month residency in the field they are enthusiastic about, then they would be eligible to fill open positions in teaching hospitals, rural hospitals, community hospitals, or wherever there is a need.

And I would disagree that new grads aren't willing to work for dirt cheap wages and be on call for that year... There are many new grads who can't get a job whatsoever, and many who are working in fields they aren't interested in just because that's the only option. When my mom graduated from nursing school, she went straight into the ICU and had a year-long training program. That was common at the time. This year there are probably about 50 new grads being trained for the ICU in the entire US, and they will likely segrtay at those hospitals. What about small community hospitals who need nurses in their specialized fields, but no one is willing to transfer because they'll lose their seniority? This would be a win-win for everyone in the end, and the so-called "nursing shortage" might be alleviated.

I wouldn't describe what you are talking about as a residency, but a long orientation period. The structure of a medical residency is much more complex and integrated into the care delivery system of a teaching hospital which is associated with a medical school. I understand that some nursing schools offer residencies associated with teaching hospitals. This is a good thing, but there aren't nearly enough spots in such residencies to cover the present number of new grad nurses and it is cost-prohibitive for smaller hospitals.

The problem new grads are facing is not due to them being ineligible to fill open positions. Back when there really was a shortage new grads were courted with all sorts of enticing perks. It's a supply-and-demand situation (there is no nursing shortage right now) where hospitals can choose to hire experienced nurses out of a large pool of applicants, because it's more cost effective. Not sure when your mom graduated, but my recollection is that nursing schools provided much more hands on training than they do now. Orientations were shorter then, not longer, and a year-long orientation would be unheard of in most of the hospitals in the 70s when I graduated. My first job was in a teaching hospital right after I graduated so I do have some real life experience in the differences between both models.

Perhaps new grads of recent months and years are willing to work for dirt cheap wages, but being familiar with the topic for almost 10 years of reading posts here, starting at less than the low-end of a narrow pay scale has been considered "insulting", and discouraged because accepting below market wages tends to have a downward effect on average wages for all nurses.

On any given day on this forum you'll find nurses "eating their young" to be a hot topic. The pecking order in a typical 3 or 4 year residency structure would have those people beside themselves. Interns know they have to earn their respect as they plug through the hell of their first year. I don't think nursing has accepted the same, and is more focussed on being treated almost as equal to their elders in the nursing world from day one.

It would be great if hospitals were willing to put a structure in place to accomplish what you're talking about, but who will pay for it, and how is it possible that all new grad nurses can have enough available spots in hospitals equipped to provide intensive orientation programs.

applewhitern I know there has been a movement to improve hours and pay for first-year residents for a while. "Dirt cheap" is probably a bad choice of words. I meant the wage when compared with the average pay of an MD is their chosen specialty post-residency. A couple of sites I checked has their pay between $40,000-45,000 - still not nearly enough for what they do.

[hodgieRN]

The pay is dirt cheap considering that we save lives. Police officers, fire firefighters, safety workers, and our military...all of us deserve way more than the suit who rips off the middle class for their golden parachutes. It's crazy that the people who make the biggest difference in our community can make less than $50,000/year.

To be back on point, I like the fact that we aren't molded for a specific job title. I enjoy the flexibility. Seems like every nurse has worked in 3 different positions within the first decade of their career. Doctors usually stay in their practice or they have to additional training and board certification. Nurses like the idea of bouncing around and just needing on the job training. That's one of the reasons nursing is popular. You can work in any area you want. If you don't like it, you can transfer into something else. I don't think nurses would approve of needing to take a new entrance exam just to change the career path.

[LadyFree28, BSN, LPN, RN]

I live in a area that most if not ALL of the hospitals have a new grad residency program, even in the areas considered "rural." Most are specific to specialty. The organization I work for has a new residency program, as well as a clinical ladder model program. In six months I get a 3% raise, then I get a 13% raise (includes my previous experience as a LPN) and status...

I work in a ICU setting and have 10 weeks orientation/preceptorship, skills classes, and ICU classes, and training between 8-12 months post orientation, as well as credit hours and plan to become CCRN certified. Education and competent care is paramount and encouraged at this org and the hospitals in the area. I also have a contact person to speak to regarding personal struggles and challenges and unit challenges, selection of a mentor, and unit/nurse governance is required.

When I had Research nursing and was preparing a research proposal, I did come across studies implying that a residency program is correlated with decrease in turnovers.

I hope that there is a push to either include in the funding used for medical residencies to include nursing, especially in rural areas. Despite the idea that nurses are the "bottom line" we are the front line, and that cannot be eliminated. Improvement is needed to help foster success in nursing profession, though residency programs, skills and staff development, and even a collaborative push to mentor each other, regardless of new grad, new staff nurse, seasoned nurse that need honing of skills, and everything in between.

[Rhody34]

I was hired into a nurse residency program as a new grad at the hospital where I work now. It was 16 weeks and I floated and was precepted in their "critical care track"... they have other tracks as well like med-surg, home health, OR, Psych, etc... I floated on the telemetry, PCU, CCU, and ER. At the completion of the residency I was eligible for hire on any of the units I floated to- I was picked for their telemetry unit, and I continue to work there today. This hospital has a very successful nurse residency program, and they bring, on average- 40 new grad nurses into their hospital per year. I think more hospitals SHOULD implement this into their hospitals and as it really builds a close knit nurse culture in the hospital. Many of my preceptors had been through the residency themselves!

[LadyFree28, BSN, LPN, RN]

I was hired into a nurse residency program as a new grad at the hospital where I work now. It was 16 weeks and I floated and was precepted in their "critical care track"... they have other tracks as well like med-surg home health, OR, Psych, etc... I floated on the telemetry, PCU, CCU, and ER. At the completion of the residency I was eligible for hire on any of the units I floated to- I was picked for their telemetry unit, and I continue to work there today. This hospital has a very successful nurse residency program, and they bring, on average- 40 new grad nurses into their hospital per year. I think more hospitals SHOULD implement this into their hospitals and as it really builds a close knit nurse culture in the hospital. Many of my preceptors had been through the residency themselves![/quote']

^So was my preceptor in the program I am in.

[KatieMI, BSN, MSN, RN]

OK. Here is something not all of you probably know.

First, the process of applying for physician's residency costs A WHOLE LOT of money. There is an organization, popularly known as "The Match" which takes from about $50 for each application prospective candidate sends to a particular hospital. Counting that for most competitive specialties even the cream of US grads have to apply for every single program in the country, and that no program will put the candidate in its "list" without a formal interview, the total lump can easily go over a few thousands. And that's not paying for the residency - just for a mere chance to get into it. There is absolutely no chance to avoid this money sucker.

Second, the "match" is, basicaly, all about math and stats. Whatever "they" are saying (and they LOVE to say about inherent beneficiency of the process, blah, blah...) it really cares only, and ONLY about programs' interests. Only one way for an applicant not to end in some God-forsaken place in the middle of nowhere is not to apply in this place, or not to put it into "his" Match List. If, as it quite commonly happens, applicant still put one or two not-so-good places there, then.... well, nobody cares. You're bound for "X" years to be a resident there, and nobody cares that you may have, for example, something named "family". Also, nobody cares if after slaving out years in there everything you can get is local family medicine practice (all residency programs are known for training and connections they provide; usually applicants know exactly from the very beginning where they can get jobs and fellowships and where they can not).

Third, as it was mentioned here already, residency trainign programs bring money in hospitals. The money are paid by All Mighty Medicare in amount approximately $200000/year/resident's head. The hospital has absolute freedom in how to spend these money. They not only pay less than $10/hour (counting the real time worked), they laso charge residents for things like parking, meals and sometimes library using. Recently there appeared a trend to increase training time for family practice residents from 3 years to 4, with presumption that the time can be used for learning "management skills"... got the idea??

Fourth and the worst of it. The problem is, the resident is, like a slave, personally bound with the program for the time of his or her training while the program is not. Not only resident cannot immediately leave program and just join another, in some specialties he has to stay in the place for "X" years just in order to be, with time, eligible for Boards and license. After that condition, the absolutely, bloody worst kind of "nurses eating their youngs" looks like innocent babies' play comparing with what is considered to be a norm in medical residencies, including things like sabotage, diversions and physical aggression for those unfortunate ones who didn't figure out immediately that 75% of residency is about politiking and not about medicine. The attendings who know that their behavior will one day or another bring them loss of their licences tend to gather in residency programs because there they can do whatever they like and be happy with their reputation of "strong guys" and because, once canned out (for whatever reason, legal or not), a resident has close to 0 chance to get into another program. And that's the main difference. A newly graduated nurse can switch floors, hospitals, specialties and states as often as he/she wishes, and unless there were VERY dubious circumstances, his/her licence looks nice and blemish-free. A resident who switched programs within the same specialty just in order to be able to visit his dying mother once every week can be legally denied licensing simply because of it, or can be "sentenced" to repeating couple of years of training... again, because of it, alone.

I'd known a guy who managed to go through surgical residency (5 years) traume fellowship (2 years) and thoracic surgery (3 more years) and broke his spine while skiing during his second year of practice, ending with his both legs paralyzed. Everybody though that, after reading thousands upon thousands of X-rays of every kind, he would do just fine as radiologist. But in order to do so he must complete another full residency (4 years, if not more) in order to become qualified to, basically, read chest X-rays and the like. The doctor carefully collected his pain and sleeping pills for a while, went home and took them there all at once. He left a note mentioning, among other things, that he was dying happy knowing that his widow and three small kids won't carry his $$$$$ educational debths.

Nursing has a whole lot of problems of its own, and to copy blindly a system widely recognized as arcane, wasteful, deceptive and inherently prone to supporting the worst features of human nature would be the worst mistake possible.

[PMFB-RN, RN]

You didn't complete a nurse residency? I did. Nurse residency in Critical Care. Nurse residencies already exsist. Obviously not wide spread and what some organizations call "residency" can be something pathetic like meeting for 4 hours a week or some brief four month orientation.