Educating new nurses

Student4_life · Jun 22, 2011

Nurses will need to take 10 cents on the dollar while in residency like Doctors do. But no-one wants to get paid 2.50 an hour.

wazeout · Jun 22, 2011

I think you make some good points, and I would hope hospitals that are seeking Magnus status by pushing all nurses to become BSN's would take a page from your essay.

Amparo Pagan Titmus, MSN, RN · Jun 22, 2011

I applaud your efforts. You are thinking, looking for solutions and that is wonderful. I am not sure the a residency program similar to physicians is needed however a well structured orientation program certainly is. As part of my work, I developed a 16 week orientation program. As educator, I met with the preceptor and orientee every 2 wks to review progress and set goals. These feedback and goals were written and required input from each. It was time consuming but very productive.

As you continue your research, you will see that reasons for high turnover of RNs in the first year are many. Proper orientation is just one. Unrealistic expectations is another. Lateral violence, how receptive and helpful are the existing staff? Of course the setting is key. Having been a travel nurse for many years, I have seen huge differences in the ambience, the culture, of a facility and units. BTW, I have worked at Magnet hospitals and they have been hands down the best places to work. Thus the reason the term magnet is used, it attracts nurses and historically have very little turnover. Studying this model would be very helpful to your project.

Thank you for caring and best wishes

Amparo Pagan Titmus, MSN, RN · Jun 22, 2011

Oh and follow through after orientation is done is important. Maybe a quarterly meeting, "How are things going?, What can we do better?" type thing. We bring them in and love on them for such a short while and then we just push them off the edge?

This is an area that I have strong feelings about.

HouTx, BSN, MSN, EdD · Jun 22, 2011

Actually, there is a "subsidy" already available for nurse training programs - by way of Medicare cost reports. Organizations can "pass through" their costs on their annual Medicare Cost Reports. The programs have to meet very specific criteria:

* Be approved for CE -- this means they cannot be a repetition of basic nursing education

* Be graded - measurable outcomes based on a logical grading scale

The organization has to establish a very careful financial tracking process to ensure that all reported costs are clean. It's almost certain that these claims will be audited because they are so rarely included on cost reports. If you want to research this, it is in the CMS rule # 413.85 Cost of approved nursing and allied health education activities.

This is the way most hospital-based diploma programs stay(ed) afloat for so many years. Unfortunately, it seems that the financial wizards who manage hospital financial systems are clueless in this area, so hardly anyone is taking advantage of this funding opportunity.

classicdame, MSN, EdD · Jun 22, 2011

THANKS, HouTx. Good info.

As for the original post, I realize there is a gap between nursing school and nursing practice, but it is sad to me that someone who is deemed competent to have a license does not know how to do their job. We have to spend lots of time and money RETRAINING new grads. Rather than residency programs I am more in favor of BSN as entry level to nursing in a hospital. We have better results with BSN students because they have "become" a nurse in that longer period of time.

DogWmn · Jun 22, 2011

While that's all well and good, I don't feel you are getting to the big elephant in the room. WHY are new grads so poorly educated that they need prolonged preceptorships. I believe nursing programs overall need to be re-evaluated. When they did away with the Diploma programs they shot themselves in the foot. Those new grad nurses could do the job with minimum orientation (30 days), why because they had a hospital based program with tons of clinical hours that were REAL clinical hours, they were trained to do the jobs they were hired for when they graduated, if you didn't cut it - you flunked out period. My LPN program was based on the Diploma school model and we had tons of clinical hours,we worked full shifts and were expected to do the work and class after and before the shifts - if not we were gone. When I graduated from nursing school, my first job was a med/surg floor, I had a few weeks orientation and off I went. In my area when the ADN programs were started, their requirments were you HAD to have been an LPN, nurse aid or medic for so many years, they didn't take just "someone off the street" with no medical training or background, the experience was to suppliment the lack of clinical hours offered in those programs.

Preceptorships are a "nice idea" but I think you really need to look at why they are needed in the first place, new grads should be able to hit the ground running with basic orientation. It's not the hospital's job to train a new grad for months on end, they are supposed to be functional but they no longer are.

I think the whole nursing education model needs to be revamped and return to more hands on and less fluff.

llg, PhD, RN · Jun 22, 2011

I agree with most of what is being said in the responses to this thread. While the OP is doing fine with her beginner-level thinking on these issues, most of us who have been "in the trenches" for a while know that things are a lot more complicated than they may appear to a newbie.

I too believe that hospitals should not be expected to bear such enormous costs for the "re-training" of new grads. New grads should not be licensed or expect a professional salary unless they are prepared to function as a professional in the RN role. That means that we need to either:

1. Upgrade nursing education and eliminate those programs that don't prepare their students to function. (And yes, it can be done in a standard 4-year BSN program. We regularly hire from a few high quality schools that do a great job. Their graduates don't NEED fancy residencies/internships unless they are hired into special care units.) It means eliminating many "accelerated programs" and ones designed to "fit the student's lifestyle" -- at the expense of preparing students for the real world of professional practice.

or

2. New grads need to accept a dramatically reduced "training wage" similar to that of physician residents. If the employer is going to be expected to provide new grads with what is essentially an "apprenticeship," then the new grad need to accept the fact that they are, indeed, "apprentices" and not yet professional nurses. Alternatives could be the signing of work contracts in which the new grad would pay for the training if they didn't stay on the job for a specified length of time, etc. But my point is clear. Hospitals can't afford to pay the tens of thousands of dollars that such programs cost with no promise of getting anything back in return.

Personally, I think both approaches should be taken simultaneously -- ASAP.

sethmctenn · Jun 22, 2011

In our area, residency programs are common. Graduate nurses make around $13/hour until licensed and undergo extensive training that continues into their practice after they are licensed. Once licensed, they make their full rate. A typical program consists of two 12 hour shifts shadowing and two eight hour shifts of classroom work. This program continues for around 3 months (typically 1 month or more before licensed and 2 months after licensing). It has been very successful. Training programs are expensive but you only have to prevent one CLABSI, fall, or pressure sore to pay for several nurses to go through them.

The residency classes do repeat some of nursing school. Most of it, however, is facility specific training and enhancement of clinical thinking skills and skills not commonly taught in nursing schools (glucostabilizer, advanced dysrhythmia recognition, alsius, ACLS, PALS, NRP, etc...).

WildcatFanRN, BSN, RN · Jun 23, 2011

THANKS, HouTx. Good info.
As for the original post, I realize there is a gap between nursing school and nursing practice, but it is sad to me that someone who is deemed competent to have a license does not know how to do their job. We have to spend lots of time and money RETRAINING new grads. Rather than residency programs I am more in favor of BSN as entry level to nursing in a hospital. We have better results with BSN students because they have "become" a nurse in that longer period of time.

Nurse Residency programs are not "re-training" nurses, at least not the ones in my research. Most of the classroom work is on things not covered in nursing school and are unit specific. Some residencies do review some things, but not all.

I don't understand how a BSN student can "become" a nurse by virtue of being in a 4 year program vs a 2-3 year program. Not all BSN programs have the same kind of clinical experiences same as ADN programs. Residency programs are not for hand holding new graduates who are not competent to do the job, they are for transitioning people from classroom nursing to floor nursing something that a lot of people have trouble with. Competence has nothing to do with it.

WildcatFanRN, BSN, RN · Jun 23, 2011

I agree with most of what is being said in the responses to this thread. While the OP is doing fine with her beginner-level thinking on these issues, most of us who have been "in the trenches" for a while know that things are a lot more complicated than they may appear to a newbie.
I too believe that hospitals should not be expected to bear such enormous costs for the "re-training" of new grads. New grads should not be licensed or expect a professional salary unless they are prepared to function as a professional in the RN role. That means that we need to either:
1. Upgrade nursing education and eliminate those programs that don't prepare their students to function. (And yes, it can be done in a standard 4-year BSN program. We regularly hire from a few high quality schools that do a great job. Their graduates don't NEED fancy residencies/internships unless they are hired into special care units.) It means eliminating many "accelerated programs" and ones designed to "fit the student's lifestyle" -- at the expense of preparing students for the real world of professional practice.
or
2. New grads need to accept a dramatically reduced "training wage" similar to that of physician residents. If the employer is going to be expected to provide new grads with what is essentially an "apprenticeship," then the new grad need to accept the fact that they are, indeed, "apprentices" and not yet professional nurses. Alternatives could be the signing of work contracts in which the new grad would pay for the training if they didn't stay on the job for a specified length of time, etc. But my point is clear. Hospitals can't afford to pay the tens of thousands of dollars that such programs cost with no promise of getting anything back in return.
Personally, I think both approaches should be taken simultaneously -- ASAP.

Why does everyone think a residency program is for re-training what was already taught in nursing school? From what I understand about residencies new nurses are taking full loads of patients long before the year is out, but what they do get is extra support. Why is supporting new nurses during that difficult first year so anathema to people?

I'm not not a beginner in all this, granted I haven't really worked as an RN yet I was an LPN for 13 years. I went to school to get my ADN and that program built upon what I had already learned as an LPN. However I didn't appreciate the real differences in RN and LPN's until I was attempting my first job as an RN. I would have loved to have been in a residency program as hind sight being 20/20 I was having trouble with the transition between the thinking as an LPN and thinking as an RN.

Hospitals CAN afford to pay for these programs if the actually started looking at nurses as assets. It costs tens of thousands for these programs, ok. How much does it cost to train a new nurse who then quits, train the replacement, who then quits, train that replacement, who then quits, etc, etc, etc?

IMHO the "hit the floor running" mentallity is fine and good, but there is no BSN program or ADN for that matter that produces nurses able to function at full capacity fresh out of school. But the attitude I'm getting from a lot of the posts are that if your not, then you shouldn't be able to get your license.

I don't have a problem with lower wages while in the residency program as that might help allow more people to participate, however what's to keep the hospital from making the lower "residency" pay rate the new entry level pay? There also needs to be an agreement between the hospital and the new nurse that you will pay back x amount of funds if you quit or are fired from said residency. Nor should residencies be "easy", you should learn a lot and experience a lot of different patient areas that you usually don't actually to practice in during clinicals at school.

I guess my point with my paper and what I'm interested in doing is helping more new nurses make a successful transition to practice. I know there are more reasons than orientation for the reason that new nurses quit the profession. But this is a huge one that can be fixed with more support. Fixing the other ones require not tolerating lateral violence in the workplace and creating a culture of mutual support and well, camraderie. Actually it will take A LOT more than that, but it's a start.