Nurse Residency Program Manual

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Nurse Residency Program

Manual

Authored by:

Louise M. Rebello, RN, MSN/ED

Maria Tassoni, RN, BSN

Edited by:

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 DEDICATED TRANSITION UNIT

The purpose of this manual is to describe the Dedicated Transition Unit (DTU) model utilized at Southcoast ® Hospitals Group (SHG). The DTU serves as the Nurse Residency Program (NRP) outlined by the IOM recommendation number three. The manual is intended to communicate the strategic, operational, and tactical pursuits of the DTU. The manual user should be able to apply this information and replicate the SHG DTU processes and outcomes.

Mission

To provide and foster support to the newly licensed registered nurse (NLRN) during their transition from student to professional nurse so that the NLRN can continue to carry out the mission set forth by Southcoast in its commitment to improve the health of, and promote the wellness of individuals and communities we serve.

Vision

With support and guidance, the NLRN will model professional behavior as an advocate for Southcoast.

By providing much needed support to the NLRN, Southcoast will increase its retention rate of highly qualified RN’s.

Values

Communication/Teamwork: Foster an atmosphere of open communication, mutual respect and trust and aligned commitment to organizational goals.

Value-driven: Strive to provide demonstrably high-quality, cost-effective health services that meet the needs of the diverse communities we serve.

Commitment: Demonstrate through our behavior and individual and collective belief in the values, mission and goals of Southcoast Health System.

Proactive: Embrace the opportunity to create a new model of community based, integrated health financing and delivery.

Customer First: Exceed the quality and services expectations of our multiple customers, including our patients, their families and the communities we serve.

Excellence: In partnership with our associates/employees and affiliated physicians, make Southcoast the best place to work and, therefore, the best place to obtain health care.

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 Stewardship: Foster personal and professional accountability for the good of the overall organization and the communities served.

Community Driven: Promote continued local community ownership, governance and active involvement in the development of Southcoast.

Unit Selection

Unit Selection involves identifying a manager who has the ability to assume ownership for a program that serves the needs of the institution, not only their unit. The DTU requires attention away from the typical responsibilities of a nurse manager to focus on developing their current staff as ambassadors and educators; as well as shepherd NLRNs into their professional nursing careers. The nurse manager must also partner with a unit based educator. The manager must share the mission, vision, values, and goals of Southcoast Hospitals Group and those of the DTU.

Unit Based Educator Role

The educator, or DTU coordinator, should have an understanding of adult learning theory, the teaching/learning process, domains of learning, evidence based practice, transitions of theory to practice, a contemporary view of nursing higher education, a strong clinical back ground, and experience in teaching. The educator should be a partner with the nurse manager, who is able to articulate the educational and experiential needs of the NLRN. The educator also needs to be aware of the preceptors’ abilities, strengths, and weaknesses. In addition, the unit educator will focus on the population served by the unit and tailor educational opportunities to meet those specific needs.

Preceptor Education

All registered nurses on the DTU are expected to act as preceptors for NLRNs. The process of education provided to the unit staff as preceptors includes the institutions general preceptor class and a class regarding “Nurse of the Future Core Competencies” (NOFCC) as outlined in the Massachusetts Department of Higher Education Nurse Initiative (MDHENI). Focus of the SHG preceptor class describes the preceptor role related to teaching strategies that assist the NLN with the transition to professional practice. The expectation for the nurses that complete these two courses is that they will have the knowledge base that will allow them to synthesize the

information and apply it to the variety of teaching and learning circumstances occurring during times with the NLRN.

The unit staff members should also be clear about the expectation that they are the professional example for NLRNs and serve as mentors, colleagues, friends, experts, teachers, and general resources.

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013

Hiring Practices

Although there are six positions available for each cohort within the DTU, only one job is posted on the job board. This prevents each applicant from applying to six different job postings. Cover letters and resumes are reviewed by the nurse manager and DTU coordinator to screen applicants prior to the interview process. Things to focus on within these documents include; date of

licensure (to qualify as a NLRN, the candidate should receive initial licensure within the past 12 months), distance the candidate will have to travel to get to work, degree held, work history, community service, and whether they are an internal (current employee of SHG) applicant or an external applicant.

Each applicant is granted an interview. Light conversation includes those items from their cover letter or resume the interviewer finds interesting. A list of interview questions was developed with a purpose to solicit specific information about the applicant (see appendix A). If community service is noted on the resume, a discussion about such service takes place to gain an

understanding of the applicant’s interests and endeavors. While community service is not a requirement, we believe it shows a dedication of service to others and humility.

Pay Rate

The NLRN’s entering the DTU are paid a graduated salary. The pay rate is $18 an hour for the first nine weeks. This includes the first week of mandatory Southcoast Hospitals Group

orientation and the eight weeks they spend on the DTU. When the NLRN transitions to his or her unit and shift of hire, the pay increases to the current rate associated with a nurse of equivalent experience and education.

Preceptor Assignment

Each NLRN is assigned, or paired with, at least two preceptors. They usually have about four preceptors within their 8 week DTU experience. This is based on availability, preceptors

schedule, vacations, requested time off, float shifts, and sick days. It is important to the NLRN’s success that the preceptors be consistent however, there are times when changes are needed. For example, if the NLRN and preceptor have different learning or teaching styles, personality conflicts, or perceived views of their relationship that will not facilitate the NLRN’s transition to professional nursing, a change in preceptor is evaluated.

If the NLRN becomes concerned regarding two or more preceptors, a conversation ensues to reassure the NLN that it is beneficial to witness a variety of styles in providing quality nursing care.

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Structure

The program is 40 hours a week Monday through Friday 7am to 3:30 pm, no weekends, no holidays, and no overtime. The NLRN’s attend the Southcoast Hospitals Group orientation in the first week of employment. They spend eight 40 hour weeks on the DTU following that first week of orientation. Therefore, in total, the first nine weeks are paid at $18 an hour. The NLRN’s are on the unit Monday, Tuesday, Thursday, and Friday for clinical practice with a preceptor. Wednesday is enrichment day (see description below).

During the first full week on the unit (usually week two), the NLRN is assigned one patient from their preceptors assignment. The next week they are assigned two patients and so on until each NLRN is managing a four patient assignment. Not all NLRN’s progress at the same rate. Some are very comfortable with increasing their patient assignment ahead of schedule; while others may need a few days with fewer patients to hone their organizational and time management skills.

Wednesday has two components including enrichment experiences and didactic classes.

Enrichments

The enrichment experiences have two purposes. The first is to have the NLRN appreciate the contributions from all departments in providing quality care for each patient. The enrichment experiences also give the NLRN an opportunity to observe other professional nurses in roles different from their own.

Enrichments include:

 Time with the health unit coordinator (HUC). This experience is meant to show all the

responsibilities a HUC has, how the HUC manages his/her job while taking care of the many requests by nurses, physicians, ancillary departments, and patients and families all the while entering orders and answering the phone.

 Case management or care coordination is fascinating to the NLRN. This experience is

helpful for the NLRN to understand why the patient may be discharged and the costs and reimbursement involved in each case. This experience helps the NLRN understand criteria necessary for admission to the hospital and what needs to be done to safely discharge a patient.

 The cardiac catheterization lab is a favorite of the NLRN. This experience allows the

NLRN to work with a group of highly skilled professional nurses and to observe interventional procedures that occur for patients with cardiac disease.

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 Complete rounds with the Wound and Ostomy nurse. This experience opens up

opportunities to the NLRN as he or she gains practice experience. The NLRN spends the morning making rounds with the WOCN nurse and learns how to stage a wound, how to document the staging, and which dressings are used.

 The experience with the bed flow facilitator (BFF) allows the NLRN to appreciate how

important and difficult it may be to place each patient in an appropriate bed on an appropriate unit.

 Knowles Diagnostic Procedures (KDP) is an outpatient and infusion department. The

NLRN’s learn IV insertion skills under the direct guidance of Dawn Richards RN. Dawn offers the NLRN an opportunity to practice IV insertion, selection of polycath, and experience with blood transfusions.

 Each NLRN spends a morning in the outpatient pre-op area. Here, he or she works with

an experienced RN learning and honing IV insertion skills.

 Respiratory Therapy takes the NLRN’s on a shadow day so the new nurse can understand

the different respiratory therapies provided to the patients of Southcoast.

Didactic

The classroom experiences are meant to focus on practice issues. See descriptions below.  Congestive Heart Failure (CHF) is usually one of the first classes provided. This class

focuses on such clinical questions as, “what do I do if my patient suddenly goes into flash pulmonary edema?” Other factors include patient teaching focusing on making sure the patient receives all of the required CHF teaching, discharge instructions including teach back, and proper documentation.

 The NLRN’s are provided a review of Type 1 and Type 2 diabetes. Diabetes educator

Madeline Su RN utilizes case studies to guide the NLRN into making decisions consistent with positive patient outcomes based on the diabetes protocol, policy and procedure. One scenario includes the following: What do I do if my patient has an order for “nothing by mouth” (NPO), scheduled for surgery, and has an elevated blood sugar, along with basal and sliding scale insulin ordered?

 The class on quality initiatives informs the NLRN about why we are measuring certain

outcomes. It also offers the NLRN an opportunity to become involved and feel like part of the team. Knowing the quality initiatives within Southcoast and those that are unit-based provided the NLRN an opportunity to practice within the guidelines set to achieve the outcomes expected.

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 Pain and Culture is a class offered so that the NLRN can become aware of how to

measure pain and discomfort in patients with diverse backgrounds. For example, the NLRN is taught to rely on objective and subjective data in addition to the standard pain scale currently utilized. A separate class on culture is offered to the NLRN to help with acceptance of others who are different from themselves. For example, sexual orientation, obesity, and nationality.

 The class on National Patient Safety Goals is given so the NLRN can be aware of specific

areas of concern in regard to The Joint Commission. For example, in 2012, catheter-associated urinary tract infection (CAUTI) was added as a NPSG.

 Infection Prevention comes to talk with the NLRN’s to reiterate the importance of proper

hand washing. In addition, the infection control nurse will review the different

precautions signs, what they mean to the nurses practice, and explain the algorithm to use when assessing a patient that may be removed from precautions.

 The patient advocate, Joanne Dunphy, speaks to the NLRN regarding customer service,

attitudes and behaviors, and service recovery. She uses a variety of teaching methods including discussion, question and answer, video, and case scenarios.

 The skin nurse conducts a class with a focus on staging wounds, when to initiate the skin

care protocol, who can initiate it, and what types of dressings to put on which types of wounds. The skin care nurse conducts a Pressure Ulcer Staging game where the NLRN’s are shown different pictures of wounds and are expected to pick the card with correct stage of the wound depicted.

 The bed flow manager does a class on the role of the bed flow facilitator (BFF) and what

role he/she plays in placing patients. The BFF also goes over the difference in capacity status and what is expected during capacity status green, capacity status yellow, capacity status orange, and lastly capacity status red.

 The NLRN’s receive a class on time management and delegation. During this class they

are shown how important it is to be organized, how to set up a user-friendly work sheet, and strategies to stay above water during a busy shift. They are also guided on delegation. Many NLRN’s are uncomfortable delegating to another and this class gives them hints on how to feel comfortable delegating a task to another and the roles and responsibilities of each person as per the Massachusetts Board of Registration in Nursing.

 Abnormal Labs is a class that came about because as a new grad myself, I never knew if I

should call the doctor or not. Here the NLRN is given a refresher on Arterial Blood Gases (ABG’s) and strategies on knowing when to call the doctor for an abnormal lab. They are

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 also taught about critical lab results and when it is appropriate to follow hospital protocol and when they need to call the MD.

 A mock code is conducted with Pat Mullins, RN, critical care nurse educator. The

purpose of this class is to expose the NLRN to the sequence of an actual code, the role of the primary nurse, how to record the events, and most importantly, how to be effective in an actual code. As a side note, each NLRN is taught how to and practices checking the code cart during orientation.

 A class on CIWA is given to help the NLRN understand the alcohol protocol, how to use

the scoring system, and the importance of monitoring patients.

 A class on restraints is given so that the NLRN is familiar with the policy set forth by Southcoast based on state mandate. It is important for the NLRN to learn alternative interventions and when it is acceptable to utilize restraints.

 One of the medical surgical nurse educators conducts a class on fall prevention. Here the

NLRN learns about safety scores, utilizing bed/chair alarms, and interventions to help reduce falls and falls with injury.

 A class on Central Venous Access Device (CVAD) is provided to all NLRN’s. The

NLRN is expected to complete two computer based learning modules (CBL’s) prior to the class. Here they learn about the different devices, flushing and blood draw policies, and dressing changes. This information is reinforced on the clinical unit with the educator and the preceptor.

 The manager of the inpatient psych unit meets with the NLRN’s to talk about behaviors

and ways to deal with patients who have brain illness.

Lunches

Part of enrichment day includes eating lunch together as a group. Each Wednesday during the 12 weeks of orientation, the NLRN’s have lunch together with the nurse manager and the DTU coordinator. The lunches are private and are meant to offer an outlet to the NLRN. It is usually during this time when the NLRN will talk about experiences they had on the clinical unit during the week, what things went well for them, what things didn’t go so well.

It is a relaxed format for the lunches. They are held in the conference room on the unit so as to keep the conversation private. During the week the educator should be aware of different experiences, conversations, and teaching opportunities that everyone could benefit from. For example, if an NLRN discovers the wrong IV fluid hanging, or a code is called on one of the

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 patients, or an NLRN performs a new task, the educator or nurse manager will say to the NLRN, “this would be a good topic for Wednesday.”

The educator may start the conversation by asking if everyone had a good week, or if anyone has something specific he or she would like to discuss. There is a conversation with each NLRN regarding the morning’s enrichment experiences. The lunch conversation usually ends with the educator asking everyone if they feel supported, if there are specific things anyone wants more experience with, and a reminder that they can speak to the manager or educator at any time.

Continued Support

When the NLRN’s complete their 12 week orientation period, they continue to come back together as a group meeting with the DTU coordinator and unit manager once a month for 12 months. They are each told during the interview process that these monthly lunch meetings are a program requirement.

Although it is called a “lunch meeting”, lunch is optional. Each person supplies his or her own lunch. The conversation is structured around experiences each NLRN has had on their new unit, and what resources are available to them. For example, one of the NLRN’s was hired onto the Progressive Care Unit (PCU) during a time when PCU was split between the 2nd and 5th floors for a short time. The NLRN talked about the challenges of being on a new unit, orienting on two floors, having to move equipment in the elevators, and what level of support was offered to her from the manager and the resource nurse.

The main focus is to touch base with each group and continue to offer support as they transition into their new roles.

How Progress is Measured

Progress is measured by frequent review of the NLRN’s competency packet. There are 4 ratings included within the packet and they are; introductory, novice, proficient, and expert. The NLRN may start as introductory for each competency listed, and move up in rating as they become more proficient.

The preceptors sign off each competency as it is completed. The NLRN is expected to bring his or her packet to the following; safe patient handling and the IV experience. These competencies can be signed off by Nellie Cabral in Safe Patient Handling class and Dawn Richard in KDP, and Aryle Drury, RN in the pre-op area.

The competency packet is reviewed by the DTU coordinator on or about the fourth week and the seventh week. By reviewing the competency packet in the fourth week, the DTU coordinator can then focus each NLRN’s learning experiences to meet the required competencies. For example,

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 if an NLRN has not been signed off on lab draws from a internal venous access device (IVAD)or a peripherally inserted central catheter (PICC line), the DTU coordinator can ensure that the NLRN gains that experience. Reviewing the packet in the seventh week ensures all required competencies are signed off and that the NLRN is progressing.

If there is a required competency that the NLRN has not completed, it is the responsibility of the DTU coordinator to seek out those experiences for the NLRN. For example, ensuring the NLRN has three successful peripheral IV starts.

There is also an Orientee Progress Assessment packet. This measures the NLRN’s progress in the following domains; Organization/Planning, Assessment/Manager of Care, Communication, Implementation, Critical Thinking/Reprioritizes, and Checklist Review. This is reviewed with the NLN and the preceptor at the following intervals; Week 3 or 12 shifts, Week 4, 5, or 6 or 16-28 shifts, Week 7,8, or 9 or 16-28-36 shifts, Week 10,11, or 12 or 36-48 shifts. Each week or section of the Orientee Progress Assessment lists the expected behaviors in percentages. For example, under week 3 the NLRN is expected to administer medications 50% of the time independently. Review of the Orientee Progress Assessment packet is conducted with the NLRN and the preceptor. This gives the NLRN, the DTU coordinator, and preceptor a chance to meet together to discuss the NLRN’s progress and to identify any competencies or practice issues the NLRN may need to improve upon. It is also critical during these meetings to talk about positive progression by the NLRN.

Role of the Unit Based Educator

The role of the unit-based educator, or DTU coordinator, is to coordinate the program and facilitate the learning. The DTU coordinator schedules all the didactic classes with each

educator/presenter. It is best to have one dedicated conference room that is set aside, or blocked out on a specific day each week, such as Wednesday. All didactic classes are held in that

conference room and each presenter or educator comes to that room. The Wednesday lunches are also held in this conference room. The DTU coordinator also reserves and/or sets up the lap-top and projector to be sure it is ready when the presenter arrives. An evaluation of each lap-topic and presenter is filled out by each NLRN.

The DTU coordinator is also responsible for scheduling the enrichment experiences. A list is made of each contact person for the enrichment experiences. The DTU coordinator will send a list to the secretary that includes the name of each NLRN, the date he or she will be there, and the time each will spend. A sample Wednesday is provided in Appendix B. In addition, a list of enrichment experiences, dates, and times is provided to each NLRN. See Appendix C.

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 In addition to coordinating the Wednesday didactic classes and enrichment experiences, the DTU coordinator spends most of his or her time on the unit on scheduled clinical days. The DTU coordinator will work from 0630 to 1500. Arriving at 0630 allows the DTU coordinator to assign the NLRN to the preceptor and the patient(s). The preceptor is responsible for the NLRN during their time on the unit with the DTU coordinator available for support to the NLRN and the preceptor. In addition, the DTU coordinator is to seek out learning opportunities. For example, to make sure each NLRN gains experience with admissions. There are times when an NLRN will leave the preceptor with the assignment and go with the DTU coordinator to do admissions, place a Foley, or draw labs from a port. The DTU coordinator is responsible for keeping a check-list to ensure each NLRN is granted the same learning opportunities.

Expected Outcomes

The initial expected outcome of the DTU is to improve the turnover rate of NLRN’s while providing the much needed support that was lacking. The expected outcomes have grown with this program. While we continue to look for ways to offer support to the NLRN so they will continue their employment with Southcoast, we find our own expectations have multiplied. One expectation is that we turn out nurses that are more confident in themselves and in their practice. We do not want new nurses to be hesitant to ask questions of nurses with more experience. In fact, we encourage it. The NLRN is taught, through positive role models and direct instruction to advocate for their patients and their families in a way to provide positive outcomes or comfort at the end of life. For example, if a patient’s pain is not controlled with a current medication regime, the preceptor and the NLRN contact the physician and/or consult pharmacy to make changes in the medications to provide the patient with optimal pain control. The NLRN is taught, again through positive role models and instruction, that it is a responsibility to advocate for the patient and their families.

The manager and DTU coordinator are expected to orient the NLRN according to the

competencies set forth by Southcoast so that we turn out more competent, confident nurses that feel supported in their role as professional care givers.

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 References

Ready, R, Fater, K, Conley, C, Rebello, L, & Cordeira, S. (2012). The Transition of Newly Licensed Nurses into the Workplace: Implementing a designated transition unit in a community hospital healthcare system. Nurse Leader, 10(4): 26-30.

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Appendix A

Interview Questions

1. Can you give me an example from a clinical experience or from a current job where you

feel you made a difference in a patient’s life?

Answering this question gives the applicant an opportunity to reflect on prior experiences and share a time that has meaning to them. The lack of an answer may indicate the applicant‘s indifference to the patient.

2. Can you give me an example of a situation where you had a co-worker you did not get

along with and how you dealt with that?

This will show the applicants ability to put professionalism ahead of personal feelings and the ability to get along with others as well as the capability to problem solve.

3. Can you give me an example of a time when you received negative feedback or a less

than positive performance review and what steps you took to correct it?

The answer to this question shows the applicants ability to accept constructive criticism and the ability to make positive changes to his or her practice based on those observations, and provide an insight to his or her reflective practice. In addition, it will highlight the applicant’s ability to remediate those things identified to be less than adequate.

4. Tell me about one of your best supervisors, professors, or coaches and how that person

made a positive impact on your career?

The answer to this question will show what qualities the applicant looks for in those in leadership roles.

5. Can you tell me something negative about yourself?

The answer o this question highlights the applicant’s ability to turn a negative into a positive. For example, the applicant may say something like, “I tend to take on too much responsibility.”

6. What positive qualities will you bring to Southcoast?

This question gives the applicant the ability to do a little self-promoting. Listen for those things that are important to Southcoast’s values such as;

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 Commitment/dedication

Team player Hard working

7. In regard to your nursing career, where do you want to be in five years? This question gives a perspective of the applicant’s goals.

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 Appendix B

WEDNESDAY, August 29, 2012

1. Sara 7-1130 KDP 12-13 Lunch 13-15 Diabetes

2. Jennifer 7-1130 Bed Flow 12-13 Lunch 13-15 Diabetes

3. Katelyn 8-1130 Skin 12-13 Lunch 13-15 Diabetes

4. Kristen 7-1130 Case Mgmt 12-13 Lunch 13-15 Diabetes

5. James 7-8 Cath Lab 12-13 Lunch 13-15 Diabetes

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Louise M. Rebello, RN, MS/ED & Maria Tassoni, RN, BSN 2013 Appendix C BED FLOW CASE MNGMT HUC MOCK CODE

ASU KDP SKIN CATH

LAB Sara 8/1 7-11:30 8/22 7-1130 9/26 7-1130 10/3 10-12 9/19 8-1130 8/29 7-11:30 9/12 8:30-11:30 8/15 7-11:30 Jennifer 8/29 7-11:30 9/26 7-1130 9/19 7-1130 10/3 10-12 9/12 8-11:30 8/15 7-11:30 8/22 830-1130 8/1 7-11:30 Katelyn 9/12 7-1130 8/1 7-11:30 8/15 7-1130 10/3 10-12 8/29 8-11:30 8/22 7-11:30 9/19 8:30-11:30 9/26 7-11:30 Kristen 9/19 7-11:30 8/29 9-11:30 8/1 7-1130 10/3 10-12 8/15 8-11:30 9/12 7-11:30 9/26 8:30-11:30 8/22 7-1130 James 8/22 7-1130 8/15 7-11:30 9/12 7-9 10/3 10-12 9/26 8-11:30 9/19 7-11:30 8/1 8:30-11:30 8/29 711:30 Jessica 9/26 7-11:30 9/12 9-11:30 8/29 7-1130 10/3 10-12 8/22 8-11:30 8/1 7-11:30 8/15 8:30-11:30 9/19 7-11:30