RESIDENCY PROGRAM IN REGARD TO THEIR PREPARATION TO CARE FOR CRITICALLY
ILL PATIENTS ____________
A Thesis Presented To the Faculty of
California State University, Chico ____________
In Partial Fulfillment
Of the Requirements for the Degree Master of Science In Nursing ____________ By Tamara Zupanc Spring 2010
PERSPECTIVES OF NURSES THAT COMPLETE THE NURSE
RESIDENCY PROGRAM IN REGARD TO THEIR PREPARATION TO CARE FOR CRITICALLY
ILL PATIENTS
A Thesis by Tamara Zupanc
Spring 2010
APPROVED BY THE INTERUM DEAN OF THE SCHOOL OF GRADUATE, INTERNATIONAL, AND INTERDISCIPLINARY STUDIES:
______________________________ Mark J. Morlock, Ph.D.
APPROVED BY THE GRADUATE ADVISORY COMMITTEE: _________________________________ ______________________________ Irene S. Morgan, Ph.D. Jennifer Lillibridge, Ph.D. Chair Graduate Coordinator
______________________________ Irene S. Morgan, Ph.D.
iii TABLE OF CONTENTS PAGE Acknowledgments... v Abstract... vi CHAPTER I. Introduction ... 1 Background ... 4 Problem Statement... 7 Relevance to Nursing... 8 Theoretical Framework... 9 Purpose... 11 Research Question ... 12 Definitions... 12
Qualifications of the Researcher ... 13
Summary ... 13
II. Literature Review... 15
Developing a Nurse Residency Program ... 15
Types of New Nurse Residency Programs ... 18
Evaluation of Current Nurse Residency Programs... 24
Summary ... 26
III. Research Methodology... 28
Sample ... 28
Ethical Considerations ... 30
Methods of Data Collection ... 31
Process for Data Analysis ... 32
Process to Establish Rigor... 35
iv
CHAPTER PAGE
IV. Study Findings ... 37
Orientation Process... 38
Solidifying Concepts ... 40
Importance of Debriefing and Discussion ... 41
Integration of Computer Content... 42
Value of Preceptors... 45
Becoming a Critical Care Nurse... 47
Areas for Improvement ... 54
Summary ... 55 V. Discussion ... 57 Role Transition ... 58 Preceptors... 58 Socialization ... 59 Skill Acquisition ... 60 Professional Development ... 61 Knowledge Application ... 62 Novice to Expert... 63 Implications ... 64 Study Limitations ... 69 Conclusion... 69 References ... 71 Appendices... 84
A. California State University, Chico – Human Subjects in Research Committee Clearance... 85
B. Marshfield Clinic Research Foundation – Institutional Review Board Clearance... 87
C. Research Invitation... 89
D. Significant Statements, Formulated Meanings and Themes ... 93
E. California State University, Chico - Human Subjects in Research Committee Post Data Collection Form ... 111
v
I would like to express my gratitude to the to my thesis advisor, Jennifer Lillibridge RN, Ph.D. who was abundantly helpful and offered invaluable assistance, support and guidance during this endeavor – aw thanks mate. I look forward to working again with you on getting this published.
I would also like to thank the nurses that participated in my study as well as my program manager for allowing me time to work on this project.
I want to thank my family; for their understanding & love, through the duration of my studies.
Last but in no way the least, I wish to express my love and gratitude my husband Jimmie who took on more than his share of maintaining the household, and watching and entertaining our little squirt, so I could have time to get this accomplished.
vi ABSTRACT
PERSPECTIVES OF NURSES THAT COMPLETE THE NURSE RESIDENCY PROGRAM IN REGARD TO THEIR
PREPARATION TO CARE FOR CRITICALLY ILL PATIENTS
by Tamara Zupanc Master of Science in Nursing California State University, Chico
Spring 2010
A phenomenological qualitative study was conducted to investigate the perceptions of nurses that completed the nurse residency program in regard to their preparation to care for critically ill patients. The main objective of the study was to evaluate if the combination of the components in the CCNRP were the appropriate tools, education and support to assist not only the new graduate nurse, but nurses new to critical care nursing. A purposive sample of six nurses participated in the study. Seven major themes emerged: orientation process, solidifying concepts, importance of debriefing and discussion, integration of computer content, value of the preceptors, becoming a critical
vii
care nurse, and areas for improvement. The theme of becoming a critical care nurse was further broken down into five subthemes: Becoming socialized, becoming a critical thinker, becoming independent, becoming a good time manager and recognizing
unrealistic expectations. The study results echoed the critical need for support of the new nurse to allow for transition and integration into nursing practice and hospital processes and systems. By understanding the new nurse needs and understanding the appropriate tools, education and support to meet those needs, this study has the potential to benefit other facilities that want to provide support for their new nurses coming into their critical care units.
1
INTRODUCTION
There is a global nursing shortage, which is expected to grow over the next two decades. The American Association of Colleges of Nursing (2008) project a United States (US) shortage of 500,000 registered nurses by the year 2025. The shortage is fueled by aging baby boomers as their heath care needs grow, as well as the many registered nurses that are approaching retirement age. The nursing shortage is especially acute in specialty areas. Critical care nurses account for an estimated 37% of the total nurses working in the hospital setting (American Association of Critical Care Nurses, 2008b).
Technology is currently expanding at a rapid rate to accommodate for sicker patients, creating a greater demand for critical care nurses, and experienced critical care nurses are retiring. This is making it difficult for hospitals to fill needed positions with experienced nurses. Hospitals are forced to hire from the pool of new graduates into specialty rotations. There are unique issues that arise for the new graduate in transitioning from nursing school. “Graduate nurse transition from an educational program into a practice setting has been widely recognized as a period of stress, role adjustment, and reality shock” (Casey, Fink, Krugman, & Propst, 2004, p. 303). The work place
environment challenges the new nurse to perform competently and proficiently in a short period of time (Owens et al., 2001). Transitioning from nursing school into specialty
practice adds to the new graduate’s challenges. According to the American Association of Critical Care Nurses (2008a) “critical care nurses practice in settings where patients require complex assessment, high-intensity therapies and interventions, and continuous nursing diligence” (para.5). The challenge of meeting the new graduate nurse’s transition needs as well as the advanced patient care requirements, poses specific educational issues as well. It is important that graduate nurses entering critical care receive an orientation that meets their transition needs and gives them a strong basic foundation in critical care.
There has been extensive literature on new graduate transition experiences in nursing, with re-occurring topics including: adjustments and experience during transition into practice (Casey, Fink, Krugman, & Propst, 2004; Ellerton, Gregor, 2003; Thomka, 2001), socialization and professionalism (Tradewell, 1996; Duchscher, 2001; Reising, 2002; Schoessler & Waldo, 2006), the role of preceptors (Delaney, 2003; Godinez, Schweiger, Gruver,& Ryan, 1999; Johantgen, 2001; Proulx & Bourcier, 2008), stress levels (Oermann & Moffitt-Wolf, 1997; Delaney, 2003), special programs to meet transition needs (Beecroft, Kunzman, Taylor, Devenis & Guzek, 2004), job satisfaction (Roberts, Jones & Lynn, 2004; Winter-Collins & McDaniel, 2000), role conception and role discrepancy (Young, Stuenkel & Bawal-Brinkley, 2008) and graduates perceptions of competence (Ramritu, & Barnard, 2001).
Tradewell (1996) estimated that it takes one year to master transition into practice. This was echoed in a study by Casey, Fink Krugman and Propst (2004) where they found graduate nurses felt that it took at least twelve months to feel confident and
comfortable practicing in the acute care setting. It was also noted that the most difficult period of role adjustment was between six and twelve months (Halfer & Graf, 2006). Benner (2001) proposed that a new graduate will be in practice for 18 months to two years before completing transition to being a competent nurse. The first years in nursing are a critical learning period during which the new graduate nurse enters as a novice and ideally receives experience, ongoing education, and support to socialize into the role of a competent and satisfied professional nurse.
When new graduate nurses needs are not being met, they have a higher turnover rate. While average nurse turnover rates at hospitals are 8.4%, average new graduate nurse turnover rates are 27.1%, which results in a high financial loss to the institution (Pricewaterhouse, 2007).
Nationally it has become recognized that there is a need to offer orientation programs for new graduate nurses. Hospital educators are challenged to offer transition programs for the new graduate nurses that will foster satisfaction, develop proficiency and encourage retention (Scott, Engelke, Swanson, 2008). “The specific knowledge required to practice nursing in today’s acute care hospitals has increased the need for a nurse residency program” (Altier & Krsek, 2006, p.71). Nurse Residency programs are becoming an emerging industry standard; they have been shown to increase recruitment and aid in retention of graduate nurses (Joint Commission on Accreditation of Healthcare Organizations, 2002). Residency programs are not a new idea; they have come and gone out of favor (Dracup & Morris, 2007). The current nursing shortage is growing, and to
prepare the thousands of nurses needed to fill upcoming positions, requires development of residency programs that will take the new nurse graduate novice learner to a more competent provider, especially in the critical care setting.
Background
A central Wisconsin hospital is a 500+ bed tertiary care teaching institution and is the only major rural referral medical center in Wisconsin. This facility is a level II trauma center. There are 26 beds in the surgical intensive care unit, 30 beds in the critical care unit and eight beds in the pediatric intensive care unit. With this many critical care beds there is a need for a large staff of critical care nurses. Due to the ongoing nationwide nurse shortage, and the inability to hire experienced nurses, the hospital started hiring new graduate nurses and training them on the units. The orientation program consisted of twelve weeks working at the patient bedside with a preceptor, and attendance at unit-specific proficiency classes. The newly trained graduate nurses had a very high turnover rate. When the exit interviews were reviewed, a common theme of “lack of educational preparation for caring for critically ill patients” was noted (J. Katzenberger, personal communication, September 10, 2007). Meyer and Meyer (2000) found that there is a direct correlation between nurse retention and adequate orientation.
The hospital formed a committee to address the issue, and their solution was the creation of a nurse residency program. In June 2006, the hospital began a formal critical care training program. This program is called the Critical Care Nurse Residency
Program (CCNRP). The formal goal of the program is to increase the knowledge and critical thinking skills of the new critical care nurse, and to increase retention. The hospital saw the nurse residency program as a way to train not only new graduates, but also nurses that had been practicing in other fields and desired to go into the intensive care nurse setting. This would encourage professional growth of the current nursing staff, and support the new nurse graduate in the transition into the role of critical care nurse. The goal of the increased retention could hopefully be realized by increased job satisfaction, which the nurses would have because of the hospital supporting their development. “Nursing retention is directly associated with job satisfaction” (Letvak & Buck, 2008, p 160).
The CCRNP is a seven month program that consists of three phases: The General Hospital Phase, the Advanced Medical-Surgical Phase and the Critical Care Phase. The curriculum is offered through various methods as it is recognized that it is important to provide a variety of orientation methods to give each of the nurse residents an opportunity to learn in their individual learning style (Alspach, 1984).
The General Hospital Phase consists of the general hospital orientation. This is attended by all new hospital staff. Covered in this phase are the hospital specific and universal competencies, quality and safety initiatives, Performance Based Development System (PBDS) testing, equipment and computer training, and the opportunity to learn about the health system. This phase is altered for nurses that are currently employed or
have done internships with the hospital and have attended some of the classes. This phase lasts two weeks.
The Advanced Medical-Surgical Phase curriculum consists of two eight hour classes per week that include expert nurse and physician speakers on critical care topics, professional development, the Essential of Critical Care Orientation (ECCO) computer program from the Association of Critical Care Nurses (AACN), hemodynamic
monitoring, and a class on electrocardiograms. Hands-on classes are also provided to instruct the nurse residents on the equipment within the critical care units. Simulation using SIM Man is also used to practice case scenarios. The nurse residents also work 24 hours on the medical-surgical floor with a trained preceptor. The nurses also have an expanded experience, which allows them to spend a day in one of several other departments in the hospital. These are departments that the critical care patients may encounter. The goals of this clinical time are to become competent in basic nursing skills, learn time management skills, prioritization, increase medication knowledge base, learn the hospital routines, and increase confidence in providing patient care and management. This phase lasts 12 weeks.
The final phase is the Critical Care Phase, which is 14 weeks in length. Classroom time during this phase is four hours a week, and advanced critical care topics are covered. Nurse residents complete additional classes in Advanced Cardiac Life Support, 12 lead Electrocardiograms, Intra-aortic balloon pump, Trauma Nurse Core
Curriculum, and Continuous Renal Replacement Therapy. During this phase residents spend 36 hours a week in the critical care units working with trained preceptors.
The program intakes two cohorts per year; February and June. The size of the class is dependent on the critical care nursing unit needs at that time. To date a total of five cohorts have completed the program. The first cohort of thirteen nurses began June 2006 and graduated in March 2007. The second cohort of seven nurses started February 2007 and graduated in October 2007. Cohort three consisted of 13 nurses that began in June 2007; they graduated February 2008. Cohort four had eight nurses, started February 2008 and graduated in August 2008. The fifth cohort, which started July 2008, graduated in January 2009.
Problem Statement
The shortage of nurses is having an impact on safe staffing and patient care (American Association of Colleges of Nursing, 2008). The current shortage of nurses is especially acute in critical care. This is impacted by a high turnover rate and loss of nurses to retirement. The American Association of Critical Care Nurses (2008b) describes how requests for temporary and traveling critical care nurses needed to fill staffing gaps have skyrocketed. Also described are how hospitals are trying all means available to recruit experienced nurses, and offering various types of orientation programs for new graduate nurses.
While hospitals can have minimal affect on retirement rates, they can impact retention rates by the programs they offer to support nurses, such as investing in a better orientation for new graduate nurses (Kovner et al., 2007). Meyer and Meyer (2000), state “effective orientation programs can result in increased retention of new nurses” (p 202).
From June 2007 to August 2008, Critical Care Nurse magazine published articles (Chesnutt & Everhart, 2007; Morris et al., 2008) on three different types of orientation programs for new graduate nurses. This is reflective of the growing use of new nurse graduates into critical care and the need to have sufficient education to support their success. Dracup (2007) states “given the considerations of patient safety and the financial cost of high turnover rates, residency programs may be our best answer” (p 330).
One measure of success of the new CCNRP could be new nurse retention rates in the critical care units. However, this does not provide data regarding the nurses perceptions of feeling prepared to practice in critical care areas or their level of job satisfaction related to their preparation. As this was one of the factors for the program development, it is important to evaluate this component as well.
Relevance to Nursing
This program specifically prepares nurses to work in critical care units. Results from this study investigated the perception of the effectiveness of the program
curriculum to prepare nurses to work in the critical care setting from the standpoint of the nurses that completed the program.
The intent of this study was to determine the value of the nurse residency program from the perspective of the new critical care nurse. When published, the findings from this study could assist other facilities in evaluating the benefits of a critical care nurse residency program, and to assist them in setting up their own curriculum.
Theoretical Framework
Patricia Benner’s Novice to Expert theoretical model will be used to guide the study. Benner (1984) stated that “experience-based skill acquisition is safer and quicker when it rests upon a sound education base” (p. xix). This would support the need for a strong critical care educational program for nurses to build their skills upon.
Benner (2001) adapted the Dreyfus skill acquisition model to clinical nursing practice. There are five levels of skill acquisition and development. The five stages are; novice, advanced beginner, competent, proficient and expert. Novice: the person has no background or experience in critical care nursing; they have difficulty discerning the important information and prioritizing it. This is applicable to the new graduate nurse and the experienced nurse that would be entering an area unfamiliar to them. Advanced Beginner: the advanced beginner developed some experience to grasp aspects of the situation, but has trouble with the larger perspective. They are able to demonstrate adequate performance. Competent: The nurse in this stage shows some mastery of the
situation through time management and organization of tasks. They demonstrate
conscious and deliberate planning. Proficient: The nurse looks at the situation as a whole; now with background information they can grasp the changing importance of a situation. Expert: At this stage the nurse is able to intuitively know the situation and adapt for changes in the plan of care based on the patient’s changing status, all on the basis of deep experiential background (Benner, 2001).
Novices and advanced beginners need specific rules to guide their actions (Benner, 2001). The medical-surgical phase provides the nurse residents with this
opportunity. This is a place where they are introduced to the policies and procedures that guide the patient care provided. This is the phase where they can strengthen their
procedural skills and the new nurses can begin to develop time management and critical thinking skills. They have a preceptor by their side to help guide them, provide clinical instruction, and lead by example. Having a strong base in those skills, gives the new nurse confidence upon entering the critical care units.
When the new nurses move into the critical care phase of the CCNRP they are developing some of the characteristics of the advanced beginner. As an advanced
beginner they are eager to learn, still easily overwhelmed with multiple tasks, and not yet attuned to subtle changes in their patients’ condition. They do not yet realize that there is a wealth of information that they do not know. As an advanced beginner, they can demonstrate a marginally acceptable performance. They organize their days work and structure according to the tasks that they must accomplish. The preceptors provide
assistance in setting priorities as the advanced beginner operates on general guidelines and is just beginning to see the whole clinical picture. Guidance is also provided to help the advance beginner to recognize unique aspects of the individual patient situations. This is the time when the new nurses are able to start applying the theoretical information they have been given and applying it in practice. There are opportunities to apply the
classroom theory and critical thinking skills with human simulation opportunities throughout this phase.
The goal of the CCRNP is to assist the nurse to develop over the course of the program from a novice phase to a proficient provider of an advanced level of care based on the quality and relevance of the education provided in the program. The program is also designed to help the new graduate nurse mature from the role of student nurse into the role of a professional nurse. This study will assessed the nurses’ perception of how the nurse residency program facilitated their progression from an advanced beginner to a proficient provider of an advanced level of care.
Purpose
The purpose of this research study was to describe and explore the
experiences of new critical care nurses’ and their perceptions of preparation for caring for critically ill patients through participation in the CCNRP. Through this study, the various components and pacing of the CCNRP were reflected upon ascertaining whether the combination of components were the appropriate tools, education and support to assist
the new nurse graduate to progress from advanced beginner to a proficient provider of care.
Research Question
What are the perceptions of the registered nurses that complete the CCNRP in regard to their preparation for caring for critically ill patients? It is hoped that within this question, the various components of the nurse residency might be commented upon during the interviews and then compared to the nurse’s needs and expectations. Does the Critical Care Nurse Residency Program meet the educational needs of the new critical care nurse to prepare them to work in the critical care unit? Interview comments may reflect the efficiency and effectiveness as well as the strengths and weaknesses of the different areas of the nurse residency program, and possibly highlight and identify any unmet needs. This can lead to changes that can be made to improve the program and fulfill any unmet needs of the new nurse.
Definitions
A Nurse is a person that has passed the National Council Licensure
Examination (NCLEX) and obtained Registered Nurse licensure. A New Graduate is a nurse that has graduated from a diploma, associate degree or bachelor’s degree nursing program in the last five months, has passed the registered nurse exam, and has not been employed in a nursing position prior to beginning the program. A registered nurse (RN) is a nurse that has passed the registered nurse exam, and has employed in a nursing
position prior to beginning the program, but not in the critical care arena. Registered nurses that enter the program can be either new graduates or RNs with no prior critical care experience.
The Nurse Residency Program is a postgraduate experience that is designed to support the development of proficiency in critical care nursing practice. It is designed as a transition from academia to practice (Herdrich & Lindsay, 2006).
Qualifications of the Researcher
The researcher’s background includes a Bachelor of Science in Nursing, Critical Care Registered Nurse certification, sixteen years as a critical care nurse, and four years as a nursing instructor at the university and college level for nursing students, three years as a nurse educator within the hospital system teaching critical care classes, current Master of Science in Nursing student in nursing education. The researcher has completed graduate level course in nursing research, and is currently employed as the critical care nurse educator for the critical care nurse residency program.
Summary
The nursing shortage in the United States is projected to grow. The Health Resources and Services Administration (HRSA) (2004) predict a shortfall of 36% by 2020. This greatly impacts the ability of the hospitals to provide experienced nurses in critical care areas. Hospitals are forced to hire new graduate nurses into critical care to meet the staffing needs. New nurses into critical care need orientation programs to
develop into nurses competent to provide care to critically ill patients. When nurses perceive they are not trained sufficiently to provide care, their stress levels increase, and job satisfaction decreases; this can lead to increased job turnover. Nurse retention is directly associated with job satisfaction (Letvak & Buck, 2008).
For a number of hospitals, the answer is a nurse residency program (Dracup, 2007). Nurse Residency Programs are fast becoming an emerging industry standard. There are many different types of nurse residency programs being offered. Because healthcare is a fast changing field, the programs need to be evaluated on a regular basis to assess from the nurse perspective if the program goals and educational needs of the nurse are being met.
15 CHAPTER II
LITERATURE REVIEW
An extensive search and review of the existing literature on the topic of Nurse Residencies was conducted through several databases including CINHAL, MedLine, Academic Elite, and PubMed. The keywords used: Nurse residency, program evaluation, new graduates, education, critical care orientation, new graduate orientation, outcome measurement and orientation. Many acute care facilities now recognize that a new
graduate nurse program is essential to drawing in new graduates and so these facilities are working to develop new graduate nurse programs of their own. Numerous articles were obtained regarding the new graduate nurse programs developed by many acute care facilities. The main themes that evolved from the search were: developing a nurse residency program, types of nurse residency programs, and evaluation of current nurse residency programs.
Developing a Nurse Residency Program
It was noted through the literature search that there were varying approaches to the development of programs designed to prepare new graduate nurses. A common thread through both the research and discussion articles was the statement that an
orientation program was needed for the new graduate nurse. Beecroft, Kunzman, Taylor, Devenis and Guzek (2004) state “new graduate nurses are inadequately prepared to begin
work in the clinical setting” (p.338). Chesnutt and Everhart (2007) discuss the
requirements of the new nurse graduate and go on to state” it is imperative that graduate nurses receive a clinical orientation that meets their needs as new nurses and gives them a strong basic foundation” (p. 36). New graduate nurses need the education and support to be successful in their nursing practice in the clinical arena.
A group process of major nursing stakeholders or appointment of a task force to help define the theoretical basis and curriculum was noted in many articles (Beecroft et al., 2004; Goode & Williams, 2004; Herdich & Lindsay, 2006; Proulx & Bourcier, 2008; Owens et al., 2001; Rashotte & Thomas, 2002; Seago & Barr, 2003; Williams, Goode, Krsek, Bednash & Lynn, 2007; Williams, Sims, Burkhead & Ward, 2002). It was stressed that a theoretical basis was critical to set up the learning structure. It was important to include nursing stakeholders to increase commitment to the program. Nursing
stakeholders included nursing administration, managers and nursing staff that would be working with the program on a daily basis. It is important to include nurses that are at the bedside who would know current practice needs. Herdich and Lindsey (2006) commented “a program’s effectiveness however, fundamentally depends on the implementation of a learning structure that support development of critical thinking, professional practice behaviors, job satisfaction, organizational commitment, clinical judgment, and
knowledge generation” (p. 56). Benner’s novice to expert theory was common theoretical base for much of the literature.
Santucci (2004) discussed the important components to take into
consideration when setting up a new nurse residency program. The author listed these as: A structured residency program, administrative support, preceptor development,
innovative strategies for integrating theory and practice and tools for documenting learning and performance. Lavoie-Tremblay et al. (2002) described their program and discussed what they believed were the key elements to facilitate new nurse orientation. The authors listed them as the welcome element, the training element, the supervisory training element, the support element and the evaluation element.
Redesign of existing programs was covered in the discussion articles by Chesnutt and Everhart (2007), Morris et al. (2007); Proulx and Bourcier (2008), and Seago and Barr (2003). Facilities that had existing new nurse orientation programs that were no longer successful at retaining the nurses, identified that they needed to redesign their programs. The redesign sought to improve on the previous program curriculum. Proulx and Bourcier, and Seago and Barr worked to foster critical thinking skills sooner through increasing technical proficiency. They also reviewed the preceptor teaming and patient loads. Chesnutt and Everhart added to this a preceptor education program. They proposed that by offering education programs to the preceptors that they were better able to precept the new graduate. Morris et al. redesigned a twelve week program to include computer orientation, human simulators, use of case studies as well as a preceptor program.
Curriculum development in the literature focused on the specific type of nursing area, for example, critical care, pediatrics, emergency department, and operating room. The content was planned to enable the new nurse graduate to synthesize clinical knowledge and apply it in a comprehensive fashion. The commonality of each of the programs was to provide training in the areas that were identified as issues with new graduate nurses, such as reality shock, delegation, professionalism, communication, peer support, mentoring, and to foster professional growth and commitment.
Types of New Nurse Residency Programs
It was revealed in the literature that the existing new nurse residency programs were highly variable in structure, content and resource requirements. They were also further defined by the types of hospital systems that the programs were used in. Hospital based new graduate nurse orientation programs frequently used the titles “nurse
internship” or “nurse residency”. Many of the programs were created by and used in individual hospitals, and some programs were used throughout a hospital system. There was also the National Post-Baccalaureate Graduate Nurse Residency Program, which was a specific identified program that was used at several individual hospitals.
The varied structures of the nurse residency programs fell under many titles: Post baccalaureate program (Goode & Williams, 2004; Krugman et al., 2006; Williams et al., 2007), competency based orientation programs (Fey & Miltner, 2000; Geslak, 2005; Herdrich & Lindsay, 2006; Proulx & Bourcier, 2008; Rashotte & Thomas, 2002;
Everhart, 2007), preceptor program (Johantgen, 2001), new graduate internship (Hall & Marshall, 2006; Jones, Mims & Luecke, 2001; Owens et al., 2001), shared leadership model (Williams et al., 2002), evidenced based model (Beecroft et al., 2004), and progressive orientation (Marcum & West, 2004; Seago & Barr, 2003).
The National Post-Baccalaureate Graduate Nurse Residency Program was the result of a task force comprised of members of the University Health System Consortium (UHC) and the American Association of Colleges of Nursing (AACN). The program was designed to increase the number of Bachelor of Science nurses (BSN) in the workforce through increased retention of satisfied and supported BSN nurses, however they also wanted to provide a more consistent, uniform transition into practice for the graduates (American Association of Colleges of Nursing, n.d.).
Goode and Williams (2004) and Krugman et al. (2006) both describe the beginnings of the post baccalaureate residency program. The authors then described the program objectives, conceptual framework and curriculum. The program started with six pilot sites and has grown to be used in 34 academic hospitals. The program’s curriculum is one year in length, composed of two phases.
Data from their respective evaluations of the program’s first cohort (n=259) surveyed turn over rates, nurse satisfaction, resident perception of autonomy, skill development and support, as well as the new graduates perception of his/her first year of work experience as a registered nurse. Findings showed positive results such as a
Williams, Goode, Kresk, Bednash and Lynn in 2007, evaluated the program at length. The authors felt that the data suggested “that internships or residencies that terminate before one year may not provide sufficient time for new graduates to establish
equilibrium in the clinical environment and may leave new graduates ‘on their own’ at an especially difficult time” (p. 364). This was due to a “V” shaped pattern (over length of the program) in scores from the McCloskey-Mueller Satisfaction Scale (MMSS) and Gerber’s Control Over Nursing Practice Scale (CONPS). Graduates rated themselves highly at the beginning of the program, lower in the middle, and then again highly at the end of the program. The authors concluded that the “V” shaped pattern reflected the vulnerability of new graduate nurses after they have been in practice for four to six months. These articles confirmed how one defined program could be used at many different facilities with successful results.
Competency based curriculum is defined as “an educational system that emphasizes a learner’s ability to demonstrate the proficiencies that are of central
importance to a given task, activities or career” (Alspach, 1984, p.655). Fey and Miltner (2000) add “for RNs, competence means that the caregiver can integrate knowledge, skills and personal attributes consistently in daily practice to meet established standards of performance” (p. 126). The AACN states in their Scope and Standards for Acute and Critical Care Nursing Practice (2008a) that nurses are required to have the competence to care for critically ill patients. In 1996 the Joint Commission on Accreditation of
competency based training for their staff (Decker & Strader, 1997). These issues were many times the driver for the development of the described competency based training programs. The six articles reviewed with a competency based format varied in length from the shortest at twelve weeks (Proulx & Bourcier, 2008) to the longest at one year (Rosenfeld et al., 2004). They covered different areas of nursing: critical care (Rashotte & Thomas, 2002; Proulx & Bourcier, 2008), emergency room (Williams et al., 2002), pediatrics (Beecroft et al., 2004), surgery (Geslak, 2005), and medical (Rosenfeld et al., 2004; Herdrich & Lindsay, 2006). In a competency based training program, the
orientation was more individualized to meet the learner’s needs. The focus of each of the programs was on specific competencies for the types of departments the trainings were for. This way the program developers were able to consistently evaluate those
competencies against a set of standards and expectations. The information in these articles demonstrated that a specific focus (competency) of orientation for nurses could be successful in orienting new graduate nurses.
A staged orientation program was the focus of a program developed by Chesnutt and Everhart (2007). The authors covered the redesign of an existing program by implementation of a staged program. The staged program was developed to address inconsistencies in the prior program’s content. The program evaluations of positive feedback from participants regarding the program stages validated the need to provide a consistent curriculum to the new nurse graduates.
Johantgen (2001) discussed the development of a preceptor program. The author focused on the idea that if the preceptors completed a strong training program, they can better provide an orientation to new graduates. Preceptors are an important part of the new graduate nurse orientation as they assume the roles of role model, teacher, mentor and assist in the socialization of the new nurse (Brasler, 1993). Preceptor education had been the topic of several other articles but not addressed as the guiding design of programs.
The articles addressing new nurse internships covered both single facility (Jones, Mims & Luecke, 2001) and system wide implementation (Hall & Marshall, 2006; Owens et al., 2001). Jones et al., discussed the two branches of their program: critical care and trauma nurse internship, and critical care nurse residency. Development of basic clinical competence is important to both programs; however, the residency focused in both cognitive knowledge base and clinical exposure. The programs were both 28 weeks in length. Owens et al., expound on the development of their twelve week program that was instituted within their medical system to five hospitals. Alternatively, Hall and Marshall (2006), describe a sixteen week critical care internship that was instituted at two hospitals within a health system. These articles described programs similar in nature to other nurse residency programs, just with a different title.
The article by Williams et al. (2002), illustrated the changes to an existing nurse residency program by implementing a shared leadership model. The authors stressed the need in their facility for a staff driven program to guide the needs of the
nurse residents, and the importance of a close relationship between the education department and nursing management. The authors discussed that through this collaboration, they were able to show a decreased turnover rate between floors that participated in the program, and floors that did not, in their 404 bed facility.
Beecroft et al. (2004) reported on the development of an evidence based new nurse curriculum. The authors commented on the importance of wanting to give the new graduates current and relevant information, utilizing major nursing stakeholders, and utilized a research based infrastructure. They stated that their approach to curriculum development was to provide “what RNs actually do in practice and what they need to know to perform successfully” (p.339). Beecroft et al. highlighted the importance of using current, evidenced based information to develop a program curriculum and complemented Williams et al. (2002), on utilizing collaboration from major nursing stakeholders.
Marcum and West (2004) reported on a structured progressive orientation. They developed a thirteen week program that had a scheduled progression for the new nurse graduate. There were specific foci for each step of the structured unit orientation. A similar progressive new nurse graduate orientation was detailed by Seago and Barr (2003). They discussed an eleven week program that had a set clinical progression. Should the new graduate nurses be unable to function at any of the expected levels of the program, the nurse was released from employment or placed in a less demanding unit. Both articles concluded with recommendations for improvements and changes to the
program for future use, such as avoidance of duplication of material, timing and sequence of material presented, monitoring the patient acuity assignments to match the needs of the new graduate, and that an eight hour shift of learning was more beneficial than a twelve hour shift.
Evaluation of Current Nurse Residency Programs
Several of the articles that evaluated new nurse residency programs utilized specific evaluation tools. Some facilities developed their own evaluation tools based on what the facility was evaluating about the program. The tools varied depending on what the authors intended to measure about their program. Some of the articles had no program evaluations discussed.
Marcum and West (2004) utilized several different tools to evaluate their program. Performance Based Development System (PBDS) was used to measure critical thinking and interpersonal skills. The American Society of Training and Development Evaluation Tool was used to evaluate the program training and effectiveness from the perspective of the new graduate. When this tool was evaluated in closer detail, it was a short thirteen question survey that asked general satisfaction questions directed toward a class as opposed to a program. The Professional Judgment rating form classified critical thinking skills. This form was a twenty question survey that an observer would fill out to rate an individual’s behavior.
Hall and Marshall (2006), utilized a Basic Knowledge Assessment Test (BKAT) to assess baseline critical care knowledge at the beginning of their program, and
then again at six months. They also developed their own tool, a Staff Development Program Effectiveness Evaluation (SDPEE), that evaluated the individual components of their program as well as summarizing the program overall. The results described in the article only covered cost effectiveness of the program.
The BKAT was also used by Herdrich and Lindsay (2006) in evaluating their program. The authors used established research and evaluation instruments to assess measurement of learner goals, but do not list what ones they used. They do describe using the Watson-Glaser Critical Thinking Inventory to assess critical thinking in their new nurse residents’ pre and post program.
The programs utilizing the postbaccalaureate nurse residency program
(Williams et al., 2007; Krugman et al., 2006; Goode & Williams, 2004) utilized a specific set of tools in the evaluation of their programs. The tools included the
McCloskey-Mueller Satisfaction Scale (MMSS), the Gerber Control Over Nursing Practice Scale (CONPS), the Casey-Fink Graduate Nursing Experience Survey, and an investigator developed residency program evaluation form and the University HealthSystem Consortium (UHC) demographic data base.
The MMSS was used to assess the nurse resident’s level of job satisfaction. This survey was also used by Altier and Krsek (2006) in evaluation of their nurse residency program. The CONPS was used to measure nurse residents’ perceived autonomy, or control over their work. To measure new graduate nurses’ perception of their first year of work experience as a professional nurse, the Casey-Fink Graduate
Nurse Experience Survey was utilized. The UHC demographic data base was used to track turnover rates, hospital and demographic data. The UHC program utilized a web-based database through a special portal on the UHC website to complete an investigator developed residency program evaluation form.
The postbaccalaureate nurse residency program evaluations took place at several times post program. Williams et al. (2007) evaluated the different nurse responses over a twelve month period. What they found was that the new nurse graduates “may be particularly vulnerable after they have been in a position for four to six months” (p. 364). This is an important piece of information to consider when many of the programs that were reviewed were only 12 to sixteen weeks in length. If these shorter programs evaluated after program completion, the authors missed a critical one year window to evaluate the residents when they have gained equilibrium.
Summary
The research on new graduate nurse residency programs focuses on three areas: development, type of program and evaluation of programs. The development and type of programs reflect the different needs of each facility as well as the curriculum plan. The literature review revealed that there are many existing new nurse residency programs that are variable in design and methods; this makes it hard to compare and analyze the different programs results. Each program evaluation focused on a different aspect of the program. Only a few programs focused on the new nurse’s perception of a nurse residency program. None directly addressed the new nurse’s feelings of preparation
for critical care nursing. None of the articles addressed a program that is a combination of instructional methods (to meet the various learning styles) using classroom and computer based learning, as well as preceptored clinical experiences. Computer based learning is commonplace and its addition to an orientation program should be evaluated. In the evaluation of all the literature, the program discussed by Morris et al. (2007) was the closest to our critical care nurse residency. The program was shorter in length than our program and does not include a portion of clinical time on the medical surgical floor. An evaluation of the perceptions of the nurses that completed the CCNRP in regard to their preparation will help to determine if the program’s design, content and length meet the educational needs of the new graduate nurse.
Chapter three will focus on the study design, research methods, and data collection for this study.
28 CHAPTER III
RESEARCH METHODOLOGY
This was a phenomenological qualitative study. A qualitative study involves the description and interpretation of a human experience so that the experience can be better understood. Phenomenological research seeks to describe experiences as they are lived, to capture the lived experience of the study participants (Burns & Grove, 2005). Phenomenological research requires that the integrated whole be explored, therefore it is a suitable method for the investigation of phenomena important to nursing education (Speziale & Carpenter, 2003). This study looked at the new graduates’ unique perspective on their experience as they went through a critical care nurse residency program. It also sought out their perspective on the various program components and how the program had assisted the new nurse to progress from advanced beginner to a proficient provider of care.
Sample
Qualitative research uses a small sample and participants are “hand picked” because of the important story they have to tell. This study used a nonprobability purposeful sampling because it did not involve random selection (Trochim, 2006) and was directed towards a specific population (Speziale & Carpenter, 2003). The
program over a two year period. This comprised of four cohorts of nurses. The nurses had to have been in practice for a minimum of one year. Literature supports that it takes at least a year for a nurse to transition to a competent provider (Tradewell, 2006; Casey et al. 2004; Halfer & Graf, 2006). They were all be nurses still employed by the facility and currently working in the critical care units.
A total of six nurses responded to the study requests to participate. Of these six nurses, four were females and two were males. Four of the six nurses had Bachelor of Science in Nursing degrees while the remaining two had an Associate Degree in Nursing. All six were Caucasian, and four of the nurses were 25 years of age, with the remaining two nurses stating an age of 26 years. One of the nurses was from PICU, two from CCU and three from SICU. As each critical care unit’s patient populations are different and require a slightly different set of knowledge and skills, information on the specific unit would show if the program provided the educational foundation needed to work in the specific units.
The nurses all varied in their prior nursing experience. Two of the nurses had no prior experience in the nursing field. The remaining nurses had Certified Nursing Assistant (CNA) experience. Two of the nurses had worked as a CNA, one for a year, the other for three and a half years. The third nurse worked as a CNA for two years then as Licensed Vocational Nurse for two years before entering the Registered Nurse
program. The last nurse worked as a CNA for 2 years, then worked as a Med Surg RN for 6 months prior to starting the program. Prior nursing experience was important to collect
because that experience would affect the level of knowledge and skill that the nurse resident had prior to entering the program. This would affect their perception of the needed education to work in the critical care units.
Ethical Considerations
Protecting of human rights is an important part of nursing research. This study fell under the exempt categories for California State University, Chico’s Human Subjects in Research Committee (HSRC) (Appendix A and E). As per the guidelines accessed in November 2007:
Exempt categories include: Research conducted in established or commonly accepted educational settings, involving normal educational practices, such as research on regular or special education instructional strategies, comparison among instructional techniques, curricula, or classroom management methods (California State University Chico, n.d., p. 1).
Hospital research is controlled by the Marshfield Clinic Research Foundation Institutional Review Board (IRB). Because the research project was an evaluation of an educational program, it was exempt from their IRB review, only an exemption form was submitted, and a request submitted to the Research Foundation (Appendix B).
The right to self determination is based on the ethical principle of respect for all persons. In this view, all prospective participants, were informed about the study and allowed to voluntarily choose to participate or not and have the right to withdraw at any time without penalty. The right to privacy is the right for individuals to determine when
and how much information will be shared with others. With this in mind, the participants were informed that participating was voluntary. The right to autonomy and
confidentiality is the right to assume that data collected would be confidential, and that any quotes that may be used in the final report would be unidentified.
Methods of Data Collection
The list of nurse graduates meeting the sample requirements was reviewed, and each nurse was sent an email through the hospital web-mail system. The email described the study and invited participation (Appendix C). Contact information for the researcher was included in the email for any participant questions. The potential
participants were advised that there was an appreciation gift of a ten dollar Culver’s gift card, upon completion of the study. The email also described how the information would be coded to protect participant confidentiality. Attached to the email was the consent and demographics form. The email was repeated once after four weeks as only two nurses has responded to the first email. Four additional nurses responded to the second email for a total of six nurses.
The participants were instructed to return the demographics form and consent form via email within two weeks of the date of the email. Upon receipt of the
demographics and consent forms, an identification number was assigned to the
participant, and a file was started. Each file was labeled with the identification number and kept in a locked cabinet. Subject demographics were entered into a computer file labeled only by identification number. The files were password protected and accessible
only by the researcher. Each participant was contacted within five days and an interview time was set up at a date and time of the participants’ preference. The researcher advised the participants that the interview was going to be tape recorded and that it would take approximately thirty minutes to an hour to complete. The participants were also informed that there would be a second contact email to allow their examination of the researchers’ analysis of their experiences to maintain study rigor.
The study was conducted with audio taped interviews, using open ended questions. The open ended questions were designed to capture the perception of the nurse on the Critical Care Nurse Residency Program (CCNRP). The initial interview questions were developed by the researcher and reviewed by the Marshfield Clinic Research
Foundation Institutional Review Board, and the thesis advisor for appropriateness prior to use. The interview was piloted on one nurse that had completed the CCNRP to see how the interview technique would work and observe how long the interview took. The opening interview question began with “Can you tell me about your experience in the critical care nurse residency program?”
Process for Data Analysis
All interviews began with recognition of the assigned identification number, and contained no other identifying information. Identification numbers were also attached to all documents and computer data. Microsoft Excel spreadsheets were used for
organizing the demographic data. The recorded interviews were transcribed into computer files and stored by identification number. A professional medical
transcriptionist provided transcription services. Confidentiality of all information was conveyed to the transcriber. These transcripts were compared to the taped interviews to assure completeness, and the transcripts were validated with the study participants. All files were backed up and securely stored.
Data analysis requires the researcher to become immersed in the data. The purpose of data analysis is to preserve the uniqueness of the participant’s lived experience while permitting an understanding of the phenomenon under investigation (Speziale & Carpenter, 2003).
Colaizzi’s (1978) methodological framework was used to guide the evaluation of the participants’ statements of their lived experience by looking at their responses to research questions relating to the phenomenon under study. Colaizzi’s (1978) method encompasses seven procedural steps:
1. Read each of the participants’ transcripts in order to acquire a feeling, or a sense of the whole, from them.
2. Extract significant statements and phrases from each transcript that pertain to the phenomenon being studied.
3. Formulation of meanings from each significant statement. 4. Organize the formulated meanings into clusters of themes.
5. The results are then integrated into an exhaustive description of the investigated phenomenon.
7. Final validation from the participants to compare the researcher’s descriptive results with their lived experiences.
Each transcript was read six times while listening to the audio tape of the interview, to gain a sense of the total content. Significant statements were highlighted in each transcript. A total of 87 significant statements were identified. A chart was
developed that was separated into each of these specific areas. The 87 identified significant statements pertaining to each of these areas was placed on the chart. These statements were numbered to identify which interview the statement was extracted from. At this point the underlying meaning of each statement was formulated (Appendix D). Colaizzi describes this step as a “precarious leap” (1978, p.59). It is important that the meanings formulated should continue to remain true to the original statement, that the formulated statement “... must discover and illuminate those meanings hidden within the various contexts and horizons of the investigated phenomenon” (Colaizzi, 1978, p. 59). To determine if the interpretive process was clear and auditable, the original transcripts, significant statements and formulated meanings were reviewed by the thesis advisor. This confirmation led to agreement of the formulated meanings with minimal changes.
The next step was to organize the formulated meanings into clusters of themes. The same chart layout used in developing the formulated meanings was used. The formulated meanings were then sorted into groups that represented themes
(Appendix D). The 87 formulated meanings were sorted into 12 specific themes. This data was again returned to the thesis advisor for review to insure that the interpretive
process was clear and accurate. It was decided at this juncture by the thesis advisor, that an exhaustive description was beyond a master’s level work, and so the process was stopped at theme development.
Process to Establish Rigor
“The goal of rigor in qualitative research is to accurately represent study participant’s experiences” (Speziale & Carpenter, 2003, p. 38). The processes that contribute to rigor have been identified by Lincoln and Guba (1985) as: credibility, transferability, dependability, and confirmability. Credibility encompasses activities that increase the probability that credible findings will be produced. To help establish
credibility of the findings, the statements and themes from the interviews, were validated with the participants to see if they are true to their experiences. This is referred to as “member checking” (Lincoln & Guba, 1985). Transferability addresses the ability of the findings to apply beyond the bounds of the project. The complete set of data analysis documents will be on file and available on request to provide a “paper trail” for other researchers to make a transferability judgment. Dependability addresses the question of: How dependable are these results? This looks at the quality of the integrated processes of data collection, data analysis, and theory origination. Confirmability is a measure of how well the studies findings are supported by the data collected (Lincoln & Guba, 1985). The objective is to delineate as precisely as possible the thought processes and evidence that lead to the conclusions. To attend to dependability and confirmability, this study was
evaluated by an auditor and someone skilled in qualitative data analysis to evaluate the completeness of the study and the study findings.
Summary
This study was done using a phenomenological qualitative approach.
Qualitative research seeks a wide understanding of the entire situation; it uses subjective information and participant observation to describe the context, of the variables under consideration, as well as the interactions of the different variables in the context (Speziale & Carpenter, 2003). The purpose of phenomenology is to describe the lived experience.
Evaluation is an important part of any educational program. To evaluate the CCNRP and to see the effect of the various components, it was appropriate to use the phenomenological qualitative approach. The feedback of the participants that have “lived the experience” gave the most accurate reflection as to if the program prepared them to care for critically ill patients.
37 CHAPTER IV
STUDY FINDINGS
The purpose of this study was to describe and explore the experiences of the new critical care nurses and their perceptions of preparation for caring for critically ill patients through participation in the Critical Care Nurse Residency Program (CCNRP). The main objective of the study was to evaluate if the combination of the components in the CCNRP were the appropriate tools, education and support to assist not only the new graduate nurse, but nurses new to critical care nursing.
The experiences of the nurses were tempered depending on whether they had any prior experience in nursing before starting the CCNRP. The experiences were also affected by their learning styles and preceptor experiences. The seven major themes that emerged were: orientation process, solidifying concepts, importance of debriefing and discussion, integration of computer content, value of the preceptors, becoming a critical care nurse, and areas for improvement. The theme of becoming a critical care nurse was further broken down into five subthemes: Becoming socialized, becoming a critical thinker, becoming independent, becoming a good time manager and recognizing unrealistic expectations.
Orientation Process
The nurses reflected on the program phases, both medical-surgical and critical care. The views of the phases were different depending on their prior nursing experience. One experienced nurse commented:
The first phase was a little bit long and drawn out but you have to do what you have to do I guess with that part. (Participant 6)
The new nurses reflected:
I felt like the med-surg part was, for the most part, an appropriate length of time, especially if you were brand new and had not done any of that stuff really before. (Participant 5)
There was a good amount of time in the tower [med-surg] to get situated. (Participant 2)
Overall nurses commented that the length was worthwhile and good starting point for critical care.
Although I did not enjoy the med-surg phase because I knew I wanted to be a critical care nurse, I felt like I needed to be there that long because I was really getting the hang of things at the end. (Participant 3)
The importance of flexibility in scheduling was discussed as a positive aspect throughout the orientation process:
I actually, for myself to feel more comfortable, extended my orientation part for another two weeks for the critical care stuff. That, I thought was nice that they allowed you that kind of flexibility. If you weren’t feeling comfortable you could go ahead and extend it and it doesn’t affect it, but if you’re feeling comfortable at the end, that was good too. (Participant 5)
The Critical Care Nurse Residency Program’s seven month program is longer than most orientation programs. Comments reflected the learning opportunities offered by the program by having a longer orientation period.
Also, the longer orientation in the critical care piece of it was also very helpful because it gave you a longer range of time to see the more sicker and different patient populations. (Participant 1)
...I got to see quite a bit for the longer orientation. I got to see a patient with CRRT, and got to have a patient death, I got to work with a big trauma. So these are
educational experiences I might not have gotten if I just had a four week or six week orientation. (Participant 1)
The expanded experience opportunity affords the new graduate the ability to spend a day in other departments that have a connection to the critical care units. One nurse commented on the benefits of spending a day in the different departments, and how it helped his patient care:
…so the broadness of the program I think really helped me. Even just because I spent a day over in palliative, I think I have been able to utilize that as a resource so much more than other nurses that have not had the program because I was able to go over there and see what it is like and what they are accomplishing. (Participant 2)
The comments by the nurses reflected the aspects of the CCNRP that they felt were important to their orientation process. The overall length of the program, the
different phases, the expanded opportunities within the phases and the schedule flexibility to adapt to the individual nurses progress were the important features that the nurses felt best supported them through their orientation.
Solidifying Concepts
A challenge of many new nurses is to take the many concepts and theories learned in school and to apply them in real world practice. Several of the nurses commented on how the program helped them to solidify concepts from nursing school and to apply them in practice:
So, the program, I think, really kind of took those broad concepts you learned in med-surg general nursing school and broke them down and said, “okay, well now you have a patient with heart failure.” They’re going back up and send to the pulmonary unit and they’re going to need intubating, you know, X, Y and Z. (Participant 5)
It was a good learning experience that helped me take what I learned in school and solidify it into an occupation. (Participant 2)
...brought together all of the things from nursing school and then also looked at a higher level of critical care level to bring that together. (Participant 1)
Evidence based practice is important in today’s nursing care arena. Access to evidence in nursing practice can be challenging due to the vast amounts of literature to interpret and time constraints. There were comments on the program providing current practice information and support with learning.
…they kind of kept you on track and up to date with the latest information, new studies that came out with fresh articles to read. (Participant 1)
…coordinators of course were also very helpful in that they checked up on you in clinicals to see how things were going, what experiences you had gotten and they were just kind of making sure you got all of the experience that you needed to be successful. (Participant 1)
Human Patient Simulation, SIM Man, is used throughout the program to assist with learning in a safe environment. The use of SIM Man in the program was commented on as being a good part of the program:
I really think that SIM Man was really good. (Participant 3)
Applying concepts learned in school and applying them to actual patient care is often a challenge for new nurses. The use of case studies and classroom discussion expanded upon the previously learned concepts. The classroom content also introduced them to evidenced based practice and how to take research and apply it to patient care. The learning opportunities provided by the SIM Man exercises also provided an opportunity to apply newly learned concepts in a safe environment.
Importance of Debriefing and Discussion
Opportunities for debriefing and discussion of patient experiences are
scheduled into the medical-surgical phase of the program. The nurses commented on how the debriefing and discussion was important to their learning and being able to
understand the rationales for patient care and outcomes:
I really liked when we would get to go spend a day or two up on the tower units and then come back and talk about the patients that we had. (Participant 2)
...to have that experience in the floor gave a confirmation of the care needed. (Participant 1)
This participant gave a good analogy of how the sharing and debriefing assisted with the learning process:
I think she [preceptor] kind of started with the gradual association of patients. I mean, you kind of do the hokey-pokey thing; you go in a little bit and then you back out and you talk about it. You get a chance to actually talk about what you saw and about what you’ve learned. You get to discuss it a little bit versus you go home and you’re like, “wow, you know what I learned today, okay great.” You get to talk about it a little bit and ask questions a little bit when you get back to the classroom part. I think you get a little bit more broader knowledge base just from that part. (Participant 6)
Nurses also commented that they would have liked to have more debriefing and discussion especially in the critical care phase:
Basically the tower patients are just busy work and getting things done and sure you learn a lot about the complicated diseases and how certain medications affect and altogether I would have liked to have spent more time talking about my patients there and understanding things better. (Participant 2)
I thought the actual residency in the critical care phase was a pretty good time. I wish we would have, I don’t want to say more classroom time in the critical care phase but maybe toward the end, more of that classroom where you can talk about what is going on in the unit. (Participant 3)
Debriefing and discussion time gives the new nurses the opportunity to explore and discuss their experiences with patient care, physicians, and other staff. There is the opportunity to ask questions regarding the patient care choices and the rationales for them. It also provides an opportunity to reflect on the care provided by the nurse as well as the opportunity to look for improvements to that care for the future.
Integration of Computer Content
The computer program is an important part of the CCNRP. The computer program was changed after the first two cohorts of the program to the Essentials of Critical Care Orientation (ECCO) due to issues with usability. The ECCO program has
been more user friendly and covers the topics in a better format for the learner. Two of the participants had exposure to the old computer program used in the residency. Their reflections supported and confirmed the change to the ECCO program:
The Indiana University one that we used, I think, it had its limitations and it was nice to a point but at other times it was like, I don’t really know how much I was learning from it. (Participant 5)
… we did the Indiana University too. As confirmation, it was very broad, like as the meat and potatoes, so to speak, of what you need to know. So, if you wanted to actually, like, understand the processes that they were talking about, you had to go into the book and look it up. (Participant 6)
Time to complete the ECCO program is scheduled into classroom sessions to allow adequate time to complete the program. The amount of time allotted in the
schedule to do the computer work was voiced by one participant as needing to be shortened:
Like the allotted time for the computers, every time that we did them was just too much for whatever section we were working on because you could just finish it faster than that. Maybe for other people it worked but I know for the majority of us it was just a lot of downtime. (Participant 4)
It was anticipated that some nurses may not do well with the computer program portion of the residency. Some learning styles do not do well with computer learning.
One nurse added her comment:
I did not like ECCO. Although I thought the information was important, I felt like when we were in class discussing stuff I got a lot more out of it…. I don’t know, it might be just the way I learn, versus the way everybody else learns. (Participant 3)