Nowadays, almost all health organizations do not have

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1 Original Aricle The Developmen of Nurse Residency Program OBJECTIVE: To sudy new graduae nurses work problems; o design raining program courses as well as he experimenal evaluaion of he effeciveness of he courses afer he nurses have been rained. Gaesawahong R, RN Rungarun Gaesawahong, RN, MSN 1 Keywords: nurse residency program, NRP, menoring program for new graduae nurses 1 Assisan Nursing Division Manager, Samiivej Hospial Sukhumvi, Bangkok Hospial Group, Bangkok, Thailand. MATERIAL AND METHODS: Sudying work problems of new graduae nurses hrough a research survey. The quesionnaires were given o he sample group of 168 new nurses who have a leas one year of experience in a 200-bed size privae hospial in he Bangkok area. The resul of he survey led o he developmen of wo raining programs. They were he Nurse Residency Program (NRP) and Menoring for new graduae nurses. The aciviies and eaching mehods were on he job raining (OJT) for 20 new graduae nurses and 20 menors in inensive care unis (ICU). The NRP was analyzed afer one group was rained for pre-es, and pos-es design as well as hree monhs laer. The menoring program was analyzed for pre-es, and pos-es design. T-es saisics were used for hese programs. RESULTS: The work problems of new graduae nurses were: 1) clinical knowledge compeency for nurse s noes; 2) nursing inervenion for he procedure of inravenous adminisraion; 3) anxiey adjusmen; 4) and leadership and communicaion for lack raining i was found ha he clinical knowledge compeency was raining i was higher sill excep for he area of criical care nursing of gasroinesinal and endocrine paiens as well as paiens wih shock. These remained he same. The compeency of nursing inervenions was found o be higher afer raining and afer hree monhs of raining he compeency was found o be higher han adjusmen before, afer and afer hree monhs of raining was no saisically differen. The leadership and communicaion, before, afer and afer hree monhs of raining were no saisically differen graduae nurses, and he reenion rae was 80% in a year. CONCLUSION: These raining courses, he NRP and Menoring program, were appropriae and suiable, and were successful in solving work problems faced by new graduae nurses. * Address Correspondence o auhor: Ms. Rungarun Gaesawahong Nursing Division, Samiivej Hospial 133 Sukhumvi 49, Klongan Nua, Vadhana, Bangkok 10110, Thailand. rungarun.ga@samiivej.co.h Received: December 6, 2013 Revision received: December 12, 2013 Acceped afer revision: December 21, 2013 Bangkok Med J 2014;7: E-journal: hp:// Nowadays, almos all healh organizaions do no have This problem occurs around he world, no only in Thailand, a resul, he lack of RNs impaced he economy negaively because i is necessary o fund and rain new graduae nurses o become a ISSN (online)/ (prin) 25

2 Gaesawahong R Wih regard o jobs of new graduae nurses, hey have o face an ever-changing amosphere of a new workplace, he hospial s sysems, rules and policies. These all affec he work of new graduae nurses. Some of he nurses may 1,2 The role ransiion from a suden nurse o a RN is a challenge. In a hospial conex, his recognized as being more sressful han being a suden nurse working under he supervision of a nurse insrucor. Therefore, suden nurses who become RNs have o adap hemselves o a nursing sociey and adjus heir minds in In addiion, RNs are required o follow he rules and regulaions of heir new workplace. If hey fail o do so, hey will be worried and sressed as well as run he risk no able o perform work asks assigned o hem by senior nurses or if hey canno manage o provide adequae care o paiens under heir own auhoriy, hey will lose self-eseem. This in urn will affec he qualiy of care for his migh resul in he nurses aking a day off, quiing, ransferring, abandoning heir poss or even resigning from heir jobs. This problem can become an obsacle for he advancemen of heir nursing career as well as affecing hem negaively boh physically and menaliy. Realiy Shock a he beginning of a nursing career is imporan sabiliy, willingness o work and can lead o inerpersonal 3 In addiion, a new workplace can be a shock o new graduae nurses. If new graduae nurses compare heir expecaions of a workplace and heir acual realiy, hey will be more likely o qui heir job. 4 Realiy Shock is a ransiion period when a suden nurse becomes a RN which can be divided ino 4 periods 3 which are: he Honeymoon Phase, he Shock Phase, he Recovery Phase as a sep in becoming a RN, divided ino 3 phases 4 : Doing, Being and Knowing (see Figure 1). of a career oo. 5 Even hough some organizaions arrange precepor nurses o assis new graduae nurses in heir budge for raining and diminishes he workforce ha drives he organizaion forward. Preceporship programs or menoring programs help new graduae nurses o work and i increases he saff reenion rae from 62% o 92%. 7 In conras, some organizaions do no have his program and hence new graduae nurses canno do heir work nurses are crucial o he raining of new graduae nurses because hey help he apprenices o overcome obsacles in he beginning of heir career. 6,7 The way o overcome Realiy Shock is o esablish a program ha helps new graduae nurses o be able o ener he nursing career, reducing sress (see Figure 1) and, especially, prevening hem from resigning. 2,4,8-11 The program is called Nurse Residency Program or NRP. The researcher works in he human resources developmen deparmen of he nursing division, and saes ha he urnover rae of new graduae nurses in privae eriary level career. Moreover, in Thailand, here is sill no NRP and his is he reason why he researcher inends o esablish a raining NRP as par of he pahway of a suden nurse o becoming a regisered nurse. Maerial and Mehods 1. The sudy of he work problems of new graduae nurses working in a 200-bed privae hospial in he Bangkok area wih under a year s work experience were included in he research survey. The work problems cover four perspecives: clinical knowledge; nursing skills; anxiey adjusmen in a new workplace; and leadership and communicaion skills. 2. The analysis from he resul of he research survey and he inerview of privae hospials execuives o design a NRP and a menoring program. anoher 20 experienced nurses who have worked in an ICU. 4. The course consised of a NRP and a Menoring program. 5. The NRP es and he course evaluaion from four perspecives immediaely before and afer raining, as well as hree monhs afer raining. 6. One group pre-es and pos-es design. Mehodology Firs: To sudy he work problems of new graduae nurses. 1. Conduc a lieraure review inerviewing seven new nurses abou how o work in a new workplace, seleced four work problem areas; clinical knowledge; nursing skills; anxiey adjusmen; leadership and communicaion. 2. Gahering informaion from quesionnaires. Then, 1 X O 2 O 3 objecive s congruence and laer o adjus he quesionnaire in accordance wih expers and advisors recommendaions. 3. Tesing he quesionnaire wih 30 new graduae nurses wih work experience of less han a year in a he iem-oal correlaion and reliabiliy by alpha 26 ISSN (online)/ (prin)

3 The Developmen of Nurse Residency Program Figure 1: Shows period of nurse residency program (NRP) and relaed menoring program. 4. Using he approved quesionnaire. Disribuing o 168 new graduae nurses or 93.3% and analysis using descripive saisics, such as mean and sandard division. Second: Design he Nurse Residency Program o rain new graduae nurses. 1. Synhesize he daa gahered from he sudy of new graduae nurses work problems, inerviews wih hospial execuives and he ICU manager o creae he Nurse Residency Program and Menoring program Menoring program for precepor nurses: - New graduae nurses work problems. 12,13 - Precepor nurses role. 12,13 - Mehods o manage sress, roles and duy of precepor nurses, apply o on he job raining (OJT), encourage leadership and communicaion and evaluaion of new graduae nurses work performance. - Game o encourage new graduae nurses. program consising of lecures, brainsorming aciviies, clinical eaching in bedside care using he OJT mehod. - Precepor nurses evaluaion and apiude esing Nurse Residency Program: NRP for new graduae nurses: - New graduae nurses problems on clinical knowledge, nursing skills, anxiey adjusmen, leader - ship and communicaion. Inegraed course: 2,4, Increase new graduae nurses abiliy o solve heir work problems. - Increase new graduae nurses developmen of clinical knowledge, nursing skills, success in adjusing hemselves o new work environmens, improved sress managemen, leadership and communicaion. - Course descripion consiss of six fields of clinical knowledge such as: nursing for inensive care paiens of cardiovascular, respiraory, cerebrovascular, renal paien and balancing in body, gasroinesinal and endocrine sysem as well as shock-phase inensive care paiens for 64 hours or eigh days and seven sucioning, and inravenous inervenions. This raining for nursing skills akes 56 hours or seven days. In addiion, here is 24 hours (3 days ) raining for new graduae nurses o help hem o adjus o new work environmens and ISSN (online)/ (prin) 27

4 Gaesawahong R improve heir sress managemen. Then, new graduae nurses have o rain o improve heir leadership and communicaion skills. For example, hey need o know how o wrie nurses noes, and how o work collaboraively as well as learning from case sudies. sorming aciviies, discussions, learning from case sudies hrough media such as handous, slides, - Evaluaion for he program is carried ou by observing new graduae nurses working problems from four perspecives using four ools: subjecs before and afer raining and also 3 monhs afer raining. checklis, before and afer raining and also 3 monhs afer raining. hemselves o he work environmen: Pagana s Clinical Sress Quesionnaire 17 and Spiel- 18, before and afer raining and also hree monhs afer raining. Fink graduae nurse survey 1, before and afer raining and also hree monhs afer raining. order o approve he srucure and verify ha i is relevan and appropriae. 3. Use commens from he expers o improve he program. Third: es he program: 1. Tes he approved program hrough he: 1.1. Menoring program esed by 20 ICU nurse voluneers. There were wo days of pre-es and pos-ess Nurse Residency Program esed by 20 new graduae nurses who work full-ime in he ICU. The raining ook place every Thursday and Friday, over nine weeks, for a oal of 21 days. There were pre-ess and pos-ess as well as a The four ools used for research were: 1. The ools for new graduae nurses working problems synhesized from he lieraure and an inerview wih 2. Three ools used were Pagana s Clinical Sress Quesionnaire-CSQ 17 for clinical sress es, Spielberger sae-rai anxiey invenory 18 for he anxiey 1 es and he Casey-Fink graduae nurse survey 1 for leadership and communicaion evaluaion. Three ools are in English and he researcher ranslaed hese from English o Thai. Then, hree expers validaed he correlaion beween he source ex and esed on 30 non-example new graduae nurses Finally, his ool was used along wih he pre-es, pos-es and pos-es again hree monhs afer he end of he raining. quesion es in 6 subjecs. The es for new graduae nurses is produced by lecurers. Firs, he es is used along wih he pre-es, pos-es and pos-es again hree monhs afer he end of he raining. was seven checkliss from he ICU. Resuls The research resuls showed new graduaes nurses work problems from four perspecives: 1. Clinical knowledge perspecive was found in he op hree scores; 1) new graduae nurses canno wrie nurses noes 2) compeency of nursing assessmen is relevan as well as being unable o predic a paiens sympoms and 3) changing in accordance wih paiens curren sympoms. 2. Nursing skills perspecive was found in he op hree scores; 1) nursing inervenion for he procedure of inravenous adminisraion 2) nursing services for he discharge process 3) nursing compeency abou seps of cardiopulmonary resusciaion (CPR) or basic life suppor. 3. Anxiey adjusmen perspecive was found in he op hree scores; 1) new graduae nurses work performance was affeced by heir emperamenal colleagues, 2) feeling of failure caused by working o he work environmen. 4. Leadership and communicaion perspecive was informaion o oher nurses and colleagues and 3) inabiliy o solve unexpeced problems. The NRP and Menoring raining programs were found o be appropriae and a a high level and he highes level and congruence for all facors. The resuls afer he Menoring raining program compared o before and afer paricipaing in he program was found o be a saisically when compared beween levels before raining and hree monhs afer raining, apar from criical care nursing of Gasro-inesinal and Endocrine paiens as well as he paiens wih shock (Table 1). These remained he same. The compeency of nursing inervenions was found o be compeency was higher han afer raining a he saisically 28 ISSN (online)/ (prin)

5 The Developmen of Nurse Residency Program before, afer and afer hree monhs of raining remained he same (Table 3). The leadership and communicaion, before, afer and afer hree monhs of raining remained have been rained in he Nurse Residency Program, hey have more clinical knowledge, beer skills han before and are able o adjus heir anxiey abou heir workplace. During he research period, here were four of 20 new here were 16 new graduae nurses who were sill eligible for he sudy. Table 1: Resul of clinical knowledge es compared before and afer, afer and afer 3 monhs program implemenaion (n = 16). Clinical knowledge Afer Afer 3-monh Afer 1. Criical care nursing of cardiovascular paiens 2. Criical care nursing of respiraory paiens 3. Criical care nursing of cerebrovascular paiens 4. Criical care nursing of renal paien and balancing in body 5. Criical care nursing of gasroinesinal and endocrine paiens 6. Criical care nursing paien of shock * 10.96* 8.88* 17.00* 20.33* 18.25* * 2.53* 6.21* 4.84* Table 2: Resul of nursing pracice skill compared before and afer, afer and afer 3 monhs program implemenaion (n = 16). Nursing pracice skill Afer Afer 3-monh Afer 1. Venilaor use 2. Airway sucioning 3. Inravenous adminisraion 4. Nursing care of invasive 5. Nursing care of inercosal drainage 6. Nursing care of nasogasric ube 7. Nursing care of Foley caheer * 25.46* 20.07* 28.65* 16.26* 17.42* 11.36* * 21.00* 9.59* 83.71* 33.17* 7.34* 17.82* Table 3: Resul of clinical sress and anxiey es compared before and afer, afer and afer 3 monhs program implemenaion (n = 16). Tes Afer Afer 3-monh Afer X Clinical sress es Threa Challenge Harm Bene Sae & Trai Anxiey Sae Anxiey -Posiive Sae Anxiey -Negaive Trai Anxiey -Posiive Trai Anxiey -Negaive * * * * ISSN (online)/ (prin) 29

6 Gaesawahong R Table 4: Resul of leaderships and communicaion compeency compared before and afer, afer and afer 3 monhs program implemenaion. Compeency n Afer Afer 3-monh Afer Leadership Communicaion Discussion This research found ha mos new graduae nurses fel a profound lack of preparaion for heir new role. Problems included: being able o wrie nurses noes, nursing pracices and oher issues. When suden nurses were incorrec, heir nurse insrucor would remedy he errors and explain. Precepor nurses are needed o supervise new graduae nurses a he beginning of heir regisered nurses review, coach on criical hinking, improving clinical judgmen, nursing processes and many oher areas in precepor assigned o hem for coaching for a ime, hey need more supervision. They also feel worried and insecure 13, 14 ha hey will no be able handle pressure. So, hey always have o consul heir precepor nurses This aspec of raining was a simulaor for new graduae in a new environmen can make people sressed and each person will have a differen reacion when hey are sressed. 16 Hence, each nurse should eliminae sress in heir own way and ry o undersand problems hey have o encouner. Furhermore, i was found ha new graduae nurses have a problem abou leadership and communicaion. and o solve unexpeced problems. Mos of hem canno make ohers undersand hem even hough communicaion is a way o make friends among colleagues. They should be friends wih heir colleagues. There were some group aciviies for new graduae nurses o help hem o ge o because hey do no have much work experience and hence hey may feel nervous o communicae wih ohers. New graduae nurses problems migh be solved by he nurse s abiliy o adjus o he work environmen is also imporan. Being a nurse in an ICU requires an undersanding of he needs of heir paiens and heir families. nurses fel he mos sressed was when hey have aken care of paiens and he paiens sympoms change. Therefore, he program has simulaed aciviies for new graduae nurses, aiming for hem o be able o deal wih sress well The sress of new graduae nurses in he 3 periods generaion Y people who like o learn new hings and are will ry heir bes o adjus hemselves o he work envi- have posiive hinking and ry o accomplish heir goals. 4 Evaluaion of his program showed ha new graduae nurses have more clinical knowledge in he six aspecs afer hey received raining. They also improved more in four aspecs (excep for caring for paiens who need care in gasroinesinal and endocrine as well as paiens who were in shock phase) afer he raining program ended for 3 monhs because heir inensive care uni did no assign hese 2 asks o new graduae nurses because i was oo dangerous for hem o ake care of paiens wih severe condiions. I showed ha raining and assigning work asks for hem can improve new graduae nurses clinical knowledge afer hey have been rained in his program. Conclusion This research suggesed he program s lengh should be six monhs in order o cover he realiy shock period of new graduae nurses. raining in his program, new graduae nurses should have work experience of 3-6 monhs. Moreover, he program s lengh should be one year in order o maximize he qualiy of raining. Elemens in he raining program should be in accordance wih problems ha happen in he real lives of new graduae nurses. 30 ISSN (online)/ (prin)

7 The Developmen of Nurse Residency Program References 1. Casey K, Fink R, Krugman M, e al. The graduae nurse experience. J Nurs Adm 2004;34: The essenials of baccalaureae educaion for professional edu/educaion/pdf/baccessenials08.pdf) nursing graduae professional role ransiion. J Conin Educ Nurs 2008;39: ;39: Hansen J. Nurse Residency Program Builder: Tools for a Successful New Graduae Program. HCPro, Inc., Danvers, model on nursing compeency of newly graduaed nurses. Thai J of Nursing Council 2011;24: New Hanover Healh nework. Nurse Menor pos-baccalaureae graduae nurse residency program: a model for excellence in ransiion o pracice. J Nurses Saff Dev 2006;22: Based Regisered Nurse Program residency programme for new graduae regisered nurses. J Nurs Manag 2010;18: Welding NM. Creaing a nursing residency: decrease urnover and increase clinical compeence. Medsurg Nurs 2011;20: Boonyanuraksa P. Wisdom in nursing science 2003; clinical pracice Swihar D. Nurse Precepor Program Builder: Tool for Successful Precepor Program 2 nd ed, Krugman M, Breschneider J, Horn PB, e al. The naional pos-baccalaureae graduae nurse residency program: a model for excellence in ransiion o pracice. J Nurses Saff Dev 2006;22: Pagana KD. Sresses and hreas repored by baccalaureae sudens in relaion o an iniial clinical experience. J Nurs Educ 1988;27: Consuling psychologiss press ISSN (online)/ (prin) 31