PERSPECTIVES OF NURSES THAT COMPLETE THE NURSE RESIDENCY PROGRAM IN REGARD TO THEIR PREPARATION TO CARE FOR CRITICALLY ILL PATIENTS.

Transcription

1 PERSPECTIVES OF NURSES THAT COMPLETE THE NURSE 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

2 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. Graduate Coordinator Jennifer Lillibridge, Ph.D. Chair Irene S. Morgan, Ph.D.

3 TABLE OF CONTENTS PAGE Acknowledgments... Abstract... v vi CHAPTER I. Introduction... 1 Background... 4 Problem Statement... 7 Relevance to Nursing... 8 Theoretical Framework... 9 Purpose Research Question Definitions Qualifications of the Researcher Summary II. Literature Review Developing a Nurse Residency Program Types of New Nurse Residency Programs Evaluation of Current Nurse Residency Programs Summary III. Research Methodology Sample Ethical Considerations Methods of Data Collection Process for Data Analysis Process to Establish Rigor Summary iii

4 CHAPTER PAGE IV. Study Findings Orientation Process Solidifying Concepts Importance of Debriefing and Discussion Integration of Computer Content Value of Preceptors Becoming a Critical Care Nurse Areas for Improvement Summary V. Discussion Role Transition Preceptors Socialization Skill Acquisition Professional Development Knowledge Application Novice to Expert Implications Study Limitations Conclusion References Appendices A. California State University, Chico Human Subjects in Research Committee Clearance B. Marshfield Clinic Research Foundation Institutional Review Board Clearance C. Research Invitation D. Significant Statements, Formulated Meanings and Themes E. California State University, Chico - Human Subjects in Research Committee Post Data Collection Form iv

5 ACKNOWLEDGEMENTS 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. v

6 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 vi

7 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. vii

8 CHAPTER I 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 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 1

9 2 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

10 3 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

11 4 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 unitspecific 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

12 5 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

13 6 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

14 7 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 The second cohort of seven nurses started February 2007 and graduated in October Cohort three consisted of 13 nurses that began in June 2007; they graduated February Cohort four had eight nurses, started February 2008 and graduated in August The fifth cohort, which started July 2008, graduated in January 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.

15 8 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

16 9 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

17 10 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

18 11 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

19 12 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

20 13 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 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

21 14 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.

22 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 15

23 16 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.

24 17 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.