2. Retention of new nurses
The problem of retention of new nurses in a hospital has become a global issue that
is often debated in nursing. Retention of graduate nurses during the first year
of employment is crucial and challenging in an acute care hospital. The high
turnover rate, the high cost of recruitment and replacement costs seem an
insoluble problem (Pine, 2007). According to a National League for Nursing
study(1999) cited by Pine (2007), 25.3% of graduate nurses at 6 to 8 month post
graduation have already worked for two or more institution. In a current survey
of newly graduate nurses in 35 states in United Stated (Kovner et al. 2007),
approximately 13% of responders had changed principle jobs after 1 years and 37% reported that they
planned to change jobs in the near later. In Malaysia, there are 39,000 nurses
and in the year 2000, the was an average of 1.69 nurses per 1,000 populations
located in the low-density cluster in the world (Masroor & Fakir, 2010).
This demonstrates that Malaysia has the lower nurse density in the area or
cluster and is believed to be suffering from too much nurse migration, poor
retention, lower job satisfaction and high turnover (Casey & Fink, 2004).
According to the Malaysian Association of Nurses, until 2009, there are no
concrete plans implemented by the Government of Malaysia to increase the
motivation of nurses in Malaysia (Masroor & Fakir, 2010). Nevertheless, in
2008 the Malaysian Prime Minister, saw the significance of the contribution
from nurses to the country and decided to increase the allocation in the
government’s annual budget for nurses in order to appreciate.
Nursing literature report that poor training, a lack
of support systems, and the stress related to the intense working situation and
high patient acuity are main reasons nurses are living during their first year
after graduation (Bowles & Candela, 2005; Mathews & Nunley, 1992;
Patrick, 2000). This is quite similar statement in the literature by Halfer &
Graf (2006) cited from Beecroft, Kunzman, & Krozek, (2001) that the
inability to handle the intense working environment advanced medical
technology, and high patient acuity results in new graduate turnover rates 35%
to 60% within the first year of employed.
Much of this nursing shortage has its roots in human resource management
issues, such as failure to control workplace bullying (Canadian Institute for
Health Information, 2007). In a survey of National Health Trust community
workers in the UK, 38% of staff reported having experienced bullying and were
likely to leave their job as a result, whereas 42% had witnessed the bullying
of others (Cooper &
Swanson, 2002).
A high turnover and influx of new graduate have led
to a higher proportion of inexperienced nurses in direct patients care, which
may not only be traumatic for a new profesional nurse but may also threaten
patient safety (Santucci, 2004 cited by Mihyun Park, 2010).
Therefore, with the high turnover among the new
graduate nurses within the first year of employment, there is an increased need
to plan the effectiveness of retention strategies. The strategies may varies by
institution but the most effective programs in retaining nurses were new
registered nurse preceptor program, nurse residency program and some
pre-graduation program but most facilities do have some sort of orientation in
place. Several organizations with
high rates of new graduate nurse turnover have implemented orientation
programs, such as a preceptor model, and found this to have a positive impact
on new graduate nurse retention. Residency programs are of great cost, since
the programs last so long. Preceptorship programs appear to work the best, but
require collaboration of nurse leaders, managers, and educated preceptors.
According to Linda,
Jessica, Tommie, et al.(2010), the positive impact from the retention strategies include
greater job satisfaction, greater percentage of retention and decrease costs
related to orientation of nurses. In this article, the author will explore the strategies of retention of new nurse using Benner’s
framework.
2.0 Discussion
The Benner’s From Novice to Expert Framework
Figure 1: Benner’s Stages of Clinical Excellence (‘novice
to expert’ model)
Benner’s (1984) Novice to Expert theory used as a
theoretical framework for profesional development department’s work.
Stage 1 (Novice) - Beginners have had no experience
of the situations in which they are expected to perform. Novices are taught
rules to help them perform. The rules are context-free and independent of
specific cases, hence the rules tend to be applied universally. The
rule-governed behavior typical of the novice is extremely limited and
inflexible. As such, novices have no "life experience" in the
application of rules. "Just tell me what I need to do and I'll do
it."
Stage 2 (Advanced Beginner) - Advanced beginners are
those who can demonstrate marginally acceptable performance, those who have
coped with enough real situations to note, or to have pointed out to them by a
mentor, the recurring meaningful situational components. These components
require prior experience in actual situations for recognition. Principles to guide
actions begin to be formulated. The principles are based on experience.
Stage 3 (Competent) - Competence, typified by the
nurse who has been on the job in the same or similar situations two or three
years, develops when the nurse begins to see his or her actions in terms of
long-range goals or plans of which he or she is consciously aware. For the
competent nurse, a plan establishes a perspective, and the plan is based on
considerable conscious, abstract, analytic contemplation of the problem.
Stage 4 (Proficient) - The proficient performer
perceives situations as wholes rather than in terms of chopped up parts or
aspects, and performance is guided by maxims. Proficient nurses understand a
situation as a whole because they perceive its meaning in terms of long-term
goals. The proficient nurse learns from experience what typical events to
expect in a given situation and how plans need to be modified in response to
these events. The proficient nurse can now recognize when the expected normal
picture does not materialize.
Stage 5 (The Expert) - The expert performer no
longer relies on an analytic to connect her or his understanding of the
situation to an appropriate action. The expert nurse, with an enormous
background of experience, now has an intuitive grasp of each situation and
zeroes in on the accurate region of the problem without wasteful consideration
of a large range of unfruitful, alternative diagnoses and solutions. The expert
operates from a deep understanding of the total situation.
New
Registered Nurse (RN) Residency Program
The New
Graduate Nurse Residency Program is designed to ease the transition from
nursing student to skilled registered nurse. The versant RN Residency
curriculum include classes with case studies, structured clinical immersion,
experiences with team precepting, structured mentoring and debriefing or
self-care sessions, looping to related department and competency validation. The RN residency continues to be
based on Benner’s framework, emphasizing the novice to expert progression for
residents as well as for preceptors, mentors, debriefers, and subject matter
experts. New graduates are coached into independence by the experienced and
accomplished nursing staff. This competency-based orientation is coordinated by
masters-prepared Clinical Nurse Specialists, Professional Development
Specialists and skilled registered nurse preceptors. Each cohort receives a
strategic, planned blend of classroom and hands-on experience. Progress is
evaluated on a regular basis with input from the preceptor(s) and Clinical
Nurse Specialists, according to established objectives.
Clinical immersion. Clinical immersion is vital to the success of
new graduates. A critical aspect of the new graduate’s clinical immersion is
dedicated preceptors. Preceptors are educated in working with new graduates.
The RN residency began by using the traditional model of precepting –assigning
a preceptor and an alternate preceptor, and using the same
expert RNs over and over as
preceptors. In team precepting, the new graduate begins with a novice preceptor
who has an experience level closer to that of the new graduate. As the new
graduate gains expertise and knowledge, a preceptor with more clinical
experience takes over. Critical to this team precepting model is transparency,
accountability, and communication between preceptors that allows all involved
to be up to-date on residents’ strengths, needs, and individual performance
goals. As a part of the clinical immersion component, each resident rotates or
“loops” to other areas outside of the resident’s home unit during guided
clinical experiences. These structured looping experiences allow the residents
to understand what their patients experience in other areas of the hospital and
offer them opportunities to meet and begin to form relationships with staff in
these areas.
Mentoring and debriefing- Providing support to new graduate nurses through
structured mentoring is very important to their success. Structured mentoring
includes scheduled meetings, guidelines for conducting mentoring sessions, and
providing specific content as well as discussions geared to individual needs.
In evaluating study of the mentor component of the RN residency, Beecroft,
Santer, Lacy,Kuntzman, and Dorey (2006) found that when residents met with
their mentors regularly, guidance and support were provided and resident stress
was reduced. In mentor circles, two to three mentors assume responsibility for
a group of residents. Residents also participate in scheduled, facilitated,
structured debriefing/self-care sessions which provide opportunities for
residents to safely voice and share their feelings about their experiences such
as death of a patient, personal life balance or dealing with disruptive
behavior. Implementing a structured RN residency requires the organization to
review the competencies and knowledge required of RNs and to review the related
processes and systems so they can be effectively communicated to new graduate
nurses (Beth, Charles, Sean, et al. 2010)
Preceptorship program
A preceptorship is a formal
agreement between or among individuals to engage in a time-limited apprenticeship.
The preceptorship program has been introduced to assist newly qualified staff
in consolidating their course content and helping them to translate theoretical
knowledge into practical skills within general practice nursing. It is also a
useful tool for those moving into general practice nursing for the first time. Preceptors and mentors provide life-long lessons to
new graduates and younger nurses that ensure the quality of knowledge within
the nursing profession will remain strong for years to come. Preceptors
support the development of clinical competence and confidence in a way that
allows the junior nurse to grow professionally, but also provides immense
rewards for the preceptor.
The
research identified many roles and responsibilities of the preceptor that
facilitated the transition of the new graduate nurse. These included serving as
a role model, integrating the new graduate nurse into the unit culture,
advocating for the new nurse graduate, encouraging and evaluating performance,
debriefing after critical situations, offering support and helping adjust to
the profession, fostering the development of relationships on the unit, serving
as a resource, and teaching clinical skills (Salt, Cummings, &
Profetto-McGrath, 2008, Pine & Tart, 2007, Orsini, 2005, Shermont &
Krepcio, 2006, Halfer, 2007). Other than that, by sharing their knowledge
with junior nurses, preceptors help improve job satisfaction, decrease
orientation time and have a direct impact on how well the nurse will perform on
the job.
The most
common approach taken was the preceptor program model-new nurse graduate focus,
which were designed for each new graduate nurse to have a preceptor-guided
clinical experience in a one-on-one manner (Salt, Cummings, &
Profetto-McGrath, 2008, Pine & Tart, 2007, Orsini, 2005, Shermont &
Krepcio, 2006). Precepting occurs in
patient care situations, allowing the preceptor to guide the new nurse through
the procedures required to provide the best care. Preceptors introduce
preceptees to their new roles and responsibilities, coach them on “the basics” (where
to park; when to report; where to find supplies and resources; how to find and
use unit/area specific equipment, area rules or guidelines, and the
organization’s strategic plan, etc.), support and shape critical-thinking
skills, evaluate performance and give feedback for improvement, and introduce
the nurse to a wider network of nurses, frequently recommending preceptees for
projects, committees, advancements, and honors within the professional practice
environment and community (Nurse
Preceptor Program Bulider, 2007).
This role is crucial to ensuring future nurses can perform at a
high level and with confidence in a clinical setting.
Orientation
program
Each
orientation strategy implemented by the organizations examined outlined goals
for their new graduate nurse orientation programs. Overreaching goals of all
programs were to support the development of both competency and role transition
with narrower focus on areas such as partnership, coaching and collaboration,
communication, professional role development, critical thinking, improving
patient outcomes, leadership, and sense of belonging (Shermont & Krepcio,
2006, Halfer, 2007, Pine & Tart, 2007). It is expected that a orientation
program develops the nurse from novice to advanced beginner, and ongoing
education and clinical experience develops the nurse to be practicing at competent.
Comprehensive new graduate nursing orientation is a 10-16 week
program that provides nurses with the classroom and clinical experiences needed
to get them started on a successful career in pediatric nursing.
Classes during the first
week of orientation provide general employment information and cover the health
system's philosophy and policies, role expectation and special services. Ward concepts
are highlighted and core clinical skills are reviewed. Topics addressed during
that first week include organization services and resources, policy highlight,
ward clinical concepts and skills, interpersonal skills and networking
opportunities.
The
following weeks will immerse the new graduate nurse in their specific
department. Information covered include patient population and patient care
routines, department environment and unit specific policies. Dedicated staff
nurse preceptors will also provide supervised clinical experiences and bedside
instruction, all overseen by unit based education coordinators and/or mastered
prepared nurse specialists. The length of this preceptor clinical component
varies with each department, and with the previous experience of the new
graduate nurse. Additional orientation programs are included depending on the
department and role. These programs include classroom sessions, computer
assisted modules and self-learning activities. Some of examples include such as
Computer training (hospital information systems), life support training,
including CPR, pre-arrest Decisions course, Pediatric Advanced Life Support,
and Neonatal Resuscitation Program. Additional clinical programs are provided
as appropriate for each department and may include Building Excellence in
patient Nursing Care, Central Venous Line Management and CPR & Safety
Awareness.
Once
orientation is complete, each new nurse is assigned a mentor for a period of
one year to provide further support and role modeling. Both preceptors and
mentors are hand-picked, specially trained staff nurses.
3.
Conclusion
First
year turnover rates of new nurses ranging from 35% to 61% demonstrate the
challenges of transitioning from nursing school to clinical practice. To
implement and successful in the strategies approaches requires the engagement
and active participation of people from throughout the hospital organization
including nurses in management, education and
administrative. One example of successful outcome after implemented
residency program strategy is from Methodist Hospital who report that retention
of nurse graduate has dramatically improved from 50% to 89 % (Pine, 2007).
(Total words: 2460)
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