Nurse Residency Programs Column Editor: Jim Hansen, MSN, RN-BC

Nurse Residency Programs Why Now?


ith the recommendation to ‘‘implement nurse residency programs’’ nationwide, the Institute of Medicine’s report on The Future of Nursing joins an ever-expanding cadre of support from healthcare industry researchers and policymakers across the nation. When it comes to nurse residency programs (NRPs), the Robert Wood Johnson Foundation recommends them, the Carnegie foundation advocates for them, the Association of Colleges of Nursing can accredit them, the Advisory Board Company exemplifies them, the National Council of State Boards of Nursing is modeling them, healthcare organizations need them, nursing schools teach their students about them, and new nurses shop for them. A larger question is: Why? What is going on in the nursing world that makes NRPs seemingly essential now, when nurses have been navigating academia and industry for over a century? To understand why NRPs came into being, what their purpose is, and how they benefit the healthcare industry, it is necessary to turn the clock back and see how nursing arrived at the place it is today and why NRPs are needed more than ever before.

NURSING EDUCATION: THEN AND NOW In the first half of the 20th century, nursing education was very different. Most of nursing education was done in situVat the bedside in a hospital unit. Nursing students spent years working in the hospital, doing basic nursing tasks under the supervision of experienced clinical RNs. Evenings were filled with lectures and classes offered in the hospital by nursing faculty who were bedside clinicians by day and nurse educators by night. The system had pros and cons. On the upside, students were well grounded in technical nursing practice and had

Jim Hansen, MSN, RN-BC, is Clinical Supervisor, New Graduate and Student Services, Kootenai Health, Coeur d’Alene, Idaho. The author has disclosed that he has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. ADDRESS FOR CORRESPONDENCE: Jim Hansen, MSN, RN-BC, New Graduate and Student Services, Kootenai Health, 2003 Kootenai Health Way, Coeur d’Alene, ID 83814 (e-mail: [email protected]). DOI: 10.1097/NND.0b013e31829e9cda Journal for Nurses in Professional Development

spent thousands of hours in direct patient care by the time they received their diplomas and took the licensure exam. On the other hand, nursing school curricula reinforced technical nursing practice and viewed nurses as members of a practice discipline as opposed to the credentialed professional practitioners so sorely needed today. In an effort to elevate the status of nursing and provide a liberal arts and sciences foundation to a quickly developing field, nursing education moved gradually out of the hospital and into the collegiate classroom. As it did, nursing gained ground in providing a scientific foundation and unique identity to nursing, but did so at the cost of time spent at the bedside; nursing students would attain licensure and enter the healthcare industry with only a fraction of the bedside hours their older colleagues once had. This fundamental shift in nursing education allowed the nursing academia and the healthcare industry to begin to drift apart like two slowly diverging continents, creating a gap between them that newly licensed nurses had to leap as they finished nursing school and began their nursing careers. In 1974, Marlene Kramer (1974) documented the ‘‘reality shock’’ new graduates felt as they struggled to bridge the gap to practice nursing in a very different environment from what they had anticipated. Kramer’s research revealed that about 12% of new nurses, unable to make the transition into practice, essentially ‘‘fall into the gap’’ and leave nursing altogether. As the millennium dawned, new policy reforms, technologies and practice standards widened the preparationY practice gap into a chasm. In a 2002 white paper, the Joint Commission flatly stated: There is what has been described as a ‘‘continental divide’’ between nursing education and nursing practice. In the academic setting, nurses, like other health professional disciplines, are educated in a silo. This problem is compounded by the lack of awareness of nursing faculty about actual nursing practice today; the virtual absence of clinical experience from the nursing school curriculum; and the lack of involvement of nurse clinicians in the education process ( Joint Commission, 2002, p. 30).

In 2008, the Advisory Board illustrated how wide the preparationYpractice gap had widened by asking over a thousand hospital nurse executives (industry) and nursing www.jnpdonline.com

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.



Nurse Residency Programs

school leaders (academia) if they agreed with the statement: ‘‘Overall, new graduate nurses are fully prepared to provide safe and effective care in a hospital setting.’’ In this study, 90% of nursing school leaders agreed with the statement, but only 10% of hospital nurse executives did (Nursing Executive Center, 2008). These research findings over the years may seem to imply that the academic world has grown out of touch with the current industry demands placed on nurses, but it is important to remember that the preparationYpractice gap is not academia’s doing. Nursing schools realize that their primary mission is to educate nurses according to industry demand, and they evolve curricula over time to adapt to new standards of nursing practice. Unfortunately for all, the rate at which health care in America is changing is accelerating exponentially. Healthcare organizations struggle mightily to keep abreast of industry reforms, and currently, they are changing to meet industry demands faster than the nursing schools can change to meet healthcare organizations’ needsVand the gap grows even wider. As we continue into the 21st century, it is apparent from the Future of Nursing report that nurses will increasingly assume more professional domains of health care that require greater professional competencyVcompetencies that are not fully taught and developed in nursing schools. Therefore, ‘‘the ways in which nurses were educated and practiced during the 20th century are no longer adequate for dealing with the realities of health care in the 21st century. Outdated regulations, attitudes, policies, and habits continue to restrict the innovations [that] the nursing profession can bring to health care at a time of tremendous complexity and change’’ (Institute of Medicine, 2010, pp. 1Y8).

SPANNING THE PREPARATIONYPRACTICE GAP Fortunately, industry and academia are collaborating more than ever before in finding ways to shrink the gap. On the academic side, a new call for transforming the way nurses are initially educated is championed in the 2010 Carnegie Foundation report titled ‘‘Educating Nurses: A Call for Radical Transformation.’’ It acknowledges that nursing education has not evolved fast enough or to the same degree that nursing practice has and that ‘‘radical changes’’ are sorely needed if new nurses are going to possess the competency and skill required of American healthcare workers. Academia can do this in three main ways (Benner, Sutphen, Leonard, & Day, 2010): n Move from covering abstract knowledge to teaching the student to recognize the important aspects of a situation, think in context of patient needs, and act deliberately. n Integrate classroom education and clinical experience instead of approaching them as separate entities. n Shift from critical thinking to clinical reasoning in patient care. 48


On the industry side, the NRP functions as a bridge that spans the preparationYpractice gap. The fundamental purpose of the NRP is rather simple: to prepare new nurses (including new advanced practice nurses and those making the transition into different specialties) to provide safe, effective care in the 21st century healthcare environment. The NRP does this by establishing those competencies in nurses that they might not have had the opportunity to develop (or sufficiently develop) in nursing school. Although this mainly includes professional competencies, it is certainly not limited to them and can include technical competencies as well, if those technical competencies are not fully developed in nursing school. NRPs are still a relatively new creation (the oldest of them is only about 10 years old), and there is still a great deal of research to be done to determine what parts of NRPs do the most good, what parts are needed, and how best to bridge the preparationYpractice gap. The current research is beginning to consistently show, however, that NRPs generally do a good job of helping new nurses feel better about their transition into practice. They feel less stressed and more supported as they make the leap across the gap. Additional articles are frequenting the literature, suggesting that organizations that have NRPs report the following: n Easier recruitment of new graduate nurses in the hospital. n Lower rates of new graduate turnover. n Accelerated practice readiness of new graduates. n Higher populations of younger nurses. n A positive return on investment for the costs of the NRP. n Greater commitment of nurses to their own professional development. n Nursing staff who align themselves with the tenets of professional practice upheld by the ANCC Magnet Recognition Program. Although no one knows for sure what the future holds, odds are that, as long as the preparationYpractice gap exists, there will be a function and a role for the NRP in preparing the nursing workforce of the future. Until next time...

References Benner, P., Sutphen, M., Leonard,V., & Day, L. (2010). Educating nurses: A call for radical transformation. Stanford, CA: The Carnegie Foundation for the Advancement of Teaching. Nursing Executive Center. (2008). Bridging the preparation-practice gap, Volume 1: Quantifying new graduate nurse improvement needs. Washington, DC: The Advisory Board Company. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: Mosby. The Joint Commission. (2002). Healthcare at the crossroads: Strategies for addressing the evolving nursing shortage.Retrieved from http://www.jointcommission.org/assets/1/18/health_care_at_ the_crossroads.pdf January/February 2014

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Nurse residency programs: why now?

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