From The Floor
New Grad RN Residency Programs
Excellent programs at LAC+USC and City of Hope
I’ve written before about how difficult it is for newly graduated nurses to get the acute care experience many hospitals demand. I’ve also written about the nursing shortage, which is predicted to become more acute in the near future. This time, I want to talk about a way to solve both problems: the new- grad RN residency program.
The First Two Years
Why are hospitals so insistent that nurses have at least two years of previous acute care experience? A 2012 survey conducted by the American Nurses Association journal American Nurse Today found that “only 10 percent of nurse executives believed that new graduate nurses (NGNs) were fully prepared to practice safely and effectively.”
On top of that, NGNs’ turnover and attrition rates are too high for most hospitals’ comfort. The same 2012 survey found that attrition can be “as much as 57 percent” by the second year of practice. Considering those factors, it’s no wonder many facilities prefer to hire only nurses who have already made it “over the hump” of those first two critical years.
Beyond Nursing School
An alternative that many hospitals are now choosing is to offer residency programs designed to give NGNs the experience and guidance they need to become full-time staff nurses. These programs are generally about 75 percent clinical and 25 percent didactic and blend classroom instruction and clinical/lab simulation with precepted clinical experience and mentorship. There is skill testing throughout the process, which may last anywhere from eight to 22 weeks.
From an outside perspective, residency programs look like an extension of nursing school. The difference is that nursing school focuses on generalized skills and the knowledge needed to pass the NCLEX-RN. The residency program’s goal is to help new RNs develop autonomy and decision-making skills in real-world clinical scenarios. They also learn to assimilate into the organizational culture of the hospital and unit in which they will be working.
To learn more about these programs, I interviewed participants, preceptors and recruiters from the residency programs at two local hospitals: LAC+USC Medical Center and City of Hope National Medical Center.
LAC+USC Medical Center offers new-graduate-RN residency programs in several departments, including med/surg, emergency, OR and their many ICUs. The programs’ length varies by department, but is typically around nine weeks, the first six weeks of which are each divided into three days of class lectures and two days of clinical work. However, new RN residents are not considered to have “graduated” from the program until after they successfully complete their first year at the hospital.
Ready for Patient Care
NGN residents in the med/surg unit spend their first week learning the layout, working the desk and shadowing a preceptor like James Nimnualrat, RN. Actual patient care begins on the second week, starting with one patient. All of the NGN’s direct patient care during this period is observed by the preceptor to ensure that the new grad is providing safe, appropriate care.
If all goes well, residents will be assigned an additional patient each week until they have five patients. If the preceptors feel an NGN needs more time, they can ask the nurse manager for approval to extend the precepted period for a few additional weeks.
The Preceptor’s Imprint
Each preceptor has his or her own style. For example, Nimnualrat says he focuses on modeling how to chart, providing examples of his charting methods, explaining why he charts the way he does and helping his preceptees develop a style that works best for them.
Nimnualrat’s fellow med/surg preceptor Ramona Paolim, RN, BSN, encourages NGNs to self-assess. She says that learning to identify your own weakness as a nurse helps you become better grounded.
Another of Paolim’s strategies is to assign the NGN resident one very sick patient and one with a much lower acuity, which helps to keep the new grad from becoming overwhelmed. Paolim and fellow preceptor Christine Mercado, RN, add that they strive to teach NGNs the need to, as Paolim puts it, “always know why they are doing what they are doing.” For instance, if the new grads are administering Tylenol, the preceptor asks if they know what the patient’s liver function is.
Paolim says she enjoys being able to explain to the new RN “why we do what we do and how the various systems connect.” Mercado just loves being part of the process that helps mold a good team player, which she says is a beautiful thing to see.
LAC+USC Emergency Department
The new-RN-residency program in LAC+USC’s very busy emergency department is similar to the med/surg program: six weeks of combined classroom and clinical work followed by three weeks of exclusively clinical work in the high-acuity North unit.
Each NGN resident typically works with a preceptor for about a month, during which the new RN is gradually assigned additional patient booths, up to a maximum of four. After the preceptors turn in their final evaluations at the end of the month, the new grads are expected to be able to handle their four booths, but will still have access to a resource nurse for additional help if needed.
Fast Pace and High Acuity
The ED program differs from the med/surg program in the high acuity of the patients and the constant pressure to turn over the booth to the next patient. The 136-bed ER at LAC+USC is one of the largest and busiest in the country, so NGNs who want to make a career in emergency nursing will often bide their time waiting for a slot in this program.
Hannah Deloria, RN, is an alumna of the program in which she is now a preceptor. Her preceptor during the residency program was Paul Triamarit, RN, BSN, MICN, who she says would keep her on her toes with pop quizzes. She now tries to follow the example Triamarit and her other preceptors set for her, helping “to not only ensure that these new grads will be able to take care of patients safely but to also help them become comfortable and confident in their role as an ER nurse.”
Novice Nurses Become Great
Deloria urges NGNs to learn something new every day, whether it is a piece of equipment they have never used before, a disease process with which they are unfamiliar or a different nursing function in the department. She assures new grads that their initial anxiety will pass as their experience and knowledge grow.
Triamarit is still a preceptor in the program, a role he has now had for 10 years and says never gets old. “There is nothing more rewarding than seeing these novice nurses mature to become the great nurses that they inspired to be,” he says.
City of Hope
The new-graduate-RN residency program at City of Hope National Medical Center is a little different than most because of City of Hope’s focus on oncology.
Recruiters LeVell Romeyn, Teresa McCormac and Leilani Patacsil, BSN, MBA, told me that one of their priorities is to find nurses who understand and have a passion for the specific personal and emotional challenges of oncology nursing. Recruiters will ask about candidates’ personal experience with cancer, whether they have previous experience working or volunteering with cancer patients and if the candidate is active in any of the many oncology nursing organizations, such as the Oncology Nursing Society, National Coalition of Oncology Nurse Navigators and the Association of Pediatric Hematology/Oncology Nurses.
Candidates who are accepted for the program spend their first week becoming familiar with their unit’s policies and procedures, meeting other team members and learning basics like the locations of the equipment. By the second week, the NGN resident can expect to begin working hands-on with at least one patient. As the program progresses, the new grad will gradually take on additional patients.
More Than Dressing-Changers
These NGN residents will learn to perfect their craft with the help of City of Hope preceptors like Zhen Afable-Torres, RN, BSN, and Jessica Belko, RN, BSN. Afable-Torres, a preceptor for about 10 years, stresses that the NGN needs to have a strong grasp of “Nursing 101” before beginning the program. However, Belko, herself an alumna of the residency program, says that the preceptor can make or break a nurse’s foundation.
The NGN resident will typically shadow his or her preceptor for a time while also taking classes. The preceptor will observe and provide feedback on each procedure the new grad performs. Belko says she divides the coaching into three distinct steps: show, observe and return the demonstration.
As a preceptor, Belko tries to ensure that her preceptee gets a well-rounded experience with a variety of patient-care scenarios. If a specific patient-care experience isn’t available in her unit, she will seek out a suitable opportunity in another unit. She says she looks for preceptees to show her that they are able to think for themselves and be more than just dressing-changers.
Every one of the NGN participants I interviewed at both hospitals spoke with great enthusiasm about the residency program. They agreed that it provided them with much-needed skills and grounding in their specialty areas. All of the participants recommended these programs very highly.
The bad news is that competition to get into these programs is fierce, to say the least. Also, since most of the participants will eventually become full-time staff nurses, the hospitals are very choosy about whom they accept.
For its most recent cohort, City of Hope had about 1,000 applicants, of whom 80 finalists were invited to the next stage — an informational breakfast — and only 15 were ultimately accepted!
How to Increase Your Chances of Getting Accepted
I asked the participants to share some words of wisdom for RNs who wish to follow in their footsteps.
Apply early. The No. 1 tip was to apply as early as possible, even if that means applying as soon as you enter nursing school.
Volunteer and join. They also recommend volunteering for every healthcare-related role you can find to build up your real-world nursing experience. Joining a professional organization in your desired specialty area is also a good idea.
Pay attention to detail. The recruiters at the two programs stressed the importance of following the application instructions to the letter and making sure your application and resume are free of typos and spelling errors. These things may seem trivial, but nurses must pay constant attention to the smallest details, so any glitches here will definitely send the wrong message.
Send a thank-you note. Since there are so many applicants for each program, LAC+USC nurse recruiter Susanna Mortimer, RN, MSN, says follow-up calls and thank-you notes are a good idea.
Be flexible. Mortimer adds that it’s also important to be flexible. She says too often, a new RN wants to step directly into a management or teaching role and may be overly resistant to shift work.
Research programs. Another tip is to do your homework on the programs currently available in your specific area. The University of Pennsylvania offers a list of BSN residency programs, but hospitals add or close programs all the time. One of the nurses in the City of Hope program applied first to an RN residency program at another L.A.-area hospital that discontinued the program soon afterwards.
Make sure you qualify. Also, be clear on the application requirements for the program you’re interested in. For example, the City of Hope program is only open to nurses who have a degree (BSN or higher) attached to their RN license.
Don’t get discouraged. Above all, the NGNs I spoke with emphasized the importance of not getting discouraged. In fact, their poise and confidence was inspirational and gave this experienced nurse great hope for the future of the profession.
I’m glad that new-graduate-RN residency programs are helping passionate new RNs become the best nurses they can be.
CITY OF HOPE RESIDENTS
I interviewed five NGNs from the City of Hope program. One had already completed the program at the time we spoke while all the others were close to completion. I asked the nurses about how they came to be in the residency program and their experiences with it. The answers were surprisingly diverse.
Allison Winacoo, RN, MSN, who is from Massachusetts, says that RN residency programs like these are rarer on the East Coast than they are here, although newly licensed nurses there have similar problems finding jobs. She sent out more than 200 job applications before applying for the City of Hope RN residency program in pediatric oncology. When she was accepted, she decided to hop on a plane and make a go of it in Southern California.
Tiffini Gosha, RN, BSN, enrolled in the BSN program at National University using the G.I. Bill benefits she earned in the Navy. After graduating in 2012, she worked in a variety of surgical and laser clinics, but her lack of acute care experience stymied her efforts to find a hospital job. She actually took a computer information systems (CIS) position at City of Hope while waiting to find out whether she would be accepted for the RN residency program.
Derek David, RN, BSN, faced what he calls a “quarter-life crisis” after earning his undergraduate degree in business. On the advice of his mother, who is a nurse, he decided to pursue a BSN at Samuel Merritt University. He applied for the RN residency program in City of Hope’s hematology department and, like Gosha, took a CIS job while waiting to learn if he would be accepted. Unlike many of the nurses in his cohort, David says he only sent out about 20 applications before entering the program, something he credits to being a male nurse in a predominantly female field.
Jessica West, RN, BSN, had a more frustrating experience. She earned her BSN from Cal State Long Beach, but found that her degree and her experience working with Alzheimer’s patients and as a camp nurse weren’t enough to land her a hospital-based job. After an eight-month search and innumerable applications, she landed a slot in City of Hope’s ICU residency program, which she considers her ideal unit. Even so, it took three tries before she was finally accepted. Like Gosha and David, she took a CIS job at City of Hope while waiting for a slot.
Mackenzi Kawachi, RN, BSN, had a degree in combined science before setting her sights on nursing. Kawachi, who originally hoped to become a physical therapist for the L.A. Lakers, was inspired to become a nurse during the year she spent as a service coordinator for the Jesuit Volunteer Corps center in Atlanta. She says she was struck by how many of the individuals the center served could have really used a nurse, so when she returned to Southern California, she decided to pursue her BSN from Concordia University in Irvine. Kawachi had the amazing good fortune to be selected for the City of Hope new-graduate RN program on her very first application.
I interviewed five participants of the new-graduate-RN residency program at LAC+USC:
Ruth Moreno, RN, completed her ADN at Antelope Valley Community College and was fortunate enough to land a nursing job shortly after graduation thanks to one of her nursing school instructors, a nurse manager at nearby Antelope Valley Hospital. However, Moreno was eager for even greater challenges. She learned about the new-graduate RN residency program at LAC+USC from LAC-DHS human resources and now commutes from the Santa Clarita Valley to work in the LAC+USC ICU.
Although Moreno feels that nursing school gave her the basics and prepared her well for her chosen career, she says that the RN residency program helped round out her skills and gave her the opportunity to learn from the various mentors and preceptors whom she shadowed and worked with in the ICU. She now has her sights set on becoming a nurse practitioner and has already been accepted in the BSN program at Azusa Pacific University.
Michael Rivera, RN, BSN, is from the Philippines, but he was born in the States. As a U.S. citizen, he was able to sit for the NCLEX in the Philippines and receive his California RN license without jumping through too many hoops. Unfortunately, that didn’t make finding a nursing job any easier. In seven or eight months of searching, he received only two job offers, one of which was from a long-term care facility where he was volunteering. When he learned of the RN residency program at LAC+USC, it seemed like it was meant to be: Rivera was actually born in that hospital.
Rivera is also in the ICU program, which he says has involved some culture shock — LAC+USC has some equipment he had never even seen in the Philippines. However, he seems to be adjusting well and now intends to pursue his MSN with an educational component.
The other three LAC+USC nurses I spoke with are all graduates of the Los Angeles County Department of Health Services’ own College of Nursing and Allied Health. Joanna Centeno, RN, who is currently in LAC+USC’s emergency room residency program, waited eight months to get a slot in this specific program. Although she says she still feels like a deer in the headlights at times, she credits her education, mentors and preceptors with giving her the skills and support to weather those brief moments of uncertainty. She loves the autonomy of the ER and says its population makes her feel the most needed.
Lester Juarez, RN, became a CNA in 1998 and then practiced for 10 years as an LVN before completing his ADN at the LAC-DHS College of Nursing and Allied Health. Prior to entering the LAC+USC residency program, he worked at Orthopaedic Hospital (now known as Orthopaedic Institute for Children) and for a time in the jail system. His goal now is to become an orthopedic practitioner. Nursing is a family affair for Juarez: His mother is also a nurse, as is his wife. In fact, he met his wife while they were both CNAs and she is currently in the oncology nurse residency program at City of Hope.
Ronnay Cato, RN, originally wanted to be a doctor, but when her mother fell ill while Cato was in junior high, Cato concluded that it was actually nurses who did the things she most admired. After a few detours, she graduated from the LAC-DHS College of Nursing and Allied Health ADN program and entered the OR residency program at LAC+USC. She also took per diem to work to keep her basic nursing skills sharp while she was focused on the OR-specific aspects of her residency. By the time this article appears, she will have completed her BSN at Cal State Dominguez Hills.
This article is from workingnurse.com.