University of Colorado Hospital: The First Nationally Accredited Nurse Residency Program

Whether we are consulting with a lawyer, an architect or an accountant, we always hope the work is being done by the most capable professionals available. This is especially true when it comes to our health care. In U.S. hospitals, however, roughly one quarter of newly registered nurses leave their first job in less than two years. This high turnover rate reduces the number of competent—and confident—nurses; it destabilizes a health care team; and, significantly, puts patient safety and quality of care at risk at a time when the U.S. patient population is becoming both older and sicker. While most nurses do move into nursing positions in other facilities, starting over in a new workplace inevitably disrupts and slows the development of a nurse’s expertise, and can potentially compromise patient care in each subsequent hospital to which he or she moves. Obviously, such high rates of turnover do not serve employers, nurses or the patients for whom they care, but the good news is that at a growing number of U.S. hospitals, this problem is being addressed by new nurse residency programs.

Modeled on those already in place for physicians and pharmacists, these standardized programs actively mentor, educate and support new nurses, preparing every nurse who passes through them to deliver the highest quality care wherever they might work. As one of the first hospitals in the nation to launch such a program, the University of Colorado Hospital (UCH) in Denver is setting the standard for both curriculum development and implementation, while its patients are reaping the benefits of a highly trained, highly professional and stable nurse workforce.

The nurse leaders who designed the pioneering Post-Baccalaureate Nurse Residency Program at UCH will tell you that it’s about retaining newly-graduated nurses, creating a work environment that brings job satisfaction for those nurses, and, importantly, building a nurse workforce with the knowledge, skills and professionalism needed to care for today’s hospital patients. With aging baby boomers and new hospital practices, patients are older and sicker than ever before. Whether at the level of an individual facility or nationally, reducing turnover and cultivating a highly skilled nurse workforce means improving patient care and patient outcomes; study after study shows these figures rise and fall together.
 
UCH began exploring the idea of a residency program for newly hired nurses in 1999, when Colleen Goode, PhD, RN, FAAN, NEA-BC served as Chief Nursing Officer (CNO) and Vice President for Patient Services and  also chaired the University Health System Consortium (UHC) Chief Nursing Officers Council.  The deans from the American Association of Colleges of Nursing (AACN) and the CNO’s from the UHC entered into a partnership to develop a national nurse residency program. Colleen Goode and Carolyn Williams, President of AACN at that time, co-chaired a task force that initiated a team to develop the residency program. Goode hoped to make her home institution a model site for this new nurse residency program. “We realized that even the best nursing schools in the country can’t prepare nurses to enter a hospital and hit the ground running,” explains Goode. “New medical technologies and management practices mean all of our patients are acute.”

To create a residency program that would give nurses at UCH the same kind of learning-in-practice that produces professional physicians and pharmacists, Goode and her UHC and AACN colleagues devoted two years to gathering research on new graduates, planning, then developing the curriculum. They reviewed research, including surveys of what employers identified as areas in which graduate nurses needed further education and experience. Every element of the residency curriculum was reviewed to ensure the program provided new information so the content did not repeat courses from their undergraduate programs. Evaluation measures were selected to monitor program outcomes, including use of the Casey-Fink Graduate Nurse Experience Survey, a self-assessment instrument developed by a nurse scientist and clinical educator at UCH. This survey is administered to graduate nurses upon employment, at six months, and upon completion of the year-long residency program.  “The program planning was very much evidence-based,” says Goode. “We knew the measurements were vital for continually improving the curriculum to be sure we met our goals.”

And what are those specific goals? Beyond reducing  turnover, Goode describes several areas in which UCH designed its residency program to help new nurses become confident and fully participating health care professionals: organizing and prioritizing; communicating with patients, families and colleagues; clinical leadership; critical thinking and clinical reasoning; and mastering the technology and practices in different medical specialties.

At UCH, the year-long residency program begins with the “on boarding” of the new nurses. “That’s a Human Resources term,” explains, Mary Krugman, PhD, RN, FAAN, Director of Professional Resources, “describing the process  from job application to orientation for our new graduate nurses,” which happens in three hiring cycles each year. Owing to the residency program’s national reputation and measurable success since its 2002 launch, UCH has a large and talented pool of newly minted bachelor’s degree nurses to choose from—500 applicants for the 30 openings they’ll have in July 2010, for example. As part of the applicant screening, UCH administers a supplemental essay questionnaire designed to help  identify candidates who are “motivated to learn and appreciate an evidence-based environment,” according to JoAnn DelMonte, RN, MSN, Manager of Clinical Education and Professional Development, who created the supplemental form. Adds Krugman: “We are so privileged that we can select outstanding applicants who care about nursing, have often done volunteer work and already have demonstrated leadership.”

The Post-Baccalaureate Nurse Residency Program at UCH consists of three basic components: a 12 to 24 week preceptorship on a clinical unit; specialty classes built into the paid work week; and monthly seminars, also paid, lasting from four to eight hours each. Both Krugman and DelMonte credit the institutional support they get from the hospital, (“we get no pushback from the nurse managers” for taking their nurses off the unit for education and development, notes DelMonte) and their strong partnership with the University of Colorado College of Nursing in helping UCH establish what has become a model nurse residency program. While the preceptorship and specialty classes are key components of the “protected learning time” the program provides, it is the monthly seminars that make the residency unique—and especially effective.

The seminars are about much more than new content; they help the nurse residents build relationships within their class cohort and provide a safe space to share problems and concerns as well as successes and breakthroughs. DelMonte explains that the way the curriculum is delivered helps foster this supportive environment. For example, UCH uses a hand held clicker technology that allows seminar participants to give anonymous answers to sometimes difficult questions about such things as medication errors or conflicts with co-workers. No one wants to be the first to raise their hand and admit to a shortcoming, but the entire class benefits from discussions that ensue once these kinds of challenges are acknowledged.

Outside of seminars, there are two other activities that help nurse residents develop skills and maturity over the course of their residency year. One of those is writing clinical narratives in which the nurses examine, through the writing process, a specific case or event they experienced. Anyone who has journaled or taken a writing workshop can appreciate this as a powerful exercise in self-reflection and education. While the narrative writing is a solitary activity, residents share these narratives in their seminars. Also required are evidence-based practice projects, done either alone or in teams. For this learning experience, the residents systematically gather information from published studies and present their work in the form of a poster. Many of these UCH projects have subsequently been accepted for poster sessions at professional conferences around the country. In addition, five residents collaborated with Dr. Goode to write an article on their evidence-based practice projects.   This article addressed ways in which the residents improved patient care or the work environment and was published in the 2010, Current Issues in Nursing textbook.

Just as developing the residency program and curriculum began with evidence, the team at UCH is constantly gathering evidence as to how it’s working. DelMonte says one goal of the program is “raising nurses” and “socializing them into the profession.” There is abundant evidence those goals are being met:

• The national retention rate for hospital nurses in the first two years of nursing practice is just over  70 percent; at UCH it is 98 percent.
• At UCH, fully 60 percent of the current nursing staff has been through the residency program, a sign of high retention rates and a clear indicator of a highly trained, professional nurse workforce.
• In a 2009 survey, UCH found that of the 400 alumni of its residency program, all who responded, had gone on to assume leadership or management roles at UCH or elsewhere; many were enrolled in graduate education or  had already attained advanced degrees in nursing.

Goode, Krugman and DelMonte agree that UCH had some advantages going in when they launched their Post-Baccalaureate Nurse Residency Program in 2002. Their experienced nurses already embraced and excelled in their mentoring role given UCH’s longstanding practice of bringing on cohorts of new hires every four months. UCH had also run a “boutique” residency program in its critical care unit that laid some of the institutional groundwork. But these three nurse leaders repeatedly cite their reliance on evidence-based planning and rigorous measurement in allowing them to create—and constantly improve this exemplary program. 

They also believe that it is this level of rigor that led to UCH becoming the first post-baccalaureate nurse residency program to be accredited by the American Association of Colleges of Nursing (AACN). AACN began accepting applications for formal accreditation in 2009, and on May 27, 2010, UCH received the honor of being the first hospital-based program to receive this stamp of approval, making UCH a bona fide model of how to run a nurse residency program. Goode and her colleagues emphasize that national accreditation is a vital step in nursing’s coming of age as a health care profession. They look forward to the day when residencies are not only available for all new nurse graduates, but required—and funded by the Centers for Medicare and Medicaid Services—just as they are for physicians and pharmacists.