Should New-Graduate Nurses Consider a Nursing Residency Program?

This essay was written by my student Benjamin Howell-Little as an assignment in his Clinical II junior-level course in the University of Wisconsin-Madison School of Nursing. I am publishing it here with his permission, as I believe this issue is relevant to many nursing students who are considering their options for transition into RN practice after graduation.

BACKGROUND/SIGNIFICANCE:

For the last few months, I've garnered increasing interest in the possibility of a nursing residency program (NRP) as opposed to just “jumping into” RN nursing. Looking towards our options after the end of next year, I think it would be prudent to learn about what exactly we can and can't do off-the-bat (which is information I've found to be lacking in the nursing program thus far, and wish that weren't the case). Much of what I've focused on this rotation for these Evidence-Based Practice (EBP) essays is patient-centered practices. While I think that is vastly important, I also believe every once in awhile we as students and future nurses need to also examine EBP in the context of our own careers, so that we can most proficiently serve our patients. I am an avid believer in the adage that one must first take care of themselves before they can help others.

For those who are not yet familiar with NRPs, I will quickly explain what they are. NRPs are offered by some institutions that employ RNs to provide an extended transition between graduation from nursing school to taking on full responsibility for nursing care. Whereas many institutions offer an orientation period (which often lasts only several months) for new-graduates and nurses with experience alike – to become familiar with the unit and institutional policies – NRPs often are typically only offered to new-graduates and generally consist of an entire extra year of limited responsibility and emphasis on continuing education and transition. Nursing Residents are typically paid the same amount as new-graduate hires, but also train for a longer period under another nurse, as well as attend classes and discussions with peer residents; NRPs are also more competitive to get into, due to limited financial resources and high demand (Goode et al., 2009).

In my initial research I have looked at local Madison-area options for NRPs, as well as a few articles about NRPs online. I intend to integrate the two in this post. Since I can't cover everything you should know here, I suggest actually checking out the references at the end for more information, as they are really interesting articles. I believe we are in the midst of a transition from sending new-graduate nurses straight off to work to recognizing the benefits of NRPs to new-graduate staff retention and quality of care.

INFORMATION/SUGGESTIONS:

According to two studies, NRPs are cost-effective, partly because they improve patient safety, as well as new-graduate job-satisfaction, and subsequently reduce turnover rates (Cappel et al., 2013; Goode et al., 2009). One study found that as many as a fourth of new graduate nurses had worked at two or more institutions by only 6-8 months after graduation (as cited in Goode et al, 2009). This article also notes that because many orientees take full responsibility for patients within 3-6 months of starting, they often experience a dip in self-perception and confidence; whereas after one year, this confidence becomes regained as new-graduates begin to master their position (2009). These studies exemplify how NRPs can not only increase career-satisfaction, but also new-graduate employee retention rates, patient safety and new-graduate competence.

In terms of Madison Wisconsin NRP opportunities, I've looked into programs offered at UWHC, Meriter and the VA. UWHC offers one that must be applied to in the Fall of the year of graduation, and (according to one previous clinical instructor), is quite competitive. Meriter apparently offers NRPs to all new-graduates upon being hired there as an RN, recognizing their need for a transitional experience. The VA has two NRP programs; the one which I checked out is the “Post Baccalaureate Nurse Residency Program,” which offers a year of residency training and is relatively new. This program you must apply for in the Spring of the year of your graduation.

RECOMMENDATION:

My recommendation, based on these studies about the career-satisfaction and smoother transition aspects of NRPs is that all nursing students should consider this potential option for post-graduate work. While they may be competitive to get into, I suspect that increasing awareness of the benefits of NRPs will lead to a greater number of opportunities in the future.

References

Cappel, C. A., Hoak, P. L., & Karo, P. A. (2013). Nurse residency programs: What nurses need to know. Pennsylvania Nurse, 68(4), 22-28. Retrieved May 15, 2014, from CINAHL database (Try this link: http://search.ebscohost.com.ezproxy.library.wisc.edu/login.aspx?direct=true&AuthType=ip,uid&db=rzh&AN=2012449180&site=ehost-live&scope=site).

Goode, C., Lynn, M., Krsek, C., Bednash, G., & Jannetti, A. (2009). Nurse residency programs: an essential requirement for nursing. Nursing Economics, 27(3), 142. Retrieved May 15, 2014, from CINAHL database (Try this link:http://search.ebscohost.com.ezproxy.library.wisc.edu/login.aspx?direct=true&AuthType=ip,uid&db=rzh&AN=2012449180&site=ehost-live&scope=site).

Student Perceptions of Active Learning in Undergraduate Nursing Education

I've recently completed a study examining the perceptions of nursing undergraduates on active learning.

Here is a link to the slide set. 


Thanks to the University of Wisconsin-Madison School of Nursing Research Committee for funding this research through a Scholarship of Teaching and Learning Grant.

Critical Reflection: A Powerful Way to Add Depth and Breadth to Student Learning

Critical Reflection Adds Depth and Breadth to Student Learning

Critical reflection- a powerful tool in our active learning armory. I've come to understand this over the years as I've taught nursing students in the clinical setting. I came across a discussion of critical reflection today in a Faculty Focus posting by Mary Bart, and it got me thinking about the power of this tool. 

“Critical reflection is not a neat and tidy exercise that closes an experience with a nice, tidy, little bow. Rather, reflection is ongoing, it’s often messy, and it provides more openings than closings,” said Barbara Jacoby, PhD., senior scholar at the University of Maryland, College Park. “This is one of the challenges that faculty who engage students in critical reflection find all the time. We don’t know where students will go with their reflection, and … we have to let go of thinking of ourselves as the expert in a certain topic, because critical reflection opens questions that we are not necessarily going to be the expert on.”

And yet, critical reflection continues to gain momentum as a powerful way of adding depth and breadth to learning by asking students to analyze, reconsider and question their experiences within a broad context of issues and content knowledge, Jacoby said.

In Roger's concept analysis of reflection the author identifies factors common to reflection, summarized in the table below. 

The outcomes of reflection are learning and enhanced personal and professional effectiveness. 

Critical reflection has been an important tool in my teaching in the last few years. I've used with students in the classroom, in having them summarize and apply the concepts we've learned, 

I have also used critical reflection teaching in simulated patient care situations, where students are put in a realistic, challenging situation and they have to make decisions, act on those decisions, and do this while working as a team, They see the patient outcomes based on what they do, and they see how well (or how poorly) they actually function in a team. After they've had a chance to see some outcomes, we pause  the scenario, and discuss what was happening. In most cases, at this point they are very critical of their performance (probably more critical than I would be). This is GOOD! They are critically reflecting, figuring out how they personally and as a team can improve, and what they would do differently next time. We then restart the simulation with scene 2, which is usually a few hours or days later. Almost universally, after the critical reflection, the students do so much better! This year, I was able to also see that what they learned is a lesson that is maintained over time, when they go into other simulations. 

Critical reflection has been particularly effective tool in my clinical teaching with undergraduate nursing students. A reflective journal is part of their weekly assignment for me, requiring them to reflect on what they saw, did and learned that week. They have to write about what went well and what they would do differently in the future, setting progressively greater goals for their development. One of the keys to success in the critical reflection process, is that there is no "right answer". Students need to be able to be honest and to grow without worrying about how this will impact their grade, and enabling you to constantly guide and motivate them forward in their growth and development.  

Instructional design and educational technologies

Tim & I have been thinking about the importance of focusing on instructional design, rather than just technologies. So often people get really excited about a new technology that they can use in teaching their students. However, the focus needs to be on the teaching and learning, not the tools, if technology is going to to help our students.

The importance of focusing on teaching rather than tools has never been so clearly illustrated as it has been recently in the Los Angeles School District. With the advent of iPads, and all of the cool applications they can have, the LA school district invested a billion dollars (yes, B as in a thousand million), in buying iPads for students. The problem is, the teachers don't know how to teach with them, and the curriculum is not designed for them. It may have been a good idea, but it was implemented too soon.

The focus of the work Tim & I have done for the last decade has been helping educators learn how to use technologies in their teaching. This is an issue we've seen since we began. So we need to get back to the basics of instructional design, and thinking about what we want our students to be able to do.

In looking for resources about instructional design, I came across a great blog called An Ethical Island where there are many terrific teaching resources that have been created using infographics. One of the things I found there is an Instructional design video series that has been created by Epigogy. Each video is just a few minutes long, but it presents concepts in a clear and concise way.

A foundation of instructional design principles can guide us in making choices about

• what we want our students to know and do
• what curriculum we need to teach
• which teaching and learning approaches we will use
• which educational technologies and tools can best facilitate these learning experiences with a focus on what we already have available and what our ed tech resource people can support

After we've done this planning, we can integrate these technologies into the teaching and learning process, hopefully avoiding the type of fiasco that's going on in LA.

Group Quizzing: Teaching Pearls

Group Quizzing

Group quizzing using the IF AT sheets is an element of the Team-Based Learning model that promotes student discussion and engagement with the content at a higher level of learning than quizzing individually, or lecturing by itself. Students work together to answer challenging quiz questions based on the content required for the class session. Each group has only one chance to get the right answer to a question, and they learn if they were correct if they see a start when they scratch off their choice on the IF AT answer sheet. This provides immediate feedback. If they don’t get it right, they lose points on that question, and they have to keep answering until they get the right answer, with half points awarded for the correct answer on the second attempt. Learning the correct answer to a question is important, as student will remember the last answer they put on a quiz or test. If was the wrong answer, that’s what they remember as correct; therefore, providing immediate feedback is important to student’s learning the correct information.

During the group quizzes, it’s exciting to see students engaged in discussions about the nuances of the content, and students rarely miss class on quiz days. During the group quiz, walk around the room and listen to what they are saying in their discussions. This information is very helpful in reviewing things that were most important, or concepts that they didn’t understand, as well as in determining how to write future quiz questions

·         Were the questions too easy? If there was little discussion and they finish the quiz in  a couple of minutes, the answer is probably yes.

·         Were the questions too hard, or were they poorly written, based on the content? If the discussions goes on for a long time, particularly on a few questions, this is probably the case. At this point, find out what the students are saying and thinking, to clarify content and maybe even revise the question, giving credit to students where it is due.

Inevitably, the students working as a group get 100% most of the time, because they have discussed their rationale and have had to come to a consensus about the correct answer. In doing so, they have taught each other (peer instruction).

Later, compare the group quiz scores  with the scores you see on the individual quizzes- if you wrote good questions that are not too easy and not too hard, they should follow a normal distribution bell-curve, with scores ranging from 50 or 60 to 100%. (Stats are available for quizzes on your course management site)

This individual quizzing followed by group quizzing method from TBL is particularly beneficial to students’ learning if the questions are challenging and they need to “dig” for the answers in the content, or if they have to make a challenging decision based on what they’ve learned. I’ve found that 10 questions is a good length for a group quiz so that it takes just a few minutes at the beginning of class to complete. Be sure to write good questions for this, that require them engage with the content you’ve provided for class prep.

It’s also very important for students to do this quiz first on their own without getting any feedback or score. This gives them time to think about the questions themselves and look for the answers in the learning materials you’ve provided before they do the quiz with their group.  I don’t know about you, but I learn best when I have a question that I’m faced with, and I have to find information to answer the question. This is often how students learn too, and many will do the quiz and content review at the same time- I encourage this- when they have plenty of time to answer the questions on their own, they will often go through the key parts of the content several times- helping them learn it. Individual quizzing before class is also important in holding them accountable for class preparation  as well as limiting the amount of time needed in class for the group quiz. I usually plan on about 15 minutes in class, which allows time for discussion and clarification of a few questions.

A few things about using the IF AT scratch sheets: questions must be in multiple choice format with choices for each ordered  based on the specific form being used. Getting the answers in the correct order is streamlined if you use the free IF AT testmaker site. Also, each question can only have one answer. More information about IF AT sheets is available on their website  .  

Welcome

Welcome to my blog- Active Learning in Nursing Education.

I've started this blog to share information, and promote collaboration with educators who are interested in active learning. This is not just for nursing educators- anyone who teaches may find useful information here. However, many of the applications and examples will emphasize nursing education, as that is what I teach.

A little about me: I currently teach in the undergraduate nursing program at the University of Wisconsin-Madison. It's a beautiful city, and an exciting university of about 46,000 students with many opportunities and resources, and an atmosphere that encourages and supports educational innovation. However during most of my teaching career, I've taught in much smaller universities that did not have so many resources. I was often in the minority in using innovative approaches to teaching and learning, and at times felt that my efforts in teaching were not really appreciated.

My philosophy and approach to teaching and learning has been informed by numerous influences:

• My own learning experiences
• My student's feedback about how they learn
• My educational mentors- Ruby Englund at Seattle Pacific University and Annalee Oakes at SPU and then at Northwest University
• My educational coursework, particularly what I learned in "The Role of the Professoriate" at the University of Wisconsin-Milwaukee during my PhD. 
• My passion for research, exploration and developing new knowledge
• Most importantly, my husband Tim Fahlberg, who is always on the bleeding edge of educational technology, and whose passion for teaching is a constant inspiration in my day to day life. 

What you will find here, I hope, will be informative as well as practical. I invite you to add comments and to share your own experiences to this blog, so that we can teach and support each other, as we work together to become better teachers, and as we guide our students in their development.

Beth Fahlberg