Evidence-Based Strategies for Implementing and Sustaining a Successful Nurse Residency Program

EVIDENCE-BASED STRATEGIES FOR IMPLEMENTING AND SUSTAINING A SUCCESSFUL NURSE RESIDENCY PROGRAM

Deidra Denise Lyon

A DNP project submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice in the School of Nursing.

Chapel Hill 2020

Approved by:

Jennifer Alderman

Ashley Kellish

Jennie Wagner

ABSTRACT

Deidra Denise Lyon: Evidence-based Strategies for Implementing and Sustaining a Successful Nurse Residency Program (Under the direction of Jennifer Alderman)

Purpose: The purpose of this DNP project is to develop a toolkit that organizations can use as a blueprint for building a sustainable nurse residency program (NRP) that will prepare nurse residents for practice.

Rationale/Background: New graduates are the largest source of staff for hospitals, and are expected to transition into professional practice in a relatively short amount of time without the clinical decision-making skills needed to provide safe patient care. Stress during this transition can lead to high turnover within the first year. Although NRPs have been identified as a strategy to improve the transition of new graduate nurses from academia to professional practice and improve retention, many healthcare organizations have been reluctant to implement these evidence-based programs due to concerns about costs.

Methods: The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in

Health Care© (Iowa Model Collaborative, 2017) was utilized to guide this 14-day pilot study.

The pilot study employed a qualitative approach using the feedback of participants. Open-ended questions were incorporated to address the clinical question. After the pilot study, the toolkit was deployed in the Department of Nursing Education and Professional Development in an acute care facility. The toolkit was evaluated by internal stakeholders utilizing the formative evaluation process.

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Conclusion: Organizations need capable leaders to guide employees through organizational change. Successful change involves support of formulated strategies and the facilitation of change recipients being mindful during change efforts. Leadership at the project site has contemplated pursuing NRP implementation as new change initiative, yet has not proceeded due to uncertainty regarding readiness. Insights gained will clarify if the organization has the necessary resources and conditions in place to support successful implementation of a sustainable program.

To my parents, children, siblings and best friend who have shown me continuous love and support throughout my endless journey of learning

ACKNOWLEDGEMENTS

I want to first thank God for the strength and knowledge He grants me to fulfill my dreams. I cannot express enough thanks to my committee for their continued support and encouragement: Dr. Jennifer Alderman, my committee chair; Dr. Ashley Kellish; Dr. Jennie

Wagner. They not only provided me with the support I needed to complete my scholarly project, they also provided me with the emotional support I needed; encouraging me each step of the way. Thanks to the individuals who have lifted me up in prayer, beat me over the head when I got off course, said kind words along way, shared a concept or view, provided a citation or an article, as well as those who just outright believed in me. I would also like to thank my parents; whose love and guidance are with me in whatever I pursue. They are the ultimate role models.

Most importantly, I wish to thank my three wonderful children, Kiana, Christopher and Alexis, who provide unending inspiration. Finally, I would like to thank my best friend Tyrrencé for continual encouragement, genuine care and true patience. He was my best support in good and bad times. I would not have made it without him.

TABLE OF CONTENTS

LIST OF TABLES ...... ix

LIST OF FIGURES ...... x

LIST OF ABBREVIATIONS...... xi

CHAPTER 1: RELEVANCE TO NURSING PRACTICE...... 1

Introduction ...... 1

Transition to Professional Practice ...... 2

Readiness for Practice...... 3

Problem Statement...... 5

Purpose Statement ...... 5

CHAPTER 2: REVIEW OF THE LITERATURE ...... 6

Search Criteria ...... 6

Identification ...... 7

Screening...... 7

Eligibility ...... 7

Included ...... 7

Synthesis Table ...... 8

Evidence Synthesis ...... 9

NRP models...... 9

NRP designs...... 9

Instruments used to evaluate...... 10

NRP on satisfaction...... 11

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NRP on retention...... 12

Summary ...... 12

CHAPTER 4: METHODOLOGY ...... 17

Introduction ...... 17

Clinical Question ...... 17

Implementation Model...... 17

Project Design ...... 18

Identify the problem...... 18

Develop the checklist and strategies...... 18

Establish the team and research assembly...... 19

Project design and piloting the change...... 19

Data collection...... 21

Results ...... 21

CHAPTER 5: DISCUSSION ...... 22

Implications for Practice ...... 22

Recommendations for Future Research ...... 23

Conclusion ...... 23

APPENDIX A: THE IOWA MODEL REVISED ...... 25

APPENDIX B: RECOMMENDATIONS ...... 26

APPENDIX C: CHECKLIST FOR CULTURE AND READINESS ...... 30

APPENDIX D: PERMISSION TO USE THE IOWA MODEL REVISED: EVIDENCE-BASED PRACTICE TO PROMOTE EXCELLENCE IN HEALTH CARE ...... 31

APPENDIX E: JHNEBP MODEL AND TOOLS PERMISSION ...... 32

REFERENCES ...... 33

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LIST OF TABLES

Table 1: Johns Hopkins Nursing EBP: Levels of Evidence ...... 8

Table 2: Instruments to Measure Satisfaction ...... 11

LIST OF FIGURES

Figure 1: Inclusion Criteria ...... 7

LIST OF ABBREVIATIONS

CINAHL Cumulative Index of Nursing and Allied Health Literature

IOM Institute of Medicine

JHEBP John Hopkins Nursing Evidence-Based Practice

NLRN Newly-licensed Registered Nurse

NRP Nurse Residency Program

RN Registered Nurse

CHAPTER 1: RELEVANCE TO NURSING PRACTICE

Introduction

With 2.8 million members, nursing is the largest, fastest-growing health profession in the

United States (U.S.) (U.S. Department of Labor, Bureau of Labor Statistics, 2017). While the number of Registered Nurses (RNs) in the workforce is projected to grow by 15 percent between

2016 and 2026 (U.S. Department of Labor, Bureau of Labor Statistics, 2017), the demand for nurses is outpacing the supply bringing the number of job openings to 2.96 million by 2026 (U.S.

Department of Labor, Bureau of Labor Statistics, 2017). The nursing shortage in the U.S. has been brewing for decades and is expected to intensify as Baby Boomers age, and the need for health care grows (Buerhaus et al., 2017). The Baby Boomer generation, those born between

1946 and 1964, are living longer with multiple chronic illnesses (Gerteis, et al., 2014). In 2014,

71 million Americans were 65 years or older, and by 2060, that number is projected to reach 98 million (Ortman, et al., 2014). Along with an aging population, the Patient Protection and

Affordable Care Act (PPACA) allowed states to extend Medicaid coverage to nearly 14 million nonelderly Americans with income below the poverty line (Gilead, et al., 2017). Adding more covered lives into an already diminished system healthcare system further increase the demand for competent RNs.

Pivotal to meeting the demand for more nurses will be attracting and keeping new nurses.

Approximately 17.5 percent (Kovner, et al., 2014) of newly-licensed registered nurses (NLRN) leave their first job and 8 percent leave the profession (Kovner et al.,2014) within their first year of employment. Beyond that, the current nursing workforce is aging just as is the general

population. Over the next 10 to 15 years, approximately one million RN’s over the age of 50 will be eligible for retirement (American Association of Colleges of Nursing, 2017). As these experienced RNs leave the workforce, nursing administrators will turn to the NLRN pipeline to fill current and projected vacancies (Race & Skees, 2010).

According to Varner and Leeds (2012), 83 percent of NLRNs are employed in acute care settings. Since NLRNs are the largest source of staff for hospitals, it is important that organizations find a way to halt these costly turnovers (Welding, 2011). Jones (2008) estimated it costs organizations $88,000 per NLRN that leaves his or her position. The current nursing shortage and the need for fiscal responsibility have necessitated the need to develop effective nurse residency programs (NRP) that contribute to the recruitment and retention of NLRNs

(Goode, et al., 2013; Welding, 2011).

Transition to Professional Practice

The transition process from academia into professional practice is a time when NLRNs experience increased stress, interpersonal conflicts, and shock (Duchscher, 2009; Kramer, 1974;

Kramer, et al., 2013). During this time, NLRNs report struggling with the demands of assimilating to their new roles and the need for clinical expertise (Duchscher, 2009; Kramer,

1974; Kramer, et al., 2013). This phenomenon was coined, “reality shock” by Marlene Kramer in

1974 to describe the reaction of NLRNs who discover the expectations of the profession they prepared for in school are inconsistent with the actual day-to-day responsibilities of the practice

(Kramer, 1974). The process is characterized by four phases: honeymoon, shock, recovery, and resolution. This discussion will focus only on the honeymoon and shock phases.

During the honeymoon phase, NLRNs are excited to be finished with school and start their new role (Kramer, 1974). They perceive their work environment and colleagues in a positive light (Kramer, 1974). Within a relatively short amount of time, the NLRN begins to

realize they do not possess all the knowledge they need to navigate in today’s complex healthcare system (Kramer, 1974). They recognize there are flaws in the system, and may develop negative feelings towards the nursing profession, causing them to leave their position or the profession within their first year of employment (Kramer, 1974). This dissatisfaction is highest after six months of employment (Duchscher, 2009; Fink, et al., 2008; Goode, et al.,

2013). In an attempt to decrease the high turnover rates and improve job satisfaction, several professional organizations strongly recommend the implementation of NRPs to bridge the theory-to-practice gap and ease the transition of NLRNs from academia to professional practice

(Commission on Collegiate Nursing Education (CCNE), 2015; Institute of Medicine (IOM),

2010; National Council of State Boards of Nursing (NCSBN), 2011; The Joint Commission

(TJC), 2002).

Readiness for Practice

In today’s rapidly changing healthcare environment, the U.S. government transitioned its healthcare system from an episodic fee-for-service care model to a value-based preventive care model that ties the organizations’ reimbursements to the quality of care they deliver (Brooks,

2017). Due to this shift from episodic care to preventive care, healthcare leaders may find themselves succumbing to the pressures of a decreasing supply of medical personnel, equipment, and funds and the growing demands for high quality and safe care. As patient needs and care environments have become more complex, nurses will play a central role in increasing the value of health care by improving outcomes and lowering costs.

Nursing is a complex interplay of skill acquisition and competency development. Nurses not only need to meet the needs of their patients, but they must demonstrate technical competencies and critical thinking skills (Krueger, et al., 2013). However, NLRNs enter professional practice unprepared to care for today’s complex patients (Berwick, et al., 2008;

Ulrich et al., 2010). They lack confidence in their clinical and critical thinking skills (Fink, et al., 2008). They also struggle to integrate knowledge learned in nursing school with professional practice (Benner, et al., 2010; Huston, et al., 2018; Scully, 2011; Sullivan, 2010). The competence of NLRNs and their readiness for professional practice has been a major focus of nursing leaders for many years (Berkow, et al., 2008; Casey, et al., 2004; ; Ulrich, et al., 2010).

The primary goal of nursing education is to prepare highly educated and competent nurses ready to enter the workforce (Shalala, et al., 2010). Despite the emphasis on graduating nurses ready to provide quality, safe patient care, there continues to be a gap between academia’s perception of NLRNs readiness for practice and that of nurse administrators. Research conducted by Berkow, Virkstis, Stewart, and Conway (2008) from the Nursing Executive Center, found that “90 percent of academic leaders believed their nursing students are prepared to provide safe and effective care compared to only 10 percent of hospital and health system nurse executives.” Kavanagh and Szweda (2017) conducted a five-year study which assessed the entry-level competency and practice readiness of NLRNs. Out of the 5,000 participants, only 23 percent were able to demonstrate a readiness for practice (Kavanagh & Szweda, 2017). del

Bueno (2005) found that 50 percent of NLRNs miss signs of life-threatening conditions. At the

University of Pittsburgh Medical Center, only 43 percent of surveyed nurses felt that NLRNs were able to practice safely (Keller, et al., 2006). While an employer survey carried out by the

NCSBN, found 42 percent of employers felt NLRNs were clinically competent to provide safe, quality nursing care in today’s complex acute care settings (Goode, et al., 2009). Although the healthcare industry recognizes the inexperience of NLRNs, these new graduates are expected to work independently in a relatively short amount of time, without the clinical decision-making skills needed to provide safe patient care (Dowdle-Simmons, 2013; Fink, et al., 2008).

Problem Statement

Within their first year of professional practice, NLRNs face many challenges such as reality shock, lack of competencies, absence of role modeling and social support (Haggerty, et al., 2013; Kelly & Mcallister 2013; Rosenfeld & Glassman 2016). These challenges play an important role in NLRNs intentions to remain in their current position or the nursing profession

(Duchscher, 2009; Kramer, 1974). In its 2010 report The future of nursing: Leading change, advancing health, the IOM recommended the development and implementation of nurse residency programs to improve retention of NLRNs and expand existing competencies to improve patient outcomes (IOM, 2010). Research has shown that participation in NRPs increases competency level, enhances satisfaction and decreases turnover of NLRN’s in their first year of professional practice (Anderson, et al., 2012; Fiedler, et al., 2014; Goode, et al.,

2013; Kowalski & Cross, 2010). Despite the evidence supporting the effectiveness of NRPs, less than half of the hospitals in the U.S. have established NRPs (Barnett, et al., 2014). Many organizations lack the infrastructure or capacity to implement or sustain these programs (Frantz

& Weathers, 2015); however, anticipating such barriers can minimize resistance and promote the change initiative (Melnyk, et al., 2011; Kotter, 2012; Weiner, 2009).

Purpose Statement

The purpose of this DNP project is to develop a toolkit that organizations can use as a blueprint for building a sustainable NRP that will prepare nurse residents for practice.

CHAPTER 2: REVIEW OF THE LITERATURE

Search Criteria

A review of the literature was conducted utilizing PubMed, ProQuest, EBSCOhost, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases. The following keywords were used during the search: nurse residency program, nurse transition program, newly licensed registered nurses, new graduate nurse, attrition, nurse retention, and nurse turnover. The Boolean phrases nurse “residency program and retention or satisfaction,”,

“new graduate nurse and nurse residency program,” and “nurse transition program and newly licensed registered nurse and attrition” were used in order to narrow the results. The inclusion criteria for this literature review was limited to articles published in English, peer-reviewed, and addressed retention of nurses with less than one-year employment in acute care hospitals located in the U.S. Articles produced between January 2001 and January 2018 (a time frame reflective of

The Joint Commissions 2001 White Paper) were considered for the review. Articles that were excluded from the review were written in languages other than English, non-peer reviewed, programs that focused on preceptor or mentorship orientation program, did not discuss staff turnover or retention rates, and focused on nurses that were licensed over one-year, associate degree to baccalaureate degree nurses, and nurse practitioners.

The search yielded 387 articles, duplicates (n= 200) were eliminated, 150 articles were eliminated after abstract review, leaving 37 articles for full-text assessment. Thirteen articles were excluded because they did not fall within the inclusion and exclusion criteria leaving 24 articles to be included in this literature review (Figure 1).

Figure 1: Inclusion Criteria

Records identified Additional records through database identified through searching other sources (n = 387) (n = 0)

Identification

Records after duplicates removed (n =187)

Records screened Records excluded

(n =187) (n = 150)

Screening

Full-text articles excluded, with reasons

Full-text articles (n = 13) assessed for eligibility (n =37) • Not full-text and available online Eligibility • Focused on nurses licensed over one-year, associate degree to baccalaureate degree nurses, new nurse practitioners, and nurse empowerment

Studies included (n =24)

Included

Synthesis Table

The 24 articles that met the inclusion criteria were analyzed for strength and quality using

The John Hopkins Nursing Evidence-Based Practice (JHEBP)Rating Scales (Dearholt & Dang,

2017). See Table 1 for the level of evidence framework utilized. In order to organize the findings, the data extracted from the included articles are documented in an evaluation table.

Based on this assessment, the strength of the evidence gathered from the data ranged from Level

I to Level IV, with the majority of the articles being level III.

Table 1: Johns Hopkins Nursing EBP: Levels of Evidence

Level I Experimental study, randomized controlled trial (RCT) Quasi-experimental Study

Systematic review of a combination of RCTs and quasi-experimental, or quasi- experimental studies only, with or without meta-analysis. Level II Quasi-experimental Study

Systematic review of a combination of RCTs and quasi-experimental, or quasi- experimental studies only, with or without meta-analysis. Level III Non-experimental study

Systematic review of a combination of RCTs, quasi-experimental and non- experimental, or non-experimental studies only, with or without meta-analysis.

Qualitative study or systematic review, with or without meta-analysis Level IV Opinion of respected authorities and/or nationally recognized expert committees/consensus panels based on scientific evidence. Includes: - Clinical practice guidelines - Consensus panels Level V Based on experiential and non-research evidence. Includes: - Literature reviews - Quality improvement, program or financial evaluation - Case reports - Opinion of nationally recognized expert(s) based on experiential evidence. Modified from Johns Hopkins nursing evidence-based practice: Models and Guidelines Dearholt, S., Dang, Deborah, & Sigma Theta Tau International. (2012). Johns Hopkins nursing evidence-based practice: Models and guidelines

Evidence Synthesis

NRP models. Hospitals are seeking ways to ease the transition of NLRNs into professional practice with the expectations of increasing clinical competence and decreasing turnover within the first year of employment (Fiester, 2013; Kovner, et al., 2013; Ulrich, et al.,

2010; Unruh, et al., 2014). These transition programs are identified in the literature as one solution to bridge the theory-to-practice gap, ease the transition from academia to professional practice, and increase retention of NLRNs (CCNE, 2015; IOM, 2010; TJC, 2002). As NRPs have grown, there have been considerable variations in how they are modeled, designed, and implemented by organizations across the country. Seven studies evaluated NRPs established through a partnership between the University Health Consortium (UHC) and the American

Association of Colleges of Nursing (AACN) (Goode, et al., 2013; Fiedler et al., 2014; Friday, et al., 2015; Kowalski & Cross, 2010; Rosenfeld, et al., 2015; Setter, et al., 2011; Thomson, 2011).

One NRP implemented and evaluated human patient simulations to enhance clinical decision- making of NLRNs during common and uncommon life-threatening clinical events (Beyea, et al.,

2010). Ulrich, Krozek, Early, Ashlock, Africa, and Carman (2010) evaluated the Versant NRP and Bratt, Baernholdt, and Pruszynski (2014) evaluated the Wisconsin NRP. The remaining studies looked at NRPs that were investigator-developed for their specific institution.

NRP designs. Most programs used Benner’s novice to expert model to design their curriculum, but varied with regards to the eligibility requirements, program length, content delivery and measured outcomes (Anderson, et al.,, 2012; Barnett, et al., 2014; Spector et al.,

2015). One program lasted twelve weeks (Beyea, et al., 2010) while the others were a year-long.

Although there are variations amongst programs, they typically involve a reduced clinical load; an element of didactic (classroom) education; and an assigned preceptor, mentor, or both

(Anderson, et al., 2012; Edwards, et al., 2015; Salt, et al., 2008; Van Camp & Chappy, 2017).

Instruments used to evaluate. The integrative review of the literature shows that participation in NRPs has a positive impact on the satisfaction of NLRNs. Satisfaction rates of the programs implemented in these studies were analyzed using various instruments. The majority of the instruments were used to evaluate the NRPs of 12-months duration. Seven quantitative instruments and one qualitative instrument were used in twenty studies to measure job satisfaction. The Casey-Fink Graduate Nurse Experience Survey was used in five studies

(Friday,et al., 2015; Goode, et al., 2013; Harrison & Ledbetter, 2014; Kowalski & Cross, 2010;

Olson-Stiki, et al., 2012). The McCloskey/Mueller Satisfaction Scale was used in four separate studies (Altier & Krsek, 2006; Fiedler, et al., 2014; Medas, et al., 2015; Thomson, 2011).

Spector et al., (2015) used the Brayfield and Rothe Index of Job Satisfaction. The Nurse Job

Satisfaction Scale was found twice in the literature (Bratt & Felzer, 2011; Ulrich, et al., 2010), and two instruments were developed by investigators for their specific NRPs (Beyea, et al.,

2010; Rosenfeld, et al., 2015). The validity and reliability were confirmed for both the

McCloskey-Muller Satisfaction Survey and the Casey-Fink Graduate Nurse Experience Survey with total satisfaction (Altier & Krsek, 2006; Anderson, et al., 2012; Goode, et al., Bednash, &

Murray, 2013; Ulrich, et al., 2010). However, the Nurse Job Satisfaction Scale and Work

Organization Scale used by Ulrich, et al. (2010) reported reliability, but not validity ratings. The

Brayfield and Rothe Index of Job Satisfaction utilized by Spector et al. (2015) reported reliability and validity. The two investigator-developed instruments reported neither validity nor reliability ratings. Each instrument is included in Table 2.

Table 2: Instruments to Measure Satisfaction

Instruments Frequency Psychometrics of Use Casey-Fink Graduate Nurse 5 Cronbach’s  = 0.74 -0.89 Experience Survey Positive validity by expert panel McCloskey/Mueller 4 Cronbach’s  = 0.89-0.90 Satisfaction Scale Brayfield and Rothe Index of 1 Cronbach’s  = 0.883 Job Satisfaction Authors reported validity and reliability tested in numerous studies Nurse Job Satisfaction Scale 2 Cronbach’s  = 0.78-0.86

Investigator Developed 2 Not Reported

NRP on satisfaction. The terms professional satisfaction and job satisfaction are used interchangeably in the literature. Fourteen of the articles explored new nurse satisfaction as a result of the NRP (Altier & Krsek, 2006; Anderson, et al., 2009; Bratt, et al., 2014; Edwards, et al., 2015; Fiedler et al., 2014; Friday, et al., 2015; Goode, et al., 2013; Harrison & Ledbetter,

2014; Medas et al., 2015; Olsen-Sitki, et al., 2012; Setter, et al., 2011; Spector et al., 2015);

Thomson, 2011; Van Camp and Chappy, 2017). Two studies reported that participation in NRPs was not significantly related to job satisfaction (Altier & Krsek, 2011; Setter, et al., 2011). The study that examined job satisfaction in rural nurse residents found that rural nurses had significantly higher job satisfaction scores at NRP completion compared to urban residents

(Bratt, et al., 2014). Two studies reported professional satisfaction was highest at the start of the

NRP, significantly decreased at six months and remained stable at one year (Friday, et al., 2015;

Goode, et al., 2013); however, the authors do not state if the dissatisfaction was related to the

NRP or other organizational factors. Two studies showed a high level of perceived job satisfaction at each data collection point (Fiedler et al., 2014; Olson-Stiki, et al.,, 2012). The

other studies showed a decline from perceived satisfaction at six months; however, the level of satisfaction was found to be back up to baseline at 12 months (Edwards, et al., 2015; Goode, et al., 2013; Medas et al., 2015; Van Camp and Chappy, 2017).

NRP on retention. All studies reviewed showed positive outcomes regarding NRP’s impact on retention rates of NLRNs during their first year of professional practice. The

University Health Consortium (UHC)/American Association of Colleges of Nursing (AACN) and Versant are the two most widely used evidenced-based NRPs. Both programs have a 93 percent retention rate among NLRN residents (Goode, et al., 2013; Ulrich, et al., 2010). Two studies compared cohorts that participated in a yearlong NRP to those that did not. Of the studies that compared NLRN retention rates pre-NRP showed a decrease in turnover from 17 percent to

7.1 percent (Ulrich, et al., 2010) and from 50 percent to 10 percent (Bratt, et al., 2014) after the implementation of the NRP.

Summary

The transition from academia to professional practice can be extremely stressful. The

NRP is intended to ease the transition to professional practice, improve job satisfaction, and decrease turnover of NLRNs. Evidenced demonstrates a positive relationship between participation in an NRP and decrease turnover of NLRNs during their first year of practice.

Unfortunately, as NRPs have grown, there has been considerable variation in how they are modeled, designed, implemented, and measured outcomes which leads to variable experiences by the NLRN. In addition, the age of the instruments found in the literature, as well as the lack of reliability and validity statistics provided, makes it difficult to perform a comparison analysis of programs and draw a conclusion of what constituted an NRP best practice.

CHAPTER 3: THEORETICAL FRAMEWORK

Health care systems are continually changing in response to new public health policies, emerging market necessities, and technological advances (Bazzoli, et al., 2004). Implementing change in today’s complex healthcare systems can be a complicated process. Change is vital to any organization. It allows employees to learn new skills, explore new opportunities, and exercise their creativity in ways that ultimately benefit the organization through new ideas and increased commitment. Successful change requires essential elements including vision, belief, strategic planning, action, persistence and patience (Melnyk, et al., 2011). Without change organizations, will lose their competitive edge and ability to survive (Melnyk, et al., 2011).

Organizational readiness for change refers to the extent to which organizational members believe they share a commitment and capability to implement organizational change (Weiner,

2009). When organizational readiness is high, members invest more in the change effort and exhibit greater persistence to overcome obstacles and setbacks (Weiner, 2009). Change management experts recognize organizational readiness for change as a critical precursor to the successful implementation and adoption of complex changes in the health care environment

(Weiner, 2009). For change initiatives such as undergoing the accreditation process to occur in the desired direction, a state of readiness must be present or created.

Initiating a change is a complicated process, and following a framework can provide a basis for making informed decisions that allow for better control over the outcomes of action

(Weiner, 2009). John Kotter’s (2012) 8-Step Process for Leading Change provides a solid framework to support the necessary behavioral changes to guide the organization through the

NRP accreditation process. John Kotter has spent decades observing what facilitates and impedes the success of organizational change. In 1995, Kotter wrote an article titled “Leading

Change: Why Transformational Efforts Fail” for the Harvard Business Review (Kotter, 1995).

In the article, he notes that up to 70 percent of organizations often fail to implement new programs, practices, or policies, because leaders do not create a sufficient environment to facilitate organizational change (Kotter, 1996). He goes on to highlight eight errors organizational leaders make that results in a failure to implement change. The eight errors are: allowing too much complacency, failing to create a sufficiently powerful guiding coalition, underestimating the power of vision, under-communicating the vision, permitting obstacles to block the new vision, failing to create short-term wins, declaring victory too soon, and neglecting to anchor changes firmly in the corporate culture (Kotter, 1995). While the article highlights reasons organizational change can fail, the book “Leading Change” (Kotter, 1996) outlines an eight-step process he developed as a solution to preventing these errors while improving the organization’s ability to effectively implement change (Kotter, 1996). Kotter’s original model consisted of the following eight steps: Establishing a sense of urgency, creating the guiding coalition, developing a vision and strategy, communicating the change vision, empowering employees for broad-based action, generating short-wins, consolidating gains and producing more change, and anchoring new approaches in the culture (Kotter, 1996).

In today’s ever-changing business environment, organizations not only need to continuously seek opportunities to remain competitive, but they need to be flexible and ready to take immediate action when opportunities arise (Kotter, 2012). This reality led Kotter to update his 1996 eight-step process in the article “Accelerate!” (Kotter, 2012). In “Accelerate!”, he explains that the traditional hierarchal corporate structures are preventing companies from being

creative and fast enough to compete effectively in today’s fast-moving economy (Kotter, 2012).

Kotter (2012) poses that organizations will be more successful in today's fast-moving economy if they operate in a dual operating system composed of the existing hierarchy which carries out the daily business and a second network operating system that is able to quickly respond to change demands and opportunities (Kotter, 2012). This second system is a network system that compliments the existing hierarchy. The two systems work as one, “with a constant flow of information and activity between them” (Kotter, 2012). There are five principals at the core of the dual operating systems (Kotter, 2012). The eight accelerators are an updated version of

Kotter’s eight-step process (Kotter, 2012). The major differences between Kotter’s “Leading

Change” and “Accelerator!” are: Steps are often used in a rigid, finite and sequential manner, when making or responding to episodic changes, while accelerators are concurrent and always at work; the steps are usually conducted by a small central group of the hierarchy, while the accelerators attract as many people as possible from the entire organization to form an “army of volunteers”; the steps are designed to work within a traditional hierarchical system, while the accelerators require the flexibility and agility of a network (Kotter, 2012).

Managing change is about handling the complexity of the process. It is about evaluating, planning and implementing operations, tactics and strategies and making sure that the change is worthwhile and relevant (Melnyk, et al., 2011; Kotter, 2012; Weiner, 2009). Successful change requires essential elements including vision, belief, strategic planning, action, persistence and patience (Melnyk, et al., 2011). Nurse leaders need to be prepared with skills for the successful implementation of innovative strategies to guarantee optimal patient outcomes. If organizations are to experience a greater level of success in their development efforts, managers and executives need to have a better framework for thinking about change and understand the barriers and

facilitators that accompany change management. Implementing a sustainable NRP takes time, patience and focus on the end results. Deliberate strategic planning, dedication of resources, and a cohesive team built on mutual trust are essential to developing an effective NRP. Having a dedicated internal change agent who cares deeply about improving the organizations output and efficiency is the most critical factor to bring about lasting, meaningful change (Melnyk, et al.,

2011; Kotter, 2012; Weiner, 2009). Applying Kotter’s eight-step change process can provide a framework for organizations to identify these factors; allowing for the adoption of a sustainable

NRP.

CHAPTER 4: METHODOLOGY

Introduction

As NRPs have grown, there has been considerable variation in how they are modeled, designed, and implemented by organizations across the country. There are programs developed within institutions that build upon a new nurse’s orientation, yet others that are distinct from orientation lasting up to twelve months. Despite the lack of standardization, NRPs are cited in the literature as an effective intervention to ease the transition from academia to professional practice, decrease turnover rates and improve job satisfaction for NLRNs (Goode et al., 2009;

Ulrich, et al., 2009); yet limited numbers of organizations offer these programs especially in rural settings (Bratt, et al., 2014).

Clinical Question

The following clinical question provides the foundation for this DNP project: What concepts and strategies are fundamental in developing a sustainable NRP in an acute care setting?

Implementation Model

The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health

Care© (Iowa Model Collaborative, 2017) was utilized to guide this quality improvement project.

The Iowa Model Revised is designed to guide the evaluation and implementation of research into clinical practice, with the ultimate goal of answering the clinical question (Buckwalter et al.,

2017; Iowa Model Collaborative, 2017). The model takes into account the entire system, including the patient, provider and organization (Iowa Model Collaborative, 2017). The step-by-

step flowchart (Appendix A) provides the user with three defined decision points (find a problem, find the evidence and improve practice) and feedback loops that could lead to an increase in the sustainability of the practice change (Iowa Model Collaborative, 2017).

Project Design

Identify the problem. In Phase 1 of the Iowa Model Revised, a focused trigger is identified (Iowa Model Collaborative, 2017). The knowledge-focused trigger identified in this project was what factors have deterred organizations from implementing NRPs. Despite the overwhelming evidence supporting the benefits of NRPs, not all organizations had such programs. This trigger presented an opportunity to develop a toolkit for organizations to use as a blueprint for developing a sustainable NRPs.

Develop the checklist and strategies. During the development of the toolkit, I set out to investigate the facilitators and barriers that impede organizations from developing and implementing NRPs. An integrative literature review was conducted to gain an understanding of

NRP program fidelity and outcomes. Numerous facilitators of implementation were identified in the literature. These facilitators include, allocating appropriate resources, creating partnerships, evaluating efforts, and having a sustainability plan contribute to effective residency programs

(Bratt, 2013). Securing the support of stakeholders such as chief nursing officers (Goode, et al.,

2016), and appointing a nurse residency coordinator may also contribute to program success

(Greene, et al., 2016). Barriers to the implementation of NRPs includes the cost of developing or purchasing an existing NRPs (Goode et al., 2009; Pittman, et al., 2013), inadequate administrative support (Bratt, 2013) a perceived lack of relevance (Wierzbinski-Cross, et al.,

2013), and a lack of resources (Warren, et al., 2018).

While external policies like the recommendations from the IOM can spur adoption and initial implementation of NRPs, long-term implementation requires committed engagement by

all relevant stakeholders. Developing a stakeholder engagement model may be beneficial for organizations to maintain successful implementation by highlighting the facilitators and barriers of the NRP.

Establish the team and research assembly. Establish the Team and Research

Assembly. The next steps of the Iowa Model include forming a team, assembling relevant research, critiquing and synthesizing the research, and determining a sufficient base for the project (Iowa Model Collaborative, 2017). A committed pilot team that understood the necessity of the planned change agreed to participate. Since the IOWA Model emphasizes that a positive change is possible once the changes are explained, shared, and accepted, the collaboration of the team is requisite to success (Iowa Model Collaborative, 2017). I served as the project manager for this quality improvement initiative. The purpose of the toolkit is to provide a broad, flexible framework which address the critical elements for designing a sustainable NRP. The toolkit is composed of two documents a checklist (Appendix B) and strategies (Appendix C). The checklist and evidence-based recommendations and strategies regarding each phase of the implementation process was informed by the best evidence. The steps in the checklist reflect a dynamic-interactive process rather than linear. Thus, during each phase, it is essential organizations prepare for the next phases and reflect on the previous phases (Iowa Model

Collaborative, 2017).

Project design and piloting the change. Pilot studies are smaller versions of the main study to refine process, improve questions and test whether the components of the main study will work well together (Lancaster, 2015; Yin, 2009). The target population for this pilot consisted of professional development leaders, NRP coordinators and subject matter experts versed in the accreditation of NRPs. I conducted a 14-day pilot study using participants who

represented the larger sample. Nursing staff was invited to participate in the study through a letter of invitation. A committed pilot team that understood the necessity of the planned change agreed to participate. I selected five participants who were not affiliated with the intervention site, but were familiar with NRPs to allow for all portions of the toolkit to be evaluated with the most realistic sample possible.

The pilot study employed a qualitative approach using the feedback of participants. I incorporated open-ended questions to address the clinical question. Open-ended questions are the most beneficial approach to exploring individuals’ lived experiences and perspectives regarding a concept or phenomenon (Kahlke, 2014; Marshall & Rossman, 2016). All participants were asked the following questions:

• How would you describe your experience of using the toolkit?

• How did you implement the toolkit?

• What did you like most about the toolkit?

• How could the toolkit be improved?

Survey participation was voluntary. The basis of the survey was to solicit feedback on the relevance, accuracy comprehensiveness of the toolkit. Feedback was used to refine the toolkit before implementation.

After a successful pilot study, the toolkit was deployed in the Department of Nursing

Education and Professional Development in an acute care facility. Key nursing leaders, involved in and impacted by the NRP, were invited via email to participate in the project. I presented information about the project to stakeholders within the organization. During this phase, internal stakeholders evaluated the toolkit, utilizing the formative evaluation process. The formative evaluation process for evaluating programs during early implementation to allow

developers, stakeholders and educators to make changes early in the process (Melnyk, et al.,

2011; Rossett, & Sheldon, 2001). Melnyk et al., (2011) contended that evaluation of outcomes must be documented to show improvement during the process. Participants were asked the same open-ended questions.

Data collection. Due to geographical challenges, the feedback was solicited via email.

During the 14-day pilot study, I was available via email or phone to answer questions.

Results

Since the IOWA Model emphasizes that a positive change is possible once the changes are explained, shared, and accepted, the collaboration of the team was vital to success.

I was able to sufficiently test the usability and feasibility of the toolkit with a small-scope pilot study using participants who represented the real sample. The pilot participants recommended modifications were to add examples that help clarify each question on the survey. Four out of five pilot study participants stated that this modification was necessary if the open-ended questions were to be understood clearly by the participants at the implementation site. I therefore added to the online survey to provide question clarity. The project was well received by stakeholders at the implementation site. Participants reported easy integration and adherence of the toolkit. Department leaders will use the toolkit as a guide to develop a business case to capture the reasoning and potential for proposing an NRP to senior leaders.

CHAPTER 5: DISCUSSION

Implications for Practice

Change is seldom easy. This is particularly true when dealing with today’s complex healthcare systems. The healthcare industry is changing at a record-breaking pace. New public health policies and emerging markets are putting intense pressure on healthcare systems to control costs, improve the efficiency and efficacy of care provided to the populations they serve

(Center for Medicare and Medicaid Services [CMS], 2018; Fiorio, Gorli, & Verzillo, 2018).

Payors are linking pay-for-performance initiatives to quality and the patient’s satisfaction with their service experience (CMS. 2018). As baby boomer nurses leave the profession, NLRNs will be inundating hospitals, unprepared for the demanding role of the professional nurses (Goode et al., 2009). The gaps in quality of care related to the skill level of NLRNs has long been an issue for nurse leaders (Berkow et al., 2008; Casey et al., 2004; Ulrich et al., 2010). The challenges and constant changes related to health and illness require them to have sound critical thinking and clinical reasoning skills (IOM, 2010; Edwards, et al., 2015; Olson-Stiki, et al., 2012).

As frontline employees, RNs are in prime position to act as change agents in positively influencing patient outcomes while creating solutions that guarantee the delivery of safe, quality care (IOM, 2010). Hence, the inability of organizations to retain a nursing workforce can negatively impact its productivity, quality of care and financial bottom line. Developing innovative strategies to reduce the turnover rates of NLRNs and support their transition to practice will be a priority for healthcare organizations moving forward (Rush, et al., 2013). The

NRP has been identified as an intervention to ease NLRNs transition-to-practice and build a

culture of retention (CCNE, 2015; IOM, 2010; TJC, 2002). Furthermore, these programs have the ability to expand NLRNs competency level and improve patient outcomes (Anderson, et al.,

2012; Fiedler, et al., 2014; Goode et al., 2013; Kowalski & Cross, 2010). Implementing a sustainable NRP takes time, patience and focus on the end results. Deliberate strategic planning, dedication of resources, and a cohesive team built on mutual trust are essential to developing an effective NRP.

Recommendations for Future Research

The evidence suggests that NRPs are valued and produce positive results. The most frequently reported outcome is the retention of NLRNs during their first year of professional practice. Less commonly reported is long-term retention of this cohort. Further studies are needed to examine the retention rates of NLRN cohorts as they progress from advanced-beginner to experienced nurse in a longitudinal format. There is considerable variation in how NRPs are modeled, designed, and implemented as well as the evaluation methods used to make it difficult to perform unbiased evaluations of multiple programs. Identifying the key components to successful and sustainable NRPs is most beneficial for organizations invested in the recruitment and retention of NLRNs. Thus, more research is needed comparing the various transition-to- practice models to each other. Finally, these programs should also be provided as a means to improve quality of care and patient safety. Future studies that concentrate on the performance of

NRP residents related to not only the expansion of clinical competencies, but also how participation in the program attributes to patient outcomes would further validate the business case for implementing an NRP.

Conclusion

Organizations must make fundamental changes in how they conduct business in order to remain successful in today’s increasingly competitive, challenging healthcare environment.

Leaders should demonstrate a willingness to embrace change if they want to recruit and retain a qualified nursing workforce. In an environment of increased patient acuity in the acute care setting, workforce shortages, and increasing consumer expectations for quality, managing and implementing change is becoming more important in today’s business environment than ever before and has a direct impact on the bottom-line as well as organizational culture. The shift to value-based healthcare is reshaping hospital staffing at every level, from hiring to education to teamwork. As frontline employees, RNs are in prime position to act as change agents in positively influencing patient outcomes while creating solutions that guarantee the delivery of safe, quality care. Hence, the inability of organizations to retain a nursing workforce can negatively impact their productivity and quality of patient care.

Nursing retention, anticipated turnover, and intent to leave has been the topic of many research studies. The purpose of the toolkit is to provide a broad, flexible framework that addresses critical elements for developing a sustainable NRP to transition NLRNs into the practice of professional nursing. In particular, this toolkit will be most valuable for implementation teams who are responsible for implementing NRPs in their organizations; however, the toolkit may be adapted for use as a framework in any healthcare setting desiring to shed outdated, ineffective approaches to tackle the nursing shortage and are willing to embrace progressive change in the nursing profession. The pilot study for this DNP project was small in scope because it (a) supported the short time constraints, (b) was significantly less costly than a large-scale study, and most importantly, (c) still provided adequate testing of the toolkit. This user-friendly toolkit delineates a systematic, well-planned implementation process and is designed to bring sustainable success to all change initiatives.

APPENDIX A: THE IOWA MODEL REVISED

Used/reprinted with permission from the University of Iowa Hospitals and Clinics, copyright 2015. For permission to use or reproduce, please contact the University of Iowa Hospitals and Clinics at 319-38

APPENDIX B: RECOMMENDATIONS

Recommendations Best Practice Strategies Assess the Organizations • A culture comprised of low morale, poor patient outcomes and job Motivation and Capacity dissatisfaction must be addressed by nursing leadership before for Change change can be implemented.

• Identify your competing forces (resisters) o Driving Forces (Positive change agents; empowered o Restraining forces (Resisting forces; Status quo)

• Select a tool to assess both subjective and objective data Subjective Objective Focus groups (views and opinions) Individual adaptability Reflect on past attempts Job Satisfaction

• Develop and nurture well-positioned communicator and program champion (preferably the Chief Nursing Officer)

• Conduct a gap analysis and/or needs assessment of current onboarding practice

• Collect internal baseline data such as newly-licensed registered nurse (NLRN) turnover rates within the first year of hire (voluntary and involuntary), current registered nurse vacancies, accrued overtime, cost of agency nurses and quality/patient safety report Create an Organizational • Shared Vision Culture for Supporting o Clearly communicate the mission, vision, goals and Change benefits of the Nurse Residency Program (NRP) to all Stakeholders. o Develop a communication plan

• Effective Leadership o Chief Nursing Officer ▪ Establishes a culture of engagement throughout the facility that champions the nurse residency program (NRP) contributing to the program’s overall success.

▪ Develops a system wide policy that outlines the expectation that all Newly-Licensed Registered Nurses will participate in the Nurse Residency Program as a condition of employment.

▪ Participate in weekly Unit Rounds with the Nurse Residency Program (NRP) Coordinator. • Conveys a clear message to all stakeholders that he/she is involved with

what is happening with Nurse Residents (NR) at the unit level. Get everyone onboard • It is crucial to secure buy-in across organizational stakeholders o Eg. nursing leadership, clinical nurse educators, staff nurses/preceptors, hospital administration, patient safety and quality managers and human resources department

• Clearly communicate the mission, vision, goals and benefits of the Nurse Residency Program (NRP) to all Stakeholders.

• Encourage input from all stakeholders throughout the development, implementation and evaluation of the NRP

• Make sure the program fits with the organization’s overall mission, vision and goals. Institutional Commitment • The chief nursing officer has the fiscal and organizational and Resources authority to allocate resources and supports the program in achieving its mission, goals, and expected outcomes.

• Designate a nurse residency program planning committee with representatives across all levels of the organizations to maximize the human, financial, and institutional resources to enable the program to fulfill its vision, mission, goals, expected outcomes. o These resources are reviewed regularly and revised as needed. ▪ People (nursing leadership, clinical nurse educators, staffing specialists, mentors, preceptors, simulation center educator) ▪ Equipment (simulation center) ▪ Management (program content; requirements of GNs, mentors, & preceptors) ▪ Processes (evaluate & update if needed) ▪ Environment (clinical training combined with socialization) ▪ Regulation (develop policies re: hiring process; criteria for selection of GNs, preceptors, mentors, & educators)

• Develop an academic partnership with local colleges, universities or healthcare systems to collaborate services such as data or technology systems, teaching and learning facilities and other capabilities to foster the achievement of the vision, mission, goals, and expected program outcomes.

• A residency coordinator is designated who is academically and experientially qualified to provide effective leadership to the program in achieving its mission, goals, and expected outcomes. o The NRP Coordinator nurse should have a Master’s Degree in Nursing with a background in pedagogy and curriculum development.

• The program faculty have the appropriate education and experience to achieve the mission, goals, and expected program outcomes.

• The program faculty are oriented to their roles and responsibilities with respect to the program and these roles and responsibilities are clearly defined. • Actively facilitate the recruitment and cultivation of qualified preceptors and mentors to support the learning and professional growth of NLRNs, and implement strategies to sustain their engagement and commitment. Seek Out Best Practices • Critically appraise existing evidence and review the perspectives to Build Your Nurse from appropriate regulatory agencies (the Joint Commission, Residency Program Centers for Medicare and Medicaid Services, Institute of Medicine, and the National Council of State Boards of Nursing) and/or accreditation organizations ( ANCC Practice Transition Accreditation Program and Commission on Collegiate Nursing Education).

• Use a theoretical model as a blueprint to develop core competencies and guide professional and clinical role development. o Include a remediation process for residents who are unsuccessful at meeting incremental goals

• Create a curriculum crosswalk to align the NRP with national accreditation standards.

• Model program components after organizations deemed successful

• Clearly communicate the programs goals, its ability to produce positive outcomes and how it fits into the larger organization environment.

• Develop a written evaluation and dissemination plan that includes guidelines on how program data systematically collected and analyzed, who will present results and which audiences will receive the results. Implement your program • Program should support the NLRNs development (6-18 months) in stages to support the and focus on clinical skills, critical thinking development, NLRN as he/she expands communication skills, and managing patient responsibilities and the knowledge, skills and priorities. abilities required to move from one stage of • Core nursing curriculum should complement precepted unit development to another. orientation and initial competency development. • Further support the NLRNs professional development, assimilation and socialization through monthly residency seminar sessions in a face-to-face environment.

• Foster professional growth and personal satisfaction by incorporating individual development plans that includes psychosocial, short-term, and long-term goals o Plan should be reviewed by the preceptor, preceptee and unit leadership every 3 months to guarantee the NLRN is meeting their goals.

• The unit manager and/or clinical nurse specialist/clinical educator should meet with the preceptor and preceptee weekly to discuss the NLRNs competency development.

• Develop and utilize mentor relationships to support the NLRN’s professional development throughout the NRP. Quality educational • Examination of reliable, measurable program outcomes (at program evaluation baseline, 6 months, & 1 year) should be an ongoing priority of includes both quantitative your program, allowing you to modify components of the NRP to and qualitative measures meet the needs of changing healthcare environment. o Program satisfaction data are collected from residents, as well as from others who are responsible for or otherwise involved in the program. • Evaluation of learning outcomes should include assessing the learners perception of the quality of the NRP, change in behavior, knowledge, skill, or attitude of the NLRN compared to before the intervention. • Program faculty, preceptors and mentors are evaluated for their performance in achieving the mission, goals, and expected program outcomes.

• To demonstrate a positive return on investment (ROI), assess the impact of the NRP on organizational performance indicators, such as financial and quality outcomes. Sustain your program. • Continued collaboration with organizational stakeholders and community partners is key to sustaining your program long-term; keep them apprised of what’s going on with the program and disseminate outcomes.

• A process is in place to address formal complaints about the program; information is used, as appropriate, to foster ongoing program improvement.

• Use communication and marketing strategies that generate interest in the NRP.

APPENDIX C: CHECKLIST FOR CULTURE AND READINESS

Yes/No/Short

Response DEFINE THE NEED 1. What are the organizations top priorities? 2. Has the NRP been mapped to larger organizational strategies? 3. What are the internal or external influencing the implementation of the

NRP? ORGANIZATIONAL CULTURE 4. Who are the key leaders in your organization that support change initiative? 5. Will key stakeholders and executive leaders support the change initiative

and the related efforts required to implement and sustain it? 6. Are there internal or external facilitators that could influence the practice

change? TIME, RESOURCES & PERSONNEL 7. Have you identified a project leader or developed a project team? 8. Does your organization have “champion(s)” (ideally including clinicians)

who will lead the effort? 9. Does the organization have a process for reviewing or implementing

evidence-based pilot studies? SUSTAINING CHANGE 10. Will your organization be willing and able to measure outcomes and

continue to assess the NRP in terms of its return on investments? 11. Will your organization be able to reward positive outcomes?

APPENDIX D: PERMISSION TO USE THE IOWA MODEL REVISED: EVIDENCE- BASED PRACTICE TO PROMOTE EXCELLENCE IN HEALTH CARE

APPENDIX E: JHNEBP MODEL AND TOOLS PERMISSION

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