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Transition to Practice: Onboarding Components for Establishing and Sustaining Healthy Work Environments

2019; Lippincott Williams & Wilkins; Volume: 30; Issue: 4 Linguagem: Inglês

10.4037/aacnacc2019329

2149-0481

Sandy Hall, Suzanne Taylor, Charissa Altobar,

Adolescent and Pediatric Healthcare

Work environments that support excellence in nursing practice should be established for all levels of nurses, but it is essential to provide this solid foundation for nurses beginning their professional careers. By providing an evidence-based and relationship-centered onboarding structure for new graduate nurses and those who transition from one specialty to another, we can put into place structures and processes to prevent unhealthy work environments that contribute to medical errors, ineffective delivery of care, and conflict and stress among health care professionals.1 At Children's Hospital Los Angeles (CHLA), we have established 2 nationally accredited transition-to-practice programs that provide a robust infrastructure for onboarding nurses that enhances staff recruitment and retention and encourages nurses to practice to their utmost potential.The Versant RN Residency in Pediatrics was founded at CHLA in 1999 to support new graduate nurses as they transition from school to professional practice. The 1-year residency program consists of a 22-week immersion period and 2 additional postresidency education and support (PRES) days in the remaining months before the residents' 1-year anniversary. The RN Residency is used for all inpatient units, including medical/surgical, hematology/oncology, cardiology, rehabilitation, float team, and critical care areas, as well as the emergency department, operating room, and postanesthesia care unit. Thus far, 38 cohorts and more than 1500 new graduate nurses have completed the program at CHLA.In addition, the Versant Transition RN Fellowship in Pediatrics was founded at CHLA in 2015 and is operated through the RN Residency department. This program provides a safe and supportive transition for experienced nurses transitioning from one area of specialty to another. Most participants in this program are transitioning from care of adults to pediatrics. This 6-month fellowship program consists of a 12- to 16-week immersion period and one additional post-immersion education and support (PIES) day in the remaining months before the fellows' 6-month program ends. The Transition RN Fellowship is used in all areas that hire RN residents, as well as our outpatient hematology/oncology clinics. Thus far, 7 cohorts and more than 130 nurses have completed this program at CHLA.The overarching goal of these programs is to create a safe and supportive environment conducive to learning for nurses undergoing a practice transition, whether from student to professional or between areas of specialty. Achievement of targeted outcomes, including group cohesion, organizational commitment, turnover, and self-efficacy, demonstrate that these programs are overwhelmingly successful in contributing to a healthy work environment for our nursing staff.Our new graduate nurses face the challenge of integrating what was taught in nursing school with the reality of what occurs daily in a hospital setting with patient care. Equally as challenging, our transition fellows must adjust from one area of nursing to a pediatric specialty. In addition to the adjustments that come from this role transition, nurse residents and fellows must find a way to navigate professional development opportunities offered both inside and outside the hospital setting.In order to create an environment that is conducive to growth and development, CHLA established Mentor Circles, a structured mentorship model and program built in as part of the residency curriculum. Mentors serve as teachers, counselors, and coaches who guide the RN residents and fellows in their careers and professional development. Each mentee (resident or fellow) is assigned to a Mentor Circle, consisting of 5 or 6 mentees from various units and 2 mentors who are not from the same unit as any of their mentees. This creates a space where mentors and mentees can share openly in a safe and confidential environment. Mentor Circle discussion topics include professional development opportunities within the hospital, academic advancement, professional organizations and certifications, collaborative governance councils and committee opportunities, special pay practices, and confronting ethical dilemmas. In this capacity, our Mentor Circle model plays a critical role in fostering a healthy work environment.In 2007, after 8 years of using a one-on-one mentoring structure, we changed to using the Mentor Circle model exclusively in all our residency cohorts. By heeding resident and fellow feedback and end-of-cohort evaluations, changing to the Mentor Circle model has proven to be one of the most successful components of our program. See the Table for a list of problems we encountered using the one-on-one mentoring model and reasons why we champion Mentor Circles. This Mentor Circle model provides a solid foundation that is evidence-based and relationship-centered, which is necessary for establishing and sustaining healthy work environments.While all our residency stakeholders strive to create an easy transition for our residents and fellows, practice transitions remain a stressful experience. Nurses in transition must learn new parameters and strategies for providing care to acutely and critically ill children. Both residents and fellows encounter stressful situations that warrant the need for additional support. For this reason, one of the cornerstones of our residency and fellowship programs is debriefing. Residents and fellows are assigned to a debriefing group that consists of 6 to 10 residents or fellows, respectively, from their unit and similar units within the hospital. Each debriefing group is facilitated by 2 debriefers: one nurse manager from a different practice area and a social worker or chaplain. This ensures that each group of residents is supported both by a nurse manager, who knows the struggles the residents may be facing as well as the best methods for addressing interpersonal or organizational issues that may arise, and by someone who is training in counseling techniques and can support the residents through difficult situations.RN Residency debriefing groups meet 5 times during the 22-week immersion and have 2 additional meetings during PRES days. Transition RN Fellowship debriefing groups meet twice during the 12- to 16-week immersion and have one additional meeting during PIES days. The main purpose of debriefing is to support residents and fellows in processing difficult or traumatic events they have encountered at the bedside. Debriefers help the residents and fellows manage stress and include self-care tips in sessions when appropriate. Debriefers can offer different perspectives, act as a sounding board, assist in interpreting communications, and serve as safe individuals to go to during difficult or stressful times. These meetings also allow residents and fellows to normalize their experiences, knowing that others are experiencing the same doubts and concerns. Debriefers give our residents and fellows a safe, confidential support system that fosters the reflection process and provides a foundation for continued development of coping and self-care skills.Perhaps the most essential element for successful role transition is an organization's preceptor program. Time spent with preceptors represents approximately 75% of the RN Residency and Transition RN Fellowship programs, and we recognize that without consistent and supportive precepting, all other interventions to promote a healthy work environment in our transition-to-practice programs would be in vain. Residents and fellows rely on preceptors to create a safe environment within their areas of practice to ensure open communication and, ultimately, optimal learning outcomes. For this reason, preceptors must be prepared with the knowledge, skills, and tools to meet the high standards we set for the role.Preceptors are selected based on clinical skill and attitude and are required to participate in multiple training modalities prior to assuming the role. We offer both house-wide and unit-based preceptor workshops, as well as e-learning opportunities, to impart key concepts such as application of adult learning theory and promoting critical thinking and to set expectations and ensure that preceptors receive consistent messaging regarding role expectations. Throughout the years since inception of the RN Residency program, we have continuously strived to transform our culture to eliminate all traces of the "nurses eat their young" mentality and to foster an understanding that nurses in transition learn best when they feel safe and supported.In addition to ensuring adequate training, we strive to support our preceptors through a number of interventions, including unit-based support from managers, debriefing on an as-needed basis, and meaningful recognition. Members of the RN Residency Steering Committee have conducted preceptor satisfaction surveys and identified opportunities to improve the precepting experience. RN residents and Transition RN fellows are encouraged to recognize their preceptors during appreciation luncheons held twice a year for program contributors, and each RN Residency cohort selects one preceptor to receive the Most Valuable Preceptor, or MVP, award, which is recognized throughout our organization as a prestigious honor held by very few nurses.The RN Residency and Transition RN Fellowship programs employ a number of classroom activities to assimilate new and transitioning nurses. These activities foster growth and independence and introduce the nurses to experiences that can support them in promoting healthier work environments. During the first week of the RN Residency program, all the RN residents are randomly divided into teams, or "houses," to which they belong throughout the course of the program. They can earn points for their houses by completing assignments on time, responding to emails, and participating in classroom activities. The houses are effective in increasing classroom participation, timeliness and accountability, leadership skills, peer support, and group cohesion, all while giving residents the opportunity to get to know peer residents from other work areas. The incorporation of houses fosters a collaborative environment in which residents must work together toward a common goal, preparing them for what they will encounter in their day-to-day nursing profession. Additionally, each house serves as a committee with accountability for contributing to one or more aspects of the residency experience.Other activities are used throughout the programs to create experiences for the residents, employing concepts such as teamwork, collaboration, and communication. These activities typically take the form of games followed by a debriefing to ensure that the targeted learning outcome is achieved. Whether working as a large group to solve a complex problem or collaborating in small groups to assemble a puzzle with limited communication, residents and fellows ultimately engage in discussions about how the team worked together, what did and did not work, and how the activities translate into teamwork within the interprofessional team.The residency and fellowship programs also provide numerous opportunities for socialization, which is an important component in the nurse's healthy transition into his or her new role. Several activities are used to build camaraderie among these new and transitioning nurses while also introducing them to CHLA's culture and values. In the classroom, residents and fellows take ownership over their experience in the program and plan fun events such as potlucks and after-work outings. We involve the residents and fellows in planning an appreciation luncheon for program stakeholders, and our Community Outreach resident committee organizes cohort activities to support our philanthropic mission. These activities provide opportunities for employees to feel valued and ultimately result in increased employee engagement and group cohesion.The program curricula for the CHLA RN Residency and Transition RN Fellowship provide foundational pediatric knowledge, supporting and preparing the residents and fellows for deeper learning within their area of specialty. Each curriculum contains multiple components to support the Quality and Safety Education for Nurses (QSEN) competencies of patient-centered care, quality improvement, teamwork and collaboration, evidence-based practice, informatics, and safety.2 The programs incorporate a number of teaching strategies to engage all residents and fellows in the learning experience. Many of the subject-matter experts incorporate games, interactive activities, videos, audience polling, simulation, case scenarios, and group discussion into their presentations.For the specialty curriculum, residents and fellows attend unit-specific didactic classes to receive further guidance in developing their knowledge base within their area of specialty. For example, in critical care orientation, offered for residents and fellows hired to work in the Pediatric Intensive Care Unit and Cardiothoractic Intensive Care Unit, nurses attend 8 additional class days that are dedicated to critical care–specific topics such as hemodynamics, vasoactive infusions, and ventilator management. Each of these classes is taught by expert interprofessional staff employing a variety of teaching strategies. Prior to the lecture series, residents and fellows complete a preassessment to gauge their current knowledge about the topics being presented.At the end of critical care orientation, a post-test is given to ascertain the effectiveness of the curriculum in transfer of knowledge. Also, within the specialty curriculum, each nurse must choose a topic of interest and create a short presentation to share with peers, preceptors, and managers. Both the presentation and a score of 85% or better on the post-test are required to pass critical care orientation. The RN Residency, Transition RN Fellowship, and critical care curriculum have been designed to build competence and confidence in the new nurse's transition to practice.Throughout our years of experience in administration of transition-to-practice programs, we have gained a deeper understanding of the challenges faced by RN residents and transition RN fellows. We know that role transitions are difficult and that, despite our best intentions, there is no way to mitigate every unforeseen obstacle that our residents and fellows may face. However, by ensuring that we provide sincere and earnest support of our residents and fellows and by showing them daily that we are passionate about their success, we have created a positive environment that fosters curiosity, collaboration, open communication, and optimal learning outcomes. This creates a foundation on which to build a healthy and collaborative work environment.