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Developing Future RN Workforce and Addressing Educa:onal Redesign
A Community Based New RN Transi:on to Prac:ce New Program in Hospice SeDngs
L. Jessie Jones-‐Bell MSN, RN [email protected]; [email protected]
University of San Francisco California Ins:tute for Nursing & Healthcare
SuPer Care at Home
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• By the end of the presenta:on, the par:cipant will be able to:
• Iden:fy 2 major strategies in developing entry to prac:ce programs in hospice care seDngs.
• Iden:fy 2 major educa:on strategies for New RN graduates that assist in their professional role development and support a successful transi:on from student to nursing professional.
• Benefits of developing community partnerships for RN Residency Programs to develop the future hospice RN workforce.
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Preceptors and Transi:on RNs
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• Building the Case for Transition Programs in California – high unemployment rate, IOM report
• Nursing Education Redesign White Paper and Recommendations
• Taking notes from past programs- San Diego Hospice, Buffalo Hospice, and VNA Program
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VISION: WELL-PREPARED NURSES FOR THE 21ST CENTURY
1. ACADEMIC/SERVICE PARTNERSHIPS & STANDARDS
2. PROFESSIONAL AND CLINICAL ROLE FORMATION & COMPETENCIES
3. COLLABORATIVE EDUCATION MODEL: EDUCATION HIGHWAY
4. FACULTY DEVELOPMENT/RECRUITMENT
5. SIMULATION, INFORMATICS, TECHNOLOGY
7. CENTER FOR KNOWLEDGE
21st CENTURY RN WORKFORCE
6. TRANSITION/RESIDENCIES
Institute of Medicine Future of Nursing
Report
Recommendation #3:
Implement Nurse Residency
Programs
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Start-‐ups Ambulatory Care Transi:on to Prac:ce Programs-‐Why this area?
• Care is shi\ing to outpa:ent care areas 1. fewer posi:on in the inpa:ent care area for New RNs
2. Insurance reimbursing for shorter inpa:ent care days 3. Services are moving to outpa:ent care services
4. Learning specific skill sets and model of pa:ent centered care for outpa:ent seDngs
5. Having a variety of ambulatory care sites ac:ve learning in care across the con:nuum
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What can hospice prac:ce areas provide:
• Need for new entry to prac:ce areas • Ensure future RN workforce for outpa:ent care areas • Fewer inpa:ent New RN Programs
• New areas to learn shi\ of care model paradigm to learn care management and collabora:on
• Provide increase exposure to pediatric popula:on with complex care management needs
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• Mul:disciplinary services help prevent unnecessary readmissions
• ACA promotes outpa:ent and primary care expansion
• Aging of our baby boomer popula:on • More adults & children living with chronic condi:ons • Hospice / Homecare / pallia:ve seDngs provide prac:ce areas that don’t compete with pre-‐licensure
• Family centered care and coaching transferable to all health seDngs
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Steps to Program Development
• Researching new scope and standards of prac:ce specific to outpa:ent care
• Finding money to support cost of the program • Program current cost is approximately $4,300 per par:cipant
• Decrease cost with a standardized hybrid curriculum to reach more par:cipants.
• Currently successful resident receives a s:pend at end of the program and partners receive an honoraria
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Steps to Developing a Hospice RN Transi:on Program
• Developing post licensure assessment tool using Quality & Safety Educa:on for Nursing • Developing standardized applica:on process and requirements specific to ambulatory care sites
• Faculty recruitment, development, new skill sets, curriculum and model of care delivery
• Recruitment and educa:on to clinical service partners-‐ a labor of love
• Developing incen:ves for partners-‐working together for shared governance, support for management and preceptors
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Internal Structural Needs
• Support internally from university team
• Developing regular communica:on with university team, grant funders, managing partners, clinical partners
• Have a clear process for tracking grant funds • Contracts, honoraria payments, cost, and invoicing templates
• Crea:ve use of facility use to keep costs down • Ini:al investment from University to cover cost above grant
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External Needs
• Communica:on-‐promo:ng open communica:on & partnership with service partners, state departments, grant funders
• Helping with candidate selec:on with partners to develop a formal selec:on process
• Preceptor and management support • Preceptor Pearls and Guidelines-‐Benner’s model, Neal’s Theory
• Preceptor support and training –new area of precep:ng ( how do you precept a new RN Grad?)
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Benner’s Model Novice to Expert Progression of professional Role Development
1. Novice 2. Advance Beginner 3. Competent
4. Proficient 5. Expert
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Neal’s Theory of HH Nursing Prac:ce • Stage One-‐ • Dependence stage (lack confidence, insecure) • Lasts 1-‐2 years in HH prac:ce • Unasser:ve, anxious, afraid of missing something
• Concrete Thinker-‐ difficulty understanding global picture of HH model
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• Stage Two-‐ • More experienced becoming confident over :me with decision making and how pa:ent learn
• Moderately dependent • Worked in HH over 2 years • S:ll does not fully understand organiza:onal and regulatory issues
• Learning how to manage caseload-‐s:ll need support at :mes
• Easily reverts back to stage one if a new or stressful situa:on arises
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Neal’s Theory HH Nursing • Stage Two-‐ • Calmer, learning asser:veness, communica:on skills, adap:ng
• Ask fewer ques:ons, serves as resource • Picking things previously missed, less fearful of new clinical situa:ons
• Defines own role and role of team, can self evaluate
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• Stage Three-‐ • Feel increasingly independent-‐autonomy, asser:ve • Can s:ll move back to stage 2 to a new challenge • When assigned a new role may ini:ally become more dependent for a :me (preceptor, supervisor, etc.)
• Has global understanding or system and processes (problem solver, organized, rapid decisions)
• Accepts own limita:ons with humor • Knows what they don’t know
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Challenges in Ambulatory Programs
• Support to Preceptors and Management-‐Labor intensive
• Staff and Management turn over, decreased preceptor produc:vity, finding the :me for check ins
• Developing brand new curriculum • Determining compensa:on paid from grant funding • Breaking the myth a New RN needs one year acute experience-‐HOW and WHERE?
• Changing image of what new RN is-‐ profile now second career for many
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Partner Successes in Ambulatory Care Programs-Filling a Need
• New prac:ce areas for New RNs (may start as MA, per diem, transferable skills, new recruitment pool for home health and hospice)
• Changing mind set of new RNs about the role of what a nurse is, learning to network, ongoing coaching post program
• Working with the State Department of Public Health to develop a standardized entry to prac:ce program
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Ongoing Pearls for Sustainability of Ambulatory Program
• Communica:on is key! • Get Help finding the money-‐consider different fee structures • Ongoing educa:on demys:fying the myth that New RNs need
one year acute care. • Con:nue to improve support and training to clinical partners
and share resources • Start to develop formal ongoing contracts with outpa:ent
care partners which outline the benefits of such partnerships • Advocate for changes in the way we educate nurses • Change the image and expecta:on of pre-‐licensure students
about entry prac:ce areas for nursing-‐be visionary!
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Why New Nurses Can’t Find Jobs (No Really!)
• Between 2011 & 2012 employment in healthcare has seen a net gain of 340,000 jobs
• New-‐graduate nurses can find work in rural seDngs • In most U.S. ci:es, especially on the West coast, a nursing
glut exists • > 40% of recent grads failed to find jobs this year! • Supply of nurses has spiked at both ends of the age scale! • Aging Nurses • Students in their early 20’s are earning nursing degrees at a
rate not seen in decades • Advance degree programs have increased the number of
second career nurses
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Importance of Transi@on Programs in Ambulatory SeEngs
IOM Report is a roadmap for healthcare reform Greater % of nursing care will be provided in the community to help meet the needs of burgeoning popula:on of seniors
Community care may provide improved: Models of Wellness and Preven:on services Diagnosis & Management of uncomplicated acute
illnesses Chronic Disease Management BoPom Line: Nurses must be prepared to provide care in non-‐tradi:onal seDngs to improve pa:ent outcomes
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Importance of Ambulatory Transi@on Programs-‐Timely
Bridging the Gap to Prac:ce: • Development of transi:on programs in ambulatory care to keep newly graduated RNs in the workforce and facilitate employability
• Fastest area of job growth over the next 5-‐10 years will be in outpa:ent seDngs
• Innova:ve strategy that ensures RNs maintain and gain competencies during employment lull
• Provides addi:onal educa:on & clinical experience • Recipe for success for new grads
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Why Ambulatory Transi@on Programs are Important
Improving Pa:ent Outcomes by: • Preserving knowledge, experience & competence gained during 1st year of professional prac:ce
• Increased clinical judgment & performance EBP • Improves staff stability that promotes pa:ent safety & increases pa:ent sa:sfac:on
• Contributes to con:nuity of care • Transforma:ve organiza:onal change = Posi:ve influence on pa:ent care
• Developing and growing nurse leaders for future
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Program Strategies for Professional Development
• Quality and Safety Educa:on for Nursing (QSEN) • Quality Improvement Project • SBARR-‐ reflec:on, EBP, case studies • Simula:on-‐ Scenario development using EBP • Skills Review • E-‐Learning Components • Casey-‐Fink, Kim Preceptorship experience • Professional guest speakers • Preceptor Training and mentoring
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QSEN Follow Quality and Safety Educa:on for Nurses (QSEN) competencies for Professional Prac:ce
QSEN improves pa:ent care quality and content
Develops the knowing, skills, aDtudes to work in a variety of ambulatory care seDngs
QSEN Competencies-‐Pa:ent centered care, Informa:cs, Teamwork & Collabora:on, EBP, Quality Improvement, Safety
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QSEN Tool • Pa:ent Centered Care • Safety • Evidence Based Prac:ce • Teamwork and Collabora:on
• Professionalism
• Quality • Informa:cs
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Quality Improvement Project A major educa:on strategy for transi:on RNs
Par:cipants iden:fy an area of need in individual agencies and design a quality improvement project to meet that need
Secondary benefit is preceptor, agency staff peripheral learning about the importance of Quality Measurement and Outcomes in EBP development
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Quality Improvement • How need determined for change • What types of outcomes projected to improve • System, Pa:ent, agency or a combina:on • How will outcomes be measured • What EB informa:on are being used to research and develop
• What other disciplines are working on QI • What is your part • What did you learn, were QSEN Competencies used on project
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SBARR Case Reflec@on • Another major educa:on strategy for transi:on RNs
• Organizes pa:ent informa:on • Clarifies communica:on • Tool for reflec:on upon pa:ent care • Peer-‐Reviewed ar:cle that depicts pa:ent care issue, EBP interven:ons
• Secondary peripheral learning for agency staff what’s SBARR
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SBARR Case Study • Situa:on-‐ Brief intro and demographic info • Background-‐ History & what is happening, what has been happening, and who is involved
• Assessment-‐ Compare to previous, subjec:ve & objec:ve findings, global, tools used
• Recommenda:on-‐ What was done, suggested, what EBP resources used
• Reflect-‐ What did you learn, preceptor response, pa:ent, family response, communica:on, culture
1. QI-‐What could have been done differently, how will this experience influence your prac:ce
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Laboratory and Clinical Components • Skills Lab • Simula:on • Blackboard /Canvas Courseware • Par:cipa:on in Professional Organiza:ons-‐Local level • Mini Teaches • Formal interviews
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Simula:on / Skills
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Casey-‐Fink Tool
• Build confidence through Na:onally-‐ recognized tool: Graduate Nurse Experience Survey which was modified for Transi:on to Prac:ce Programs
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A Process of Transi@on to Workforce
• Content Experts as guest speakers 1. Relevant to par:cipants’ clinical experiences 2. Facilitates employability 3. Broadens understanding of EBP and improved
outcomes 4. Provides a broader world view-‐ a way of
knowing 5. Promotes collabora:on, support, and
ques:oning
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Employability
• 4 flex waivers from the State Department of Health and Safety for direct hire into homecare
• Cross over employment of Transi:on RNs
• Those who were not hired in their pediatric seDngs during program went on to be hired in other pediatric areas in inpa:ent and outpa:ent
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Employment Trends • Spring 2012 1. 13 par:cipants-‐ 10 employed 2. 10 in HH Hospice 3. Of those in HH and hospice 4 accepted posi:on with agency 1 clinic RN hired inpa:ent hospice 1 hired as Triage RN (hopes to go back to hospice) 2 hired specialty inpa:ent New Grad programs 1 hired as school nurse 1 had a baby 1 to be hired into HH
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Employment Trends • Fall 2012 1. 17 total; 15 obtained jobs; 2 le\ personal reasons 2. Seven in hospice / HH 4 hired into hospice 1 was hired in Pediatric Specialty Program inpa:ent as
her preceptorship was a small inpa:ent pedi hospice 1 hired VA Inpa:ent New Grad program 1 Le\ personal reasons
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Current Cohort Fall 2013 • 18 Transi:on RNs, 6 hospice Sites • UCSF Clinics, SFDPH Urgent Care Clinic, Transi:onal Care Program, 2 primary preven:ve care community clinics, Kaiser Clinic, 2 School Districts
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Evalua@on: Next Steps • Ongoing curriculum revision and standardiza:on • Adult and Pediatric Track • Preceptor Support & training • Standardiza:on of preceptor experience for par:cipants
• Expansion of transi:on program following demonstra:on project
• Post Licensure Program as part of Nursing Educa:on Redesign
• Develop cost effec:ve program design to reach more par:cipants and outlying areas
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Par:cipant Tes:monials “I think that I got the job because of this program. Being in the program helped me to feel more confident during the interview!”
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Par:cipant Tes:monials
“I want to say that I would NEVER have been hired in my current posi:on without the help of the New RN Transi:on program. No way. The skills, the experience, and the confidence and mentoring this program gave me were invaluable.”
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Par:cipant Tes:monials “ I am working as a school nurse for LA county, working with students with specials needs… and I love it. I also started working as a hospice nurse. I eventually want to be a public health nurse in LA county but it requires 2 years so I am star:ng on my second year…I am very grateful to you and the program because it taught me about other fields of nursing, it helped me get a job, it con:nued my nursing educa:on, it provided support to us new grads, increased my confidence in myself to not "act" like a nurse but actually "be" a nurse, and it gave me a sense of purpose in a :me that felt hopeless. If you ever need anything, please let me, I would love to help in anyway.”
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Par:cipant Tes:monials “Even though I worked in a Primary Care HIV Clinic during the program, I was hired into a small inpa:ent hospice program because of the hospice content and focus that was included in our curriculum. I was just offered my dream job as a diabetes coach RN full :me. I will be keeping my per diem hospice job while working as a diabetes coach as I love what I am doing. It wouldn’t have happened without the program and I can’t thank you enough.”
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Par:cipant Tes:monial • “Without the program I would never have been able to start in my dream job as a hospice nurse. I enjoyed learning the skills in acute care during my nursing educa:on but always knew I did not want to work as an inpa:ent nurse. I love working closely with my pa:ents and their families outside the hospital.”
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Contact Informa:on:
Lillian Jessie Jones-‐Bell MSN, RN, PHN Program Director University of San Francisco
Community Partnership between the University of San Francisco and Local Hospices
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