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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  ljjonesbell@usfca.edu;    belll2@suPerhealth.org  

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  

ljjonesbell@usfca.edu  

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