On nurse Jordan McNab’s first day at Barnes-Jewish Hospital in St. Louis in 2017, a patient stopped breathing. She had to immediately start giving him CPR.
“I vividly remember with my hands on a chest and going too fast,” she said. “You just can’t prepare for it.”
For many beginning nurses, the stress of a new job can be particularly acute. Dealing daily with life, death and illness along with normal new job strain can put them at risk of burnout during the transition from school to work.
To help new nurses deal with stress and keep them in the workforce, the region’s hospitals have developed nurse residency programs that focus on their well-being.
Programs such as the one Jordan McNab went through at Barnes-Jewish Hospital aim to reduce turnover by combining traditional job orientation sessions with continuing education, group support and mentorship.
“Not all hospitals and not all floors or units have a very welcoming environment,” said nurse Becky Boesch, who started her job and her residency at St. Luke’s hospital in Chesterfield in May. “It can be really hard to get comfortable there and to feel confident when you have a lot of critical people around you not helping you out and giving you an environment to learn.”
Research shows nurses have some of the highest turnover rates of any healthcare profession. A recent study from the Robert Wood Johnson Foundation shows 20 percent of new nurses leave their job within a year.
Sometimes the residencies include sessions in which new nurses can vent or share their stories. Barnes-Jewish Hospital’s program has adapted a practice called “Tales from the Bedside” in which nurse residents split into small groups to discuss particularly emotional experiences such as the death of a patient. Other programs include training on how to cope with death and dying and rundowns of what mental health services are available to employees.
Boesch said the programs helped her feel less alone on the job.
“I never felt like I was just thrown into the deep end,” Boesch said. “The whole time I had someone for support and for backup questions.”
The programs can last from a few months to more than a year. Most residencies also include a classroom component.
The hospital system SSM health includes a year of monthly continuing education classes. During a recent class, Bridget Royal, an experienced nurse, told residents about her first year on the job.
“I was one of those people when I was a new nurse ... I was all over the place,” Royal told the group of close to 50 nurses. “I would start with one thing, then I would stop, wouldn’t even finish that, then there’d be a call light, and then I’m running over here, and the I’m like, oh Lord! I still need to pass meds on this person.”
A hallmark of many residencies is connecting new nurses to experienced ones. Royal is a clinical educator in addition to her job as an RN.
“Block out your groups of time in groups of two hours to make sure you have things accomplished during that time,” she told the class.
After the segment on time management, the nurses split into groups and talk about mistakes they’ve made on the job. New pediatric nurse Lauren Hunter and her group discussed a patient who was almost given the wrong brand of insulin.
Hunter said that after she graduated, she was on her own. She sometimes felt lonely.
“I was the only one who went to pediatrics," she said. "My whole support system that I had built for two years was gone."
The morning of the class, Hunter was tired. She had just gotten off an overnight shift, a common duty for beginning nurses. But she said the classes help her to stop second guessing herself.
“Sometimes you feel like you don’t have the support, and then you come there and you’re like, ‘OK, it’s not just me. It’s a new nurse,’” Hunter said.
Because the programs vary so much across hospitals systems, there’s not a lot of conclusive evidence showing how well they help hospitals retain new hires, said Jean Davis, senior associate dean for research and doctoral studies at the Goldfarb School of Nursing in St. Louis.
The programs have been correlated with higher retention rates for specific types of nurses, she said. And there’s evidence that new nurses feel more competent and confident after completing programs.
Less proven is the value of classroom instruction for nurse residents, Davis said. Nurses who have already graduated from nursing schools can find continuing education classes demeaning and boring. They can also grow annoyed when paired with a preceptor (a more experienced nurse in a similar job) for longer than a few months, she said.
But despite concrete academic evidence, most hospital systems have some kind of nurse residency or transition program in place.
“I think they’re desperate,” Davis said, “We’re short on nurses, and about a million will retire in the next few years. They’ve got them, they feel like they have to do something to retain them.”
It’s difficult to discern why nurses leave their job in their first year, Davis said. Many nurses aren’t leaving the profession; they’re leaving for a position in their preferred specialty or one with better pay. Because there are more positions than nurses, workers often shuffle through positions until they find a good fit.
And other problems that could cause a nurse to leave, such as chronic understaffing, aren’t problems that could be solved with a residency program, no matter how competent it is, Davis said.
More standardized residency programs and research could potentially make the residencies more effective, Davis said.
Research has shown that residencies improve new nurse retention, said Bobbi Shatto, an assistant professor at the St. Louis University School of Nursing.
The most important component of any residency is support, Shatto said. Nurses who feel supported are less likely to leave.
“If they’re not exactly sure about something they can count on their coworkers and count on someone to bounce things off of,” she said.
Shatto said hospitals need to take the residencies seriously, or else nurses won’t feel that community support. That means not scheduling training after nurses’ long shifts and paying them for their time.
“Nursing in general is a very high pressure job and so I think it’s important that the nurses feel supported in order to want to stay,” Shatto said. “You’re literally making decision that are life and death bout these people and about your patients.”
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