Less than 10 years ago, when employers were predicting dire shortages of nurses, no one would have imagined that graduates fresh out of nursing school with an associate's degree would be unable to find jobs. But the recession changed the equation, with nurses staying put instead of retiring. Most acute care hospitals, including Temple University Hospital, could afford to hire more experienced nurses and those with four-year degrees.
Temple, however, has chosen to hire fresh-out-of-school nurses on the theory, according to Karen Rafferty, director of nursing education, that these nurses will stick around longer. Temple, she said, is still bracing for a shortage when baby boomers feel more comfortable with the economy and retire. So, Temple has put considerable effort into its year-long orientation process, which it calls its "new-to-practice" program.
New nurses come on slowly. In fact, said Rafferty, many feel frustrated that they can't jump right in and handle a full case load immediately. "They come in with the biggest expectations of hitting the ground running," she said. Instead, "we slowly increase their work load."
Key to success is a cohort approach. The new nurses start as a class. Some enter the class as part of a $3 million U.S. Department of Labor grant which funds on-the-job training through a program established the District 1199C Training and Upgrading Fund, a joint union-and-employer funded health care educational program. (You can click here to read my story about it in Wednesday's Inquirer.)
"They all come in with some amount of anxiety," said Rafferty.
At first, each new nurse is paired with a preceptor, someone to be shadowed. This is a much more intense relationship than a mentor, since the new nurse and preceptor are really double teaming -- two people handling one set of patients. That allows time for the in-depth discussion of the patient's conditions, their treatment and other issues. Over time, the new nurse gains more individual patients.
Several times a week there are classes. Part of the training includes simulations in Temple's simulation lab. I've been there and it's amazing. There are about eight rooms staged to look like medical examination rooms. They are arranged around a central corridor. The students enter from one side. The other side is a one-way window. Anyone in the central corridor can watch what the students are doing and pick up a headset to monitor the conversations. There is an ability to videotape these sessions for later quarterbacking.
"When you are put in a real life situation, it really gives you an opportunity to strengthen your skills," said new nurse Marianne Pecora, of South Philadelphia, who went through the program a year ago. She has an associate's degree in nursing and is now taking advantage of Temple's tuition reimbursement policy to gain her bachelor's degree.
The nurses are required to keep journals that detail their questions, concerns, anxieties, successes and fears. "You can see the growth and development of their critical thinking," Rafferty said.
But the journals have an unexpected use. Rafferty has been doing this long enough to know that just about at week 10, the overwhelming demands of the work strain whatever time management skills the student has developed. Discouragement often sets in at just that point. That's when Rafferty can pull out the journals and show the students how much they've accomplished so far. They can read in their own words about their earlier anxieties and how they conquered them. The students encourage themselves with what they've written in the past.
Lunch-and-learn sessions allow them to debrief. One nurse, Rafferty said, was petrified of being involved in a "code" situation -- the emergency effort to save a life. Sure enough, she was the first one in the class to experience it and her reactions and the situation provided grist for group discussion in a lunch-and-learn session.
More encouragement is provided by class visits from the previous cohort. They tell the latest set of newbies what they've learned and experienced. Temple makes an effort, Rafferty said, to keep each cohort connected to provide ongoing support.
Eventually, as the nurse assumes a full case load, the preceptor is replaced by a mentor, available to answer questions.
"We are very invested in the success of everyone we bring on," Rafferty said. Surveys tell them that the nurses and others who go through this process report more engagement, less anxiety and more commitment to Temple.
When I was interviewing Pecora and Rafferty on Tuesday, Pecora turned to me and let me know that she really wanted me to understand something. "The first position you get," she said, "that's your foundation. That's what you take with you throughout your career. I couldn't have asked for a better foundation for my nursing career."