Beginning at the bedside: Nurse residency program shepherds new graduates from student to expert

Beginning at the bedside: Nurse residency program shepherds new graduates from student to expert

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As a nursing resident at Virginia Commonwealth University Medical Center, Katherine Houston attended a lecture by Shelly Brown, forensic nurse examiner in the VCU emergency department. Brown spoke to the room of new nurses about the importance of screening and education for intimate partner violence. Houston, who graduated from the VCU School of Nursing in December 2013, had been working as a clinical nurse in the acute care medicine unit for almost a year when she attended the lecture. Brown’s presentation sparked an idea.

“Even though the emergency department was doing a three-question screening, none of it was being transferred to the patients’ medical records,” Houston said. At the time, the only other unit with an intimate partner violence screening tool was in labor and delivery. Working on a floor of the hospital that saw everything from chronic pain issues to suicide attempts, Houston determined that she could improve the quality of care for her patients by implementing a universal intimate partner violence screening tool in the acute care unit.

Along with fellow nurse resident Ashley Best, Houston embarked on the development of the in-patient screening tool as the capstone project of her yearlong residency. Houston implemented the tool on her unit in January and she is currently working toward developing a hospitalwide protocol. The 28-year-old nurse attributes much of the success of the initiative to the guidance and support she received as a resident at VCU Medical Center.

Nurses at the bedside are really involved in developing patient care plans on every level at VCU Medical Center and making sure that patients are getting every resource they need.

“Nurses at the bedside are really involved in developing patient care plans on every level at VCU Medical Center and making sure that patients are getting every resource they need,” Houston said. “Everybody here believes in evidence-based practice, so we are constantly rolling out new initiatives.”

Earlier this year, the VCU Medical Center nurse residency program received a five-year accreditation by the Commission on Collegiate Nursing Education, making the health system home to one of 17 CCNE-accredited nurse residency programs in the country and the only such program in Virginia. The accreditation confirmed what health care providers and patients at the teaching hospital already knew — that the nurse residency program at VCU Medical Center prioritizes ongoing education for its staff, which helps to develop highly competent nurses who will use researched evidence to guide practice, ensure patient safety and provide quality care.


Better education, better care

Representatives from VCU Medical Center were involved in the development of the national University Health System Consortium/American Association of Critical-Care Nurses residency program curriculum since its beginnings in the early 2000s. The medical center started offering the post-baccalaureate program to all new nurses in 2004.

“The transition from student to expert nurse needs to be thoughtful and given the same kind of attention as our physician colleagues,” said Deborah Zimmermann, D.N.P., chief nursing officer and vice president of patient care services at VCU Medical Center. “It needs to be a sound foundation that nurses will be able to reflect upon throughout their careers.”

Most hospitals have some type of orientation program for new nurses, but a yearlong course that includes an evidence-based practice project is not as common. “We believe it is important that our program have the rigor that the research and evidence suggests leads to a sound foundation,” Zimmermann said. “That is why we believed that accreditation was so important.”

The first six months of the program centers around skill acquisition and the second six months is focused on practice change. Nurses enrolled in the program meet for eight hours once a month to attend seminars designed to cover key topics of interest to new nurses and to work on a capstone project. They then work with the nurse manager and nurse clinician on their floor for four hours to discuss topics that are more specific to their individual units. Upon completion of the program, the new nurses demonstrate what they have learned through an evidence-based poster presentation that addresses a specific issue.

The transition from student to expert nurse needs to be thoughtful and given the same kind of attention as our physician colleagues.

“An essential piece of being an academic health science center is making the value of being a learning organization real at every level of the enterprise,” said John Duval, vice president for clinical services and CEO of VCU Hospitals. “We prepare our nurses to have the background to continue to identify issues that need improvement and then use the literature and develop the interprofessional skills needed to take an issue forward and offer improvements.”

VCU Medical Center has made organizational changes based on recommendations from the nurse residency capstone projects.

One nurse resident from the psychiatry department presented a capstone project related to the uniforms that nurses wear in the pediatric psychiatry unit. When the resident started on the unit, nurses weren’t required to wear uniforms. “They were wearing street clothes, which was very common at the time,” Zimmermann said. The nurse resident’s research identified confusion among pediatric patients about who their caregiver was. She proposed that nurses wear standard uniforms. The proposal got buy-in from the psychiatry department and the hospital supported it, leading to a permanent change requiring all nurses to wear uniforms.

“Research suggests that when nurses have better education and ongoing support that patients have better outcomes,” Zimmermann said. “When our new nurses have not only the didactic background, but also the skills and support, it leads to better outcomes for our patients. It all comes back to better care.”


Ahead of the game

Katherine Houston. Photo by Thomas Kojcsich, VCU University Marketing
Katherine Houston. Photo by Thomas Kojcsich, VCU University Marketing

Since implementing the intimate partner violence screening tool in January, nurses on the acute care unit have identified six patients as victims of domestic abuse. When the screening is positive, patients are connected with a social worker at the medical center who works in injury and violence prevention.

The unit uses a modified version of the HITS (Hurt, Insult, Threaten and Scream) screening tool for intimate partner violence, which includes four questions that nurses ask patients via a questionnaire to assess risk for intimate partner violence. The series of questions addresses how often the individual’s partner hurts, insults, threatens or screams at them. Individuals have five answers — never, rarely, sometimes, fairly often and frequently. The answer for each question is given a point value and a score above a 10 shows medical care providers that the individual is suffering from abuse.

The acute care unit tends to have a lot of repeat patients for issues such as gastrointestinal problems, chronic pain, substance abuse and other problems that are symptomatic of intimate partner violence.

“When we have repeat patients we develop a rapport that you’re not going to have time to develop in the emergency department,” Houston said, adding that some patients stay at the hospital for months and come back frequently.

Of the six patients who were identified as abuse victims in the past six months, two had tested negative when they were screened originally. Later, after developing a rapport with their nurse, they started to disclose details about their relationship that indicated abuse. When the nurses screened them a second time, the results came back positive.

“Even if people don’t feel comfortable disclosing when we’re doing the screening initially, if we’re making it clear that we care about this and are available to provide help maybe down the road they will be more comfortable disclosing with nurses that they have developed a rapport with,” Houston said.

Houston presented the initial findings from her nurse residency capstone project at the annual UHC/AACN Residency Conference earlier this year.

“I was amazed at how ahead of the game we are,” she said. “Our nurses and nurse residents are functioning at a much higher level than other people around the country. They are very involved in improving practice within the hospital.”


Featured image up top :  Katherine Houston talks with Wilbur Talley, 62, of Henrico County, who is being treated for pancreatic cancer at VCU Medical Center. Photo by Thomas Kojcsich, VCU University Marketing


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