From Advance for Nurses By Beth Puliti

The Institute of Medicine recently appealed for a change in nurses' roles, responsibilities and education, proposing to implement nurse residency programs to assist in the clinical practice transition (Advancing Health, October 2010).

The Hospital of the University of Pennsylvania, Philadelphia, identified the need for support much earlier.

Its Gateway to Critical Care Program started 10 years ago and offers new nurses and registered nurses with less than 1 year of critical care experience the opportunity to work alongside experienced ICU nurse preceptors to become safe and competent critical care nurses.

"The competency-based orientation program helps foster the knowledge and skills necessary to care for patients within the different critical care units in our hospital," said Lisa Fidyk, MSN, MS, RN, coordinator of the Gateway to Critical Care Program.

Catering to the Adult Learner

Participants enrolled in the program adhere to an educational plan that defines competency expectation, patient assignment and preceptor/learner responsibilities.

"We base our program on Patricia Benner's From Novice to Expert model. We work to assist the graduate nurse's progress from advanced beginner to competent nurse utilizing her framework," explained Fidyk, who is also a professional development specialist in the Department of Nursing Education, Innovation and Professional Development.

As Fidyk mentioned, Benner's framework of skill acquisition and development of the essence of critical thinking is utilized in the Gateway to Critical Care Program. Goals are reached through segmented learning, faculty guidance, a supportive environment and preceptor/orientee relationships.

The 16- to 20-week program consists of 4-5 weeks of classroom/clinical and 11-16 weeks of full-time clinical. It enrolls new-to-practice surgical, cardiac, neuroscience, cardiothoracic and medical ICU nurses, as well as nurses from the emergency department. Fidyk noted the nurses learn from various teaching strategies, including classroom instruction, clinician-supervised skill labs and clinical experiences.

"The program caters to the adult learner and provides different ways for these nurses to learn about the critical care arena. We incorporate case studies, lectures, discussions and simulation to help them develop the skills they would need to care for critically ill patients," she said.

Throughout the program, nurses learn the following core competencies: airway and ventilator management; cardiac monitoring; critical care pharmacology; hemodynamic monitoring; arterial blood gases analysis; acid-based balance; pain, sedation, neuromuscular blockade; and end-of-life care.

Working Alongside Experienced Nurses

Clinical support comes in the way of clinical preceptors, Gateway to Critical Care faculty and critical care advanced practice nurses/clinical nurse specialists/clinical nurse IV staff nurses.

While enrolled in the program, nurses work beside experienced ICU nurse preceptors.

"A preceptor is a mentor," Fidyk said. "They work with that person when they are on the unit taking care of patients. Preceptors are experienced nurses who know what it's like to go through the Gateway Program, how to collaborate and how to make it a great experience."

When the nurses return to their floor, they practice and hone their skills with a preceptor for the duration of the program.

"My nurse preceptor was a nurse on the unit for 5 years," recalled Lauren Mang, BSN, RN, clinical nurse I in the neuro ICU at the Hospital of the University of Pennsylvania. "She was fabulous. She really gave me the confidence and courage I needed to become a better nurse."

Mang noted preceptors help new nurses become more at ease because, as an experienced nurse who knows the ins and outs, they are able to impart their knowledge at a comfortable level.

"She was there side by side with me until toward the end when she started to hide from me so I would learn how to answer questions on my own. She gave me the confidence to be able to do that," she said.

New Graduate Nurse Retention

After the Gateway to Critical Care program, nurses are enrolled in the Nurse Residency Program, a yearlong series of learning and work experiences designed to support nurses as they transition into professional nursing practice.

The Hospital of the University of Pennsylvania participates in the United HealthSystem Consortium (UHC)/American Association of Colleges of Nursing (AACN) National Nurse Residency Program and was actually the first Philadelphia hospital to participate in the National Nurse Residency Program.

The UHC/AACN Nurse Residency Program consists of an evidence-based curriculum developed by academic and nursing experts across the country. It boasts a reduction in voluntary turnover rate for first-year nurses to well below the median of 27.1 percent. Programs that have implemented this residency program model have attained retention rates of more than 94 percent.

Fidyk commented that both the Gateway to Critical Care Program and the Residency Program at the Hospital of the University of Pennsylvania act as a great support system, and with that support she's seen a "huge" increase in retention. A 98 percent retention rate to be exact.

A higher nurse retention rate delivers better patient outcomes by increasing the nursing staff's experience and competency. Retention also helps preserve new graduate nurses' knowledge, experience and competence gained during the first year of professional practice.

"I know a lot of hospitals don't have these programs, and when I was in a leadership class in nursing school, we actually talked about Penn's Gateway program. That really opened my eyes to research this program more," Mang said. "I needed just a little bit of extra help one-on-one and it really helps you with that. Right now, I'm only 11 months into this and I feel very confident and have learned a lot from this program."

Fidyk noted that, for most of the nurses who come into the program, it's their first job - and it's an intense arena.

"You're saving people's lives, you're dealing with emotional aspects of your job, you're coming in contact with many different healthcare providers - it's all very overwhelming. The Gateway to Critical Care Program is a great way to help new nurses figure everything out and have someone to talk to who will listen," she concluded.