Orientation and retention of new graduate RNs to the specialty area of labor, delivery, recovery, and postpartum (LDRP) creates challenges for nurse managers and preceptors. Onboarding requires time, effort, and patience as new graduate RNs transition from nursing school to clinical practice. Further, nursing schools have difficulty providing the clinical experiences that reflect the complexity of the acute care LDRP environments. This gap in preparation can lead to new graduate RNs experiencing feelings of failure, insecurity, self-doubt, and high levels of burnout (Friedman et al., 2013; Guerrero et al., 2017; Hatzenbuhler et al., 2019). Additionally, this lack of preparation and experience can lead to potentially fatal errors and poor patient outcomes (Krozek, 2017). In contrast, job satisfaction and retention rates of nurses are directly correlated with a quality orientation process (Kuhrik et al., 2011).
The purpose of this article is to describe the design and implementation of a perinatal internship for new graduate RNs participating in a nurse residency program. Although the organization was not adequately tracking retention of staff or performing exit interviews during this time, prior to the implementation of the perinatal internship, new graduate RNs either failed to stay through the entirety of their orientation or became “burned out” due to the high-risk nature of the environment. Anecdotally, some reports noted up to 50% staffing with agency nurses and high staff turnover. The perinatal internship was proposed to address the unique issues faced by new graduate nurses transitioning from school to practice.
Description of Organization
The organization is a two-hospital academic facility comprising the primary teaching hospitals for a large Midwestern school of medicine. Each hospital has a unique labor and delivery unit that provides care to a specific patient population. The urban campus is located in a major metropolitan area and houses a 34-bed, high-risk labor and delivery, antepartum and postpartum unit. This unit provides care for patients with a variety of obstetrical and fetal complications managed solely by obstetricians and gynecologists (OBGYNs) (residents and attending physicians). The second campus is located in a suburban area and houses 19 beds that provide low-risk obstetrical care managed by OBGYNs, family practice (residents and attending physicians), and certified nurse midwives.
The Perinatal Clinical Mentor
Education in the health system is provided by corporate educators assigned to a specific area within the hospital. The corporate educators maintain a presence at both campuses and address unit specific needs as necessary. Using the perinatal internship to onboard graduate nurses in a specialty area requires additional educational support. A new permanent, full-time role within the organization was developed, called the perinatal clinical mentor, to support the delivery of the program.
Mentoring assists the new graduate nurse with confronting challenges in a new environment while acquiring the skills, knowledge base, and abilities needed to provide quality patient care in a high-risk environment. The perinatal clinical mentor's role is to assist in the delivery of didactic and simulation content, as well as to be present when graduate RNs are on the floor to provide just-in-time teaching. The mentor is also critical in providing professional and emotional support in guiding new graduate RNs into practice and aiding in a successful transition from novice to advanced beginner, as outlined by Benner's stages of clinical competence (Benner, 1982; Vinales, 2015). Two experienced RNs certified in inpatient obstetric care through the National Certification Corporation were hired as perinatal clinical mentors. One of the mentors is a Master of Science in Nursing–prepared nurse, and the other mentor is a Bachelor of Science in Nursing–prepared nurse who is also a sexual assault nurse examiner. The two mentors collaborated with the corporate nurse educator in developing the content and simulations for the perinatal internship.
Description of Program
After a scripted perinatal orientation program was reviewed, it was decided that the subject matter was too general. To provide specialized education and training specific to our high-risk patient population, the team developed an obstetrical content–based outline that evolved into 14 modules that directly addressed the care provided at the organization. The team also created low-fidelity simulations using either a manikin or one of the instructors as a standardized patient. The content and simulations were developed in alignment with standardized recommendations from the Association of Women's Health, Neonatal and Obstetric Nurses, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the California Maternal Quality Care Collaborative.
Over the course of 2.5 years, each cohort participated in course evaluations that aided in the redesign of content based on feedback requesting more hands-on experience and organizational specific content. Course and program evaluations are ongoing to ensure better development of the graduate RNs regarding preparedness in caring for obstetrical patients and ending orientation at the advanced beginner stage.
The perinatal internship starts with an introductory week of modules that provide the foundation of knowledge necessary to begin caring for patients on the LDRP unit. The introductory week also includes team-building activities and competencies to prepare the graduate RNs for the initial transition from school to the role of the RN. When necessary, the perinatal educators change the sequence of when these modules are offered to ensure that graduate RNs receive didactic content as close as possible to when they are actually orienting to a specific clinical area (i.e., labor and delivery, postpartum and antepartum).
During the didactic portion of the internship, clinical orientation occurred only during the day shift. The perinatal mentors were present in the unit to address educational needs and to seek opportunities where the graduate nurse could improve their assessment and psychomotor skills. Graduate RNs were provided with a competency worksheet with a grid for each area of practice to track the expected progression of skill acquisition and competence. The mentors also kept track of each graduate nurses's daily experiences and identified new learning opportunities. This process was critical in ensuring that the graduate nurse received a well-rounded orientation.
For the urban campus, each graduate RN spends 6 weeks of orientation dedicated to postpartum care and 6 weeks of orientation dedicated to high-risk antepartum care. Labor orientation consists of 8 weeks of orientation with 2 weeks dedicated to assimilating to the role of operating room circulator (20 weeks total). For the suburban campus, each graduate RN spends 6 weeks of orientation focusing on postpartum care and 12 weeks focusing on labor, with 2 weeks dedicated to assimilating to the role of operating room circulator (18 weeks total). The suburban campus has a longer labor orientation because they do not provide high-risk antepartum care. After the 14 modules are completed, typically within the first 12 to 14 weeks of employment, the graduate RNs are moved in succession to their assigned shift to assimilate with the other employees. The perinatal mentors would occasionally work night shifts to support the graduate RNs as they transitioned to their new schedule and role.
Fourteen modules were created that focus on evidence-based obstetrical care for high-risk populations. The modules include:
- Antepartum Care
- Care of Obstetrical Patients in the Perioperative Setting
- Newborn Complications and Neonatal Abstinence Scoring
- Perinatal Loss and Bereavement
- Physiologic and Psychosocial Adaptations to Pregnancy
- Breastfeeding and Baby-Friendly Care
- Introduction to Fetal Monitoring
- Obstetrical Procedures
- Postpartum Maternal & Newborn Care
- Maternal Factors Affecting the Newborn & Fetus
- Perinatal Infections
- Pharmacology for LDRP
- Preconception and Interconception Care
- The Process of Labor and Birth.
Lectures, videos, case studies, games, and discussions are some of the instructional strategies that are used to teach the content. As mentioned earlier, the sequence of the modules can be tailored to coincide with the specific area where the new graduate RNs are orienting. Table 1 provides a brief content synopsis of each module.
Perinatal Internship Modules
Competencies and Simulation
Competencies and simulations were designed to meet the unique educational needs of the LDRP units. Examples of competencies addressed by the perinatal educator and mentors during the perinatal internship include maternal and newborn head-to-toe assessment, sterile vaginal/cervical examination, fetal scalp electrode placement, intrauterine pressure catheter placement, Leopold's maneuver, phenylketonuria and bili-rubin draw, breastfeeding positions, labor positions to promote comfort and successful vaginal delivery, Bakri balloon assistance and placement, placental examination, calling a time-out, opening a vaginal delivery table, performing vaginal preparation prior to cesarean delivery, performing sterile abdominal preparation, and assessing and interpreting a fetal heart tracing.
To support implementation into practice, simulations were designed that addressed the specific diagnoses and obstetrical emergencies that one is most likely to encounter in the labor and delivery unit. Table 2 lists the names of the simulations commonly used in the perinatal internship.
Escape Room Description
The perinatal internship escape room is designed as a team-building activity, as well as to synthesize the content learned during the internship. The goal of the escape room is for the graduate RNs to safely deliver a patient's (manikin's) infant before she has an eclamptic seizure. The activity culminates with the discovery of three codes to combination locks. The escape room is divided into two separate rooms. In the first room, using clues, the participants must determine the patient's name, gravida and para, gestational age, obstetric history, current vital signs, and symptoms and diagnosis to gain access to the larger room. Once in the larger room, the participants are expected to begin piecing together clues and solve riddles, allowing them to gain access to the patient and deliver her infant.
The immediate data that are available pertains to retention rates. Of the 47 new graduates who participated in the nurse residency program from July 2017 through October 2019, 12 left, resulting in an overall retention rate of 74%. Of the 24 new graduates hired at the urban campus, five left because of career growth opportunities, such as transferring to a different unit within the organization, moving to another state to work in the same specialty, or scheduling issues. This resulted in a retention rate of 79%. Of the 23 new graduates hired at the suburban campus, seven left; one was terminated for lack of knowledge and qualifying skills, one transferred to a different unit in the organization, one was unhappy with practice, and the other four left for personal reasons not related to the job. This resulted in a retention rate of 70%. The authors continue to track retention rates for all incoming graduate nurses. Additionally, 30% of current nurses who have matriculated through the perinatal internship are now currently leadership appointed preceptors for the incoming graduate nurses.
It is also worth noting that the use of agency nurses has also decreased dramatically. There are no agency nurses used at the suburban campus. Due to an unusually high volume of deliveries, four agency nurses are currently employed at the urban campus.
Ongoing evaluation of the program is currently underway to identify factors that could increase the retention rates of staff at both campuses. Areas that are being examined include the participants' evaluations of perinatal internship modules, success in obtaining obstetrical specific certifications, and suggestions from employment exit surveys. The authors are in the process of determining a validated scale to use for perceived competence and confidence of the graduate nurses at the end of orientation and the end of their first year of employment.
Overall, orientation for graduate nurses was extended by 2 to 4 weeks on average to accommodate the in-person class schedule. This extension was done to ensure the nurses did not miss a significant portion of the hands-on experience attained from providing patient care. Funding for the salary of the perinatal clinical mentors came from the unit budget and is an ongoing cost. Cost from simulation and escape room materials came either from the unit or from items the perinatal clinical mentors or the corporate educator already possessed.
The perinatal internship consists of 14 modules, clinical competencies, simulations, an escape room, exposure to a variety of patient care opportunities in the unit and maintaining close collaboration with the peri-natal clinical mentor. The role of the perinatal clinical mentor is to not only provide education expertise but also emotional support to new graduate RNs as they progress through their orientation. Ultimately, the goal of the internship is to provide a tailored specialty orientation experience that improves retention rates and job satisfaction for new graduate RNs.
- Benner, P. (1982). From novice to expert. The American Journal of Nursing, 82(3), 402–407 PMID:6917683
- Friedman, M. I., Delaney, M. M., Schmidt, K., Quinn, C. & Macyk, I. (2013). Specialized new graduate RN pediatric orientation: A strategy for nursing retention and its financial impact. Nursing Economic$, 31(4), 162–170 PMID:24069715
- Guerrero, S., Chênevert, D. & Kilroy, S. (2017). New graduate nurses' professional commitment: Antecedents and outcomes. Journal of Nursing Scholarship, 49(5), 572–579 doi:10.1111/jnu.12323 [CrossRef] PMID:28715609
- Hatzenbuhler, N. J. & Klein, J. E. (2019). Educational preparation for clinical practice: Reflections of newly graduated RNs. Nurse Educator, 44(2), 93–97 doi:10.1097/NNE.0000000000000550 [CrossRef] PMID:29794883
- Krozek, C. F. (2017). Psychodynamics of onboarding new graduate nurses. The Journal of Continuing Education in Nursing, 48(7), 299–301 doi:10.3928/00220124-20170616-05 [CrossRef] PMID:28658496
- Kuhrik, N., Laub, L., Kuhrik, M. & Atwater, K. (2011). An interdepartmental team approach to develop, implement, and sustain an oncology nursing orientation program. Oncology Nursing Forum, 38(2), 115–118 doi:10.1188/11.ONF.115-118 [CrossRef] PMID:21356650
- Vinales, J. J. (2015). The mentor as a role model and the importance of belongingness. British Journal of Nursing, 24(10), 532–535 doi:10.12968/bjon.2015.24.10.532 [CrossRef] PMID:26018020
Perinatal Internship Modules
|Antepartum Care||Addresses specific diagnoses, management, treatment, and nursing care of high-risk antepartum complications including preterm rupture of membranes, preterm premature rupture of membranes, preterm labor (e.g., neonatal complications), acute pyelonephritis, hydrops fetalis, and fetal supraventricular tachycardia.|
|C/S and PACU Care||This course equips the nurse to prepare the obstetrical patient for surgery and to successfully circulate and manage an operating room (OR) through the use of sterile technique, description of roles in the OR, outline of patient and fire safety in the OR, and standards of AORN. The course also outlines assisting anesthesia in the OR and the standards of care in the PACU.|
|Newborn Complications and Neonatal Abstinence Scoring||The following complications are covered: neonatal respiratory distress syndrome, meconium aspiration syndrome, transient tachypnea of the newborn, neonatal cardiac lesions, neonatal sepsis, gastroschisis, hypoglycemia, hyperbilirubinemia, late preterm infant and sudden unexpected postnatal collapse of the newborn. Neonatal abstinence scoring is also covered.|
|Perinatal Loss and Bereavement||This course is designed to describe perinatal loss, grief and bereavement, and the nursing care and documentation necessary to care for this patient population. This course also provides guidance on specialized postbirth care of the infant to include memento and the fetal and neonatal cooling system. Finally, considerations for nursing self-care during and after caring for the bereaved patient and family is covered.|
|Physiologic and Psychosocial Adaptations to Pregnancy||This course is designed to describe embryonic and fetal development throughout pregnancy by reviewing the process of implantation and fertilization, identify the maternal physiologic changes that occur during pregnancy, describe the normal psychosocial and developmental adaptations through pregnancy, and outline the testing and screening necessary to complete related to trimester and gestational age.|
|Breastfeeding and Baby-Friendly Care||This course is designed to describe the baby-friendly designation and organizational expectations. The course covers the anatomy and physiology of breastfeeding, as well as benefits and expectations of infant feeding correlated with days of life. Concepts of baby-friendly care including the importance of skin-to-skin and rooming-in are covered, and tools to increase successful breastfeeding are outlined as well. Considerations for supplementation with breastmilk and/or formula are outlined, and a competency is completed for breast pump set up. Special considerations for exclusively formula feeding patients is also covered.|
|Introduction to Fetal Monitoring||This course is designed to outline the NICHD terminology for baseline, variability, accelerations and decelerations, categorization and uterine activity, as well the pathophysiology behind fetal tracings and the physiological based interventions required for category II and III tracings. The course provides a review of maternal–fetal physiology, the basics of reading a strip, acid-based values, and antepartum testing.|
|Obstetrical Procedures||This course is designed to describe the commonly performed obstetrical procedures, including the indications and contradictions; nursing responsibilities before, during, and after the procedure; and the complications that may arise.|
|Postpartum Maternal & Newborn Care||This course is designed to address the normal and abnormal changes in the postpartum period, outline maternal and newborn care postdelivery, identify postpartum related complications and care, describe the required documentation in the postpartum period, and outline the procedure for hospital discharge.|
|Maternal Factors Affecting the Newborn & Fetus||This course is designed to describe the disease processes that can adversely affect the pregnant woman and/or her fetus or newborn, guide the nurse in choosing appropriate disease-specific interventions for pregnant women, describe the etiology and pathophysiology of disease processes, identify the cause of electronic fetal heart rate tracings that are associated with fetal distress, and outline the care that is to be provided for pregnant women with addiction.|
|Perinatal Infections||This course is designed to address the common STIs seen in the prenatal and intrapartum period to include signs and symptoms and treatment, as well as other significant infections that can impact patient care in the prenatal and intrapartum period.|
|Pharmacology for LDRP||This course is designed to address the common medications administered in the labor and delivery unit and include maternal pain and gastrointestinal medication, well-newborn medications, medications for induction, delivery, and recovery in the LDRP setting, uterotonic and postpartum hemorrhage medications, common antibiotics and medications for hypertensive crisis, and eclampsia prevention.|
|Preconception and Interconception Care||This course is designed to describe how preconception and interconception care improves birth outcomes, identify how chronic health conditions affect pregnancy outcomes, address guidance for care and education in special populations, and describe how previous pregnancy history has an impact on subsequent pregnancies.|
|The Process of Labor and Birth||This course is designed in two distinct sections: (a) the process of labor and birth, and (b) pain management in childbirth. The course describes the stages of labor and nursing care associated with each stage, the 5 Ps of labor, the management of common labor complications, normal and dysfunctional labor process and maternal and fetal conditions that can impact labor outcomes, and methods of induction and augmentation of labor. The pain management section of the course is designed to discuss the physiological sources of pain during childbirth, methods of pharmacological and nonpharmacological pain management for childbirth, epidural emergencies and the nurse's role, and a review and practice related to the impact maternal positioning during labor has on comfort and fetal descent.|
|Prolapsed cord and fetal heart rate interventions|
|Sterile technique identification in the operating room|
|Safe sleep with the initial steps for neonatal resuscitation|