Nurse navigators are an emerging, valuable asset in today's health care arena. According to Zangerle (2015), “Nurse navigators address patients' needs from a logistics perspective with a clinical lens, explaining treatment options and providing advice and support. Nurse navigators guide, educate, advocate for, and encourage patients and their families within the particular diagnosis and related elements” (p. 27). The nurse navigator expedites a patient's health care journey, serving as educator, facilitator, and clinician. These three interrelated roles are applicable in direct and nondirect care areas, such as nursing education. An education navigator expedites novice nurses' professional practice journeys as they navigate employment within a health care system.
The impetus for establishing the nurse residency education navigator position began in December 2017, when our health system was experiencing an RN vacancy rate of 6.9%. To ease this staffing strain, during a 12-month period (January 2018 through December 2018), we hired 105 new graduate nurses into our existing nurse residency program. Recognizing the need for an experienced educator to facilitate the nurse residents' journey from novice to competent staff nurses, health system administrators, educators, and human resource staff created the nurse residency education navigator job description and standard work. The nurse residency education navigator job description was modeled after existing nurse navigator job descriptions within the health system. The standard work, based on peer coaches and how they support front line staff (Advisory Board, 2018), encompassed the three nurse navigator roles of educator, facilitator, and clinician. In April 2018, the nurse residency education navigator was hired. The purpose of this article is to describe how the nurse residency education navigator implemented the roles of educator, facilitator, and clinician to support nurse residents' journeys through their residency program and improved graduate nurse retention.
Our health system consists of three community hospitals with 578 licensed beds, employing 1,400 RNs. In 2012, we implemented a 1-year nurse residency program; over a 6-year period, this original residency evolved into its current 2-year version. Our residency program is a comprehensive endeavor designed to foster novice nurses' development into their core professional nursing roles of clinician and leader. This residency reflects the standards set forth by the Practice Transition Accreditation Program (American Nurses Credentialing Center, 2020). To qualify for our residency, candidates must be newly graduated nurses and/or nurses with 1 year or less of acute care experience. Nurse residents are hired into one of three cohorts throughout the year (cohort 1: January–April; cohort 2: May–August; cohort 3: September–December), which coincide with nursing school graduations. In 2018, the organization hired 105 nurses into one of three cohorts (cohort 1, n = 34; cohort 2, n = 62; cohort 3, n = 9).
The nurse residency education navigator strategizes with the unit-based nurse educators, clinical directors, and staff preceptors to integrate the nurse residents into the work environment (Table 1). The nurse residency education navigator's standard work is to support nurse residents' education and transition into their professional role (navigator as educator); assist nurse residents with unit operations (navigator as facilitator); and provide clinical leadership for nurse residents (navigator as clinician) (Table 2). Objectives for the nurse residents focus on and support growth in their career, build collaborative relationships with the health care team, transition through Benner's (2010) beginning levels of practice, develop critical thinking skills, incorporate evidence-based practice into patient care, grow clinically and professionally, and develop an individualized career pathway.
Professional Staff Roles with Nurse Residents
Examples of Standard Work of Nurse Residency Education Navigator Role
The 2-year nurse residency program (Table 3) is divided into two phases, whose hallmarks coincide with Benner's (Benner et al., 2010) progression from novice to advanced beginner, with the goal of practicing at the competent level at the completion of their residency. Over the 2-year residency program, nurse residents learn how to bridge gaps in clinical competence, knowledge, and skill. Their understanding of the health care delivery system expands by becoming involved with shared governance and professional networking. Nurse residents' critical thinking skills develop through clinical experiences and support from their nurse residency education navigator, unit-based educator, clinical director, preceptor, and colleagues.
Overview of the NR Program
To evaluate their experiences in the nurse residency program, nurse residents complete the Casey-Fink Graduate Nurse Survey (Fink et al., 2008) four times throughout their first year in the program (baseline [week 1], 3, 6, and 12 months postemployment.) This nationally used survey was designed to measure new nurses' self-reported skill level and comfort, stressors both within the work environment and external, role transition difficulties, support and integration to the unit, and employment satisfiers and dissatisfiers (Fink et al., 2008). The survey, comprising 31 statements, required approximately 10 minutes to complete. An open-ended comment section offered nurse residents an opportunity to share their comments or concerns. Survey reliability ranged from .71 to .90, and internal consistency was estimated at .89 (Casey & Fink, 2015). Content validity was established by expert review from nurse educators and directors in clinical and academic settings (Casey & Fink, 2015). The nurse residency education navigator analyzes the survey data and initiates appropriate changes to the program based on the residents' responses. One example of a program change that was initiated based on Casey-Fink results was the addition of a charge nurse shadowing experience. Nurses (25.3%) stated that role expectations such as autonomy, more responsibility, being a preceptor, or functioning in the role as a charge nurse was an area of difficulty in the transition from the student to RN role. To help ease this difficulty, a charge nurse shadowing experience was added to the program at the 6-month mark. Nurse residents are paired with their charge nurse for 4 hours to review tasks such as collaborative care rounding to aid in communication with the health care team, scheduling and staff supervision to support a healthy work environment, and problem solving to help ensure patient safety.
The Nurse Residency Education Navigator as Educator
As an educator, the nurse residency education navigator supports the unit-based educator, clinical director, and preceptor in identifying nurse residents' education needs and opportunities for learning. The nurse residency education navigator offers one-to-one clinical support and education when a need is identified by the nurse resident or staff. This support includes real-time education in the unit or postevent education scheduled by the nurse resident. For example, nurse residents identified time management as a skill requiring extra attention. To facilitate residents' time management skills, the nurse residency education navigator provides one-to-one coaching with nurse residents to teach them prioritization of patients' needs and delegation of tasks. Nurse residents rely heavily on their preceptor to guide them through their day to help prioritize care. As they transition to the advanced beginner stage of Benner's (2010) level of practice, the nurse residents are more confident in their ability to manage their time more appropriately, develop a shift routine, and prioritize care as their patients' needs change. These skills require coaching and the availability of the nurse residency education navigator to assist and coach on the unit in real-time and guide the nurse residents. One example of an education opportunity based on Casey-Fink Survey data was the need for additional experience with emergency responses. Three-month Casey-Fink Survey data revealed that 32% of nurse residents were uncomfortable with code and emergency response skills. In response to this finding, the nurse residency education navigator implemented a system-wide crash cart education program, which included hands-on training with a crash cart, creation of a pocket card resource, and mock codes. This example demonstrates the nurse residency education navigator's response to the needs of the nurse residents based on survey results.
The Nurse Residency Education Navigator as Facilitator
The nurse residency education navigator serves as a facilitator of the nurse residents' passage through the novice and advanced beginner to competent levels of Benner's (2010) stages of practice development. When nurse residents are struggling with specific clinical skills, the nurse residency education navigator is available to work one-to-one with the nurse resident in the unit to guide them through the procedure. An example is helping nurse residents with skills such as flushing drains, medication administration, admission database completion, or providing discharge instructions. During their residency, the unit-based educators, clinical directors, preceptors, and nurse residency education navigator guide the nurse residents to reach the stage of advanced beginner. The nurse residency education navigator serves as a facilitator to the nurse residents over their first 2 years of employment to ensure their goal attainment. Goal development after the preceptor-led orientation varies among nurse residents. For example, goals may be specific to clinical psychomotor skills achievable with continued practice within a short time frame. For most residents, goals have consisted of cognitive and decision-making skills that require additional time to master, such as time management, increase in confidence, getting involved with health system projects, and further education. In time, with the continuous support of the nurse residency education navigator and peers, the nurse residents evolve into their professional nursing roles.
One of the main aspects of the nurse residency education navigator role is to ensure that the nurse residents are supported as they mature into competent nurses. Such support translates into job satisfaction, which leads to increased retention. Comments from the Casey-Fink Survey that demonstrate the benefit of the one-to-one support include “I feel very supported in my new nurse role and so far, this has gone above my expectations and I'm very satisfied with the nurse residency program,” and “I am excited to have this support while starting my nursing career.”
The Nurse Residency Education Navigator as Clinician
In the role as clinician, the nurse residency education navigator models professional nursing behavior and clinical skills for the nurse residents while assisting with patient care as needed. Upon completion of their orientation, nurse residents create a routine that works best for them. The nurse residency education navigator assures that residents are developing a routine that is safe, timely, and effective. Approximately 2 weeks after the completion of Phase 1, the nurse residency education navigator and nurse resident reestablish their rapport and share experiences. Monthly meetings are convened between the nurse residency education navigator and the nurse resident to answer questions, provide resources, and reinforce education. Along with the formal meetings, the nurse residency education navigator conducts unit-based rounds in the nursing units to interact with the nurse residents. The nurse residency education navigator acts as a resource in the nursing unit, remains in contact with the unit educator to assist with unit-based education and communicates regularly with the clinical directors to ascertain the nurse residents' progress.
Three-month Casey-Fink Survey data found that the top three items rated as the most difficult for transition to practice were: lack of confidence, which includes communication skills, delegation, knowledge deficit, and critical thinking (44.2%); workload, which consists of organization, prioritization, feeling overwhelmed, ratios, and patient acuity (40.38%); and role expectation, which is autonomy, responsibility, being a preceptor, or in charge (23%). The nurse residency education navigator continues to support nurse residents with critical thinking and clinical reasoning skills, such as prioritization, communication with physicians, and practicing with autonomy in nursing by assisting the nurse residents side by side on the unit.
The Nurse Residency Education Navigator and Nurse Resident Retention
In 2017, we hired 65 nurse residents. The 1-year (77%) and 2-year (65%) retention rates for nurse residents demonstrated that our health system was having a significant loss in nurses between the 1- and 2-year mark of employment. Although it is too soon to compare 2-year retention rates among nurse residents hired before (2017) and after (2018, 2019), there is a trend toward increased retention at the 1-year mark. To assess the trends, we compared 2017 cohort 1, 2018 cohort 1, and 2019 cohort 1 at 1 year of employment. The 1-year retention rate of the 2017 cohort 1 was 72.2% (13 of 18 nurse residents remaining). In 2018, the retention rate of cohort 1 increased to 88.2% (30 of 34 nurse residents remaining), representing an increase of 16 percentage points. Between 2018 cohort 1 and 2019 cohort 1, the nurse residency education navigator role was developed to influence retention rates by increasing the level of support. In 2019 cohort 1, at 1 year of employment the organization retention rate increased to 96% (24 of 25 nurse residents remaining). Increased retention rates among cohorts may be directly related to the nurse residency education navigator's oversight of the nurse residency program and facilitation of the nurse residents' journey into professional nursing practice.
Implications for Practice
Hospitals and health care systems must creatively engage and retain new nurses to deliver safe and effective care. The nurse residency education navigator guides nurse residents during their transition into professional nursing. As an educator, facilitator, and clinician, the nurse residency education navigator engages nurse residents throughout their residency by offering them individualized guidance and mentoring within an established program. The nurse residency education navigator works with the nurse residents on core essential skills that will apply regardless of the specialty throughout the nurse residents' career. In addition to the nurse residency education navigator, each unit has an educator available to help with unit-specific skills. The resident retention rate exemplifies the success of the nurse residency education navigator's role.
Future improvement strategies to the nurse residency program are under consideration and include analysis of exit interviews from nurse residents to improve existing retention strategies. Also, assuring consistent completion of the Casey-Fink Graduate Nurse Experience Survey will provide meaningful data that can be analyzed over time for trends in resident performance and retention, as well as program modifications and improvements. Furthermore, synthesizing the residency's objectives, nurse residency education navigator's standard work, and data obtained from the Casey-Fink Graduate Nurse Experience Surveys and staff feedback will generate researchable questions and glean topics for future study. Comparing and contrasting retention rates by demographics (e.g., residents' ages, licensure program, NCLEX® pass rates) and system (e.g., unit of employment, involvement in shared governance) activities over time will offer insight into why nurse residents leave the organization and why they remain.
The nurse residency education navigator plays a significant role in the development of newly graduated nurses' professional development by serving as their dedicated educator, facilitator, and clinician. Cultivating and retaining new nurses requires a transformational leadership approach. Leadership within health systems encompasses both the senior-level administrators supporting the nurse residency program and the nurse residency education navigator, thus facilitating the journey of newly graduated nurses. Human development is a strategic pillar for our health system. Strategies within this pillar focus on hiring and retaining exemplary nurses who provide high-quality care. When nurses have mentors and leaders they can rely upon for support and guidance, an organizational culture is created where performance is optimized and staff are retained. A supportive culture enhances a professional work environment, clinical practice, and education.
- Advisory Board. (2018, June13). Create care standards your frontline nurses will embrace: 12 tactics for care standard prioritization, design, and rollout. https://www.advisory.com/en/topics/nursing-care-quality-and-service/2018/06/create-care-standards-your-frontline-nurses-will-embrace
- American Nurses Credentialing Center. (2020). Practice transition accreditation program. https://www.nursingworld.org/organizational-programs/accreditation/ptap/
- Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. Jossey-Bass.
- Casey, K. & Fink, R. (2015). The Casey-Fink Graduate Nurse Experience Survey. Survey validity and reliability. https://www.uchealth.org/wp-content/uploads/2016/10/PROF-CF-reliability-and-validity-2014.pdf
- Fink, R., Krugman, M., Casey, K. & Goode, C. (2008). The graduate nurse experience: Qualitative residency program outcomes. The Journal of Nursing Administration, 38(7–8), 341–348 doi:10.1097/01.NNA.0000323943.82016.48 [CrossRef] PMID:18690125
- Zangerle, C. (2015). Nurses as navigators. Nursing Management, 46(10), 27–28 doi:10.1097/01.NUMA.0000471587.08691.ba [CrossRef]
Professional Staff Roles with Nurse Residents
|Staff Member||Role in Nurse Residency|
Facilitates biweekly meetings with the nurse residents during Phase 1 of their residency
Works closely with the preceptor, clinical director, and nurse residency education navigator to ensure the nurse resident's timely professional development through the application of the necessary knowledge, skills, and abilities to function independently in a safe and effective manner
|Clinical director||• Provides support for the nurse resident throughout employment|
|Staff preceptor||• Mentors the nurse residents during Phase 1 of their residency|
Examples of Standard Work of Nurse Residency Education Navigator Role
|Educator Role: Support Continuous Learning||Facilitator Role: Assist NRs With Unit Operations||Educator Role: Provide Leadership for NRs|
Ensure regular 1:1 touch points with NR
Participate in shared governance and educate NR on organizational activities
Educate and develop NR; facilitate teamwork through coaching and mentoring
Ensure NRs are adhering to standard work, established policies/protocols and nurse practice act.
Contribute to the evaluation on the NR experience
Work collaboratively with NR on new clinical skills/procedures
Respond to critical situations to provide emotional support postexperience
Guide NR during admission and discharge process
Aid NR with assessment and documentation practices
Assist NR with prioritizing and delegation
Support NR with medication administration
Lead, motivate and initiate change
Coach/mentor NR and provide guidance
Role model teamwork
Help NR identify care practices that lead to less than desired outcomes
Assist NR to identify evidence-based practice projects
Teach NR to practice within an interdisciplinary environment
Encourage the development of the components of the staff nurse roles of professional, clinician, and leader
Overview of the NR Program
|Time Frame||Residency Curriculum||NR Goals||Benner Level of Practice (Benner et al., 2010)|
| Week 1||New employee orientation
Standardized for all new hires
EN meets separately with NRs for 1 hour to introduce themselves, their role, and the program
NR completes baseline Casey-Fink Survey
|• Develop the foundation to launch career at our organization||Novice:
Limited practice experience
Perform practice under guidance
Relate theoretical knowledge to clinical practice in a noncritical thinking manner
| Weeks 2–8|
Biweekly meetings with the educator, director, preceptor
Educator and preceptor are the main support for the NR
Begin to build collaborative relationships
Grow clinically and professionally with the help of their preceptor
| Week 8||Phase 1 completion:
Meeting held with educator, director, preceptor, and EN
NR is complete with preceptor-led orientation
EN is main support for the NR
NR completes 3-month Casey-Fink survey
Transition from novice to advanced beginner
Develop critical thinking skills
Worked as a professional for 6 months or less
Routine and task-oriented
Difficulty making independent decisions and implementing individualized nursing care
Trial and error to learn new way to affect situations
Require special guidance from more experienced coworkers
|Phase 2, Part 1|
| Week 8–1 year|
EN meets monthly with NR in unit to support clinically
NR attends four 4-hour sessions facilitated by EN to develop professional and leadership skills
NR completes 6-month and 12-month Casey-Fink surveys at the desired sessions
NR works on an evidence-based practice project and then presents at completion of 1 year
Progress clinically and professionally with the support of the EN
Incorporate evidence-based practice into patient care
Develop clinical reasoning skills
|Phase 2, Part 2|
| Year 2|
EN meets monthly with NR on unit to support clinically
NR attends a 4-hour session to continue to work on professional development
At completion of year 2, NR attends a career advancement session to explore other opportunities offered by the health system and to highlight their completion of the NR program
Develop an individualized career pathway
Grow clinically and professionally with the support of the EN
Worked as a professional for 1 to 2 years
Can cope with a wide range of nursing situations
Still learning about patient priority and urgency
Ability to predict immediate likely events and changing needs