Long-term care (LTC) nurses provide complex care in a highly regulated environment with high resident to RN ratios and high RN and certified nursing assistant turnover (Cramer et al., 2014). Many nurses practicing in LTC have not had adequate preparation in gerontology, communication, clinical leadership, and management of interdisciplinary teams necessary to provide optimum care for older adult patients in the LTC environment (Al-Dossary et al., 2014; American Association of Colleges of Nursing & The Hartford Institute for Geriatric Nursing at New York University, 2010; Cramer et al., 2014). LTC–specific nurse residency programs (NRPs) may be a way to address these knowledge deficits for novice and experienced LTC RNs alike. The purposes of the current article are to: (a) provide an overview of the LTC environment and nursing roles within; (b) describe the current state of NRPs; and (c) outline the development of a distance-based LTC NRP to address the increasingly complex care provided by LTC nurses.
Long-Term Care Nursing
In 2016, there were more than 1.3 million nursing home residents; 57% of these residents had a nursing home stay >100 days (Harris-Kojetin et al., 2019). Yet nationally, only 7% of RNs work in nursing and residential care facilities (Bureau of Labor Statistics, 2020). LTC nurses are often the most highly trained health care providers within a LTC facility at a given time. The staffing of an average 107-resident LTC facility is typically two RNs, 11 licensed practical nurses, and 35 nursing assistants (Harrington et al., 2016). Therefore, LTC nurses need to be adept at leading, delegating, and supervising the care of a large number of medically complex residents at one time.
The challenges of LTC nurses are different from those of nurses working in a hospital setting in the following defining ways:
The majority of LTC residents are older than 65 years and often limited in activities of daily living and cognition (Centers for Medicare & Medicaid Services [CMS], 2015).
LTC residents require individualized care for multiple chronic conditions and a variety of complex issues, including pressure ulcers, restraint use, incontinence, feeding tubes, unintended weight loss, antipsychotic medication use, and cognitive disorders (e.g., Alzheimer's disease) (CMS, 2015).
LTC nurses must rely on their knowledge and skillset to respond effectively to changes in a resident's status as collaborating providers are not readily available.
Nurses need to be effective communicators between the interdisciplinary care team and residents and their families and have appropriate communication skills regarding care preferences and end-of-life decisions.
Long-Term Care Nursing Challenges
Today's LTC nurses face increasing time demands. The number of direct nursing care hours per resident is rising for all levels of nursing staff because of the increasing complexity of care required by today's LTC resident (American Health Care Association, 2014). More patients are admitted to LTC after discharge from a hospital for post-acute skilled nursing care; however, these patients generally have short-term stays, which raise the resident acuity level and create a rapid turnover of admissions and discharges from the LTC facility. This strain on nursing staff time and resources can eventually lead to nursing burnout and turnover (Harrington et al., 2016).
In 2012, the median turnover rate for RNs was 50%, an 11% increase from 2011 (American Health Care Association, 2014). The LTC industry struggles to maintain adequate nursing staffing levels necessary for nursing homes to remain eligible for Medicare and Medicaid funding (Harris-Kojetin et al., 2019). Insufficient staffing negatively affects the amount of time nurses can spend with patients and leads to individual and organizational consequences of malcontent, low morale, frustration, and higher nursing turnover (American Health Care Association, 2014). In addition, staffing turnover results in novice LTC nurses quickly being placed in leadership positions, often without proper training or guidance (Corazzini et al., 2010).
An approach to decrease turnover and increase competency among novice nurses is through implementation of a sound transition-to-practice program that can provide a setting-based orientation (Al-Dossary et al., 2013; Joint Commission on Accreditation of Healthcare Organizations, 2002). Targeted education in LTC has been shown to improve staff–resident interaction and positively impact symptoms of dementia (Gilster et al., 2018). One way to enhance novice nurses' knowledge and skill in their setting-specific role is through a NRP designed to extend and supplement nurses' base education by including geriatric care content and competencies.
Nurse Residency Programs
The Joint Commission (2002) report, Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis, outlined tactics for bolstering nursing educational infrastructure and standards of practice, including the development and implementation of standardized postgraduate NRPs. NRPs became popular in the acute care environment because they addressed transition-to-practice challenges for novice nurses and contributed to a decrease in nurse turnover (Goode et al., 2016). NRPs vary in location, format, and length but often share commonalities, including a formal professional education component, establishment of a novice nurse/experienced nurse (preceptor) relationship, opportunities for professional growth, and preceptor education (Cadmus et al., 2017; Cadmus et al., 2016). Research has demonstrated that NRPs help novice nurses develop skills related to prioritization, communication, clinical practice, competence, and confidence (Goode et al., 2016). Furthermore, new graduates are attracted to settings that offer NRPs.
LTC Nurse Residency Programs
Although the success of NRPs in acute care settings is well documented, few NRPs have been developed for the LTC setting (Al-Dossary et al., 2013; Cline et al., 2017; Fink et al., 2008). Cadmus et al. (2017) developed and implemented the first documented NRP for nurses new to the LTC environment. This residency program was centrally located between LTC facilities to promote participation of new hires. The curriculum focused on teaching novice nurses to apply the knowledge they gained in nursing school to the LTC setting (Cadmus et al., 2017). Each novice nurse was assigned a preceptor who served as a resource and mentor during the program.
The University of Wisconsin-Madison developed an online LTC NRP, Geri-Res, which offers two curricula geared toward novice LTC nurses and experienced clinical coaches who mentor nurses new to the LTC environment. Novice nurses are encouraged to complete the 16 LTC nursing modules over a minimum of 4 months, but they retain access to the content for 1 year (University of Wisconsin-Madison, 2020). The nursing and clinical coach courses are designed to be a collaborative effort with the goal of creating a successful, mentored learning environment for novice nurses (University of Wisconsin-Madison, 2020).
Benefits of LTC Nurse Residency Programs
Spector et al. (2015) demonstrated a higher 1-year retention rate for nurses working in non-hospital settings, including LTC, who participated in a non-hospital transition-to-practice program when compared to nurses who participated in a traditional orientation program. Nurses who participated in a non-acute care NRP that offered facility support and mentors reported they were more confident and competent and had better communication skills (Salmond et al., 2017; Spector et al., 2015).
The 1-year retention rate for the first cohort of the LTC NRP described above was 86%, much higher than the reported retention rate of nurses working in LTC facilities in New Jersey (Cadmus et al., 2016). Nurses who completed the NRP reported increased confidence, clinical practice skills, role development, and job satisfaction (Salmond et al., 2017).
Barriers to LTC Nurse Residency Programs
There are numerous barriers to the implementation of LTC NRPs. NRPs can be expensive in terms of paying for education hours for novice nurses and their preceptors and covering their potential time away from resident care (Goode et al., 2016). There is often lack of administration buy-in (Salmond et al., 2017; Spector et al., 2015) and funding to support another training program in addition to orientation or traditional onboarding programs for the novice nurse. Another limitation is the high level of nursing turnover and the quick transition from direct patient roles to administrative roles of nurses who stay in LTC (Corazzini et al., 2010). This transition contributes to fewer experienced nurses qualified or with enough time to mentor novice nurses (Spector et al., 2015). Further, LTC facilities often hire one new nurse at a time, which hinders implementation of a cohort-based NRP curriculum. Finally, for LTC nurses who work in rural areas, a face-to-face NRP may be difficult or impossible to attend due to geographical distances.
Opportunities for Distance-Based LTC Nurse Residency Programs
Distance-based NRPs can partially alleviate the barriers of time and access by allowing nurses to participate asynchronously when they have time. Online content delivery allows nurses in rural areas an opportunity to participate in a LTC NRP while remaining in their home community. A hybrid NRP can integrate asynchronous content delivery with real-time mentoring from experienced nurses and other members of the LTC team in their facility or organization. In addition, synchronous live web-based discussions can be incorporated to offer customizable content based on the educational needs of individual nurse residents.
Development of the University of UTAH Geriatric Education Consortium LTC NRP
The goal of the University of Utah Geriatric Education Consortium (UGEC), funded by a Health Resources and Services Administration (HRSA) Geriatric Workforce Enhancement Program (GWEP), is to integrate primary care and geriatric care into the LTC setting to improve health care delivery to residents. We partnered with two LTC organizations, both of which have geographic challenges and high nursing turnover.
Recognizing that NRPs have been successful in reducing nursing turnover in other settings and that LTC nurses often lack formal geriatric and leadership training, we developed a distance-based NRP comprised of asynchronous and synchronous activities accessible to LTC nurse residents in urban and rural areas. Results of the first four cohorts of students who have completed the UGEC LTC NRP will be reported in a future article.
LTC Nurse Residency Program Development
The LTC NRP content development was guided by available literature on acute care and LTC NRPs. In particular, the LTC NRP successfully developed by Cadmus et al. (2017) provided an initial framework for content and evaluation. An international expert consensus study identified 16 future distinguishing competencies of baccalaureate-educated RNs working in LTC. These competencies were related to leadership and coaching, communication, client assessment, and geriatric expertise (Backhaus et al., 2015). Based on these competencies, we designed our LTC NRP around three core topic areas: nursing leadership and communication, geriatric nursing competencies, and the expansive roles required of LTC nurses.
Using these core topic areas, we worked with University of Utah nursing faculty, partnering LTC organization administrators and nurses, and our state Quality Improvement Organization, Comagine Health, to develop specific content within each of the core topic areas. We incorporated content from the 19 gerontological nursing competency statements identified in the Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults (American Association of Colleges of Nursing & The Hartford Institute for Geriatric Nursing at New York University, 2010).
The resulting 9-month NRP comprises 12 weekly modules in each of the three core topic areas—leadership and communication, caring for the older adult patient (age ≥65 years), and working in the LTC regulatory environment. The leadership and communication topic focuses on developing LTC nurses as interprofessional team leaders with strong communication skills (Table 1). The caring for the older adult patient content teaches assessment and intervention of geriatric syndromes (Table 2). The LTC nursing topic area introduces the novice nurse to the LTC regulatory environment (Table 3). Nurse residents are trained to use the Interventions to Reduce Acute Care Transfers (INTERACT) tools, including SBAR (Situation, Background, Assessment, Recommendation) method, STOP and WATCH tool, and the Medication Reconciliation worksheet (Ouslander et al., 2014).
Topic Area 1: Nursing Leadership and Communication Modules
Topic Area 2: Nursing Care of the Older Adult Patient Modules
Topic Area 3: Long-Term Care (LTC) Environment Modules
Our LTC organizational partners stressed the need to embed resilience training throughout the NRP. Low resilience has been associated with reduced job satisfaction and retention, decreased ability to work in teams, higher turnover, and decreased patient safety (Cline et al., 2017). Higher levels of resilience among nurse residents improve job engagement confidence, teamwork, ability to perform tasks, clinical reasoning, and adaptability (Cline et al., 2017). Resiliency content specific for the LTC setting was woven throughout the program. Our goals were to build resilience in LTC nurses themselves (Topic Area 1), provide nurses with skills to improve the resilience of the interprofessional LTC team (Topic Area 2), and prepare nurses to provide resilience skills to LTC residents and family members (Topic Area 3).
LTC Nurse Residents and Mentors
The UGEC LTC NRP is designed for licensed RNs with <1 year of LTC nursing experience who are paired with experienced nurse mentors working within the same LTC facility. Mentors are expected to meet regularly with nurse residents and be available for clinical support and quality improvement activities. Residents and mentors are selected by nursing administrators from partnering LTC organizations.
LTC NRP Content Delivery
The UGEC LTC NRP starts with a 1-day boot camp attended by nurse residents, their mentors, LTC partner educators and leaders, and program faculty. The boot camp begins with an evaluation of attendee demographics, education and work experience, and pre-program knowledge of the three content areas. An overview of the benefits, purpose, and expectations of the LTC NRP are provided. An overview of INTERACT and quality improvement is provided in the context of the NRP.
The didactic portion of the NRP is delivered via an online learning management system. Content for each of the three core topic areas is delivered asynchronously in weekly modules that take approximately 4 hours to complete (Tables 1–3). Nurse residents and mentors attend a biweekly videoconference where nurse residents synthesize module content with their practice experience.
The quality improvement project is completed in nurse residents' home facilities. Quality improvement nurses employed by Comagine Health visit the facilities several times throughout the NRP to help nurse residents identify a quality improvement need in their facility, with input from administration and recent survey deficiency tags, and then to develop, implement, and evaluate an intervention to improve the area of concern. Nurse residents present their project posters at the annual UGEC retreat.
LTC NRP Evaluation
Evaluation of the LTC NRP includes demographic, knowledge attainment, and workforce data collected at baseline and completion of the program, as well as 6- and 12-months post-completion. Demographic data include, but are not limited to, gender, race and ethnicity, highest level of education, licensure type, years of experience, current role, and geriatric training. Knowledge data include the Advancing Geriatric Education through Quality Improvement Scale (Weir et al., 2017), Casey-Fink Graduate Nurse Experience Survey revised (Casey et al., 2004; Fink et al., 2008), Interprofessional Attitudes Scale (Norris et al., 2015), and Nursing Home Survey on Patient Safety Culture (Agency for Healthcare Research and Quality, 2019). Nurse residents rate their satisfaction with the program, its delivery, content, and the amount of time the program takes, as well as satisfaction with the quality improvement project. Workforce data include nurse residents' intent to stay in their current position and to continue working in LTC as well as LTC organizational data regarding facility turnover.
As part of the Rapid Cycle Quality Improvement (RCQI) process employed by the UGEC, nurse residents, mentors, LTC partners, and Comagine Health partners provide feedback frequently during each residency program cycle. We use RCQI to assess nurse resident progress and attrition and to refine the program content and delivery. As a result of RCQI and program evaluation, the NRP is continually adapted to better meet the needs of nurse residents and our LTC partners.
Initial Results and Clinical Implications
Findings indicate that overall, nurse residents had higher levels of intention to stay in their current positions and remain working in LTC. In addition, nurse residents reported an increase in (a) confidence in their ability to engage in and complete quality improvement projects, (b) understanding of recommended gerontological nursing competencies, and (c) knowledge in applying best practices in all aspects of resident care, including end of life. These initial results indicate that this program facilitates realization of the recommended gerontological nursing competencies and impacts nurse resident intent to stay in LTC.
Another benefit this program provides is the necessary contact hours required to sit for the American Nurses Credentialing Center Gerontological Nursing board certification examination (RN-BC). LTC nurses who receive this certification have improved clinical competencies in the care of older adults (Cramer et al., 2014). Certification is a significant accomplishment for the individual nurse and an important differentiation of the specific knowledge and competency needed to provide quality gerontological care. Many of the LTC organizations we have worked with realize the value of having specifically educated nurses providing quality care to residents and are committed to paying for the geriatric certification examination for nurses who complete the residency program.
There are challenges to an NRP such as ours. Although the program is online, allowing nurse residents flexibility in completing the modules, high turnover and absenteeism within their home facilities can result in nurse residents working overtime, creating time constraints. One nurse resident reported, “I did not have time to complete very much of it.” Although LTC organizations endorse the need for a better educated nursing workforce, individual facilities struggle to provide tangible support, such as funding and time, which are necessary for successful completion of the NRP. To ensure program success, LTC organizations need to carefully assess nurse resident needs and motivation to participate and provide nurse residents with administrative support that includes protected time and/or relevant incentives for program completion.
Increasing LTC nursing capacity and competencies is a major challenge. Organizations including the Institute of Medicine, Commission on Collegiate Nursing Education, and Joint Commission recognize the value of NRPs, particularly in acute care. Although there are few reported LTC NRPs, early research suggests that LTC NRPs can increase the competencies of LTC nurses, providing them with additional tools, resources, and support that allow them to manage the care of an increasingly high acuity population with multiple comorbidities. Further, LTC NRPs have the potential to provide nurses with greater confidence in communication, leadership, time-management, and geriatric-specific knowledge to lead interprofessional teams and improve care transitions. Finally, LTC NRPs have the potential to improve job satisfaction and retention rates and improve continuity of care and resident satisfaction. The current article describes the conceptualization and implementation of the first 9-month online UGEC LTC NRP. The UGEC aims to provide LTC nurses with these benefits through the implementation of an online asynchronous LTC NRP that allows participation of nurses regardless of time or geographic location.
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Topic Area 1: Nursing Leadership and Communication Modules
|1||Nursing leadership and communication|
|2||Leading and communicating in teams|
|3||Tools for interprofessional communication|
|4||Health literacy and communicating with older adults and family caregivers|
|7–8||Building individual resilience|
|9||Cultural competency and diversity|
|11||Information and technology|
|12||Evidence-based practice and quality improvement|
Topic Area 2: Nursing Care of the Older Adult Patient Modules
|1||Theories and developmental considerations in caring for an older population|
|3||Interpretation of findings of geriatric assessment|
|4||Oral/dental care—systemic links|
|5||Depression and mental health|
|6||Dementia care/management alternatives|
|10||Resiliency in long-term care residents and families|
|11||End of life|
|12||Presentations of quality improvement projects|
Topic Area 3: Long-Term Care (LTC) Environment Modules
|1||History of LTC nursing|
|3–6||LTC ratings and quality measures|
|7||Reimbursement: Medicare, Medicaid, and private insurance|
|8||Care plans and the Minimum Data Set (MDS)|
|11||LTC interdisciplinary team members and roles|