An interview with Rebecca Monteau on Mayo Clinic’s Orientation and Residency Program

As the Nurse Residency Program Coordinator at the Mayo Clinic, Jacksonville, Florida, Rebecca Monteau, MSN, RN-BC, has helped the organization maintain a 96.6% retention rate in the midst of nursing diversity.

With a 96.6% retention rate, Mayo Clinic in Jacksonville, Florida, believes that its nursing orientation and residency program has played a significant role in reducing new nurse turnover. "We've leveraged our program to improve new nurse satisfaction, engagement, and ultimately, retention," states Rebecca. To find out more about the program, Elsevier conducted an interview with Rebecca.

What's most challenging about serving as a nurse residency program coordinator?
Challenging components of my job relate to developing and adapting the program curriculum, setting objectives, and monitoring outcomes. Another key challenge centers on addressing the needs of diverse learners in the program at this Mayo campus.

Tell us more about the type of diversity that you have to address.
Nurses may relocate to Jacksonville from another state to work here. For example, in a recent cohort, we accepted two newly-licensed nurses from California who were masters prepared. Since the program began, 230 nurses have been admitted into the nurse residency program in 14 cohorts. This includes 75 ADNs, 153 BSNs (traditional and second-degree nurses), and 2 MSNs. Generally, our spring cohort includes traditional newly-licensed nurses, and the fall cohort includes second-degree nurses from accelerated programs. At this Mayo campus, we are challenged to provide a comprehensive curriculum from orientation through the end of residency that meets the needs of nurses in our cohorts.

What clinical or professional practice gaps have you identified among nurses who have different educational backgrounds?
Every nurse is unique and different. However, we have noticed a few trends. For example, BSNs tend to have stronger communication, leadership, and problem solving skills than ADNs. Second degree nurses who are generally older in age may have an advantage in leadership skills but may require extra help with clinical skills. Finally, although MSNs may have an advantage in educational preparation and have good research and leadership skills, they need the same level of clinical orientation and competency validation as our traditional new nurses. A common theme is that newly-licensed nurses need a great deal of clinical time on their assigned units.

With new nurses having such diverse backgrounds, how do you prepare your preceptors to lead unit-based orientation?
Preceptors complete three days of an interactive course that introduces the fundamentals of preceptorship. The course covers information about newly-licensed nurses and experienced nurses and focuses on the diverse characteristics of nurses who are hired at this Mayo campus. We also provide an additional seminar that is designed to help preceptors understand our nurse residency program.

A strong nurse starts with thoughtful training.A strong nurse starts with thoughtful training.

How do you prevent preceptor burnout?
This is a great question! I believe that preceptors have a tough job and are at a high risk for burnout. The support of managers and educators is demonstrated by frequent communication with preceptors as well as new nurses. As a team, we make sure that preceptors are prepared to orient new nurses before assignments are made. Finally, we work with preceptors and new nurses to determine the best match up for unit-based orientation.

What drives quality improvement related to the residency program?
Quality improvement is driven by market changes, our organization's strategic priorities, and feedback from nurse residents, preceptors, executive leaders, and members of the interprofessional team. The Mayo Clinic Enterprise Nurse Residency Program Advisory Board meets quarterly to discuss different programs within the Mayo Clinic System and our outcomes. Our program needs to reflect the current direction of our profession and this organization.

I believe in keeping what works, but I'm not afraid to make changes to the program to achieve organizational goals and to continue to improve patient-care outcomes. Before I took this position two years ago, nurse residents had been meeting every three months for a total of 12 hours in the program. After researching evidence-based practices, I worked with nursing leadership to improve the program. We now offer 43 hours of interactive classes that focus on communication, leadership, the nurse's professional role, and patient outcomes. To improve unit-based orientation, we also added a four-week ECG course during residency because all of our nursing units have monitoring capability.

What is most innovative about Mayo's orientation and residency program?
Recognizing that 80% of errors can be traced to communication breakdowns, we stress communication techniques in every class. Mayo caters to its diverse cohorts through use of various teaching and learning strategies, including simulation of a full patient-care assignment, debriefing, and scenario- and case study-based learning. Other innovative approaches include:

  • Collaboration: Class time is collaborative and is designed to foster collegiality. Medical and nursing providers as well as clinical nurse educators, chaplains, respiratory therapists, and physical therapists participate in the classes to create an interprofessional learning experience. These experiences improve the confidence of new nurses and help them realize their value as members of the interprofessional team.
  • Journaling: Residents are required to journal by answering pre-developed questions on their own and then, they discuss their answers in small groups. This allows them to hear what others are experiencing. The critical point here is that the residents develop a sense of community and realize that they are not alone. I think this is one of the best aspects of the residency program because most new nurses experience similar issues regardless of their geographical, educational or generational backgrounds.
  • Individual case-based presentation: At the end of the program, nurse residents are required to create presentations about their most challenging or interesting patients. I help guide their selection. The presentations center on case-based learning whereby the residents present an analysis of a patient population or problem, propose solutions, evaluate the solutions, and then work to solve the problems.

Why did Mayo decide to develop its own residency program instead of purchasing an established program?
Our program combines general new nurse orientation with unit-based clinical orientation and seminar classes that continue through the first year of employment. It creates a cohesive experience. The nurse residency program was created specifically for Mayo Clinic-Jacksonville to help our diverse cohorts develop the skills they needed to safely manage patient care, improve quality outcomes, and become leaders in direct care. The program also was intended to instill a desire in nurses to commit to lifelong learning and evidence-based practice. Research shows that newly-licensed nurses are at their most vulnerable after being on the job for 6 months. During this timeframe, we use team building exercises and include a seminar on self-care for nurses led by our chaplain.

Support and collaboration help nurses build skills and confidence.Support and collaboration help nurses build skills and confidence.

Can you describe what newly-licensed nurses experience in Mayo's robust orientation and residency program?
After passing the NCLEX licensure exam, nurses are admitted to the nurse residency program. In orientation and residency, classes are aligned with Mayo Clinic's strategic plan. Therefore, we want everyone to go through all of our classes regardless of their educational background. Residents attend one and a half weeks of interactive new nurse orientation, including information about documenting in the electronic health record. Then, residents advance to preceptor-led clinical orientation on their units. Mandatory nurse residency classes also begin at this time. Initially, classes are held weekly and the first month includes an introduction to residency and a basic ECG course. After that, the schedule depends on the nurse's clinical area. Each resident receives hands-on instruction that's associated with the clinical topics that are covered.  As needed, residents are provided with more time in orientation and additional learning opportunities. We don't want anyone to fail.

How do you measure the outcomes of the orientation and residency program?
Nurse residents complete the Casey-Fink Graduate Nurse Experience Survey at the start of the program, at 6 months, and after completing the one-year program. Overall, the feedback received from residents has been positive. They think that the program offers a safe environment because other nurses are traveling the same journey.

What happens after residency?
After the first year of practice, nurse residents transition into their professional role. Often, these new nurses inspire experienced nurses to continue their journey in professional development. Incidentally, we've noticed increased participation in nursing committees from our nurse residents and a strong desire to become preceptors. In particular, we've experienced a boost in professional development: 15% of our nurse residents have become certified and 28% have earned advanced degrees, and 37% of our past residents now serve as preceptors in the residency program.

Acknowledgement: The nurse residency program at the Mayo Clinic in Jacksonville, Florida, was initiated in 2010 by Debra Harrison, DNP, RN, and Kathryn Moreno, MSN, RN. The program continues to be a key priority for executive leadership at the Mayo Clinic.

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