Education Partnerships Enhance Nurses’ Skills, Encourage Retention

by Candi Helseth

After her grandmother became sick, Shelly Deyo decided she wanted to be a nurse working with the elderly. Deyo also wanted to teach and work in management. She has found the perfect job in her current position as director of assisted living at St. Clare Meadows Care Center, a nursing facility licensed for 25 beds in Baraboo, Wis. In addition, Deyo works as a coach and preceptor with the Wisconsin Nurse Residency Program (WNRP), helping new nurses develop the critical thinking skills and knowledge base they need to successfully handle the unique demands of rural nursing.

Shelly Deyo

Shelly Deyo, director of an assisted living facility in Baraboo, Wis., credits the Wisconsin Nurse Residency Program for giving her the skills and knowledge necessary for the unique demands of rural nursing.

Deyo credits WNRP for providing the support she needed to succeed when she was a new nurse graduate. “Being in the nurse residency program gave me a better foundation, more confidence and more knowledge in core nursing areas,” Deyo said.

Wisconsin’s program grew out of the need to improve nurse retention rates; many nurses change jobs or leave the profession within two years of graduating, according to Cella Janisch-Hartline, a nurse consultant with Rural Wisconsin Health Cooperatives (RWHC), which worked in conjunction with Marquette University to develop the federally funded WNRP. Janisch-Hartline pointed out that Deyo’s first job, in a hospital where she often worked alone and was responsible for as many as six patients at a time, wasn’t unique. Janisch-Hartline noted that studies show rural nurses often work alone on a shift and care for a wide variety of patient needs.

“Typically, these nurses were just out of school and had just passed their boards,” Janisch-Hartline said. “This setting places many demands and a lot of stress on new graduates to develop competency in a relatively short period of time. Since we implemented WNRP, retention rates have soared.”

In Oregon, the N2K Nursing Education Program, housed in the Oregon Health Career Center, is a response to critical nursing shortages, particularly in rural areas. The N2K program brings together health care providers and Oregon colleges in a partnership that recruits and trains employees from participating hospitals’ existing work forces. Since it began in 2001, approximately 120 nurses have graduated and returned to their home communities to practice.

At Mountain View Hospital, a 25-bed critical access hospital in Madras, Ore., Will Bean, nursing education and emergency department manager, welcomed four new nurses to the staff in March, all of whom had come through the N2K program. Three formerly worked as Certified Nursing Assistants at the hospital and one was a phlebotomist there.

“I’m confident we’ll still have at least three of the four here 10 years from now because they have deep ties to this community,” Bean said. “We’ve gotten four great nurses that we had a hand in selecting because of their strengths, and we trained them within our own system. If they’d left to go to another nursing school, we’d have had to fill their current position and there’s no guarantee they’d return here. This program is definitely a better alternative for us.”

Nursing shortages and retention problems in rural areas will likely be even greater issues nationwide as the baby boom generation retires and more RNs continue to work outside the rural areas where they live, according to an April 2009 Policy Brief released by the WWAMI Rural Health Research Center (WWAMI). The proposed solutions WWAMI lists in the Policy Brief mirror much of what Wisconsin and Oregon are already doing: support and expand nursing and distance education, encourage students from rural locations to pursue nursing because they are more likely to return to rural areas, and better prepare rural RNs through the use of rural-relevant curricula and opportunities.

N2K: a different type of education

N2K Nursing Program

Nurses Carolyn Dawson (left) and Jessica Draper, who graduated from Oregon’s N2K nursing program in mid-March, prep for surgery at Harney District Hospital in Burns, Ore.

The Oregon Office of Rural Health has been a partner in bringing N2K to the state’s small, rural hospitals. Calling it “our most ambitious project to date,” Oregon Health Career Center CEO Gary Wappes said the Oregon Consortium for Nursing Education partnered with Mount Hood Community College at Gresham to develop a rural cohort separate from already existing nursing programs that were offered through Oregon colleges. Nursing students selected for N2K complete didactic education requirements from home via an on-line educational system and do their clinical training in their home communities and hospitals.

The advantage, Wappes said, is that students continue their jobs in the facility where they are employed, do coursework without having to leave their community, and then do most of their clinical instruction within the facility where they already work. Upon entering N2K, they agree to return to work for their employer for a specified period of time.

Bean said N2K’s OCNE (Oregon Consortium for Nursing Education) component is particularly advantageous for rural nursing because, unlike traditional nursing programs, OCNE starts nurses at a base level working in several different departments.

“That’s similar to what is happening in real working experiences in rural facilities,” he explained. “And as they gain experience, their level of educational challenges gets more intense. But they continue to work in all areas such as pediatrics, orthopedics, acute care, etc. So they get very well-rounded.”

The Office of Rural Health also pursued development funding through Medicare and Medicaid that allows rural hospitals to be reimbursed for a major portion of their costs for N2K. Robert Duehmig, Office of Rural Health communications director, said the funding mechanism reduces strain on rural hospitals’ budgets.

WNRP: sustaining new nurse graduates

Marquette University and RWHC developed WNRP six years ago, with funding from the Health Resources and Services Administration (HRSA), to continue education for new nurse graduates and to retain them long-term. Curriculum includes monthly educational sessions and mentoring by preceptors and clinical coaches that spans at least 15 months of a new nurse graduate’s employment. To date, nearly 400 rural nurses have completed the WNRP or are currently enrolled in the year-long program, and WNRP has trained more than 700 preceptors.

The nurse retention rate in RWHC rural-supported hospitals from 2005-2008 was 88 percent, Janisch-Hartline said. Prior to WNRP’s implementation, some participating hospitals had new graduate turnover rates that exceeded 50 percent.

Nurse replacement costs are reported to be equal to a nurse’s average annual salary, which is $62,140 for Wisconsin nurses according to the Bureau of Labor Statistics (2008). Therefore, if the residency program prevents at least one new graduate nurse from leaving the organization, the program becomes cost neutral, Janisch-Hartline said. The RWHC organizations typically pay the fee for participating nurses in their employment.

WNRP’s success has attracted attention from health care organizations facilities across the country. Marilyn Meyer Bratt, Assistant Professor at Marquette University and Project Director/Primary Investigator of the WNRP, has applied for an additional HRSA grant that will address the unique needs of newly licensed nurses practicing in rural hospitals. Building cultures to retain and advance role competency in rural nurses and coordinate dialogue on a national level to support rural nursing practice are the primary purposes of this proposal. To accomplish this, Bratt intends to develop partnerships with rural-based community and Critical Access Hospitals and health networks in Idaho, Illinois, Pennsylvania and Wisconsin. The grant will enable the delivery of a nurse residency program and other supportive services that are tailored to rural nursing practice.

For Deyo, WNRP has made all the difference. “I encourage everyone I know to go through this program,” Deyo said. “Something like this should be available for nurse graduates in all rural facilities. Being a rural nurse is a specialty in itself.”


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