About the Project
The Internship Project is an endeavor of the Vermont Nurses In Partnership (VNIP), a not-for-profit nurse leadership coalition that institutes resources for supporting the developing nurse. The programs developed by VNIP promote a workplace culture of nurture, support and professional growth for novice nurses or those in transition to a new specialty. VNIP includes nurse leaders from academia, regulation and various practice settings. The collaboration has grown from the initial 45 Vermont-based members, to a coalition of over 300 nurse leaders from across the nation and around the world. These proactive healthcare leaders provide the intellectual resources that allow us to develop and deliver intern, orientee, and preceptor development programs.
Unique aspects of the project include:
- Establishment of a statewide, standardized approach to preceptor development and support
- Preceptor development that is applicable for a broad audience of direct care providers
- An internship model suitable for multiple healthcare agencies instead of a single site or system
- A research and theory based model that is being adapted to community health settings and a variety of disciplines
To create a formal and sustainable nurse internship program that provides the clinical experience necessary to support the novice's entry into practice, their growth along the continuum of expertise, and their professional practice within the complex and demanding field of healthcare.
The Vermont Board of Nursing, Schools of Nursing, and practice sites work in a collaborative, statewide, partnership to maintain a nationally recognized Nurse Internship Program. The internship is available in multiple settings and supports the transition from new graduate nurse to a self confident, adaptable, and independent professional.
Model development and implementation
Roles and responsibilities required to support the model
Bibliography and Resource list
The Vermont Nurse Internship Project (VNIP) is a healthy workplace strategy that has proven its worth. It is a project that was undertaken in response to the looming staffing issues identified in 1999 by the Vermont Organization of Nurse Leaders (VONL). VONL partnered with the Vermont Association of Hospitals and Health Systems (VAHHS) to commission research on nursing workforce issues specific to Vermont. The resulting report, the Vermont Nursing Report became the basis for further collaborative work and then strategic planning relating to the pending workforce crisis. Six (6) strategic goals for dealing with the crisis were identified in VONL - Current State of Nursing in Vermont.
Two of these goals became the focus of the internship project:
- Create a formal nursing internship program that provides adequate practical clinical experience for novice nurses to function at a competent level when they enter the work force. This would force a marriage of schools of nursing and fields of practice that could strengthen both institutions, while promoting the preparation of nurses able to handle the currently complex and demanding field of health care.
- Expand clinical opportunities for students by increasing the use of clinical staff as preceptors in specialty areas.
Grant funding was obtained to support a half time Director’s position to lead development and implementation of the model/project, and the Vermont Nurse Internship Project (VNIP) was established.
At the initial VNIP meeting, it was determined that three (3) levels of internship were needed: 1. Student (extern program) for expanded undergraduate clinical experience. 2. Graduate level (transition to practice) internship – to provide an organized, supportive transition to practice that included educational support, competency development, and skills evaluation. 3. Specialty care internships – to provide the extensive additional education and support for work in a specialty care area such as OR, ICU, Home care, Long term Care, etc. The initial model development targeted the new graduate RN and transition to practice. It was decided that the internship would be based in a precepted delivery model. As a result two programs were developed: one for the interns (new graduates) and another for the development and support of clinical staff preceptors.
Unique aspects of this project include the collaborative workgroup comprised of Nurse Leaders from Practice settings, Academia, and the Board of Nursing and the focus on a model configuration that can be applied statewide and across the continuum of care. The Internship model used Lenburg’s Competency Outcomes Performance Assessment (COPA) model (Lenburg, 1999) for the core outline for the role of the RN and competency-based skills verification. The specific sub skills for each of Lenburg’s Eight Core Practice Competencies were identified with input from all practice areas to establish a competency verification form that outlined the core role of the generalist RN in most, if not all, direct care settings. The initial form was used in the first pilot during the summer of 2000. Based on outcomes data and feedback from the educators and preceptors using the model within the pilot, it was modified then underwent a second pilot during 2001. Thus the model and its components were validated as a standardized model for delivery in multiple settings. It was found to be a model that provides structure for experiential learning that can address the needs of the new graduate, specialty care internships, and/or the clinical component of a re-entry program.
The initial outcomes analysis resulted in recognizing the urgent need for added preparation for preceptors. A preceptor development focus group convened that included the directors of three of the state’s nursing programs. They assisted in shifting this essential preparation into theory and research based education that is delivered via an independent learning module and two (2) days of workshop presentation. This initial education totals 18.6 contact hours of interactive teaching/learning. Thanks to a partnership with grant funded specialty care internships, we have been able to offer this standardized education to direct care providers from all regions and specialties within the state. The preceptor workshops have offered an ideal venue for collecting demographic data on these clinical experts with a focus on identifying those who might be interested in a future teaching role.
The statewide, standardized approach to preceptor development is another unique aspect of this project. It has led into development of a credentialing process for preceptors. This credentialing offers recognition and reward for this key teaching/support role, while establishing a pool of clinical preceptors who have all had the same educational preparation, support, and skills development/evaluation.
The internship has been in place as an active educational process since 2000 and has seen annual growth and expansion. Its impact has expanded through collaboration with various non-Vermont healthcare agencies who request consulting time and model adoption. The project currently has grant funding that will: 1) strengthen the VNIP coalition 2) expand implementation at additional sites/settings 3) develop the model for use in home care and public health settings 4) continue/expand preceptor development and 5) collect data specific to nurse retention in rural and/or medically under served areas. The National Council of State Boards of Nursing (NCSBN) is finalizing plans for a research project that will be done collaboratively with the VNIP to evaluate both program outcomes and differences in clinical practice resulting from the model.
- 2000 Satisfaction Survey – Transition to work - Survey data shows greater than 40% improvement in satisfaction with transition to practice and new grad competency
- For initial pilot, 49% of the Nurse Interns came from out of state residence and/or schools
- Retention data from tertiary care center - Retention of those who completed their Orientation in 1999 was 75%, while the new grads that completed an Internship showed a 93% retention rate for each of the following two years.
- Position Vacancy rate – At one participating agency, the Medical - Surgical unit had suffered an unrelenting vacancy rate of 20%. This agency credits the Internship/Preceptor program with the current vacancy rate of 0% for the entire nursing department. This hospital now has no recruitment or position advertising costs for nursing positions.
The Internship is a formal, post-licensure educational program designed to extend the basic nurse education preparation, proficiency, and/or skills of new graduate and transitioning nurses. Each intern has completed a guided course of nursing education. The Internship curriculum is designed to give experience and repeated practice application to demonstrate successful transition of this learning into the specific clinical practice setting. It includes individual studies, staff development courses, clinical conferences, and one-on-one support and instruction from a preceptor. The purpose of the internship is to advance clinical practice skills needed to deliver safe, comprehensive care in existing and emerging organized health care systems.
The Clinical Educator directs the facility specific internship, provides didactic sessions for the intern, and offers ongoing support and resources for the preceptor/intern team. The Preceptor develops learning goals/objectives in collaboration with the intern and clinical educator, assesses the intern’s experience level and learning style, and plans learning experiences accordingly. He/she is responsible for choosing the patient assignment based on educational goals and objectives and sharing that assignment by progressively assigning patient care responsibilities to the intern. Along with planning, the preceptor provides daily feedback to the intern and collaborates with the clinical educator and nurse manager to evaluate progress and address issues. The intern is responsible for active participation in all components of the Internship and completion of documentation.
An Internship session may include up to 5 preceptor/intern teams starting at the same time and the duration is 10 weeks. There are at least 40 hours devoted to didactic components within the program with required content topics that include, but are not limited to: standards of care, managed care, cultural competence, quality improvement, IV access/therapy, medication administration, and pain management. Interns are not considered as part of the staffing mix and each is paired with a qualified Preceptor. The patients assigned to interns will also be part of their preceptor’s assignment and preceptors progressively allocate patient care activities to the intern. The preceptors act as mentors and role models, leading the intern through his or her daily clinical experiences on the unit. On a weekly basis, the intern, preceptor, and/or clinical educator will meet to establish/evaluate goals and work with Critical Thinking skills .Delivery of the Internship requires release time for support of educational preparation, didactic instruction, goal setting, weekly conference, and support group meetings – approximately 200 hours of educator time for each Internship session.
The Internship provides practice and verification of competencies that are based on the COPA model (Lenburg, 1999). The Internship’s competency verification form delineates specific criteria that address Lenburg’s essential skills of Assessment and Interventions, Communications, Critical Thinking, Human caring/Relationships, Management, Leadership, Teaching, and Knowledge Integration.
Along with investing in transition programs for new graduates, our healthcare systems need to ensure the development and support of preceptors in the clinical setting. Most of today’s transition programs use preceptor-based systems, but not many have consistently invested in the development and support of those preceptors. To be effective, preceptors require an educational foundation, ongoing support, and “time to precept”. A commitment to this teaching time serves the development of both the preceptor and the novice with whom they work.
Our project has identified two groups that require intensive education and support. The first target audience is the preceptor. Teaching, mentoring, interpersonal, and competency assessment skills must be developed in these individuals. A foundation must be laid with comprehensive, theory-based education related to interpersonal communication, roles/responsibilities, principles of teaching/learning, assessment, planning, and feedback skills. The vitally important roles of the preceptor include “protector” and “competency validator”. These roles require specific preparation and support. Once this foundation is laid, the preceptor’s effectiveness should be evaluated on an ongoing basis, within a system that focuses on performance development for both the preceptor and the novices with whom they work. This ensures the necessary structure for skills development and competency assessment that protects the safety of our clients as well as the professional development of our nurses.
The second target audience is the novice nurse. This nurse may be a new graduate, a re-entry candidate, or a nurse that is transitioning into a new specialty area. Each of these novices needs advanced support, instruction, and precepting to develop the reflective learning, critical thinking, and specialty practice skills that are essential to safe, effective nursing care in our multiple and challenging settings.
To deliver this, an effective preceptor/internship program needs to include:
- Clearly identified roles and responsibilities that also delineate where to find the “time for precepting”
- A Clinical Coaching plan that outlines specific goals, activities, and measurable outcomes. This plan must follow principles of teaching/learning, to foster the progression of the novice through all core competency requirements.
- Specific planning for critical thinking development through weekly meetings, case scenarios, documentation tools, discussion and/or problem solving.
- Valid and reliable tools for competency verification that identify specific, measurable criteria for assessment
Investment in these target groups has paid dividends in recruitment, retention, and improved satisfaction for Vermont nurses. We are succeeding in changing the culture of the workplace towards one of support, nurture, learning, and professional advancement.
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