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Nurs Outlook 62 (2014) 174e184
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A description of U.S. post-graduation nurse residency programs James S. Barnett, PhD, RNa,*, Ann F. Minnick, PhD, RN, FAANb, Linda D. Norman, DSN, RN, FAANb a
Jeanette C. Rudy School of Nursing, Cumberland University, Nashville, TN b Vanderbilt University School of Nursing, Nashville, TN
article info
abstract
Article history: Received 23 August 2013 Revised 12 December 2013 Accepted 27 December 2013 Available Online 26 February 2014
Background: Concern regarding newly licensed registered nurses’ abilities to cope
Keywords: Nurse residency program Nurse resident Role transition program
with the increasing complexity of care has led to the development of a variety of nurse residency program (NRP) initiatives. The unknowns are the extent to which and how various program elements are implemented across NRPs. Without understanding the extent to which NRPs deliver the same program, determination of their impact on care is limited. The purpose of this study was to describe U.S. NRPs and thereby identify the extent of treatment fidelity across programs. Methods: Program attributes were measured using a 24-item survey based on the outcomes production conceptual framework. The survey was sent to known NRP directors or chief nursing officers at the 1,011 U.S. hospitals having 250 or more inpatient beds; 203 surveys (a 20% response rate) were returned. Results: Almost half (48%) of hospitals reported operating an NRP. NRP models included University HealthSystems Consortium (22%), facility based (54%), and “other” (24%). Significant ( p < .01) differences were noted among and within program model types in terms of career planning, project requirements and types, and mentoring. Conclusions: The extent of differences within and across program types indicates a lack of treatment fidelity needed to detect objectively the impact of the NRP as a discrete intervention on patient outcomes. NRP expansion may be limited by the number of hospitals of a size most likely able to support such programs. Cite this article: Barnett, J. S., Minnick, A. F., & Norman, L. D. (2014, JUNE). A description of U.S. postgraduation nurse residency programs. Nursing Outlook, 62(3), 174-184. http://dx.doi.org/10.1016/ j.outlook.2013.12.008.
A variety of programs exist to support the transition from student to professional nurse. Examples of these role transition programs include internship models (Eigsti, 2009; Newhouse, Hoffman, Suflita, & Hairston, 2007), mentorship models (Halfer, Graf, & Sullivan, 2008; Hayes & Scott, 2007; Sherrod, Roberts, & Little, 2008; Santucci, 2004; Persaud,
2008), and preceptorship models (Beecroft, McClureHernandez, & Reid, 2008; Olson et al., 2001; Sorenson & Yankech, 2008). Within the last decade, another program type that combines various elements from these models, the Nurse Residency Program (NRP), has emerged (Anderson, Linden, Allen, & Gibbs, 2009; Beyea, von Reyn, & Slattery, 2007; Bratt,
* Corresponding author: James S. Barnett, Cumberland University, Jeanette C Rudy School of Nursing, 1200 Forrest Avenue, Nashville, TN 37206. E-mail address: [email protected] (J.S. Barnett). 0029-6554/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2013.12.008
Nurs Outlook 62 (2014) 174e184
2009; Diefenbeck, Plowfield, & Herrrman, 2006; Krugman et al., 2006).
Literature Review The NRP is gaining the attention of new graduate nurses and hospital leaders (Nursing Executive Center, 2006). New nurse graduates are attracted to these programs because they offer an extensive orientation focusing on skill improvement, professional development, and role transition. Hospital leaders are attracted to these programs because they have the potential to reduce costs related to turnover and to provide a better-prepared workforce. Beginning in 2004, six academic medical centers piloted NRPs based on the collaborative effort of members of the American Association of Colleges of Nursing (AACN) and University HealthSystem Consortium (UHC). These programs are intended to be 1 year in length, to offer monthly residency sessions with expert facilitators, and to be affiliated with one or more local schools of nursing as an academic partner. Monthly course content is supposed to focus on professional role development and select patient outcomes (e.g., fall prevention, medication safety, discharge teaching, pain management, infection control, and skin care management) (University HealthSystem Consortium, 2010). There are now 92 programs using the AACN/UHC model in 30 states (American Association of Colleges of Nursing, 2013). Other NRPs, some resulting from local or state level initiatives and others from facility-based initiatives, have developed their own nurse residency models (Beyea et al., 2007; Bratt, 2009; Diefenbeck et al., 2006; Wandel, 1995). State-based and facility-based programs are mission driven to meet local or statewide needs. The aim for these programs is described as increasing nurse retention. In 2010, the Institutes of Medicine recommended that all new nurse graduates attend an NRP (National Academy of Sciences, 2012); however, some residency program leaders have proposed that there are differences in how NRPs are implemented and the outcomes that are evaluated (D. Ruth, personal communication, October 21, 2008). In 2002, the Joint Commission suggested that any return on investment in nurse transition programs would stem from savings from the avoidance of continuous orientation and from improvements in the safety and quality of nursing care (Joint Commission on Accreditation of Healthcare Organizations, 2002). To date, only human resourcee related (i.e., recruitment, retention, and nurse satisfaction) and professionalism-related (i.e., self-reported autonomy, confidence, and competence) outcomes have been explored as results of NRPs (Altier & Krsek, 2006; Halfer et al., 2008; Pine & Tart, 2007; Williams, Goode, Krsek, Bednash, & Lynn, 2007). The effects of NRPs on patient outcomes have not been described. If NRPs are merely a way to control cost
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associated with nurse recruitment and retention, it is difficult, if not impossible, to justify the projected costs of NRPs. Before the impact on patient outcomes can be ascertained, it is essential to understand if there are differences in and among NRPs. If there were differences, then treating NRP as a single intervention contributing to patient outcomes would be erroneous. If program components vary, the attribution of effects on outcomes may be understated or overstated. Moreover, describing these programs will help determine what investments in NRPs might provide if all graduates are required to complete NRPs. The purpose of this study was to describe selected components of U.S. NRPs.
Conceptual Framework Minnick (2009) described a variable category framework based on von Bertalanffy’s general system theory (von Bertalanffy, 1973). Developed by Minnick and Roberts in 1991, this conceptual framework identified system-specific attributes (e.g., capital, employment requirements, and organizational structures) and offered potential relationships among these attributes as they relate to patient outcomes. Figure 1 depicts the modified, variable restricted version of the framework that was used for this study.
Methods The study’s design was descriptive and cross-sectional. Concepts were operationally defined based on literature reviews, tacit knowledge, and experience. A 24item survey tool was developed based on concepts in the study framework. Figure 1 includes the items’ descriptions by conceptual categories that are reported in this article.
Survey Tool Validity Two independent researchers tested item validity using a card sort method. Each item was assigned to a category within the conceptual framework with greater than 90% agreement. Four NRP experts unrelated to the investigative team participated in a pilot test. The average content validity index among the four expert participants was 0.93, supporting sound content validity of the tool as a method to identify NRP components (Gelinas, Fillion, & Puntillo, 2009; Polit, Beck, & Owen, 2007; Waltz, Strickland, & Lenz, 1991).
Subject Recruitment Institutional review board approval was obtained before recruitment and distribution of any survey materials. Returning a survey served as consent. U.S. hospitals listed in the 2010 American Hospital Association (AHA) Guide (AHA, 2009) and identified as teaching, community, or public health hospitals with more than 250 beds were included as subjects
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Figure 1 e A Conceptual Framework of NRP-related Variables Influencing Patient Outcomes Modified from Minnick (2009). *Concepts described in this article. **To be described in a future article. The following definitions were used: career plan requirements: the process used by nurse residents to identify work and educational opportunities and to set career goals; COTH membership includes major teaching hospitals affiliated with a medical school and who sponsor at least four active medical residency programs; degree requirements includes all entry-level, associate, and baccalaureate registered nurse degrees conferred by accredited schools of nursing; facilitator: the person who assists the program coordinators by leading group discussions during residency sessions; length of programs: the total number of weeks nurse residents were enrolled in the NRP; Magnet status includes those hospitals that have attained AACN Magnet designation; mentor: an RN who is responsible for guiding the new graduate in goal setting and role transition; NRP activities includes educational sessions, NRP events, and reflective journaling; patient care activities: activities performed by the nurse during a typical hospital shift; program coordinator: the person who is responsible for day-to-day activities, leads residency sessions, and manages the NRP; project requirements: any activities having a start and a finish that are completed to accomplish a specific function to an established quality within specified cost and time limits; shared governance represents an organizational structure and professional practice model in which all nurses have a voice in shaping the standards of nursing practice and quality of care within their practice environment; UHC membership includes hospitals that are members of the University HealthSystems Consortium; and unstructured professional activities includes preparation for National Council Licensure Examination for Registered Nurses, reading journal articles, and policy guidelines.
(n ¼ 1,011). Inclusion criteria were based on reports indicating AACN/UHC intern and extern modeled programs were most likely to be located at hospitals with the specified size (Goode & Williams, 2004; Krugman et al., 2006; Wandel, 1995). Prisons and military, psychiatric, and veterans’ hospitals were excluded because these types of facilities have employment policies, missions, and, to some extent, resources that are unavailable to other hospitals. Survey packets included a cover letter describing risks and benefits of participation, confidentiality, and response aggregation; a paper survey; a list of definitions; and a self-addressed stamped envelope. The first mailing to all eligible hospitals’ chief nursing officers or,
if known, the NRP directors occurred in late fall 2011. Two additional packets were mailed 3 weeks apart to allow time for returns. The survey response rate was 19.6% (n ¼ 198). The chief nursing officer completed most surveys (n ¼ 97, 49.2%), NRP directors completed 13 (6.6%), and program coordinators or “other, as assigned” completed the remainder (n ¼ 88, 44.2%). Less than 1% of the data were missing. Missing responses were random; therefore, available case analysis was used.
Hospital Description Survey data were linked with the following hospital characteristics: control, geographic region, bed size, and Council of Teaching Hospital (COTH) membership
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based on the 2010 AHA Guide. Magnet status was defined as the presence on the American Nurses Credentialing Center Magnet-designated hospital list.
Analyses The IBM SPSS Statistics 19.0 (IBM Corporation, 2010) software program was used. Cross-tabulations; chisquare tests of independence, Kruskal-Wallis, and Pearson chi-square; and repeated measures analysis of variance were used to evaluate differences among the program models. A critical alpha level of .01 was used to determine statistically significant differences because of the large number of tests performed. Twelve (13%) surveys were excluded because of cluster required missing values, leaving 83 (87%) surveys in the two-step cluster analysis, which was used to analyze patterns of NRP characteristics and components.
Results Comparison of Respondents and Nonrespondents The characteristics of participating hospitals were compared with those of all sample hospitals (Table 1). There were no statistically significant differences in regional representation, bed size, Magnet designation, or COTH status among respondents compared with the
total population. Only the type of hospital control was statistically significantly different ( p ¼ .002). There were proportionally more government-controlled hospitals in the total population than were represented in the returned sample. For-profit organizations were proportionally underrepresented in the returned sample.
NRP Components Operation and Capacity Almost half (n ¼ 95, 48%) reported operating an NRP. Of these, 21 (22%) reported using the AACN/UHC model. More than half (n ¼ 51, 54%) reported using a facilitybased model type (FBM). State, regional, and unspecified models were coded as “other” because of the small number of each. These “other” models accounted for 24% (n ¼ 23) of the model types reported. Table 2 provides a comparison of the NRP and non-NRP hospitals. Table 3 summarizes the numbers of nurse residents by program type and hospital size.
Employment Terms Nurse Resident Degree Status Seven (7%) programs did not provide residents’ degree status at entry. Eighty-four (88%) programs reported at
Table 1 e Comparison of Selected Characteristics of the Total Group (n [ 1,011) and Respondent Hospitals (n [ 198) Total Group, (%) n Respondents, (%) n Statistic p Value AHA control code Government Not-for-profit For profit AHA regions 1 (CT/ME/MA/NH/RI/VT) 2 (NJ/NY/PA) 3 (DC/DE/KY/MD/NC/VA/WV) 4 (AL/FL/GA/MS/SC/TN) 5 (IL/IN/MI/OH/WS) 6 (IA/KS/MN/MO/NE/ND/SD) 7 (AR/LA/OK) 8 (AZ/CO/ID/MT/NM/UT/WY) 9 (AK/CA/HA/NV/OR/WA) Bed size 250e299 300e399 400e499 >500 AACN Magnet status Designated Not designated COTH member status Yes No
14.0 (141) 74.7 (753) 11.3 (114)
19.2 (38) 75.3 (149) 5.5 (11)
4.2 (42) 16.8 (169) 19.9 (201) 15.7 (158) 7.3 (74) 7.2 (73) 10.5 (106) 5.3 (53) 13.1 (132)
3.5 (7) 14.1 (28) 15.7 (31) 21.2 (42) 10.6 (21) 8.1 (16) 9.1 (18) 5.6 (11) 12.1 (24)
22.5 (227) 33.1 (335) 18.2 (184) 26.2 (265)
21.7 (43) 33.3 (66) 18.2 (36) 26.8 (53)
18.1 (182) 81.9 (826)
23.2 (46) 76.8 (152)
25.2 (255) 74.8 (756)
c2(2) ¼ 11.993
.002
c2(8) [ 12.849
.117
c2(3) ¼ 0.109
.991
c2(1) ¼ 4.463
.035
c2(1) ¼ 1.588
.208
28.8 (57) 71.2 (141)
AACN, American Association of Colleges of Nursing; AHA, American Hospital Association; COTH, Council of Teaching Hospitals. a ¼ .01.
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Table 2 e A Comparison of Characteristics of Hospitals Offering Nurse Residency Programs and Those That Do Not Offer NRP (n ¼ 95) Do Not Offer NRP (n ¼ 103) UHC AACN (n ¼ 21) FBM (n ¼ 51) Other (n ¼ 23) Total AHA control code Government Not-for-profit For profit AHA regions 1 (CT/ME/MA/NH/RI/VT) 2 (NJ/NY/PA) 3 (DC/DE/KY/MD/NC/VA/WV) 4 (AL/FL/GA/MS/SC/TN) 5 (IL/IN/MI/OH/WS) 6 (IA/KS/MN/MO/NE/ND/SD) 7 (AR/LA/OK) 8 (AZ/CO/ID/MT/NM/UT/WY) 9 (AK/CA/HA/NV/OR/WA) Bed size 250e299 300e399 400e499 >500 AACN Magnet status Designated Not designated COTH member status Yes No
6 (28.6) 14 (66.6) 1 (4.8)
6 (11.8) 42 (82.3) 3 (5.9)
3 (13.0) 18 (78.3) 2 (8.7)
15 (15.8) 74 (77.9) 6 (6.3)
23 (22.3) 75 (72.8) 5 (4.9)
(4.8) (19.0) (14.3) (19.0) (14.3) (4.8) (9.5) (9.5) (4.8)
2 (3.9) 6 (11.8) 12 (23.5) 9 (17.6) 4 (7.8) 2 (3.9) 5 (9.8) 2 (3.9) 9 (17.6)
0 1 (4.3) 5 (21.8) 6 (26.1) 1 (4.3) 1 (4.3) 1 (4.3) 3 (13.1) 5 (21.8)
3 (3.2) 11 (11.6) 20 (21.1) 19 (20.0) 8 (8.4) 4 (4.2) 8 (8.4) 7 (7.4) 15 (15.8)
4 (3.9) 17 (16.5) 11 (10.7) 23 (22.3) 13 (12.6) 12 (11.7) 10 (9.7) 4 (3.9) 9 (8.7)
1 (4.8) 4 (19.0) 4 (19.0) 12 (57.1)
9 (17.6) 18 (35.3) 7 (13.7) 17 (33.3)
5 (21.7) 11 (47.8) 4 (17.4) 3 (13.1)
15 (15.8) 33 (34.7) 15 (15.8) 32 (33.7)
28 (27.2) 33 (32.0) 21 (20.4) 21 (20.4)
14 (66.7) 7 (33.3)
15 (29.4) 36 (70.6)
6 (26.1) 17 (73.9)
35 (36.8) 60 (63.2)
17 (16.5) 86 (83.5)
16 (76.2) 5 (23.8)
17 (33.3) 34 (66.7)
3 (13.0) 20 (87.0)
36 (37.9) 59 (62.1)
21 (20.4) 82 (79.6)
1 4 3 4 3 1 2 2 1
AACN, American Association of Colleges of Nursing; COTH, Council of Teaching Hospital; FBM, facility-based model; UHC, University HealthSystems Consortium.
least some residents with a bachelor of science in nursing (BSN), 72 (76%) programs reported at least some residents with an associate degree in nursing (ADN), and 13 (14%) programs reported at least some residents with initial licensure at the masters of science in nursing (MSN) level. Twelve (13%) programs Table 3 e Number of Nurse Residents* by Reported Nurse Residency Program Model Type and Hospital Size Mean (SD) Median Minimum Maximum Reported NRP model UHC/AACN 53.24 (41.66) FBM 26.42 (25.47) Other 25.95 (22.49) Bed size 250e299 17.87 (11.58) 300e399 20.13 (16.61) 400e499 43.27 (28.76) >500 46.74 (41.15) COTH membership Yes 49.74 (40.35) No 21.88 (17.09)
30.00 17.50 19.50
10 5 4
138 117 95
13.00 14.50 28.00 28.00
7 4 14 5
46 91 100 138
28.00 16.00
9 4
138 91
AACN, American Association of Colleges of Nursing; FBM, facility-based model; COTH, Council of Teaching Hospital; NRP, nurse residency program; SD, standard deviation; UHC, University HealthSystems Consortium. * Number reflects most recently completed cohort.
reported residency programs encompassing only BSN graduates. Hospitals were assigned to one of three categories: BSN only, BSN þ MSN, and mixed (ADN þ BSN MSN). There was no statistically significant difference among the three program models (c2[4] ¼ 4.115, p ¼ .391). Respondents reported that 833 (29%) nurse residents were ADNs. Of these, 168 (20%) were in UHC programs, 431 (52%) were in FBM programs, and 234 (28%) were in “other” programs. A majority (n ¼ 1,948, 67%) of nurse residents’ degrees were BSNs; accelerated BSN degrees accounted for 136 (7%) of these. Of the total BSN nurse residents, 739 (38%) were in UHC programs, 771 (40%) were in FBM programs, and 438 (22%) were in “other” programs. Initial licensure at the MSN level residents accounted for 110 (4%) of all degree types. Of the initial licensure MSN residents, 18 (16%) were in UHC programs, 90 (82%) were in FBM programs, and 2 (2%) were in “other” programs. No statistically significant difference in terms of degree mix among the 3 model types was observed.
Length of NRP Among respondents (n ¼ 92), nearly one third reported program lengths less than or equal to 12 weeks (Table 4). The majority (37 [40%]) reported a program length of 52 weeks. Fifteen (16%) reported program lengths less than or equal to 10 weeks, 12 (13%) reported program lengths equal to 12 weeks, and 25 (27%)
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Table 4 e Program Requirements and Labor Inputs by Model Type Labor: Mentorship Mentor (n [%]) Assigned Resident choice No mentor Importance discussed Not part of program Mean no. of MNT per MTR (median) Project Required Not required Career planning Required Optional Not part of NRP Program length Mean (SD) Median IQR 25th percentile IQR 75th percentile
UHC (n ¼ 21) 1 (4.8) 1 (4.8)
FBM (n ¼ 51)
“Other” (n ¼ 22)
Total (n ¼ 94)
16 (31.4) 7 (13.7)
5 (22.7) 7 (31.8)
22 (23.4) 15 (16.0)
9 (42.9) 10 (47.6) 12.2 (7.4)
17 (33.3) 11 (21.6) 2.98 (1.2)
5 (22.7) 5 (22.7) 3.17 (1.0)
31 (33.0) 26 (27.7) 4.71 (1.2)
17 (81.0) 4 (19.0)
13 (25.5) 38 (74.5)
8 (34.8) 15 (65.2)
38 (40.4) 57 (60.6)
9 (42.9) 7 (33.3) 5 (23.8)
11 (22.0) 12 (24.0) 27 (54.0)
4 (18.2) 3 (13.6) 15 (68.2)
24 (25.8) 22 (23.7) 47 (50.5)
49.19 (10.62) 52.00 52.00 52.00
27.17 (21.90) 16.00 12.00 52.00
28.52 (18.94) 18.00 12.00 52.00
32.53 (21.03) 26.00 12.00 52.00
FBM, facility-based model; IQR, interquartile range; MNT, mentee; MTR, mentor; UHC, University HealthSystems Consortium.
reported program lengths between 14 and 50 weeks. Three (3%) reported program lengths greater than 52 weeks. UHC model programs were longer than FBM programs (z ¼ 4.039, p < .001) and “other” programs (z ¼ 3.850, p < .001). No other statistically significant differences in length by program were noted.
Residents’ Time Allocation during NRP Eighty-two (86%) programs provided estimates of residents’ time spent providing direct patient care and participating in NRP-related activities and in unstructured professional-related activities. The estimated percentage of time allocated to direct patient care activities increased from a median of 17.5 the first week to 75.00 at midpoint and 90.00 in the final week. There was no statistically significant difference in the allocation of time among the program types (interaction effect: [F(3.11, 122.88) ¼ 2.597, p ¼ .053]) nor was there a statistically significant main effect of type of program (F[2, 79] ¼ 0.163, p ¼ .850). The overall amount of time allocated to NRP-related activities decreased from a median of 17.50 in week 1 to 10.00 at midpoint and 5.00 in the final week (F[1.63, 128.84] ¼ 10.188, p < .001). There was no statistically significant difference by program type [interaction effect: (F[3.26, 128.84] ¼ .572, p ¼ .649)] nor was there a statistically significant main effect of type of program (F[2, 79] ¼ 1.687, p ¼ .192). The overall amount of time allocated to unstructured professional activities decreased from a median of 15 hours in the first week to 4 in the last week (F[1.55, 122.30] ¼ 20.940, p < .001). There was no statistically significant difference in the time devoted to professional activities over the course of the NRP among the program types [interaction effect: (F[3.10, 122.30] ¼ 1.424, p ¼ .238) nor was there a statistically significant main effect of type of program (F[2, 79] ¼ .252, p ¼ .778).
Requirements to Complete Projects Thirty-eight (40%) programs reported completion of a project as a requirement, with a majority (n ¼ 34) reporting an expectation that the project be completed at or before the end of the program. The existence of a project requirement was not statistically significantly different among the three model types ( p < .001). Post hoc analysis revealed that UHC model programs had a greater proportion of completed projects compared with FBM programs (c2[1] ¼ 18.825, p < .001) and “other” programs (c2[1] ¼ 9.537, p ¼ .002). Differences between FBM programs and “other” programs were not statistically significant (c2[1] ¼ .673, p ¼ .412).
Career Planning Forty-seven (51%) of 93 respondents to this item reported that career planning was not part of the NRP. Twenty-four required a career plan and 22 reported that it was optional. There was no statistically significant difference among the three model types regarding career planning (c2[2] ¼ 8.482, p ¼ .014).
Organizational Facets Magnet Status There was a statistically significant difference in Magnet designation status among the three model types (c2[2] ¼ 10.381, p ¼ .006). A greater proportion of UHC model programs were located in hospitals designated as Magnet compared with FBM programs (c2[1] ¼ 8.583, p ¼ .003) and “other” programs (c2[1] ¼ 7.291, p ¼ .007). There was no statistically significant difference between FBM programs and “other” programs (c2[1] ¼ .086, p ¼ .769).
COTH Status There was a statistically significant difference in terms of COTH designation status among the three program
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models (c2[2] ¼ 19.573, p < .001). A greater proportion of UHC model programs had COTH status compared with FBM programs (c2[1] ¼ 11.005, p ¼ .001) and “other” programs (c2[1] ¼ 17.841, p < .001). There was no statistically significant difference between FBM and “other” programs in terms of COTH designation (c2[1] ¼ 3.309, p ¼ .069).
Shared Governance Status Eighty-one (86%) of NRPs reported the presence of a shared governance model. There was no statistically significant difference in the presence of a shared governance model among the three program model types (c2[2] ¼ 1.944, p ¼ .378).
Association of Organizational Facets Magnet designation status was statistically significantly associated with COTH status (F ¼ .356, p < .001) and the presence of a shared governance model (F ¼ .268, p ¼ .009). COTH status and shared governance were not significantly associated (F ¼ .054, p ¼ .603). Within UHC programs, Magnet designation status was statistically significantly associated with COTH status (F ¼ .645, p ¼ .002) but not with the presence of a shared governance model (F ¼ .254, p ¼ .281). Within the “other” model types, there were no significant associations noted (Magnet with COTH status [F ¼ .503, p ¼ .014], Magnet with shared governance status [F ¼ .178, p ¼ .417]). Within the FBM programs, the patterns of associations were not statistically significant (F ¼ .031, p ¼ .829; F ¼ .285, p ¼ .043, respectively).
Labor Inputs There was a median of one program coordinator (PC), two residency facilitators (RFs), and six and a half mentors among all reporting programs. Nineteen programs (19.4%) reported using only one labor type (RFs ¼ 2 [2%], PCs ¼ 14 [14.3%], mentor ¼ 3 [3.1%]). Thirty programs (30.6%) reported a combination of at least one RF, one PC, and one mentor. Twenty-six programs (26.5%) reported at least one RF and one PC but no mentors. The remainder varied in composition.
statistically significant differences in the proportion of PCs per model or PC degree status among the model types.
RFs Thirty-four (36%) participants reported no RFs. Ten (11%) reported at least one RF. Seven (7%) reported at least two RFs, and 43 (46%) reported at least three or more RFs. In all, 429 RFs were reported. There were no statistically significant differences in RF degree status among the three model types.
Cluster Analysis Three distinct groups were identified. The first group included 27 (33%) programs. The second and third groups numbered 28 (34%) NRPs each. Table 5 provides the labeled attributes of categoric and continuous variables that were used in the analyses as well as the distribution of these attributes by cluster. Each NRP type was represented in each of the clusters (Table 5).
Cluster 1 All hospitals identified in cluster 1 had AACN Magnet designation. A majority had 400 or more beds, and most were not-for-profit organizations. Programs typically lasted 12 months and enrolled the highest volume of nurse residents. If mentors were used, they were assigned to the nurse resident. These programs may or may not have had project completion requirements, and most did not require the completion of an individual, formalized career plan.
Cluster 2 Hospitals identified in cluster 2 were not Magnet designated. A majority had less than 400 beds. Most were not-for-profit with a lesser mix of for-profit. Programs at these organizations typically lasted 3 months and enrolled a moderate volume of nurse residents. Most of these programs had no project or career planning requirements, but in contrast to other clusters, mentorship was provided at 32%.
Cluster 3
The mentee/mentor ratio (M ¼ 4.7, standard deviation ¼ 1.2) was calculated by dividing the number of mentees by the number of mentors for respondents. Almost two thirds (60.7%) of all respondents reported not using mentors (Table 4). There was no statistically significant difference in the use of mentors among all program model types (c2[6] ¼ 15.010, p ¼ .020).
Some hospitals identified in cluster 3 had AACN Magnet designation, but most did not. The majority had less than 300 beds, and most were not-for-profit with a lesser mix of government institutions. Programs at these organizations typically lasted 6 months and enrolled the lowest volume of nurse residents. More often than not, these programs required both a project and a career plan to be completed at or before the program’s end.
PCs
Conceptual Framework Variables and Clusters
Ten (11%) NRPs reported that no PCs were used. Sixtynine (73%) reported one PC. Eight (8%) reported two PCs, and seven (8%) reported three or more PCs. In all, 131 PCs were reported. A majority (n ¼ 81, 62%) held MSNs, and 46 (35%) held BSNs. There were no
There were no statistically significant differences in programs’ model type or academic degree characteristics or in assigned PC and RF activities by cluster. There was a statistically significant difference in
Mentors
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Table 5 e Comparison of Program Attributes by Cluster Program Attribute Present Magnet status Shared governance model Mentorship Career plan Required Optional Not required Project completion Required by NRP end Required, okay after NRP end Not required Control code Government Not-for-profit For profit Bed size 250e99 300e399 400e499 500 Length of NRP Median (in weeks) Minimum/maximum Number completing NRP Median Minimum/maximum
Cluster 1, n (%)
Cluster 2, n (%)
Cluster 3, n (%)
c2
df
p Value
27 (100) 27 (100) 6 (22.2)
0 23 (82.1) 9 (32.1)
4 (14.3) 23 (82.1) 20 (71.4)
68.348 5.482 15.389
2 2 2
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A description of U.S. post-graduation nurse residency programs James S. Barnett, PhD, RNa,*, Ann F. Minnick, PhD, RN, FAANb, Linda D. Norman, DSN, RN, FAANb a
Jeanette C. Rudy School of Nursing, Cumberland University, Nashville, TN b Vanderbilt University School of Nursing, Nashville, TN
article info
abstract
Article history: Received 23 August 2013 Revised 12 December 2013 Accepted 27 December 2013 Available Online 26 February 2014
Background: Concern regarding newly licensed registered nurses’ abilities to cope
Keywords: Nurse residency program Nurse resident Role transition program
with the increasing complexity of care has led to the development of a variety of nurse residency program (NRP) initiatives. The unknowns are the extent to which and how various program elements are implemented across NRPs. Without understanding the extent to which NRPs deliver the same program, determination of their impact on care is limited. The purpose of this study was to describe U.S. NRPs and thereby identify the extent of treatment fidelity across programs. Methods: Program attributes were measured using a 24-item survey based on the outcomes production conceptual framework. The survey was sent to known NRP directors or chief nursing officers at the 1,011 U.S. hospitals having 250 or more inpatient beds; 203 surveys (a 20% response rate) were returned. Results: Almost half (48%) of hospitals reported operating an NRP. NRP models included University HealthSystems Consortium (22%), facility based (54%), and “other” (24%). Significant ( p < .01) differences were noted among and within program model types in terms of career planning, project requirements and types, and mentoring. Conclusions: The extent of differences within and across program types indicates a lack of treatment fidelity needed to detect objectively the impact of the NRP as a discrete intervention on patient outcomes. NRP expansion may be limited by the number of hospitals of a size most likely able to support such programs. Cite this article: Barnett, J. S., Minnick, A. F., & Norman, L. D. (2014, JUNE). A description of U.S. postgraduation nurse residency programs. Nursing Outlook, 62(3), 174-184. http://dx.doi.org/10.1016/ j.outlook.2013.12.008.
A variety of programs exist to support the transition from student to professional nurse. Examples of these role transition programs include internship models (Eigsti, 2009; Newhouse, Hoffman, Suflita, & Hairston, 2007), mentorship models (Halfer, Graf, & Sullivan, 2008; Hayes & Scott, 2007; Sherrod, Roberts, & Little, 2008; Santucci, 2004; Persaud,
2008), and preceptorship models (Beecroft, McClureHernandez, & Reid, 2008; Olson et al., 2001; Sorenson & Yankech, 2008). Within the last decade, another program type that combines various elements from these models, the Nurse Residency Program (NRP), has emerged (Anderson, Linden, Allen, & Gibbs, 2009; Beyea, von Reyn, & Slattery, 2007; Bratt,
* Corresponding author: James S. Barnett, Cumberland University, Jeanette C Rudy School of Nursing, 1200 Forrest Avenue, Nashville, TN 37206. E-mail address: [email protected] (J.S. Barnett). 0029-6554/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2013.12.008
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2009; Diefenbeck, Plowfield, & Herrrman, 2006; Krugman et al., 2006).
Literature Review The NRP is gaining the attention of new graduate nurses and hospital leaders (Nursing Executive Center, 2006). New nurse graduates are attracted to these programs because they offer an extensive orientation focusing on skill improvement, professional development, and role transition. Hospital leaders are attracted to these programs because they have the potential to reduce costs related to turnover and to provide a better-prepared workforce. Beginning in 2004, six academic medical centers piloted NRPs based on the collaborative effort of members of the American Association of Colleges of Nursing (AACN) and University HealthSystem Consortium (UHC). These programs are intended to be 1 year in length, to offer monthly residency sessions with expert facilitators, and to be affiliated with one or more local schools of nursing as an academic partner. Monthly course content is supposed to focus on professional role development and select patient outcomes (e.g., fall prevention, medication safety, discharge teaching, pain management, infection control, and skin care management) (University HealthSystem Consortium, 2010). There are now 92 programs using the AACN/UHC model in 30 states (American Association of Colleges of Nursing, 2013). Other NRPs, some resulting from local or state level initiatives and others from facility-based initiatives, have developed their own nurse residency models (Beyea et al., 2007; Bratt, 2009; Diefenbeck et al., 2006; Wandel, 1995). State-based and facility-based programs are mission driven to meet local or statewide needs. The aim for these programs is described as increasing nurse retention. In 2010, the Institutes of Medicine recommended that all new nurse graduates attend an NRP (National Academy of Sciences, 2012); however, some residency program leaders have proposed that there are differences in how NRPs are implemented and the outcomes that are evaluated (D. Ruth, personal communication, October 21, 2008). In 2002, the Joint Commission suggested that any return on investment in nurse transition programs would stem from savings from the avoidance of continuous orientation and from improvements in the safety and quality of nursing care (Joint Commission on Accreditation of Healthcare Organizations, 2002). To date, only human resourcee related (i.e., recruitment, retention, and nurse satisfaction) and professionalism-related (i.e., self-reported autonomy, confidence, and competence) outcomes have been explored as results of NRPs (Altier & Krsek, 2006; Halfer et al., 2008; Pine & Tart, 2007; Williams, Goode, Krsek, Bednash, & Lynn, 2007). The effects of NRPs on patient outcomes have not been described. If NRPs are merely a way to control cost
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associated with nurse recruitment and retention, it is difficult, if not impossible, to justify the projected costs of NRPs. Before the impact on patient outcomes can be ascertained, it is essential to understand if there are differences in and among NRPs. If there were differences, then treating NRP as a single intervention contributing to patient outcomes would be erroneous. If program components vary, the attribution of effects on outcomes may be understated or overstated. Moreover, describing these programs will help determine what investments in NRPs might provide if all graduates are required to complete NRPs. The purpose of this study was to describe selected components of U.S. NRPs.
Conceptual Framework Minnick (2009) described a variable category framework based on von Bertalanffy’s general system theory (von Bertalanffy, 1973). Developed by Minnick and Roberts in 1991, this conceptual framework identified system-specific attributes (e.g., capital, employment requirements, and organizational structures) and offered potential relationships among these attributes as they relate to patient outcomes. Figure 1 depicts the modified, variable restricted version of the framework that was used for this study.
Methods The study’s design was descriptive and cross-sectional. Concepts were operationally defined based on literature reviews, tacit knowledge, and experience. A 24item survey tool was developed based on concepts in the study framework. Figure 1 includes the items’ descriptions by conceptual categories that are reported in this article.
Survey Tool Validity Two independent researchers tested item validity using a card sort method. Each item was assigned to a category within the conceptual framework with greater than 90% agreement. Four NRP experts unrelated to the investigative team participated in a pilot test. The average content validity index among the four expert participants was 0.93, supporting sound content validity of the tool as a method to identify NRP components (Gelinas, Fillion, & Puntillo, 2009; Polit, Beck, & Owen, 2007; Waltz, Strickland, & Lenz, 1991).
Subject Recruitment Institutional review board approval was obtained before recruitment and distribution of any survey materials. Returning a survey served as consent. U.S. hospitals listed in the 2010 American Hospital Association (AHA) Guide (AHA, 2009) and identified as teaching, community, or public health hospitals with more than 250 beds were included as subjects
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Figure 1 e A Conceptual Framework of NRP-related Variables Influencing Patient Outcomes Modified from Minnick (2009). *Concepts described in this article. **To be described in a future article. The following definitions were used: career plan requirements: the process used by nurse residents to identify work and educational opportunities and to set career goals; COTH membership includes major teaching hospitals affiliated with a medical school and who sponsor at least four active medical residency programs; degree requirements includes all entry-level, associate, and baccalaureate registered nurse degrees conferred by accredited schools of nursing; facilitator: the person who assists the program coordinators by leading group discussions during residency sessions; length of programs: the total number of weeks nurse residents were enrolled in the NRP; Magnet status includes those hospitals that have attained AACN Magnet designation; mentor: an RN who is responsible for guiding the new graduate in goal setting and role transition; NRP activities includes educational sessions, NRP events, and reflective journaling; patient care activities: activities performed by the nurse during a typical hospital shift; program coordinator: the person who is responsible for day-to-day activities, leads residency sessions, and manages the NRP; project requirements: any activities having a start and a finish that are completed to accomplish a specific function to an established quality within specified cost and time limits; shared governance represents an organizational structure and professional practice model in which all nurses have a voice in shaping the standards of nursing practice and quality of care within their practice environment; UHC membership includes hospitals that are members of the University HealthSystems Consortium; and unstructured professional activities includes preparation for National Council Licensure Examination for Registered Nurses, reading journal articles, and policy guidelines.
(n ¼ 1,011). Inclusion criteria were based on reports indicating AACN/UHC intern and extern modeled programs were most likely to be located at hospitals with the specified size (Goode & Williams, 2004; Krugman et al., 2006; Wandel, 1995). Prisons and military, psychiatric, and veterans’ hospitals were excluded because these types of facilities have employment policies, missions, and, to some extent, resources that are unavailable to other hospitals. Survey packets included a cover letter describing risks and benefits of participation, confidentiality, and response aggregation; a paper survey; a list of definitions; and a self-addressed stamped envelope. The first mailing to all eligible hospitals’ chief nursing officers or,
if known, the NRP directors occurred in late fall 2011. Two additional packets were mailed 3 weeks apart to allow time for returns. The survey response rate was 19.6% (n ¼ 198). The chief nursing officer completed most surveys (n ¼ 97, 49.2%), NRP directors completed 13 (6.6%), and program coordinators or “other, as assigned” completed the remainder (n ¼ 88, 44.2%). Less than 1% of the data were missing. Missing responses were random; therefore, available case analysis was used.
Hospital Description Survey data were linked with the following hospital characteristics: control, geographic region, bed size, and Council of Teaching Hospital (COTH) membership
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based on the 2010 AHA Guide. Magnet status was defined as the presence on the American Nurses Credentialing Center Magnet-designated hospital list.
Analyses The IBM SPSS Statistics 19.0 (IBM Corporation, 2010) software program was used. Cross-tabulations; chisquare tests of independence, Kruskal-Wallis, and Pearson chi-square; and repeated measures analysis of variance were used to evaluate differences among the program models. A critical alpha level of .01 was used to determine statistically significant differences because of the large number of tests performed. Twelve (13%) surveys were excluded because of cluster required missing values, leaving 83 (87%) surveys in the two-step cluster analysis, which was used to analyze patterns of NRP characteristics and components.
Results Comparison of Respondents and Nonrespondents The characteristics of participating hospitals were compared with those of all sample hospitals (Table 1). There were no statistically significant differences in regional representation, bed size, Magnet designation, or COTH status among respondents compared with the
total population. Only the type of hospital control was statistically significantly different ( p ¼ .002). There were proportionally more government-controlled hospitals in the total population than were represented in the returned sample. For-profit organizations were proportionally underrepresented in the returned sample.
NRP Components Operation and Capacity Almost half (n ¼ 95, 48%) reported operating an NRP. Of these, 21 (22%) reported using the AACN/UHC model. More than half (n ¼ 51, 54%) reported using a facilitybased model type (FBM). State, regional, and unspecified models were coded as “other” because of the small number of each. These “other” models accounted for 24% (n ¼ 23) of the model types reported. Table 2 provides a comparison of the NRP and non-NRP hospitals. Table 3 summarizes the numbers of nurse residents by program type and hospital size.
Employment Terms Nurse Resident Degree Status Seven (7%) programs did not provide residents’ degree status at entry. Eighty-four (88%) programs reported at
Table 1 e Comparison of Selected Characteristics of the Total Group (n [ 1,011) and Respondent Hospitals (n [ 198) Total Group, (%) n Respondents, (%) n Statistic p Value AHA control code Government Not-for-profit For profit AHA regions 1 (CT/ME/MA/NH/RI/VT) 2 (NJ/NY/PA) 3 (DC/DE/KY/MD/NC/VA/WV) 4 (AL/FL/GA/MS/SC/TN) 5 (IL/IN/MI/OH/WS) 6 (IA/KS/MN/MO/NE/ND/SD) 7 (AR/LA/OK) 8 (AZ/CO/ID/MT/NM/UT/WY) 9 (AK/CA/HA/NV/OR/WA) Bed size 250e299 300e399 400e499 >500 AACN Magnet status Designated Not designated COTH member status Yes No
14.0 (141) 74.7 (753) 11.3 (114)
19.2 (38) 75.3 (149) 5.5 (11)
4.2 (42) 16.8 (169) 19.9 (201) 15.7 (158) 7.3 (74) 7.2 (73) 10.5 (106) 5.3 (53) 13.1 (132)
3.5 (7) 14.1 (28) 15.7 (31) 21.2 (42) 10.6 (21) 8.1 (16) 9.1 (18) 5.6 (11) 12.1 (24)
22.5 (227) 33.1 (335) 18.2 (184) 26.2 (265)
21.7 (43) 33.3 (66) 18.2 (36) 26.8 (53)
18.1 (182) 81.9 (826)
23.2 (46) 76.8 (152)
25.2 (255) 74.8 (756)
c2(2) ¼ 11.993
.002
c2(8) [ 12.849
.117
c2(3) ¼ 0.109
.991
c2(1) ¼ 4.463
.035
c2(1) ¼ 1.588
.208
28.8 (57) 71.2 (141)
AACN, American Association of Colleges of Nursing; AHA, American Hospital Association; COTH, Council of Teaching Hospitals. a ¼ .01.
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Table 2 e A Comparison of Characteristics of Hospitals Offering Nurse Residency Programs and Those That Do Not Offer NRP (n ¼ 95) Do Not Offer NRP (n ¼ 103) UHC AACN (n ¼ 21) FBM (n ¼ 51) Other (n ¼ 23) Total AHA control code Government Not-for-profit For profit AHA regions 1 (CT/ME/MA/NH/RI/VT) 2 (NJ/NY/PA) 3 (DC/DE/KY/MD/NC/VA/WV) 4 (AL/FL/GA/MS/SC/TN) 5 (IL/IN/MI/OH/WS) 6 (IA/KS/MN/MO/NE/ND/SD) 7 (AR/LA/OK) 8 (AZ/CO/ID/MT/NM/UT/WY) 9 (AK/CA/HA/NV/OR/WA) Bed size 250e299 300e399 400e499 >500 AACN Magnet status Designated Not designated COTH member status Yes No
6 (28.6) 14 (66.6) 1 (4.8)
6 (11.8) 42 (82.3) 3 (5.9)
3 (13.0) 18 (78.3) 2 (8.7)
15 (15.8) 74 (77.9) 6 (6.3)
23 (22.3) 75 (72.8) 5 (4.9)
(4.8) (19.0) (14.3) (19.0) (14.3) (4.8) (9.5) (9.5) (4.8)
2 (3.9) 6 (11.8) 12 (23.5) 9 (17.6) 4 (7.8) 2 (3.9) 5 (9.8) 2 (3.9) 9 (17.6)
0 1 (4.3) 5 (21.8) 6 (26.1) 1 (4.3) 1 (4.3) 1 (4.3) 3 (13.1) 5 (21.8)
3 (3.2) 11 (11.6) 20 (21.1) 19 (20.0) 8 (8.4) 4 (4.2) 8 (8.4) 7 (7.4) 15 (15.8)
4 (3.9) 17 (16.5) 11 (10.7) 23 (22.3) 13 (12.6) 12 (11.7) 10 (9.7) 4 (3.9) 9 (8.7)
1 (4.8) 4 (19.0) 4 (19.0) 12 (57.1)
9 (17.6) 18 (35.3) 7 (13.7) 17 (33.3)
5 (21.7) 11 (47.8) 4 (17.4) 3 (13.1)
15 (15.8) 33 (34.7) 15 (15.8) 32 (33.7)
28 (27.2) 33 (32.0) 21 (20.4) 21 (20.4)
14 (66.7) 7 (33.3)
15 (29.4) 36 (70.6)
6 (26.1) 17 (73.9)
35 (36.8) 60 (63.2)
17 (16.5) 86 (83.5)
16 (76.2) 5 (23.8)
17 (33.3) 34 (66.7)
3 (13.0) 20 (87.0)
36 (37.9) 59 (62.1)
21 (20.4) 82 (79.6)
1 4 3 4 3 1 2 2 1
AACN, American Association of Colleges of Nursing; COTH, Council of Teaching Hospital; FBM, facility-based model; UHC, University HealthSystems Consortium.
least some residents with a bachelor of science in nursing (BSN), 72 (76%) programs reported at least some residents with an associate degree in nursing (ADN), and 13 (14%) programs reported at least some residents with initial licensure at the masters of science in nursing (MSN) level. Twelve (13%) programs Table 3 e Number of Nurse Residents* by Reported Nurse Residency Program Model Type and Hospital Size Mean (SD) Median Minimum Maximum Reported NRP model UHC/AACN 53.24 (41.66) FBM 26.42 (25.47) Other 25.95 (22.49) Bed size 250e299 17.87 (11.58) 300e399 20.13 (16.61) 400e499 43.27 (28.76) >500 46.74 (41.15) COTH membership Yes 49.74 (40.35) No 21.88 (17.09)
30.00 17.50 19.50
10 5 4
138 117 95
13.00 14.50 28.00 28.00
7 4 14 5
46 91 100 138
28.00 16.00
9 4
138 91
AACN, American Association of Colleges of Nursing; FBM, facility-based model; COTH, Council of Teaching Hospital; NRP, nurse residency program; SD, standard deviation; UHC, University HealthSystems Consortium. * Number reflects most recently completed cohort.
reported residency programs encompassing only BSN graduates. Hospitals were assigned to one of three categories: BSN only, BSN þ MSN, and mixed (ADN þ BSN MSN). There was no statistically significant difference among the three program models (c2[4] ¼ 4.115, p ¼ .391). Respondents reported that 833 (29%) nurse residents were ADNs. Of these, 168 (20%) were in UHC programs, 431 (52%) were in FBM programs, and 234 (28%) were in “other” programs. A majority (n ¼ 1,948, 67%) of nurse residents’ degrees were BSNs; accelerated BSN degrees accounted for 136 (7%) of these. Of the total BSN nurse residents, 739 (38%) were in UHC programs, 771 (40%) were in FBM programs, and 438 (22%) were in “other” programs. Initial licensure at the MSN level residents accounted for 110 (4%) of all degree types. Of the initial licensure MSN residents, 18 (16%) were in UHC programs, 90 (82%) were in FBM programs, and 2 (2%) were in “other” programs. No statistically significant difference in terms of degree mix among the 3 model types was observed.
Length of NRP Among respondents (n ¼ 92), nearly one third reported program lengths less than or equal to 12 weeks (Table 4). The majority (37 [40%]) reported a program length of 52 weeks. Fifteen (16%) reported program lengths less than or equal to 10 weeks, 12 (13%) reported program lengths equal to 12 weeks, and 25 (27%)
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Table 4 e Program Requirements and Labor Inputs by Model Type Labor: Mentorship Mentor (n [%]) Assigned Resident choice No mentor Importance discussed Not part of program Mean no. of MNT per MTR (median) Project Required Not required Career planning Required Optional Not part of NRP Program length Mean (SD) Median IQR 25th percentile IQR 75th percentile
UHC (n ¼ 21) 1 (4.8) 1 (4.8)
FBM (n ¼ 51)
“Other” (n ¼ 22)
Total (n ¼ 94)
16 (31.4) 7 (13.7)
5 (22.7) 7 (31.8)
22 (23.4) 15 (16.0)
9 (42.9) 10 (47.6) 12.2 (7.4)
17 (33.3) 11 (21.6) 2.98 (1.2)
5 (22.7) 5 (22.7) 3.17 (1.0)
31 (33.0) 26 (27.7) 4.71 (1.2)
17 (81.0) 4 (19.0)
13 (25.5) 38 (74.5)
8 (34.8) 15 (65.2)
38 (40.4) 57 (60.6)
9 (42.9) 7 (33.3) 5 (23.8)
11 (22.0) 12 (24.0) 27 (54.0)
4 (18.2) 3 (13.6) 15 (68.2)
24 (25.8) 22 (23.7) 47 (50.5)
49.19 (10.62) 52.00 52.00 52.00
27.17 (21.90) 16.00 12.00 52.00
28.52 (18.94) 18.00 12.00 52.00
32.53 (21.03) 26.00 12.00 52.00
FBM, facility-based model; IQR, interquartile range; MNT, mentee; MTR, mentor; UHC, University HealthSystems Consortium.
reported program lengths between 14 and 50 weeks. Three (3%) reported program lengths greater than 52 weeks. UHC model programs were longer than FBM programs (z ¼ 4.039, p < .001) and “other” programs (z ¼ 3.850, p < .001). No other statistically significant differences in length by program were noted.
Residents’ Time Allocation during NRP Eighty-two (86%) programs provided estimates of residents’ time spent providing direct patient care and participating in NRP-related activities and in unstructured professional-related activities. The estimated percentage of time allocated to direct patient care activities increased from a median of 17.5 the first week to 75.00 at midpoint and 90.00 in the final week. There was no statistically significant difference in the allocation of time among the program types (interaction effect: [F(3.11, 122.88) ¼ 2.597, p ¼ .053]) nor was there a statistically significant main effect of type of program (F[2, 79] ¼ 0.163, p ¼ .850). The overall amount of time allocated to NRP-related activities decreased from a median of 17.50 in week 1 to 10.00 at midpoint and 5.00 in the final week (F[1.63, 128.84] ¼ 10.188, p < .001). There was no statistically significant difference by program type [interaction effect: (F[3.26, 128.84] ¼ .572, p ¼ .649)] nor was there a statistically significant main effect of type of program (F[2, 79] ¼ 1.687, p ¼ .192). The overall amount of time allocated to unstructured professional activities decreased from a median of 15 hours in the first week to 4 in the last week (F[1.55, 122.30] ¼ 20.940, p < .001). There was no statistically significant difference in the time devoted to professional activities over the course of the NRP among the program types [interaction effect: (F[3.10, 122.30] ¼ 1.424, p ¼ .238) nor was there a statistically significant main effect of type of program (F[2, 79] ¼ .252, p ¼ .778).
Requirements to Complete Projects Thirty-eight (40%) programs reported completion of a project as a requirement, with a majority (n ¼ 34) reporting an expectation that the project be completed at or before the end of the program. The existence of a project requirement was not statistically significantly different among the three model types ( p < .001). Post hoc analysis revealed that UHC model programs had a greater proportion of completed projects compared with FBM programs (c2[1] ¼ 18.825, p < .001) and “other” programs (c2[1] ¼ 9.537, p ¼ .002). Differences between FBM programs and “other” programs were not statistically significant (c2[1] ¼ .673, p ¼ .412).
Career Planning Forty-seven (51%) of 93 respondents to this item reported that career planning was not part of the NRP. Twenty-four required a career plan and 22 reported that it was optional. There was no statistically significant difference among the three model types regarding career planning (c2[2] ¼ 8.482, p ¼ .014).
Organizational Facets Magnet Status There was a statistically significant difference in Magnet designation status among the three model types (c2[2] ¼ 10.381, p ¼ .006). A greater proportion of UHC model programs were located in hospitals designated as Magnet compared with FBM programs (c2[1] ¼ 8.583, p ¼ .003) and “other” programs (c2[1] ¼ 7.291, p ¼ .007). There was no statistically significant difference between FBM programs and “other” programs (c2[1] ¼ .086, p ¼ .769).
COTH Status There was a statistically significant difference in terms of COTH designation status among the three program
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models (c2[2] ¼ 19.573, p < .001). A greater proportion of UHC model programs had COTH status compared with FBM programs (c2[1] ¼ 11.005, p ¼ .001) and “other” programs (c2[1] ¼ 17.841, p < .001). There was no statistically significant difference between FBM and “other” programs in terms of COTH designation (c2[1] ¼ 3.309, p ¼ .069).
Shared Governance Status Eighty-one (86%) of NRPs reported the presence of a shared governance model. There was no statistically significant difference in the presence of a shared governance model among the three program model types (c2[2] ¼ 1.944, p ¼ .378).
Association of Organizational Facets Magnet designation status was statistically significantly associated with COTH status (F ¼ .356, p < .001) and the presence of a shared governance model (F ¼ .268, p ¼ .009). COTH status and shared governance were not significantly associated (F ¼ .054, p ¼ .603). Within UHC programs, Magnet designation status was statistically significantly associated with COTH status (F ¼ .645, p ¼ .002) but not with the presence of a shared governance model (F ¼ .254, p ¼ .281). Within the “other” model types, there were no significant associations noted (Magnet with COTH status [F ¼ .503, p ¼ .014], Magnet with shared governance status [F ¼ .178, p ¼ .417]). Within the FBM programs, the patterns of associations were not statistically significant (F ¼ .031, p ¼ .829; F ¼ .285, p ¼ .043, respectively).
Labor Inputs There was a median of one program coordinator (PC), two residency facilitators (RFs), and six and a half mentors among all reporting programs. Nineteen programs (19.4%) reported using only one labor type (RFs ¼ 2 [2%], PCs ¼ 14 [14.3%], mentor ¼ 3 [3.1%]). Thirty programs (30.6%) reported a combination of at least one RF, one PC, and one mentor. Twenty-six programs (26.5%) reported at least one RF and one PC but no mentors. The remainder varied in composition.
statistically significant differences in the proportion of PCs per model or PC degree status among the model types.
RFs Thirty-four (36%) participants reported no RFs. Ten (11%) reported at least one RF. Seven (7%) reported at least two RFs, and 43 (46%) reported at least three or more RFs. In all, 429 RFs were reported. There were no statistically significant differences in RF degree status among the three model types.
Cluster Analysis Three distinct groups were identified. The first group included 27 (33%) programs. The second and third groups numbered 28 (34%) NRPs each. Table 5 provides the labeled attributes of categoric and continuous variables that were used in the analyses as well as the distribution of these attributes by cluster. Each NRP type was represented in each of the clusters (Table 5).
Cluster 1 All hospitals identified in cluster 1 had AACN Magnet designation. A majority had 400 or more beds, and most were not-for-profit organizations. Programs typically lasted 12 months and enrolled the highest volume of nurse residents. If mentors were used, they were assigned to the nurse resident. These programs may or may not have had project completion requirements, and most did not require the completion of an individual, formalized career plan.
Cluster 2 Hospitals identified in cluster 2 were not Magnet designated. A majority had less than 400 beds. Most were not-for-profit with a lesser mix of for-profit. Programs at these organizations typically lasted 3 months and enrolled a moderate volume of nurse residents. Most of these programs had no project or career planning requirements, but in contrast to other clusters, mentorship was provided at 32%.
Cluster 3
The mentee/mentor ratio (M ¼ 4.7, standard deviation ¼ 1.2) was calculated by dividing the number of mentees by the number of mentors for respondents. Almost two thirds (60.7%) of all respondents reported not using mentors (Table 4). There was no statistically significant difference in the use of mentors among all program model types (c2[6] ¼ 15.010, p ¼ .020).
Some hospitals identified in cluster 3 had AACN Magnet designation, but most did not. The majority had less than 300 beds, and most were not-for-profit with a lesser mix of government institutions. Programs at these organizations typically lasted 6 months and enrolled the lowest volume of nurse residents. More often than not, these programs required both a project and a career plan to be completed at or before the program’s end.
PCs
Conceptual Framework Variables and Clusters
Ten (11%) NRPs reported that no PCs were used. Sixtynine (73%) reported one PC. Eight (8%) reported two PCs, and seven (8%) reported three or more PCs. In all, 131 PCs were reported. A majority (n ¼ 81, 62%) held MSNs, and 46 (35%) held BSNs. There were no
There were no statistically significant differences in programs’ model type or academic degree characteristics or in assigned PC and RF activities by cluster. There was a statistically significant difference in
Mentors
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Table 5 e Comparison of Program Attributes by Cluster Program Attribute Present Magnet status Shared governance model Mentorship Career plan Required Optional Not required Project completion Required by NRP end Required, okay after NRP end Not required Control code Government Not-for-profit For profit Bed size 250e99 300e399 400e499 500 Length of NRP Median (in weeks) Minimum/maximum Number completing NRP Median Minimum/maximum
Cluster 1, n (%)
Cluster 2, n (%)
Cluster 3, n (%)
c2
df
p Value
27 (100) 27 (100) 6 (22.2)
0 23 (82.1) 9 (32.1)
4 (14.3) 23 (82.1) 20 (71.4)
68.348 5.482 15.389
2 2 2
