JNPD
Journal for Nurses in Professional Development & Volume 30, Number 2, 76Y82 & Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nurse Residency Programs Outcome Comparisons to Best Practices Debra Harrison, DNP, RN, NEA-BC
ƒ
Carol Ledbetter, PhD, APRN, BC, FAAN
First-year turnover of newly licensed registered nurses is reported as high as 40%Y60%. Turnover can be reduced to 10% or less with a nurse residency program. This study compared three best practices within a single health system. The three aims were to determine first-year turnover of newly licensed registered nurses for three sites, compare outcomes after one-year posthire, and examine intent to stay. Although there were only a few statistically significant differences, the trend was positive for the site with a nurse residency program.
T
ransition into practice is not a new issue or concept. Since the publication of Kramer’s (1974) Reality Shock , followed by Benner’s (1984) Novice to Expert, newly licensed registered nurses (NLRNs) have experienced improved orientations, preceptors, internships, and coaching. Over the past 10 years, however, institutions began reporting high first-year turnover for NLRNs. An emerging strategy to decrease that turnover is nurse residency programs (NRPs). In this article, the authors describe the best available evidence associated with NRPs and the results of a study comparing three different NLRN programs within a single health system. The purpose of this study was to compare all three sites relative to first-year turnover, outcomes measured by the CaseyYFink Graduate Nurse Experience Survey (CFGNES), and intent to stay.
BACKGROUND High turnover in the first year of employment for NLRNs has been recognized in recent literature. Price Waterhouse Coopers’ Health Research Institute found that the national average turnover of all RNs in hospitals was 8.4%, whereas it was 27.1% for NLRNs (Rosseter, 2009). Case studies have reported first-year turnover as high as 40%Y60%. A current Debra Harrison, DNP, RN, NEA-BC, is Chief Nursing Officer, Mayo Clinic, Jacksonville, Florida. Carol Ledbetter, PhD, APRN, BC, FAAN, is Professor & Director, Doctor of Nursing Practice Program, Brooks College of Health School of Nursing, University of North Florida, Jacksonville. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. ADDRESS FOR CORRESPONDENCE: Debra Harrison, 3717 Wexford Hollow Road E, Jacksonville, FL 32224 (e-mail: Harrison.debra@ mayo.edu)R DOI: 10.1097/NND.0000000000000001
76
www.jnpdonline.com
review of the literature reporting outcomes for NRPs includes studies showing a reduction in first-year turnover (Altier & Krsek, 2006; Bratt, 2009; Hillman & Foster, 2011; Salt, Cummings, & Profetto-McGrath, 2008; Ulrich et al., 2010; Williams, Goode, Krsek, Bednash, & Lynn, 2007). The Commission on Collegiate Nursing Education (CCNE) defines NRP as a series of learning sessions and work experiences that occur continuously over a 12-month period designed to assist NLRNs as they make the transition into their first professional nursing role (CCNE, 2008). The recent increase in the complexity and specialization of nursing in acute care and the effect nurses have on patient safety and outcomes have contributed to the need for a new transition to practice model (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Agency for Healthcare Research and Quality, 2004; Myers et al., 2010; Rosseter, 2011). The need for NRPs is now gaining national consensus. Professional nursing organizations such as the American Organization of Nursing Executives, American Nurses Association, American Association of Colleges of Nursing (AACN), and the National Council of State Boards of Nursing all support the need to standardize the transition to practice via NRPs (Spector, 2007; The Advisory Board, 2007). The recent landmark report from the Institute of Medicine (2010) supports NRPs. In 2008, the CCNE Board of Commissioners approved the Standards of Postbaccalaureate Nurse Residency Programs (CCNE, 2008). The standards were developed to improve the quality of patient care by providing additional training and support to new baccalaureate nursing graduates. Because of the wide variety of transition-to-practice programs and their characteristics, the nationally recognized CCNE accreditation standards were developed to ensure uniformity of quality, content, and structure of postbaccalaureate NRPs. The broad applicability of the CCNE standards is reflected in the current characteristics of accredited programs and the evolving characteristics of new applicants. Benjamin Murray, MPA, CCNE Associate Director (personal communication, June 20, 2013), reported that 18% of current CCNE-accredited postbaccalaureate programs are not affiliated with the University Health System Consortium (UHC) program and 80% of the new applicant programs are not UHC affiliated. Currently, there are 10 programs holding CCNE accreditation in Colorado, Florida, Kansas, Kentucky, New Mexico, New York, Texas, and Wisconsin. March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
At a time when national support is gathering for NRPs, the current national RN vacancy rate remains at 8.1% or over 135,000 vacancies (Rosseter, 2011). Fifty-five percent of nurses in a national survey reported their intention to retire between 2011 and 2020 (Rosseter, 2011). As these baby boomers retire, the supply of RNs will grow only 0.2% per year between 2015 and 2025. However, the demand for RNs will grow by 2%Y3% each year (Buerhaus, Staiger, & Auerbach, 2009). Projected need for RNs will be more than 1 million nurses by the year 2020 (Rosseter, 2011). The need for a reliable educational pipeline of graduating new nurses, as well as their retention in the workforce, is evident.
The economics of decreasing nursing turnover can be impressive and have a significant, positive effect on the economics of the healthcare workforce; the cost of turnover is not only a nursing problem but an organizational burden. Decreasing turnover from 50% to 13% will result in a return on investment as high as 884% (Pine & Tart, 2007). As an example, calculations can range from $62,140 to $82,000 for new graduate replacements and $88,000 for experienced RN replacements (Bratt, 2009; Jones, 2008). NRP costs per resident range from approximately $2,000 to $6,000, depending on how programs are structured (Bratt, 2009; Pine & Tart, 2007). Retention of one or more NLRNs can result in the NRP being cost neutral.
LITERATURE REVIEW
METHOD
A number of different models for NRP, all using the term ‘‘residency,’’ were identified in the recent literature. The length of the program is often the distinguishing characteristic between an orientation and an NRP. Programs are typically 1 year, with a range reported to be 16 weeks to 15 months (Bratt, 2009; Goode, Lynn, Krsek, & Bednash, 2009; Herdrich & Lindsay, 2006; Ulrich et al., 2010). Williams et al. (2007) noted a V-shaped pattern to job satisfaction when measured at the beginning of the program, 6 months, and 1 year. The drop in job satisfaction occurred at 6 months, a typical time to complete orientation for NLRNs. Job satisfaction rebounded from the 6-month low to almost baseline at the end of 1 year. The authors concluded programs 1 year in length are an appropriate time period to provide support to an NLRN. The mentor component is a factor in determining the length of NRPs. For instance, although the Versant program, a precepted program, is 16Y22 weeks long, Ulrich et al. (2010) discussed adding a mentor for up to a year following the program. Messmer et al. (2011) looked at the correlation of job satisfaction and burnout related to turnover. These authors observed that many NLRNs believed they were coping effectively related to the patient care stresses but may have been experiencing serious interpersonal conflicts in their own relationships. Teaching effective methods of coping for both personal and work-related stress was incorporated into the mentor and social support components. Ulrich et al.’s (2010) longitudinal study describes the revisions, metrics, and outcomes over 10 years for nearly 6,000 NLRNs. The NLRNs were enrolled in the Versant RN Residency. Versant is a corporation formed by Children’s Hospital Los Angeles in response to the challenges facing nursing. In the beginning, the reported turnover averaged 7.1%. As the number of cohorts completing the program increased, turnover decreased. By the fifth cohort, turnover was 4.3%. This finding is significant and will be used as a basis of comparison as future studies report long-term experience with NRPs.
This study employed a cross-sectional, descriptive design using quantitative instruments, employment data to determine turnover rates, intent to stay, and the CFGNES outcomes (Casey, Fink, Krugman, & Probst, 2004). The PICO question was as follows: In new graduate RNs (Population), does an RN residency (Intervention) versus standard orientation (Comparison) increase recruitment and retention (Outcomes)? Expedited approval from the participating institutional review boards of the academic healthcare system at three acute care facilities (Sites A, B, and C) and the participating university was obtained. The aims of the project were as follows: 1. Determine the first year turnover of NLRNs for all three sites. 2. Compare NLRNs’ comfort and confidence outcomes measured by the CFGNES after 1-year posthire between all three sites. 3. Examine NLRNs’ intent to stay in their current unit positions and in the hiring institution at 1 year posthire at all three sites.
Journal for Nurses in Professional Development
Participants and Settings A convenience sample of NLRNs hired at the three sites between November 1, 2010, and September 30, 2011, was used for this study. Surveys were mailed to the participants 1 year posthire. For example, those hired in November 2010 received the survey in November 2011. Newly licensed was defined as the first employment after passing the NCLEX and being licensed in the state of employment by a board of nursing. Exclusion criteria included NLRNs who left the organization prior to 1 year or who declared they were not an NLRN upon hire. Individuals who left the organization were counted in the 1-year turnover rates. Site characteristics are described in Table 1, and demographic information for those responding is included in Table 2. Site A is the only hospital with a relatively new but formal NRP. NLRNs attend regular RN orientation and, in addition, are provided classes specific to the needs of an NLRN. The content is divided into three sections: leadership, www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
77
TABLE 1 Site Characteristics Number of NLRNs hired Percentage Total 11/1/10Y9/30/11 of total beds
Site Site A (Southeast U.S.)
46
10.2
214
Site B (Southwest U.S.)
57
10.4
268
Site C (Midwest U.S.)
358
79.4
1,200
Total
461
1,682
patient safety, and professional role. Leadership is covered in four 2-hour sessions for four consecutive weeks during regular orientation. At 6 months, 4 hours is focused on patient safety. At the 1-year mark, the focus is on the professional role. A mentor is assigned for the full year. This is someone not on the NLRN home unit and different from the clinical preceptor. The Site A NLRNs included in the study were part of the first three cohorts after establishing the program. Site B is the only site to have consistent measurement of first-year turnover since 2005. Site B changed to a 1-year
transition program with a separate job description for NLRNs after noting a high of 17% first-year turnover ranging from 11% to 17%. The turnover rates dropped to 5% in 2010, likely because of the economy and recession (Brewer, Kovner, Yingrengreung, & Dujkic, 2012). This site provides classes attended only by new graduates with content focused on communication, safe patient handling, and system reviews. Site C is a Magnet-designated organization. This site has consistently reported lower than national average turnover but has not tracked first-year turnover separately. The program includes a comprehensive orientation process lasting 3Y6 months, depending on the specialty. Table 3 summarizes components for overall orientation and NLRN-specific activities for the three sites.
Measurement The survey tool used was the CFGNES (Casey et al., 2004). The tool was developed in 1999 to measure NLRN comfort with skills over time. Casey et al. have used the survey as part of the NRP developed in collaboration between UHC and AACN. The CFCNES has a Cronbach alpha of .89; validity testing was done using an expert panel of educators
TABLE 2 Demographic Characteristics Site A
Site B
Total
Site C
n
Statistica
n
Statistic
30
27.76
25
25
83%
5
n
Statistic
n
Statistic
27.92
147
26.07
202
26.55
22
88%
130
88%
177
88%
17%
3
12%
17
12%
25
12%
26
87%
25
100%
139
95%
190
94%
Black
1
3%
1
0.5%
2
1%
Hispanic
1
3%
1
0.5%
2
1%
Asian
2
7%
4
3%
6
3%
Other
1
0.5%
1
0.5%
Not disclosed
1
0.5%
1
0.5%
Age Gender Female Male Race Caucasian
Nursing education AD
10
33%
Diploma BSN
20
67%
7
28%
1
4%
17
68%
33
114
22%
78%
50
25%
1
0.5%
151
74.5%
Note. AD = associate degree; BSN = bachelor of science. a Statistic used for age is mean, for remaining demographic characteristics, percent.
78
www.jnpdonline.com
March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE 3 Comparison of Sites for All RN Orientation New employee Nursing orientation Med/surg clinical Use of simulation NLRN class Mentor or support orientation didactic orientation center hours for NLRN Site A
16 hours
58 hours
10.5 weeks
Yes
16
1 year mentor
Site B
8 hours
40 hours
16 weeks
Yes
32
NLRN support groups
Site C
16 hours
56 hours
10 weeks
Yes
N/A
Employee support groups
and nursing directors (Casey et al., 2004). Although the entire survey was completed, results reported were from one of four sections. The section measured comfort and confidence while functioning as a professional nurse. It used a 4-point balanced-response scale (strongly disagree to strongly agree) to answer 24 questions. The subscales included stress, organizing and prioritizing, communication and leadership, and professional satisfaction.
for each site were 65% (n = 30) from Site A; 44% (n = 25) from Site B; and 43% (n = 147) from Site C for an overall rate of 45%. Methods to improve response rates were employed according to Dillman (2007). Descriptive statistics were used to describe the participants, survey responses, turnover rate, and intent to stay. All data were reported in the aggregate, and no individual data were included in reports, presentations, or publications.
Procedures
Findings
Following approval by the institutional review boards, names of the NLRNs were obtained from the human resource and/or clinical education departments at all three sites. E-mail addresses and work unit location were also collected based on an internal directory. The names and work unit locations were used to send a paper memo and sample survey. E-mail addresses were sent to a research assistant who entered them in a secure server, coded each name with a study number, and e-mailed the link for survey completion to the participants. NLRNs were invited to participate via a consent letter attached to an e-mail, which included assurance that participation was voluntary and that the information would only be used in the aggregate. The survey was administered at 1-year posthire by month; for example, those hired in November 2010 were sent a survey in November 2011. Response totals
Site A, the only site with an NRP, had the lowest first-year turnover (2%), although the difference between the three sites was not statistically significant. Site B had two cohorts in the study, one with no first-year turnover and the second with 10% for an average of 5%. Site C had monthly NLRNs hired with an average of 4% and a range of 0Y16%. Over the year studied, a downward trend was noted for Site C. There were no statistically significant differences in the CFGNES survey scores between the three sites. The score with the greatest difference was for professional satisfaction. Site A (NRP) had the highest mean score of 3.6, whereas Sites B (GN job description) and C (Magnet) had 3.48 and 3.42, respectively. The other noted difference, although not statistically significant, was a higher score for the subscale of support for Site B. Scores for each site by subscale can be found in Table 4. It is important to note that
TABLE 4 Comparison of CaseyYFink Graduate Nurse Experience Survey Subscales by Site Scale
Site A (NRP), mean (SE)
Site B (GN job description), mean (SE)
Site C (Magnet), mean (SE)
F ratio
p
Stress
2.27 (0.14)
2.36 (0.16)
2.29 (0.06)
0.1058
.8997
Support
3.49 (0.06)
3.55 (0.07)
3.45 (0.03)
1.1476
.3195
Organize and prioritize
1.77 (0.07)
1.68 (0.08)
1.70 (0.03)
0.4402
.6445
Communication/leadership
3.29 (0.06)
3.32 (0.07)
3.33 (0.03)
0.0806
.9226
3.6 (0.09)
3.48 (0.10)
3.42 (0.04)
1.3923
.2509
Professional satisfaction
Note. SE = standard error. Answers were reported based on a 4-point Likert scale: 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree. Strongly agree was stated as a positive response for questions, with the exception of the subscales of stress and organize/prioritize. A positive response for those scores would be strongly disagree or 1.
Journal for Nurses in Professional Development
www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
79
TABLE 5 Subscale Scores by Nursing Degree AD, BSN, mean (SD) mean (SD) F ratio
Scale
p
Stress
2.42 (0.11)
2.26 (0.06)
1.6143 .2054
Support
3.46 (0.33)
3.47 (0.32)
0.0580 .8099
Organize and prioritize
1.78 (0.45)
1.68 (0.38)
2.4799 .1169
Communication 3.28 (0.31) and leadership
3.34 (0.37)
1.1254 .2900
Professional satisfaction
3.44 (0.56)
0.8840 .3483
3.52 (0.48)
Note. AD = associate degree; BSN = bachelor of science; SD = standard deviation.
a positive response for three of the subscales is a higher score; however, a positive response for the stress and organize/prioritize scales would be a lower score. This is because of the wording of the questions (e.g., I am experiencing stress in my personal life.). Intent to stay was evaluated by assigning a numerical value to time interval and calculating an average score. Values assigned were 1 = less than 1 year, 2 = 1Y3 years, 3 = 4Y5 years, 4 = 5+ years. Average scores were Site A 3.0, Site B 2.58, and Site C 2.44. Site A with the NRP was compared with the other sites, and there was a statistically significant difference (*p = .0044) between Site A (NRP) and Site C (Magnet) related to the intent to stay in their current position. On average, Site A participants planned to stay longer in their current position than those at Site C. There were no statistical differences between sites related to intent to stay in the institution. Site A was 3.52, Site B 3.22, and Site C 3.53. Because there is controversy in the literature about whether to include NLRNs with an associate degree in an NRP, a comparison was done of the CFGNES subscale scores by nursing degree using t test and nonparametric Wilcoxon. There was no statistically significant difference in scores on any of the subscales between those NLRNs with an associate’s degree (AD) or those with a bachelor’s of science in nursing (BSN; see Table 5). The trend of scores for the BSN was slightly more positive than the AD group, with the exception of professional satisfaction.
DISCUSSION AND IMPLICATIONS There was a trend toward positive outcomes with the NRP based on the first-year turnover rates and professional satisfaction scores, supporting the evidence as reported. The similarity in CFGNES scores is positive from a system perspective. It would mean that all NLRNs in the system are achieving comparable support and orientations. They are 80
www.jnpdonline.com
also comparable to those found in a recent publication of the 10-year experience with UHC/AACN NRP (Goode, Lynn, McElroy, Bednash, & Murray, 2013). Intent to stay, however, is a complicated and multifaceted measurement. Although those in the NRP had a higher intent to stay in the position, it may not be affected by an NRP as much as other factors (Beecroft, Dorey, & Wenten, 2007; Kovner, Brewer, Green, & Fairchild, 2009). This study also supports the need for standardization of terminology, program components, and metrics of success. Using the title ‘‘Nurse Residency Program’’ is consistent with the CCNE accreditation process and this strategic approach for transition into practice. It is also important that nursing develop a common metric for measuring first-year turnover, overall turnover, and retention of RNs. Definitions have not been consistent, making benchmarking difficult. In some cases, it is defined as voluntary terminations, whereas in others it is defined as all terminations. Tracking turnover of the first year is needed to justify the financial investment of an NRP. Overall turnover is needed for a sense of the entire nursing workforce and retention by year can help identify strategies to target at various career points (Brewer, Kovner, Greene, Tukov-Shuser, & Djukic, 2011). All are needed, but definitions and common metrics are critical. A consistent definition for turnover might be ‘‘measured annually, number of RNs leaving an organization divided by the total number of RNs, including voluntary and involuntary.’’ First-year turnover might be defined as ‘‘turnover measured only for a selected group of newly licensed registered nurses at one year.’’ The mentor component of the NRP in Site A is one of the differences between the three sites. Messmer et al. (2011) found that NLRNs believed they were coping effectively but had difficulties in their personal relationships. A psychologist facilitator helped point out the correlation between stress and these difficulties. A mentor outside the assigned work unit could serve to identify personality changes found in stress responses. The mentor component also reinforces the need to ensure that values, not just skills, are passed on to each generation of nurses. Mentors also help navigate organizational politics and improve communication skills in stressful situations (Bleich, 2012). The CCNE accreditation process for NRPs requires institutions to have an academic partnership. An academic partner could assist with the development of a theoretical framework for the NRP. The academic partner can also initiate the need for future research through the evaluation process (Herdrich & Lindsay, 2006). Collaboration with practice and education also allows an exchange of ideas related to curriculum in both basic education and an NRP. It should become the norm that, following formal education, clinical learning continues in the practical work environment and specialization evolves, both benefited by the structured NRP. March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Versant program includes the AD NLRN, and the UHC/AACN program is now considering an AD curriculum, altered slightly from the BSN curriculum (Poynton, Madden, Bowers, & Keefe, 2007). Poynton et al. pointed out that over time there are performance differences between graduates of those programs, but initially the two groups are more similar in characteristics. This project was consistent in the finding that no significant difference was seen on survey responses between AD and BSN graduates. Some programs also make the NRP an option rather than a planned part of NLRN transition into practice. It is important that NLRNs are supported and that systems are designed in a way to meet the needs of all in order to realize the benefits. Further study is needed related to effectiveness of the components of the NRP, length of time for mentorship, and the effect of the accumulation of cohorts. Compelling statistics show improved retention as programs continue (Ulrich et al., 2010). Continued research on the retention of NLRNs beyond the first year is needed to determine further interventions to minimize turnover (Setter, Walker, Connelly, & Peterman, 2011). There is also evidence that these RN residents carry a greater engagement for professional practice and improving patient outcomes (Bratt & Feltzer, 2011; Kramer et al., 2012). Managers working with NLRNs have observed that, following the residency, a greater percentage of residents participate in nursing committees and projects than more experienced staff. With each cohort, there are more applications, better screening, and excellent candidates. This was also supported by Goode et al. (2013) as the residency focus on quality, safety, and evidence-based practice changes the overall institutional culture. Further research is needed to determine the resulting effect on patient outcomes. Continued research is also needed on return on investment. Because there is an upfront cost of the program, the chief nursing officers will need to justify the cost to administrators. Turnover alone is one way to show a cost/benefit ratio, but there may also be outcomes that show that the investment is worthwhile. Raising the professionalism of staff, increased use of evidence-based practice, and improved job satisfaction are factors that recur with additional cohorts of residents. Funding opportunities should also be considered, including government dollars for residency support. A regional program could be possible to assure that organizations with limited financial means could benefit from an NRP (Bleich, 2012). Many organizations, such as those described in the study, have excellent orientation programs and support for NLRNs. It may not take much more money or time to develop the program into an NRP. Adding a mentor component for up to a year and courses designed to specifically address needs of the NLRN may be enough to start. Journal for Nurses in Professional Development
STUDY LIMITATIONS The limitations of the study include the use of a convenience sample. Because of the smaller number of new graduates, response rates were limited in the smaller sites (Sites A and B), making statistical comparison difficult. The academic setting of the three sites limits generalization to community hospitals. The survey used was designed to measure changes over time in graduate nurse experience and confidence. This study only measured a single point in time, 1 year, in order to compare sites. Although the CFGNES was not designed for this, it did confirm that outcomes were similar between organizations in this healthcare system and are a standard tool used in other NRPs.
SUMMARY NRPs are increasingly viewed as different from traditional orientation programs. Competencies for graduates of NRPs also include increased ability to use evidence-based decision making, management of conflict, improved communication with physician, and other healthcare team members, network building, and patient-centered care. The data from this quality improvement study support the evidence-based practice of reducing first-year turnover with an NRP. With the future of a nursing shortage looming, investing in the new workforce is worth the time and money to assure quality nurses who want to stay in their jobs. NRPs will also help others to recognize that nursing is a complex and challenging profession that deserves the time to develop professional competencies. This could be an exciting trend for clinical education and nursing leaders in practice to embrace the opportunity to partner with academic colleagues in order to prepare nurses for the future.
References Agency for Healthcare Research and Quality. (2004). Hospital nurse staffing and quality of care. Research in action, 14. Rockville, MD: U.S. Department of Health and Human Services. Retrieved from http://www.ahrq.gov/research/nursestaffing/nursestaff.pdf Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288(16), 1987Y1993. Altier, M. E., & Krsek, C. A. (2006). Effects of a 1-year residency program on job satisfaction and retention of new graduate nurses. Journal Nurses in Staff Development, 22(2), 70Y77. Beecroft, P. C., Dorey, F., & Wenten, M. (2007). Turnover intention in new graduate nurses: A multivariate analysis. Journal of Advanced Nursing, 62(1), 41Y52. doi:10.1111/j.1365-2648.2007.04570.x Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-Wesley. Bleich, M. R. (2012). In praise of nursing residency programs. American Nurse Today, 7(5), 47Y49. Bratt, M. (2009). Retaining the next generation of nurses: The Wisconsin nurse residency program provides a continuum of support. Journal of Continuing Education in Nursing, 40(9), 416Y425. doi:10.3928/00220124-20090824-05 Bratt, M., & Feltzer, H. (2011). Perceptions of professional practice and work environment of new graduates in a nurse residency www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
81
program. Journal of Continuing Education in Nursing, 42(12), 559Y568. doi:10.3928/00220124-20110516-03 Brewer, C., Kovner, C., Greene, W., Tukov-Shuser, M., & Djukic, M. (2011). Predictors of actual turnover in a national sample of newly licensed registered nurses employed in hospitals. Journal of Advanced Nursing. doi:10.1111/j.1365-2648.2011.05753.x Brewer, C., Kovner, C., Yingrengreung, S., & Dujkic, M. (2012). New nurses: Has the recession increased their commitment to their jobs? American Journal of Nursing, 112(3), 34Y44. doi:10.1097/ 01.NAJ.0000412637.63022.d4 Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2009). The future of the nursing workforce in the United States: Data, trends, and implications. Sudbury, MA: Jones and Bartlett Publishers. Casey, K., Fink, R., Krugman, M., & Probst, J. (2004). The graduate nurse experience. Journal of Nursing Administration, 34(6), 303Y311. Commission on Collegiate Nursing Education. (2008). Standards for accreditation of post-baccalaureate nurse residency programs. Washington, DC: Author. Dillman, D. A. (2007). Mail and internet surveys: The Tailored Design Method 2007 update with new internet, visual, and mixed-mode guide. Hoboken, NJ: John Wiley & Sons, Inc. Goode, C. J., Lynn, M. R., Krsek, C., & Bednash, G. D. (2009). Nurse residency programs: An essential requirement for nursing. Nursing Economic$, 27(3), 142Y147, 159. Goode, C. J., Lynn, M. R., McElroy, D., Bednash, G. D., & Murray, B. (2013). Lessons learned from 10 years of research on a postbaccalaureate nurse residency program. Journal of Nursing Administration, 43(2), 73Y79. doi:10.1097/NNA.0b013e31827f205c Herdrich, B., & Lindsay, A. (2006). Nurse residency programs: Redesigning the transition into practice. Journal for Nurses in Staff Development, 22(2), 55Y62. Hillman, L., & Foster, R. (2011). The impact of a nursing transitions programme on retention and cost savings. Journal of Nursing Management, 19(1), 50Y56. doi:10.1111/j.1365-2834.2010.01187.x Institute of Medicine. (2010). The future of nursing: Leading change, advocating health. Washington, DC: National Academies Press. Retrieved from http://www.iom.edu/Reports/2010/The-Futureof-Nursing-Leading-Change-Advancing-Health.aspx Jones, C. (2008). Revisiting nurse turnover costs: Adjusting for inflation. Journal of Nursing Administration, 38(1), 11Y18. doi:10.1097/01.NNA.0000295636.03216.6f Kovner, C., Brewer, C., Green, W., & Fairchild, S. (2009). Understanding new registered nurses’ intent to stay at their jobs. Nursing Economic$, 27(2), 81Y98. Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: The C.V. Mosby Company. Kramer, M., Maguire, P., Halfer, D., Budin, W., Hall, D., Goodloe, L.,
82
www.jnpdonline.com
& Lemke, J. (2012). The organizational transformative power of nurse residency programs. Nursing Administrative Quarterly, 36(2), 155Y168. Messmer, P., Bragg J., & Williams P. (2011). Support programs for new graduates in pediatric nursing. Journal of Continuing Education in Nursing, 42(4), 182Y192. Myers, S., Reidy, P., French, B., McHale, J., Chisholm, M., & Griffin, M. (2010). Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. Journal of Continuing Education in Nursing, 41(4), 163Y171. doi:10.3928/00220124-20100326-02 Pine, R., & Tart, K. (2007). Return on investment: Benefits and challenges of a baccalaureate nurse residency program. Nursing Economic$, 25(1), 13Y18, 39. Poynton, M., Madden, C., Bowers, R., & Keefe, M. (2007). Nurse residency program implementation: The Utah experience. Journal of Healthcare Management, 52(6), 385Y397. Rosseter, R. J. (2009). Nursing shortage fact sheet. Washington, DC; American Association of Colleges of Nursing (AACN). Retrieved from: http://www.aacn.nche.edu/media-relations/fact-sheets/ nursing-shortage Rosseter, R. J. (2011). Nursing shortage fact sheet. Washington, DC; American Association of Colleges of Nursing (AACN). Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/ nursing-shortage Salt, J., Cummings, G., & Profetto-McGrath, J. (2008). Increasing retention of new graduate nurses. Journal of Nursing Administration, 38(6), 287Y296. Setter, R., Walker, M., Connelly, L., & Peterman, T. (2011). Nurse residency graduates’ commitment to their first positions. Journal for Nurses in Staff Development, 27(2), 58Y64. doi:10.1097/ NND.0b013e31820eee49 Spector, N. (2007). Transitioning new nurses to practice: The importance of collaboration [PowerPointA]. Chicago, IL: National Council of State Boards of Nursing. Retrieved from https://www .ncsbn.org/07_June_Transition.ppt The Advisory Board. (2007). Nursing Executive Center essay: Assessing the trend toward nurse residency programs. Washington, DC: Retrieved from http://www.advisory.com/Research/NursingExecutive-Center/Studies/2006/Transitioning-New-Graduates-toHospital-Practice Ulrich, B., Krozek, C., Early, S., Ashlock, C. H., Africa, L. M., & Carman, M. L. (2010). Improving retention, confidence, and competence of new graduate nurses: Results from a 10-year longitudinal database. Nursing Economic$, 28(6), 363Y375. Williams, C. A., Goode, C. J., Krsek, C., Bednash, G. D., & Lynn, M. R. (2007). Post baccalaureate nurse residency 1-year outcomes. Journal of Nursing Administration, 37(7Y8), 357Y365.
March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal for Nurses in Professional Development & Volume 30, Number 2, 76Y82 & Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nurse Residency Programs Outcome Comparisons to Best Practices Debra Harrison, DNP, RN, NEA-BC
ƒ
Carol Ledbetter, PhD, APRN, BC, FAAN
First-year turnover of newly licensed registered nurses is reported as high as 40%Y60%. Turnover can be reduced to 10% or less with a nurse residency program. This study compared three best practices within a single health system. The three aims were to determine first-year turnover of newly licensed registered nurses for three sites, compare outcomes after one-year posthire, and examine intent to stay. Although there were only a few statistically significant differences, the trend was positive for the site with a nurse residency program.
T
ransition into practice is not a new issue or concept. Since the publication of Kramer’s (1974) Reality Shock , followed by Benner’s (1984) Novice to Expert, newly licensed registered nurses (NLRNs) have experienced improved orientations, preceptors, internships, and coaching. Over the past 10 years, however, institutions began reporting high first-year turnover for NLRNs. An emerging strategy to decrease that turnover is nurse residency programs (NRPs). In this article, the authors describe the best available evidence associated with NRPs and the results of a study comparing three different NLRN programs within a single health system. The purpose of this study was to compare all three sites relative to first-year turnover, outcomes measured by the CaseyYFink Graduate Nurse Experience Survey (CFGNES), and intent to stay.
BACKGROUND High turnover in the first year of employment for NLRNs has been recognized in recent literature. Price Waterhouse Coopers’ Health Research Institute found that the national average turnover of all RNs in hospitals was 8.4%, whereas it was 27.1% for NLRNs (Rosseter, 2009). Case studies have reported first-year turnover as high as 40%Y60%. A current Debra Harrison, DNP, RN, NEA-BC, is Chief Nursing Officer, Mayo Clinic, Jacksonville, Florida. Carol Ledbetter, PhD, APRN, BC, FAAN, is Professor & Director, Doctor of Nursing Practice Program, Brooks College of Health School of Nursing, University of North Florida, Jacksonville. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. ADDRESS FOR CORRESPONDENCE: Debra Harrison, 3717 Wexford Hollow Road E, Jacksonville, FL 32224 (e-mail: Harrison.debra@ mayo.edu)R DOI: 10.1097/NND.0000000000000001
76
www.jnpdonline.com
review of the literature reporting outcomes for NRPs includes studies showing a reduction in first-year turnover (Altier & Krsek, 2006; Bratt, 2009; Hillman & Foster, 2011; Salt, Cummings, & Profetto-McGrath, 2008; Ulrich et al., 2010; Williams, Goode, Krsek, Bednash, & Lynn, 2007). The Commission on Collegiate Nursing Education (CCNE) defines NRP as a series of learning sessions and work experiences that occur continuously over a 12-month period designed to assist NLRNs as they make the transition into their first professional nursing role (CCNE, 2008). The recent increase in the complexity and specialization of nursing in acute care and the effect nurses have on patient safety and outcomes have contributed to the need for a new transition to practice model (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Agency for Healthcare Research and Quality, 2004; Myers et al., 2010; Rosseter, 2011). The need for NRPs is now gaining national consensus. Professional nursing organizations such as the American Organization of Nursing Executives, American Nurses Association, American Association of Colleges of Nursing (AACN), and the National Council of State Boards of Nursing all support the need to standardize the transition to practice via NRPs (Spector, 2007; The Advisory Board, 2007). The recent landmark report from the Institute of Medicine (2010) supports NRPs. In 2008, the CCNE Board of Commissioners approved the Standards of Postbaccalaureate Nurse Residency Programs (CCNE, 2008). The standards were developed to improve the quality of patient care by providing additional training and support to new baccalaureate nursing graduates. Because of the wide variety of transition-to-practice programs and their characteristics, the nationally recognized CCNE accreditation standards were developed to ensure uniformity of quality, content, and structure of postbaccalaureate NRPs. The broad applicability of the CCNE standards is reflected in the current characteristics of accredited programs and the evolving characteristics of new applicants. Benjamin Murray, MPA, CCNE Associate Director (personal communication, June 20, 2013), reported that 18% of current CCNE-accredited postbaccalaureate programs are not affiliated with the University Health System Consortium (UHC) program and 80% of the new applicant programs are not UHC affiliated. Currently, there are 10 programs holding CCNE accreditation in Colorado, Florida, Kansas, Kentucky, New Mexico, New York, Texas, and Wisconsin. March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
At a time when national support is gathering for NRPs, the current national RN vacancy rate remains at 8.1% or over 135,000 vacancies (Rosseter, 2011). Fifty-five percent of nurses in a national survey reported their intention to retire between 2011 and 2020 (Rosseter, 2011). As these baby boomers retire, the supply of RNs will grow only 0.2% per year between 2015 and 2025. However, the demand for RNs will grow by 2%Y3% each year (Buerhaus, Staiger, & Auerbach, 2009). Projected need for RNs will be more than 1 million nurses by the year 2020 (Rosseter, 2011). The need for a reliable educational pipeline of graduating new nurses, as well as their retention in the workforce, is evident.
The economics of decreasing nursing turnover can be impressive and have a significant, positive effect on the economics of the healthcare workforce; the cost of turnover is not only a nursing problem but an organizational burden. Decreasing turnover from 50% to 13% will result in a return on investment as high as 884% (Pine & Tart, 2007). As an example, calculations can range from $62,140 to $82,000 for new graduate replacements and $88,000 for experienced RN replacements (Bratt, 2009; Jones, 2008). NRP costs per resident range from approximately $2,000 to $6,000, depending on how programs are structured (Bratt, 2009; Pine & Tart, 2007). Retention of one or more NLRNs can result in the NRP being cost neutral.
LITERATURE REVIEW
METHOD
A number of different models for NRP, all using the term ‘‘residency,’’ were identified in the recent literature. The length of the program is often the distinguishing characteristic between an orientation and an NRP. Programs are typically 1 year, with a range reported to be 16 weeks to 15 months (Bratt, 2009; Goode, Lynn, Krsek, & Bednash, 2009; Herdrich & Lindsay, 2006; Ulrich et al., 2010). Williams et al. (2007) noted a V-shaped pattern to job satisfaction when measured at the beginning of the program, 6 months, and 1 year. The drop in job satisfaction occurred at 6 months, a typical time to complete orientation for NLRNs. Job satisfaction rebounded from the 6-month low to almost baseline at the end of 1 year. The authors concluded programs 1 year in length are an appropriate time period to provide support to an NLRN. The mentor component is a factor in determining the length of NRPs. For instance, although the Versant program, a precepted program, is 16Y22 weeks long, Ulrich et al. (2010) discussed adding a mentor for up to a year following the program. Messmer et al. (2011) looked at the correlation of job satisfaction and burnout related to turnover. These authors observed that many NLRNs believed they were coping effectively related to the patient care stresses but may have been experiencing serious interpersonal conflicts in their own relationships. Teaching effective methods of coping for both personal and work-related stress was incorporated into the mentor and social support components. Ulrich et al.’s (2010) longitudinal study describes the revisions, metrics, and outcomes over 10 years for nearly 6,000 NLRNs. The NLRNs were enrolled in the Versant RN Residency. Versant is a corporation formed by Children’s Hospital Los Angeles in response to the challenges facing nursing. In the beginning, the reported turnover averaged 7.1%. As the number of cohorts completing the program increased, turnover decreased. By the fifth cohort, turnover was 4.3%. This finding is significant and will be used as a basis of comparison as future studies report long-term experience with NRPs.
This study employed a cross-sectional, descriptive design using quantitative instruments, employment data to determine turnover rates, intent to stay, and the CFGNES outcomes (Casey, Fink, Krugman, & Probst, 2004). The PICO question was as follows: In new graduate RNs (Population), does an RN residency (Intervention) versus standard orientation (Comparison) increase recruitment and retention (Outcomes)? Expedited approval from the participating institutional review boards of the academic healthcare system at three acute care facilities (Sites A, B, and C) and the participating university was obtained. The aims of the project were as follows: 1. Determine the first year turnover of NLRNs for all three sites. 2. Compare NLRNs’ comfort and confidence outcomes measured by the CFGNES after 1-year posthire between all three sites. 3. Examine NLRNs’ intent to stay in their current unit positions and in the hiring institution at 1 year posthire at all three sites.
Journal for Nurses in Professional Development
Participants and Settings A convenience sample of NLRNs hired at the three sites between November 1, 2010, and September 30, 2011, was used for this study. Surveys were mailed to the participants 1 year posthire. For example, those hired in November 2010 received the survey in November 2011. Newly licensed was defined as the first employment after passing the NCLEX and being licensed in the state of employment by a board of nursing. Exclusion criteria included NLRNs who left the organization prior to 1 year or who declared they were not an NLRN upon hire. Individuals who left the organization were counted in the 1-year turnover rates. Site characteristics are described in Table 1, and demographic information for those responding is included in Table 2. Site A is the only hospital with a relatively new but formal NRP. NLRNs attend regular RN orientation and, in addition, are provided classes specific to the needs of an NLRN. The content is divided into three sections: leadership, www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
77
TABLE 1 Site Characteristics Number of NLRNs hired Percentage Total 11/1/10Y9/30/11 of total beds
Site Site A (Southeast U.S.)
46
10.2
214
Site B (Southwest U.S.)
57
10.4
268
Site C (Midwest U.S.)
358
79.4
1,200
Total
461
1,682
patient safety, and professional role. Leadership is covered in four 2-hour sessions for four consecutive weeks during regular orientation. At 6 months, 4 hours is focused on patient safety. At the 1-year mark, the focus is on the professional role. A mentor is assigned for the full year. This is someone not on the NLRN home unit and different from the clinical preceptor. The Site A NLRNs included in the study were part of the first three cohorts after establishing the program. Site B is the only site to have consistent measurement of first-year turnover since 2005. Site B changed to a 1-year
transition program with a separate job description for NLRNs after noting a high of 17% first-year turnover ranging from 11% to 17%. The turnover rates dropped to 5% in 2010, likely because of the economy and recession (Brewer, Kovner, Yingrengreung, & Dujkic, 2012). This site provides classes attended only by new graduates with content focused on communication, safe patient handling, and system reviews. Site C is a Magnet-designated organization. This site has consistently reported lower than national average turnover but has not tracked first-year turnover separately. The program includes a comprehensive orientation process lasting 3Y6 months, depending on the specialty. Table 3 summarizes components for overall orientation and NLRN-specific activities for the three sites.
Measurement The survey tool used was the CFGNES (Casey et al., 2004). The tool was developed in 1999 to measure NLRN comfort with skills over time. Casey et al. have used the survey as part of the NRP developed in collaboration between UHC and AACN. The CFCNES has a Cronbach alpha of .89; validity testing was done using an expert panel of educators
TABLE 2 Demographic Characteristics Site A
Site B
Total
Site C
n
Statistica
n
Statistic
30
27.76
25
25
83%
5
n
Statistic
n
Statistic
27.92
147
26.07
202
26.55
22
88%
130
88%
177
88%
17%
3
12%
17
12%
25
12%
26
87%
25
100%
139
95%
190
94%
Black
1
3%
1
0.5%
2
1%
Hispanic
1
3%
1
0.5%
2
1%
Asian
2
7%
4
3%
6
3%
Other
1
0.5%
1
0.5%
Not disclosed
1
0.5%
1
0.5%
Age Gender Female Male Race Caucasian
Nursing education AD
10
33%
Diploma BSN
20
67%
7
28%
1
4%
17
68%
33
114
22%
78%
50
25%
1
0.5%
151
74.5%
Note. AD = associate degree; BSN = bachelor of science. a Statistic used for age is mean, for remaining demographic characteristics, percent.
78
www.jnpdonline.com
March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE 3 Comparison of Sites for All RN Orientation New employee Nursing orientation Med/surg clinical Use of simulation NLRN class Mentor or support orientation didactic orientation center hours for NLRN Site A
16 hours
58 hours
10.5 weeks
Yes
16
1 year mentor
Site B
8 hours
40 hours
16 weeks
Yes
32
NLRN support groups
Site C
16 hours
56 hours
10 weeks
Yes
N/A
Employee support groups
and nursing directors (Casey et al., 2004). Although the entire survey was completed, results reported were from one of four sections. The section measured comfort and confidence while functioning as a professional nurse. It used a 4-point balanced-response scale (strongly disagree to strongly agree) to answer 24 questions. The subscales included stress, organizing and prioritizing, communication and leadership, and professional satisfaction.
for each site were 65% (n = 30) from Site A; 44% (n = 25) from Site B; and 43% (n = 147) from Site C for an overall rate of 45%. Methods to improve response rates were employed according to Dillman (2007). Descriptive statistics were used to describe the participants, survey responses, turnover rate, and intent to stay. All data were reported in the aggregate, and no individual data were included in reports, presentations, or publications.
Procedures
Findings
Following approval by the institutional review boards, names of the NLRNs were obtained from the human resource and/or clinical education departments at all three sites. E-mail addresses and work unit location were also collected based on an internal directory. The names and work unit locations were used to send a paper memo and sample survey. E-mail addresses were sent to a research assistant who entered them in a secure server, coded each name with a study number, and e-mailed the link for survey completion to the participants. NLRNs were invited to participate via a consent letter attached to an e-mail, which included assurance that participation was voluntary and that the information would only be used in the aggregate. The survey was administered at 1-year posthire by month; for example, those hired in November 2010 were sent a survey in November 2011. Response totals
Site A, the only site with an NRP, had the lowest first-year turnover (2%), although the difference between the three sites was not statistically significant. Site B had two cohorts in the study, one with no first-year turnover and the second with 10% for an average of 5%. Site C had monthly NLRNs hired with an average of 4% and a range of 0Y16%. Over the year studied, a downward trend was noted for Site C. There were no statistically significant differences in the CFGNES survey scores between the three sites. The score with the greatest difference was for professional satisfaction. Site A (NRP) had the highest mean score of 3.6, whereas Sites B (GN job description) and C (Magnet) had 3.48 and 3.42, respectively. The other noted difference, although not statistically significant, was a higher score for the subscale of support for Site B. Scores for each site by subscale can be found in Table 4. It is important to note that
TABLE 4 Comparison of CaseyYFink Graduate Nurse Experience Survey Subscales by Site Scale
Site A (NRP), mean (SE)
Site B (GN job description), mean (SE)
Site C (Magnet), mean (SE)
F ratio
p
Stress
2.27 (0.14)
2.36 (0.16)
2.29 (0.06)
0.1058
.8997
Support
3.49 (0.06)
3.55 (0.07)
3.45 (0.03)
1.1476
.3195
Organize and prioritize
1.77 (0.07)
1.68 (0.08)
1.70 (0.03)
0.4402
.6445
Communication/leadership
3.29 (0.06)
3.32 (0.07)
3.33 (0.03)
0.0806
.9226
3.6 (0.09)
3.48 (0.10)
3.42 (0.04)
1.3923
.2509
Professional satisfaction
Note. SE = standard error. Answers were reported based on a 4-point Likert scale: 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree. Strongly agree was stated as a positive response for questions, with the exception of the subscales of stress and organize/prioritize. A positive response for those scores would be strongly disagree or 1.
Journal for Nurses in Professional Development
www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
79
TABLE 5 Subscale Scores by Nursing Degree AD, BSN, mean (SD) mean (SD) F ratio
Scale
p
Stress
2.42 (0.11)
2.26 (0.06)
1.6143 .2054
Support
3.46 (0.33)
3.47 (0.32)
0.0580 .8099
Organize and prioritize
1.78 (0.45)
1.68 (0.38)
2.4799 .1169
Communication 3.28 (0.31) and leadership
3.34 (0.37)
1.1254 .2900
Professional satisfaction
3.44 (0.56)
0.8840 .3483
3.52 (0.48)
Note. AD = associate degree; BSN = bachelor of science; SD = standard deviation.
a positive response for three of the subscales is a higher score; however, a positive response for the stress and organize/prioritize scales would be a lower score. This is because of the wording of the questions (e.g., I am experiencing stress in my personal life.). Intent to stay was evaluated by assigning a numerical value to time interval and calculating an average score. Values assigned were 1 = less than 1 year, 2 = 1Y3 years, 3 = 4Y5 years, 4 = 5+ years. Average scores were Site A 3.0, Site B 2.58, and Site C 2.44. Site A with the NRP was compared with the other sites, and there was a statistically significant difference (*p = .0044) between Site A (NRP) and Site C (Magnet) related to the intent to stay in their current position. On average, Site A participants planned to stay longer in their current position than those at Site C. There were no statistical differences between sites related to intent to stay in the institution. Site A was 3.52, Site B 3.22, and Site C 3.53. Because there is controversy in the literature about whether to include NLRNs with an associate degree in an NRP, a comparison was done of the CFGNES subscale scores by nursing degree using t test and nonparametric Wilcoxon. There was no statistically significant difference in scores on any of the subscales between those NLRNs with an associate’s degree (AD) or those with a bachelor’s of science in nursing (BSN; see Table 5). The trend of scores for the BSN was slightly more positive than the AD group, with the exception of professional satisfaction.
DISCUSSION AND IMPLICATIONS There was a trend toward positive outcomes with the NRP based on the first-year turnover rates and professional satisfaction scores, supporting the evidence as reported. The similarity in CFGNES scores is positive from a system perspective. It would mean that all NLRNs in the system are achieving comparable support and orientations. They are 80
www.jnpdonline.com
also comparable to those found in a recent publication of the 10-year experience with UHC/AACN NRP (Goode, Lynn, McElroy, Bednash, & Murray, 2013). Intent to stay, however, is a complicated and multifaceted measurement. Although those in the NRP had a higher intent to stay in the position, it may not be affected by an NRP as much as other factors (Beecroft, Dorey, & Wenten, 2007; Kovner, Brewer, Green, & Fairchild, 2009). This study also supports the need for standardization of terminology, program components, and metrics of success. Using the title ‘‘Nurse Residency Program’’ is consistent with the CCNE accreditation process and this strategic approach for transition into practice. It is also important that nursing develop a common metric for measuring first-year turnover, overall turnover, and retention of RNs. Definitions have not been consistent, making benchmarking difficult. In some cases, it is defined as voluntary terminations, whereas in others it is defined as all terminations. Tracking turnover of the first year is needed to justify the financial investment of an NRP. Overall turnover is needed for a sense of the entire nursing workforce and retention by year can help identify strategies to target at various career points (Brewer, Kovner, Greene, Tukov-Shuser, & Djukic, 2011). All are needed, but definitions and common metrics are critical. A consistent definition for turnover might be ‘‘measured annually, number of RNs leaving an organization divided by the total number of RNs, including voluntary and involuntary.’’ First-year turnover might be defined as ‘‘turnover measured only for a selected group of newly licensed registered nurses at one year.’’ The mentor component of the NRP in Site A is one of the differences between the three sites. Messmer et al. (2011) found that NLRNs believed they were coping effectively but had difficulties in their personal relationships. A psychologist facilitator helped point out the correlation between stress and these difficulties. A mentor outside the assigned work unit could serve to identify personality changes found in stress responses. The mentor component also reinforces the need to ensure that values, not just skills, are passed on to each generation of nurses. Mentors also help navigate organizational politics and improve communication skills in stressful situations (Bleich, 2012). The CCNE accreditation process for NRPs requires institutions to have an academic partnership. An academic partner could assist with the development of a theoretical framework for the NRP. The academic partner can also initiate the need for future research through the evaluation process (Herdrich & Lindsay, 2006). Collaboration with practice and education also allows an exchange of ideas related to curriculum in both basic education and an NRP. It should become the norm that, following formal education, clinical learning continues in the practical work environment and specialization evolves, both benefited by the structured NRP. March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Versant program includes the AD NLRN, and the UHC/AACN program is now considering an AD curriculum, altered slightly from the BSN curriculum (Poynton, Madden, Bowers, & Keefe, 2007). Poynton et al. pointed out that over time there are performance differences between graduates of those programs, but initially the two groups are more similar in characteristics. This project was consistent in the finding that no significant difference was seen on survey responses between AD and BSN graduates. Some programs also make the NRP an option rather than a planned part of NLRN transition into practice. It is important that NLRNs are supported and that systems are designed in a way to meet the needs of all in order to realize the benefits. Further study is needed related to effectiveness of the components of the NRP, length of time for mentorship, and the effect of the accumulation of cohorts. Compelling statistics show improved retention as programs continue (Ulrich et al., 2010). Continued research on the retention of NLRNs beyond the first year is needed to determine further interventions to minimize turnover (Setter, Walker, Connelly, & Peterman, 2011). There is also evidence that these RN residents carry a greater engagement for professional practice and improving patient outcomes (Bratt & Feltzer, 2011; Kramer et al., 2012). Managers working with NLRNs have observed that, following the residency, a greater percentage of residents participate in nursing committees and projects than more experienced staff. With each cohort, there are more applications, better screening, and excellent candidates. This was also supported by Goode et al. (2013) as the residency focus on quality, safety, and evidence-based practice changes the overall institutional culture. Further research is needed to determine the resulting effect on patient outcomes. Continued research is also needed on return on investment. Because there is an upfront cost of the program, the chief nursing officers will need to justify the cost to administrators. Turnover alone is one way to show a cost/benefit ratio, but there may also be outcomes that show that the investment is worthwhile. Raising the professionalism of staff, increased use of evidence-based practice, and improved job satisfaction are factors that recur with additional cohorts of residents. Funding opportunities should also be considered, including government dollars for residency support. A regional program could be possible to assure that organizations with limited financial means could benefit from an NRP (Bleich, 2012). Many organizations, such as those described in the study, have excellent orientation programs and support for NLRNs. It may not take much more money or time to develop the program into an NRP. Adding a mentor component for up to a year and courses designed to specifically address needs of the NLRN may be enough to start. Journal for Nurses in Professional Development
STUDY LIMITATIONS The limitations of the study include the use of a convenience sample. Because of the smaller number of new graduates, response rates were limited in the smaller sites (Sites A and B), making statistical comparison difficult. The academic setting of the three sites limits generalization to community hospitals. The survey used was designed to measure changes over time in graduate nurse experience and confidence. This study only measured a single point in time, 1 year, in order to compare sites. Although the CFGNES was not designed for this, it did confirm that outcomes were similar between organizations in this healthcare system and are a standard tool used in other NRPs.
SUMMARY NRPs are increasingly viewed as different from traditional orientation programs. Competencies for graduates of NRPs also include increased ability to use evidence-based decision making, management of conflict, improved communication with physician, and other healthcare team members, network building, and patient-centered care. The data from this quality improvement study support the evidence-based practice of reducing first-year turnover with an NRP. With the future of a nursing shortage looming, investing in the new workforce is worth the time and money to assure quality nurses who want to stay in their jobs. NRPs will also help others to recognize that nursing is a complex and challenging profession that deserves the time to develop professional competencies. This could be an exciting trend for clinical education and nursing leaders in practice to embrace the opportunity to partner with academic colleagues in order to prepare nurses for the future.
References Agency for Healthcare Research and Quality. (2004). Hospital nurse staffing and quality of care. Research in action, 14. Rockville, MD: U.S. Department of Health and Human Services. Retrieved from http://www.ahrq.gov/research/nursestaffing/nursestaff.pdf Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288(16), 1987Y1993. Altier, M. E., & Krsek, C. A. (2006). Effects of a 1-year residency program on job satisfaction and retention of new graduate nurses. Journal Nurses in Staff Development, 22(2), 70Y77. Beecroft, P. C., Dorey, F., & Wenten, M. (2007). Turnover intention in new graduate nurses: A multivariate analysis. Journal of Advanced Nursing, 62(1), 41Y52. doi:10.1111/j.1365-2648.2007.04570.x Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-Wesley. Bleich, M. R. (2012). In praise of nursing residency programs. American Nurse Today, 7(5), 47Y49. Bratt, M. (2009). Retaining the next generation of nurses: The Wisconsin nurse residency program provides a continuum of support. Journal of Continuing Education in Nursing, 40(9), 416Y425. doi:10.3928/00220124-20090824-05 Bratt, M., & Feltzer, H. (2011). Perceptions of professional practice and work environment of new graduates in a nurse residency www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
81
program. Journal of Continuing Education in Nursing, 42(12), 559Y568. doi:10.3928/00220124-20110516-03 Brewer, C., Kovner, C., Greene, W., Tukov-Shuser, M., & Djukic, M. (2011). Predictors of actual turnover in a national sample of newly licensed registered nurses employed in hospitals. Journal of Advanced Nursing. doi:10.1111/j.1365-2648.2011.05753.x Brewer, C., Kovner, C., Yingrengreung, S., & Dujkic, M. (2012). New nurses: Has the recession increased their commitment to their jobs? American Journal of Nursing, 112(3), 34Y44. doi:10.1097/ 01.NAJ.0000412637.63022.d4 Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2009). The future of the nursing workforce in the United States: Data, trends, and implications. Sudbury, MA: Jones and Bartlett Publishers. Casey, K., Fink, R., Krugman, M., & Probst, J. (2004). The graduate nurse experience. Journal of Nursing Administration, 34(6), 303Y311. Commission on Collegiate Nursing Education. (2008). Standards for accreditation of post-baccalaureate nurse residency programs. Washington, DC: Author. Dillman, D. A. (2007). Mail and internet surveys: The Tailored Design Method 2007 update with new internet, visual, and mixed-mode guide. Hoboken, NJ: John Wiley & Sons, Inc. Goode, C. J., Lynn, M. R., Krsek, C., & Bednash, G. D. (2009). Nurse residency programs: An essential requirement for nursing. Nursing Economic$, 27(3), 142Y147, 159. Goode, C. J., Lynn, M. R., McElroy, D., Bednash, G. D., & Murray, B. (2013). Lessons learned from 10 years of research on a postbaccalaureate nurse residency program. Journal of Nursing Administration, 43(2), 73Y79. doi:10.1097/NNA.0b013e31827f205c Herdrich, B., & Lindsay, A. (2006). Nurse residency programs: Redesigning the transition into practice. Journal for Nurses in Staff Development, 22(2), 55Y62. Hillman, L., & Foster, R. (2011). The impact of a nursing transitions programme on retention and cost savings. Journal of Nursing Management, 19(1), 50Y56. doi:10.1111/j.1365-2834.2010.01187.x Institute of Medicine. (2010). The future of nursing: Leading change, advocating health. Washington, DC: National Academies Press. Retrieved from http://www.iom.edu/Reports/2010/The-Futureof-Nursing-Leading-Change-Advancing-Health.aspx Jones, C. (2008). Revisiting nurse turnover costs: Adjusting for inflation. Journal of Nursing Administration, 38(1), 11Y18. doi:10.1097/01.NNA.0000295636.03216.6f Kovner, C., Brewer, C., Green, W., & Fairchild, S. (2009). Understanding new registered nurses’ intent to stay at their jobs. Nursing Economic$, 27(2), 81Y98. Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: The C.V. Mosby Company. Kramer, M., Maguire, P., Halfer, D., Budin, W., Hall, D., Goodloe, L.,
82
www.jnpdonline.com
& Lemke, J. (2012). The organizational transformative power of nurse residency programs. Nursing Administrative Quarterly, 36(2), 155Y168. Messmer, P., Bragg J., & Williams P. (2011). Support programs for new graduates in pediatric nursing. Journal of Continuing Education in Nursing, 42(4), 182Y192. Myers, S., Reidy, P., French, B., McHale, J., Chisholm, M., & Griffin, M. (2010). Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. Journal of Continuing Education in Nursing, 41(4), 163Y171. doi:10.3928/00220124-20100326-02 Pine, R., & Tart, K. (2007). Return on investment: Benefits and challenges of a baccalaureate nurse residency program. Nursing Economic$, 25(1), 13Y18, 39. Poynton, M., Madden, C., Bowers, R., & Keefe, M. (2007). Nurse residency program implementation: The Utah experience. Journal of Healthcare Management, 52(6), 385Y397. Rosseter, R. J. (2009). Nursing shortage fact sheet. Washington, DC; American Association of Colleges of Nursing (AACN). Retrieved from: http://www.aacn.nche.edu/media-relations/fact-sheets/ nursing-shortage Rosseter, R. J. (2011). Nursing shortage fact sheet. Washington, DC; American Association of Colleges of Nursing (AACN). Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/ nursing-shortage Salt, J., Cummings, G., & Profetto-McGrath, J. (2008). Increasing retention of new graduate nurses. Journal of Nursing Administration, 38(6), 287Y296. Setter, R., Walker, M., Connelly, L., & Peterman, T. (2011). Nurse residency graduates’ commitment to their first positions. Journal for Nurses in Staff Development, 27(2), 58Y64. doi:10.1097/ NND.0b013e31820eee49 Spector, N. (2007). Transitioning new nurses to practice: The importance of collaboration [PowerPointA]. Chicago, IL: National Council of State Boards of Nursing. Retrieved from https://www .ncsbn.org/07_June_Transition.ppt The Advisory Board. (2007). Nursing Executive Center essay: Assessing the trend toward nurse residency programs. Washington, DC: Retrieved from http://www.advisory.com/Research/NursingExecutive-Center/Studies/2006/Transitioning-New-Graduates-toHospital-Practice Ulrich, B., Krozek, C., Early, S., Ashlock, C. H., Africa, L. M., & Carman, M. L. (2010). Improving retention, confidence, and competence of new graduate nurses: Results from a 10-year longitudinal database. Nursing Economic$, 28(6), 363Y375. Williams, C. A., Goode, C. J., Krsek, C., Bednash, G. D., & Lynn, M. R. (2007). Post baccalaureate nurse residency 1-year outcomes. Journal of Nursing Administration, 37(7Y8), 357Y365.
March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
