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Advanced Practice

Creating a Nursing Residency:


Decrease Turnover and Increase
Clinical Competence
Nicole M. Welding
ew graduates are now the
largest source of registered
nurses available for recruitment in the nation, facing difficult
psychological and intellectual challenges as they adapt to their new
careers. Organizational leaders
struggle with new graduates preparedness to practice. Clinical competency and management of multiple transitions not only affect the
new graduate, but also the care of
patients and the health care organization (Dracup & Morris, 2007).
Nursing residency programs (NRPs)
were designed to establish a smooth
transition from student life into professional life. These programs seek to
establish clinical competence, provide emotional support through
transition, and facilitate recruitment
and retention of strong nurse beginners (Diefenbeck, Plowfeild, &
Herrman, 2006).

Background
In recent years, the nursing workforce has experienced a profound
shortage of professionals in patient
care. Recent strong growth of the
nursing profession has been suggested, but growth in the workforce has
been fueled largely by foreign nurses
and those returning to the workforce. The retirement of baby
boomer nurses will impact the nursing shortage, forcing hospitals to
turn to new graduates to staff their
beds and provide patient care
(Diefenbeck et al., 2006).
As new employees and beginning
professionals, new graduates present
a myriad of challenges to their
employers. These include being
unprepared to perform basic skills
and lacking the ability to connect
their classroom experiences to reallife clinical practice. Research by the

New graduates are the largest source of registered nurses available


for recruitment, and graduates are expected to transition quickly
into professional practice. Stress of this transition can lead to high
turnover within the first year. The design and goals of a graduate
nurse residency program to increase competence, leadership, and
job satisfaction, and ultimately decrease turnover are reported.
Nursing Executive Center (2005)
found employers believed only 41%
of baccalaureate graduates were definitely prepared to care for patients.
Graduates face new emotional stressors, such as navigating a new environment and working overnight
shifts, which contribute to increased
turnover in the first year. When they
leave within a year, the hospital
loses its investment in their orientation (Nursing Executive Center,
2005).
Although nursing school enrollment is increasing (Tang & Titler,
2003), reliance on new graduates to
staff hospital beds presents certain
problems. First, new graduate nurses
often lack the skills to transition
quickly to the bedside role. They
also are more likely to resign than
experienced hires; 75% of new graduate nurses leave their job within
the first year, with estimated
turnover cost per nurse of $22,420$77,200 (Nursing Executive Center,
2005). Reduction in turnover costs is
a high-priority goal for institutions
that initiate and utilize NRPs
(Lindsey & Kleiner, 2005).
Most NRPs last 1 year. While different organizations employ multiple strategies for nursing residency
programs, some commonalities
exist. A typical NRP consists of preceptorship on a chosen unit incor-

porated with classroom lecture and


seminars. Each nursing resident has
a mentor, preceptor, or clinical
coach. Along with administrators of
the residency program, these individuals teach new nurses how to
search for support when needed.
Nursing leaders tend to place residents in cohorts of the same specialty, such as critical care, oncology, or
labor and delivery, to allow more
focused discussions that address
clinical situations appropriately.
Nursing residents also are given
opportunities to discuss stressors
and emotional hardships with mentors, who provide advice about
responding in these situations
(Krugman et al., 2006).

Outcomes of Nursing
Residency Programs
Nursing residency programs are
designed to increase retention and
provide essential tools to promote
graduate nurse success and productivity. The University Health System
Consortium (UHC) and the American Association of Colleges of
Nursing (AACN) indicated 95.6%
retention for residents involved in
their NRP. This can be considered a
monumental success compared to
published reports indicating turnover rates of 30% within the first
year of employment (AACN, 2010).

Nicole M. Welding, DNP, RN, is Manager, Nursing SWAT Team, University of Pittsburgh Medical
Center, Pittsburgh, PA.

January-February 2011 Vol. 20/No. 1

37

Advanced Practice
During classroom seminars, nursing residents are introduced to professional practice through discussions of evidence-based practice, critical thinking development, and nursing research. Seminar programs are
developed to enhance job satisfaction, develop clinical competence,
expand and foster critical thinking,
and develop professional practice
behaviors. The goal is to decrease 1year turnover (Rosenfeld, Smith,
Iervolino, & Bowar-Ferres, 2004).
Research found improvement in
competency testing through the
Basic Knowledge Assessment Test
(BKAT) at the completion of a 1-year
NRP (Krugman et al., 2006). BKAT is
used to measure basic knowledge
necessary for providing safe nursing
care and entry into nursing practice.
Herdrich and Lindsay (2006) administered the tool to nursing residents
at Wheaton Franciscan Healthcare
in southeast Wisconsin before they
began the NRP and immediately following program completion. Test
scores improved 12%. The WatsonGlaser Critical Thinking Appraisal
also was administered to the nurse
residents. This tool was designed to
composite the nursing residents
ability to recognize the need for evidence in support of what is asserted
to be true, knowledge of the nature
of valid inferences, and skills in
employing and applying this knowledge. Nurse residents showed 41%
improvement upon completion of
the 1-year NRP. A marked improvement in collaboration, leadership
skills, and communication among
the residents also was reported
(Herdrich & Lindsay, 2006).
In February 2005, the AACN/UHC
Nurse Residency Program Interim
Outcomes Committee published a
report with compelling research outcomes. Besides decreased turnover,
this report documented increased
confidence, competence, and mastery among nurse residents. Nurse
residents felt professionally empowered through their learning experiences and had positive testimonies
regarding the residency. According to
Herdrich and Lindsay (2006), nurse
residents described feelings of overall
job satisfaction, confidence in practice, and empowerment through new
38

knowledge established in the nursing


residency program.

A Western Pennsylvania
Medical Center Nursing
Residency Program
Nurse leaders at a western
Pennsylvania medical center initiated the first nursing residency program in August 2008. This medical
center is an integrated global health
enterprise and one of the leading
nonprofit health systems in the
United States. The program was
designed to encompass two cohorts
of graduate nurses entering the system beginning in June 2008. Of the
20 hospitals affiliated with the center, six were chosen to initiate the
program with plans to expand the
initiative in the future.
The nurse residency team comprises members from administration
and education. Members of the
organizations nursing administration spearheaded the program and
designed the team, which included
the vice president for the system,
the director for academic partnerships, a clinical educator, and two
nursing instructors from the organizations diploma nursing programs.
Chief nursing officers (CNOs)
from the six hospitals were contacted to identify their top-performing
nurse managers. Each CNO chose
these nurse managers based on
patient satisfaction, overall nursing
satisfaction, and historically low
nursing turnover rates. Twenty-five
nurse managers and their newly
hired graduate nurses within the six
hospitals were asked to participate.
Each nurse manager was able to hire
as many graduate nurses as necessary, and each graduate was part of
the NRP.
Each graduate nurse on the pilot
units began orientation during June,
July, and August based on the date
of hire. Each graduate attended hospital orientation at the specific hiring institution, including human
resources orientation, 1 week of general nurse orientation, and 1 week of
basic arrhythmia class. Graduates
hired into critical care units were
expected to attend a week-long critical care class and pass a critical care
exam.

After the basic hospital orientation, each graduate began the yearlong clinical orientation with a chosen preceptor. Within the first week
of graduate hire, a readiness tool was
administered electronically to each
new graduate, preceptor, and nurse
manager. The tool assessed the graduates readiness to participate in the
NRP, and required the graduate
nurse to specify the preferred cohort
to enter in August and October.
Program Implementation. Beginning in July 2008, each preceptor
and nurse manager attended the
first of six 1-day intensive leadership
development activities offered over
a 9-month period. Courses were
held in August, October, and
November 2008, and February,
March, and April 2009. The nurse
managers and preceptors received
the first orientation session, followed by the nurse residents. The
main goal of these six sessions was
to help nurse managers and preceptors learn about their management,
leadership, and learning styles.
Once participants gain knowledge
about their unique styles of communication and behavior, they can
begin a journey toward positive
change, leadership, and mentorship
as necessary attributes for mentors.
During the first session (see Table
1), a program overview was provided, and leadership and coaching
were discussed. The second session
focused on personality styles and
the management of horizontal violence within the nursing profession
(see Table 2). At the following two
sessions, these topics were expanded
with discussion of trust in the workplace (see Table 3) and positive
change within organizations (see
Table 4). Session five (see Table 5)
challenged participants to incorporate systems thinking leadership
into case studies, and the final session concluded the program with a
presentation about spiritual intelligence (see Table 6).
The nurse residents participated
in the same curriculum as the preceptors and nurse managers. A
monthly session was held for the residents throughout the year, and the
last session in April included the
entire group of residents, preceptors,

January-February 2011 Vol. 20/No. 1

Creating a Nursing Residency: Decrease Turnover and Increase Clinical Competence

TABLE 1.
Session 1
Objective

Activity

Provide a program overview.

15-minute presentation

Analyze communication styles and


personality attributes.

Disc assessment inventory distributed

Discuss adult learning styles and


principles of adult learning.

1-hour presentation

Define generational differences.

1-hour presentation

Discuss how to provide positive


feedback and coaching.

1-hour presentation

Discuss the fundamental elements of


leadership accountability.

1-hour presentation

TABLE 2.
Session 2
Objective

Activity

Identify the impact of personality styles


on leadership and human interaction.

Distribution of the
Myers-Briggs Inventory

Discuss the developmental journey of


the graduate nurse.

1-hour presentation entitled:


From Chaos to Confidence

Define horizontal violence in the


workplace and discuss appropriate
interventions.

1-hour presentation

Identify concepts of change and barriers


to becoming a positive change agent.

2-hour presentation

TABLE 3.
Session 3
Objective

Activity

Define trust; understand trusts


relationship to high performance and
organizational success.

4-hour workshop presenting concepts


from the book The speed of trust: One
thing that changes everything (Covey,
2006)

Identify the importance of trust in


leadership positions.

3-hour panel presentation by the hospital systems top executives

TABLE 4.
Session 4
Objective

Activity

Identify different conflict handling modes


affecting group dynamics; identify
appropriate communication strategies
during conflict.

Distribution of the Thomas Kilman


Conflict Mode Inventory; 2-hour
presentation/discussion on conflict and
communication

Identify the impact of change on


organizations; discuss the importance of
positive change.

2-hour presentation on positive change

Renew ways to build trust within groups

Group activity: Rocky Mountain Ice

January-February 2011 Vol. 20/No. 1

and unit managers. Leaders at the


medical center decided to use the
UHC curriculum throughout the
program. UHC partnered with the
AACN to develop a nursing residency program curriculum that has been
adopted widely by health care systems in the United States; research
suggests this curriculum is beneficial
to graduate nurses (AACN, 2010).
The goal was to promote leadership
thinking and nursing excellence, as
well as foster critical thinking skills
and safe clinical practice.
Program Evaluation. Evaluation
of program effectiveness will be
ongoing. Each session for the first
year was evaluated for effectiveness.
A basic evaluation was distributed
after each speaker and results were
tallied by the nurse residency team.
Data were entered into a software
system at the medical center, and
team members tracked participants
analyses of each presenter. In addition, the final session in April 2009
ended with an evaluation of the
entire program. All nurse residents,
preceptors, and nurse managers
involved in the program were asked
to complete an online survey.
Results were tallied electronically,
generating real-time graphics for
effective analysis of results.
A major goal for the NRP was to
decrease graduate nurse turnover
within the first year of employment.
The nursing residency team and the
chief nursing officer set the goal to
decrease system-wide turnover from
15% to 10% within the first year of
creation of the NRP. Staff in each
institutions human resources department was asked to track turnover and send a monthly report to
the nursing residency team and the
CNO. Queries of these data were
maintained in Peoplesoft (Laramie,
WY, 1987). This system allows data
to be created and compiled easily in
order to track turnover precisely.
A final major goal of the nursing
residency program was to increase
residents comfort with clinical
skills, thereby enhancing their critical thinking abilities and communication with the health care team.
Residents progress during the first
year of practice was tracked through
regular communication with nurse
39

Advanced Practice
TABLE 5.
Session 5
Objective

Activity

Learn to measure leadership


competencies; apply Kouzes and
Posners 5 Practices of Exemplary
Leadership to organizational
challenges (Kouzes & Posner, 2003).

Distribution and analysis of Leadership


Practices Inventory

Define systems thinking leadership;


apply systems thinking into the health
care system.

2-hour presentation on systems


thinking

Incorporate systems thinking


leadership into case study scenarios.

Group activity/case study: Friday Night


in the ER

TABLE 6.
Session 6
Objective
Identify unique dimensions of diversity
in both nursing staff and patients;
explain and define spiritual intelligence
and its implications for the nursing profession.

preceptors who were responsible for


ensuring residents safe skills performance as well as documenting
their weekly progress. Every nursing
resident had a 6-month evaluation
in which the nurse manager and
preceptor discussed with the resident his or her progress and anticipated goals for the remainder of the
orientation period.
True evaluation of the impact of
this program will not be evident
until the program has been in effect
for several years. The nurse residents
involved in the program will be followed throughout their careers within the medical center. Evaluation
will include residents annual performance reviews, continuing education endeavors, contributions to
their unit development, and professional advancement.

Activity
4-hour presentation on Spiritual
Intelligence

ing on a journey to maintain an efficient NRP that will produce competent bedside nurses prepared to be
professional leaders. Nursing residency programs are not a quick
solution for nursing turnover or skill
building; however, they offer an
effective way to address the needs of
new nurse graduates. Nurse leaders
at this medical center and other hospital systems offering NRPs will
need to evaluate the programs regularly and revise them based on the
needs of the served populations.
Nursing residency programs may be
a solution to the need for mentorship and smooth transition into
professional nursing practice, and
hospital leaders have the responsibility to create programs that will
contribute to the development of
strong nurses who provide outstanding patient care.

Conclusion
Many nursing leaders throughout
health care are turning to the nursing residency program as a means to
combat new graduate nurse turnover and lack of skills needed to succeed in the hospital environment.
This medical center is now embark-

40

REFERENCES
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Covey, S. (2006). The speed of trust: One thing
that changes everything. New York:
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Diefenbeck, C.A., Plowfeild, L.A., & Herrman,


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January-February 2011 Vol. 20/No. 1

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