Effective transitions

nurse residency program

ANA, nurse leaders support RN residency programs.

Although most new nurses are excited when they finally begin their careers, their enthusiasm can be dampened by worries about keeping pace with new workloads, becoming familiar with policies and procedures, and—even worse—harming a patient.

More than 50% of new nurse graduates leave their first position within 12 months of employment, and some 6% leave the profession entirely in the first year of practice, according to information provided in support of an ANA House of Delegates (HOD) resolution, introduced by ANACalifornia (ANAC) last year and designed to curb this disturbing trend. A background report accompanying the resolution further noted that the reasons for their departure include job dissatisfaction, stress, and poor physician-staff relationships.

Today’s work environment is much different from the one former ANAC president and long-time nurse educator Louise Timmer, EdD, RN, entered in 1970 as a freshly minted diploma program graduate. To begin with, she felt better prepared to enter the workforce after spending her entire senior year building her clinical skills on convalescing patients and functioning as a team leader and charge nurse.

“Back then people stayed in the hospital for 2 weeks, so patients were in various phases of recovery,” Timmer says. “Now we’re putting the burden on neophyte nurses to take care of the sickest patients right away and with little clinical judgment. These new nurses are expressing fear and concern about taking care of very sick patients with only a few weeks of orientation. And what we’re finding is that some new graduates are hospital-hopping until they accrue 6 or 9 months of orientation.”

To help new nurses succeed and to stabilize the workforce, Timmer and her ANAC colleagues submitted the HOD resolution, which nurse delegates subsequently approved. The resolution calls for ANA to support nurse residency programs and other initiatives that facilitate new RNs’ successful integration into the work environment. It also asks that ANA bolster nursing research identifying principles and components for new nurse orientation programs, as well as research evaluating the effectiveness of those programs.

The American Association of Colleges of Nursing (AACN) also advocates for hospitals to adopt 1-year residency programs. “If physicians are given 3-plus years to make this transition, why are nurses expected to hit the ground running?” says AACN president Fay Raines, PhD, RN. “The data are very clear that nurses who complete a comprehensive residency are much more likely to stay in their positions for more than a year’s time and are more satisfied in their work.”

Even with an economy that’s tightening up opportunities for new nurses in some geographic areas, experienced nurses still view RN residency programs as a good investment for new graduates, hospitals, and the profession.

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A national model

While serving as the director of research and education at Childrens Hospital, Los Angeles (CHLA) in the late 1990s, ANAC member Charles Krozek, MN, RN, FAAN, developed the hospital’s RN residency program. “We were having difficulty hiring experienced pediatric nurses, so we were using a fair amount of travelers and asking staff to work overtime,” Krozek says. Further, the hospital’s turnover rate for new graduates was 36% at 12 months and 56% at 2 years. We wanted to have a quality workforce that was stable and practicing in a standardized way, and we knew that new graduates were important to maintaining a workforce,” he says.

With an $800,000 California workforce grant, Krozek and his colleagues created a new nurse orientation framework in 1999 that relies heavily on strengthening new RNs’ skills at the bedside using evidence-based practice, and uses senior nurses to serve as preceptors, mentors, and debriefers.

Because the highly structured program proved to be effective at CHLA and three other children’s hospitals in Southern California, its developers created a nonprofit corporation and took the program nationwide in 2004. To date, Versant Nurse Residency has been implemented at more than 70 hospitals with more than 5,000 residency graduates, reports Krozek, president and managing director of Versant.

The pediatrics residency lasts 22 weeks, and the adult acute-care residency, started in 2005, lasts 18 weeks. Both include a skills lab component and content-building sessions; however, 80% of nurse residents’ time is spent at the bedside working with a trained preceptor.
“The benefits of having new nurses go through a standardized immersion program are that the residents get confident and competent in a relatively short period of time,” Krozek says. Further, the overall turnover rate in hospitals using Versant is 7% in 12 months and 19% at 24 months. The retention rate at 5 years is 65%.

Gina Greco, MSN, RN, is a clinical nurse specialist in neuroscience and a nurse mentor at the University of Southern California (USC) University Hospital, which uses the Versant residency. “When I started in the ICU, I remember thinking, ‘Please let me get through the shift without harming anyone,’” says Greco, whose career now spans 10 years. “Many new nurses have similar fears but they don’t want to vocalize them because they think they’ll be viewed as incompetent. The residency adds many layers of support for new nurses.”

As a nurse mentor, Greco co-leads peer-group sessions, which focus largely on practice issues, and maintains an open-door policy. “Because I don’t work directly with nurse residents on their units, they can come to me with any question, such as how to navigate a policy or perform a procedure, or ask me career advice,” Greco says. Overall, she believes that nurses who go through the residency are better prepared to be team players and are able to communicate more effectively with patients. “That leads to increased patient satisfaction and better care,” Greco says.

Joy Chunghee Kim, RN, completed the residency and has been working on her own as a staff nurse in the surgical ICU at USC University Hospital since July 2008. Kim says the residency helped her feel accepted on the unit, and the support of her preceptor, nurse manager, and charge nurses “empowered” her to function successfully as a nurse. “Sometimes I still struggle about whether I can handle a very sick patient, but I have my preceptor who is there to support me even though I’m through with the residency,” she says.

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A single-center model

At Vanderbilt University Medical Center (VUMC), nurses express similar positive outcomes with their nurse residency program, which they started 7 years ago with only a pediatrics track. “It was seen as a great success in helping new nurses transition from the student nurse role to the professional nurse role,” says Debianne Peterman, PhD, RNC-NIC, NE-BC, VUMC director of nursing education and development and a Tennessee Nurses Association (TNA) member.

Two years ago, VUMC expanded the program to include specialty tracks in women’s health, adult critical care, adult health-medical, and adult health-surgical. Nurse residents, who typically take their NCLEX early in the program, first complete a 6-week general orientation in which they rotate to several units within their specialty track. After that they are placed on a specific unit where they continue their residency program for 6 to 12 weeks. “Nurse residents are nurtured by preceptors and coaches all along the way,” says Tracey Fargo, RN, the program’s nurse recruiter and a TNA member.

In addition to its own unit-specific curriculum, VUMC uses core competencies that are part of the University HealthSystem Consortium (UHC)/AACN residency program, which the hospital helped pilot in 2004, Peterman reports. (The UHC/AACN Residency Program™ now provides a year-long curriculum focused on leadership, nurse-sensitive outcomes, and professional development, and has a first-year retention rate of 94.4%.) “Our two major goals are that we want graduates to make a successful transition into the workplace, and we want them to provide safe, quality care,” Peterman says.

A key feature of the VUMC residency is the matching process in which nurse residents, management, and unit staff have input into the new nurses’ final placement. “Sometimes nurse graduates come to us and say they want to be in specific critical care units, because their image of them is slick and exciting,” Peterman says. “Once they get an inside view of some of the units, they can make informed decisions about which unit might be right for them, and that helps with nurse retention.”

Fargo says the program has led to decreased nurse turnover and a more satisfied nursing workforce. This January, VUMC accepted 117 nurse graduates into the program and more than 350 candidates were selected for interviews for the summer program.

Timmer believes that RN residency programs should be part of all new nurses’ transition into the workplace. She acknowledges that these programs require a financial investment up front, but the cost is recouped by having reduced recruitment, hiring, and orientation expenses because of lower turnover.

“There have been many changes in health care,” Timmer says. “It’s time for nurses to change along with it by supporting residency programs that help new nurses gain confidence and clinical judgment, and hospitals gain a more knowledgeable and experienced nursing staff.”


Susan Trossman is senior reporter in ANA’s Communications Department.

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