For New Nurses, Residency Program Improves Confidence, Competence, and Retention

A new registered nurse (RN) has a 26 percent likelihood of leaving his or her first job within 2 years.¹ Often, newly hired nurses with less clinical experience, are expected to perform complex work done by veteran nurses. In addition to the need for nurses with enough education and experience to deliver the high quality health care patients require and deserve, there is a bottom line for hospital administrators to hire and orient a new nurse—a hospital will spend an average of $88,000 per nurse—which makes nurse turnover a threat not only to patient health, but to hospitals’ financial health as well.²

These challenges—helping new nurses transition into their jobs, stay in those jobs, and helping hospitals control their costs, are all addressed by the Nurse Residency Program developed by the University Healthsystem Consortium (UHC) and the American Association of Colleges of Nursing (AACN). While a physician spends a minimum of three years in residency training as an MD, a new nurse often will receive only weeks of clinical orientation before fully assuming an RN patient assignment. The transition into the real world workplace can be daunting and discouraging without support, and a sink-or-swim system contributes to the high turnover rates among newly graduated nurses.

“This residency project is about education and practice coming together,” said Kathy McGuinn, AACN’s Director of Special Projects. “We have nursing faculty and hospital staff working together to bridge the gap and continue a nurse’s education into his or her first year as a practicing professional.”  McGuinn points to Patricia Benner’s landmark 'Novice to Expert' theory as the model around which the one-year residency program was built. "There is a learning curve in every field, explains McGuinn, but in a high stakes, high stress health care setting, you need help keeping your confidence up. The residency program offers moral support, and builds skills that build confidence. It’s common sense, and it’s working extremely well for the hospitals [that] have adopted our program.”

In 2008, hospitals implementing the UHC/AACN residency program (currently 55 in 26 states) saw impressively high retention rates of nearly 95 percent for their new nurses, with a turnover rate of 5.6 percent, far below the national average. At 11 of the participating hospitals, fully 100 percent of new nurses remained on staff at the end of their first year. Based on surveys conducted among the new nurse residents six months into the program and again at the end of the year, the nurses show dramatic improvements in confidence and competence, communication and leadership skills, and reduced stress levels. McGuinn points out that the strength of these results after 12 months, versus at the 6 months mark, makes a powerful case for the full year program.

What does the Nurse Residency Program look like? To begin with, hospitals who purchase the curriculum receive initial and ongoing training for their designated staff facilitators who administer and evaluate the program. The nurse participants themselves have regular classes or meetings where they discuss academic as well as practical knowledge and personal experience. They also perform case scenarios in which the nurses call upon their own clinical experience and ongoing study to solve complex patient cases. The program culminates in new nurses undertaking independent projects informed by published, evidence-based research. For example, participants have completed projects on implementing patient- and family-centered care in the cardiac intensive care unit and the reduction of infections through increased stethoscope decontamination. In many cases, these research projects lead to improved practices at the hospital, such as a new method for settling elderly confused patients at nighttime that was developed by a resident nurse at the University of Wisconsin Hospital.

At the University of Colorado Hospital (UCH) in Denver, adopting the UHC/AACN residency program is benefitting not only new nurses, but the entire nursing staff. UCH's Graduate Nurse Residency Program (GNRP), which the hospital runs in partnership with the University of Colorado, Denver College of Nursing, provides one year of post-baccalaureate education, including 12 to 24 weeks of precepted experience on a clinical unit, specialty coursework, and monthly support meetings. It also relies heavily on the outstanding experienced nurses who serve as mentors for their junior colleagues. In this Denver hospital, newly hired nurses who participate in the residency program also agree to spend at least one additional year working at UCH; which is just one of the ways that the hospital gets a return on its investment in these exceptionally prepared nurses. According to UCH administrators, their residency program is resulting in a large number of applications for the school's three yearly class cohorts. The July 2009 class, for example, had more than 300 nurses from around the country to apply for the 45 openings. 

The looming nursing shortage has multiple causes and multiple effects from which hospitals are striving to protect their patients. Nurses are on the front lines, increasingly providing higher and more complex levels of patient care, and several studies have shown that staffing and education levels of nurses have a direct impact on health outcomes for patients, from reducing the number of infections to increasing overall survival. Yet according to a survey conducted by the National Council of State Boards of Nursing in 2002, health care employers believe that newly licensed RNs do not match experienced nurses in areas like handling emergencies, dealing with unusual diagnoses or quickly performing routine tasks like checking blood pressure. The UHC/AACN Nurse Residency Program addresses these problems by helping hospitals keep more nurses on staff and accelerating the speed at which new nurses become fully participating staff members. “There is a strong business case to be made,” said AACN’s McGuinn. “Not only is it costly to hire or replace a new nurse, it is invaluable to patients to have the highest quality, best educated nurses at their bedside.”

^1. The Robert Wood Johnson Foundation reviews some studies of new nurse turnover rates here, and here.
^2. Journal of Nursing Administration, January 2008.