Nurse Residency Programs
& New Registered Nurses
Developing Skills and Improving Retention
Deidre Dennison
Preceptor: Reina Kurrelmeyer, MBA, BSN RN
NUR444
12/08/13
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The main objective of this project was to determine if nurse residency programs (NRPS)
are effective in decreasing the rates of new graduate nurse turnover within the first year of
employment at Albany Medical Center (AMC), and compare that to the findings of programs
nationally. As a former participant/graduate of a NRP, I also had a personally professional
objective of exploring what goes into the process by the facilitators, the overall efficacy of the
program, and how the program at AMC has been altered based on feedback.
New graduate nurse attrition is an ongoing problem that plagues the profession
nationwide. Little, Ditmer, and Bashaw (2013) report that the attrition rate for new graduate
registered nurses in the first year to range between 35% - 61% (p. 361). This impacts a variety
of components related to delivery of care, institution costs, and the perceived nursing shortage.
According to the American Association of Colleges of Nursing, nurse residency programs have
been implemented in almost 100 sites nationwide in an effort to assist the new registered nurse in
a successful transition from novice learner to a more competent provider. The purpose of the
project was to highlight the problem of high new nurse attrition rates, its causes/effects, and the
implementation of NRPs as a possible way to reduce this problem.
High rates of attrition amongst new graduate registered nurses is a problem within the
profession, and has many implications specific to nursing. However, this also has implications
related to the delivery of care, and becomes a healthcare issue as well. Many novice nurses lack
skills such as time management, appropriate delegation, interdisciplinary communication, and
prioritizing patients – things that are difficult to learn in school. All of these can translate into
lower quality of care for the patient, despite the best intentions of the nurse. Although there is
limited data regarding the direct impact of NRPs on quality of care, it is important to remember
that it can be difficult to measure ‘care’ in quantitative terms. Instead, it is useful to focus on
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how well the nurses are developing the skills necessary to be a competent provider through the
implementation of NRPs. After reading some of the pool of data on the topic of NRPs, the
literature shows an overwhelming positive experience with NRPs increasing retention in general,
and more specifically the skills that the new graduate needs to be successful and effective. For
example, primary research conducted by Rhodes et al.(2013), shows an increase in all 36
qualities/skills that were examined. Among these 36 items there were marked increases in
proficiency in skills such as documentation, physician/team communication, interpretation of
assessment data, amongst other things.
My project included observation/participation in 6 four-hour nurse residency sessions in
groups that were at different times in the 12-month program. The remaining clinical hours I
spent going to the units that my preceptor was assigned to check in with nurses in her ‘cohort’
groups in their clinical setting to see how things are going and to offer support. During these
rounds we also talked with the unit managers to see how things were progressing from their
prospective. In most cases it was going well, although there was one instance when we followed
up with a nurse manager a number of times regarding an employee who was having trouble for
various reasons. We also spent approximately 4 combined hours going to a Clinical Standards
meeting as well as a Resuscitation Committee meeting. In general there seemed to be a
favorable response to the sessions in personal and professional ways. Something unique to
Albany Medical Center’s NRP is the development of a project within a smaller ‘cohort’ group
based on specialty (surgical, medical, critical care, women/children). The projects required that
the groups chose a research topic, find academic quality references/sources, make a Power Point
project, and present it to the nursing leadership at the last of the 12-month sessions. Time, and
assistance by a variety of nurse educators, were available during every session. The
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presentations are a highlight of the program, and some have been implemented as policy or
changed policy within the organization.
Many of the skills that are introduced, or reinforced/developed in NRPs are also
consistent with leadership skills. This applies especially to proficiency in communication,
accountability, delegation, prioritization, and conflict management. These are all skills which
are important not only in clinical work, but also leadership roles. According to information
shared with me by a different nurse educator at Albany Med, approximately a dozen NRP
graduates have received a ‘Success Stories’ at award presented from the person who nominated
the individual as well as the nursing leadership within the organization. I am among the group of
recipients; I was nominated by my assistant nurse manager. The benefits of NRPs go beyond
new graduate nurse retention, and also have positive effects on patient care and the overall work
environment. According to Rhodes et al., based on research they conducted, experienced nurses
working with the newly licensed nurses viewed the program as beneficial, and expressed
increased performance on the part of the new nurses. Therefore, “it benefits the experienced
nurse to have better prepared NLRNs [newly licensed registered nurses], which results in better
work collaboration, teamwork, professionalism, and ultimately, job satisfaction” (Rhodes et al.,
2013 p. 528).
The theory that immediately struck me as perfect in this instance was Benner’s Novice-to
Expert Model. Benner’s Model “describes stages in the progression of patient care expertise”
that is related to experience (Hood, 2010 p. 13). According to Benner’s theory, there are 5 stages
of proficiency in nursing: Novice, Advanced Beginner, Competent, Proficient, and Expert. The
novice is considered a student/graduate with little to no background and is focuses primarily on
rules and exhibits “rule governed behavior” (Hood, 2010 P.13). The advanced beginner is a new
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graduate that is marginally acceptable in their performance and typically need help when setting
clinical priorities. According to Hood (2010), “advanced beginners typically become very
uncomfortable when they encounter chaotic clinical situations” (p.14). The competent
practitioner can identify long-range goals, critical thinking skills, and are efficient and organized.
They also need to think of their actions/interventions when in a chaotic clinical situation. The
proficient practitioner is more fluid in the care they provide because they do not have to think
about their interventions on the same level as less proficient practitioners. They tend to notice
more of the nuances in situations, which make them more clinically astute. They are also
creative and adaptive in unfamiliar or chaotic clinical situations. The final stage is the expert.
This is reached after extensive clinical experience. The expert practitioner acts effectively and
naturally in any clinical situation.
Although the experience aspect of this theory will come with continued practice by the
new nurse until they develop into ‘proficient’ or ‘expert’ providers, NRPs can help the
novice/advanced beginner graduate transition into competent nurses. This is accomplished by
providing support and skills that foster critical thinking, organization, and prioritization. The
residency sessions that I attended during this clinical project included speakers on topics such as
health literacy as it related to patient/family teaching, dealing with difficult families and patients,
appropriate delegation, prioritization, and simulation teaching. Sitting in on different sessions
that were at varied points of the program, it was interesting to hear the situations they had
experienced, the ways in which they dealt with certain situations with patients and physicians,
and how they felt they were doing overall. Developing the skills necessary to be an effective
practitioner can be augmented by the addition of NRPs. The insight into a nurse’s practice that is
encouraged through the use of NRPs fosters professional growth.
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The implementation of my project was smooth, with minimal roadblocks. One of the
more difficult aspects included scheduling blocks of time that were typically 7:30am-11:30am
for the NRPs sessions, and time in the afternoon, typically 12:30pm- 4:30pm for meetings. The
NRP sessions required that I be off during the morning of clinical, and not have worked the night
before. Upon requesting to work with my preceptor I was welcomed into the group at the Center
for Learning, included in the sessions, and encouraged to add information relevant to my own
experience. I was asked by one of the leaders of the NRP if I would speak at a session for groups
in order to provide feedback from being in practice for a few years after completing a NRP.
Aside from scheduling, the only other interesting ‘snag’ was that after sharing specific data with
me in relation to Albany Medical Center’s retention rates, costs, etc., I was asked not to share it
based on the fact that the organization is attempting to publish their own research findings. Of
course I agreed to comply with their request and am permitted to say that the NRP has, in fact,
reduced rates of attrition of new graduate registered nurses at Albany Medical Center in general.
I think that the implementation of my project was successful as a result of the time I had spent
reviewing the literature I had gathered prior to beginning a majority of the clinical time
I experienced. I also had the benefit of being in a teaching hospital, and as there is a lot of
emphasis on continuing education for nurses, the leaders at the Center for Learning are
enthusiastic in having eager clinical students.
Based on the objectives listed in the beginning of this report, the project was successful in
its endeavors. I was able to determine that as a whole, NRPs are effective in increasing new
registered nurse retention rates, developing skills that are necessary for professional practice, and
preparing nurses to become more competent practitioners. Although I am not at liberty to give
specific information about Albany Medical Center’s NRP, it certainly has increased rates of
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retention, which is consistent with the literature review that I performed. A personally
professional objective that I mentioned initially was to explore what when into running a NRP
from the side of the nurse educators involved. I was able to spend time with my preceptor, and
take an active role in some things with her. I felt as though she trusted me with information
about the institution, and shared with me the effort that comes with the development and constant
assessment of a NRP. The information that I read in relation to Albany Medical Center included
feedback from approximately 40% of the NRP graduates at Albany Med, and reinforced the idea
that fostering professional skills in transition from student to effective registered nurse through a
year-long NRP is beneficial to the nurses as well as the institution.
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References
Hood, L. J. (2010). Leddy & pepper's conceptual bases of professional nursing. Philadelphia,
PA: Wolters Kluwer Health.
Little, J. P., Ditmer, D., & Bashaw, M. A. (2013). New graduate nurse residency: A network
approach. Journal Of Nursing Administration, 43(6), 361-366
Theisen, J. L., & Sandau, K. E. (2013). Competency of new graduate nurses: A review of
their weaknesses and strategies for success. Journal Of Continuing Education In
Nursing, 44(9), 406-414.
Trepanier, S., Early, S., Ulrich, B., & Cherry, B. (2012). New graduate nurse residency
program: A cost-benefit analysis based on turnover and contract labor usage.
Nursing Economic$, 30(4), 207-214
Rhodes, C., Radziewicz, R., Amato, S., Bowden, V., Hazel, C., McClendon, S., & ... McNett, M.
(2013). Registered nurse perceptions after implementation of a nurse residency program.
Journal Of Nursing Administration, 43(10), 524-529