Anderson, Teresa MSN, RNC-OB, NE-BC; Linden, Lois EdD, RN; Allen, Marsha MSN, RN; Gibbs, Elizabeth MS, RN
In highly complex healthcare environments,1 new graduates face patients requiring high-intensity care, heavy workloads, unfamiliar technologies and psychological stressors. Turnover rates for new graduate nurses are estimated at a staggering 55% to 61% during the first year.2,3 New graduate nurses' first positions shape perceptions of nursing roles, professional growth, and job satisfaction.4 To improve retention of new graduates, innovative orientation approaches, such as our interactive nurse residency curriculum, need to be developed and evaluated. New technologies and innovative approaches engage new graduates in the workplace. Kovner et al5 examined the work satisfaction factors of registered nurses (RNs). Work-group cohesion, autonomy, and supervisor support (entities that are fostered by the nurse residency curriculum) were significantly related to RNs' job satisfaction. Satisfied nurses became engaged. A 2006 study6 demonstrated that nurse engagement increased retention and resulted in improved patient satisfaction, outcomes, and safety.
Over the past several years, our organization, a healthcare system in the Midwest with 5 metropolitan hospitals, has invested millions of dollars to recruit new graduate nurses to fill the many openings, which have resulted from significant growth and turnover. Organizations across the nation have been faced with similar circumstances, as experienced nurses are not available in many regions.
In 2001, 1-year retention rates for new graduates hired into our system were below 60%, and orientation costs were creating a significant drain on budgeted dollars. At that time, a $10,000 welcome bonus program and a didactic nurse residency were implemented. The bonus was essentially a loan, which was forgiven in its entirety if the nurse remained employed within our system for 2 years from the date of hire. Further data in 2006 revealed that the bonus program and didactic residency had resulted in a 1-year retention rate consistently above 85%; however, 2-year retention remained at 71%. Turnover had merely been delayed from 1 to 2 years. Orientation dollars were still being paid at a high rate, and novice nurses, approximately 150 per year, consistently joined our system.
It became evident that changes would need to occur. A transition from welcome bonus dollars to retention bonus dollars to retain more nurses at the 2-year employment anniversary was needed. In 2006, a task force was formed to begin the development of a nursing excellence award program for nurses employed for more than 2 years that would provide annual awards of $3,700, $4,200, or $6,300 for high-performing nurses with 2, 3, or more than 5 years of experience, institutional review board approved study, meeting criteria related to advanced education, certifications, committee/professional organization participation, evidence-based practice/research, and quality improvement activities. This program, Advancing Professional Excellence in Nursing (APEx-N), was launched in 2007.
Second, a revised approach to the nurse residency that would move new graduate nurses from novices to advanced beginners sooner seemed an appropriate step. The authors searched the literature and created a plan for a highly interactive nurse residency curriculum using a number of educational strategies, including high-fidelity simulators, as a means to promote critical thinking and team building in new graduate nurses.7 A proposal that outlined the implementation plan for the transition to the new curriculum and the expected benefits of the program, including cost savings, was presented to the chief nursing executives of our system for their approval, and the new curriculum was implemented in September 2006. The effectiveness of this nurse residency in impacting job satisfaction and engagement of new graduate nurses was simultaneously studied as the change was implemented.
A New Nurse Residency
The revised nurse residency program was introduced to 120 new graduate nurses hired within our system in the summer of 2006. Ninety of those nurses participated in the research to evaluate the change.
Each new nurse completed the 1-year nurse residency, which included 2 ½ days of interactive sessions, followed by e-mail communication with peers and faculty, the completion of a professional portfolio, and monthly guided journal assignments, submitted to system advanced nurse specialists for feedback and mentoring. In addition, the nurse residents were paired with the traditional experienced nurse preceptors to orient them to their specific nursing units. The interactive sessions followed 3 themes: professionalism, clinical practice, and interdisciplinary care planning. The first day, which focused on professionalism, provided an 8-hour experience offering critical thinking related to priority practices of service excellence, ethics, quality, values, and safety. The second day, or Clinical Practice Day, consisted of 5 patient scenarios facilitated with high-fidelity simulators that offered each participant the opportunity to interact with peers to apply the nursing process, psychomotor skills, critical thinking, and communication to plan and coordinate care for their "patients" with 5 different diagnoses. Scenario diagnoses included chronic obstructive pulmonary disease, cancer, gastrointestinal bleeding, congestive heart failure, and drug overdose. During the final session, participants explored interdisciplinary patient care planning, collaborative networking, and professional career coaching and goal setting.
The residents were asked to provide input about the teaching methodologies and content at the end of each session. This feedback was incorporated into future nurse residency sessions. Program outcomes and career goals developed by each resident were shared, with permission, with each corresponding nursing operations director, the frontline nursing managers within our system. Each resident was asked to schedule a meeting with his/her director to discuss career goals and competency needs. The overall outcomes of the program were evaluated in the research study.
Measuring the Overall Outcomes
Nurse residents participating in the IRB-approved study completed a demographic data form, our system employee engagement custom questions survey, and the Halfer-Graf Job/Work Environment Nursing Satisfaction Survey before and after attending nurse residency education sessions. The employee engagement survey, an unpublished tool, consisted of 14 questions seeking degree of agreement using a 5-point Likert scale, used with the Gallup Q-12 Employee Engagement survey, which was not a part of this study. Common factors of engaged nurses such as feeling valued, recommending the organization to others, inclusion in decision making, trust, safety, support for innovation, and effective leadership were assessed. The Halfer-Graf Job/Work Environment Nursing Satisfaction Survey was developed by Halfer and Graf8 to determine RNs' perceptions of their work environment and job satisfaction, including sources of professional fulfillment and perception of the work environment over time. Parts A and B of the Nurse Residency Teaching Strategy Effectiveness Survey were completed after the nurse residency to measure perceived value of teaching strategies, both immediate perceptions and over the 1-year nurse residency period.
The quantitative data from these surveys were analyzed using a nonparametric Mann-Whitney U test to determine if posttest scores differed from baseline scores. Before this quantitative analysis, the responses to the 4 Halfer-Graf open-ended questions were classified into themes by 2 of the authors based upon general response categories and frequency of responses falling within those categories. Individual coding of responses by 2 researchers, followed by collaborative validation of individual findings, resulted in identified themes.9 Essentially, all recorded responses were grouped by key words, and these groups emerged as themes.
Patients, Patient Satisfaction, and Patient Outcomes
Respondents felt strongly that "helping patients and watching them get better" were a major satisfier. Patient satisfaction responses were also coded within this theme. This theme seems to address the need for the nurses to establish a therapeutic relationship with the patient and family, facilitating goal setting and allowing the nurse to help them directly. This resulting nurse satisfaction and a sense of success demonstrate the powerful relationship between patient satisfaction and nurse satisfaction, which Gallup describes as the "human sigma."10
Teamwork and support of tenured staff were important to these nurse residents. An exemplar was "Teamwork-it helps to have people work together and have positive attitudes." The availability of trusted preceptors and mentors allows the new nurse to feel supported in his/her learning during the transition period.11 Belonging to the "team" is facilitated by a visible and accessible immediate supervisor, who connects with the new nurse to guide development.12 A consistent and supportive manager was noted as an important aspect of the environment at the conclusion of the residency, which is consistent with previous study findings.3
Lack of teamwork was characterized by comments such as "backstabbing" and "grumbling and gossiping among staff." The strength of feeling related to the importance to good teamwork as a satisfier makes it logical that an environment lacking this essential component would be equally dissatisfying. The role of the manager to assess and maintain a culture of supportive, collaborative practice is crucial for the success of new graduates as they integrate into the team.
Scheduling and Staffing
Before completing the nurse residency, new graduates suggested adequate staffing and increased knowledge as ways to improve the work environment. One year later, hours and scheduling replaced lack of knowledge as important factors. Staffing consistently remained the top suggestion to improve job satisfaction at all 3 points of data collection, with the need for more ancillary staff also suggested by a few respondents. "Having enough nurses to give the best patient care" is seen as the solution to job dissatisfaction. Evaluation of current care delivery systems and medical surgical staffing plans and ratios occurred secondary to this and other feedback, resulting in increased staffing ratios and RN/LPN partnership models and other strategies across the health system. Technological advances to improve care delivery efficiencies included medication bar coding, electronic nurse-to-nurse hand-off technology (VoiceCare), and electronic monitoring by intensivists and critical care nurses for the most acutely ill patients (eFocus). A computerized self-scheduling software package has been implemented, which has provided staff with more control over requests and individualized schedules (Smart Square).
Physician disrespect was more evident early in the patient care experience and was characterized by statements such as "lack of respect from physicians and feeling degraded by them at times" and "physicians assuming I am incompetent." One-year follow-up data did not reflect this as a strong theme, which would be consistent with increased confidence and competence as the nurse leaves the novice role behind. System strategies to improve interdisciplinary communication and conflict management, as well as mandatory diversity training, are ongoing efforts to continue to strengthen mutual respect and collaboration.
The revised nurse residency program was designed to assist new graduates to transition into our system environment successfully, to support them in becoming competent and confident in their nursing role, and to increase their level of job satisfaction with the hope of improving year 2 retention. The employee engagement scores of the nurse residents before completing the nurse residency, after completing the education sessions, and 1 year later were measured using the surveys mentioned. There were 3 nurse residency groups that completed the program, each one starting 3 weeks apart. The engagement of all 3 groups was similar to that before the nurse residency, except for one group that felt more positively than the others on how well the organization lived the mission every day, departments work together to provide excellent service to our patients, and supervisors are open to ideas and suggestions. After the nurse residency, a significant number of residents believed in the organization's commitment to living out its mission every day, which was a job satisfier for them.
After the nurse residency sessions and 1 year later, the quantitative findings on the Halfer-Graf survey revealed that the nurse residents significantly perceived that they were able to perform their job, identify resources, understand performance expectations, accomplish work tasks, and manage the demands of the job effectively. They also perceived that they had developed effective work relationships, that they were accepted by other disciplines as members of the team, and that their professional contributions were valued. Nurse residents reported a decrease in overall job satisfaction at the end of the first year of employment. In addition, there was a significant decrease in the perception that staffing schedules were managed fairly. The findings in this study compare to the validity and reliability data previously reported for the Halfer-Graf Job/Work Environment Nursing Satisfaction Survey. Reliability and validity of the Halfer-Graf tool were supported.
Valuable Teaching Strategies
E-mail communication, simulation scenarios with postsession debriefings, and professional portfolio development are valuable strategies identified by the nurse residents. Clinical journaling assignments received mixed evaluations, with some nurse residents perceiving them as "busy work," whereas others found them to be a helpful tool to guide reflection and professional role development. Journaling topics directly related to clinical situations, such as patient rights, pain management, and service excellence, were better perceived than professional role topics such as professional development and career advancement. Some residents reported support in their transition from the advanced practice nurse advisors who were available. Others used these mentors sparingly but were aware of the resource available.
Discussion and Implications
An interactive nurse residency program can positively impact the satisfaction and engagement of new graduate nurses. These findings are consistent with those of other studies related to new graduate nurse employee engagement and work satisfaction.13,14 Unlike Kovner et al,5 this study found that nurse residents rated caring for patients, seeing positive results for those patients, and teamwork as the most satisfying aspects of the work environment. These results were consistent, before and after nurse residency sessions and at 1 year of employment. Conversely, staffing challenges, lack of physician support, and lack of teamwork were the most dissatisfying aspects of the environment before the residency. Postresidency and 1-year follow-up results found physician disrespect no longer an issue, largely because of increased competence, confidence, and acceptance of nurse residents into the team. At 1 year of employment, these nurses recognized their continued need for flexible hours, fair staff scheduling, adequate staffing, and teamwork. Service volume growth and campus expansions created staffing challenges throughout the health system during this time period. Patient volumes at capacity, resulting in the need for contingency staffing strategies, may have contributed to these perceptions by new graduates. Strong concerns related to staffing may have been a primary factor in the statistically significant decrease in employee engagement and work satisfaction measured at 1 year of employment. However, 90% retention existed among these nurse residents, which is a slight increase over the past 5-year average of 86% retention. The continued need to retain nurses is fiscally mandatory. Robert Wood Johnson Foundation cites nurse replacement costs as much as twice the annual salary of a medical-surgical nurse, estimated at approximately $92,000.15 Although it was hoped that the new nurse residency design would impact 2-year retention, this was not the case, and second-year retention remained at 70%. It is impossible to determine if other intervening variables have affected these rates. With new graduate RNs comprising 12.7% of clinical nursing staff,14 it becomes imperative that administrative attention focus on programs that engage novice nurses addressing key issues such as staffing, scheduling, and physician-nurse communication.16 "Dysfunctional work environments are a significant contributor to stress and burnout."17
Resources dedicated to interactive nurse residency programs have the potential to offer the support related to engagement and also uncover the stressors and dissatisfiers that contribute to the high level of turnover seen with new nurses entering the profession.
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