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Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e3182a3e8e4

Registered Nurse Perceptions After Implementation of a Nurse Residency Program

Rhodes, Catherine MSN, RN, WHNP-BC, RNC-OB, SANE-A; Radziewicz, Rosanne MSN, RN, PMHCNS-BC, RMT, RYT-200; Amato, Shelly MSN, RN, CRRN, CNRN; Bowden, Victoria MSN, RN, ACNS-BC, CHPN; Hazel, Coletta MSN, RN; McClendon, Susan MSN, RN, CNS-BC; Medas, Julie MSN, RN, CNS; McNett, Molly PhD, RN, CNRN

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Author Affiliations: Advanced Practice Registered Nurse (Mss Rhodes, Radziewicz, Amato, Bowden, Medas); Coordinator, Wisdom Works (Ms Hazel); Ambulatory Care Clinical Nurse (Ms McClendon); Director, Nursing Research (Dr McNett), The MetroHealth System, Cleveland, Ohio.

The authors declare no conflicts of interest.

Correspondence: Ms Rhodes, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH 44109-1998 (

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

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Nurse residency programs (NRPs) are an effective mechanism for transitioning newly licensed registered nurses (NLRNs) to practice. No studies have investigated how experienced nurses view NLRN performance after NRPs. The purpose of this quality initiative was to identify experienced nurses’ satisfaction with NLRN proficiency before and after implementation of an NRP using the Nursing Practice Readiness Tool. Findings indicate that experienced nurses are more satisfied with the performance of NLRNs after the new nurse participated in an NRP.

Newly licensed registered nurses (NLRNs) comprise approximately 10% of clinical nurses in hospitals and health systems.1 With numbers expected to rise, hospitals must be prepared to hire and orient increasing numbers of NLRNs. Although 90% of academic nurse leaders perceive NLRNs to be ready to practice in the hospital setting, hospital nurse leaders have voiced concerns regarding the ability of NLRNs to function independently in care settings.2 The transition of NLRNs is complicated by high patient acuities and the stressors of technology.1 Hospitals have responded to the preparation-practice gap by implementing nurse residency programs (NRPs).3,4 Nurse residency programs have demonstrated effectiveness in elevating clinical competency and communication,5,6 as well as retention, thus resulting in cost savings.7-14 Information is lacking with regard to how experienced nurses view the proficiency and clinical competence of NLRNs after the implementation of an NRP. Thus, the purpose of this project was to compare experienced nurses’ satisfaction with NLRNs’ proficiency before and after implementation of an NRP.

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The nursing shortage in the United States is projected to increase to 260000 registered nurses (RNs) by the year 2025.15 Because of the growing population of elderly patients, creating more roles, and older nurses in the workforce, it is anticipated that the shortage will be twice as large as any other experienced since the 1960s. Impending retirements in the nursing workforce and high turnover rates among NLRNs will contribute to this shortage.16

Further complicating the issue is the fact that a gap remains between perceptions of academic leaders and hospital nurse executives about the preparedness of new nurses.2 Although many NLRNs meet basic expectations of patient care assessments and changes, learning needs still exist regarding initiating decisions, differentiating urgency, reporting essential data, anticipating relevant medical orders, and identifying rationale for decision-making.17 Preceptors report concerns about NLRN preparation with regard to performing complex skills, prioritizing and organizing patient care responsibilities, and critical thinking.18 These skills are increasingly more important as acuity levels among patients continue to rise. As a result, 1-year turnover rates among NLRNs are as high as 40%.16 In addition, NLRNs report unanticipated role changes, lack of confidence, information overload, and high workloads and expectations as key reasons behind decisions to leave their 1st nursing positions.19 Because the basic education for RNs varies, many NLRNs come to the workforce with varying skill levels for nursing practice.

A strategy to address these issues has been the initiation of NRPs.3 Nurse residency programs were targeted to bridge the preparation-practice gap, enhance the expertise of the nursing workforce, improve safety by decreasing clinical errors, and minimize burnout and turnover in new nurses who may be underprepared.3,16 Research indicates that NRPs are effective in improving outcomes of the NLRN, such as job performance,20,21 job satisfaction, autonomy,22,23 critical thinking,21 professional identity, and intent to stay.20 Administrative and organizational outcomes, such as decreased orientation time,24 increased performance and productivity,20,25 organizational commitment,23 safe patient care, patient satisfaction, and nurse retention,26 have been reported as outcomes of NRPs.

Although research has demonstrated the positive effects of NRPs, there are no data regarding how experienced nurse peers view NLRNs’ proficiency after participating in an NRP. This information is important because these individuals must work collaboratively with one another as key members of the healthcare team. Therefore, our organization assessed experienced nurses’ satisfaction with NLRN proficiency before and after implementation of our NRP as a quality improvement initiative.

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NRP Description

The primary aim of nursing orientation is to provide new nurse employees with experiential learning that concentrates on skill acquisition and application of the nursing process in the context of policies, protocols, and procedures specific to the organization. Our NRP is a comprehensive program designed to orient the NLRN over 12 months using 4 phases: prehire, core, clinical, and professional development. It was developed after review of the literature including aspects considered paramount to ensure success of the program, which included core and clinical content, simulation training, and professional development. In addition, focus group interviews with experienced nurses (both preceptors and non-preceptors), managers, and newly licensed graduate nurses within our organization provided additional information to guide development. Most of the phases were developed based on literature review. The topics for the professional development content as well as the extension for support during the months after official orientation was complete were driven by focus group discussion. The prehire phase of shadowing as well as limiting the number of preceptors was also derived from focus group results.

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Phase 1 (Prehire)

Prehire ensures that the most qualified candidates are chosen for NLRN positions. Ideally, this process starts approximately 6 weeks before NRP begins. In developing our NRP, the prehire phase was considered essential. This is an opportunity for the potential employee to get a feel for the unit as well as those working on the unit to evaluate the fit of the potential employee. Although not all organizations may include a prehire phase in residency programs, our objective in this is to be sure that the candidate possesses the knowledge, skills, and professional attributes that match the department of nursing’s vision and mission. This is achieved through shadowing experiences on the anticipated nursing unit for the NLRN, as well as comprehensive interviews with potential preceptors and nursing staff.

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Phase 2 (Weeks 1-4)

Core provides the NLRN a general overview of the organizational policies and procedures that guide their nursing practice and provide the tools for safe patient care. The NLRNs participate in classroom, skills laboratory, and patient care environments to demonstrate core competence on universal skills and safe patient care. Trained instructors assess clinical skills, communication, critical thinking, and organizing priorities. The classes are integrated and interactive and blend structured didactic content with foundational skills acquisition and electronic medical record training. It includes a skills integration session, which takes place in the simulation laboratory. This session is designed to assist the NLRN in integrating the concepts and skills learned and participating in patient care scenario–based controlled learning experiences.

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Phase 3 (Months 1-4)

Clinical experiences develop and enhance critical-thinking skills as complex clinical situations are encountered.9 Research, evidence-based practice (EBP), and outcome-based decision making are supported. The NLRNs must demonstrate competence with skills specific to their patient population using the nursing process and appropriate standards. At the end of this phase, the NLRN should be able to safely manage a moderately complex patient assignment; articulate the nursing process in complex patient situations using appropriate policies, procedures, and standards; and report incidents in a timely and appropriate manner. The clinical preceptors are key participants at this phase. The NLRN should have a primary preceptor who reviews orientation goals daily, with written summary weekly reviewed with manager. The focus is on patient population care delivery system, accomplishing unit-based skills acquisition, and participating in population-based continuum of care to foster a more global understanding of patient care and enhance staff communication during transfer.

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Phase 4 (Months 4-12)

Professional development at this phase centers on actively engaging the NLRN in the role of clinical nurse, exploring opportunities to participate and contribute to the nursing department goals and career advancement program and becoming an expert caregiver and future mentor. This is partially accomplished through classes that all NLRNs are required to attend. Guest speakers present topics such as ethics, communication, delegation, time management, EBP, and research. Facilitation of small group activities and discussion is the focus for learning. There is participation in a multidisciplinary scenario-based high-fidelity simulation experience during this phase. The NLRN demonstrates characteristics of an advanced beginner, including acceptable performance and responding to experiential recognition of patient situations.27,28

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Tool, Setting, Sample

To evaluate experienced nurses’ satisfaction with NLRN proficiency before and after implementation of this NRP, the Nursing Executive Center (NEC)1 was contacted to administer the Nursing Practice Readiness Tool (NPRT). The NPRT is an anonymous computer-based survey designed to measure experienced nurses’ level of satisfaction with NLRNs’ proficiency on 36 critical competencies. Development of the NPRT has been previously described.1,2,29 Competency items are categorized by clinical knowledge, technical skills, critical thinking, communication, professionalism, and management of responsibilities (Figure 1). Respondents are asked to rate their satisfaction with NLRNs’ proficiency in each competency area using a 6-point Likert scale ranging from strongly agree to strongly disagree. The NEC tabulates and reports aggregate responses for participating hospitals and maintains a database of cumulative scores for national benchmarking purposes.

Figure 1
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This project received approval by the organization’s institutional review board as a quality initiative with an intent to disseminate findings outside the organization. A list of eligible nurses (ie, RNs working for at least 1 year in the inpatient or emergency department, clinical nurse specialists, nurse managers, and nursing directors) was obtained from the human resources department, and an e-mail was sent with a description of the project and a link that directed nurses to the NEC site where they could complete the survey. Respondents were instructed to complete the survey only if they had worked with an NLRN in the previous year. The NPRT was administered 3 months before commencement of the NRP and again 2 years later, after the NRP had been in place for 18 months.

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Data Analysis

Data were aggregated by the NEC and reported comparing results from before/after implementation of the NRP. The report included descriptive statistics on demographics and percentage of respondents who were satisfied or strongly satisfied with each listed competency. For these analyses, satisfaction was defined as responses of agree and strongly agree.

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In 2009, 283 (41.8%) nurses completed the NPRT before implementation of the NRP. After NRP implementation, 108 nurses (16.7%) completed the survey. A summary of the demographic characteristics of each sample is provided in Table, Supplemental Digital Content 1, For both time points, most of the sample were from critical care areas (34% and 31%, respectively) and a higher percentage were preceptors (39% and 49%, respectively).

When examining scores for experienced nurses’ satisfaction with NLRN overall proficiency, mean scores before NRP were 34.9% (range, 18.4%-59.3%). Highest satisfaction scores were noted for utilization of information technologies (59.3%), rapport with patients and families (53.4%), and documentation of patient assessment data (48.7%). After NRP implementation, the overall mean satisfaction score was 47.9% (range, 24.6%-72.9%), and scores were again highest for utilization of information technologies (72.9%), documentation of patient assessment data (68.6%), and rapport with patients and families (67.1%).

Scores for all 36 items increased after NRP, with satisfaction of 24 proficiencies increasing by at least 10 percentage points. Twelve of the 24 proficiencies increased by 15 percentage points and are displayed Figure 2. Higher gains were reported with the following proficiencies: communication with physicians (24.8% increase), documentation of assessment data (19.9% increase), utilization of clinical technologies (19% increase), communication with the professional team (18.7% increase), ability to work independently (18.1% increase), administration of medication (17.4% increase), interpretation of assessment data (16.3% increase), understanding of quality improvement methodologies (15.9% increase), accountability for actions (15.8% increase), compliance with legal/regulatory issues relevant to nursing practice (15.7% increase), ability to take initiative (15.4% increase), and conducting patient assessment (15.3% increase).

Figure 2
Figure 2
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Specifically among nurse preceptors, satisfaction scores after NRP for NLRN proficiency also increased (Figure 3). Preceptors reported improved satisfaction on 33 of 36 items, with 13 items increasing by 10 percentage points or more. Figure 3 displays items with the highest increases. The 3 items that had a decrease in scores (work as team, 0.1%; recognizing when to ask for assistance, 3.9%; and recognizing change in patient status, 3.5%) experienced small changes.

Figure 3
Figure 3
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Use of the NPRT allowed for comparison of satisfaction of NLRN proficiency on units staffed primarily (≥70%) with associate degree (ADN) prepared nurses versus those staffed primarily with bachelor of science in nursing (BSN) nurses. Experienced nurses working on units staffed primarily with BSN graduates reported higher satisfaction with new nurse proficiency both before NRP implementation (primarily BSN unit satisfaction, 43.3%; primarily ADN unit satisfaction, 34.7%) and after NRP participation (BSN satisfaction, 57.8%; ADN satisfaction, 36.4%) when compared with satisfaction of nurses on units staffed with mostly ADN graduates. Satisfaction scores for both ADN and BSN nurses increased after NRP, with larger gains seen in the BSN group (14.5% increase for BSN, 1.7% increase for ADN).

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There are several limitations to this study. First, using a convenience sample, the findings cannot be generalized to the entire population of interest. Because of fact that this was a voluntary, anonymous, computer-based survey, the individual responses were not paired before and after implementation. The response rate was also lower (42% vs 17%) after implementation of the NRP. This can be partially explained by fact that nurses were asked to complete the postimplementation survey only if they had experience with the NLRN in the NRP. There are other limitations with regard to the survey tool that was used. The resulting dataset did not allow for a breakdown in responses based on respondent type. For example, data could not be stratified by experienced nurse role (ie, manager, clinical nurse specialist, or clinical nurse). Perceptions of NLRN proficiency could be influenced by the respondent’s role within the organization and the capacity with which they interacted with NLRNs. The data on perceptions of NLRN proficiency based on educational preparation (BSN vs ADN) are limited to the percentage of BSN or ADN nurses on a specific unit, and not on individual NLRN performance. Thus, there are likely some ADNs on a primarily BSN unit, and proficiency scores may not accurately reflect experienced nurses’ perceptions based on individual educational preparation. Despite these limitations, the data reported here do highlight an effective tool that can be used to evaluate experienced nurse perceptions of NLRNs, which is currently absent from the research literature.

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Conclusions and Implications for Nursing

Findings from this project contribute information about experienced nurses’ satisfaction with NLRN proficiency after implementation of an NRP. Overall, experienced nurses and preceptors in our organization reported increased satisfaction with the proficiency of NLRNs’ competency after participating in an NRP, thus supporting use of an NRP for NLRNs.

Previous reports indicate that NRPs are effective in aiding NLRNs’ transition from academia to the workplace. Newly licensed RNs participating in NRPs have reported higher confidence, greater job satisfaction, and less intent to leave their organization.9,16,21,30 Our project indicates that experienced nurses working with these NLRNs also view participation in an NRP as beneficial, as it better prepares NLRNs to function independently across a multitude of responsibilities. Experienced nurse satisfaction with NLRNs’ performance is particularly important because these experienced nurses are the peers who will be working side by side as members of the healthcare team. Therefore, it benefits the experienced nurse to have better prepared NLRNs, which results in better work collaboration, teamwork, professionalism, and ultimately, job satisfaction.

Our findings have been used to further refine our NRP. Individual and interdisciplinary collaborative simulation experiences have been refined to further develop assessment, clinical decision making, and communication skills. Although our findings indicate higher satisfaction with BSN graduates than ADN graduates, this warrants further investigation before limiting entry into NRP strictly for BSN graduates. Nonetheless, information from our project does support use of an NRP for the NLRN from the perspective of experienced nurses and preceptors.

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The authors thank the NEC, The Advisory Board Company, for use of their proprietary online assessment tool and for their assistance with providing support and compiling the results of the NPRT. We would also like to thank Jane Fusilero, former vice president (VP) and chief nursing officer (CNO) of MetroHealth (MH) System, for the vision and leadership in supporting the development of the NRP and sending out the original survey used in this study, and Mavis Bechtle, VP and CNO of MH System, for support of the NRP and sending out the 2nd survey.

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