Pittman, Patricia PhD; Herrera, Carolina MA; Bass, Emily BA; Thompson, Pamela MS, RN, CENP, FAAN
Research reveals that between 35% and 65% of nurses change jobs in the 1st year of employment1,2 and that nurse turnover is a major cost driver in hospitals. Studies show that the costs associated with nurse turnover range from $10,000 to $88,000 per nurse, depending on factors such as geography and clinical specialty.3 New nurse graduates consistently report that their general education has not provided them with the necessary skills to transition into practice.4,5 Healthcare leaders believe the resulting lack of confidence and stress contributes to rising new nurse turnover. The primary business response to this problem has been for nurse employers to complement orientation programs with the longer and more intense residency programs.6 A nurse residency (NR), sometimes referred to as a residency internship, is a structured postlicensure program lasting between 3 months and 1 year. These are usually designed to transition nurses from school to professional practice, although the programs may be used to transition experienced nurses to new clinical areas, such as primary care, home health, or hospice care. Most nurses are paid during the NR and then required to work for the employer for a period of up to 2 years after completing the residency.6
Research to date demonstrates that NR programs have a promising effect, lowering turnover to between 7% and 14%, with considerable savings realized by organizations. An evaluation of a 1-year postbaccalaureate NR program developed by the University Health System Consortium and the American Association of Colleges of Nursing found improved communication and organization skills, as well as higher perceived levels of support and reduced stress in 12 US sites.7 The 12-month turnover rate among the 1st and 2nd groups of residents to graduate from the program was significantly lower (12% and 9%, respectively) than the average rate of 35% to 60% reported in the literature for hospitals with no program.8-10 An internal evaluation of a pilot program created to transition newly licensed RNs through a 6-month residency program reported a turnover rate for participants at the end of the program of 14%, compared with 36% among the control group. Graduates of the program scored as well as their control counterparts who had more than 1-year additional experience on measures of clinical skills confidence, professional autonomy, and commitment to remain at the institution. The researchers estimated that the program benefits in terms of reduced turnover exceeded the cost by 67.3%, saving the hospital more than $500,000 in its 1st year.7 An analysis of data collected by the Versant NR program found a strongly positive effect on nurse competencies, job satisfaction, self-confidence, group cohesion, and turnover intent at the end of an 18-week residency period.11 In hospitals where accurate comparisons were possible, dramatic reductions in turnover were observed. Actual 12-month turnover decreased from 27% before the program to 7.1% after, resulting in estimated savings of millions of dollars at many hospitals.12
Based on this research, 1 of the 8 recommendations issued by the Institute of Medicine’s (IOM’s) committee on the future of nursing in 2010 was that “State boards of nursing, accrediting bodies, the federal government, and healthcare organizations should take actions to support nurses’ completion of a transition-to-practice program (nurse residency).”13(p11) Similarly, the Carnegie Foundation study on nursing education recommended implementation of nurse residencies,14 and the National Council of State Boards of Nursing15 has an ongoing initiative to build the evidence on transition-to-practice programs.
Given the uncertainty surrounding the new healthcare payment systems and the abatement of the nursing shortage, it seems reasonable to ask whether residencies are still a priority. With older nurses postponing their retirements, others coming back to work full time, and with the increase in new nurse graduates,16 competition to hire new nurses and the urgency to retain them seem to have diminished, making residency programs with proven effects in reducing turnover potentially less necessary. It is in this context that we asked how widespread hospital residencies are, what types of hospitals have them, how they are funded, and what barriers exist to greater adoption rates.
In August and September 2011, we administered a Web-based survey to chief nursing officers (CNOs) and chief nursing executives of hospitals and health systems who were members of the American Organization of Nurse Executives (AONE). Of 2,513 nurse leaders invited to participate, 15.7% (n = 353) of eligible AONE members responded. For the purposes of this analysis, we then excluded the CNOs from health systems, since their member hospitals were also surveyed, leaving 219 respondents (9.7%) each representing a single hospital. This research was conducted under approval from the George Washington University institutional review board.
We classified each hospital by geography, ownership, and size. A hospital was identified as being urban if the nurse leader provided a hospital location whose zip code was in a core-based statistical area; if the zip code was not within a core-based statistical area, the hospital was considered rural. Respondents who did not provide a zip code had their responses removed from our analysis. Respondents represented rural hospitals (24.3%) and urban hospitals (75.7%). The majority of rural and urban hospitals were nonprofit (69.2%), with 10% being public institutions, 8% in a university setting, and 13% being for profit. This breakdown is similar to the percentages of community hospitals who were members of the American Hospital Association in fiscal year 2009; 50.4% were nongovernmental nonprofits, 17.2% were for-profit institutions, and 18.8% were publicly owned. Using the number of beds as a proxy for size, results show that 26% of responding hospitals were small (number of beds = 6-99), 50% were medium-sized (beds = 100-399), and 24.0% were large (beds = 400+). (Note: The number of hospitals that reported their bed size was 205.)
Nurse leaders were asked if their institutions offered nurse residencies and whether they were (1) optional (new RNs may be hired directly), (2) mandatory (all new RN hires must participate in the residency), (3) for RNs or advanced practice RNs (APRNs), (4) developed internally or externally, and (5) funded internally or externally. We also asked questions about other types of continued education and training of nurses to determine what, if any, additional training opportunities were offered and if they were competing with residency programs. Institutions were asked if they
* offered quality and/or safety training for nurses performing direct patient care.
* offered training to improve the supervisions and management skills of nurses.
* conducted training for nurses on multidisciplinary/interdisciplinary team–based care.
We then performed statistical analysis on questions regarding residency prevalence, design, and alternative training programs. We performed χ2 testing on the differences between hospitals with, and without a residency.
Overall, there was a relatively high level of adoption of residencies. Approximately 36.9% of all hospitals in our study offered nurse residencies in 2011 (Table 1). Almost 85% of residencies were located in urban hospitals and 15% in rural hospitals. Residencies were more common in midsized hospitals with 100 to 399 beds (53.5%), not-for-profit hospitals (64.4%), and the South (40.5%). Hospitals without residencies also were mostly based in urban areas (70.4%), were medium sized (48.5%), and were not-for-profit (71.4%). Unlike hospitals with residencies, a greater share of hospitals without residencies was located in the Northeast.
We asked nurse leaders questions about the type of NR their hospital offered, as well as whether it was mandatory. We also asked those with residencies about their sources of funding and whether the program had been designed internally or by consultants. Among hospitals with residencies, almost all indicated that the program was optional. Only 7.2% in dicated it was mandatory (Table 2). Most residencies were for RNs (79.7%), and a much smaller share were for APRNs (20.3%). Of optional residencies, 78.1% were for RNs, and only 21.9% were for APRNs. We think that the greater number of optional residencies could be attributed to institutions’ need to have unrestricted hiring practices. New hires may have adequate training and do not need to participate in the residency program. We find that most institutions designed and funded their own new RN residencies, a likely function of the added cost of engaging outside consultants. Only 32% of hospitals reported that their new RN residency program was developed externally, and just one-fifth of all hospitals received external funding (Table 2). Among those that received external funders, sources included private donors and foundations, as well as grants from the Health Resources and Services Administration.
We asked nurse leaders about the challenges they experienced starting a residency program (Figure 1). Challenges were scaled on a 3-point scale, with 1 = not a challenge and 3 = major challenge. Hospitals with a residency and hospitals without a residency rated financial cost as the greatest challenge (2.33 and 2.5) to implementing a residency.
Other Training Programs
In order to assess the degree to which residencies tend to complement or compete with other nurse training programs, we asked nurse leaders if their hospital offered training in (1) leadership, (2) quality and safety, or (3) multidisciplinary/interdisciplinary team–based care. We found the prevalence of training programs, especially on multidisciplinary care and quality and safety, was almost universal. We also found that these programs do not appear to compete with residencies for internal funding. On the contrary, hospitals that have residencies have higher odds of having other training programs. Leadership training was offered in 82.3% of hospitals with a residency and 70.0% of hospitals without a residency (Table 1). Quality and safety training was offered by 98.7% of hospitals with a residency and 91.4% of hospitals without. Training on multidisciplinary/interdisciplinary team–based care was offered by 58.2% of hospitals with a residency and 43.6% without a residency (Table 1).
Covariates most commonly associated with hospitals that have residencies are not-for-profit status, midsize, and being located in the South. According to workforce projections by Buerhaus et al,17 the RN workforce in the South is younger and is expected to grow at a faster rate than other regions. These factors may influence the higher number of residency programs in this region. Our findings suggest that nurse residencies appear to have become more pervasive across in the United States since the 1st studies on their effectiveness in reducing turnover appeared in the early 2000s. Because this is a cross-sectional survey with no historic reference, it is impossible to know if the prevalence was higher prior to the 2008 recession or the 2010 passage of healthcare reform. Nevertheless, it is encouraging that so many hospitals have maintained residencies despite economic constraints.
In our sample, we also find that hospitals that offer residency programs are also more likely to have other training programs. This suggests that the institutional culture, including perhaps the type of nursing leadership, could be an even more important determinant of these programs, than cost calculations alone, which tend to focus on retention. Hospitals that do not have residencies, however, are slightly more likely than those that do to cite cost as a major obstacle.
Our analysis has several limitations. First, it is based on a convenience sample of nurse healthcare leaders who were members of AONE in July 2011. As with other research using convenience samples, there is the possibility that our survey did not reach a representative sample of hospital CNOs and chief nursing executives.
A 2nd limitation is potential response bias. It is common with Web-based surveys to have lower response rates than seen in mailed or personally given surveys.18 Our study was no different, with only 15% of the sample responding. This raises the possibility that better performing hospital leaders, with regard to the IOM recommendations on nursing, may have been more likely to respond to the survey than CNOs unfamiliar or in disagreement with the recommendations. Our response rate is close to American Hospital Association’s typical response rate for Web-based surveys, which is approximately 20% (S. Gergely, e-mail communication, January 2, 2013).
Lastly, it is the nature of cross-sectional data that it is just one point in time. To capture changes in the prevalence of residencies, or other variables explored in this study, longitudinal comparisons are needed. Thus, the findings in this article are associative, not causal. This team intends to perform a follow-up survey in 2013 and to address some of the questions raised by the current survey.
The proliferation of residencies, as well as other types of continuing education programs, is an encouraging sign that nurse leaders are looking beyond the economics of nurse retention to pursue broader goals of learning healthcare organizations.19 The IOM recommendations focus on the spread of residencies in their 3rd recommendation, but 3 more of the 8 recommendations also focus on nurse educational progression, including increasing the proportion of baccalaureate-prepared nurses to 80%, doubling the numbers of nurses with a doctoral degree, and advancing a culture of “lifelong learning.”13(p11) It is important to continue to monitor the existence and outcomes of these programs to confirm the continued expansion and growth and to support a program of research to examine the long-term impact of residencies, not just on retention, but on clinical outcomes.
The authors thank the Robert Wood Johnson Foundation for funding this research.
1. Pelico L, Djukic M, Kovner C, et al. Moving on, up, or out: changing work needs of new RNs at different stages of their beginning nursing practice. Online J Issues Nurs. 2010; 15 (1): 8.
2. Halfer D, Graf E. Graduate nurse perceptions of the work experience. Nurs Econ. 2006; 24 (3): 150–155.
3. Li Y, Jones C. A literature review of nursing turnover costs. J Nurs Manag. 2013; 21: 405–418.
4. Little J, Ditmer D, Bashaw M. New graduate nurse residency: a network approach. J Nurs Adm. 2013; 43 (6): 361–366.
5. Kovner CT, Brewer CS, Fairchild S, et al. Newly licensed RNs’ characteristics, work attitudes, and intentions to work. Am J Nurs. 2007; 107 (9): 58–70.
7. Goode CJ, Lynn MR, McElroy D, et al. Lessons learned from 10 years of research on a post-baccalaureate nurse residency program. J Nurs Adm. 2013; 43 (2): 73–79.
8. Krugman M, Bretscneider J, Horn P, et al. The national post-baccalaureate graduate nurse residency program. J Nurses Staff Dev. 2006; 22 (4): 196–205.
9. Williams CA, Goode CJ, Krsek C, et al. Postbaccalaureate nurse residency 1-year outcomes. J Nurs Adm. 2007; 37 (7/8): 357–365.
10. Beecroft P, Kunzman L, Krozek C. RN internship: outcomes of a one-year pilot program. J Nurs Adm. 2001; 31 (12): 575–582.
12. Ulrich B, Krozek C, Early S, et al. Improving retention, confidence, and competence of new graduate nurses: results from a 10-year longitudinal database. Nurs Econ. 2010; 28 (6): 363–375.
13. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010.
14. Benner P, Stutphen M, Leonard V, et al. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass; 2010.
16. Staiger DO, Auerbach DI, Buerhaus PI. Registered nurse labor supply and the recession—are we in a bubble? N Engl J Med. 2012; 366 (16): 1463–1465.
17. Buerhaus P, Auerbach D, Staiger D, et al. Projections of the long-term growth of the registered nurse workforce: a regional analysis. Nurse Econ. 2013; 31 (1): 13–17.
18. Windle J. Comparing responses from internet and paper-based collection methods in more complex stated preference environmental valuation surveys. Econ Anal Policy. 2011; 41 (1): 83–97.
19. deBurca S. The learning health care organization. Int J Health Care Qual. 2000; 12 (6): 457–458.