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Working smarter

Building a better nurse residency program

Garrison, Frank W., DNP, MBA, MSN, RN, NE-BC; Dearmon, Valorie, DNP, RN, NEA-BC; Graves, Rebecca J., PhD, NP-C

doi: 10.1097/01.NUMA.0000512898.76048.0b
Department: Performance Potential

Frank W. Garrison is the vice president of patient care services at CHI St. Luke's Sugar Land (Tex.) Hospital. At the University of South Alabama College of Nursing in Mobile, Ala., Valorie Dearmon is an associate professor and chair of the adult health department, and Rebecca J. Graves is an assistant professor in the adult health nursing department.

The authors have disclosed no financial relationships related to this article.



A nursing shortage, whether at the individual market level or the national level, profoundly impacts healthcare delivery.1 Nurse administrators continually seek ways to address nursing shortages by attracting new nurses to the profession and supporting their success as novice practitioners. Nurse residency programs (NRPs) are commonly employed to develop and support new graduate RNs (NGRNs), reducing vacancy and turnover.2-4 Putting an effective NRP into practice can be challenging in any setting, but particularly so for smaller hospitals where resources are seriously limited.

In 2015, our 100-bed community hospital hurriedly implemented an NRP to address the facility's critical nursing shortage. Predictably, we identified opportunities for improvement of the newly developed NRP soon after implementation. Here, we explain how we optimized our NRP at minimal cost to achieve sustained improvements in nursing vacancy and turnover.

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A quick fix

Our hospital implemented its original NRP in response to a 2014 nursing vacancy rate of 17% and a turnover rate of 37%. We needed a solution to provide immediate relief from our nursing shortage, but a policy was in place that prohibited hiring nurses with less than 2 years of experience. The CNO and management team decided to revise the policy to allow the hiring of NGRNs contingent on their completion of an NRP, which the hospital quickly developed and implemented.

Although the NRP brought significant relief to the nursing vacancy crisis, the CNO and nurse managers feared that the program was only a quick fix. They wanted to replace it with a well-developed and evidence-based solution able to sustain vacancy reduction and prevent future turnover. For the NRP to be most effective, the team believed that it needed greater emphasis on competence development of NGRNs and preceptors alike to support the hospital's mission of excellence. However, with substantial capital already invested—approximately $20,000 per NGRN over traditional orientation, predominantly for salary dollars—requesting further funds to enhance the NRP presented a challenge.

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Identifying best practices

The CNO and project team, which included nurse managers, nurse educators, and recent graduates from the hospital's NRP, conducted a comprehensive literature review to identify NRP best practices. The use of NRPs to improve competence and reduce vacancy and turnover is well documented in the literature, but program variations make it difficult to define best-practice strategies.4,5 Agencies such as the American Association of Colleges of Nursing have established guidelines for NRPs, and accreditation status is awarded for a fee to organizations meeting the established guidelines.6 However, as with our organization, resource limitations prevent some facilities from seeking accreditation. Nonetheless, criteria found within the accreditation standards underscore best practices and can guide the selection of evidence-based strategies within the context and constraints of any organization.

Our literature review identified that competent preceptors are essential to NGRN development.2,7 The preceptor-NGRN bond is vital to NGRN confidence and skill building.8 Effective preceptors possess clinical expertise combined with the knowledge and ability to facilitate another's competence.2,7 Interprofessional collaboration is also key to NGRN success.9,10 Engaging NGRNs in collaborative work promotes decision making, confidence, and communication.9-11

Simulation can facilitate competence and help develop collaborative skills.8,9,12 It allows novice nurses to practice skills without fear or risk of hurting patients, honing critical-thinking and decision-making abilities.12-14 A recent landmark study validated the effectiveness of high-fidelity simulation as a substitute for up to half of traditional clinical hours for nursing students.14

Lastly, studies repeatedly find that socialization and long-term support are vital to NGRN competence, retention, and professional commitment.2,5,7 Other strategies, such as extending the duration of NRP class time, are recommended, but these were eliminated by our team due to prohibitive cost.

The project team carefully examined the evidence and selected best practices appropriate to our setting and circumstances. Three measurable objectives guided NRP improvement: 1) increase NGRN competence through practical skill-building methods; 2) increase preceptor competence, with NGRN competence correlating with preceptors' teaching and mentoring skills; and 3) develop a social and professional support system for NGRNs to promote competence and foster professional and organizational loyalty.

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Getting to work

The project team formalized the competence development plan, obtained institutional review board approval, and set out to implement the NRP improvements for an incoming 2016 class of NGRNs (N = 6). The team began the implementation process by partnering with a local university's school of nursing for simulation lab use with faculty instruction. Next, the team purchased validated assessment tools from a national company for NGRN and preceptor pre- and posttraining competence assessment. The instruments consisted of an NGRN clinical competence assessment tool and a preceptor clinical and precepting competence tool. Assessment findings were analyzed by the contracted company, providing detailed reporting of each individual's strengths and weaknesses.

A group of seven preceptor nurses within the facility completed the nurse preceptor competence assessments; the project team used the assessment results to tailor the preceptors' education to areas of needed improvement. The hospital hadn't previously assessed preceptor competence, and the new approach allowed for customized education to improve preceptors' abilities. The hospital's education department conducted the training; afterward, the preceptors took a posttraining assessment.

During the course of the project, three of the preceptors had to be replaced due to unforeseen circumstances. The substitute preceptors received training but weren't in the initial preassessment group, so only the assessments of the remaining four preceptors from the original group were considered as part of the study results. The costs for assessments for both the preceptors and NGRNs were minimal, as shown in Table 1.

Table 1

Table 1

The enhanced NRP commenced a few weeks after the preceptors completed training. Each of the six NGRNs took nationally validated NGRN-specific nursing competence assessments aligned to clinical specialty areas of interest to establish pre- and posttraining competence; three of the six NGRNs took an additional pre- and posttraining competence assessment necessary for the combined clinical focus of their selected department.

The NGRNs completed an initial hospital orientation and then began the competence development curriculum consisting of simulation lab training, didactic interprofessional collaboration training, preceptor-guided nursing shifts, and social and professional support group meetings. (See Table 2.) Many of the simulation scenarios and the didactic interprofessional collaboration lessons were based on findings from the NGRNs' baseline competence assessments and feedback from the hospital's recent NRP graduates. The project team analyzed this information to identify areas of needed improvement and allocated didactic instruction time accordingly to those areas.

Table 2

Table 2

Collaborative skills were practiced during interprofessional simulation scenarios. Furthermore, numerous NGRN classes were taught by various hospital leaders, again focusing on improvement areas identified from the baseline assessments and the previous NRP class feedback. Class time included a variety of role-play scenarios, allowing the NGRNs to practice the skills necessary to communicate accurately, effectively, and collaboratively. Faculty from the nursing school also taught classes on time management skills and the impact of effective collaboration on overall time management.

The NGRNs worked scheduled shifts to care for patients under the direction and guidance of their preceptors, observing and/or participating in all nursing activities, including multidisciplinary rounds. As the NRP progressed, the amount of nursing work performed independently by the NGRNs increased steadily as preceptors observed improvement in the NGRNs' skills and readiness.

The importance of socialization and professional support to the NGRNs' success can't be understated. Providing social and professional support requires a time investment as opposed to capital. During each NRP class day, a 1-hour catered lunch was scheduled as social and professional support time. Some of these lunch meetings focused on strengthening NGRN peer relationships, whereas others included preceptors and managers for fostering social and professional networks outside of the NGRNs' peer group.

When the didactic portion of the NRP was complete, the social and professional functions were changed to a breakfast meeting at morning shift change. The breakfast meetings continue for a full year to provide time for NGRNs to engage with each other, their preceptors, the CNO, and other nurse leaders by asking questions, resolving challenges, making suggestions, and sharing successes in their transition to professional practice.

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The project was an enormous success from the perspective of the project team and hospital administration. The best practices integrated into the existing NRP markedly strengthened the program. Incorporating simulation lab training was highly valuable, but even more efficacious was the relationship between our hospital and the university.

Developing the infrastructure for the partnership between the hospital and university required a significant time commitment for both parties because a number of meetings were required to understand each other's needs and goals. As the parties grew to understand what each had to offer, a mutually beneficial contractual agreement for simulation training was formalized. The contract established a partnership with the school for use of its high-fidelity simulation lab and faculty instruction in the lab to facilitate NGRN skill building.

The fees for simulation training required an investment that was significant to the hospital's budget, but the resulting partnership between the hospital and university was well worth it. The relationship helped meet the hospital's need for nursing staff and the school's need for NGRN placement in the workforce. Faculty also volunteered a significant amount of time, at no additional cost to the hospital, to assist the project team in educating the NGRNs during the NRP didactic class times. The partnership led to an agreement for the school's family NP students to perform clinical rotations in the hospital and its clinics, and for the hospital to be the school's sole provider for women's services clinical rotations. The relationship even resulted in the CNO's placement on a university advisory council.

Competence assessment data also revealed project success. Pre- and posttraining assessment data were analyzed using statistics software. Measures of central tendency and variance were evaluated and, because of the normal distribution of all variables, differences in the means were analyzed by paired-samples t tests.

The itemized score reports from the preceptors' initial competence assessments revealed opportunities for improvement in the areas of communication, critical thinking and problem solving, and orientation plans. The competence assessment group mean score for the four preceptors who participated in the entire project increased from a pretraining score of 77.00 (SD = 2.94) to a posttraining score of 79.00 (SD = 4.55); however, statistical significance wasn't found (t(3) = -.608, P = .586). Also, the reassessment itemized score reports for the individual preceptors revealed an improvement in the pre- and posttraining mean score in the three identified areas of need.

Similarly, the NGRN competence development curriculum, as informed by the NGRNs' baseline assessments and feedback from the hospital's recent NRP graduates, led to improved NGRN competence. The posttraining assessments demonstrated a statistically significant improvement in overall NGRN competence. The mean for the nine baseline tests was 72.11 (SD = 6.03) and for the nine reassessment tests, 81.22 (SD = 3.59). A significant increase from the baseline assessment to the reassessment was found (t(8) = -3.833, P = .005).

The NGRNs also completed the Casey-Fink Graduate Nurse Experience Survey at the end of didactic training. The Casey-Fink survey is a valid and reliable self-assessment of NGRN competence, with content validity established by expert review and a Cronbach's alpha coefficient of 0.89 after repeated measures.15,16 The survey findings provided additional insight into project effectiveness by revealing the NGRNs' self-perceptions of nursing competence after the NRP. For example, in the 24-question Likert scale portion of the survey, 83.3% of the responses from the six NGRNs demonstrated a favorable view of the transition experience. The survey results were also useful in departmental placement of the NGRNs at the end of didactic training and for planning additional education for individual NGRNs in areas of self-perceived need.

The hospital's nursing vacancy continued to improve during the enhanced NRP. The current vacancy rate dropped from 17% at the end of 2014 to 7.5% by mid-2016, and that reduction has occurred even as the hospital has increased nursing positions by 20% to account for growth since the inception of the NRP. The vacancy rate is impacted by a variety of factors; implementation of an NRP is one such factor. In our case, the NRP resulted in an impactful reduction in vacancies.

Although the small cohort size for the NRP improvement project limits the generalizability of our study, the improvements significantly increased NGRN competence, which has been linked to increased retention.3 Whether improvements in the NRP will impact nurse retention and sustain lower vacancy rates downstream is yet to be determined, but early findings are promising.

In summary, at the onset of the NRP, a valuable partnership was established benefitting all parties involved. Areas of preceptor weakness were identified and successfully addressed in preparation for the NRP, although the improvement in preceptor competence wasn't statistically significant. However, NGRN competence did significantly improve from baseline after the NRP. The Casey-Fink survey indicated a favorable view of the NGRNs' transition experience and identified areas to target individualized education going forward. Finally, the facility's nursing vacancy rate improved, decreasing by more than half.

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In progress

The costs of implementing and operating an NRP are considerable, but the expenses required to make impactful best-practice improvements to an existing NRP are far less substantial. With the exception of the simulation lab fees, the overall costs of the improvement project were minimal. Although simulation added to the costs, the long-term benefits of the relationship between the hospital and university, along with improved NGRN competence, were deemed a solid return on investment.

The expense for the competence assessment tools and analysis of findings wasn't an additional cost to the improvement project because our parent company was already requiring us to use an outside company to measure new employee competence. A hospital interested in NGRN competence assessment but lacking the resources to engage an outside company can use other assessment instruments free of charge, such as the Casey-Fink survey or an internally developed tool.

Nurse leaders in community hospitals with limited capital for NGRN recruitment and retention need to evaluate the in-house resources available to support NGRNs and strategize ways to optimize those resources. For example, the project team realized that a tactic as simple as involving various hospital departments in NGRNs' education can improve their interdepartmental knowledge and collaboration. We also learned that purposefully designed social and professional support activities are a far more productive use of lunch and breakfast hours than unstructured break times.

Nurse leaders also need to consider looking beyond the four walls of the hospital for any available resources.7 Not every community hospital has access to a nearby university or nursing school, but other community resources may be available. For example, a long-term acute care facility may be willing to conduct educational in-services for NGRNs on how the facilities work collaboratively for safe care transitions. Learning from and partnering with sister hospitals can also serve as an excellent NRP improvement resource. Perhaps partnering with a sister hospital can allow for specialty training of NGRNs that one facility's NRP isn't equipped to provide. Even pharmaceutical and medical representatives may be willing to provide in-services on medications and equipment to increase NGRNs' knowledge about the nursing care they provide and further their understanding of how hospitals work with these entities.

By identifying both the internal and external resources available, hospitals with limited capital to direct toward recruitment and retention of NGRNs can work smarter to increase nursing competence and support long-term retention.

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