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Building a workforce pipeline

Development of an ambulatory nurse residency program

Gilland, Deena E. DNP, MSN, RN, NEA-BC; Muirhead, Lisa DNP, RN, APRN-BC, ANP, FAAN, FAANP; Toney, Sharlene PhD, RN; Coburn, Caroline DNP, MS, RN, ANP-BC

doi: 10.1097/01.NUMA.0000558520.60241.1f

Learn about a successful partnership between a large academic healthcare system and a university school of nursing to develop an undergraduate curriculum and practicum experiences in ambulatory care and build an ambulatory nurse residency program.

In Atlanta, Ga., Deena E. Gilland is the vice president of patient services and CNO, ambulatory care, at Emory Healthcare; Lisa Muirhead is an associate clinical professor at Emory University School of Nursing; Sharlene Toney was the corporate director of professional nursing practice and development (retired) at Emory Healthcare; and Caroline Coburn is an assistant clinical professor at Emory University School of Nursing.

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



The US Health Resources and Services Administration data show 86.6% growth in ambulatory care delivery between 2000 and 2013.1 Across the nation, ambulatory care continues to expand and become the focal point for patient care delivery and the driver of preventive health education. The increasing demand for ambulatory care nurses, coupled with the decreasing supply of experienced RNs, makes strengthening the nursing workforce pipeline essential. With the need for RNs projected to grow by 26% by 2020 and the continued aging of the current workforce along with retirement plans, formal residency programs for new graduate nurses are a necessity to meet these employment challenges.1,2

Healthcare has become increasingly complex: Patient acuity is rising, work environments are more intense, and the nursing shortage is expanding in some areas. Historically, the practice belief has been that only experienced RNs can function in the ambulatory setting. In addition, there's an absence of undergraduate nursing program content that incorporates practicum experiences in ambulatory care settings and a reluctance of ambulatory settings to hire new graduates. Consequently, there's a lack of evidence on the development of infrastructures to support new graduates entering ambulatory practice settings.

Structural components, such as formal preceptorships, education platforms, and residency programs tailored for novice RNs, are essentially absent in the ambulatory setting. Additionally, as graduates transition into their new nursing role, there's a crucial need to assist them in developing clinical decision-making and leadership skills to enable them to flourish in dynamic and complex work environments.3 The need for nurse residencies was supported by the Carnegie study on nursing education, reported in Educating Nurses: A Call for Radical Transformation.4 The study recommended that new graduate nurses be required to complete a 1-year residency program focused on one clinical area of specialization.

This article highlights the partnership between a large academic healthcare system in the southeastern US and a university school of nursing to develop an undergraduate curriculum and practicum experiences in ambulatory care and build an ambulatory nurse residency program (ANRP). The development of an ANRP is an integral part of the healthcare system's success by enhancing training programs and strengthening the workforce pipeline of BSN-prepared nurses to meet volume demands and system growth.

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Theoretical model

Dorothy del Bueno's competency-based development model provided a framework for the ANRP.5 This model demonstrates the linkage of technical, interpersonal, and critical-thinking skills in an orientation program, which yields the most competent nurses entering a work environment. The model's key elements include determination of outcomes, development of evaluation tools to measure outcomes, assessment of learners' mastery of outcomes, and evaluation of achievement of outcomes/cost-effectiveness of methods/satisfaction of learners.

Each component has measurable initiatives that can be used as the basis for outcomes evaluation:

  • technical skills—safe, effective, and efficient
  • interpersonal skills—team building, conflict resolution, and customer satisfaction
  • critical-thinking skills—problem recognition, risk management, and priority setting.
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New graduates were recruited biannually from BSN programs at the school of nursing associated with the healthcare system. An ambulatory nursing course was added to the BSN curriculum as part of the overall ANRP initiative. The new graduates were recruited into designated ambulatory areas that had developed infrastructure to support the new residency program. This infrastructure included trained preceptors, available and supportive leaders, and service lines budgeted for new graduate nurse positions. The ambulatory surgery centers, ambulatory infusion centers, and oncology and cardiology clinics were the pilot sites for the first and second cohorts.

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The academic healthcare system has a tripartite mission of research, education, and clinical care. These tenets are the foundation for the ANRP. To enhance new graduate competencies, the year-long ANRP has an evidence-based curriculum focused on strengthening the application of critical-thinking and technical skills. The program also contains a variety of experiences that extend beyond traditional orientation. The curriculum includes a clinical experience with a trained preceptor; completion of an evidence-based practice project; formative and summative evaluation of the resident's professional development; and seminars built on a standardized core curriculum based on patient outcomes, leadership, and the professional RN role.

Development of the ANRP was reliant on several key groups within the healthcare system. Having executive-level leadership support and buy-in was crucial to the project. Introducing new graduate nurses into ambulatory clinic practices is a relatively new concept nationally. Historically, the ambulatory clinic hasn't been accepted as an appropriate setting for entry-level nurses. Adoption of this model into the ambulatory setting required innovative ways of thinking, new care models, role expansion, and evidence-based outcomes.

Another key partnership group was the experienced RNs currently practicing in the ambulatory care areas. These nurses serve as the residents' preceptors and are essential for the success and sustainability of the ANRP. An important strategy to ensure their buy-in was employing the principle of shared decision-making. Experienced RNs were included in the initial planning and development of the program, which fostered ownership and value. The RNs' role as preceptors wasn't only critical for integration and education of the new nurses, but also key for retention.

An essential component for preceptor engagement was the development of a comprehensive preceptor training program that included initial training as well as ongoing preceptor workshops. Having a fully developed preceptor education program proved indispensable to the program to gain acceptance of new graduates in ambulatory areas and foster robust onboarding. Preceptors are required to have a BSN degree or higher and attend the courses and workshops. In addition, hosting a preceptor community offers networking and educational opportunities for preceptors, allowing for continued professional growth for this important group.

An additional vital component of the ANRP is a dedicated nurse educator position to plan, implement, and oversee the program, including coordinating preceptor training and functioning as the liaison between the healthcare system and school of nursing. Having effective communication between the coordinator, residents, and preceptors is important for success. This position serves as the main touchpoint for the new graduates, providing support and guidance in addition to education as the residents integrate into their new role as RNs, which helps decrease stress and increase professional satisfaction. Frequent electronic and in-person check-ins, in addition to formal progress reports, are components of increasing nurse resident engagement.

Other modes of communication, such as a web page, emails, texts, and social media pages, are utilized to maintain consistent engagement. With the new graduates working in various locations across a large metropolitan area, optimizing communication has been pivotal. Allowing the new graduates to communicate with the ANRP coordinator using multiple modes of communication has provided more real-time connectedness and access to support, which the new graduates have expressed as being very important to them.

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The ANRP was developed using several metrics. Demographic data included age, gender, ethnicity, and nursing degree. Additional data gathered and evaluated included new graduates' clinical competency assessment, measurement of successful transition into practice, and professional satisfaction scores from the Casey-Fink GraduateNurse Experience Survey.6 The comprehensive Casey-Fink survey measures several components of the new graduate's transition into practice: stress level, support, organization and prioritization, communication and leadership, professional satisfaction, and mastery of foundational and high-intensity skills. The ARNP focused on key competency measures from the tool that are pertinent to ambulatory practice. Data analytics were used to compare the results from the first ambulatory cohort at baseline, 6 months, and 12 months. (See Table 1.) The second cohort, which began 6 months after the initial cohort, was also given the Casey-Fink survey at the same time intervals. (See Table 2.) The survey results of the two cohorts were compared at baseline and 6 months to measure trends over time and differences among the two groups, as well as compared with national benchmarks.

Table 1

Table 1

Table 2

Table 2

The data show positive results, demonstrating successful transition into practice and increased retention of the new graduate RNs. Positive changes were seen in support, professional satisfaction, organization and prioritization, and communication and leadership for the second cohort from baseline to 6 months, although not statistically significant. The stress level for the second cohort was below the national comparison score. After the first year of the ANRP, the retention rate was 94.6% among the residents, exceeding reported ratios for new graduates of 83% nationally.7

Continued, long-term evaluation of the two initial cohorts' retention should be studied. Additionally, comparing the healthcare system's historically robust inpatient nurse residency program and the ANRP survey results may potentially yield data that can inform program design and execution.

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There are notable limitations in this study. The time frame limits comparison of the first and second cohorts for the full 12 months. There were 16 residents in the two cohorts, so the sample size is relatively small. Because the ANRP is the inaugural program in this healthcare system, the departments eligible to take new graduates were purposely narrowed to ambulatory surgery, oncology, and cardiology to confirm that the infrastructure was fully in place to help ensure the residents' and program's success. Expanding sites to additional departments and specialties is needed to fully assess the ANRP in an academic, multispecialty ambulatory system.

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Onboarding success

The development of an ANRP has led to successful recruitment and initial onboarding of 16 new BSN-prepared RNs into outpatient practice, fulfilling the goal of building a workforce pipeline. The ANRP also had unanticipated benefits, including developing a rigorous infrastructure of experienced nurse preceptors, enhancing preceptors' professional development, adding new ambulatory nursing leadership roles, strengthening the partnership between the healthcare system and school of nursing, and highlighting the role of RNs within ambulatory care practice. The intentional and careful design of the support infrastructure for the ANRP was vital to its success and sustainability.

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1. US Health Resources and Services Administration. Health workforce data. 2018.
2. AL-Dossary R, Kitsantas P, Maddox PJ. The impact of residency programs on new nurse graduates' clinical decision-making and leadership skills: a systematic review. Nurse Educ Today. 2014;34(6):1024–1028.
3. Levine J. AAACN ambulatory RN residency taskforce white paper. American Academy of Ambulatory Care Nursing. 2014.
4. Benner P, Stephen M, Leonard V, Day L, eds. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass; 2009.
5. del Bueno D., Dorothy del Bueno RN, EdD. J Contin Educ Nurs. 1985;16(1):29–32.
6. Fink R, Krugman M, Casey K, Goode C. The graduate nurse experience: qualitative residency program outcomes. J Nurs Adm. 2008;38(7–8):341–348.
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