When Yvonne VanDyke became a vice president of Seton Healthcare Family in Austin, Texas, in 2007, she encountered a serious problem: One of every two new graduate nurses was quitting after just two years on the job—a phenomenon that was affecting the quality, safety, and cost of care. Making matters worse, she had trouble finding new nurses to fill the never-ending vacancies.
“We spent quite a bit of our resources to recruit new graduate nurses,” says VanDyke, MSN, RN, a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow (2013-2016) who is now senior vice president of nurse practice and clinical education. “We had great difficulty getting even one or two new grads” to apply for an opening. The situation was exacerbated by Austin’s rapid population growth, a long-standing regional nurse shortage, and the facility’s physical and clinical expansion.
To meet employment needs, Seton decided to try something new: a residency program to help recent nursing school graduates transition into clinical practice. In 2007, Seton implemented an 18-week program that included guided clinical experiences with preceptors; mentoring and debriefing sessions; and evaluation and measurement of the program’s effects.
Seven years later, Seton has seen vast improvements in retention and recruitment. Now, three out of four new graduate nurses make it to the two-year point, and five or six new nurse graduates apply for each vacant position. Hospital administrators have also observed improvements in the skills and competency of newly graduated nurses, and fewer are involved in quality-related problems, VanDyke says.
The residency program, she notes, appears to have played a role in the changes. “Implementing the residency was the only major change we made during a five-year period, and an analysis of turnover data indicated that the economy did not appear to have any impact on nurse retention.”
The program has improved the hospital’s bottom line too. The cost of nurse turnover ranges from $10,000 to $88,000 per nurse, according to a 2013 study in the Journal of Nursing Administration. That’s much more than the price tag for a nurse to participate in the nurse residency program, VanDyke says. “There is a business case to be made.”
Many other hospitals and health care facilities are coming to that realization, too, says Patricia Farmer, DNP, RN, a nurse expert at the Center to Champion Nursing in America, a joint initiative of RWJF and AARP that is working to strengthen the nursing workforce. Administrators are realizing that residency programs, long in place to help new physicians transition to practice, make sense for new nurses too, she says.
More than one-third (37 percent) of hospitals offered nurse residency programs in 2011, according to the study in the Journal of Nursing Administration. One such hospital is Rapid City Regional Hospital in South Dakota. With funding from Partners Investing in Nursing’s Future, a joint project of RWJF and the Northwest Health Foundation, Rapid City Regional Hospital implemented a 12-month nurse residency program in 2009 that includes group discussions, classroom and simulation activities, and mentorship.
Ever since, the hospital improved retention rates and clinical competency among new nurses, according to Rita Haxton, RN, DNP, NEA-BC, the hospital’s vice president of patient care and its chief nursing officer. Haxton has observed other benefits as well: “At the end of the year, participants really feel like they can make a difference in their involvement in committees and in helping us make decisions about practice,” she says.
Nurse residency programs are popping up in other states as well.
Last year, the New Jersey Action Coalition received $1.6 million from the Centers for Medicare & Medicaid Services to develop a long-term-care residency program for new RNs. Also last year, the Rhode Island Action Coalition launched its own new nurse residency and mentoring program with support from RWJF and other public and private-sector groups. Part of the Future of Nursing: Campaign for Action, Action Coalitions are state-level groups of nurses and other stakeholders that are working to transform health care through nursing by mobilizing nurses, other health providers, consumers, educators, and businesses.
Officials from about a dozen other states are also actively engaged in creating nurse residency programs, many with the help of State Implementation Program (SIP) grants from RWJF, Farmer says. SIP grants support Action Coalitions that have made substantial progress toward implementing recommendations from a groundbreaking report on the future of nursing that was released in 2010 by the Institute of Medicine (IOM). The SIP grants call for states to obtain matching funds.
Training new nurses, of course, is nothing new. Hospitals have long had orientation sessions for nurses, Farmer says. But health care experts began to push for longer, more formalized nurse residency programs about two decades ago as demands on new nurse graduates intensified.
Today’s patients are living longer, are more diverse, and are managing multiple and more complex chronic conditions, according to Beverly Malone, PhD, RN, FAAN, chief executive officer of the National League for Nursing. Nurses now have to manage more sophisticated technology, keep up with an explosion of medical advances, and handle more rapid patient turnarounds. “That requires them to function at a very high level,” Malone said in a recent blog post.
The pressure can be particularly heavy on new nurses in rural or remote areas, where they are expected to provide a wider range of care, Farmer adds. “As nursing has become more complex over the last couple of decades, there’s been an increasing recognition that academic programs, even the very high-caliber ones, face difficulties preparing nurses for the intensity and acuity of patient care and patient care systems that they are called upon to interact with.”
The demands on new nurses are contributing to high turnover rates, according to health care experts. Nationwide, 18 percent of new nurses leave their first nursing employer within a year of starting their jobs, and 26 percent leave within two years, according to the RN Work Project, a national study of new nurses that is funded by RWJF.
Retaining new nurses is critical in light of changing nurse workforce demographics, experts say. The average age of the RN population is 47, according to the 2008 National Sample Survey of Registered Nurses, and more than 1 million RNs will reach retirement age within the next 10 to 15 years, according to the Health Resources and Services Administration.
Health care experts are increasingly touting nurse residency programs as a solution to high turnover among new graduate nurses. In 2002, the Joint Commission issued a nursing workforce report that recommended that hospitals implement standardized post-graduate nurse residency programs. That recommendation was endorsed in 2009 by a Carnegie Foundation study on the nursing profession and by the IOM in its report on the future of the nursing profession.
Residency programs contribute to significant reductions in turnover rates, studies show. Participants in a one-year post-baccalaureate nurse residency program developed by the University HealthSystem Consortium and the American Association of Colleges of Nursing showed improved communication and organization skills, less stress, higher perceived levels of support, and lower turnover rates, according to nurse researchers.
The IOM report, meanwhile, highlighted a study by Versant, a nonprofit group that provides, supervises, and evaluates transition-to-practice residency programs for acute care hospitals. A self-evaluation showed a “profound reduction” in turnover rates among participants.
“When the Institute of Medicine came out with its report recommending that a residency should be part of nursing, we were like, ‘O.K., We’re ahead of the game. We’ve already done that,’” Haxton says. “We plan on continuing it indefinitely, if we can. The cost varies depending on how many new graduates participate, but if it continues to decrease my turnover in that first year, it’s worth the money.”