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T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Residency for Transition Into Practice An Essential Requirement for New Graduates From Basic RN Programs

Colleen J. Goode, PhD, RN, NEA-BC, FAAN

Patricia Reid Ponte, DNSc, RN, FAAN

Donna Sullivan Havens, PhD, RN, FAAN

Nurse residency programs have been developed with the goal of helping newly licensed nurses successfully transition to independent practice. The authors pro-pose that all newly licensed nurses hired in acute care hospitals be required to complete an accredited resi-dency program. An evidence table examines the state of the science related to transition-to-practice pro-grams and provides the basis for recommendations.

The role of clinical nurses grows increasingly com-plex, given the advancement of care technologies, the acuity level of patients, specialization, quality and safety requirements, evidence-based practice expectations, the rapid turnover of acute care patients due to shortened lengths of stay, and the need for increased coordina-tion of care across practice settings. It is very difficult for schools of nursing to prepare new nursing grad-uates with the capacity needed to practice in acute care settings immediately upon graduation.1,2 Accord-ing to Kramer et al,3 7 major challenges have been identified by newly licensed RNs: delegation, prior-

Author Affiliations: Professor (Dr Goode), Healthcare Systems, College of Nursing, University of Colorado Denver, Aurora; Senior Vice President, Patient Care Services, Chief Nursing Officer, Dana-Farber Cancer Institute, and Executive Director, Oncology Nursing and Clinical Services (Dr Reid Ponte), Brigham and Women_s Hos-pital, Boston, Massachusetts; Interim Dean and Professor (Dr Sullivan Havens), Healthcare Systems and Outcomes, University of North Carolina School of Nursing at Chapel Hill.

The authors declare no conflicts of interest. Correspondence: Dr Goode, Healthcare Systems, College of

Nursing, University of Colorado Denver, 13120 E 19th Ave, C288-19, Aurora, CO 80045 ([email protected]).

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 (www.jonajournal.com).

DOI: 10.1097/NNA.0000000000000300

itization, managing patient care delivery, autonomous decision making, collaboration with other disciplines, constructive conflict resolution, and utilizing feedback to restore self-confidence.

One innovation to address the transition-to-practice challenge is the nurse residency program (NRP), which has been shown to impact the socialization of new graduates with other disciplines; increase evidence-based practice; decrease turnover; improve new grad-uates_ confidence, competence, and ability to organize and prioritize work; improve communication and clinical leadership; and lead to transformative changes in organizations.

1,3,4 This position paper describes

the current state of the science for new-graduate RN transition-to-practice residency programs and presents policy recommendations.

Background

In a call for radical transformation of nursing edu-cation, Benner et al5 determined that nurses are un-dereducated for current practice demands and called on the nursing profession and healthcare providers to implement 1-year residency programs focused on 1 clinical area of specialization.

5 The Institute of Med-

icine report, The Future of Nursing: Leading Change, Advancing Health,6 also recommended the implemen-tation of nurse residencies to facilitate transition to practice. A 2011 survey of chief nursing officers found that only a minority of hospitals, approximately 37%, offered an NRP.7

In the last decade, a number of professional nurs-ing organizations have taken steps to promote wider adoption of NRPs. In 2002, the National Council of State Boards of Nursing (NCSBN) developed a model

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for transitioning new graduates.8 The American As-sociation of Colleges of Nursing (AACN) partnered with the University HealthSystem Consortium (UHC) to develop and implement a postbaccalaureate, 1-year NRP.1,2,9 AACN and UHC also worked with the Com-mission on Collegiate Nursing Education (CCNE) to promote the creation of an accreditation process for postbaccalaureate NRPs that are developed in part-nership with academic nursing programs.10 The 1st residency program was accredited by CCNE in 2009.1

Currently, 18 residencies are accredited by CCNE and they include UHC/AACN, Veterans Administra-tion and residencies with self-developed curricula. The National League for Nursing (NLN) has announced the BAcceleration to Practice Program.[11 Seven aca-demic and practice partners have joined NLN to de-velop the program, which will be available in 2015 and will focus on transitioning all newly licensed RNs.11

Many hospitals have developed their own NRPs for newly licensed nurses. The American Nurses Cre-dentialing Center (ANCC), a subsidiary of the American Nurses Association, has established an accreditation program to ensure new-graduate residencies conform to evidence-based standards.12 The ANCC Practice Transition Accreditation Program does not require a partnership with a school of nursing. Currently 5 resi-dency programs are accredited by ANCC. Because most residency programs for new RNs are currently not accredited, there is considerable variation in pro-gram structure, content, and outcomes.

The State of the Science

An evidence table (Supplemental Digital Content 1, http://links.lww.com/JONA/A454) contains articles published between 2006 and January 2015. The fol-lowing clinical questions drove the search: BIs there evidence to support transition to practice programs for newly licensed RNs?[ and BWhat does the evi-dence tell us about how these programs can be im-proved?[ The search was conducted using the Ovid, MEDLINE, CINAHL, and Google Scholar systems. The search included studies involving hospitals, long-term care, home care, and clinics. The level of evidence associated with each article was assigned using the framework developed by Melnyk and Fineout-Overholt.13 Twenty-three articles met our criteria for inclusion and are summarized in the evidence table (Supplemental Digital Content 1, http://links.lww.com/ JONA/A454). The articles include 13 quantitative studies, 4 qualitative studies, 2 integrative reviews, and 3 systematic reviews and a historic article.14

Articles from the Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A454, with large sample sizes and the systematic and integrative reviews

are summarized. Two articles reported on 10 years of data from specific residency programs: the UHC/AACN residency and the Versant New Graduate RN Resi-dency.1,4 The UHC/AACN postbaccalaureate program is 1 year in length and uses an evidence-based standard-ized curriculum that addresses 3 core areas: leadership, patient safety and outcomes, and the professional role.1 A preceptor training program and completion of an evidence-based practice project in the last 6 months of the residency are components of the program. More than 57 000 new graduates have completed the pro-gram. In examining data obtained from program participants between 2002 and 2012, Goode and colleagues1 found that residents_ self-assessments of their overall confidence and competence, ability to or-ganize and prioritize work, and ability to communicate and provide leadership increased significantly over the course of the program. Retention rates increased over the 10-year study period, from 88% to 94.6%.

Ulrich and colleagues4 used a similar approach to evaluate the Versant residency program, analyz-ing data obtained from more than 6000 nurses who participated in the program over the course of 10 years. The Versant program started by Becroft, Kunzman & Krozek as a pilot project in children_s hospitals15

and is now used in both pediatric and general hos-pitals and is open to diploma, associate degree in nursing (ADN), and baccalaureate graduates. The program is based on Benner and colleagues,5 frame-work and includes an evidence-based curriculum. The curriculum includes classes with case studies, struc-tured clinical immersion, team precepting experiences, mentoring and debriefing, self-care, and competency validation.4 Program participants experienced gains in self-confidence, and ratings of satisfaction were high, with the highest ratings assigned to the work enjoyment, quality, and time to work subscales. Hos-pitals experienced lower new-graduate turnover, pro-viding them with significant savings.16 Data showed the need for ongoing support and guidance and a plan for structured mentoring and debriefing for 1 year.

The qualitative study by Kramer et al3 involved 907 nurses from 20 MagnetA hospitals. The researchers found that participating in an NRP positively impacted the socialization of newly licensed RNs, and the tran-sition stage (when the preceptor is dominant) and the integration stage (when residents are integrated into the professional practice role) are most effective in developing new-graduate competencies.3 When or-ganizations institute theory based transition plus integration-stage nurse residency programs, the authors demonstrated that NRP’s lead to improved practice which empirically leads to improved outcomes.3

The integrative review by Rush et al included 47 articles.17 Thirteen articles reported retention rates

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averaging 90.1%. Articles examining turnover re-ported an average rate of 10.5%. Residency length ranged from 3 months to more than 6 months. Stress levels were highest, and job satisfaction was lowest at 9 months, and both improved by the end of 1 year. The integrative review by Park and Jones18 included 17 studies involving programs that varied from 6 weeks to 1 year. All programs included classroom learning and clinical experience with a preceptor and 7 studies reported an increase in self confidence. Retention, examined by 15 studies, also improved.18

The systematic review by Anderson et al19 included 20 studies. Findings highlighted the need for stan-dardization of curricula and program procedures. The nurse residency educational intervention was not well described in many of the studies and was the most unstable variable. The review found a lack of consistency in tools used for evaluations, great varia-tion in program length, and lack of a standardized evidence-based curriculum.19 The systematic review by Lin et al20 looked at articles related to the job satisfaction of residents. Dissatisfaction with extrinsic rewards did not change significantly during the resi-dency; satisfaction with praise and recognition was mixed, and satisfaction with professional opportunities in the residency improved nurse satisfaction. Dissat-isfaction with the work environment and the hospital system was not alleviated by the residency. A sys-tematic review by Chappell and Richards21 evaluated 2 areas: the relationship between new graduates and their clinical leadership skill and between new-graduate transition to practice programs and clinical leadership skill.21 More than 4000 new graduates participated in the study. Study designs were mostly repeated measures with or without a comparison group. Curricula for the transition programs were developed by the UHC/AACN, the Versant program, or the organization running the program. 21 Transition programs that were at least 24 weeks long demonstrated a positive impact on clinical leadership skill. The UHC/AACN program curriculum had the greatest positive impact on new graduates, and the Versant program curriculum had the 2nd greatest impact.21

A recent study, by Spector et al,22 examined the experiences of 105 hospitals that were randomly as-signed to implement the NCSBN Transition to Practice Model (TTP) program (intervention group) or to con-tinue using their existing on-boarding programs (con-trol group). They found some of the control hospitals had Bestablished programs,[ which used a structured curriculum and included at least 6 of 11 elements that the literature describes as essential for transition-to-practice programs.22 The remaining control hospitals offered Blimited programs,[ which did not use a struc-tured curriculum and included fewer than 6 of the

essential elements. Patient errors and negative safety practices were highest in sites with limited residency programs, and overall nurse competence in the limited group began decreasing at 6 months and remained lower than in the other 2 groups for the rest of the year. New nurse turnover in the limited group was also approximately 2 times higher than in the TTP and established groups.

Summary of Evidence

Because of the wide variation in tools used to mea-sure the outcomes of residency programs, the dif-ferences in the length of the programs, the lack of standardization of evidence-based curricula, and the lack of a set of standards for program procedures and education and experience of preceptors and edu-cators, it is difficult to meaningfully compare different graduate nurse residency programs. The residency educational intervention in the studies listed in the Table, Supplemental Digital Content 1, http://links. lww.com/JONA/A454, is the least described and most unstable variable and could introduce measurement and statistical error.19 At the same time, the evidence suggests that structured, evidence-based transition programs can be effective in improving new-graduate retention, job satisfaction, competence, confidence, and leadership, and better outcomes are associated with longer programs (ie, those lasting between 6 and 12 months).

Implementing Residency Programs in the Hospital Setting: Policy Recommendations

In light of the growing evidence demonstrating the benefits of NRPs for new-graduate nurses and health-care institutions, we propose that all newly licensed RNs hired in acute care hospital settings be required to complete an accredited residency program. Implement-ing a residency requirement for all new graduates entering acute care cannot happen overnight. It will require collaboration among nursing professional groups and the active participation of acute care hos-pitals that employ newly licensed RNs. Policy recom-mendations to help turn our proposed residency requirement into reality are outlined in the follow-ing paragraphs.

1. Residency programs for new-graduate ADN and baccalaureate-prepared nurses should be designed, implemented, evaluated, and admin-istered by hospitals, ideally in collaboration with a school of nursing. Because the nurse residency is a continuation of nursing education, it is logical to link it to a school of nursing at a college or university.

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2. Residency program completion should be a condition of hire for hospitals that hire new-graduate nurses. As the hiring agency, hospitals are singularly positioned to ensure that all newly licensed nurses who join their staff fulfill a res-idency requirement.

3. All residency programs should be accredited by national regulatory agencies to ensure consis-tent program components, standards, processes, and outcomes achievement. Accreditation agen-cies such as AACN and ANCC have taken on the accreditation role and developed standards for accreditation. To date, the evidence sug-gests the residency program of 6- to 12-month duration is most effective and should consist of an evidence-based curriculum.

4. Nursing education accrediting bodies (AACN and NLN) should require entry-level nursing education programs (ADN and BSN) to parti-cipate in the development and administration of residency programs for newly licensed nurses in acute care. This requirement will ensure that hospitals and NRPs benefit from the support and input of academic partners and that nurs-ing education programs are continually informed by an up-to-date appreciation of the challenges facing newly licensed nurses.

5. Hospitals that hire new-graduate ADN-prepared nurses should require ADN residents to sign a contract to complete a baccalaureate degree in nursing within a specified timeframe in order to maintain employment. Adopting this recom-mendation would advance ongoing efforts to meet the Future of Nursing6 recommendation to increase the proportion of nurses with a baccalaureate degree to 80% by 2020.

Cost and Funding Considerations for Residency Programs

While some hospitals may view NRPs as cost-prohibitive, recent studies suggest otherwise. For example, a cost-benefit analysis of the Versant residency program, which used data on turnover and contract labor use, found that the program was associated with a marked decrease (from 36% to 6%) in the 12-month turnover rate for new graduates, and a reduction in contract labor costs from $19 000 to $5490 per average daily census. 23 Pine and Tart24 examined 1 hospital_s expe-rience with the UHC/AACN residency and calculated the costs of the residency as $2024 per resident. Jones25 estimated turnover costs at $82 032 to $88 006 per nurse. Current anecdotal evidence suggests new graduates from entry-level nursing programs want to

enter clinical practice in organizations that have NRPs. Such an advantage would be especially beneficial in the coming years when healthcare reform, a changing economy, and nurse retirements are expected to in-crease the demand for RNs.26,27

Government and philanthropic participation and support for NRPs are needed. In Rhode Island, the Robert Wood Johnson Foundation (RWJF) is par-tnering with the Rhode Island Action Coalition and the Governors Workforce Board to help fund a state-wide nurse residency that supports new-graduate nurses who are working in hospitals or in nonacute settings in Rhode Island.28 RWJF has also helped fund the de-velopment of a 12-month NRP in Iowa that includes online modules and discussion sessions that are avail-able as webinars or conducted on site by a facility_s own personnel.29 The Iowa program is available to newly licensed nurses working in a range of settings. The New Jersey Action Coalition received a grant from the Centers for Medicare & Medicaid Services to de-velop, implement, and evaluate a transition to practice model for long-term-care facilities.30 A recent study found that only 2.2% of home health and hospice settings and 11.4% of primary care clinics are intro-ducing NRPs.31 Another study determined that resi-dency programs are being introduced in approximately 49% of hospitals.20

Conclusion

Residency programs help new-graduate nurses develop the skills, competence, and confidence required for autonomous practice. They also yield significant re-wards for healthcare organizations by improving reten-tion, organizational commitment, and the development of future nurse leaders.32

Given the preponderance of evidence supporting NRPs, we have proposed that all new graduates of ADN programs and BSN programs who are hired to work in acute care settings be required to complete an NRP. Furthermore, to ensure the quality of NRPs, we propose program accreditation as a requirement. We have also proposed that hiring organizations im-plement contracts requiring ADN residents to return to school within a specified timeframe to obtain their baccalaureate degree. This will be a major step toward achieving the Institute of Medicine Future of Nursing report which calls for 80% of nurses to be prepared at the baccalaureate level by 2020.6 Areas in need of more study include the impact of nurse residency pro-grams on patient outcomes and the required length for an NRP.

We recognize that efforts to implement our rec-ommendations will encounter multiple challenges. Fur-thermore, achieving success will require the collaboration

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of numerous stakeholders, including representatives of professional organizations, deans and faculty of schools of nursing, nursing and organizational leaders in service settings, and government and philanthropic agencies. Our hope is that through this article, we initiate a dialogue through which representatives from these different arenas begin taking steps to move nurse residencies from an option that is available to a small number of nurses, to a requirement that benefits every

newly licensed nurse, as well as healthcare organiza-tions and the patients they serve.

Acknowledgments The authors recognize the members of the American Academy of Nursing Expert Panel on Building Health-care System Excellence for their contributions to this article and Beth Kantz, MS, RN, for her editorial and writing support.

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