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THE UHC/AACN
Nurse Residency Program™ ASolution to the Problem of
First-Year Nurse Turnover
By Cathleen Krsek, RN, MSN, MBA, and Debra McElroy, RN, MPH
THEPROBLEM morethan400,000newregisterednursesjust to replace
5
Health care leaders in both academic and practice settings those whoareexpectedtoretirefromactivenursingpractice.
agree that there is an education-to-practice gap for new Wemustbegintoreplacethistremendouslossofwisdom
graduates that makes it more difficult for them to cope andexperience.
with the complex, fast-paced health care environment they Higher costs. The news isn’t any better on the financial side
face today. New nurses need knowledge and competencies of the equation. The average cost associated with nurse
above and beyond those developed in school—their training turnover is estimated at $88,000 per nurse.6 Health care
gives them the requisite theoretical knowledge but does not organizations spend an estimated $300,000 in nurse
2 Factor in
provide the clinical and situational experience they need to turnover costs for every 1% increase in turnover.
be able to apply their own intuition, clinical judgment, and decreasing revenues and increasing overall expenses, and
contextual knowledge to nursing practice and care delivery. the problem takes on even greater urgency.
This lack means that nurses new to the professional role
function by rule-governed behavior; they are not able to THECONSEQUENCES
recognize and interpret information without the situational
experiences that allow them to acquire these higher-level Theconsequencesoftheknowledgegapcombinedwiththe
skills. This experience gap contributes to several significant stress level of the new graduate can be devastating. As nurse
problems for today’s health care organizations: turnover rates climb, the negative effects on nursing staff,
patient care, and the hospital’s bottom line become more
High stress. Today’s new graduate nurses face a busy, andmoreevident.
complicated health care environment with sicker patients
thanhasbeenthecaseinthepast.Thishigh-acuityenviron- Nurse burnout.Hospitalstodayareincreasinglyfacedwith
ment,combinedwithalackofsituationalexperience,results doing more with less. However, high nurse turnover and
in high stress levels for the new nurse. High stress levels have vacancy rates result in higher nurse-to-patient ratios—and
beenshowntobeariskfactorforpatientsafetyandpractice nurses burned out by high patient loads leave the bedside,
1 and also lead to high nurse turnover: The median increasing turnover rates even more. One study reported that
errors
2 hospitals with a nurse-to-patient ratio of 1:7 had an average
voluntary turnover rate for first-year nurses is 27.1%.
turnover rate of 18%, while rates at hospitals with a ratio of
Accelerating nurse shortage. Compounding the problem 7
1:4 averaged only 9%.
of first-year nurse turnover is the fact that the shortage of
registered nurses in the United States could be as high as Compromised patient care. Morethan40%ofnew
8
3 graduates report making medication errors, and 50% of
500,000by2025. Althoughthecurrenteconomicclimate
hasloweredtheregistered nurse vacancy rate, history shows newgraduatesmayfailtorecognizelife-threatening compli-
9
that as the recession eases, the rate will rise again. The nursing cations because of their lack of experience. Research by
workforce is also aging—by 2012, nurses between the ages of Aikenetaldemonstratedthatadditionalpatientsinanurse’s
10
50and60willmakeupthelargestdemographicgroupinthe workloadincreasedthelikelihood of failure to rescue. A
4By2014,itwillbenecessarytorecruit TorontostudyreportedintheJournalofAdvancedNursing also
nursing workforce.
foundthat“theadequacyofnursestaffingandproportion
ASolution to the Problem of First-Year Nurse Turnover
of registered nurses is inversely related to the death rate of Bennersaidittakesabout1yeartomovetocompetency,so
11 16
acutemedicalpatientswithin30daysofhospitaladmission.” the newgraduateneedssupportthroughthatfirstyear.
Otherresearch has associated positive patient outcomes with Newgraduatesreportthatstress levels escalate after the
higher nurse staffing levels. Blegen and Goode, using data orientation programiscomplete,whentheynolongerhave
fromUniversity HealthSystem Consortium (UHC) hospitals, preceptor support and they are expected to function
foundthatstaffing levels and higher proportions of BSN- independently but have not yet achieved competency.
12 Finally, a
preparednursesimprovedpatientoutcomes. Experts say that an effective residency program should be
study in 2002 by Needleman et al reported that higher levels 14 It should focus on
of nurse staffing are associated with 25% fewer adverse flexible, robust, and evidence-based.
areas identified by nursing experts as being critical to the
13
patient outcomes. success of the new graduate: communication, safety, clinical
Lower revenue. As organizations seek to achieve a balance decision making/critical thinking, organizing and prioritizing,
betweenadequatestaffingandreducedcosts,theeffectof evidence-based practice, role socialization, and delegating
these 2 factors on patient outcomes becomes even more and supervising.17 It should incorporate “clearly stated
critical. The nursing workforce, always vital to a hospital’s expectations for competent performance, constructive
mission, is today an important factor in an organization’s feedback about performance, adequate resources and
18
financial success. Recent implementation of guidelines support systems, and a safe and trusting environment.”
from the Centers for Medicare & Medicaid Services on Cooperalsonotedtheimportanceofprofessionalreflection
19
nonreimbursableconditionsmeansthatnursing’simpact during the nurse’s transition.
onhospitalrevenuewillbefeltdirectly. These “never events” Anurseresidencyprogramshoulduseexpertnursefacilitators
andhospital-acquiredconditionsaredirectly linked to the to help new nurses develop effective decision-making abilities;
quality of care delivered to the patient at the bedside. improvetheirclinical judgment and performance; gain clinical
autonomyatthepointofcare;
THESOLUTION:ANEVIDENCE-BASED incorporate research-based UHC/AACNNURSE
NURSERESIDENCYPROGRAM evidence into their practices RESIDENCYPROGRAM™
Toaddresstheidentified gap between education and to advance safe, high-quality OUTCOMES
practice, the National Council of State Boards of Nursing nursing care; and strengthen Retention has improved
hasrecommendeda“transitiontopracticeregulatorymodel their commitmenttonursing every year, with 94.4%
as a career choice. retention in 2008.
designed to promote public safety by supporting newly Outcomemeasurementusing
14
licensed nurses.” This recommendationwasechoedbythe Somehealthcareleadershave the Casey-Fink Graduate Nurse
MichiganDepartmentofCommunityHealth’sTaskForceon expressed concern about the Experience Survey also shows:
NursingEducation:“Michiganshouldimplementarequired resources needed to provide • Significant decrease in stress
systemofnurseresidencypriortopracticefornewlylicensed the ideal transition program. • Significant improvement in
nurses; such residencies bridge the gap between education Webelievethattheevidence ability to organize and
andpractice, increase retention of new graduate nurses in is clear. In today’s economy, a prioritize
15 • Significant improvement in
the workforce, and improve patient care and safety.” residency program that retains
even 1 nurse is a sound invest- communicationand
Theconceptofaresidencyprograminnursingisnotnew, leadership skills
but there is tremendous variability in what is offered to the ment,giventhe$88,000price
newgraduate.Ina2000UHCsurveyofchiefnursingofficers tag on recruiting and training
at academic medical centers, transition programs were areplacementnurse.Inaddition,retaining new graduate
reported to range in length from 4 weeks to 2 years, and nurses does more than reduce costs—it preserves the knowl-
content varied from 100% didactic to 100% clinical. edge, experience, and competence gained during the first
year of professional practice so that nurses can help deliver
Theidealprogramisbasedontheevidenceofthecritical better patient outcomes. Stable staffing levels reduce stress
factors in transitioning from advanced beginner to competent andturnover, improve morale, increase efficiency, and
professional. The first element is the duration of the program. promotepatientsafety.
www.uhc.edu | e-mail: NRPinfo@uhc.edu | (630) 645-8164 2
ASolution to the Problem of First-Year Nurse Turnover
Resident nurses who receive ongoing, personalized support in • Core content, including professional reflection, is provided
their first year become professional nurses who are competent in structured monthly seminars for a minimum of 4 hours.
andstayintheirjobsbecausetheyvaluetheirorganizations. • The program offers systematic access to preceptors and
Today’s health care climate and the reality of health care expert resident facilitators.
reform underscore the critical need to ensure a stable, well- Theprogramalsosupportsefforts to obtain and main-
educated, competent, satisfied nursing staff who can provide tain Magnet designation from the American Nurses
high-quality patient care, ensure patient safety, and promote Credentialing Center.
excellent patient outcomes.
ENSURINGTHEFUTUREOFPROFESSIONAL ABOUTUHCANDAACN
NURSINGPRACTICE TheUniversity HealthSystem Consortium is an alliance
TheUHC/AACNNurseResidencyProgram™hasprovento of 107 academic medical centers and 220 of their affiliated
beaneffective model for addressing new graduate nurses’ hospitals, representing approximately 90% of the nation’s
transition needs, promoting high-quality care by providing nonprofit academic medical centers. UHC’s mission is to
professional support for almost 16,000 nurses. The program advanceknowledge,fostercollaboration, and promote
is built on an evidence-based curriculum that meets national changetohelpmemberssucceedintheirrespectivemarkets.
20 and exceeds the recom- UHC’svisionistobeacatalystforchange,acceleratingthe
residency accreditation standards achievementofclinical and operational excellence.
mendations of the National Council of State Boards of
Nursing. Developed by experts from academic medical TheAmericanAssociationofCollegesofNursingisthe
centers and schools of nursing across the country, the national voice for America’s baccalaureate- and higher-
core curriculum content focuses on 3 critical areas: degree nursing education programs, offering educational,
• Leadership: Managing resources—including staff, supplies, research, governmental advocacy, data collection, publi-
andservices—for optimal patient care and collaborating cations, and other programs to establish quality standards
with the interdisciplinary team for bachelor’s- and graduate-degree nursing education, assist
deansanddirectorstoimplementthosestandards,influence
• Patient Safety and Outcomes: Applying foundational the nursing profession to improve health care, and promote
knowledgeofcritical, nurse-sensitive topic areas to practice public support of baccalaureate and graduate education,
at the patient’s bedside research, and practice in nursing—the nation’s largest health
• Professional Role: Enhancing the growth and development care profession.
of the nurse, both professional and personal
TheUHC/AACNprogram’scurriculumwasdesignedto ABOUTTHEAUTHORS
meettheneedsofnewgraduatesasdescribedinthelitera- CathleenKrsekhasmorethan35years’experienceinhealth
ture, and the topic areas were validated by a study published care, including many years in critical care, education, and
in November 2008 that quantified areas of satisfaction (or quality improvement; she has also served as a director of
lack thereof) with new graduates’ competency on a list of nursing. She facilitated the design and development of the
21 Twenty-nine of the listed skills are included in the
36skills. UHC/AACNNurseResidencyProgram™.Duringhertenure
curriculum (the remaining 7 are technical skills, which are not as director of the program, she has overseen its growth from
the program’s focus). 6academicmedicalcenters in 2002 to almost60participat-
Following are the key features of the UHC/AACN Nurse ing organizations, including community hospitals, in 2009.
Residency Program™: DebraMcElroyco-managestheUHC/AACNNurseResidency
• The program is 1 year in length. Program™,focusingonitsdevelopmentforuseinhospitals
• The curriculum complements hospital and nursing throughoutthecountryandexpansionof the residency model
orientation and specialty training courses. to varied practice settings for nurses. She has an extensive
• All participants partner with a school of nursing, creating backgroundinnursingandhealthcare,includingoversightof
apractice and academic link. multidisciplinary health care coalitions and programs related
to health care access.
www.uhc.edu | e-mail: NRPinfo@uhc.edu | (630) 645-8164 3
ASolution to the Problem of First-Year Nurse Turnover
REFERENCES
1. National Council of State Boards of Nursing data. Presented at Transition of New Nurses to Practice: A Regulatory Perspective; February 22,
2007;Chicago,IL.
2. PricewaterhouseCoopers Health Research Institute. WhatWorks:HealingtheHealthcareStaffingShortage. New York: PricewaterhouseCoopers; 2007.
3. BuerhausPI,Staiger DO,AuerbackDI.TheFutureoftheNursingWorkforceintheUnitedStates:Data,Trends,andImplications. Sudbury, MA: Jones and
Bartlett Publishers; 2008.
4. BuerhausP.Stateofthestate:thelatestprojections of nursing’s future [presentation]. San Diego, CA: Concerro; January 2009.
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Washington,DC:HealthResourcesandServicesAdministration;USDepartmentofHealthandHumanServices;2006.
ftp://ftp.hrsa.gov/bhpr/nursing/nurptsummary.pdf. Accessed November 23, 2009.
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7. Atencio BL, Cohen J, Gorenberg B. Nurse retention: is it worth it? Nurs Econ. 2003;21(6):262-268.
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JAMA.2002;288(16):1987-1993.
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LakeBuenaVista,FL.
13. NeedlemanJ,BuerhausP,MattkeS,StewartM,ZelevinskyK.Nurse-staffinglevelsandthequalityofcareinhospitals.NewEnglJMed.
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14. Transition to Practice: Promoting Public Safety [fact sheet]. Chicago, IL: National Council of State Boards of Nursing; 2009.
https://www.ncsbn.org/Transition_factsheet_final.pdf. Accessed November 18, 2009.
15. Clark M, MundtMH;MDCHTaskForceonNursingEducation.FinalReportandRecommendationsoftheMDCHTaskForceonNursingEducation.
Lansing, MI: Michigan Department of Community Health; 2009. http://www.michigan.gov/documents/mdch/TFNEFinlRpt_1_290174_7.pdf.
Accessed November18,2009.
16. Benner P. FromNovicetoExpert:Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley Publishing Co; 1984.
17. Spector N. Description of NCSBN’s Transition to Practice Model. Chicago, IL: National Council of State Boards of Nursing; January 2009.
http://www.nyone.net/portal/LinkClick.aspx?fileticket=dA3c5XmOFd0%3D&tabid=36&mid=403.AccessedNovember23,2009.
18. Spector N, Li S. A regulatory model on transitioning nurses from education to practice. JONAS Healthc Law Ethics Regul. 2007;9(1):19-22.
19. CooperC,TaftLB,ThelenM.Preparingforpractice:students’reflections on their final clinical experience. JProfNurs. 2005;21(5):293-302.
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21. BerkowS,Virkstis K, Stewart J, Conway L. Assessing new graduate nurse performance. JNursAdm. 2008;38(11):468-474.
University HealthSystem Consortium
2001SpringRoad,Suite700 For Program and Pricing Information
OakBrook,IL 60523-1890 E-mail NRPinfo@uhc.edu
www.uhc.edu or call (630) 645-8164.
©2009UniversityHealthSystemConsortium.
All rights reserved.
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