Submitted by by Kristin vanWyngeeren, BSN Massachusetts College of Pharmacy and Health Sciences School of Nursing Tammy Stuart, MS, RN Assistant Professor Massachusetts College of Pharmacy and Health Sciences
Today’s healthcare environment demands efficient use of resources. Research shows that turnover rates are high for new nurse graduates as a result of a stressful work environment coupled with inadequate support during the transition from student to professional practice. This article seeks to define the problem of new nurse graduate retention, examine strategies implemented by specific organizations that decreased turnover rates of new graduate nurses, and offer recommendations for the new graduate nurse about to enter professional practice. Results of effective implementation of strategies to increase new graduate nurse retention show positive outcomes for the new graduate nurse and the organization, both in cost-savings and measures such as job satisfaction. Drawing from programs implemented at individual organizations recommendations are provided for organizations and new student nurse graduates programs to effectively transition the new nurse graduate into professional practice.
INTRODUCTION & BACKGROUND
In today’s dynamic health care environment it is essential to recruit new graduate nurses to organizations and ensure they have adequate resources and support to thrive in order to retain them in the profession. A survey of nurses conducted by Bowles and Candela in 2005 found that 30 percent of respondents left their first nursing position during the first year and 57 percent left by their second year. Research conducted by individual organizations supports this finding in experiencing turnover rates of new graduate nurses between 22.6% and 60% (Orsini, 2005 & Mills & Mullins, 2008). Research demonstrated this is a time of learning and stress for the new graduate in transition (Duchscher, 2008; Etheridge, 2007; Hodges, Keeley, & Troyan, 2008; Lavoie-Tremblay, et al., 2008). Organizations must be cognizant of the transition required of new graduate nurses merging into professional practice and implement strategies to support their transition, which can result in increased retention rates. Significant costs are attributed to orienting a new graduate nurse. For the year of 2004, one organization calculated RN turnover cost to be $44,000 per nurse (Baggot, Hensinger, Parry, Valdes, & Zaim, 2005). Other data revealed that the cost of hiring an RN was between 75% and 125% of a new graduate RN salary with costs attributed to recruitment, replacement through overtime, orientation, decreased productivity, and customer satisfaction (Pine & Tart, 2007).
Significant cost savings are seen when investment in transition resulted in decreased nurse turnover. Organizations must focus on retaining nurses in their organizations and the overall profession, as the United States is in the midst of a nursing shortage that is expected to worsen over the next years (American Association of Colleges of Nursing, 2008). Americans are living longer and the baby boomer generation is getting older, placing increased demands on the health care system. As patients have increased acuity, with significant pressure by third party payers to decrease the length of patient stays, the need for adequate nurse staffing is essential (Baggot, et al., 2005). Several organizations with high rates of new graduate nurse turnover have implemented orientation programs, such as a preceptor model, and found this to have a positive impact on new graduate nurse retention. This paper will examine factors contributing to poor retention rates of new graduate nurses, discuss how to attract and retain new graduate nurses in the health care field, and offer recommendations regarding the structure of an orientation program from the perspective of a student nurse to attain this goal.
NEW GRADUATE NURSE TRANSITION INTO PRACTICE
In 1982 Benner outlined a framework of how nurses progress through various stages from that of a novice to an expert. The novice stage, completed through the course of the nurse’s education, is a time of new experiences and the performance of tasks. The new nurse merging into professional practice is an advanced beginner (Benner, 1984). The advanced beginner uses “aspects,” which are characteristics of the current situation that are recognized as a result of a previous similar experience. However, the advanced beginner is unable to determine which aspects are most important and treats all aspects as having equal importance (Benner, 1984). Benner’s implications for this stage include the need for support in the clinical setting by setting priorities and ensuring patient needs do not go unattended as the new nurse is unable to discriminate what is most important in providing care (Benner, 1984). Current research supported Benner’s findings and shed light onto how the new nurse graduate transitioned into practice. Research demonstrated this is a time of learning and stress (Duchscher, 2008; Etheridge, 2007; Hodges, Keeley, & Troyan, 2008; Lavoie-Tremblay, et al., 2008). Challenges faced during the first year of practice as a new nurse include: lack of clinical knowledge and confidence in nursing skills, forming relationships with peers, workload demands, prioritization and organization related to care delivery, and interaction with physicians (Duchscher, 2008; Etheridge, 2007). New graduate nurses in their first few months of practice cited the most difficult aspect of the transition as developing competence and confidence in new situations within the realm of patient care (Hodges, et al., 2008). During this time the new nurse relied heavily on their preceptor to answer questions and serve as a resource (Hodges, et al., 2008). This point is reinforced in the literature finding that new nurse graduates feared they would not know everything that was occurring with each patient and thought it was important to be able to synthesize information and know its meaning. They encountered more responsibility and accountability for patient care than they anticipated, as this level of responsibility was not experienced as students (Etheridge, 2007; Duchscher, 2008). After several months on a unit, new graduate nurses developed the ability to align themselves with knowledgeable and accepting nurses who could serve as a resource and offer support (Etheridge, 2007; Hodges, et al., 2008). Towards the end of their first year in practice, new nurse graduates developed more self-confidence, trusted their own judgment, and were more comfortable with what information they knew, as well as what they did not know (Duchscher , 2008; Etheridge, 2007; Hodges, et al., 2008). Benner’s model has several stages after the nurse completes the advance beginner stage, which require continued support by experienced nurses and nursing leaders.
In order to have successful outcomes, organizations must provide new graduate nurses the tools necessary to succeed in their career. Successful programs found that buy-in from all levels within the organization and adequate funding allowed for full implementation of the orientation plan (Pine & Tart, 2007). The culture on the unit can also have an impact on new graduate nurse transition. Identified as key in transition by new graduate nurses was a work environment that was supportive and accepting of new nurses and offered personal direction and guidance (Hodges, et al. 2008). However, new graduate nurses often were required to develop street smarts in order to survive within the unit culture which required perseverance and resource identification (Hodges, et al., 2008). Nurse managers and informal leaders on each unit can have a significant impact in creating a culture that is more supportive of new graduate nurses, including creating a welcoming environment and emphasizing the need of the whole unit to contribute to the education of the new graduate. After orientation it is important that the nurse manager, preceptor, and teammates on the unit, continue to support the new nurse encouraging the progression through Benner’s stages with the goal of becoming an expert nurse.
Each orientation strategy implemented by the organizations examined outlined goals for their new graduate nurse orientation programs. Overreaching goals of all programs were to support the development of both competency and role transition with narrower focus on areas such as: partnership, coaching and collaboration, communication, professional role development, critical thinking, improving patient outcomes, leadership, and sense of belonging (Shermont & Krepcio, 2006, Halfer, 2007, Pine & Tart, 2007).
Several organizations found it advantageous to use classroom teaching as a framework for the orientation program; derived from this were several benefits. The Methodist Hospital of Houston, TX used this time to familiarize new nurses with the policies and procedures of the overall organization (Pine & Tart, 2007). Children’s Hospital of Boston found it beneficial to begin all new nurse graduates as a cohort in the orientation classes creating a peer group capable of offering support to one another (Shermont & Krepcio, 2006). Children’s Memorial Hospital in Chicago used classroom time to expand on knowledge of clinical competencies gained previously (Halfer, 2007).
ROLE OF THE PRECEPTOR
Different approaches were taken when implementing the role of a preceptor into the orientation program. The most common approach taken was the preceptor program model-new nurse graduate focus, which were designed for each new graduate nurse to have a preceptor-guided clinical experience in a one-on-one manner (Salt, Cummings, & Profetto-McGrath, 2008, Pine & Tart, 2007, Orsini, 2005, Shermont & Krepcio, 2006). One program implemented a phased preceptor approach where different individuals lead different aspects of orientation (Halfer, 2007). The research identified many roles and responsibilities of the preceptor that facilitated the transition of the new graduate nurse. These included: serving as a role model, integrating the new graduate nurse into the unit culture, advocating for the new nurse graduate, encouraging and evaluating performance, debriefing after critical situations, offering support and helping adjust to the profession, fostering the development of relationships on the unit, serving as a resource, and teaching clinical skills (Salt, Cummings, & Profetto-McGrath, 2008, Pine & Tart, 2007, Orsini, 2005, Shermont & Krepcio, 2006, Halfer, 2007).
To ensure the success of the preceptor-new graduate nurse relationship a few organizations ensured that the needs of the preceptor were addressed. Expanding the pool of preceptors was necessary to prevent preceptor burn-out and narrow the generation gap between new nurse graduates and their preceptors within one organization (Shermont & Krepcio, 2006). Preceptors in another program were not counted in productivity for the 12-week duration of the orienatation program in order to focus on the needs of the new graduate nurse (Orsini, 2005). The California Nurse Mentor Project outlined the training of preceptors as a key to success in their program (Mills & Mullins, 2008). The research presented here did not identify competencies required of the preceptor, which could drive future research.
It is undeniable, the significant monetary investment required on the part of organizations when transitioning the new nurse graduate to a professional nurse. However, research demonstrated that when an orientation program that increases retention rates is implemented, this initial investment will lead to cost savings later on. At Children’s Hospital in Chicago the turnover rate prior to the implementation of their orientation program was 29.5% within the first year of employment, which decreased to 12.3%. The associated cost per new graduate was $41, 624 and has resulted in a savings to the organization of $707, 608. (Halfer, 2007). Retention was at an all time low in 2003 at the Methodist Hospital of Houston, where 50% of new graduate nurses left their positions. The rate of turnover after implementation of their program was 13% as of July 2005. The organization calculated their return on investment for implementation as 884.75% (Pine & Tart, 2007). The California Nurse Mentor Program was initiated to address the major shortage of RN’s in the Bay Area, where in 2005 60% of RNs left within their first year of employment. Results showed that those participating in the program had an 8% attrition rate; those not participating had a 23% attrition rate. Estimated savings from a monetary standpoint over three years were estimated to be between $1.4 and $5.8 million (Mills & Mullins, 2008).
In addition to capturing data related to cost savings associated with new graduate orientation programs, several organizations also captured non-tangible benefits. Many of these are similar across different organizations and included: improved morale, increased nursing and health team satisfaction, increased personal confidence, and improved quality of care (Halfer, 2007; Mills & Mullins, 2008; Orsini, 2005). These benefits were seen not only in the new nurse graduate, but also the nurse preceptor and the unit as a whole. These intangible benefits could have and indirect impact the nursing retention rate of all nurses.
The issue of nurse retention is not new, nor has the problem been solved. As we move forward through the next few years, the nursing shortage is forecasted to worsen. It is critical to keep trained nurses in practice and seek ways to increase the supply of nurses. Focusing on the new nurse, it is important to examine how the transition into practice occurs as it is well-documented that there are stages necessitating different resources and varied types of support throughout the process. Qualitative research conducted surrounding this transition also reveals that there is room for needed improvement regarding organizational culture and views towards new nurses. Many nurses leave the profession within the first year as a result of high levels of psychological stress and factors related to organizational and patient care structure. In order to increase retention rates of new graduate nurses, organizations must be cognizant of the needs of the new graduate through the transition from classroom to practice and seek ways to meet these needs.
Literature is available regarding strategies implemented that increased new graduate nurse retention rates on an individual level. This review of literature revealed a gap in research related to evidence-based strategies, transferrable among healthcare organizations to increase retention rates of new graduate nurses. Studies need to be undertaken using an experimental design to outline strategies for orientation programs that address the needs of new graduate nurses in order that they may be fully integrated into and prepared for the positions into which they were hired. All programs reviewed here implemented a preceptor design into their orientation. Each organization was able to increase their retention rates and see associated cost savings; however it remains unclear if this is indeed the best method. More research needs to be conducted in regards to how the preceptor relationship should be defined and what is needed in order for both the new nurse and the preceptor to reap the greatest benefit while achieving organizational goals.
Student nurses about to enter the professional field must take several aspects of an organization into consideration when making a decision as to where to practice. First and foremost, the culture of the organization must be examined. Organizational culture is “the total of an organization’s values, language, traditions, [and] customs” (Marquis & Huston, 2009). As new graduate nurses in transition, aspects of organizational culture that are important include: the attitude of staff toward new nurses, willingness of staff to offer assistance and teach the new graduate, and support of the nurse manager in regards to career development. The nurse manager, as well as nurses on the unit, must be willing to invest time and resources into the new nurse graduate in order to facilitate transition and development into a professional nurse who can make significant contributions to the unit. The organization as a whole should have a formal orientation program in place with explicit goals and objectives, as well as interventions to meet them. Initially the new nurse graduate should be enrolled into an orientation program focusing on the new graduate nurse. This also allows the new nurse graduates to form relationships with those undergoing the same experience, which can serve as a support network. Unit orientation should include a preceptor who can serve as a bridge between the world of academics and the professional world, serving to lead by example and teach competencies. Together the new nurse graduate and the preceptor can also address issues related to the day-to-day working environment such as organization, patient care issues, and work-life balance. In order for this relationship to be successful, it is necessary that the new nurse graduate and the preceptor be compatible, work side by side on similar shifts, and have modified work assignments in order to accomplish the goals of orientation. The preceptor should be trained and willing to take on this role. The nurse manager should also seek ways to integrate the process that the new graduate nurse progresses through during the first year of practice, as well as throughout the new nurse’s career, with his/her performance expectations and develop ways to foster learning and development.
The research presented here has shown that investment of time and resources initially can produce the beneficial long-term outcome of increased nurse retention. This can help to alleviate the nursing shortage and ultimately ensure that patients get the care they deserve.
American Association of Colleges of Nursing. (2008, September). Fact Sheet: Nursing Shortage. Retrieved March 23, 2009, from AACN Web site:http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm
Baggot, D. M., Hensinger, B., Parry, J., Valdes, M. S., & Zaim, S. (2005). The New Hire/Preceptor Experience: Cost-Benefit Analysis of One Retention Strategy. The Journal of Nursing Administration , 138-145.
Benner, P. (1982). From Novice To Expert. American Journal of Nursing , 402-407.
Bowles, C., & Candela, L. (2005). First Job Experiences of Recent RN Graduates. Student Nurse Update , 16-19.
Duchscher, J. B. (2008). A Process of Becoming: The Stages of New Nursing Graduate Professional Role Transition. The Journal of Continuing Education in Nursing , 441-450.
Etheridge, S. A. (2007). Learning to Think Like a Nurse: Stories From New Nurse Graduates. The Journal of Continuing Education in Nursing , 24-30.
Halfer, D. (2007). A Magnetic Strategy for New Graduate Nurses. Nursing Economics , 6-10.
Hodges, H. F., Keeley, A. C., & Troyan, P. J. (2008). Professional Resilience in Baccalaureate-Prepared Acute Care Nurses: First Steps. Nursing Education Perspectives , 80-89.
Lavoie-Tremblay, M., Wright, D., Desforges, N., Gelinas, C., Marchionni, C., & Drevniok, U. (2008). Creating a Healthy Workplace for New-Generation Nurses. Journal of Nursing Scholarship , 290-296.
Marquis, B., & Huston, C. (2009). Leadership Roles and Management Functions in Nursing. Philadelphia: Wolters Kluwer.
Mills, J., & Mullins, A. (2008). The California Nurse Mentor Project: Every Nurse Deserves a Mentor. Nursing Economics , 310-315.
Orsini, C. (2005). A Nurse Transition Program for Orthopaedics. Orthopaedic Nursing , 240-246.
Pine, R., & Tart, K. (2007). Return on Investment: Benefits and Challenges of a Baccalaureate Nurse Residency Program. Nursing Economics , 13-18, 39.
Salt, J., Cummings, G., & Profetto-McGrath, J. (2008). Increasing Retention of New Graduate Nurses: A Systematic Review of Interventions. The Journal of Nursing Administration , 287-296.
Shermont, H., & Krepcio, D. (2006). The Impact of Culture Change on Nurse Retention. The Journal of Nursing Administration , 407-415.