Do New Graduate Nurses Need a Formal Residency Program?

The following article closely examines the current curriculum of the generic four year baccalaureate degree and questions the inherent limitations of clinical nurse training in the academic setting as well as the orientation process for new graduate registered nurses (RNs) in the hospital organization setting. The author explores the structure of medical training residency programs to address reality shock in new graduate nurses and discusses the benefits of a structured transition program for new graduate nurses.

Do New Graduate Nurses Need a Formal Residency Program?

After four years of nursing school, do nurses need this additional training? To answer this question, it is prudent to examine the traditional four year baccalaureate nursing curriculum. In general, the first two years of study are dedicated to the fulfillment of general education courses such as English, history, statistics and any other non-nursing courses mandated to meet graduation requirements. Other courses while non-nursing in scope are necessary to build a strong foundation toward nursing theory. Such courses include nutrition, chemistry, organic chemistry, microbiology, anatomy and physiology I and II and sometime physics and pathophysiology. It is not until the last two years of the curriculum that students immerse themselves in the core nursing theory and clinical practice.

What happens in the last two years? In the United States nurses are trained as generalist nurses, this means that the student is not required to focus on specialization. Therefore, the student nurse is rotated through one rotation or semester of pediatrics, obstetrics, psychiatric, and community. The emphasis is placed on adult and older adult which together may consist of two clinical rotations. The last clinical rotation is the preceptorship where students are paired one-to-one with a professional registered nurse and work more independent of clinical faculty.

It is not until the senior preceptor-preceptee training period that students have a more "real world" feel for the autonomy of nursing practice. Clinical rotations in nursing school do not mimic the full responsibilities of a professional registered nurse. Yes, during earlier rotations students are exposed to bits and pieces of various aspects of the field to learn the why and how things are done, but with clinical faculty to student ratio set at 1:10 the clinical rotation experience is limited.

What happens then during a semester rotation? If there are 12 patients on a floor and there are only 2 RN's and one technician. Ideally, the student group would be divided evenly among the two nurses so that each nurse would provide report to five students. This is not always the case as some nurses do not want to mentor students, patients refuse to have student nurses, or the patient census decreases.

For each rotation there is a new unit or hospital; the learning process in interrupted. Students must acclimate to new surroundings become familiar with the nursing staff, type of equipment; learn the layout of the unit, and everyday routines of the unit. In addition, students need to familiarize themselves with the "regulars" identified as physicians and other healthcare providers who work on the unit daily, as well as learn with charting systems and communication networks on how to contact providers and hospital departments.

Nursing and ancillary staff tend to be reserved in their interactions uncertain of student nurse scope of practice, and skill level. Clinical becomes focused on setting the patient up for the day and a how to list such as how to read and understand daily orders, how to administer medication, how to document in the electronic record, and how to work the smart pump. Students become more focused on "task", but the nurses' role exceeds far beyond the few items on a check list to accomplish during the day. It is not until the graduate nurse starts their first job that they are immersed in an overwhelming world of responsibility.

What about new nurse orientation process? Yes, each time a nurse is hired whether a newly graduated nurse or a seasoned nurse with years of experience there is the same orientation process. The orientation process is developed to familiarize nurses to the hospital and routines of the department. New hires are evaluated on their ability to function as an autonomous nurse. It is understood that a nurse with years of experience would need less time being mentored than a new graduate nurse.

The new graduate nurse needs more then what the generic orientation process offers, unlike nurses with years of practice, new graduate nurses experience high levels of anxiety, fear, and frustration related to meeting the needs of the individual patient and the needs of the setting (Kramer, 1974), learning and practicing new invasive procedural skills, delegating to ancillary staff, collaborating with and reporting to physicians on a frequent basis. For even the most experienced RN the hospital environment is considered at times very stressful, demanding, and not conducive to providing safe patient care with increasing responsibilities, more technology, high nurse-to-patient ratios, and higher acuity patients. Nurses have taken a greater role doing more invasive procedures from phlebotomy, urinary catheter insertion, nasogastric tube insertion, bladder irrigation, insertion peripheral intravenous catheter, wound and chest tube management, to name a few. Today, patients admitted to a medical/surgical floor are patients who in the past would have been admitted to the intensive care unit. The current orientation process plays a limited role to the socialization of new graduate nurse.

What's the problem? The turnover rate among newly graduated RNs is extremely high. Turnover is defined as the number of new graduate RNs that leave a position before 12 months (Trepanier, Early, Ulrich, & Cherry, 2012). In a survey conducted by Bowles and Candela (2005), perceptions of first job experience nurses new to the profession, 30% left their job within the first year of employment and 57% left their first job within two years of employment. Twenty-six percent of survey respondents cited the most common reason for leaving was stress caring for high acuity patients, feeling patient care was unsafe, and unacceptable nurse-to-patient ratios (Bowles & Candela, 2005). Similar comments were discussed by Beecroft, Kunzman, and Krozek (2001) who reported new graduate nurse turnover rates of 35% to 60% within the first year of employment. In addition to concerns about new graduate nurse turnover the loss financially is approximately $40,000 in employer hiring and orientation expenses (Halfer & Graf, 2006), but even a conservative estimate of $10,000 per RN results in a substantial financial loss (The HSM Group, Ltd, 2002). Reality shock is proposed to contribute to a majority of new graduate RN turnover.

What can we learn from medicine? What are the benefits of residency? The residency experience for medicine is now a common expectation not only from medical graduates but those who hire physicians. Dr. William Osler, a British Canadian who arrived in 1888, known as one of the four founding physicians of Johns Hopkins Medicine is best known for the establishment of the medical residency program (The Johns Hopkins University, n.d.). The success of the program is credited to the developed pyramidal structure consistent of medical students, interns, fewer assistant residents, and a single chief resident (The Johns Hopkins University, n.d.). The pyramidal hierarchy is an excellent example of well-planned socialization. Training is developed to immerse individuals and gradually increase responsibility and accountability. This gradual immersion into the profession with its built-in support system allows individuals to develop a greater sense of control and decrease level of stress.

Kramer (1974) identified that new nurse graduates experienced increase anxiety, and increase fear in the first 12 months of clinical practice. This is not to say that the nursing profession should adopt an intricate system, but at the informal level it is easy to identify a similar hierarchy in the nursing field with student nurses, new graduate nurses, nurses, and veteran nurses. The Institute of Medicine's (2011) Future of Nursing recommendations support the development of nurse residency programs for both the RN and APRN level. New graduate nurse transition programs have been documented to increase retention rates in organizations (Chappell, 2014; Mennick, 2007), greater satisfaction with mastery of work organization and clinical task (Halfer & Graf, 2006). Recently, the findings from a new graduate nurse residency program reported a decrease in the 12-month turnover rate from 36% to 6% (Trepanier et al., 2012).

What are some components to nursing residency? In addition to the normal orientation process, transition programs should be at least one-year in length, include peer-to-peer interaction, debriefing, self-reflection, mentor support programs, (Chappell, 2014) and skills development. Trepanier et al (2012) described components to nursing residency that consisted of five categories didactic direct instruction, clinical immersion and competency validation, looping, mentoring, and supportive debriefing. A brief description of each follows. The didactic direct instruction and case study takes 15-20% of RN residency incorporating core concepts and multispecialty classes such as 12 lead ECG. Clinical immersion and competency validation process promotes the application of content. At this phase, the new graduate is not primarily responsible for direct patient care, but works under close supervision of the preceptor. Looping is a term used to describe the floating of new graduates to floors outside their dedicated learning unit where patients may have been transferred or admitted to the dedicated learning unit. For example, if the dedicated learning unit is the intensive care unit then time may be spent in the emergency department and the operating room. Supportive mentoring includes assigned mentor circle groups that are facilitated by experienced RNs and includes special topics such as career development. Supportive debriefing allows new graduates to discuss their experiences and voice their feelings (Trepanier et al., 2012).

This article has highlighted many of the limitations to the training of student nurses in nursing school and the inadequacies of hospital orientation for the new graduate nurse. New graduate RN residency programs are a human capital project that assists not only nurses, but also improves patient outcomes. Kelly (2014) reported shorter patient length of stay (LOS) when RNs worked on the same unit for at least one year. Nurse residency programs are a worthwhile investment that requires more resource, funding and further consideration by nurse leadership and hospital organizations.

References

Beecroft, P., Kunzman, L., & Krozek, C. (2001). RN internship: Outcomes of a one-year pilot program. Journal of Nursing Administration, 31(12), 575-582.

Bowles, C., & Candela, L. (2005). First job experiences of recent RN graduates. JONA, 35(3), 130-137.

Chappell, K. (2014). The value of RN residency and fellowship programs for Magnet Hospitals. JONA, 44(6), 313-314.

Halfer, D., & Graf, E. (2006). Graduate nurse perceptions of the work experience. Nurse Economics, 24(3), 150-155.

The HSM Group, Ltd. (2002) Acute care hospital survey of RN vacancy and turnover rates in 2000. JONA, 32(9), 437-439.

The Johns Hopkins University. (n.d.). The four founding physicians. Johns Hopkins Medicine. Retrived on June 18, 2014 from https://www.hopkinsmedicine.org/about/history/history5.html

Kelly, J.C. (2014). Nurse tenure, education linked to shorter hospital stays. American Economic Journal: Applied Economics, 6, 231-259.

Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: Mosby.

Mennick, F. (2007). Keeping new RNs in their jobs. American Journal of Nursing, 107(12), 21.

Trepanier,S., Early, S., Ulrich, B., & Cherry, B. (2012). New graduate nurse residency program. Nurse Economics, 30(4), 207-214.

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JPCummings

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Excellent, excellent observations!

For a few years, I've asked similar questions. Perhaps registered nursing education needs to be expanded. Patient care is the goal of nursing. Nursing education should reflect that proportionately.

I advocate for basic registered nursing education to have way more clinical education than theory and other intellectual pursuits. New grads usually require considerable oversight to complete many duties of their new position.

Clinical and patient care should be the bulk of our training so new grads are ready sooner rather than later. Residencies can help but reforming nursing education to focus on DELIVERING evidence-based care is the real solution.

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Specializes in orthopedic/trauma, Informatics, diabetes.

When I was a student in an ADN program, the hospital I was at was a community hospital that did not have the budget for a long orientation program. The new hires were expected to "get it" in less than 6 weeks. While we were doing clinical, there was a big deal that the BSN nurses were not prepared to go to the floor. The ADN were clinically, more prepared to go to work. I have 600+ clinical hours. Anecdotally, the BSN students that I have spoken with have had half that. My first job was at a LTC facility w/ a rehab unit. They wanted and RN to deal with joint replacement pts. I got less than 6 weeks of orientation. After a year, I felt somewhat comfortable, but 15-18 pts was too many for me-the more I learned, the more I learned how what I was doing was not safe. I then got a job at a very large Magnet hospital and entrance to a 6 month residency. It was wonderful!!!!!! It is a huge investment in the new grad and unfortunately, any leave after (sometimes before) the two year commitment. For the level of care that is expected at my facility, I feel that I am very lucky to have had the experience. Unfortunately,money has become and issue and I think they are going to do away with the program and not hire as many new grads-they are now looking to hire more experienced nurses to fill vacancies. I hope they keep the program because it was great!

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Thank you for your feedback. I agree, it is one thing to orient a well-seasoned nurse to the setting, but it is a completely different aspect when a new graduate RN (NGRN) is asked to perform as if they were a veteran nurse. As students, there are various restrictions on practice, and it is not until licensure that practice comes full circle. It is at this point in time when residency should begin.

I understand the cost constraint with healthcare, but with the IOM's Future of Nursing Recommendations, residency programs are needed to help prepare nurses to care for the increasing high acuity patients. The saying, "A nurse, is a nurse, is a nurse" no longer applies even nurses practicing in medical surgical need to be trained for the specialty. The technology, treatments, and evidenced-based literature expand at an exponential rate monthly it is not reasonable to expect a nurse to be an expert in every area of practice. Therefore, we need nurses who are trained to care (manage) those clients. Nurses are not one size fits all.

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Specializes in ICU.

I disagree that new grads need residencies. I graduated last year and went through one, and it was totally useless to me.

Maybe it was the way my residency was done, but all it did for me was give me a once a week class to go to where they re-hashed things I already learned in nursing school. It also cut into the hours I was allowed to orient with my preceptor - my preceptor was weekend option days and worked Friday/Saturday/Sunday and my residency classes were on Friday morning. I missed report and the first four hours of my shift with my preceptor every single week. Sometimes, if we had the same two ICU patients all three days, I never got full report on my patients from the previous nurse once - my preceptor got that while I was wasting my time in class talking about things I learned in nursing school already.

I would have done just fine, maybe even better, if I hadn't wasted my time in residency class.

And, of course the residencies decrease turnover - hospitals are making new graduate nurses sign outrageous contracts for their residency programs. Mine was $12,000 - how many new graduates, many with student loans hanging over their heads as well, have $12,000 to pay off a contract? Let's be real here. If all you care about is retention, I guess you can safely discount miserable nurses wanting to leave but not being able to because they have a giant $12,000 hammer hanging over their heads. I fully recommend new grad nurses avoid hospitals with residency programs if at all possible.

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I start a residency in July. I don't really know what to expect, but the reputation is stellar. No contract to sign other than accepting my offer of employment.

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I wish we had a residency program, at my current hospital new grads and experienced nurses have a 12 week orientation. 12 weeks isn't too challenging for the experienced nurses but the New grads i've encounted feel rushed in order to meet the hospital demands and job requirements in that time frame.

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Specializes in Primary Care; Child Advocacy; Child Abuse; ED.

I like our residency program so far. We don't have anything tying us to the hospital. They seem to be going out their way to make us happy. Our classes are on Monday, half the day (4 hours) with all new nurses and the other half in our specialty. The classes seem to me to be short and sweet. Days with our preceptor are other days of the week. One thing for sure if you don't like the hospital when you are done you will be an asset some where else because of the training here.

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Specializes in burn ICU, SICU, ER, Trauma Rapid Response.

I like the article and of course agree. However I thought this was already settled and established? Yes new nurses need a formal residency program. I thought we had known this for a decade or more?

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Following Calivianya, I graduated last year and am most of the way through a nurse residency program that has been useless (and the nurses in my program agree). I also agree that from the hospital's stand point, having that two year commitment with a $5000 (in my case) non-pro-rated early quitting fee improves their retention rates and is advantageous for them, but not us nurses, or the patients.

There may be a few factors in the research that haven't been discussed. Hospitals that have residency programs (I believe) are typically larger, more prestigious, and often teaching hospitals, sometimes even at university hospitals. These hospitals already hire the 'cream of the crop' among new grad nurses. If these are often better institutions, hiring and forcing better new grads to stay longer, then of course the results, nurse confidence, patient safety, retention etc. rates are gonna be better. Are these just correlations without taking into account other factors or has it been proven that various residency programs are singularly the reason for better results?

Also my residency program can't be compared to a medical residency program. I suspect neither can many of them. The folks teaching the residency program are running a one-size-fits-all curriculum for nurses in ER, ICU, L&D, med-surg or wherever. It's kind of a joke to compare that to medical residency programs, except that the money put into the program probably results in new grads getting paid less. IMO, putting money into expanding unit orientation would have more real value and more closely mirror a medical residency program. It wouldn't look as nice on the website or to hospital administrators. But I suppose all too often, appearance is more important than substance.

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I was offered a position in a residency program as a new grad, but decided on a regular RN position instead. The residency program sounded like I would be in clinicals and lecture all over again. Basically, it felt like I would be taking a step backward instead of forward because these

programs just sound like paid nursing school. If a new grad attended a nursing program that wasn't thorough in lecture and clinicals skills, a residency program may be helpful/necessary for them. However, I don't think it can be assumed that residency programs are mandatory for any new grad to succeed.

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A residency program set up like a medical residency would work. The way they are set up for RN's now don't seem to alleviate any of the issues they mention. As someone else mentioned, these hospitals are usually large teaching hospitals who are already choosing the top of the class. Perhaps that explains the percentage differences.

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