EFFECTS OF NEW GRADUATE RN RESIDENCY PROGRAMS1
Effects of New Graduate RN Residency Programs on Job Satisfaction and Retention Rates:
A Literature Review
Karen Land, Holly McCurdy, William Scott, Barri Baas, Lisa Clark
Humboldt State University
Abstract
This paper explores published articles that report on research conducted to examine the impact of participation in new graduate registered nurse (RN) orientation or residency programs on job satisfaction and retention rates. Databases were searched with no limitations set on published dates and included a search using keywords such as, but not limited to, new graduate nurse, residency programs, job satisfaction, and retention rates. Limits were set to include only peer-reviewed articles. This review was conducted to answer the following question: Does participation in a new graduate RN orientation or residency program that lasts three months to one year increase the retention rates and job satisfaction among new graduate RNs? After a review of the literature it was found that participation in new graduate RN residency programs for a period of three to twelve months increases retention rates and job satisfaction. A significant increase in retention rates over a period of one to two years was noted by all studies. An unexpected discovery was the cost savings benefit to the healthcare institution offering the residency program. These findings have important consequences for addressing the broader topic of the projected nursing shortage.
Effects of New Graduate RN Residency Programs on Job Satisfaction and Retention Rates:
A Literature Review
A shortage of RNs is projected to spread across the United States between 2009 and 2030, and will be most severe in the South and the West (Jurashcheck, Zhang, Ranganathan, & Lin, 2012). It is expected that the number of employed RNs will increase from 2.74 million in 2010 to 3.45 million in 2020, a 26% increase (U.S. Bureau of Labor Statistics, 2012). These projections further illustrate the need for 495,500 replacements in the nursing workforce, which brings the total number of job openings due to replacements and growth to 1.2 million by 2020 (U.S. Bureau of Labor Statistics, 2012). In addition, the health care reform law will create a need for more RNs through expanded coverage to 31 million uninsured Americans (Jurascheck et al., 2012). Friedman, Cooper, Click, & Fitzpatrick (2011) also note that while current nursing shortages do exist, they are typically limited to specialty areas and are short-term.
It is projected that the number of RNs who will be retiring between 2011 and 2020 will swell to 55% (Goode, Lynn, Krsek, & Bednash, 2009). The retirement of an aging workforce will create a marked reduction in RN supply (Jurascheck et al., 2012). According to Goode et al. (2009), new graduate nurses are the sole source at hand to fill the gap created by these retirees. The issue with this is that the acuity of hospitalized patients, as well as the complexity of many acute care hospitals, requires new graduate nurses to be able to provide safe and competent care immediately upon being hired (Goode et al., 2009). However, as Goode et al. (2009) states, it is nearly impossible for even the best baccalaureate nursing programs to prepare new graduate nurses to work in the acute care environments of today.
In fact, a study undertaken by Bowles and Candela (2005), which examined first job experiences of recent graduates, found that 30% left their jobs in one year while 57% had left within two years. They also discovered that the top reason for new graduate RNs leaving their first job related to high stress associated with high patient acuity, unacceptable nurse-to-patient ratios and a concern on the part of the new graduates that patient care was unsafe. Also in support of this statement, many schools of nursing, hospital nursing leadership, and new graduates believe strongly that additional competencies and knowledge beyond what they were taught while in their educational program are needed for new graduates to successfully transition from being a student to a professional RN and to avoid dissatisfaction (Goode et al., 2009; Altier & Krsek, 2006).
Trepanier, Early, Ulrich, & Cherry (2012) cite that many new graduate RNs have described a lack of connection between what they were taught while in nursing school and their personal experiences in the profession. They cited feelings of being pushed into the role while not being ready coupled with too much work, responsibility, pressure, and a perception of being mistreated by experienced nurses and physicians as their main reasons for being dissatisfied in their new professional roles (Trepanier et al., 2012). Bowles and Candela (2005) also state that nurse dissatisfaction with their work conditions, such as patient issues and long work hours, were twice as likely as employment factors, such as rate of pay, to be the reason why they left their first RN job. Bratt (2009) supports this idea by stating that new graduate RNs’ high stress levels and feelings of incompetence, in relation to patient care issues, increases their potential for turnover.
Retaining new graduate nurses should be of the utmost importance to healthcare institutions as it affects their ability to provide the best and most consistent care to their patients. Poynton, Madden, Bowers, Keefe, & Peery (2007) state that breakdowns in communication are often the root cause of sentinel events in the hospital. When the importance of communication among members of a care team is considered, it becomes obvious that building working relationships is extremely difficult in the presence of high turnover rates or streams of temporary employees. While communication issues related to low retention rates may greatly affect the care team and the patients, the cost of replacing new graduate RNs dissatisfied with their job directly impacts the healthcare institution. A cost-benefit analysis completed by Trepanier et al. (2012) estimated that the cost of replacing a new nurse is between $49,000 and $92,000 depending on the location of the hospital and the rate of pay of the new nurse. This indicates that it is imperative for healthcare institutions and nurse executives alike to consider the retention of new graduate nurses as essential to their staffing and financial efficiency.
Purpose
The purpose of this literature review is to establish whether or not participation of new graduate nurses in a nurse residency program (NRP) lasting three to twelve months increases job satisfaction and one to two year retention rates.
Methods
Search/Inclusion Process
A population and intervention statement (PICO) was created to guide the search (see Appendix A). The studies were organized into a table of the tier, purpose, population, strengths, limitations, and results of each study in order to evaluate and analyze the data (see Appendix B, Table 1). An online search using CINAHL, Google Scholar, PubMed and Cochrane Review databases was performed in November 2012. This search strategy used the following search phrases, keywords or search strings: “new graduate nurse,” “nursing residency programs,” “new graduate nursing programs,” “new graduate role,” “nursing schools,” “growing our own,” “new nurse job satisfaction,” “new nurse retention rates,” “new graduate program,” “residency programs,” and “mentor programs.”
The abstracts of these articles (N=122) were then examined to determine whether they discussed retention rates and job satisfaction. Papers with outcome measures of job satisfaction and/or retention rates of new graduate nurses enrolled in a new graduate program lasting three to one year (n=15) were included. Date-range limitations were not set, as it was determined that RN new graduate programs were not studied until recently. The oldest study used in this literature review was published in 2005. All studies utilized were scholarly, peer reviewed articles.
Critique of Studies
Melynk and Finehout-Overholt’s GRADE was used (Godshall, 2010, p. 163) to evaluate the strength of the evidence from each study. Of the 15 studies used for this review, five were Level III, defined by Godshall (2010) as, “evidence obtained from a well-designed controlled trial without randomization” and ten were Level IV, which Godshall describes as, “evidence from well-designed case-control and cohort studies” (p. 163). Types of studies reviewed included non-randomized controlled time studies, qualitative studies, cohort longitudinal studies, case studies, and retrospective descriptive studies.
Limitations
The selected studies included small sample sizes, convenience samples, and non-randomized samples which limit the generalizability. Another limitation is that not all programs were standardized. For example, not all programs included post conferences which allowed for discussion after each shift. After performing an extensive search of the published data, it has become clear that no RCTs of nurse residency programs exist. It isthe opinion of these authors that having an RCT of a NRP would bring up ethical dilemmas. For instance, it would be unethical to deny the best possible training to a nurse in order to study the success of a program. Furthermore, giving one group of nurses better training than another could have negative consequences on patients. For this reason, no studies with RCTs were found for this review.
Results
Once research articles were reviewed and selected for inclusion, it was found that 12 of the 15 studies pertaining to nurse residency programs three months to a year long included information regarding both job satisfaction and retention rates. Three articles focused exclusively on retention rates and the economic outcomes of NRPs. All of these articles came to the conclusion that the implementation of a NRP does benefit both the healthcare institution and the residents involved in the program in some manner.
Job Satisfaction
Professional (or job) satisfaction was discussed in 12 out of 15 (80%) of the articles included in this review. High quality articles that met the search criteria and focused exclusively on levels of job satisfaction were not found. However, while job satisfaction was not universally addressed, many of the studies examined did report increases in new RNs feelings of competence and confidence (Bratt, 2009; Dyess & Parker, 2012; Goode et al., 2009; Haggarty et al., 2010; Kowalski & Cross, 2010; Olson-Sitki et al., 2012)
One study found that there was a slight reduction in professional satisfaction during the year-long residency program, though the score remained relatively high with a range of 3.4 to 3.52 on a 4.0 scale (Maxwell, 2011). Additionally, one study indicated that only two of their ten measurements of job satisfaction, satisfaction with praise and satisfaction with professional opportunities, showed statistically significant decreases in score with the other eight measures demonstrating minimal change (Altier & Krsek, 2006). In another study, no increases in job satisfaction were found, rather it was found to remain consistent throughout the program. Although this study’s results imply that there was no improvement in job satisfaction, what it may indicate is that residents who were already satisfied with their jobs maintained that level of satisfaction while in the program (Kowalski & Cross, 2010).
Another study found that there was a significant difference between new resident RNs’ satisfaction at six and twelve months of the study. Nurses reported a high level of job satisfaction upon completion of the program at 12 months. Overall, nurse satisfaction in this study included high satisfaction with salary (73%), enjoyment of their work hours (78%), and satisfaction with advancement options (68%) (Olson-Sitki, Wendler, & Forbes, 2012). Research by Halfer, Graf, & Sullivan(2008) indicate that overall job satisfaction was significantly higher in the group participating in the NRP as compared to an earlier group of new nurses that did not participate in a residency program. In addition, St. Francis Hospital and Health Centers (SFHHS) in Indiana came to the conclusion that the success of their new graduate NRP gave them a competitive advantage over other hospitals in the area by employing quality RNs who reported higher job satisfaction after completion of the program (Fox, 2010).
The remaining six studies indicate that job satisfaction increased during the program but did not specify methods of measurement. For instance, Orsini (2005) states that job satisfaction increased as evidenced by the residents being 91.2% likely to recommend the program to other new nurses and by the fact that they saw an overall improved attitude score of 94.1%. However, it did not state a figure or how much actual job satisfaction increased. A study by Dyess & Parker (2012) indicated that the increase in retention rates seen as a result of the NRP prove that its residents were more satisfied with their jobs. Haggarty, McEldowney, Wilson, & Holloway (2009) did not measure job satisfaction directly, however, participants in the program reported that as a result of their feelings of increased confidence and clinical competency, they felt satisfied with their job. In addition, Bratt (2009) states that the participants in the Wisconsin Nurse Residency Program (WNRP) reported decreases in feelings of isolation, enhanced self-confidence and critical thinking skills, better time management skills, and improved relationships with other staff members which indicated increased levels of job satisfaction.
Nurse Retention
Without exception, all of the 15 articles included in this review came to the conclusion that nurse residency programs increase the retention rates of new nurses. For instance, retention data for the WNRP reports that 90% of the participants were retained after one year, with 83% at the end of two years. This data represents a significant improvement in retention rates because the turnover rate exceeded 50% prior to implementation of the residency program (Bratt, 2009). The University Hospital Consortium/American Association of Colleges of Nursing (UHC/AACN) NRP state that at the end of 2009, 15,964 new nurses had participated in its program at a total of 56 hospitals (with five additional hospitals joining in 2010), and reported an overall retention rate of 95.6% as of 2010 (Maxwell, 2011). This is significant, especially when compared to the national average retention rate of 35-60% (Poynton et al., 2007). Though it may appear less dramatic than the high retention rates of the UHC/AACN program, retention rate at the Methodist Hospital’s UHC Baccalaureate NRP in Houston, Texas increased from 50% pre-program to 87% post-program (Pine & Tart, 2007). Findings from the other 12 studies included in this review are consistent with the findings from these three studies, though their exact statistics vary somewhat. These findings suggest that new graduate nurse residency programs are an important component for retaining new graduate nurses.
Clearly, increased retention rates benefit healthcare institutions in several ways. One unexpected finding of this review was that increased retention rates are strongly correlated to cost savings benefits for these institutions. Supporting this notion is a cost-benefit analysis completed by Trepanier et al. (2012). They found that the total cost savings (post-program implementation) to the 15 hospitals studied were estimated to be between $8.1 million and $41.7 million when the impact of nursing turnover and cost of contract labor usage were combined. Pine and Tart (2007) also noted that the cost of replacing the original 50% of new nurses that the Methodist Hospital of Houston, Texas hired prior to implementation of a residency program was estimated to be $1,372,800. However, the replacement cost of new nurses post-residency implementation fell to only $274,560 a savings of $823,680 (Pine & Tart, 2007).
Discussion
The purpose of this review was to determine whether or not participation in a nurse residency program lasting three months to one year increases levels of job satisfaction and retention rates among new graduate nurses. Resultsgatheredfromthe literature available on this topic confirm that one and/or two year retention rates of new RNs areincreased with the implementation of a residency program. While job satisfaction is believed to increase as a result of implementation of a residency program, it is not shown to do so in some of the studies used in this review. In some instances, job satisfaction was not shown to increase, but was shown to remain consistent throughout the course of a program. In rare cases, job satisfaction was slightly diminished.
Based on these results, our hypothesis that nurse residency programs have a positive effect on new nurse retention rates has been substantiated. Our hypothesis that job satisfaction increases with the implementation of NRPs has been somewhat substantiated but cannot be completely confirmed related to a lack of consistent data. In addition, an unexpected but positive finding is that as a result of increased retention rates, nurse residency programs lead to cost saving benefits for the institutions utilizing them. Additionally, new RNs participating in many of the residency programs report feeling more competent and confident in their roles as professional nurses which allows them to feel more secure in their ability to provide safe patient care.
Author Biases
The writers of this review are graduating from a baccalaureate nursing program and have varying interests in pursuing nurse residency programs. The authors’ background provided them with insight about the data and may have biased expectations. However, the authors searched for articles that would dispute the belief that residency programs are beneficial and were unable to find any. This review was conducted to determine whether participating in a new graduate residency program would provide a better opportunity to transition into the nursing profession. Although this topic may seem of concern to only new graduate nurses, it should in fact concern anyone who cares about patient safety or cost benefits for the institutions that employ nurses.