The Effectiveness of Nurse Residency Programs on Retention: A Systematic Review

The Effectiveness of Nurse Residency Programs on Retention: A Systematic Review JENNIFER VAN CAMP, MSN, RN; SHARON CHAPPY, PhD, RN, CNOR

ABSTRACT New graduates account for the highest numbers of nurses entering and exiting the profession. Turnover is costly, especially in specialty settings. Nurse residency programs are used to retain new graduates and assist with their transition to nursing practice. The purpose of this systematic review of the literature was to examine new graduate nurse residency programs, residents’ perceived satisfaction, and retention rates, and to make recommendations for implementation in perioperative settings. Results indicate increased retention rates for new graduates participating in residency programs and that residency participants experienced greater satisfaction with their orientation than those not participating in residency programs. Residency participants also perceived the residency as beneficial. Because residency programs vary in curricula and length, effectively comparing outcomes is difficult. More longitudinal data are needed. Data on residency programs specific to perioperative nursing are lacking. Considering the aging perioperative nursing workforce, residency programs could address critical needs for succession planning. AORN J 106 (August 2017) 128-144. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2017.06.003 Key words: new graduate nurses, residency program, internship, perioperative residency, retention.

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ecognizing a preparation-practice gap and the high costs associated with new graduate nurse turnover, many health care organizations across the United States have implemented nurse residency programs (NRPs) to bridge the gap and reduce turnover costs. Additionally, many new graduate nurses actively seek out health care organizations that have NRPs for their first employment to ease the transition from student to novice nurse.1 In a survey conducted by Pittman et al,1 36.9% of members of the American Organization of Nurse Executives who responded to a survey (N ¼ 219 respondents) reported that their organizations implemented an NRP to transition new graduates into practice in the hopes of retaining graduate nurses for longer than one year. However, questions remain about the effectiveness of NRPs in retaining new graduate nurses and easing their transition into practice.

BACKGROUND Many new graduate nurses struggle with the transition from novice to competent nurse, and an estimated 35% to 60% of nurses leave their first place of employment within one year of hire.1-3 Transitioning to the RN role can leave graduate nurses feeling stressed, and many have difficulty adjusting to the reality shock of caring for multiple patients with highly complex cases. New graduate nurses may doubt their clinical knowledge and lack self-assurance in performing common nursing skills, critical thinking, organizing, prioritizing, and communicating effectively.4 Interestingly, nurse executives and organizational leaders hiring new graduate nurses identify the same inadequacies that graduate nurses perceive,5 with some executives judging that as few as 10% of new graduate hires are fully prepared to enter the nursing workforce.6 http://dx.doi.org/10.1016/j.aorn.2017.06.003 ª AORN, Inc, 2017

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The current and projected nursing shortage further complicates the situation. It is estimated that by 2020, nursing positions will increase by 26% and the demand for RNs will exceed the supply.7,8 Sherman9 reported that the nursing shortage is even more critical in the perioperative setting, noting that 56% (N ¼ 256 respondents) of perioperative nurse leaders have problems with recruitment and 68% anticipate problems, primarily because of the aging perioperative nursing workforce. The perioperative nursing workforce is older than the general nursing workforce; 48.3% of 2,877 respondents to an AORN survey reported being older than 50 years.10 Problems associated with the turnover of new graduates are further complicated by the costs of orientation. In a literature review, Li and Jones11 found large discrepancies in how nursing turnover costs are calculated. The reported costs associated with each nurse turnover ranged from $10,098 to $88,000. Halfer12 reported the cost of hiring a new graduate nurse to be approximately $41,624 based on a four-month orientation. If hiring a new nurse costs more than $40,000 and replacing a nurse can cost up to $88,000, this can translate to a potential financial loss of more than $120,000 for one new graduate nurse who completes orientation and leaves the organization. These costs could be even greater when orienting a new nurse to a specialty area such as perioperative services. Because of these factors, leaders in health care organizations and educational institutions have been focusing on nurse residencies to attract, retain, and socialize new graduate nurses into practice.

PURPOSE AND OBJECTIVES The purpose of this systematic review of the literature was to examine new graduate NRPs, residents’ perceived satisfaction, and retention rates, and make recommendations for implementation in perioperative settings. Objectives included identifying  common NRPs reported in the literature,  graduate nurse satisfaction with and engagement in NRPs, and  retention outcomes. The PICOT (population, intervention, comparison, outcome, time) question that guided this review was What are the common NRPs used in practice and what effect does NRP completion have on new graduate nurses’ perceived satisfaction and retention rates compared with those of new graduates who did not participate in an NRP?

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REVIEW METHODS AND SEARCH STRATEGY The search strategy included using the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Health Source Nursing/Academic Edition, Ovid Journals Online, and Academic Search Complete using the key words graduate nurses, new graduate nurses, residency, internships and residency, perioperative, and retention. Inclusion criteria were articles  published in English,  published between 2004 and 2016, and  that addressed nurse retention rates, satisfaction, or perceptions associated with NRP participation. We excluded articles if they  addressed NRP development and curriculum without a discussion of retention rates,  focused on preceptor-only orientation processes, or  addressed NRPs implemented in the last year of nursing education. We also excluded unpublished dissertations. Applying these criteria, we identified 48 articles for potential inclusion. We manually reviewed reference lists but did not identify additional works. After reading each article, we included 22 articles that fit the inclusion criteria of the literature review.

FINDINGS Many health care organizations began incorporating NRPs in the early 2000s to help close the preparation-practice gap.13 Implementation of NRPs has gained support from the American Association of Colleges of Nursing (AACN), the National Council of State Boards of Nursing, The Joint Commission, the Robert Wood Johnson Foundation, and the Institute of Medicine as a way to transition new graduate nurses into practice by providing them with a rich educational experience and support.14 In 2010, the Institute of Medicine, with support from the Robert Wood Johnson Foundation, published The Future of Nursing: Leading Health, Advancing Change.15 This publication included recommendations that health care organizations, including community nursing settings, adopt NRPs to assist with the transition from nursing student to staff nurse. Other health care professions, such as medicine and pharmacy, have successfully used residency programs to facilitate the transition and provide guided career training. By definition, NRPs are structured postlicensure programs that are adopted by health care organizations and that incorporate didactic education, clinical support by an RN nurse

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preceptor, and mentorship to bridge the practice gap, with goals to decrease turnover rates and augment patient safety and care quality.1,16,17 Nurse residency programs are designed to expand clinical and professional nursing competencies.18 In general, NRPs vary in length from 3 to 18 months. Classroom sessions vary in frequency and topic, but many focus on the areas of concern to nursing leaders and new graduate nurses, such as critical thinking, psychomotor skills, communication, and teamwork.19 Some NRPs require the candidate to be prepared at the baccalaureate level, while others allow a mix of preparation at the diploma, associate degree, or baccalaureate levels. Some programs require a passing score on the National Council Licensure Exam before admission.20-24

University HealthSystem Consortium/ AACN NRP One of the most popular evidence-based residency programs identified in the literature is the University HealthSystem Consortium (UHC)/AACN NRP, which provides organizations with an evidence-based curriculum that follows the AACN Essentials of Baccalaureate Education for Professional Nursing Practice25 and incorporates the Benner26 novice-toexpert framework. The UHC/AACN NRP requires health care organizations to partner with a nursing education program associated with the AACN to facilitate the curriculum. The program spans one year and entails monthly face-to-face classroom educational sessions, simulation sessions, clinical guidance from a baccalaureate-prepared nurse preceptor, and mentorship with a resident facilitator who assists with the professional role.14,27-29 Nurse residents are hired as employees of the health care organization and must commit to the full-time, one-year compensated program.14,17,28,29 Qualified candidates must have passed the licensure exam. The UHC/AACN NRP pilot began in 2002, and the program grew quickly. By 2007, the program included 34 participating sites in 24 states.29 In 2013, there were more than 100 participating sites throughout the United States, with 40,823 nurses completing the program.30

Versant NRP Another widely used, evidence-based NRP called the Versant New Graduate RN Residency31 began in 1999 at Children’s Hospital Los Angeles as a research study designed to determine whether a formalized NRP could increase new graduate nurse competency, confidence, satisfaction, and retention.24 The Versant NRP follows Benner’s novice-to-expert framework,26 and includes a curriculum with educational sessions, in-depth clinical experiences with a trained preceptor, structured mentoring time, and debriefing and self-care sessions. Instead of 130 j AORN Journal

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having the nurse resident follow one preceptor, it uses a team approach where novice nurse residents are paired with newer nurses who are closer to their own level of experience. As the resident progresses in clinical experience and knowledge, a more seasoned expert nurse takes over as preceptor. The NRP does not affiliate with a nursing education program and includes graduate nurses from diploma, associate degree, baccalaureate, and entry-level master’s degree levels.24,31

Perceptions of NRP Experiences We summarize perceptions of outcomes such as graduate nurse experiences, knowledge, confidence, job satisfaction, engagement or organizational commitment, and retention rates in Table 1. The UHC/AACN NRP was the most frequently cited program.3,14,17,19,28,29 Goode et al14 disseminated 10 years of cumulative program outcome data from the UHC/AACN NRP. Maxwell28 and Pine and Tart3 reported retention rates and perceptions of graduate nurses from individual hospitals implementing the UHC/AACN NRP. Overall, new graduate nurses perceived NRPs as beneficial to their nursing career.

Confidence and competence Goode et al,14 Kowalski and Cross,21 Olson-Sitki et al,22 and Herdrich and Lindsay32 analyzed qualitative and quantitative data examining the perceptions of graduate nurses at their programs’ beginning, midpoint, and end. Bratt and Felzer33 also described the qualitative perceptions of nurse residents. Pizzingrilli and Christensen34 measured confidence pre- and post-NRP. Results were similar in all studies, with overall improvement in confidence and competence scores at the end of the NRP. Analyzing 10 years of data related to the UHC/ AACN NRP, Goode et al14 reported that graduate nurse residents consistently reported discomfort with three clinical skills: responding to codes and emergencies, ventilator care, and chest tube management at the beginning, midpoint, and end of the NRP. At NRP completion, nurses perceived significant increased confidence in leadership abilities, organization and prioritization skills, communication skills, and the ability to provide safe care.14,21,22,32-34 Overall, graduate nurse residents rated NRPs highly and many would recommend NRPs to future nurses.14,17,21,23,24,28,29,33,35

Job and professional satisfaction Several authors examined graduate nurse job satisfaction or professional satisfaction. Anderson et al35 gathered data on job satisfaction using the Halfer-Graf Job/Work Environment Nursing Satisfaction Survey.2 This tool examined nurses’ current perceptions of work environment, perceptions of work

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Table 1. Individual Evidence Summary Author and Date

Evidence Type

1

Sample, Size, Setting

Study Findings

Limitations

Quality and Evidence Level

Anderson et al,2 2009

Mixed qualitative and quantitative surveys

 90 GNs in a Midwestern hospital system

 Post 1-y NRP: o 1-y retention rate: 90% o 2-y retention rate: 70%  NRP satisfiers and dissatisfiers  GNs had lower job satisfaction after 1 y post hire  No change in engagement from pre-NRP to post-NRP period

 Retention rates limited to 2 y post NRP  Lack of control group

III B

Meyer Bratt,3 2009

Mixed qualitative and quantitative surveys

 4 y of data on 1,100 GNs  50 rural and urban hospitals in Wisconsin

 Pre-NRP retention was  Retention outcomes low: 50% at individual measured for sites only 2 y  Retention rates post  Lack of control group NRP: o 1-y: 90% o 2-y: 83% o 1-y average: 84%

III B

Meyer Bratt and Qualitative repeated Felzer,4 measures design 2011

 468 newly licensed RNs in rural and urban Wisconsin hospitals participating in the Wisconsin NRP

 Nonexperimental  Perceptions of new nurses measured 3, 6,  Lack of control group and 12 mo after hire into NRP  Clinical decision making higher at 12 mo compared with that at 3 and 6 mo  Job satisfaction significantly higher at 12 mo and lowest at 6 mo  Job stress lowest at 12 mo  Organizational commitment highest at 3 mo

III B

Friedman et al,5 2011

 90 GNs (2 cohorts)  Standard orientation retention: 53.3% in critical care units of 2 New York, NY,  Post yearlong NRP retention: 78.3% hospitals  30 GNs received standard orientation  60 GNs received NRP

Retrospective, descriptive

 Use of convenience sample  Use of retrospective comparative descriptive design  Lack of control group  Nonexperimental  Small sample size

III B

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Table 1. (continued ) Author and Date

Evidence Type

Sample, Size, Setting

Study Findings

Limitations

Quality and Evidence Level

Goode et al,6 2013

Longitudinal,  10 y of data on  Results from 10-y data  qualitative surveys 31,000 GNs across on UHC/AACN NRP and quantitative 100 hospitals in the  Some program sites retention data  United States reported pre-NRP retention rate as low as  50%   Post-NRP retention rates: o 1-y: 88% o 10-y: 94.6%  Perceptions: o GN NRP experience positive o GN would recommend NRP o Improved confidence with leadership, organization, prioritization, communication, and providing safe care o Still uncomfortable with codes and emergencies, ventilator management, and tracheotomy management  Job satisfaction high at baseline, then significantly decreased at 6 mo and plateaued through 12 mo

Poor resident participation rate in data collection Lack of control group No solid pre-NRP retention data Nonexperimental

III B

Halfer,7 2007

Case study of hospital-  GNs; sample size developed NRP; not stated quantitative  Children’s hospital retention data in Chicago

Sample size not stated Nonexperimental Lack of control group

VA

Herdrich and Lindsay,8 2006

Mixed qualitative surveys and quantitative retention data

Small sample size Lack of control group Nonexperimental Undisclosed pre-NRP retention data  2 different NRP designs with different measurements in each, making it difficult to compare results

III B

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 10 GNs in 2 Wisconsin hospitals; 5 in medical-surgical unit and 5 in cardiac-CCU

 Pre-NRP retention:  70.5%  1-y post-NRP retention:  87.7%   Pre-NRP retention data not disclosed  Qualitative data gathered at 3, 6, and 12 mo  Cardiac-CCU group had 6-mo NRP  Medical-surgical group had 12-mo NRP  Post-NRP retention in both cohorts: o 1-y: 90% o 2-y: 90%

   

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Table 1. (continued ) Author and Date

Evidence Type

Sample, Size, Setting

Study Findings

Limitations

Quality and Evidence Level

 Medical-surgical group measured job satisfaction and showed little change at all 3 time points  Stress improved overall because of ability to handle stressors better; however, more stress reported at 12 mo because of staffing issues  Improved knowledge, confidence, and competence measured in the cardiac-CCU group Hillman and Foster,9 2011

Case report on quantitative retention data

 251 GNs at a Michigan children’s hospital

  Pre-NRP retention  as low as 50%  1-y post-NRP retention  range: 75%-100%  5-y post-NRP retention: 72.5%

Keller et al,10 2006

Case report on quantitative retention data

 72 GNs at a Texas Magnet-status hospital

 Pre-NRP retention  not disclosed   1-y post-NRP retention: 89.2%  

Kowalski and Cross,11 2010

Case report of  55 GNs qualitative and o Cohort 1: n ¼ 36 quantitative o Cohort 2: n ¼ 19 surveys  2 Nevada hospitals and retention rates

Lack of control group Nonexperimental Discussed qualitative measures but did not report them

VA

Lack of control group Lack of comparison group Nonexperimental No pre-NRP retention data  Small sample size

VA

  Nondisclosed pre-NRP rate  Yearlong NRP  Retention rates post NRP: o Cohort 1: 78% o Cohort 2: 96%  Preceptor evaluation  identified improved  clinical competency  and critical thinking skills  Resident perceptions  of stress related to feeling threatened or challenged decreased from NRP start to end  GN perception of anxiety overall decreased at NRP end

Not all nurse residents were able to complete portions of the NRP as intended because of scheduling conflicts and staffing issues on respective units Nonexperimental Lack of control group No pre-NRP retention data Small sample size

III B

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Table 1. (continued ) Author and Date

Evidence Type

Sample, Size, Setting

Study Findings

Limitations

Quality and Evidence Level

 Lack of control group  Nonexperimental  No pre-NRP retention data  NRP length varied among groups, from 6 mo to 1 y  5 of 28 hospitals did not report necessary data

III A

 GNs perceived better support, ability to provide safe care, communication, and leadership skills at NRP end  Professional satisfaction remained stable at all time points Kramer et al,12 2012

Longitudinal quantitative study

 Retention data  3-y data of 5,316 compared to similar GNs at 28 Magnetcohort before NRP status hospitals in implementation both communitybased and academic  Pre-NRP retention data not disclosed settings in the  25% of all GNs left United States facility within the 3-y data collection timeframe  Post-NRP retention rates: o 6-mo: 93% o 1-y: 87% o 2-y: 79% o 3-y: 76%

Letourneau and Fater,13 2015

Literature review

 25 articles; 10 empirical and 15 on program development

 92 practice sites in  No data linking NRPs 29 states and with patient Washington, DC offer outcomes the UHC/AACN residency program with more than 26,000 nurses completing the program

III B

Little et al,14 2013

Comparative

 172 GNs at 2 Ohio hospitals o Hospital A: n ¼ 138 o Hospital B: n ¼ 34

 Lack of control group  Pre-NRP retention  Uneven sample sizes not disclosed  No pre-NRP data  Hospital A trialed disclosed yearlong adaptation of UHC/AACN NRP, with 2-y retention of 97.8%  Hospital B trialed Versant NRP, with 2-y retention of 97.05%  Hospital system then created its own NRP with retention rate of 97%

II B

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Table 1. (continued ) Author and Date Maxwell,15 2011

Evidence Type

Nonrandom, nonexperimental qualitative and quantitative surveys

Sample, Size, Setting  18 GNs at a Magnet-status hospital in Georgia implementing the UHC/AACN NRP

Nadler-Moodie Descriptive qualitative  16 GNs divided into and Loucks,16 case report; 3 cohorts at a quantitative 2011 psychiatric hospital retention data o Cohort 1: n ¼ 5 o Cohort 2: n ¼ 4 o Cohort 3: n ¼ 7

Newhouse Quasi-experimental; et al,17 2007 posttest only; control group

 452 GNs divided into 2 cohorts at academic hospital o Control: n ¼ 115 o Experimental: n ¼ 337

Study Findings

Limitations

 Pre-NRP data as low as 50% retention for GNs from 2001e2007  Yearlong NRP  End of NRP retention: 100%  Graduate nurse perceptions improved with leadership, organization, prioritization and communication skills, and ability to provide safe care

   

 Pre-NRP data not disclosed  Yearlong NRP  Cohort 1 post-NRP retention: 90%  Cohort 2 post-NRP retention: 100%  Cohort 3 post-NRP: retention not disclosed  Qualitative measures identified positive perception of NRP by the GN

   

Quality and Evidence Level

Nonrandom Nonexperimental Small sample size Lack of control group

VA

Small sample size Lack of control group Nonexperimental Lack of comparative group  Lack of pre-NRP retention data

VA

  Pre-NRP data not disclosed  Yearlong NRP  Data collection at 12,  18, and 24 mo  Retention data at 12,  18, and 24 mo: o Control: 80%, 92.1%, 86.7% o Experimental: 88.9%,  87.7%, 90.1%   Measured organizational commitment and found no significant difference between measurement timeframes

Control and experimental group unequal size Control group had low response rate Extraneous variables that can contribute to turnover not measured Potential selection bias Lack of pre-NRP retention rates

II B

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Table 1. (continued ) Author and Date

Evidence Type

Sample, Size, Setting

Study Findings

Limitations

Quality and Evidence Level

 Control group nurses more likely to consider leaving job at 6 mo compared with experimental group Olson-Sitki et al,18 2012

Descriptive qualitative  31 GNs divided  38% attrition rate  Yearlong NRP and quantitative  Lack of control group into 2 groups at  Data collected at study  Nonexperimental a Midwest Magnet6 and 12 mo status hospital in  Turnover measured the United States 2 y before NRP: 12%-15%  Turnover at 12 mo: 7%  Turnover at 24 mo: 11%  Improved GN confidence and competence in nursing skills post NRP  No difference in new nurse satisfaction at 6 and 12 mo; however, residents reported high level of satisfaction with NRP

IV A

Pine and Tart,19 2007

Case report on UHC/AACN NRP quantitative retention data

 Exact number of GN participants not disclosed  Nonexperimental  No control group

VA

 All GNs hired with BSN from 2004e2005 at a Texas hospital

 Yearlong NRP  2003 retention rate: 50%  Post-NRP retention rate: 87%

Pizzingrilli and Quasi-experimental, Christensen,20 pretest and posttest 2015 design

 Small sample size  Mental health  9 RNs and 1 nursing knowledge, practical nurse who confidence levels, participated in a and recovery 12-wk mental health attitudes were NRP significantly improved  Only 50% of the participants were retained at 2 y

Poynton et al,21 2007

 171 GNs at University  Yearlong NRP adapted Health Care in Utah from UHC/AACN to  >3 y of data incorporate associate collection degree- and BSNprepared residents  Retention of participants: 79% from 2002e2005

Case report on adaptation of UHC/AACN NRP; quantitative retention data

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 Turnover rate or retention rate for GNs not disclosed  Data only provided all nursing staff attrition  Nonexperimental  Lack of control group

II B

VA

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Table 1. (continued ) Author and Date

Evidence Type

Sample, Size, Setting

Study Findings

Limitations

Quality and Evidence Level

 Turnover for all nurse hires in 2002 was 24%; in 2005 decreased to 1.56%  25% of residents left job to pursue higher education  Improved leadership abilities in participants Rosenfeld et al,22 2004

Qualitative surveys; quantitative retention data

 112 GNs employed  Yearlong NRP  Pre-NRP retention in NRP from rates not disclosed 1996e2001  Retention rate from  New York City 1997 group: 16% hospital  Retention rate from 2001 group: 76%  Retention rate at end of data collection: 93%  89% of former participants would recommend the NRP  Role of mentor valuable  Participants found value in having educational days

Ulrich et al,23 2010

Longitudinal qualitative surveys and quantitative data

 >6,000 GNs across 85 hospitals implementing Versant NRP from 1999e2009

 Average pre-NRP retention rate after 1 y of employment: 83%, with some sites reporting as low as 15%  Data collection at 12, 24, 36, 48, and 60 mo post NRP  Retention rates post NRP: o 12 mo: 92.9% o 24 mo: 80.4% o 36 mo: 71.4% o 48 mo: 65.8% o 60 mo: 60.2%  Overall, little change in job satisfaction at 12- and 24-mo time points, but satisfaction levels were high

 Low participation rate (36%)  Mistakes in survey mailings to former participants  Retrospective, qualitative data gathered up to several years post NRP  Nonexperimental  Lack of control or comparison group

VB

 Nonexperimental  No control group  Some sites did not fully report data requested  No concrete pre-NRP retention data

III A

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Table 1. (continued ) Author and Date

Evidence Type

Sample, Size, Setting

Study Findings

Limitations

Quality and Evidence Level

 Little to no change in organizational commitment at 12 and 24 mo, but scores remain high GN ¼ graduate nurse; NRP ¼ nurse residency program; UHC/AACN ¼ University HealthSystem Consortium/American Association of Colleges of Nursing; CCU ¼ critical care unit; BSN ¼ bachelor of science in nursing. Editor’s notes: University HealthSystem Consortium is a registered trademark of Vizient, Inc, Irving, TX. ANCC Magnet Recognition is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD. Versant is a registered trademark of Versant Holdings, LLC, Ithaca, NY. References 1. Dearholt SL, Dang D. Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines. 2nd ed. Indianapolis, IN: Sigma Theta Tau International; 2012. 2. Anderson T, Linden L, Allen M, Gibbs E. New graduate RN work satisfaction after completing an interactive nurse residency. J Nurs Adm. 2009;39(4):165-169. 3. Meyer Bratt M. Retaining the next generation of nurses: the Wisconsin nurse residency program provides a continuum of support. J Contin Educ Nurs. 2009;40(9):416-425. 4. Meyer Bratt M, Felzer HM. Perceptions of professional practice and work environment of new graduates in a nurse residency program. J Contin Educ Nurs. 2011;42(12):559-568. 5. Friedman MI, Cooper AH, Click E, Fitzpatrick JJ. Specialized new graduate RN critical care orientation: retention and financial impact. Nurs Econ. 2011;29(1):7-14. 6. Goode CJ, Lynn MR, McElroy D, Bednash GD, Murray B. Lessons learned from 10 years of research on a post-baccalaureate nurse residency program. J Nurs Adm. 2013;43(2):73-79. 7. Halfer D. A magnetic strategy for new graduate nurses. Nurs Econ. 2007;25(1):6-11. 8. Herdrich B, Lindsay A. Nurse residency programs: redesigning the transition into practice. J Nurses Staff Dev. 2006;22(2):55-62. 9. Hillman L, Foster RR. The impact of a nursing transitions programme on retention and cost savings. J Nurs Manag. 2011;19(1):50-56. 10. Keller JL, Meekins K, Summers BL. Pearls and pitfalls of a new graduate academic residency program. J Nurs Adm. 2006;36(12):589-598. 11. Kowalski S, Cross CL. Preliminary outcomes of a local residency programme for new graduate registered nurses. J Nurs Manag. 2010;18(1): 96-104. 12. Kramer M, Halfer D, Maguire P, Schmalenberg C. Impact of healthy work environments and multistage nurse residency programs on retention of newly licensed RNs. J Nurs Adm. 2012;42(3):148-159. 13. Letourneau RM, Fater KH. Nurse residency programs: an integrative review of the literature. Nurs Ed Perspect. 2015;36(2):96-101. 14. Little JP, Ditmer D, Bashaw MA. New graduate nurse residency: a network approach. J Nurs Adm. 2013;43(6):361-366. 15. Maxwell KL. The implementation of the UHC/AACN new graduate nurse residency program in a community hospital. Nurs Clin North Am. 2011;46(1):27-33. 16. Nadler-Moodie M, Loucks J. The implementation of a new-graduate nurse residency training program directly into psychiatricemental health nursing. Arch Psychiatr Nurs. 2011;25(6):479-484. 17. Newhouse RP, Hoffman JJ, Suflita J, Hairston DP. Evaluating an innovative program to improve new nurse graduate socialization into the acute healthcare setting. Nurs Adm Q. 2007;31(1):50-60. 18. Olson-Sitki K, Wendler MC, Forbes G. Evaluating the impact of a nurse residency program for newly graduated registered nurses. J Nurses Staff Dev. 2012;28(4):156-162. 19. Pine R, Tart K. Return on investment: benefits and challenges of a baccalaureate nurse residency program. Nurs Econ. 2007;25(1):13-18, 39. 20. Pizzingrilli B, Christensen D. Implementation and evaluation of a mental health nursing residency program. J Nurs Ed Pract. 2015;5(1):76-84. 21. Poynton MR, Madden C, Bowers R, Keefe M. Nurse residency program implementation: the Utah experience. J Healthc Manag. 2007;52(6):385-396. 22. Rosenfeld P, Smith MO, Iervolino L, Bowar-Ferres S. Nurse residency program: a 5-year evaluation from the participants’ perspective. J Nurs Adm. 2004;34(4):188-194. 23. Ulrich B, Krozek C, Early S, Ashlock CH, Africa LM, Carman ML. Improving retention, confidence, and competence of new graduate nurses: results from a 10-year longitudinal database. Nurs Econ. 2010;28(6):363-375.

environment over time, happiness with their current job, and areas of professional enjoyment.35 The authors measured job satisfaction at the beginning, end, and one year after the yearlong NRPs. The data yielded two themes at the end of the NRPs: satisfiers and dissatisfiers. The nurse residents identified satisfiers related to caring for patients, positive patient outcomes, 138 j AORN Journal

and effective teamwork. Interestingly, the nurse residents identified ineffective teamwork as a frustration. Additionally, the nurses reported inconsistent staffing, scheduling, and physician disregard as dissatisfiers. At the one-year point, participants perceived patient care and positive patient outcomes, effective teamwork, and improved relationships

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with interdisciplinary team members as satisfiers. However, overall job satisfaction decreased at the end of the first year of employment, which could be attributed to decreased perception that staffing schedules were managed effectively, with nurses desiring more flexible hours, adequate staffing, and a sense of teamwork.35 Goode et al,14 Kowalski and Cross,21 Olson-Sitki et al,22 Ulrich et al,24 and Herdrich and Lindsay32 found similar results after analyzing quantitative data on job satisfaction at the NRP beginning, middle, and end. Goode et al14 found participants in the UHC/AACN NRP to have high perceptions of job satisfaction at program start. At the sixmonth point, satisfaction decreased significantly from baseline, and it remained stable at one year. Results in the other studies showed no change in level of satisfaction at the NRP beginning, middle, and end.21,22,32 Ulrich et al24 measured job satisfaction at 12 and 24 months after NRP end and found little change across time points.

Engagement and organizational commitment Three studies examined whether implementing an NRP increased engagement and retention rates among graduate nurse participants.24,35,36 Anderson et al35 surveyed three groups of graduate nurses (N ¼ 90) to find level of engagement at one hospital, hoping to increase the two-year retention rate by using the hospital’s employee engagement tool. Questions on the survey focused on perceptions of feeling valued, trusted, and supported by the organization. Additional questions asked nurse residents their perceptions on being included in organizational decision making. Residents were asked to complete the survey at the NRP start, after completing the NRP educational sessions, and at NRP end. Nurse residents reported no change in their level of engagement from the beginning of the NRP to the end.35 Newhouse et al36 compared engagement among two groups of new graduate hires at three different time points using a control group of graduate nurses not participating in the residency program at one hospital. Data collection began at hire, and continued at 6 and 12 months post hire using the Organizational Commitment Questionnaire and the Modified Hagerty-Patusky Sense of Belonging Instrument. The survey questions asked about whether respondents believed the organization lived up to the organizational goals and values, the willingness of participants to work above and beyond job duties for the organization, and individual perceptions of feeling valued and belonging in the organization. Results showed no difference among the two groups with respect to engagement and sense of belonging. However, feelings of

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belonging decreased in both groups by the six-month point and then increased to near baseline by 12 months.36 Ulrich et al24 measured engagement and commitment of Versant NRP nurse residents at 12 and 24 months after the NRP end. The results were compared with those of nurses from program sites before NRP implementation. Comparison demonstrated that nurse residents reported a greater sense of belonging than nurses surveyed before NRP implementation. There was no difference in organizational commitment between the two groups.24

Retention Rates Retention rate was an outcome variable in several studies, with various lengths of retention examined. Results are summarized below.

Studies with 10 years of retention data The UHC/AACN NRP pilot began in 2002, with outcomes routinely measured from the beginning. During the first evaluation from 2002 to 2004, 88% of participants in the UHC/AACN NRP stayed at the health care site after the NRP. This percentage remained constant until 2007, when it rose to 90.3%. Analysis in 2010 showed 94.6% retention, and one-year retention remained consistent and strong at 95% in the 2014 report.14,30 These percentages were based on more than 33,000 participating residents since 2002. From 1999 to 2009, Ulrich et al24 collected and analyzed data from more than 6,000 Versant NRPs regarding turnover rates and turnover intent at 12-, 24-, 36-, 48-, and 60-month intervals after completing the NRP. Data collected from hospital organizations before the Versant NRP was implemented showed an average of 27% turnover (73% retention) within the first year of employment and 48% turnover (52% retention) within two years of employment.24 One year after implementing the Versant NRP, average new graduate turnover rates from all hospitals decreased to 7.1% turnover (92.9% retention); at 24 months, 19.6% new graduates had left (80.4% retention); at 36 months, 28.6% had left (71.4% retention); at 48 months, 34.2% had left (65.8% retention); and at 60 months, 39.8% had left (60.2% retention).24

Studies with three to five years of retention data Rosenfeld et al23 reported that after implementation of a hospital-developed NRP for 112 new graduate nurses, retention rates increased. Retention data for nurses participating in the NRP from 1996 to 2001 showed that 93% of the responding nurse residency participants remained employed when surveys AORN Journal j 139

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were mailed in 2002. During the four years from 2005 to 2009, Bratt16 collected retention data from more than 1,100 graduate nurses from 50 rural and urban hospitals participating in the one-year Wisconsin NRP. Program sites reported that one-year retention rates were greater than 50% before beginning the Wisconsin NRP. Within the first year of implementation, 90% of graduate nurses remained employed at the specific program site. Data collected at the two-year mark showed 83% remained employed at the program site. Average retention rates across program sites varied from 79% to 97%, with a cumulative average of 84%. Compared with the pre-Wisconsin NRP data, retention at the one-year mark increased by 40%.16 In their descriptive quantitative study, Kramer et al37 compared the retention rates for 5,316 new graduate nurses participating in a multistage NRP with those of new graduate nurses in a transition-only program. Participants included new graduate nurses from 28 Magnet-status hospitals, 12 of which were community based and 16 of which were academic; retention data were collected at six months after beginning the NRP and annually for three years. Participation in the study required that hospitals have an NRP as part of their new graduate transition for at least three years before the study. Nurse residency program length varied among the sites, from two months to one year. Graduate nurse turnover rates were significantly lower in community-based hospitals than in academic hospitals. At six months, 93% of new graduates remained employed at the organization. At the one-year mark, 87% of the graduates remained, with decreasing retention rates at years two and three (79% and 76%, respectively). Retention data before the NRP was implemented were not identified. However, comparing these rates with the estimated average national turnover rates of 35% to 60% (40% to 65% retention) for new nurses within their first year, retention of participants in this NRP exceeded the national average.4,37 Hillman and Foster38 estimated a 22% retention increase with 251 new graduate nurses after implementing a yearlong NRP at a children’s hospital. Before implementing the NRP, the hospital’s one-year turnover rate for new graduate nurses was approximately 50%. Those leaving the hospital to pursue other nursing career options reported a lack of a consistent orientation process as a reason for leaving. The nurses were divided into nine cohorts, which participated in the NRP from June 2005 to October 2009. After starting the NRP, the cumulative average one-year overall retention rate for graduate nurses was 91%, with some cohorts’ retention data as low as 75% and others’ as high as 100%. At the five-year mark, 72.5% of participants were still employed with the hospital.

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Comparing the one-year pre-NRP rate with the one-year postNRP rate average, there was a 41% increase in retention during the four years of data collection. Poynton et al39 identified a need to incorporate a residency program that included nurses with associate’s and bachelor’s degrees, and implemented a yearlong NRP that was an adaptation of the UHC/AACN NRP with 171 residents. They collected data for three years. Before implementation of the NRP, 24% of all nurses left the hospital organization within one year (76% retention). After implementation, the turnover rate dropped to 1.56% (98.44% retention). Among the residents who left the organization, 25% stated they left to pursue higher education.

Studies with two years of retention data Newhouse et al36 compared retention data from two groups of graduate nurses; one group participated in a yearlong NRP (n ¼ 337) and the other group did not (n ¼ 115). Data showed that at 12 months, 88.9% of the NRP participants remained with the hospital organization, compared with 80% of the nonparticipants. Interestingly, at 18 months, NRP participants had a lower retention rate (87.7%) compared with that of the non-NRP group (92.1%). At the two-year mark, 90.1% of the resident participants remained, as opposed to only 86.7% of the nonresident participants. The authors noted that residents were more likely to remain at the organization over time. These numbers may be somewhat misleading, because the second-year numbers appear to be based on those residents who remained at the end of year one, not on the number of residents who began the program. Olson-Sitki et al22 reviewed turnover data on 31 graduate nurse NRP participants and found improvement in retention. One- and two-year turnover data before NRP implementation were 12% and 15% (88% and 85% retention), respectively. During the NRP implementation, the one- and two-year turnover rates among new graduate nurses decreased to 7% and 11% (93% and 89% retention), respectively. Kowalski and Cross21 collected retention data from 55 graduate nurse participants completing a voluntary nursing education program and hospital-collaborative NRP in 2007 and 2008. In 2007, 36 graduate nurses participated, with a retention rate of 78% at program end. In the second cohort of 19 graduate nurses, 96% remained employed with the hospital at program end. Data from the organization before the NRP were not disclosed. However, frequently cited reasons for leaving the organization included other employment, relocation, or being fired.

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Herdrich and Lindsay32 reported retention results from a unitspecific NRP in two Wisconsin hospitals in a multihospital system. Ten graduate nurses participated in the organization’s pilot NRP on the medical-surgical (five participants) and cardiac-critical care units (five participants). Retention rates remained stable at 90% at both 12 and 24 months; however, pre-NRP retention data were not disclosed. Interestingly, Anderson et al35 found a 20% decrease in their two-year new graduate retention rates after implementing a yearlong NRP with 90 participants. After the first year of the program, 90% of new nurses stayed with the organization. Two years after the NRP, 70% remained employed. No reason was cited as contributing to the decline. Pizzingrilli and Christensen34 similarly retained 50% of their 10 nurse residents after two years, with five residents leaving for a variety of reasons, including the desire to move closer to family, being unsuccessful on the licensure examination, and to pursue other employment. The authors reported this retention rate was much lower than expected, especially considering the significant resources devoted to the NRP in a mental health setting.34 Little et al40 implemented two different NRPs at two hospitals in a multihospital organization. Hospital A implemented a version of the UHC/AACN NRP with 138 residents and hospital B implemented the Versant NRP with 34 residents. After two years, hospital A reported 97.8% retention and hospital B reported 97.05% retention, demonstrating very similar retention rates. Shortly thereafter, the hospital system developed its own NRP using aspects of both the UHC/ AACN and the Versant NRP. The one-year retention rate for the adapted NRP was 97%.

Studies with one year of retention data Friedman et al41 compared retention data retrospectively on two groups of graduate nurses (N ¼ 90) in two critical care units in two hospitals, looking to identify the differences in retention rates. In 2004, a group of graduate nurses participated in the hospital system’s standard orientation (n ¼ 30), and in 2007, the experimental group (n ¼ 60) participated in a yearlong NRP. The retention rate for the group of nurses receiving the standard orientation was 53.3% at one year post hire. After completing the NRP, the experimental group had a retention rate of 78.3%, demonstrating a 25% improvement in retention in the experimental group. This retention rate is within the range reported nationally (73% to 82%) for all nurses.30 Maxwell28 and Pine and Tart3 reported retention rates for two hospitals that implemented the UHC/AACN NRP, and both had improved retention after implementation. Sample sizes of

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graduate nurse participants varied. Pine and Tart3 noted that before implementing the NRP, their organization had a 50% retention rate for new graduate nurses. After the first year of the program, retention rates climbed to 87%. The number of resident participants was not disclosed. Maxwell28 reported similar results with 18 graduate nurses. A review of retention data on all new nurse hires revealed that the hospital had a 50% turnover rate, yet at the end of the one-year NRP, 100% of NRP participants remained employed.

Specialty sites Halfer,12 Hillman and Foster,38 and Nadler-Moodie and Loucks42 described implementing an NRP at specialty hospitals that do not typically hire new graduate nurses. Halfer12 reported a 70.5% retention rate of new graduates at a pediatric hospital before implementation of an NRP. After NRP implementation, the retention rate increased to 87.7%. The sample size was not disclosed. Hillman and Foster38 reported one-year post-NRP retention ranging from 75% to 100%, up from 50% pre-NRP at a Michigan children’s hospital (N ¼ 251 participants); five-year retention was 72.5%.38 Nadler-Moodie and Loucks42 described implementing an NRP at a psychiatric hospital with 16 new graduates divided into three cohorts. Four out of five new graduate nurses remained employed at the end of the first year in the first cohort, and the second cohort had 100% retention. At the time of publication, results from the third cohort of seven had not been analyzed and were not included. Pizzingrilli and Christensen34 also implemented an NRP in a mental health setting, with two-year retention reported at 50% (N ¼ 10).

Cost of NRPs

Only Pine and Tart3 reported an estimated cost for their NRP in 2007 at approximately $2,000 per resident. These costs included only fees for use of the UHC program, including training fees and nurse coverage when the resident was attending classes. The residents’ salary during the time participating in the residency was not factored into the cost. Costs such as salaries of those providing education and coordinating the residency programs were also not included in overall cost. Other authors did not report costs of the residency programs.

DISCUSSION

According to Lynn,30 the current national turnover rate for all nurses is 18% to 27% (retention 73% to 82%). Turnover is costly for health care organizations, with estimates of up to $88,000 in turnover costs for a single graduate nurse who leaves the organization.11 Results from this literature review demonstrate that NRPs improve retention rates among new AORN Journal j 141

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graduate nurses to an extent, but more longitudinal research needs to be conducted to determine long-term retention. Three studies focused on NRPs in specialty areas and their effect on participant retention.12,34,42 We did not find data on NRPs being used in perioperative services specifically. In 2015, AORN issued a white paper titled Perioperative Nursing Succession Planning: Theoretical Learning, Clinical Opportunities, and Residencies43 advocating for the development and implementation of perioperative nursing residencies as one strategy to successfully bring new nursing graduates into the specialty. Evidence shows that NRPs improve satisfaction and clinical competence. Faced with a perioperative nursing workforce that is approaching retirement in the near future, there is a significant need to recruit and retain highly qualified new nurses into the specialty.9 Because new graduates represent the largest source of RNs available for recruitment, it makes sense for perioperative nurse leaders to recruit them to the specialty using a proven, evidence-based program.5 Nursing students may not be exposed to perioperative content as part of their formal education.9,43,44 If more perioperative leaders implemented NRPs to ease the transition of new graduates into practice, it could provide a rich source of data to measure retention, satisfaction, and perceptions of the residency and could facilitate research specific to the perioperative setting that could include effects on patient outcomes. The specific costs of residencies were not typically reported. Cost comparisons may be difficult considering varying program content and length and varied salaries of the participating residents. The number Pine and Tart3 reported in 2007 (approximately $2,000 per resident) would be expected to be much higher today, especially if costs of educators and resident coordinators and the salaries of the residents were included. In addition, a perioperative residency would include significantly more specialty didactic and clinical content, likely adding to the length and complexity of the residency and increasing overall costs. In 2012, Trepanier et al45 reported difficulty in defining and reporting residency costs because of varying direct and indirect costs at institutions. They predicted NRP costs per resident from $21,571 to $36,960 depending on variables such as turnover costs, insourcing or outsourcing of the program, resident salaries, and salaries of those associated with offering the program, including nonproductive time. In a secondary analysis of data, they calculated an estimated total cost-benefit of NRPs in 15 hospitals to be between $8.1 and $41.7 million, which they translated to $10 to $50 in savings per patient-day. However, the authors cautioned that they did not consider

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the effect on patient safety or quality of care, and they recommended that leaders at individual facilities determine a specific cost-benefit associated with their programs and their unique features.

Limitations and Recommendations for Future Research When adopting NRPs, health care organization leaders need to ensure more consistency in program design, outcomes, curriculum, and length. With the variety of programs being implemented, it is difficult to determine whether the NRP is indeed beneficial when the comparison measures are not the same.33 The AORN white paper on succession planning recommends using Periop 101 as the core curriculum for perioperative residencies.43 This would provide a means for standardizing education to facilitate meaningful comparisons across settings. It is also important for nursing leaders to identify NRP goals and outcomes before implementation so that accurate pre-NRP data can be gathered. For instance, if an organizational goal is retention, it is important to identify the pre-NRP retention rate among graduate nurses in that organization, along with timeframes for retention data collection. A limitation to this literature review was that many organizations did not clearly define the measurement of retention at one year. For example, it was sometimes difficult to determine whether retention was measured at the end of a yearlong program or one year after program completion. It is important to measure retention rates one year after NRP completion and routinely after that time, but even more important to clearly define measurement timepoints.1 The effectiveness of NRPs should be evaluated by conducting more quasi-experimental studies to compare retention rates among groups of graduate nurse residents with rates among groups of graduate nurse nonresidents. Without comparisons, it is difficult to measure the success of NRPs. A few studies did compare groups of graduate nurses completing a standard orientation with nurse residents; however, comparisons were not necessarily completed during the same timeframe, making the validity of the comparisons suspect. Many circumstances may influence turnover rates, so control of extraneous variables is critical.

CONCLUSION Nurse residency programs appear to have positive outcomes, and graduate nurses benefit from the education, support, and guidance that NRPs provide. Evidence shows that new graduate nurses who participate in NRPs are more prepared to face

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challenges they encounter as practicing RNs in an increasingly complex health care arena. We found no published data on perioperative NRPs; this is troubling because a large population of perioperative nurses will begin retiring in the next 5 to 10 years. Nurse residency programs appear to foster a successful transition for new graduates into RN practice to produce competent, confident nurses who may provide staffing continuity in the organization into which they were hired. We recommend that perioperative nursing leaders pilot NRPs to intentionally expose new nurses to the specialty using an evidence-based curriculum such as Periop 101. Ongoing research is needed to determine whether using NRPs is cost effective and assists in the recruitment and retention of new graduate nurses in perioperative settings.



Editor’s notes: The UHC/AACN NRP has been renamed the Vizient/AACN NRP after a merger in 2015; however, at the time of this literature review, the program was identified as the UHC/ AACN NRP in the existing literature. University HealthSystem Consortium and Vizient are registered trademarks of Vizient, Inc, Irving, TX. CINAHL and Health Source are registered trademarks of EBSCO Industries, Inc, Birmingham, AL. Ovid is a registered trademark of Ovid Technologies, Inc, New York, NY. Academic Search is a registered trademark of Academic Search, Inc, Washington, DC. Versant is a registered trademark of Versant Holdings, LLC, Ithaca, NY. ANCC Magnet Recognition is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD. Periop 101 is a trademark of AORN, Inc, Denver, CO.

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9. Sherman RO. Why we should be concerned about a shortage of perioperative nurses. Emerging RN Leader. http://www.emerging rnleader.com/periope. Published October 25, 2012. Accessed May 9, 2017. 10. Bacon DR, Stewart KA. Results of the 2016 AORN salary and compensation survey. AORN J. 2016;104(6):486-501. 11. Li Y, Jones CB. A literature review of nursing turnover costs. J Nurs Manag. 2013;21(3):405-418. 12. Halfer D. A magnetic strategy for new graduate nurses. Nurs Econ. 2007;25(1):6-11. 13. Executive summary of the post-baccalaureate residency program. University HealthSystem Consortium, American Association of Colleges of Nursing. http://www.aacn.nche.edu/leading-initiatives/ education-resources/NurseResidencyProgramExecSumm.pdf. Accessed May 9, 2017. 14. Goode CJ, Lynn MR, McElroy D, Bednash GD, Murray B. Lessons learned from 10 years of research on a post-baccalaureate nurse residency program. J Nurs Adm. 2013;43(2):73-79. 15. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academy Press; 2011. https://www.nap.edu/read/ 12956/chapter/1. Accessed May 9, 2017. 16. Meyer Bratt M. Retaining the next generation of nurses: the Wisconsin nurse residency program provides a continuum of support. J Contin Educ Nurs. 2009;40(9):416-425. 17. Krugman M, Bretschneider J, Horn PB, Krsek CA, Moutafis RA, Smith MO. The national post-baccalaureate graduate nurse residency program: a model for excellence in transition to practice. J Nurses Staff Dev. 2006;22(4):196-205. 18. Letourneau RM, Fater KH. Nurse residency programs: an integrative review of the literature. Nurs Ed Perspect. 2015;36(2): 96-101. 19. Fink R, Krugman M, Casey K, Goode C. The graduate nurse experience: qualitative residency program outcomes. J Nurs Adm. 2008;38(7/8):341-348. 20. Keller JL, Meekins K, Summers BL. Pearls and pitfalls of a new graduate academic residency program. J Nurs Adm. 2006;36(12): 589-598. 21. Kowalski S, Cross CL. Preliminary outcomes of a local residency programme for new graduate registered nurses. J Nurs Manag. 2010;18(1):96-104. 22. Olson-Sitki K, Wendler MC, Forbes G. Evaluating the impact of a nurse residency program for newly graduated registered nurses. J Nurses Staff Dev. 2012;28(4):156-162. 23. Rosenfeld P, Smith MO, Iervolino L, Bowar-Ferres S. Nurse residency program: a 5-year evaluation from the participants’ perspective. J Nurs Adm. 2004;34(4):188-194. 24. Ulrich B, Krozek C, Early S, Ashlock CH, Africa LM, Carman ML. Improving retention, confidence, and competence of new graduate nurses: results from a 10-year longitudinal database. Nurs Econ. 2010;28(6):363-375. 25. The Essentials of Baccalaureate Education for Professional Nursing Practice. American Association of Colleges of Nursing. http:// www.aacn.nche.edu/education-resources/BaccEssentials08.pdf. Published October 20, 2008. Accessed May 9, 2017.

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Van CampdChappy 26. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley Publishing Company; 1984. 27. Goode CJ, Williams CA. Post-baccalaureate nurse residency program. J Nurs Adm. 2004;34(2):71-77. 28. Maxwell KL. The implementation of the UHC/AACN new graduate nurse residency program in a community hospital. Nurs Clin North Am. 2011;46(1):27-33. 29. Williams CA, Goode CJ, Krsek C, Bednash GD, Lynn MR. Postbaccalaureate nurse residency 1-year outcomes. J Nurs Adm. 2007;37(7/8):357-365. 30. Lynn MR. UHC/AACN Nurse Residency ProgramTM 2014 Outcomes Report. University HealthSystem Consortium, American Association of Colleges of Nursing. http://www.aacn.nche.edu/ downloads/aacn-future-task-force/2014-Outcomes-Report.pdf. Published May 2014. Accessed May 9, 2017. 31. Transitioning new graduates to practice. Versant. https://www .versant.org/versant-new-graduate-rn-residency.html. Accessed May 9, 2017. 32. Herdrich B, Lindsay A. Nurse residency programs: redesigning the transition into practice. J Nurses Staff Dev. 2006;22(2):55-62. 33. Meyer Bratt M, Felzer HM. Perceptions of professional practice and work environment of new graduates in a nurse residency program. J Contin Educ Nurs. 2011;42(12):559-568. 34. Pizzingrilli B, Christensen D. Implementation and evaluation of a mental health nursing residency program. J Nurs Ed Pract. 2015; 5(1):76-84. 35. Anderson T, Linden L, Allen M, Gibbs E. New graduate RN work satisfaction after completing an interactive nurse residency. J Nurs Adm. 2009;39(4):165-169. 36. Newhouse RP, Hoffman JJ, Suflita J, Hairston DP. Evaluating an innovative program to improve new nurse graduate socialization into the acute healthcare setting. Nurs Adm Q. 2007;31(1):50-60. 37. Kramer M, Halfer D, Maguire P, Schmalenberg C. Impact of healthy work environments and multistage nurse residency programs on retention of newly licensed RNs. J Nurs Adm. 2012; 42(3):148-159. 38. Hillman L, Foster RR. The impact of a nursing transitions programme on retention and cost savings. J Nurs Manag. 2011; 19(1):50-56.

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August 2017, Vol. 106, No. 2 39. Poynton MR, Madden C, Bowers R, Keefe M. Nurse residency program implementation: the Utah experience. J Healthc Manag. 2007;52(6):385-396. 40. Little JP, Ditmer D, Bashaw MA. New graduate nurse residency: a network approach. J Nurs Adm. 2013;43(6):361-366. 41. Friedman MI, Cooper AH, Click E, Fitzpatrick JJ. Specialized new graduate RN critical care orientation: retention and financial impact. Nurs Econ. 2011;29(1):7-14. 42. Nadler-Moodie M, Loucks J. The implementation of a newgraduate nurse residency training program directly into psychiatricemental health nursing. Arch Psychiatr Nurs. 2011; 25(6):479-484. 43. AORN Transition to Practice Ad Hoc Committee. Perioperative Nursing Succession Planning: Theoretical Learning, Clinical Opportunities, and Residencies. AORN, Inc. https://www.aorn .org/-/media/aorn/guidelines/position-statements/14783-whitepaper -v6.pdf. Published November 2015. Accessed May 9, 2017. 44. Chappy S, Madigan PD, Doyle DS, Conradt LA, Tapio NC. Preparing the next generation of perioperative nurses. AORN J. 2016;103(1):104.e1-104.e7. 45. Trepanier S, Early S, Ulrich B, Cherry B. New graduate nurse residency program: a cost-benefit analysis based on turnover and contract labor usage. Nurs Econ. 2012;30(4):207-214.

Jennifer Van Camp, MSN, RN, is a nurse educator at Fox Valley Technical College, Appleton, WI. Ms Van Camp has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Sharon Chappy, PhD, RN, CNOR, is dean and professor at the School of Nursing, Concordia University Wisconsin, Mequon. As the recipient of an honorarium for her role as research editor for the AORN Journal, Dr Chappy has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

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