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Running head: DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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Does New Nurse Transition Programs Increase Retention Compared to Standard Orientation

Melinda L. Swander

University of Central Florida

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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Abstract

One of the barriers identified for new nurse graduates is their successful transition into the

clinical setting. New nurses are often overwhelmed by the ever changing health care system that

demands decrease length in stay, higher acuities, and copious amounts of electronic

documentation. These challenges are contributing factors to the increasing turnover rates that

continue to escalate. Another factor influencing turnover is the variability of orientation received

from facility to facility and unit to unit. It is stated throughout the literature that orientation must

extend beyond traditional orientation and provide new nurses with sufficient knowledge and

skills through competencies. A review of the literature was conducted using a variety of

database with multiple search terms. Each study was reviewed to ensure they met the inclusion

criteria defined. This resulted in the use of eight articles that presented two themes: nurse

retention and cost savings. The Quelly tool was used to evaluate the quality and validity of each

study. Findings revealed that the implementation of a nurse transition program can help to

improve nurse retention, decrease turnover, and provide a cost savings to the facility.

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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Table of Contents

Significance and Background

4

Research Question

5

Methods

5

Search Terms and Definitions

6

Inclusion/Exclusion Criteria

6

Validity of Findings

7

Coding/Themes

7

Increase in nurse retention

7

Cost savings

7

Findings

7

Recommendations

8

Conclusion

9

References

10

Appendix A

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DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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Does New Nurse Transition Programs Increase Retention Compared to Standard Orientation

As new graduate nurses are transitioned into the clinical setting they are faced with many

challenges in the inpatient setting from complex electronic documentation requirements,

demands for decrease in hospital length of stays, higher acuities, and reality shock (Trepanier,

Early, Ulrich & Cherry, 2012). According to Crow & Hartman (2005), as cited by Dyess &

Parker (2012), the shortage of nurses is increasing and is projected to increase as much as 20%

by the year 2020. New graduate turnover rates reported in 2014 have been documented to reach

40-60% (Harrison & Ledbetter, 2014). The retention rates of experienced nurses are much

higher when compared to the newly graduated nurses (Setter, Walker, Connelly, & Peterman,

2011). According to Beecroft, Kunzman, & Krozek (2002), as cited by Bratt (2009), the cost of

new nurse turnover within the first year of employment is equivalent to a nurse’s salary for a

whole year.

Significance and Background

In 2010, The Robert Wood Johnson Foundation and the Institute of Medicine produced

the Future of Nursing: Leading Change, Advancing Health that recommend the implementation

of nurse residency programs to facilitate and support new nurses transition into clinical practice

(Friedman, Delaney, Schmidt, Quinn, & Macyk, 2013). Throughout the literature it can clearly

be concluded that a nurse’s orientation must extend beyond basic orientation to fill the gap

between education and practice (Dyess & Parker, 2012). The knowledge base and skill level of

each new graduate can greatly be influenced by their prior experience, the school they attended,

and cannot be assumed that every new nurse graduate is equally prepared (Hillman & Foster,

2011). The goal of a nurse residency or transition program is to adequately prepare newly

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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graduated nurses to provide safe and quality care to the patients in the clinical setting (Park &

Jones, 2010).

The Quality and Safety Education for Nurses (QSEN) proposes that competencies are

incorporated into orientation and include: interdisciplinary communication, disease-specific care,

and safety (Dyess & Parker, 2012). Berkow, as cited in Trepanier et al. (2012), concluded that as

much as 10% of nurse leaders believed that graduate nurses were competent in the skills required

to provide quality care. Having a sufficient amount of time to onboard new nurses, with a

standardization of competencies, and a systematic way of evaluation, will facilitate giving the

patients skilled nursing care (Fiedler, Read, Lane, Hicks & Jegier, 2014).

Standard orientation varies significantly from one nursing unit to the next. While some

units have an all inclusive orientation, others lack structure and a defined focus (Hillman &

Foster, 2011). These inconsistencies within the same facility can leave the new graduate

frustrated and ready to leave the organization. Institutes that prioritized orientation, focused on

new nurses, and gave them adequate support, reduced the turnover by as much as 17%

(Friedman et. al, 2013).

Research Question

In graduate nurses, does the implementation of a nurse transition program compared to

standard orientation on the unit have a greater increase on nurse retention rates?

Methods

A review of the literature was conducted to compare retention rates with a standard

orientation compared to those that initiated a nurse transition program. The following databases

were utilized to conduct the literature search: One-Search, Cumulative Index to Nursing and

Allied Health Literature (CINAHL), Cochrane Database of Systematic Review, and PubMed.

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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Search Terms and Definitions

Key search terms included: Graduate nurse, nurse residency, preceptor program,

retention, employee retention, orientation program, residency program, turnover, standard

orientation, nurse retention, traditional orientation, and transition program.

The definition of a nurse transition program included any orientation program exceeding

a three month time period that consisted of a designated support person, peer networking, and

knowledge and skill reinforcement. The definition of standard orientation was generally

understood throughout the literature as the comparison prior to implementation of a structured

program and did not have other components that were listed in the nurse transition program. A

new graduate is defined as a newly licensed registered nurse within the first twelve months of

their first employment.

Inclusion/Exclusion Criteria

The inclusion criteria for the search included articles written between 2010 to present that

were written in the English Language and compared retention rates of standard orientation to

retention rates post implementation of a nurse transition program.

Exclusion criteria for the search included articles that did not specifically reveal their

retention rates prior to implementation of a nurse transition program, did not clearly define

components of the nurse transition program, studies written in non-English languages, and

articles only consisting of literature reviews.

Of the 57 studies uncovered during my search, 14 specifically addressed the research

question. However, five out of the 14 initial studies were excluded because they failed to meet

inclusion criteria. This left eight remaining studies that did not have any above listed exclusions

and clearly answered the research question.

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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Validity of Findings

The remaining eight studies were evaluated using the Quelly Tool for determining quality

and validly of findings (2007). A series of 12 criterions were utilized to score the quality and

validity of each study. Each criterion equaled one point toward the maximum score of 12. Level

I, low quality, was given for scores between zero and four. Level II, moderate quality, was

assigned for scores between five and eight. Studies receiving nine to twelve points are

considered to be high quality Level 3 (Quelly, 2007). All of the eight studies score between nine

and twelve and were considered high quality studies. A consistent finding among the evaluated

articles revealed that the sampling size was relatively small and lacked adequate evidence to

support external validity.

Coding/Themes

After reviewing the eight studies, two themes emerged. The first theme was transition

programs yielding an increase in retention rates among graduate nurses. The second theme was

transition programs resulted in cost savings for the organization.

Findings

All of the articles included in the integrated literature review met inclusion criteria and

ranged from Level IV to Level VI according to Melnyk & Fineout-Overholt’s (2011) Hierarchy

of Evidence. All eight studies compared retention rates post implementation of a nurse transition

program compared to retention rates with standard orientation, prior to implementation. The

length and content of the transition program varied from study to study, but all transition

programs were at least a year or greater. Of the eight studies, the designs included: mixed

method (Dyess 2012; Olson-Sitki 2012), descriptive (Fiedler 2014; Hillman 2011; Setter 2011;

Trepanier 2012; Friedman 2013), and cohort (Berube, 2012). Limitations identified in the

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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studies included limited participant size and undisclosed retention rates prior to the

implementation of the nurse transition program.

All eight studies produced a reduction of turnover rates or an increase in nurse retention

post implementation of the nurse transition program (Berube 2012; Dyess 2012; Fiedler 2014;

Friedman 2013; Hillman 2011; Olson-Sitki 2012; Setter 2011; Trepanier 2012). The highest

retention rate after one year post implementation of a transition program was reported by

Hillman (2011) at 100%. The lowest retention rate after initiating a residency program was 71%

but was still significantly higher then prior to implementation which was 57% (Berube, 2012).

Three of the eight studies reported their finding using the reduction of turnover rates. Turnover

rates ranged from 36.8% to 12% prior to the implementation of a transition program (Fiedler

2014; Olson-Sitki 2012; Trepanier 2012). After execution of the transition program, these same

rates were reduced from 5.6% to 11% in nurse turnover (Fiedler 2014; Olson-Sitki 2012;

Trepanier 2012).

Review of the literature also revealed that five out of the eight studies identified that the

implementation of a nurse transition program lead to a cost savings for the organization (Berube

2012; Fiedler 2014; Friedman 2013; Hillman 2011; Trepanier 2012). All five of these studies

showed a cost savings by the reduction of nurse turnover and varied in amount from facility to

facility based on the annual salary of a nurse (Berube 2012; Fiedler 2014; Friedman 2013;

Hillman 2011; Trepanier 2012). Two studies specifically highlighted their cost savings by

decdreaseing the amount of contracted labor (Berube 2012; Trepainer 2012).

Recommendations

According to the finding from the literature review, there is sufficient support that nurse

transition programs provide superior retention rates compared to standard orientation. Using the

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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Strength of Recommendation Taxonomy (SORT) the strength of this recommendation for the

evidence presented is a B because of the lack of randomized controlled studies to support these

findings.

Implementing a transition program for newly graduated nurses can facilitate the reduction

of nurse turnover rates and increase nurse retention. In addition, the reduction of nurse turnover

and decrease of contracted labor will provide the facility with significant cost savings.

Future research should be conducted to determine retention rates after the first year when

a majority of the transition programs end. Friedman (2013) concludes that more longitudinal

studies are needed to truly understand the impacts of transition programs. More research should

be devoted to determining which components of the transition program make a graduate nurse

decided to stay with the facility or leave (Settler et al., 20110).

Conclusions

Having a nurse transition program communicates to graduate nurses that the organization

knows that they need support and acknowledge that standard orientation is insufficient to prepare

them. Following the nurse transition program, the nurses are more adequately prepared to meet

daily challenges and transition into their new nursing role (Hillman, 2011). The failure to

adequately provide graduate nurses with the needed support can negatively impact the quality

and safety of patients they care for (Dyess & Parker, 2012).

The literature supports that an

environment that promotes professional growth and engages staff will positively impact nurse

retention (Fiedler et al., 2014).

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References

Berube, M., Valiquette, M., Laplante, E., Lepage, I., Belmonte, A., Tanguay, N.,

Touchette, S.

(2012). Nursing residency program: A solution to introduce new grads into critical care

more safely while improving accessibility to services. Innovation in Nursing Leadership,

25(1), 50-67.

Bratt, M. (2009). Retaining the next generation of nurses: the Wisconsin Nurse Residency

Program provides a continuum of support. The Journal of Continuing Education in

Nursing, 40(9), 416-425.

Dyess, S., & Parker, C. (2012). Transition support for the newly licensed nurse: A programme

that made a difference. Journal of Nursing Management, 20(5), 615-623.

Ebell, M., Siwek, J., Weiss, B., Woolf, S., Susman, J., Ewigman, B., & Bowman, M. (2004).

Strength of recommendation taxonomy (SORT): A patient-centered approach to grading

evidence in the medical literature. Journal of the American Board of Family Practice,

17(1), 59-67.

Fiedler, R., Read, E., Lane, K., Hicks, F., & Jegier, B. (2014). Long-term outcomes of a post

baccalaureate nurse residency program. The Journal of Nursing Administration, 44(7),

417-422.

Friedman, M., Delaney, M., Schmidt, K., Quinn, C., & Macyk, I. (2013). Specialized new

graduate RN pediatric orientation: A strategy for nursing retention and its financial

impact. Nursing Economics, 31(4), 162-170.

Harrison, D., & Ledbetter, C. (2014). Nurse residency programs: Outcome comparisons to best

practices. Journal for Nurses in Professional Development, 30(2), 76-82.

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Hillman, L., & Foster, R. (2011). The impact of a nursing transitions programme on retention

and cost savings. Journal of Nursing Management, 19(1), 50-56.

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in Nursing &

healthcare: A guide to best practice (2nd ed.). Philadelphia: Wolters Kluwer/Lippincott

Williams & Wilkins.

Olson-Sitki, K., Wendler, C., & Forbes, G. (2012). Evaluating the impact of a nurse residency

program for newly graduated registered nurses. Journal for Nurses in Staff Development,

4(28), 156-162.

Park, M., & Jones, C. (2010). A retention strategy for newly graduated nurses: An Integrative

review of orientation programs. Journal for Nurses in Staff Development, 26(4), 142-149.

Quelly, S. (2007). Determining quality and validity of findings. Retrieved from

https://webcourses2c.instructure.com/courses/1106610/files/45153531/download

Rush, K., Adamack, M., Gordon, J., Lilly, M., & Janke, R. (2013). Best practices of formal new

graduate nurse transition programs. International Journal of Nursing Studies, 50(3), 345-

356.

Setter, R., Walker, M., Connelly, L., & Peterman, T. (2011). Nurse residency graduates

commitment to their first positions. Journal for Nurses in Staff Development, 27(2), 58-

64.

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Trepanier, S., Early, S., Ulrich, B., & Cherry, B. (2012). New graduate nurse residency program:

A cost-benefit analysis based on turnover and contract labor usage. Nursing Economics,

30(4), 207-214.

Running head: DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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Literature Evaluation

Appendix A

Citation

Patient Group and Sample Size

Study Design and Level of Evidence

Outcome Variables

Key Results

Study

Coding/Themes

Weaknesses

Berube et al.

N=113graduate

Cohort study

Retention rates

Retention rates prior to implementation were 57% and post implementation was 71%

Small sample

Increase in

(2012)

nurses

design

size

retention

rates

Level IV

Cost

savings

Dyess et al.

N=109 Newly

Mixed methods design with pre- post evaluation design

Retention rates

80% retention

Limited

Increase in

(2012)

licensed RNs

rates post

participation

retention

implementation

rates

of residency

 

program

Level IV

compared to

65% pre

implementation

Fiedler et al.

N=51graduate

Descriptive

Turnover rates

5.6% Turnover rate prior to implementation compared to national average of

Small sample

Decrease in

(2014)

nurses

design

size

turnover

rate

Level VI

No pre-

Cost

retention rates

Savings

for comparison

14.7%

Friedman et

N=77 graduate

Retrospective

Retention rates

Prior to implementation rates were 84% compared to post implementation rates were 94%

Limited sample

Increase in

al.

nurses

descriptive

size

retention

(2013)

design

rates

Cost

Level VI

Savings

Hillman et

N=251 graduate

Descriptive

Retention rates

Prior to

Did not define

Increase in

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

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al. (2011)

nurses

design

 

implementation retention rates were as low as 50%. Post implementation rates at 1 year were as high as

100%

pre-

retention

implementation

Cost

Level VI

retention rates

Savings

Olson-Sitki

N=31 New

Non-

Turnover rates

2 years pre implementation of residency program turnover rates were 15% and 12%- Post implementation rates were 7% and 11%

Limited

Decrease in

et al.

graduate nurses

experimental,

Participation

turnover

(2012)

repeated

rates

measures, time

series, mixed

method design

Level VI

Setter et al.

N=100 graduate

Cross-sectional,

Retention rates

Mean retention rates for first year was 94%

Did not include pre-residency retention rates- Just indicated a increase post

Increase in

(2011)

nurses

descriptive

retention

design

Level VI

 

Trepanier et

N=524 graduate

Descriptive

Turnover rates

Mean turnover rate of 36.8% to 6.41% post implementation

Retrospective

Decrease in

al. 2012)

nurses

design

analysis

turnover

rates

Level VI

Cost

 

Savings