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The Ottawa Hospital developed an evidence-based nursing internship program to meet the challenges of new
graduates. The literature suggests many challenges that they face during their transition from student to new
graduate, with a turnover estimated as high as 60%. The program provides support to new graduates by offering
opportunities for growth and autonomy, leading to active participation as team members. Evaluation criteria
include satisfaction for interns, preceptors, clinical mangers and educators based on the program objectives, and
new graduate turnover. We were able to decrease new graduate turnover from 23% at two years to 10%, with
$360,000 in savings from the reduced turnover.
As one of the largest academic health sciences centres in Canada, the Ottawa Hospital was concerned about the
impact of the upcoming nursing shortage, estimated to be 78,000 in Canada by 2011, especially in light of the
expansion that it was undergoing (Ryten 2002). We recognized that new graduates would be the dominant pool
of new hires and developed an internal recruitment strategy that was based on Benner's transition from
advanced beginner to competent, with supported time in a medicine or surgery unit followed by the completion
of a specialty program to fill the vacancies we would have in critical care and the operating room (Benner
1984). While we did not have the funds to implement the strategy fully, we utilized the Ontario Ministry of
Health and Long-Term Care Nursing Enhancement Funds to develop our Nursing Internship program.
Program Development
A literature review was undertaken to identify the challenges that new graduates face and to guide the
development of program goals. Kramer (1985) stated that the transition from student to new graduate is a
"reality shock." The transition process is a rite of passage with three phases: separation, transition and
integration (Winter-Collins and McDaniel 2000). It is also identified that new graduates' sense of belonging is
linked to their successful transition into their professional role. New graduates were found to demonstrate stress
regarding competence, confidence, making errors and adjusting to new workplace environments and to
complain of lack of support and problems with organization, completion of tasks and quality of work (Guhde
2005; Oremann and Garvin 2002). New graduates who complete a nursing internship program have more
professional self-confidence and job satisfaction and are less stressed because they are in a supportive
environment (Casey et al. 2004; Owens et al. 2001). It has been estimated that it takes new graduates at least
one year to master a job with successful organization socialization (Tradewell 1996); they also do not feel
skilled, comfortable or confident for as long as one year after hire (Casey et al. 2004). New graduate turnover
during the first year is estimated at between 35 and 60%, with 40% of new graduates perceiving a lack of
opportunities for future career development within the organization (Casey et al. 2004; Godinez et al. 1999).
New graduates want reassurance, specific and precise guidelines and daily feedback on their clinical skill
development (Modic in Guhde 2003). Connelly and Hoffart (1998) found that new graduates need to feel
connected to people in the organization or they may not stay long enough to fit in. Novice nurses today still feel
the most frustrated by the lack of care and concern they are shown by staff (Meissner 1999).
The Nursing Internship Program
Our Nursing Internship program is an "earn while you learn" program designed to facilitate the role transition
from novice/novice beginner to competent (Benner 1984). Nursing internships are offered in medicine and
surgery, which are the typical throughput units for the specialty programs, and in mental health, where we have
a potential retirement rate of 30% over the next few years. The program provides support to new graduates by
offering opportunities for professional growth and autonomy leading to active participation as members of the
clinical team. Benefits for the new graduate include increased confidence in knowledge and assessment skills,
improved clinical skills and improved decision-making, prioritizing and problem solving skills. The program is
a 12-week fully preceptored program that includes orientation for both the preceptor and the intern, includes
education days off the unit and is open to new graduates with less than two years' experience. The two-year
point is identified as being significant. It is often when new graduates start to assume a leadership role as fully
functional team members (Casey et al. 2004).
The goals of program are to promote strategies for new graduate recruitment and retention, to provide an
opportunity to consolidate clinical nursing knowledge in new areas of practice and to provide an opportunity to
demonstrate understanding and competence in technical skills and procedures related to the specialty in which
they are practising. The program also allows for the application of sound clinical judgment and critical thinking
throughout the nursing process in the management of patient skills. The development of time-management and
delegation skills is another important goal. The interns and the preceptors are supported by a nursing
enhancement coordinator, whose job is to coordinate, implement, evaluate and report on the program.
The Preceptors
Preceptors are selected based on the RN Scope of Practice Assessment Tool; this was developed based on
Benner's model (1984). The purpose of the tool is for nurses to self-evaluate their ability to work within the full
scope of practice. The tool is based on the Ottawa Hospital's Nursing Professional Practice Model definition and
the College of Nurses of Ontario's profile of professional expectations for registered nurses and registered
practical nurses. Almada et al. (2004) report that the successful progress from novice to advanced novice nurse
is accomplished through a one-to-one relationship, with continuous guidance. The preceptors provide
continuous feedback, focusing on the positive steps interns take toward their individual learning goals. The
preceptor role begins as a teacher and gradually evolves to a resource person over the 12-week period.
Preceptors must be caring, flexible and open, have a positive attitude, be confidence builders and be clinically
confident (Guhde 2005). Preceptors are clinical experts in their area and attend a half-day workshop on the role
of the preceptor that was developed to address the differences between precepting a student and a novice nurse.
The Interns
Novice nurses apply and are interviewed for the positions. If nurses have less than one year's experience, they
are expected to complete the internship in their unit. If they have between one and two years' experience, they
complete the internship in another unit. They all attend a half-day orientation where they write their learning
objectives for the program. These objectives are reviewed with the preceptor and the nursing educator. One of
their objectives is to become familiar with the nursing and healthcare resources that are available to support
patient care at the Ottawa Hospital. Workshops and educational sessions are planned during the 12-week period
to increase their awareness of the supports available and the organization as a whole.
Qualitative and quantitative data are collected. The interns complete a post-internship survey. Results have been
consistent with the literature. Interns have reported increased job satisfaction, increased confidence, reduced
stress, an increased sense of belonging and increased knowledge, critical thinking, decision-making, time-
management and organizational skills. They also have reported learning many new psychomotor skills and
having had the time to become proficient. Finally, interns have noted an increased self-esteem, that they have a
better understanding of their role as a professional and that they are more marketable.
The clinical managers and educators have reported high satisfaction with the program and the growth that
interns demonstrate during the program.
Both the preceptors and the interns are also asked to complete a post-program survey rating how well the
program meets its goals. Overall, 94.1% of respondents have been very satisfied with the program and would
recommend it to others. The questionnaire uses a Likert scale, with 0 indicating not applicable and 4
indicatingoutstanding. Overall, they rated the program at 3.31 in meeting its goals. The results are presented in
Table 1.

New graduate turnover is identified as a major issue in the literature, with reports of turnover being as high as
60% during the first year (Casey et al. 2004; Godinez et al. 1999). Our two-year new graduate turnover rate was
23%. However, for the 96 graduates of the Nursing Internship program, we had a 10% turnover rate at two
years and a 6% rate at one year, which is well below the suggested turnover rates of new graduates. Low
turnover is defined as being between 4 and 12% (VHA 2002). Our normal turnover of registered nurses is just
over 6%, so we have decreased our turnover for the nursing internship graduates significantly.
Sixteen of the 96 participants, or 16.6%, have moved into the specialty areas such as the Intensive Care Unit,
Operating Room and Emergency Department, while 90% of the nurses who completed their internship in
mental health are still working there.
We faced several challenges when we started the program. The first was communication across our five
campuses with 11,000 employees and 4,000 nurses. The program started in September, and it turned out that the
summer was not the ideal time to get the message out. There was confusion about the program: it is not an
extended orientation program for nurses who are struggling; it is designed to meet the needs of the
novice/advanced novice nurse looking to move quickly into the specialty areas where our needs will be the
greatest. Communicating the role of interns and preceptors to the rest of the unit staff was initially an issue,
which we have subsequently resolved. We also had some problems ensuring that the interns would be
supernumerary for the complete 12 weeks. This was addressed by changing the timing of the program.
Originally, it was to be offered equally throughout the fiscal year. We changed this to have 50% of the positions
starting during the first quarter, with 30% in September and the final 20% in January. While we originally
envisioned not having interns in the summer or December, we found that many of the clinical managers liked
having interns over the summer months to ensure that new graduates had the opportunity to participate in this
The most significant benefit is the decrease in turnover for this group. The cost of turnover of registered nurses
has been estimated at $25,000 to over $60,000 per nurse who leaves a post in the United States (Bland-Jones
2004; Casey et al. 2004). If we use a conservative estimate of $30,000 Canadian, we have saved over $360,000
in turnover costs. The interns' progression was noted not just by their clinical manager but also by the
preceptors, who took pride in the role they had played. As the program is now finishing its third year, we have
developed a cadre of preceptors who are aware of the needs and benefits of supporting new graduates on their
units. The interns are not only more connected to the organization, they know the opportunities that exist at the
Ottawa Hospital. Patient outcomes have been positively linked to experienced nurses.
While the development and implementation of the Nursing Internship program based on the needs of novice
nurses was challenging at times, it has produced many rewards. We did not expect to see such a sudden
decrease in our new graduate turnover. The literature suggests that by decreasing the number of new graduates
leaving our organization, we are decreasing the number leaving the profession - and therefore contributing to
our nursing population (Ulman 2002). The graduates of the program are more confident in their role as nurses
and add to the increasing number of specialty trained nurses that we will need to meet the growing needs of our
About the Author
Cheryl Anne Smith, RN, MScN, is the corporate nursing recruitment, retention and recognition coordinator at
the Ottawa Hospital, in Ottawa, Ontario. She made a career shift in 2000 to work in this position. Her primary
responsibilities are the development, coordination, implementation and evaluation of strategic nursing
recruitment activities, monitoring of retention patterns and making recommendations. You can reach Ms. Smith
by phone at 613-761-4466, by fax at 613-761-4728 or by e-mail at
Almada, P., K. Carafoli, J.B. Flatterly, D.A. French and M. McNamara. 2004. "Improving the Retention Rate of
Newly Graduated Nurses." Journal for Nurses in Staff Development 20(6): 268-73.
Bartz, K. 1999. "The Orientation Experiences of Urgent Care Nurses: Sources for Learning." Journal for Nurses
in Staff Development 15(5): 210-6.
Benner, P. 1984. Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA:
Bland-Jones, C. 2004. "The Costs of Nurse Turnover". JONA 34(12): 552-70.
Cantrell, M.A., A.M. Browne and P. Lupinacci. 2005. "The Impact of a Nurses Externship Program on the
Transition Process from Graduate to Registered Nurse." Journal for Nurses in Staff Development 21(5): 187-95.
Casey, K., R. Fink, M. Krugman and J. Propst. 2004. "The Graduate Nurse Experience." JONA 34(6): 303-11.
Connelly, L. and N. Hoffart. 1998. "Staff Turnover among Hospital Nurses." Journal of Nursing Staff
Development14(1): 31-9.
Godinez, G., J. Schweiger, J. Gruver and P. Ryan. 1999. "Role Transition from Graduate to Staff Nurses: A
Qualitative Analysis." Journal for Nurses in Staff Development 15(3): 97-110b.
Guhde, J. 2005. "When Orientation Ends Supporting the New Nurse Who Is Struggling to Succeed." Journal
for Nurses in Staff Development 21(4): 145-9.
Kramer, M. 1985. Reality Shock: Why Nurses Leave Nursing. St. Louis: CV Mosby.
Meissner, J. 1999. "Nurses, Are We Still Eating Our Young?" Nursing 29(2): 42-4.
Oremann, M. and M.F. Garvin. 2002. "Stress and Challenges for New Graduates in Hospitals." Nurse
Education Today 22: 220-3.
Owens, D.L., M.A. Turjanica, M.W. Scanion, A.E. Sandhusen, M. Williamson, C. Hebert and L. Facteau. 2001.
"New Graduate RN Internship Program: A Collaborative Approach for System Wide Integration." Journal for
Nurses in Staff Development 17(3): 144-50.
Ryten, E. 2002. Planning for the Future. Nursing Human Resources Projection. Ottawa, ON: Canadian Nurses
Tradewell, G. 1996. "Rites of Passage: Adaptation of Nursing Graduates to a Hospital Setting." Journal of
Nursing Staff Development 12(4): 183-9.
Ulman, M. 2002. "More Nurses Quitting Careers Early: A National Survey of Recent Graduates Said More Men
and Women Finding Other Jobs, Aggravating a Shortage." Maine Nurse 4(4): 20.
VHA. 2002. The Business Case for Work Force Stability. Irving, TX: Author. Retrieved September 2004.
< >.
Winter-Collins, A. and A.M. McDaniel. 2000. "Sense of Belonging and New Graduate Job
Satisfaction." Journal for Nurses in Staff Development 16(3): 103-11.

A Retention Strategy for Newly Graduated Nurses: An Integrative Review of Orientation Programs
Journal for Nurses in Professional Development, - See more at:
To address nurse recruitment and retention issues, hospitals have increased the number of newly graduated
nurses in their hiring pools and have simultaneously established orientation programs for those nurses.
Structured orientation programs facilitate newly graduated nurse transition from novice to advanced beginner.
The outcome of these programs is twofold: First, they promote the confidence and competency level of new
nurses in providing patient care, and second, they increase nurse retention. This literature review presents the
most useful interventions used in the programs that reported positive affects on new nurses.

The U.S. Department of Labor, Bureau of Labor Statistics (2005) predicts that the need for nurses will increase
27% between 2004 and 2014. The current shortage of registered nurses (RNs) is due in part to the increasing
age of the nursing workforce, as well as the fact that fewer younger nurses are entering the field. Although the
enrollment in baccalaureate programs in nursing continues to increase (American Association of Colleges of
Nursing, 2007), the increase is not enough to solve the nursing shortage. Consequently, organizations have
responded by competitively increasing the recruitment of new graduate nurses in their hiring pools (American
Organization of Nurse Executives, 2002). Although these new graduates fill vacancies, hiring new graduate
nurses also generates problems.
The high turnover of newly graduated nurses is emerging as one of the problems that hospitals need to address.
In a current survey of newly graduated nurses in 35 states (Kovner et al., 2007), approximately 13% of
responders had changed principal jobs after 1 year, and 37% reported that they planned to change jobs in the
near future. Nursing literature reported that poor training, a lack of support systems, and the stress related to the
intense working situation and high patient acuity are the main reasons nurses are leaving during their first year
after graduation (Bowles & Candela, 2005; Mathews & Nunley, 1992; Patrick, 2000).
Furthermore, a high turnover and an influx of new graduates have led to a higher proportion of inexperienced
nurses in direct patient care, which may not only be traumatic for the new professional nurse but may also
threaten patient safety (Santucci, 2004). Therefore, for patient safety and the well-being of new nurses, hospitals
must make efforts to provide safe and effective environments that foster the integration of graduate nurses into
their systems. An effective orientation program is one strategy that may address these concerns.
The goal of an orientation program is to prepare new staff nurses to be confident and to provide competent and
safe patient care. Benner's (1984) From Novice to Expert framework is relevant to an orientation program.
Benner applied the Dreyfus model of skill development to nursing and concluded that nurses pass through five
stages of skill development: novice, advanced beginner, competent, proficient, and expert (Benner, 1984).
These different levels are accompanied by changes in three aspects of skill performance: (a) a change from
confidence about abstract principles to the application of concrete experience, (b) a change in the learner's
awareness of the demand situation as a whole, and (c) a change from observer to active performer (Benner,
1984). Nursing students entering the clinical area can be characterized as novices because their knowledge is
limited, they tend to be rather inflexible, and they are inexperienced in actual clinical situations. Successful
orientation programs should be those in which teaching and learning are provided to help the new graduate
nurse make the transition from novice to advanced beginner who can demonstrate acceptable performance and
cope in real situations with a preceptor/mentor (Benner, 1984).
Some healthcare systems have recently developed and reported orientation programs that have improved the
confidence, competency, and retention of newly graduated nurses. However, the research on the effects of these
programs is limited by small-size studies and the experiences of single institutions. There are few systematic
literature reviews focusing on orientation programs for newly graduated nurses.
The purpose of this study was to present an integrative review of the research that was conducted to explore the
effects of orientation programs for newly graduated nurses on their confidence, competency, and retention.
Recommendations also are made based on an analysis of programs reported as effective in the literature
between 1990 and 2007.
This review study followed Cooper's (1989) five-stage process for the integrative literature review: (a) problem
formulation, (b) data collection, (c) evaluation of data points, (d) data analysis and interpretation, and (e)
presentation of results. This study collected, synthesized, and analyzed published research conducted on
orientation programs that train newly graduated nurses using various methods for increasing confidence,
competency, and retention. Orientation programs in nursing literature included internships, residencies, and
structured orientation programs.
Studies were limited to research conducted in U.S. hospitals. Key words used in the search process were
new RN graduate, confidence, competency, retention, and orientation program. This review included only
English-language research studies published between 1990 and 2007. This review began with a search of
multiple library databases such as PubMed (MEDLINE), the Cumulative Index to Nursing and Allied Health
(CINAHL), and Institute for Scientific Information (ISI) Web of Knowledge. Then, through the Google and
Google Scholar Internet search engines, the search expanded to include published reports, white papers, and
working papers that were published through channels other than professional and research journals.
A total of 99 relevant citations were retrieved from library databases (n = 92) and the Internet (n = 7).
Examination of the published abstracts and studies resulted in the elimination of studies that did not match the
project inclusion criteria (n = 53), leaving 46 articles for potential inclusion in the study.
Research articles meeting the inclusion criteria were then rated using a modified version of the research quality
checklist developed by Beck (2001). The checklist included the following items: (a) author expertise, (b) type of
sample, (c) reliability and validity of measures, (d) time dimensional design, (e) research design, and (f)
research analysis. The checklist used in this study included these items and also items pertaining to new RN
orientation programs to determine whether the studies reported information on the outcomes of new RN
graduate orientation programs. Through a second level of review incorporating these quality criteria, the
researcher excluded several additional articles (n = 29) for one or more of the following reasons: (a) Studies did
not examine program outcomes, (b) studies reported programs for nursing students rather than nursing
graduates, (c) studies included both newly graduated nurses and experienced nurses as participants, and (d)
studies obtained a low score on the quality checklist. The final sample included 17 published reports.
Table 1 summarizes the research reviewed in this study and the reported outcomes of orientation programs,
including confidence, competency, and retention. This review included nine articles evaluating internship
programs, five studies related to residency programs, and three structured orientation programs (see Table 1).
Of those programs, four residency programs were designed as postbaccalaureate programs (Altier & Krsek,
2006; Herdrich & Lindsay, 2006; Krugman et al., 2006; Rosenfeld et al., 2004), whereas the other programs
were orientation programs for all new RNs. All articles dealt with hospital-based programs. Four of these
articles focused on internship programs in specialty areas including critical care, neuroscience, and the float

TABLE 1 The Summary of Program Outcomes
Seven articles of reviewed studies reported improved self-confidence of new graduates in delivering patient
care. The studies included five internship programs, one residency program, and one extended orientation
program (see Table 1). To examine new RNs' confidence, these studies asked program participants to rate their
level of confidence on a rating scale (Beecroft et al., 2001; Blanzola et al., 2004; Crimlisk et al., 2002; DiIorio
et al., 2001; Squires, 2002) or participants' confidence about their ability was extracted from logs and feedback
from the preceptor (Herdrich & Lindsay, 2006; Messmer et al., 2004).
These studies reported improved self-confidence of new RNs in delivering patient care after completing the
program. In particular, several studies revealed that the internship programs in specialty areas increased the
confidence of new nurses in delivering patient care. Evaluating the impact of an internship program in a float
pool over time, Crimlisk et al. (2002) reported that 100% of new RN respondents completing the program
believed that they were able to provide safe, competent care in the areas of assessment skills, technology,
communication skills, medication administration, and critical-thinking skills. Furthermore, DiIorio et al.
(2001) reported that new RNs in a neuroscience internship program believed the program enabled them to serve
as a resource for other nurses unfamiliar with neuroscience patient care and for other new graduates in
neuroscience nursing; nurses in this program also showed increased mean scores on the Neuroscience Nursing
Self-efficacy Scale by the end of the program. Interns in a Shadow-A-Nurse intensive care unit internship
expressed in their logs that the program was very beneficial in building self-confidence (Messmer et al., 2004).
Seven studies reported the effects of completing an orientation program on the competency of the new RN
graduates. Nursing literature defines competency as the possession of knowledge, practice skills, attitudes, and
the ability to perform to a prescribed standard (While, 1994). Professional educators also identified critical-
thinking ability in delivering patient care as the core competency that new RNs should acquire (Marcum &
West, 2004). In evaluating competency, researchers not only tested the new nurses but also obtained feedback
from participants such as nurse educators, nursing managers, peer nurses, and/or preceptors. For competency
content, these studies focused on the knowledge and critical thinking of newly graduated nurses.
Four studies administered the Basic Knowledge Assessment Test to evaluate the effect of the orientation
programs in competency as knowledge (Collins & Thomas, 2005; DiIorio et al., 2001; Herdrich & Lindsay,
2006; Messmer et al., 2004) and reported improvement in test scores between the beginning and the end of the
program. Two articles reported that the programs improved the critical-thinking ability of new graduates using
several instruments, including the Critical Thinking Inventory (Herdrich & Lindsay, 2006), the Watson-Glaser
critical thinking appraisal (Herdrich & Lindsay, 2006), and the Performance Based Development System
(Marcum & West, 2004). Peer nurses and managers also evaluated the competency of new graduates as
improved after completion of the program (Blanzola et al., 2004; Boyer, 2005).
Positive outcomes in new RN competency were also reported in critical care. Two studies, which examined the
outcomes of critical care internship programs designed and implemented to assist new nurses in making the
transition into a critical care nurse role, reported that nurses demonstrated increased competency in critical care
nursing skills and improved self-confidence after completing the program (DiIorio et al., 2001; Messmer et al.,
In 15 studies, retention of new nurses was reported as the percentage of program participants remaining
employed at the organization at 12 and 24 months after completing an orientation program (see Table 1). The
results showed increased retention rates by comparing data from treatment and control groups, before and after
programs, or with national trends. The programs reported retention rates ranging from 76% to 96%. The rates
were excellent when compared with the baseline rate of each program, ranging between 25% and 75%, and to
national data of a 64% retention rate for new RNs in their first year of practice (Nursing Executive Center,
Furthermore, several studies reported a decreased turnover rate of newly graduated nurses after participation in
the programs (Beecroft et al., 2001; Krugman et al., 2006) and a decreased vacancy rate in the institutions after
implementation of the programs (Almada et al., 2004; Boyer, 2005; Herdrich & Lindsay, 2006; Owens et al.,
2001; see Table 1). Two internship programs used the Anticipated Turnover Scale to measure new nurses'
perception of the possibility of voluntarily terminating the position (Beecroft et al., 2001; Newhouse et al.,
2007). At 6 months, program interns reported a significantly lower score on the Anticipated Turnover Scale or a
decreased possibility of leaving their jobs when compared with their counterparts in the control group.
Review of Programs
The various programs reviewed produced positive outcomes in nurse confidence, competency, and retention.
From these programs, common components, such as the length of a program, structured teaching methods,
preceptorship, support system, and evaluation, were examined to help determine effective program attributes
(see Table 2).

TABLE 2 The Summary of Programs

TABLE 2 Continued
As Table 1 shows, programs varied greatly in length, ranging from 6 weeks to 1 year. All residency programs
(n = 5) and internship programs (n = 2) were conducted over a 1-year time frame. Six studies reported program
duration of less than 3 months. Eleven of the 17 reviewed studies reported programs that lasted between 4 and
12 months (see Table 1). When an orientation program was the extension of an existing program or focused in a
specialty area, the program duration tended to cover for shorter time periods (Almada et al., 2004; Marcum &
West, 2004; Messmer et al., 2004; Squires, 2002).
All reviewed programs consisted of two main parts: (a) classroom learning and (b) clinical experience with
preceptorship. The classroom learning component not only included general hospital orientation requirements
but also dealt with various topics related to competency-based practice, including nursing assessment and
intervention, pathophysiology, pain management, quality improvement, medication administration, pain
management, and so on. Postbaccalaureate residency program curricula contained three additional parts:
leadership, evidence-based patient outcomes, and professional role (Altier & Krsek, 2006; Krugman et al.,
During classroom activities, the programs used various teaching methods and traditional lectures by educators.
The teaching methods mainly cited in the literature included conferences, seminars, group discussion, case
studies, and computer-based training (see Table 2). In particular, the studies suggested that the teaching
methods such as conferences, seminars, and group discussion encouraged mutual learning among new RNs
through sharing clinical experiences and were more effective for developing critical thinking than were the
traditional lecture format. Crimlisk et al. (2002) also reported the creation of an internship program that used the
case study format. They reported the following benefits of the case study approach: (a) sharing clinical
experiences, (b) identifying critical thinking, (c) guiding clinical decision making, (d) nurturing professional
clinical practice, and (e) facilitating transition into the RN role.
The studies evaluated that the use of a one-on-one preceptorship contributed to developing the competencies of
new graduates and to enhancing their clinical experiences. Also, key to a successful preceptorship was the
preparation of a qualified preceptor. Therefore, a preceptor training program was developed, as well as criteria
for the selection of preceptors (see Table 2). The training program focused on building characteristics believed
to be important for a preceptor, including competency in clinical practice, strong communication and leadership
skills, and interest in professional development.
Furthermore, to foster new RNs' competence in various clinical experiences, most of the programs planned
rotations through several clinical areas (e.g., medical, surgical and critical care areas, outpatient clinic, or
emergency). Two articles introduced the idea of presenting and attending rounds as one of the teaching methods
in clinical practice (Blanzola et al., 2004; DiIorio et al., 2001).
All studies described various administrative systems needed to support the program and encourage the transition
of new RNs into the organization. The systems reported focused on both personnel and programs. Within
support personnel, three essential roles were identified: (a) a program coordinator who serves as a main
resource for implementing and maintaining the program, (b) a program facilitator or clinical expert nurse who
promotes continuous learning and development through regular contact with new graduates participating in the
program, and (c) nurse managers on units who provide leadership on clinical, staffing, and administrative issues
and who evaluate the progress of new graduates.
Two program supports were reported as important aspects of orientation programs: peer group support (e.g.,
debriefing/self care session) and mentorship by senior leaders. A peer group discussion enabled new nurses to
share the problems or difficulties with peers who were experiencing similar stress and provided strategies to
deal with them. The use of mentorship as a support program was reported in seven articles. Three of the seven
articles described a mentor as one of the roles of the preceptor (Boyer, 2005; Herdrich & Lindsay, 2006;
Rosenfeld et al., 2004), whereas the other four articles reported that mentorship was a separate program
altogether (Beecroft et al., 2001; Blanzola et al., 2004; Krugman et al., 2006; Newhouse et al., 2007).
All reviewed programs used several methods and tools for program evaluation, including the use of multiple
data resources and qualitative and quantitative data gathered from preceptors, nursing managers, staff, and new
graduates. Program outcomes also varied but generally focused on retention, confidence, competency (e.g.,
critical thinking and knowledge), communication, satisfaction, and cost effectiveness. Program coordinators
were important in the continuous evaluation of orientation program processes, content, and outcomes. Guiding
and tracking learning and performance provided consistency across the programs and helped to improve them.
The findings of this study provide information on the effect of orientation programs on new RNs' confidence,
competency, and retention. The reviewed studies suggest that the orientation programs are successful in
improving new RNs' confidence in caring for patient and in enhancing their competencies such as knowledge
and critical-thinking skills in the clinical environment. By doing so, these programs may encourage new
graduates to stay and to participate in a supportive system. Furthermore, as Benner's (1984) model would
suggest, this review shows that an orientation program with certain characteristics-that is, structured teaching
methods, clinical experiences with qualified preceptors, and support systems-fosters the transition of new RNs
from novices to advanced beginners.
Reviewed studies reported a wide variability in the time frames of orientation programs, with program length
ranging from 6 weeks to 1 year. Several studies (n = 7) reported successful results in programs of 1-year length,
and the 1-year time frame is used in the National Post-Baccalaureate Graduate Nurse Residency Program, a
partnership between the University Health Systems Consortium and the American Association of Colleges of
Nursing. This program is based on the premise that transition into practice is not completed until 9 to 12 months
after starting a job and that a 1-year time frame for the successful transition of new graduates is reasonable
(Krugman et al., 2006). Given the variability in program length reported in the literature, more research is
needed to determine the most effective length of orientation programs for new RN graduates.
An extended program length, however, also poses additional costs. For example, several studies reported
benefits resulting from the recruitment and retention of newly graduated nurses, although these programs
incurred additional training costs (Beecroft et al., 2001; Krugman et al., 2006; Pine & Tart, 2007). Beecroft et
al. (2001) calculated the return on investment (ROI) to determine the cost effectiveness of their 1-year program
and reported an ROI of 67.3%, meaning that the program not only paid for itself but also saved money. Pine and
Tart (2007) also reported the cost effectiveness of a 1-year residency program with an ROI of 884.75%.
Further, Krugman et al. (2006) reported that the average budget for managing the 1-year National Post-
Baccalaureate Graduate Nurse Residency Program was less than the costs to advertise and recruit two nurses.
Although this review did not examine the cost effectiveness of newly graduated RN orientation program per se,
these studies suggest that an extended program length may be worth the added costs.
This review also revealed that the specialized orientation programs, which trained newly graduated nurses to
work in critical care units, had a positive impact on their confidence, competency, and retention. In an effort to
deal with the urgent nursing shortage, current healthcare systems increasingly recruit newly graduated nurses
for highly specialized areas that once were available only to experienced nurses. Therefore, it would be
meaningful to conduct further research to evaluate the impact of specialty orientation programs on new nurse
retention and patient safety in critical care units.
Many reviewed studies used a descriptive research design. That is, the authors described interviews with
participants in a program or the studies did not have a control group with which to compare the intern or
resident group. Therefore, the design used in the primary research may limit this study's ability to accurately
capture the extent of new RN orientation program impact. However, the authors tried to overcome this
limitation by examining data from similar hospital programs and analyzing differences and similarities between
the programs to present more comprehensive information and recommendations.
This study has several other limitations that are important to address. The focus of this integrative review was
on hospital-based new RN orientation programs. However, several articles related to new RN orientation
programs in other settings, such as long-term care, were excluded during the review process. Future reviews of
this nature are needed to compare and contrast new RN orientation programs across types of settings to better
inform future program development. Furthermore, this review was restricted to programs focusing on outcomes
in only three areas-confidence, competency, and retention. By restricting the focus in this way, other important
outcomes of new RN orientation programs could have been missed. However, given that these are three very
important outcomes of new RN orientation programs, the studies reported here and the conclusions reached
represent an important first step in the examination of outcomes across different types of hospital-based new
RN orientation programs. Finally, despite best efforts to conduct an in-depth scan of the literature, some studies
may have been missed in the search process. The authors tried to overcome this limitation by scanning the
literature broadly across numerous search engines and by incorporating extensive search and elimination
strategies. Therefore, the authors believe that the studies reviewed here adequately characterize hospital-based
new RN orientation programs during the time period of study.
In the face of a shortage of nurses, the new RN orientation program should be an initial, basic step in a
healthcare organization's retention strategy. Healthcare systems have attempted to address this concern by
revising existing orientation programs or introducing new programs to retain newly graduated nurses. This
integrative review examined the impact of orientation programs reported in the literature between 1990 and
2007. Innovative orientation programs have strong merits: They facilitate the transition from newly graduated
nurses to professional RNs and create environments that promote the retention of newly graduated nurses.
These programs have the potential to address the nursing shortage in healthcare organizations. For hospitals to
pursue successful staff retention, the information in this review can serve as a resource for evidence-based
Almada, P., Carafoli, K., Flattery, J. B., French, D. A., & McNamara, M. (2004). Improving the retention rate
of newly graduated nurses. Journal for Nurses in Staff Development, 20(6), 268-273. [Context Link]
Altier, M. E., & Krsek, C. A. (2006). Effects of a 1-year residency program on job satisfaction and retention of
new graduate nurses. Journal for Nurses in Staff Development, 22(2), 70-77. [Context Link]
American Association of Colleges of Nursing. (2007). Nursing shortage. Retrieved August 9, 2007,
from[Context Link]
American Organization of Nurse Executives. (2002). Acute care hospital survey of RN vacancy and turnover
rates in 2000. Washington, DC: Institute for Patient Care Research and Education, American Organization of
Nurse Executives. [Context Link]
Beck, C. T. (2001). Predictors of postpartum depression: An update. Nursing Research, 50(5), 275-
285. [Context Link]
Beecroft, P. C., Kunzman, L., & Krozek, C. (2001). RN internship: Outcomes of a one-year pilot
program. Journal of Nursing Administration, 31(12), 575-582. [Context Link]
Benner, P. E. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park,
CA: Addison-Wesley. [Context Link]
Blanzola, C., Lindeman, R., & King, M. L. (2004). Nurse internship pathway to clinical comfort, confidence,
and competency. Journal for Nurses in Staff Development, 20(1), 27-37. [Context Link]
Bowles, C., & Candela, L. (2005). First job experiences of recent RN graduates: Improving the work
environment. Journal of Nursing Administration, 35(3), 130-137. [Context Link]
Boyer, S. A. (2005). Vermont nurse internship project-a transition to practice model. Retrieved April 13, 2006,
from[Context Link]
Collins, M. L., & Thomas, T. L. (2005). Creation of a stepdown nurse internship program. Journal for Nurses in
Staff Development, 21(3), 115-119. [Context Link]
Cooper, H. M. (1989). Integrating research:A guide for literature reviews (2nd ed.). Beverly Hills, CA: Sage
Publications. [Context Link]
Crimlisk, J. T., McNulty, M. J., & Francione, D. A. (2002). New graduate RNs in a float pool. An inner-city
hospital experience. Journal of Nursing Administration, 32(4), 211-217. [Context Link]
DiIorio, C., Price, M. E., & Becker, J. K. (2001). Evaluation of the neuroscience nurse internship program: The
first decade. Journal of Neuroscience Nursing, 33(1), 42-49. [Context Link]
Herdrich, B., & Lindsay, A. (2006). Nurse residency programs: Redesigning the transition into practice. Journal
for Nurses in Staff Development, 22(2), 55-62. [Context Link]
Keller, J. L., Meekins, K., & Summers, B. L. (2006). Pearls and pitfalls of a new graduate academic residency
program. Journal of Nursing Administration, 36(12), 589-598.
Kovner, C. T., Brewer, C. S., Fairchild, S., Poornima, S., Kim, H., & Djukic, M. (2007). Newly licensed RNs'
characteristics, work attitudes, and intentions to work. American Journal of Nursing, 107(9), 58-70. [Context
Krugman, M., Bretschneider, J., Horn, P. B., Krsek, C. A., Moutafis, R. A., & Smith, M. O. (2006). The
national post-baccalaureate graduate nurse residency program: A model for excellence in transition to
practice. Journal for Nurses in Staff Development, 22(4), 196-205. [Context Link]
Marcum, E. H., & West, R. D. (2004). Structured orientation for new graduates: A retention strategy. Journal
for Nurses in Staff Development, 20(3), 118-124. [Context Link]
Mathews, J. J., & Nunley, C. (1992). Rejuvenating orientation to increase nurse satisfaction and
retention. Journal of Nursing Staff Development, 8(4), 159-164. [Context Link]
Messmer, P. R., Jones, S. G., & Taylor, B. A. (2004). Enhancing knowledge and self-confidence of novice
nurses: The "Shadow-A-Nurse" ICU program. Nursing Education Perspectives, 25(3), 131-136. [Context Link]
Newhouse, R. P., Hoffman, J. J., Suflita, J., & Hairston, D. P. (2007). Evaluating an innovative program to
improve new nurse graduate socialization into the acute healthcare setting. Nursing Administration
Quarterly, 31(1), 50-60. [Context Link]
Nursing Executive Center. (2002). Nursing's next generation: Best practices for attracting training and
retaining new graduates. Washington, DC: Advisory Board Company. [Context Link]
Owens, D. L., Turjanica, M. A., Scanion, M. W., Sandhusen, A. E., Williamson, M., Hebert, C., et al. (2001).
New graduate RN internship program: A collaborative approach for system-wide integration. Journal for
Nurses in Staff Development, 17(3), 144-150. [Context Link]
Patrick, S. (2000). Managers shoulder burden of retaining staff. Retrieved March 20, 2006,
from story7.html [Context Link]
Pine, R., & Tart, K. (2007). Return on investment: Benefits and challenges of a baccalaureate nursing residency
program. Nursing Economic$, 25(1), 13-18, 39. [Context Link]
Rosenfeld, P., Smith, M. O., Iervolino, L., & Bowar-Ferres, S. (2004). Nurse residency program: A 5-year
evaluation from the participants' perspective. Journal of Nursing Administration, 34(4), 188-194. [Context
Santucci, J. (2004). Facilitating the transition into nursing practice: Concepts and strategies for mentoring new
graduates. Journal for Nurses in Staff Development, 20(6), 274-284. [Context Link]
Squires, A. (2002). New graduate orientation in the rural community hospital. Journal of Continuing Education
in Nursing, 33(5), 203-209. [Context Link]
U.S. Department of Labor, Bureau of Labor Statistics. (2005). Occupational outlook handbook: Registered
nurses. Retrieved April 13, 2006, from[Context Link]
While, A. (1994). Competence versus performance: Which is more important? Journal of Advanced
Nursing, 20, 525-531. [Context Link]
For more than 28 additional continuing education articles related to educstion, go
- See more at:
The Internship Project is an endeavor of the Vermont Nurses In Partnership (VNIP), a not-for-profit nurse
leadership coalition that institutes resources for supporting the developing nurse. The programs developed by
VNIP promote a workplace culture of nurture, support and professional growth for novice nurses or those in
transition to a new specialty. VNIP includes nurse leaders from academia, regulation and various practice
settings. The collaboration has grown from the initial 45 Vermont-based members, to a coalition of over 300
nurse leaders from across the nation and around the world. These proactive healthcare leaders provide the
intellectual resources that allow us to develop and deliver intern, orientee, and preceptor development programs.
Unique aspects of the project include:
Establishment of a statewide, standardized approach to preceptor development and support
Preceptor development that is applicable for a broad audience of direct care providers
An internship model suitable for multiple healthcare agencies instead of a single site or system
A research and theory based model that is being adapted to community health settings and a variety of
To create a formal and sustainable nurse internship program that provides the clinical experience necessary to
support the novice's entry into practice, their growth along the continuum of expertise, and their professional
practice within the complex and demanding field of healthcare.
The Vermont Board of Nursing, Schools of Nursing, and practice sites work in a collaborative, statewide,
partnership to maintain a nationally recognized Nurse Internship Program. The internship is available in
multiple settings and supports the transition from new graduate nurse to a self confident, adaptable, and
independent professional.
Model development and implementation
Internship Model
Roles and responsibilities required to support the model
Program Components
Bibliography and Resource list
The Vermont Nurse Internship Project (VNIP) is a healthy workplace strategy that has proven its worth. It is a
project that was undertaken in response to the looming staffing issues identified in 1999 by the Vermont
Organization of Nurse Leaders (VONL). VONL partnered with the Vermont Association of Hospitals and
Health Systems (VAHHS) to commission research on nursing workforce issues specific to Vermont. The
resulting report, the Vermont Nursing Report became the basis for further collaborative work and then strategic
planning relating to the pending workforce crisis. Six (6) strategic goals for dealing with the crisis were
identified in VONL - Current State of Nursing in Vermont.
Two of these goals became the focus of the internship project:
I. Create a formal nursing internship program that provides adequate practical clinical experience for novice
nurses to function at a competent level when they enter the work force. This would force a marriage of
schools of nursing and fields of practice that could strengthen both institutions, while promoting the
preparation of nurses able to handle the currently complex and demanding field of health care.
II. Expand clinical opportunities for students by increasing the use of clinical staff as preceptors in specialty
Grant funding was obtained to support a half time Directors position to lead development and implementation
of the model/project, and the Vermont Nurse Internship Project (VNIP) was established.

Model development and implementation
At the initial VNIP meeting, it was determined that three (3) levels of internship were needed: 1. Student (extern
program) for expanded undergraduate clinical experience. 2. Graduate level (transition to practice) internship
to provide an organized, supportive transition to practice that included educational support, competency
development, and skills evaluation. 3. Specialty care internships to provide the extensive additional education
and support for work in a specialty care area such as OR, ICU, Home care, Long term Care, etc. The initial
model development targeted the new graduate RN and transition to practice. It was decided that the internship
would be based in a precepted delivery model. As a result two programs were developed: one for the interns
(new graduates) and another for the development and support of clinical staff preceptors.
Unique aspects of this project include the collaborative workgroup comprised of Nurse Leaders from Practice
settings, Academia, and the Board of Nursing and the focus on a model configuration that can be applied
statewide and across the continuum of care. The Internship model used Lenburgs Competency Outcomes
Performance Assessment (COPA) model (Lenburg, 1999) for the core outline for the role of the RN and
competency-based skills verification. The specific sub skills for each of Lenburgs Eight Core Practice
Competencies were identified with input from all practice areas to establish a competency verification form that
outlined the core role of the generalist RN in most, if not all, direct care settings. The initial form was used in
the first pilot during the summer of 2000. Based on outcomes data and feedback from the educators and
preceptors using the model within the pilot, it was modified then underwent a second pilot during 2001. Thus
the model and its components were validated as a standardized model for delivery in multiple settings. It was
found to be a model that provides structure for experiential learning that can address the needs of the new
graduate, specialty care internships, and/or the clinical component of a re-entry program.
The initial outcomes analysis resulted in recognizing the urgent need for added preparation for preceptors. A
preceptor development focus group convened that included the directors of three of the states nursing
programs. They assisted in shifting this essential preparation into theory and research based education that is
delivered via an independent learning module and two (2) days of workshop presentation. This initial education
totals 18.6 contact hours of interactive teaching/learning. Thanks to a partnership with grant funded specialty
care internships, we have been able to offer this standardized education to direct care providers from all regions
and specialties within the state. The preceptor workshops have offered an ideal venue for collecting
demographic data on these clinical experts with a focus on identifying those who might be interested in a future
teaching role.
The statewide, standardized approach to preceptor development is another unique aspect of this project. It has
led into development of a credentialing process for preceptors. This credentialing offers recognition and reward
for this key teaching/support role, while establishing a pool of clinical preceptors who have all had the same
educational preparation, support, and skills development/evaluation.
The internship has been in place as an active educational process since 2000 and has seen annual growth and
expansion. Its impact has expanded through collaboration with various non-Vermont healthcare agencies who
request consulting time and model adoption. The project currently has grant funding that will: 1) strengthen the
VNIP coalition 2) expand implementation at additional sites/settings 3) develop the model for use in home care
and public health settings 4) continue/expand preceptor development and 5) collect data specific to nurse
retention in rural and/or medically under served areas. The National Council of State Boards of Nursing
(NCSBN) is finalizing plans for a research project that will be done collaboratively with the VNIP to evaluate
both program outcomes and differences in clinical practice resulting from the model.
2000 Satisfaction Survey Transition to work - Survey data showsgreater than 40% improvement in
satisfaction with transition to practice and new grad competency
For initial pilot, 49% of the Nurse Interns came from out of stateresidence and/or schools
Retention data from tertiary care center - Retention of those who completed their Orientation in 1999
was 75%, while the new grads that completed an Internship showed a 93% retention rate for each of the
following two years.
Position Vacancy rate At one participating agency, the Medical - Surgical unit had suffered an
unrelenting vacancy rate of 20%. This agency credits the Internship/Preceptor program with the current
vacancy rate of 0% for the entire nursing department. This hospital now has no recruitment or position
advertising costs for nursing positions.
Internship Model
The Internship is a formal, post-licensure educational program designed to extend the basic nurse education
preparation, proficiency, and/or skills of new graduate and transitioning nurses. Each intern has completed a
guided course of nursing education. The Internship curriculum is designed to give experience and repeated
practice application to demonstrate successful transition of this learning into the specific clinical practice
setting. It includes individual studies, staff development courses, clinical conferences, and one-on-one support
and instruction from a preceptor. The purpose of the internship is to advance clinical practice skills needed to
deliver safe, comprehensive care in existing and emerging organized health care systems.
Roles and responsibilities required to support the model
The Clinical Educator directs the facility specific internship, provides didactic sessions for the intern, and offers
ongoing support and resources for the preceptor/intern team. The Preceptor develops learning goals/objectives
in collaboration with the intern and clinical educator, assesses the interns experience level and learning style,
and plans learning experiences accordingly. He/she is responsible for choosing the patient assignment based on
educational goals and objectives and sharing that assignment by progressively assigning patient care
responsibilities to the intern. Along with planning, the preceptor provides daily feedback to the intern and
collaborates with the clinical educator and nurse manager to evaluate progress and address issues. The intern is
responsible for active participation in all components of the Internship and completion of documentation.
Program components include
An Internship session may include up to 5 preceptor/intern teams starting at the same time and the duration is
10 weeks. There are at least 40 hours devoted to didactic components within the program with required content
topics that include, but are not limited to: standards of care, managed care, cultural competence, quality
improvement, IV access/therapy, medication administration, and pain management. Interns are not considered
as part of the staffing mix and each is paired with a qualified Preceptor. The patients assigned to interns will
also be part of their preceptors assignment and preceptors progressively allocate patient care activities to the
intern. The preceptors act as mentors and role models, leading the intern through his or her daily clinical
experiences on the unit. On a weekly basis, the intern, preceptor, and/or clinical educator will meet to
establish/evaluate goals and work with Critical Thinking skills .Delivery of the Internship requires release time
for support of educational preparation, didactic instruction, goal setting, weekly conference, and support group
meetings approximately 200 hours of educator time for each Internship session.
The Internship provides practice and verification of competencies that are based on the COPA model (Lenburg,
1999). The Internships competency verification form delineates specific criteria that address Lenburgs
essential skills of Assessment and Interventions, Communications, Critical Thinking, Human
caring/Relationships, Management, Leadership, Teaching, and Knowledge Integration.
Along with investing in transition programs for new graduates, our healthcare systems need to ensure the
development and support of preceptors in the clinical setting. Most of todays transition programs use
preceptor-based systems, but not many have consistently invested in the development and support of those
preceptors. To be effective, preceptors require an educational foundation, ongoing support, and time to
precept. A commitment to this teaching time serves the development of both the preceptor and the novice
with whom they work.
Our project has identified two groups that require intensive education and support. The first target audience is
the preceptor. Teaching, mentoring, interpersonal, and competency assessment skills must be developed in
these individuals. A foundation must be laid with comprehensive, theory-based education related to
interpersonal communication, roles/responsibilities, principles of teaching/learning, assessment, planning, and
feedback skills. The vitally important roles of the preceptor include protector and competency validator.
These roles require specific preparation and support. Once this foundation is laid, the preceptors effectiveness
should be evaluated on an ongoing basis, within a system that focuses on performance development for both the
preceptor and the novices with whom they work. This ensures the necessary structure for skills development
and competency assessment that protects the safety of our clients as well as the professional development of our
The second target audience is the novice nurse. This nurse may be a new graduate, a re-entry candidate, or a
nurse that is transitioning into a new specialty area. Each of these novices needs advanced support, instruction,
and precepting to develop the reflective learning, critical thinking, and specialty practice skills that are essential
to safe, effective nursing care in our multiple and challenging settings.
To deliver this, an effective preceptor/internship program needs to include:
1. Clearly identified roles and responsibilities that also delineate where to find the time for precepting
2. A Clinical Coaching plan that outlines specific goals, activities, and measurable outcomes. This plan must
follow principles of teaching/learning, to foster the progression of the novice through all core competency
3. Specific planning for critical thinking development through weekly meetings, case scenarios,
documentation tools, discussion and/or problem solving.
4. Valid and reliable tools for competency verification that identify specific, measurable criteria for
Investment in these target groups has paid dividends in recruitment, retention, and improved satisfaction for
Vermont nurses. We are succeeding in changing the culture of the workplace towards one of support, nurture,
learning, and professional advancement.
Bibliography and Resource list
1. Alfaro-LeFevre, R. Critical Thinking and Clinical Judgment: A Practical Approach, 3rd Edition. 2004
ISBN: 0721697291
2. Angelo, T.A. & Cross, K.P. (1993). Classroom assessment techniques: A handbook for faculty. (2nd
edition). University of Michigan, Ann Arbor, MI: National Center for Research to Improve Post secondary
Teaching and Learning.
3. Bargagliotti, T., Luttrell, M, & Lenburg, C.B. (Sept, 1999). Reducing threats to the implementation of a
competency-based performance assessment system. Online Journal of Issues in Nursing. Washington, DC:
ANA. (Note: This is the 4th in the sequence of the OJIN articles; others listed below. Access via ANA
home ).
4. Beecroft, P, Kunzman, L, Krozek, C. RN Internship Outcomes of a One-Year Pilot Program; JONA;
Vol 31, No.12, pp 575-582; December 2001
5. Benner, P. (1984). From Novice to expert: Excellence and power in clinical nursing practice. Menlo Park,
CA: Addison-Wesley.
6. Boyer, S. (2002). Vermont nurse internship project: A collaborative enterprise developed by nurse leaders
from education, practice and regulation. Nursing Education Perspectives. 23, 81-85.
7. Carey, S., Campbell, S. Preceptor, Mentor, and Sponsor Roles - Creative Strategies for Nurse Retention.
JONA Vol 24, Number 123, pp 39-48 1994, J.B. Lippincott.
8. Chenoweth, L. Facilitating the process of critical thinking for nursing. Nurse Education Today(1998)18,
9. Connelly, L., Hoffart, N. A Research Based Model of Nursing Orientation. JNSD Vol. 14, No. 1, 31-39
10. Corkhill, M; Undergraduate Clinical Practicum and the opportunity to practice skills in preparation for the
graduate year: A review of the literature. Contemporary Nurse Vol 7, Issue 2, June 1998
11. Craven, H. & Broyles, J. Professional Development Through Preceptorship. JNSD. Vol 12, Number 6. pp.
12. Curley, M.A.Q. (1998). Patient-nurse synergy: Optimizing patients outcomes. American Journal of Critical
Care 7 (1), 64-72.
13. Felder, R.M., Index of Learning Styles,
14. Felder, R.M., Matters of Style, ASEE Prism, 6(4), 18-23 (December 1996).
15. Fleming, N., VARK - a Guide to Learning Styles
16. Freiburger, O. (2001). A Tribute to Clinical Preceptors. Journal for Nurses in Staff Development, Vol. 17,
No. 6, 320-327
17. Godinez, G., Schweiger, J., Gruver, J., Ryan, P. (1999) Role Transition from Graduate to Staff Nurse: A
Qualitative. Analysis Journal for Nurses in Staff Development, Vol. 15, No. 3, 97-110
18. Hartshorn, J. Characteristics of Critical Care Nursing Internship Programs. JNSD. Sept/Oct 1992 pp. 218
19. Horne, C. and Medley, F. (2001). Community-Based Strategies: An interdisciplinary community-based
clinical experience for beginning students. Nurse Educator, 26, 120-121.
20. Hrobsky, P. & Kersbergen, A. Preceptors' Perceptions of Clinical Performance Failure. Journal of Nursing
Education Vol. 41 No. 12 December 2002
21. Ignatavicius, D. Critical Thinking Skills for at-the-bedside Success. Nursing Management 2001: 32 (1):
22. Internship web page & documents available via:
23. Kidd, P., and Sturt, P. Research Developing and evaluating an emergency nursing orientation
pathway Journal of Emergency Nursing Vol 21, No 6, pp. 521 531; Dec, 1995
24. Kupperschmidt, B. Understanding Net Generation Employees; JONA; Vol. 31, No. 12; December 2001
25. LaDuke, S. (2001). The Role of Staff Development in Assuring Competence. Journal for Nurses in Staff
Development, Vol. 17, No. 5, 221-135
26. Lenburg, C. The Framework, concepts and methods of the competency outcomes and performance
assessment (COPA) model. 1999 Online Journal of Issues in Nursing. Sept. 30,
27. Lenburg, C.B. (1979). The clinical performance examination: Development and implementation. NY:
Appleton Century Crofts. (Original text; currently out of print)
28. Lenburg, C.B. (2001). The competency outcomes and performance assessment model applied to nursing
case management systems. In E. Cohen & T. Cesta, Nursing Case Management: From Concept to
Evaluation (3rd edition). St. Louis: Mosby, 269-279. (4th edition in progress, 2004)
29. Lenburg, C.B. (2002a). The Influence of contemporary trends and issues on nursing education. In B. Cherry
and S. Jacob, Contemporary Nursing: Issues, Trends, and Management, 2nd edition. St Louis: Mosby. (3rd
edition in progress, 2004)
30. Lenburg, C.B. (July/Aug 2000). Promoting competence through critical self-reflection and portfolio
development: The inside evaluator and the outside context. The Tennessee Nurse, Nashville,
31. Lenburg, C.B. (Oct, 2002b). Changes that challenge nursing education. The Tennessee Nurse, Nashville,
TN. (p. 10-13)
32. Lenburg, C.B. (Sept, 1999a). Redesigning expectations for initial and continuing competence for
contemporary nursing practice. Online Journal of Issues in Nursing. Washington, DC: ANA. (Note: This is
the 1st in the OJIN sequence and describes the need for competence of practitioners, of whatever kind, the
issues, context, etc.)
33. Lenburg, C.B. (Sept, 1999b). The framework, concepts and methods of the competency outcomes and
performance assessment (COPA) Model. Online Journal of Issues in Nursing. Washington, DC: ANA.
(Note: This is the 2nd article in the OJIN sequence, and is most important for details about COPA concepts
and framework.)
34. Lenburg, C.B. and Mitchell, C.A. (1991). Assessment of outcomes: The design and use of real and
simulation nursing performance examinations, Nursing & Health Care Perspectives, 12, 68-74.
35. Letizia, M. and Jennrich, J. A Review of Preceptorship in Undergraduate Nursing Education: Implications
for Staff Development. JCEN Vol 29, No 5, , pp. 211 216; Sept/Oct 1998
36. Loring, C. Do Nurses Really Eat their Young?. AWHONN Lifelines. Feb/Mar 1999, Vol 3, Issue 1. pp 47-
37. Luttrell, M. F., Lenburg, C.B., Scherubel, J.C., Jacob, S.R., and Koch, R.W. (1999). Competency outcomes
for learning and performance assessment: Redesigning a BSN curriculum. Nursing and Healthcare
Perspectives, 20, 134-141.
38. McHugh, M., Duprat, L., Clifford, C.: Enhancing Support for the Graduate Nurse, AJN; June 1996; Vol
96, No 6; pp57 62
39. Mee, C. Nurses, are we still eating our young? Nursing99. Vol 29, No 11. pp. 48 - 50
40. Meng, A. & Conti, A. Preceptor Development - An opportunity to stimulate critical thinking. JNSD.
Vol 11, Number 2, pp 71-76
41. Norgren, J., Richardson, S., Brown Laurella, V. A Collaborative Preceptor Model for Clinical Teaching of
Beginning Nursing Students. Nurse Educator Vol. 23, No. 3, pp27-32
42. Ohrlin, K, Hallberg, I. (2000) Student nurses Lived Experience of Preceptorship.International Journal of
Nursing Studies 37 (2000) 13-23
43. Perkins, I., Vale, D.J. & Graham, M.S. (2001). Partnerships in Primary health care: A process for re-
visioning nursing education, Nursing & Health Care Perspectives22, 20-25.
44. Preceptor Development Program Resources and Links for
45. Redman, R. & Lenburg, C.B. (Sept, 1999). Competency assessment: Methods for development and
implementation in nursing education and practice. Online Journal of Issues in Nursing. Washington, DC:
ANA. (This is 3rd article in OJIN competency series.)
46. Rittman, M, Osburn, J. An Interpretive Analysis of Precepting an Unsafe Student. Journal of Nursing
Education. May 1995, Vol. 34, No. 5, pp. 217-221
47. Stevenson, B., Doorley, J., Moddeman, G., Benso-Landau, M. The Preceptor Experience - A Qualitative
Study of Perceptions of Nurse Preceptors Regarding the Preceptor Role. JNSD Vol 11, No. 3, 160-165
48. Stone, C., Rowles, C. (2002) What Rewards do Clinical Preceptors in Nursing Think are
Important? Journal for Nurses in Staff Development, Vol. 18, No. 3, 162-166
49. Vermont VNA Maternal Child Health competencies
50. VONL - Current State of Nursing in Vermont. Presentation.htm
51. Yonge, O., Krahn, H., Trojan, L., Reid, D., Haase, M. (2002) Supporting Preceptors. Journal for Nurses in
Staff Development, Vol. 18, No. 2, 73-79
52. Yonge, O., Krahn, H., Trojan, L., Reid, D., Haase, M. (2002) Being a Preceptor is Stressful! Journal for
Nurses in Staff Development, Vol. 18, No. 1, 22-27
Internships offer transition for graduate nursing students
By Rebecca Maitland, jobs correspondent | January 17, 2014
Comments 0


Hospitals and clinics provide orientations, mentors and additional training programs to assist in easing that
New graduate nursing students usually have a transition period between academics and real-world experiences
in caring for patients.
Hospitals and clinics provide orientations, mentors and additional training programs to assist in easing that
Harris Health System hires new graduates through its internship program to assist in the transition. The
internship, for those with a bachelor of science in nursing, is one year. The internship actually is a one-year
orientation, where new nurses work with a preceptor until they are ready to work independently.
"We usually have between 300 to 400 applications for each internship, and we hire 70 to 80 new graduate
nurses for each internship, of which there are three a year," said Janet Lamb, associate administrator, nursing
practice and professional advancement, Harris Health System.
The first days are filled with a general orientation, then classroom programs begin for nursing policies and
competencies. The internship group is divided into special groups assigned to areas such as the operating room,
emergency room, etc., for additional training with a preceptor.
"After four to nine months, nurses begin taking assignments independently. Internships are designed for nurses
to transition from school into practical practice of patient care," Lamb said.
Nurses at Harris Health enter the internship as a Nurse 1, and when they begin working independently, they are
promoted to Nurse 2, with a considerable salary increase, Lamb said.
Alicia Hernandez, MSN, RN, BC, director, The Center for Professional Excellence, Houston Methodist
Hospital, Texas Medical Center, hires and transitions new graduates nurses into their focused specialty area of
interest, and the program looks at ensuring the nurse's role on patient safety and outcomes.
"We work with them in a classroom basis for skill acquisition as well as other competencies. The new nurse
graduate will go through nursing orientation for about a week and then register for many other courses that are
required to help them successfully transition from a student nurse role to graduate nurse," Hernandez said.
On the unit of hire, the new nurse is assigned a preceptor, an experienced registered nurse, to work one-on-one
for approximately 12 weeks of orientation.
Memorial Hermann hires new graduates and offers an orientation that is a general nursing orientation followed
by their specialty considerations.
"Since we are an academic medical center and a Level 1 Trauma Center for both adults and pediatrics, with an
air ambulance service, Memorial Hermann Life Flight, as well as multiple specialty certifications, it is
important to provide classes, simulation and actual experience in a clinical setting with a coach/preceptor to
enhance and validate their skill set and competency.
"Nursing school curriculum is not designed to offer the level of knowledge required to provide care for these
special-patient populations," said Victoria King, chief nursing officer of Memorial Hermann-Texas Medical
King said Memorial Hermann's goal is to provide an orientation program that addresses patient safety and
quality through the development and implementation of a nursing competency-based orientation.
General nursing orientation is an interactive platform in which the nursing orientees are divided into groups and
given high-risk patient-care scenarios and critical-thinking case studies. Each group has defined objectives for
its case study/scenario and must prioritize assessment needs, anticipate physician orders, appropriately escalate
a patient's condition to other health-care team members, and provide appropriate patient education. Each group
then presents its case studies to their nursing peers.
Other areas of focus in the general nursing orientation are effective communication and collaboration with
various members of the health-care team, and nursing professionalism. After general nursing orientation, the
employee participates in his or her unit-specific orientation, tailored to meet the care needs of that patient
population, and builds from the general orientation foundation.
"New graduate nurses are not on their own until they show they can provide safe and quality care in their area
of practice. We emphasize the importance of teamwork, utilizing one's resources and never being on one's own.
It takes everyone to provide great care," King said.

Robert Wood Johnson Foundation
Nurse Educational Preparation
A 2001 survey of 754 employers of recent nursing graduates suggests that new nurses are
unprepared for many routine practice functions (NCSBN, 2002).
A cross-sectional analysis of Pennsylvania hospital surgery outcomes found that after
adjusting for patient and hospital characteristics, nurse staffing, and experience and surgeon
characteristics, each 10% increase in the proportion of nurses with a bachelor of nursing
An internal evaluation of a pilot program created to transition newly-licensed RNs through a
six-month residency program found a turnover rate for participants at the end of the program
of 14%, compared to 36% among the control group. Graduates of the program scored
as well as their control counterparts on measures of clinical skills confidence, professional
autonomy, and commitment to remain at the institution. The researchers estimated that the
program benefits exceeded its cost by 67.3%, saving the hospital over half a million dollars
in its first year (Beecroft et al., 2001).
An analysis of data collected by the Versant RN residency program found a strongly positive
effect on nurse competencies, job satisfaction, self-confidence, group cohesion, and turnover
intent at the end of a 18-week residency period. In hospitals where accurate comparisons
were possible, dramatic reductions in turnover were observed. Actual 12-month turnover
went from an average of 27% before the program to 7.1% after, resulting in estimated
savings of millions of dollars at many hospitals (Ulrich et al., 2010; Versant, 2010)
(BSN) degree was associated with a 5 percent decline in the risk of mortality and of failure to
rescue (Aiken et al., 2003).
A significant reduction in mortality was observed in a retrospective study of hospital
discharge data in Ontario, Canada. A 10% increase in proportion of BSN nurses was
associated with 9 fewer deaths per 1,000 discharged patients (a 0.9% mortality reduction)
(Tourangeau et al., 2007).
In a survey of self-reported competency of new nurse graduates in quality improvement
measures, BSN nurses reported significantly higher levels of preparation than associate
degree nurses (ADN) in measures including evidence-based practice, assessing gaps in
practice, and research competencies such as data collection, analysis, and measurement.
BSN nurses also reported greater preparation in the areas of team work and collaboration
and measuring resulting changes (Kovner et al., 2010).
A retrospective study of nearly 130,000 patients at 123 Veterans Health Administration
hospitals found no association between mortality and the proportion of BSN-trained nurses
(Sales et al., 2008).
Post-licensure Residencies
Survey data shows that graduate nurses are often overwhelmed in the first year of
employment by the demands of practice, particularly in the hospital setting, where an
estimated 87.7% of newly licensed nurses work (Kovner et al., 2007).
A survey of new nurses found that new nurses often report a lack of confidence, difficulty
with work relationships, frustrations relating to the work environment, lack of time and
guidance for developing organizational and priority-setting abilities, and overall high levels of
stress. These factors likely contribute to the high turnover rate among new nurses, estimated
at between 35% and 60% within the first year (Casey et al., 2004; Halfer and Grad, 2006).
An evaluation of a 1-year post-baccalaureate nurse residency program developed by the
University Health System Consortium and the American Association of Colleges of Nursing
found improved communication and organization skills, as well as higher perceived levels
of support and reduced stress in 12 sites around the country. The 12-month turnover
rate among the first and second group of residents to graduate from the program was
significantly lower (12% and 9%, respectively), than the average rate of 35-60% reported
in the literature for hospitals without such a program (Krugman et al., 2006; Williams et al.,
2007; Goode et al., 2009).
The Value of Nurse Education and Residency Programs

The Nurse Residency Program at Mayo Clinic in Rochester, Minnesota, is a yearlong training program that
provides you an additional opportunity as a newly licensed nurse to develop your leadership skills and receive
support during your transition from student nurse to competent professional nurse. The choice to participate in
the Nurse Residency Program is an investment in yourself and in your future as a nurse leader at Mayo Clinic.
Highlights of the program include:
Monthly learning sessions
Group discussions
Transition support from peers and program leaders
Active learning methods
Group and/or individual evidence-based practice projects
All newly licensed nurses employed at Mayo Clinic receive a comprehensive orientation that prepares them for
practicing in their nursing specialty environment. The Nurse Residency Program is an additional opportunity to
participate in a rigorous training program that will help you build your leadership and professional skills as well
as provide supplemental transition support during the first year of your career.
You may choose to apply for this optional program if you are a highly motivated individual who has a desire to
quickly become able to perform to the full scope of your nursing practice and contribute to the profession of
nursing at Mayo Clinic.
Program objectives
Transition from an entry-level, advanced beginner nurse to competent professional nurse who provides safe,
quality care
Develop effective decision-making skills related to clinical judgment and performance
Develop strategies to incorporate research-based and other evidence into practice
Develop clinical leadership skills at the point of patient care
Formulate an individual career plan that promotes a lifelong commitment to professional nursing
Eligible candidates for the Nurse Residency Program are individuals who:
Have been hired into a registered nurse position in the Department of Nursing at Mayo Clinic in Rochester,
Are graduates of an accredited baccalaureate nursing program as recognized by the Accreditation
Commission for Education in Nursing (ACEN, formerly NLN) or Commission on Collegiate Nursing
Education (CCNE)
Have less than 12 months of experience working as a licensed registered nurse
Application materials will be provided to eligible individuals upon their successful hire into a registered nurse
position at Mayo Clinic in Rochester, Minnesota.