Long-term Outcomes of a Postbaccalaureate Nurse Residency Program

JONA Volume 44, Number 7/8, pp 417-422 Copyright B 2014 Wolters Kluwer Health Lippincott Williams & Wilkins THE JOURNAL OF NURSING ADMINISTRATION Long-term Outcomes of a Postbaccalaureate Nurse Residency Program A Pilot Study Ruth Fiedler, EdD, RN, PMHCNS-BC, CNE Emily S. Read, DNP, MPH, RN-BC Kelly A. Lane, MS, FNP-BC OBJECTIVE: The purpose of this pilot study was to determine what influence a nurse residency program (NRP) has on long-term outcomes including turnover rates, career satisfaction, and leadership development. BACKGROUND: Studies examining short-term outcomes of NRPs have shown positive effects. Longterm studies of NRPs have not been reported. METHODS: This descriptive study surveyed former nurse residents, still employed at the facility. Data were collected by means of a demographic tool and the McCloskey/Mueller Satisfaction Scale, a job satisfaction tool. RESULTS: Although nursing turnover increased past the yearlong residency program, it remained well below the national average. All components of satisfaction were ranked relatively high, but coworker/peer support was most important to job satisfaction. Leadership development in the areas of certification and pursuing an advanced degree increased with longer Author Affiliations: Assistant Professor (Dr Fiedler) and Assistant Dean for Generalist Education and Professor (Dr Hicks), College of Nursing, Rush University; and Manager, Professional Nursing Practice/Educator Quality Coordinator (Dr Read), Medical Center, Rush University, Chicago, Illinois; School Health Professional (Ms Lane), Hong Kong; and Assistant Professor (Dr Jegier), The College at Brockport, New York. Funding was received from the Center for Clinical Research & Scholarship, Rush University Medical Center and Rush University College of Nursing, is gratefully acknowledged. The authors declare no conflicts of interest. Correspondence: Dr Fiedler, Rush University, 600 S Paulina St, Ste 1056A, Chicago, IL 60612 (ruth_fiedler@rush.edu). DOI: 10.1097/NNA.0000000000000092 Frank D. Hicks, PhD, RN Briana J. Jegier, PhD employment, but hospital committee involvement decreased with successive cohorts. CONCLUSION: Overall, the long-term outcomes of an NRP appear to have benefits to both the organization and the individual. Studies examining the short-term outcomes of nurse residency programs (NRPs) have shown that these programs improve retention rates and strengthen a variety of skills, as well as deepen clinical reasoning and judgment among participants. Rush University Medical Center (RUMC) subscribed to the University HealthSystem Consortium/American Association of Colleges of Nursing (UHC/AACN) program and has offered an NRP since 2008. Although the NRP has achieved acceptable short-term outcomes relative to turnover rates and resident satisfaction, the long-term outcomes of this program remain unreported. This pilot study examined the influence the NRP had on long-term outcomes including turnover rates, career satisfaction, and leadership development among residents currently employed at RUMC who have completed the program. Review of the Literature Several factors led to the development of the UHC/ AACN NRP, including the increasing acuity and complexity of patient care in acute care settings and high turnover rates among newly licensed RNs (NLRNs). 1 While many university hospitals created their own NRPs, there was a lack of standardization of content and varied length of completion time for NRPs JONA Vol. 44, No. 7/8 July/August 2014 417

(range, 4 weeks to 2 years). 2 The creation of the UHC/ AACN NRP addressed these concerns, as well as improved the transition of NLRNs from the role of student to that of professional nurse with a strong clinical foundation for practice. 1 The UHC/AACN NRP was based on the work of Benner s 3 Novice to Expert model, and assumed the NLRN enters the NRP as an advanced beginner. The goal of the NRP was to move the NLRN from advanced beginner to competent practitioner over the course of the yearlong program by supporting the NLRN s skill development and aspect recognition, developing coping mechanisms, and assisting their transition into professional practice. Decreasing Turnover The NRP was also designed to address traditionally high turnover rates among new RNs in their 1st year of practice. Nursing turnover rates negatively impact patient, nursing care, and financial outcomes. 4 Brewer et al 5 estimated that turnover costs for NLRNs are $856 million for organizations. The UHC/AACN NRP has been shown to reduce turnover rates below 10%, much lower than the national average. 6 Career Satisfaction Nurses satisfied with their jobs are more likely to maintain employment at the same institution. 6,7 Low job satisfaction of NLRNs has been linked to a variety of negative outcomes, including low group cohesion and higher turnover intentions. 8 Nurses are more satisfied with their jobs when they: have support and recognition from their managers; are empowered to perform their jobs well; have good collegial relationships; are affiliated with an organization that supports their development; and feel well compensated financially for their work. At the beginning of the UHC/AACN program, residents have a fairly high degree of professional satisfaction. However, residents have a noticeable decline in their job satisfaction after 6 months. 6 At the end of 1 year, residents have a significant increase in their job satisfaction, or at least a trend in that direction. 6,9 Leadership Development One of the goals of the UHC/AACN NRP was that NLRNs would provide clinical nursing leadership at the point of care. 2(p75) The NRP provides a structured curriculum that addresses leadership skill development to facilitate residents successful transition from students to professional nurses. Goode and colleagues 6 found that NLRNs had significantly improved leadership and communication skills, enhancing the work of the interdisciplinary team after completing a UHC/ AACN NRP. Engagement in professional development activities is an indicator of leadership potential. For the purposes of this study, we operationalized leadership development as the degree to which graduates of the NRP engaged in professional development activities. Research Aims While participation in the UHC/AACN NRP has clearly demonstrated that it improves employee retention, it is not clear whether the program ensures further longevity at the institution. Nor is there much evidence to suggest that the program improves long-term job satisfaction or leadership development. It was challenging to find published studies that established the long-term outcomes of the NRP: turnover beyond 1 year, career satisfaction, and leadership development. Thus, the aims of this study were to 1. describe the long-term (beyond the 1st year of employment) turnover rates of NRP graduates, 2. examine the long-term career satisfaction of NRP graduates beyond the 1st year of employment, and 3. explore long-term leadership development of NRP graduates beyond the 1st year of employment. Methods Design, Setting, and Sampling A descriptive design was used to address the research aims. All 170 graduates of the NRP still employed at the medical center were asked to participate in the study. These nurses, hired between July 2008 and August 2010, completed the UHC/AACN NRP at a large urban academic medical center in the Midwest. The final sample size was 51 (30.2% usable response rate). The study met all human subjects protection requirements and was approved by the institutional review board. Data were collected anonymously via survey. Data Collection Data were collected by means of e-mailed surveys via a SurveyMonkey link. The instruments included a demographic questionnaire and the McCloskey/Mueller Satisfaction Scale (MMSS). 10 The demographics section asked about employment status, type of shift worked, age, type of nursing program completed, organizational involvement, certification, advanced degree attainment, and leadership role involvement. The MMSS 10 is a multidimensional tool designed to measure nurses satisfaction with their positions and has been used in a variety of clinical settings. 11 The tool is divided into 8 subscales: extrinsic rewards, scheduling satisfaction, family/work balance, coworkers, opportunities for social contacts, professional responsibilities, 418 JONA Vol. 44, No. 7/8 July/August 2014

praise/recognition, and control/responsibility. Respondents rate their satisfaction for each item on a 5-point Likert-type scale ranging from very dissatisfied (1) to very satisfied (5). The alternate scoring method for the tool was used in which the subscale items scores were summed and then divided by the number of items. This allowed for comparison across subscales. Higher scores in 1 area indicated higher satisfaction in that particular area. Bellinger and McCloskey 12 reported a Cronbach s " of.89 for the entire instrument and a testretest reliability of.79. Mueller and McCloskey 10 reported sufficient acceptable criterion-related and construct validity. The total instrument reliability for this study was 0.94. Rosters of nurse residency cohorts were compared with medical center employee listings to determine long-term turnover. The listings were sorted by employee identification number. The records did not contain any confidential data. Data Analysis Frequencies and descriptive statistics were used to describe the data. Given the small sample size for each group, nonparametric Kruskal-Wallis tests were used to examine group differences by the MMSS outcome variables. Association between the NRP groups and all nominal variables was assessed using the 2 2 statistic. An " of.05 was used for all statistical tests. Results Description of Sample Descriptive data are summarized in Table 1. Participants were grouped according to fiscal year (FY) of NRP graduation: FY2010 (n = 23), FY2011 (n = 18), and FY2012 (n = 10). There were no statistically significant demographic differences between the 3 groups. Participants held either a BSN or MSN; the majority of these completed their nursing education as a 2nd-degree student. Most of the participants were younger than 30 years, were female, and worked primarily on either medical-surgical units, mother-child units, or critical care units. There was a trend toward transferring units in the medical center as time from graduation increased, although this was not statistically significant (P =.134). By group, none of FY2012 had transferred versus 26.1%(n=6)inFY2010and11.1%(n=2)inFY2011. The transfers in the FY2010 were from medical-surgical to mother-child or outpatient units. The most important reasons identified for transfer included type of patients on the unit, scheduling issues, and unit management. Ninety-eight percent of participants worked full time, and the majority of participants worked 12-hour shifts. In the FY2010, 78.3% (n = 18) worked days versus 38.9% (n = 7) in FY2011 and 30% (n = 3) in FY2012. The majority of FY2011 participants worked nights (50%, n = 9) compared with FY2012 where equal numbers of day-shift and night-shift nurses were represented. Turnover Rates Turnover rate was captured by dividing the number of nurse residents who left the program by the total number of nurse residents at program start. This program lost only 5.6% of its residents during the yearlong program (11 of 197 residents). Of those who remained after residency completion, 16 nurses left the organization, Table 1. Demographic Data Characteristics FY2010, n (%) (n = 23) FY2011, n (%) (n = 18) FY2012, n (%) (n = 10) P Current unit type Medical surgical 8 (34.8) 4 (22.2) 3 (30) Critical care 7 (30.7) 5 (27.8) 4 (40) Mother and children 3 (13) 6 (33.3) 2 (20) Psychiatric 1 (4.3) 1 (5.6) 0 (0) Geriatric 2 (8.7) 1 (5.6) 0 (0).734 Operating room 0 (0) 1 (5.6) 1 (10) Outpatient 2 (8.7) 0 (0) 0 (0) Transferred units 6 (26.1) 2 (11.1) 0 (0).134 Shift type Full time 22 (95.7) 18 (100) 10 (100) Part time 1 (4.3) 0 (0) 0 (0).537 Age, y 20-29 16 (69.6) 17 (94.4) 8 (80) 30-39 6 (26.1) 1 (5.6) 2 (20).349 Q40 1 (4.3) 0 (0) 0 (0) Nursing school program type 1st Degree 11 (47.8) 13 (72.2) 6 (60) 2nd Degree 12 (52.1) 5 (27.8) 4 (40).288 JONA Vol. 44, No. 7/8 July/August 2014 419

Table 2. Turnover Rate FY2010 FY2011 FY2012 Theta 1 a Theta 1A b Theta 2 Theta 3 Theta 4 Theta 5 Theta 6 Total No. at T1 c 43 19 41 34 26 15 19 197 No. at T2 d 42 18 40 33 26 11 16 186 Turnover at T2, % 2.3 5.3 2.4 2.9 0 26.7 15.8 5.6 No. at T3 e 37 15 34 32 25 11 16 170 Turnover at T3, % 14 21.1 17.1 5.9 3.8 26.7 15.8 13.7 16.5 9.3 15.8 Time since hire at RUMC at T3, mo 39 36 31 28 24 21 16 a UHC/AACN assigned a Greek letter of the alphabet to each NRP cohort launched. Theta indicates the medical center was part of the eighth launch of NRPs (eta was skipped). The number of the theta group, theta 1, for example, denotes the chronological order of the NRP group at this medical center. b Theta 1A was created because of issues associated to the death of the first NRP coordinator and a large influx of NLRNs. c T1 refers to the NRP start date. d T2 refers to the NRP end date. e T3 refers to date of the study data collection. which represents a postresidency turnover rate of 8.5% (16 of 186 remaining residents). When examining the long-term turnover rate for all groups combined over the period of the study, the turnover rate for all 7 graduated cohorts was 13.7 (27 of 197 residents). These data are summarized in Table 2. Career Satisfaction Data collected using the MMSS tool are displayed in Table 3. Both mean and median scores are reported because the data were not evenly distributed. The subscale with the highest satisfaction was coworkers. The family-work balance subscale had the lowest scores across all groups. The only statistically significant difference between the groups was found in the scheduling satisfaction subscale (P =.027). Participants in FY2010 were more satisfied with their scheduling opportunities than those in the other 2 groups. The MMSS subscale scores were generally high, with all medians greater than 3 (scale, 1-5). Scores across all subscales, with the exception of praise and control, tended to increase with time after graduation from the NRP. These, however, were not statistically different (Table 3). Indicators of Leadership Development Professional development was assessed by examining involvement in certain activities and job advancements. The items assessed included involvement in a hospital committee and/or a professional organization, certification status, opportunity to act as charge Table 3. Satisfaction Scores: MMSS Data Median (25th, 75th), Mean (SD) MMSS Components FY2010 FY2011 FY2012 P Extrinsic rewards 4 (3.67, 4) 3.67 (3.33, 4.0) 3.67 (3.33, 4.33).503 Scheduling satisfaction 3.78 (.49) 3.63 (0.66) 3.77 (0.47) 3.83 (3.67, 4) 3.75 (2.79, 2.04) 3.25 (3.13, 3.67).027 Family-work balance 3.78 (0.47) 3.36 (1.03) 3.27 (0.47) 3 (3, 3.3) 3 (3,3) 3 (2.17, 3).068 Coworkers 3.06 (0.33) 2.96 (0.22) 2.6 (0.63) 4.5 (4, 4.5) 4.5 (3.87, 4.5) 4.5 (4, 4.63).860 Interactions 4.24 (0.64) 4.22 (0.69) 4.4 (0.46) 4 (3.5, 4.5) 4 (3.5, 4.25) 3.63 (3.44, 4).627 Professional opportunities 3.97 (0.64) 3.89 (0.46) 3.78 (0.52) 3.25 (3.25, 3.27) 3.25 (3.25, 3.5) 3.13 (2.75, 3.5).388 Praise and recognition 3.37 (0.43) 3.31 (0.33) 3.18 (0.41) 3.25 (2.75, 4.5) 3.5 (2.5, 4.25) 3.13 (2.69, 4).766 Control and responsibility 3.5 (1.06) 3.36 (1.05) 3.3 (0.82) 3.9 (2.8, 4.2) 3.6 (2.8, 3.85) 3.3 (3, 3.8).709 2.47 (0.82) 3.35 (0.76) 3.38 (0.39) 420 JONA Vol. 44, No. 7/8 July/August 2014

nurse, location on the clinical ladder, opportunity to act as a preceptor, pursuance of an advanced nursing degree, and community involvement. When the 3 NRP groups were compared, the only statistically significant difference was in the opportunity to act as charge nurse (P =.016). The more experience they had, the more likely they were to be placed in charge (Table 4). Hospital Committee Involvement Involvement in a hospital committee was highest among the FY2012 participants and became less with succeeding cohorts. The Unit Advisory Committee (unitbased shared governance) was the most common hospital committee identified for each group. Of those in the FY2010, fewer were involved in more than 1 committee, compared with successive groups. Certification Status Residents pursuing certification increased as more time elapsed. The highest number certified was in the FY2010 group. Only 5.6% (n = 1) of residents from the FY2011 group had obtained certification, and none from the most current group (FY2012) was certified. Of those residents not certified in the FY2010 group, 83.3% (n = 15) plan on becoming certified. In the FY2011 group, 64.1% (n = 16) plan on getting certification, and all or 100% (n = 10) of the 2012 group plan on it. Pursuit of an Advanced Degree The number of residents pursuing an advanced degree increased with time. The majority of those planning to pursue advanced degrees were in the FY2010 group, whereas the minority was in the FY2012 group. In the FY2010 group, 52.2% (n = 12) were pursuing advanced degrees. In the FY2011 group, 27.8% (n = 5) were pursuing advanced degrees, whereas only 20% (n = 2) of the FY2012 group were pursuing an advanced degree. Of those not currently in school, 27.3% (n = 3) from FY2010, 30.8% (n = 4) from FY2011, and 50% (n = 4) from FY2012 were actively preparing to go back for an advanced degree. Discussion NRPs are designed to retain nurses for the critical period of 1 year after hire. Similar to other studies, we found the turnover rate of residents after the yearlong UHC/AACN residency to be much lower than the current national average for all RNs of 14.7%. 13 We examined turnover rates from approximately 1.5 to 3 years after graduation from the NRP. As time extends past the yearlong residency program, more nurses leave the organization. At RUMC, the cost to replace 1 nurse was calculated to be $70,200. 14 With only 5.6% of RUMC residents lost during the yearlong program (11 of 197), the cost savings for the hospital was substantial at $13,057,200 (186 $70,200). The greatest source of job satisfaction was the people the NRP graduates worked with on the unit. Coworker/peer support seems to be a major component of nurses job satisfaction. Previously published nursing literature supports the notion that peer support is an indication of job satisfaction. 15 All 3 groups in this study also indicated that they were highly satisfied with professional opportunities and praise and recognition, although no statistically significant differences were noted. In looking at the subscale scheduling satisfaction, it was found that FY2010 was more satisfied than FY2011 and FY2012. These nurses have more seniority than their less experienced coworkers andperhapsarebetterabletosecurethemoredesirable shifts. Regarding leadership development, although no significant differences were found, the trend was an increase in professional involvement as time elapsed since graduation for the following components: member of a professional organization, certification status, pursuing an advanced degree, progressing up the clinical ladder, opportunity to act as preceptor, and community involvement. One area in which this was not true was involvement in hospital committees. Residents of more recent NRP groups were more involved in hospital committees than residents who had completed Table 4. Professional Development FY2010 FY2011 FY2012 No. % No. % No. % P Committee involvement 14 60.9 8 44.4 8 80.180 Member of professional organization 14 60.9 11 61.1 5 50.819 Certified 5 21.7 1 5.6 0 0.122 Pursing advanced degree 12 52.2 5 27.8 2 20.125 Acted as charge nurse 23 100 4 22.2 4 40.016 RN III 1 4.3 0 0 0 0 Acted as preceptor 14 60.9 9 50 5 50.740 Active in community 5 21.7 3 16.7 1 10.705 JONA Vol. 44, No. 7/8 July/August 2014 421

the NRP 2 years prior. This is counterintuitive because one would expect that residents employed the longest amount of time would be more representative on hospital committees. This finding may reflect a combination of factors (returning to school, family/personal life) that take time away from committee involvement possibilities. The 1 activity that was significantly different among the groups was the opportunity to be charge nurse. This is consistent with the prevailing belief that serving as a charge nurse requires both leadership and management skills and the respect of one s peers. Thus, being a charge nurse is clearly a demonstration of one s ability to lead others. Furthermore, it is a mark of professional maturity, hence the trend that later NRP graduates are more often placed in charge of the unit. Limitations The small sample size was a limiting factor; the survey rate, 30.2%, was respectable. Furthermore, although all potential nurse residents were asked to participate, participation was voluntary. Thus, a selection bias may be present. One possible explanation for the low response rate might involve e-mail fatigue experienced by bedside clinicians. It is possible that the nurses either did not have the time or perhaps did not take the time to open and carefully read each message and would not have known about the study. Another limitation was locating nurse residents once they graduated from the yearlong program. After being employed for a few years, a portion of the residents got married with subsequent name changes and/or left the organization temporarily for maternity leave. The human resources department was unable to assist with clear identification. Implications and Conclusions Even though our overall retention rate was lower than the national average, there was a rise in the turnover rate at the 2.5- to 3-year mark. Further investigation needs to be done to determine the cause of this, but the implication is that nursing leadership should be aware that an additional intervention may be necessary to ensure longer-term retention. Data suggest that an environment that fosters continued professional development and organizational engagement tends to encourage retention of NLRNs after NRP graduation. Furthermore, encouraging additional professional development is likely to enhance the quality and safety of the practice environment. Peer support is clearly an important factor in job satisfaction. Thus, nursing leaders should assess their organizations to determine the level and efficacy of their nurses peer relationships. While the results of this pilot study provide insight into the long-term outcomes of an NRP, we recommend replication of this study at other, similar academic medical institutions to validate these results. 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