Nurturing Future Nursing Leaders:

Strategies for Improved Transition and Retention of New Graduate

Nurses

Cherry Pie de Veyra RN, BSNc

NURS 558San Francisco State University

Dr. Mercy Popoola

Issue of Nursing Retention

Approximately 30% and up to 50% of new graduate nurses will quit within the first year of employment.(Hillman & Foster, 2011)

High staff turnover is expensive – costs anywhere from $22,000 to over $64,000 per nurse. (Finkelman, 2012, p.285)

Problematic Cycle of High Turnover or Poor Retention

Turnover/

Retention

Staffing Shortage

Increased Workload

Excessive Overtime

Stress Burn Out

$$$, disrupts work teams productivity

Experienced RNs may compromise patient safety

The Crucial Two Years

The first two years…Phase 1

Anticipatory Socialization Pre-work experience

O Education: BSN vs. ADNO Other experiences r/t age, race,sex, marital status and personality

All of these determine the expectations nursing

students may have about life after graduation.

realistic expectationsvs.

unrealistic expectations reality shock

The first two years…Phase 2

Organizational Socialization Actual work experience

O Orientation – The amount of time and depth of training greatly impacts the new graduate’s perception of work stress and satisfaction.

O Working conditions and environment• Stress level r/t work demands• Relationship with supervisors and other

staff

The first two years…Phase 3

Socialization OutcomesPositive work experience

✚Effective

orientation/transition program

________________Work satisfaction

and retention

Conflict in the work environment

✚Inadequate transition

program/period✚

Unrealistic expectations of

nursing role________________

Dissatisfaction and Turnover rates

Patricia Benner’sFrom Novice to Expert

Novice

Advanced Beginner

Competent

ProficientExpert

A nursing student or any nurse transitioning to a new specialty

A nurse who has some experience, including mere observation

A nurse in the same setting for 2-3 years; able to anticipate & plan long-term goals for specific patient population

A nurse in the same setting for more than 2-3 years; able to understand situations as a whole and makes decisions based on previous experiences

A nurse with intuitive understanding of clinical situations; able to anticipate potential problems; can be a mentor to other nurses

(Potter & Perry, 2009, p.9)

Role Transition

O Survey of 270 graduate nurses working in 6 acute care hospitals in metropolitan area of Denver, Colorado in 1999.O Data collected at specific intervals: at

baseline, after 3, 6 and 12 months, additional follow-up for groups employed >1 year.

O Survey included open-ended questions asking nurses to identify any difficulties during their role transition from student to staff nurse

(Casey, Fink, Krugman, & Propst, 2004)

Factors Affecting Role TransitionO Lack of confidence

• anxiety, insecurity & feeling incompetent during the 1st year of employment

• Difficulty with making critical decisions about patient care, setting priorities and time management

O Tension among peers & preceptors• New nurses did not feel welcomed

& respected by experienced nurses

• Some preceptors were less patient and sympathetic – They forgot how it was like to be

the inexperienced nurse.

Factors Affecting Role TransitionO Struggle with dependence & independence

• Lack of a guiding figure or mentor r/t absence of consistent preceptors during orientation period

• Others were overwhelmed with responsibilities yet were uncomfortable delegating work to unlicensed personnel.

• Others felt “babied” which hindered their ability to grow & develop professionally.

O Stressful work environment• nurse-to-patient ratio r/t shortage• A few of the new nurses had to assume the role of

charge nurse or preceptor after only 9 months of experience and training stress r/t responsibility

Strategies to Improve Role Transition –

Evidenced-Based Residency program

Changes Implemented:O 5 day orientation changed

to 22 weeks (later reduced to 16 weeks in 2008) residency program

O Content experts (e.g., advanced practice nurses, respiratory therapists) lectured about the specific conditions & diseases of the pediatric population

O Mandatory preceptor workshops for both novice & advanced preceptors

O Annual recognition program for preceptors to recognize their contributions and commitment in mentoring new nurses

(Hillman & Foster, 2011)

Implemented in 2004 by the Magnet-designated Children’s

Hospital of Michigan in Detroit

BEFORE: 1-year retention rate

of newly hired RNs was 50-70%;

2-year retention rate was 40-63%AFTER: 1-year was as high as

100%; 182 of 251 new graduate

nurses, who completed the program from June 2005 to October 2009, still employed

Strategies to Improve Role Transition – Collegial Clinical Model for Orientation (CCM)

Stages of ZPD:O Stage 1: Assisted

performance – learning occurs with the support & assistance of a more experience peer or the instructor

O Stage 2: Self-directed – instructor’s support decreases & eventually ceases while the learner assumes more responsibility

O Stage 3: Assistance is no longer needed as learning has been internalized; occurs at the end of the orientation period

(Salera-Vieira, 2009)

Implemented in the Women and Infants’ Hospital in Providence, Rhode Island

CCM is the same format used

in nursing programs – one clinical instructor for several students in a clinical setting

Learning Theory used is Lev Vygotsky’s sociocultural development theory, which uses the concept known as zone of proximal development (ZPD)

What can Nurse Leaders do?

Nurse leaders can help address the issues of nursing shortage and staff retention by supporting new graduate nurses by:

O Advocating for transition or residency programs to competency, confidence & satisfaction of new RNs

O Maintaining a healthy working environment Not using novice RNs to cover for staffing shortage

before the end of orientation period Zero tolerance for lateral violence or bullying

O Supporting experienced RNs who are serving as preceptors and mentors for novice RNs

Shaping our Future Nurse Leaders

O New graduate nurses are the future employee pool

O Job satisfaction & retention are greatly influenced by the quality of orientation and support received by the new graduate nurse.

O A positive experience will encourage the now proficient nurse to mentor novice nurses & give them the same positive experience he/she had during the transition period.

The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires. - William Arthur Ward

ReferencesCasey, K., Fink, R., Krugman, M., & Propst, J. (2004). The graduate nurse

experience. Journal of Nursing Administration, 34(6), 303-311.Finkelman, A. W. (2012). Leadership and management for nurses: core

competencies for quality care (2nd ed.). Boston: Pearson.Green, C. (2012). Nursing intuition: a valid form of knowledge. Nursing

Philosophy, 13(2), 98-111. http://0-onlinelibrary.wiley.com.opac.sfsu.edu/doi/10.1111/j.1466-769X.2011.00507.x/full

Hillman, L., & Foster, R. R. (2011). The impact of a nursing transitions programme on retention and cost savings. Journal of Nursing Management, 19, 50-56.

Potter, P. A., & Perry, A. G. (2009). Fundamentals of nursing (7th ed.). St. Louis, Mo.: Mosby Elsevier.

Salera-Vieira, J. (2009). The collegial clinical model for orientation of new graduate nurses: a strategy to improve the transition from student nurse to professional nurse. Journal for Nurses in Staff Development, 25(4), 174-181. doi: 10.1097/NND.0b013e3181b1d146

Scott, E. S., Engelke, M. K., & Swanson, M. (2008). New graduate nurse transitioning: Necessary or nice?. Applied Nursing Research, 21, 75-83. http://0-dx.doi.org.opac.sfsu.edu/10.1016/j.apnr.2006.12.002