From American Nurse Today

Tripping Over the Welcome Mat

Why New Nurses Don't Stay and What the Evidence Says We Can Do About It

Renee Twibell, PhD, RN, CNE; Jeanne St. Pierre, MN, RN, GCNS-BC; Doreen Johnson, MA, RN, FACHE, NEA-BC; Deb Barton, BS, RN; Christine Davis, BS, RN, CDE; Michelle Kidd, MS, RN, ACNS-BC, CCRN; Gwendolyn Rook, BS, RN

Abstract and Introduction

Introduction

In a recently conducted survey regarding newly graduated nurses' readiness to practice in the hospital setting, only 10% of nurse executives believed that new graduate nurses (NGNs) were fully prepared to practice safely and effectively. NGNs agreed with nurse executives that they lack confidence and adequate skills for up to a year after graduation. The perceptions of nurse executives and NGNs seem to be borne out by NGN turnover rates of roughly 30% in the first year of practice and as much as 57% in the second year. At a cost of $82,000 or more per nurse, NGN attrition is costly in economic and professional terms—and can negatively impact patient-care quality.
While the current economic downturn in the United States has reduced nurse turnover, the looming retirement of Baby Boomer nurses will leave a shortfall of 260,000 nurses by 2025. Thus, hospitals continue to seek best practices for retaining NGNs and easing the transition into practice. A quick check of the evidence reveals some contributing factors to NGN turnover and highlights effective retention strategies.

Why New Nurses Leave

New nurses report that low job satisfaction is primarily related to heavy workloads and an inability to ensure patient safety. In addition, new nurses express disillusionment about scheduling, lack of autonomous practice, and the lack of intrinsic and extrinsic workplace rewards. Lastly, new nurses report dissatisfying relationships with peers, managers, and interprofessional colleagues and insufficient time with patients. Discontent peaks between 4 and 6 months and again near the end of the second year. Low salaries can contribute to a weak commitment to stay in a job but are less important if the work is rewarding, staffing is adequate, and scheduling is satisfactory. Men are twice as likely as women to leave a nursing position for higher pay.

Starting off on the Right Foot

Retention begins with hiring the right NGN. The hiring process can focus on assessing new nurses' values and attitudes and how they fit with the organization. Skills can be taught, while attitudes, values, and general behavior patterns are much more difficult, if not impossible, to change.
Two effective strategies to ensure a good fit between a new nurse and a work unit are prehire job shadowing and behavior-based interviews by both peers and managers. When new nurses job shadow on a unit, they can evaluate workload, role expectations, and cultural norms. Based on the principle that past behavior is the best predictor of future behavior, behavior-based interviewing allows managers and peers to assess communication and relational skills through exemplars the candidate shares. During the peer interview, NGNs can gain insight into potential coworkers to estimate an ability to fit in. When unit nurses help select NGNs, they have a greater interest in retaining them and engage more fully in the on-boarding process.

Smoothing the Way

Research evidence strongly supports nurse residency programs as a key strategy to retain NGNs. The Institute of Medicine, National Council of State Boards of Nursing, and Commission on Collegiate Nursing Education all advocate for nurse residency programs. Retention rates of NGNs in residency programs range from 88% to 96%. For example, in a prospective study of 111 NGNs from six academic centers across the United States, a 1-year residency program positively impacted job satisfaction, with a retention rate of 87%. Likewise, a residency program involving 679 NGNs at 12 sites across the United States showed reductions in stress for NGNs, improved clinical and communication skills, and a 1-year termination rate of 12%.
Residencies are longer than traditional orientation programs, ranging from 6 to 12 months. Residencies promote strong connections with workplace colleagues and support job embeddedness (a close fit between the nurse's new position and other aspects of the nurse's life).
Key evidence-based elements of residency programs include:

clinical coaching by a preceptor matched for compatibility with the NGN
preceptors and NGNs on the same schedules as much as possible.
evidence-based classroom curriculum with case studies and direct linkage to clinical experiences
hands-on learning of skills in a clinical setting or simulations
time spent in areas outside the NGN's home unit to understand overall system issues
participation in a support group of NGN peers
high visibility of nurse leaders
professional socialization and opportunities for development.

A frequently cited barrier to residency programs is the cost in nurses' time. Yet the cost of not retaining one NGN can fund a large portion of a residency program. One hospital reported saving over $2.7 million in three years following the initiation of a nurse residency program. If a residency program isn't feasible, hospitals can capture many elements of the residencies in a well-designed, traditional orientation.

Forming a Team

Evidence indicates that preceptors are vital support persons when NGNs enter the workplace, both in residencies and traditional orientation programs. The preceptor is the first nurse who intensely invests in the NGN, planning patient assignments on a daily basis, nurturing confidence and competence, and overseeing the development of skills and clinical judgment. Preceptors socialize NGNs into new roles, unit processes, and workplace norms. The preceptor and NGN may work together for a variable length of time from weeks to months.
Mentoring programs also improve NGN retention. Mentors differ from preceptors in that mentors invest in NGNs for years, rather than weeks or months. Some mentoring programs do not begin until the residency or orientation ends to avoid overlap between mentors and preceptors. Mentors provide professional development advice and serve as consultants for complex cases and workplace issues.
Research suggests that preceptors and mentors not only should be experienced clinicians but should have skilled communication, relational abilities, and a positive attitude toward nursing and the organization. NGNs report high anxiety in the first weeks of employment; preceptors who consistently convey caring behaviors can reduce anxiety for NGNs and facilitate learning. Some studies suggest increased NGN satisfaction when NGNs choose their own preceptors and mentors.
Both preceptors and peers can encourage nurses to stay. (See What you can do in the sidebar.)

Creating a Welcoming Work Environment

Job satisfaction for NGNs is heavily influenced by workplace culture. The American Association of Critical-Care Nurses calls for the advancement of healthy work environments, which can promote nurse retention through teamwork, meaningful recognition, collaboration, skilled communication, authentic relationships with leaders, and adequate staffing. NGNs can experience a sense of acceptance and safety on units where trust is intentionally built. On a healthy unit, gossip and humiliation of employees constitute workplace maltreatment and are as serious as errors in patient care. Respectful collegial relationships modeled by all staff help the newest nurse feel safe and able to admit shortcomings.
Healthy work cultures encourage new nurses to practice good self-care, such as taking breaks away from the bedside, limiting overtime hours, and achieving life-work balance. NGNs can experience burnout when they do not feel competent to care for patients safely, especially if the NGN is experiencing other life stress outside of the workplace. Strategies to address compassion fatigue can be implemented in a timely manner and may include debriefing after difficult shifts, team-building events, celebration of meaningful work, and rotating difficult patient assignments. Peers, managers, or a counseling center can provide emotional support when NGNs experience moral distress or the recurring painful memories of high-impact events, known as secondary trauma. NGNs need encouragement when they make errors, since errors may shame and weaken one's confidence and sense of belonging. NGNs may withdraw from relationships, call in sick, or begin to think about terminating their job. A manager, preceptor, or any nurse peer can reach out to express acceptance and understanding.
Nurse-physician rounding on patients not only improves patient-care outcomes but allows new nurses to build relationships with physician partners. Nurse-physician relationships are a key component to nurses' job satisfaction and perceived competence. A zero-tolerance policy regarding uncivil actions or words among professionals is particularly important for a healthy work environment.

Using Simulated Learning for New Nurses

Simulation laboratories are another way to support NGNs' transition into practice. Simulations can bridge the gap between knowledge already gained in academic curricula and skills needed to care for multiple, complex patients. Simulations allow a wide range of clinical scenarios to be analyzed in the safety of a lab where patients cannot be harmed. Simulations can be via high-tech, robotic dummies that display real-life physiological symptoms or via live persons from nearby communities who have medical conditions and are willing to role play and be assessed by NGNs in a laboratory setting. While simulation labs can be costly to start up if advanced technology is desired, grants may be available. Multiple facilities can share labs or partner with academic centers that have labs.

Becoming an Owner

A professional development program such as a clinical ladder can give NGNs a way to objectively confirm their abilities and worth. Furthermore, after initial job anxiety eases, NGNs can be encouraged to pursue new professional roles on unit councils and work groups. Being part of process improvement teams and collaborative interprofessional work groups helps the new nurse develop communication skills and a system-level perspective. When new nurses believe they have influence and are empowered, they feel more engaged in work and more committed to the organization. Organizations that value autonomous nursing and empower nurses to shape and own their practices have higher nurse retention.

Providing Support

Nurse managers and senior administrators play a pivotal role in new nurse retention, beginning on the first day of orientation. Administrators can welcome new nurses by name and begin fostering a warm relationship. Early in the orientation, administrators can outline the mission, vision, values, and strategic direction of the organization, making it clear to all new staff the vital role they play in achieving excellence in care.
During residencies or traditional orientations, staff development personnel can make frequent contact with NGNs and schedule structured interviews at 30, 60, and 90 days and at 6 months. The interviews provide opportunities for individualized feedback and identification of nurses at risk for terminating. Feedback from NGNs can be solicited and incorporated into the design of future orientation and residency programs.
Managers can commit to rounding on NGNs each week to ensure new employees have the tools, equipment, and support they need. Senior administrators can schedule follow-up meetings with new nurses at predetermined times, such as 60 days and 6 months after beginning work. The administrator can seek feedback for program improvement and explore the fit between what NGNs expected and what they are experiencing. If a reported problem can be addressed, act quickly and let the NGN know the resolution.
Administrators can ask NGNs to recognize individuals who have been an instrumental, positive influence in their orientation. The administrator can write thank-you notes or thank these role models face to face for their positive impact on the on-boarding of the newest staff members. This culture of gratitude and recognition can encourage peers and preceptors that their contribution to the NGNs' transition is valued.
Organizational leaders can arrange for formal and informal support groups for NGNs in which they can meet with other NGNs and share experiences. Conversation with peers who understand the transition can bring new insight, reduce isolation, and build a sense of community.

Feeling Like Home

In environments where NGNs move smoothly across the threshold into practice, nurses at all levels of the organization accept responsibility for job retention. Ideally, nurses know the retention rates on their unit and have retention plans in place based on local data and feedback from recently hired nurses. Nurses know the evidence-based strategies, including residency programs, strong preceptor and mentor support, a healthy work environment, simulations, visible leadership, and trusting relationships with peers.
New nurses start to feel at home and committed to stay in an organization when they are empowered in practice, have a sense of belonging in a work group, and perceive that resources balance job stress. Before long, NGNs who commit to stay become the peer group for the next wave of new nurses, smoothing out wrinkles in the welcome mat and opening wide the door to a successful professional transition.

Sidebar

What You Can Do

Arrange time away from the patient to review clinical judgments and decisions.
Offer emotional support, especially during highly stressful times (errors, angry patients, shame from colleagues).
Shape expectations for workload and scheduling.
Introduce new nurses to key personnel and "manage up" the new nurse.
Socialize informally and build caring relationships.
Monitor the NGN for compassion fatigue and strategize for work-life balance.
Be alert to how generational differences may influence work attitudes and relationships.
Share your stories and lessons learned to shape clinical judgment.

[ CLOSE WINDOW ]

References

American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. Aliso Viejo, CA: 2005. http://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf. Accessed May 17, 2012.
Benner P, Stephen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass; 2010.
Berkow S, Virkstis K, Stewart J, Conway L. Assessing new graduate nurse performance. J Nurs Adm. 2008;38(11):468–474.
Bratt MM. Retaining the next generation of nurses: the Wisconsin nurse residency program provides a continuum of support. J Contin Educ Nurs. 2009;40(9):416–425.
Brewer CS, Kovner CT, Greene W, Cheng Y. Predictors of RNs intent to work and work decisions 1 year later in U.S. national sample. Int J Nurs Stud. 2009;46:940–956.
Buerhaus P. The shape of the recovery: economic implications for the nursing workforce. Nurs Econ. 2009;27(5):338–340, 336.
Coomber B, Barriball KL. Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature. Int J Nurs Stud. 2007;44(2):297–314.
Eaton-Spiva L, Buitrago P, Trotter L, Macy A, Lariscy M, Johnson D. Assessing and redesigning the nursing practice environment. J Nurs Adm. 2010;40(1):36–42.
Halfer D. Job embeddedness factors and retention of nurses with 1 to 3 years of experience. J Contin Educ Nurs. 2011;42(10):468–476.
Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx. Accessed May 17, 2012.
Jones CB. Revisiting nurse turnover costs: adjusting for inflation. J Nurs Adm. 2008; 38(1):11–18.
Kovner C, Brewer C, Greene W, Fairchild S. Understanding new registered nurses' intent to stay at their jobs. Nurs Econ. 2009;27(2):81–98.
Kramer M, Maguire P, Halfner D, al. The organizational transformative power of nurse residency programs. Nurs Adm Q. 2012:36(2):155–68.
Myers S, Reidy P, French B, McHale J, Chisholm M, Griffin M. Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. J Contin Educ Nurs. 2010;41(4):163–171.
Pellico LH, Brewer CS, Kovner CT. What newly licensed registered nurses have to say about their first experiences. Nurs Outlook. 2009;57(4):194–203.
Ulrich B, Krozek C, Early S, Ashlock CH, Africa LM, Carman ML. Improving retention, confidence, and competence of graduate nurses: results from a 10-year longitudinal database. Nurs Econ. 2010;28(6):363–375.
Williams CA, Goode CJ, Krsek C, Bednash GD, Lynn MR. Postbaccalaureate nurse residency 1-year outcomes. J Nurs Adm. 2007;37(7/8):357–365.

-->

Wednesday, August 1, 2012