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Running head: DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

Does New Nurse Transition Programs Increase Retention Compared to Standard Orientation
Melinda L. Swander
University of Central Florida

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

Abstract
One of the barriers identified for new nurse graduates is their successful transition into the
clinical setting. New nurses are often overwhelmed by the ever changing health care system that
demands decrease length in stay, higher acuities, and copious amounts of electronic
documentation. These challenges are contributing factors to the increasing turnover rates that
continue to escalate. Another factor influencing turnover is the variability of orientation received
from facility to facility and unit to unit. It is stated throughout the literature that orientation must
extend beyond traditional orientation and provide new nurses with sufficient knowledge and
skills through competencies. A review of the literature was conducted using a variety of
database with multiple search terms. Each study was reviewed to ensure they met the inclusion
criteria defined. This resulted in the use of eight articles that presented two themes: nurse
retention and cost savings. The Quelly tool was used to evaluate the quality and validity of each
study. Findings revealed that the implementation of a nurse transition program can help to
improve nurse retention, decrease turnover, and provide a cost savings to the facility.

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

Table of Contents
Significance and Background .........................................................................................................4
Research Question ..........................................................................................................................5
Methods............................................................................................................................................5
Search Terms and Definitions ..............................................................................................6
Inclusion/Exclusion Criteria ................................................................................................6
Validity of Findings .............................................................................................................7
Coding/Themes ....................................................................................................................7
Increase in nurse retention .......................................................................................7
Cost savings .............................................................................................................7
Findings............................................................................................................................................7
Recommendations ............................................................................................................................8
Conclusion .......................................................................................................................................9
References ......................................................................................................................................10
Appendix A ....................................................................................................................................12

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

Does New Nurse Transition Programs Increase Retention Compared to Standard Orientation
As new graduate nurses are transitioned into the clinical setting they are faced with many
challenges in the inpatient setting from complex electronic documentation requirements,
demands for decrease in hospital length of stays, higher acuities, and reality shock (Trepanier,
Early, Ulrich & Cherry, 2012). According to Crow & Hartman (2005), as cited by Dyess &
Parker (2012), the shortage of nurses is increasing and is projected to increase as much as 20%
by the year 2020. New graduate turnover rates reported in 2014 have been documented to reach
40-60% (Harrison & Ledbetter, 2014). The retention rates of experienced nurses are much
higher when compared to the newly graduated nurses (Setter, Walker, Connelly, & Peterman,
2011). According to Beecroft, Kunzman, & Krozek (2002), as cited by Bratt (2009), the cost of
new nurse turnover within the first year of employment is equivalent to a nurses salary for a
whole year.
Significance and Background
In 2010, The Robert Wood Johnson Foundation and the Institute of Medicine produced
the Future of Nursing: Leading Change, Advancing Health that recommend the implementation
of nurse residency programs to facilitate and support new nurses transition into clinical practice
(Friedman, Delaney, Schmidt, Quinn, & Macyk, 2013). Throughout the literature it can clearly
be concluded that a nurses orientation must extend beyond basic orientation to fill the gap
between education and practice (Dyess & Parker, 2012). The knowledge base and skill level of
each new graduate can greatly be influenced by their prior experience, the school they attended,
and cannot be assumed that every new nurse graduate is equally prepared (Hillman & Foster,
2011). The goal of a nurse residency or transition program is to adequately prepare newly

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

graduated nurses to provide safe and quality care to the patients in the clinical setting (Park &
Jones, 2010).
The Quality and Safety Education for Nurses (QSEN) proposes that competencies are
incorporated into orientation and include: interdisciplinary communication, disease-specific care,
and safety (Dyess & Parker, 2012). Berkow, as cited in Trepanier et al. (2012), concluded that as
much as 10% of nurse leaders believed that graduate nurses were competent in the skills required
to provide quality care. Having a sufficient amount of time to onboard new nurses, with a
standardization of competencies, and a systematic way of evaluation, will facilitate giving the
patients skilled nursing care (Fiedler, Read, Lane, Hicks & Jegier, 2014).
Standard orientation varies significantly from one nursing unit to the next. While some
units have an all inclusive orientation, others lack structure and a defined focus (Hillman &
Foster, 2011). These inconsistencies within the same facility can leave the new graduate
frustrated and ready to leave the organization. Institutes that prioritized orientation, focused on
new nurses, and gave them adequate support, reduced the turnover by as much as 17%
(Friedman et. al, 2013).
Research Question
In graduate nurses, does the implementation of a nurse transition program compared to
standard orientation on the unit have a greater increase on nurse retention rates?
Methods
A review of the literature was conducted to compare retention rates with a standard
orientation compared to those that initiated a nurse transition program. The following databases
were utilized to conduct the literature search: One-Search, Cumulative Index to Nursing and
Allied Health Literature (CINAHL), Cochrane Database of Systematic Review, and PubMed.

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

Search Terms and Definitions


Key search terms included: Graduate nurse, nurse residency, preceptor program,
retention, employee retention, orientation program, residency program, turnover, standard
orientation, nurse retention, traditional orientation, and transition program.
The definition of a nurse transition program included any orientation program exceeding
a three month time period that consisted of a designated support person, peer networking, and
knowledge and skill reinforcement. The definition of standard orientation was generally
understood throughout the literature as the comparison prior to implementation of a structured
program and did not have other components that were listed in the nurse transition program. A
new graduate is defined as a newly licensed registered nurse within the first twelve months of
their first employment.
Inclusion/Exclusion Criteria
The inclusion criteria for the search included articles written between 2010 to present that
were written in the English Language and compared retention rates of standard orientation to
retention rates post implementation of a nurse transition program.
Exclusion criteria for the search included articles that did not specifically reveal their
retention rates prior to implementation of a nurse transition program, did not clearly define
components of the nurse transition program, studies written in non-English languages, and
articles only consisting of literature reviews.
Of the 57 studies uncovered during my search, 14 specifically addressed the research
question. However, five out of the 14 initial studies were excluded because they failed to meet
inclusion criteria. This left eight remaining studies that did not have any above listed exclusions
and clearly answered the research question.

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

Validity of Findings
The remaining eight studies were evaluated using the Quelly Tool for determining quality
and validly of findings (2007). A series of 12 criterions were utilized to score the quality and
validity of each study. Each criterion equaled one point toward the maximum score of 12. Level
I, low quality, was given for scores between zero and four. Level II, moderate quality, was
assigned for scores between five and eight. Studies receiving nine to twelve points are
considered to be high quality Level 3 (Quelly, 2007). All of the eight studies score between nine
and twelve and were considered high quality studies. A consistent finding among the evaluated
articles revealed that the sampling size was relatively small and lacked adequate evidence to
support external validity.
Coding/Themes
After reviewing the eight studies, two themes emerged. The first theme was transition
programs yielding an increase in retention rates among graduate nurses. The second theme was
transition programs resulted in cost savings for the organization.
Findings
All of the articles included in the integrated literature review met inclusion criteria and
ranged from Level IV to Level VI according to Melnyk & Fineout-Overholts (2011) Hierarchy
of Evidence. All eight studies compared retention rates post implementation of a nurse transition
program compared to retention rates with standard orientation, prior to implementation. The
length and content of the transition program varied from study to study, but all transition
programs were at least a year or greater. Of the eight studies, the designs included: mixed
method (Dyess 2012; Olson-Sitki 2012), descriptive (Fiedler 2014; Hillman 2011; Setter 2011;
Trepanier 2012; Friedman 2013), and cohort (Berube, 2012). Limitations identified in the

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

studies included limited participant size and undisclosed retention rates prior to the
implementation of the nurse transition program.
All eight studies produced a reduction of turnover rates or an increase in nurse retention
post implementation of the nurse transition program (Berube 2012; Dyess 2012; Fiedler 2014;
Friedman 2013; Hillman 2011; Olson-Sitki 2012; Setter 2011; Trepanier 2012). The highest
retention rate after one year post implementation of a transition program was reported by
Hillman (2011) at 100%. The lowest retention rate after initiating a residency program was 71%
but was still significantly higher then prior to implementation which was 57% (Berube, 2012).
Three of the eight studies reported their finding using the reduction of turnover rates. Turnover
rates ranged from 36.8% to 12% prior to the implementation of a transition program (Fiedler
2014; Olson-Sitki 2012; Trepanier 2012). After execution of the transition program, these same
rates were reduced from 5.6% to 11% in nurse turnover (Fiedler 2014; Olson-Sitki 2012;
Trepanier 2012).
Review of the literature also revealed that five out of the eight studies identified that the
implementation of a nurse transition program lead to a cost savings for the organization (Berube
2012; Fiedler 2014; Friedman 2013; Hillman 2011; Trepanier 2012). All five of these studies
showed a cost savings by the reduction of nurse turnover and varied in amount from facility to
facility based on the annual salary of a nurse (Berube 2012; Fiedler 2014; Friedman 2013;
Hillman 2011; Trepanier 2012). Two studies specifically highlighted their cost savings by
decdreaseing the amount of contracted labor (Berube 2012; Trepainer 2012).
Recommendations
According to the finding from the literature review, there is sufficient support that nurse
transition programs provide superior retention rates compared to standard orientation. Using the

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

Strength of Recommendation Taxonomy (SORT) the strength of this recommendation for the
evidence presented is a B because of the lack of randomized controlled studies to support these
findings.
Implementing a transition program for newly graduated nurses can facilitate the reduction
of nurse turnover rates and increase nurse retention. In addition, the reduction of nurse turnover
and decrease of contracted labor will provide the facility with significant cost savings.
Future research should be conducted to determine retention rates after the first year when
a majority of the transition programs end. Friedman (2013) concludes that more longitudinal
studies are needed to truly understand the impacts of transition programs. More research should
be devoted to determining which components of the transition program make a graduate nurse
decided to stay with the facility or leave (Settler et al., 20110).
Conclusions
Having a nurse transition program communicates to graduate nurses that the organization
knows that they need support and acknowledge that standard orientation is insufficient to prepare
them. Following the nurse transition program, the nurses are more adequately prepared to meet
daily challenges and transition into their new nursing role (Hillman, 2011). The failure to
adequately provide graduate nurses with the needed support can negatively impact the quality
and safety of patients they care for (Dyess & Parker, 2012).

The literature supports that an

environment that promotes professional growth and engages staff will positively impact nurse
retention (Fiedler et al., 2014).

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

10

References
Berube, M., Valiquette, M., Laplante, E., Lepage, I., Belmonte, A., Tanguay, N.,...Touchette, S.
(2012). Nursing residency program: A solution to introduce new grads into critical care
more safely while improving accessibility to services. Innovation in Nursing Leadership,
25(1), 50-67.
Bratt, M. (2009). Retaining the next generation of nurses: the Wisconsin Nurse Residency
Program provides a continuum of support. The Journal of Continuing Education in
Nursing, 40(9), 416-425.
Dyess, S., & Parker, C. (2012). Transition support for the newly licensed nurse: A programme
that made a difference. Journal of Nursing Management, 20(5), 615-623.
Ebell, M., Siwek, J., Weiss, B., Woolf, S., Susman, J., Ewigman, B., & Bowman, M. (2004).
Strength of recommendation taxonomy (SORT): A patient-centered approach to grading
evidence in the medical literature. Journal of the American Board of Family Practice,
17(1), 59-67.
Fiedler, R., Read, E., Lane, K., Hicks, F., & Jegier, B. (2014). Long-term outcomes of a post
baccalaureate nurse residency program. The Journal of Nursing Administration, 44(7),
417-422.
Friedman, M., Delaney, M., Schmidt, K., Quinn, C., & Macyk, I. (2013). Specialized new
graduate RN pediatric orientation: A strategy for nursing retention and its financial
impact. Nursing Economics, 31(4), 162-170.
Harrison, D., & Ledbetter, C. (2014). Nurse residency programs: Outcome comparisons to best
practices. Journal for Nurses in Professional Development, 30(2), 76-82.

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

11

Hillman, L., & Foster, R. (2011). The impact of a nursing transitions programme on retention
and cost savings. Journal of Nursing Management, 19(1), 50-56.
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in Nursing &
healthcare: A guide to best practice (2nd ed.). Philadelphia: Wolters Kluwer/Lippincott
Williams & Wilkins.
Olson-Sitki, K., Wendler, C., & Forbes, G. (2012). Evaluating the impact of a nurse residency
program for newly graduated registered nurses. Journal for Nurses in Staff Development,
4(28), 156-162.
Park, M., & Jones, C. (2010). A retention strategy for newly graduated nurses: An Integrative
review of orientation programs. Journal for Nurses in Staff Development, 26(4), 142-149.
Quelly, S. (2007). Determining quality and validity of findings. Retrieved from
https://webcourses2c.instructure.com/courses/1106610/files/45153531/download
Rush, K., Adamack, M., Gordon, J., Lilly, M., & Janke, R. (2013). Best practices of formal new
graduate nurse transition programs. International Journal of Nursing Studies, 50(3), 345356.
Setter, R., Walker, M., Connelly, L., & Peterman, T. (2011). Nurse residency graduates
commitment to their first positions. Journal for Nurses in Staff Development, 27(2), 5864. 0
Trepanier, S., Early, S., Ulrich, B., & Cherry, B. (2012). New graduate nurse residency program:
A cost-benefit analysis based on turnover and contract labor usage. Nursing Economics,
30(4), 207-214.

Running head: DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION

12

Appendix A
Literature Evaluation
Citation
Patient Group and Study Design
Sample Size
and Level of
Evidence
Berube et al.
(2012)

N=113graduate
nurses

Cohort study
design

Outcome Variables

Retention rates

Level IV

Dyess et al.
(2012)

N=109 Newly
licensed RNs

Mixed methods
design with prepost evaluation
design

Retention rates

Turnover rates

Level IV

Fiedler et al.
(2014)

N=51graduate
nurses

Descriptive
design
Level VI

Friedman et
al.
(2013)

N=77 graduate
nurses

Retrospective
descriptive
design

Retention rates

Level VI

Hillman et

N=251 graduate

Descriptive

Retention rates

Key Results

Study
Weaknesses

Coding/Themes

Retention rates
prior to
implementation
were 57% and
post
implementation
was 71%
80% retention
rates post
implementation
of residency
program
compared to
65% pre
implementation
5.6% Turnover
rate prior to
implementation
compared to
national
average of
14.7%
Prior to
implementation
rates were 84%
compared to
post
implementation
rates were 94%
Prior to

Small sample
size

Increase in
retention
rates
Cost
savings

Limited
participation

Increase in
retention
rates

Small sample
size

No preretention rates
for comparison

Decrease in
turnover
rate
Cost
Savings

Limited sample
size

Did not define

Increase in
retention
rates
Cost
Savings

Increase in

DOES NURSE TRANSISTION PROGRAMS INCREASE RETENTION


al. (2011)

nurses

design
Level VI

Olson-Sitki
et al.
(2012)

N=31 New
graduate nurses

Nonexperimental,
repeated
measures, time
series, mixed
method design

Turnover rates

Retention rates

Turnover rates

Level VI
Setter et al.
(2011)

N=100 graduate
nurses

Cross-sectional,
descriptive
design
Level VI

Trepanier et
al. 2012)

N=524 graduate
nurses

Descriptive
design
Level VI

13
implementation
retention rates
were as low as
50%. Post
implementation
rates at 1 year
were as high as
100%
2 years pre
implementation
of residency
program
turnover rates
were 15% and
12%- Post
implementation
rates were 7%
and 11%
Mean retention
rates for first
year was 94%

preimplementation
retention rates

retention
Cost
Savings

Limited
Participation

Decrease in
turnover
rates

Did not include


pre-residency
retention ratesJust indicated a
increase post

Increase in
retention

Decrease in
turnover
rates
Cost
Savings

Mean turnover Retrospective


rate of 36.8%
analysis
to 6.41% post
implementation