Residency programs help prepare competent nurses

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After reading this article, you will be able to:

  • Discuss how nursing residency prepares new nurses for practice

by Vicky Goeddeke, RN, MS, CEN, CPEN

Editor’s note: This article is part one of a two-part series about nurse residency programs. Keep an eye out for part two on how to implement a program in an upcoming issue of Strategies for Nurse Managers.

Offering a nurse residency program is an important strategy for planning for the future in nursing, but many hospitals are finding these programs costly, considering the current economic conditions affecting many healthcare organizations. Despite the financial and personnel resources it takes to support a nurse residency program, there are sound reasons to continue or begin such a program in your organization.

Nurse orientations cost an estimated $20,000–$50,000 per nurse (Blanzola et al., 2004). In addition to orientation costs, turnover costs include marketing and recruitment expenses, salaries for overtime and/or external staffing resources to cover clinical staffing needs, and the potential effect on customer satisfaction scores. Nursing turnover has been estimated to cost 75%–125% of the average annual salary of an organization’s nurses (Pine et al., 2007).

Organizations must weigh the cost of a nurse residency program against the cost avoidance of nurse turnover. A successful nurse residency program can lead to positive outcomes for organizations, such as lower turnover and the development of competent clinical practitioners. Anticipated future returns include improvements in staff satisfaction, clinical productivity, outcomes of care, patient safety, and, as a result, customer satisfaction (Keller et al., 2006). A successful nurse residency program helps nurses develop advanced nursing skills that contribute to these outcomes.

Challenges for new graduate nurses

Although 90% of academic nurse leaders feel new nurse graduates are fully prepared to practice, only 10% of hospital nurse leaders share this opinion (Berkow, 2009). The challenges of transitioning from nursing school to clinical practice for new nurse graduates leads to first-year turnover rates of 35%–60% (Blanzola).

New nurse graduates face a huge challenge as they transition from student to competent practitioner. New nurses must adjust to the clinical demands and environment of a new work arena, which have increasingly complex patients and specialties that are becoming more technology-focused.

In addition, new nurse graduates often work demanding alternate or rotating shifts that they were unaccustomed to as students.

For these reasons, new nurse graduates are attracted to organizations offering nurse residency programs that facilitate their transition to professional practice. Many have identified an interest in and desire to begin work in specialty areas that require strong clinical knowledge.

Cultural considerations that may lead to a new nurse graduate selecting an organization’s nurse residency program include professional growth opportunities, coworker and physician relationships, nursing autonomy, scheduling, and recognition of nurses.

Orientation structure

Orientation programs are generally structured to introduce new hires to the new work environment and their new unit’s scope of services. Programs typically provide information regarding the organization and the unit. Programs also assess new hires’ knowledge and skill base and connect them to peer resources who can role-model expectations for nurses on that unit, as well as facilitate a sense of belonging to the team. The orientation period gives nurse leaders time to evaluate clinical competency, efficiency, communication skills, productivity, and customer service focus. Orientation programs are usually designed to guide nurses’ transition to a different work arena, not a different role.

New nurse graduates have a different transition challenge—one from student to the role of a nurse—and a nurse residency program needs to be more than an extended orientation. There are a wide range of goals, program lengths, and outcomes reported for nurse resident programs (Keller et al., 2006). New nurse graduates can become competent practitioners more quickly with the guidance of a nurse residency program. Programs should offer didactic and leadership components in addition to the standard clinical components offered in an orientation program. Incorporating didactic and leadership components supports the nurse resident’s development beyond clinical skills, enhancing clinical judgment and critical thinking skills (see “Components of a nurse residency program” on p. 3).

Residency design

Nurse residency is not a new concept—programs were first documented in 1980s literature (Altier & Krsek, 2006), and most are based on Benner’s theory of novice to expert. Benner felt competence was typified by nurses who had been on the job in the same or similar situations and were consciously aware of connecting their actions to a long-range plan (Benner, 1984). Benner noted that competence was generally reached only after years of gaining experience as a practicing nurse. A nurse residency can facilitate new nurse graduates to advance more quickly from novices to competent nurses, lessening time as advanced beginners. A nurse residency, focused on developmental concepts, attracts new nurse graduates, and the organization enjoys the benefits of competent nurses and the bonus of low turnover.

Our experience at Northwest Community Hospital reflects these ideals. The initial nurse residency program was founded in 1995 and, based on Benner’s theory, was originally a 24-month program. We discovered in the early nurse resident groups that through the mentorship of the residency program, nurses reached competence more quickly, and the program was reset first to 18 months and then to 12 months. These nurses come out of the program as competent practitioners. There remains some turnover among our nurse residents, but there is also longevity: 30% of the first nurse residents were still employed at our organization after 10 years. We have a culture of longevity at Northwest Community Hospital, but our nursing work force, like nursing in general, is aging. We are fortunate that our turnover rate is currently below the national and Greater Chicago–area averages. Because of our low nursing turnover, we enjoy a low nursing vacancy rate. But ours is a forward-thinking organization, so we continue to offer and support our nurse residency program. It’s the smart thing to do.

Editor’s note: Goeddeke is the ANCC Magnet Recognition Program® and nursing excellence manager at Northwest Community Hospital in Arlington Heights, IL.


Altier, M., and Krsek, C. (2006). “Effects of a one-year residency program on job satisfaction and retention of new graduate nurses.” Journal for Nurses in Staff Development 22(2): 70–77.

Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley.

Berkow, S., Virkstis, K., Stewart, J., and Conway, L. (2009). “Assessing new graduate nurse performance.” Nurse Educator 34(1): 17–22.

Pine, R., and Tart, K. (2007). “Return on investment: Benefits and challenges of a baccalaureate nurse residency program.” Nursing Economics 25(1): 13–18, 39.

Blanzola, C., Lindeman, R., and King, L. (2004). “Nurse internship pathway to clinical comfort, confidence, and competency.” Journal for Nurses in Staff Development 20(1): 27–37.

Keller, J., Meekins, K., and Summers, B. (2006). “Pearls and pitfalls of a new graduate academic residency program.” Journal of Nursing Administration 36(12): 589–598.

U.S. Department of Health and Human Services, Health Resources and Services Administration (2004). “What is behind HRSA’s projected supply, demand, and shortage of registered nurses?”