JONA
Volume 46, Number 2, pp 82-86
Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N
Residency for Transition Into Practice
An Essential Requirement for New Graduates From Basic
RN Programs
Colleen J. Goode, PhD, RN, NEA-BC, FAAN
Patricia Reid Ponte, DNSc, RN, FAAN
Donna Sullivan Havens, PhD, RN, FAAN
Nurse residency programs have been developed with
the goal of helping newly licensed nurses successfully
transition to independent practice. The authors pro-
pose that all newly licensed nurses hired in acute care
hospitals be required to complete an accredited resi-
dency program. An evidence table examines the state
of the science related to transition-to-practice pro-
grams and provides the basis for recommendations.
The role of clinical nurses grows increasingly com-
plex, given the advancement of care technologies, the
acuity level of patients, specialization, quality and safety
requirements, evidence-based practice expectations, the
rapid turnover of acute care patients due to shortened
lengths of stay, and the need for increased coordina-
tion of care across practice settings. It is very difficult
for schools of nursing to prepare new nursing grad-
uates with the capacity needed to practice in acute
care settings immediately upon graduation.1,2 Accord-
ing to Kramer et al,3 7 major challenges have been
identified by newly licensed RNs: delegation, prior-
Author Affiliations: Professor (Dr Goode), Healthcare Systems,
College of Nursing, University of Colorado Denver, Aurora; Senior
Vice President, Patient Care Services, Chief Nursing Officer, Dana-
Farber Cancer Institute, and Executive Director, Oncology Nursing
and Clinical Services (Dr Reid Ponte), Brigham and Women_s Hos-
pital, Boston, Massachusetts; Interim Dean and Professor (Dr Sullivan
Havens), Healthcare Systems and Outcomes, University of North
Carolina School of Nursing at Chapel Hill.
The authors declare no conflicts of interest.
Correspondence: Dr Goode, Healthcare Systems, College of
Nursing, University of Colorado Denver, 13120 E 19th Ave, C288-19,
Aurora, CO 80045 ([email protected]).
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal_s Web site
(www.jonajournal.com).
DOI: 10.1097/NNA.0000000000000300
itization, managing patient care delivery, autonomous
decision making, collaboration with other disciplines,
constructive conflict resolution, and utilizing feedback
to restore self-confidence.
One innovation to address the transition-to-practice
challenge is the nurse residency program (NRP), which
has been shown to impact the socialization of new
graduates with other disciplines; increase evidence-
based practice; decrease turnover; improve new grad-
uates_ confidence, competence, and ability to organize
and prioritize work; improve communication and
clinical leadership; and lead to transformative changes
in organizations.
1,3,4
This position paper describes
the current state of the science for new-graduate RN
transition-to-practice residency programs and presents
policy recommendations.
Background
In a call for radical transformation of nursing edu-
cation, Benner et al5 determined that nurses are un-
dereducated for current practice demands and called
on the nursing profession and healthcare providers
to implement 1-year residency programs focused on
1 clinical area of specialization.
5
The Institute of Med-
icine report, The Future of Nursing: Leading Change,
Advancing Health,6 also recommended the implemen-
tation of nurse residencies to facilitate transition to
practice. A 2011 survey of chief nursing officers found
that only a minority of hospitals, approximately 37%,
offered an NRP.7
In the last decade, a number of professional nurs-
ing organizations have taken steps to promote wider
adoption of NRPs. In 2002, the National Council of
State Boards of Nursing (NCSBN) developed a model
JONA � Vol. 46, No. 2 � February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
82
for transitioning new graduates.8 The American As-
sociation of Colleges of Nursing (AACN) partnered
with the University HealthSystem Consortium (UHC)
to develop and implement a postbaccalaureate, 1-year
NRP.1,2,9 AACN and UHC also worked with the Com-
mission on Collegiate Nursing Education (CCNE) to
promote the creation of an accreditation process for
postbaccalaureate NRPs that are developed in part-
nership with academic nursing programs.10 The 1st
residency program was accredited by CCNE in 2009.1
Currently, 18 residencies are accredited by CCNE
and they include UHC/AACN, Veterans Administra-
tion and residencies with self-developed curricula.
The National League for Nursing (NLN) has announced
the BAcceleration to Practice Program.[11 Seven aca-
demic and practice partners have joined NLN to de-
velop the program, which will be available in 2015 and
will focus on transitioning all newly licensed RNs.11
Many hospitals have developed their own NRPs
for newly licensed nurses. The American Nurses Cre-
dentialing Center (ANCC), a subsidiary of the American
Nurses Association, has established an accreditation
program to ensure new-graduate residencies conform
to evidence-based standards.12 The ANCC Practice
Transition Accreditation Program does not require a
partnership with a school of nursing. Currently 5 resi-
dency programs are accredited by ANCC. Because
most residency programs for new RNs are currently
not accredited, there is considerable variation in pro-
gram structure, content, and outcomes.
The State of the Science
An evidence table (Supplemental Digital Content 1,
http://links.lww.com/JONA/A454) contains articles
published between 2006 and January 2015. The fol-
lowing clinical questions drove the search: BIs there
evidence to support transition to practice programs
for newly licensed RNs?[ and BWhat does the evi-
dence tell us about how these programs can be im-
proved?[ The search was conducted using the Ovid,
MEDLINE, CINAHL, and Google Scholar systems.
The search included studies involving hospitals, long-
term care, home care, and clinics. The level of evidence
associated with each article was assigned using the
framework developed by Melnyk and Fineout-
Overholt.13 Twenty-three articles met our criteria for
inclusion and are summarized in the evidence table
(Supplemental Digital Content 1, http://links.lww.com/
JONA/A454). The articles include 13 quantitative
studies, 4 qualitative studies, 2 integrative reviews,
and 3 systematic reviews and a historic article.14
Articles from the Table, Supplemental Digital
Content 1, http://links.lww.com/JONA/A454, with large
sample sizes and the systematic and integrative reviews
are summarized. Two articles reported on 10 years of
data from specific residency programs: the UHC/AACN
residency and the Versant New Graduate RN Resi-
dency.1,4 The UHC/AACN postbaccalaureate program
is 1 year in length and uses an evidence-based standard-
ized curriculum that addresses 3 core areas: leadership,
patient safety and outcomes, and the professional
role.1 A preceptor training program and completion of
an evidence-based practice project in the last 6 months
of the residency are components of the program. More
than 57 000 new graduates have completed the pro-
gram. In examining data obtained from program
participants between 2002 and 2012, Goode and
colleagues1 found that residents_ self-assessments of
their overall confidence and competence, ability to or-
ganize and prioritize work, and ability to communicate
and provide leadership increased significantly over the
course of the program. Retention rates increased over
the 10-year study period, from 88% to 94.6%.
Ulrich and colleagues4 used a similar approach
to evaluate the Versant residency program, analyz-
ing data obtained from more than 6000 nurses who
participated in the program over the course of 10 years.
The Versant program started by Becroft, Kunzman
& Krozek as a pilot project in children_s hospitals15
and is now used in both pediatric and general hos-
pitals and is open to diploma, associate degree in
nursing (ADN), and baccalaureate graduates. The
program is based on Benner and colleagues,5 frame-
work and includes an evidence-based curriculum. The
curriculum includes classes with case studies, struc-
tured clinical immersion, team precepting experiences,
mentoring and debriefing, self-care, and competency
validation.4 Program participants experienced gains
in self-confidence, and ratings of satisfaction were
high, with the highest ratings assigned to the work
enjoyment, quality, and time to work subscales. Hos-
pitals experienced lower new-graduate turnover, pro-
viding them with significant savings.16 Data showed
the need for ongoing support and guidance and a plan
for structured mentoring and debriefing for 1 year.
The qualitative study by Kramer et al3 involved
907 nurses from 20 MagnetA hospitals. The researchers
found that participating in an NRP positively impacted
the socialization of newly licensed RNs, and the tran-
sition stage (when the preceptor is dominant) and the
integration stage (when residents are integrated into
the professional practice role) are most effective in
developing new-graduate competencies.3 When or-
ganizations institute theory based transition plus
integration-stage nurse residency programs, the authors
demonstrated that NRP’s lead to improved practice
which empirically leads to improved outcomes.3
The integrative review by Rush et al included
47 articles.17 Thirteen articles reported retention rates
JONA � Vol. 46, No. 2 � February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
83
averaging 90.1%. Articles examining turnover re-
ported an average rate of 10.5%. Residency length
ranged from 3 months to more than 6 months. Stress
levels were highest, and job satisfaction was lowest at
9 months, and both improved by the end of 1 year.
The integrative review by Park and Jones18 included
17 studies involving programs that varied from 6 weeks
to 1 year. All programs included classroom learning
and clinical experience with a preceptor and 7 studies
reported an increase in self confidence. Retention,
examined by 15 studies, also improved.18
The systematic review by Anderson et al19 included
20 studies. Findings highlighted the need for stan-
dardization of curricula and program procedures.
The nurse residency educational intervention was not
well described in many of the studies and was the
most unstable variable. The review found a lack of
consistency in tools used for evaluations, great varia-
tion in program length, and lack of a standardized
evidence-based curriculum.19 The systematic review
by Lin et al20 looked at articles related to the job
satisfaction of residents. Dissatisfaction with extrinsic
rewards did not change significantly during the resi-
dency; satisfaction with praise and recognition was
mixed, and satisfaction with professional opportunities
in the residency improved nurse satisfaction. Dissat-
isfaction with the work environment and the hospital
system was not alleviated by the residency. A sys-
tematic review by Chappell and Richards21 evaluated
2 areas: the relationship between new graduates and
their clinical leadership skill and between new-graduate
transition to practice programs and clinical leadership
skill.21 More than 4000 new graduates participated in
the study. Study designs were mostly repeated measures
with or without a comparison group. Curricula for the
transition programs were developed by the UHC/AACN,
the Versant program, or the organization running the
program. 21 Transition programs that were at least
24 weeks long demonstrated a positive impact on
clinical leadership skill. The UHC/AACN program
curriculum had the greatest positive impact on new
graduates, and the Versant program curriculum had
the 2nd greatest impact.21
A recent study, by Spector et al,22 examined the
experiences of 105 hospitals that were randomly as-
signed to implement the NCSBN Transition to Practice
Model (TTP) program (intervention group) or to con-
tinue using their existing on-boarding programs (con-
trol group). They found some of the control hospitals
had Bestablished programs,[ which used a structured
curriculum and included at least 6 of 11 elements that
the literature describes as essential for transition-to-
practice programs.22 The remaining control hospitals
offered Blimited programs,[ which did not use a struc-
tured curriculum and included fewer than 6 of the
essential elements. Patient errors and negative safety
practices were highest in sites with limited residency
programs, and overall nurse competence in the limited
group began decreasing at 6 months and remained
lower than in the other 2 groups for the rest of the
year. New nurse turnover in the limited group was
also approximately 2 times higher than in the TTP
and established groups.
Summary of Evidence
Because of the wide variation in tools used to mea-
sure the outcomes of residency programs, the dif-
ferences in the length of the programs, the lack of
standardization of evidence-based curricula, and
the lack of a set of standards for program procedures
and education and experience of preceptors and edu-
cators, it is difficult to meaningfully compare different
graduate nurse residency programs. The residency
educational intervention in the studies listed in the
Table, Supplemental Digital Content 1, http://links.
lww.com/JONA/A454, is the least described and most
unstable variable and could introduce measurement
and statistical error.19 At the same time, the evidence
suggests that structured, evidence-based transition
programs can be effective in improving new-graduate
retention, job satisfaction, competence, confidence,
and leadership, and better outcomes are associated
with longer programs (ie, those lasting between 6 and
12 months).
Implementing Residency Programs in the
Hospital Setting: Policy Recommendations
In light of the growing evidence demonstrating the
benefits of NRPs for new-graduate nurses and health-
care institutions, we propose that all newly licensed
RNs hired in acute care hospital settings be required to
complete an accredited residency program. Implement-
ing a residency requirement for all new graduates
entering acute care cannot happen overnight. It will
require collaboration among nursing professional
groups and the active participation of acute care hos-
pitals that employ newly licensed RNs. Policy recom-
mendations to help turn our proposed residency
requirement into reality are outlined in the follow-
ing paragraphs.
1. Residency programs for new-graduate ADN
and baccalaureate-prepared nurses should be
designed, implemented, evaluated, and admin-
istered by hospitals, ideally in collaboration with
a school of nursing. Because the nurse residency
is a continuation of nursing education, it is
logical to link it to a school of nursing at a
college or university.
JONA � Vol. 46, No. 2 � February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
84
2. Residency program completion should be a
condition of hire for hospitals that hire new-
graduate nurses. As the hiring agency, hospitals
are singularly positioned to ensure that all newly
licensed nurses who join their staff fulfill a res-
idency requirement.
3. All residency programs should be accredited
by national regulatory agencies to ensure consis-
tent program components, standards, processes,
and outcomes achievement. Accreditation agen-
cies such as AACN and ANCC have taken on
the accreditation role and developed standards
for accreditation. To date, the evidence sug-
gests the residency program of 6- to 12-month
duration is most effective and should consist
of an evidence-based curriculum.
4. Nursing education accrediting bodies (AACN
and NLN) should require entry-level nursing
education programs (ADN and BSN) to parti-
cipate in the development and administration
of residency programs for newly licensed nurses
in acute care. This requirement will ensure that
hospitals and NRPs benefit from the support
and input of academic partners and that nurs-
ing education programs are continually informed
by an up-to-date appreciation of the challenges
facing newly licensed nurses.
5. Hospitals that hire new-graduate ADN-prepared
nurses should require ADN residents to sign a
contract to complete a baccalaureate degree
in nursing within a specified timeframe in order
to maintain employment. Adopting this recom-
mendation would advance ongoing efforts to
meet the Future of Nursing6 recommendation
to increase the proportion of nurses with a
baccalaureate degree to 80% by 2020.
Cost and Funding Considerations for
Residency Programs
While some hospitals may view NRPs as cost-prohibitive,
recent studies suggest otherwise. For example, a cost-
benefit analysis of the Versant residency program,
which used data on turnover and contract labor use,
found that the program was associated with a marked
decrease (from 36% to 6%) in the 12-month turnover
rate for new graduates, and a reduction in contract
labor costs from $19 000 to $5490 per average daily
census. 23 Pine and Tart24 examined 1 hospital_s expe-
rience with the UHC/AACN residency and calculated
the costs of the residency as $2024 per resident.
Jones25 estimated turnover costs at $82 032 to $88 006
per nurse. Current anecdotal evidence suggests new
graduates from entry-level nursing programs want to
enter clinical practice in organizations that have NRPs.
Such an advantage would be especially beneficial in the
coming years when healthcare reform, a changing
economy, and nurse retirements are expected to in-
crease the demand for RNs.26,27
Government and philanthropic participation and
support for NRPs are needed. In Rhode Island, the
Robert Wood Johnson Foundation (RWJF) is par-
tnering with the Rhode Island Action Coalition and
the Governors Workforce Board to help fund a state-
wide nurse residency that supports new-graduate nurses
who are working in hospitals or in nonacute settings in
Rhode Island.28 RWJF has also helped fund the de-
velopment of a 12-month NRP in Iowa that includes
online modules and discussion sessions that are avail-
able as webinars or conducted on site by a facility_s
own personnel.29 The Iowa program is available to
newly licensed nurses working in a range of settings.
The New Jersey Action Coalition received a grant from
the Centers for Medicare & Medicaid Services to de-
velop, implement, and evaluate a transition to practice
model for long-term-care facilities.30 A recent study
found that only 2.2% of home health and hospice
settings and 11.4% of primary care clinics are intro-
ducing NRPs.31 Another study determined that resi-
dency programs are being introduced in approximately
49% of hospitals.20
Conclusion
Residency programs help new-graduate nurses develop
the skills, competence, and confidence required for
autonomous practice. They also yield significant re-
wards for healthcare organizations by improving reten-
tion, organizational commitment, and the development
of future nurse leaders.32
Given the preponderance of evidence supporting
NRPs, we have proposed that all new graduates of
ADN programs and BSN programs who are hired to
work in acute care settings be required to complete
an NRP. Furthermore, to ensure the quality of NRPs,
we propose program accreditation as a requirement.
We have also proposed that hiring organizations im-
plement contracts requiring ADN residents to return
to school within a specified timeframe to obtain their
baccalaureate degree. This will be a major step toward
achieving the Institute of Medicine Future of Nursing
report which calls for 80% of nurses to be prepared
at the baccalaureate level by 2020.6 Areas in need of
more study include the impact of nurse residency pro-
grams on patient outcomes and the required length
for an NRP.
We recognize that efforts to implement our rec-
ommendations will encounter multiple challenges. Fur-
thermore, achieving success will require the collaboration
JONA � Vol. 46, No. 2 � February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
85
of numerous stakeholders, including representatives
of professional organizations, deans and faculty of
schools of nursing, nursing and organizational leaders
in service settings, and government and philanthropic
agencies. Our hope is that through this article, we
initiate a dialogue through which representatives from
these different arenas begin taking steps to move nurse
residencies from an option that is available to a small
number of nurses, to a requirement that benefits every
newly licensed nurse, as well as healthcare organiza-
tions and the patients they serve.
Acknowledgments
The authors recognize the members of the American
Academy of Nursing Expert Panel on Building Health-
care System Excellence for their contributions to this
article and Beth Kantz, MS, RN, for her editorial and
writing support.
References
1. Goode CJ, Lynn MR, McElroy D, Bednash GD, Murray B.
Lessons learned from 10 years of research on a post-baccalaureate
nurse residency program. J Nurs Adm. 2013;43(2):73-79.
2. Goode CJ, Lynn MR, Krsek C, Bednash GD. Nurse residency
programs: an essential requirement for nursing. Nurs Econ.
2009;27(3):142-147, 159.
3. Kramer M, Maguire P, Halfer D, et al. The organizational
transformative power of nurse residency programs. Nurs
Adm Q. 2012;36(2):155-168.
4. Ulrich B, Krozek C, Early S, Ashlock CH, Africa LM, Carman
ML. Improving retention, confidence and competence of new
graduate nurses: results from a 10-year longitudinal database.
Nurs Econ. 2010;28(6):363-376.
5. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A
Call for Radical Transformation. San Francisco, CA: Jossey-Bass;
The Carnegie Foundation for the Advancement of Teaching; 2010.
6. Institute of Medicine. The Future of Nursing: Leading Change,
Advancing Health. Washington, DC: National Academies Press;
2010.
7. Pittman P, Herrera C, Bass E, Thompson P. Residency pro-
grams for new nurse graduates: how widespread are they and
what are the primary obstacles to further adoption? J Nurs
Adm. 2013;43(11):597-602.
8. Spector N, Echternacht M. Update on the national council of
state boards of nursing_s regulatory model for transitioning new
nurses to practice. JONAS Healthc Law Ethics Regul. 2010;
12(1):12-14.
9. Williams CA, Goode CJ, Krsek C, Bednash GD, Lynn MR.
Post baccalaureate nurse residency 1-year outcomes. J Nurs
Adm. 2007;37(7-8):357-365.
10. Commission on Collegiate Nursing Education. Standards for
accreditation of post- baccalaureate nurse residency programs.
2008. http://www.aacn.nche.edu/ccne-accreditation/
resstandards08.pdf. Accessed April 15, 2015.
11. National League for Nursing. Accelerating to practice. The
NLN Report. 2014. http://dlsii.com/blog/nursing-education-2/
nationalleaguefornursingaccelerationtopractice. Accessed
December 23, 2015.
12. American Nurses Credentialing Center. ANCC 2014 Practice
Transition Accreditation Program. http://www.nursecredentialing.
org/PTAP-EligibilityInfo. Accessed April 2015.
13. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in
Nursing and Healthcare: A Guide to Best Practice. Philadelphia,
PA: Lippincott, Williams & Wilkins; 2011.
14. McHugh M, Duprat LJ, Clifford JC. Enhancing support for
the graduate nurse. Am J Nurs. 1996;96(6):57-62.
15. Beecroft PC, Kunzman L, Krozek C. RN internship: outcomes
from a one year pilot program. J Nurs Adm. 2001;31(12):575-582.
16. Beecroft PC, Dorey F, Wenten M. Turnover intention in new
graduate nurses: a multivariate analysis. J Adv Nurs. 2008;
62(1):41-52.
17. Rush KL, Adamack M, Gordon J, Lilly M, Janke R. Best
practices of formal new graduate nurse transition programs:
an integrative review. Int J Nurs Stud. 2013;50(3):345-356.
18. Park M, Jones CB. A retention strategy for newly graduated
nurses. J Nurses Staff Dev. 2010;26(4):142-149.
19. Anderson G, Hair C, Todero C. Nurse residency programs: an
evidence-based review of theory, process and outcomes. J Prof
Nurs. 2012;28(4):203-212.
20. Lin PS, Viscardi MK, McHugh MD. Factors influencing job
satisfaction of new graduate nurses participating in nurse
residency programs: a systematic review. J Contin Educ Nurs.
2014;45(10):439-450.
21. Chappell KB, Richards KC. New graduate nurses, new graduate
nurse transition programs, and clinical leadership skill. J Nurses
Prof Dev. 2015;31(3):128-137.
22. Spector N, Blegen MA, Silvestre J, et al. Transition to prac-
tice study in hospital settings. J Nurs Regulat. 2015;5(4):
24-38.
23. Trepanier S, Early S, Ulrich B, Cherry B. New graduate nurse
residency program: a cost-benefit analysis based on turnover
and contract labor usage. Nurs Econ. 2012;30(4):207-214.
24. Pine R, Tart K. Return on investment: benefits and challenges
of a baccalaureate nurse residency program. Nurs Econ. 2007;
25(1):13-18, 39.
25. Jones CB. Revisiting nurse turnover costs: adjusting for inflation.
J Nurs Adm. 2008;38(1):11-18.
26. Auerbach DI, Staiger DO, Muench U, Buerhaus PI. The
nursing workforce in an era of healthcare reform. N Engl J
Med. 2013;368(16):1470-1472.
27. Bureau of Labor Statistics. Employment by major occupational
group, 2012 and projected 2022. http://www.bls.gov/news.
release/ecopro.t06.htm. Accessed March 20, 2015.
28. Rhode Island Launches Innovative Nurse Residency Program.
2013. http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-
content/2013/07/rhode-island-launches-innovative-nurse-residency-
program.html. Accessed April 15, 2015.
29. Iowa Nurses Build Affordable Online Residency (2014) http://
www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/
2014/03/iowa-nurses-build-affordable–online-nurse-residency-
program.html. Accessed March 20, 2015.
30. Cadmus E. NJAC receives $1.6 million to implement a long
term care residency program. 2013 http://campaignforaction.
org/community-post/njac-receives-16-million-implement-long-
term-care-residency-program. Accessed March 20, 2015.
31. Pittman P, Horton K, Terry M, Bass E. Residency programs
for home health and hospice nurses: prevalence, barriers and
potential policy responses. Home Health Care Manage Pract.
2014;26(2):86-91.
32. Krugman M, Bretschneider J, Horn PB, Krsek CA, Moutafis RA,
Smith MO. The national post-baccalaureate graduate nurse
residency program. J Nurses Staff Dev. 2006;22(4):196-205.
JONA � Vol. 46, No. 2 � February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
86
