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 below.)
What you can do
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.
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.
Renee Twibell is the nurse researcher at Indiana University Health Ball Memorial Hospital and associate professor at Ball State University School of Nursing in Muncie, Indiana. Jeanne St. Pierre is the gerontological clinical nurse specialist at Salem Hospital in Salem, Oregon. Doreen Johnson is vice president and chief nursing officer, Deb Barton is a direct care oncology nurse, Christine Davis is a nursing professional development educator, Michelle Kidd is a critical care clinical nurse specialist, and Gwendolyn Rook is a direct care nurse in the neonatal ICU; all work at Indiana University Health Ball Memorial Hospital.
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This article speaks the truth. I’m a new grad nurse on my unit and it has been hell. I feel like I’m being bullied (eating their young) for just breathing. Spoke to nurse manager and educator, and she gave everyone online training. WoW really. Honestly, the environment is so toxic and the other NGN quit on day 4. I’m not surprise. The second degree nurses are coming from different background and experiences. We are not threats to the oldie nurses, we are here to learn and applied what we learn from classes.
Very good article,reinforces the reality of nursing in a lot of facilities.
I have experience being criticized and complained about by my peers, for working too slow, or questioning care . I have always placed myself as my patients advocate especially to deliver safety concerns. This of coarse covers a lot of appropriate & professional care.
I took 2 yrs off, to assists my parents with their senior issues.
I have been a RN for 30ys, but need advice on reentering the work force? Do I attain different certificates, to show my commitment or other?
This article is spot on and showcases that it is a myriad of factors that have impact on the new graduate, and that a Comprehensive and systematic approach is necessary. Without having the up front selection and onboarding infrastructure, as well as the residency experiences and an organizational plus nursing culture to engage the new hire….it all falls apart. The pre-hire PXT Select Assessment has a nursing “performance model” which assesses a candidate’s thinking style (cognition), behaviors, and interests. It also has a section of behavioral interview questions based on the candidate’s score, then a multitude of additional reports as to best onboard that candidate into the organization. Very exciting evidence based process. Trying to implement in Connecticut.
Hi there, thanks for the great article. I have a question I’m hoping you might be able
to answer. I was wondering, What is the difference between anxiety disorder
and paranoia. I have bad fits of paranoia sometimes and I’m thinking I might look into anxiety medication. I would appreciate any insight you can provide.
I am right there in the burnout phase. I am a male nurse and come from the EMS world as a Paramedic for 28 years. I have been a nurse for 2 years and 5 months now. I work for a large hospital system, and our hospital will see over 90,000 patients in the ED this year. We are understaffed on most days. There are several doctors that are very rude to the nurses and other staff. I feel on a daily basis that I do not have the time I need to spend with my patients to keep them safe during their visit. It seems that I am just going from room to room and not patient to patient. I have just enough time to chart a quick note and it is no where what I need to chart. When I have serious patients and slow down to make certain that they are safe is when I hear little smirks from other nurses and staff that “well, he’s slow or where have you been while I’ve been bringing patients back and discharging them” This really ticks me off. This is where my frustration builds during the day and by end of shift I am thinking to myself, “Is this really worth it” I’m not in it for the money. I am in Nursing because I enjoy helping people and love the science and medicine. I enjoy learning something every day. I will keep on until I find my nitch and regardless of peer comments, I will keep my patients safe at all costs.
Though I agree that the “eating their young” does continue to exist (where I now work less than my previous job), a large part of the problem does seem to be that new nurses coming out of school don’t get the necessary training in school. What they don’t experience in school does astound me! As someone else pointed out, the online programs with 1-2 weeks of clinicals does not consitute an education in nursing. One must experience the grind of taking care of patients day after day and week after week. Another thing I have seen is a program that sends their students to multiple locations with one instructor “supervising” from afar (not on location–how can she be if she has students in 4-5 hospitals on any given clinical day?) These programs are dangerous not just for the new nurse, but for the hospitals that hire them, and for the patients that they care for! That said, I also think that a big reason that nurses (of any age or experience) are hired being told patient to nurse ratios are low (2:1 for ICUs, 3-4:1 for teles, 4-5:1 for general floors) and it might be that way during orientation. Then in real life, when the floor is busy (it always is) the stated ratio goes out the window, and you fight to stay afloat. When I finish my shift I want to be able to say “I took great care of my patients today!” NOT “Well, at least no one died!”
So what do you do when you’re a new RN and you get a bad preceptor and she has now made your life miserable, talking about you and making you uncomfortable on the unit. I feel like I will never be excepted. She talks about me, tried to make me look bad to my supervisors. It’s only been a couple of weeks and I already want to quit. I talked to educator and it’s just worse now. I love nursing and it’s really not fair that I’ve worked this hard to be treated like this. Been an LPN for 3 years before that at a different job.
wow!!! i`m so happy, i just regain my position in office after 3months. thanks to mother esango shrine. http://esangoshrine.webs.com/article-finding-a-spell
So True. Great article! It would be nice to see your citations in the body of the article correlating to your references.
What level of evidence does your article provide?
I have been a nurse for 35 years and I could have written this article as a new grad. I could have written it as a new CNS and a new NP. I love my career but I am convinced that the more things change the more they stay the same. We need to perform a “root cause” on why any nurse leaves.
It isn’t just new grads that have to run the gauntlet! I’m a 30 yr. RN and as a military wife, had to change jobs more often than most. Instead of being welcomed aboard and oriented properly, most times I was left to my own devices to figure out the new system, and treated like an interloper by the staff. How any medical facility expects to retain nurses like that is beyond me! Charge nurses and DON’s should make themselves aware of how any new employee is being assimilated – or NOT!!
Nursing science courses of real substance that include clinicals should be available starting in high school through post graduate studies.
God forbid we actually address the issues which NGN’s complain about. Ironically, it’s the same thing most nurses have been complaining about for the last 3o years!
It appears mandated ratios are the only way to get this industry to respond to nursing concerns. not just for our concerns for ourselves, but in order to provide safe patient care.
To be an authenic leader, one must know, understand, & appreciate the ability to follow at certain times to promote effective leaders of the future. In addition, to educate another, one must have the desire and true passion to want to see another person surpass them in the near future. We have too many micro- managers and not enough leaders in the field; and that is when one see high turnover rates of new graduates in most field of studies.
This article/research is very timely and much needed. However, I think that before an individual begin to even consider nursing as a major/career, they need to do a self-evaluation and know thy self. If you have certain behaviors (e.g. lazy,in it for money only,interpersonal skills, enjoy holidays off, not a team player, etc.) they need to go and shadow or volunteer in various areas of Nursing to see what will be their best fit before taking up space/wasting excessive money & time in the major.
Maybe we need to rethink criteria for becoming a nurse. Perhaps personality test as part of admission to nursing school? It seems a profession with a reputation for ” eating its young” has members with issues. I’m so happy to see articles like this starting to crop up. I’ m just afraid the profession as a whole will just try to chase its tail to find ANY reason except the obvious–what is the personality of those “who eat their young”. Who are we letting in? Why don’t we change it? RCA needed
The nurse recruiters or interviewers typically describe the best scenerio to new perspective nurses and then when the NGN gets to their unit they see a much different environment. The nurse patient ratio is much higher than what was stated during the interview.
From AACN’s Healthy Work Environments (HWE) standards on authentic leadership: “Nurse managers in particular are key to the retention of satisfied staff…Nurse leaders must be skilled communicators, team builders, agents for positive change, committed to service, results oriented and role models for collaborative practice.” Skilled communication and team building include interpersonal effectiveness. The HWE Assessment Tool evaluates nurses’ “positive relationship with (their) nurse leaders.”
Actually, the “authentic relationships with leaders” is incorrectly stated. The AACN calls for “authentic leadership” and it is the glue to creating a healthy work environment. Authentic leaders are to set the example & lead by influence-an aspect calling for transparency. The way it is worded in this article is actually misleading and a watered down version of authentic leadership. Leadership sets the example with the purpose of influencing others to become authentic leaders.
Residency programs offer great support to the new grad, but if the nursing unit is a toxic environment with bitter nurses & little support from management, the grad will walk, no matter what.The work environment is key to the success or non-success of the new nurse. Patients are sicker, families more demanding & co-workers less supportive because we are all in survival mode. Healthcare orgainzations need to focus on improving the work environment first, or it will never change.
What a mess we’ve created for our new graduates- the least we can do is make sure they are transitioned from education to practice in the least traumatic way possible. I’m all for a recognized structured residency program- and when done right it gets the whole hospital on board and involved!
Thanks for the all comments on our article. One theme seems to be that nurses have too much to do and inadequate resources to do it. Let me ask: What tasks do RNs currently do that they could stop doing? For example, do we need I&O’s if we have daily weights? What can RNs delegate to unlicensed personnel? For example, do RNs have to give oral medications in acute care settings? How can technology better support us so that nurses – young and old, new and experienced – stay in the workplace?
Why are NGNs not fully prepared to practice safely and effectively, lack confidence and adequate skills? When will practice setting barriers to learning be broken down? When will student nurses be able to practice within their full scope in each clinical setting? If we want to graduate, we need student nurses to function at their full scope of practice.
I am retired from nursing now for just one year. The bottom line for me is enough nurses to do the job safely. Administration does not get it, nor do I see them getting it in the near future. I also think senior nurses look at new grads as threatening, when they should be ready to see what they can learn from this new individual. The problems are as old as time, and when one does develope a working solution, it goes away because of the budget.
Well if we were all honest, no new nurse knows what it will be like to have to take care of the current patient assignment. No where is any nurse prepared to care for patients who are demanding and what everything, and then the family who comes in and wants even more. Even though acuity has gone up, patient to nurse ration has never readjusted except in ICU… So why aren’t we happy?
It also starts in nursing school. I graduated 31 years ago from a BSN program and we were teaching bed baths, back rubs and how to change a bed with the patient in the bed; It is not just technology, tubes, machines measuring the patient’s vitals without looking them in the face and reading the behaviors for an assessment. Are schools teaching the reality of nursing? I purposely went to a hospital that had a new grad program because I knew I would sink if I didn’t.
Leadership behaviors was cited as the single most important area that impacts nurse retention. But, continues to be the topic that everyone dances around and minimizes. It does appear that there has been a concentrated effort to decrease the stressors on new nurses because the 1st year flight has been cut in half.
Let’s face it. Nurses eat their young. Being allowed-encouraged-to torture the new nurse seems to be a perk of having been there longer than she has. All of the things you mentioned would have helped me in my many new jobs (obviously, going to work someplace else doesn’t help). One thing I tried, though, seems to be of some small value: don’t work at a place where the director of nurses is sleeping with the adminstrator. Nursing always gets the short shrift in these circumstances.
Many of the supports recommended in this article apply to any new nurse on a unit, regardless of experience. I am an experience RN new to a toxic work environment and have hit that 6-month wall where I just want to quit.
These strategies are well known to those who thoughtfully manage new nurses.
Problem is, you are preaching to the choir.
A manager may embrace these strategies but when upper management dictates bare-bones or staffing micromanagement, nothing else matters
I have witnessed seasoned nurses upset…struggling to provide safe care when understaffed. What chance do new nurses have?
No amount of training can substitute for fragmented, dollars first staffing policies.
When the ANA rises the bar and no longer allows on-line nursing degrees we will improve nursing performance. How can we expect nursing students to learn interdisciplinary team collaboration & critical skills decision making with the proliferation of nursing degrees offered via the Internet? Remember POGO?We have met the enemy and the enemy is us.
This is a very needed article for what is happening presently in our profession. Thanks to you all. 🙂
This is a great article and every institution of nursing should read as the strategies include many that I have witness on units where I have taken my students and where some of my students have been hired successfully.