HWS Perspectives | Health Workforce Solutions LLC

The second in a continuing series of timely articles brought to you quarterly by HWS

A Significant and Costly Problem for Many
The current and projected growth in inpatient care coupled with a shortage of experienced nurses is driving many of the nation’s leading hospitals to invest heavily in new graduate nurse hires. In 2002, the Health Care Advisory Board estimated that 42% of new nurse hires were new graduates. Many hospitals today seem to be relying even more heavily on new graduate nurse hires. Last year, New York Presbyterian Weill Cornell Hospital hired 319 staff nurses, of which 198 were new graduates. M.D. Anderson is using new grad hires as their preferred new nurse supply; over the last 20 months, they have hired 150 BSN-prepared new graduate nurses.

Unfortunately, the turnover rate for new grad nurse hires is high. According to various studies, between 35 and 61 percent of new graduate RNs turn over within their first year of employment.¹

The cost of turnover is high for any nurse, as staff time needs to be devoted to interviewing and selecting a new hire and bringing that new hire up to speed. Estimates of the cost of turnover range up to $81,000 per nurse.² But it can be even higher for new grad hires. In order to bring in these new graduates, many hospitals have dedicated significant financial resources though marketing campaigns, loan forgiveness and scholarship programs, strategic partnerships with schools, and signing bonuses. Signing bonuses alone can add $3,000 to $15,000 to the cost of a new graduate nurse hire.³

In addition to being financially costly for an institution, high nurse turnover can have negative impacts on patient quality. A JCAHO report from 2002 linked lower nursing turnover rates with better quality of care evaluations, and several studies have found that high nurse turnover can cause organizational stress and instability.

Why is new grad turnover so high? A recent HWS survey of twenty CNOs from hospitals throughout the country revealed many different reasons:


•	High mobility of the new entry nurses

•	Different ideas about loyalty and work-life balance

•	Availability of lucrative traveler positions after one year of acute care experience

•	Inability to cope with the stressful work environment

But the most-often cited problem was the increasing gap between nursing education and clinical practice. Many CNOs felt that newly graduated nurses did not yet have the skills to enter clinical practice, and that hospitals were left to assume the burden of completing a new nurse’s education. Diana McBroom, RN, MBA, CNA-BC, CNO of Carondelet St. Mary’s Hospital, noted, “There is an increasing gap between the preparation of new graduate nurses and the competencies needed in the acute care setting. In the last 5 years, there have been rapid changes in the practice environment propelled by the patient safety agenda. It's critical that academic and hospital leaders collaborate and align strategies to prepare nurses for success in the current and future practice environment."

Successful Programs Extend Length and Intensity of New Grad Orientation
Across the country, hospitals are tackling the problem of new graduate turnover in a variety of ways. First, hospitals are focusing on who they hire, implementing programs designed to find new graduate hires who are likely to have a good fit with the organization. A few examples of such programs are provided below.

Assisting incumbents to get a nursing degree

Leading hospitals around the country are recognizing the many benefits of helping existing employees attend nursing school, including the high degree of loyalty engendered through programs that offer flexible schedules and tuition assistance. The COO of Children’s Mercy Hospital attributes its low new grad turnover, in large part, to the fact that 70% of its new grad hires previously worked for the hospital as technicians and assistants.

Employee bonus referral plan

Seton Family of Hospitals, which offers a bonus referral plan of $2,000 per person hired, has found that employee referrals have a higher hire rate and retention rate than non-referrals. The referral plan also encourages staff to develop stronger relationships with students during rotations.

Smarter recruiting practices

To increase the effectiveness of its recruiting, UAB hired a full-time educational liaison to build strong relationships with nursing schools and students. The liaison also helped reduce new grad turnover by ensuring that new grad hires fully knew what to expect from UAB as well as serving as a friendly, support person during the first few months of a new nurse’s employment.

In order to address the growing gap between nurse education and clinical practice, many hospitals have revamped their orientation programs, adding more clinical content and extending the length of the orientation. In addition, many hospitals have developed new programs to provide more support to new graduate nurses.

Mentorship program

Emory Healthcare offers a mentor to each of its new grad hires. These mentors are separate from the preceptors who teach orientation classes. The mentorship program has the additional benefit of offering experienced nurses an interesting professional development opportunity.

Peer group support

Many hospitals are grouping their new nurse hires into cohorts or classes to encourage the development of peer networks.

Nurse internship program

UAB developed a six-month long nurse internship program where new graduate hires receive two months of orientation in three different clinical areas. Upon completion of the program, nurses can choose which area they would like to work in.

"There is an increasing gap between the preparation of new graduate nurses and the competencies needed in the acute care setting."
- Diana McBroom, CNO, Carondelet St Mary’s Hospital

The most comprehensive response to the difficulty new graduate nurses experience adjusting to hospital practice has been the development of yearlong nurse residency programs. These programs combine some of the elements listed above with more intense clinical training and class participation. One of the leading innovators, the University HealthSystem Consortium (UHC), offers a Post-Baccalaureate Residency Program that incorporates peer cohort groups, clinical narratives, an evidence-based curriculum, and mentors to assist with professional development. In addition, UHC’s program emphasizes the celebration of new nurses’ accomplishments throughout the residency culminated in a graduation ceremony.⁴ The first six pilot sites achieved a low turnover rate of eight percent with the first cohort of residents, and the program has now been implemented in 34 UHC hospitals.

HWS Perspective: A Worthwhile Investment
Now is the time for both hospitals and nursing schools to invest in ensuring successful transition for new grads from nursing school to clinical practice

Clearly the need for a highly competent sustainable nursing workforce coupled with the prevailing shortages requires strategic investment in new graduate nurses. The challenge for hospitals is ensuring a successful transition for new graduates from school to clinical practice and a successful bonding of new nurses to their institution. For most hospitals, addressing these challenges will require an evaluation of current onboarding programs and potentially the development of new, more intensive programs.


•	What is your turnover for new graduates within one year of employment? Is that rate acceptable?

•	Are your current orientation programs sufficient to help new graduates attain competency?

•	If not, do you have the expertise and capacity to develop new programs or do you need assistance?

•	What level of investment is required to upgrade your programs and what is the internal process to get it approved? How will you justify the costs?

•	Is your incumbent nursing staff willing and prepared to take on the necessary instruction and mentoring?

In addition to hospital-based efforts, there is a critical role for nursing schools to play here. Graduating nurses need a more realistic picture of clinical practice, as well as clinical skills that are responsive to the realities to clinical practice today. Nursing schools should start assessing how they can help reduce the gap between nursing education and clinical practice.

It is in everyone’s interest to make sure that funding invested in increasing nursing school capacity actually yields productive nurses who stay in clinical practice. Both hospitals and nursing schools have a clear interest in this, and both should work to ensure the successful development of a new nursing workforce.

¹ Halfer D. & Graf E. “2006 Graduate Nurse Perceptions of the Work Experience.” Nursing Economics. 24(3) 150-155. Goode C. & Williams C. “2004 Post Baccalaureate Nurse Residency Program.” Journal of Nursing Administration. 34(2) 71-77. Casey K. et al. “2004. The Graduate Nurse Experience.” Journal of Nursing Administration. 34(6) 303-311.

²Krugman, M. et al. “The National Post-Baccalaureate Graduate Nurse Residency Program.” Journal for Nurses in Staff Development. July/August 2006.

³“Fruits of Labor”. Nurse Week. June, 2002 as cited by Versant. www.versant.org.

⁴Krugman, M. et al. Supra N.2.