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Throw them out there

February 15, 2009 -- Today many press outlets ran a very good Associated Press story by Rasha Madkour about nascent efforts to keep new nurses at the bedside through nurse residency programs. The San Diego Union-Tribune headlined the piece "Amid nurse shortage, hospitals focus on retention." But the article really focuses on the particular problem of helping new nurses adjust to the intense demands of practice through formal, hospital-based training programs. The report gives a good basic sense of some of the major types of residency programs and how they can reduce the remarkably high 20% attrition rate for new nurses in the U.S. The article might have included more detail about features of the longer nurse residencies--which are still just one year--and more context regarding the far more extensive physician residencies, including the billions of dollars in federal government support those receive. We thank Madkour and the AP for this very helpful report on an important but often overlooked factor in the nursing shortage.

In the report, the story of new nurse Katie O'Bryan shows how "many novice nurses ... are thrown into hospitals with little direct supervision, quickly forced to juggle multiple patients and make critical decisions for the first time in their careers." O'Bryan lasted only nine months at a busy Dallas emergency department, where she left "the hospital every day wanting to quit." The piece reveals the stress of trying to keep her patients alive, describing the "breaking point" as a day when a child with seizures probably would have died if O'Bryan had not chosen to ignore advice that she could wait to check on him. Even though O'Bryan's hospital had a 3-month training program, with weekly classes and a shadowing element, after the program ended she was "abruptly alone, even as she continued to face new situations that she wasn't sure how to handle."

"When things are going good and I'm not overwhelmed and I'm able to help people, I love it," she said, recalling the gratification of seeing a bedridden patient finally manage to take a few steps. "There are always those moments," she said, "but they're interrupted pretty quickly." The 27-year-old is currently looking for a new job. She's not sure it will be in nursing.

The piece explains that many such novice nurses get little direct supervision. It quotes nursing professor Diane Vines of the University of Portland, who describes the traditional approach as "Throw them out there and let them learn." One study found that about 1 in 5 "newly licensed nurses quits within a year," which the report notes is a key factor in the growing nursing shortage. This is a critical point, because many recent articles seem to suggest that just training more nurses will resolve the shortage. The reality is that the shortage can't be resolved unless nurses receive far more clinical resources and support, since injecting new nurses will not help in the long term if they do not stay at the bedside.

The article reports that many hospitals are now trying to address the situation through residency programs. Some have set up shorter programs like O'Bryan's hospital did, but others are developing more extensive programs which "can cost roughly $5,000 per resident." The piece rightly notes, though, that recruiting and training a replacement nurse costs about $50,000.

The article spends significant time on specific efforts to develop residency programs. It explains that the American Association of Colleges of Nursing and the University HealthSystem Consortium developed a year-long program in 2002 that is now in place at 52 "sites." In 2007, the turnover rate in that program was an impressive 7%. AACN president Polly Bednash is quoted as saying that "all new graduates should be given this kind of support system." The piece reports that since 2003, the federal government has provided $17 million in grants for 75 hospitals to start such programs. The piece makes that sound like a lot, but it might have asked how the figure compares to the $6,400 million dollars the federal government has given to support physician residency programs during the same time period of 2003-2008 (which is about 375 times as much as the amount given for nursing residencies). The piece does note that medical school graduates undergo residencies for 3-7 years, but it might have explored how all of those costs are met, and whether more extensive nursing residencies should be funded in similar ways. The piece does note that the National Council of State Boards of Nursing is considering making some kind of "transition program" standard for nurses, citing a study showing a link between nurse residencies and fewer errors. The article might have explored both of those issues further.  

The piece reports extensively on the Versant RN Residency program, which operates at 70 hospitals nationwide, including Baptist Health South Florida, where the program has cut the turnover rate from 22% to 10%. The 18-week Versant program pairs new nurses with veterans. They share patients to start, but the new nurses gradually assume a greater role. The new nurses must also complete an extensive checklist, learning to master tasks like starting IV's, interpreting heart rhythms, doing full patient assessments, and keeping families informed. There is a classroom element (which the report does not explain), and program participants get support from mentors and a peer group, which allows regular "debriefing" or "venting" sessions. The piece profiles current participant Yaima Milian, who stresses how much better the program is than her first hospital experience at a New Jersey hospital with a six-week orientation. In New Jersey, Milian had a mentor, but they did not see patients together, and she had to handle complex patient issues by herself right away, which "felt very unsafe." Milian praises Baptist's peer debriefing element:

Here you have this group that is pretty much experiencing the same things you're experiencing, and it makes you feel better.

The article might have addressed how the Versant program differs from the one-year residences it explains elsewhere--after all, at 18 weeks the Versant program is only one third as long as those others.

On the whole, though the report could have used more detail and context in some areas, it is a very helpful look at the promising trend toward nurse residencies.

Take Action!

Please contact your elected officials about the disparity in funding for nursing and medical residencies. There are four times more nurses than there are physicians. If the government put a comparable amount of funding into each nursing residency slot, that would be roughly $32 billion per year, not the single-digit million dollar figures that nursing residencies now receive. Please ask your elected officials for the $32 billion per year for nursing residencies that nurses need and our patients deserve. Click here to contact your representatives. Please copy us on your letters at Thank you!


See the Associated Press item "Amid nurse shortage, hospitals focus on retention" by Rasha Madkour, posted on February 15, 2009 on the San Diego Tribune site.


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