1. Windey, Maryann PhD, MS, MSN, RN-BC

Article Content

Healthcare organizations across the country are challenged to recruit nurses for specialty areas, including acute, postacute, and community practice areas. Also of concern are the turnover rates of newly licensed nurses (NLN) and of experienced nurses transitioning to new specialty area. The Institute of Medicine's (2011)Future of Nursing: Leading Change, Advancing Health Report recommends transition-to-practice programs for NLNs, advanced practice nurses, and nurses transitioning to new practice areas to improve retention. Costs to replace an RN can exceed $88,000 (Kovner, Brewer, Fatehi, & Jun, 2014). As a result, many healthcare organizations have developed residency programs for NLNs, and the literature is replete with research articles and narratives attesting to the positive impact of nurse residencies. I recently struggled, however, to find more than a few rigorous, research studies solely focused in the area of transitioning experienced nurses to new clinical practice areas. The American Nurses Credentialing Center Practice Transition Accreditation Program has defined experienced nurse transition programs as RN fellowships, "[horizontal ellipsis]registered nurses with 12 or more months of experience can acquire the knowledge, skills and professional behaviors to deliver safe, quality care that meets defined (organizational or professional society) standards of practice[horizontal ellipsis]" (American Nurses Credentialing Center, 2014, p. 4). In my healthcare organization, the number of experienced nurse applicants for our residency program has grown exponentially, and we made adjustments to meet experienced, transitioning nurses' needs. We have seen both opportunities for growing our residency program with experienced nurses, and we have experienced some challenges. This column will outline both.



Although our robust nurse residency for NLNs has grown over the last 16 years, we have seen a steady increase in experienced nurses interested in changing areas. In 2015, 50 of the 333 residents that completed our residency program were experienced nurses transitioning into different specialties. These 50 experienced nurses came with varied backgrounds, were a mix of internal transfers and external new hires, and had applied to work in at least 11 different specialties. Some of these areas included neonatal intensive care, pediatric intensive care, intensive care, emergency department, home health, post anesthesia care unit, operating room, labor and delivery, and mom/baby. This unique situation meant that we needed to work closely with the Human Resources and the Finance departments, as well as nursing unit directors and unit-based clinical educators, to support these nurses transitioning into new specialties.



The central education department partnered with the Human Resources department to create a recruitment and selection strategy. One component was experienced nurse applicants to interview with residency development specialists and the unit directors. The residency development specialist is an RN, who is a graduate-prepared nurse with at least 10 years of acute care and education experience, who can assist in matching experienced nurses to new clinical areas. Although our NLN residents agree to a 2-year work commitment, many request to change specialties before the work commitment is completed. This is consistent with a recent survey demonstrating that 91% of Millennials expect to stay in a job for less than 3 years (Meister, 2012). This situation has created a unique dilemma, in which we struggled between growing our nurses on their timeline or destabilizing a unit's staffing with internal transfers. It has also been a challenge for nursing leaders to accept that the lower acuity areas, such medical/surgical units, have become feeder units for the organization. The medical/surgical units are a way to on-board NLNs and also serve as a jumping off point after 1-2 years, allowing nurses to transition to a higher acuity or specialty areas. Although we hire new graduates directly on to high acuity units, it is usually the medical/surgical nurses who want to move after a year or two. It is imperative that we allow the interested nurses to move, within the organization, in order to retain them for the system.



In addition to human resource recruitment challenges, there needs to be close alignment with the Finance department to ensure adequate dollars to support the program. With our current low residency turnover and avoidance of hiring expensive contract staff, we were able to make the case to expand the residency to experienced nurses. Tracking mechanisms were put into place to measure a return on investment for the program. These measures include turnover, length of orientation, and competency assessment.



Experienced nurses moving into a different clinical area have unique needs, not unlike NLNs (Benner, 1984). New knowledge and skills must be attained, and clinical judgment, in the new context, must be developed. Using both the Benner (1984) and Del Bueno (2005) models as a framework, we were able to formulate guidelines in developing these experienced nurses. The goal was to provide practice-based learning at the bedside, rather than Nursing 101 in a classroom. There were many challenges in determining the length of orientation with the varied backgrounds of the experienced nurses. We budgeted approximately half the number of weeks of bedside orientation for the experienced transitioning nurses than we did for the NLN, but there were no hard or set rules. Each nurse receives the number of weeks of bedside development that are needed based on initial competency (critical thinking) assessment findings. We determined that the resident development specialist would provide support, consultation, and mentoring to the transitioning nurse, preceptor, unit-based educator, and director as needed.



The residency development specialist worked with both the director and unit-based educators to formulate individualized length of orientation goals for the experienced nurses transitioning and curriculum development guidance. In addition, individual educational plans were developed to determine which general residency classes the experienced nurse should attend (if any) and which unit- specific educational offerings they would complete. Many specialty units used a blended approach, which provided written and online modules, and didactic instruction. Preceptors were identified and additional development was provided in order to prepare them as clinical coaches for the transitioning experienced nurses.



As nurse professional development (NPD) practitioners, we should be using the current evidence in creating and improving experienced nurse residencies or fellowships. Although there is not a plethora of available, current, and rigorous studies solely focused on transitioning experienced nurses, we can draw from some of what has worked for NLN residencies. As we develop or work to improve our experienced nurse transition programs, it is essential to build-in evaluation methods to monitor outcomes. We need to be publishing and disseminating our efforts in order to further develop the current body of knowledge on transitioning experienced nurses. Moreover, we need to determine the return on investment of our experienced nurse residency or fellowship programs and communicate to organizational leadership.



The Institute of Medicine's (2011) report on the future of nursing was clear in its recommendation for developing residencies for transitioning experienced nurses. In addition, the American Nurses Credentialing Center Practice Transition Accreditation Program has defined the standards for experienced RN fellowships or residencies. The nursing shortage is forecasted to continue over the next decade, so healthcare organizations must reach out to not only the NLN but also the nurse who is interested in changing specialties. These transitional pathways must be available for the experienced nurse. NPD practitioners should partner with their nursing leadership, unit-based educators, human resource associates, and finance representatives in creating residencies or fellowship pathways for transitioning nurses. In addition, NPD practitioners should be diligent in ensuring high-level evaluations and disseminating their program outcomes.




American Nurses Credentialing Center. (2014). Practice transition accreditation program application manual. Silver Springs, MD: Author. [Context Link]


Benner P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. [Context Link]


Del Bueno D. (2005). A crisis in critical thinking. Nursing Education Perspectives, 26(5), 278-282. [Context Link]


Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. [Context Link]


Kovner C. T., Brewer C. S., Fatechi F., Jun J. (2014). What does nurse turnover rate mean and what is the rate? Policy, Politics & Nursing Practice, 15(3-4), 64-71. [Context Link]


Meister J. (2012). Job hopping is the "new normal" for Millennials: Three ways to prevent a human resource nightmare. Retrieved from[Context Link]