Impact of Healthy Work Environments and Multistage Nurse ...

JONAVolume 42, Number 3, pp 148-159Copyright B 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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

Impact of Healthy WorkEnvironments and Multistage NurseResidency Programs on Retentionof Newly Licensed RNs

Marlene Kramer, PhD, RN, MSN, FAAN

Diana Halfer, MSN, RN, NEA-BC

Pat Maguire, MN, RN, NEA-BC

Claudia Schmalenberg, MSN, RN

The objective of the study was to examine effectsof nurse-confirmed healthy unit work environmentsand multistage nurse residency programs (NRPs) onretention rates of newly licensed RNs (NLRNs). Es-tablishing a culture of retention and healthy clinicalnurse practice environments are two major challengesconfronting nurse leaders today. Nurse residencyprograms are a major component of NLRN workenvironments and have been shown to be effectivein abating nurse turnover. Sample for this study con-sisted of 5,316 new graduates in initial RN roles in28 MagnetA hospitals. There were no differences inretention rates by education or patient populationon clinical unit. NLRN retention rate was higher incommunity than in academic hospitals. More thanhalf of NLRNs were placed on units with veryhealthy work environments. Newly licensed RNs onunits with work environments needing improve-ment resigned at a significantly higher rate than didother NLRNs. The quality of clinical unit work envi-ronments is the most important factor in NLRNretention.

Two major challenges confront nurse leaderstodayVcreating cultures of retention and fosteringhealthy work environments (HWEs).1-3 Job turn-over and abandonment of the profession by newlylicensed RNs (NLRNs) are a major source of cy-clical, sustained nurse shortages.4 The 2004 Insti-tute of Medicine1 (IOM) report, Keeping PatientsSafe: Transforming the Work Environment ofNurses, identified solutions to environmental prob-lems threatening patient safety. This report andother experts strongly recommend improvements inclinical nurses’ work environments as the best strat-egy for promotion of patient safety and increasednurse retention.3,5,6 NLRNYspecific professionalsocialization-transition programs, collectively la-beled nurse residency programs (NRPs) in thisstudy, are structural components of work environ-ments whose effectiveness in NLRN retention hasbeen demonstrated.7-11 The purpose of this researchwas to examine main and interaction effects ofhealthy unit professional practice environments andNRPs on NLRN retention.

Background

HWEs Defined

Nightingale12,13 defined nursing as the planned, sci-entific alteration of patients’ internal and externalenvironments placing patients in the best possiblesituation for the laws of nature to act, thereby facil-itating the healing process. Accordingly, a work envi-ronment is an ‘‘alterable medium’’ that can be usedto improve the structures/conditions and processes

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Author Affiliations: Vice President (Dr Kramer), HealthScience Research Associates, Apache Junction, Arizona; Admin-istrator (Ms Halfer), Clinical and Organizational Development,and On-site Investigator, Children’s Memorial Hospital, Chicago,Illinois; Senior Kaizen Specialist (Ms Maguire), MetroWestMedical Center, Framingham, Massachusetts; President (MsSchmalenberg), Health Science Research, Associates, Tahoe City,California.

The authors declare no conflict of interest.Correspondence: Dr Kramer, Health Science Research Asso-

ciates, 3285 N Prospector Rd, Apache Junction, AZ 85219([email protected]).

DOI: 10.1097/NNA.0b013e31824808e3

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

of practice and subsequently patient outcomes.12

Healthy work environments enable and facilitate es-sential nursing processes, the force of natural laws,and ultimately result in improvement in patientoutcomes.13,14

In 2001, the Essentials of MagnetismB tool,EOMB, was developed to measure the work pro-cesses and relationships that constitute healthy,productive clinical unit work environments.15 Suchenvironments enable nurses to engage in the steps/components of 8 work processes identified by clin-ical nurses in 14 MagnetA hospitals as essential todelivery of quality patient care. The 8 processesVindependent/interdependent clinical decision mak-ing, collaborative RN-MD relationships, perceivedadequacy of staffing, working with clinically com-petent peers, supportive nurse manager relation-ships, control over the context of nursing practice,support for education, and working in a patient-centered cultureVare interrelated and codependent.Together, they define a productive, healthy work/professional practice environment. In 2004, theIOM1 defined nurses’ work environments as anyphysical, personal, or system component that pro-motes or enables nurses to enact the work processesand establish the interpersonal relationships essentialto safe, quality patient care. Healthy work environ-ments contained the basic production processes and5 bundles of safeguards needed for safe patient care.Six of the 8 EOM are included in the IOM pro-duction processes or bundles of safeguards.1(p315)

There is a great deal of inconsistency as towhether HWEs are defined and measured at thehospital level or at the unit level. Healthy work en-vironments have been defined broadly as ‘‘a practicesetting that maximizes the health and well-being ofnurses, quality patient/client outcomes, organizationperformance, and societal outcomes.’’16(p11) Otherstudies17,18 that utilize the Practice EnvironmentScale of the Nursing Work Index (PES/NWI) measurework environments at the hospital level and almostas synonymous with the presence of the forces ofMagnetismA. Items for the PES/NWI are derivedfrom the same source, the 1983 original Magnet hos-pital report,19 as the forces or structures of Magnetismthat must be evidenced for Magnet designation.20

Comprehensiveness and accuracy of each NWI itemwere verified by 3 of the 4 original Magnet hospi-tal researchers.21

Another common way of defining and measur-ing healthy, productive work environments is byequating them with nurse job satisfaction.4,6,22,23

Four general categories of job satisfiers have beenidentified: (1) organizational components (workschedule, staffing ratio, workload, resources); (2)

structural conditions (facility and physical layout);(3) interpersonal relationships with peers, clients,administrators, healthcare providers; and (4) pro-fessional factors such as autonomy, interdisciplinarycollaboration, career development, and advance-ment.24 Clinical nurses differentiate job satisfaction/satisfiers (categories 1 and 2) from professional prac-tice satisfaction/satisfiers (categories 3 and 4 above).Job satisfiers attract, whereas professional practicesatisfiers retain, nurses in their positions.25

Nurse Residency Programs

Since the empirical testing of the initial federallyfunded anticipatory socialization program and re-flective new graduate seminars in 8 major medicalcenters from 1966 to 1974,26,27 NLRN professionalsocialization programs have developed and flour-ished nationwide. These programs vary with respectto length, number of stages, theory-based and -drivengoals, components, expected role performance, andtitlesVinternships, residencies, mentorships, fellow-ships, and new-graduate orientations. Most containa short, standard hospital orientation, followed by acognitive apprenticeship period and then a guided, in-dependent practice stage. With increasing recognitionof nursing as a profession and the increasing demandsfor professional performance and accountability, nurs-ing has moved from the training-orientation model ofthe 20th century28,29 to the professional socializationmodel utilized in most professions and in all otherhealthcare professions.30-32

The professional socialization model consists of3 stages, each with its own theme, goal, and expectedrole performance. ‘‘Knowing’’ is the academic prep-aration stage, characterized by knowledge and role/skill acquisition. ‘‘Becoming’’ is the transition stageand, in nursing, tends to be 2 to 3 months in lengthand has 3 goals: (1) stress management, (2) skill com-petence, and (3) dependent practice or a cognitiveapprenticeship in ‘‘real life’’ situations with a precep-tor. ‘‘Integrating/affirming’’ is the theme of the thirdstage, which usually extends from 9 to 12 months.The goal of this stage is independent performance ofthe dominant professional role as well as integrationinto professional communities and peripheral rolesassociated with the professionVteaching, research,risk manager, political and societal participation, andrepresentation on committees and councils. In nurs-ing, the dominant professional role in hospitals is pro-vision of care and management of clinical situationsfor multiple patients, simultaneously.30-32 Key com-ponents of the integration stage are evidence-basedmanagement practice, recognition of complex sys-tems assisted by clinical coaches and career planning,

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development, and meeting of professional and soci-etal responsibilities assisted by mentors.30-33

Conceptual Model and Framework forNLRN Program of Research

This 7 study NLRN research program utilized theSystems Research Organizational Model (SROM)34

to assess the differential impact of client, contextual,and action focus variables on 7 outcomesVNLRNs’expectations of the professional practice environment,environmental reality shock, shock-related issuesand concerns, professional work satisfaction, nurse-assessed quality of patient care, retention, and degreeof professional role integration/affirmation.30-32,35,36

Based on the American Academy of Nursing qualityhealth outcomes model and Donabedian’s14 struc-ture, process, outcome (S-P-O) paradigm, the SROMprovides an avenue for systematizing and organizingmultiple variables, thereby facilitating theory devel-opment, hypothesis generation, and ultimately theformulation of strategies to improve the dynamic, in-teractive environment in which nurses practice.

Donabedian’s14 S-P-O paradigm was used to ex-amine interrelationships among variables in all stud-ies in this research program. Major premises of thisframework are that assessment of outcomes such asquality patient care, patient falls, professional practicesatisfaction, and nurse retention requires examinationof relationships among all 3 linearly related variablesin the paradigm: ‘‘Process is a more direct measure ofquality than is either structure or outcome.’’14(p81)

Outcomes can be predicted directly through identi-fication of processes or indirectly by assessment ofprocesses associated with specific structures.37 Omis-sion or improper sequencing of any of the compo-nents, such as in structure-outcome studies, can leadto faulty outcomes or conclusions.38

Structures include components such as physicallayout, staffing ratio, personnel policies, committeestructure/composition, leadership practices, equip-ment, and technology. Respondents’ perceptions ofthe absence or degree of presence are appropriateevidence of structures, but they are not an adequatemeasure of work/practice processes.14 The latterrequires measurement of the steps and componentsthat constitute the process or make up the relation-ship. As in any process, some steps are more essen-tial than others; these must be weighted in itemresponses.37

The field of measurement must be appropriateto the component being measured. Presence of ex-cellent magnetic structures can be validly measuredat the hospital level, as well as at the unit level suchas in the nationwide ICU study.38 Accurate measure-

ment of work processes and relationships must bedone in the environment that is central to the actionfocus which, in hospitals, is the clinical unit, clinic,or professional practice group. Outcomes can bemeasured in either the hospital or clinical unit field,depending on their focus.14

Research Questions

1. To what extent is the aggregate of excellent,magnetic organizational structures as evi-denced by Magnet hospital designation pos-itively related to healthy, productive, clinicalunit work environments as evidenced by the8 work processes and relationships essentialfor quality patient care? (S-P)

2. Do NLRNs working on clinical units withconfirmed very healthy work environments(VHWE) have higher 3-year retention ratesthan do NLRNs working on units with lessHWEs? (P-O)

3. Do NLRNs who have multistaged NRPsreport smoother transition and higher reten-tion rates than do NLRNs who experiencetransition stageYonly NRPs (S-P-O)? Is therean interactive (HWE � multistage NRP) effectbetween NRPs and NLRN retention?

Methods

Design, Setting, and Samples

Hospital SampleIn this longitudinal quantitative study, a descriptivedesign was used to examine the impact of excellent,magnetic organizational structures and multistageNRPs on professional nurse practice and transitionprocesses, and on the outcome, NLRN 3-year reten-tion rate. Forty Magnet hospitals were selected onthe basis of (1) ‘‘excellence’’ designations (Balridge,100 Top Hospitals, Best Places to Work) in additionto Magnet; (2) type of hospital (community teaching,academic, community), geographical location (censustrack regions), and size of community in which thehospital was located (G100,000; 100,000 to 500,000;500,000 to 1 million; and 91 million); and (3) length,components, goals, and parameters of NRPs. To par-ticipate, hospitals had to have a NRP operative for atleast 3 years. Hospitals were selected for represen-tation from national, multihospital NRPsYUniversityHospital Consortium, Versant, Milwaukee, dedicatedtransition units, TRAC (transitioning across thecontinuum), PACE (practical application clinicalexperience)Y and from hospital-developed programs,particularly those with published, empirically testedoutcomes. The sample selection goal was to select

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the ‘‘best of the best’’ hospitals with considerationof national representation of geographic contextualvariables. Each hospital appointed on-site investiga-tors who obtained all necessary institutional reviewboard approvals.

Clinical Unit Sample and HWE DesignationTo test the impact of HWE status on NLRN reten-tion, the EOMII was administered to experienced(not new graduates) nurses on clinical units in the40 selected Magnet hospitals. Hospitals had a choiceof administering the EOMII to nurses on all unitsor only on those usually onboarding NLRNs. TheEOMII is described in the HWE background sec-tion. Development, content/criterion validity, itemweighting, reliability, and factor analysis are detailedin the studies of Kramer and Schmalenberg.39,40

Cronbach !’s for total EOMII and 8 subscales rangefrom .83 to .97. For valid and reliable data aggre-gation from individuals to the group (unit) level, a40% EOMII unit response rate is needed.41

To obtain a national picture of the extent towhich clinical nurses perceive they practice in clin-ical environments that enable provision of safe, qual-ity patient care, a national Magnet hospital profile(NMHP) utilizing samples from EOM administrationto clinical nurses in more than 1,000 hospitals (n =253 Magnet hospitals) was established. Analysis ofvariance (ANOVA) with post hoc multiple compar-isons using Tukey statistical procedures on unit-aggregated data identified the statistically significant(P Q .05) homogeneous subsets.40 The highest subsetwas labeled the NMHP, the middle subset was iden-tified as the Magnet -aspiring profile, and the lowestsubset was named the non- Magnet profile. NationalMagnet hospital profiles are updated periodically;data from 124 Magnet and Magnet -aspiring hospi-tals were used to construct the latest profiles.40

The EOMII was administered to 12,233 expe-rienced nurses (new graduate nurses excluded) work-ing on 717 units in 40 selected hospitals.36 Resultsare based on responses from 10,752 nurses practic-ing on 540 units in 34 hospitals meeting the 40%unit response rate requirement for valid dataaggregation. The designation of VHWE was givento units with EOMII scores greater than 1 SD abovethe NMHP mean, whereas HWE-designated unitsare those with EOMII scores between 1 SD aboveand 1 SD below the NMHP mean. Clinical unitswith EOMII scores of greater than 1 SD below theNMHP mean were designated as work environmentsneeding improvement (WENIs).40

NRP SampleThe multistaged sample of NRPs was obtained byanalyzing extensive residency program question-

naires completed by facilitators in each hospital.32

Based on theories, components, content analysis,and synthesis of professional socialization literature,these surveys were used to assess the extent to whichNRPs reflect the professional socialization processutilized in other professions. The NRP sample con-sisted of 3 groups: (1) 4 hospitals that had NRPsconsisting of a clearly defined, 2-stage transition(first 3 months) plus integration (7-12 months) pro-gram ranging in length from 10 months to 12 years,(M = 1 year); (2) 14 hospitals with NRPs rangingin length from 8 months to 1 year, (M = 1 year),with a definite transition-stage program, and someevidence of integration stage components; and (3)10 hospitals with transition stageYonly NRPs rang-ing in length from 2 to 5 months (M = 3 months).

Data Collection Tool

Three years (2006, 2007, and 2008) of NLRN re-tention data were collected for this study, utilizinga retention history form developed with the assis-tance of human resource specialists from 2 Magnethospitals not participating in the study. They ad-vised on clarity, availability of requested informa-tion, and ease of completion. The form was thencritiqued and evaluated for clarity and ready avail-ability of data by nurse residency coordinators andhuman resource specialists in 3 additional Magnethospitals. Data requested included nursing educa-tion, hire date, unit assignment, resignation date,reason for resignation, transfer date, and unit trans-ferred to, if applicable.

Data Analysis

NLRN retention rates at 6 months and 1, 2, and 3years post hire, based on the number of employedmonths, were used for correlational analyses. Thenumber of months employed was the interval leveldata used to test direct and interactive (univariateand multivariate) relationships (contrasts) betweenand among multiple independent and dependentvariables.42

Results

Description of Hospital Sample

Twenty-eight of the 34 hospitals submitted 3-yearretention data for 5,316 NLRNs employed from2006 through 2008. Contextual variables, which in-cluded type of hospital, regional location, and pop-ulation of community in which the hospital waslocated, were used to check whether the nationalrepresentativeness of the 28 hospitals was close

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to that of the original sample. Results indicatedsignficantly fewer Midwest and fewer academichospitals (#2 = 30.914; P 9 .000) in the 28-hospitalretention study sample than in the 34-HWE con-firmation36 study sample.

Educational Preparation of the NLRN SampleData were provided for 85.6% of the NLRN sam-ple (n = 4,555) employed during 2006, 2007, and2008. Seventy percent of the sample (n = 3,188)was prepared at the bachelor’s (BSN) level; 28%(n = 1,253) had associate degrees (ADN); 2% (n =73) had diplomas, and 0.09% (n = 41) had earnedMSN or PhD degrees as their initial preparation.

Patient Population on NLRN-AssignedClinical UnitsMore than 40% of the NLRNs (n = 2,262; 42.9%)began their initial professional practice experienceon surgical specialty (12.7%), general medical surgi-cal (10.6%), telemetry (10.2%), and medical spe-cialty (9.4%) units. Almost 30% (n = 1,420; 27%)began practice in ICUs. The remaining 30% weredivided among oncology (6.5%), emergency depart-ment (5.7%), orthopedic (4.8%), obstetric (4.7%),operating room (OR)/postanesthesia care (PACU)(4.7%), and pediatric (3.8%) units. Thirty-eightNLRNs (0.7%) were assigned to psychiatric units(Table 1).

HWE Designation of Clinical Units to WhichNLRNs Were AssignedThere were significant differences in the number ofNLRN assignments by HWE unit designation. Halfof the 5,316 NLRNs (n = 2,659; 50.1%) wereassigned to VHWE units. The other half were splitbetween HWE (n = 1,444; 27.2%) and WENI units(n = 1,213; 22.7%) (Table 1). Multivariate analysisindicated a significant interactive effectYNLRNclinical unit placement by HWE unit designation(F ratio = 42.077; p 9 .000). Significantly fewerNLRNs were placed on medical-surgical, medicalspecialties, and telemetry HWE units than onsimilar VHWE and WENI units. Fewer NLRNs wereplaced on WENI orthopedic units than on HWEorthopedic units. Fewer NLRNs were placed onVHWE OR/PACU units than on HWE- and WENI-confirmed OR/PACU units.

Outcomes: Research Question 1: Are MagnetOrganizational Structures Positively Relatedto HWEs? (S-P)

In the confirmation study,36 experienced nurses con-firmed VHWE on 54% (n = 291) of the 540 clinicalunits in the 34 Magnet hospitals that submittedsufficient data (940% unit response rate) for valid,reliable data aggregation; 28% of the units (n =150) were confirmed as HWE units; 18% (n = 99)were confirmed as WENI. In 1 hospital, all 28clinical units were confirmed to have VHWEs. In

Table 1. Significance of Differences in Placement of NLRNs (n = 5,316) by Unit PatientPopulation and HWE Designationa

Patient Population of Clinical Unit

VHWE HWE WENI Total

No. % No. % No. % No. %

Surgical specialties 289 10.9 225 15.6 156 12.9 670 12.6General medical-surgical and resource pool 356 13.3 84 5.8 135 11.1 569 10.7Medical specialties including dialysis, rehabilitation,

outpatient care clinics275 10.3 111 7.7 159 13.1 551 10.4

Telemetry 319 12.0 56 3.9 162 13.4 537 10.1Neonatal-pediatric ICU 258 9.7 133 9.2 100 8.2 491 9.2Surgical-trauma ICU 194 7.3 77 5.3 77 6.3 348 6.5Oncology 154 5.8 124 8.6 66 5.5 344 6.4Medical-neurological ICU 166 6.3 66 4.5 83 6.8 315 5.9Emergency department 161 6.1 85 5.9 55 4.5 301 5.7Medical-surgical ICU 173 6.5 61 4.2 32 2.6 266 5.0Orthopedic 105 4.0 118 8.2 30 2.5 253 4.8Obstetric 94 3.5 88 6.1 65 5.4 247 4.7OR/PACU, same-day surgery 25 0.9 136 9.4 86 7.1 247 4.7Pediatric (in general hospitals)b 79 3.0 60 4.2 0 0.0 139 2.6Psychiatric 11 0.4 20 1.4 7 0.6 38 0.7

Total 2,659 50.1 1,444 27.2 1,213 22.7 5,316 100.0

aPearson #2 = 584.807; P 9 .000. Sources of significant differences are in bold font.bFour children’s hospitals participated in this study. The clinical units in these hospitals were classified by medical diagnoses/treatment,not by patient population.

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7 additional hospitals, all clinical units surveyedwere confirmed to have either VHWE or HWEs.

Outcomes: Research Question 2: Do NLRNsWorking on Clinical Units With ConfirmedVHWE Have Higher 3-Year Retention RatesThan Do NLRNs Working on HWE oron WENI Units? (P-O)

Retention Rates by HWE Unit Designation andMonths/Years After HireRetention rates are significantly lower on WENIunits than on HWE and VHWE units at all 4 periods(Table 2). Differences are greatest at 6 months and1 year after hire. Drop in retention rates betweenyears 2 and 3 was less on WENI and HWE unitsthan on VHWE units. There was a significant drop(14%) in overall retention rates from 6 months to2 years and from 6 months to 3 years after hire(17%). Drops in retention rates from 6 months to1 year (6%), from 1 to 2 years (8%), and from 2 to3 years after hire (3%) were not significant. Differ-ences in interval-level retention data are significantin the predicted direction for all possible compar-isons. NLRNs practicing on WENI units resign with

significantly greater frequency than do their counter-parts on HWE and WENI units (Table 3).

ResignationsAlmost a quarter of the 5,316 NLRNs (n = 1,264;23.777%) resigned during their first 3 years of pro-fessional practice. Significantly more (#2 = 86.499;P 9 .000) NLRNs on WENI units (n = 209; 55%)resigned during their first 6 months after hire thandid NLRNs on HWE (n = 111; 33%) or VHWE(n-77; 14%) units. Resignation rates during the sec-ond 6 months post hire were similar by HWE unitdesignationsV22% on WENI units, 23% on HWE,and 25% on VHWE units. (Data not shown).

Reasons for ResignationsSignificantly more NLRNs on VHWE units (n = 514;45%) resigned voluntarily than did those on HWE(n = 309; 27%) and WENI units (n = 319; 28%).Significantly more NLRNs on WENI units (n = 64;52%) resigned involuntarily than NLRNs on HWE(n = 28; 23%) and VHWE (n = 31; 25%) units. Thetotal number of involuntary resignations was 123(9.7%) (Table 4).

Table 2. Significance of Difference in NLRN Retention Rates at 6 Months, 1 Year, 2 Years,and 3 Years After Hire by HWE Unit Designationsa

Periods

VHWE Units HWE Units WENI Units RRVAll Units

22 PNo. RR No. RR No. RR No. RR

186.499 9.0006 mo 2,582 97 1,333 92 1,004 83 4,919 931 y 2,443 92 1,257 87 921 76 4,621 872 y 2,209 91 1,147 79 856 71 4,212 793 y 2,114 80 1,108 77 830 68 4,052 76

Abbreviation: RR, retention rate.aRetention rates are based on voluntary and involuntary resignations; 9.7% of the resignations were involuntary. Excluding these had littleeffect on overall retention rates. At year 3, excluding involuntary resignations raises the retention rate for NLRNs on VHWE units from80% to 81%, on HWE units from 77% to 79%, and for NLRNs on WENI units from 68% to 69%.

Table 3. Significance of Differencesa in NLRN 3-Year Retention Rate (Length of Employment)by Paired HWE Unit Designations

Paired HWE Unit Designations Mean Difference Standard Error P F P

77.092 .000Very healthyYhealthy 0.2948b 0.0490 .000

Needs improvement 0.5825b 0.0471 .000HealthyYvery healthy j0.2948b 0.0490 .000

Needs improvement 0.2878b 0.0528 .000Needs improvementYvery healthy j0.5825b 0.0471 .000

Healthy j0.2878b 0.0528 .000

aANOVA with post hoc multiple comparisons.bMean square between groups = 38.527. Mean difference between paired HWE unit designation is significant at the .05 level.

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Effect of Contextual Variables on NLRN 3-YearRetention Rates

Retention Rate by NLRN Cohort YearThere were significant differences (#2 = 224.797;P 9 .000) in the 3-year retention rate among the2006, 2007, and 2008 cohorts. Newly licensed RNsin the 2008 cohort had significantly higher retentionrates (87.2%) than did those in the 2007 (74.5%)or the 2006 cohorts (65.5%). On-site investigatorsvolunteered the information that the higher 2007 and2008 retention rates may have been due to theeconomyVspecifically, that NLRNs remained in theirpositions because their spouses lost their jobs or be-cause of other variables requiring financial stability.

Retention Rate by Type of HospitalThree-year NLRN retention rates in the 12 com-munity hospitals were significantly higher (#2 =

596.731; P 9 .000) than retention rates in the 16academic medical centers. Community hospital ratesranged from 76% to 93% (M = 85%). Academicmedical center retention rates ranged from 55% to89% (M= 75%; median = 78%).

Retention Rates by NLRN EducationalPreparation and HWE Unit DesignationRetention rates by educational preparation were notsignificant either alone or interactively with HWE unitdesignation. The only significant relationship was re-tention rate by HWE unit designation (Tables 2 and 5).

Retention Rates by Patient Population andHealthy Environment Unit DesignationThere were no significant differences in NLRN re-tention rates by clinical units (F = 1.486; P = .115),nor was there an interactive effect between patient

Table 5. Significance of Difference in 3-Year Retention Rate (of NLRNs) by EducationalPreparation of Nurse and HWE Designation of Unita

Education VHWE RR HWE RR WENI RR

Education

FP for HWE

Group F

P forEducation

Group F

P for HWEGroup �EducationNo. RR

8.070 9.000 2.323 .074 0.516 .797ADN 84 87 70 1,253 81Diploma 82 68 75 73 74BSN 81 78 70 3,188 77MSN/PhD 70 54 80 40 66RR � HWE 82 79 70 4,555 78

Abbreviation: RR, retention rate.aEducational program data were not provided for 761 of the 5,316 NLRNs. Total sample size = 4,555

Table 4. Significance of Difference in NLRN Resignations by HWE Unit Designationa

Reasons for Resignation

VHWE HWE WENI Total

No. % No. % No. % No. %

VoluntaryVno specific reason provided 171 39.8 144 33.6 114 26.6 429Relocation 122 49.8 68 27.8 55 22.4 245Personal (family, travel, pregnant, care for elderly) 78 48.1 36 22.2 48 29.6 162Better job, more pay, better commute, better schedule 55 37.9 35 24.1 55 37.9 145Dissatisfied with job, hours, work schedule, conflict 45 53.6 12 14.3 27 32.1 84Professional advancement, school, career opportunity 34 65.4 7 13.5 11 21.2 52Leaving nursing profession, career change 8 33.3 7 29.2 9 37.5 24

Total voluntary resignations 514 45.0 309 27.1 319 27.9 1,142 (90.3)

InvoluntaryVno specific reason given 6 27.3 7 31.8 9 40.9 22Performance issues 12 30.8 6 15.4 21 53.8 39Counseled out 3 14.3 9 42.9 9 42.9 21Job abandonment 1 7.7 0 .0 12 92.3 13Quit in lieu of discipline 3 25.0 3 25.0 6 50.0 12Terminated 2 22.2 2 22.2 5 55.6 9Lapse in legal authorization 5 71.4 0 0.0 2 28.6 7

Total involuntary resignations 31 25.2 28 22.8 64 52.0 123 (9.7)TotalVvoluntary and involuntary resignations 545 43.1 336 26.6 383 30.3 1,264 (100.0)

aPearson #2 = 124.761; P 9 .000.

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population and HWE unit designation (F = 1.454;P = .069). The only significant difference in thisANOVA was that NLRN retention rates werehigher on VHWE units than on HWE and WENIunits (F = 42.077; P 9 .000). Three-year retentionrates ranged from 72% to 74% on medical-surgical,OR/PACU, obstetrics, pediatrics, and neonatal ICU/pediatric ICU units to 78% to 80% on telemetry,medical-surgical ICU, emergency department, med-ical ICU, oncology, and orthopedic units. Retentionrates on medical and surgical specialty units and inthe surgical ICU were 75%. Overall retention rateon VHWE units was 80%; on HWE units, 76%;and on WENI units, 68% (F = 77.092; P 9 .000).

Retention Rates by Unit TransfersAlmost 10% (n = 490; 9.2%) of the 5,316 NLRNstransferred to another unit at some time during theirfirst 3 years of practice. Of these, 401 (82%) weresuccessful, that is, the nurse remained employed afterthe transfer. Although not significant (#2 = 5.080; P =.079), 48% of these successful transfers (n = 191)were by NLRNs who transferred to VHWE units;28% (n = 112) were by NLRNs who transferred toHWE units, and 24% of the NLRNs transferred toWENI units.

There were highly significant (#2 = 168.51; P 9.000) differences in transfer pattern by hospital.Four hospitals had no transfers. However, in one ofthese, the NRP was centered in a 9-unit medical-surgical resource pool30-32 that functioned as a dedi-cated transition unit.43 At the end of the 10-monthNRP, NLRNs had the option of choosing to remainin the resource pool or become a member of the staffon 1 of the 9 units to which they had rotated duringthe NRP. This reassignment was not considered atransfer. In 3 other hospitals, two-thirds of the 91

transferees (n = 62; 68%) resigned. In the remain-ing 21 hospitals, there were a higher percentage ofsuccessful transfers, that is, NLRNs who remainedemployed for at least 1 year after transfer. In 15 ofthese 21 hospitals, all NLRNs who transferred re-mained employed. In 7 of the 15 hospitals, resigna-tion rates of NLRNs who transferred to anotherunit ranged from 5% to 22%. In 1 of these 7 hos-pitals, all 53 NLRNs who transferred remained em-ployed at the 3-year period. Many of the retentionhistory forms containing the transfer data containednotations such as ‘‘transfers are used as a strategyfor finding the best fit between the new graduate,the community of nurses on the unit, and the pa-tients on the unit.’’ Some hospitals indicated thatthey always start NLRNs out on units known tobe excellent unitsVwell-organized, very competentnurses who are kind to new graduates.

Outcomes: Research Question 3: Do NLRNsWho Experience Multistaged, that is, Transition +Integration Stage NRPs Have Higher RetentionRates than do NLRNs Practicing in HospitalsWith Transition StageYOnly NRPs? Is there anInteraction Effect (HWE by MultistageNRP by NLRN Retention)?

None of the relationships between retention ratesat stated periods and number of stages of NRPswere significant (Table 6). The relationship closestto what was expected was the 7-point difference(83%-90%) in retention rates between NLRNs intransition stageYonly programs and those in transition+ integration stage, and transition and integrationstages possible at 6 months after hire. Retention ratesat 1 year after hire ranged from 86% to 89% with amean of 87%; at 2 years, they ranged from 78% to82% with a mean of 83%; at 3 years, they ranged

Table 6. Significance of Difference in NLRN Retention Ratesa at 6 Months, 1 Year, 2 Years,and 3 Years After Hire by Number of Stages of NRP

Periods

Transition +Integrationb

Transition; Integration StagePossiblec

Transition StageOnlyd

Totale byPeriod

22 PNo.e RR No. RR No. RR No. RR

11.313 9.0796 mo 413 90.4 3,230 90.0 1,176 83.5 4,919 92.51 y 391 86.0 3,110 86.3 1,120 89.1 4,621 86.92 y 364 79.6 2,809 78.0 1,039 82.6 4,212 79.23 y 350 76.6 2,683 74.5 1,019 81.0 4,052 76.2

Abbreviations: MANOVA, multivariate ANOVA; RR, retention rate.aUnless otherwise specified, retention rates are based on voluntary and involuntary resignations. Pearson #2 could report as MANOVA.bFour NRPs, ranging in length from 10 months to 12 years, mean of 1 year.cFourteen NRPs ranging in length from 8 months to 1 year with a mean of 1 year.dTen NRPs ranging in length from 2 to 5 months with a mean of 3 months.eNumber of NLRNs who remained employed at the time period.

JONA � Vol. 42, No. 3 � March 2012 155


from 75% to 81% with a mean of 77%. Newlylicensed RNs in transition + integration stage NRPsor in NRPs of sufficient length to have both stageswere closer together in retention rates than wereNLRNs in transition stageYonly NRPs.

Analysis of variance on retention rates by num-ber of NRP stages and by healthy unit designationindicated no significant differences among NRPgroups (F =.749; P = .473), nor was there a signif-icant interaction effect between the number of NRPstages by healthy unit designation (F = 1.755; P =.136). The only significant effect in retention ratewas by healthy unit designation (F = 40.606; P 9.000). NLRNs on VHWE units had higher retentionrates than did NLRNs on HWE and WENI units(data on this variable are not shown.)

LimitationsThis study may not have adequately tested the im-pact of multistage NRPs on NLRN retention. Res-idency program questionnaires32 were used to groupNRPs on the basis of length, precepted experience,2-stage goal differentiation, expected role perfor-mance, and inclusion of major components in eachstage. Differences between dependent-transition andindependent-integration stages are clearer when thesestages are cast into 2 separate programs, such asmedical clerkships (transition) and first-year residen-cies (integration/affirmation). In nursing, the 2 stagesare almost always combined into a single residencyprogram, or a transition-only stage NRP is offered.

In the conduct of the organizational trans-formation power of NRP study,30,31 many of the 927NLRN (6 months to 1 year after hire), clinical nurse,and nurse manager interviewees discussed the sig-nificance of ‘‘rites of passage,’’ particularly gradu-ation exercises and placement of nurses’ names onthe staffing roster after completion of the preceptedtransition stage (3 months after hire). These ritessignified to nurses, physicians and others that the newgraduate had completed the NRP, was now consid-ered competent to fly solo, and also was a countedmember of the unit professional staff.44 When in-terviewees in hospitals with transition stageYonlyprograms identified socialization components or ac-tivities such as peer/clinical coaching and mentoring,usually found in the integration stage as helpful,30,31

and if graduation had already occurred, these hos-pitals may have been misclassified. They were clas-sified as transition stageYonly programs, when in fact,NLRNs were receiving some integration-stage help.

In addition to this misclassification of NRPs,premature rites of passage signifying to NLRNs thatthey were ready to handle the dominant nurse roleVcare and management of clinical situations for mul-

tiple patients, simultaneously32Vwhen they judgedthemselves as inadequate resulted in a marked lossof self-confidence or evaluation of the NRP as inad-equate. In either case, increased turnover was likelyto result.

Another limitation in the effective assessmentof the impact of multistage NRPs on NLRN reten-tion is that 5 of the 6 hospitals that did not provide3-year retention data were academic medical centers;in 4 of these 6 hospitals, NRPs were classified astransition stageYonly programs based on residencyprogram questionnaires. Findings indicate that re-tention rates are significantly higher in communitythan in academic hospitals. Based on professionalsocialization theory, it was expected that NLRNsin transition stageYonly NRPs would have lowerretention rates than would NLRNs in multistageNRPs. The loss of 5 academic centers may well havecontributed to an inadequate test of the impact ofmultistage NRPs on NLRN retention.

Discussion

Conclusions from this NLRN retention study willbe organized around 4 major problematic issuesrelated to clinical nurses’ work and work environ-ments that were identified by nurse leaders in anational research forum45: (1) the need for a con-sensus definition of what constitutes HWEs; (2)increasing awareness of and need to study pro-cesses inherent in the professional practice of nurs-ing. Process measurement, although more complexthan structure or outcome measurement, is neces-sary because ‘‘you cannot improve what you cannotmeasure’’46(p6); (3) need for ‘‘staff nurses to tell usabout their work environments,’’ about what it isreally like to be a clinical nurse; and (4) where/how dowe study nurses’ work environment and the issuesrelated to data aggregation to unit/group level?

Conclusions

Healthy Professional Practice Environments

The most consistent, significant finding in thisstudy is that healthy unit work environments makea difference. Not all, but 82% of the units in theseMagnet hospitals were confirmed to have VHWEsor HWEs. Newly licensed RNs practicing on VHWEunits report higher professional work satisfaction,less environmental reality shock, expectations morein line with role conceptions30,32,35 and have higherretention rates than do NLRNs working on HWEand WENI units. Validity and reliability of thesefindings are enhanced by the fact that HWE desig-nations were made from data provided, not by nurse

156 JONA � Vol. 42, No. 3 � March 2012


executives, managers, or NLRNs but by a valid andreliable (Q40%) sample of clinical nurses practicing onthe clinical unit for at least 1 year (median, 12 years).

Whether viewed from a structure or a processperspective, there is a strong need for consensus onwhat constitutes HWEs. Structural componentsVphysical layout, work characteristics, attributes ofleaders, policies, and best leadership practicesVneeded for HWEs have been identified by manyprofessional and regulatory agencies, the Joint Com-mission, and numerous nursing organizations includ-ing the National Council of State Boards of Nursing,American Nurses’ Credentialing Center, AmericanAssociation of Critical Care Nurses, and the RobertWood Johnson/IOM report on the future of nurs-ing.3 Nine structures/best leadership practices neededfor execution of the 8 processes essential for qualitycare were identified through interviews with almost1,500 staff nurses, nurse managers, physicians, andtherapists in 21 Magnet hospitals.47 Now may wellbe the time for nurse leaders to advance strategicimprovements in nurse work environments, throughagreement on a definition, by consolidation of themost effective structures needed for excellent practiceenvironments from the various lists mentioned above,and by assessment of the quality of work environ-ments at the unit level.

Selection of Magnet hospitals for a study automat-ically identifies the structures of interest since Magnetdesignation is based on evidentiary achievement of theForces of Magnetism and the Magnet Model compo-nents derived from these Forces and from the originalMagnet hospital report.19 Structure-outcome studiesthat omit the process component of Donabedian’sparadigm run the risk of faulty conclusions and/orlack of direction for strategic improvements.38,48-50 Inthis NLRN research program, a representative sampleof nurses on 99 clinical units in 34 Magnet hospitalsindicated that their unit work environments neededimprovement; they could not engage in the profes-sional work processes or establish the relationshipsessential for quality patient care.36 Since this deter-mination was made through a process instrument(EOMII), gap analysis based on the survey items(steps and components of each process) points thedirection for strategic improvements.51

The jury is still out on the differential effective-ness of multistage NRPs in NLRN retention, al-though the overall value of these programs hasbeen strongly and consistently proclaimed in termsof other outcomes. Although NLRN retention rateswere higher in hospitals with more complete, mul-tistaged, theoretically derived NRPs than in hospi-tals with short, transition stageYonly programs, thedifferences were not significant. Longer programs

with well-developed integration stages address theunique aspects of the dominant nurse role in thehospitalsVthe conversion of what is perceived aschaos into mastery of the simultaneity complexitythat characterizes this role.47 The finding that NLRNretention rates are lower in academic than in com-munity hospitals may be related to the greatercomplexity of care delivery and clinical situation man-agement systems in academic hospitals. Nurse resi-dency programs can equip NLRNs with skills neededfor improvements in professional practice and patient/nurse outcomes by incorporating evidence-basedmanagement projects as advocated by the IOM1(p314)

and as identified by NLRNs and experienced nursesin the 20-hospital interview study.30,31

Retention

To develop cultures of retention, organizations mustprovide nurses with HWEs that enable them to en-gage in professional practice, provide quality patientcare and feel fulfilled with the quality of care theyprovide. Such environments also promote nurses’allegiance and loyalty to the hospital organizationand its professional communities and thus promoteretention. Nurse residency programs, regardless oflength or number of stages, are effective in NLRNretention based on comparisons of residents withnonresidents.9-11 The financial investment that hos-pitals make with NRPs is clearly understood andappreciated by NLRNs and others; it contributesmarkedly to development of cultures of retention,loyalty, and allegiance.30-32

How organizations handle placement of NLRNsaffects turnover and transition. Half of the NLRNsin this study were initially assigned to VHWE units.Anecdotal comments from hundreds of intervieweesindicate that nurses, as well as physicians, are wellaware of the quality of the practice environmenton clinical units30,31: which units are ‘‘good,’’ whichsupport NLRNs, and which are struggling to createhealthy environments. Initial placement of NLRNson VHWE units provides excellent transition. Whenplaced on WENI units at the beginning of the NRP,NLRNs have higher, involuntary turnover, most no-tably in the first 6 months. Whether NLRNs areinitially placed on WENI units or are transferred tothese units because staffing support is needed be-cause of high turnover, NLRN turnover is likely toincrease.

As NRPs become multi-staged, more structured,embody professional socialization principles, processes,theories, and components and more standardized inlength, retention data will be needed to assess theeffectiveness of these programs. One-year turnoverdata more likely measures NLRNs’ satisfaction with

JONA � Vol. 42, No. 3 � March 2012 157


NRPs and associated role performance, rather thanbeing an indication of satisfaction with their perfor-mance of the dominant professional practice role ofthe nurse. The narrow drop in retention rates be-tween the second and third years post hire suggeststhat the first year after completion of a 12-monthNRP (second year after hire) is when turnover datashould be collected for accurate measurement of theeffect of structured, complete NRP on NLRN retention.

Process Measurement

Process measurement has 3 major benefits over struc-ture measurement: it is more accurate; it requires in-put of clinical nurses in defining the steps/componentsof work processes; and process measurement enablesmore accurate selection of needed strategic improve-ments. Accuracy is advanced when nurses are con-sulted in tool development. Items in a process toolmust be weighted on the extent to which the itemcontributes to achievement of the process. Clinicalnurses are in the best position to identify steps/components of work processes and inform as to thedifferential weight of each step. In structure scales,respondents indicate extent of agreement that anitem is present or characteristic of their work setting.For example, the item ‘‘nurses function autono-mously on this clinical unit’’ will yield inaccurateresults when there are multiple definitions of a con-struct such as autonomy.52

Agreement among clinical nurses, administra-tors, and professional organizations on definitionand components of HWEs is a much-needed firststep to empirically studying and improving workenvironments so as to enable practice resulting inimproved patient/nurse outcomes. Subsequent stepsare an accurate measurement of process components,obtaining response rates adequate for valid, reliabledata aggregation to the group level, and involvementof clinical nurses in gap analyses.45,51 Participatorygap analysis leads to identification of ‘‘what needsto be fixed’’ and facilitates implementation of stra-tegic improvements. Study findings suggest thatdevelopment and empirical testing of a tool to mea-sure NLRN integration into the dominant profes-sional practice role could produce data to informthe continued evolution of quality NRPs that arecritical to NLRN socialization, professional worksatisfaction, organizational loyalty, cost effective-ness and retention.

Acknowledgments

Participation in this 5-year, 7-study research pro-gram required considerable time, interest, and in-vestment on the part of the participating hospitals.On behalf of new graduates yet to come, the au-thors thank the participating facilities, chief nurseexecutives, on-site investigators, and residency pro-gram facilitators.

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