Strengthening the nursing workforce requires investment throughout the professional pipeline, and a particularly important moment is the transition from nursing school to clinical practice.

Many nursing students report a significant gap between what they learned in school and the real-world challenges in the field, such as administering medication, night shifts, complex procedures, scheduling, and handling multiple patients. Only 20 percent of new nurses surveyed in 2020 reported feeling strong in their general knowledge of nursing enough to practice, a score no higher than the response given eight years prior. This mismatch between the classroom and clinical practice is one of many factors driving one in five nurses to leave the bedside in just one year.

Three health systems – UConn Health, Los Angeles Medical Center and NYC Health + Hospitals – are responding to this dynamic with nurse residency programs designed to ease new nursing graduates’ path from classroom to hospital room through coaching, mentorship and peer support. RN residencies have long been known as a best practice for keeping nurses at the bedside, yet as of 2020, only about half of US health systems had these in place.

Below, nurse leaders share their learnings and successes, which hospital and health system leaders across the country can apply to their own workforce initiatives.

At Los Angeles General Hospital, Nancy Blake, PhD, RN, Chief Nursing Officer, and Debra Hunt, Nursing Director of Education, saw a need to support new graduates not just at the beginning of their career but beyond, and the New Graduate Transition to Practice Program was launched in October 2022.

Previously, new graduates had a standard orientation followed by specific training in their specialties. With the new residency program, the graduates go in-depth beyond their specialties, with intensified skills training to make up for lost hands-on experience during the pandemic and enhanced interdepartmental lectures.

The program saw rapid success, beginning with a cohort of 42 students in the first year, 84 in the second, and 150 in the third, totaling more than 350 participants in just two years. Unlike other programs, LA General takes a rolling approach to its residency, as new nurses are hired and onboarded every two weeks. Each resident experiences the process a little differently, depending on their hiring cycle.

As a result of the residency program, LA General’s turnover rate dropped from 22% in the year the program started to 13% one year later. The program blends personal and professional development, as evidenced by feedback from the residents who report a very supportive environment and strong relationships with both instructors and facilitators. Blake emphasizes the program’s focus on helping new graduates pursue aspirations beyond the first year of their career, like moving into critical care roles.

Improving the transition to practice for new nurses not only addresses workforce challenges broadly, but it also helps to diversify the profession and improve care for all communities. LA General is in downtown Los Angeles and treats patients from areas of critical need, so it’s essential that the hospital hires nurses who understand the lived experiences of their patients – and provides the necessary support to those nurses so they succeed in their roles.

“We’re not just offering a job. We’re offering more,” said Hunt. “Many are the first in their families to attend college, and we’re providing support beyond employment.”

“Ultimately, we’re striving to support these individuals not just as employees but as unique individuals with diverse needs,” said Blake.

Historically, UConn Health had never had more than three or four new nursing graduates join the system all at once. Recently, that number ballooned to 32, necessitating a more formalized onboarding program to ensure each new nurse was able to receive the hands-on support they needed. In July 2023, the system established a residency program that runs concurrently during a new hire’s first six months on the job.

Developing the residency has been a group effort among program lead Amy Zipf, PhD, RN, CMSRN, Clinical Nurse Specialist, Creedance Mongillo, MSN, RN, Clinical Nurse Specialist, educational and development specialist Elaine Cournean, MSN, APRN, APHN-BC, and Larissa Morgenthau MSN, RN, MEDSURG-BC, NPD-BC, Nursing Director of Professional Practice & Clinical Excellence.

With decades of diversified experience among them, from ICU and cardiac nursing to yoga-inspired resilience training, they are leading residency cohorts and helping the new grads find belonging as a UConn Health nurse, as well as coaching in areas like hands-on patient care, diversity and inclusion, and workplace-specific protocols. It’s here that open dialogue and building a sense of community is most critical, said Cournean.

“It’s remarkable what they share,” she said. “We have conversations about challenges and experiences that are impactful and meaningful – it helps build connections and understanding.”

While the UConn residency program is still in its first year, the instructors are seeing strong early successes and compiling data to demonstrate learnings.

NYC Health + Hospitals is the largest municipal healthcare system in the US, comprising 11 hospitals, 30 health centers and 5 long-term care centers. Naturally, the system’s nursing workforce needs are substantial.

As part of New York City Mayor Eric Adams’ Citywide Nurse Residency Program, which launched in December 2018, the system has enrolled 1,800 nurse residents, with 600 graduated and 800 actively progressing through the program. The city covers administrative and vendor costs for the program through the New York Alliance for Careers in Healthcare.

Mayor Adams with NYC Health + Hospitals nursing staff and City Councilmember Mercedes Narcisse, a former nurse.

NYC Health + Hospitals’ Nurse Residency Program rapidly scaled up from an initial cohort of just 30 nurse residents to enroll all newly-hired nurses under the leadership of Senior Vice President and Chief Nursing Officer Natalia Cineas, DNP, RN, NEA-BC, FAAN, who joined the system in March 2019. A cornerstone of this expansion was building a dedicated support team and enlisting support from nurse leadership across the system and at each individual facility.

“Our Nurse Residency Program is intended to be a dynamic and powerful experience designed to provide our newest nurses with real-world, on-the-job training covering practically all aspects of our profession,” said Dr. Cineas. “Participants use their experiences in the Nurse Residency Program to learn, grow and develop into exciting new roles, which include meaningful and vital nursing positions in virtually every segment of our greater NYC Health + Hospitals system.”

The program is spearheaded by Albert Belaro, DNP, MA, RN, Senior Director of Professional Practice/Education, who engaged in a collaborative effort with new project managers, program coordinators, nurse leadership, preceptors, facilitators and nurse educators to actively engage newly-graduated nurses and keep them on the career ladder. Both internal stakeholders, including Human Resources, IT and Finance, and external partners, including the City University of New York, were enlisted to support the tenfold expansion, helping to eliminate barriers to enrollment.

According to Belaro, the secret sauce is having residents apply their new skills to real processes, building individual autonomy in a safe and collaborative environment.

Four years later, the system’s nurse residency program spans more than 28 health care facilities city-wide and has led to retention rate improvement from 54 percent to 83 percent for new nurses and exceeding 96 percent year-to-date at participating campuses.

The residency programs developed by LA General, UConn Health, and NYC Health + Hospitals share several core attributes. All have formalized clinical skill development and professional mentoring components and leverage the peer support that new nurses provide to one another to build a community and strengthen the workforce. Critically, they ensure participants find their footing not only within the profession, but in the specific system where they start their career. Each provides a shining example of best practices to support and develop the skills of new nurses, so they thrive as they transition to clinical practice.

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