Meaningful Support in the Transition to Practice

Hawai’i Nurse Residency Program facilitates massive 351% enrollment increase for nurse residency programs across the state

In 2012, the Hawai’i State Center for Nursing established the first nurse residency program partnership in the nation. The Hawai’i Nurse Residency Program (HNRP) is a collaborative partnership between healthcare facilities and schools of nursing with an intended goal of supporting new nurse transition to practice, as well as incentivizing new nurses to stay at facilities within the state beyond their first year of practice. As of 2021, there are 14 partner hospitals covering all counties within the state and the scope continues to expand.

The statewide nurse residency program was the first of its kind in the U.S., designed to provide support for retention and transition to successful nursing practice. Such a trailblazing program would require a consistent solution with integration and data analytics to take it to the next level. Partner facilities also indicated they wanted more standardization of learning content and a greater breadth of specialty nurse content to provide the best level of support. Nurse educators were already stretched thin with other responsibilities, so it was important to find a vendor eager to support HNRP’s goals. 

The HNRP began re-evaluating their program and vendors in 2018, and transitioned to HealthStream in 2020, just as the pandemic was beginning. This presented some obvious challenges. Turnover hadn’t yet increased significantly, but the goal was to proactively transition facilities to the new HealthStream program. The pandemic definitely heightened the need for training – not only was it utilized for new nurses, the program also helped with rapid training and placement for FEMA nurses during this time.

Since the rollout of the HealthStream program, facilities have seen immediate results:

• New graduate nurse enrollment rate skyrocketed 351% from 2020 to 2021. This was due to a variety of factors, including HealthStream’s support in onboarding 10 new hospital partners to the program.
• A 99% completion rate for 2022 – this was 26% higher than the national rate, which had declined sharply due to the pandemic.
• Since the program’s inception, more than 1600 new nurses have participated.
• The introduction of evidence-based patient opioid practice standards training for new and expert nurses. The HNRP received a grant from the Hawai’i State Department of Health in 2021, which was instrumental in implementing this new training through the HealthStream platform. By the time the grant ended in 2022, there were 12 hospitals implementing opioid education modules, 80% of which were grant funded. There were 489 new graduate nurse residents who participated.

Decreasing first-year attrition rates has long been a goal for HNRP – like most states, new nurses are prone to leave their positions or the profession entirely for a variety of reasons. According to 2021 survey results from the Hawai’i State Center for Nursing¹, 57% of new graduate nurses indicated they were either uncertain, likely, or very likely to leave their current position within the next 12 months. However, nurses in acute care settings – those most likely to have a nurse residency program – were least likely to indicate uncertainty of interest in leaving (45%), whereas at least half of all new nurses in non-acute settings indicated uncertainty or a desire to leave.

To help with attrition and further strengthen the competency and satisfaction levels of new nurses, HNRP hopes to expand the nurse residency program to other non-acute settings, particularly at long-term care facilities. The state’s surveys indicated that 60% of nurse graduates whose first job was in an acute-care setting participated in nurse residency, while only 6% of those in non-acute settings did. Hilo Medical Center has started the first long-term care/post-acute care NRP cohort in the state. As a current priority for the expansion of transition to practice training, it will likely be the first of many.

Preceptor training, another HNRP priority and welcomed addition for facilities, was essential to meeting the need for more preceptors and opportunity for career laddering. Even smaller residency programs utilized the preceptor training, given the benefits of increased job satisfaction and improved retention. An added benefit, grant funding also helped to facilitate Preceptor Pathway training costs for partners and helped enroll 418 expert nurses in the preceptor training, as well as the opioid training.

Of course, the statewide standardization of nurse residency program has led to other benefits, such as a local community for nurse educators to exchange ideas, resources, and support and the ability to track cohorts together as well as on a statewide basis for better decision making. Because the program is standardized, it provides heightened transferability. New nurses can rest assured that no matter the specialty or location they’re working in, their nurse residency program will fundamentally look the same but will be customized to reflect their clinical setting and population.

The transition to practice can be very challenging for new nurses. It is important to get ahead of these challenges and provide adequate support for new nurses entering the workforce, because the statistics are dire: Researchers at the National Council of State Boards of Nursing (NCSBN) released a report in April 2023² that states 100,000 nurses left the workforce over the past two years. Perhaps even worse, they project that one-fifth of the nursing workforce will leave the profession by 2027 for a variety of reasons – increased workload since the pandemic, fatigue, and emotional distress, among others.

The success achieved by the Hawai’i State Center for Nursing serves as a bellwether and model for future successful state nursing programs nationwide. Priorities for further expanding the transition-to-practice support include more specialty development initiatives, expanded preceptor training, and nurse residency programs in post-acute/long-term care settings. 

¹ https://www.hawaiicenterfornursing.org/wp-content/uploads/2022/04/Hawaiis-New-Graduate-Nursing-Workforce-v.Final_.pdf

² https://www.ncsbn.org/news/ncsbn-research-projects-significant-nursing-workforce-shortages-and-crisis