Nationally, health care executives are challenged by consumers

Innovation Advancing New Nurse Graduate Education Through Implementation of Statewide, Standardized Nurse Residency Programs Joan I. Warren, PhD, RN-BC, NEA-BC, FAAN; Sherry Perkins, PhD, RN, FAAN; and Mary Ann Greene, DNP, RN, NEA-BC Establishment of nurse residency programs (NRPs) for newly licensed registered nurses is foundational to new nurse graduates transition and retention. This article describes the implementation of a statewide, standardized, scientific, and sustainable NRP model. Through multiyear coalition building among hospital and academic nurse leaders and in partnership with professional organizations and a government agency, the state of Maryland s Action Coalition successfully formed the Maryland Nurse Residency Collaborative under the auspices of the Maryland Organization for Nurse Leaders. A standardized and validated NRP was implemented statewide across acute-care hospitals of diverse sizes, populations, and geography. Through the use of innovative partnerships and funding mechanisms, the number of standardized NRPs increased from two in 2012 to 22 by 2016. Hospitals with NRPs demonstrated a 6% to 10% reduction in voluntary turnover rates, equating to approximately $17.6 million in annual statewide cost savings. The statewide model is easily scalable, transferable, and replicable. Achieving the national goal of making NRPs available to all newly graduated nurses hinges on strong leaders, partners, and innovators who can unite and transform practices. Keywords: Newly licensed registered nurses, nurse residency programs Nationally, health care executives are challenged by consumers and their demands for accessible, equitable, high-quality, safe, patient-centered and cost-effective care focused on prevention and the community. Registered nurses (RNs), by their sheer numbers, can positively drive and substantially impact the health care system (Henry J. Kaiser Family Foundation, 2017; Institute of Medicine, 2010). Yet, nursing is plagued by reoccurring workforce shortages. Contributing to these shortages is the excessive loss by hospitals of newly licensed RNs (NLRNs). Almost one in five NLRNs leave their place of employment during their first year of practice, and one in three leave within 2 years (Kovner, Brewer, Fatehi, & Jun, 2014). Nearly half a century ago, Kramer (1974) conceptualized the theory of nurse reality shock, or the shock experienced by new graduates as they transition from nursing programs to real-world expectations to explain why newly graduated nurses left nursing. The issue of NLRNs exiting places of employment or the profession remains to this day. Evidence supports the use of transition-to-practice programs, referred to as nurse residencies, for NLRNs as a strategy for preparing a stable workforce ready to practice at the highest level of their ability (Institute of Medicine, 2010; National Academies of Sciences, Engineering and Medicine [NASEM], 2015). The purpose of this article is to describe establishment of a statewide nurse residency collaborative, including its structure, model, funding sources, and program outcomes. Background Bridging the knowledge and practice gap from nursing student to licensed professional nurse is a concern among nursing leaders. Many NLRNs are ill prepared to assume the responsibilities of patient care. Although 90% of academicians believe nurse students are prepared to provide safe and competent care as new entrants to the workforce, only 10% of hospital and health care system nurse leaders agree (Berkow, Virkstis, Stewart, & Conway, 2008). Moreover, the gap continues to widen. Performance assessments of more than 5,000 NLRNs hired by an academic health care system found only 23% met entry-level competency and practice readiness requirements (Kavanagh & Szweda, 2017). As concluded by Hickerson, Taylor, and Terhaar (2016) in their systematic review of 50 articles examining the preparation-practice gap, the gap is real, costly, and requires changes in undergraduate education and on-the-job remediation through nurse residency programs (NRPs) or preceptor programs. Historically, NRPs 14 Journal of Nursing Regulation

emerged to facilitate NLRNs transition into practice and prevent NLRNs from leaving the workforce or the profession. As in other professions, residencies have been instituted to integrate the NLRN into the workplace, by transitioning them from advanced beginners to competent professional nurses (Lin, Viscardi, & McHugh, 2014; Rush, Adamack, Gordon, Lilly, & Janke, 2013). NRPs enhance traditional hospital orientation and are composed of structured experiences that facilitate the obtainment of clinical and professional skills and knowledge necessary for new graduate nurses to provide safe and quality care (Lin et al., 2014, p. 440). Common features generally include a defined resource person, education using clinical exemplars or narratives, preceptorship, mentorship, peer support opportunities, and extra time for evidence-based practice projects (Krugman et al., 2006; Lin et al., 2014; Rush et al., 2013). Strong research evidence from systematic reviews, integrative literature reviews, and multisite studies support implementation of NRPs for preparing NLRNs as competent professionals and retaining them in the workforce. Evidence suggests formal NRPs improve performance (Goode, Lynn, McElroy, Bednash, & Murray, 2013; Rosenfeld, Glassman, & Capobianco, 2015; Spector et al., 2015), organizational commitment and job satisfaction (Letourneau & Fater, 2015; Spector et al., 2015), clinical decision-making and leadership skills (Chappell & Richards, 2015; Goode et al., 2013), professionalism (Letourneau & Fater, 2015), and retention, and result in lower turnover of NLRNs (Al-Dossary, Kitsantas, & Maddox, 2014; Goode, Ponte, & Havens, 2016; Letourneau & Fater, 2015; Rush et al., 2013). However, admissible research evidence comes from multiple residency program models and structures. Varying models include the National Council of State Boards of Nursing Transition to Practice Model (Spector et al., 2015), state developed programs such as Wisconsin s NRP (Bratt, 2009), commercially available programs such as Vizient (formerly University HealthSystem Consortium)/American Association of Colleges of Nursing (AACN) (Goode et al., 2013) and Versant (Ulrich et al., 2010), and institutionally developed programs such as the one implemented at the University of Texas (Cline, La Frentz, Fellman, Summers, & Brassil, 2017). More than 50 urban and rural hospitals in Wisconsin are participating in an academicservice partnership and structured education NRP developed by stakeholders (Bratt, 2009). The Iowa Action Coalition (Frantz & Weathers, 2015) similarly used best practices from the literature and consulted with national experts to create an accessible and affordable 1-year online NRP. Hawaii, Pennsylvania, and Maryland adopted the Vizient/AACN program (Future of Nursing, 2014; Horn, 2017). Although common elements may be found among NRPs, programs vary widely in their use of theory for designing the educational intervention, curricular content, program duration, teaching and learning strategies, and outcome measures for examining effectiveness (Anderson, Hair, & Todero, 2012; Barnett, Minnick, & Norman, 2014; Edwards, Hawker, Carrier, & Rees, 2015; Pittman, Herrera, Bass, & Thompson, 2013). Curricular content includes topics such as patient safety, quality, and evidence-based practice; critical thinking and clinical reasoning; communication and teamwork; patient-centered care and population health; informatics; and professional development (Anderson et al., 2012; Rush et al., 2013). Commonly defined resource persons or formally educated preceptors or mentors, and academic and practice partnerships are used to support residents learning (Anderson et al., 2012; Blegen et al., 2015; Rush et al., 2013). Duration of NRPs varies from less than 1 month to more than 1 year; however, empirical evidence supports NRPs lasting between 6 to 12 months (Goode et al., 2016; Rush et al., 2013). Despite the wide variability among NRPs, their beneficial outcomes are similar (Cline et al., 2017; Edwards et al., 2015). Edwards and colleagues (2015) attributed these positive outcomes to the increased attention provided to the NLRNs rather than the type of support strategies instituted. Due to the lack of theoretical frameworks, common research definitions, implementation, and outcome measurements, and to varying NRP designs, few conclusions can be drawn about the key characteristics of successful NRPs. Consequently, the ability to recommend one common, unified, validated residency program is not possible. Hospital nurse leaders must choose among the many commercially available products or institute their own. Growth of NRPs NRPs are growing exponentially following national calls for their establishment by the Future of Nursing report (Institute of Medicine, 2010) and the Carnegie Foundation study (Benner, Sutphen, Leonard, & Day, 2010). In 2011, reported NRP adoption by nationally surveyed hospitals ranged from approximately 37% (n=79/214) (Pittman et al., 2013) to 48% (n=95/203) (Barnett et al., 2014). In a later national study by Pittman, Bass, Hargraves, Herrera, and Thompson (2015), the number of NRPs between 2011 and 2013 grew by approximately 10%, from 32% to 42%. Differences among and within program model types were found due to hospitals using institutionally based NRPs compared to nationally published and researched NRP models (Barnett et al., 2014). Although national nurse leaders advocate for NRPs, unlike other professions, NRPs are not mandated by the nursing profession for integrating NLRNs into the workplace. In hopes of stimulating this movement, Goode et al. (2016) wrote an evidence-based position paper advocating for all NLRNs hired in acute care hospitals be required to complete an accredited residency program (p. 82). Additionally, nurse leaders have advocated for using Title VIII nursing workforce funds to support NRPs; however, requests have not been supported by legislators (Goode, 2015). Nationally, statewide initiatives have been instituted by Hawaii (Future of Nursing, 2014), Pennsylvania (Horn, Volume 8/Issue 4 January 2018 www.journalofnursingregulation.com 15

2017), Rhode Island (Lorenz, 2013), Iowa (Frantz & Weathers, 2015), Wisconsin (Bratt, 2009), and Maryland (Greene, Warren, & Perkins, 2016) to achieve this goal. Implementation of the Maryland Nurse Residency Collaborative Currently, more than 70,000 RNs are actively licensed in Maryland (Henry J. Kaiser Family Foundation, 2017). Hospitals are the largest employer of RNs in Maryland. Growing health care demands by consumers, the aging population, and the increased numbers of consumers with chronic diseases, coupled with the upturn in the economy and the growing numbers of older nurses exiting the workforce, are escalating RN workforce requirements in Maryland. Maryland is projected to have a workforce shortage by 2030 (Aurbach, Buerhaus, & Staiger, 2017). Thus, in response to the compelling benefits and calls for NRPs, the Maryland Action Coalition (MDAC) started on its journey to implement a statewide, standardized, scientific, hospital-based NRP model in 2012. Defining NRP A year after the MDAC was established as a statewide body to implement the eight recommendations from the Future of Nursing report (Institute of Medicine, 2010), the nurse residency subcommittee was formed. Statewide nurse leaders from hospitals and academic nursing programs were invited to a summit to explore the implementation of NRPs in Maryland. One of the first challenges was clearly defining and differentiating an NRP from nursing orientation. A discussion about program similarities and differences took place among summit attendees. Many perceived that the purpose of the NRP was to facilitate attainment of unit-based competencies and skills; hence, they viewed it as an extended orientation program. To assist nurse leaders in better understanding its purpose, MDAC subcommittee leaders presented the history and research evidence supporting NRPs. After lengthy discussions among members of the MDAC subcommittee, an in-depth literature review, and conversations with national leaders, the following conclusions and definitions were reached. First, an NRP is not a prolonged orientation, but rather a complement to an orientation program (Bleich, 2012, para 7). Orientation programs were defined as programs providing participants with requisite knowledge and skills required by the state licensing body, regulatory bodies/agencies, and hospital organization to function competently at their job and may be aimed at both NLRNs and experienced RNs. An NRP was defined as a 12-month program consisting of a series of learning and work experiences designed to assist NLRNs graduating from a basic prelicensure nursing program as they transition into their first professional roles (Commission on Collegiate Nursing Education, 2008). Using concepts from the literature, the NRP subcommittee defined NLRNs as newly graduated nurses from any basic licensure nursing program (diploma, associate, baccalaureate, and master s degree) with less than 1-year experience and holding direct care roles in the hospital setting. Because NRP research focuses on hospital-based NRPs and Maryland hospitals are the largest employee of RNs, subcommittee members decided to focus on that setting. Finally, committee members established a clear vision to guide strategies. Moving beyond simple promotion and buyin by stakeholders for NRPs, the MDAC NRP subcommittee established the bold goal of implementing nurse residencies in all acute-care hospitals throughout Maryland. Moreover, to reduce program and outcome measurement variability, members recommended using a standardized, validated program and standardized metrics to examine program outcomes. Structure An evidence-based approach was used as a model to fund, implement, and evaluate NRPs in Maryland. This required combining innovative partnerships among academic nursing programs, hospitals, the state Organization of Nurse Leaders, and the Maryland statewide hospital regulatory agency for program funding. As recommended by Bratt (2013), securing stakeholder buy-in at program inception, allocating sufficient and appropriate resources, and capitalizing on partnerships are key to optimizing successful implementation of NRPs. Engaging the chief nursing officers (CNOs) who directly impact hospital initiatives and manage the budgets was identified as key to program success. To target hospital CNOs and other hospital nurse leaders, a partnership with the Maryland Organization of Nurse Leaders (MONL, formerly known as the Maryland Organization of Nurse Executives) was formed. This statewide organization comprises hospital nurse executives, academicians, and nursing stakeholders. The nonprofit professional organization provided a neutral forum to engage statewide nursing and nonnursing leaders in discussions about NRP benefits. Moreover, members of the MDAC NRP subcommittee teamed together to engage and educate the CNOs about NRPs through face-to-face and one-to-one phone calls. The goal of implementing hospital-based acute-care NRPs aligned well with the MONL mission and that of its hospital members. Hence, in 2013, the Maryland Nurse Residency Collaborative (MNRC) was formed under its auspices. The purpose of the MNRC is to build a network of hospitals interested in pursuing NRP implementation and for sharing strategies and ideas. Next steps included the creation of an advisory board and a statewide NRP coordinator position for program sustainment. The role of the nurse residency advisory committee, consisting of statewide nurse leaders from hospitals and nursing programs, community stakeholders, and policy makers, is to perform environmental scanning and strategic planning for the MNRC. The NRP coordinator position, a funded 0.2 fulltime equivalent 16 Journal of Nursing Regulation

employee, was developed to drive membership, manage hospital contracts, and coordinate the program, including education sessions for hospitals. The NRP coordinator also highlights achievements of the MNRC during quarterly meetings with the MONL, maintaining engagement of CNOs and other nurse leaders. Standardization Reducing NRP variability was a primary objective of the MDAC subcommittee. In 2012, of the 19 hospitals in Maryland reporting use of an NRP, only two hospitals reported offering nurse residencies using validated NRPs. All others used institutionally developed NRPs with varying content, teaching and learning strategies, and duration. After a literature review, input from national experts, and meetings with hospital leaders, consensus was achieved to standardize using the Vizient/AACN model. For many hospitals, this meant giving up well-established programs to achieve the goal of standardizing statewide postlicensure education for RNs. The Vizient/AACN model is a nationally recognized commercially offered program with more than 10 years of outcome research demonstrating its effectiveness (Goode et al., 2013). It has been implemented in more than 300 organizations and across multiple states. The curriculum focus includes professional role, patient outcomes, and leadership. The curriculum is designed to support the new graduate across multiple nursing care settings within the hospital in areas such as ethics, end-of-life issues, and the development of professional portfolios, which include the use of evidence-based practice. In addition to the standardized curriculum and training materials, a national database allows the individual hospitals and the state collaborative to benchmark expected improvements in nurse residents first-year experiences. Cost Cost is the major hurdle hospitals must overcome to achieve successful buy-in from hospital leaders. Costs for hospitals belonging to the MNRC include an initial payment at the time of joining the collaborative and annual dues to cover licensure fees and management costs, including the NRP coordinator position. Additionally, hospitals have associated costs of program implementation, such as salaries and wages for mentors, preceptors, and nurse residents, as well as program costs for educational materials. Although data suggest that the average cost for a cohort of 10 NLRNs is approximately the cost of replacing one RN who leaves the organization, it remains the greatest barrier to implementation (Bratt, 2013). Exploration of funding sources from government agencies and philanthropic organizations is a recommended strategy to reduce NRP program costs (NASEM, 2015). MDAC NRP members invited staff from the Health Services Cost Review Commission (HSCRC) to join the subcommittee. The HSCRC is an independent Maryland state agency responsible for setting and regulating hospital rates for all payers, including Medicare and Medicaid. In 2001, the HSCRC initiated a 5-year, hospital-based, noncompetitive grant program titled the Nurse Support Program I (NSP I) grant to increase the number of hospital bedside nurses through retention and recruitment activities. Annually, hospitals are eligible to receive up to 0.1% of the hospital s gross patient revenue that is provided through hospital rate adjustments. For example, if the hospital s annual patient gross revenue is $500,000,000, the hospital is eligible to receive $500,000 through the NSP I. Approved funding may be used by hospitals to pay for professional advancement projects, such as tuition assistance or certification programs for RNs. All acute-care Maryland hospitals are eligible to participate in this grant, which has been renewed three times since its inception, most recently in July 2017. As part of the grant process, hospitals are required to annually collect and report metrics associated with each NSP I funding category to the HSCRC. HSCRC uses these metrics to examine the impact of NSP I. HSCRC staff agreed that the vision for statewide NRPs met the goal of the NSP I grant program. To that end, MDAC NRP subcommittee members partnered with HSCRC staff to make recommendations for programmatic changes to NSP I. Timing was critically important as the NSP I was up for renewal in 2013. Members suggested modifications to the approved NSP I, programs including defined financial support and outcome metrics for hospital-based NRPs to measure program success. In 2013 and again at renewal in 2017, hospitals were approved to use NSP I grant dollars for salaries and wages of nursing personnel implementing the program, NLRNs attending the program, or RNs backfilling NLRN staff positions as well as for project costs,such as licensure agreements, simulation activities, or educational materials. Outcome Metrics As stated by the Institute of Medicine report (2010), health care organizations offering NRPs should evaluate program effectiveness in improving retention, competencies, and patient outcomes. To continue to maintain and sustain these programs, hospital leaders must see a cost benefit. In 2013, nurse and hospital leaders with HSCRC staff revised the mandatory reporting requirements for the NSP I to include standardized outcome metrics that addressed NRPs. Program outcome metrics were operationalized using nationally accepted definitions when possible. After extensive deliberation, chosen NRP metrics of interest include the number of NLRN hires by type of nursing degree, attrition rates of NLRNs, including voluntary and involuntary turnover rates by type of nursing degree, type of NRP model used (Vizient/ AACN or another 12-month program such as facility-developed), membership status in the MNRC, and end-of-year expenses for administrative and project costs. Volume 8/Issue 4 January 2018 www.journalofnursingregulation.com 17

In addition to the statewide data collected by HSCRC, benchmarking and statewide data for hospitals belonging to the MNRC are provided by Vizient/AACN. Outcome metrics allow the MNRC to evaluate new nurse graduate, organizational, and health care outcomes. Information gained from HSCRC and Vizient/AACN is used to support continued statewide program funding and expansion of NRPs across Maryland. Sustainability Program sustainability starts at the moment of program conception (Bratt, 2013, p. 107). Keeping the program front and center, using a cost-benefit approach, and providing funding mechanisms to defray NRP costs are recommended methods to sustain NRPs (Bratt, 2013). Quarterly reports about MNRC hospital enrollment and success stories are shared with nurse leaders and stakeholders at MONL meetings. Presentations highlighting NRP implementation have also been disseminated at the statewide MDAC summit meetings attended by nurse leaders and stakeholders in Maryland as well as at regional and national conferences. Using empirical evidence from the literature and statewide analyses, cost savings and improved NLRN retention rates nationally and at Maryland hospitals has helped to build the case for further NRP adoption by CNOs. Furthermore, the ability to explain how statewide NSP I grant funds may be used to defray costs of a hospital-based NRP has increased the numbers of hospitals enrolled in the MNRC. The NRP coordinator position has been instrumental in maintaining, sustaining, and growing the number of hospitals joining the MNRC. In this role, the coordinator has promoted the program to individual hospitals, assisted with hospital contracts, met monthly with MNRC members for networking and sharing of best practices, and managed the budget. Due to the rapid growth of the MNRC, an accountant was engaged to manage the collaborative finances. Barriers, such as lack of resources and too few new RN graduates hired by the hospital, impede many smaller and lessresourced hospitals from joining the collaborative. Philanthropic funding from the Maryland Healthcare Education Institute, an affiliate of the Maryland Hospital Association, was obtained in July 2017 by the MNRC to provide continued support for developing new and mature NRPs, building coalitions among lessresourced and/or more rural hospitals, developing scalable models for future expansion of NRPs in diverse settings, and continuing analysis of outcomes, including quality, nurse retention, and expense avoidance. Many of the individual hospitals or health care systems have also sought additional philanthropic funding from benefactors supporting their organizations. Outcomes Multiple data sources, including a survey of hospitals before implementation of the MNRC, HSCRC-required hospital metrics and the Vizient/AACN data, have been used to examine statewide nurse residency outcomes. The growth and impact of the newly formed MNRC during the 4-year data collection time frame is evident. Although a greater number of hospitals (n=35/50, 2012; n=37/50, 2014) onboarded NLRNs in FYs 2012 to 2014, the number of NLRNs hired by hospitals declined from 1,547 (2012) to 1,317 (2014). Reduced patient volumes and subsequent contraction of services by hospitals in response to new global payment systems and health care reform may explain the decline in the number of NLRN hires. Subsequently, as the economy stabilized, the number of NLRN hires by acute-care hospitals increased 13% between 2015 and 2016 (n=1,778, 2015; n=2,038, 2016). Correspondingly, the number of hospitals offering NRPs also substantially increased from 19 in FY 2012 to 32 in FY 2016. In addition to the steady increase in NRPs, hospitals transitioned from institutionally based NRPs to the evidence-based Vizient/AACN standardized program. In 2012, only two out of the 19 hospitals offering NRPs used this program. By 2016, 22 out of the 35 hospitals with NRPs had implemented the Vizient/ AACM program and 20 of these hospitals had joined the MNRC. The MNRC has grown from 9 in 2013 to 23 by 2017. The number of residents hired by MNRC hospitals has also increased by almost tenfold from 166 (2013) to 1,124 (2016). Financing of NRPs Much of the growth in NRPs can be attributed to the financial partnership with HSCRC. Approximately half of the responding hospitals invested a quarter or more of their HSCRC NSP I grant funds into NRPs over the 4 years, equating to $13.6 million. NSP I dollars supported program coordinators, instructors, facilitators, and preceptors (nurse residents or other staff salaries that facilitate resident attendance), and program expenses such as educational and simulation materials. Workforce Data More than 5,800 NLRNs participated in NRPs supported by NSP I during the 4-year reporting period. A notable decline of 12% to 7% occurred in nurse resident turnover rates between 2013 and 2014, whereas voluntary turnover of NLRNs slightly increased from 7.5% to 9% in 2015 and 2016. However, voluntary turnover rates by hospitals offering NRPs demonstrated a reduction upwards of 10% compared to hospitals not offering NRPs. Cost savings associated with decreased attrition (cost to recruit and retain a replacement RN) are estimated at $88,000 per RN (Jones, 2008). A 10% (200 RNs) reduction in turnover rates equates to an annual statewide cost savings of $17.6 million. Hence, in 1-year, Maryland hospitals demonstrated a cost savings greater than the amount invested for the 4-year time frame. Comparing hospital hiring practices for RNs with a bachelor of science in nursing (BSN) and associate-degree (AD) RNs, hospitals offering 1-year NRPs preferred hiring BSN nurses. In 18 Journal of Nursing Regulation

fact, nurses with BSNs were almost twice as likely to be hired (greater than 50% or more of hires) compared to their AD counterparts (25% or fewer of hires), whereas hospitals with no residency program are more likely to hire RNs with ADs (greater than 50% or more of hires). These findings are not unexpected. Hospitals offering NRPs are more likely to be affiliated with urban academic medical centers, and have achieved Magnet or Pathway to Excellence designation, whereas hospitals not offering NRPs are often smaller and more rural and the available basic licensure nursing programs are more likely offered by community colleges. Vizient/AACN data support the data obtained by the HSCRC. From 2014 through 2016, 3,689 NLRNs were hired by hospitals belonging to the MNRC. Retention rates have steadily increased from 91% in 2014 to 96% in 2016. Discussion Implementation of a well-structured, standardized, scientific, sustainable, and replicable statewide nurse residency model for NLRNs to enhance their transition into the workplace and improve quality of care is the ultimate goal. However, many barriers must be overcome before a requirement for a standardized NRP can be mandated by the state for RN licensure. Although the selected Vizient/AACN NRP curriculum is standardized, implementation by hospitals remains variable. How hospitals offer the curricular content, amount of time and the number of resident classes, and teaching and learning methods such as use a facilitators or preceptors often differ. Additionally, requiring program implementation at smaller or less-resourced hospitals, which hire few new graduates, is not sound fiscal policy. Furthermore, not all NLRNs are hired by hospitals. Hence, offering NRPs to NLRNs in multiple clinical work environments may be fiscally prohibitive and present difficulty in tracking. Finally, statewide buy-in by nurse leaders, the Maryland Board of Nursing, and stakeholders must be obtained. Overcoming these barriers requires strong collaborative academic and health care organization partnerships. First, nurse leaders need to be further educated about the residency experience, starting with faculty in the nursing programs. Proposed organizational structures for NRPs include the formation of academic-practice partnerships as both share the similar goal of preparing nurses for their professional role (Bratt, 2013). The curricular content of NRPs is often not well aligned with academic prelicensure curricula and lacks sound teaching and learning principles. Anecdotally, nurse residents often complain that the learning is repetitive with nursing school. The academic partner is well positioned to assist hospitals with curriculum design, educational methods, preceptor development, and NRP program evaluation (Bratt, 2013). The hospital partner is also well positioned to assist prelicensure programs in standardizing and strengthening their curriculum. It is well acknowledged that to fully prepare the generalist RN, academicians and hospital nurse leaders must work together and set realistic expectations for the education and training of the prelicensure RN and NLRN. Therefore, nursing faculty and hospital nurse leaders must team together to integrate the prelicensure curricular content with standardized postlicensure hospital-based NRPs if a smooth and efficient transition of RNs is to be achieved. Academic-practice partnerships may also be used to support the smaller or less-resourced hospitals in offering NRPs. Part of the future strategic plan for the MNRC is to develop coalitions to support these hospitals. Insistence on NRP accreditation is another method to achieve NRP standardization and excellence. Effective in 2019, the American Nurses Credentialing Center Magnet Recognition Program will accept nationally accredited transition-to-practice programs as meeting the relevant Magnet standard (Graystone, 2017). This national movement will directly impact many of the hospitals in Maryland. The MNRC is currently discussing program accreditation; however, as expected, hospitals are expressing concern about the time commitment and accreditation costs. The competition and demand by hospitals for highly qualified nurse residents is steadily increasing in Maryland as the workforce shrinks. Nurse leaders may want to consider implementing a nurse resident matching program, similar to the National Resident Matching program for medical residents. Nursing programs and hospitals offering an accredited standardized NRP could team together to provide such a service. More needs to be learned about NRP characteristics and successful implementation models before the profession of nursing can require NRPs as a requirement for licensure. Examining residency models used by other professions may assist the profession of nursing as it continues to pursue this path. Conclusion Substantial progress has been made in achieving the vision of implementing NRPs in acute-care hospitals across the state of Maryland. Data suggest hospitals offering NRPs have lower turnover rates. For the future, innovative strategies such as nursing coalitions are suggested to support the smaller and less-resourced hospitals implementing NRPs. An adequate pipeline of nurses is essential to meet the complex, chronic multiple conditions of Americans and ensure a safe and effective health care system (Shen, Peltzer, Teel, & Pierce, 2015). Maryland is in the forefront of the nurse residency movement. NRPs have been endorsed by deans and directors in academe, the MONL, the Maryland Nurses Association, and the HSCRC. CNOs and nurse educators from across the state are volunteering to implement the NRP curriculum in a collaborative fashion with uniform measurement of results. A stable, clinically competent, well-educated, professional nursing workforce is required to meet the ever-increasing demand for health care services. Our findings may drive the future transformation of new nurse graduate education and state licensure by Volume 8/Issue 4 January 2018 www.journalofnursingregulation.com 19

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National Academies of Sciences, Engineering and Medicine. (2015). Assessing progress on the Institute of Medicine report The Future of Nursing. Washington, DC: The National Academies Press. Retrieved from http://www.nationalacademies.org/hmd/reports/2015/assessing- Progress-on-the-IOM-Report-The-Future-of-Nursing.aspx Pittman, P., Bass, E., Hargraves, J., Herrera, C., & Thompson, P. (2015). The future of nursing: monitoring the progress of recommended change in hospitals, nurse-led clinics, and home health and hospice agencies. Journal of Nursing Administration, 45(2), 93 99. doi:10.1097/nna.0000000000000167 Pittman, P., Herrera, C., Bass, E., & Thompson, P. (2013). Residency programs for new nurse graduates: How widespread are they and what are the primary obstacles to future adoption? Journal of Nursing Administration, 43(11), 597 602. doi:10.1097/01. NNA.0000434507.59126.78 Rosenfeld, P., Glassman, K., & Capobianco, E. (2015). Evaluating the short- and long-term outcomes of a post-bsn residency program. Journal of Nursing Administration, 45(6), 331 338. doi:10.1097. NNA.0000000000000211 Rush, K. L., Adamack, M., Gordon, J., Lilly, M., & Janke, R. (2013). Best practices of formal new graduate nurse transition programs: An integrative review [Epub 2012 Jul 12]. International Journal Of Nursing Studies,50(3), 345 356. doi 10.1016/j.ijnurstu.2012.06.009. Shen, Q., Peltzer, J., Teel, C., & Pierce J. (2015). The initiative to move toward a more highly educated nursing workforce: Findings from the Kansas registered nurse workforce survey [Epub 2015 Apr 20]. Journal of Professional Nursing, 31(6), 452 463. doi:10.1016/j.profnurs.2015.04.003. Spector, N., Blegen, M., Silvestre, J., Barnsteiner, J., Lynn, M. R., Ulrich, B., Alexander, M. (2015). Transition to practice study in hospital settings. Journal of Nursing Regulation, 5(4), 24 38. Ulrich, B., Krozek, K., Early, S., Ashlock, C. H., Africa, l. M., & Carman, M. L. (2010). Improving retention, confidence, and competence of new graduate nurses: Results from a 10-year longitudinal database. Nursing Economics, 28(6), 363 375. Joan I. Warren, PhD, RN-BC, NEA-BC, FAAN, is Associate Professor, University of Maryland School of Nursing, Baltimore. Sherry Perkins, PhD, RN, FAAN, is Executive Vice President and Chief Operating Officer, Dimensions Healthcare System, Laurel, Maryland. Mary Ann Greene, DNP, RN, NEA-BC, is Program Coordinator, Maryland Nurse Residency Program/ Maryland Organization of Nurse Leaders, Glen Burnie. Volume 8/Issue 4 January 2018 www.journalofnursingregulation.com 21