In 2002, Barsky and Lewis (2002) reported between 20% to 25% of new RN graduates chose to work in another state after graduating from a nursing program. At the time, the state's nursing vacancy rate was approximately 14% (Quigley, 2003). In 2004, the University of New Mexico College of Nursing (UNM CON) and the University of New Mexico Hospitals (UNMH) engaged in a cooperative effort to create a paid internship program for prelicensure RN students to increase prelicensure experience in the clinical setting, mitigate low RN retention rates, and increase the number of RNs who work in the state after graduation. Although no historical data regarding RN retention rates were available, the current UNMH nurse residency manager reported anecdotal information that the 1-year RN retention rate for UNMH was 70% or higher at the time of the internship's inception.
Hospital-based nursing student development programs have been shown to increase students' critical thinking, socialization, and enhanced transition to the RN role (Starr & Conley, 2006). Additionally, nurse managers are able to identify potential candidates from these programs to use as a newly graduated RN (Redding & Flatley, 2003). The goals of the UNM CON/UNMH internship program were to allow nursing students to:
- focus on organizing work and setting priorities,
- communicate effectively,
- develop clinical leadership skills,
- develop technical skills needed to provide safe care,
- practice quality care with acutely ill patients, and
- learn to work in emergency and end-of-life situations.
CON students are eligible for the internship program during the final two semesters of their nursing program (University of New Mexico Health Sciences, n.d.b). All students who are successfully progressing through their undergraduate program coursework are eligible to enroll in the internship course. These nursing student interns work in a clinical environment under the close supervision of an RN preceptor (University of New Mexico Health Sciences, n.d.b). Nursing student interns are hired, paid employees of the hospital, and they must also enroll in an associated 1-credit course provided by the UNM CON during all semesters in which the nursing student intern is used as a nurse intern by UNMH (University of New Mexico Health Sciences, n.d.b). The course uses student-centered learning principles, which allow nursing student interns to collaboratively problem solve and learn from each other. This course focuses on developing leadership, prioritization, and delegation abilities and also covers various issues in nursing, such as appropriate charting and hand-off techniques, avoiding medication errors, and handling emergency situations. Additionally, the course provides a safe space to debrief and share experiences from the various clinical units where the nursing student interns are working.
Students must work to balance their school responsibilities with their internship schedule. Their eligibility to participate in the program is directly related to their success in their other nursing courses. Nursing student interns who fail a course must resign from the internship position, which can create a financial hardship for the nursing student interns and the loss of a valuable employee for the hospital. Nursing student interns typically work between 6 and 36 hours every 2 weeks depending on the nursing student intern's schedule and the unit's needs.
Once student nurse interns graduate and are employed by UNMH, they are on-boarded to the organization directly to their area of practice, and the newly hired RNs are enrolled in the Nurse Residency Program (NRP) to assist with their transition to practice (University of New Mexico Health Sciences, n.d.a). UNMH implemented the Vizient NRP in 2003. The NRP uses a curriculum to focus on ensuring quality patient outcomes, growing in the professional role as an RN, and developing effective clinical judgement (University of New Mexico Health Sciences, n.d.a). Nurse residents attend a monthly 4-hour seminar and complete an evidence-based practice project (University of New Mexico Health Sciences, n.d.a). The NRP has an additional goal to reduce RN turnover. At the time the NRP was being implemented, lower RN retention rates had increased recruiting expenses for the hospital. There is evidence that transition to practice programs, such as the Vizient NRP, provide support and increased retention of newly graduated RNs to over 90% during the first year of employment compared with health care organizations without a nursing transition to practice program (Goode et al., 2013).
Although the NRP is an evidence-based program (American Association of Colleges of Nursing, n.d.), no formal evaluation had been undertaken to evaluate whether the UNM CON Nurse Internship Program/UNMH NRP has been effective in increasing RN retention. Therefore, this study was undertaken to answer the following questions:
- What percentage of newly graduated RNs who participated in the UNM CON Nurse Internship Program were employed by UNMH?
- What are the 1-year and 5-year retention rates of RNs who participated in the UNM CON Nurse Internship Program/UNMH NRP?
- Do 1-year and 5-year retention rates of RNs who participated in the UNM CON Nurse Internship Program/UNMH NRP differ based on demographic variables?
Design and Sample
This study was reviewed and approved by the UNM Health Science Center's Human Research Review Committee. After approval was obtained, an analysis of existing data of individuals who had enrolled in both the UNM CON nurse internship and nursing residency programs was completed. First, academic records maintained by the UNM CON were used to identify and create a data set of students who had completed at least one semester of the UNM CON nurse internship course between January 2008 and May 2017. Student identification numbers were obtained from existing records at the UNM CON and added to the data set. These identification numbers would remain the same if the former students had been employed by UNMH as nurse interns. Then, the data set was submitted to the UNMH Human Resources department.
The UNMH Human Resources department and the NRP Nurse Manager were able to identify if these former nursing student interns had been employed as a RN by UNMH and if the new hires had completed the NRP. Demographic information, dates of employment, and the locations of employment at years 1 and 5 or the date of separation, as applicable, for the former nursing student interns who had been employed by UNMH were added to complete the data set.
IBM® SPSS® (version 25) was used to complete the statistical analysis. Descriptive statistics, including frequencies and percentages, were used to characterize 1-year and 5-year retention rates of RNs who participated in the both the UNM CON Nurse Internship Program and UNMH NRP. Of note, the UNMH Human Resources department did not collect race and ethnicity data as distinct categories. Therefore, race and ethnicity were analyzed as a single variable. Chi-square tests were used to assess for significant differences in 1-year and 5-year retention rates based on age, gender, and ethnicity/race. For all analyses, a p value of .05 or less was considered statistically significant.
Table 1 provides a summary the sample's descriptive characteristics.
Participant Demographic Characteristics (N = 472)
Employment of Graduates
Of the 472 former nurse interns who graduated from the UNM CON Bachelor of Science in Nursing program, 85.6% (n = 404) were hired by UNMH. The majority of newly hired RNs were 34 years of age or younger, female, and White or Hispanic.
RN Retention Rates
After 1 year, 341 (84.4%) former interns who had completed the NRP continued their employment at UNMH. Because we examined data from January 2008 to May 2017, only 203 RNs could have been employed for a period of 5 years at UNMH and were included in the analysis of 5-year retention rates. Of the individuals who potentially could have been employed for 5 years, 43.3% (n = 88) remained employed at UNMH. The majority of those employed by UNMH for 5 years were also 34 years of age or younger, female, and White or Hispanic.
Retention Rates and Demographic Variables
Chi-square tests showed no significant differences in the demographic characteristics and percentage of those employed for 1 year and RNs hired by UNMH after completing their undergraduate nursing programs. Chi-square tests also showed no significant differences in 1-year and 5-year employment based on age and race/ethnicity. There were no significant differences in initial and 1-year employment based on gender. However, a higher percentage of males remained employed at UNMH for 5 years or longer, χ2 (1) = 5.797, p = .023. For those who remained employed at UNMH for 5 or more years, 63.6% continued to work in the same location as they had at 1 year of employment.
This study was the first known formal evaluation of the recruitment of former UNM CON student nurse interns by UNMH, and the success of the UNMH NRP in retaining newly graduated nurses. This evaluation advances the current body of knowledge by demonstrating the effectiveness of a joint innovative effort between a college of nursing and university hospital to improve the quality of undergraduate RN students' educational experience and improve RN retention after their employment. The UNM CON nurse internship program was effective in recruiting newly graduated RNs for UNMH. In comparison to Barsky's and Lewis's (2002) report that 20% to 25% of RNs worked in other states after graduation, only 14.4% of former nursing student residents chose not to work at UNMH after graduation. A higher percentage of those who completed the NRP remained at UNMH after 1 year of employment in comparison to studies reporting a 1-year retention rate ranging from 77% to 83% for newly hired RNs (Blegen et al., 2017; Kovner et al., 2014). One-year RN retention rates for UNMH also improved to 84.4% in comparison to anecdotal 1-year retention rates of 70% or less.
Although no similar studies with nurse internship and NRP programs were found in the literature, one previous study reported a 1-year retention rate of 92% for those who participated in a student externship and residency program (Friday et al., 2015). Although we found only 43.3% of individuals who could been employed for 5 years remained at UNMH, information was not available to explain why RNs did not remain employees of UNMH over time. Prospective data collection of the reason for RN separation from the hospital would be beneficial to understand the reasons why RNs chose not to remain employed by UNMH and how these employees could be better retained.
Many benefits exist for colleges of nursing, students, and health care organizations collaborating to offer nurse internship programs and for health care organizations to provide NRPs. For example, the primary organizational cost for UNM CON student nurse intern positions is salary, as the interns do not receive additional benefits, such as health care insurance, tuition reimbursement, or tuition remission. Although UNMH RNs work directly with the interns, they are already employed by the hospital, and the RN preceptor/intern are usually assigned higher acuity patients as part of their assignment. The nurse interns benefit from additional clinical experiences, including the opportunity for more patient interactions, skills practice, and hands-on training. Nursing student interns are also provided a source of additional income while they are completing their undergraduate nursing program.
Health care organizations benefit from reduced costs for recruitment and retention of newly graduated RNs. Knowledge of a future employee's performance prior to hiring can be valuable. Front line nurse managers and staff have the opportunity to get to know and evaluate a nurse intern as a potential future employee of the health care organization. Unfortunately, we were unable to discern how many of the nurse interns were not hired by the organization due to poor performance or if the former intern simply chose to take a position elsewhere. However, the high rate of hires from the UNM CON internship program indicates that both the UNMH clinical areas and former interns were satisfied with their experiences with the program.
Despite the successes of the nursing student intern program, the program has limitations that have been identified for improvement. The NRP Nurse Manager reported that some unit directors have discussed inconsistencies in the program application in the past. After hiring the new RN, some units did not assess the experience of the intern or the intern's previous completion of an orientation. This could result in some duplication during the orientation process for a former nurse intern. In some cases, due to school schedules and various other commitments, the intern's number of work hours can be minimal, which can lead to varied work hours and limited experiences. Therefore, orientation needs for each individual in the program can vary greatly based on the prelicensure program exposure. Likewise, additional work must be undertaken to individualize the NRP for previous nursing student interns to reduce duplication in content learned during their internship. Other program barriers included some former nurse interns taking positions in a different area as a RN at the UNMH. An example might include a nurse intern who worked on a medical–surgical unit choosing to apply for a position on a pediatric unit after graduation. Many of the previously gained skills may not translate to the different area of practice. Finally, each clinical area is responsible for implementing the program for its nurse interns. Given the acuity of the patients and their experience in the clinical environment, some nurse interns are not given the opportunity to consistently work within the full scope of practice under their preceptor's supervision on their assigned unit.
This study had several limitations. The retrospective nature of this study prevented us from gaining a deeper understanding of causes of retention and attrition of RNs at UNMH. Additionally, the collection of race and ethnicity data as a single variable limited our understanding of the racial and ethnic characteristics of the sample. Finally, because the sample included graduates from only one UNM CON and one hospital, the findings may or may not be generalizable to similar programs.
In designing a student internship program, several considerations need to be taken into account, especially the utilization of the nursing student intern in complex clinical situations or assigning nurse interns to an experienced preceptor. The program should be designed in a way that the nurse preceptor and nursing student intern should never have more than one assignment based on unit and patient acuity, and preceptor supervision should be required for all nursing activities, such as medication administration. Although the results of this study demonstrated favorable recruitment and program retention and serve as an example of how colleges and hospitals can partner to improve RN hiring and retention, the results were comparable to other newly hired RNs at UNMH who did not participate in the UNM CON nurse internship program.
Many student intern programs discussed in the literature only offer employment during the summer months. In contrast, this program is offered year-round to students in the final two semesters of the nursing program and includes nursing faculty facilitation of internship experiences. This allows professional reflection and debriefing, which offers an integral program component that can add significant value to the nursing student interns' experience. Due to the limited amount of research in the literature, future studies should evaluate levels of satisfaction, retention, and increased hiring efficiency provided by nurse internship programs.
Organizations need to be creative in developing strategies to engage newly graduated nurses in an effort to recruit and retain these individuals. Based on our finding that 85.6% of former nursing student interns were hired by UNMH after graduation, it is evident that the UNM CON nurse internship program has been an effective recruiting method for UNMH. The UNM CON nursing student internship program has provided students with work experience, nursing knowledge, and skills that enrich their future careers while also providing a source of income. UNMH enjoys more newly graduated RNs who have hands-on nursing experience guided by an UNMH nurse preceptor and an 84.4% employee 1-year retention rate of former nursing student interns. On the basis of our findings, we would encourage the implementation of the similar programs between other undergraduate nursing programs and hospitals.
- American Association of Colleges of Nursing. (n.d.). Nurse residency program. https://www.aacnnursing.org/Nurse-Residency-Program
- Barsky, L. & Zilke, S. (2002, December5). Addressing the state's nursing shortage: A statewide strategy framework. Report from the NM Nursing Shortage Statewide Strategy Sessions (NS4). https://files.eric.ed.gov/fulltext/ED476889.pdf
- Blegen, M. A., Spector, N., Lynn, M. R., Barnsteiner, J. & Ulrich, B. T. (2017). Newly licensed RN retention: Hospital and nurse characteristics. The Journal of Nursing Administration, 47(10), 508–514 doi:10.1097/NNA.0000000000000523 [CrossRef] PMID:28957869
- Friday, L., Zoller, J. S., Hollerbach, A. D., Jones, K. & Knofczynski, G. (2015). The effects of a prelicensure extern program and nurse residency program on new graduate outcomes and retention. Journal for Nurses in Professional Development, 31(3), 151–157 doi:10.1097/NND.0000000000000158 [CrossRef] PMID:25993454
- Goode, C. J., Lynn, M. R., McElroy, D., Bednash, G. D. & Murray, B. (2013). Lessons learned from 10 years of research on a post-baccalaureate nurse residency program. The Journal of Nursing Administration, 43(2), 73–79 doi:10.1097/NNA.0b013e31827f205c [CrossRef] PMID:23314789
- Kovner, C. T., Brewer, C. S., Fatehi, F. & Jun, J. (2014). What does nurse turnover rate mean and what is the rate?Policy, Politics & Nursing Practice, 15(3–4), 64–71 doi:10.1177/1527154414547953 [CrossRef] PMID:25156041
- Quigley, W. (2003, June7). Economist: Nurse shortage building to crisis. Albuquerque Journal (NM), C1. https://infoweb-newsbank-com.libproxy.unm.edu/apps/news/document-view?p=NewsBank&docref=news/0FB931A8D6A628B5.
- Redding, D. & Flatley, D. (2003). Successful implementation of a student nurse externship program. Clinical Research and Regulatory Affairs, 20(4), 479–485 doi:10.1081/CRP-120026129 [CrossRef]
- Starr, K. & Conley, V. M. (2006). Becoming a registered nurse: The nurse extern experience. The Journal of Continuing Education in Nursing, 37(2), 86–92 doi:10.3928/00220124-20060201-08 [CrossRef] PMID:16883672
- University of New Mexico Health Sciences. (n.d.a). Nurse residency program. https://hsc.unm.edu/health/careers/nurse-residency-program.html
- University of New Mexico Health Sciences. (n.d.b). Nursing intern & extern program. https://hsc.unm.edu/health/careers/nursing-intern-extern-program.html
Participant Demographic Characteristics (N = 472)
|Characteristic||Completed Intern Course, n (%)||Employed by UNMH, n (%)||Employed by UNMH After 1 Year, n (%)||Employed by UNMH After 5 Years, n (%)|
| Male||73 (15.5)||64 (15.8)||51 (15)||18 (20.5)|
| Female||399 (84.5)||340 (84.2)||290 (85)||70 (79.5)|
| 18–24||258 (54.7)||228 (56.4)||195 (57.2)||30 (53.6)|
| 25–34||148 (31.4)||123 (30.4)||100 (29.3)||20 (35.7)|
| 35–44||47 (10)||37 (9.2)||34 (10)||6 (10.7)|
| ≥ 45||19 (4)||16 (4)||12 (3.5)||0 (0)|
|Race and ethnicity|
| American Indian or Native Alaskan||9 (1.9)||7 (1.7)||5 (1.5)||2 (2.3)|
| Asian||21 (4.4)||19 (4.7)||16 (4.7)||2 (2.3)|
| Black or African American||8 (1.7)||7 (1.7)||6 (1.8)||1 (1.1)|
| Native Hawaiian or Unknowna||11 (2.3)||8 (2)||8 (2.3)||3 (3.4)|
| White||251 (53.2)||208 (51.2)||174 (51)||49 (55.7)|
| Hispanicb||159 (33.7)||143 (35.4)||122 (35.8)||29 (33)|
| Two or more races||13 (2.8)||12 (3)||10 (2.9)||2 (2.3)|