Josephine H. Silvestre Beth T. Ulrich Tricia Johnson Nancy Spector Mary A. Blegen A Multisite Study on a New Graduate Registered Nurse Transition to Practice Program: Return on Investment

UCCESSFULLY TRANSITIONING The National Council of State EXECUTIVE SUMMARY new graduate registered Boards of Nursing (NCSBN) has nurses (NGRNs) into prac - done extensive research on new Many healthcare organizations tice is crucial. The demands graduate nurse transition and, in have been reluctant to imple - Son the new nurse are increasing as collaboration with more than 35 ment evidence-based transition the patient population is present - nursing organizations and stake - to practice (TTP) programs due ing with complex health condi - holders, developed an evidence- to concerns about costs. tions and new healthcare technol - based standardized TTP model It is necessary to demonstrate ogy continues to emerge. Despite (NCSBN, 2014). The goal of the to nursing practice leaders and national calls for new graduate model is to promote public safety healthcare executives the mon - nurse residencies (Benner, Sut - by supporting NGRNs during their etary value for providing a phen, Leonard, & Day, 2010; critical entry period and progres - structured TTP program for Goode, Lynn, Krsek & Bednash, sion into practice. The model is new graduate registered nurses 2009; Hofler, 2008; Institute of dependent on a well-developed (NGRNs). Medicine, 2011; The Joint Com - preceptor-nurse relationship using The findings of this study show mission, 2002), many healthcare preceptors trained for the role. a positive return on investment organizations still have not imple - From 2011 to 2013, NCSBN and provide additional evidence to support the business case mented transition to practice conducted a TTP study, based on for implementing a TTP pro - (TTP) programs. Clearly costs as- its TTP model, following 1,464 gram in hospitals to decrease sociated with a TTP program may NGRNs in three states (Illinois, NGRN turnover. be contributing to the reluctance North Carolina, and Ohio) using Additionally, the results suggest of organizations to implement study and control groups. The the immediate investment in a these programs. Healthcare execu - methodology and results includ - NGRN TTP program has a tives need information on the ing additional outcomes such as financial benefit that accrues return on investment (ROI) to sup - NGRN competency, work stress, relatively quickly due to higher port a structured TTP program in and job satisfaction from that nurse retention rates. hospitals. study were reported previously

JOSEPHINE H. SILVESTRE, MSN, RN, is TRICIA JOHNSON, PhD, is Associate Professor and Associate Chair of Education and Associate of Regulatory Innovations, Research, Department of Health Systems Management, and Director, Rush Center for the National Council of State Boards of Advancement of Healthcare Value, Rush University, Chicago, IL. Nursing, Baltimore, MD. NANCY SPECTOR, PhD, RN, FAAN, is Director, Regulatory Innovations, National Council BETH T. ULRICH, EdD, RN, FACHE, FAAN, of State Boards of Nursing, Baltimore, MD. is Professor, University of Texas Health Science Center at Houston School of MARY A. BLEGEN, PhD, RN, FAAN , is Professor Emerita, Department of Community Nursing, Houston, TX, and Editor, Health Systems, University of California, San Francisco, CA. Nephrology Nursing Journal .

110 NURSING ECONOMIC$/May-June 2 017/Vol. 35/No. 3 (Spector et al., 2015). The ROI 40 nursing units and used the other relevant indices and break - results from that study are report - term churn to describe the con - ing out the vacancy-related costs ed here. stant movement of staff, thus cre - of closed beds and patient defer - ating changes to skill mix and rals (Jones, 2008). For July 2007, Literature Review challenges in scheduling, per - the range for turnover costs per While there are many direct formance management, and super - RN was determined to be from and indirect outcomes of TTP pro - vision. They stressed the impact $82,000 (if the vacancy was filled grams, retention/turnover of NGRNs of continuity of care, highlighting by an experienced RN) to $88,000 is the most frequently used out - a unit in their study with a high (if the vacancy was filled by a come. Most studies of TTP report churn rate that had a higher rate of NGRN). This methodology has turnover decreases when there is a adverse patient safety outcomes also been used outside of nursing supportive TTP program for NGRNs than other units in the study. The to study turnover costs of emer - (Anderson, Hair, & Todero, 2012; churning creates problems with gency medical services personnel Goode, Lynn, McElroy, Bednash, & continuity of care in addition to (Patterson et al., 2010). While Murray, 2013; Spector et al., 2015; management and economic issues these turnover costs have not been Ulrich et al., 2010). A recent for the organization. Bae and col - updated using Jones’ detailed NCSBN NGRN TTP study found leagues (2010) studied the rela - methodology, what is known is an overall 12-month turnover rate tionship between temporary nurs - the annual mean wage for RNs in of 17% (Spector et al., 2015). es and patient safety outcomes general and surgical hospitals rose Further, lower turnover rates have and found there were greater num - from $63,820 in 2007 to $70,590 been reported in two national TTP bers of patient falls when nurses in 2013, an increase of 10.6% programs, which have been in worked on units with high levels (U.S. Department of Labor, 2015). place for more than 10 years of temporary nurses (15% or more). The Robert Wood Johnson (Goode et al., 2013; Ulrich et al., NGRN turnover has a negative (RWJ) Wisdom at Work evaluation 2010). Ulrich and colleagues financial impact on institutions performed by The Lewin Group (2010) reported an overall 12- (Jones, 2004; Jones, 2005; Jones, (2009) reported that, based on cost month turnover rate of 7.1% 2008; Trepanier, Early, Ulrich, & data collected from 14 RWJ (which dropped to 4.3% after the Cherry, 2012; Ulrich et al., 2010). grantees, the average replacement fifth cohort of NGRNs by which The total cost of turnover is often cost for a full-time equivalent RN time the program was fully inte - difficult to calculate and varies by was $36,567 in 2007 dollars with a grated into the organization), com - what costs are included. Some of range from $14,225 to $60,102. pared to a 27% 12-month turnover the most detailed analyses of the This replacement cost did not prior to implementation of the costs of nursing turnover have include the cost of bed closures or TTP program. Goode and co- been performed by Jones (2004, patient deferrals, but did include authors (2013) found similar re- 2005, 2008). Based on retrospec - costs for termination, unfilled sults with 12-month turnover tive, descriptive studies, Jones positions, ads/recruiting, hiring, decreasing from 12% in the early developed a Nursing Turnover and orientation/training. The cost years of program implementation Cost Calculation Methodology reported by The Lewin Group (2009) to 5.4% in later years. with all costs of turnover includ - did not appear to differentiate bet - Kovner, Brewer, Fatehi, and ing vacancy costs incurred while ween the replacement cost for an Jun (2014) reported data from a the position is vacant, orientation NGRN and an experienced RN. nationally representative sample and training costs, newly hired Trepanier and associates (2012) of newly licensed registered nurs - RN productivity costs (found to be conducted a cost-benefit analysis es during the beginning years of higher with NGRNs than with from 2007 to 2010 of a multisite their careers. The researchers experienced RNs), advertising and NGRN residency program utiliz - found approximately 17.5% of recruiting costs, pre-turnover pro - ing turnover rate and temporary newly licensed RNs leave their ductivity costs, and hiring and ter - nurse usage data from 15 commu - first nursing job within the first mination costs, with the first four nity-based hospitals, which are year and approximately 33.5% categories accounting for more part of a large for-profit healthcare leave within 2 years. than 90% of the total cost (Jones, corporation. They found a major Additionally, researchers found 2005). Jones notes these are not all reduction in 12-month turnover a relationship between turnover costs associated with turnover, but from 255 NGRNs pre-residency to and patient safety outcomes (Bae, they are the costs that could be 39 NGRNs post-residency with an Mark, & Fried, 2010; Duffield, quantified. Jones updated the estimated savings of $15.2 million Roche, O’Brien-Pallas, & Catling- methodology in 2007, using more (average cost per NGRN turnover Paull, 2009; Spector et al., 2015). detailed information that was of $70,500). There were additional Duffield and associates (2009) available from data sources such costs associated with the residen - evaluated staff consistency across as the Consumer Price Index and cy of $13,460 per NGRN due to the

NURSING ECONOMIC$/May-June 2 017/Vol. 35/No. 3 111 cost of the structured residency in nurses’ roles, responsibilities, lected from several sources, and an additional 8 weeks of and practice settings occur. Each including surveys of NGRNs, NGRN salary ($28/hour) from 10 NGRN in the TTP group and the nurse preceptors, and site coordi - weeks in the traditional orienta - control group went through the nators, as well as publicly avail - tion to 18 weeks in the residency. hospital’s existing orientation pro - able data from the Bureau of Labor In addition, there was a major cost gram. Upon enrollment into the Statistics (U.S. Department of savings in contract labor usage study, each NGRN in the TTP Labor, 2013a). The retention and from pre-residency to post-resi - group was partnered with a turnover data of each NGRN who dency, with an estimated savings trained preceptor who worked participated in the TTP study was of up to $33.7 million. within the same unit/department. recorded by the site coordinators The results of the current Additionally, each NGRN and pre - at each of the participating study study can provide nurse leaders ceptor in the TTP group complet - and control sites and were submit - with additional evidence on ed online training modules, which ted via online surveys. The site demonstrating an ROI when were designed based on the TTP coordinators noted the reasons for implementing a TTP program. The model, and actively participated leaving which included the fol - ROI of the TTP program in this in a preceptorship within the TTP lowing voluntary and involuntary study was determined by compar - program for 6 months. The NGRNs reasons: ing the cost of NGRN turnover at were followed for 1 year after hospitals that did not have a struc - enrollment onto the study. Voluntary tured program for their NGRN The researchers examined the • Moved to another geographic onboarding against the cost of onboarding methods used by the area NGRN turnover at hospitals with a control hospitals and noted wide • Return to school to pursue TTP program. variation in these methods. There additional nursing education were 26 control sites that did not • Stressful nature of the work Method have a structured curriculum and • Took a different position in Design. This was a compari - had fewer than six elements the clinical/patient care nursing son study using a randomized, literature describes as essential to • Took a different position in controlled, multisite design. De- transition (patient-centered care, non-clinical/patient care nurs - tails on the methodology have communication and teamwork, ing been published previously (Spector quality improvement, evidence- • Took time out for family or et al., 2015). based practice, informatics, safety, other personal reasons Institutional review board clinical reasoning, feedback, re- • Other, not specified (IRB) approval. IRB approval was flection, preceptorship, and spe - obtained for all sites to protect the cialty knowledge in the area of Involuntary rights of participants. NCSBN staff practice). These were classified as • Medical, injury, death submitted and maintained IRB limited programs. Other control • Terminated, for cause applications for the sites that sites had some structure in their could use a central IRB (Western curriculum, which meant they These data were reviewed for Institutional Review Board). The had six or more elements essential accuracy and completeness and remaining sites submitted IRB to transition, offered a preceptor - verified with the site coordinators applications to and obtained IRB ship, and were not included in as necessary. Each NGRN was approval from their local IRBs. this analysis. For the purpose of coded as retained at 1 year, left Procedure. NCSBN evaluated this article, the researchers evalu - voluntarily, or left involuntarily. the ROI on a TTP program utiliz - ated the ROI of the TTP group and Data were collected on the ing overall turnover rates from the control group with the limited opportunity cost of participating Phase I of NCSBN’s TTP study programs (hereafter referred to as in the program for both NGRNs (Spector et al., 2015). The TTP Limited Control group), which and nurse preceptors. The oppor - program in this study did not together represented 1,032 NGRNs tunity cost was estimated by mul - replace the hospital’s current ori - from 70 hospitals. The program tiplying the amount of time spent entation program. Orientation, costs for each of the Limited in the TTP program by the nation - which is separate from TTP, Control groups were not collected al hourly wage for new nurses and includes the process of introduc - because the curriculum of each nurse preceptors. The NGRN ing staff to the philosophy, goals, program was limited and varied opportunity cost included time policies, procedures, role expecta - across the Limited Control groups spent completing the training tions, and other factors needed to but any cost expended by the modules and time spent with the function in a specific work setting. Limited Control groups would nurse preceptor (20 hours total). Orientation takes place both for increase the ROI of the TTP group. The nurse preceptor opportunity new employees and when changes Data collection . Data were col - costs also included the time spent

112 NURSING ECONOMIC$/May-June 2 017/Vol. 35/No. 3 completing training modules and the completion of the TTP pro - Results time spent with the NGRNs (43 gram was a critical element, $35 Sample. Data were analyzed hours total). The time spent in the was included for each preceptor- on 1,032 NGRNs from 70 hospi - precepting relationship by the NGRN pair and $2.57 for a TTP tals. The demographic characteris - NGRNs and nurse preceptors was lapel pin. All costs were calculated tics of the NGRNs and the hospi - collected through surveys at 6 and per NGRN and summed to calcu - tals in the TTP group and Limited 12 months. late the total program and partici - Control group are provided in Additionally, time spent orga- pant cost per NGRN participant. Table 1. The number of NGRNs nizing the training was collected The effectiveness of the TTP hired varied greatly across these by the site coordinator. The site program was measured by cost hospitals, which differed in size coordinators were surveyed about savings associated with the reduc - and type. The average number of the amount of time (182 hours) tion in nurse turnover. The Robert NGRNs hired was 15 and the they spent enrolling NGRNs and Wood Johnson Wisdom at Work median was 11. Hospitals in the preceptors in the program, check - evaluation (The Lewin Group, Limited Control group were gener - ing the status of module comple - 2009) reported the replacement ally smaller than TTP hospitals; tion for NGRNs and preceptors, cost for a full-time equivalent RN however, one large hospital in the and troubleshooting information in an average-sized hospital as Limited Control group hired 85 technology issues. The time spent $36,567 in 2007 dollars (or NGRNs, which increased the in the program by NGRNs was $41,085 in 2013 dollars). The mean. Overall, 81.2% of these converted to costs by multiplying Lewin Group estimates are conser - NGRNs were still at the hospitals the average total hours in the pro - vative compared to other re - at the end of the first year (84.5% gram by the 25th percentile for searchers (Jones, 2008; Trepanier nurse salaries nationally as of May et al., 2012). Jones estimated the in the TTP group and 73.7% in the 2013 ($26.05) to reflect the lower replacement cost of an NGRN as Limited Control group). The num - salaries of NGRNs (U.S. Depart- $88,006 in 2007 dollars (adjusted bers of NGRNS and their reasons ment of Labor, 2013a). Nurse pre - for inflation, $98,879 in 2013). To for leaving are categorized in ceptor time was converted to costs calculate the cost savings, the Table 2. The number of NGRNs by multiplying the average total replacement cost was multiplied who left was statistically signifi - hours in the program by the 50th by the reduction in the turnover cant. Voluntary reasons for leaving percentile for nurse salaries rate for the TTP group hospitals accounted for 181 NGRNs (17.5%) nationally in May 2013 ($31.84). relative to the Limited Control no longer at the hospitals and 13 For site coordinators, the average group hospitals (turnover rate for (1.3%) left involuntarily due to time spent by the site coordinators TTP group hospitals – turnover either termination or illness and was multiplied by an average of rate for the Limited Control group injury. There were too few NGRNs the 50th and 75th percentiles of hospitals). who left involuntarily to analyze nurse salaries nationally ($35.20) Data analysis . Descriptive the data further. Additionally, due (U.S. Depart ment of Labor, 2013a). analysis was used to examine the to the small numbers in each cate - Fringe benefits were calculated at data and provide characteristics of gory, the reasons for leaving were approximately 34.45% (U.S. De- the NGRNs. An analysis of vari - not statistically significant. partment of Labor, 2013b). ance (ANOVA) was used to ana - The NGRNs who left were Modules and a web platform lyze the differences between the compared by their demographic were developed specifically for this groups in the primary TTP study. characteristics and by the hospital TTP program. In a sensitivity analy - Chi-square analysis was used to characteristics (see Table 3). Age, sis, the cost of this development analyze the differences in turn- education, location, hospital size, was calculated as $723 per NGRN. over and turnover characteristics Magnet ® status, and presence of a This is a one-time cost based on between the TTP group and the TTP program were all related to development of the modules and Limited Control group. In the ROI turnover. NGRNs were less likely web platform for the 788 new nurs - analysis, ongoing cost of the TTP to leave the hospital by the end of es enrolled into the TTP group program (excluding module and the first year if they were younger across all TTP group hospitals. A web development costs) was first than age 30 ( p<0.05) and had a total of 734 NGRNs in the TTP compared with the cost savings basic bachelor’s education (not sta - group were included in the analy - from reduced turnover to calcu - tistically significant). NGRNs were sis, which represents the number of late net cost (or cost savings) of the less likely to leave in hospitals that NGRNs who responded to surveys. program. In a secondary analysis, were in Illinois, between 100-199 The ongoing website and mo - program development costs were beds in size, or that have achieved dule revision costs for the TTP included in the costs to calculate Magnet designation ( p<0.05). program were estimated at $100 net cost (or cost savings) of the TTP group vs. Limited Control per NGRN. Because celebration at program. group turnover . The 12-month

NURSING ECONOMIC$/May-June 2 017/Vol. 35/No. 3 113 Table 1. NGRN and Hospital Demographic Information for TTP and Limited Control Groups

Limited Limited TTP Group Control Group Control Group Total n TTP Group % n % n* NGRN Characteristics Total NGRNs 734 298 1,032* Age Younger than 30 426 72.3% 128 68.8% 554 30-40 105 17.8% 42 22.6% 147 Older than 40 58 9.9% 16 8.6% 74 Education Associate’s degree 290 49.2% 79 42.7% 369 Bachelor’s degree 246 41.8% 97 52.4% 343 Accelerated BS/Master’s degree 53 9.0% 9 4.9% 62 Hospital Characteristics Total Hospitals 44 26 70 State Illinois 101 13.8% 56 18.8% 157 North Carolina 190 25.9% 102 34.2% 292 Ohio 443 60.4% 140 47.0% 583 Hospital Location Rural 86 11.7% 36 12.1% 122 Suburban 249 33.9% 114 38.3% 363 Urban 399 54.4% 148 49.7% 547 Hospital Size 25-99 beds 39 5.4% 24 8.1% 63 100-199 beds 126 17.5% 21 7.1% 147 200-299 beds 167 23.2% 85 28.7% 252 300-399 beds 83 11.5% 81 27.4% 164 400+ beds 305 42.4% 85 28.7% 390 Type of Organization Government not federal 23 3.1% 9 3.0% 32 Not for profit 695 94.7% 282 94.6% 977 For profit 16 2.2% 7 2.3% 23 Magnet No 421 57.5% 271 90.9% 692 Yes 311 42.5% 27 9.1% 338 University Affiliated No 673 91.7% 265 88.9% 938 Yes 61 8.3% 33 11.1% 94 * Some respondents did not provide a response to all survey questions. BS = bachelor of science, NGRN = new graduate registered nurse, TTP = transition to practice

114 NURSING ECONOMIC$/May-June 2 017/Vol. 35/No. 3 per NGRN retained. After account - Table 2. ing for initial program develop - NGRN Reasons for Leaving ment cost ($723 per NGRN), the net cost saving was $735 per Limited NGRN retained. Using the replace - TTP Control ment cost reported by Jones Group Group p -Values (2008), net replacement cost sav - Number H ired 734 298 ings for an NGRN in the hospital setting for the TTP group versus Number (%) left 113 (16%) 80 (27%) Statistically significant the Limited Control group was p<0.00 $11,173 (turnover cost for one NGRN in the TTP group minus the Reasons for Leaving Not turnover cost for one NGRN in the significant Limited Control group). Com - Voluntary paring the net replacement cost savings with total cost per NGRN Moved to another 20 (17.7%) 21 (26.2%) to maintain the TTP program geographic area ($3,185), there was a net cost sav - Return to school to pursue 1 (0.08%) 1 (1.2%) ings of $7,988 per NGRN retained. additional nursing education After accounting for the initial Stressful nature of the work 4 (3.5%) 1 (1.2%) program development cost ($723 per NGRN), the net cost savings Took a different position in 56 (50%) 34 (42.5%) was $7,265 per NGRN retained. clinical/patient care nursing It is often helpful to look at Took a different position in 2 (1.8%) 0 “What if” scenarios. In this study, non-clinical/patient care 44 hospitals with the TTP pro - nursing gram experienced a 12-month turnover of 15.5% (114 NGRNs) Took time out for family or 3 (2.6%) 1 (1.2%) other personal reasons compared to a 26.8% turnover (80 NGRNs) in 26 Limited Control Other, not specified 21 (18.6%) 16 (20%) hospitals. If hospitals with the Involuntary TTP program experienced the same higher turnover percentage Medical, injury, death 2 (1.8%) 3 (3.8%) as the Limited Control hospitals Terminated, for cause 5 (4.4%) 3 (3.8%) (26.8%), they would have lost 197 NGRNs, an increased turnover of NGRN = new graduate registered nurse, TTP = transition to practice 83 NGRNs. Replacement costs to the TTP hospitals for those addi - total turnover rate of the TTP ongoing web maintenance and tional 83 NGRNs could have group was compared to the Limit- module revisions. The addition of ranged from a conservative esti - ed Control group. The TTP group the one-time cost to develop mod - mate of $3.1 million (based on the had a turnover rate of 15.5%, ule content and the web platform replacement costs reported by The while the Limited Control group added $723 per NGRN. The calcu - Lewin Group less the $3,912 cost had a 26.8% turnover rate lations for the total development per NGRN for the TTP program) to (p<0.00). and ongoing cost of the TTP pro - $7.9 million (based on the replace - TTP group cost and savings. gram per NGRN are provided in ment costs reported by Jones less The total ongoing maintenance Table 4. the $3,912 cost per NGRN for the cost per NGRN in the TTP group Using the replacement cost TTP program). was $3,185 in the hospital setting, reported by The Lewin Group which includes new nurse and (2009), the net replacement cost Discussion preceptor opportunity costs (time savings for an NGRN in the hospi - The ROI for the TTP program spent to complete TTP modules tal setting for the TTP group ver - was analyzed by comparing the and face-to-face time between sus the Limited Control group was turnover rates of the TTP group NGRN and preceptor within $4,643 (see Table 5). Comparing with the Limited Control group. active preceptorship), site coordi - net replacement cost savings with There was a significant difference nator time to organize and main - total cost per NGRN to maintain in the turnover rate of the TTP tain the program, celebration costs the TTP program ($3,185), there group (15.5%) and the turnover for TTP program completion, and was a net cost savings of $1,458 rate of the Limited Control group

NURSING ECONOMIC$/May-June 2 017/Vol. 35/No. 3 115 (26.8%). These data support that a Table 3. structured, evidence-based TTP Differences in Turnover by Characteristics program results in decreased (N = 1,032*) turnover. A limitation of this study is that it occurred over only NGRN Chi-Square a 1-year period. Other longitudi - Turnover Values p-Values nal studies of NGRN TTP pro - Age grams found NGRN turnover rate declines over time as the TTP pro - Younger than 30 13.7% 8.174 p = 0.017 gram becomes fully integrated 30-40 23.1% into the organization. For exam - Older than 40 18.9% ple, Ulrich and colleagues (2010) found turnover for their first Education cohort was 7.1%, though this Associate’s Degree 18.7% improved to 4.3% by the fifth 5.575 p = 0.062 Bachelor’s Degree 12.5% cohort. Using the replacement costs Accelerated BS/Master’s Degree 19.4% reported by The Lewin Group State (2009), the cost analysis shows a Illinois 9.6% positive ROI when using a struc - 24.195 p < 0.001 tured TTP program compared to a North Carolina 27.4% limited program, with a cost sav - Ohio 17.0% ings of $735 per NGRN (consider - Hospital Location ing initial development costs). There is an even larger cost sav - Rural 19.7% ings of $1,458 per NGRN once the 3.185 p = 0.203 Suburban 21.5% program is implemented and in place. These savings are conserva - Urban 16.8% tive compared to those of other Hospital Size researchers, who have reported 25-99 beds 19.0% higher estimates for replacement costs (Jones, 2008). Using the 100-199 beds 12.9% 11.563 p = 0.021 replacement costs identified by 200-299 beds 25.0% Jones (2008), net development 300-399 beds 20.1% cost savings is $7,265 per NGRN and net ongoing maintenance cost 400+ beds 16.9% savings is $7,988 per NGRN. Jones Type of Organization (2008) estimates represent the cost Government not federal 15.6% to hire a new nurse to fill an open 2.270 p = 0.321 hospital position and include the Not for profit 18.6% direct costs of bed closures and For profit 30.4% patient deferrals. This study provides nursing Magnet practice leaders with evidence of No 24.1% 38.479 p < 0.001 cost savings considering invest - Yes 8.0% ment associated with implement - ing a TTP program. Even when University Affiliated considering the costs of develop - No 19.2% 1.033 p = 0.191 ing and maintaining online train - Yes 14.9% ing modules, releasing the new nurse and preceptor to complete TTP their training modules, and oppor - Sites with TTP 15.5% tunity cost of the preceptor work - 17.775 p < 0.001 ing closely with new nurses, there Limited-control group 26.8% hospitals without TTP was a cost savings for each new nurse hired. This is important for * Some respondents did not provide a response to all survey questions. nursing practice leaders, since BS = bachelor of science, NGRN = new graduate registered nurse, TTP = transition to even small organizations that hire practice

116 NURSING ECONOMIC$/May-June 2 017/Vol. 35/No. 3 Table 4. Calculation of Total Development and Ongoing Cost of TTP Program per NGRN

Description Cost per NGRN TTP Program Development (includes module content development and website development) Initial TTP Program Development Cost ÷ Number of NGRNs that Utilized the TTP Program = $570,000 ÷ 788 = $723 Ongoing Costs per NGRN Program Maintenance (includes website maintenance and module revisions) $100 New Nurse Opportunity Cost Release time to complete TTP modules and meet with preceptor X NGRN hourly rate X (1 + fringe benefit rate) = 20 hours X $26.05 X (1 + (7.5 ÷ 21.77)) = $700.44 Preceptor Opportunity Cost Release time to complete TTP modules and meet with NGRN X preceptor hourly rate X (1 + fringe benefit rate) = 43 hours X $31.84 X (1 + (7.5 ÷ 21.77)) = $1,840.80 Site Coordinator Cost to Organize TTP Program for One NGRN [Time spent organizing TTP program X site coordinator hourly rate X (1 + fringe benefit rate)] ÷ average number of NGRNs per TTP site = [182 hours X $35.20 X (1 + (7.5 ÷ 21.77))] ÷ 17 = $506.67 Celebration Cost Celebratory lunch for NGRN and preceptor pair $35 TTP lapel pin awarded to NGRN $2.57 Total Ongoing Costs per NGRN $3,185

NGRN = new graduate registered nurse, TTP = transition to practice

Table 5. Turnover Cost Savings Calculations

The Lewin Group Jones Formula (2009) (2008) Turnover Costs and Rates Turnover cost to replace one NGRN (in 2013 USD) a $41,085 $98,879 Limited Control group b 26.8% 26.8% TTP Group c 15.5% 15.5% Net Replacement Cost Savings for One NGRN in TTP Group vs. Limited Control Group (in 2013 USD) Limited Control group d = a x b $11,011 $26,499 TTP Group e = a x c $6,368 $15,326 Turnover savings for one nurse NGRN with TTP f = d - e $4,643 $11,173 Cost of TTP Ongoing cost of TTP Program g $3,185 $3,185 Net cost of TTP Program with ongoing costs ($ savings) h = f - g $1,458 $7,988 De velopment Cost of TTP Program i $723 $723 Development and Ongoing Costs of TTP Program j = i + g $3,908 $3,908 Net Cost of TTP Program with Development and Ongoing k = f - j $735 $7,265 Costs ($ savings)

NGRN = new graduate registered nurse, TTP = transition to practice

NURSING ECONOMIC$/May-June 2 017/Vol. 35/No. 3 117 only a few new nurses can expect turnover. Additionally, results Jones, C.B. (2008). Revisiting nurse turn- a cost savings when implementing suggest the immediate investment over costs: Adjusting for inflation. Journal of Nursing Administration, and maintaining a TTP program. in a NGRN TTP program has a 38 (1), 11-18. Additionally, one option to de- financial benefit that accrues rela - Kovner, C.T., Brewer, C.S., Fatehi, F., & Jun, crease costs for smaller organiza - tively quickly due to higher nurse J. (2014). What does nurse turnover tions even further might be to nur - retention rates. $ rate mean and what is the rate? Policy, ture partnerships with schools of Politics, & Nursing Practice, 15 (3-4), 64-71. REFERENCES nursing or other organizations to National Council of State Boards of Nursing Anderson, B., Hair, C., & Todero, C. (2012). facilitate the initial implementa - (NCSBN). (2014). Why transition to Nurse residency programs: An evi - practice? Chicago, IL: Author. Re - tion of a TTP program. Nursing dence-based review of theory, trieved from https://www.ncsbn. org/ practice leaders can use this evi - process, and outcomes. Journal of transition-to-practice.htm Professional Nursing, 28 (4), 203-212. dence in efforts to convince Patterson, P.D., Jones, C.B., Hubble, M.W., Bae, S.H., Mark, B., & Fried, B. (2010). Use administration to implement TTP Carr, M., Weaver, M.D., Engberg, J., & of temporary nurses and nurse and Castle, N. (2010). The longitudinal programs. The cost analysis de- patient safety outcomes in acute care study of turnover and the cost of monstrated the information tech - hospital units. Health Care Manage- turnover in emergency medical servic - nology costs associated with a ment Review, 35 (3), 333-344. es. Prehospital Emergency Care, 14 (2), Benner, P., Sutphen, M., Leonard, V., & transition program are small, due 209-221. Day, L. (2010). 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