INTRODUCTION

The transition from nursing academia to professional practice is a pivotal period for newly graduated nurses, marked by the need to integrate theoretical knowledge with practical skills in the clinical setting. This transition can be challenging due to the need for proficiency in complex decision-making, a distinguishing feature of professional work. New nurses often struggle with the
application of academic learning in real-world settings, role adaptation, and professional role identity formation, leading to attrition (Baharum et al., 2023; Mbuthia et al., 2021; Mellor et al., 2022; Prosen & Ličen, 2023; Zhao et al., 2024). This
comes at a high cost to the organization. In a systematic review by Mohamed and Al-Hmaimat (2024), the cost to replace one nurse was found to range from $40,385 to $88,000. The review also identified that new graduate nurses have higher turnover costs compared to experienced nurses, including extended precepting and increased time with educators. To address these challenges, structured transition programs and tools are essential in supporting newly graduated nurses as they develop the competence and confidence required for independent professional practice. In a nurse residency program (NRP), systems thinking becomes essential because competent practice is not merely an individual skill set; it is the ability to enact the professional role effectively within a complex adaptive system. This manuscript
describes how a NRP utilized the Professional Role Identity Formation Theory and related Model of the Professorial Role Applied to Nursing (O'Rourke, 2019) as guiding framework to articulate and sequence the core competencies expected of the Registered Nurse. By aligning the NRP with this theory, the program promotes a professional role-driven approach and commitment to the profession. The implementation of this framework, paired with an evidence-based competency evaluation tool, supported residents to independent practice in accordance with the American Nurses Association (ANA) Nursing Scope and Standards of Practice and professional characteristics (ANA, DOI: 10.1097/NND.0000000000001189 2008, 2010; O'Rourke & White, 2007).

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BACKGROUND

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Despite the long history of transition programs, many newly graduated nurses continue to experience difficulties adapting to independent nursing practice and meeting the expectations of their professional role (Baharum et al., 2023; Kulikowski & O'Rourke, 2010; Prosen & Ličen, 2023). The gap between academic preparation and independent nursing practice can lead
to high anxiety, job dissatisfaction, and attrition (Baharum et al., 2023; Zhao et al., 2024). There is a pressing need for validated models and tools that can effectively bridge this gap, ensuring that new nurses are well-prepared to meet the demands of their professional role and remain committed to the profession. A competency tool is often used to document the competence of newly graduated nurses. The ANA distinguishes between competence and competency: Competence is defined as the demonstration of knowledge, skills, and attributes, whereas competency refers to the expected criteria of performance for these elements (ANA, 2008, 2010). Effective evaluation of professional role competence is essential to ensure fine-tuned decision-making skills that maintain public safety; however, adequately validating competency remains a persistent challenge in nursing (Mrayyan et al., 2023). Benner's (1984) novice-to-expert model emphasized skill acquisition through lived clinical experiences but has been critiqued for its limited focus on leadership and collaboration (Altmann, 2007). In the 2000s, structured NRPs, endorsed by organizations such as the Institute of Medicine, were introduced to address these gaps (Laflamme & Hyrkas, 2020). Many of these programs were seen as prioritizing task-based competencies at the expense of professional role development. The Practice Transition Accreditation Program® (PTAP), provides a global standard for NRPs, grounded in ethical decision-making and interprofessional collaboration (Cosme, 2023); however, at the time of this writing, less than 300 programs in the United States have achieved this distinction (American Nurses Credentialing Center, n.d.). Despite these advancements, significant challenges remain in developing
robust evaluation methods to support nurses' full professional role integration and real-time clinical decision-making (Letourneau & Fater, 2015; Mrayyan et al., 2023).
The NRP leadership of a community–academic medical center identified fragmented assessments and overreliance on
routine checklists as factors contributing to poor retention among the newly graduated nurses of their NRP, as indicated by human resource data. To address these issues, the Professional Role Identity Formation Theory was chosen to restructure the program with a focus on professional role identity formation (O'Rourke, 2003, 2006, 2019). Created by the same nursing theorist, the Model of the Professional Role Applied to Nursing™ (Model) was selected for its ability to define and clarify the nursing professional role (see Figure 1). Guided by both the theory and the Model, the NRP leadership led a comprehensive redesign of the NRP to better support nurses' transition to independent practice. Ongoing mentorship from Dr. O'Rourke provided intellectual and theoretical input, as well as oversight in writing the manuscript.

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THEORETICAL FRAMEWORK 

Distinct from a job description or title, a professional role reflects the obligations outlined in the standards applicable to individuals who hold that license (ANA; The Professional Role Identity Formation Theory posits that professional role clarity extends beyond knowledge of role expectations to include the internal acceptance and integration of professional obligations as central to one’s professional self-concept (O’Rourke, 2019, 2021). From this perspective, professional role clarity is not merely demonstrated through task completion or behavioral compliance, but through intentional enactment of practice grounded in an understanding of the authority, accountability, and ethical responsibilities inherent in the professional role of the Registered Nurse (Deci & Ryan, 2000; Edmondson, 1999; O'Rourke & White, 2007, 2011) Gracyke, 2024). Conversely, role ambiguity can impede decision-making and disengage nurses from core values responsibilitie  Cengiz et al., 2021; Meleis, 2007). The Model (see Supplemental Digital Content 1, http://links.lww.com/JNPD/A106) offers a structured framework to enhance role clarity by explicitly defining professional obligations and expected behaviors, thus supporting nurses in aligning their practice with characteristics of the nursing professional role and fostering professional role identity formation. The Model encompasses four primary dimensions: Leader/Decision Maker, Scientist, Transferor of Knowledge, and Practitioner. Each dimension is both
Independent and interdependent, reflecting the ethical, social, and practice standards of the professional nurse (see Supplemental Digital Content 2, http://links.lww.com/JNPD/A107). The Model guided revisions in the NRP curriculum, competency, and preceptor tools, while providing a structured framework to examine professional role responsibilities, decision-making, and interprofessional collaboration in clinical practice.

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READINESS TO PRACTICE INCIDATORS

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Readiness to Practice Indicators Partnership with a nursing development platform supported the residents and preceptors to document and track competency and progression as they operationalize their professional role in the clinical setting. The Readiness to Practice Indicators (RPIs) align with core competencies as established by leading healthcare organizations, including the ANA, American Association of
Colleges of Nursing (AACN), National Academy of Medicine (formally Institute of Medicine [IOM]), National Council of State Boards of Nursing, World Health Organization, National Institutes of Health, Quality Safety and Education for Nursing, and American Association of Critical-Care Nurses (Martin, 2016; Martin & LaVigne, 2023). Core competency statements were cross-walked against the 2021 ANA Scope and Standards of Practice and the 2024 PTAP® manual. Emerging themes, including leadership, professionalism, ethics, lifelong learning, resource utilization, and population health, are incorporated into the RPIs (Martin & LaVigne, 2023). The final tool encompasses 12 categories, each with specific criteria: professional accountability, assessment, medication management, communication with the healthcare team, delegation and collaboration, prioritization, admissions, discharges and transfers, quality measures and nursesensitive indicators, time management, documentation, coordination of care, and competent management of a full patient assignment. The tool incorporates regular assessments and feedback mechanisms, according to Benner's novice-to-expert framework (Benner, 1984). This continuous evaluation supports tracking progress, identifying areas for improvement, and fostering ongoing professional development (Wright, 2015). Grounded in this work within nursing, it was determined that the RPIs aligned with the nursing professional role depicted in the Model. The NRP leadership selected the platform for its comprehensive method of evaluating professional role competence in the practice setting through the RPIs (see Supplemental Digital Content 1, http://links.www.com/JNPD/A106).

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THE NRP

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Leadership of the NRP led a comprehensive redesign of the curriculum and pedagogy for both residents and preceptors, including revisions to the resident competency evaluation tools. The evidence-based content within the residency curriculum was reframed through the lens of the professional role obligations to explicitly illustrate how nurses internalize behaviors of the Leader/ Decision Maker, Scientist, Transferor of Knowledge, and Practitioner. To support this link, a lecture was added at the beginning of the program to introduce the professional role of the nurse, reinforcing the obligations and characteristics from the Scope and Standards of Practice, Code of Ethics for Nurses, and Social Policy Statement (ANA, 2010, 2021, 2025). The NRP was restructured using a scaffolded approach with four distinct phases: foundations, communication and teamwork, coordination of patient care, and delivering safe, patient-centered care. Each phase introduces increasing complexity in decision-making and skill integration, progressively deepening the application of the four dimensions of the nursing professional role outlined in the Model. Additional changes include a journal to support the resident's introspection. Scenarios and practice-based questions within the journal prompt residents to consider how they might better integrate obligations and characteristics of the professional role into their practice. Mentor Moments provide residents time for open discussions with an experienced nurse preidentified as having strong professional role clarity. During simulation exercises, residents are encouraged to narrate their decision-making and to identify the opportunities to delegate and collaborate with other professionals. Residents are also assigned to shadow with interprofessional colleagues and provided role-driven discussion questions, in part to facilitate role clarity among professions.

Preceptor preparation

Preceptor development was enhanced to emphasize the core obligations of the professional role, alongside evidence-based precepting strategies (Benner, 1984; McClure & Thomas, 2013; Young, 2020). Preceptors participated in events and online courses and received materials reinforcing their critical professional role in protecting the public and validating the competence of nurse residents. Role modeling and constructive feedback were emphasized to guide residents during their transition. Preceptors were equipped with tools and strategies to coach residents in critical thinking, decisionmaking, and leadership, aligning with the Leader/Decision Maker and Practitioner dimensions from within the Model. During the training, the preceptors practiced discussing complex patient scenarios, reviewing their decision-making processes, and explaining the rationale behind their actions, while integrating dimensions of their professional role
(O'Rourke, 2024). Preceptors were introduced to a feedback technique and script designed to support the delivery of specific and actionable feedback aligned with dimensions of the professional role. For instance, a preceptor might provide feedback on a resident's patient documentation by assessing leadership and decision-making in clinical judgment, the transfer of knowledge through communication with the care team, and the practical application of clinical policies. The integration of RPIs was a key component of preceptor preparation. Preceptors were trained to use RPI categories and criteria to set goals, identify gaps in clinical competence, and create focused plans with targeted interventions to help residents achieve professional role proficiency.

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Outcomes

Eighty-one newly licensed registered nurses entered the program between 2021 and 2024, with a 100% completion rate. The residents represented a diverse group of individuals hired into a range of clinical areas, including medical-surgical units, labor and delivery, the emergency department, and the operating room. The first cohort to complete the redesigned program achieved a 12-month retention rate of 92%, reflecting a 13% improvement compared to the average retention during The 12 months before the redesign. Subsequent cohorts maintained retention rates exceeding 95%.

The redesigned NRP resulted in several additional improvements, notably enhancing the transition of residents to independent practice consistent with the scope of practice and professional role obligations and characteristics. By incorporating RPIs, the program established a clear framework that allowed preceptors and residents to set specific goals and monitor incremental progress. This systematic approach enabled timely adjustments to individual development plans based on real-time observations. Preceptors assessed residents’ readiness for independent practice using objective evidence rather than task-based checklists or subjective perceptions. Additionally, a centralized platform facilitated transparency and streamlined communication among residents, preceptors, educators, and nurse managers, contributing to increased program satisfaction. For example, one preceptor noted in an evaluation, “As a new preceptor, the [RPIs] helped a lot to guide me in becoming an effective preceptor…. [They] helped guide [me] in the steps and actions to help the nurse resident become more competent in their skills and profession as a registered nurse.” Another preceptor commented, “As a preceptor, it guides me to determine if a new graduate can care for their full patient assignment independently.”

Residents also provided feedback in their evaluations. One resident wrote, “[RPIs] made me more confident in being able to work independently…. You were able to pause, reflect, and critically think about delivering safe patient care.” Another resident stated, “[They] broke down the various aspects of managing a patient assignment into understandable and concise pieces. [It] ensured I was addressing all aspects of patient care and not glossing over less obvious requirements.” A different resident noted, “Our preceptors were able to easily determine what phase we were in and what level of care we could handle,” whereas another shared, “It prepared me to work independently, how to prioritize and delegate.” These responses demonstrate how RPIs reinforced role clarity and professional development for both preceptors and residents. Preceptors used RPIs to evaluate readiness for independent practice through a role informed lens, tailor developmental support, and intentionally guide residents’ progression toward autonomous practice. Residents, in turn, developed greater confidence and clinical judgment as they increasingly understood, accepted, and enacted the professional obligations inherent in their role. This shared understanding highlights the value of structured, evidence-based evaluation in strengthening competence and professional role identity formation. Additionally, following the redesign, the program was awarded PTAP® accreditation, demonstrating that it meets national transition-to-practice standards.

DISCUSSION

The redesigned NRP represents a paradigm in transition-topractice design. It was purposefully restructured from a fragmented, task-oriented model centered on clinical skills and checklists to a scaffolded curriculum grounded in professional role identity formation, emphasizing introspection, socialization, and competencies aligned with the professional role. The redesigned
program foregrounds professional role-informed decision-making and interprofessional collaboration as essential to safe, ethical, and competent nursing practice. The NRP redesign also exemplifies a systems-thinking approach by addressing the interconnected factors influencing the transition from academia to clinical practice. Aligning with AACN core competencies (AACN, 2021), the program emphasized Professionalism (Domain 9) to foster a sustainable professional identity and Interprofessional Partnerships (Domain 6) to enhance collaboration across disciplines. Additionally, the program met PTAP® accreditation requirements. This recognition affirms the program's success in promoting professionalism by supporting new nurses in internalizing and integrating the ethical, social, and practice standards within nursing; strengthening their clinical judgment; and fostering interprofessional collaboration, core elements to a successful transition into practice. Notably, these requirements were inherently fulfilled, as the NRP was structured around the scope and standards of practice and professional role characteristics, ensuring new nurses seamlessly integrated these principles into their practice.

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CONCLUSION

The restructured NRP facilitates a seamless transition to practice by integrating theory, evidence, and system thinking. Its phased curriculum fosters professional roledriven competencies, leveraging RPIs for real-time evaluation and skill development. Enhanced preceptor training reinforces the professional role and clinical expertise through role modeling and constructive feedback. By embedding the scope and standards of practice and professional role characteristics, the NRP bridges academic preparation and clinical practice, strengthening decisionmaking, clinical competence, and professional role identity. Aligned with the AACN Essentials and PTAP® standards, the program cultivates sustainable professionalism in nursing. Its successful outcomes, including PTAP® accreditation, validate its alignment with best practices for NRPs. This theory-guided approach provides a blueprint for institutions seeking to enhance transition-to-practice programs while advancing professional role identity formation, professional role clarity, and competence.

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