Formal transition to practice programs for nurse residents are well reported in the literature as successful approaches to assist new graduate nurses.1–10 The complexity and high volume of demands placed on newly licensed nurses have driven the need to standardize an evidence-based, nurse residency curriculum. Our organization has had a centralized transition to practice nurse residency program in place for more than 15 years. The goals of this robust, yearlong program are to decrease nurse resident turnover, build nurse resident confidence and competence, provide organizational support, promote nurse resident socialization, and positively affect patient outcomes. However, even in the presence of this comprehensive program, we identified the need for additional unit level support. In response, we developed a pilot orientation program on a unit that includes a 12-bed, medical-surgical, solid-organ transplant and hepatology practice and a 24-bed progressive care unit.The preceptors, educator, supervisor, and manager of our progressive care unit observed that nurse residents experienced difficult transitions to registered nurse practice. Difficulties included lack of the following: organizational support, professional socialization, critical thinking skills, and knowledge about patient safety and time management. Specific concerns regarding the nurse resident skill set are related to safety and the ability to effectively care for patients with multiple diagnoses, treatment options, medications, and assessment findings. In particular, patients who undergo solid-organ transplant have a variety of needs that are not traditionally covered in prelicensure programs, such as administration and monitoring of immunosuppressant medications and monitoring for signs and symptoms of organ rejection. These issues combined with the complex, psychosocial needs of the patient population and the extensive education patients need for self-care proved to be overwhelming for nurse residents. Our team, including the preceptors, educator, supervisor, and manager, evaluated opportunities for improvement and decided to try a new approach to enhance the existing nurse residency program. The focus of the program enhancement was to address the unique needs and challenges related to caring for patients in this specialty area.The transition difficulties we noted among nurse residents led us to evaluate unit level support, and the first step of the process was a literature review. Themes reported in the literature related to positive outcomes during the transition to practice included group support, socialization, facilitation of learning, learning groups, supportive clinical practice, and feedback on performance.1–7 We noted that the transition to practice program should include ongoing customization to enhance relevancy and support that continued after the official orientation phase.3,8 Such customization and support were part of the institution’s centralized nurse residency program but were not offered at the unit level. The results of our review and our experience and observation of past cohorts confirmed the need for additional support for nurse residents on the multispecialty, progressive care unit. The nurse residency program coordinator and educator for the unit collaborated to develop a pilot program to address these concerns. The pilot program was an enhancement of the institution’s centralized residency program and provided an opportunity to meet the unique needs of learners in a small group setting.The planning phase of the pilot program began with alignment of the unit-based program curriculum with the centralized curriculum. We modified the orientation pathway to provide focus areas for the nurse resident who was working on the unit caring for patients. For example, the first 2 weeks of the orientation focused on pain management, time management, critical thinking, diabetes management, and communication. Additional topics were added throughout the orientation. The pathway provided a structured platform upon which to focus clinical experiences and track specific situations.Our unit level program was designed to target unit-specific clinical practice experiences in a small group setting. The program included 6 meeting sessions that were 2 to 4 hours long to facilitate learning, assist with socialization, and provide supportive clinical practice experiences and performance feedback in real time. Each resident spent 16 hours in the pilot orientation program; 6 nurse residents participated in the first cohort and 3 participated in the second cohort. The time they spent in this program was in addition to scheduled orientation shifts on the unit and the centralized nurse residency program. We focused on support of the nurse residents in an intimate setting apart from the larger residency program group and patient care to help them transition into care of complex patients.We leveraged small group meetings as opportunities for open dialogue. During these meetings, the nurse residents talked about their experiences, which built cohesiveness, assisted with socialization, and helped us identify topics for subsequent meetings. Topics guided by such input included clinical information (medication titration, lumbar drains), policy and use of resources, collaboration with the team leader, professional opportunities, and transition after orientation. Each meeting allowed time for the nurse residents to bond as a cohesive group and to socialize; they openly shared their struggles and discussed issues they faced as they became enculturated to the unit. For example, during one meeting, the nurse residents expressed discomfort with managing continuous insulin infusions. We provided information on that topic at the next scheduled meeting, including discussion of order protocol and use of scenarios for hands-on practice to adjust medication using the infusion pump. This information built on the basic concepts of management of a patient with diabetes provided in the centralized nurse residency program by the certified diabetic nurse educator.Nurse residents came to the meetings with a copy of their orientation pathways, which were integral to spark their memories about clinical experiences and guide group case study work on complex, patient care issues. We used a variety of learning techniques to explore these issues in the small group setting, including storytelling, reflection, and summarizing implications for future practice. Meetings included 3 to 6 participants, which facilitated clinical learning and navigation of the electronic health record. The focus of the orientation program was first on the higher acuity, progressive care environment and then on the medical-surgical environment.The central and unit-based educators facilitated the meetings, highlighted key learning objectives, and directed the conversation toward aspects of patient care that were unique to our unit, such as lumbar drains, titration of intravenous infusions, and hemodynamic monitoring. During these meetings, the nurse residents had many questions about finding and putting into practice the policies and procedures of the organization. One such topic was defining moderate sedation and reviewing the required components of care when managing a patient who received sedation for a bedside procedure. During another session, a team leader described her role on the unit and the resources available to the nurse residents at any given time. The team leader, a cochair of the unit-based team who had achieved professional nursing certification, also provided insight into professional development opportunities. One nurse resident described her experience with a patient who went into cardiac arrest. She recognized the change in condition, called a code, and provided initial resuscitative care. She talked through the stressors she experienced, which provided a learning opportunity for the others in the group.The nurse residents talked openly about challenging patients they cared for on the unit and learned from each other about how to identify their learning needs regarding the management of complex patients. For example, several of the nurse residents cared for a patient with a liver transplant, complex medical and psychosocial histories, and an extended hospitalization. The nurse residents shared their struggles and common perceptions of feeling overwhelmed when caring for this patient. The small group meetings provided a space away from the clinical practice setting in which to explore this complex case.As a result of participation in the pilot program, nurse residents achieved their incremental orientation goals sooner than previous nurse residents had done. To measure the transitions of the nurse residents to practice, we compared results on the Casey Fink Graduate Nurse Experience Survey9,10 for the pilot groups to those for the 11 nurse residents in the 2 previous cohorts. The 4 sub-scales of this survey include patient safety, communication and leadership, support, and professional satisfaction, and responses are scored as follows: 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree. For 3 of the 4 subscales, we noted higher mean scores in the pilot groups compared to the 2 previous cohorts: mean scores on the patient safety subscale increased from 2.35 to 3.11, mean scores on the communication and leadership subscale increased from 3.06 to 3.43, and mean scores on the support subscale increased from 3.31 to 3.32 in the pilot groups. However, compared to the previous 2 cohorts, mean scores on the professional satisfaction subscale decreased from 3.36 to 3.33 in the pilot groups.Another positive outcome of the pilot program was that the duration of the orientation was shorter for the pilot groups than for the 2 previous cohorts. At our organization, clinical time on the unit caring for patients and time away from the unit for orientation activities (eg, education, classes, simulation) are counted together as orientation time. The nurse residents in the 2 previous cohorts averaged 598 hours of orientation time, the nurse residents in the first pilot cohort averaged 491 hours of orientation time (107 fewer hours), and the nurse residents in the second pilot cohort averaged 465 hours of orientation time (133 fewer hours). These average times represent a reduction of 3 weeks of orientation time.To calculate return on investment, we used information on occupational employment and wages from the Bureau of Labor Statistics for May 2018. We calculated nurse resident wages at the 25th percentile ($31.09/h) and nurse educator wages at the 75th percentile ($42.72/h).11 We used these figures because nurse residents are early in their careers and likely earn less than nurse educators, who often have many more years of experience. We estimated that before our intervention, the cost to orient 1 nurse resident averaged $18 592. Because of the decrease in orientation time, the estimated cost decreased to $15 265 in the first cohort and to $14 457 in the second cohort (see Figure).Even when we accounted for the additional time required for the pilot project, we achieved an overall cost savings. The cost of the additional orientation time for each nurse resident in the pilot was $497. We estimated that the 2 educators spent 20 hours each to prepare for and facilitate the sessions, which represented 40 hours total per cohort. Because our first cohort had 6 nurse residents and the second cohort had 3 nurse residents, the additional educator time cost $285 per resident for the first cohort and $570 per resident for the second cohort. However, we still realized an overall cost savings of $2545 per nurse resident in the first cohort and $3068 per nurse resident in the second cohort (see Figure).Through this pilot program, we successfully provided additional unit level support for the nurse residents who transitioned to practice on a multispecialty unit. By targeting identified gaps in professional socialization, knowledge, and skills, our program empowered nurse residents to address the unique needs and challenges related to caring for patients in our specialty. This program eased the transition to professional practice for our novice colleagues, was feasible to implement, and provided cost savings through decreased orientation time.