the effectiveness of orientation programs on professional

JBI Database of Systematic Reviews & Implementation Reports 2014;12(5) 2 -14

10.11124/jbisrir-2014-1532 Page 2

The effectiveness of orientation programs on professional competence and organizational commitment of newly graduated nurses in specialized health care: a systematic review protocol

Kirsi Lindfors RN, MNSc1

Kristiina Junttila RN, PhD1

1. Hospital District of Helsinki and Uusimaa, Finland, University of Tampere, Finnish Center for

Evidence-Based Health Care: An Affiliated Center of the Joanna Briggs Institute

Corresponding Author

Kirsi Lindfors

[email protected]

Review question/objective

The objective of this review is to identify the effective orientation programs and their effects on the

professional competence and organizational commitment of newly graduated nurses.

Background

It is estimated that between 2008 and 2060, the population of the European Union aged 65 and over

will increase by almost 70 million and people over 80 years of age will be the fastest growing

population.1 Alongside the aging population, the work force is aging too. Baby boomers are retiring

and the next generations are unable to fill the growing demand for nursing resources: fewer nurses

are entering the nursing profession.

The nursing shortage is a global problem. It is estimated that in the United States at the end of the

year 2018, there will be approximately 581,000 vacant positions for nurses alone.2 In Europe by 2020,

it is estimated that the shortage of nurses will be 590,000 and in which case 14% of care cannot be

covered.3 Nursing shortage has negative outcomes including increased mortality rates, adverse

events after surgery and increased risk of infections, e.g. pneumonia and urinary tract infections.4-7

Aiken et al. reported that adequate nurse staffing and the quality of the hospital work environment can

be associated with higher patient satisfaction, quality and safety of care, and nurse workforce

outcomes.8 Hospitals that patients rated as excellent indicated a good working environment,

satisfaction in management and lower levels of burn out of nurses. Here, excellence meant that

patients were treated with respect, listened to carefully and explained things in a clear manner.8

At the same time, when the healthcare sector is struggling with the nursing shortage, nurses are

leaving the profession; especially newly graduated nurses. Godinez et al. estimated in their study that

between 35 and 60% of newly graduated nurses resign in their first year of practice.9 In Kovner et al’s


10.11124/jbisrir-2014-1532 Page 3

study, 13% of newly licensed nurses had changed their principal jobs after 12 months and 37% were

going to search for a new position in the near future.10

Nearly 42% of respondents desired to obtain

another job, if only possible. Buchan and Aiken stated in their article that nursing shortage is not

always a matter of shortage of individuals with nursing qualifications, but individuals who do not want

to work as nurses in healthcare organizations.11

Attracting and retaining new nurses in the working life

and in the nursing profession is one of the main issues to be solved in healthcare organizations

worldwide.12

Reasons why newly graduated nurses are leaving their first position include unacceptable nurse-to-

patient ratios, unsafe patient care, lack of support and guidance, and too much responsibility.13,14

According to Wu et al., nurses who had been working for less than two years experienced higher

levels of work-related stress, especially in nursing skills, than nurses with –three to five or more years

of experience. Newly graduated nurses do not trust their ability to perform given duties as expected.

Critical thinking and decision-making are difficult and their knowledge base is inadequate.15-20

Their

expectations and anticipations of work are often more idealistic than realistic.21

It takes almost one

year to achieve a sufficient level of confidence and the most difficult role adjustment time is between 6

and 12 months after commencing the role.16

The first 12 months encompasses a wide range of

emotional, intellectual, physical, sociocultural and developmental tasks, which in turn affect a nurse’s

personal and professional growth and future.21

During the first year of practice a newly graduated

nurse begins to focus on the patient and their family, the healthcare team and the healthcare

organization, instead of single tasks and duties. A person who has asked questions becomes a

professional answering those questions.22

Experiences of incivility and bullying are also associated with higher job and career turnover

intentions, especially in nurses in their first year of practice.23

According to Laschinger’s previous

studies, between 26 and 33% of newly graduated nurses were bullied;24,25

and according to Berry et

al., 21.3% were exposed to daily workplace bullying in the past six months.26

Bullying experiences

lead to emotional exhaustion, cynicism and poor physical and mental health.24

Structural empowerment, better working conditions (manageable workloads, control over work,

rewarding, fairness, a sense of belonging, congruence between personal and organizational values)

and authentic leadership are significantly related to job and career satisfaction and turnover intentions

among new nurses. The more new graduates felt that their initial orientation met their needs, the more

satisfied they were with their career and less likely to leave the nursing profession.23

Orientation

programs add to novice nurses’ ability to perform prescribed duties, increases confidence,

competence and job satisfaction of graduate nurses, but also collegiality among experienced and

novice nurses.15,27-29

It lowers the turnover rates, reduces turnover costs and enhances the quality of

nursing care by, for example, decreasing medication errors.29-31

According to Lee et al., the

orientation program decreased the turnover rates of new nurses by almost 47%, which decreased

turnover costs by $186,102USD.31

A systematic orientation program also enhances organizations’

good employer reputation and attracts new employees.30

Orientation means actions are taken to ensure a new employee is familiarized with the working

environment, to its demands and expectations, to prepare newly qualified nurses to be confident and

to provide safe patient care. The main goal of an orientation program is to provide as competent

nurses as possible.32

Competence is a concept which is difficult to define.33-35

In the behaviorist


10.11124/jbisrir-2014-1532 Page 4

model, competence means the skills and ability to get work done in a satisfactory manner.33

According to Patricia Benner, a competent nurse has the ability to perform a task with a desirable

outcome under various conditions of the real world.36

Meretoja defines competence in terms of

functional adequacy, capacity to integrate knowledge, skills, attitudes and values in specific

contextual situations of practice.35

There are a number of ways to evaluate competence, but

insufficient testing of validity and reliability often limits the use of those instruments.37

The Six-

Dimension Scale of Nurse Performance by Schwirian (6-D Scale),37

the Nurse Competence Scale by

Meretoja (NCS)35

and the Australian National Competency Standards (ANCI)33

have been well tested

for validity and reliability.

A successful orientation program creates a sense of belonging and eases socialization.27,38

It includes

personal preceptorship, regular feedback from the ward manager and preceptor(s) and supportive

learning environment.16,19,39-41

The preceptor plays a significant role in newly graduated nurses’ job

satisfaction and competency development. They are in a key position to facilitate new nurses’ role

adjustments and professional behaviors.16

A welcoming atmosphere, i.e. an atmosphere which

appreciates new employees and allows them to be new and ask questions is perceived as a

supportive environment. Regular feedback enables new graduates to foster confidence as nurses and

it is essential for gaining nursing experience.42

According to a preliminary search for previous systematic reviews about newly qualified nurses’

orientation programs, one existing systematic review on a similar topic was found. This previous

systematic review focused on effective strategies and interventions that assist the transition from

student to a newly qualified nurse.43

In this systematic review, the focus will on the predefined

orientation programs, their effects on the professional competence and organizational commitment.

The context for the review will be in specialized healthcare defined as services organized according to

medical subspecialties and including investigation and treatment of disease and disability by highly

specialized personnel. It offers centralized care to the population of a large region.

Keywords

orientation*; orientation program; in-service-training; employee orientation; preceptor*; preceptorship*;

externship*; internship*; transition; novice nurse; new graduate; graduate nurse; newly graduate

nurse; neophyte graduate; preceptee; competence*

Inclusion criteria

Types of participants

This review will consider studies that include newly graduated nurses. Study participants include

nurses (bachelor, associated degree) graduated within one year, working their first year of practice in

specialized healthcare.

Types of intervention(s)/phenomena of interest

This review will consider studies that evaluate orientation programs and their effects on newly

graduated nurses’ professional competence and organizational commitment.


10.11124/jbisrir-2014-1532 Page 5

Types of outcomes

This review will consider studies that include the following outcome measures:

The primary outcome is nurses’ professional competence level measured by an objective and

quantitative instrument such as the Nurse Competence Scale (NCS), the Australian National

Competency Standards (ANCI) and the 6-D Scale (the Six-Dimension Scale of Nursing Performance).

The secondary outcome is nurses’ organizational commitment measured by an instrument such as

the Organizational Commitment Questionnaire (OCQ), the Organizational Commitment Scale (OCS)

and the Affective, Continuance, and the Normative Commitment Scale. In addition, organizational

commitment can be measured by early resignation from the workplace or the profession (within the

first year of practice). The reasons for early resignation will include all work-related reasons (e.g.

unsafe patient care, perceived stress, unsatisfactory work environment, insufficient support, poor

management, perceived bullying and employment factors including dissatisfaction with salary and/or

few possibilities for career development), excluding reasons related to personal life (marriage,

maternity leave, moving to another state/city/country).

The most appropriate comparators would be no specific orientation programs, or study context

outside specialized health care (e.g. primary health care, occupational health care).

Types of studies

This review will consider experimental study designs including randomized controlled trials, non-

randomized controlled trials, quasi-experimental, before and after studies, prospective and

retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search

strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be

undertaken, followed by analysis of the text words contained in the title and abstract and of the index

terms used to describe the article. A second search using all identified keywords and index terms will

then be undertaken across all included databases. Thirdly, the reference lists of all identified reports

and articles will be searched for additional studies.

Studies published in English, Finnish and Swedish will be considered for inclusion in this review.

Studies published from 2003 to 2013 will be considered for inclusion in this review because of the

many changes that have encountered specialized healthcare during the last decade: nursing

shortage, fast growing retirement, new generation entering the workforce and nurses’ lack of

commitment.

The databases to be searched include:

CINAHL, Medline, Medic, Arto, PubMed, ASSIA, SCOPUS, LEO, EBSCOhost Academic Search

Premier, Web of Science, Arbline.

The search for unpublished studies will include:

MedNar


10.11124/jbisrir-2014-1532 Page 6

Initial keywords to be used will be:

In English: orientation*, orientation program, in-service-training, employee orientation, preceptor*,

preceptorship*, externship*, internship*, transition, novice nurse, new graduate, graduate nurse,

newly graduate nurse, neophyte graduate, preceptee, competence*, professional competence,

commitment*, effectiveness, efficacy, turnover, resign*

In Finnish: perehdyty*, perehdyttäjä*, perehtyjä*, pätevyy*, "ammatillinen pätevyys", komptenssi*,

"sairaanhoitaja, vastavalmistunut", sairaanhoita*, sitoutu*, organisaatio*, irtisanoutu*

In Swedish: arbetsplatsorientering*, mentor*, sjukskötare*, kompetens*, yrkeskompetens,

professionell kompetens, "praktik under handledning", förbindning*

The Boolean operators AND/OR/NOT will be used.

Assessment of methodological quality

Quantitative papers selected for retrieval will be assessed by two independent reviewers for

methodological validity prior to inclusion in the review using standardized critical appraisal instruments

from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-

MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through

discussion, or with a third reviewer.

Data collection

Quantitative data will be extracted from papers included in the review using the standardized data

extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about

the interventions, populations, study methods and outcomes of significance to the review question

and specific objectives. Reviewers will extract data independently. Where necessary, study authors

will be contacted to request missing data or clarification of unclear reporting.

Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All

results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data)

and weighted mean differences (for continuous data) and their 95% confidence intervals will be

calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and

also explored using subgroup analyses based on the different study designs included in this review.

Where statistical pooling is not possible, the findings will be presented in narrative form including

tables and figures to aid in data presentation where appropriate.

Conflicts of interest

None

Acknowledgements

None.


10.11124/jbisrir-2014-1532 Page 7

References

1. European Union. Green paper on the European Workforce for Health. [Cited 2013 Sept 18].

Available from: http://europa.eu/legislation summaries/public_health_strategy/sp0005_en.htm.2008.

2. Halfer D. Job embeddedness factors and retention of nurses with 1 to 3 years of experience. J

Contin Educ Nurs. 2011;42(10):468-476.

3. Matrix Insight. EU level collaboration on forecasting health workforce needs, workforce planning

and health workforce trends - a feasibility study. [Cited 2013 Sept 18]. Available from:

http://ec.europa.eu/health/workforce/key_documents/study_2012/index_en_htm.2012.

4. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient

mortality, nurse burnout, and job dissatisfaction. JAMA.2002;288(16):1987-1993.

5. Rafferty AM, Clarke SP, Coles J, Ball J, James P, McKee M, et al. Outcomes of variation in hospital

nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. Int

J Nurs Stud. 2007;44(2):175-182.

6. Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in US hospitals.

Image: Journal of Nurs Scholars. 1998;(30):315-321.

7. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality

of care in hospitals. N Engl J Med. 2002;346(22):1715-1722.

8. Aiken LH, Sermeus W, Van den Heede K, Sloane DM, Busse R, McKee M, et al. Patient safety,

satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12

countries in Europe and the United States. BMJ. 2012;(344):1717.

9. Godinez G, Schweiger J, Gruver J, Ryan P. Role transition from graduate to staff nurse: a

qualitative analysis. J Nurses Staff Dev. 1999;15(3):97-110.

10. Kovner CT, Brewer CS, Fairchild S, Poornima S, Kim H, Djukic M. Newly licensed RNs'

characteristics, work attitudes, and intentions to work. Am J Nurs. 2007;107(9):58-70.

11. Buchan J, Aiken L. Solving nursing shortages: a common priority. J Clin Nurs. 2008;17(24):3262-

3268.

12. Berliner HS, Ginzberg E. Why this hospital shortage is different. JAMA. 2002;288(21):2742-2744.

13. Bowles C, Candela L. First job experiences of recent RN graduates: improving the work

environment. J Nurs Adm. 2005;35(3):130-137.

14. Wu TY, Fox DP, Stokes C, Adam C. Work-related stress and intention to quit in newly graduated

nurses. Nurse Educ Today. 2012;32(6):669-674.

15. Almada P, Carafoli K, Flattery JB, French DA, McNamara M. Improving the retention rate of newly

graduated nurses. J Nurses Staff Dev. 2004;20(6):268-273.

16. Casey K, Fink R, Krugman M, Propst J. The graduate nurse experience. J Nurs Adm.

2004;34(6):303-311.

17. Cavanaugh DA, Huse AL. Surviving the nursing shortage: developing a nursing orientation

program to prepare and retain intensive care unit nurses. J Contin Educ Nurs. 2004;35(6):251-256.

http://europa.eu/legislation%20summaries/public_health_strategy/sp0005_en.htm.2008

http://ec.europa.eu/health/workforce/key_documents/study_2012/index_en_htm.2012


10.11124/jbisrir-2014-1532 Page 8

18. Etheridge SA. Learning to think like a nurse: stories from new graduates. J Contin Educ Nurs.

2007;38(1):24-30.

19. Fink R, Krugman M, Casey K, Goode C. The graduate nurse experience: qualitative residency

program outcomes. J Nurs Adm. 2008;38(7-8):341-348.

20. Kramer M, Maguire P, Halfer D, Budin WC, Hall DS, Goodloe L et al. The organizational

transformative power of nurse residency programs. Nurs Adm Q. 2012;36(2):155-168.

21. Duchscher JB. A process of becoming: the stages of new nursing graduate professional role

transition. J Contin Educ Nurs. 2008;39(10):441-450.

22. Schoessler M, Waldo M. The first 18 months in practice: a developmental transition model for the

newly graduated nurse. J Nurses Staff Dev. 2006; 22( 2): 47-52.

23. Laschinger HK. Job and career satisfaction and turnover intentions of newly graduated nurses. J

Nurs Manag. 2012;20(4):472-484.

24. Laschinger HK, Grau AL. The influence of personal dispositional factors and organizational

resources on workplace violence, burnout, and health outcomes in new graduate nurses: a cross-

sectional study. Int J Nurs Stud. 2012;49(3):282-291.

25. Laschinger HK, Grau AL, Finegan J, Wilk P. New graduate nurses´ experiences of bullying and

burnout in hospital settings. J Adv Nurs. 2010;66(12):2732-2742.

26. Berry PA, Gillespie GL, Gates D, Schafer J. Novice nurse productivity following workplace

bullying. J Nurs Scholarsh. 2012;44(1):80-87.

27. Galt RG. The value of training and orientation programs in large medical organizations. J Nurses

Staff Dev. 2000;16(4):151-156.

28. Miettinen M, Kaunonen M, Tarkka M. Laadukas perehdyttäminen. Osa 1, Hoitotyön

perehdytyksen perusta. Hallinnon tutkimus. [High quality orientation. Part 1, A basis of nursing

orientation. Administration studies.] 2006;(2):63-70.

29. Ulrich B, Krozek C, Early S, Ashlock CH, Africa LM, Carman ML. Improving retention, confidence,

and competence of new graduate nurses: results from a 10-year longitudinal database. Nurs Econ.

2010;28(6):363-376.

30. Halfer D. A magnetic strategy for new graduate nurses. Nurs Econ. 2007;25(1):6-11.

31. Lee TY, Tzeng WC, Lin CH, Yeh ML. Effects of a preceptorship programme on turnover rate, cost,

quality and professional development. J Clin Nurs. 2009;18(8):1217-1225.

32. Park M, Jones CB. A retention strategy for newly graduated nurses: an integrative review of

orientation programs. J Nurses Staff Dev. 2010;26(4):142-149.

33. Cowin LS, Hengstberger-Sims C, Eagar SC, Gregory L, Andrew S, Rolley J. Competency

measurements: testing convergent validity for two measures. J Adv Nurs. 2008;64(3):272-277.

34. Khomeiran RT, Yekta ZP, Kiger AM, Ahmadi F. Professional competence: factors described by

nurses as influencing their development. Int Nurs Rev. 2006;53(1):66-72.

35. Meretoja R. Nurse competence scale. Annales Universitatis Turkuensis D 578. Helsinki, Finland:


10.11124/jbisrir-2014-1532 Page 9

Yliopistopaino; 2003.

36. Benner P. Issues in Competency-Based Testing. Nurs Outlook.1982;30(5):303-309.

37. Meretoja R, Leino-Kilpi H. Instruments for evaluating nurse competence. J Nurs Adm. 2001;31(7-

8):346-352.

38. Malouf N, West S. Fitting in: a pervasive new graduate nurse need. Nurse Educ Today.

2011;31(5):488-493.

39. Charnley E. Occupational stress in the newly qualified staff nurse. Nurs Stand. 1999;13(29):33-36.

40. Connelly LM, Hoffart N. A research-based model of nursing orientation. J Nurs Staff Dev.

1998;14(1):31-39.

41. Cubit KA, Ryan B. Tailoring a graduate nurse program to meet the needs of our next generation

nurses. Nurse Educ Today. 2011;31(1):65-71.

42. Wangesteen S, Johansson IS, Nordstrom G. The first year as a graduate nurse - an experience of

growth and development. J Clin Nurs. 2008;17(14):1877-1885.

43. Edwards D, Hawker C, Carrier J, Rees C. The effectiveness of strategies and interventions that

aim to assist the transition from student to newly qualified nurse. JBI Library of Systematic Reviews.

2011;9(53):2215-2323.

Insert page break


10.11124/jbisrir-2014-1532 Page 10

Appendix I: Appraisal instruments

MAStARI appraisal instrument

this is a test message

Insert page break


10.11124/jbisrir-2014-1532 Page 11


Insert page break


10.11124/jbisrir-2014-1532 Page 12


Insert page break


10.11124/jbisrir-2014-1532 Page 13

Appendix II: Data extraction instruments

MAStARI data extraction instrument

Insert page break


10.11124/jbisrir-2014-1532 Page 14

the effectiveness of orientation programs on professional

Documents