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Supplemental Digital Content # 1

Evidence Table: Residency Programs for Licensed New Graduate Registered Nurses

Author,Year, Title

AimPurpose

Design/Methods, Level of Evidence, Instruments

Sample Outcomes StrengthsLimitations

Mc Hugh, Dupart, Clifford

1996

Enhancing Support for the Graduate Nurse

Describes how a new Clinical Entry Nurse Residency Program helped beginning nurses’ advance along Benner’s path toward expertise.

DescriptiveProgram Evaluation Qualitative Methods

Evidence Level 6(single descriptive study)5 objectives were identified for residents in this 2 year program.-Demonstrate the centrality of the professional nurse-patient-family relationship to clinical practice-Demonstrate competence in providing quality, cost effective nursing care-Demonstrate leadership in all aspects of professional practice-Formulate a plan for continued development & overall career goals-Appreciate the larger context of the health care delivery system & how it affects nurses clinical practice

The residency started in 1992 by hiring of some new graduates into residency & by 1994 all new grads hired into the residency. The role of the sponsor was to coach & support the resident to meet the program objectives Sponsors make 2 year commitment and received no financial compensation, meet weekly with resident, work with resident a minimum of one day per month attend support & development meetings with manager & resident, & collaborates with manager on performance evaluation

The Historical Context of this article & its significance related to identifying the need for transition to practice residency programs for new graduates must be understood. Using Benner’ theoretical framework, a 2 year transition program was designed & implemented at Beth Israel Hospital of Boston. The residency program was a possible solution to challenges that new graduates face in their first work experience.Residency moves beyond skill acquisition to socialization to the profession, by review of cases, journal articles, participation in support groups, & writing clinical narrative. A resident summarized: “I had the opportunity to refine & expand my clinical skills & develop my knowledge. I use resources as a member of an interdisciplinary team and as a part of the Clinical Entry Nurse Residency Program. This has given me the ability to be self-directed in developing my practice”

Limitations”Number of residents per year not provided

Article is not research but an evaluation of a new program & how objectives were met.

No control group.

Strengths:This article laid the groundwork for the need for nurse residency transition to practice programs & greatly influenced today’s development of residency programs for new graduates.New graduates enter residency as advanced beginners & end the 2 year program at “competent level.”

Altier & Krsek

2006Effects of a 1 year Residency Program on Job Satisfaction & Retention of New

To measure job satisfaction on hire & at completion of residency program & to measure retention.

Prospective longitudinal design.

Evidence Level 4 (cohort study)Methods: Comparison of the MMSS Job Satisfaction Instrument scores at hire & at completion of one year residency using paired t test.Instrument administered online.

316 BSN new grads from 6 academic medical centers.Residency Type--University HealthSystem Consortium/American Association Colleges of Nursing (UHC/AACN) one year nurse residency.

Subscale--Satisfaction with praise & professional opportunities had a statistically significant reduction in scores. Other subscales had minimal changeSatisfaction scores for Non-White residents (24%) were dissatisfied with their co-workers, interaction opportunities & professional opportunities.

Residency retention rate was 87% (275

Limitations:No control group.Limited to inpatient hospital setting.This study was for the first year of the UHC/AACN residency (pilot year)Strengths;Provided data for program improvement.Need to increase job

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Graduate Nurses

Retention rate measured by number of students at start divided by number at program completion.

111 residents completed the job satisfaction survey on hire & on completion.

of 316). satisfaction with residency & understand job satisfaction needs of minority students.

Krugman, Bretschenider Horn, Krsek, Moutafis, Smith

2006

The National Post-Baccalaureate Graduate Nurse Residency Program:A Model for Excellence in Transition to Practice

To describe the UHC/AACN nurse residency structure, curriculum specialty roles & responsibilities & program evaluation.

Report outcomes form the 6 original pilot sites.

Descriptive Longitudinal

Evidence Level 4(cohort study)Hospital Educators responsible for implementation of the UHC/AACN nurse residency & a UHC Director describe the development & outcomes of a national post-baccalaureate nurse residency program.Outcomes from the original 6 pilot sites were measured using the Gerber Control Over Practice, the McCloskey Mueller Satisfaction Scale, the Casey- Fink Graduate Nurse Experience Survey & the Resident Program Evaluation Instrument

N not reported. Six academic medical centers reported outcome data for the pilot post-baccalaureate nurse residency

Residents were primarily women (92%) and Caucasian (75%) with a mean age of 25 years.

Turnover rate in pilot sites was 8%.Residents rated high in control over practice on hire with a decline at 6 months & increase at end. Of the eight domains of the satisfaction scale, professional interaction opportunities are reported due to it being a key retention element. Results show positive satisfaction. Reported stress was high on start of program & decreased over time-- organizing & prioritizing outcomes reported improvement over timeOne pilot site (egrets) had significant less positive views of the residency than other sites due to the lack of monthly support sessions & lack of a cohort group. This speaks to importance of the cohort group role & monthly support sessions. The Egret program is under revision in light of these findings

Limitations:A pilot programNo control group for comparison.N not reported for outcome measuresStrengths:Provides strong description of the residency & its components & importance of following curriculum & how scores decline when curriculum not followedResearch outcomes strongly indicate transition into practice is not completed until 9 to 12 months after hire.

Beecroft, Dorey & Wenten

2007

Turnover Intention in New Graduate Nurses: A Multivariate Analysis

Determine relationship of new nurse graduate turnover intent with:individualcharacteristics, work environment variables, organization factors and compare turnover intent with actual turnover 18 months post residency

Prospective Longitudinal Survey Design.Evidence Level 4(multiyear cohort study)Data collected from 1999 to 2006Instruments/scales: Self Confidence Survey, Slater Competencies Rating, Nursing Role Conception, Ways of Coping. Work environment measures:Conditions for Work Effectiveness Questionnaire,Professional Nurse Autonomy Clinical Decision Making Work Satisfaction, Nurse Job Satisfaction, Organizational Factors Measures, Leader

889 pediatric nurses who completed the same standardized 22 week nurse residency

All hospitals were not for profit & similar in size.

Hospitals that submitted data on 50 or more respondents with at least a one year follow up were included.

Younger respondents & those with higher level of education more likely to indicate turnover intent.Older respondents (>30) 4.5 times more likely to have turnover intent if they did not get their ward choice.

Higher scores on work environment & organizational characteristics contributed to the nurse not being in the turnover intent group.Factors listed above distinguished turnover intent 79% of the time.

Nurse seeking increased social support to cope with transition is related to turnover intent.

Lower scores on skills self-confidence

Limitations:Another variable to measure stress level during transition could help explain link between increase in seeking social support & turnover intentResponse rate not reported.

Strengths:Number of measures used to determine resultsFindings indicate turnover has impact on patient safety & health outcomes.Findings indicate when new graduates are

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Empowerment Behaviors, Group Cohesion and Organization CommitmentTurnover intention measured with single item scale & actual turnover by records

and perceptions of nursing competence contributed to turnover intent.

satisfied with their jobs & pay & feel committed to the organization, the odds against turnover intent decrease.

Newhouse, Hoffman Suflita, Hairston

2007

Evaluating an Innovative Program to Improve New Nurse Graduate Socialization Into the Acute Healthcare Setting

Test whether the internship program, “Social & Professional Reality Integration for Nurse Graduates” (SPRING) improves new nurse graduate retention, sense of belonging, organizational commitment & anticipated turnover.

Quasi-experimental, posttest only, control group design.

Evidence Level 4Theoretical Basis for Study- Donabedian’s structure, process & outcomesResearch Questions:1. Is there a difference in organizational commitment, sense of belonging & anticipated turnover for new graduates who complete the SPRING internship program in comparison with new graduates who do not complete the SPRING program?2. Does participation in SPRING result in higher retention of new nurse graduates than those who do not attend SPRING?Measurement instruments: Organizational Commitment Questionnaire;Modified Hagerty-Patusky Sense of Belonging ; Anticipated Turnover Scale

N for the 3 comparison groups: baseline 159, 6 months 321, 12 months, 304.Intervention measured over a three year period.

Baseline—control group hired in 2001- consisted of one department.

SPRING groups hired May 2002 through December 2005.

Survey’s distributed at baseline, 6 months & 12 months.

Response rates for surveys were 46% baseline, 74% 6 months & 70% 12 months.

Means generally high for sense of belonging antecedents & psychological concepts & organizational commitment. Anticipated turnover means varied with psychological sense of belonging perceptions decreasing at 6 months and increasing at 12 months. Outcomes from question 1: No differences in organizational commitment between times. There was a difference for anticipated turnover with baseline nurses being more likely to consider leaving their positions then 6 month SPRING nurses. SPRING graduates have higher retention rates at 12 month than non-SPRING grads. Significant difference in 6 month Spring respondents & baseline & 12 month SPRING respondents---with 6 month nurses having a lower antecedent sense of belonging.Outcomes from Question 2:Significant differences with 12 month retention between the SPRING group & the comparison group chi square= 6.032, p=.014, the SPRING graduates were higher descriptively for both 18 & 24 months but not statistically significant

Limitations;Baseline data were gathered from nurses with less than 1 year experience. N for baseline nurses who did not complete Spring not clear.Baseline subjects were from multiple units with their own clinical orientation programs.Baseline data had low response rate.Nurse characteristics not included so no relationship established with nurse characteristics.

Strengths:Program included targeted education, social support, group exercises needs-driven dialogue & exchange of ideas to meet new graduate needs & was effective in the first year of employment in improving nurse retention

Pine & Tart

2007

Return on Investment: Benefits & Challenges of a

Make a positive change in turnover rates of new graduates by implementing the UHC/AACN

DescriptiveEvidence Level 4 (cohort study)Assist new nurse graduates in transitioning from the role of advanced beginner to competent nurse.Calculate residency program costs & return on investment

48 residents in UHC/AACNDetermine return on investment with implementation of the residency program.Compare turnover rate of 50% in new graduates to turnover

The Return on Investment (ROI) was calculated based on comparing the traditional method of bringing new graduates to the facility & having a 50% turnover rate & to the new method using the UHC/ACCN & a 13% turnover rate.Traditional method costs were $1,372,800, & the new method costs

Limitations:Results from one hospital only & saving dependent on local salaries for nurses

Strengths:Documents how program costs are greatly impacted

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Baccalaureate Nurse Residency Program

nurse residency program.

with implementation of the residency program compared to traditional on boarding.

rate after implementing the UHC/AACN residency program.

using the UHC/ACCN residency was $274,560. A savings of $1,098,240 for years 2004-2005.

by turnover costs. Provides methodology for calculating savings

Williams, Goode, Krsek, Bednash & Lynn

2007

Baccalaureate Nurse Residency 1-Year Outcomes

Document 1 year outcomes from UHC/ACCN residency program.

Determine turnover rate for residency program.

Descriptive, longitudinal studyRepeated Measures DesignEvidence Level 4 (cohort study)ANOVA used to compare scale scores on hire, at 6 months & one year. Program components: Evidence-based core curriculum, nurse preceptor, access to a facilitator for professional role development & guidance.Turnover Rate = residents entering program & number completing.Instruments:Casey/Fink Graduate Nurse Experience, Gerber, Control over Practice, McCloskey Mueller SatisfactionQuestions developed by UHC/AACN taskforce forEvaluation of Program: satisfaction with recruitment & welcome, with program topics, overall program goals, professional growth, & satisfaction with faculty.

N= 679 residents12 academic medical center acute care hospitalsData from first 2 cohorts who used the UHC/AACN Residency Curriculum.

Curriculum based on research studies of new graduates’ transition to practice needs

Sample-BSN new graduates had mean age 25.16 to 25.55. Alpha group had 7% male & Beta had 12% maleBeta residents more diverse with34% compared to 17% in Alpha.

Casey/Fink instrument results: increases from program entry to exit in the total score, & in ability to organize and prioritize, and in communication & leadership subscales.Gerber’s scale demonstrated a V shape pattern with mean at entry & exit higher than the mean at 6 months. Overall, data on the CONP show a pattern of perceived growth.The MMSS job satisfaction showed a statistically significant decline from hire to six months & scores beginning to recover at program end.Turnover rate was 12%- compared to35% to 55% reported in the literature. Residents who are younger, had lower GPA’s, were less content with their experience & professional satisfaction were more likely to be in the termination group. Residents’ view of the 1 year program: means ranged from 3.07 to a high of 3.26 on a 4 point scale.Data suggest residencies that are less than a year may not provide sufficient time for resident successful transition to practice.

Limitations:No Control Group

Unable to control for site related variables which could influence results.

Strengths:Curriculum evidence-based & designed for transition to practice for BSN new graduates.

Research provided data to revise measurements.

Research provided data for decision to expand residency to more sites.

Consistent emergence of the decline in scores at 6 months, suggest new graduates may be vulnerable at this time period.

Fink, Krugman, Casey, Goode

2008

The Graduate Nurse Experience: Qualitative Residency Program

Aim-- Evaluate qualitative responses to the Casey-Fink Graduate Nurse Experience Survey.

Qualitative Study

Evidence Level 6

Survey Administered to graduate nurse residents in the UHC/AACN Post Baccalaureate Nurse Residency Program.Report of qualitative data from 2 cohorts in the UHC/AACN post baccalaureate nurse

434 residents who completed the surveys for all 3 time periods (on hire, six months, & one year—41% response rate12 academic medical center hospitals.

Average respondent was 26 year old Caucasian women with

Top 3 Skills & Procedures Residents Uncomfortable Performing:On Hire (IV starts, blood draws, assessment skills) At Six Months (IV starts, codes/ emergency response arterial, venous, Swan Ganz) At OneYear (Code and emergency responses, IV starts, Trach care.) Stressors Reported: Adjusting to independent life style, expectations of the work environment & new RN role, and family responsibilities.

Limitations:

Numbers of qualitative comments diminished over the 3 time periods. Could indicate measurement fatigue

Strengths:Qualitative data added to the body of evidence regarding residency

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Outcomes residency programAnalysis included 5 open ended questions, where residents could voice their experiences about the work environments & role transition. The questions included: skill and procedures residents uncomfortable performing, stressors, transition difficulties, and support and integration.Key Words from respondents were independently identified by 2 investigators & validated by co-authors.

BSN degree.

No statistical differences in demographic outcomes related to number of preceptors, length of orientation, and work in health field before coming a resident or area of clinical practice.

Transition Difficulties: At 1 year, 42% of resident’s still perceived difficulties. 5 overall themes emerged: 1.Role changes, 2 Lack of confidence, 3.Workload/organizing & prioritizing, 4.Fears/patient safety/harming, 5.Orientation Issues--learning unit technology, information overload, multiple preceptors, and choice of unit. Manager Support & feedback was identified as one of top ways they could have felt more supported along with consistent preceptors. Open ended comments: Residents liked support from peers, Position would have been overwhelming without residency

programsData from study used to revise the research instrument.Data from study used to focus skills labsResidents identified the need to develop skills & confidence in directing assistive personnel. Residents requested the desire to have a resource person or mentor during the last 6 months of practice.

Goode, Lynn, Krsek, Bednash

2009

Nurse Residency Programs: An Essential Requirement for Nursing

Analysis of outcomes from BSN residents who completed UHC/AACN instruments on hire, at 6 months, & 1 year for 2004-2005Build the case for residency accreditationPresent need for CMS to support accredited residencies with pass through dollars.

Descriptive, Repeated measures DesignEvidence Level 4 (cohort study)ANOVA used to compare scores over time. Evaluation of a one year residency offered by a hospital & a school of nursing. Instruments used to measure outcomes-The Casey/Fink Graduate Nurse Experience, Gerber Control over Practice; McCloskey Mueller RN Job Satisfaction & a Program Evaluation Scale developed by research team.The least significant difference procedure for post hoc comparison used to identify significant differences between the data collection periods.

665 residents from 26 academic medical center hospitals; 46% response rate.Residents hired from September 2004 & September 2005.Mean age of residents 25.6 years with 9.2% males. 27.9% had a baccalaureate or higher degree in another field.Sample included 75.9% Caucasian/White; 8.4 % African American, 6% Asian, 5.8% Hispanic & other unknown 3.4%.Resident considered an advanced beginner (Benner’s Theory)

Residents had statistically significant increases over the three time periods in overall confidence in their skills, ability to organize & prioritize their work (means 2.68-3.01-3.24), comfort in communicating with patients & families & in providing leadership on their units (means 2.74-3.07-3.23).Stress scores declined from beginning to end of residency (means 1.34-1.18-1.05). Residents showed declines in many scores at the 6 month measure.Residents enter the program by rating themselves high in most areas, a decline is seen at 6 months & a rebound at 1 year. Research suggests 6 month is a difficult time for residents. Need for CMS support for nurse residencies presented. Turnover rates continued to decline from 12% to 9%.

Limitations:Lack of a control group.Unable to control for site related variables which could influence resultsDifficult to maintain high response rates in repeated measures ANOVAStrengths: Curriculum based on studies that identified areas where new grads needed additional skills & knowledge & on outcomes from previous studies of the UHC/AACN nurse residency program.Curriculum revised and focused to provide peer, preceptor & manager support & recognition. Provided data to expand to more sites.

Park, Jones

2010

A retention strategy for newly

An integrative literature review to present the most useful interventions used in

Integrative ReviewEvidence Level 5

Study followed Cooper’s five-stage process for the integrative literature review & were limited to studies in the

17 studies met criteria for inclusionRN Sample size ranged from 9 to 212Articles published between 1990 and 2007.

Confidence: 7 articles reported improved self confidence (5 internship programs, one residency program & one extended orientation program) Internships in specialty areas increased confidence of new nursesCompetency: 7 studies reported an

Limitations:Hospital-based programs only reviewed.

Focused only on 3 outcomes

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graduated nurses

programs that reported positive effects on new nurses.

US

Analysis of studies using various methods to increase confidence, competency & retention.

Articles rated using modified research quality check list developed by Beck.

9 articles evaluated internship programs,5 studies were related to residency programs (4 of which were post-baccalaureate), 2 structured orientation programs and 1 preceptorship

Outcomes for confidence, competency, & retention were reported.

increase in competency. Competency content focused on the knowledge & critical thinking of new graduates.Retention: In 15 studies retention of new nurses was reported as the percentage of participants employed at 12 & 24 months. Results showed increased retention rates76% to 96% compared to baseline of 25% and 75%.Programs varied in length from 6 weeks to one year. All programs consisted of classroom learning & clinical experience with preceptor. Two program supports (peer group & mentorship by senior leadership) were reported as important. More research is needed to determine program length.

Strengths:

Programs facilitate transition of new graduates to professional RN’sCreated environments that promoted retention of newly graduated RN’s.

Study demonstrated improved resident self confidence and increase in competency

Ulrich, Krozek, Early, Hipps-Aslock, Africa, Carman

2010

Improving Retention, Confidence,& Competence of New Graduate Nurses: Results from a 10 year Longitudinal Database

Facilitate transition of new graduate nurses to professional RN’s,Prepare beginning-level staff nurses who are confident & provide competent & safe patient care, increase commitment & retention of new graduate nurses within the organization.

Descriptive Longitudinal DesignDescriptive statistics for demographic variablesEvidence Level 4 (cohort study)Regression Analysis with employment as outcome variable & the measurement instrument data as predictor variables. Instruments included Organizational job Satisfaction, Organization Commitment, Nurse Satisfaction, Leader Empowering Behavior, & Group Cohesion, & Conditions for Work Effectiveness.Based on Benner’s theory. Includes core evidence-based curriculum and specialty curricula. Clinical immersion begins with a novice preceptor and then an experienced preceptor. Residents rotate or “loop” to other areas. Mentoring includes scheduled

N = over 6000 new graduates who completed residency during 10 years.

Sites ranged from small rural hospitals to large health care systems with cohorts sizes from 4 to 110.

Graduates wereDiploma 2%, AD 49%, BSN 47% Masters 2%.

Turnover- Pre Versant new graduate turnover at 12 months was 27%, & average cumulative turnover at 24 months was 49%. Average turnover in Versant program at 12 months was 7.1% and at 24 months 19.6%. The Nursing Competencies Rating Scale was used for resident self-assessment & trained observers did random sample observations with significant progress start to finish. Satisfaction was measured using both work (organizational) satisfaction & nurse job satisfaction The nurse satisfaction enjoyment subscale was rated highest followed by quality & time to work with both showing increases over time. The organizational satisfaction with pay was rated lowest & declines over time.The Skill Competency Self-Confidence Survey, a self-rating completed by residents, found self-confidence grew.Empowerment measurements found the enhancing meaningfulness of work was rated lowest & expressing confidence was rated highest. Higher satisfaction correlated with lower intent to leave.

Limitations:

No control group

Unable to control for site related variables.

Extensive measures used to evaluate program. This complexity would make it difficult for replication.

Strengths:Multiple measures used to evaluate the programs. Rigorous evaluation.

Evidence of a dedicated research team which used multiple instruments to evaluate the program.

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meetings and guidelines for sessions and use of Mentoring circles- 2 to 3 assume responsibility for a group of residents. Each client organization has a Versant Performance & Outcomes Manager.

Results support the need for the 18 week clinical immersion with dedicated preceptors and a need for support and guidance and structured mentoring and debriefing throughout the year.

Bratt & Felzer

2011

Perceptions of Professional Practice & Work Environment of New Graduates in a Nurse Residency Program

Measure new graduates perception of their professional competence & work environment.

Repeated Measures design with Descriptive & Inferential StatisticsANOVA used to compare total & subscale scores.Evidence Level 4(multisite cohort study)Developed structured program, model, curriculum & delivery methods.Wisconsin Nurse Residency Program (WNRP) graduates professional practice competency was measured by the Clinical Decision Making in Nursing Scale & the Modified 6-D scale of Nursing Performance.WNRP perceptions of their work environment measured by The Nurse Job Satisfaction & the Job Stress Scale. The Organizational Commitment Questionnaire measured turnover intent.

468 newly licensed RN’s employed in acute care hospitals in Wisconsin from 2005 to 2008’Nurses who completed a survey at all 3 time points was 227.Resident participants from multihospital systems, community hospitals (urban & rural) & critical access hospitals.Participation not based on type of nursing degree. Mean age was 30 --participants were selected via application process or the program was mandatory for all new graduates.

Clinical decision-making scores significantly higher at 12 months than at 6 months.Job Satisfaction scores significantly higher at 12 months than at baseline or 6 months.Job stress at program conclusion significantly lower than at baseline or midpointStaffing related stress declined from 6 month to 12 months.Baseline subscales for stress were related to personal competence & gaining team respect.Organizational Commitment was significantly higher at baseline than 6 or 12 months.Quality of performance significant upward trend in mean scores over time.6 month decline in job satisfaction, organizational commitment & clinical decision making is consistent with literature.

Limitations:Participation was voluntary & could contribute to selection bias.Most participants were white females which may limit generalizability.Strengths:Critical thinking improved by program end. Stress at midpoint & endpoint caused by workload & staffing --provided evidence for addressing stress in curriculum. Research contributes to data indicating programs are an emerging evidence-based strategy for easing transition to practice & intent to stay.

Clark & Springer

2011

Nurse Residents’ First-Hand Accounts on Transition to Practice

To examine the lived experiences of new graduates & to assess job satisfaction during the first year of nursing practice.

Qualitative Descriptive Study

Evidence Level 6

Kruger’s systematic Process was used to conduct 9 focus groups.Research Questions:1. How do new graduates describe their typical workday.2. What are the most satisfying

37 of 83 (44.6%) employed in a 600 bed public hospital in Northwest participated in focus groups

All were members of a new Residency program—32 female & 5 male with length of employment ranging

Responses organized into themes;Describe a typical day; There is no typical day. Workload & frantic pace sometimes overwhelming. Shifts have established routines. Quote-“It’s chaos from time I arrive to time I leave. I am running & thinking & trying to get my brain to work. I really wish I had more time to stop & think about what is going on with each patient.” Describe what you found most satisfying. Four

Limitations:

Small sample for one large hospital.

Some participants length of time in program quite short

Strengths:

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aspects of the new nurse graduate nursing.3. What are the most concerning aspects of the new graduate nurses practice4. What educational topics do new graduates want to know more about5. Where do new graduates nurses see themselves practicing nursing in the future.

from 8 days to 18 weeks.

subthemes emerged---being viewed as vital & contributing team member, making a difference in patient’s lives seeing them improve, gaining experience & expertise, working with supportive preceptors.Describe what concerned you most about nursing practice. Themes that emerged---stress and stress associated with not knowing & daily operational conflicts. What topics related to nursing practice did you want to know more about? The 8 subthemes expressed were; communication, professionalism, dealing with incivility & bullying, teamwork, anticipating adapting, & leading change, stress management, prioritizing & delegation & patient assessment & documentation.Residents wanted greater choice of preceptors, greater shift selection, input into scheduling & assignments & a longer transition & orientation period.

Research questions well thought out & add evidence for residency program improvement.

Provides resident voice regarding the residency programs strengths & need for improvement.

Nearly all new graduate nurses predicted they would be in the nursing profession in 10 years particularly if they encountered supportive preceptors & nursing staff, felt valued by the health care team & felt they contributed as a vital member of the organization.

Rush, Adamack, Gordon, Lilly, Janke

2011

Best Practices of Formal New Graduate Nurse Transition Programs: An Integrative Review

Review existing research to identify best practices of formal new graduate nurse residency nurse transition programs.

Integrative Review

Level of Evidence 5

Coopers (1989) five stage approach to integrative review as guide for study.

Inclusion criteria included; empirical research, new grads in a formal transition program, acute care settings, published in English.

Transition program was defined as occurring in addition to general orientation.A level of evidence score was assigned to each article.

47 Articles included in review & included quasi-experimental, longitudinal, descriptive & qualitative.Literature dominated by US UHC/AACN nurse residency.

Length of program varied; 14 did not specify length, 8 were 3 months or less, 5 were 4 to 6 months, 19 longer than 6 months.

A defined resource person was identified in 15 articles but no standard definition

13 papers had a retention rate of 90.1% & papers examining turnover had a rate of 10.5% compared to Canadian attrition rate of 28% & US national rates averaging 55 to 61%Transition program costs ranged from $2023.91 to $12,125 per resident. Transition savings by reducing turnover were reported at $1,040,153; $330,481; $186,102; & $823,680.Three articles presented partnership models between academic program &healthcare organizations & benefits of for retention. Education related to practice was delivered via course work & classroom sessions & included topics such as pain management, end of life and professional development topics such as leadership .New graduate satisfaction from 6 to 9 months was associated with highest levels of stress

Limitations

Measurement varied across programs & variability in research designs limits ability to describe best practices & outcomes.

Strengths:

Manuscript provides stronger evidence that new graduate education should focus on skill development; the need for preceptor formal training, inclusion of formal support in 6 to 9 month period, opportunities for residents to meet &

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existed.

Peer support & providing opportunities for new grads to meet with other new grads for socialization & support was important.

& lowest levels of job satisfaction indicating an initial level of reality shock that is overcome by end of residency. Reality Shock is less when work environments are identified as healthy or very healthy. Evidence suggests positive outcomes related to new graduate-preceptor relationship when the preceptor has formal training. More rigorous study designs needed & improved work environments to support new graduate transition.

provide peer support & the need for healthy work environments in order to have successful transition programs.

Programs that end before one year may not provide sufficient support or time for adjustment

Anderson, Hair, Todero

2012

Nurse Residency Programs: An Evidence-Based Review of Theory, Process & Outcomes

Describe & evaluate the quality of the science, report recommendations & lessons learned about implementing & evaluating nurse residency programs.

Identify English speaking research reports about nurse intern, extern, transition, & nurse residency programs.

Systematic Review

Evidence Level 5Describe the evidence behind NRP’s.Report Recommendations & Lessons Learned about evaluating NRP’s.15 of the studies used a quasi-experimental one group design & two studies used an ex post facto 2 group design.Programmatic components of each NRP compared across studies using content analysis.Research Questions:What is the best design for a new NRPWhat variables have been used to measure the efficacy of this educational interventionTheories used: Benner’s Novice to Expert. Schon’s organizational learning theory.Kolbs theory of experiential learning

20 studies fit the criteria for inclusion; RN characteristics, program goals, theoretical perspectives, program components & processes, outcome measures, lessons learned & recommendations.A quality appraisal & scoring of studies rated the level of evidence & 8 criteria were used to evaluate the studies.Strengths & weaknesses. Each study was scored into three categories—high, medium, low qualityData synthesis to examine similarities & differences in programs.

The Casey-Fink Graduate Nurse Experience Survey was most used measurement tool. The NRP educational intervention was the least described & consequently the most unstable variable that introduces measurement & statistical error in all studies. Due to wide variation in program curriculum, methods of delivery & qualifications of educators & preceptors it is impossible to determine which program is better.Consistency in the intervention & addition of matcher or true comparison groups will add needed rigor & control over confounding variables that now go unchecked. Need standardization of curriculum & program procedures and a Preceptor Leadership Council to sustain program over time. Need a business case for the NRP to sustain support from Managers & CNO’s; Essential Requirements: Need a NRP coordinator, a resident facilitator & competent preceptors who get professional development. Lack of consistency in tools used, great variation in length of programs & lack of standardized evidence based curriculum make it difficult to compare quality across programs.

Limitations:

If organizational culture & work place climate are important should there be a recommendation to measure these concepts in hospitals using NRP’s.No discussion of the need for accreditation of NRP’s to standardize curriculum & program components.

Strengths:Quality appraisal methods extensive.Search techniques & decisions for inclusion well defined.

Need for theory guided NRP educational content,Strategies & evaluation measures well described & provides evidence for the need for change.

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Kramer, Maguire, Halfer, Budin, Hall, Goodloe, Klaristenfeld Teasley, Forsey, Lemke

2012

The Organizatio-nal Transform-ative Power of Nurse Residency Programs

Questions: 1.What people, component processes & activities & the work environment are instrumental for transition of Newly Licensed RN’s(NLRN’s) into professional practice.2. What does this hospital do to helpNLRN’s make an effective transition from academia to work & become integrated into professional nurse practice role & professional communities.

Mixed Method-Primarily Qualitative

Evidence Level 6 (Qualitative study).

Interview nurses from 20 Magnet Hospitals with confirmed Healthy Work environments.

Describe major challenges identified by NLRN’s.

Site visits of 1 & ½ to 4 days by investigators to conduct interviews & participant observations.The NLRN interviews were between 9 & 12 months post hire & 29% evenly distributed between those with 6 to 8 months experience & with 13 to 15 months experience.8 hospitals had published NRP’s others had home grown programs or programs adapted from national programs—All programs were empirically evaluated.

907 nurses interviewedDuring 20 site visitsInterviews digitally recorded & transcribedSample included:330 NLRN’s,401experienced nurses including preceptors,138 nurse managers38 nurse educators.Selected best units in the best hospitals—best hospitals selected on ‘published excellent hospital designations.”Residency had to be operative for at least 3 years.Sample worked on 174 units and interviews with a mean of 45 nurses per hospital. Almost 80% of the NLRN’s were prepared at the baccalaureate level & 5% had a master’s

Qualitative data collection centered on the major challenges identified by NLRN’s; delegation, prioritization, managing patient care delivery, autonomous decision making collaboration with other disciplines, constructive conflict resolution, & utilizing feedback to restore self-confidence.Nurse residency program positively impacted the professional socialization of NLRNs leading to transformative changes in the organization & the practice of other health care professionals.Transition plus integration-stage NRP’s are most effective in developing competencies.NRP’s 10 to 15 months offered integration stage goals & expected role performance, & more content than NRP’s of 2 to 4 months.Well-structured-theory based transition plus integration phase residency programs leads to improved practice empirically related to improved patient outcomes. NRP’s may well be the most cost-effective, hospital organizational transformation instituted by nurse leaders in recent years.

Limitations:

Sample included Magnet hospitals only.

Lack of control group---magnet hospitals without residency.

Strengths:

Large sample of interviews of NLRN residents.

Key interviews with those impacting residency content & performance.

Study of residency programs in hospitals with confirmed healthy work environments.

Author with strong background in new graduate reality shock.

Barnett, Minnick & Norman

2013

A Description of U.S. Post Graduation Nurse Residency Programs

Study purpose was to describe US Nurse Residency Programs (NRP’s) & identify treatment fidelity across programs.

Descriptive & Cross Sectional

Level of Evidence 4 (cohort study)

Methods: Use of a 24 item scale based on the outcomes production conceptual framework. Scale tested for item validity using card sort method. (90% agreement) Pilot tested by 4 NRP experts (content validity 0.93).

Sample—203 surveys returned by CNO’s or NRP. Directors.48% reported having NRP.20% response rate on the survey. (92 hospitals)Hospital samples showed no statistical differences in region, bed size, Magnet, or Coth compared with total population.

Provided snapshot of Characteristics of NRP’s:Program lengths-1/3 had less than or equal to 12 weeks, 13% had 12 weeks, 40% had 52 weeks.Great variability among programs including length of program, allocated resident time, mentoring & academic degree required for participation.Resident time allocation provided by 86% of programs. Estimated percentage of time in direct patient care increased from a median of 17.5% in first week, to 75% at midpoint to 90% in final

Limitations:

Response rate low.

Limited to hospitals 250 beds & over.

Hospitals with NRP’s may be more willing to complete survey.

Strengths:

Identified Weaknesses of

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Survey sent to known NRP directors or chief nursing officers at 1100 US hospitals with 250 or more beds. (Prisons, Military, Psychiatric & Veterans Hospitals omitted).

Hospital control was different with more government hospitals represented.Respondents were 29% ADN, 67% BSN,, 4% MSNType of Residency Sample:22% UHC/AACN; 54% Facility based; 24% other.

week. Time allocated to unstructured professional activities decreased from a median of 15 hours in the first week to 4 in the last week. 40% of programs required residents to complete a project.51% of respondents reported that career planning was not part of the NRP. A greater proportion of the AACN/UHC programs were located in Magnet hospitals. Magnet status showed statistically significant association with COTH status and shared governance.Almost 2/3rds of programs reported not using mentors. There was a median of one program coordinator and 2 residency facilitators and six and ½ mentors among all programs.Study describes the great variability of programs. Differences in & across program types was indicative of lack of treatment fidelity needed to detect the impact of the residency on discrete patient outcomes.

NRP’s.

Variability in NRP’s does not enhance consumer confidence. Demonstrated need for operational definitions & standardization ofNRP components.

Provided evidence for need for residency program accreditation standards.

Goode, Lynn, McElroy, Bednash & Murray

2013

Lessons Learned from 10 Years of Research on a Post-Baccalaureate Nurse Residency Program.

Examine outcomes from 10 years of research on a post-baccalaureate nurse residency program/

Report Lessons Learned.

Descriptive, longitudinal study.

Evidence Level 4 (cohort study)Evaluate data from new graduates who participated in the UHC/AACN residency over a 10 year period-2002 to 2012.Analysis of Variance on hire at 6 months & one yearInstruments: Casey/Fink Graduate Nurse Experience Scale; Analysis of outcomes from the Program Evaluation Instrument. Measure of retention rates for new graduates.NRP curriculum delivered in monthly residency seminars in

Sample included 31,000 post baccalaureate nurses from 86 organizations and 100 hospitals.NRP curriculum composed of 3 core content areas;1. Leadership with a focus on managing resources & collaborating with interprofessional team; 2.patient safety & outcomes; 3.professional role of nurse including managing patient changing condition, ethics, end of life care

Evaluation measures for the UHC/AACN residency changed over time. The MMSS (McCloskey Muller Satisfaction Scale) & the CONP (Control) over Practice scale were eliminated after 3 years due lack of fit for new graduates.The Casey-Fink Graduate Nurse Experience Scale was used for all 10 years along with the Graduate Nurse Residency Program Evaluation instrument.Repeated Measures ANOVA found significant increase over the 1 year program in residents’ self-assessment of their overall confidence & competence, ability to organize and prioritize their work, and communicate and provide clinical leadership over all ten years on the Casey-Fink Instrument.

Limitations:Lack of a control group.Difficulty to maintain high response rate in repeated measures ANOVA.Unable to control for site related variables.Strengths:Changes over time included enhancements to the curriculum, greater standardization of new site on boarding & more assistance provided to new sites by established successful sites.Development of AACN accreditation standards has increased

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face to face environment. Case studies based on actual complex clinical situations.Seminars include a resident facilitator to coach residents & seasoned expert nurse. Academic partners & hospital clinicians bring expertise to content & learning methodologies.Program components and curriculum designed to meet CCNE accreditation.

Requirement to complete individually or as a team member an EBP project.

The self-perceptions of support and professional satisfaction continued to show a significant decline from program start to midpoint with a rebound at year’s end.Retention rates over the 10 years increase from 88% to 94.6%Resident’s evaluation of the program has stayed positive over the 10 years with overall welcome & program faculty getting highest ratings, along with program goals, & topics.

standardization of curriculum and program components across accredited sites.The Evidence-Based Practice project in the last 6 months of the program has been highly valued by nurse managers, CNO’s & the organization & has a significant impact on nursing practice.

Fiedler, Read, Lane, Hicks, Jegier

2014

Long-term Outcomes of a Post baccalaureate Nurse Residency Program

Describe long term (beyond the 1st year of employment) turnover rates of NRP graduates.

Examine the long-term career satisfaction of NRP graduates beyond the 1st year of employment.

Explore long term leadership development of NRP graduates beyond the 1st year of employment.

Descriptive pilot study at large urban medical center in Midwest.

Evidence Level 5

A demographic tool & the McCloskey/Mueller Job Satisfaction (MMSS) tool were utilized to collect data.Frequencies & descriptive statistics were used---given small sample size nonparametric Kruskal-Wallis tests were used to examine group differences using Chi-Square statistics.

Sample: All 170 graduates between July 2008 & August 2010 were asked to participate.

51 completed survey (30.2% response rate).

Survey emailed to former nurse residents who completed the UHC/AACN nurse residency & were still employed at the hospital.Data collected anonymously

Participants had either a BSN or Masters & majority younger than 30 years & worked med-surg, mother child, or critical care

No statistical differences between the 3 groups (FY 2010, FY 2011, FY 2012). Long term turnover rate for all groups combined of the period of the study was 13.7% (27 of 197 residents) well below national average. The MMSS subscales were generally high with all medians greater than 3 on a scale of 1-5. All subscales tended to increase with time after graduation but were not statistically different. Co-worker/ peer support were most important to job satisfaction. Professional development was assessed by examining involvement in activities & job advancements; The more experience, the more likely to function as a charge nurse; trend for increased professional involvement such as member of professional organization, getting certification, pursing advanced degrees, progression on clinical ladder, acting as preceptor & community involvement. There was not a trend for increased involvement in committees.

Limitations:

Outcomes are for pilot study from one hospital only & only one residency.

Strengths:

First study to examine long-term outcomes from the UHC/AACN nurse residency program.

Certification & pursing advanced degree increased with longer employment.

Turnover remained well below the national average.

Lin, Viscardi, McHugh

2014

Factors

Describe the various determinants of job satisfaction.

Systematic Review

Evidence Level 5

Inclusion criteria includedNew Graduate measures of job

11 articles met criteria for inclusion in study.

The 11 studies were published between 2006 & 2013 &

21 factors contributing to job satisfaction were synthesized through content analysis into7 broad categories; extrinsic rewards, scheduling, interaction & support, praise & recognition, professional opportunities,

Limitations:

No control group.

Authors suggest randomized controlled

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Influencing Job Satisfaction of New Nurse Graduate Nurses Participating in Nurse Residency Programs: A Systematic Review

Explore the relationship between nurse residency programs & new graduate nurses’ job satisfaction.

Identify areas for future research of nurse residency programs & new graduate job satisfaction & retention.

satisfaction (quantitative & qualitative).Alpha coefficients of at least 0.70 were considered favorable regarding reliability levels and were met in all 11 studies.Nurse Residency programs intervention & program techniques were clearly defined, sample size was provided, implemented in US & article written in English.

Quality Review for methodological quality used Cummings & EstabrooksQuality Rating Tool.

included more than 9000 nurses with Baccalaureate or Associate Degrees with mean age of 27.7 years with a diverse range of geographic regions & locations represented.

4 themes assessed in each study: research design, sample, measurement, statistical analysis

Studies ranked on 14 point scale as strong, moderate & weak. Articles with weak validity discarded.

work environment & hospital system.Satisfaction with extrinsic rewards does not change significantly during the residency. Satisfaction with scheduling stays the same or decreases during the residency.Findings suggest non-nursing interactions (with physicians, patients, & families) identified as positive were more significantly related to nurses’ job satisfaction. Satisfaction with praise & recognition was mixed & more information is needed to understand this concept. Results showed satisfaction with professional opportunities. .New graduates dissatisfaction with the work environment persists during the residency program. Findings suggest that residency programs do not alleviate dissatisfaction with the hospital system.

trails.

Strengths:

Identified need for determination of which nurse residency components influence new grad perception of job satisfaction in order to make policy & residency program recommendations.

Identified need for changes to improve work environment and hospital system

Chappell,Richards, Barnett

2014

New Graduate Nurse Transition Programs and Clinical Leadership Skills in Novice RN’s

Determine predictors of clinical leadership skill for RN’s with 24 months of clinical experience or less

Non Experimental RetrospectiveDesignEvidence Level 6On line electronic survey tool. Tool was distributed within each participating organization through study site coordinatorsParticipating hospitals used standardized curriculum developed either by UHC/AACN or Versant, and 2 were organization developed. Instrument---Clinical Leadership Survey (CLS)—The instrument subscales (clinical expertise, effective communication, collaboration, coordination and interpersonal understanding) were mapped to the leadership practices of Posner and Kouzes model.Final Instrument had 15 items with 3 items measuring each

Total RN’s in participating hospitals was 4,617. N=306 RN surveys were analyzed (6.6%)Twenty Three US hospitals from Colorado Hawaii, Kansas, Illinois, Nevada, New York, Pennsylvania, Texas, Virginia and Washington DC.Participants had 24 months of clinical experience or less.Respondents were 90.5% female, non-Hispanic 91.9%, Caucasian/white 74.2%.Mean length of experience as RN was 10.91 monthsAverage New Graduate

Almost ½ of all NGNTP programs included mentor support (49.7%), and 84.6% included professional development skill classes. Mean value for quality of programs was 3.98 (5 point Likert scale)Longer NGNTP’s were perceived to have higher quality when compared with those 12 weeks or less (P=.05) and RN’s in longer transition programs were significantly more likely to stay in hiring organization.New graduates who participated in transition programs that were greater than 24 weeks in length were 21 times more likely to stay in the organization compared with new graduates who were in transition programs that were 12 weeks or less.Predictors of Clinical Leadership Skill (CLS) correlated positively with months of clinical experience and was a statistically significant predictor of CLS (p=.039)

Limitations:Retrospective study design limited ability to control for specific characteristics including; curriculum, number and quality of supplemental experiences, and hours of mentor supportLow response rate 6.6%Asking RN’s to accurately recall data about their transition program could lead to error

Strengths:Diverse sample from multiple hospitals

Standardized curricula used in all organizationsAdds important evidence regarding longer programs having higher quality, greater

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clinical leadership construct—final Cronbach’s alpha .86

Nurse Transition Program (NGNTP) was 22.6 weeks (range 4-52 weeks)

Quality of mentor support was strongest predictor of overall NGNTP (p=000) and CLS (P=.01)

retention and significant impact on Clinical Leadership Skill development.

Spector, Blegen, Silvestre, Barnsteiner, Lynn, Ulrich, Fogg & Alexander

2015

Transition to Practice Study in Hospital Setting

Conduct a randomized controlled multisite study examining quality and safety, stress, competence, job satisfaction and retention in new graduate nurses using an evidence-based Transition to Practice Program (TTP);Compare outcomes from a control group of hospitals that had pre-existing onboarding programs and obtain diverse samples that include rural, suburban or urban hospitals ranging in size from small rural to large medical centers

Longitudinal randomized multisite design Evidence Level 2Research Questions:1. How effective is NCSBS’s TTP program in terms of safety, competence, stress, job satisfaction and retention when compared with a control group of various onboarding methods and programs customarily used by hospitals enrolled in the study.2.Do transition to practice programs make a difference in new graduate outcomes in terms of safety, competence, stress, job satisfaction and retention?Hospitals were randomized into a control or study group. Hospitals in the study group adopted the entire NCSBN TTP program for the study period June 1 2011-September 30 2012. New nurses asked to participate i and provide data about their experiences for the first 12 months after hire. Assigned preceptors completed a training module and provided the data on new graduate performance.Control hospitals maintained their usual on-boarding and site coordinators provided data on control hospitals demographics, new nurse. Retention and information on their existing programs for new graduates.

Power analysis done to determine sample size. 105 hospitals in Illinois, North Carolina and Ohio volunteered for the study. 1554 new nurses were hired and 1088 (70%) volunteered to be in the study. There were 94 hospitals 51 controls and 43 study. No significant difference in nurse demographics between study and control hospitalsEducation for the sample was ADN or Diploma (49%), BS (44%) and accelerated baccalaureate or master’s entry (7%). Educational levels did not differ between control and study groups.A larger % of new nurses in the study group worked in university-affiliated hospitals (46%) than those in control(39%) A second analysis was done stratifying hospitals into established programs and limited programs compared to TTP

Analysis # 1 Results: Control group made fewer errors at 6 months and fewer percentages over time. No differences for positive safety practices between control and study groups. Control group had fewer negative safety practices. No differences on the overall competence tool between the groups. Specific Competence tool showed groups improved over time with the TTP group rating significantly higher for patient-centered care, use of technology, and communication and teamwork. Stress increased from baseline to 6 months and then began to decline with control group seeing significant decrease in stress over time. The TTP group had 15% voluntary new nurse turnover and control 16.7%.Analysis # 2 Results: Additional analysis of on boarding methods used by control hospitals:Out of the 51 hospitals 29 were classified as Established Programs (300 RN’s); 22 were Limited Programs (186 RN’s) and 43 were TTP (577 RN’s.) The limited group had the highest mean percentage of negative safety practices at 6, 9 and 12 months; Overall Competence: the limited group began decreasing around 6 months and remained lower than the other two groups for the year. Work Stress--established programs experienced the least stress. Stress at 6 months increased for all 3 groups and then began to decrease. For Job Satisfaction, new nurses were less satisfied in all groups at 6 and 9 months than at baseline. Established program nurses

Limitations: It is possible that hospitals who volunteer may be different from those who do not volunteerObjective data on errors is not possible to attain due to protected information laws.Study did not include western region of US because no applications for participation came from those states.Attrition rate increased over timeStrengths:First study to randomize sites to control and study groupsStudy provides evidence that structured transition to practice programs including evidence-based components can improve quality and safety practices in new graduates and increase job satisfaction, reduce work stress and decrease turnover.Study provides evidence for: need of support from organization and CNO and other administrators; program at least 6 months in length; a preceptor program; a curriculum that includes patient safety, teamwork, EBP, communication informatics, QI, clinical reasoning and patient-centered care; need to customized to provide specialty knowledge needed

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Survey Tools/Instruments used: NCSBN Practice Issues Index, Overall Competence Tool, Specific Competence Tool, NCSBN Work Stress Tool; Brayfield & Roth Index of Job Satisfaction. Multilevel analysis used data from all respondents by accounting for missing data with predictive equations.

had highest level of satisfaction between 9 and 12 months but all groups began having an increase in job satisfaction by program end. Turnover: Established programs had the lowest rate of turnover 12% (p ≤.001) TTP had 14.7% and limited programs had nearly 25%

to work on the unit; and allow time for new graduate to learn and apply content, get feedback and share reflections. .Research identified shorter programs with limited onboarding have more negative safety practices, more errors and 2 times higher turnover.