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153The Journal of Continuing Education in Nursing · Vol 50, No 4, 2019
Newly Licensed Nurse Resiliency and Interventions to Promote Resiliency in the First Year of Hire: An Integrative Review Lisa Concilio, MSN-ED, RN, CCRN; Joan Such Lockhart, PhD, RN, CNE, ANEF, FAAN; Marilyn H. Oermann, PhD, RN, ANEF, FAAN; Rebecca Kronk, PhD, MSN, CRNP, CNE, FAAN; and James B. Schreiber, PhD
The nursing shortage has been a long-standing problem in the United States and spans eight decades (National League for Nurses, 2017). Newly licensed nurses (NLNs) are graduate RNs who have passed the National Council Licensure Exam-RN (NCLEX-RN®) and are employed for the !rst time in the role as a professional nurse. NLN turnover has been reported in recent years to a"ect patient safety and com- pounds the global nursing shortage (Boamah & Las- chinger, 2015; Bradbury-Jones, 2015; Kovner, Brewer,
Fatehi, & Katigbak, 2014; Spence Laschinger, Zhu, & Read, 2016; #omas & Kellgren, 2017; World Health Organization, 2017). #e American population is liv- ing longer with chronic diseases and expanding disabili- ties; more well-prepared RNs are needed as health care is ever-advancing and technology is at the forefront to help solve health care problems and improve quality of life (Academy of Medical-Surgical Nurses, 2018; Ghe- breyesus, 2018; National Academy of Medicine, 2017; Reinhard, 2014).
PROBLEM IDENTIFICATION AND SIGNIFICANCE #e American Association of Colleges of Nursing
(2017) reported that 1.2 million RN positions will be vacant between 2014 and 2022 and that approximately 700,000 nurses will retire or leave the workforce by 2024. Cline, La Frentz, Fellman, Summers, and Brassil (2017)
abstract Background: Lack of resiliency contributes to grow-
ing dissatisfaction among newly licensed nurses (NLNs) and often leads to clinical errors and job resignations. Method: An integrative review synthesized current re- search investigating NLNs’ resiliency within their first year of hire and interventions that may affect their re- siliency. Results: Key database searches (2008 to 2018) yielded 16 studies. Insufficient resiliency among NLNs has been correlated with intentions to leave current jobs and decreased job satisfaction. Residency pro- grams, well-prepared preceptors, and peer support promoted NLN resilience and enhanced patient safety. Lack of coworker support has led to NLNs’ intentions to leave their current jobs or the profession entirely. Conclusion: NLN turnover has been interpreted to be an outcome of poor NLN resilience. The first year of practice is stressful and affects NLNs’ mental health and cognitive reasoning, thereby risking patient safe- ty. Resiliency should be measured using a resiliency scale rather than turnover rates. [J Contin Educ Nurs. 2019;50(4):153-161.]
Ms. Concilio is PhD Student, Dr. Lockhart is Professor and MSN Nurs- ing Education Track Coordinator, Dr. Kronk is Associate Professor, and Dr. Schreiber is Professor of Epidemiology/Statistics, Duquesne University School of Nursing, Pittsburgh, Pennsylvania; and Dr. Oermann is !elma M. Ingles Professor of Nursing, Duke University School of Nursing, Dur- ham, North Carolina. Ms. Concilio is also Lecturer and Clinical Instructor, School of Nursing, San Diego State University, San Diego, California.
!e authors thank Dr. Jane Brannan, EdD, Professor of Nursing, Ken- nesaw State University, Kennesaw, Georgia, for her content expertise and support. !e authors also thank David Nol", MLS, AHIP Head, Research Engagement, Health Sciences/STEM Initiatives, Assessment Coordinator Gumberg Library, Duquesne University, Pittsburgh, Pennsylvania, for on- going support.
!e authors have disclosed no potential con#icts of interest, "nancial or otherwise.
Address correspondence to Lisa Concilio, MSN-ED, RN, CCRN, Lec- turer and Clinical Instructor, School of Nursing, San Diego State Uni- versity, 10006 Maya Linda Rd. #5207, San Diego, CA 92126; e-mail: [email protected].
Received: August 13, 2018; Accepted: October 22, 2018 doi:10.3928/00220124-20190319-05
154 Copyright © SLACK Incorporated
reported that training one NLN may cost a health care system $60,000 to $96,000; therefore, increasing NLN resiliency is imperative to maintain patient safety and is a !nancial priority. NLNs experience immense stress, leading to a state of shock while transitioning to practice (Duchscher, 2009) and resulting in burnout and turn- over (Laschinger et al., 2016; Pfa", Baxter, Jack, & Ploeg, 2014). Dyrbye et al. (2017) de!ned burnout as a syndrome characterized by emotional exhaustion that leads to poor performance and an attitude that is contrary to caring. Nurse burnout has led to sta$ng shortages and increased turnover rates, which has resulted in the use of physical re- straints, patient falls, and the formation of pressure ulcers (Aiken et al., 2014; Robert Wood Johnson Foundation [RWJF], 2012).
Resiliency has been identi!ed as a key factor in manag- ing the stress of nursing work–life, bu"ering burnout, and positively in%uencing NLNs’ intentions to stay their cur- rent jobs (Chesak et al., 2015; Cope, Jones, & Hendricks, 2016; Delgado, Upton, Ranse, Furness, & Foster, 2017; Reyes, Andrusyszyn, Iwasiw, Forchuk, & Babenko-Mould, 2015). Mudd (2016) stated that the concept of resiliency is elusive and a closer examination of resiliency is needed in order to decrease burnout and decrease turnover. With- out resiliency or ways to cope with the emotional stressors and workplace adversities (Delgado et al., 2017), nurses (including NLNs) may develop inconsistent thoughts, be- liefs, and values that will render them unsafe for practice and increase intentions to leave their jobs (Hart, Brannan, & De Chesnay, 2014; Stephens, 2012; Tahghighi, Rees, Brown, Breen, & Hegney, 2017). #is article describes an integrative review of the literature that examined NLNs’ resiliency within their !rst year of hire and interventions that a"ect their resiliency.
EXPLORING THE CONCEPT OF RESILIENCE IN NURSING
#e youngest generation of nurses are the most likely group of nurses to lack the protective factors of resilien- cy and leave the profession within the !rst year of hire (Flinkman, Isopahkala-Bouret, & Salanterä, 2013; RWJF, 2014). Resilience assists a nurse’s psyche to cope with the negative consequences of workplace stress (Fletcher & Sarkar, 2013). Stressors encountered by nurses in health care organizations include an increasing aging population, growing numbers of patients with chronic illnesses, and an aging nursing workforce (American Association of Col- leges of Nursing, 2017). To overcome these organizational and systemic stressors, nurses have been remediated to provide excellent customer service and uphold standards of care; yet, these approaches have not addressed the afore- mentioned stressors or bolstered nurses’ resilience (Insti-
tute of Medicine, 2014; Spence Laschinger et al., 2016; Wonder, York, Jackson, & Sluys, 2017).
A resilient nurse receives information and acts on it to safeguard patients and advocate for their needs (Sieg, 2015). Resiliency is the ability to command psychomotor skills (the ability to perform tasks and communicate cor- rectly and in a timely manner) and cognitive-behavioral skills (cognitive re-framing, mindfulness, compassion, and emotional intelligence) in order to perform success- fully while stressed (Academy of Medical-Surgical Nurses, 2018; McAllister & Lowe, 2011). In this article, we pro- vide current knowledge on the concept of NLN resilience during the !rst year of hire because the lack of resiliency causes nurses to act in a manner that is contrary to caring. As dissatisfaction builds, it leads to an increase in errors and contributes to NLNs leaving their current jobs (Ga- briel, Diefendor", & Erickson, 2011; Hart et al., 2014). #erefore, a need exists to understand NLN resilience during the !rst year of hire.
PURPOSE AND SPECIFIC AIMS #e purpose of this integrative review is to summarize
and synthesize NLN resiliency and interventions used to promote NLN resiliency within the !rst year of hire in an e"ort to guide future research in this area. Although resilience has been widely studied in nurses (Delgado et al., 2017; Hart et al., 2014; Stephens, Smith, & Cherry, 2017) and nursing students (Stephens, 2012, 2013), few studies have examined NLN resilience. #is integrative review explores the past literature to describe factors as- sociated with a lack of resiliency or its protective factors and to investigate approaches that increase NLN resil- iency. #e following speci!c aims guided this integrative review: t� What is the state of NLNs’ resiliency within their !rst
year of practice? t� What are the contributing factors that promote or hin-
der NLNs' resilience? t� What are the outcomes associated with NLNs' resil-
ience or lack of resiliency? t� What are the current interventions or strategies used to
build protective factors of resilience that lead to NLNs’ intention to stay at their current jobs?
t� What tools have been used to measure NLNs' resiliency and have been correlated with intentions to leave jobs?
METHOD An integrative approach by Whittemore and Kna%
(2005) guided this review of the literature. #is model included !ve stages (problem identi!cation, literature search, data evaluation, data analysis, and presentation) to enhance accuracy and ensure a thorough search.
155The Journal of Continuing Education in Nursing · Vol 50, No 4, 2019
Literature Search A systematic process was used to review the pri-
mary studies of qualitative and quantitative research designs (Whittemore & Kna%, 2005). #e process of conducting an integrative review is to provide an unbi- ased review of the literature. To retrieve relevant litera- ture, searches were conducted with the assistance of a health science librarian using the Cumulative Index to Nursing and Allied Health Literature (CINAHL®) and PubMed® databases and restricted to English-language articles published from January 2008 to May 2018. #e following subject headings were used to retrieve articles that included descriptions about NLNs: newly licensed nurses, resiliency, and intention to leave. #e Boolean operators AND and OR were used to com- bine these terms with newly licensed nurse* and nurs* (Table A; available in the online version of this arti- cle). Inclusion criteria included (a) the topic addressed resilience or protective factors leading to resilience in NLNs; (b) study participants were NLNs within their !rst year of practice; (c) any research design was used; (d) the studies were conducted in the United States; and (e) publication was between January 2008 and May 2018. #e review excluded nonresearch publications, gray literature, and publications that did not address the inclusion criteria.
A total of 789 articles were identi!ed from CINAHL and PubMed using the initial search terms; 56 duplicates were removed, resulting in 733 publications. As shown in the PRISMA %ow diagram (Figure 1), 570 articles were removed based on their abstracts, which did not meet the inclusion criteria. Next, 163 articles were re- trieved for full-text evaluation; 147 of these were exclud- ed as they did not meet the inclusion criteria, leaving 16 articles that comprised the !nal sample for this review (Anderson, Linden, Allen, & Gibbs, 2009; Bontrager, Hart, & Mareno, 2016; Clark & Springer, 2012; Cline et al., 2017; Clipper & Cherry, 2015; Fiedler, Read, Lane, Hicks, & Jegier, 2014; Fink, Krugman, Casey, & Goode, 2008; Gill, Deagan, & McNett, 2010; Hodges, Keeley, & Troyan, 2008; Hodges, Troyan, & Keeley, 2010; Kramer et al., 2013; Li, Early, Mahrer, Klaristenfeld, & Gold, 2014; Martin & Wilson, 2011; McCalla-Graham & De Gagne, 2015; Olson, 2009; Pellico, Brewer, & Kovner, 2009). #ere was no follow-up with authors to retrieve additional information.
Sample studies included qualitative (n = 8), quantita- tive (n = 5), and mixed-methods (n = 3) designs. Quali- tative studies used case study (n = 2), phenomenological (n = 3), and grounded theory analyses (n = 3). Quantita- tive studies were nonexperimental (n = 5) and included causal-comparative (n = 1) and descriptive analyses (n =
4). Mixed-methods studies used sequential, exploratory designs (n = 3).
Data Evaluation #e data evaluation stage used a methodological ap-
proach to appraise the quality of each publication (Whit- temore & Kna%, 2005). Each quantitative study was evaluated and categorized based on its quality of evidence and recommendation level for practice using the GRADE (Grading of Recommendations, Assessment, Develop- ment, and Evaluations) Guideline Criteria for Appraising Quality of Evidence (Schünemann, Ahmed, & Morgan, 2011); for qualitative studies, the GRADE-CERQual Con!dence in the Evidence from Review of Qualitative Research (Lewin et al., 2018) was used. Qualitative stud- ies were evaluated using GRADE-CERQual and catego- rized using a systematic approach to increase transparency in the appraisal process. Four components were used to evaluate qualitative studies: methodological limitations, coherence, adequacy of data, and relevance. Publication bias is also important and was considered in the appraisal of qualitative evidence and placed as a !fth criterion. Elev-
Figure 1. Graphical representation of the flow of citations reviewed. Adapted from “Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff, and D.G. Altman, 2009, Physical Therapy, 89, pp. 873-880. Copyright 2009 by Moher et al. Adapted with permission.
156 Copyright © SLACK Incorporated
en studies were rated as moderate to low quality (quali- tative, n = 8; mixed-methods, n = 3) and the remaining !ve quantitative studies were rated moderate to very low quality.
A matrix was created to track key data extracted from each study using the following subheadings: author, pub- lication year, design, sample population, setting, purpose/ aims, variables, instruments, and the quality appraisal (Table B; available in the online version of this article). Evidence was recorded as high, moderate, low, or very low (Table B). Observational designs were noted using ++, and experimental studies were noted using ++++ (Lewin et al., 2018; Ryan & Hill, 2016).
Data Analysis During data analysis, primary studies were organized,
categorized, summarized, and integrated into a conclu- sion about the research problem of each study based on (a) NLNs’ resiliency within the !rst year of practice, (b) contributing factors of NLNs that promote or hinder re- silience, (c) the outcomes associated with NLNs' resilience or the lack thereof, (d) methods found to build resilience in NLNs, and (e) an examination of the tools that have been used to measure NLNs' resiliency and correlated with intentions to leave their jobs. Results were synthesized us- ing a consistent, correlative method to identify patterns and relationships, create themes, draw conclusions, and provide a comprehensive summary (Whittemore & Kna%, 2005).
RESULTS Presentation of data is the !nal stage of an integrative
review, which exhibits detailed evidence from each sample study (Whittemore & Kna%, 2005). #e presentation also includes a synthesis of sample studies based on the review’s purpose and aims.
Description of Sample All 16 sample studies were published in the United
States and distributed from 2008 to 2017; most studies (n = 3) were published in 2009, and none were published in 2013. Studies were published in nine di"erent journals, and more than one study was included in the Journal of Nursing Administration (n = 4), !e Journal of Continuing Education in Nursing (n = 3), and Nursing Outlook (n = 3).
A wide range of sample sizes existed by study designs: qualitative studies (7 to 612 participants); quantitative (51 to 558 participants); and mixed-methods (7 to 434 participants). Both male and female NLNs were included as study participants in half of the studies, with female NLNs comprising the majority of study participants, ranging from 83.4% to 94.2%. #e percentage of male
NLNs included as study participants ranged from 5.8% to 16.6%. Conversely, the remaining half of the studies did not disclose participants’ gender. Reported age ranges of participants varied among studies, with most NLNs rang- ing from 21 to 25 years; two studies repeated mean ages of 33 and 33.4 years; and one study reported a median age of 38.6 years. Other studies reported diverse age ranges: 18 years or over (n = 1); 21 to 50 years (n = 1); 20 to 25 years (n = 1); and younger than 30 years (n = 1).
Only four studies reported the participants’ race/eth- nicity. Caucasian was the highest group represented (n = 4, 54.7%) followed by Black (n = 4, 13.6%), Latino (n = 3, 6.1%), and Asian (n = 2, 16.7%). Study settings were mainly inpatient care settings in medical centers and hos- pitals across the United States.
NLN Resiliency Literature published over the past decade revealed that
NLNs' resiliency must be fostered for NLNs to remain at their current jobs. Insu$cient resiliency among NLNs has been correlated with intentions to leave current jobs, turnover, and decreased job satisfaction. According to the sample studies (n = 14), most NLNs want to leave their jobs due to dissatisfaction with nursing work and/or their work environments (Anderson et al., 2009; Bontrager et al., 2016; Clark & Springer, 2012; Cline et al., 2017; Clipper & Cherry, 2015; Fiedler et al., 2014; Fink et al., 2008; Gill et al., 2010; Hodges et al., 2008; Hodges et al., 2010; Kramer et al., 2013; Li et al., 2014; Martin & Wil- son, 2011; McCalla-Graham & De Gagne, 2015; Olson, 2009; Pellico et al., 2009).
Factors That Promote or Hinder NLN Resiliency Residency programs and coworker support were re-
ported to enhance NLNs’ intentions to remain in their current jobs and the nursing profession. Residency pro- grams speci!cally designed to address the needs of NLNs positively a"ected NLN resiliency (Anderson et al., 2009; Cline et al., 2017; Fiedler et al., 2014). #e protective fac- tors of resilience that emerged among the sample studies were social support (Clipper & Cherry, 2015; Fiedler et al., 2014; Hodges et al., 2008; Li et al., 2014; Martin & Wilson, 2011), group cohesion (Anderson et al., 2009; Bontrager et al., 2016; Gill et al., 2010; Li et al., 2014), well-prepared preceptors (Bontrager et al., 2016; Clip- per & Cherry, 2015), relationship-based care practices (Clark & Springer, 2012; Clipper & Cherry, 2015; Fink et al., 2008; Kramer et al., 2013; McCalla-Graham & De Gagne, 2015; Olson, 2009; Pellico et al., 2009), organi- zational support (Fiedler et al., 2014; Fink et al., 2008; Olson, 2009), and plentiful clinical support (Fink et al., 2008).
157The Journal of Continuing Education in Nursing · Vol 50, No 4, 2019
NLN resiliency decreased when NLNs experienced verbal abuse from physicians and incivility among other sta" nurses (Kramer et al., 2013; Martin & Wilson, 2011; Olson, 2009; Pellico et al., 2009). #eir inability to meet expectations of preceptors, unengaged preceptors, and de- creased support when making errors also hindered NLNs’ con!dence and job satisfaction which, in turn, negatively a"ected their resiliency (Gill et al., 2010; Li et al., 2014).
Outcomes Associated With NLN Resiliency Positive Outcomes. NLN resiliency, which has been in-
ferred as NLNs who want to stay in their jobs (McAllister & Lowe, 2011), improves empathy toward patients, job engagement, augmented teamwork, enhanced ability to perform tasks, boosted con!dence, adaptability, and im- proved clinical reasoning. All these outcomes of resiliency assist in closing the preparation–practice gap and enhance patient safety (Fink et al., 2008; Martin & Wilson, 2011; Olson, 2009).
Negative Outcomes. #e most common outcome as- sociated with poor NLN resiliency cited in the nurs- ing literature is high turnover (Anderson et al., 2009; Bontrager et al., 2016; Clark & Springer, 2012; Cline et al., 2017; Clipper & Cherry, 2015; Fiedler et al., 2014; Fink et al., 2008; Gill et al., 2010; Hodges et al., 2008; Hodges et al., 2010; Kramer et al., 2013; Li et al., 2014; Martin & Wilson, 2011; McCalla-Graham & De Gagne, 2015; Olson, 2009; Pellico et al., 2009). Second, a lack of support from preceptors, sta", physicians, and other NLNs increases NLNs’ intentions to leave their jobs or the profession entirely (Anderson et al., 2009; Li et al., 2014; Martin & Wilson, 2011; Olson, 2009). Finally, poor resiliency decreases an NLN’s capability to work in a team setting (Bontrager et al., 2016; Clark & Springer, 2012; Fink et al., 2008; Gill et al., 2010; Hodges et al., 2008; Hodges et al., 2010; Kramer et al., 2013; Mar- tin & Wilson, 2011; Pellico et al., 2009). Teamwork is the cornerstone of patient care delivery as clinicians col- laborate and use enhanced communication to bene!t patients to attain mutual goals (World Health Organiza- tion, n.d.). As NLN resiliency decreases, so does patient safety.
Methods to Build Resiliency and Decrease Turnover
Nurse residency programs have been reported to build NLN resiliency and decrease turnover or the intention to leave a job (Anderson et al., 2009; Bontrager et al., 2016; Clark & Springer, 2012; Cline et al., 2017; Fiedler et al., 2014; Fink et al., 2008; Gill et al., 2010; Kramer et al., 2013; Li et al., 2014). Residency programs coordinate group learning and utilize a buddy system approach to
on-the-job learning; residency programs were reported to increase socialization, which Dyer and McGuinness (1996) reported is a protective factor of resiliency. Eleven of the sample studies concluded that collegial relation- ships, social support, and professional acculturation were formidable and essential to cope with stress of a chaotic, foreign, and challenging work environment (Anderson et al., 2009; Bontrager et al., 2016; Fiedler et al., 2014; Fink et al., 2008; Gill et al., 2010; Hodges et al., 2008; Hodges et al., 2010; Li et al., 2014; Martin & Wilson, 2011; McCalla-Graham & De Gagne, 2015; Olson, 2009). Hodges et al. (2010) and Fiedler et al. (2014) de- scribed NLNs building comradery with others to negate feelings of inadequacy as method to protect themselves from the daily assault of stress and self-doubt. Addition- ally, Martin and Wilson (2011) described NLNs forming caring groups to enhance collegial relationships; these supportive groups helped to decrease feelings of doubt and stress experienced during their transition from aca- demia to practice.
Measuring Resiliency and the Outcomes #is integrative review presents studies that correlated
resiliency using satisfaction surveys, evaluations of precep- tor e"ectiveness, and intention to leave surveys to best un- derstand the reasons why NLNs leave their jobs. Table C (available in the online version of this article) outlines the tools used in sample studies (n = 8) to evaluate strategies to build NLN resiliency (Anderson et al., 2009; Bontrager et al., 2016; Clark & Springer, 2012; Cline et al., 2017; Clipper & Cherry, 2015; Fiedler et al., 2014; Fink et al., 2008; McCalla-Graham & De Gagne, 2015). Studies did not evaluate patient outcomes while measuring NLN satisfaction or intention to leave. Yet, Gill et al. (2010) explored NLNs’ work perspectives to gauge nursing qual- ity by using the 10-item abbreviated version of the Na- tional Database of Nursing Quality Indicators (NDNQI) (reliability coe$cient = .91; Taunton et al., 2004). #e NDNQI was correlated with intentions to leave one’s job, yet the majority of the participants (n = 7) in this study intended to leave their current job despite indicating they were satis!ed. #e same !nding was reported by Clark and Springer (2012), in which NLNs expressed intentions to leave their jobs despite being satis!ed with the care they delivered (n = 37).
DISCUSSION An iterative process of examining each sample study to
identify patterns, themes, noting intervening factors, and relationships between variability (Whittemore & Kna%, 2005) was done to clarify, summarize, and synthesize what is known about the phenomenon of resiliency in NLNs,
158 Copyright © SLACK Incorporated
within the !rst year of hire, in an e"ort to guide future research in this area.
First, the concept of NLN resiliency is not well un- derstood as NLN turnover has been interpreted to be an outcome of poor NLN resiliency. Second, the expec- tation of NLNs is to take on new responsibilities and overcome numerous challenges to integrate themselves into a practice environment that stresses teamwork; this belief is so overwhelming that it negatively a"ects NLNs’ mental health. #ird, these feelings drain NLNs, which, in turn, can cause cognitive and emotional la- bility and a"ect clinical reasoning, a clear and present danger to patient welfare. Finally, resiliency should be measured using a resiliency scale, as the decision or in- tention to leave one’s job is not a surrogate to determine NLN resilience.
A growing body of research indicates NLNs’ attri- tion is increasing at an alarming rate, despite residency programs assisting in their transition to help them as- sume professional responsibilities for which they may be unprepared (Clark & Springer, 2012; Cline et al., 2017; RWJF, 2014). Nurse incivility among sta", in- cluding NLNs, occurs due to the high-stakes climate and coworkers’ ine"ective communication skills (Las- chinger, Wong, Regan, Young-Ritchie, & Bushell, 2013). A paradox ensues as NLNs believe they would be cared for by caring professionals in a caring environ- ment (Hart et al., 2014; Hodges et al., 2008; Marine, Ruotsalainen, Serra, & Verbeek, 2006; Martin & Wil- son, 2011; Pariyo, Kiwanuka, Rutebemberwa, Okui, & Ssengooba, 2008).
Implications for Practice, Policy, and Research #e implications for this integrative review provide
information to hospital educators and administrators re- garding the trends and needs of NLNs and adds a new perspective on workforce readiness in an e"ort to pro- mote patient safety. Nursing research has used a positiv- ist approach to assess NLN resiliency, a philosophy that has not advanced nursing science in this area. Millennials (ages 22 to 37) (Dimock, 2019) comprise the majority of newcomers to the nursing workforce and have the high- est attrition rate among any generation that has entered the nursing profession (RWJF, 2014). #erefore, nurse researchers must apply a social constructivist approach, as there is much to learn about the Millennial generation in the workplace (Veesart, 2018). A social constructivism approach encourages a participant’s own interpretation of the situation to better understand the meaning of their experience (Dahnke & Dreher, 2010). #is sociological lens may help researchers, managers, and educators evalu- ate NLN resilience as a truth created by their own per-
ceptions rather than through job satisfaction surveys or intention to leave scales. #e American Academy of Nurs- ing Policy agrees there is a need to build NLNs’ resilience (Goode, Glassman, Ponte, Krugman, & Peterman, 2018) to mitigate the negative e"ects of stress and encourage in- tention to stay at their !rst job is paramount. Research regarding low-cost, social support strategies to encourage NLNs’ motivation and engagement in nursing is needed to garner patient safety.
Limitations Several limitations existed among the sample studies
that may result in the !ndings not being applicable to each NLN’s experience during their !rst year of hire or to their abilities to build resiliency. For example, detailed information was not provided regarding sample char- acteristics such as age in nine studies (Anderson et al., 2009; Clark & Springer, 2012; Fink et al., 2008; Hodges et al., 2008; Kramer et al., 2013; Li et al., 2014; Martin & Wilson, 2011; McCalla-Graham & De Gagne, 2015; Olson, 2009). Additionally, there was minimal represen- tation of men in all sample studies, as well as a poor representation of ethnic/racial diversity. Various prac- tice settings among the studies limited generalizability of the !ndings as the settings included medical centers, hospitals, and specialty units (i.e., oncology). Each set- ting used di"erent ways to orient NLNs and participants faced varying types of experiences, which may not repre- sent all NLNs’ experiences when transitioning into their !rst jobs.
#e designs of the 16 sample studies were primar- ily surveys or qualitative interviews. One study did not report the reliability and validity of the instrument used (Anderson et al., 2009). Researchers did not directly mea- sure participants’ resilience in any of the sample studies yet inferred that participants’ resilience was low if they intended to leave their jobs. #is ambiguity may have led to a lack of di"erentiation among the search terms, as turnover and intention to leave have been correlated with resilience. However, strategies that encourage group cohe- siveness, managerial involvement, and adequately prepare preceptors for what Duchscher (2007, p. 23) referred to as the “transition shock” period may increase resiliency and decrease intentions to leave (Anderson et al., 2009; Bon- trager et al., 2016; Clark & Springer, 2012; Cline et al., 2017; Clipper & Cherry, 2015; Fiedler et al., 2014; Fink et al., 2008; Gill et al., 2010; Hodges et al., 2008; Hodges et al., 2010; Kramer et al., 2013; Li et al., 2014; Martin & Wilson, 2011; McCalla-Graham & De Gagne, 2015; Olson, 2009; Pellico et al., 2009; RWJF, 2014). Despite these e"orts, NLN attrition rates continue to rise each year.
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CONCLUSION #is integrative review provides pertinent informa-
tion to researchers, managers, educators, and health care administrators about the concept of NLN resiliency. De- creased resiliency threatens patient safety. NLNs expressed di$culties feeling con!dent, which, in turn, a"ects profes- sional development—a factor that is crucial to preparing a competent workforce. A supportive sta" of nurses and physicians who are empathetic to the challenges NLNs face during the !rst year of hire is a proven facilitator of NLN resiliency; these supportive attributes increase NLN job engagement, con!dence, and enhances team building skills. Additionally, resilience may be an indicator of prac- tice readiness, a vital key to motivate and retain NLNs.
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Table A Search Terms by Databases Used in the Literature Search
Database Search Term Headings Used: Newly Licensed Nurse, Leaving within First Year, and Resiliency
No. of Titles and Abstracts
CINAHL search terms
( (“Newly licensed nurse*” OR (MH "New Graduate Nurses") OR ((MH "Nurses+") OR nurse*) AND (MH (“Internship and Residency) OR MH (“Transitional Programs) OR MH (“Employee Orientation) OR MH (“Preceptorship))) ) AND ( (MH "Personnel Retention") OR (MH "Personnel Turnover") OR Retention OR Turnover OR Attrition OR Quit OR Stay OR “Negative Nurse Outcomes” OR “Intention to Leave” OR “Intention to Quit” OR (MH "Intention") OR (MH “Personnel Attitudes”) OR (MH “Motivational factors for turnover intention”) OR (MH “Professional Identity”) OR (MH “Locus of control”) OR (MH “Negative Patient Outcomes”) OR (MH “Willingness to leave”) OR Manpower OR “Motivational factors” OR “Psychosocial Factors” OR “negative patient outcomes”) AND ( (MH ("Adaptation, Occupational") OR (MH "Avoidance (Psychology)" OR (MH "Coping") OR (MH "Cultural Safety") OR (MH "Disengagement") OR (MH "Disruptive Behavior") OR (MH "Hardiness") OR (MH "Job Satisfaction") OR (MH "Optimism") OR (MH "Reality Shock") OR (MH "Self-Efficacy") OR (MH "Social Adjustment") OR (MH "Stress Disorders, Post-Traumatic+") OR (MH "Stress, Occupational") OR (MH "Support, Psychosocial") OR (MH "Symptom Distress") OR (MH "Symptom Distress") OR (MH "Vulnerability") OR “Nurse Shock” OR “Occupational Adaptation” OR “occupational shock” OR “personal identity disturbance” OR “Post- Traumatic Stress Disorder” OR “Professional ident*” OR “psychological capital” OR “Reality Shock” OR Coping OR Optimis* OR Protective factors OR PTSD OR Resiliency) OR (MH “Motivation”) OR (MH “Psychological Factors”) OR (MH “Occupational Coping”) OR (MH “Shared decision-making”) OR (MH “Workplace empowerment”) OR (MH “growth mindset”) OR (MH “Prevention and Control”) OR (MH “Occupational Commitment”) OR (MH “Professional commitment”) OR (MH “Controlled Motivation”))
397
PubMed search terms
(((( "Emotional Adjustment"[Mesh]) AND "Sense of Coherence"[Mesh] OR "Resilience, Psychological"[Mesh] OR "Adaptation, Psychological"[Mesh] OR "Problem Behavior"[Mesh] OR “disruptive behavior”[tiab] OR “disruptive behavior”[ot] OR "Job Satisfaction"[Mesh] OR "Absenteeism"[Mesh] OR
392
Note. CINAHL = Cumulative Index to Nursing and Allied Health Literature.
"Presenteeism"[Mesh] OR "Optimism"[Mesh] OR "Self Efficacy"[Mesh] OR "Social Adjustment"[Mesh] OR "Stress Disorders, Post-Traumatic"[Mesh] OR "Social Support"[Mesh] OR “Nurse Shock” [tiab] OR “Occupational Adaptation” [tiab] OR “occupational shock” [tiab] OR “personal identity disturbance” [tiab] OR “Post-Traumatic Stress Disorder” [tiab] OR “Professional identity” [tiab] OR “Professional identities”[tiab] OR “psychological capital” [tiab] OR “Reality Shock” [tiab] OR Coping[tiab] OR Optimis*[tiab] OR “Protective factor” [tiab] OR “Protective factors” [tiab] OR PTSD[tiab] OR Resiliency[tiab] OR “Nurse Shock” [ot] OR “Occupational Adaptation” [ot] OR “occupational shock” [ot] OR “personal identity disturbance” [ot] OR “Post-Traumatic Stress Disorder” [ot] OR “Professional identity” [ot] OR “Professional identities”[ot] OR “psychological capital” [ot] OR “Reality Shock” [ot] OR Coping[ot] OR Optimis*[ot] OR “Protective factor” [ot] OR “Protective factors” [ot] OR PTSD[ot] OR Resiliency[ot] OR "Motivation"[Mesh] OR "psychology" [Subheading] OR "Decision Making"[Mesh] OR “Prevention and Control”[Subheading]))) AND ((Quit[ot] OR Quit[tiab] OR retention[ot] OR Retention[tiab] OR Stay[ot] OR Stay[tiab] OR Turnover[ot] OR Turnover[tiab] OR "Personnel Turnover"[Mesh] OR "Personnel Loyalty"[Mesh] OR Retention[tiab] OR Retention[ot] OR Turnover[tiab] OR Turnover[ot] OR Attrition[tiab] OR Attrition[ot] OR Quit[tiab] OR Quit[ot] OR Stay[tiab] OR Stay[ot] OR “Negative Nurse Outcomes”[tiab] OR “Negative Nurse Outcomes”[ot] OR “Intention to Leave”[tiab] OR “Intention to Leave”[ot] OR “Intention to Quit”[tiab] OR “Intention to Quit”[ot] OR Manpower[tiab] OR “Motivational factors” [tiab] OR “Psychosocial Factors” [tiab] OR “negative patient outcomes” [tiab] OR Manpower[ot] OR “Motivational factors” [ot] OR “Psychosocial Factors” [ot] OR “negative patient outcomes” [ot]))) AND ((“Newly licensed nurse”[tiab] OR “Newly licensed nurse”[ot] OR “Newly licensed nurses”[tiab] OR “Newly licensed nurses”[ot] OR "New Graduate Nurse"[ot] OR "New Graduate Nurse"[ot] OR "New Graduate Nurses"[ot] OR "New Graduate Nurses"[ot] OR “Novice nurse” [tiab] OR "Novice Nurse"[ot] OR “Novice nurses” [tiab] OR "Novice Nurses"[ot] OR “Newly licensed nurse*”[tiab] OR "New Graduate Nurses"[ot] OR “Novice nurse” [tiab] OR "Novice Nurses"[ot] OR ("Nurses"[Mesh] OR nurse*[tiab] OR nurse*[ot]) AND ("Internship, Nonmedical"[Mesh] OR "Inservice Training"[Mesh] OR "Preceptorship"[Mesh]))
Total no. of citations including duplicates
789
T able B
Sum
m ary of F
indings from R
esearch Studies (N =
16) __________________________________________________________________________________________________________ A
uthor/year D
esign/M ethod
Sam ple population/ Purpose, A
im s, Findings A
ppraisal R ating/
Setting V ariables, and Q
uality of E vidence
Instrum ents using G
R A
D E
or G
R A
D E
-C E
R Q
ual
_____________________________________________________________________________________ A
nderson et al. (2009)
m ixed m
ethods/ sequential exploratory
90 new graduate
nurses, gender and ethnicity not reported/interactive nurse residency
Purpose: to com pare
perceived job satisfaction and em
ployee engagem
ent of new
graduate nurses com
pleting an interactive nurse residency. A
im s: to m
easure job satisfaction and engagem
ents perceptions of new
nurses after com
pleting interactive residency m
odules and to test the environm
ent nursing satisfaction survey. V
ariables: change for nurse residency –
Q ualitative results
revealed 2 them es
(protective factors of resiliency em
erged): w hat
satisfied nurses (patients, patient outcom
es, and team
w ork) and w
hat did not satisfy nurses (staffing/scheduling, lack of team
w ork,
M D
disrespect). Q
uantitative results: “A
fter the nurse residency sessions and 1 year later, the quantitative findings on the H
alfer-G raf
survey revealed that the nurse residents
+ +
⨁ ◯ ◯ ◯
R
isk of bias: T here
w ere lim
itations in detailed design as the outcom
e w as not
confidently determ
ined as the tool’s psychom
etrics w
ere not discussed. T
here w as no
discussion about the H
alfer-G raf Job/W
ork E
nvironm ent N
ursing Satisfaction Survey other than stating it w
as reliable and valid as previously stated in previous studies. M
ost inform ation w
as stated from
studies at
im plem
entation of a 2- day interactive nurse residency. Instrum
ents: H alfer-
G raf Job/W
ork E
nvironm ent N
ursing Satisfaction Survey (psychom
etrics not reported)
significantly perceived that they w
ere able to perform
their job, identify resources, understand perform
ance expectations, accom
plish w ork
tasks, and m anage
the dem ands of the
job effectively” (p. 168). A
n interactive learning environm
ent assists new
graduate nurses in job satisfaction and em
ployee engagem
ent. M ost
valuable strategy w
as em ail
com m
unication as a form
of support (a protective factor of resiliency).
low or unclear risk of
bias. T his denotes
serious risk of bias, dow
n grade one level (R
yan, 2016). Inconsistency: the sam
ple w as from
one cohort of new
graduate nurses and one period in tim
e. T
his denotes som e
inconsistency and a dow
ngrade of one point is recom
m ended
(R yan, 2016).
Indirectness: the author answ
ered the question of w
hether this particular cohort w
ere satisfied and engaged by using interactive residency m
odules. Im
precision: C
onfounding variables w
ere not discussed as to other reasons to the 4%
increase of new
graduate nurse retention w
hen com
pared to past years. T
here w as not
enough inform ation to
detect a precise estim
ate of the effect (interactive residency m
odules on new
graduate satisfaction and job engagem
ent). Publication bias: N
ot detected, Journal of N
ursing A
dm inistration has
various studies of size and design.
B ontrager et
al. (2016) quantitative/ descriptive, prospective, cross- sectional
84 new ly licensed
registered nurses enrolled in a residency program
. 5.8% of
participants w ere m
ale. 66.7%
participants w
ere C aucasian, 17.9%
w
ere black, 3.6%
L atino, and 7.1%
A
sian.
Purpose: to understand how
preceptor role effectiveness and group cohesion affect N
L N
s’ satisfaction and intent to stay. A
im s: W
hat w ere the
relationships am ong
preceptor role effectiveness, group cohesion, and job satisfaction am
ong N
L N
s? W hat w
ere the relationships am
ong preceptor role effectiveness, group cohesion, job satisfaction, and
H igh levels of
intention to stay at job w
as perceived by nurses due to the role of preceptors, job satisfaction, and group cohesion (protective factor of resiliency). Preceptors that are effective ensure a quality orientation and can help socialize a new
nurse and encourage job satisfaction. G
roup cohesion w as
found to be vital to increase feelings of
+ +
⨁ ⨁ ◯ ◯
R
isk of bias: T ool
psychom etrics w
ere reported and C
ronbach D scores
show ed reliability and
validity. T he
tools/scales w ere
justly chosen to predict the outcom
e level. Inconsistency: the sam
ple w as not
discussed regarding units w
orked on or shift w
orked. T he
ability to exam ine
intent to stay am ong
N L
N s?
V ariables: D
V :
preceptor role effectiveness, group cohesion, and job satisfaction Instrum
ents: Preceptor R
ole E
ffectiveness Scale, N
urse Job Satisfaction Scale, Intent to Stay Scale.
value, reduce burnout, stress and anxiety. G
roup cohesion is im
portant to reduce transition shock and intention to stay.
changes during the orientation period w
as not discussed. D
oubtful that there are large variations in the degree to w
hich the outcom
e is affected, no dow
ngrade if on the basis that it does not seem
to be an issue. Indirectness: T
here w
as evidence of indirectness as the outcom
e w as assessed
at only one period in tim
e w hich lim
ited the ability to exam
ine changes. T
he evidence that w
as found w
as m ore
restrictive than the review
question and m
ay not directly answ
er the review
question, “W hat w
ere the relationships am
ong preceptor role effectiveness, group cohesion, and job satisfaction am
ong N
L N
s? W hat w
ere the
relationships am ong
preceptor role effectiveness, group cohesion, job satisfaction, and intent to stay am
ong N
L N
s?” D ow
ngraded one point as som
e indirectness exists. Im
precision: good correlation w
ith prim
ary studies, no im
precision detected. Publication bias: N
ot detected, T
he Journal of C
ontinuing E
ducation in N ursing
has various studies of size and design.
C lark &
Springer (2012)
qualitative/ case study m
odel
37 new graduate nurses
in a nurse residency program
across m any
specialty areas/ northw
estern U S
15.6% of participants
w ere m
ale. T he
ethnicity of participants w
as not reported.
Purpose: to exam ine
the lived experience as new
nurses to assess the level of job satisfaction during the first year of practice. A
im s: 1. H
ow do new
graduate nurses describe their typical w
orkday? 2. W
hat are the m ost
satisfying aspects of
T hem
es that em
erged: learning to w
ork in chaos, feeling valued, stress of the unknow
n, life-long learning, and preserving the profession. Preceptors and staff are vital to enhancing job satisfaction and
+ +
⨁ ⨁ ⨁ ◯
M
ethodical lim
itations: Prim ary
studies revealed conflicting evidence regarding the lived experiences of new
nurses. W
e are confident that the findings in this study reflect this sm
all
the new graduate
nurses’ nursing? 3. W
hat are the m ost
concerning aspects of the new
graduate nurses’ practice? 4. W
hat educational topics do new
graduate nurses w
ant to know m
ore about? 5. W
here do the new
graduate nurses see them
selves practicing nursing in the future? V
ariables: D V
: job satisfaction Instrum
ents: open- ended questions
com m
itm ent to
nursing. Support (protective factor of resiliency) w
as m
entioned to im
prove job satisfaction. T
he stress of life-long learning w
as divided into sub- them
es that included dealing w
ith incivility, adapting to change, and stress m
anagem ent.
Participants described being valued by colleagues as a m
ajor contributor to job satisfaction. O
rganizations can help new
nurses feel valued by using relationship-based care and increasing collegial relationships as w
ays for enhancing satisfaction and feelings of com
petence. Som e
sam ple’s lived
experience as it did represent w
hat w as
found in prim ary
studies discussed. R
elevance: N ew
nurses are experiencing a new
environm
ent and w ay
to function yet one of the research questions asked about educational topics they m
ay w ant to
know m
ore about. T
he prem ise of being
“new ” and the chaos
this brings, it seem s
contrary and not relevant to pursue this aim
. N ot applicable to
the context specified in describing the lived experience of a new
nurse; dow
ngraded one point. C
oherence: T here is
good fit betw een the
data from the prim
ary studies and the review
findings. A
dequacy of data: T
here is good
participants stated preceptors w
ere unsupportive and disinterested and this decreased job satisfaction. T
his also increased stress and decreased new
nurses’ ability to w
ork in team s.
am ounts of data
supporting the review
finding and this aligns w
ith prim ary studies
about the lived experiences of new
nurses. Publication bias: N
ursing O utlook has
published diverse studies designs w
ith various sam
ple sizes.
C line et al.
(2017) Q
uantitative/ descriptive, retrospective analysis of 10 years of residency data
First stated over 1,000 participants’ data w
ere analyzed then table show
ed 558 new nurses
w ithin 12 m
onths of hire/residency program
in a cancer center w
ithin the U S 8.9%
w
ere m ale participants.
Percentage of C
aucasian participants w
as 36% , B
lack 21.6%
, L atino 12.2%
, A
sian 26.3% .
Purpose: to present a 10-year retrospective review
of outcom es
from an internally
developed nurse residency program
A
im s: an analysis of
an internally developed residency program
on the developm
ent of new
nurses. V
ariables: “custom
ized” nurse residency program
at one cancer care center and w
as “enhanced” over tim
e, sim ulation w
as
Scores in support declined over the course of the residency program
w
hich decreased professional satisfaction. T
he C
asey-Fink scores revealed participants’ stress levels w
ere low
during this residency program
, this is not consistent w
ith prim ary studies
or new ly licensed
nurses’ experiences in the literature. T
he authors suggested that findings
+ +
⨁ ◯ ◯ ◯
R
isk of bias: there w
ere lack of details in the design and execution as the residency program
over tim
e had m any
changes. Inconsistency: there w
as little understanding of the outcom
es from this
longitudinal study and how
the data supported the outcom
e that residency program
s assist in new
nurse
also added through the years. Instrum
ents: C asey-
Fink G raduate N
urse E
xperience Survey, institutional retention m
etrics
developed in this “custom
” residency program
em
phasized that a program
just about entry to practice can com
fort new nurses
and prom ote
confidence (protective factor of resiliency) w
hich w
ill lead to positive retention.
job satisfaction and therefore retention. Indirectness: applicability of this custom
ized residency program
(undetailed) did not help reader to understand the phenom
enon of new
nurse retention or the ability to enhance dealing w
ith stress or adversity (resilience). Im
precision: there is a large am
ount of inadequacy due to the levels of stress reported and the confounding variables such as the possibilities of financial stress due to the level of support the hospital m
ay have offered participants as opposed to the actual stress of the job. Publication bias: yes, this study w
as m ost
likely published due to the positive findings that a residency program
can possibly influence new
nurse retention.
C lipper &
C
herry (2015)
quantitative/ descriptive, com
parative
59 participants/ gender and ethnicity w
ere not specified
Purpose: to describe the im
plem entation
and evaluation of a preceptor developm
ent program
and its effect on the new
graduate nurse’s transition to practice and m
easure first- year turnover. A
im s: to assess new
nurses’ perceptions of their transition and preceptors betw
een 2 groups of preceptors (one group trained in a structured and w
ell- developed program
: details w
ell explained, and the other group w
as untrained). V
ariables: ID : new
nurses w
ithin the first year of hire. D
V :
perceptions of transition to practice betw
een 2 groups of preceptors. T
rained
T he study evaluated
the effectiveness of a preceptor program
by m
easuring perceptions of transition to practice and 1
st year retention of 2 groups of form
er nurse graduates and the other group w
as those that did not participate in structured training. N
ew graduates have
m ore positive
perceptions regarding safe care giving and have a slightly better retention rate than those w
ho did not have a structured new
graduate program
. Preceptors need to address them
es of socialization (protective factors
+ +
⨁ ⨁ ◯ ◯
R
isk of bias: Possible lim
itations in the design – obviously w
ell-trained preceptors w
ould better understand the needs of new
nurses and help m
itigate the stress of transition, but the study did not reveal reasons for consistent turnover or new
nurse dissatisfaction during the first year of hire. It w
as clear from
previous literature that a w
ell prepared and trained preceptor w
ill decrease transition shock, but still not a big change in new
nurse retention. Inconsistency: the findings w
ere consistent w
ith the
preceptors and untrained preceptors. Instrum
ents: 16-item
investigator developed surveyed based on the attributes of transition shock theory w
as used to obtain data regarding new
nurse perceptions of the transition process and the effectiveness of their preceptors.
in resiliency) in order to build confidence and foster good relationships to build form
s of support. N
ew nurses that had
trained preceptors expedited to a higher level of practice faster than the untrained preceptor cohort. It w
as anticipated that those that w
ere in the cohort of untrained preceptor w
ould stay at the organization due to lack of confidence and that w
as not the case. C
onfidence w as
found to directly im
pact patient outcom
es positively and increase w
hen new
nurses had a good relationship
phenom enon of new
nurses during the first year of hire. Indirectness: inform
ation in this study w
as not very applicable to understanding new
nurse turnover or how
transition shock m
itigation strategies can decrease turnover. Im
precision: inadequate am
ount of data regarding new
nurse confidence, the support a new
nurse receives, and the intention to leave first job. Publication bias: N
ot found. T
he Journal of C
ontinuing E ducation
in N ursing publishes
m any types of studies
that reveal positive and negative findings such as this study.
w ith his or her
preceptor. T his also
w as correlated w
ith the new
nurse having a safer practice than those w
ith an ineffective preceptor.
Fiedler et al. (2014)
quantitative/ descriptive
51 new nurses in a
residency program
(m ost w
ere second degree students) on diverse units/ m
edical center in the M
idw est,
a U H
C /A
A C
N
program . G
ender and ethnicity of participants w
ere not specified.
Purpose: to determ ine
w hat influence a
nurse residency program
has on long- term
outcom es
including turnover, career satisfaction, and leadership developm
ent. A im
s: 1. describe the long- term
(beyond the 1st year of em
ploym ent)
turnover rates of N R
P graduates, 2. exam
ine the long-term
career satisfaction of N
R P graduates
beyond the 1st year of em
ploym ent,
and 3. explore long- term
leadership developm
ent of N
R P graduates
beyond the 1st year of em
ploym ent.
T he long-term
outcom
es of a nurse residency program
have benefits to the organization and individual turnover rates low
er than the national average of 14.7%
(1.5-3 years after the residency program
. T
he literature review
in this study points out that w
ithin 6 m onths,
residents noticed decrease job satisfaction, yet at the end of the year, significant increase in satisfaction resulted. Support (protective factor of resiliency) from
the
+ +
⨁ ◯ ◯ ◯
R
isk of bias: D
etected. U sing one
instrum ent, w
hich m
easures satisfaction to evaluate turnover lim
ited the execution of the study and other data or qualitative factors w
ere m issed
for reasons or intentions to leave. Inconsistency: D
etected. Sam ple size
w as sm
all, it w as
diverse yet getting in touch w
ith participants that have left but filled out the survey w
as difficult and possibly lead to inconsistencies w
ith results.
V ariables: IV
: A A
C N
residency program
. D
V ’s: career
satisfaction, leadership developm
ent, hospital com
m ittee
involvem ent,
certification status, pursing an advanced degree. Instrum
ents: M
cC loskey/M
ueller Satisfaction Scale (M
M SS) has 8
subscales: extrinsic rew
ards, scheduling satisfaction, fam
ily/w ork balance,
cow orkers,
opportunities for social contacts, professional responsibilities, praise/ recognition, and control/responsibility.
organization, m
anagers, and recognition leads to satisfaction and w
ell as good collegial relationships. Peer support w
as ranked as a m
ajor com
ponent of nurses’ job satisfaction.
Indirectness: N one
detected as the applicability is reasonable as residency program
s are supportive and foster new
nurses’ careers, therefore increased retention is very probable. Im
precision: D
etected. D
issatisfaction results in turnover yet the tool w
as m easuring
satisfaction and that w
as assum ed the
reason for turnover, m
ore investigation regarding w
hat led to dissatisfaction w
ould have been m
ore helpful in understanding if a residency program
, over years, affects retention rates alone. Publication bias: N
ot detected. T
he Journal of N
ursing A
dm inistration
publishes pilot studies w
ith negative results
and also larger sam ple
sizes.
Fink et al. (2008)
m ixed m
ethod/ sequential exploratory
434 graduate nurse residents in the U
niversity H
ealthSystem
C onsortium
/A A
C N
nurse residency program
at 12 academ
ic hospital sites. G
ender and ethnicity of participants w
as not specified.
Purpose: T o evaluate
if qualitative responses to C
asey- Fink G
raduate N urse
E xperience Survey
could be analyzed quantitatively to easily analyze new
nurses’ experiences during a post B
SN
nurses residency program
. A
im s: 1. to analyze
the qualitative voices of the resident respondents to determ
ine if com
m ents could
further enrich the quantitative data and 2. to determ
ine if analysis of the them
es m ined from
the qualitative data could be used to convert the open- ended questions on the C
asey-Fink G
raduate N urse
E xperience Survey
“T he results of this
qualitative analysis perm
itted further revisions of the C
asey-Fink G
raduate N urse
E xperience Survey.
T hem
es identified from
data analysis of the 3 top skills difficult to m
aster at each period, and the 5 open-ended questions asked on the original survey, w
ere of sufficient strength to convert these item
s to m
ultiple-choice form
at. T he one
open-ended item
that the authors retained w
as the final survey question that asked residents to com
m ent on their
experiences” (p.347). N
ew nurse
stressors w ere
+ +
⨁ ⨁ ◯ ◯
M
ethodical lim
itations: D etected.
T he design and
execution of the study w
as to use a quantitative tool to gather qualitative data and revision of the tool w
as suggested. R
elevance: T he body
of evidence from
prim ary studies
supported review
findings that is applicable to the context specified in the review
questions. C
oherence: T here is a
clear fit betw een the
data from prim
ary studies and the review
findings, yet the sam
ple is hom
ogeneous, dow
ngraded 1 point. A
dequacy of data: T
here is a good
into quantitative questions for ease of test adm
inistration and analytic procedures. V
ariables: D V
s: role changes, lack of confidence, w
orkload, fears, orientation issues. IV
: residency program
w
ithin the first year of hire. Instrum
ents: C asey-
Fink G raduate N
urse E
xperience Survey. Q
ualitative data outcom
es w ere
gathered via open ended questions from
the author.
issues w ith skills
over a period of tim
e, they w ere not
getting easier. T his
w as attributed to
constant preceptor assistance and lack of being able to perform
skills independently during com
plex patient cases. W
ork/life balance w
as a m ajor stressor
and im pacted the
ability to function at the job. B
eing able to com
m unicate w
ith M
D s (a protective
factor of resiliency) and organize their w
orkload w ere
barriers to transitioning into their new
role w hich
reflected K ram
er et al. (2013) and H
alfer and G raf’s
(2006) results.
am ount of qualitative
data to represent the hom
ogeneity sam ple.
Publication bias: N ot
detected. T he Journal
of N ursing
A dm
inistration publishes pilot studies w
ith negative results and also larger sam
ple sizes. Q
uality increased by 1 point due to all plausible residual confounding factors dem
onstrated an effect.
C om
m unication
from m
anagem ent
and the desire to be a part of the unit’s culture w
ere pointed out to be a m
uch- needed support. T
he top 3 m ost
satisfying aspects of graduate nurse residents’ w
ork environm
ent included as follow
s: support, cam
araderie, and caring for patients. “T
here is not enough socialization in the residency program
. B ecom
ing a new
nurse in a new
environm ent is
difficult’’ (p.347).
G ill et al.
(2010) cohort study using m
ixed m ethods/
sequential exploratory
7 participants/ inpatient care areas at L
evel 1 traum
a center. 7.7%
participants w ere m
ale. T
he ethnicity of
Purpose: to investigate the expectations, perceptions, and satisfaction of graduate nurses after
N ew
graduates are fairly satisfied. T
w o
them es em
erged: establishing relationships and learning the job.
+ +
⨁ ⨁ ⨁ ◯
M
ethodical lim
itations: N ot
detected as the
participants w as not
specified. 6 and 12 m
onths of em
ploym ent.
A im
s: to describe new
graduates during the first year of practice. V
ariables: D V
: perceptions regarding the first year of practice such as social support, stress, professional values Instrum
ents: 10-item
abbreviated version of the N
ational D
atabase of N ursing
Q uality Indicators
(N D
N Q
I) revised survey for R
N s w
hich is a series of statem
ents relating to the nurses’ perceptions of their w
ork. It has been show
n to be both reliable. “A
t the com
pletion of the final interview
, graduate nurses w
ere asked to com
plete a brief three-item
survey on intent to leave. Individuals
Strong tie to prim
ary studies that states group cohesion (a protective factor of resiliency) and satisfaction can increase the ability to stay at one’s job and in nursing. A
t the end of the 12-m
onth study, m
any graduates considered leaving their until and the organization, but few
participants thought of leaving the profession entirely.
prim ary studies are
reflected in the review
findings. R
elevance: T he study
w as relevant. T
he body of evidence from
prim ary studies
supported the review
finding and is applicable to the context of new
nurse graduates and the aim
s of the study. C
oherence: T he study
w as coherent, and the
findings w ere a fit
betw een the prim
ary studies and the review
finding. A
dequacy of data: T
here w as adequate
data supporting the review
finding but the sam
ple w as very
sm all.
Publication bias: T
here is no detection of publication bias as results revealed perceptions and w
ere not deem
ed as positive or negative.
w ere asked to
indicate how often
they contem plated
leaving their unit, the organization, or the profession of nursing on a 5-point L
ikert scale” (p. E
13).
H odges et
al. (2008) qualitative: phenom
enological m
odel/ exploratory
11 new nurses/
southeastern U S and
had experience betw
een 12 and 18 m
onths. 9% of
participants w ere m
ale. T
he ethnicity of participants w
as not specified.
Purpose: T o explore
the nature of professional resilience in new
B
SN nurses in the
acute care setting and to extrapolate pedagogical strategies that can be developed to support resilience and career longevity. A
im s: to explore the
existence and social structure of professional resilience am
ong practicing nurses to evolve a m
iddle range theory to explain the relationships of constructs w
ithin the concept.
N ew
nurses spend a significant am
ount of tim
e learning their place in the social structure and need positive experiences to feel they are a part of the w
ork environm ent.
R esilience is needed
to ensure new nurse
self-protection, risk taking, and m
oving forw
ard w ith
reflective know
ledge of self. T
hem es that
em erged w
ere learning the m
ilieu (developing confidence and skills), discerning fit (accepted by the culture), and
+ +
⨁ ⨁ ◯ ◯
M
ethodical lim
itations: N ot
detected as prim ary
studies revealed sim
ilar findings. R
elevance: the study is relevant due to its context to the aim
w
hich explored professional resilience and as a protective factor, social support. C
oherence: it is clear that social support is needed to be professionally resilient, yet it w
as not coherent regarding how
to garner social support to ensure the
V ariables: D
V :
experiences of social support of new
nurses. Instrum
ents: open- ended questions
m oving through
(recovering from
stress and identifying those they can trust in order to develop protective factors against w
ork-life issues). Participants noted significant am
ount of adapting that m
ust take place to be accepted socially and also the disparity betw
een academ
ics and practice. T
his distressed new
nurses as they actualized the discrepancies. N
ew nurses’
em otional energy is
consum ed by
cognitive w ork;
resilience is necessary for such w
ork in order to grow
from
adversity.
developm ent of
resiliency, dow
ngraded a point. A
dequacy of data: T
here is an adequate am
ount of data but is from
a sm all sam
ple yet does reflect current findings regarding the phenom
enon of new
nurse resilience. Publication bias: T
here is no detection of publication bias as results revealed perceptions and w
ere not deem
ed as positive or negative.
C onstruction of a
new nurse’s social
identity w as found
to be im portant to
create their professional identity.
H odges et
al. (2010) qualitative: grounded theory/ descriptive
19 new and
experienced B SN
nurses w
orking in direct patient care (9 participants w
ere 11 to 18 m
onths in practice)/southeast U
S- m
ultiple levels of m ed
centers and hospitals. N
o gender or ethnicity of participants w
ere specified.
Purpose: to explain how
B SN
acute care nurses understand, adapt to, and negotiate challenge and change in acute care settings in the context of social and structural features and career persistence. A
im s: to understand
career persistence in B
SN acute care
nurses and create a m
iddle range theory to place into practice to encourage career resilience. V
ariables: nurses spanning 11 m
onths – over 5 years. Instrum
ents: open- ended questions
T he central them
e w
as building professional resilience, w
as noted to be the central social process. V
erifying fit: participants stated incongruent personal principles and values regarding nursing practice and incom
patibility w ith
the environm ent
(the environm ent
does not m atch their
strengths). Stage setting: how
to protect one’s self and form
relationships in
+ +
⨁ ◯ ◯ ◯
M
ethodical lim
itations: D etected
as the studied w as
com posed of new
nurses (w
ithin 11-18 m
onths of practice to those w
ith 5 or m ore
years). T hat is a large
breath of experience to find out about nurse’s resilience as the stress of a new
job tests one’s resilience and those that have overcom
e adversity are know
n as resilient. D
ow ngraded
one point. R
elevance: G ood
relevance as the concept of an ever- changing health care
order to feel secure and supported (protective factors of resiliency). O
ptim izing the
environm ent:
seeking activities that help one attain professional goals. T
he key to understanding professionalism
of nurses is to understand one’s social group.
arena is obvious, career resilience is a characteristic one needs to stay in the career. C
oherence: T he data
aligns to the prim ary
studies. A
dequacy of data: T
he data is com ing
from a sm
all population of different ages and tim
e fram es w
ithin their careers (18 m
onths to over 5 years), dow
ngraded one point. Publication bias: M
ost likely this study w
as published because of its “sensibility” regarding recom
m endations to
help nurses stay engaged w
ith their w
ork life and w ork
environm ent,
dow ngraded one
point.
K ram
er et al. (2012)
qualitative: grounded theory/ exploratory
82 participant interview
s w ere done.
A t the tim
e of interview
ing, 71% (n =
236) of the 330 N L
N s
w ere betw
een 9 and 12 m
onths post hire/local M
agnet hospitals. G
ender and ethnicity of participants w
ere not specified.
Purpose: to elicit from
new nurses and
experienced nurses on clinical units w
ith very healthy w
ork environm
ents, the com
ponents and strategies of nurse residency program
s and effective in new
nurse integration into professional practice. A
im s: W
hat N R
P com
ponents and strategies do N
L N
s and clinical nurses practicing on clinical units w
ith V ery
H ealthy W
ork E
nvironm ents
(V H
W E
) identify as effective in N
L N
transitioning and integrating into professional practice? V
ariables: D V
s: delegation, prioritization, conflict resolution w
ere used to construct the interview
schedule and as the basis for selection of
First them e w
as about delegation. Second them
e w as
about prioritization. T
hird them e w
as about getting w
ork done. Fourth them
e clinical autonom
y and how
to m ake
the right decisions. T
ext m essages to
M D
s to relay info and data w
as citing as an effective com
m unication
technique in hospitals. Fifth them
e: constructive conflict resolution. Sixth: feedback to restore self- confidence (a protective factor of resiliency). R
esults of this study support the recom
m endation
that developm ent of
tw o-stage,
T ransition plus
Integration, N R
Ps are no longer an
+ +
⨁ ⨁ ⨁ ◯
M
ethodical lim
itations: D etected.
Interview s w
ere conducted w
ith 2 or 4 new
nurses and experienced nurses (contam
ination possible as responses m
ay not have been as genuine if nurses w
ere alone) in each of the units and w
ere interview
ed by various hospital unit educators. D
ecreased one point. R
elevance: V ery
relevant as learning about w
hat creates a healthy w
ork environm
ent can help prepare a strong w
orkforce and good transition experience is very desirable for organizations. C
oherence: Som e
hospitals had clinical coaches and others did not, this m
ay have
participant observations. Instrum
ents: open- ended questions
option but a necessity. T
hese N
R Ps need to have
clearly differentiated goals, com
ponents, expected role perform
ance, and rites of passage.
affected participants’ responses and experiences lim
iting generalizability yet since all program
s w
ere enrolled at hospitals w
ith residency program
s greater than 3 years, and since not every hospital has coaches, the sam
ple size w as
large enough to represent the population of those in residency program
s. A
dequacy of data: T
here is adequate data to support the finding that residency program
s are preferred w
hen transitioning to first year of practice. Publication bias: findings w
ere not positive or negative, therefore none detected.
L i et al.
(2014) quantitative, correlational/ descriptive,
A convenience sam
ple of 251 nurse residents (0-3 m
onths of w orking
Purpose: T he purpose
of the study exam
ined protective
“O rganizational
com m
itm ent
+ +
⨁ ⨁ ◯ ◯
predictive
on a pediatric unit in L
os A ngeles, C
A ).
7.9% of participants
w ere m
ale. Percentage of C
aucasian participants 30.3%
, B
lack 0.8% , L
atino 2.4%
, and other ethnicities w
ere not reported.
factors that m ay
decrease burnout and increase job satisfaction in a nurse residency program
over 3 m
onths. G roup
cohesion optim izes
practice w hereas
organizational com
m itm
ent helps to create an intention to stay at current job (p. 96). A
im : to determ
ine w
hether factors such as group cohesion and organizational com
m itm
ent w ould
be protective and m
oderate the association betw
een stress exposure and posttraum
atic stress sym
ptom s and other
negative nurse outcom
es w hich
w ould create positive
ones. V
ariables: D V
s: stress, com
passion, satisfaction, group cohesion, and
w as not found to
protect nurse residents from
negative nurse outcom
es, it did play an im
portant role in prom
oting job satisfaction” (p. 95). “R
esults confirm
ed previous findings that stress exposure and PT
SD
sym ptom
s have serious im
plications for a range of affective outcom
es for new
resident nurses” (p. 95). Inform
ation w as
provided about the relationships that group cohesion and negative nurse outcom
es have and that establishing a relationship in a group can serve as a protective factor in helping bounce back from
negative nurse outcom
es like burnout and com
passion fatigue.
R isk of bias: sam
ple bias due to convenience sam
pling and collection of inform
ation w as not
reliable and only at one hospital, one type of floor. Inconsistency: findings w
ere consistent w
ith other findings w
ithin the context of group social support decreases the adverse effects of stress. Indirectness: Findings w
ere applicable to the context of the study. Im
precision: relevant only to one hospital on one floor, dow
ngraded one point. Publication bias: not likely as findings w
ere neither positive or negative.
organization com
m itm
ent. Instrum
ents: L ife
E vents C
hecklist good reliability, PT
SD C
hecklist C
ivilian V ersion,
C om
passion Satisfaction and Fatigue T
est, N urse
Job Satisfaction Scale, G
roup C
ohesion Scale, and O
rganizational C
om m
itm ent Scale
**Social support could also im
pact how
nurses respond to stress (p. 97).
M artin &
W
ilson (2011)
qualitative/ interpretive phenom
enology, descriptive
7 new nurses w
ithin the first year of practice w
ho participated in an intensive transition program
designed as a com
ponent of an orientation program
to ease new
graduates into nursing practice on various m
edical/surgical units/ purposive convenience sam
ple. 14% of
participants w ere m
ale. Percentage of C
aucasian participants w
as 85.7% , B
lack
Purpose: to exam ine
the lived experience of new
ly licensed R
N s in their first year
of practice in a hospital setting. A
im s: to extract the
m eaning and
understand from the
hum an experience,
new nurses, during
their first year of hire. V
ariables: D V
: experiences of new
nurses during their first year of hire.
T hem
es: real nurse w
ork, guidance, transitional processes, institutional context, and interpersonal dynam
ics. “T he
cum ulative effects
of socialization, skill acquisition, and stress on new
nurses indicate that research is needed to answ
er questions regarding recruitm
ent, retention, and job
+ +
⨁ ⨁ ⨁ ◯
M
ethodical lim
itations: som ew
hat detected as convenience sam
ple w
as used to recruit sam
ple yet fram ew
ork for the study m
atched the purpose and aim
s for this study. R
elevance: the findings are very applicable to the context of new
nurse experiences.
14% , there w
ere no other ethnicities reported. (purposive: the researcher deliberately selects subjects m
ost know
ledgeable about the issue under study.)
Instrum ents:
interview questions
satisfaction” (p. 21). C
aring of the profession vs non- caring w
ithin the profession is posed as an argum
ent for a new
orientation objective – possibly the form
ation of a “caring group” (better know
n as support group). “Professional acculturation is a com
plex process that requires tim
e to navigate. T
he success of the process is often dependent upon the degree of perceived support the new
ly licensed R
N
receives” (p.22). R
elationships are required to adapt to the stress of starting nursing. C
ollegial relationships w
ith all nursing staff and M
D s, and ancillary
staff m atters to new
nurses.
C oherence: good
coherence w ith
previous studies of professional acculturation and struggle to create a professional identity w
hile transitioning to practice w
hich is deem
s extrem ely
stressful. A
dequacy of data: findings aligned w
ith K
ram er’s sem
inal w
ork (1974), R eality
Shock, and reconfirm
ed via D
uchscher’s w ork on
Transition Shock Theory. Publication bias: none detected as the study did not report positive or negative findings.
M
cC alla-
G raham
&
D e G
agne (2015)
qualitative: phenom
enological/ exploratory
10 participants, using a purposive, snow
ball sam
pling/southw est
Florida, m ost w
ere experiencing their second career. G
ender and ethnicity w
ere not specified.
Purpose: to explore the lived experiences of new
graduate nurses em
ployed in an acute care setting. A
im s: to best
understand new
graduate nurses’ experiences in the acute setting V
ariables: D V
: acute care setting in the first year of hire. Instrum
ents: 11 open- ended questions
Participants stated that nursing school did not prepare them
for current roles or responsibilities and that the goal of nursing school w
as only to assist the new
grad in passing the N
C L
E X
. “T he
findings suggest that the graduate nurses thought that if they developed good coping skills, the acute care clinical setting m
ight be less stressful for them
” (p. 125). Participants also stated they w
ere very overw
helm ed
by the w orkload and
that positive reinforcem
ent helped m
itigate this stress.
+ +
⨁ ⨁ ⨁ ◯
M
ethodical lim
itations: none detected as the findings reflected sim
ilar findings as prim
ary studies, there w
ere very little issues, other the sam
pling m
ethod, in the w ay
the study w as
designed/ conducted. R
elevance: the findings w
ere relevant and the extent of the body of evidence from
the prim ary
studies supported and is applicable to the context of the new
nurse shortage phenom
enon occurring w
ithin the first year of practice. C
oherence: T he
researchers discussed a clear fit betw
een the data from
prim ary
studies and the review
findings. A
dequacy of data: there w
as rich data and the am
ount to support the findings w
ere adequate. Publication bias: none detected as the results are neither positive or negative influencing the preference to publish.
O lson
(2009) qualitative/ exploratory, interpretive, phenom
enological, longitudinal
12 participants/ purposive sam
ple of 2 groups of new
graduates: 6 B
SN and 6
A D
N nurses – full tim
e staff nurses at the tim
e of data collection. 16.6%
of participants w
ere m ale. E
thnicity of participants not specified.
Purpose: to understand the experience of new
ly licensed nurses from
their perspective. A
im s: to understand
m illennial, novice
nurses’ experiences throughout the first year of practice V
ariables: D V
: new
nurse experiences Instrum
ents: open ended interview
s at 3, 6, and 12 m
onths
T hem
es that em
erged: being in unfam
iliar surroundings w
hich seem
ed confusing and overw
helm ing
because they had spent lim
ited tim e in
acute care as students. A
fter a year, participants expressed fear about being oriented to a different place. T
he second them
e, “out of the blue,” w
hich are the “never to be forgotten” experiences – so
+ +
⨁ ⨁ ⨁ ◯
M
ethodical lim
itations: lim itation
regarding sm all
sam ple yet findings
w ere analyzed w
ell, and researcher dem
onstrated a good ability to reflect on participants’ experiences to create com
m on them
es that are applicable to the phenom
enon of new
graduate experiences. R
elevance: Prim ary
studies support the
chaotic and the difficulty of trying to keep up – this w
as relayed to researchers as feelings of helplessness, guilt, and extrem
e sadness as novices coped w
ith death or a m
edical error for the first tim
e. T he third
them e: finding m
y voice, this w
as a description of novices’ relationships w
ith preceptors, M
D s,
and other staff m
em bers. Feeling
w elcom
ed and confronting incivility w
ith other nurses w
ere crucial to feeling successful in the transition. T
he fourth them e
w as “am
I ok?” O
btaining feedback, trust w
ith know ing
som eone w
ould tell them
they w ere
doing som ething
findings and it is applicable to m
illennial, novice nurses’ and their intentions to do everything really w
ell regardless of how
foreign som
ething is and the need for im
m ediate attention
and feedback to continually grow
and learn. C
oherence: there is a good fit betw
een the prim
ary studies and the findings in this study. A
dequacy of data: the quantity and degree of richness in prim
ary studies support the review
findings. Publication bias: D
oubtful due to neither positive or negative results w
ere shared, only reported experiences of a sam
ple of new nurses.
w rong w
as very im
portant to participants as they expressed great anxiety regarding m
aking m istakes.
T he acute setting is
very unfam iliar, and
socialization can assist w
ith the stressful adjustm
ent w
hich m akes it
difficult to grow and
continue to learn. M
illennials w ant
nurturing, attention, and continuous feedback w
hich places an extensive value on social support (a protective factor of resiliency).
Pellico et al. (2009)
qualitative: case study m
odel/ descriptive
612 participants in 12- 18 m
onths of practice /stratified sam
pling in m
etropolitan m idsize
areas in the U S
w orking inpatient.
E thnicity and gender of
participants not specified.
Purpose: “T he
purpose of this article w
as to explore the perceptions of 612 N
L N
s’ nascent experiences as reflected in their com
m ents provided
in a national survey
“5 them es w
ere discovered. “C
olliding expectations” describes conflicts betw
een nurses’ personal view
of nursing and their
+ +
⨁ ⨁ ⨁ ◯
M
ethodical lim
itations: this w as
secondary findings from
a parent study and there w
ere no lim
itations in the
that sought to gain a better understanding of the w
ork life of N
L N
s” (p. 194). A
im s: to understand
N L
N ’s w
ork-life experiences. V
ariables: m ultiple
areas across the U S
Instrum ents: 16-page
survey w ith 207
item s.
lived experience. “T
he need for speed” describes the pressure related to a variety of tem
poral issues. “Y
ou w ant
too m uch”
expresses the pressure and stress N
L N
s feel personally and professionally. “H
ow dare you”
describes unacceptable com
m unication
patterns betw een
providers. “C hange
is on the horizon” suggests optim
ism
for the future as N
L N
s speak of transform
ing the system
s w here care
is provided (a protective factor of resiliency). T
his content analysis reveals that the w
orking environm
ent w here
N L
N s begin their
design of the findings of the prim
ary studies. R
elevance: the findings are applicable to the context specified to explore perceptions of new
nurses’ w ork life.
C oherence: T
here is a good fit betw
een the data from
the prim ary
studies and the findings yet prim
ary studies did not reveal any m
ention of w
anting to change new
nurses’ experiences as stated in the review
of findings in this study. A
dequacy of data: the data underlying a review
finding are rich and com
e from
different num bers of
participants per study. Publication bias: doubtful as the results w
ere neither positive or negative but reported the
career is in need of reform
” (p. 194). experiences of participants.
N ote. N
L N
= new ly licensed nurse; ⨁
⨁ ⨁ ⨁
= high; ⨁
⨁ ⨁ ◯
= m
oderate; ⨁ ⨁ ◯ ◯
= low
; ⨁ ◯ ◯ ◯
= very low ; +
+ =
observational design; +
+ +
+ =
experim ental study.
T able C
Tools U
sed in Studies to D eterm
ine N LN
R esiliency or P
rotective F actors of R
esiliency Study
T ool
N L
N O
utcom es R
eflecting N L
N R
esiliency A
nderson, L
inden, A
llen, &
G ibbs (2009)
T he H
alfer-G raf Survey (validity/reliability not reported)
(H alfer &
G raf, 2006) and open-ended questions
C om
pared job satisfaction and em ployee
engagem ent after com
pleted 2-day interactive residency m
odules w hich assisted N
L N
s to perform
job, identify resources, and job expectations. M
ost valuable strategy to satisfy N L
N s w
as em ail
com m
unication as a form of support, follow
ed by positive patient outcom
es and team w
ork.
B ontrager,
H art, &
M
areno (2016)
Preceptor R ole E
ffectiveness Scale (reliability coefficient = .75) (R
auen, 1974); G roup C
ohesion Scale (reliability coefficient = .81) (H
inshaw &
A tw
ood, 1983); N urse Job
Satisfaction Scale (overall internal consistency reliability coefficient = .88) (H
inshaw &
A tw
ood, 1983); and Intent to Stay Scale (reliability coefficient = .85) (K
im , Price,
M ueller, &
W atson, 1996)
Preceptors, job satisfaction, and group cohesion w
ere found to be im portant to reduce transition
shock and intention to leave.
C lark &
Springer (2012)
O pen-ended questions
L earning the w
ork flow , feeling valued, preceptors,
and cow orkers enhanced satisfaction and
com m
itm ent to the profession and the ability to w
ork in a team
.
C line et al.
(2017) C
asey-Fink G raduate N
urse E xperience Survey: the section
on com fort and confidence (C
ronbach = .78). T
he next section consists of 5 factors, nam
ely, support ( = .90),
patient safety ( = .79), stress (
= .71), com
m unication/leadership (
= .75), and professional
A custom
ized residency program m
ay im prove
N L
N s’ experiences as they enter practice w
hich increases confidence and m
ay lead to intention to stay at current job.
satisfaction ( = .83) (C
asey, Fink, K rugm
an, & Propst,
2004) and institutional retention m etrics
C lipper &
C
herry (2015)
16-item investigator developed survey assessing the
attributes of transition shock to obtain N L
N perceptions and
effectiveness of their preceptors (C ronbach
= .954) (D
uchscher, 2009)
N L
N s w
ere m ore positive regarding practices and a
slightly better retention rate w hen a structured
preceptor program w
as provided.
Fiedler, et al. (2014)
M cC
loskey/M ueller Satisfaction Scale (C
ronbach = .94)
(M ueller &
M cC
loskey, 1990) R
esidency program s can low
er turnover rates yet at 6 m
onths, job dissatisfaction decreased yet at 12 m
onths satisfaction increased.
Fink et al. (2008)
C asey-Fink G
raduate N urse E
xperience Survey (C ronbach
= .89) (C asey et al., 2004) and open-ended questions
C onstant preceptor assistance increased N
L N
satisfaction.
G ill, D
eagan &
M cN
ett (2010)
10-item abbreviated version of the N
ational D atabase of
N ursing Q
uality Indicators (reliability coefficient = .91) (T
aunton et al., 2004) and open-ended questions
E stablishing relationships and learning the job
positively affected N L
N satisfaction. D
espite positive results, som
e N L
N s considered leaving the
organization but few stated they thought of leaving
the profession.
H odges,
K eeley, &
T
royan (2008)
open-ended questions D
eveloping confidence by learning skills, being accepted by others, and recovering from
stress because of the academ
ic/practice disparity w as
found im portant for N
L N
s to build professional identities and a social connection in order to adapt and negotiate career stress.
H odges,
T royan, &
K
eeley (2010)
open-ended questions T
he practice environm ent does not m
atch N L
N
strengths. Feeling supported is key and establishing a social group is necessary to develop career persistence.
K ram
er et al. (2013)
open-ended questions D
elegation, prioritization, accom plishing w
ork, clinical autonom
y, effective clinical decision-
m aking, constructive conflict resolution, and
restoring self-confidence are im portant factors to
prom ote N
L N
professional practice.
L i et al.
(2014) L
ife E vents C
hecklist (reliability > .50, test-retest
reliability r = .82) (G ray, L
itz, H su, &
L om
bardo, 2004), PT
SD C
ivilian C hecklist (internal consistency
= .94, test- retest reliability r = .88) (W
eathers, L itz, H
uska, & K
eane, 1991), C
om passion Satisfaction and Fatigue T
est (test produces three subscales: com
passion satisfaction, burnout, and C
F/ST S. E
ach scale show s good internal consistency in
this sam ple (α = .87, .90, and .87) (Stam
m , 2002), N
urse Job Satisfaction Scale (
= .90) (M ueller &
M cC
loskey, 1990), G
roup C ohesion Scale (
= .89) (B yrne &
N elson, 1965),
and O rganizational C
om m
itm ent Scale (
= .89) (Porter, Steers, M
ow day, &
B oulian, 1974)
R elationships and social support can buffer stress
and com passion fatigue.
M artin &
W
ilson (2011)
open-ended questions Socialization, the ability to perform
skills, and collegial relationships help to garner job satisfaction and retain N
L N
s.
M cC
alla- G
raham &
D e
G agne (2015)
open-ended questions N
L N
s reported m ore training needed for coping
skills to deal w ith stress.
O
lson (2009) open-ended questions
T he overw
helm ing w
ork atm osphere confused N
L N
s as w
ell as new experiences not encountered w
hile in nursing school translated into feelings of helplessness. Inabilities to speak w
ith M D
s and not know
ing w ho to trust verified extensive social
support and continuous feedback are needed in m
illennial N L
N s the first year of hire.
Pellico, B
rew er, &
K
ovner (2009)
open-ended questions Poorly understood N
L N
expectations, the expectations for N
L N
s to perform quickly, and
incivility am ong clinicians inform
s organizations and leaders that the w
ork environm ent needs reform
. N
ote. N L
N = N
ew ly licensed nurse.
R eproduced w
ith perm ission of copyright ow
ner. F urther reproduction prohibited w
ithout perm ission.