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To address nurse recruitment and retention issues, hospitals have increased the number of newly graduated nurses in their hiring pools and have simultaneously established orientation programs for those nurses. Structured orientation programs facilitate newly graduated nurse transition from novice to advanced beginner. The outcome of these programs is twofold: First, they promote the confidence and competency level of new nurses in providing patient care, and second, they increase nurse retention. This literature review presents the most useful interventions used in the programs that reported positive affects on new nurses.
The U.S. Department of Labor, Bureau of Labor Statistics (2005) predicts that the need for nurses will increase 27% between 2004 and 2014. The current shortage of registered nurses (RNs) is due in part to the increasing age of the nursing workforce, as well as the fact that fewer younger nurses are entering the field. Although the enrollment in baccalaureate programs in nursing continues to increase (American Association of Colleges of Nursing, 2007), the increase is not enough to solve the nursing shortage. Consequently, organizations have responded by competitively increasing the recruitment of new graduate nurses in their hiring pools (American Organization of Nurse Executives, 2002). Although these new graduates fill vacancies, hiring new graduate nurses also generates problems.
The high turnover of newly graduated nurses is emerging as one of the problems that hospitals need to address. In a current survey of newly graduated nurses in 35 states (Kovner et al., 2007), approximately 13% of responders had changed principal jobs after 1 year, and 37% reported that they planned to change jobs in the near future. Nursing literature reported that poor training, a lack of support systems, and the stress related to the intense working situation and high patient acuity are the main reasons nurses are leaving during their first year after graduation (Bowles & Candela, 2005; Mathews & Nunley, 1992; Patrick, 2000).
Furthermore, a high turnover and an influx of new graduates have led to a higher proportion of inexperienced nurses in direct patient care, which may not only be traumatic for the new professional nurse but may also threaten patient safety (Santucci, 2004). Therefore, for patient safety and the well-being of new nurses, hospitals must make efforts to provide safe and effective environments that foster the integration of graduate nurses into their systems. An effective orientation program is one strategy that may address these concerns.
The goal of an orientation program is to prepare new staff nurses to be confident and to provide competent and safe patient care. Benner's (1984) From Novice to Expert framework is relevant to an orientation program. Benner applied the Dreyfus model of skill development to nursing and concluded that nurses pass through five stages of skill development: novice, advanced beginner, competent, proficient, and expert (Benner, 1984). These different levels are accompanied by changes in three aspects of skill performance: (a) a change from confidence about abstract principles to the application of concrete experience, (b) a change in the learner's awareness of the demand situation as a whole, and (c) a change from observer to active performer (Benner, 1984). Nursing students entering the clinical area can be characterized as novices because their knowledge is limited, they tend to be rather inflexible, and they are inexperienced in actual clinical situations. Successful orientation programs should be those in which teaching and learning are provided to help the new graduate nurse make the transition from novice to advanced beginner who can demonstrate acceptable performance and cope in real situations with a preceptor/mentor (Benner, 1984).
Some healthcare systems have recently developed and reported orientation programs that have improved the confidence, competency, and retention of newly graduated nurses. However, the research on the effects of these programs is limited by small-size studies and the experiences of single institutions. There are few systematic literature reviews focusing on orientation programs for newly graduated nurses.
The purpose of this study was to present an integrative review of the research that was conducted to explore the effects of orientation programs for newly graduated nurses on their confidence, competency, and retention. Recommendations also are made based on an analysis of programs reported as effective in the literature between 1990 and 2007.
This review study followed Cooper's (1989) five-stage process for the integrative literature review: (a) problem formulation, (b) data collection, (c) evaluation of data points, (d) data analysis and interpretation, and (e) presentation of results. This study collected, synthesized, and analyzed published research conducted on orientation programs that train newly graduated nurses using various methods for increasing confidence, competency, and retention. Orientation programs in nursing literature included internships, residencies, and structured orientation programs.
Studies were limited to research conducted in U.S. hospitals. Key words used in the search process were new RN graduate, confidence, competency, retention, and orientation program. This review included only English-language research studies published between 1990 and 2007. This review began with a search of multiple library databases such as PubMed (MEDLINE), the Cumulative Index to Nursing and Allied Health (CINAHL), and Institute for Scientific Information (ISI) Web of Knowledge. Then, through the Google and Google Scholar Internet search engines, the search expanded to include published reports, white papers, and working papers that were published through channels other than professional and research journals.
A total of 99 relevant citations were retrieved from library databases (n = 92) and the Internet (n = 7). Examination of the published abstracts and studies resulted in the elimination of studies that did not match the project inclusion criteria (n = 53), leaving 46 articles for potential inclusion in the study.
Research articles meeting the inclusion criteria were then rated using a modified version of the research quality checklist developed by Beck (2001). The checklist included the following items: (a) author expertise, (b) type of sample, (c) reliability and validity of measures, (d) time dimensional design, (e) research design, and (f) research analysis. The checklist used in this study included these items and also items pertaining to new RN orientation programs to determine whether the studies reported information on the outcomes of new RN graduate orientation programs. Through a second level of review incorporating these quality criteria, the researcher excluded several additional articles (n = 29) for one or more of the following reasons: (a) Studies did not examine program outcomes, (b) studies reported programs for nursing students rather than nursing graduates, (c) studies included both newly graduated nurses and experienced nurses as participants, and (d) studies obtained a low score on the quality checklist. The final sample included 17 published reports.
Table 1 summarizes the research reviewed in this study and the reported outcomes of orientation programs, including confidence, competency, and retention. This review included nine articles evaluating internship programs, five studies related to residency programs, and three structured orientation programs (see Table 1). Of those programs, four residency programs were designed as postbaccalaureate programs (Altier & Krsek, 2006; Herdrich & Lindsay, 2006; Krugman et al., 2006; Rosenfeld et al., 2004), whereas the other programs were orientation programs for all new RNs. All articles dealt with hospital-based programs. Four of these articles focused on internship programs in specialty areas including critical care, neuroscience, and the float pool.
Seven articles of reviewed studies reported improved self-confidence of new graduates in delivering patient care. The studies included five internship programs, one residency program, and one extended orientation program (see Table 1). To examine new RNs' confidence, these studies asked program participants to rate their level of confidence on a rating scale (Beecroft et al., 2001; Blanzola et al., 2004; Crimlisk et al., 2002; DiIorio et al., 2001; Squires, 2002) or participants' confidence about their ability was extracted from logs and feedback from the preceptor (Herdrich & Lindsay, 2006; Messmer et al., 2004).
These studies reported improved self-confidence of new RNs in delivering patient care after completing the program. In particular, several studies revealed that the internship programs in specialty areas increased the confidence of new nurses in delivering patient care. Evaluating the impact of an internship program in a float pool over time, Crimlisk et al. (2002) reported that 100% of new RN respondents completing the program believed that they were able to provide safe, competent care in the areas of assessment skills, technology, communication skills, medication administration, and critical-thinking skills. Furthermore, DiIorio et al. (2001) reported that new RNs in a neuroscience internship program believed the program enabled them to serve as a resource for other nurses unfamiliar with neuroscience patient care and for other new graduates in neuroscience nursing; nurses in this program also showed increased mean scores on the Neuroscience Nursing Self-efficacy Scale by the end of the program. Interns in a Shadow-A-Nurse intensive care unit internship expressed in their logs that the program was very beneficial in building self-confidence (Messmer et al., 2004).
Seven studies reported the effects of completing an orientation program on the competency of the new RN graduates. Nursing literature defines competency as the possession of knowledge, practice skills, attitudes, and the ability to perform to a prescribed standard (While, 1994). Professional educators also identified critical-thinking ability in delivering patient care as the core competency that new RNs should acquire (Marcum & West, 2004). In evaluating competency, researchers not only tested the new nurses but also obtained feedback from participants such as nurse educators, nursing managers, peer nurses, and/or preceptors. For competency content, these studies focused on the knowledge and critical thinking of newly graduated nurses.
Four studies administered the Basic Knowledge Assessment Test to evaluate the effect of the orientation programs in competency as knowledge (Collins & Thomas, 2005; DiIorio et al., 2001; Herdrich & Lindsay, 2006; Messmer et al., 2004) and reported improvement in test scores between the beginning and the end of the program. Two articles reported that the programs improved the critical-thinking ability of new graduates using several instruments, including the Critical Thinking Inventory (Herdrich & Lindsay, 2006), the Watson-Glaser critical thinking appraisal (Herdrich & Lindsay, 2006), and the Performance Based Development System (Marcum & West, 2004). Peer nurses and managers also evaluated the competency of new graduates as improved after completion of the program (Blanzola et al., 2004; Boyer, 2005).
Positive outcomes in new RN competency were also reported in critical care. Two studies, which examined the outcomes of critical care internship programs designed and implemented to assist new nurses in making the transition into a critical care nurse role, reported that nurses demonstrated increased competency in critical care nursing skills and improved self-confidence after completing the program (DiIorio et al., 2001; Messmer et al., 2004).
In 15 studies, retention of new nurses was reported as the percentage of program participants remaining employed at the organization at 12 and 24 months after completing an orientation program (see Table 1). The results showed increased retention rates by comparing data from treatment and control groups, before and after programs, or with national trends. The programs reported retention rates ranging from 76% to 96%. The rates were excellent when compared with the baseline rate of each program, ranging between 25% and 75%, and to national data of a 64% retention rate for new RNs in their first year of practice (Nursing Executive Center, 2002).
Furthermore, several studies reported a decreased turnover rate of newly graduated nurses after participation in the programs (Beecroft et al., 2001; Krugman et al., 2006) and a decreased vacancy rate in the institutions after implementation of the programs (Almada et al., 2004; Boyer, 2005; Herdrich & Lindsay, 2006; Owens et al., 2001; see Table 1). Two internship programs used the Anticipated Turnover Scale to measure new nurses' perception of the possibility of voluntarily terminating the position (Beecroft et al., 2001; Newhouse et al., 2007). At 6 months, program interns reported a significantly lower score on the Anticipated Turnover Scale or a decreased possibility of leaving their jobs when compared with their counterparts in the control group.
The various programs reviewed produced positive outcomes in nurse confidence, competency, and retention. From these programs, common components, such as the length of a program, structured teaching methods, preceptorship, support system, and evaluation, were examined to help determine effective program attributes (see Table 2).
As Table 1 shows, programs varied greatly in length, ranging from 6 weeks to 1 year. All residency programs (n = 5) and internship programs (n = 2) were conducted over a 1-year time frame. Six studies reported program duration of less than 3 months. Eleven of the 17 reviewed studies reported programs that lasted between 4 and 12 months (see Table 1). When an orientation program was the extension of an existing program or focused in a specialty area, the program duration tended to cover for shorter time periods (Almada et al., 2004; Marcum & West, 2004; Messmer et al., 2004; Squires, 2002).
All reviewed programs consisted of two main parts: (a) classroom learning and (b) clinical experience with preceptorship. The classroom learning component not only included general hospital orientation requirements but also dealt with various topics related to competency-based practice, including nursing assessment and intervention, pathophysiology, pain management, quality improvement, medication administration, pain management, and so on. Postbaccalaureate residency program curricula contained three additional parts: leadership, evidence-based patient outcomes, and professional role (Altier & Krsek, 2006; Krugman et al., 2006).
During classroom activities, the programs used various teaching methods and traditional lectures by educators. The teaching methods mainly cited in the literature included conferences, seminars, group discussion, case studies, and computer-based training (see Table 2). In particular, the studies suggested that the teaching methods such as conferences, seminars, and group discussion encouraged mutual learning among new RNs through sharing clinical experiences and were more effective for developing critical thinking than were the traditional lecture format. Crimlisk et al. (2002) also reported the creation of an internship program that used the case study format. They reported the following benefits of the case study approach: (a) sharing clinical experiences, (b) identifying critical thinking, (c) guiding clinical decision making, (d) nurturing professional clinical practice, and (e) facilitating transition into the RN role.
The studies evaluated that the use of a one-on-one preceptorship contributed to developing the competencies of new graduates and to enhancing their clinical experiences. Also, key to a successful preceptorship was the preparation of a qualified preceptor. Therefore, a preceptor training program was developed, as well as criteria for the selection of preceptors (see Table 2). The training program focused on building characteristics believed to be important for a preceptor, including competency in clinical practice, strong communication and leadership skills, and interest in professional development.
Furthermore, to foster new RNs' competence in various clinical experiences, most of the programs planned rotations through several clinical areas (e.g., medical, surgical and critical care areas, outpatient clinic, or emergency). Two articles introduced the idea of presenting and attending rounds as one of the teaching methods in clinical practice (Blanzola et al., 2004; DiIorio et al., 2001).
All studies described various administrative systems needed to support the program and encourage the transition of new RNs into the organization. The systems reported focused on both personnel and programs. Within support personnel, three essential roles were identified: (a) a program coordinator who serves as a main resource for implementing and maintaining the program, (b) a program facilitator or clinical expert nurse who promotes continuous learning and development through regular contact with new graduates participating in the program, and (c) nurse managers on units who provide leadership on clinical, staffing, and administrative issues and who evaluate the progress of new graduates.
Two program supports were reported as important aspects of orientation programs: peer group support (e.g., debriefing/self care session) and mentorship by senior leaders. A peer group discussion enabled new nurses to share the problems or difficulties with peers who were experiencing similar stress and provided strategies to deal with them. The use of mentorship as a support program was reported in seven articles. Three of the seven articles described a mentor as one of the roles of the preceptor (Boyer, 2005; Herdrich & Lindsay, 2006; Rosenfeld et al., 2004), whereas the other four articles reported that mentorship was a separate program altogether (Beecroft et al., 2001; Blanzola et al., 2004; Krugman et al., 2006; Newhouse et al., 2007).
All reviewed programs used several methods and tools for program evaluation, including the use of multiple data resources and qualitative and quantitative data gathered from preceptors, nursing managers, staff, and new graduates. Program outcomes also varied but generally focused on retention, confidence, competency (e.g., critical thinking and knowledge), communication, satisfaction, and cost effectiveness. Program coordinators were important in the continuous evaluation of orientation program processes, content, and outcomes. Guiding and tracking learning and performance provided consistency across the programs and helped to improve them.
The findings of this study provide information on the effect of orientation programs on new RNs' confidence, competency, and retention. The reviewed studies suggest that the orientation programs are successful in improving new RNs' confidence in caring for patient and in enhancing their competencies such as knowledge and critical-thinking skills in the clinical environment. By doing so, these programs may encourage new graduates to stay and to participate in a supportive system. Furthermore, as Benner's (1984) model would suggest, this review shows that an orientation program with certain characteristics-that is, structured teaching methods, clinical experiences with qualified preceptors, and support systems-fosters the transition of new RNs from novices to advanced beginners.
Reviewed studies reported a wide variability in the time frames of orientation programs, with program length ranging from 6 weeks to 1 year. Several studies (n = 7) reported successful results in programs of 1-year length, and the 1-year time frame is used in the National Post-Baccalaureate Graduate Nurse Residency Program, a partnership between the University Health Systems Consortium and the American Association of Colleges of Nursing. This program is based on the premise that transition into practice is not completed until 9 to 12 months after starting a job and that a 1-year time frame for the successful transition of new graduates is reasonable (Krugman et al., 2006). Given the variability in program length reported in the literature, more research is needed to determine the most effective length of orientation programs for new RN graduates.
An extended program length, however, also poses additional costs. For example, several studies reported benefits resulting from the recruitment and retention of newly graduated nurses, although these programs incurred additional training costs (Beecroft et al., 2001; Krugman et al., 2006; Pine & Tart, 2007). Beecroft et al. (2001) calculated the return on investment (ROI) to determine the cost effectiveness of their 1-year program and reported an ROI of 67.3%, meaning that the program not only paid for itself but also saved money. Pine and Tart (2007) also reported the cost effectiveness of a 1-year residency program with an ROI of 884.75%. Further, Krugman et al. (2006) reported that the average budget for managing the 1-year National Post-Baccalaureate Graduate Nurse Residency Program was less than the costs to advertise and recruit two nurses. Although this review did not examine the cost effectiveness of newly graduated RN orientation program per se, these studies suggest that an extended program length may be worth the added costs.
This review also revealed that the specialized orientation programs, which trained newly graduated nurses to work in critical care units, had a positive impact on their confidence, competency, and retention. In an effort to deal with the urgent nursing shortage, current healthcare systems increasingly recruit newly graduated nurses for highly specialized areas that once were available only to experienced nurses. Therefore, it would be meaningful to conduct further research to evaluate the impact of specialty orientation programs on new nurse retention and patient safety in critical care units.
Many reviewed studies used a descriptive research design. That is, the authors described interviews with participants in a program or the studies did not have a control group with which to compare the intern or resident group. Therefore, the design used in the primary research may limit this study's ability to accurately capture the extent of new RN orientation program impact. However, the authors tried to overcome this limitation by examining data from similar hospital programs and analyzing differences and similarities between the programs to present more comprehensive information and recommendations.
This study has several other limitations that are important to address. The focus of this integrative review was on hospital-based new RN orientation programs. However, several articles related to new RN orientation programs in other settings, such as long-term care, were excluded during the review process. Future reviews of this nature are needed to compare and contrast new RN orientation programs across types of settings to better inform future program development. Furthermore, this review was restricted to programs focusing on outcomes in only three areas-confidence, competency, and retention. By restricting the focus in this way, other important outcomes of new RN orientation programs could have been missed. However, given that these are three very important outcomes of new RN orientation programs, the studies reported here and the conclusions reached represent an important first step in the examination of outcomes across different types of hospital-based new RN orientation programs. Finally, despite best efforts to conduct an in-depth scan of the literature, some studies may have been missed in the search process. The authors tried to overcome this limitation by scanning the literature broadly across numerous search engines and by incorporating extensive search and elimination strategies. Therefore, the authors believe that the studies reviewed here adequately characterize hospital-based new RN orientation programs during the time period of study.
In the face of a shortage of nurses, the new RN orientation program should be an initial, basic step in a healthcare organization's retention strategy. Healthcare systems have attempted to address this concern by revising existing orientation programs or introducing new programs to retain newly graduated nurses. This integrative review examined the impact of orientation programs reported in the literature between 1990 and 2007. Innovative orientation programs have strong merits: They facilitate the transition from newly graduated nurses to professional RNs and create environments that promote the retention of newly graduated nurses. These programs have the potential to address the nursing shortage in healthcare organizations. For hospitals to pursue successful staff retention, the information in this review can serve as a resource for evidence-based management.
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