Authors

  1. Lindfors, Kirsi RN, MNSc
  2. Junttila, Kristiina RN, PhD

Abstract

Review question/objective: The objective of this review is to identify the effective orientation programs and their effects on the professional competence and organizational commitment of newly graduated nurses.

 

Background: It is estimated that between 2008 and 2060, the population of the European Union aged 65 and over will increase by almost 70 million and people over 80 years of age will be the fastest growing population.1 Alongside the aging population, the work force is aging too. Baby boomers are retiring and the next generations are unable to fill the growing demand for nursing resources: fewer nurses are entering the nursing profession.

 

The nursing shortage is a global problem. It is estimated that in the United States at the end of the year 2018, there will be approximately 581,000 vacant positions for nurses alone.2 In Europe by 2020, it is estimated that the shortage of nurses will be 590,000 and in which case 14% of care cannot be covered.3 Nursing shortage has negative outcomes including increased mortality rates, adverse events after surgery and increased risk of infections, e.g. pneumonia and urinary tract infections.4-7 Aiken et al. reported that adequate nurse staffing and the quality of the hospital work environment can be associated with higher patient satisfaction, quality and safety of care, and nurse workforce outcomes.8 Hospitals that patients rated as excellent indicated a good working environment, satisfaction in management and lower levels of burn out of nurses. Here, excellence meant that patients were treated with respect, listened to carefully and explained things in a clear manner.8

 

At the same time, when the healthcare sector is struggling with the nursing shortage, nurses are leaving the profession; especially newly graduated nurses. Godinez et al. estimated in their study that between 35 and 60% of newly graduated nurses resign in their first year of practice.9 In Kovner et al's study, 13% of newly licensed nurses had changed their principal jobs after 12 months and 37% were going to search for a new position in the near future.10 Nearly 42% of respondents desired to obtain another job, if only possible. Buchan and Aiken stated in their article that nursing shortage is not always a matter of shortage of individuals with nursing qualifications, but individuals who do not want to work as nurses in healthcare organizations.11 Attracting and retaining new nurses in the working life and in the nursing profession is one of the main issues to be solved in healthcare organizations worldwide.12

 

Reasons why newly graduated nurses are leaving their first position include unacceptable nurse-to-patient ratios, unsafe patient care, lack of support and guidance, and too much responsibility.13,14 According to Wu et al., nurses who had been working for less than two years experienced higher levels of work-related stress, especially in nursing skills, than nurses with -three to five or more years of experience. Newly graduated nurses do not trust their ability to perform given duties as expected. Critical thinking and decision-making are difficult and their knowledge base is inadequate. 15-20 Their expectations and anticipations of work are often more idealistic than realistic.21 It takes almost one year to achieve a sufficient level of confidence and the most difficult role adjustment time is between 6 and 12 months after commencing the role.16 The first 12 months encompasses a wide range of emotional, intellectual, physical, sociocultural and developmental tasks, which in turn affect a nurse's personal and professional growth and future.21 During the first year of practice a newly graduated nurse begins to focus on the patient and their family, the healthcare team and the healthcare organization, instead of single tasks and duties. A person who has asked questions becomes a professional answering those questions.22

 

Experiences of incivility and bullying are also associated with higher job and career turnover intentions, especially in nurses in their first year of practice.23 According to Laschinger's previous studies, between 26 and 33% of newly graduated nurses were bullied;24,25 and according to Berry et al., 21.3% were exposed to daily workplace bullying in the past six months.26 Bullying experiences lead to emotional exhaustion, cynicism and poor physical and mental health.24

 

Structural empowerment, better working conditions (manageable workloads, control over work, rewarding, fairness, a sense of belonging, congruence between personal and organizational values) and authentic leadership are significantly related to job and career satisfaction and turnover intentions among new nurses. The more new graduates felt that their initial orientation met their needs, the more satisfied they were with their career and less likely to leave the nursing profession.23 Orientation programs add to novice nurses' ability to perform prescribed duties, increases confidence, competence and job satisfaction of graduate nurses, but also collegiality among experienced and novice nurses.15,27-29 It lowers the turnover rates, reduces turnover costs and enhances the quality of nursing care by, for example, decreasing medication errors.29-31 According to Lee et al., the orientation program decreased the turnover rates of new nurses by almost 47%, which decreased turnover costs by $186,102USD.31 A systematic orientation program also enhances organizations' good employer reputation and attracts new employees.30

 

Orientation means actions are taken to ensure a new employee is familiarized with the working environment, to its demands and expectations, to prepare newly qualified nurses to be confident and to provide safe patient care. The main goal of an orientation program is to provide as competent nurses as possible.32 Competence is a concept which is difficult to define.33-35 In the behaviorist model, competence means the skills and ability to get work done in a satisfactory manner.33 According to Patricia Benner, a competent nurse has the ability to perform a task with a desirable outcome under various conditions of the real world.36 Meretoja defines competence in terms of functional adequacy, capacity to integrate knowledge, skills, attitudes and values in specific contextual situations of practice.35 There are a number of ways to evaluate competence, but insufficient testing of validity and reliability often limits the use of those instruments.37 The Six-Dimension Scale of Nurse Performance by Schwirian (6-D Scale),37 the Nurse Competence Scale by Meretoja (NCS)35 and the Australian National Competency Standards (ANCI)33 have been well tested for validity and reliability.

 

A successful orientation program creates a sense of belonging and eases socialization.27,38 It includes personal preceptorship, regular feedback from the ward manager and preceptor(s) and supportive learning environment.16,19,39-41 The preceptor plays a significant role in newly graduated nurses' job satisfaction and competency development. They are in a key position to facilitate new nurses' role adjustments and professional behaviors. 16 A welcoming atmosphere, i.e. an atmosphere which appreciates new employees and allows them to be new and ask questions is perceived as a supportive environment. Regular feedback enables new graduates to foster confidence as nurses and it is essential for gaining nursing experience. 42

 

According to a preliminary search for previous systematic reviews about newly qualified nurses' orientation programs, one existing systematic review on a similar topic was found. This previous systematic review focused on effective strategies and interventions that assist the transition from student to a newly qualified nurse.43 In this systematic review, the focus will on the predefined orientation programs, their effects on the professional competence and organizational commitment. The context for the review will be in specialized healthcare defined as services organized according to medical subspecialties and including investigation and treatment of disease and disability by highly specialized personnel. It offers centralized care to the population of a large region.

 

Article Content

Inclusion criteria

Types of participants

This review will consider studies that include newly graduated nurses. Study participants include nurses (bachelor, associated degree) graduated within one year, working their first year of practice in specialized healthcare.

 

Types of intervention(s)/phenomena of interest

This review will consider studies that evaluate orientation programs and their effects on newly graduated nurses' professional competence and organizational commitment.

 

Types of outcomes

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

 

The primary outcome is nurses' professional competence level measured by an objective and quantitative instrument such as the Nurse Competence Scale (NCS), the Australian National Competency Standards (ANCI) and the 6-D Scale (the Six-Dimension Scale of Nursing Performance).

 

The secondary outcome is nurses' organizational commitment measured by an instrument such as the Organizational Commitment Questionnaire (OCQ), the Organizational Commitment Scale (OCS) and the Affective, Continuance, and the Normative Commitment Scale. In addition, organizational commitment can be measured by early resignation from the workplace or the profession (within the first year of practice). The reasons for early resignation will include all work-related reasons (e.g. unsafe patient care, perceived stress, unsatisfactory work environment, insufficient support, poor management, perceived bullying and employment factors including dissatisfaction with salary and/or few possibilities for career development), excluding reasons related to personal life (marriage, maternity leave, moving to another state/city/country).

 

The most appropriate comparators would be no specific orientation programs, or study context outside specialized health care (e.g. primary health care, occupational health care).

 

Types of studies

This review will consider experimental study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion.

 

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies.

 

Studies published in English, Finnish and Swedish will be considered for inclusion in this review. Studies published from 2003 to 2013 will be considered for inclusion in this review because of the many changes that have encountered specialized healthcare during the last decade: nursing shortage, fast growing retirement, new generation entering the workforce and nurses' lack of commitment.

 

The databases to be searched include:

 

CINAHL, Medline, Medic, Arto, PubMed, ASSIA, SCOPUS, LEO, EBSCOhost Academic Search Premier, Web of Science, Arbline.

 

The search for unpublished studies will include:

 

MedNar

 

Initial keywords to be used will be:

 

In English: orientation*, orientation program, in-service-training, employee orientation, preceptor*, preceptorship*, externship*, internship*, transition, novice nurse, new graduate, graduate nurse, newly graduate nurse, neophyte graduate, preceptee, competence*, professional competence, commitment*, effectiveness, efficacy, turnover, resign*

 

In Finnish: perehdyty*, perehdyttaja*, perehtyja*, patevyy*, "ammatillinen patevyys", komptenssi*, "sairaanhoitaja, vastavalmistunut", sairaanhoita*, sitoutu*, organisaatio*, irtisanoutu*

 

In Swedish: arbetsplatsorientering*, mentor*, sjukskotare*, kompetens*, yrkeskompetens, professionell kompetens, "praktik under handledning", forbindning*

 

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

 

Assessment of methodological quality

Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

 

Data collection

Quantitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Reviewers will extract data independently. Where necessary, study authors will be contacted to request missing data or clarification of unclear reporting.

 

Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

 

Conflicts of interest

None

 

Acknowledgements

None.

 

References

 

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Appendix I: Appraisal instruments

 

MAStARI appraisal instrument[Context Link]

Appendix II: Data extraction instruments

 

MAStARI data extraction instrument[Context Link]

 

Keywords: orientation*; orientation program; in-service-training; employee orientation; preceptor*; preceptorship*; externship*; internship*; transition; novice nurse; new graduate; graduate nurse; newly graduate nurse; neophyte graduate; preceptee; competence*