Internship and residency, mentorship, new nurse graduates, preceptorship, transition



  1. Edwards, Deborah


Review question/objective: The objective of this systematic review update is to evaluate recent available research on the effectiveness of strategies and interventions aiming to assist the transition from student to newly qualified nurse for job satisfaction, confidence, competence, knowledge, stress, anxiety, retention, turnover and costs.


Article Content


This protocol is for an update of a previous systematic review conducted in 2011.1


Nurses finding the transition from nursing student to qualified nurse stressful is a worldwide phenomenon, not limited to any particular country. Newly qualified nurses can have difficulty adjusting to working in a clinical environment;2-6 negative experiences, including reality shock and burnout, have been reported during the first year of practice.5,7 Within the first year of employment as a newly qualified nurse, the intention to leave is high6 with many leaving their first job in less than 12 months,8,9 or leaving the profession altogether.2,10,11


To address this, a wide variety of strategies and interventions have been developed and reported in the international literature to ease the transition period. These include programs where qualified nursing staff are specifically trained and allocated to support and work alongside newly qualified staff within the clinical environment, including mentorship12-14 and preceptorship.15,16 Programs that aim to bridge the gap between academic preparation and the demands of clinical practice by including a period of structured didactic style teaching for specific periods of time during the first year of practice have also been reported. These include both longer periods of teaching, such as residency17,18 and internship programs,8,19 and shorter periods of teaching in the form of graduate orientation20,21 or graduate nurse programs.22,23 Other initiatives include simulation programs where newly qualified nurses are exposed to a number of patient scenarios they are likely to encounter, providing the opportunity to develop knowledge and skills in a safe environment;24,25 and externship programs which are undertaken by nursing students who have completed the substantive components of their course prior to commencing formal employment.26,27


All of these approaches seek to have a direct impact across a number of outcomes, including increased confidence, competence and job satisfaction, and reduced anxiety and stress for the individual nurse. It is hoped that this in turn will lead to decreased turnover rates and improved retention levels for the employer.


Our previous review considered the effects of transition support on a wide variety of organizational and individual outcomes, demonstrating beneficial effects irrespective of the type of support offered. However, the drawing of firm conclusions, in regard to the effectiveness of strategies used to support newly qualified nurses during the transition into the clinical workplace, was limited due to the poor methodological quality of the included studies. The review recommended that further research was needed. This update aims to establish whether research published since 2011 has filled the existing gap in the evidence base and to evaluate any further progress on efficacious interventions that aim to achieve a smooth transition from student to qualified nurse in the first year of qualification.


A preliminary search for other quantitative reviews published since 2011 on CINAHL, MEDLINE, the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews and the PROSPERO international prospective register of systematic reviews was undertaken. These searches identified a number of reviews that have been conducted on mentorship,13 preceptorship,14,28,29 nurse residency programs,3,30,31 and new graduate nurse transitional programs (GNTP).22,32 We did not find any reviews that explored simulation or externship programs. The review by Zhang et al.13 evaluated the effectiveness of mentoring programs and revealed that mentoring programs have positive effects on the mentors, mentees and organizations. However, the included papers were not limited to new graduate nurses, were either published before 2011 or were in Chinese and only focused on experimental or quasi-experimental study types. Ke et al.29 in their review revealed that preceptorship can improve newly qualified nurses' competence, from the six included studies; three of these were included in our original review and the other three were in Chinese. Even though all study types were included in the review of preceptorship by Whitehead et al.14 the majority of the included papers were qualitative and involved newly qualified allied health professionals as well as nurses.14 The remaining review on preceptorship looked specifically for articles that investigated transitioning to burn specialty practice between 1995 and 2011 but did not retrieve any relevant articles.28 Of the three reviews for nurse residency programs, the searches looked for papers up until 2013,31 2014,30 and 20163 yet only one included a quality appraisal.30 The review by van Camp and Chappy3 was the most recent, including 20 papers, and the results showed increased retention rates and greater satisfaction for those participating in residency programs. The other two reviews on nurse residency, due to limited search strategies only retrieved small numbers of papers (five papers,30 four papers31). The study conducted by Al-Dossary et al.31 did not include a quality appraisal. Lin et al.30 found that the evidence for improved job satisfaction was mixed and Al-Dossary et al.31 found that residency programs reduced turnover and promoted professional growth. Of the final two reviews that looked at GNTP, one integrative review with no quality appraisal demonstrated that GNTP resulted in good retention and improved competency.22 The other well conducted systematic review overlapped in time span with our previous review1 searching from 2000 to 2012 and demonstrated increased job satisfaction and retention rates. These previous reviews focused on a single support strategy, explored limited outcomes or did not apply quality criteria to the literature.


This updated systematic review will address these limitations by systematically reviewing and assessing the quality of international studies across a full range of support strategies, including individual and organizational outcomes. From the preliminary search across CINAHL and MEDLINE it is known that there are a number of research papers conducted that have not been included in any of the reviews retrieved.25,33-36


This updated systematic review aims to determine the effectiveness of strategies used to support newly qualified nurses during the transition into the clinical workplace and, where identified, will evaluate the impact of these on individual and organizational level outcomes.


Inclusion criteria


This update review will consider all studies that focus on newly qualified nurses during their first year of practice in the clinical area. This will include diplomates (those who qualified on a Diploma level course) and graduates, depending on the scheme of education. It will also consider student nurses who have completed the substantive components of their course and are involved in externship programs or other such programs prior to commencing formal employment.



This update review will consider studies that evaluate support strategies or programs that assist newly qualified nurses in their transition from student to practitioner. These include strategies/programs:


* Where qualified nursing staff are specifically trained and allocated to support and work alongside newly qualified staff within the clinical environment (e.g. mentorship and preceptorship).


* That aim to bridge the gap between academic preparation and the demands of clinical practice by including a period of structured didactic style teaching for specific periods of time during the first year of practice (e.g. longer periods of teaching as in residency and internship programs, and shorter periods of teaching as in graduate orientation programs, graduate nurse programs).


* Where newly qualified nurses are exposed to patient scenarios that they are likely to encounter, with the opportunity to develop knowledge and skills in a safe simulated environment.




This update review will consider studies that compare interventions against passive comparators, defined as usual practice or placebo, and active comparators, which will include studies in which any of the included interventions are compared against one another.



The primary outcomes for this update review will be outcomes that evaluate the impact of support strategies and programs on both the individual and the organization. More specifically, this update review will consider studies that include the following primary outcomes: job satisfaction, confidence, competence, knowledge, stress and anxiety. Studies will be included if they objectively measure the above primary outcomes using scales that are specific to each outcome as reported across the studies.


This update review will also include studies that measures the primary outcomes subjectively and findings of such studies will be reported the findings in a narrative summary.


Secondary outcomes will be costs, retention and turnover. Studies will be included if these outcomes have been measured objectively.


* For costs: cost benefit/savings


* For retention: one-year, two-year, five-year, 10-year retention rates


* For turnover (actual turnover): one-year, two-year, five-year, 10-year turnover rates, turnover intent or anticipated turnover.



Types of studies

This update review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. This update review will also consider descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion in a narrative summary to enable the identification of current best evidence regarding effectiveness of support strategies and interventions for newly qualified nurses.


Studies published in English will be included. Studies published from April 2011, the end date of the search from the previous review,1 to the present will be included.


Papers that do not report empirical studies and studies that focus on nurses in new areas of employment and not their first year of employment will be excluded.



The title has been registered with Joanna Briggs Institute and the proposed update systematic review will be conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of effectiveness evidence37


Search strategy

The search strategy will aim to find both published and unpublished studies. An initial limited search of MEDLINE and CINAHL has been undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source.


The reference list of all included studies will be screened for additional studies. The following journals will be handsearched to ensure that any relevant papers that may not be indexed in the major databases are located: Journal of Nursing Staff Development, Journal of Nursing Management, Journal of Nursing Administration, Journal of Advanced Nursing, and Australian Journal of Advanced Nursing.


Information sources

The databases to be searched include:


For published material:


* On the Ovid Platform: MEDLINE, Embase, PsycINFO


* On the EBSCO Platform: CINAHL, ERIC


* On the ProQuest Platform: British Nursing Index (BNI), ProQuest Digital Dissertations


* For clinical trials: Wiley: Cochrane Central Register of Controlled Trials (CENTRAL).



For unpublished material: Open Grey.


Study selection

Following the search, all identified citations will be collated and uploaded into Endnote V7.7.1 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the Joanna Briggs Institute's System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.38


Assessment of methodological quality

Eligible studies will be critically appraised by two independent reviewers at the study level for methodological quality using standardized critical appraisal instruments from JBI37,39 for the following study types: randomized controlled trials, quasi-experimental studies, case control studies,cohort studies cases series, case reports and analytical cross sectional studies. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in narrative form and in a table. Any deviations from the recommended JBI approach will be reported and justified.


Following critical appraisal, studies that do not meet a certain quality threshold will be excluded. This decision will be based on questions that relate to the outcomes being measured in a reliable way and whether appropriate statistical analysis was used. If the answer to any of these questions is "no" then the studies will be excluded and a full explanation will be provided in the text and within a table.


Data extraction

Data will be extracted from studies included in the update review by two independent reviewers using the standardized data extraction tool available from JBI SUMARI.40 Data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. The data extraction form will be piloted with reviewers prior to use to ensure consistency; data extractors will be trained prior to commencement. Results will be cross checked to minimize errors. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of included papers will be contacted to request missing or additional data where required.


Data synthesis

Studies will, where possible, be pooled in statistical meta-analysis using JBI SUMARI. Effect sizes will be expressed as either odds ratios (for dichotomous data) and weighted (or standardized) mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis of measured outcomes based on participants' scores in the scales used. Heterogeneity will be assessed statistically using the standard chi-squared and I squared tests. The choice of model (random or fixed effects) and method for meta-analysis will be based on the guidance by Tufanaru et al.41 Where statistical pooling is not possible the findings will be presented in narrative form for each outcome, taking into account the various preparation of nurses (i.e. diploma, degree or master's entry) including tables and figures to aid in data presentation where appropriate.


A funnel plot will be generated to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed where appropriate.


Assessing certainty in the findings

The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence will be followed and a Summary of Findings (SoF) will be created using GRADEPro GDT software (McMaster University, ON, Canada). The SoF will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision and risk of publication bias of the review results. The outcomes reported in the SoF will be job satisfaction, stress, anxiety, confidence, competence and knowledge, where there is sufficient homogeneity across outcome measures.


Appendix I: Initial search strategy (MEDLINE via Ovid)



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