This completed study describes the effects of a structured Nurse Residency Program featuring reflective learning on nurses’ organizational enculturation from Year 1 (Y1) to Year 2 (Y2).
It has been reported that 6% of new graduate nurses leave the profession within their first year of practice because of job dissatisfaction, poor transition from the student role to the work environment, poor social integration within the work unit, concerns about their competency levels, and poor coping and self-efficacy (Kramer, Halfer, Maguire & Schmalenberg, 2012). Nurse Residency Programs (NRPs) have been viewed as an effective way to prepared and new nurse graduates for work in the complex healthcare environment (Al-Dossary, Kitsantas & Maddox, 2016; Bratt, 2013; Bratt & Felzer, 2012; Green, Warren,& Perkins, 2016). While NRPs are discussed in the literature, specific attributes of NRPs facilitating nurses’ integration into the organization and the work unit have not actually been measured for their effectiveness in facilitating the enculturation and retention of the new graduate nurse. The NRP in this study uses an evidence-based curriculum (Anderson, Hair & Todero, 2012) with Knowles adult learning theory (Knowles, Holton & Swanson, 2015) and Kirkpatrick’s Four Stage Model of Evaluation (Kirkpatrick & Kirkpatrick, 2006) and features a dedicated Nurse Manager (NM) for oversight of the program, reflective learning where the nurse residents (NRs) discuss their feelings in a structured group experience related to clinical interactions and experiences and looping where the NRs are rotated through specific clinical and support departments exposing them to care delivery in different settings. The study measured changes in nurse residents’ perceptions of person-organizational enculturation defined by person-organizational fit (POF), social support (SS), coping self-efficacy (CSE), knowledge and skills (K&S), organizational commitment (Org Com), organizational citizenship behaviors (OCB), civility norms (CIV), occupational commitment (Occ Com), and burnout (BO) over a two-year period. These variables were used to measure the effectiveness of the NRP featuring the reflective learning component.
Methods:
After Institutional Review Board approval, the study was conducted in a large metropolitan hospital located in the Southwestern region of the United States. New graduate nurses were interviewed by the NRP Nurse Manager and hired directly into the NRP rather than an assigned clinical area. All NRs were invited to participate in the study and their completion of study surveys at Y1 and Y2 indicated their consent to participate. The questionnaire consisted of 82 items with a 5-point response set (5 = strongly agree to 1 = strongly disagree) measuring the variables of interest. Eleven demographic items were used to describe the samples in Y1and 2, and an additional 14 items provided more information about the NRs at Year 2. Sample: There were 105 respondents in Y1 and 24 respondents in Y2 from a population of 129 new graduate nurses for a response rate of 82% in Y1 and 19% in Y2. There were 16 nurses whose responses could be matched from Y1 to Y2. The data was analyzed using SPSS v 23 to analyze the data for the matched pairs sample (n = 16) and independent samples (n = 105, 24) for differences in study variables from Y1 and 2. The entire sample was analyzed to determine correlations among variables in Y1 and 2.
Results:
All of the scales in the questionnaire had reliabilities greater than a = .70 in both Y1 and Y2 with the exception of the Org Com scale (alpha = .67) in Y2. The total survey with all items had a reliability of Cronbach’s a of .80. The matched pairs sample included 81% female and 19% male. The majority of the respondents were White (66%), with 14% Asian, 10% Hispanic/Latino, 4% Black, 4% Pacific Islander, and 2% other. NRs reported their job titles as 70% Associate Nurse and Clinical Nurse 30% in Y1 and 18% Associate Nurse and 73% Clinical Nurse in Y2. This change occurred because the progression in job title from Associate Nurse to Clinical Nurse is expected from Y1 to Y2. The majority of the matched NRs had Baccalaureate degrees (64%), Master’s degrees (16%), and only 11% reporting Associate Degrees. Some of the NRs had prior employment with the organization (39%), but 61% did not. Significance level was set at p < .10 because of the small sample size nested within the larger non-matched sample. There were no significant differences in the following variables from Y1 to Y2: Org Com, OCB, CIV, Occ Com, and BO. Significant improvements in mean scores were noted between Y1 to Y2 in NRs’ perceptions of CSE (M1 = 3.60, M2 = 3.87; p < .015) and K&S (M1 = 3.13, M2 = 3.30; p < .060), but significant declines in mean scores were noted in POF (M1 = 4.31, M2 = 4.02; p < .038) and SS(M1 = 3.31, M2 = 3.09; p < .041).
With the data analyzed as two independent samples in Y1 (n = 105) and Y2 (n = 24), there were no significant differences in age, gender, job title (Associate Nurse or Clinical Nurse), nursing degree, or assigned shift. With the significance level set at .05, three significant differences were noted in the study variables between Y1 and Y2 (assuming unequal variances related to unequal group sizes). The mean scores for Org Com decreased from Y1 (M = 4.45) to Y2 (M = 4.10, p = .003); POF (Y1, M = 4.44; Y2, M = 4.15, p = .05); and SS (Y1, M = 3.45; Y2, M = 3.23, p = .04). Associate nurses rated CIV significantly higher (M = 4.18) than clinical nurses (M = 3.89) at Y1 (p < .05), but that difference was not observed in Y2. NRs working the day shift reported higher SS (M = 3.57) than those working evenings/nights (M = 4.36) at Y1 (p < .01), but that difference was also not observed in Y2. NRs who had prior experience at the employing hospital reported higher Org Com (M = 4.71) than those who did not have prior employment (M = 4.39) at Y1 (p < .05), but that difference was not observed in Y2. Similarly, NRs with prior experience at the employing hospital reported higher perceived POF(M = 4.67) at Y1 as compared to those who did not have prior experience (M = 4.34, p < .05), but that difference was not observed in Y2.
For the independent samples, significant correlations were noted between Org Com and Occ Com (Y1, r = .632, p < .01 and Y2, r = .632, p < .01); POF and Org Com (Y1, r = .613, p < .01 but not significant in Y2); SS and Org Com (Y1, r = .487, p < .01; Y2, r = .766, p < .01); and SS and CSE ( Y1, r = .236, p < .01; Y2, r = .50, p < .01). Negative correlations between SS and BO were noted in Y1 (r = -.345, p < .01) and Y2 (r = -.602, p < .01). All of the correlations between SS and the other study variables were higher in Y2 as compared to Y1 with the exception of the correlation between SS and POFwhich was not significant in Y2.
A regression analysis was done using Org Com as the dependent variable and all other variables as IVs, and the model was significant (R2 = .587, p = .000) with Occ Com (B = .315, p = .000) and POF (B = .394, p = .000) as the strongest predictors of Org Com.
Conclusions:
The results indicate the NRP with the reflective learning was effective in improving matched NRs’ perceptions of CSE and K&S in Year 2, but unfortunately, mean scores declined for POF and SS in Year 2, which is a critical time when nurse residents decide to continue employment at the organization or leave the organization and/or profession. The strong, significant correlations between SS, CSE, and Org Com indicate the importance of reflective learning in a NRP as a means of providing structured social support for the NRs. The negative relationship between SS and BO indicate the strong need for program elements like reflective learning to enhance social support, diminish burnout and the potential to leave the organization. The strong relationship between Org Com and Occ Com reinforce the importance of reflective learning with discussion of professionalism in nursing (occupational commitment) and other forms of social support to prevent new graduate nurses from leaving the professional all together. This notion is supported by Occ Com and POF significant predictors of Org Com. This study supports findings from other studies on the effect of nurse residency programs on retention and enculturation into the organization (Rosenfeld & Glassman, 2016).
This study provides new knowledge about attributes of a successful NRP featuring reflective learning and the effectiveness of the program in enhancing CSE and K&S from Year 1 and Year 2. The study has global implications since the transition of new nurses into practice and the retention of nurses are important issues to nursing.
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