The majority of new graduate nurses (NGNs) work in acute care contexts after graduation, with 67% to 85% of novices employed in hospital settings (Gilmour et al., 2017; Huntington et al., 2012; Parker et al., 2014; U.S. Department of Health and Human Services, 2010). Although NGNs are increasingly entering practice in specialty areas, medical-surgical units continue to be the launch sites for the majority of neophyte nurses (Gilmour et al.; Parker et al.). Acute care environments are particularly challenging for new nurses, owing to greater patient acuity, rapid patient turnover, technological advancements, and demanding workloads (Hussein et al., 2017). These environmental and work management challenges are compounded by the nursing shortage, a product of retiring baby boomer nurses and NGNs leaving the profession within the first 2 years of practice due to unreasonable workloads, lack of support from employers, unhealthy work environments and poor working relationships (Hunsberger et al., 2013).
Internationally, there has been a burgeoning of NGNs transition programs intended to support NGNs. New graduate nurse transition support programs have been referenced in the literature using a variety of terms: transition to practice, nurse entry to practice, first year of clinical practice, residency, NGN and early career nursing programs (Doughty et al., 2018). Across jurisdictions, professional, regulatory, and/or governmental bodies have recommended these programs to target the challenges of professional workplace transition and have, in some cases, mandated them. Scotland’s Flying Start (Banks et al., 2012) and New Zealand’s National Nurse Entry to Practice (NETP) programs (Doughty et al.; Ministry of Health, 2004) are required of all NGNs in these countries. Since 2002, and subsequently mandated by the 2010 ‘The Future of Nursing’ joint report by the Robert Wood Johnson Foundation and Institute of Medicine (2010), the United States has escalated the development of residency programs. Dominated by Versant (Ulrich, 2010), the University Health System Consortium (UHC)/American Association of Colleges of Nursing (AACN), and the more recently developed National Council of State Boards of Nursing model for transition to practice (Transition to PracticeTMregulatory model) (National Council of State Boards of Nursing, 2009; Spector et al., 2009), these residency programs offer a more formalized and credentialed approach to transition facilitation. In the United Kingdom (UK), the Department of Health and the Nursing and Midwifery Council have introduced policy requiring NGN support through a preceptorship framework developed by England’s Department of Health (Department of Health, 2010; Forde-Johnston, 2017; Marks-Maran et al., 2013). Similarly in some Canadian jurisdictions, provincial ministries of health have introduced funded NGN supernumerary positions for up to 6 months to assist with transition (Hunsberger et al., 2013).
Methods:
The intent of this review was summarize existing research evidence (2012-2018) and to identify developments in the state of the science and best practices of formal NGN transition programs. With 1337 evaluated, 37 articles were reviewed using Cooper’s (1989) five-stage approach: problem formulation, data collection, evaluation of data points, data analysis and interpretation, and presentation of results.
Results:
This integrative review demonstrated that the quality of evidence related to NGN programs was variable; (Spector et al., 2015) over half of the evidence was of moderate to high quality and only 9% of the evidence would be considered of high quality. Compared to Rush et al.’s previous review (2013), there was a greater representation of qualitative evidence. Despite the valuable insights this evidence provides into new graduate experiences in NGN programs, findings often recycled existing knowledge without serving to advance the science. The findings reflected limited response in the NGN program research literature to the call for well-designed quasi-experimental studies (Anderson et al., 2012).
Education was an important component of NGN transition programs and generally well detailed as to content, delivery modalities, and timing. Despite this, the reports on educationally-based transition initiatives were largely descriptive, with limited exploration of the relationships between educational components and their unique or combined contributions to the transition experience. There was a notable shift in the majority of programs from the inclusion of education primarily during orientation, to staggering it over time. This evolution seemed intent on paralleling the evolving developmental needs of NGNs during their first year of practice. Although a staggered approach seems intuitively sound, evidence has not confirmed this approach as advantageous in easing NG transition and warrants further study. The unique contributions of NGN educational content, delivery modalities, and timing is also an area for continued study. For example, empirical evidence that targets the interactions of content and timing would facilitate greater intentionality in approaches that maximize benefit for the NGN. Surprisingly, simulation was used in only four studies; its specific role in facilitating transition was not easily determined as it was often one of several program components. Strategic use of simulation could be tested further to optimize its value in enhancing the transitional experience of NGNs.
Despite the continuing mixed evidence related to NGNs satisfaction with their preceptored experiences, the area of greatest advancement in transition programs was strengthening the quality of preceptor support. Although a range of strategies were described to enhance preceptor support, few strategies have been evaluated. The strongest evidence pointed to the use of strategy bundling that gave preceptors dedicated time with the NGN (Blegen et al., 2015), and use of a staging model to incrementally progress the NGN into the realities of practice (Figueroa et al., 2016). There was increasing support for attention to the quality of the preceptor experience versus the frequency of interaction with the preceptor, and expressed need for preceptor training as well as infrastructure support; all fruitful areas for further research.
The support provided to NGNs beyond the supernumerary period was clearly recognized as imperative for their success. The types of resource supports were wide ranging, but few were evaluated. Whether NGNs benefit from multiple or single supports, for how long, and for which critical aspects of transition, remain unknown. Mentorship has been touted as an important approach to support, but was formalized in few studies and highly variable in terms of how mentors were selected. Best practices related to mentor selection are an important area of further development. Issues related to preceptor assignment or NGN self-selection of preceptors may be worth studying, as these approaches relate to the quality of the NGNs transition experience.
The work environment has been documented as an influence on the NGN transition and yet was addressed in few studies. The limited evidence indicated that supportive unit cultures compensated for inadequate preceptorship/mentorship in easing the transition. Transition programs would benefit from attention to creating cultures in which there is a team or unit-based approach to integrating the novice practitioner into the workplace. Beginning evidence suggests that NGN transition programs mitigate bullying cultures by providing access to support not always available to those not participating in programs. Creating healthy work environments that have zero tolerance for bullying would provide support to NGNs navigating the stressful transition to professional practice.
The development of competence within the practice environment is a valued outcome of NGN transition. The evidence consistently showed that competence developed over time regardless of the type of transition program available. The strongest evidence suggested that more established, standardized, and evidence-based programs had the best outcomes. This suggests that NGN programs should be well thought out, framed by theory specific to the NGN transition experience, outcome-based in accordance with contemporary evidence, and evaluated on an ongoing basis.
Conclusion:
Despite the growing evidence of the value of NGN programs, there is an ongoing need for more robust study designs. Even the strongest evidence lacked rigor (e.g., lack of randomization, lack of control/comparison group) to draw definitive conclusions about the impact and effectiveness of formalized support programs on the NGN transition experience.