Nurse Education Today 34 (2014) 1024–1028

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The impact of residency programs on new nurse graduates' clinical decision-making and leadership skills: A systematic review Reem AL-Dossary a,⁎, Panagiota Kitsantas b,1, P.J. Maddox b,2 a b

George Mason University, School of Nursing, MS: 3C4, 4400 University Drive, Fairfax, VA 22030-4444, USA George Mason University, Department of Health Administration and Policy, MS: 1J3, 4400 University Dr., Fairfax, VA 22030-4444, USA

a r t i c l e

i n f o

Article history: Accepted 16 October 2013 Keywords: Decision-making Clinical leadership New graduate nurse Residency programs

s u m m a r y Background: Health care institutions have adapted residency programs to help new graduate nurses to become fully competent and transition from a student nurse to an independent practicing nurse and a bedside leader. Objectives: The study's aim is to review the literature on the impact of residency programs on new graduate nurses' clinical decision-making and leadership skills. Review Methods: An electronic search was conducted between 1980 and 2013 using databases of the scientific literature in Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo using a range of keywords. Information gathered was evaluated for relevance. Results: Thirteen studies that met the inclusion criteria were used in this systematic review. In several studies considered in this review, residency programs were developed to improve new graduates skills and promote their transition into the nursing workforce. In fact, the transition programs reduced turnover in that first year of practice and promoted professional growth of the new graduate such as hand-on nursing skills, clinical decision-making and leadership skills, satisfaction, and retention. Conclusion: There is a need for effective residency programs that are designed to prepare new graduate nurses in providing safe, competent and effective patient care. © 2013 Elsevier Ltd. All rights reserved.

Introduction The Bureau of Labor Statistics reports that registered nurses' employment is expected to grow by 26% by 2020. Ten percent of the nursing workforce in hospital settings is composed of new graduate nurses, and this number is expected to increase as a result of the aging nurses reaching retirement (U.S. Bureau of Labor Statistics' Occupational Outlook Handbook, 2010–2011 Edition). Because of the intense working environment, increasing patient acuity, nursing shortages, and complex technologies, health care settings create challenges for new graduate nurses. As health care needs are becoming increasingly complex and technology is expanding to accommodate patients' needs (Taylor, 2008), the new graduate nurse is required to possess clinical decision-making (CDM) and leadership skills (LS). Although approximately 90% of nurse education leaders in the United States believe that new nurse graduates are adequately prepared to enter the workforce and practice, 90% of nurse leaders in the hospital setting disagree (Berkow et al., 2009). This discrepancy in views of the new nurse graduate's preparation between nursing educators and

⁎ Corresponding author. Tel.: +1 571 337 8557. E-mail addresses: [email protected] (R. AL-Dossary), [email protected] (P. Kitsantas), [email protected] (P.J. Maddox). 1 Tel.: +1 703 993 9164. 2 Tel.: +1 703 993 1982. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.

nurse leaders might be explained by the new graduate's ability to put knowledge into practice. The journey from education to practice can be extremely stressful for the new graduates. The transition experience for the new graduate nurse is described as the “experience of moving from the known role of a student to the relatively less familiar role of professionally practicing nurse” (Duchscher, 2009, p.1105). Also, the transition can be associated with a reality shock “apparent contrast between the relationships, roles, responsibilities, knowledge and performance expectations required within the more familiar academic environment to those required in the professional practice setting” (Duchscher, 2009, p. 1105). The high levels of stress are associated with the inability of new nurses to properly transition from education into practice (National Council of State Boards of Nursing, 2012) leading to negative consequences such as increased turnover and potentially disastrous outcomes for patient care. To alleviate this problem, many healthcare institutions have adopted residency programs (RPs) to help new graduate nurses to transition and become fully competent independent practicing nurses and bedside leaders. In the nursing profession, the transition period for new graduate nurses between graduation and the first year has been an issue for many years (Fink et al., 2008). Nurse RPs support new graduate nurses, ease the transition period, and help with skill acquisition. Nurse RPs have helped to increase recruitment, improve retention, and/or increase commitment to the organization, and have led to the satisfaction of new graduate nurses (Olson-Sitki et al., 2012).

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The Institute of Medicine (IOM) report (2011) on the Future of Nursing emphasized the need to establish RPs for new graduate nurses at clinical settings, and highlighted the advantages of developing these programs. In fact, implementing RPs in clinical settings provide advantages to new graduate nurses, organizations, and patients. Residency programs can equip new graduate nurses with the skills needed to navigate the complex health settings. The RPs are an opportunity to support the new graduate nurse transition to practice and to develop proficiency. However, there is a need to understand how to improve new graduate nurses' transition from student role to practitioner, and specifically how RPs influence this transition with regards to CDM and LS. Despite a growing body of knowledge on this topic, the impact of RPs on new graduate nurses' CDM and LS remains underexplored. Few studies measured the impact of RPs on new graduate nurses' CDM and LS (Halfer et al., 2008; Anderson et al., 2009; Goode et al., 2009; Kowalski and Cross, 2010). It is essential that the new graduate nurse acquire CDM and LS to provide patients with safe and competent care (Patrick et al., 2011). Therefore, the purpose of this review paper is to provide a detailed description and assessment of the current knowledge on how RPs influence new graduate nurses' CDM and LS. This review includes identifying gaps in knowledge about the impact of RPs on new graduate nurses' CDM and LS as well as compiling the best possible research evidence in order to develop evidence-based practice about RPs. The findings of this integrated literature review might be helpful to health care administrators and nursing educators in designing effective RPs that can ease the transition of new graduates from education to practice. Further, findings from this review study can assist efforts in improving the work environment and educational practices. Methods Search Methods for Identification of Studies An electronic search was conducted between 1980 and 2013 using databases of the scientific literature in Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo. The search terms used were decisionmaking, CDM, clinical leadership, leadership, nursing, new graduate nurse, residency and RPs. A literature search was conducted to identify primary published studies with data on CDM, clinical leadership, new graduate nurse, and RPs. All peer-reviewed journal articles that studied the impact of RPs on new graduate nurses' CDM and LS, and were published in English were examined. A total of thirteen articles were included. Inclusion Criteria for Considering Studies for this Review Studies evaluating the impact of RPs on new graduate nurses' CDM and LS were included in this systematic review. Specifically, we included studies that discussed the content, components, content, processes, goals, and duration of the RP. However, case reports, pilot studies, and non-English articles were excluded. Further, studies were rejected if they did not include CDM and LS as the outcomes that can be affected by RPs. Study participants in the reviewed studies were new graduate nurses and newly licensed registered nurses, with no previous experience. The review is focused on two specific outcomes, namely CDM and LS. Data Extraction and Analysis Studies were grouped based on the RP content, teaching and learning strategies approach used. We also examined the methodological rigor and quality of study design, recruitment methods, sample size and outcome measures employed by each study. Further, we


evaluated the findings of the intervention presented in each study as they pertain to the impact of RPs on CDM and LS. Limitations, future research directions and implications for the nursing profession are discussed. Results Over the period of 33 years, we identified 756 studies using the key word RPs. The search resulted in 59 studies when key words such as RPs and nursing were used. When search was restricted even further by using more precise key words such as RPs and decision-making, we retrieved 32 studies. Finally, 17 articles were retrieved when the terms RPs, clinical, and leadership were used. Of these, only 13 studies met the inclusion criteria. What follows is an analysis of peerreviewed studies on nurse RPs, focusing on study methods and findings. Nurse Residency Programs In nursing literature, RPs were first reported in the 1980s (Altier and Krsek, 2006). According to Fink et al. (2008), numerous hospitals have developed RPs for new graduate nurses due to the impending expertise gap and the need to assist the new graduate nurse in the transition process. Herdrich and Lindsay (2006, p. 55) defined RPs as “a joint partnership between academia and practice that is learner focused. [And where the] post-graduate experience [is] designed to support the development of competency in nursing practice. The role of the academic partner is to aid in the development of the theoretical framework and conduct the research based program evaluation, whereas the role of the practice partner is to actualize and guide the program itself”. According to the National League for Nursing (1983), RPs are formal contracts between the new graduate nurse and the employer, describing and defining activities. Altier and Kresk (2006) indicate that nurse RPs contribute significantly to the success of the new graduate nurse. In fact, nurse RPs are designed to provide the new graduate nurse with additional support, mentoring and guidance as they transition into practice. Further, nurse RPs provide the novice nurse with a supportive and protective environment to develop her/his critical thinking, problem solving, CDM and LS. Residency programs are developed to improve new graduates skills, confidence, and experience in promoting their transition into the nursing workforce. Numerous studies demonstrated that nurse RPs improved new graduate nurses' competencies, skills and increased self-confidence, and decreased the turnover rate (Valdez, 2008; Goode et al., 2009). In Blanzola et al. (2004) study, the nurse residents significantly improved self-confidence (t = −4.61, p-value = 0.002). Further, evidence has shown that nurse RPs have improved the new graduate nurse commitment to the nursing profession, and have increased the overall retention of new graduate nurses (Fink et al., 2008; Scott et al., 2008). According to the National Council of State Boards of Nursing, the transition programs reduced turnover in that first year of practice (NCSBN, 2009); and promoted professional growth of the new graduate such as hands-on nursing skills, CDM and LS, satisfaction, and retention (Scott et al., 2008). Further, RPs offer the new graduate nurses guidance and support to cope with the stressors in the first year of practice (Fink et al., 2008). Clinical Decision-making and Leadership in the Nursing Literature According to Standing (2007, p.266), clinical decision-making is defined as “a complex process involving information processing, critical thinking, evaluating evidence, applying relevant knowledge, problemsolving skills, reflection, and clinical judgment to select the best course of action which optimizes a patient's health and minimizes any potential harm.” Furthermore, the American Association of Colleges of Nursing (AACN) (2008) states in the second essential of nursing


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education, that decision-making is a key leadership skill. Surprisingly, there is no agreement about the terminology that is used when discussing decision-making in the nursing literature. The following terms were found to be used interchangeably in nursing literature, including “clinical decision-making” (Torunn Bjørk, and Hamilton, 2011), “clinical judgment” (Benner and Tanner, 1987), “clinical inference” (Hammond et al., 1966), and “diagnostic clinical human reasoning” (Evans and St, 1990). According to De Graaff (1989), there is “terminological chaos” where these different terms are used exchangeable. The phenomenon of clinical leadership at the patient bedside is a new area of research (Patrick et al., 2011). Clinical leadership focuses on patients and health care teams compared to nurse executive leadership. According to Patrick et al. (2011, p. 450), clinical leadership is defined as “staff nurse behaviors that provide direction and support to clients and the health care team in the delivery of patient care. A clinical leader is a registered nurse who influences and coordinates patients, families and health care team colleagues for the purpose of integrating the care they provide to achieve positive patient outcomes”. Thus, it can be said that every registered nurse is a clinical leader; particularly clinical nurses at the bedside (Erickson and Ditomassi, 2005). However, in nursing literature, the concept of clinical leadership is usually associated with nurse executives and formal leadership roles. In fact, nursing leadership is rarely linked to bedside nursing practice. Clinical leadership is illustrated by the nurse leader actions at the bedside by applying nursing skills during practice within the therapeutic nurse– patient relationship and between health care team members. Cowin and Hengstberger-Sims (2006) report that it is unrealistic to expect new nurse graduates to be ready for practice because it normally takes six months or longer for them to adapt, develop confidence, and begin to independently apply what they have learned. Thus, it is assumed that RPs will offer the new graduate nurse an experience that will support the development of the full practitioner role. The Effect of Nursing Residency Programs on New Graduate Nurses' Clinical Decision-making and Leadership Skills A 5-year longitudinal study (Dyess and Sherman, 2011) was conducted in the U.S. with four cohorts of new nurse graduates (N = 109) who participated and completed a ten month program, namely Novice Nurse Leadership Initiative (NNLI). The NNLI started in 2006 and it is a practice education program. It was designed to support the new nurse graduates' transition from theory to practice in the first year. One of the outcomes that was measured in this study was change in the Student Leadership Practice Inventory scores. The new nurse graduates' scores improved significantly (p-value b 0.005) after attending the NNLI program. The overall post-scores for the NNLI subjects increased by 8.1% (p-value = 0.004). Further, a longitudinal study was conducted to compare selfreported changes in both frequency and quality of performance of nursing behaviors in new nurse graduates (N = 33) enrolled in a oneyear entry to practice program in a large Aotearoa/New Zealand metropolitan hospital (Roud et al., 2005). This study surveyed new graduate nurses at two points in time (seven weeks after beginning the program, and seven months after beginning the program) using a modified version of the Six-Dimension Scale of Nursing Performance. The study reported significant increases in the frequency of new graduate nurses' performance of leadership (p-value = 0.002) seven weeks and seven months after beginning the program. The study found no significant difference in quality of leadership behavior as measured by before and after program participation (p-value = 0.063). This study employed a small sample, representing an important limitation to generalizability of the findings. A Canadian study (Bérubé et al., 2012) developed a one-year nursing RP to facilitate the safe integration of new graduate nurses into critical care and its outcomes. This study found a 46% increase in the recruitment rate of newly graduated nurses compared to the period of

time before implementing the RP; the retention rate also increased by 26%. Similarly, a study conducted in United Arab Emirates (Nematollahi and Isaac, 2012) found that the RP helped inexperienced nurses with their transition to practice, thus improving their retention. An Australian study reported findings from a study of a nurse RP that was developed by a university and three mental health services. The program was developed to help new graduate nurses in the transition process from new graduate to beginning nurse (McCloughen and O'Brien, 2005). This study found the RPs to be important in helping new graduate nurses transition into professional roles and contributed to retaining new nurses in the mental health settings. Furthermore, a U.S. study, conducted by Goode et al. (2009), examined outcomes of 655 residents enrolled at three separate time periods (upon hiring, at six months, and at 1-year program completion) using four instruments, including the Casey-Fink Graduate Nurse Experience Survey, the Gerber Control Over Nursing Practice Scale, the McCloskey Mueller Registered Nurse Job Satisfaction Scale, and a Program Evaluation Scale developed by the research team. The study found statistically significant increases over the three time periods in the new graduate nurses' overall confidence in their skills (p-value = 0.000), their ability to organize and prioritize their work (p-value = 0.000), being comfortable communicating with team members, patients and families and in providing clinical leadership in their units (p-value = 0.000). Another study conducted in the U.S. by Kowalski, and Cross (2010) reported initial findings of new graduate nurses (N = 55) enrolled in a one-year RP at two hospitals in Las Vegas. The study found that the new graduate nurses' clinical competencies and critical thinking improved over time at 3, 6, 8 weeks and 3, 6, 8 months (p-value b 0.001), and improved communication/LS over time at 3 months (n = 37) and at 12 months (n = 14) (p-value = 0.022). Williams et al. (2007) also documented the1-year outcomes of the post-baccalaureate RP developed and implemented by the University Health System Consortium and the AACN. The data from two cohorts of residents (N = 679: Alpha residents, n = 486; Beta residents, n = 193) in 12 sites across the U.S. was analyzed at different times: at entry into the program, at six months, and at 1 year, using 3 instruments (the Casey-Fink Graduate Nurse Experience Survey, the Gerber's Control Over Nursing Practice Scale, and the McCloskey Mueller Satisfaction Scale). Findings indicate an improvement in outcomes compared to new graduate nurses from the time they entered the program to the time they completed it. The residents' ability to organize, prioritize, and communicate, as well as LS for both cohorts improved significantly. Further, a quasi-experimental study conducted at a U.S. Navy hospital reported the outcomes of a nurse internship program (Blanzola et al., 2004) by comparing an experimental group (n = 8) to a control group (n = 10). The study found that the experimental group (group of nurses enrolled in the nurse RP) scored significantly higher compared to the control group on organizational core competencies. In fact, these nurses were more comfortable with their leadership and management roles as a result of being in a RP. The limitation of this study is the extremely small sample size. Similarly, a study conducted by DeSimone (1999) found that an internship program for nurses improved new graduate nurses' perceptions of LS for nurses in the program. Each nurse enrolled in the internship program was assigned to a preceptor who provided the new graduate nurse with clinical expertise for patient care management. In this study, perceptions of leadership competencies were measured using the Leadership Performance Competence Profile. The study found that the perceptions of leadership competencies improved in all areas measured. Furthermore, a study conducted at two Wisconsin healthcare systems reported that there were improvements in the residents' (n = 5 in the Medical–Surgical unites, Cardiac/Critical Care n = 5 first cohort, n = 4 second cohort) professional nursing behaviors and LS at 6 and 12 months compared to baseline, using the Six-Dimensional Scale (Herdrich and Lindsay, 2006). However, this study had a small sample

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size, thus, statistical significance cannot be claimed, and findings cannot be generalized. Another study implemented a pediatric nurse internship program based on Halfer and Graf (2006) research to mentor and retain new graduate nurses in the first year of practice (Halfer et al., 2008). The study compared two cohort groups: (n = 84) new graduate nurses in the pre-implementation group hired between September 2001 and August 2002, and (n = 212) new graduate nurses in the postimplementation group hired between September 2003 and August 2005. In this study, the Halfer-Graf Job/Work Environment Satisfaction Survey was used to measure the new graduate nurse perceptions at different points in time. The study found that the outcomes that improved significantly over time were 1) understanding leadership expectations (from baseline to 18 months, p-value b 0.0001), 2) ability to manage the demands of the job (increased from baseline to 6months, p-value b 0.0001), and 3) using input to address unit issues (increased over time, p-value b 0.005). Furthermore, another study used the Halfer-Graf Job/Work Environment Nursing Satisfaction Survey to measure job satisfaction and engagement perceptions of new nurses after completing Interactive Nurse Residency (Anderson et al., 2009). This study used a mixedmethods design to compare (N = 90) residents' perceived job satisfaction and employee engagement after completing the RP. The study found that the new graduate nurses who completed the 1-year RP have improved perception about their ability to perform their job, identify resources, understand performance expectations, accomplish work tasks, and manage the demands of the job effectively. Conclusions The international nursing literature reinforces on-going interest and concerns about the practice readiness of new graduates. According to Bérubé et al. (2012) nursing RPs may contribute to meeting the needs of new graduate nurses to integrate them into high-acuity settings and to improve the quality of care provided in such settings. This study asserts the effectiveness of nurse RPs in promoting new graduate nurses' skills, clinical competence, confidence, retention, and satisfaction. In this study, the transition programs reduced turnover in that first year of practice and promoted professional growth of the new graduate such as CDM and LS. While unique from other research reported, these findings are consistent with others (Williams et al., 2007; Goode et al., 2009; Kowalski and Cross, 2010) that also assert the merit of RPs on new graduate nurse retention and performance (Bérubé et al., 2012; Olson-Sitki et al., 2012; Anderson et al., 2009; Fink et al., 2008; Scott et al., 2008; Valdez, 2008; Halfer et al., 2008). Confounding these findings is Roud et al. (2005) study that was not able to identify a significant relationship between RP and nurse performance (Roud et al., 2005). According to the Canadian Institute for Health Information (2012), RPs vary by program components such as educational content and approach, type of preceptorships, mentorships, and unit specific orientation. They also differ by program length and the number, and type of clinical rotations (Rush et al., 2013). While there is wide anecdotal agreement that new graduate nurses need knowledge and competencies beyond those developed in nursing schools, there is no agreement on the best approach for acquiring new nurse competencies that are aligned with the work setting. The need/interest remains the same however, because of environments that continue to produce ever-changing complex health care systems, requiring the new graduate nurse to be able to apply his/her CDM and LS, integrate and apply them in practice (University Health System Consortium, 2006). Limitations of Current Research Studies The literature indicates considerable inconsistency in the description and content of nurse RPs and the methods utilized to rigorously


evaluate their impact. Further, studies vary widely in their overall design, research focus and findings. Research studies reported in this review have generated limited findings that contribute to conclusions about the relationship between nurse RPs and their results. Because of variation and limited research findings, the literature at present does not provide a body of work from which to identify ‘best practices’ for new graduate nurse RPs. In addition, while anecdotal assertions provide support for nurse RPs for improving nurses' skills, clinical competence, confidence, retention and satisfaction, there is as yet not a robust body of research to support albeit widely varying assertions reported. There remains a paucity of research on nurse's actual transition from student to practicing nurse and their integration/application of knowledge and skills from basic nursing programs to work settings. The nursing literature reports some studies on the relationship of RPs to new graduate CDM and LS, however findings and their generalizability are limited because of limitation in research methods utilized and small sample sizes.

Future Research Studies Recommended The majority of published studies assessed how a nurse RP has impacted clinical leadership skill only, satisfaction only, or nurse retention and turns over. There was no study that assessed the impact of RPs on the new graduate nurses' on both CDM and LS using multiple measurements over time since their enrollment in the program. Further, having a control group that is not exposed to a RP will provide a true comparison between groups. Overall, there is a need for proper designed quasi-experimental studies (Anderson et al., 2012), and mixed method designs. In addition, conducting correlational studies would assist nursing administrators and educators in understanding what are the best predictors of nurses' RPs success and cost-effectiveness. Most importantly, there is a need to have a standardized definition of what a RP is, the length of the program, and who is the target population. Should a RP aimed towards new nurse graduates only or should it consider registered nurses who are transitioning to a new role in their profession. There is a lack of evidence about the impact of nurse RPs on health care organizations, which is a significant aspect that needs to be addressed in future research. Therefore, there is an urgent need to explore the impact of RPs on new graduate nurses' CDM and LS over time in experimental type of designs using large sample sizes.

Implications for the Nursing Profession Nurse RPs help the new graduate nurse in skills acquisition. This review supports the importance of implementing and standardizing a nurse RP for new graduate nurses to promote the development of competencies and to support their transition process while promoting positive clinical learning environment. Further, there is an urgent need to implement standardized RPs to be able to research the influence on such program on the transition of new graduate nurses and to support the safety and effectiveness of their patient care. This issue is complex; thus, nurse educators and administrators should consider implementing nurse RPs based on evidence-based approaches to make available structured and systematic programs. In addition, there is a need to improve communication between academia and health care organizations in order to address the gap between education and practice. Finally, new graduate nurse retention is crucial and cost-effective; nurse RPs may help to prevent avoidable turnover among new nurse graduates within the first year of practice. Thus, it is imperative that nurse managers seek funding to support such programs.


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The impact of residency programs on new nurse graduates' clinical decision-making and leadership skills: a systematic review.

Health care institutions have adapted residency programs to help new graduate nurses to become fully competent and transition from a student nurse to ...
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