What is the the level of evidence and describe the theoretical…

Question Answered step-by-step What is the the level of evidence and describe the theoretical… What is the the level of evidence and describe the theoretical bases for this study, if there is not one mention that.What is the validity and reliability of the measurement tools used? Ackerson, K., & Stiles, K. A. (2018). Value of nurse residency programs in retaining new graduate nurses and their potential effect on the nursing shortage. The Journal of Continuing Education in Nursing, 49(6), 282-288. https://doi.org/10.3928/00220124-20180517-09Historically, the United States has seen a cyclical trend in nursing shortages, which is not predicted to change. Fifty-five percent of the nursing work-force is over the age of 50 years and more than 1 million RNs will reach retirement age in the next 10 to 15 years (Budden, Zhong, Moulton, & Cimiotti, 2013). Limited retention (ability to keep employees), especially of newly licensed nurses, increases vacancies and organizational costs, possibly affecting the nursing shortage. According to the National Healthcare Retention & RN Staffing Report (NSI Nursing Solutions, 2016), nurse vacancies increased to 8.5% in 2015, a 1.3% increase from the previous year. Some hospitals have greater than 10% nurse vacancies (NSI Nursing Solutions, 2016) The national average 1-year turnover rate (the rate that nurses leave an organization and are replaced) among all newly licensed RNs is 17.1% (NSI Nursing Solutions, 2016), and the 2-year turnover rate is 33.5% (Kovner, Brewer, Fatehi, & Jun, 2014).The average cost of turnover for a bedside RN is estimated to be between $37,700 and $58,400 (NSI Nursing Solutions, 2016). These costs are incurred from overtime payment to existing staff, hiring temporary staff, closing beds, and new staff training and orientation. One strategy to address retention and turnover in new graduate nurses (NGNs) is the implementation of a nurse residency program (NRP).Many NGNs are not prepared for the fast-paced, high-acuity health care environment (Twibell & Pierre, 2012). The complexity of the environment often leads to high stress levels for the new RN and as a result leads to higher turnover. As NGNs enter professional practice, they require additional resources to enable a smooth and successful transition from student to professional. One resource is an NRP, which focuses on providing not only additional skills and knowledge but also the peer support and mentorship needed for the transition. Therefore, the purpose of this review was to explore what the literature informs us regarding the implementation of NRPs in acute care settings and their ability to retain nurses.MethodA search was conducted using Cumulative Index to Nursing and Allied Health Literature (CINAHL)®, Ovid Nursing Journals®, and ProQuest Health and Medical Complete® databases. A combination of keywords was used, which included nurse residency programs, retention rates (RR), and nursing turnover. Articles had to be primary research or reporting NRP outcomes and published in peer-reviewed academic journals within the past 10 years. Articles were included if they involved an NRP specifically for NGN in an acute care hospital setting in the United States. The research also had to address RR or turnover in the outcomes. Articles were excluded if programs were not in a hospital setting, included more than just new graduate RNs, or focused solely on a specialty area such as critical care. Grey literature (i.e., technical reports, government documents, and evaluations) were not included in this review. A literature search strategy was employed, limits applied, and results recorded (Table 1). The results were a mix of quantitative and qualitative research, along with reports on program outcomes. After the searches were completed with the limits applied, database results were referenced for repeat articles and abstracts reviewed for inclusion-exclusion criteria. This resulted in 42 articles retrieved for review.The relevant articles were examined, and several were eliminated. Eliminated articles either addressed a mentorship program instead of formally described NRP or program specific to a specialized area of nursing with program components not comparable to NRP. Following detailed article screening, 26 were found to fit the review criteria.ResultsTable A (available in the online version of this article) summarizes the articles reviewed. Of the 26 articles, the majority used descriptive designs (n = 21; 80.8%), followed by mixed methods (n = 2; 7.7%), outcome (n = 2; 8%), and quasi-experimental (n = 1; 3.8%).NRPInternally developed programs were reported in nine (34.6%) of the studies. Of these internally developed programs, four (44%) were developed based on a theoretical framework. Theoretical frameworks used were Benner’s novice to expert and Dreyfus’s theory of skill acquisition (Altier & Krsek, 2006), Donabedian’s constructs of structure, process, and outcome (Newhouse, Hoffman, Suflita, & Hairston, 2007), Benner’s novice to expert, Bridges’ transition management and Kolb’s experiential learning cycle (Olson-Sitki, Wendler, & Forbes, 2012), and stages of transition theory (Varner & Leeds, 2012).Seventeen (65%) studies reported using established programs, the majority of which (n = 10; 59%) used the University Healthsystem Consortium/American Association of Colleges of Nursing Program (UHC/AACN; Fiedler, Read, Lane, Hicks, & Jegier, 2014; Goode, Lynn, Krsek, & Bednash, 2009; Holland & Moddeman, 2012; Krugman et al., 2006; Maxwell, 2011; Pine & Tart, 2007; Rosenfeld & Glassman, 2016; Rosenfeld, Glassman, & Capobianco, 2015; Setter, Walker, Connelly, & Peterman, 2011; Williams, Goode, Krsek, Bednash, & Lynn, 2007). Other programs used were the Versant RN Residency Program (Baldwin, Black, Normand, Bonds, & Townley, 2016; Ulrich et al., 2010) and the Wisconsin NRP (Bratt, 2009; Bratt & Felzer, 2012). The UHC/AANC and Versant RN Residency Program are based on Benner’s theory of novice to expert. The Wisconsin NRP is based on Benner’s theory and Duchsher’s transition theory. Both the UHC/AACN and Wisconsin NRP require an academic partner. One study reported using a formal NRP but did not provide what that was (Harrison & Ledbetter, 2014). Two studies reported using outside agencies to provide the NRP (Hillman & Foster, 2011; Trepanier, Early, Ulrich, & Cherry, 2012)NRP Retention and TurnoverRetentionOf those studies that reported retention rates, regardless of the NRP used (established versus internally developed), reported improved RR. Small differences were noted in RR between internally developed NRPs and established NRPs. Internally developed programs, regardless of whether the program was based on theory, average RR was less than NRPs using established programs by 2.77% (Table 2). Of the 18 (69%) studies providing information on RR, only one study used a control group (Newhouse et al., 2007). Significant differences were noted in RR when comparing the NRP group with the control group. The NRP group had greater RR (88.9%) compared with the control group (80%; p = .014). Five studies (19%) compared pre- and post-NRP RR (Anderson, Linden, Allen, & Gibbs, 2009; Baldwin et al., 2016; Dyess & Parker, 2012; Hillman & Foster, 2011; Maxwell, 2011). However, the differences between pre- and post-NRP RR were not statistically analyzed in any of those studies. The remaining studies simply provided NRP RR (Altier & Krsek, 2006; Bratt, 2009; Bratt & Felzer, 2012; Friday, Zoller, Hollerbach, Jones, & Knofczynski, 2015; Goode et al., 2009; Holland & Moddeman, 2012; Kowalski & Cross, 2010; Medas et al., 2015; Pine & Tart, 2007; Rosenfeld et al., 2015; Rosenfeld & Glassman, 2016; Setter et al., 2011). Although all these studies reported improved RR, the study that used a comparison (e.g., control) group provides a better understanding of NRP RR effectiveness.TurnoverAn important factor in evaluating the effectiveness of an NRP is turnover. Turnover rates were reported in nine (35%) of the studies (Fiedler et al., 2014; Harrison & Ledbetter, 2014; Krugman et al., 2006; Olson-Sitki et al., 2012; Pine & Tart, 2007; Trepanier et al., 2012; Ulrich et al., 2010; Varner & Leeds, 2012; Williams et al., 2007). Turnover was not defined in any of these studies. However, three studies provided explanation on how turnover was measured for that study. One study divided the number of nurse residents who left by total number of nurse residents who stayed (Fiedler et al., 2014). Trepanier et al. (2012) indicated turnover was the number of NGNs leaving before 12 months postresidency by total number of resident nurses who completed residency. The last study measured turnover by termination rate (Williams et al., 2007). Pre-NRP with post-NRP turnover rates were compared in four studies, reporting decreased turnover (Olson-Sitki et al., 2012; Pine & Tart, 2007; Trepanier et al., 2012; Ulrich et al., 2010). The rates of turnover after NRP implementation ranged from a low of 6.41% (Trepanier et al., 2012) to a high of 13% (Pine & Tart, 2007). Statistical significance in turnover pre- and post-NRP was not reported in any of these four studies. Harrison and Ledbetter (2014) compared post-NRP turnover rates in three sites, one with a formal NRP, one with a transitional program, and the third with a comprehensive 3- to 6-month orientation. No significant differences in turnover among the three sites were found, although turnover decreased at all three sites. Possibly having a program directly aimed at providing NGNs with additional skills and learning opportunities helps to decrease turnover. The remaining studies (15%; n = 4) reported only post-NRP turnover rates (Fiedler et al., 2014; Krugman et al., 2006; Varner & Leeds, 2012; Williams et al., 2007).Two-Year RetentionSeveral studies documented RR at 2 years posthire (Anderson et al., 2009; Bratt, 2009; Fiedler et al., 2014; Friday et al., 2015; Ulrich et al., 2010; Varner & Leeds, 2012). Although positive outcomes were noted for first year RR, most traditional 12-month NRP have minimal effect on 2-year RR. Anderson et al. (2009) noted that a new NRP increased the 12-month RR; however, the 2-year RR did not improve, remaining at 70%. A possible reason that new nurses leave in year two may be that they are no longer benefiting from learning in a structured program or from a mentor. However, there were two studies that demonstrated improved 2-year RR (Bratt, 2009; Varner & Leeds, 2012). A 15-month-long program using the Wisconsin NRP (Bratt, 2009) demonstrated improved RR, with an average 83% 2-year RR. Prior to NRP implementation, some sites had rates as low as 50%. Varner and Leeds (2012) reported that an optional second-year program, referred to as the exploration phase, resulted in a 0% to 9% 2-year turnover rate. The exploration phase included quarterly meetings with debriefings, continuing education, and leadership development.Return on InvestmentReturn on investment compares the cost of implementing and sustaining the program to the net benefits of the NRP. Several studies revealed a positive return on investment. Pine and Tart (2007) compared replacement costs prior to the NRP (50% turnover) to replacement costs post-NRP (13% turnover), estimating a replacement cost savings of $823,680. Using an estimated cost of $50,000 per nurse, Hillman and Foster (2011) compared preresidency turnover costs with costs over 4 years postresidency, revealing $4 million in savings over the 4 years. Preresidency implementation turnover costs were estimated to be $17,977,500 and postresidency turnover $2,749,500, at savings of $15,228,000 (Trepanier et al., 2012). There were additional costs of $13,460 per NGNs in the residency program (versus traditional orientation), equating to a total cost of $7,053,040 for the 524 NGNs in that study. Factoring in additional costs and savings in turnover and contract labor, the total cost benefit was between $8.1 million and $41.7 million (Trepanier et al., 2012).Measurement ToolsTo evaluate NRP effectiveness, a variety of measurement tools were utilized. Some tools utilized had established reliability and others were internally developed, with no reported reliability or validity testing. The three most commonly used tools were the Casey-Fink Graduate Nurse Experience Survey (CFGNES; α = .89; n = 10, 38%), the McCloskey-Mueller RN Job Satisfaction Scale (MMSS; α = .79. to .89; n = 7, 27%), and the Gerber Control Over Nursing Practice scale (CONP; α = .89 to .96; n = 3, 12%).The CFGNES is a 24-item scale with five subscales and Likert-style responses (1 = strongly disagree to 4 = strongly agree). Nurse resident experiences are measured in five areas: (a) support, (b) patient safety, (c) stress, (d) communication and leadership, and (e) professional satisfaction (Kowalski & Cross, 2010). Five studies reported over-all scale significance for that study (Friday et al., 2015; Goode et al., 2009; Harrison & Ledbetter, 2014; Olson-Sitki et al., 2012; Williams et al., 2007). In evaluating individual subscales regarding NGN experiences, subscales found to be significant were support, stress, communication and leadership, and professional satisfaction (Goode et al., 2009; Holland & Moddeman, 2012; Kowalski & Cross, 2010; Olson-Sitki et al., 2012; Williams et al., 2007). Stress was found to significantly decrease from entry to exit (Goode at al., 2009, p = .014; Williams et al., 2007; p ⩽ .05). Other studies reported a decrease in stress throughout the program (time 1, time 2, time 3), but the decreases were not statistically significant (Krugman et al., 2006; Maxwell, 2011). Professional communication significantly increased from entry to exit (Holland & Moddeman, 2012, p ⩽ .001; Kowalski & Cross, 2010, p = .022) and from the 6-month time point to exit (Olson-Sitki et al., 2012). However, professional satisfaction dipped significantly at the 6-month time point, with no significant change at exit (Goode et al., 2009, p = .000; Williams et al., 2007, p ⩽ .05). Holland and Moddeman (2012) found that professional satisfaction had a downward trend, significantly decreasing from start to exit (p = .037). One possible explanation might be that the new nurses may not feel engaged or feel fully competent at this time point (6 months and 12 months), thus decreasing professional satisfaction.A 31-item scale, the MMSS measures nurses’ career satisfaction, with Likert-style responses (1 = very dissatisfied to 5 = very satisfied) in eight subscales: (a) extrinsic rewards, (b) scheduling satisfaction, (c) family and work balance, (d) coworkers, (e) opportunities for social contacts, (f) professional responsibilities, (g) praise recognition, and (h) control and responsibility. (Fiedler et al., 2014). Overall, scale significance was reported in two studies (Goode et al., 2009; Williams et al., 2007). Both studies used the MMSS at program start at 6 months and 12 months. At the 6-month evaluation time point, the mean scores was lower, indicating decreased overall satisfaction at midpoint, increasing at exit (Goode et al., 2009, p = 0.000; Williams et al., 2007, p = .05). Altier and Krsek (2006) found that opportunities for social contacts (p = .007) and praise recognition (p = .001) decreased from start to finish. To correlate job satisfaction and intent to leave, both Medas et al. (2015) and Setter et al. (2011) used the MMSS scale and correlated it with an investigator-developed scale. The analysis revealed satisfaction was statistically significant with intent to stay (p = .05; p = .000, respectively). The only statistically significant finding Fiedler et al. (2014) found among the three cohorts was in scheduling satisfaction, with one cohort more satisfied than the other two (p = .027).CONP, used to measure freedom and power to make autonomous decisions in one’s nursing practice, is a 21-item survey with Likert-scale responses ranging from 1 = disagree to 7 = agree, with three subscales: clinical leader, evaluation, and skillful team member (Krugman et al., 2006). Significant differences were found between time points, with scale scores lower at midpoint compared with entry and exit (Goode et al., 2009, p = .05; Williams et al. 2007, p = ⩽ .05). Krugman et al. (2006) found similar results, with new nurse residents rating their autonomy high at the beginning and end of residency but rated it lowest 6 months into residency. Outside of a figure in their report, no specific significant values were provided.DiscussionIn addressing the purpose of this review, we found that NRPs in acute care settings are successful in retaining NGNs, which decreases organizational costs. However, the success in keeping NGNs was only at the 1 year mark. Most organizations used formal, established programs, with a smaller percentage using internally developed programs. However, based on the average RR between established and internally developed programs, the differences were small. Well established evidenced-based NRP programs, such as the UHC/AACN and Versant, had slightly higher RRs, compared with internally developed programs without a defined theoretical basis (90.3% versus 87.5%, respectively). These results indicate that the effectiveness of the program may not be due to the use of an established program based on a theoretical framework, but rather to the content of the NRP. Some internally developed programs included a social aspect for the NGN that allowed them time to debrief and share experiences with other cohort members. This appears to be an important NRP component, as evidenced by significantly lower MMSS scores at a site that did not offer monthly support sessions and debriefings (Krugman et al., 2006).Several programs based their program either on Benner’s novice to expert theory or on two or more theories, with Benner’s theory being one of them (n = 18, 69%). Benner’s (1984) framework provides a model to structure the transition from student to professional nurse. The five proficiency stages are novice, advanced beginner, competent, proficient, and expert. An advanced beginner is a nurse with some prior experience who is efficient in parts of the practice area but does not have in-depth knowledge, requiring some supportive cues. This phase is appropriate for the first year of NGN employment. An advanced beginner needs to concentrate on learned rules, making it difficult to see the big picture, and nurses in this phase require support to prioritize and to think critically (Benner, 1984). Although many studies were based on this theory, the theoretical model may not be as relevant, given the drastic changes that have occurred in acute care nursing over the past 30 years. For example, health care delivery has changed, and hospitalized patients are more complex than they were 30 years ago. NRP outcomes used, based on this theoretical framework, may not be representative of NGNs working in acute care settings currently and in the future. To determine the representativeness of Benner’s novice to expert theory in today’s NGNs, empirical research may be needed.All NRPs included in this review, regardless of the model, resulted in improved retention. Even one of the shortest programs (16 weeks; Hillman & Foster, 2011) had the lowest and greatest RR variation from the other studies, at 72.5%. One could speculate that the reason for the lower success of this program was the time frame, although Trepanier et al. (2012) reported on an 18-week program, with a turnover rate of 6.41% (below national average), which provided content that included didactic direct instruction, case studies, clinical immersion, competency validation, and looping to related departments. Whereas, the other program (Hillman & Foster, 2011) consisted of centralized and unit-specific courses, preceptor classes, and simulation. Both NRPs were internally developed, although only one was based on theory (Trepanier et al., 2012).For organizations to see value in implementing an NRP, evidence of return on investment must be demonstrated. Although an NRP can be expensive, findings demonstrate savings in recruitment and replacement costs result in favorable investment returns. RN replacement costs are estimated to be between 75% and 125% of a nurse’s salary, and it is estimated that health care organizations spend $300,000 annually for every 1% increase in nursing turnover (Jones, 2008). This is the most current source; however, cost estimates may be greater due to increases in average RN salary since the information was published.Tools to measure NGNs’ experiences should be selected based on the tool’s ability to measure its intended purpose. Their use provides insight, in part, into the outcomes of the NRP. Many of the studies used the CFGNES, a tool specifically developed to measure NGNs’ experiences entering the workplace and transition into the profession (Casey, Fink, Krugman, & Propst, 2004). However, the MMSS and CONP were not developed specifically to evaluate NGNs. The MMSS was developed to measure nurse satisfaction, but not specifically developed to measure new graduate nurse satisfaction (Tourangeau, McGillis Hall, Doran, & Petch, 2006). Job satisfaction in nurses new to the profession is most likely different than that of more experienced or seasoned nurses. In our search for articles providing information regarding reliability and validity testing of this tool on NGNs, nothing was found. CONP is commonly used in research to evaluate control over nursing practice. It was developed by Gerber, Murdaugh, Verran, and Milton in 1990 to measure nurses’ autonomy (Weston, 2009). However, it was not indicated that this tool was developed specifically for NGNs or if additional research was conducted to evaluate reliability when applied to NGNs. This tool was not used in any study evaluated for this report after 2007. A possible reason for this was that the tool may not align with NRPs.LimitationsThe levels of evidence available in this review were limited, and the methods used to evaluate the programs were weak. A majority of studies used a descriptive design. Although some studies had a comparison group, which provides information, they do not inform us on whether the NRPs’ effect is significant. Only one study in this review conducted a quasi-experimental study with a control group (Newhouse et al., 2007). Although descriptive and comparison studies are informative and have provided information toward understanding the benefits of these programs, these types of studies do not evaluate the effect of an NRP on nurse retention.Several studies that included retention and turnover rates pre-NRP with post-NRP initiation. However, not one study reported any statistics on the differences between the two time points. Even though the rates improved, it is not evident whether the differences were significant and of any importance outside of the rates provided.Retention and turnover were not defined in any of the studies. Some used retention and turnover as interchangeable terms. However, these terms are not interchangeable; they mean different things and are measured differently. Although retention may not necessarily need defining, turnover does. Turnover is determined by the number of nurses who leave the field and are replaced (Kovner et al., 2014). Depending on how data were measured, reported turnover rates can reflect different things. Although the findings indicated nurse turnover rates improved, the effects of the NRP on turnover can only be surmised, especially with no comparison or baseline data. Therefore, turnover rates provided in this review should be viewed with caution.Outside of the CFGNES, it is not evident from the information provided in the articles whether the tools used were developed to evaluate NGNs. If the tool selected was not developed for this population, then additional testing was needed prior to its use to ensure validity and reliability (Polit & Beck, 2014) and should have been identified. A majority of the authors reported Cronbach alphas with high values in the measurement tools they used, not always from their study but values from prior studies. However, that does not equate to the tool’s validity—is it measuring what it is supposed to measure (Polit & Beck, 2014).Comparing two different time points, such as retention before initiation of an NRP with retention post-NRP initiation would have provided more support to make inferences about the difference NRPs made. However, that was not done in any of the studies providing pre- and postretention or turnover rates.RecommendationsIt is evident, based on RRs, that NRPs positively affect retention at 1 year. Given that retention was not maintained at year two, it does not seem that NRPs will have much, if any, effect on the nursing shortage. Why retention rates were not maintained may have little to do with the NRP, but much to do with the culture of the organization once a new nurse is no longer involved in a structured program. A recommendation would be to qualitatively explore with NGNs who intend to leave and those who have resigned which factors influenced their decision. The information gleaned from those interviews may help administrators focus on the problem areas affecting retention. These interviews can also help develop a valid and reliable survey tool that can be used as a form of organizational retention evaluation.ConclusionThese studies do provide evidence of emerging trends that nurse residency programs that are beneficial to a new nurse. Organizational savings were also found at 1 year when retention was high; however, retention was not sustained. Therefore, the benefit to the organization at year one may be lost by year two. Maybe there are still savings (or break-even [balance between profit and loss]) even though retention is not there, but that analysis was missing. Health Science Science Nursing NURS 6052 Share QuestionEmailCopy link Comments (0)