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Graduate nurse experiences of support: A review
Nurse Education Today 40 (2016) 7–12
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Review
Graduate nurse experiences of support: A review Isabelle Gardiner ⁎, Jade Sheen 1 Deakin University, Building HC, 221 Burwood Highway, Burwood, VIC 3125, Australia
a r t i c l e
i n f o
Article history: Accepted 20 January 2016 Keywords: Graduate nurse Graduate nurse program Support Education Stress Feedback
s u m m a r y The first year of practice as a nurse is recognized as stressful. Graduate nurses (GNs) report gaps in their education, reality shock, burnout and other negative experiences that influence their intentions to remain in nursing. Objectives: The aim of this literature review was to gain a greater understanding of the experiences of GNs. Review methods: It included thirty-six articles that focused on GNs and their transition to nursing, as part of a graduate nurse program (GNP), from 2005 to present. Result: The review identified three main themes that influence the transition from student to registered nurse. These themes included, 1) feeling stressed and overwhelmed by nursing responsibilities, 2) the amount of support from senior nurses and 3) the importance of feedback on their performance as nurses. Conclusions: Further research that is focused on the support and feedback provided to new nurses is needed. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction Nursing is recognized as a demanding profession and the transition from student nurse to registered nurse can be a challenging time. The first year and initial experiences of nurses have been shown to influence their intention to remain in nursing (Scott et al., 2008). In Australia, (and other countries including United Kingdom and Canada), first year nurses who have completed a university degree are referred to as Graduate Nurses (GNs). A bachelor of nursing is a three-year degree that includes practical and theoretical classes at a university and clinical placement at hospitals. GNs are fully qualified registered nurses, however there have been concerns raised over the adequacy of their education in preparation for work readiness. GNs have reported marked discrepancies between what they were taught at university and the reality of nursing (Duchscher, 2009; Evans et al., 2010). This has been shown to cause stress and a reality shock for new nurses (Martin and Wilson, 2011). Reality shock is experienced when after years of preparation for specific employment a new employee suddenly discovers they are not prepared at all (Harwood, 2011). Such negative experiences potentially stem from, and are influenced by, the theory-practice gap. The theory-practice gap refers to incongruence between theoretical content taught in university and the realities of clinical practice (Harwood, 2011; Scully, 2011). This gap was identified when nursing education was moved from hospitals to universities in the 1980s (Evans et al., 2010; Harwood, 2011; Kelly
⁎ Corresponding author. Tel.: +61 423 945 700. E-mail addresses: [email protected] (I. Gardiner), [email protected] (J. Sheen). 1 Tel.: +61 9251 7634.
http://dx.doi.org/10.1016/j.nedt.2016.01.016 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
and Ahern, 2009). Clinical placements in hospitals form part of the university curriculum, and are often the only opportunity for students to perform patient care and practice clinical skills in a non-simulated setting prior to registration. For many Australian students their total clinical placements over a three year degree make up approximately 25 weeks (Phillips et al., 2014). Furthermore, with universities reporting issues in providing appropriate and high quality clinical placements for students, it is possible to see how gaps in learning can arise (Andre and Barnes, 2010; Harwood, 2011). To overcome this gap, many hospitals offer a non-compulsory graduate nurse program (GNP) to assist and support GNs in their transition (Andre and Barnes, 2010). GNPs are often twelve months in length. They are run at the discretion of the organization and offer varying amounts of support and opportunities. These programs are designed to be supportive and to build the confidence and competence of GNs as they develop professionally. Despite these programs being in place for a number of years, GNs continue to report high levels of stress, emotional exhaustion and disillusionment in their chosen profession (Haggerty et al., 2013). GNs have reported lack of support and supervised learning opportunities during GNPs. This is concerning as skills performed without support dramatically increase the chance of an error occurring (Australian Nursing Federation, 2009; (Saintsing et al., 2011). These errors can cause various complications that may lead to longer patient stays and potential morbidity, which are costly for patients and hospitals. Factors influencing GN errors include, stress, gaps in education, low confidence and poor communication with other health professionals (Andre and Barnes, 2010; Saintsing et al., 2011). In addition, GNs have reported low confidence in their clinical ability and have reported concerns for the safety of patients in their care. Managers and organizations share these safety concerns (Australian Nursing Federation, 2009). There is a dearth of
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literature regarding the implications of these safety concerns and associated consequences for patients and also nurses. To assist transition many GNP often commence with an orientation followed by a variable number of days working with a senior nurse. After this workplace introduction, the GN is given a full workload of patients, along with the accountability, liability and responsibility for their care (Andre and Barnes, 2010). Added to this responsibility is the observation that patient acuity is increasing due to the growing number of patients with complex comorbidities as well as the expanding and aging population (Andre and Barnes, 2010; Needleman, 2013; Tschannen and Kalisch, 2009). GNs are confronted with new and complex medical interventions as part of their everyday patient care, which can be overwhelming. This can lead to stress, if stress is not addressed and managed, it can lead to burnout of GNs. Burnout and job dissatisfaction have been found to increase turnover and reduce staff retention (Rudman and Gustavsson, 2011). Furthermore, GNs report professional relationship problems with other nurses. Some report negative cultures of bullying and unsupportive workplace environments (Laschinger et al., 2009). Newly qualified nurses are the future of the profession and are central to health care delivery. With GNs continuing to feel isolated and excessively stressed, there is a growing need to understand their experiences in order to ascertain what can be done to improve GN transitions and retention of nurses. This literature review aims to address some of these concerns by answering the following questions: • What is currently known about the experiences of graduate nurses? • What does the literature indicate regarding support provided to nurses undertaking graduate programs? • What factors have been shown to assist graduate nurses in their transition to practice? • What methods have been used to study graduate nurses' experiences?
2. Method The search terms were extracted from the above questions. The search terms used are presented in Table 1, along with alternative search terms, including truncation as indicated by *. A search was undertaken using CINAHL, Medline, PSYCHinfo and Scopus with the search terms presented in Table 1. No significant results were found from gray literature, however, 4 additional articles were identified from the final selected articles' reference lists. The results were exported into endnote where they were screened by title and abstract. They were evaluated using the inclusion and exclusion criteria in Table 2. Fig. 1 shows the selection process of the final 36 articles that were analyzed in this review.
Table 1 Search terms and alternative terms. Search term
Alternative terms
#1 graduate nurse
“graduate nurs*” OR “new* nurs*” OR “new* registered nurs*” OR “novice nurs*” OR “first year nurs*” OR “new* qualified* nurs*” support* OR program OR “graduate year” OR “first year” OR orientation OR residency OR transition OR preceptor* OR supervis* OR clinical experience* OR feedback OR practice OR learn* OR stress* OR “reality shock” medical OR patient* OR family OR carer
#2 support
#3 experience #4 NOT #5 #1 AND #2 AND #3 NOT #4
Table 2 Inclusion and exclusion criteria. Included
Excluded
• Studies focusing on participants who • Published in English language were not graduate nurses e.g. Student • Published 2005 — present nurses or nurse managers • Peer reviewed • Single participants of personal reflec• Full text tions or editorials • Qualitative and/or quantitative • Studies focused on graduate nurse methods of studying graduate programs different from Australia nurse experiences • Not directly related to the research • Studies focused on graduate nurse questions programs and nurse training that • Not published in English are comparative to Australia e.g. USA, and Canada
3. Results The studies that met the inclusion criteria are summarized in Table 4. It can be seen from Table 3 that the most common method of studying GN experiences was individual interviews, followed by the use of surveys and questionnaires. It is interesting to note that mixed method approaches have also been utilized. 4. Discussion Three dominant themes that were relevant to the research questions emerged from this literature review. These were firstly, stressful experiences, secondly, the need for a supportive environment and thirdly, constructive feedback during the transition to practice. 4.1. A Stressful experience Stress was a common experience of GNs. This section will discuss three themes that influenced stress. They include incidence of burnout, feeling unprepared and overwhelmed by responsibility, and finally, bullying amongst nurses. The most frequently reported experience of GNs during their first year of nursing was stress (Horsburgh and Ross, 2013; Johnstone et al., 2008; Kelly and McAllister, 2013; Laschinger, 2012; Lavoie-Tremblay et al., 2008a,b; Parker et al., 2014; Phillips et al., 2014). GNs reported high levels of physical and psychological stress, which can lead to burnout (Duchscher, 2009; Kelly and Ahern, 2009; Lavoie-Tremblay et al., 2008a, 2008b; Martin and Wilson, 2011; Parker et al., 2014). Burnout is defined as emotional exhaustion resulting from sustained stress (Rudman and Gustavsson, 2011). Sources of stress for GNs include, but are not limited to, feeling unprepared, overwhelmed, unsupported and concerned for their patients' safety. High levels of emotional exhaustion have been found to correlate with an intention to resign leading to increased nurse turnover (Cleary et al., 2013; Laschinger, 2012; Laschinger et al., 2009; Lavoie-Tremblay et al., 2008a; Rudman and Gustavsson, 2011). Rudman and Gustavsson (2011) estimated that at least one in five nurses will experience high levels of burnout at some time during their career. A further concerning finding was that the highest levels of burnout were reported by younger nurses (b35 years), (Rudman and Gustavsson, 2011). Many GNs report excitement and enthusiasm on commencement of their GNP. However, these feelings can change to anxiety and dread (Duchscher, 2009; Dyess and Sherman, 2009; Kumaran and Carney, 2014). GNs report feeling unprepared, lacking confidence, knowledge and skills to perform adequate patient care (Danielson and Berntsson, 2007; Duchscher, 2009; Evans et al., 2008; Ferguson, 2011; O'Shea and Kelly, 2007; Parker et al., 2014). These fears are heightened by the GNs' knowledge of new responsibility and accountability for their patients (Lavoie-Tremblay et al., 2008a; Lavoie-Tremblay et al., 2008b; O'Shea and Kelly, 2007).
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Fig. 1. Literature review process.
The workload of the GNs was repeatedly reported as heavy and unmanageable. Increasing patient acuity on wards was recognized as a stressor for GNs (Duchscher, 2009; Dyess and Sherman, 2009; Halfer and Graf, 2006; Johnstone et al., 2008; Lavoie-Tremblay et al., 2008a, 2008b; Phillips et al., 2014; Scott et al., 2008). Caring for patients who require full assistance, and the increasing numbers of patients with complex co-morbidities, can lead to physical and emotional exhaustion of GNs (Evans et al., 2008; Laschinger, 2012; Lavoie-Tremblay et al., 2008a, 2008b; Parker et al., 2014). GNs also experienced stress from interactions with other nurses. Most negative interactions stemmed from other nurses being perceived as unavailable or disinterested in helping GNs (Beecroft et al., 2006; Johnstone et al., 2008; Parker et al., 2014; Saghafi et al., 2012). Some GNs reported experiencing bullying or horizontal violence directly (Dyess and Sherman, 2009; Evans et al., 2008; Kelly and Ahern, 2009; Parker et al., 2014; Rush et al., 2014). Horizontal violence is hostile or aggressive behavior towards an individual within the same work group (Dyess and Sherman, 2009). Such behaviors are often displayed as power games, with one individual being ignored or excluded. It also Table 3 Methods used to study graduate nurse experiences. Method
Frequency (%)
Individual interview Survey/questionnaire Focus group Survey/questionnaire + focus group Individual interview + focus group Survey/questionnaire + individual interview Survey/questionnaire + Individual interview + focus group Survey/questionnaire + reflective journal
14 (38.9) 12 (33.3) 3 (8.3) 2 (5.6) 2 (5.6) 1 (2.8) 1 (2.8) 1 (2.8)
includes general rudeness and incivility from some nurses (Johnstone et al., 2008). These negative behaviors have been shown to make GNs reluctant to approach and request assistance from senior nurses (Kelly and Ahern, 2009; Kelly and McAllister, 2013; Laschinger et al., 2009). Further, Rush et al. (2014) found that GNs who experienced bullying reported less access to support. Without the appropriate assistance from senior nurses, it is evident that this could negatively impact on patient care and outcomes. Lack of support from experienced nurses increases stress and hinders the transition from novice to competent nurse (Martin and Wilson, 2011). Encouragingly, GNs reported increased job satisfaction and reduced levels of stress when they felt welcomed and accepted as part of the nursing team (Ferguson, 2011; Halfer and Graf, 2006; Kelly and McAllister, 2013; Kumaran and Carney, 2014; Saghafi et al., 2012).
4.2. Supportive environments Three main themes emerged with regards to environmental support during GNPs. Firstly, adequate staffing skill mix and supervision of GNs, secondly, the use of preceptors and finally, the presence of educators. GNPs are often marketed as a supported transition in a positive learning environment. Many GNs report their expectations of their GNP were not met during the program. For example, Parker et al. (2014) and Lea and Cruickshank (2014) found many participants were promised support throughout their GNPs, which was not forthcoming or available. One factor that negatively impacted on GNs was problematic staffing, such as shifts where few, or no, experienced senior staff members were working. This left GNs feeling that there was no one to ask for support or help. These findings have been supported in other studies using a diverse range of methodologies over recent years (Cubit
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and Ryan, 2011; Danielson and Berntsson, 2007; Pineau Stam et al., 2015; Rush et al., 2014; Scott et al., 2008). It can be seen that inadequate supervision, lack of support and unaddressed learning deficits can lead to potential negative patient outcomes. Martin and Wilson (2011) found that the first months of GNs employment were associated with the highest rates of errors and mistakes. Safer and improved patient care was reported when GNs had experienced nurses available to support them (Ferguson, 2011; Horsburgh and Ross, 2013; Johnstone et al., 2008; Lewis and McGowan, 2015; Martin and Wilson, 2011; Pineau Stam et al., 2015). Strategies such as the implementation of preceptors can assist the GN to feel supported and become part of the nursing team by building positive relationships (Ferguson, 2011; Haggerty et al., 2013). A preceptor is intended to be an experienced nurse who has education or additional training in assisting students and new staff members (Haggerty et al., 2013). GNs reported that having someone to talk to and receive emotional and practical support from was highly beneficial (Cubit and Ryan, 2011; Danielson and Berntsson, 2007; Duchscher, 2009; Ferguson, 2011; Martin and Wilson, 2011). Social support has been shown to be an essential element in positively influencing retention of new nurses (Lavoie-Tremblay et al., 2008a, 2008b). When the GN is allocated a full patient load without assistance, the reality and responsibility of professional nursing can be a shock in contrast to the experience of being a student (Cubit and Ryan, 2011; Duchscher, 2009; Kelly and Ahern, 2009; Martin and Wilson, 2011). During undergraduate clinical experiences, student nurses remain under the direction of registered nurses who supervise all patient interactions and are available to advise and provide feedback and evaluation. Evans et al. (2008) found that participants reported this stark contrast in availablity of supervision, as distressing and frustrating. Other nurses described this time as one of vulnerability and as if the “safety net” had been removed (Johnstone et al., 2008). GNs have reported feelings of isolation and being alone when they commence GNPs (Dyess and Sherman, 2009; Ekström and Idvall, 2015; Evans et al., 2008; Horsburgh and Ross, 2013; Kelly and Ahern, 2009; Kelly and McAllister, 2013). This has led to suggestions that the most important time for support to be provided is in the first few months after graduation (Clark and Holmes, 2007; Duchscher, 2009; Evans et al., 2008; Lea and Cruickshank, 2014; Parker et al., 2014; Rush et al., 2014). Many GNPs start with an orientation to the work environment (Cleary et al., 2013; Dyess and Sherman, 2009; Ferguson, 2011; Scott et al., 2008). This is usually followed by a number of shifts shadowing an experienced nurse, (ideally a preceptor), while sharing a full patient workload. Marks-Maran et al. (2013) found that 83% of GNs in their study reported that their preceptor helped reduce stress at work. However, it has been reported that ensuring GNs work alongside their allocated preceptor is often not possible due to roster difficulties (Beecroft et al., 2006; Cubit and Ryan, 2011; Evans et al., 2008; Haggerty et al., 2013). Furthermore, many hospitals reported insufficient numbers of experienced or appropriately educated nurses to be preceptors (Evans et al., 2008; Johnstone et al., 2008). This may be linked to a lack of professional development available for the role, which often led to inappropriately selected preceptors, resulting in less than ideal outcomes (Haggerty et al., 2013). Haggerty et al. (2013) found several limitations in the use of preceptor, they include, negative relationships, lack of interest from preceptors, and preceptors being too busy with their own heavy workload to support the GN. These results are consistent with the research on outcomes of preceptor programs (Beecroft et al., 2006; Clark and Springer, 2012; Johnstone et al., 2008; Lea and Cruickshank, 2014; Ostini and Bonner, 2012; Parker et al., 2014). Many GNPs offer GNs more than one preceptor in order to ensure that there is support available for the GN when nurses have different rosters or leave commitments (Cubit and Ryan, 2011; Haggerty et al., 2013). This approach has had varying results. Some GNs reported this caused confusion and lack of consistency (Johnstone et al., 2008; Laschinger, 2012). In
contrast, others stated that they enjoyed being able to observe and learn from different nursing practitioners (Haggerty et al., 2013). Horsburgh and Ross (2013) described the allocation to a preceptor as random, with little consideration going into the allocation of preceptors, while some GNs were never allocated a preceptor at all (Ekström and Idvall, 2015; Ferguson, 2011). To assist GNs, many Australian GNPs offer clinical educators for additional support (Evans et al., 2008; Lea and Cruickshank, 2014; Ostini and Bonner, 2012; Parker et al., 2014). Educators do not have a patient load so are theoretically available to help GNs and provide targeted education for knowledge deficits (Evans et al., 2008; Parker et al., 2014). However, GNs reported being disappointed with the availability of educators, especially out of business hours. Out of hours was reported as a time when GNs felt particularly lost and unsupported (Evans et al., 2008; Ostini and Bonner, 2012). Lea and Cruickshank (2014) found that GNs stated there should be more educators available in order to meet their needs. Provision of adequate supportive educational measures for GNs in the clinical work environment, depends on adequate recognition, staffing and investment from the senior organizational level (Haggerty et al., 2013; Halfer and Graf, 2006; Phillips et al., 2014; Pineau Stam et al., 2015). Nurse managers and leaders are under immense pressure from budget and roster constraints that can negatively influence the environment GNs are exposed to (Duchscher, 2009; Haggerty et al., 2013; Johnstone et al., 2008). 4.3. Feedback assisting the transition A recurring theme is that GNs expect, and feel the need for, adequate acknowledgement and feedback during their GNP. This section will discuss the reported importance of feedback and what feedback was, (and conversely was not), given to GNs. Saghafi et al. (2012) found GNs reported that feedback was important in boosting their confidence. These findings were supported by the identification that feedback is an essential element of learning and central to assisting GNs in recognizing how their performance is perceived (Beecroft et al., 2006; Marks-Maran et al., 2013; Wangensteen et al., 2008). GNs valued friendly and respectful conversations regarding their progress and performance (Beecroft et al., 2006; Haggerty et al., 2013). When feedback was delivered abruptly and without adequate consideration to context or timing, it was more likely to be viewed as unhelpful, and potentially damaging to the GN's confidence (Haggerty et al., 2013; Wangensteen et al., 2008). Johnstone et al. (2008) found that the commencement of GNPs was the time GNs wanted feedback most in order to build their confidence. There was an overwhelming number of GNs who reported that they lacked sufficient feedback in their GNPs (Duchscher, 2009; Parker et al., 2014; Phillips et al., 2014; Saghafi et al., 2012; Wangensteen et al., 2008). When feedback was lacking or absent, a cycle of selfdoubt and isolation can arise which leads to reduced confidence (Duchscher, 2009). Furthermore, the absence of feedback has been reported to contribute to anxiety for GNs as they worried about their progress and performance (Marks-Maran et al., 2013; Ostini and Bonner, 2012; Wangensteen et al., 2008). Some GNs assumed that the absence of feedback was an indication that they had not made any major mistakes (Parker et al., 2014; Phillips et al., 2014). As indicated in the findings of Pineau Stam et al. (2015) and Wangensteen et al. (2008), GNs stated that they were open to constructive criticism and stated that negative feedback was better than no feedback. Furthermore, GNs were requesting more regular and frequent feedback to help them feel supported and reinforce their learning (Duchscher, 2009; Parker et al., 2014; Saghafi et al., 2012). Laschinger et al. (2009) stated that an important factor of GN transition is their level of work empowerment. Work empowerment refers to an employee's ability to access support, feedback and information that they require in order to fulfill their role. High levels of work
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empowerment have been found to correlate with decreased levels of burnout and stress (Ekström and Idvall, 2015; Laschinger, 2012; Pineau Stam et al., 2015). From the literature it is evident that GNs experience positive transitions to nursing when they receive adequate and appropriate support into their new role and environment (Duchscher, 2009; Parker et al., 2014). In addition, the provision of feedback and supervision may decrease stress and anxiety. It is in the community's best interest to invest in successful transitions of GNs as they will be caring for the most vulnerable and sick. Safe and supported transition programs could assist in promoting patient safety. 5. Limitations This review included articles that utilized quantitative and qualitative methods. Including both quantitative and qualitative articles in the review allowed for a broad understanding of the methods and samples. The results varied depending on method used, which prevented easy comparison between articles. As can be seen in Appendix 1, sixteen studies had sample sizes of less than twenty. While some of the sixteen stated that they reached saturation in data collection, others were unable to recruit enough participants to generalize their findings to the population of GNs. The studies with small sample sizes often used individual interviews. Some interviews were described as semi structured while other studies did not define the method or structure. A further limitation regarding the samples was that they were often recruited by convenience from the same program or hospital. This did not provide a great variation in programs offered, therefore making it hard to know if these experiences are unique or similar to GNs outside that particular hospital. While the literature showed that GNs reported stress and anxiety, these feelings have most commonly been reported and studied by qualitative measures, for example, from interviews or focus groups. Occasionally they were measured to see if there are relationships with other factors, but were often reported subjectively. Qualitative findings are important in directing what areas of GN experiences can be studied with further tests that are valid and reliable. The area of feedback, (which has been repeatedly reported as playing an important role in GNs transitions), has not been studied in detail. There is much that is unknown regarding the topic of feedback. The amount, type, timing and approaches of feedback have not been the focus of research with respect to GNs. There is a need to understand the feedback process and how it might be implemented in a more systematic way. The application of a quantitative method focusing on feedback is an area for further research. It might also be beneficial to include a stress scale in order to discover if a relationship exists between feedback and stress. Including open-ended questions could help obtain extra details regarding feedback experiences, and create a mixed methods approach. The findings could be generalized to a greater degree if recruitment included GNs from a variety of programs and hospitals. 6. Conclusions GNs continue to report lack of support and difficult working environments that are resulting in high levels of stress. GN transitions are more likely to be positive when they are welcomed and supported by the nursing team. Supportive preceptors and educators have been shown to assist GNs in their transition to competent nurses. However, there appears to be a lack of appropriate preceptors available for support and supervision of GNs. Furthermore, there are workload pressures preventing preceptors from adequately supporting GNs. GNs valued regular and honest feedback regarding their performance and progress. Feedback and supervision are particularly important in the first few months of the GNP. This requires supporting colleagues to have adequate knowledge, skill and time to spend with
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GNs in order to supervise and assess them. The environments where GNs are placed vary considerably in the amount of support offered and their treatment of GNs. The provision of adequate support for GNs leads to increased confidence and job satisfaction. Nursing leaders and management need to encourage and develop friendly and supportive environments. Awareness and additional resources are required to ensure experienced nurses are able to engage and support GNs. Supportive nursing environments that facilitate successful transitions benefit GNs, hospitals and patients. There is a need to understand more about GNs experiences particularly those that involve feedback and support. Such research may guide and direct education for future preceptors and devise better ways to support the novice nurse in becoming an expert practitioner. Appendix 1
Table 4 Studies included in literature review. Study
Focus
Methods and sample size
Beecroft et al. (2006) Clark and Springer (2012) Clark and Holmes (2007) Cleary et al. (2013) Cubit and Ryan (2011) Danielson and Berntsson (2007) Duchscher (2009) Dyess and Sherman (2009) Ekström and Idvall (2015) Evans et al. (2008) Ferguson (2011)
GN relationships with preceptors Lived experience of GN
Questionnaire (n = 318) including and Dorey open ended questions Focus groups (n = 37, n = 9 groups)
Expectations of GN and competency GN views of nursing
Focus groups (n = 105, n = 12 groups), interviews (n = 5) Structured individual interviews (n = 17) Questionnaire (n = 16), focus group (n = 6) Questionnaire (n = 216)
Haggerty et al. (2013)
GNP and generational differences GN perceptions of preparedness and development Transition shock of GN
Semi structured interviews (n = 15)
GN transition and learning needs
Focus group pre and post program (n = 81)
GN experience with teams and leadership Strengths and weakness of GNP GN perspectives on effective preceptors Preceptors in GNP
Individual interviews (n = 12)
Halfer and Graf (2006)
Work environments and GN
Horsburgh and Ross (2013) Johnstone et al. (2008)
GN perceptions of companionate care Implications of support during GNP
Kelly and Ahern (2009) Kelly and McAllister (2013) Kumaran and Carney (2014) Laschinger (2012) Laschinger et al. (2009) Lavoie-Tremblay et al. (2008a) Lavoie-Tremblay et al. (2008a, 2008b) Lea and
Expectations and experiences of GN GN evaluation of preceptors
Semi-structured interviews (n = 22) Individual interviews, 2–3 time points (n = 25) Questionnaires 3 cohorts, 2 time points (n=389, n = 348, n = 104) interviews with Preceptors and key stakeholders Questionnaire, 4 time points (n = 67) Including open ended questions Focus groups (n = 42), (n = 7 groups) Questionnaires (n = 63), focus groups (n = 14 groups), individual interviews (n = 21) Semi structured interviews, 3 time points (n = 13) Semi structured interviews, 3 time points (n = 13)
GN experience of role transition GN work experiences
Individual interviews (n = 10)
Factors that influence burnout in GN Environment and intention to quit in GN Work environment influence on GN
Questionnaire (n = 342)
Experience of GN rural
Individual interviews, 3 time points
Questionnaire (n = 342)
Questionnaire (n = 309) Questionnaire (n = 309)
(continued on next page)
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Table 4 (continued) Study
Focus
Methods and sample size
Cruickshank (2014) Lewis and McGowan (2015) Marks-Maran et al. (2013) Martin and Wilson (2011) O'Shea and Kelly (2007) Ostini and Bonner (2012) Parker et al. (2014) Phillips et al. (2014)
transition
(n = 15)
GN experience with preceptors in GNP
Semi structured individual interviews (n = 8)
GN evaluation of preceptors Lived experiences of GN Lived experiences of GN GN transition in rural Australia GN experiences and transition Factors influencing GN transition
Questionnaire (n = 44) + journal or recording (n = 44) Semi structured individual interviews (n = 7) Individual interviews (n = 10)
Pineau Stam et al. (2015) Rudman and Gustavsson (2011) Rush et al. (2014)
Influences of GN personal attributes Burnout in GN
GN experiences of support and bullying Saghafi et al. Lived experiences of (2012) GN in ICU Scott et al. (2008) Factors influencing GN transition Wangensteen Experiences of GN et al. (2008)
Individual interviews (n = 5) Questionnaire (n = 282) Questionnaire (n = 392) with open ended questions, focus group/interviews (n = 67) Questionnaire (n = 205) Questionnaire, 3 time points (n = 687) Questionnaire (n = 245) Semi structured individual interviews (n = 10) Questionnaire (n = 329) Individual interviews (n = 12)
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Review
Graduate nurse experiences of support: A review Isabelle Gardiner ⁎, Jade Sheen 1 Deakin University, Building HC, 221 Burwood Highway, Burwood, VIC 3125, Australia
a r t i c l e
i n f o
Article history: Accepted 20 January 2016 Keywords: Graduate nurse Graduate nurse program Support Education Stress Feedback
s u m m a r y The first year of practice as a nurse is recognized as stressful. Graduate nurses (GNs) report gaps in their education, reality shock, burnout and other negative experiences that influence their intentions to remain in nursing. Objectives: The aim of this literature review was to gain a greater understanding of the experiences of GNs. Review methods: It included thirty-six articles that focused on GNs and their transition to nursing, as part of a graduate nurse program (GNP), from 2005 to present. Result: The review identified three main themes that influence the transition from student to registered nurse. These themes included, 1) feeling stressed and overwhelmed by nursing responsibilities, 2) the amount of support from senior nurses and 3) the importance of feedback on their performance as nurses. Conclusions: Further research that is focused on the support and feedback provided to new nurses is needed. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction Nursing is recognized as a demanding profession and the transition from student nurse to registered nurse can be a challenging time. The first year and initial experiences of nurses have been shown to influence their intention to remain in nursing (Scott et al., 2008). In Australia, (and other countries including United Kingdom and Canada), first year nurses who have completed a university degree are referred to as Graduate Nurses (GNs). A bachelor of nursing is a three-year degree that includes practical and theoretical classes at a university and clinical placement at hospitals. GNs are fully qualified registered nurses, however there have been concerns raised over the adequacy of their education in preparation for work readiness. GNs have reported marked discrepancies between what they were taught at university and the reality of nursing (Duchscher, 2009; Evans et al., 2010). This has been shown to cause stress and a reality shock for new nurses (Martin and Wilson, 2011). Reality shock is experienced when after years of preparation for specific employment a new employee suddenly discovers they are not prepared at all (Harwood, 2011). Such negative experiences potentially stem from, and are influenced by, the theory-practice gap. The theory-practice gap refers to incongruence between theoretical content taught in university and the realities of clinical practice (Harwood, 2011; Scully, 2011). This gap was identified when nursing education was moved from hospitals to universities in the 1980s (Evans et al., 2010; Harwood, 2011; Kelly
⁎ Corresponding author. Tel.: +61 423 945 700. E-mail addresses: [email protected] (I. Gardiner), [email protected] (J. Sheen). 1 Tel.: +61 9251 7634.
http://dx.doi.org/10.1016/j.nedt.2016.01.016 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
and Ahern, 2009). Clinical placements in hospitals form part of the university curriculum, and are often the only opportunity for students to perform patient care and practice clinical skills in a non-simulated setting prior to registration. For many Australian students their total clinical placements over a three year degree make up approximately 25 weeks (Phillips et al., 2014). Furthermore, with universities reporting issues in providing appropriate and high quality clinical placements for students, it is possible to see how gaps in learning can arise (Andre and Barnes, 2010; Harwood, 2011). To overcome this gap, many hospitals offer a non-compulsory graduate nurse program (GNP) to assist and support GNs in their transition (Andre and Barnes, 2010). GNPs are often twelve months in length. They are run at the discretion of the organization and offer varying amounts of support and opportunities. These programs are designed to be supportive and to build the confidence and competence of GNs as they develop professionally. Despite these programs being in place for a number of years, GNs continue to report high levels of stress, emotional exhaustion and disillusionment in their chosen profession (Haggerty et al., 2013). GNs have reported lack of support and supervised learning opportunities during GNPs. This is concerning as skills performed without support dramatically increase the chance of an error occurring (Australian Nursing Federation, 2009; (Saintsing et al., 2011). These errors can cause various complications that may lead to longer patient stays and potential morbidity, which are costly for patients and hospitals. Factors influencing GN errors include, stress, gaps in education, low confidence and poor communication with other health professionals (Andre and Barnes, 2010; Saintsing et al., 2011). In addition, GNs have reported low confidence in their clinical ability and have reported concerns for the safety of patients in their care. Managers and organizations share these safety concerns (Australian Nursing Federation, 2009). There is a dearth of
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literature regarding the implications of these safety concerns and associated consequences for patients and also nurses. To assist transition many GNP often commence with an orientation followed by a variable number of days working with a senior nurse. After this workplace introduction, the GN is given a full workload of patients, along with the accountability, liability and responsibility for their care (Andre and Barnes, 2010). Added to this responsibility is the observation that patient acuity is increasing due to the growing number of patients with complex comorbidities as well as the expanding and aging population (Andre and Barnes, 2010; Needleman, 2013; Tschannen and Kalisch, 2009). GNs are confronted with new and complex medical interventions as part of their everyday patient care, which can be overwhelming. This can lead to stress, if stress is not addressed and managed, it can lead to burnout of GNs. Burnout and job dissatisfaction have been found to increase turnover and reduce staff retention (Rudman and Gustavsson, 2011). Furthermore, GNs report professional relationship problems with other nurses. Some report negative cultures of bullying and unsupportive workplace environments (Laschinger et al., 2009). Newly qualified nurses are the future of the profession and are central to health care delivery. With GNs continuing to feel isolated and excessively stressed, there is a growing need to understand their experiences in order to ascertain what can be done to improve GN transitions and retention of nurses. This literature review aims to address some of these concerns by answering the following questions: • What is currently known about the experiences of graduate nurses? • What does the literature indicate regarding support provided to nurses undertaking graduate programs? • What factors have been shown to assist graduate nurses in their transition to practice? • What methods have been used to study graduate nurses' experiences?
2. Method The search terms were extracted from the above questions. The search terms used are presented in Table 1, along with alternative search terms, including truncation as indicated by *. A search was undertaken using CINAHL, Medline, PSYCHinfo and Scopus with the search terms presented in Table 1. No significant results were found from gray literature, however, 4 additional articles were identified from the final selected articles' reference lists. The results were exported into endnote where they were screened by title and abstract. They were evaluated using the inclusion and exclusion criteria in Table 2. Fig. 1 shows the selection process of the final 36 articles that were analyzed in this review.
Table 1 Search terms and alternative terms. Search term
Alternative terms
#1 graduate nurse
“graduate nurs*” OR “new* nurs*” OR “new* registered nurs*” OR “novice nurs*” OR “first year nurs*” OR “new* qualified* nurs*” support* OR program OR “graduate year” OR “first year” OR orientation OR residency OR transition OR preceptor* OR supervis* OR clinical experience* OR feedback OR practice OR learn* OR stress* OR “reality shock” medical OR patient* OR family OR carer
#2 support
#3 experience #4 NOT #5 #1 AND #2 AND #3 NOT #4
Table 2 Inclusion and exclusion criteria. Included
Excluded
• Studies focusing on participants who • Published in English language were not graduate nurses e.g. Student • Published 2005 — present nurses or nurse managers • Peer reviewed • Single participants of personal reflec• Full text tions or editorials • Qualitative and/or quantitative • Studies focused on graduate nurse methods of studying graduate programs different from Australia nurse experiences • Not directly related to the research • Studies focused on graduate nurse questions programs and nurse training that • Not published in English are comparative to Australia e.g. USA, and Canada
3. Results The studies that met the inclusion criteria are summarized in Table 4. It can be seen from Table 3 that the most common method of studying GN experiences was individual interviews, followed by the use of surveys and questionnaires. It is interesting to note that mixed method approaches have also been utilized. 4. Discussion Three dominant themes that were relevant to the research questions emerged from this literature review. These were firstly, stressful experiences, secondly, the need for a supportive environment and thirdly, constructive feedback during the transition to practice. 4.1. A Stressful experience Stress was a common experience of GNs. This section will discuss three themes that influenced stress. They include incidence of burnout, feeling unprepared and overwhelmed by responsibility, and finally, bullying amongst nurses. The most frequently reported experience of GNs during their first year of nursing was stress (Horsburgh and Ross, 2013; Johnstone et al., 2008; Kelly and McAllister, 2013; Laschinger, 2012; Lavoie-Tremblay et al., 2008a,b; Parker et al., 2014; Phillips et al., 2014). GNs reported high levels of physical and psychological stress, which can lead to burnout (Duchscher, 2009; Kelly and Ahern, 2009; Lavoie-Tremblay et al., 2008a, 2008b; Martin and Wilson, 2011; Parker et al., 2014). Burnout is defined as emotional exhaustion resulting from sustained stress (Rudman and Gustavsson, 2011). Sources of stress for GNs include, but are not limited to, feeling unprepared, overwhelmed, unsupported and concerned for their patients' safety. High levels of emotional exhaustion have been found to correlate with an intention to resign leading to increased nurse turnover (Cleary et al., 2013; Laschinger, 2012; Laschinger et al., 2009; Lavoie-Tremblay et al., 2008a; Rudman and Gustavsson, 2011). Rudman and Gustavsson (2011) estimated that at least one in five nurses will experience high levels of burnout at some time during their career. A further concerning finding was that the highest levels of burnout were reported by younger nurses (b35 years), (Rudman and Gustavsson, 2011). Many GNs report excitement and enthusiasm on commencement of their GNP. However, these feelings can change to anxiety and dread (Duchscher, 2009; Dyess and Sherman, 2009; Kumaran and Carney, 2014). GNs report feeling unprepared, lacking confidence, knowledge and skills to perform adequate patient care (Danielson and Berntsson, 2007; Duchscher, 2009; Evans et al., 2008; Ferguson, 2011; O'Shea and Kelly, 2007; Parker et al., 2014). These fears are heightened by the GNs' knowledge of new responsibility and accountability for their patients (Lavoie-Tremblay et al., 2008a; Lavoie-Tremblay et al., 2008b; O'Shea and Kelly, 2007).
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Fig. 1. Literature review process.
The workload of the GNs was repeatedly reported as heavy and unmanageable. Increasing patient acuity on wards was recognized as a stressor for GNs (Duchscher, 2009; Dyess and Sherman, 2009; Halfer and Graf, 2006; Johnstone et al., 2008; Lavoie-Tremblay et al., 2008a, 2008b; Phillips et al., 2014; Scott et al., 2008). Caring for patients who require full assistance, and the increasing numbers of patients with complex co-morbidities, can lead to physical and emotional exhaustion of GNs (Evans et al., 2008; Laschinger, 2012; Lavoie-Tremblay et al., 2008a, 2008b; Parker et al., 2014). GNs also experienced stress from interactions with other nurses. Most negative interactions stemmed from other nurses being perceived as unavailable or disinterested in helping GNs (Beecroft et al., 2006; Johnstone et al., 2008; Parker et al., 2014; Saghafi et al., 2012). Some GNs reported experiencing bullying or horizontal violence directly (Dyess and Sherman, 2009; Evans et al., 2008; Kelly and Ahern, 2009; Parker et al., 2014; Rush et al., 2014). Horizontal violence is hostile or aggressive behavior towards an individual within the same work group (Dyess and Sherman, 2009). Such behaviors are often displayed as power games, with one individual being ignored or excluded. It also Table 3 Methods used to study graduate nurse experiences. Method
Frequency (%)
Individual interview Survey/questionnaire Focus group Survey/questionnaire + focus group Individual interview + focus group Survey/questionnaire + individual interview Survey/questionnaire + Individual interview + focus group Survey/questionnaire + reflective journal
14 (38.9) 12 (33.3) 3 (8.3) 2 (5.6) 2 (5.6) 1 (2.8) 1 (2.8) 1 (2.8)
includes general rudeness and incivility from some nurses (Johnstone et al., 2008). These negative behaviors have been shown to make GNs reluctant to approach and request assistance from senior nurses (Kelly and Ahern, 2009; Kelly and McAllister, 2013; Laschinger et al., 2009). Further, Rush et al. (2014) found that GNs who experienced bullying reported less access to support. Without the appropriate assistance from senior nurses, it is evident that this could negatively impact on patient care and outcomes. Lack of support from experienced nurses increases stress and hinders the transition from novice to competent nurse (Martin and Wilson, 2011). Encouragingly, GNs reported increased job satisfaction and reduced levels of stress when they felt welcomed and accepted as part of the nursing team (Ferguson, 2011; Halfer and Graf, 2006; Kelly and McAllister, 2013; Kumaran and Carney, 2014; Saghafi et al., 2012).
4.2. Supportive environments Three main themes emerged with regards to environmental support during GNPs. Firstly, adequate staffing skill mix and supervision of GNs, secondly, the use of preceptors and finally, the presence of educators. GNPs are often marketed as a supported transition in a positive learning environment. Many GNs report their expectations of their GNP were not met during the program. For example, Parker et al. (2014) and Lea and Cruickshank (2014) found many participants were promised support throughout their GNPs, which was not forthcoming or available. One factor that negatively impacted on GNs was problematic staffing, such as shifts where few, or no, experienced senior staff members were working. This left GNs feeling that there was no one to ask for support or help. These findings have been supported in other studies using a diverse range of methodologies over recent years (Cubit
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and Ryan, 2011; Danielson and Berntsson, 2007; Pineau Stam et al., 2015; Rush et al., 2014; Scott et al., 2008). It can be seen that inadequate supervision, lack of support and unaddressed learning deficits can lead to potential negative patient outcomes. Martin and Wilson (2011) found that the first months of GNs employment were associated with the highest rates of errors and mistakes. Safer and improved patient care was reported when GNs had experienced nurses available to support them (Ferguson, 2011; Horsburgh and Ross, 2013; Johnstone et al., 2008; Lewis and McGowan, 2015; Martin and Wilson, 2011; Pineau Stam et al., 2015). Strategies such as the implementation of preceptors can assist the GN to feel supported and become part of the nursing team by building positive relationships (Ferguson, 2011; Haggerty et al., 2013). A preceptor is intended to be an experienced nurse who has education or additional training in assisting students and new staff members (Haggerty et al., 2013). GNs reported that having someone to talk to and receive emotional and practical support from was highly beneficial (Cubit and Ryan, 2011; Danielson and Berntsson, 2007; Duchscher, 2009; Ferguson, 2011; Martin and Wilson, 2011). Social support has been shown to be an essential element in positively influencing retention of new nurses (Lavoie-Tremblay et al., 2008a, 2008b). When the GN is allocated a full patient load without assistance, the reality and responsibility of professional nursing can be a shock in contrast to the experience of being a student (Cubit and Ryan, 2011; Duchscher, 2009; Kelly and Ahern, 2009; Martin and Wilson, 2011). During undergraduate clinical experiences, student nurses remain under the direction of registered nurses who supervise all patient interactions and are available to advise and provide feedback and evaluation. Evans et al. (2008) found that participants reported this stark contrast in availablity of supervision, as distressing and frustrating. Other nurses described this time as one of vulnerability and as if the “safety net” had been removed (Johnstone et al., 2008). GNs have reported feelings of isolation and being alone when they commence GNPs (Dyess and Sherman, 2009; Ekström and Idvall, 2015; Evans et al., 2008; Horsburgh and Ross, 2013; Kelly and Ahern, 2009; Kelly and McAllister, 2013). This has led to suggestions that the most important time for support to be provided is in the first few months after graduation (Clark and Holmes, 2007; Duchscher, 2009; Evans et al., 2008; Lea and Cruickshank, 2014; Parker et al., 2014; Rush et al., 2014). Many GNPs start with an orientation to the work environment (Cleary et al., 2013; Dyess and Sherman, 2009; Ferguson, 2011; Scott et al., 2008). This is usually followed by a number of shifts shadowing an experienced nurse, (ideally a preceptor), while sharing a full patient workload. Marks-Maran et al. (2013) found that 83% of GNs in their study reported that their preceptor helped reduce stress at work. However, it has been reported that ensuring GNs work alongside their allocated preceptor is often not possible due to roster difficulties (Beecroft et al., 2006; Cubit and Ryan, 2011; Evans et al., 2008; Haggerty et al., 2013). Furthermore, many hospitals reported insufficient numbers of experienced or appropriately educated nurses to be preceptors (Evans et al., 2008; Johnstone et al., 2008). This may be linked to a lack of professional development available for the role, which often led to inappropriately selected preceptors, resulting in less than ideal outcomes (Haggerty et al., 2013). Haggerty et al. (2013) found several limitations in the use of preceptor, they include, negative relationships, lack of interest from preceptors, and preceptors being too busy with their own heavy workload to support the GN. These results are consistent with the research on outcomes of preceptor programs (Beecroft et al., 2006; Clark and Springer, 2012; Johnstone et al., 2008; Lea and Cruickshank, 2014; Ostini and Bonner, 2012; Parker et al., 2014). Many GNPs offer GNs more than one preceptor in order to ensure that there is support available for the GN when nurses have different rosters or leave commitments (Cubit and Ryan, 2011; Haggerty et al., 2013). This approach has had varying results. Some GNs reported this caused confusion and lack of consistency (Johnstone et al., 2008; Laschinger, 2012). In
contrast, others stated that they enjoyed being able to observe and learn from different nursing practitioners (Haggerty et al., 2013). Horsburgh and Ross (2013) described the allocation to a preceptor as random, with little consideration going into the allocation of preceptors, while some GNs were never allocated a preceptor at all (Ekström and Idvall, 2015; Ferguson, 2011). To assist GNs, many Australian GNPs offer clinical educators for additional support (Evans et al., 2008; Lea and Cruickshank, 2014; Ostini and Bonner, 2012; Parker et al., 2014). Educators do not have a patient load so are theoretically available to help GNs and provide targeted education for knowledge deficits (Evans et al., 2008; Parker et al., 2014). However, GNs reported being disappointed with the availability of educators, especially out of business hours. Out of hours was reported as a time when GNs felt particularly lost and unsupported (Evans et al., 2008; Ostini and Bonner, 2012). Lea and Cruickshank (2014) found that GNs stated there should be more educators available in order to meet their needs. Provision of adequate supportive educational measures for GNs in the clinical work environment, depends on adequate recognition, staffing and investment from the senior organizational level (Haggerty et al., 2013; Halfer and Graf, 2006; Phillips et al., 2014; Pineau Stam et al., 2015). Nurse managers and leaders are under immense pressure from budget and roster constraints that can negatively influence the environment GNs are exposed to (Duchscher, 2009; Haggerty et al., 2013; Johnstone et al., 2008). 4.3. Feedback assisting the transition A recurring theme is that GNs expect, and feel the need for, adequate acknowledgement and feedback during their GNP. This section will discuss the reported importance of feedback and what feedback was, (and conversely was not), given to GNs. Saghafi et al. (2012) found GNs reported that feedback was important in boosting their confidence. These findings were supported by the identification that feedback is an essential element of learning and central to assisting GNs in recognizing how their performance is perceived (Beecroft et al., 2006; Marks-Maran et al., 2013; Wangensteen et al., 2008). GNs valued friendly and respectful conversations regarding their progress and performance (Beecroft et al., 2006; Haggerty et al., 2013). When feedback was delivered abruptly and without adequate consideration to context or timing, it was more likely to be viewed as unhelpful, and potentially damaging to the GN's confidence (Haggerty et al., 2013; Wangensteen et al., 2008). Johnstone et al. (2008) found that the commencement of GNPs was the time GNs wanted feedback most in order to build their confidence. There was an overwhelming number of GNs who reported that they lacked sufficient feedback in their GNPs (Duchscher, 2009; Parker et al., 2014; Phillips et al., 2014; Saghafi et al., 2012; Wangensteen et al., 2008). When feedback was lacking or absent, a cycle of selfdoubt and isolation can arise which leads to reduced confidence (Duchscher, 2009). Furthermore, the absence of feedback has been reported to contribute to anxiety for GNs as they worried about their progress and performance (Marks-Maran et al., 2013; Ostini and Bonner, 2012; Wangensteen et al., 2008). Some GNs assumed that the absence of feedback was an indication that they had not made any major mistakes (Parker et al., 2014; Phillips et al., 2014). As indicated in the findings of Pineau Stam et al. (2015) and Wangensteen et al. (2008), GNs stated that they were open to constructive criticism and stated that negative feedback was better than no feedback. Furthermore, GNs were requesting more regular and frequent feedback to help them feel supported and reinforce their learning (Duchscher, 2009; Parker et al., 2014; Saghafi et al., 2012). Laschinger et al. (2009) stated that an important factor of GN transition is their level of work empowerment. Work empowerment refers to an employee's ability to access support, feedback and information that they require in order to fulfill their role. High levels of work
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empowerment have been found to correlate with decreased levels of burnout and stress (Ekström and Idvall, 2015; Laschinger, 2012; Pineau Stam et al., 2015). From the literature it is evident that GNs experience positive transitions to nursing when they receive adequate and appropriate support into their new role and environment (Duchscher, 2009; Parker et al., 2014). In addition, the provision of feedback and supervision may decrease stress and anxiety. It is in the community's best interest to invest in successful transitions of GNs as they will be caring for the most vulnerable and sick. Safe and supported transition programs could assist in promoting patient safety. 5. Limitations This review included articles that utilized quantitative and qualitative methods. Including both quantitative and qualitative articles in the review allowed for a broad understanding of the methods and samples. The results varied depending on method used, which prevented easy comparison between articles. As can be seen in Appendix 1, sixteen studies had sample sizes of less than twenty. While some of the sixteen stated that they reached saturation in data collection, others were unable to recruit enough participants to generalize their findings to the population of GNs. The studies with small sample sizes often used individual interviews. Some interviews were described as semi structured while other studies did not define the method or structure. A further limitation regarding the samples was that they were often recruited by convenience from the same program or hospital. This did not provide a great variation in programs offered, therefore making it hard to know if these experiences are unique or similar to GNs outside that particular hospital. While the literature showed that GNs reported stress and anxiety, these feelings have most commonly been reported and studied by qualitative measures, for example, from interviews or focus groups. Occasionally they were measured to see if there are relationships with other factors, but were often reported subjectively. Qualitative findings are important in directing what areas of GN experiences can be studied with further tests that are valid and reliable. The area of feedback, (which has been repeatedly reported as playing an important role in GNs transitions), has not been studied in detail. There is much that is unknown regarding the topic of feedback. The amount, type, timing and approaches of feedback have not been the focus of research with respect to GNs. There is a need to understand the feedback process and how it might be implemented in a more systematic way. The application of a quantitative method focusing on feedback is an area for further research. It might also be beneficial to include a stress scale in order to discover if a relationship exists between feedback and stress. Including open-ended questions could help obtain extra details regarding feedback experiences, and create a mixed methods approach. The findings could be generalized to a greater degree if recruitment included GNs from a variety of programs and hospitals. 6. Conclusions GNs continue to report lack of support and difficult working environments that are resulting in high levels of stress. GN transitions are more likely to be positive when they are welcomed and supported by the nursing team. Supportive preceptors and educators have been shown to assist GNs in their transition to competent nurses. However, there appears to be a lack of appropriate preceptors available for support and supervision of GNs. Furthermore, there are workload pressures preventing preceptors from adequately supporting GNs. GNs valued regular and honest feedback regarding their performance and progress. Feedback and supervision are particularly important in the first few months of the GNP. This requires supporting colleagues to have adequate knowledge, skill and time to spend with
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GNs in order to supervise and assess them. The environments where GNs are placed vary considerably in the amount of support offered and their treatment of GNs. The provision of adequate support for GNs leads to increased confidence and job satisfaction. Nursing leaders and management need to encourage and develop friendly and supportive environments. Awareness and additional resources are required to ensure experienced nurses are able to engage and support GNs. Supportive nursing environments that facilitate successful transitions benefit GNs, hospitals and patients. There is a need to understand more about GNs experiences particularly those that involve feedback and support. Such research may guide and direct education for future preceptors and devise better ways to support the novice nurse in becoming an expert practitioner. Appendix 1
Table 4 Studies included in literature review. Study
Focus
Methods and sample size
Beecroft et al. (2006) Clark and Springer (2012) Clark and Holmes (2007) Cleary et al. (2013) Cubit and Ryan (2011) Danielson and Berntsson (2007) Duchscher (2009) Dyess and Sherman (2009) Ekström and Idvall (2015) Evans et al. (2008) Ferguson (2011)
GN relationships with preceptors Lived experience of GN
Questionnaire (n = 318) including and Dorey open ended questions Focus groups (n = 37, n = 9 groups)
Expectations of GN and competency GN views of nursing
Focus groups (n = 105, n = 12 groups), interviews (n = 5) Structured individual interviews (n = 17) Questionnaire (n = 16), focus group (n = 6) Questionnaire (n = 216)
Haggerty et al. (2013)
GNP and generational differences GN perceptions of preparedness and development Transition shock of GN
Semi structured interviews (n = 15)
GN transition and learning needs
Focus group pre and post program (n = 81)
GN experience with teams and leadership Strengths and weakness of GNP GN perspectives on effective preceptors Preceptors in GNP
Individual interviews (n = 12)
Halfer and Graf (2006)
Work environments and GN
Horsburgh and Ross (2013) Johnstone et al. (2008)
GN perceptions of companionate care Implications of support during GNP
Kelly and Ahern (2009) Kelly and McAllister (2013) Kumaran and Carney (2014) Laschinger (2012) Laschinger et al. (2009) Lavoie-Tremblay et al. (2008a) Lavoie-Tremblay et al. (2008a, 2008b) Lea and
Expectations and experiences of GN GN evaluation of preceptors
Semi-structured interviews (n = 22) Individual interviews, 2–3 time points (n = 25) Questionnaires 3 cohorts, 2 time points (n=389, n = 348, n = 104) interviews with Preceptors and key stakeholders Questionnaire, 4 time points (n = 67) Including open ended questions Focus groups (n = 42), (n = 7 groups) Questionnaires (n = 63), focus groups (n = 14 groups), individual interviews (n = 21) Semi structured interviews, 3 time points (n = 13) Semi structured interviews, 3 time points (n = 13)
GN experience of role transition GN work experiences
Individual interviews (n = 10)
Factors that influence burnout in GN Environment and intention to quit in GN Work environment influence on GN
Questionnaire (n = 342)
Experience of GN rural
Individual interviews, 3 time points
Questionnaire (n = 342)
Questionnaire (n = 309) Questionnaire (n = 309)
(continued on next page)
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I. Gardiner, J. Sheen / Nurse Education Today 40 (2016) 7–12
Table 4 (continued) Study
Focus
Methods and sample size
Cruickshank (2014) Lewis and McGowan (2015) Marks-Maran et al. (2013) Martin and Wilson (2011) O'Shea and Kelly (2007) Ostini and Bonner (2012) Parker et al. (2014) Phillips et al. (2014)
transition
(n = 15)
GN experience with preceptors in GNP
Semi structured individual interviews (n = 8)
GN evaluation of preceptors Lived experiences of GN Lived experiences of GN GN transition in rural Australia GN experiences and transition Factors influencing GN transition
Questionnaire (n = 44) + journal or recording (n = 44) Semi structured individual interviews (n = 7) Individual interviews (n = 10)
Pineau Stam et al. (2015) Rudman and Gustavsson (2011) Rush et al. (2014)
Influences of GN personal attributes Burnout in GN
GN experiences of support and bullying Saghafi et al. Lived experiences of (2012) GN in ICU Scott et al. (2008) Factors influencing GN transition Wangensteen Experiences of GN et al. (2008)
Individual interviews (n = 5) Questionnaire (n = 282) Questionnaire (n = 392) with open ended questions, focus group/interviews (n = 67) Questionnaire (n = 205) Questionnaire, 3 time points (n = 687) Questionnaire (n = 245) Semi structured individual interviews (n = 10) Questionnaire (n = 329) Individual interviews (n = 12)
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