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AbstractThe Ottawa Hospital developed an evidence-based nursing internship program to meet the challenges of newgraduates. The literature suggests many challenges that they face during their transition from student to newgraduate, with a turnover estimated as high as 60%. The program provides support to new graduates by offeringopportunities for growth and autonomy, leading to active participation as team members. Evaluation criteriainclude satisfaction for interns, preceptors, clinical mangers and educators based on the program objectives, andnew graduate turnover. We were able to decrease new graduate turnover from 23% at two years to 10%, with

$360,000 in savings from the reduced turnover.

As one of the largest academic health sciences centres in Canada, the Ottawa Hospital was concerned about theimpact of the upcoming nursing shortage, estimated to be 78,000 in Canada by 2011, especially in light of theexpansion that it was undergoing (Ryten 2002). We recognized that new graduates would be the dominant poolof new hires and developed an internal recruitment strategy that was based on Benner's transition fromadvanced beginner to competent, with supported time in a medicine or surgery unit followed by the completionof a specialty program to fill the vacancies we would have in critical care and the operating room (Benner1984). While we did not have the funds to implement the strategy fully, we utilized the Ontario Ministry ofHealth and Long-Term Care Nursing Enhancement Funds to develop our Nursing Internship program.

Program DevelopmentA literature review was undertaken to identify the challenges that new graduates face and to guide thedevelopment of program goals. Kramer (1985) stated that the transition from student to new graduate is a"reality shock." The transition process is a rite of passage with three phases: separation, transition andintegration (Winter-Collins and McDaniel 2000). It is also identified that new graduates' sense of belonging islinked to their successful transition into their professional role. New graduates were found to demonstrate stressregarding competence, confidence, making errors and adjusting to new workplace environments and tocomplain of lack of support and problems with organization, completion of tasks and quality of work (Guhde2005; Oremann and Garvin 2002). New graduates who complete a nursing internship program have moreprofessional self-confidence and job satisfaction and are less stressed because they are in a supportiveenvironment (Casey et al. 2004; Owens et al. 2001). It has been estimated that it takes new graduates at least

one year to master a job with successful organization socialization (Tradewell 1996); they also do not feelskilled, comfortable or confident for as long as one year after hire (Casey et al. 2004). New graduate turnoverduring the first year is estimated at between 35 and 60%, with 40% of new graduates perceiving a lack ofopportunities for future career development within the organization (Casey et al. 2004; Godinez et al. 1999).New graduates want reassurance, specific and precise guidelines and daily feedback on their clinical skilldevelopment (Modic in Guhde 2003). Connelly and Hoffart (1998) found that new graduates need to feelconnected to people in the organization or they may not stay long enough to fit in. Novice nurses today still feelthe most frustrated by the lack of care and concern they are shown by staff (Meissner 1999).

The Nursing Internship ProgramOur Nursing Internship program is an "earn while you learn" program designed to facilitate the role transition

from novice/novice beginner to competent (Benner 1984). Nursing internships are offered in medicine andsurgery, which are the typical throughput units for the specialty programs, and in mental health, where we havea potential retirement rate of 30% over the next few years. The program provides support to new graduates byoffering opportunities for professional growth and autonomy leading to active participation as members of theclinical team. Benefits for the new graduate include increased confidence in knowledge and assessment skills,improved clinical skills and improved decision-making, prioritizing and problem solving skills. The program isa 12-week fully preceptored program that includes orientation for both the preceptor and the intern, includeseducation days off the unit and is open to new graduates with less than two years' experience. The two-yearpoint is identified as being significant. It is often when new graduates start to assume a leadership role as fullyfunctional team members (Casey et al. 2004).


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The goals of program are to promote strategies for new graduate recruitment and retention, to provide anopportunity to consolidate clinical nursing knowledge in new areas of practice and to provide an opportunity todemonstrate understanding and competence in technical skills and procedures related to the specialty in whichthey are practising. The program also allows for the application of sound clinical judgment and critical thinkingthroughout the nursing process in the management of patient skills. The development of time-management anddelegation skills is another important goal. The interns and the preceptors are supported by a nursingenhancement coordinator, whose job is to coordinate, implement, evaluate and report on the program.

The PreceptorsPreceptors are selected based on the RN Scope of Practice Assessment Tool; this was developed based onBenner's model (1984). The purpose of the tool is for nurses to self-evaluate their ability to work within the fullscope of practice. The tool is based on the Ottawa Hospital's Nursing Professional Practice Model definition andthe College of Nurses of Ontario's profile of professional expectations for registered nurses and registeredpractical nurses. Almada et al. (2004) report that the successful progress from novice to advanced novice nurseis accomplished through a one-to-one relationship, with continuous guidance. The preceptors providecontinuous feedback, focusing on the positive steps interns take toward their individual learning goals. Thepreceptor role begins as a teacher and gradually evolves to a resource person over the 12-week period.Preceptors must be caring, flexible and open, have a positive attitude, be confidence builders and be clinicallyconfident (Guhde 2005). Preceptors are clinical experts in their area and attend a half-day workshop on the role

of the preceptor that was developed to address the differences between precepting a student and a novice nurse.

The InternsNovice nurses apply and are interviewed for the positions. If nurses have less than one year's experience, theyare expected to complete the internship in their unit. If they have between one and two years' experience, theycomplete the internship in another unit. They all attend a half-day orientation where they write their learningobjectives for the program. These objectives are reviewed with the preceptor and the nursing educator. One oftheir objectives is to become familiar with the nursing and healthcare resources that are available to supportpatient care at the Ottawa Hospital. Workshops and educational sessions are planned during the 12-week periodto increase their awareness of the supports available and the organization as a whole.

Evaluation

Qualitative and quantitative data are collected. The interns complete a post-internship survey. Results have beenconsistent with the literature. Interns have reported increased job satisfaction, increased confidence, reducedstress, an increased sense of belonging and increased knowledge, critical thinking, decision-making, time-management and organizational skills. They also have reported learning many new psychomotor skills andhaving had the time to become proficient. Finally, interns have noted an increased self-esteem, that they have abetter understanding of their role as a professional and that they are more marketable.

The clinical managers and educators have reported high satisfaction with the program and the growth thatinterns demonstrate during the program.

Both the preceptors and the interns are also asked to complete a post-program survey rating how well theprogram meets its goals. Overall, 94.1% of respondents have been very satisfied with the program and wouldrecommend it to others. The questionnaire uses a Likert scale, with 0 indicating not applicableand 4indicatingoutstanding. Overall, they rated the program at 3.31 in meeting its goals. The results are presented inTable 1.


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New graduate turnover is identified as a major issue in the literature, with reports of turnover being as high as60% during the first year (Casey et al. 2004; Godinez et al. 1999). Our two-year new graduate turnover rate was23%. However, for the 96 graduates of the Nursing Internship program, we had a 10% turnover rate at twoyears and a 6% rate at one year, which is well below the suggested turnover rates of new graduates. Lowturnover is defined as being between 4 and 12% (VHA 2002). Our normal turnover of registered nurses is justover 6%, so we have decreased our turnover for the nursing internship graduates significantly.

Sixteen of the 96 participants, or 16.6%, have moved into the specialty areas such as the Intensive Care Unit,Operating Room and Emergency Department, while 90% of the nurses who completed their internship inmental health are still working there.

Challenges

We faced several challenges when we started the program. The first was communication across our fivecampuses with 11,000 employees and 4,000 nurses. The program started in September, and it turned out that thesummer was not the ideal time to get the message out. There was confusion about the program: it is not anextended orientation program for nurses who are struggling; it is designed to meet the needs of thenovice/advanced novice nurse looking to move quickly into the specialty areas where our needs will be thegreatest. Communicating the role of interns and preceptors to the rest of the unit staff was initially an issue,which we have subsequently resolved. We also had some problems ensuring that the interns would besupernumerary for the complete 12 weeks. This was addressed by changing the timing of the program.Originally, it was to be offered equally throughout the fiscal year. We changed this to have 50% of the positionsstarting during the first quarter, with 30% in September and the final 20% in January. While we originally


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envisioned not having interns in the summer or December, we found that many of the clinical managers likedhaving interns over the summer months to ensure that new graduates had the opportunity to participate in thisinitiative.

Benefits

The most significant benefit is the decrease in turnover for this group. The cost of turnover of registered nurseshas been estimated at $25,000 to over $60,000 per nurse who leaves a post in the United States (Bland-Jones2004; Casey et al. 2004). If we use a conservative estimate of $30,000 Canadian, we have saved over $360,000

in turnover costs. The interns' progression was noted not just by their clinical manager but also by thepreceptors, who took pride in the role they had played. As the program is now finishing its third year, we havedeveloped a cadre of preceptors who are aware of the needs and benefits of supporting new graduates on theirunits. The interns are not only more connected to the organization, they know the opportunities that exist at theOttawa Hospital. Patient outcomes have been positively linked to experienced nurses.

Conclusion

While the development and implementation of the Nursing Internship program based on the needs of novicenurses was challenging at times, it has produced many rewards. We did not expect to see such a suddendecrease in our new graduate turnover. The literature suggests that by decreasing the number of new graduatesleaving our organization, we are decreasing the number leaving the profession - and therefore contributing toour nursing population (Ulman 2002). The graduates of the program are more confident in their role as nursesand add to the increasing number of specialty trained nurses that we will need to meet the growing needs of ourcommunity.

About the Author

Cheryl Anne Smith, RN, MScN, is the corporate nursing recruitment, retention and recognition coordinator atthe Ottawa Hospital, in Ottawa, Ontario. She made a career shift in 2000 to work in this position. Her primaryresponsibilities are the development, coordination, implementation and evaluation of strategic nursingrecruitment activities, monitoring of retention patterns and making recommendations. You can reach Ms. Smithby phone at 613-761-4466, by fax at 613-761-4728 or by e-mail [email protected].

References

Almada, P., K. Carafoli, J.B. Flatterly, D.A. French and M. McNamara. 2004. "Improving the Retention Rate ofNewly Graduated Nurses."Journal for Nurses in Staff Development20(6): 268-73.

Bartz, K. 1999. "The Orientation Experiences of Urgent Care Nurses: Sources for Learning."Journal for Nursesin Staff Development15(5): 210-6.

Benner, P. 1984.Novice to Expert: Excellence and Power in Clinical Nursing Practice.Menlo Park, CA:Addison-Wesley.

Bland-Jones, C. 2004. "The Costs of Nurse Turnover".JONA34(12): 552-70.

Cantrell, M.A., A.M. Browne and P. Lupinacci. 2005. "The Impact of a Nurses Externship Program on theTransition Process from Graduate to Registered Nurse."Journal for Nurses in Staff Development21(5): 187-95.

Casey, K., R. Fink, M. Krugman and J. Propst. 2004. "The Graduate Nurse Experience."JONA34(6): 303-11.

Connelly, L. and N. Hoffart. 1998. "Staff Turnover among Hospital Nurses."Journal of Nursing StaffDevelopment14(1): 31-9.

Godinez, G., J. Schweiger, J. Gruver and P. Ryan. 1999. "Role Transition from Graduate to Staff Nurses: AQualitative Analysis."Journal for Nurses in Staff Development15(3): 97-110b.
mailto:[email protected]:[email protected]


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Guhde, J. 2005. "When Orientation Ends Supporting the New Nurse Who Is Struggling to Succeed."Journalfor Nurses in Staff Development21(4): 145-9.

Kramer, M. 1985.Reality Shock: Why Nurses Leave Nursing.St. Louis: CV Mosby.

Meissner, J. 1999. "Nurses, Are We Still Eating Our Young?" Nursing29(2): 42-4.

Oremann, M. and M.F. Garvin. 2002. "Stress and Challenges for New Graduates in Hospitals."NurseEducation Today22: 220-3.

Owens, D.L., M.A. Turjanica, M.W. Scanion, A.E. Sandhusen, M. Williamson, C. Hebert and L. Facteau. 2001."New Graduate RN Internship Program: A Collaborative Approach for System Wide Integration."Journal forNurses in Staff Development17(3): 144-50.

Ryten, E. 2002.Planning for the Future. Nursing Human Resources Projection.Ottawa, ON: Canadian NursesAssociation.

Tradewell, G. 1996. "Rites of Passage: Adaptation of Nursing Graduates to a Hospital Setting."Journal ofNursing Staff Development12(4): 183-9.

Ulman, M. 2002. "More Nurses Quitting Careers Early: A National Survey of Recent Graduates Said More Menand Women Finding Other Jobs, Aggravating a Shortage."Maine Nurse4(4): 20.

VHA. 2002. The Business Case for Work Force Stability.Irving, TX: Author. Retrieved September 2004..

Winter-Collins, A. and A.M. McDaniel. 2000. "Sense of Belonging and New Graduate JobSatisfaction."Journal for Nurses in Staff Development16(3): 103-11.

http://www.longwoods.com/content/19620

A Retention Strategy for Newly Graduated Nurses: An Integrative Review of Orientation Programs

Journal for Nurses in Professional Development,- See more at:

http://www.nursingcenter.com/lnc/cearticle?tid=1052774#sthash.EieXAXcV.dpuf

Abstract

To address nurse recruitment and retention issues, hospitals have increased the number of newly graduatednurses in their hiring pools and have simultaneously established orientation programs for those nurses.Structured orientation programs facilitate newly graduated nurse transition from novice to advanced beginner.The outcome of these programs is twofold: First, they promote the confidence and competency level of new

nurses in providing patient care, and second, they increase nurse retention. This literature review presents themost useful interventions used in the programs that reported positive affects on new nurses.

TheU.S. Department of Labor, Bureau of Labor Statistics (2005)predicts that the need for nurses will increase27% between 2004 and 2014. The current shortage of registered nurses (RNs) is due in part to the increasingage of the nursing workforce, as well as the fact that fewer younger nurses are entering the field. Although theenrollment in baccalaureate programs in nursing continues to increase (American Association of Colleges ofNursing, 2007), the increase is not enough to solve the nursing shortage. Consequently, organizations have
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responded by competitively increasing the recruitment of new graduate nurses in their hiring pools (AmericanOrganization of Nurse Executives, 2002). Although these new graduates fill vacancies, hiring new graduatenurses also generates problems.

The high turnover of newly graduated nurses is emerging as one of the problems that hospitals need to address.In a current survey of newly graduated nurses in 35 states (Kovner et al., 2007), approximately 13% ofresponders had changed principal jobs after 1 year, and 37% reported that they planned to change jobs in thenear future. Nursing literature reported that poor training, a lack of support systems, and the stress related to the

intense working situation and high patient acuity are the main reasons nurses are leaving during their first yearafter graduation (Bowles & Candela, 2005; Mathews & Nunley, 1992; Patrick, 2000).

Furthermore, a high turnover and an influx of new graduates have led to a higher proportion of inexperiencednurses in direct patient care, which may not only be traumatic for the new professional nurse but may alsothreaten patient safety (Santucci, 2004). Therefore, for patient safety and the well-being of new nurses, hospitalsmust make efforts to provide safe and effective environments that foster the integration of graduate nurses intotheir systems. An effective orientation program is one strategy that may address these concerns.

The goal of an orientation program is to prepare new staff nurses to be confident and to provide competent andsafe patient care. Benner's (1984)From Novice to Expertframework is relevant to an orientation program.

Benner applied the Dreyfus model of skill development to nursing and concluded that nurses pass through fivestages of skill development: novice, advanced beginner, competent, proficient, and expert (Benner, 1984).These different levels are accompanied by changes in three aspects of skill performance: (a) a change fromconfidence about abstract principles to the application of concrete experience, (b) a change in the learner'sawareness of the demand situation as a whole, and (c) a change from observer to active performer (Benner,1984). Nursing students entering the clinical area can be characterized as novices because their knowledge islimited, they tend to be rather inflexible, and they are inexperienced in actual clinical situations. Successfulorientation programs should be those in which teaching and learning are provided to help the new graduatenurse make the transition from novice to advanced beginner who can demonstrate acceptable performance andcope in real situations with a preceptor/mentor (Benner, 1984).

Some healthcare systems have recently developed and reported orientation programs that have improved theconfidence, competency, and retention of newly graduated nurses. However, the research on the effects of theseprograms is limited by small-size studies and the experiences of single institutions. There are few systematicliterature reviews focusing on orientation programs for newly graduated nurses.

The purpose of this study was to present an integrative review of the research that was conducted to explore theeffects of orientation programs for newly graduated nurses on their confidence, competency, and retention.Recommendations also are made based on an analysis of programs reported as effective in the literaturebetween 1990 and 2007.

METHODS

This review study followed Cooper's (1989)five-stage process for the integrative literature review: (a) problemformulation, (b) data collection, (c) evaluation of data points, (d) data analysis and interpretation, and (e)presentation of results. This study collected, synthesized, and analyzed published research conducted onorientation programs that train newly graduated nurses using various methods for increasing confidence,competency, and retention. Orientation programs in nursing literature included internships, residencies, andstructured orientation programs.

Studies were limited to research conducted in U.S. hospitals. Key words used in the search process werenewRN graduate, confidence, competency, retention, and orientation program. This review included only
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English-language research studies published between 1990 and 2007. This review began with a search ofmultiple library databases such as PubMed (MEDLINE), the Cumulative Index to Nursing and Allied Health(CINAHL), and Institute for Scientific Information (ISI) Web of Knowledge. Then, through the Google andGoogle Scholar Internet search engines, the search expanded to include published reports, white papers, andworking papers that were published through channels other than professional and research journals.

A total of 99 relevant citations were retrieved from library databases (n= 92) and the Internet (n= 7).Examination of the published abstracts and studies resulted in the elimination of studies that did not match the

project inclusion criteria (n= 53), leaving 46 articles for potential inclusion in the study.

Research articles meeting the inclusion criteria were then rated using a modified version of the research qualitychecklist developed byBeck (2001).The checklist included the following items: (a) author expertise, (b) type ofsample, (c) reliability and validity of measures, (d) time dimensional design, (e) research design, and (f)research analysis. The checklist used in this study included these items and also items pertaining to new RNorientation programs to determine whether the studies reported information on the outcomes of new RNgraduate orientation programs. Through a second level of review incorporating these quality criteria, theresearcher excluded several additional articles (n= 29) for one or more of the following reasons: (a) Studies didnot examine program outcomes, (b) studies reported programs for nursing students rather than nursinggraduates, (c) studies included both newly graduated nurses and experienced nurses as participants, and (d)

studies obtained a low score on the quality checklist. The final sample included 17 published reports.

RESULTS

Table 1 summarizes the research reviewed in this study and the reported outcomes of orientation programs,including confidence, competency, and retention. This review included nine articles evaluating internshipprograms, five studies related to residency programs, and three structured orientation programs (seeTable 1).Of those programs, four residency programs were designed as postbaccalaureate programs (Altier & Krsek,2006; Herdrich & Lindsay, 2006; Krugman et al., 2006; Rosenfeld et al., 2004), whereas the other programswere orientation programs for all new RNs. All articles dealt with hospital-based programs. Four of thesearticles focused on internship programs in specialty areas including critical care, neuroscience, and the float

pool.

TABLE 1 The Summary of Program Outcomes

Confidence

Seven articles of reviewed studies reported improved self-confidence of new graduates in delivering patientcare. The studies included five internship programs, one residency program, and one extended orientationprogram (seeTable 1). To examine new RNs' confidence, these studies asked program participants to rate theirlevel of confidence on a rating scale (Beecroft et al., 2001; Blanzola et al., 2004; Crimlisk et al., 2002; DiIorio

et al., 2001; Squires, 2002)or participants' confidence about their ability was extracted from logs and feedbackfrom the preceptor (Herdrich & Lindsay, 2006; Messmer et al., 2004).

These studies reported improved self-confidence of new RNs in delivering patient care after completing theprogram. In particular, several studies revealed that the internship programs in specialty areas increased theconfidence of new nurses in delivering patient care. Evaluating the impact of an internship program in a floatpool over time,Crimlisk et al. (2002) reported that 100% of new RN respondents completing the programbelieved that they were able to provide safe, competent care in the areas of assessment skills, technology,communication skills, medication administration, and critical-thinking skills. Furthermore,DiIorio et al.(2001) reported that new RNs in a neuroscience internship program believed the program enabled them to serve
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as a resource for other nurses unfamiliar with neuroscience patient care and for other new graduates inneuroscience nursing; nurses in this program also showed increased mean scores on the Neuroscience NursingSelf-efficacy Scale by the end of the program. Interns in a Shadow-A-Nurse intensive care unit internshipexpressed in their logs that the program was very beneficial in building self-confidence (Messmer et al., 2004).

Competency

Seven studies reported the effects of completing an orientation program on the competency of the new RN

graduates. Nursing literature defines competency as the possession of knowledge, practice skills, attitudes, andthe ability to perform to a prescribed standard (While, 1994). Professional educators also identified critical-thinking ability in delivering patient care as the core competency that new RNs should acquire (Marcum &West, 2004). In evaluating competency, researchers not only tested the new nurses but also obtained feedbackfrom participants such as nurse educators, nursing managers, peer nurses, and/or preceptors. For competencycontent, these studies focused on the knowledge and critical thinking of newly graduated nurses.

Four studies administered the Basic Knowledge Assessment Test to evaluate the effect of the orientationprograms in competency as knowledge (Collins & Thomas, 2005; DiIorio et al., 2001; Herdrich & Lindsay,2006; Messmer et al., 2004)and reported improvement in test scores between the beginning and the end of theprogram. Two articles reported that the programs improved the critical-thinking ability of new graduates using

several instruments, including the Critical Thinking Inventory (Herdrich & Lindsay, 2006), the Watson-Glasercritical thinking appraisal (Herdrich & Lindsay, 2006), and the Performance Based Development System(Marcum & West, 2004). Peer nurses and managers also evaluated the competency of new graduates asimproved after completion of the program (Blanzola et al., 2004; Boyer, 2005).

Positive outcomes in new RN competency were also reported in critical care. Two studies, which examined theoutcomes of critical care internship programs designed and implemented to assist new nurses in making thetransition into a critical care nurse role, reported that nurses demonstrated increased competency in critical carenursing skills and improved self-confidence after completing the program (DiIorio et al., 2001; Messmer et al.,2004).

Retention

In 15 studies, retention of new nurses was reported as the percentage of program participants remainingemployed at the organization at 12 and 24 months after completing an orientation program (seeTable 1). Theresults showed increased retention rates by comparing data from treatment and control groups, before and afterprograms, or with national trends. The programs reported retention rates ranging from 76% to 96%. The rateswere excellent when compared with the baseline rate of each program, ranging between 25% and 75%, and tonational data of a 64% retention rate for new RNs in their first year of practice (Nursing Executive Center,2002).

Furthermore, several studies reported a decreased turnover rate of newly graduated nurses after participation in

the programs (Beecroft et al., 2001; Krugman et al., 2006)and a decreased vacancy rate in the institutions afterimplementation of the programs (Almada et al., 2004; Boyer, 2005; Herdrich & Lindsay, 2006; Owens et al.,2001;seeTable 1). Two internship programs used the Anticipated Turnover Scale to measure new nurses'perception of the possibility of voluntarily terminating the position (Beecroft et al., 2001; Newhouse et al.,2007). At 6 months, program interns reported a significantly lower score on the Anticipated Turnover Scale or adecreased possibility of leaving their jobs when compared with their counterparts in the control group.
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Review of Programs

The various programs reviewed produced positive outcomes in nurse confidence, competency, and retention.From these programs, common components, such as the length of a program, structured teaching methods,preceptorship, support system, and evaluation, were examined to help determine effective program attributes(seeTable 2).

TABLE 2 The Summary of Programs

TABLE 2 Continued

AsTable 1 shows, programs varied greatly in length, ranging from 6 weeks to 1 year. All residency programs(n= 5) and internship programs (n= 2) were conducted over a 1-year time frame. Six studies reported programduration of less than 3 months. Eleven of the 17 reviewed studies reported programs that lasted between 4 and12 months (seeTable 1). When an orientation program was the extension of an existing program or focused in aspecialty area, the program duration tended to cover for shorter time periods (Almada et al., 2004; Marcum &West, 2004; Messmer et al., 2004; Squires, 2002).

All reviewed programs consisted of two main parts: (a) classroom learning and (b) clinical experience withpreceptorship. The classroom learning component not only included general hospital orientation requirementsbut also dealt with various topics related to competency-based practice, including nursing assessment andintervention, pathophysiology, pain management, quality improvement, medication administration, painmanagement, and so on. Postbaccalaureate residency program curricula contained three additional parts:leadership, evidence-based patient outcomes, and professional role (Altier & Krsek, 2006; Krugman et al.,2006).

During classroom activities, the programs used various teaching methods and traditional lectures by educators.The teaching methods mainly cited in the literature included conferences, seminars, group discussion, casestudies, and computer-based training (seeTable 2). In particular, the studies suggested that the teachingmethods such as conferences, seminars, and group discussion encouraged mutual learning among new RNsthrough sharing clinical experiences and were more effective for developing critical thinking than were thetraditional lecture format.Crimlisk et al. (2002) also reported the creation of an internship program that used thecase study format. They reported the following benefits of the case study approach: (a) sharing clinicalexperiences, (b) identifying critical thinking, (c) guiding clinical decision making, (d) nurturing professionalclinical practice, and (e) facilitating transition into the RN role.

The studies evaluated that the use of a one-on-one preceptorship contributed to developing the competencies ofnew graduates and to enhancing their clinical experiences. Also, key to a successful preceptorship was thepreparation of a qualified preceptor. Therefore, a preceptor training program was developed, as well as criteriafor the selection of preceptors (seeTable 2). The training program focused on building characteristics believedto be important for a preceptor, including competency in clinical practice, strong communication and leadershipskills, and interest in professional development.

Furthermore, to foster new RNs' competence in various clinical experiences, most of the programs plannedrotations through several clinical areas (e.g., medical, surgical and critical care areas, outpatient clinic, oremergency). Two articles introduced the idea of presenting and attending rounds as one of the teaching methodsin clinical practice (Blanzola et al., 2004; DiIorio et al., 2001).

All studies described various administrative systems needed to support the program and encourage the transitionof new RNs into the organization. The systems reported focused on both personnel and programs. Within
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support personnel, three essential roles were identified: (a) a program coordinator who serves as a mainresource for implementing and maintaining the program, (b) a program facilitator or clinical expert nurse whopromotes continuous learning and development through regular contact with new graduates participating in theprogram, and (c) nurse managers on units who provide leadership on clinical, staffing, and administrative issuesand who evaluate the progress of new graduates.

Two program supports were reported as important aspects of orientation programs: peer group support (e.g.,debriefing/self care session) and mentorship by senior leaders. A peer group discussion enabled new nurses to

share the problems or difficulties with peers who were experiencing similar stress and provided strategies todeal with them. The use of mentorship as a support program was reported in seven articles. Three of the sevenarticles described a mentor as one of the roles of the preceptor (Boyer, 2005; Herdrich & Lindsay, 2006;Rosenfeld et al., 2004), whereas the other four articles reported that mentorship was a separate programaltogether (Beecroft et al., 2001; Blanzola et al., 2004; Krugman et al., 2006; Newhouse et al., 2007).

All reviewed programs used several methods and tools for program evaluation, including the use of multipledata resources and qualitative and quantitative data gathered from preceptors, nursing managers, staff, and newgraduates. Program outcomes also varied but generally focused on retention, confidence, competency (e.g.,critical thinking and knowledge), communication, satisfaction, and cost effectiveness. Program coordinatorswere important in the continuous evaluation of orientation program processes, content, and outcomes. Guiding

and tracking learning and performance provided consistency across the programs and helped to improve them.

DI SCUSSION

The findings of this study provide information on the effect of orientation programs on new RNs' confidence,competency, and retention. The reviewed studies suggest that the orientation programs are successful inimproving new RNs' confidence in caring for patient and in enhancing their competencies such as knowledgeand critical-thinking skills in the clinical environment. By doing so, these programs may encourage newgraduates to stay and to participate in a supportive system. Furthermore, asBenner's (1984) model wouldsuggest, this review shows that an orientation program with certain characteristics-that is, structured teachingmethods, clinical experiences with qualified preceptors, and support systems-fosters the transition of new RNs

from novices to advanced beginners.

Reviewed studies reported a wide variability in the time frames of orientation programs, with program lengthranging from 6 weeks to 1 year. Several studies (n= 7) reported successful results in programs of 1-year length,and the 1-year time frame is used in the National Post-Baccalaureate Graduate Nurse Residency Program, apartnership between the University Health Systems Consortium and the American Association of Colleges ofNursing. This program is based on the premise that transition into practice is not completed until 9 to 12 monthsafter starting a job and that a 1-year time frame for the successful transition of new graduates is reasonable(Krugman et al., 2006). Given the variability in program length reported in the literature, more research isneeded to determine the most effective length of orientation programs for new RN graduates.

An extended program length, however, also poses additional costs. For example, several studies reportedbenefits resulting from the recruitment and retention of newly graduated nurses, although these programsincurred additional training costs (Beecroft et al., 2001; Krugman et al., 2006; Pine & Tart, 2007).Beecroft etal. (2001) calculated the return on investment (ROI) to determine the cost effectiveness of their 1-year programand reported an ROI of 67.3%, meaning that the program not only paid for itself but also saved money.Pine andTart (2007) also reported the cost effectiveness of a 1-year residency program with an ROI of 884.75%.Further,Krugman et al. (2006) reported that the average budget for managing the 1-year National Post-Baccalaureate Graduate Nurse Residency Program was less than the costs to advertise and recruit two nurses.Although this review did not examine the cost effectiveness of newly graduated RN orientation program per se,these studies suggest that an extended program length may be worth the added costs.
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This review also revealed that the specialized orientation programs, which trained newly graduated nurses towork in critical care units, had a positive impact on their confidence, competency, and retention. In an effort todeal with the urgent nursing shortage, current healthcare systems increasingly recruit newly graduated nursesfor highly specialized areas that once were available only to experienced nurses. Therefore, it would bemeaningful to conduct further research to evaluate the impact of specialty orientation programs on new nurseretention and patient safety in critical care units.

Many reviewed studies used a descriptive research design. That is, the authors described interviews with

participants in a program or the studies did not have a control group with which to compare the intern orresident group. Therefore, the design used in the primary research may limit this study's ability to accuratelycapture the extent of new RN orientation program impact. However, the authors tried to overcome thislimitation by examining data from similar hospital programs and analyzing differences and similarities betweenthe programs to present more comprehensive information and recommendations.

This study has several other limitations that are important to address. The focus of this integrative review wason hospital-based new RN orientation programs. However, several articles related to new RN orientationprograms in other settings, such as long-term care, were excluded during the review process. Future reviews ofthis nature are needed to compare and contrast new RN orientation programs across types of settings to betterinform future program development. Furthermore, this review was restricted to programs focusing on outcomes

in only three areas-confidence, competency, and retention. By restricting the focus in this way, other importantoutcomes of new RN orientation programs could have been missed. However, given that these are three veryimportant outcomes of new RN orientation programs, the studies reported here and the conclusions reachedrepresent an important first step in the examination of outcomes across different types of hospital-based newRN orientation programs. Finally, despite best efforts to conduct an in-depth scan of the literature, some studiesmay have been missed in the search process. The authors tried to overcome this limitation by scanning theliterature broadly across numerous search engines and by incorporating extensive search and eliminationstrategies. Therefore, the authors believe that the studies reviewed here adequately characterize hospital-basednew RN orientation programs during the time period of study.

CONCLUSIONS

In the face of a shortage of nurses, the new RN orientation program should be an initial, basic step in ahealthcare organization's retention strategy. Healthcare systems have attempted to address this concern byrevising existing orientation programs or introducing new programs to retain newly graduated nurses. Thisintegrative review examined the impact of orientation programs reported in the literature between 1990 and2007. Innovative orientation programs have strong merits: They facilitate the transition from newly graduatednurses to professional RNs and create environments that promote the retention of newly graduated nurses.These programs have the potential to address the nursing shortage in healthcare organizations. For hospitals topursue successful staff retention, the information in this review can serve as a resource for evidence-basedmanagement.

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- See more at:http://www.nursingcenter.com/lnc/cearticle?tid=1052774#sthash.EieXAXcV.dpuf

B O U T T H E P R O J E C T

The Internship Project is an endeavor of the Vermont Nurses In Partnership (VNIP), a not-for-profit nurseleadership coalition that institutes resources for supporting the developing nurse. The programs developed byVNIP promote a workplace culture of nurture, support and professional growth for novice nurses or those intransition to a new specialty. VNIP includes nurse leaders from academia, regulation and various practicesettings. The collaboration has grown from the initial 45 Vermont-based members, to acoalition of over 300
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nurse leaders from across the nation and around the world. These proactive healthcare leaders provide theintellectual resources that allow us to develop and deliver intern, orientee, and preceptor development programs

Unique aspects of the project include:

Establishment of a statewide, standardized approach to preceptor development and support Preceptor development that is applicable for a broad audience of direct care providers An internship model suitable for multiple healthcare agencies instead of a single site or system A research and theory based model that is being adapted to community health settings and a variety of

disciplinesINTERNSHIP FACT SHEET

I S S I O N

To create a formal and sustainable nurse internship program that provides the clinical experience necessary tosupport the novice's entry into practice, their growth along the continuum of expertise, and their professionalpractice within the complex and demanding field of healthcare.

I S I O NThe Vermont Board of Nursing, Schools of Nursing, and practice sites work in a collaborative, statewide,partnership to maintain a nationally recognized Nurse Internship Program. The internship is available inmultiple settings and supports the transition from new graduate nurse to a self confident, adaptable, andindependent professional.

CONTENTS

BackgroundModel development and implementationOutcomes

Internship ModelRoles and responsibilities required to support the modelProgram ComponentsCompetenciesRecommendationsBibliography and Resource list

Background

The Vermont Nurse Internship Project (VNIP) is a healthy workplace strategy that has proven its worth. It is aproject that was undertaken in response to the looming staffing issues identified in 1999 by the VermontOrganization of Nurse Leaders (VONL). VONL partnered with the Vermont Association of Hospitals and

Health Systems (VAHHS) to commission research on nursing workforce issues specific to Vermont. Theresulting report, theVermont Nursing Reportbecame the basis for further collaborative work and then strategicplanning relating to the pending workforce crisis. Six (6) strategic goals for dealing with the crisis wereidentified inVONL - Current State of Nursing in Vermont.

Two of these goals became the focus of the internship project:

I. Create a formal nursing internship program that provides adequate practical clinical experience for novicenurses to function at a competent level when they enter the work force. This would force a marriage of
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schools of nursing and fields of practice that could strengthen both institutions, while promoting thepreparation of nurses able to handle the currently complex and demanding field of health care.

II. Expand clinical opportunities for students by increasing the use of clinical staff as preceptors in specialtyareas.

Grant funding was obtained to support a half time Directors position to lead development and implementation

of the model/project, and the Vermont Nurse Internship Project (VNIP) was established.

TOP

Model development and implementation

At the initial VNIP meeting, it was determined that three (3) levels of internship were needed: 1. Student (externprogram) for expanded undergraduate clinical experience. 2. Graduate level (transition to practice) internshipto provide an organized, supportive transition to practice that included educational support, competencydevelopment, and skills evaluation. 3. Specialty care internshipsto provide the extensive additional educationand support for work in a specialty care area such as OR, ICU, Home care, Long term Care, etc. The initialmodel development targeted the new graduate RN and transition to practice. It was decided that the internship

would be based in a precepted delivery model. As a result two programs were developed: one for the interns(new graduates) and another for the development and support of clinical staff preceptors.

Unique aspects of this project include the collaborative workgroup comprised of Nurse Leaders from Practicesettings, Academia, and the Board of Nursing and the focus on a model configuration that can be appliedstatewide and across the continuum of care. The Internship model used Lenburgs Competency OutcomesPerformance Assessment (COPA) model (Lenburg, 1999) for the core outline for the role of the RN andcompetency-based skills verification. The specific sub skills for each of Lenburgs Eight Core PracticeCompetencies were identified with input from all practice areas to establish a competency verification form thatoutlined the core role of the generalist RN in most, if not all, direct care settings. The initial form was used inthe first pilot during the summer of 2000. Based on outcomes data and feedback from the educators and

preceptors using the model within the pilot, it was modified then underwent a second pilot during 2001. Thusthe model and its components were validated as a standardized model for delivery in multiple settings. It wasfound to be a model that provides structure for experiential learning that can address the needs of the newgraduate, specialty care internships, and/or the clinical component of a re-entry program.

The initial outcomes analysis resulted in recognizing the urgent need for added preparation for preceptors. Apreceptor development focus group convened that included the directors of three of the states nursing

programs. They assisted in shifting this essential preparation into theory and research based education that isdelivered via an independent learning module and two (2) days of workshop presentation. This initial educationtotals 18.6 contact hours of interactive teaching/learning. Thanks to a partnership with grant funded specialtycare internships, we have been able to offer this standardized education to direct care providers from all regions

and specialties within the state. The preceptor workshops have offered an ideal venue for collectingdemographic data on these clinical experts with a focus on identifying those who might be interested in a futureteaching role.

The statewide, standardized approach to preceptor development is another unique aspect of this project. It hasled into development of a credentialing process for preceptors. This credentialing offers recognition and rewardfor this key teaching/support role, while establishing a pool of clinical preceptors who have all had the sameeducational preparation, support, and skills development/evaluation.
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The internship has been in place as an active educational process since 2000 and has seen annual growth andexpansion. Its impact has expanded through collaboration with various non-Vermont healthcare agencies whorequest consulting time and model adoption. The project currently has grant funding that will: 1) strengthen theVNIP coalition 2) expand implementation at additional sites/settings 3) develop the model for use in home careand public health settings 4) continue/expand preceptor development and 5) collect data specific to nurseretention in rural and/or medically under served areas. The National Council of State Boards of Nursing(NCSBN) is finalizing plans for a research project that will be done collaboratively with the VNIP to evaluateboth program outcomes and differences in clinical practice resulting from the model.

TOP

Outcomes

2000 Satisfaction SurveyTransition to work- Survey data showsgreater than 40% improvementinsatisfaction with transition to practice and new grad competency

For initial pilot, 49% of the Nurse Interns came from out of stateresidence and/or schools Retention data from tertiary care center- Retention of those who completed their Orientation in 1999

was 75%, while the new grads that completed an Internship showed a 93% retention rate for each of thefollowing two years.

Position Vacancy rateAt one participating agency, the Medical - Surgical unit had suffered anunrelenting vacancy rate of 20%. This agency credits the Internship/Preceptor program with the currentvacancy rate of 0% for the entire nursing department. This hospital now has no recruitment or positionadvertising costs for nursing positions.

TOP

Internship Model

The Internship is a formal, post-licensure educational program designed to extend the basic nurse educationpreparation, proficiency, and/or skills of new graduate and transitioning nurses. Each intern has completed aguided course of nursing education. The Internship curriculum is designed to give experience and repeatedpractice application to demonstrate successful transition of this learning into the specific clinical practicesetting. It includes individual studies, staff development courses, clinical conferences, and one-on-one supportand instruction from a preceptor. The purpose of the internship is to advance clinical practice skills needed todeliver safe, comprehensive care in existing and emerging organized health care systems.

TOP

Roles and responsibilities required to support the model

The Clinical Educator directs the facility specific internship, provides didactic sessions for the intern, and offersongoing support and resources for the preceptor/intern team. The Preceptor develops learning goals/objectivesin collaboration with the intern and clinical educator, assesses the interns experience level and learning style,

and plans learning experiences accordingly. He/she is responsible for choosing the patient assignment based oneducational goals and objectives and sharing that assignment by progressively assigning patient careresponsibilities to the intern. Along with planning, the preceptor provides daily feedback to the intern andcollaborates with the clinical educator and nurse manager to evaluate progress and address issues. The intern isresponsible for active participation in all components of the Internship and completion of documentation.

TOP
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Program components include

An Internship session may include up to 5 preceptor/intern teams starting at the same time and the duration is10 weeks. There are at least 40 hours devoted to didactic components within the program with required contenttopics that include, but are not limited to: standards of care, managed care, cultural competence, qualityimprovement, IV access/therapy, medication administration, and pain management. Interns are not consideredas part of the staffing mix and each is paired with a qualified Preceptor. The patients assigned to interns willalso be part of their preceptors assignment and preceptors progressively allocate patient care activities to the

intern. The preceptors act as mentors and role models, leading the intern through his or her daily clinicalexperiences on the unit. On a weekly basis, the intern, preceptor, and/or clinical educator will meet toestablish/evaluate goals and work with Critical Thinking skills .Delivery of the Internship requires release timefor support of educational preparation, didactic instruction, goal setting, weekly conference, and support groupmeetingsapproximately 200 hours of educator time for each Internship session.

TOP

Competencies

The Internship provides practice and verification of competencies that are based on theCOPA model (Lenburg,1999). The Internships competency verification form delineates specific criteria that address Lenburgs

essential skills of Assessment and Interventions, Communications, Critical Thinking, Humancaring/Relationships, Management, Leadership, Teaching, and Knowledge Integration.

TOP

Recommendations

Along with investing in transition programs for new graduates, our healthcare systems need to ensure thedevelopment and support of preceptors in the clinical setting. Most of todays transition programs usepreceptor-based systems, but not many have consistently invested in the development and support of thosepreceptors. To be effective, preceptors require an educational foundation, ongoing support, and time to

precept. A commitment to this teaching time serves the development of both the preceptor and the novicewith whom they work.

Our project has identified two groups that require intensive education and support. The first target audience isthe preceptor. Teaching, mentoring, interpersonal, and competency assessment skills must be developed inthese individuals. A foundation must be laid with comprehensive, theory-based education related tointerpersonal communication, roles/responsibilities, principles of teaching/learning, assessment, planning, andfeedback skills. The vitally important roles of the preceptor include protector and competency validator.These roles require specific preparation and support. Once this foundation is laid, the preceptors effectivenessshould be evaluated on an ongoing basis, within a system that focuses on performance development for both thepreceptor and the novices with whom they work. This ensures the necessary structure for skills development

and competency assessment that protects the safety of our clients as well as the professional development of ournurses.

The second target audience is the novice nurse. This nurse may be a new graduate, a re-entry candidate, or anurse that is transitioning into a new specialty area. Each of these novices needs advanced support, instruction,and precepting to develop the reflective learning, critical thinking, and specialty practice skills that are essentialto safe, effective nursing care in our multiple and challenging settings.

To deliver this, an effective preceptor/internship program needs to include:
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1. Clearly identified roles and responsibilities that also delineate where to find the time for precepting2. A Clinical Coaching plan that outlines specific goals, activities, and measurable outcomes. This plan must

follow principles of teaching/learning, to foster the progression of the novice through all core competencyrequirements.

3. Specific planning for critical thinking development through weekly meetings, case scenarios,documentation tools, discussion and/or problem solving.

4. Valid and reliable tools for competency verification that identify specific, measurable criteria forassessment

Investment in these target groups has paid dividends in recruitment, retention, and improved satisfaction forVermont nurses. We are succeeding in changing the culture of the workplace towards one of support, nurture,learning, and professional advancement.

TOP

Bibliography and Resource list

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