Introduction

Ackerson and Stiles [1] stated, “More than one million nurses are expected to retire in the next 10-15 years. Retaining new nurses is important to help decrease turnover, vacancies, and organizational cost”. The journey from education to clinical practice can be extremely stressful for new graduate nurses as they struggle to put knowledge into practice. Camp and Chappy [2], postulated, “Many new graduate nurses struggle with the transition from novice to competent nurse, and an estimated 35-60% of nurses leave their first place of employment within one year of hire”. Evidence reveals new graduate licensed Registered Nurses (RN’s) often feel inadequate as they transition from a structured academic setting to the healthcare environment where they must make rapid, serious decisions related to critical patient events. New graduate licensed RN’s convey there is a reality shock with an apparent contrast between their relationships, roles, responsibilities, and knowledge and performance expectations in their known roles of a student to the less familiar role of professionally practicing nurse [3]. Many healthcare institutions have adopted innovative approaches to assist new graduate RN’s to transition as independent practicing nurses and bedside leaders.

Camp and Chappy [2] expressed, “Nurse Executives judge that as few as 10% of new graduate hires are fully prepared to enter the nursing workforce”. According to Ackerson and Stiles [1], “The average cost of turnover for a bedside RN is estimated to be between $37,700 and $58, 400. One strategy to address retention and turnover in new graduate nurses is the implementation of a nurse residency program”. In an integrated literature review, Asber [4] conveyed nursing residency programs, “Increase retention rates and organizational commitment and decrease costs of turnover… and has the potential to decrease job stress while building confidence and increasing prioritization, communication, and leadership skills”. Chant and Westendorf’s [5] integrative literature review supports nurse residency programs stating, “Nursing residency programs are valued and produce results”. In a systematic review, Camp and Chappy [2] suggested, “Nurse Residency programs appear to have positive outcomes and graduate nurses benefit from the education, support, and guidance…evidence shows new graduate nurses who participate in NRPs are more prepared to face challenges they encounter as practicing RNs”.

Walsh [6] conveyed, Growth in the four foundational skills of communication, organization, critical thinking, and stress management through nurse residency programs helps build the confidence and self-reported competency of new graduates. Regardless of the structure, completion of any type of nurse residency program has been shown through qualitative studies and surveying to be associated with increased levels of confidence, competency, and job satisfaction, with a reduction in stress and anxiety of the new graduate. Nurse residency programs have been one method used by healthcare organizations to address this issue, however, development and implementation can be costly and often challenging. In response to this need, two nurse educators from a local four-year university worked collaboratively with a small rural hospital in Alabama to develop the New Graduate Orientation and Leadership Series (GOALS). The GOALS program is an illustration of a pioneering approach to assist with the transition of a new graduate licensed RN from academia to autonomous practice. Martin and Wilson [7] suggested that newly licensed RN’s need support and encouragement during the transitional phase as they are prone to make errors in clinical reasoning and judgment.

Background

In today’s healthcare environment nurses need to be confident and competent to meet the needs of complex patients. Nurses must possess excellent assessment skills, the ability to think critically, reveal comprehensive clinical judgment and possess communication skills, which produce positive patient outcomes. The complexity of the healthcare environment requires a competent, stable nursing workforce where quality and safety in patient care are at the forefront. In 2010, the Institute of Medicine [8] published The Future of Nursing; Focus on Education, with a goal for institutions to support the development of Nurse Residency Programs thus; “Improving the retention of nurses, expanding competencies, and improving patient outcomes”. The GOALS Nurse Residency Program is one example of creative efforts to promote perceived self-efficacy, competence, effective communication and resiliency in newly graduated licensed RN’s. Students enrolled in the GOALS program meet with course faculty monthly for an interactive, engaging workshop. In an effort to foster these desirable attributes storytelling/nurse lore and empowerment training using stress management techniques are used as creative teaching strategies.

Literature Review

Transitioning to Practice

Martin and Wilson [7] conducted an ethnographic research study, which included observation, interviews, and document analysis. These techniques were used to gain insight into nurses’ daily work from the perspective of newly graduated licensed RN’s. Thirteen nurses were monitored closely during their first year in a hospital setting in Norway. These new nurses generally entered the field with empathy for their patients, enthusiasm for the profession, and readiness to learn more about being a good nurse. However, their more experienced colleagues seemed to neither respect nor nurture this attitude. The new nurses experienced heavier responsibilities than expected, fragmentation of patient care, and stressful interactions with colleagues. The lack of a supportive work environment and role models increased the new nurses’ experience of overwhelming responsibility in their daily work situations. The nurses learned to cope the hard way, despite the organizational culture, not because of it. Adjusting the profession’s expectations of new nurses, and offering good role models and more comprehensive support programs, would markedly ease the transition for new nurses.

Self-Efficacy

Maslach and Jackson [9] originally conceptualized burnout as a psychological syndrome affecting helping professionals exposed to prolonged job strain characterized by feelings of emotional exhaustion, depersonalization and personal inefficacy. Occupational coping self-efficacy is defined as an employee’s appraisal of their ability to meet job demands and that individuals perceived confidence in his/her ability to cope with work demands. Effective occupational coping self-efficacy has been associated with lower levels of strain and higher adaptive coping skills. Laschinger, et al. [10] conducted a cross-sectional survey of Canadian new graduate nurses. The study tested a model linking authentic leadership, areas of work-life balance, occupational coping self-efficacy, burn out and mental health. The study revealed that authentic leadership had a positive effect on areas of work life balance and in turn a positive effect on occupational coping selfefficacy, resulting in lower burnout and improved mental health.

Resiliency and Empowerment

Studies related to stress resiliency and empowerment date back to the 1800’s in both physiological and psychological literature. Stress resiliency has been linked to psychological empowerment in a number of studies of RN’s in the workplace. Pines, et.al. [11] conducted a correlational study to examine relations of stress resiliency, psychological empowerment and demographic characteristics on baccalaureate nursing students. Findings revealed that students could benefit from primary prevention learning initiatives to increase the range of behavioral skills to effectively manage interpersonal conflict in the workplace. The transition from student to working nurse has long been recognized as challenging. The complexity of the healthcare environment creates additional stress for practicing nurses. The evolving role of nurses predispose nurses to experience interpersonal conflict in the workplace as they meet the actions and reaction effect of both internal and external environmental demands [11].

A growing body of knowledge supports the association of stress resiliency with psychological empowerment for RN’s. Stress resiliency and empowerment are human traits, combining the strength of an individual to respond to stressors. Evidence further supports the power of resiliency in relation to positive outcomes among children, adolescents, adults and survivors of trauma. Resiliency is the ability to bounce back after a traumatic or stressful event. Personal attributes of resilient people include an internal locus of control pro-social behaviors, empathy, positive selfimage, optimism and the ability to organize daily responsibilities. Empowerment is considered a psychological process that enables individuals to establish and attain goals. The concept of empowerment connotes power, control, ability, competence, selfefficacy, autonomy, knowledge, development, self-determination and strengthening of one’s own group in society [11].

Storytelling/Nurse lore

Narrative storytelling, often referred to as “Nurse Lore”, has been established as an innovative approach for new graduate nurses to share rich, complex, clinical decision-making scenarios. In an article on the use of nursing lore, Timbrell [12] stated, “Instructional Storytelling (IST) provides a vicarious experience in which students may participate in the same encounter and learning from one another”. Continuing on discussing the educational innovation, Timbrell [12] articulated, “Students may practice their skills by identifying priorities or trying out new communication skills, exchanging ideas with one another, or imagining alternatives just by working through a clinical situation or problem conveyed through IST”.

In an article on teaching tips, Billings [13] related, “A story can provide structure for helping learners connect interrelated facts and concepts, while providing a context for learning. When learners develop or listen to a story, they use critical thinking skills, empathy and acquire different points of view”. In her article, Billings [13] further summarized with, “Storytelling is one additional teaching-learning strategy that nurse educators can use to facilitate active and engaged learning. Storytelling provides a context for learning, connects theory and evidence to nursing practice”. Wheeler, et al. [14] revealed in the educational innovation and study on storytelling, “Utilizing a guided reflection activity resulted in the students experiencing a broader, deeper understanding of reflective professional practice”.

In the GOALS program, new graduates share stories, which have been encountered as they strive to successfully apply theoretical concepts learned in school to complex, real-life clinical situations. Narrative storytelling encourages communication among peers and is considered to be a type of reflective practice where meaningful dialogue can occur between the peer group and facilitators. New nurses are able to reflect upon their current practice, analyze complex situations and problem solve with their peer group. Resiliency and empowerment strategies which can be incorporated into narrative storytelling sessions as a method for students to share, reflect, brainstorm and often “Bounce Back from Setbacks” they may have experienced while transitioning from academia to real-world practice. Stress management techniques were taught and utilized to promote resiliency and empowerment in the newly graduated RN’s.

GOALS Program Aim

The overarching objective of GOALS was to increase job satisfaction, improve morale, and expand competence and confidence while promoting resiliency in new graduate licensed RN’s. Research findings support innovative programs, such as GOALS can aid in bridging the gap from the academic setting to the practice setting and increase retention, job satisfaction, competence, and confidence of newly licensed RN’s [15]. In the article on nurse residency programs and the retention, Ackerson and Stiles [1], indicated, “It is evident based on retention rates, that Nurse Residency Programs positively affect retention at one year”. Cochran [16] stated, “Nurse Residency programs expand new graduate nurse knowledge base as well as improve clinical and critical thinking skills”. Walsh [6] affirmed, “The literature demonstrates improving the transitional experiences of new graduate nurses with a focus on communication, organization, critical thinking, and stress management has, in turn, improved job satisfaction, and nursing retention”. The aim of using storytelling and nurse lore as an innovative teaching strategy was to promote the development of the newly graduated licensed RN’s perceived level of self-confidence in clinical decision making while providing a sense of professional identity and belonging. The supportive learning environment served a safe zone where newly graduated licensed RN’s could develop the knowledge, skills, and abilities needed to be successful in a complex healthcare setting.

Method and Design

The research was conducted using a Qualitative Method. The students were scholarship recipients selected by the Chief Nursing Office (CNO) at the local hospital where the nurse residency program took place. The data were collected using focused group interview questions and semi-structured interviews. The interviews were conducted in the education department at the facility. Five students participated in the small group interviews for one hour and the interviews were audio recorded. The interviews were transcribed, and thematic analysis was conducted. All data was coded, then data was identified and reviewed, revealing the key themes. The student’s perceptions were examined in each theme.

Institutional Review Board (IRB)

The IRB at the hospital is a specified committee charged with the responsibility of safeguarding the rights of human subjects. The nursing researchers proactively completed human subject training prior to submitting an application to the IRB committee. The certificate and training have been maintained throughout the research study. The nursing researchers submitted the proposed research application for initial review and were granted IRB approval from the hospital IRB committee. Prior to the GOALS Program, student participants were provided with knowledge related to the research study and were provided with clear instructions indicating their participation in the study was strictly voluntary and non-participation would not result in any negative consequences for the student participant. Student participants who elected to participate in the study signed a confidential, informed consent form. These forms were signed and witnessed by the nursing researchers while adhering to well established procedures to maintain confidentiality. The student participant’s signed informed consent forms are stored in a locked cabinet in the primary nursing researcher’s office.

Study Setting and Population

The study was conducted at a small rural hospital in the southeast United States. Student participants were recruited as a cohort sample. Inclusion criteria were students that were actively enrolled in the GOALS program, exclusion criteria were nurses who were not enrolled in the GOALS program. The GOALS Program was held in a common area which is easily accessible to all student participants, hospital staff, and nurse researchers. Students and the hiring manager were provided a letter of invitation with clearly articulated meeting dates and times for the entire program.

Research Design

The nursing researchers used a qualitative research design for this study. According to Rebar & Gersch (2015), “qualitative methods focus on understanding the complexity of humans with the context of their lives. Research that uses qualitative methods involve the collection of information as it is expressed by people within the normal context of their lives. Qualitative methods focus on subjective information and never attempt to predict or control the phenomenon of interest”. The qualitative research design was chosen for many reasons. Nurse researchers wanted to assess if completing the GOALS Program fostered social engagement, facilitated transition into practice, provided a system of support and mentoring (someone the student believes will “Understand Them”), enhanced critical thinking and problem-solving ability, and supported a connection to the hospital and their peer group. Furthermore, nurse researchers were interested in student’s honest feedback regarding the educational experience.

Data Collection and Instrumentation

Qualitative data which included the collection of focused group interview questions and semi-structured questions has been and will continue to be utilized as a method of collecting data. To maintain rigor in this qualitative study, a strict, consistent process is used in the collection of the focus group and semi-structured questions. Trustworthiness, a vital component of qualitative research rigor, was established throughout the year as the nursing researchers establish rapport with the student participants. The student participants were encouraged to communicate their feelings and insights related to learning experience. Rapport was established as the nursing researchers showed continual interest in obtaining feedback from student participants.

Confirmability was used by the nursing researchers by using the same format and approach to collection of data. The nursing researchers have developed an audit/checklist system approach to ensure a consistent approach to collecting and maintaining data security. During the data collection process, focus group and semi-structured questions were asked in a face-to-face classroom setting. Students from each cohort were asked the same focus group questions and allotted the same amount of time to respond. This data was recorded and transcribed. Transferability was displayed as the nurse researchers assess for emerging themes which surface in different cohorts of student participants.

During the focus group interview session, each student participant was asked the following six questions:

• What were your initial feelings about participating in the GOALS Program?

• What is your perception of the GOALS Program in regard to promoting a seamless transition from student to new graduate nurse?

• How has your participation in this program influenced your thoughts and feelings about the hospital?

• What did you like most about the GOALS Program?

• What did you like least about the GOALS Program?

• Suppose you were the administrator of the GOALS Program; what would you do differently?

Following the focus group interview session; the student participants were asked to complete four Semi-Structured questions as follows:

• Convey how participation in the GOALS program facilitated your problem solving abilities related to unpredictable events?

• Describe how participation in the GOALS program may have fostered decision-making related to unpredictable events in the clinical practice setting?

• Which key elements of the GOALS classroom and learning experiences did you find beneficial in preparing you for success in clinical practice?

• How confident did you feel about the role of a practicing nurse after participating in the GOALS program?

Data Analysis Strategies

Diverse methods are used to analyze the data obtained from the focus group and semi-structured questions. One approach used by the nursing researchers was to read the responses from the focus group and semi-structured questions and organize the responses into sentences or groups of sentences which addressed the same ideas. Ideas were then paired with other responses which focused on the same ideas or concepts in an effort to find meaning and relevancy. By organizing, ordering and synthesizing the data the nursing researchers were able to successfully describe the feelings, behaviors, experiences and ideas of the student participants. Coding was used to break down and label the data collected. Themes were identified as ideas or concepts that were recurrent in the focus group and semi-structured question responses. The nursing researchers sought to categorize the responses, understand the meaning behind the words expressed, and to conceptualize the data into emerging themes.

Implementation of Program

The implementation of the GOALS program occurred as a face-to-face workshop between two nurse researchers and student participants. The workshops transpired on the third Thursday of each month and attendance was mandatory. The length of the GOALS program was for one year. The workshop began with a period allocated as nurse lore-a storytelling approach- where students were encouraged to share stories that involved scenarios encountered in the clinical practice setting. Student participants discussed coping skills, methods of decreasing stress level, and strategies to achieve work-life balance. Dialogue and debate were encouraged during this time of self-reflection. Socialization to the professional role was fostered as students actively problem solved and resolved conflicts. Critical thinking and clinical reasoning were enhanced as students engaged in crucial conversations surrounding complex patient scenarios.

An innovative curriculum was developed for the GOALS program and was delivered thorough out the year. The curriculum included concepts based upon the Quality and Safety Education for Nurses (QSEN) [17] competencies. These concepts included Patient Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-based Practice (EBP), Quality Improvement (QI), Patient Safety (S), and Informatics (I). Stress, coping, and empowerment content was incorporated into the workshops on a monthly basis. Diverse teaching strategies were utilized as students were encouraged to use the knowledge, skills and abilities they obtained to solve real life scenarios.

Results

The GOALS pilot program has been conducted for one cohort for a period of one year and is ongoing. At this time, five students have participated in the GOALS program. As mentioned earlier, researchers will continue to collect data in the form of focused group interview and semi-structured questions as well as anecdotal comments from students [18]. Thematic coding has not been conducted at this time because data collection is ongoing. However, we do have some anecdotal comments to share as follows:

• “At first; I did not want to participate. I saw the meeting dates and times and I thought like we all did. I just got out of school. I don’t want more class time and more homework. I already have NCLEX and a new job orientation; I don’t need more work and more stress than I already have as a new nurse”.

• “I liked the GOALS program. I learned a lot”.

• “I could tell the difference between me (being in GOALS) and people I graduated with (not in GOALS). I knew more than them in areas such as policies and procedures, etc.”.

• “It helped me so much because I never worked in a hospital before”.

• “I liked coming to class. It is nice to be around new nurses like me who are struggling, to be able to talk and vent to each other”.

• “It was a good support system”.

• “GOALS opened us up to more than what the instructor taught us in nursing school for two years. There is another world out there besides what the instructor said. We saw things from another perspective”.

• “When I am working on the floor, I do not feel heard. I offer ideas to improve processes, to make things better and I feel like it just goes right out the window and does not go any further. During the GOALS program, I feel my views and opinions were heard and something actually happens. You guys actually listened to us”.

• “We needed a safe place to vent, our support time”.

• “As a student, I looked at things one way and after the GOALS program, I could see more of the bigger picture”.

• “The GOALS Program needed more buy-in from the nurse managers. I felt they viewed the program as a nuisance instead of an advantage”.

• “In a program like GOALS; the facilitator needs to be an outsider. Someone who is non-biased”.

• “My favorite part was the Simulation Labs. They were great and we all wanted more”.

• “Simulation is very beneficial and increases our critical thinking skills”.

• “It helped me transition into the role of nurse”

• The researchers anticipate some limitations that must be considered when interpreting the results. These limitations could include a potential for bias as this is a risk associated with the use of convenience sampling.

In addition, there were geo graphic limitations related to the research study being conducted in a hospital in a rural area.

Final Recommendations

The nursing researchers gained insight into diverse components of a successful transition into practice program. The importance of relationship building with key stakeholders was recognized as a key strategy to facilitating organizational buy-in. The nursing researcher’s garnered understanding related to relevant and meaningful content which could be included into the established curriculum of the GOALS program. Final recommendations for the GOALS program would be to:

• Ensure buy-in from nursing managers for the residency program.

• Incorporate more simulation into the workshop days for the residency program.

• Use a facilitator who is not affiliated with the hospital.

• Increase the length of the GOALS program to a two-year period (first year workshops and second year mentoring).

• Collaborate with an academic institution to develop and teach workshop content.

• In regard to future research studies based upon what has been learned; the nursing researchers would recommend the following:

• Implement a small-scale qualitative study across multiple cohorts.

• Design a larger scale research study in a rural hospital using both quantitative and qualitative data collection.

• Conduct a larger scale research study in a metropolitan hospital using both quantitative and qualitative data collection.

• Assess perceived occupational coping self-efficacy related to socialization to professional practice using both quantitative and qualitative data collection.

• Measure stress resiliency with psychological empowerment using both quantitative and qualitative data collection.

Conclusion

Based upon student feedback obtained thus far, the researchers believe the GOALS Pilot Program to be a success. One student participant summed up the GOALS Program in such a profound way stating, “I would say the program was successful. I feel like it has helped us grow as a nurse and helped us transition – it did what it was supposed to do. I feel being a part of the GOALS program helps me remember when I go back to the floor; this is why I love the hospital - this is why I became a nurse - this is why I work here - and every month, I had that feeling”. The researchers believe the GOALS Program benefitted our student participants by fostering social engagement, facilitating their transition into practice, providing a system of support and mentoring (someone the student believes will “Understand Them”), enhancing critical thinking and problem-solving ability, and supporting a connection to the hospital and their peer group.

References

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