The Journal of Continuing Education in Nursing

Original Article 

Newly Licensed Nurse Resiliency and Interventions to Promote Resiliency in the First Year of Hire: An Integrative Review

Lisa Concilio, MSN-ED, RN, CCRN; Joan Such Lockhart, PhD, RN, CNE, ANEF, FAAN; Marilyn H. Oermann, PhD, RN, ANEF, FAAN; Rebecca Kronk, PhD, MSN, CRNP, CNE, FAAN; James B. Schreiber, PhD

Abstract

Background:

Lack of resiliency contributes to growing dissatisfaction among newly licensed nurses (NLNs) and often leads to clinical errors and job resignations.

Method:

An integrative review synthesized current research investigating NLNs' resiliency within their first year of hire and interventions that may affect their resiliency.

Results:

Key database searches (2008 to 2018) yielded 16 studies. Insufficient resiliency among NLNs has been correlated with intentions to leave current jobs and decreased job satisfaction. Residency programs, well-prepared preceptors, and peer support promoted NLN resilience and enhanced patient safety. Lack of coworker support has led to NLNs' intentions to leave their current jobs or the profession entirely.

Conclusion:

NLN turnover has been interpreted to be an outcome of poor NLN resilience. The first year of practice is stressful and affects NLNs' mental health and cognitive reasoning, thereby risking patient safety. Resiliency should be measured using a resiliency scale rather than turnover rates. [ J Contin Educ Nurs. 2019;50(4):153–161.]

Abstract

Background:

Lack of resiliency contributes to growing dissatisfaction among newly licensed nurses (NLNs) and often leads to clinical errors and job resignations.

Method:

An integrative review synthesized current research investigating NLNs' resiliency within their first year of hire and interventions that may affect their resiliency.

Results:

Key database searches (2008 to 2018) yielded 16 studies. Insufficient resiliency among NLNs has been correlated with intentions to leave current jobs and decreased job satisfaction. Residency programs, well-prepared preceptors, and peer support promoted NLN resilience and enhanced patient safety. Lack of coworker support has led to NLNs' intentions to leave their current jobs or the profession entirely.

Conclusion:

NLN turnover has been interpreted to be an outcome of poor NLN resilience. The first year of practice is stressful and affects NLNs' mental health and cognitive reasoning, thereby risking patient safety. Resiliency should be measured using a resiliency scale rather than turnover rates. [ J Contin Educ Nurs. 2019;50(4):153–161.]

The nursing shortage has been a long-standing problem in the United States and spans eight decades ( National League for Nurses, 2017 ). Newly licensed nurses (NLNs) are graduate RNs who have passed the National Council Licensure Exam-RN (NCLEX-RN ® ) and are employed for the first time in the role as a professional nurse. NLN turnover has been reported in recent years to affect patient safety and compounds the global nursing shortage ( Boamah & Laschinger, 2015 ; Bradbury-Jones, 2015 ; Kovner, Brewer, Fatehi, & Katigbak, 2014 ; Spence Laschinger, Zhu, & Read, 2016 ; Thomas & Kellgren, 2017 ; World Health Organization, 2017 ). The American population is living longer with chronic diseases and expanding disabilities; more well-prepared RNs are needed as health care is ever-advancing and technology is at the forefront to help solve health care problems and improve quality of life ( Academy of Medical-Surgical Nurses, 2018 ; Ghebreyesus, 2018 ; National Academy of Medicine, 2017 ; Reinhard, 2014 ).

Problem Identification and Significance

The American Association of Colleges of Nursing ( 2017 ) reported that 1.2 million RN positions will be vacant between 2014 and 2022 and that approximately 700,000 nurses will retire or leave the workforce by 2024. Cline, La Frentz, Fellman, Summers, and Brassil ( 2017 ) reported that training one NLN may cost a health care system $60,000 to $96,000; therefore, increasing NLN resiliency is imperative to maintain patient safety and is a financial priority. NLNs experience immense stress, leading to a state of shock while transitioning to practice ( Duchscher, 2009 ) and resulting in burnout and turnover ( Laschinger et al., 2016 ; Pfaff, Baxter, Jack, & Ploeg, 2014 ). Dyrbye et al. ( 2017 ) defined burnout as a syndrome characterized by emotional exhaustion that leads to poor performance and an attitude that is contrary to caring. Nurse burnout has led to staffing shortages and increased turnover rates, which has resulted in the use of physical restraints, patient falls, and the formation of pressure ulcers ( Aiken et al., 2014 ; Robert Wood Johnson Foundation [RWJF], 2012 ).

Resiliency has been identified as a key factor in managing the stress of nursing work–life, buffering burnout, and positively influencing NLNs' intentions to stay their current jobs ( Chesak et al., 2015 ; Cope, Jones, & Hendricks, 2016 ; Delgado, Upton, Ranse, Furness, & Foster, 2017 ; Reyes, Andrusyszyn, Iwasiw, Forchuk, & Babenko-Mould, 2015 ). Mudd ( 2016 ) stated that the concept of resiliency is elusive and a closer examination of resiliency is needed in order to decrease burnout and decrease turnover. Without resiliency or ways to cope with the emotional stressors and workplace adversities ( Delgado et al., 2017 ), nurses (including NLNs) may develop inconsistent thoughts, beliefs, and values that will render them unsafe for practice and increase intentions to leave their jobs ( Hart, Brannan, & De Chesnay, 2014 ; Stephens, 2012 ; Tahghighi, Rees, Brown, Breen, & Hegney, 2017 ). This article describes an integrative review of the literature that examined NLNs' resiliency within their first year of hire and interventions that affect their resiliency.

Exploring the Concept of Resilience in Nursing

The youngest generation of nurses are the most likely group of nurses to lack the protective factors of resiliency and leave the profession within the first year of hire ( Flinkman, Isopahkala-Bouret, & Salanterä, 2013 ; RWJF, 2014 ). Resilience assists a nurse's psyche to cope with the negative consequences of workplace stress ( Fletcher & Sarkar, 2013 ). Stressors encountered by nurses in health care organizations include an increasing aging population, growing numbers of patients with chronic illnesses, and an aging nursing workforce ( American Association of Colleges of Nursing, 2017 ). To overcome these organizational and systemic stressors, nurses have been remediated to provide excellent customer service and uphold standards of care; yet, these approaches have not addressed the aforementioned stressors or bolstered nurses' resilience ( Institute of Medicine, 2014 ; Spence Laschinger et al., 2016 ; Wonder, York, Jackson, & Sluys, 2017 ).

A resilient nurse receives information and acts on it to safeguard patients and advocate for their needs ( Sieg, 2015 ). Resiliency is the ability to command psychomotor skills (the ability to perform tasks and communicate correctly and in a timely manner) and cognitive-behavioral skills (cognitive re-framing, mindfulness, compassion, and emotional intelligence) in order to perform successfully while stressed ( Academy of Medical-Surgical Nurses, 2018 ; McAllister & Lowe, 2011 ). In this article, we provide current knowledge on the concept of NLN resilience during the first year of hire because the lack of resiliency causes nurses to act in a manner that is contrary to caring. As dissatisfaction builds, it leads to an increase in errors and contributes to NLNs leaving their current jobs ( Gabriel, Diefendorff, & Erickson, 2011 ; Hart et al., 2014 ). Therefore, a need exists to understand NLN resilience during the first year of hire.

Purpose and Specific Aims

The purpose of this integrative review is to summarize and synthesize NLN resiliency and interventions used to promote NLN resiliency within the first year of hire in an effort to guide future research in this area. Although resilience has been widely studied in nurses ( Delgado et al., 2017 ; Hart et al., 2014 ; Stephens, Smith, & Cherry, 2017 ) and nursing students ( Stephens, 2012, 2013 ), few studies have examined NLN resilience. This integrative review explores the past literature to describe factors associated with a lack of resiliency or its protective factors and to investigate approaches that increase NLN resiliency. The following specific aims guided this integrative review:

  • What is the state of NLNs' resiliency within their first year of practice?
  • What are the contributing factors that promote or hinder NLNs' resilience?
  • What are the outcomes associated with NLNs' resilience or lack of resiliency?
  • What are the current interventions or strategies used to build protective factors of resilience that lead to NLNs' intention to stay at their current jobs?
  • What tools have been used to measure NLNs' resiliency and have been correlated with intentions to leave jobs?

Method

An integrative approach by Whittemore and Knafl ( 2005 ) guided this review of the literature. This model included five stages (problem identification, literature search, data evaluation, data analysis, and presentation) to enhance accuracy and ensure a thorough search.

Literature Search

A systematic process was used to review the primary studies of qualitative and quantitative research designs ( Whittemore & Knafl, 2005 ). The process of conducting an integrative review is to provide an unbiased review of the literature. To retrieve relevant literature, searches were conducted with the assistance of a health science librarian using the Cumulative Index to Nursing and Allied Health Literature (CINAHL ® ) and PubMed ® databases and restricted to English-language articles published from January 2008 to May 2018. The following subject headings were used to retrieve articles that included descriptions about NLNs: newly licensed nurses, resiliency, and intention to leave. The Boolean operators AND and OR were used to combine these terms with newly licensed nurse * and nurs * ( Table A ; available in the online version of this article ). Inclusion criteria included (a) the topic addressed resilience or protective factors leading to resilience in NLNs; (b) study participants were NLNs within their first year of practice; (c) any research design was used; (d) the studies were conducted in the United States; and (e) publication was between January 2008 and May 2018. The review excluded nonresearch publications, gray literature, and publications that did not address the inclusion criteria.


Search Terms by Databases Used in the Literature Search

Search Terms by Databases Used in the Literature Search

Table A :

Search Terms by Databases Used in the Literature Search

A total of 789 articles were identified from CINAHL and PubMed using the initial search terms; 56 duplicates were removed, resulting in 733 publications. As shown in the PRISMA flow diagram ( Figure 1 ), 570 articles were removed based on their abstracts, which did not meet the inclusion criteria. Next, 163 articles were retrieved for full-text evaluation; 147 of these were excluded as they did not meet the inclusion criteria, leaving 16 articles that comprised the final sample for this review ( Anderson, Linden, Allen, & Gibbs, 2009 ; Bontrager, Hart, & Mareno, 2016 ; Clark & Springer, 2012 ; Cline et al., 2017 ; Clipper & Cherry, 2015 ; Fiedler, Read, Lane, Hicks, & Jegier, 2014 ; Fink, Krugman, Casey, & Goode, 2008 ; Gill, Deagan, & McNett, 2010 ; Hodges, Keeley, & Troyan, 2008 ; Hodges, Troyan, & Keeley, 2010 ; Kramer et al., 2013 ; Li, Early, Mahrer, Klaristenfeld, & Gold, 2014 ; Martin & Wilson, 2011 ; McCalla-Graham & De Gagne, 2015 ; Olson, 2009 ; Pellico, Brewer, & Kovner, 2009 ). There was no follow-up with authors to retrieve additional information.


Graphical representation of the flow of citations reviewed. Adapted from “Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff, and D.G. Altman, 2009, 

Physical Therapy, 89,

 pp. 873–880. Copyright 2009 by Moher et al. Adapted with permission.

Figure 1. :

Graphical representation of the flow of citations reviewed. Adapted from “Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff, and D.G. Altman, 2009, Physical Therapy, 89, pp. 873–880. Copyright 2009 by Moher et al. Adapted with permission.

Sample studies included qualitative ( n = 8 ), quantitative ( n = 5 ), and mixed-methods ( n = 3 ) designs. Qualitative studies used case study ( n = 2 ), phenomenological ( n = 3 ), and grounded theory analyses ( n = 3 ). Quantitative studies were nonexperimental ( n = 5 ) and included causal-comparative ( n = 1 ) and descriptive analyses ( n = 4 ). Mixed-methods studies used sequential, exploratory designs ( n = 3 ).

Data Evaluation

The data evaluation stage used a methodological approach to appraise the quality of each publication ( Whittemore & Knafl, 2005 ). Each quantitative study was evaluated and categorized based on its quality of evidence and recommendation level for practice using the GRADE ( G rading of R ecommendations, A ssessment, D evelopment, and E valuations ) Guideline Criteria for Appraising Quality of Evidence ( Schünemann, Ahmed, & Morgan, 2011 ); for qualitative studies, the GRADE-CERQual Confidence in the Evidence from Review of Qualitative Research ( Lewin et al., 2018 ) was used. Qualitative studies were evaluated using GRADE-CERQual and categorized using a systematic approach to increase transparency in the appraisal process. Four components were used to evaluate qualitative studies: methodological limitations, coherence, adequacy of data, and relevance. Publication bias is also important and was considered in the appraisal of qualitative evidence and placed as a fifth criterion. Eleven studies were rated as moderate to low quality (qualitative, n = 8; mixed-methods, n = 3 ) and the remaining five quantitative studies were rated moderate to very low quality.

A matrix was created to track key data extracted from each study using the following subheadings: author, publication year, design, sample population, setting, purpose/aims, variables, instruments, and the quality appraisal ( Table B ; available in the online version of this article ). Evidence was recorded as high, moderate, low, or very low ( Table B ). Observational designs were noted using ++, and experimental studies were noted using ++++ ( Lewin et al., 2018 ; Ryan & Hill, 2016 ).


Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Summary of Findings from Research Studies (N = 16)

Table B :

Summary of Findings from Research Studies (N = 16)

Data Analysis

During data analysis, primary studies were organized, categorized, summarized, and integrated into a conclusion about the research problem of each study based on (a) NLNs' resiliency within the first year of practice, (b) contributing factors of NLNs that promote or hinder resilience, (c) the outcomes associated with NLNs' resilience or the lack thereof, (d) methods found to build resilience in NLNs, and (e) an examination of the tools that have been used to measure NLNs' resiliency and correlated with intentions to leave their jobs. Results were synthesized using a consistent, correlative method to identify patterns and relationships, create themes, draw conclusions, and provide a comprehensive summary ( Whittemore & Knafl, 2005 ).

Results

Presentation of data is the final stage of an integrative review, which exhibits detailed evidence from each sample study ( Whittemore & Knafl, 2005 ). The presentation also includes a synthesis of sample studies based on the review's purpose and aims.

Description of Sample

All 16 sample studies were published in the United States and distributed from 2008 to 2017; most studies ( n = 3 ) were published in 2009, and none were published in 2013. Studies were published in nine different journals, and more than one study was included in the Journal of Nursing Administration ( n = 4 ), The Journal of Continuing Education in Nursing ( n = 3 ), and Nursing Outlook ( n = 3 ).

A wide range of sample sizes existed by study designs: qualitative studies (7 to 612 participants); quantitative (51 to 558 participants); and mixed-methods (7 to 434 participants). Both male and female NLNs were included as study participants in half of the studies, with female NLNs comprising the majority of study participants, ranging from 83.4% to 94.2%. The percentage of male NLNs included as study participants ranged from 5.8% to 16.6%. Conversely, the remaining half of the studies did not disclose participants' gender. Reported age ranges of participants varied among studies, with most NLNs ranging from 21 to 25 years; two studies repeated mean ages of 33 and 33.4 years; and one study reported a median age of 38.6 years. Other studies reported diverse age ranges: 18 years or over ( n = 1 ); 21 to 50 years ( n = 1 ); 20 to 25 years ( n = 1 ); and younger than 30 years ( n = 1 ).

Only four studies reported the participants' race/ethnicity. Caucasian was the highest group represented ( n = 4, 54.7% ) followed by Black ( n = 4, 13.6% ), Latino ( n = 3, 6.1% ), and Asian ( n = 2, 16.7% ). Study settings were mainly inpatient care settings in medical centers and hospitals across the United States.

NLN Resiliency

Literature published over the past decade revealed that NLNs' resiliency must be fostered for NLNs to remain at their current jobs. Insufficient resiliency among NLNs has been correlated with intentions to leave current jobs, turnover, and decreased job satisfaction. According to the sample studies ( n = 14 ), most NLNs want to leave their jobs due to dissatisfaction with nursing work and/or their work environments ( Anderson et al., 2009 ; Bontrager et al., 2016 ; Clark & Springer, 2012 ; Cline et al., 2017 ; Clipper & Cherry, 2015 ; Fiedler et al., 2014 ; Fink et al., 2008 ; Gill et al., 2010 ; Hodges et al., 2008 ; Hodges et al., 2010 ; Kramer et al., 2013 ; Li et al., 2014 ; Martin & Wilson, 2011 ; McCalla-Graham & De Gagne, 2015 ; Olson, 2009 ; Pellico et al., 2009 ).

Factors That Promote or Hinder NLN Resiliency

Residency programs and coworker support were reported to enhance NLNs' intentions to remain in their current jobs and the nursing profession. Residency programs specifically designed to address the needs of NLNs positively affected NLN resiliency ( Anderson et al., 2009 ; Cline et al., 2017 ; Fiedler et al., 2014 ). The protective factors of resilience that emerged among the sample studies were social support ( Clipper & Cherry, 2015 ; Fiedler et al., 2014 ; Hodges et al., 2008 ; Li et al., 2014 ; Martin & Wilson, 2011 ), group cohesion ( Anderson et al., 2009 ; Bontrager et al., 2016 ; Gill et al., 2010 ; Li et al., 2014 ), well-prepared preceptors ( Bontrager et al., 2016 ; Clipper & Cherry, 2015 ), relationship-based care practices ( Clark & Springer, 2012 ; Clipper & Cherry, 2015 ; Fink et al., 2008 ; Kramer et al., 2013 ; McCalla-Graham & De Gagne, 2015 ; Olson, 2009 ; Pellico et al., 2009 ), organizational support ( Fiedler et al., 2014 ; Fink et al., 2008 ; Olson, 2009 ), and plentiful clinical support ( Fink et al., 2008 ).

NLN resiliency decreased when NLNs experienced verbal abuse from physicians and incivility among other staff nurses ( Kramer et al., 2013 ; Martin & Wilson, 2011 ; Olson, 2009 ; Pellico et al., 2009 ). Their inability to meet expectations of preceptors, unengaged preceptors, and decreased support when making errors also hindered NLNs' confidence and job satisfaction which, in turn, negatively affected their resiliency ( Gill et al., 2010 ; Li et al., 2014 ).

Outcomes Associated With NLN Resiliency

Positive Outcomes . NLN resiliency, which has been inferred as NLNs who want to stay in their jobs ( McAllister & Lowe, 2011 ), improves empathy toward patients, job engagement, augmented teamwork, enhanced ability to perform tasks, boosted confidence, adaptability, and improved clinical reasoning. All these outcomes of resiliency assist in closing the preparation–practice gap and enhance patient safety ( Fink et al., 2008 ; Martin & Wilson, 2011 ; Olson, 2009 ).

Negative Outcomes . The most common outcome associated with poor NLN resiliency cited in the nursing literature is high turnover ( Anderson et al., 2009 ; Bontrager et al., 2016 ; Clark & Springer, 2012 ; Cline et al., 2017 ; Clipper & Cherry, 2015 ; Fiedler et al., 2014 ; Fink et al., 2008 ; Gill et al., 2010 ; Hodges et al., 2008 ; Hodges et al., 2010 ; Kramer et al., 2013 ; Li et al., 2014 ; Martin & Wilson, 2011 ; McCalla-Graham & De Gagne, 2015 ; Olson, 2009 ; Pellico et al., 2009 ). Second, a lack of support from preceptors, staff, physicians, and other NLNs increases NLNs' intentions to leave their jobs or the profession entirely ( Anderson et al., 2009 ; Li et al., 2014 ; Martin & Wilson, 2011 ; Olson, 2009 ). Finally, poor resiliency decreases an NLN's capability to work in a team setting ( Bontrager et al., 2016 ; Clark & Springer, 2012 ; Fink et al., 2008 ; Gill et al., 2010 ; Hodges et al., 2008 ; Hodges et al., 2010 ; Kramer et al., 2013 ; Martin & Wilson, 2011 ; Pellico et al., 2009 ). Teamwork is the cornerstone of patient care delivery as clinicians collaborate and use enhanced communication to benefit patients to attain mutual goals ( World Health Organization, n.d. ). As NLN resiliency decreases, so does patient safety.

Methods to Build Resiliency and Decrease Turnover

Nurse residency programs have been reported to build NLN resiliency and decrease turnover or the intention to leave a job ( Anderson et al., 2009 ; Bontrager et al., 2016 ; Clark & Springer, 2012 ; Cline et al., 2017 ; Fiedler et al., 2014 ; Fink et al., 2008 ; Gill et al., 2010 ; Kramer et al., 2013 ; Li et al., 2014 ). Residency programs coordinate group learning and utilize a buddy system approach to on-the-job learning; residency programs were reported to increase socialization, which Dyer and McGuinness ( 1996 ) reported is a protective factor of resiliency. Eleven of the sample studies concluded that collegial relationships, social support, and professional acculturation were formidable and essential to cope with stress of a chaotic, foreign, and challenging work environment ( Anderson et al., 2009 ; Bontrager et al., 2016 ; Fiedler et al., 2014 ; Fink et al., 2008 ; Gill et al., 2010 ; Hodges et al., 2008 ; Hodges et al., 2010 ; Li et al., 2014 ; Martin & Wilson, 2011 ; McCalla-Graham & De Gagne, 2015 ; Olson, 2009 ). Hodges et al. ( 2010 ) and Fiedler et al. ( 2014 ) described NLNs building comradery with others to negate feelings of inadequacy as method to protect themselves from the daily assault of stress and self-doubt. Additionally, Martin and Wilson ( 2011 ) described NLNs forming caring groups to enhance collegial relationships; these supportive groups helped to decrease feelings of doubt and stress experienced during their transition from academia to practice.

Measuring Resiliency and the Outcomes

This integrative review presents studies that correlated resiliency using satisfaction surveys, evaluations of preceptor effectiveness, and intention to leave surveys to best understand the reasons why NLNs leave their jobs. Table C (available in the online version of this article) outlines the tools used in sample studies ( n = 8 ) to evaluate strategies to build NLN resiliency ( Anderson et al., 2009 ; Bontrager et al., 2016 ; Clark & Springer, 2012 ; Cline et al., 2017 ; Clipper & Cherry, 2015 ; Fiedler et al., 2014 ; Fink et al., 2008 ; McCalla-Graham & De Gagne, 2015 ). Studies did not evaluate patient outcomes while measuring NLN satisfaction or intention to leave. Yet, Gill et al. ( 2010 ) explored NLNs' work perspectives to gauge nursing quality by using the 10-item abbreviated version of the National Database of Nursing Quality Indicators (NDNQI) (reliability coefficient = .91; Taunton et al., 2004 ). The NDNQI was correlated with intentions to leave one's job, yet the majority of the participants ( n = 7 ) in this study intended to leave their current job despite indicating they were satisfied. The same finding was reported by Clark and Springer ( 2012 ) , in which NLNs expressed intentions to leave their jobs despite being satisfied with the care they delivered ( n = 37 ).


Tools Used in Studies to Determine NLN Resiliency or Protective Factors of Resiliency

Tools Used in Studies to Determine NLN Resiliency or Protective Factors of Resiliency

Tools Used in Studies to Determine NLN Resiliency or Protective Factors of Resiliency

Tools Used in Studies to Determine NLN Resiliency or Protective Factors of Resiliency

Table C :

Tools Used in Studies to Determine NLN Resiliency or Protective Factors of Resiliency

Discussion

An iterative process of examining each sample study to identify patterns, themes, noting intervening factors, and relationships between variability ( Whittemore & Knafl, 2005 ) was done to clarify, summarize, and synthesize what is known about the phenomenon of resiliency in NLNs, within the first year of hire, in an effort to guide future research in this area.

First, the concept of NLN resiliency is not well understood as NLN turnover has been interpreted to be an outcome of poor NLN resiliency. Second, the expectation of NLNs is to take on new responsibilities and overcome numerous challenges to integrate themselves into a practice environment that stresses teamwork; this belief is so overwhelming that it negatively affects NLNs' mental health. Third, these feelings drain NLNs, which, in turn, can cause cognitive and emotional lability and affect clinical reasoning, a clear and present danger to patient welfare. Finally, resiliency should be measured using a resiliency scale, as the decision or intention to leave one's job is not a surrogate to determine NLN resilience.

A growing body of research indicates NLNs' attrition is increasing at an alarming rate, despite residency programs assisting in their transition to help them assume professional responsibilities for which they may be unprepared ( Clark & Springer, 2012 ; Cline et al., 2017 ; RWJF, 2014 ). Nurse incivility among staff, including NLNs, occurs due to the high-stakes climate and coworkers' ineffective communication skills ( Laschinger, Wong, Regan, Young-Ritchie, & Bushell, 2013 ). A paradox ensues as NLNs believe they would be cared for by caring professionals in a caring environment ( Hart et al., 2014 ; Hodges et al., 2008 ; Marine, Ruotsalainen, Serra, & Verbeek, 2006 ; Martin & Wilson, 2011 ; Pariyo, Kiwanuka, Rutebemberwa, Okui, & Ssengooba, 2008 ).

Implications for Practice, Policy, and Research

The implications for this integrative review provide information to hospital educators and administrators regarding the trends and needs of NLNs and adds a new perspective on workforce readiness in an effort to promote patient safety. Nursing research has used a positivist approach to assess NLN resiliency, a philosophy that has not advanced nursing science in this area. Millennials (ages 22 to 37) ( Dimock, 2019 ) comprise the majority of newcomers to the nursing workforce and have the highest attrition rate among any generation that has entered the nursing profession ( RWJF, 2014 ). Therefore, nurse researchers must apply a social constructivist approach, as there is much to learn about the Millennial generation in the workplace ( Veesart, 2018 ). A social constructivism approach encourages a participant's own interpretation of the situation to better understand the meaning of their experience ( Dahnke & Dreher, 2010 ). This sociological lens may help researchers, managers, and educators evaluate NLN resilience as a truth created by their own perceptions rather than through job satisfaction surveys or intention to leave scales. The American Academy of Nursing Policy agrees there is a need to build NLNs' resilience ( Goode, Glassman, Ponte, Krugman, & Peterman, 2018 ) to mitigate the negative effects of stress and encourage intention to stay at their first job is paramount. Research regarding low-cost, social support strategies to encourage NLNs' motivation and engagement in nursing is needed to garner patient safety.

Limitations

Several limitations existed among the sample studies that may result in the findings not being applicable to each NLN's experience during their first year of hire or to their abilities to build resiliency. For example, detailed information was not provided regarding sample characteristics such as age in nine studies ( Anderson et al., 2009 ; Clark & Springer, 2012 ; Fink et al., 2008 ; Hodges et al., 2008 ; Kramer et al., 2013 ; Li et al., 2014 ; Martin & Wilson, 2011 ; McCalla-Graham & De Gagne, 2015 ; Olson, 2009 ). Additionally, there was minimal representation of men in all sample studies, as well as a poor representation of ethnic/racial diversity. Various practice settings among the studies limited generalizability of the findings as the settings included medical centers, hospitals, and specialty units (i.e., oncology). Each setting used different ways to orient NLNs and participants faced varying types of experiences, which may not represent all NLNs' experiences when transitioning into their first jobs.

The designs of the 16 sample studies were primarily surveys or qualitative interviews. One study did not report the reliability and validity of the instrument used ( Anderson et al., 2009 ). Researchers did not directly measure participants' resilience in any of the sample studies yet inferred that participants' resilience was low if they intended to leave their jobs. This ambiguity may have led to a lack of differentiation among the search terms, as turnover and intention to leave have been correlated with resilience . However, strategies that encourage group cohesiveness, managerial involvement, and adequately prepare preceptors for what Duchscher ( 2007 , p. 23) referred to as the “transition shock” period may increase resiliency and decrease intentions to leave ( Anderson et al., 2009 ; Bontrager et al., 2016 ; Clark & Springer, 2012 ; Cline et al., 2017 ; Clipper & Cherry, 2015 ; Fiedler et al., 2014 ; Fink et al., 2008 ; Gill et al., 2010 ; Hodges et al., 2008 ; Hodges et al., 2010 ; Kramer et al., 2013 ; Li et al., 2014 ; Martin & Wilson, 2011 ; McCalla-Graham & De Gagne, 2015 ; Olson, 2009 ; Pellico et al., 2009 ; RWJF, 2014 ). Despite these efforts, NLN attrition rates continue to rise each year.

Conclusion

This integrative review provides pertinent information to researchers, managers, educators, and health care administrators about the concept of NLN resiliency. Decreased resiliency threatens patient safety. NLNs expressed difficulties feeling confident, which, in turn, affects professional development—a factor that is crucial to preparing a competent workforce. A supportive staff of nurses and physicians who are empathetic to the challenges NLNs face during the first year of hire is a proven facilitator of NLN resiliency; these supportive attributes increase NLN job engagement, confidence, and enhances team building skills. Additionally, resilience may be an indicator of practice readiness, a vital key to motivate and retain NLNs.

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Search Terms by Databases Used in the Literature Search

Database Search Term Headings Used: Newly Licensed Nurse, Leaving within First Year, and Resiliency No. of Titles and Abstracts
CINAHL search terms ( (“Newly licensed nurse * ” OR (MH “New Graduate Nurses”) OR ((MH “Nurses+”) OR nurse * ) AND (MH (“Internship and Residency) OR MH (“Transitional Programs) OR MH (“Employee Orientation) OR MH (“Preceptorship))) ) AND ( (MH “Personnel Retention”) OR (MH “Personnel Turnover”) OR Retention OR Turnover OR Attrition OR Quit OR Stay OR “Negative Nurse Outcomes” OR “Intention to Leave” OR “Intention to Quit” OR (MH “Intention”) OR (MH “Personnel Attitudes”) OR (MH “Motivational factors for turnover intention”) OR (MH “Professional Identity”) OR (MH “Locus of control”) OR (MH “Negative Patient Outcomes”) OR (MH “Willingness to leave”) OR Manpower OR “Motivational factors” OR “Psychosocial Factors” OR “negative patient outcomes”) AND ( (MH (“Adaptation, Occupational”) OR (MH “Avoidance (Psychology)” OR (MH “Coping”) OR (MH “Cultural Safety”) OR (MH “Disengagement”) OR (MH “Disruptive Behavior”) OR (MH “Hardiness”) OR (MH “Job Satisfaction”) OR (MH “Optimism”) OR (MH “Reality Shock”) OR (MH “Self-Efficacy”) OR (MH “Social Adjustment”) OR (MH “Stress Disorders, Post-Traumatic+”) OR (MH “Stress, Occupational”) OR (MH “Support, Psychosocial”) OR (MH “Symptom Distress”) OR (MH “Symptom Distress”) OR (MH “Vulnerability”) OR “Nurse Shock” OR “Occupational Adaptation” OR “occupational shock” OR “personal identity disturbance” OR “Post-Traumatic Stress Disorder” OR “Professional ident*” OR “psychological capital” OR “Reality Shock” OR Coping OR Optimis* OR Protective factors OR PTSD OR Resiliency) OR (MH “Motivation”) OR (MH “Psychological Factors”) OR (MH “Occupational Coping”) OR (MH “Shared decision-making”) OR (MH “Workplace empowerment”) OR (MH “growth mindset”) OR (MH “Prevention and Control”) OR (MH “Occupational Commitment”) OR (MH “Professional commitment”) OR (MH “Controlled Motivation”)) 397
PubMed search terms (((( “Emotional Adjustment”[Mesh]) AND “Sense of Coherence”[Mesh] OR “Resilience, Psychological”[Mesh] OR “Adaptation, Psychological”[Mesh] OR “Problem Behavior”[Mesh] OR “disruptive behavior”[tiab] OR “disruptive behavior”[ot] OR “Job Satisfaction”[Mesh] OR “Absenteeism”[Mesh] OR“Presenteeism”[Mesh] OR “Optimism”[Mesh] OR “Self Efficacy”[Mesh] OR “Social Adjustment”[Mesh] OR “Stress Disorders, Post-Traumatic”[Mesh] OR “Social Support”[Mesh] OR ‘Nurse Shock’ [tiab] OR ‘Occupational Adaptation’ [tiab] OR ‘occupational shock’ [tiab] OR ‘personal identity disturbance’ [tiab] OR ‘Post-Traumatic Stress Disorder’ [tiab] OR ‘Professional identity’ [tiab] OR ‘Professional identities’[tiab] OR ‘psychological capital’ [tiab] OR ‘Reality Shock’ [tiab] OR Coping[tiab] OR Optimis * [tiab] OR ‘Protective factor’ [tiab] OR ‘Protective factors’ [tiab] OR PTSD[tiab] OR Resiliency[tiab] OR ‘Nurse Shock’ [ot] OR ‘Occupational Adaptation’ [ot] OR ‘occupational shock’ [ot] OR ‘personal identity disturbance’ [ot] OR ‘Post-Traumatic Stress Disorder’ [ot] OR ‘Professional identity’ [ot] OR ‘Professional identities’[ot] OR ‘psychological capital’ [ot] OR ‘Reality Shock’ [ot] OR Coping[ot] OR Optimis * [ot] OR ‘Protective factor’ [ot] OR ‘Protective factors’ [ot] OR PTSD[ot] OR Resiliency[ot] OR “Motivation”[Mesh] OR “psychology” [Subheading] OR “Decision Making”[Mesh] OR ‘Prevention and Control’[Subheading]))) AND ((Quit[ot] OR Quit[tiab] OR retention[ot] OR Retention[tiab] OR Stay[ot] OR Stay[tiab] OR Turnover[ot] OR Turnover[tiab] OR “Personnel Turnover”[Mesh] OR “Personnel Loyalty”[Mesh] OR Retention[tiab] OR Retention[ot] OR Turnover[tiab] OR Turnover[ot] OR Attrition[tiab] OR Attrition[ot] OR Quit[tiab] OR Quit[ot] OR Stay[tiab] OR Stay[ot] OR ‘Negative Nurse Outcomes’[tiab] OR ‘Negative Nurse Outcomes’[ot] OR ‘Intention to Leave’[tiab] OR ‘Intention to Leave’[ot] OR ‘Intention to Quit’[tiab] OR ‘Intention to Quit’[ot] OR Manpower[tiab] OR ‘Motivational factors’ [tiab] OR ‘Psychosocial Factors’ [tiab] OR ‘negative patient outcomes’ [tiab] OR Manpower[ot] OR ‘Motivational factors’ [ot] OR ‘Psychosocial Factors’ [ot] OR ‘negative patient outcomes’ [ot]))) AND ((‘Newly licensed nurse’[tiab] OR ‘Newly licensed nurse’[ot] OR ‘Newly licensed nurses’[tiab] OR ‘Newly licensed nurses’[ot] OR “New Graduate Nurse”[ot] OR “New Graduate Nurse”[ot] OR “New Graduate Nurses”[ot] OR “New Graduate Nurses”[ot] OR ‘Novice nurse’ [tiab] OR “Novice Nurse”[ot] OR ‘Novice nurses’ [tiab] OR “Novice Nurses”[ot] OR ‘Newly licensed nurse * ’[tiab] OR “New Graduate Nurses”[ot] OR ‘Novice nurse’ [tiab] OR “Novice Nurses”[ot] OR (“Nurses”[Mesh] OR nurse * [tiab] OR nurse * [ot]) AND (“Internship, Nonmedical”[Mesh] OR “Inservice Training”[Mesh] OR “Preceptorship”[Mesh])) 392
Total no. of citations including duplicates 789

Summary of Findings from Research Studies (N = 16)

Author/year Design/Method Sample population/Setting Purpose, Aims, Variables, and Instruments Findings Appraisal Rating/Quality of Evidence using GRADE or GRADE-CERQual
Anderson et al. ( 2009 ) mixed methods/sequential exploratory 90 new graduate nurses, gender and ethnicity not reported/interactive nurse residency Purpose: to compare perceived job satisfaction and employee engagement of new graduate nurses completing an interactive nurse residency.Aims: to measure job satisfaction and engagements perceptions of new nurses after completing interactive residency modules and to test the environment nursing satisfaction survey.Variables: change for nurse residency – implementation of a 2-day interactive nurse residency.Instruments: Halfer-Graf Job/Work Environment Nursing Satisfaction Survey (psychometrics not reported) Qualitative results revealed 2 themes (protective factors of resiliency emerged): what satisfied nurses (patients, patient outcomes, and teamwork) and what did not satisfy nurses (staffing/scheduling, lack of teamwork, MD disrespect). Quantitative results: “After the nurse residency sessions and 1 year later, the quantitative findings on the Halfer-Graf survey revealed that the nurse residents significantly perceived that they were able to perform their job, identify resources, understand performance expectations, accomplish work tasks, and manage the demands of the job effectively” (p. 168). An interactive learning environment assists new graduate nurses in job satisfaction and employee engagement. Most valuable strategy was email communication as a form of support (a protective factor of resiliency). ++ ⊕○○○ Risk of bias: There were limitations in detailed design as the outcome was not confidently determined as the tool's psychometrics were not discussed. There was no discussion about the Halfer-Graf Job/Work Environment Nursing Satisfaction Survey other than stating it was reliable and valid as previously stated in previous studies. Most information was stated from studies at low or unclear risk of bias. This denotes serious risk of bias, down grade one level ( Ryan, 2016 ).Inconsistency: the sample was from one cohort of new graduate nurses and one period in time. This denotes some inconsistency and a downgrade of one point is recommended ( Ryan, 2016 ).Indirectness: the author answered the question of whether this particular cohort were satisfied and engaged by using interactive residency modules.Imprecision: Confounding variables were not discussed as to other reasons to the 4% increase of new graduate nurse retention when compared to past years. There was not enough information to detect a precise estimate of the effect (interactive residency modules on new graduate satisfaction and job engagement).Publication bias: Not detected, Journal of Nursing Administration has various studies of size and design.
Bontrager et al. ( 2016 ) quantitative/descriptive, prospective, cross-sectional 84 newly licensed registered nurses enrolled in a residency program. 5.8% of participants were male. 66.7% participants were Caucasian, 17.9% were black, 3.6% Latino, and 7.1% Asian. Purpose: to understand how preceptor role effectiveness and group cohesion affect NLNs' satisfaction and intent to stay.Aims: What were the relationships among preceptor role effectiveness, group cohesion, and job satisfaction among NLNs? What were the relationships among preceptor role effectiveness, group cohesion, job satisfaction, and intent to stay among NLNs?Variables: DV: preceptor role effectiveness, group cohesion, and job satisfactionInstruments: Preceptor Role Effectiveness Scale, Nurse Job Satisfaction Scale, Intent to Stay Scale. High levels of intention to stay at job was perceived by nurses due to the role of preceptors, job satisfaction, and group cohesion (protective factor of resiliency). Preceptors that are effective ensure a quality orientation and can help socialize a new nurse and encourage job satisfaction. Group cohesion was found to be vital to increase feelings of value, reduce burnout, stress and anxiety. Group cohesion is important to reduce transition shock and intention to stay. ++ ⊕⊕○○ Risk of bias: Tool psychometrics were reported and Cronbach α scores showed reliability and validity. The tools/scales were justly chosen to predict the outcome level.Inconsistency: the sample was not discussed regarding units worked on or shift worked. The ability to examine changes during the orientation period was not discussed. Doubtful that there are large variations in the degree to which the outcome is affected, no downgrade if on the basis that it does not seem to be an issue.Indirectness: There was evidence of indirectness as the outcome was assessed at only one period in time which limited the ability to examine changes. The evidence that was found was more restrictive than the review question and may not directly answer the review question, “What were the relationships among preceptor role effectiveness, group cohesion, and job satisfaction among NLNs? What were the relationships among preceptor role effectiveness, group cohesion, job satisfaction, and intent to stay among NLNs?” Downgraded one point as some indirectness exists.Imprecision: good correlation with primary studies, no imprecision detected.Publication bias: Not detected, The Journal of Continuing Education in Nursing has various studies of size and design.
Clark & Springer ( 2012 ) qualitative/case study model 37 new graduate nurses in a nurse residency program across many specialty areas/northwestern US 15.6% of participants were male. The ethnicity of participants was not reported. Purpose: to examine the lived experience as new nurses to assess the level of job satisfaction during the first year of practice.Aims: 1. How do new graduate nurses describe their typical workday? 2. What are the most satisfying aspects of the new graduate nurses' nursing? 3. What are the most concerning aspects of the new graduate nurses' practice? 4. What educational topics do new graduate nurses want to know more about? 5. Where do the new graduate nurses see themselves practicing nursing in the future?Variables: DV: job satisfactionInstruments: open-ended questions Themes that emerged: learning to work in chaos, feeling valued, stress of the unknown, life-long learning, and preserving the profession. Preceptors and staff are vital to enhancing job satisfaction and commitment to nursing. Support (protective factor of resiliency) was mentioned to improve job satisfaction. The stress of life-long learning was divided into sub-themes that included dealing with incivility, adapting to change, and stress management. Participants described being valued by colleagues as a major contributor to job satisfaction. Organizations can help new nurses feel valued by using relationship-based care and increasing collegial relationships as ways for enhancing satisfaction and feelings of competence. Some participants stated preceptors were unsupportive and disinterested and this decreased job satisfaction. This also increased stress and decreased new nurses' ability to work in teams. ++ ⊕⊕⊕○ Methodical limitations: Primary studies revealed conflicting evidence regarding the lived experiences of new nurses. We are confident that the findings in this study reflect this small sample's lived experience as it did represent what was found in primary studies discussed.Relevance: New nurses are experiencing a new environment and way to function yet one of the research questions asked about educational topics they may want to know more about. The premise of being “new” and the chaos this brings, it seems contrary and not relevant to pursue this aim. Not applicable to the context specified in describing the lived experience of a new nurse; downgraded one point.Coherence: There is good fit between the data from the primary studies and the review findings.Adequacy of data: There is good amounts of data supporting the review finding and this aligns with primary studies about the lived experiences of new nurses.Publication bias: Nursing Outlook has published diverse studies designs with various sample sizes.
Cline et al. ( 2017 ) Quantitative/descriptive, retrospective analysis of 10 years of residency data First stated over 1,000 participants' data were analyzed then table showed 558 new nurses within 12 months of hire/residency program in a cancer center within the US 8.9% were male participants. Percentage of Caucasian participants was 36%, Black 21.6%, Latino 12.2%, Asian 26.3%. Purpose: to present a 10-year retrospective review of outcomes from an internally developed nurse residency programAims: an analysis of an internally developed residency program on the development of new nurses.Variables: “customized” nurse residency program at one cancer care center and was “enhanced” over time, simulation was also added through the years.Instruments: Casey-Fink Graduate Nurse Experience Survey, institutional retention metrics Scores in support declined over the course of the residency program which decreased professional satisfaction. The Casey-Fink scores revealed participants' stress levels were low during this residency program, this is not consistent with primary studies or newly licensed nurses' experiences in the literature. The authors suggested that findings developed in this “custom” residency program emphasized that a program just about entry to practice can comfort new nurses and promote confidence (protective factor of resiliency) which will lead to positive retention. ++ ⊕○○○ Risk of bias: there were lack of details in the design and execution as the residency program over time had many changes.Inconsistency: there was little understanding of the outcomes from this longitudinal study and how the data supported the outcome that residency programs assist in new nurse job satisfaction and therefore retention.Indirectness: applicability of this customized residency program (undetailed) did not help reader to understand the phenomenon of new nurse retention or the ability to enhance dealing with stress or adversity (resilience).Imprecision: there is a large amount of inadequacy due to the levels of stress reported and the confounding variables such as the possibilities of financial stress due to the level of support the hospital may have offered participants as opposed to the actual stress of the job.Publication bias: yes, this study was most likely published due to the positive findings that a residency program can possibly influence new nurse retention.
Clipper & Cherry ( 2015 ) quantitative/descriptive, comparative 59 participants/gender and ethnicity were not specified Purpose: to describe the implementation and evaluation of a preceptor development program and its effect on the new graduate nurse's transition to practice and measure first-year turnover.Aims: to assess new nurses' perceptions of their transition and preceptors between 2 groups of preceptors (one group trained in a structured and well-developed program: details well explained, and the other group was untrained).Variables: ID: new nurses within the first year of hire. DV: perceptions of transition to practice between 2 groups of preceptors. Trained preceptors and untrained preceptors.Instruments: 16-item investigator developed surveyed based on the attributes of transition shock theory was used to obtain data regarding new nurse perceptions of the transition process and the effectiveness of their preceptors. The study evaluated the effectiveness of a preceptor program by measuring perceptions of transition to practice and 1 st year retention of 2 groups of former nurse graduates and the other group was those that did not participate in structured training. New graduates have more positive perceptions regarding safe care giving and have a slightly better retention rate than those who did not have a structured new graduate program. Preceptors need to address themes of socialization (protective factors in resiliency) in order to build confidence and foster good relationships to build forms of support. New nurses that had trained preceptors expedited to a higher level of practice faster than the untrained preceptor cohort. It was anticipated that those that were in the cohort of untrained preceptor would stay at the organization due to lack of confidence and that was not the case. Confidence was found to directly impact patient outcomes positively and increase when new nurses had a good relationship with his or her preceptor. This also was correlated with the new nurse having a safer practice than those with an ineffective preceptor. ++ ⊕⊕○○ Risk of bias: Possible limitations in the design – obviously well-trained preceptors would better understand the needs of new nurses and help mitigate the stress of transition, but the study did not reveal reasons for consistent turnover or new nurse dissatisfaction during the first year of hire. It was clear from previous literature that a well prepared and trained preceptor will decrease transition shock, but still not a big change in new nurse retention.Inconsistency: the findings were consistent with the phenomenon of new nurses during the first year of hire.Indirectness: information in this study was not very applicable to understanding new nurse turnover or how transition shock mitigation strategies can decrease turnover.Imprecision: inadequate amount of data regarding new nurse confidence, the support a new nurse receives, and the intention to leave first job. Publication bias: Not found. The Journal of Continuing Education in Nursing publishes many types of studies that reveal positive and negative findings such as this study.
Fiedler et al. ( 2014 ) quantitative/descriptive 51 new nurses in a residency program (most were second degree students) on diverse units/medical center in the Midwest, a UHC/AACN program. Gender and ethnicity of participants were not specified. Purpose: to determine what influence a nurse residency program has on long-term outcomes including turnover, career satisfaction, and leadership development.Aims: 1. describe the long-term (beyond the 1st year of employment) turnover rates of NRP graduates, 2. examine the long-term career satisfaction of NRP graduates beyond the 1st year of employment, and 3. explore long-term leadership development of NRP graduates beyond the 1st year of employment.Variables: IV: AACN residency program. DV's: career satisfaction, leadership development, hospital committee involvement, certification status, pursing an advanced degree.Instruments: McCloskey/Mueller Satisfaction Scale (MMSS) has 8 subscales: extrinsic rewards, scheduling satisfaction, family/work balance, coworkers, opportunities for social contacts, professional responsibilities, praise/recognition, and control/responsibility. The long-term outcomes of a nurse residency program have benefits to the organization and individual turnover rates lower than the national average of 14.7% (1.5–3 years after the residency program. The literature review in this study points out that within 6 months, residents noticed decrease job satisfaction, yet at the end of the year, significant increase in satisfaction resulted. Support (protective factor of resiliency) from the organization, managers, and recognition leads to satisfaction and well as good collegial relationships. Peer support was ranked as a major component of nurses' job satisfaction. ++ ⊕○○○ Risk of bias: Detected. Using one instrument, which measures satisfaction to evaluate turnover limited the execution of the study and other data or qualitative factors were missed for reasons or intentions to leave.Inconsistency: Detected. Sample size was small, it was diverse yet getting in touch with participants that have left but filled out the survey was difficult and possibly lead to inconsistencies with results. Indirectness: None detected as the applicability is reasonable as residency programs are supportive and foster new nurses' careers, therefore increased retention is very probable.Imprecision: Detected. Dissatisfaction results in turnover yet the tool was measuring satisfaction and that was assumed the reason for turnover, more investigation regarding what led to dissatisfaction would have been more helpful in understanding if a residency program, over years, affects retention rates alone.Publication bias: Not detected. The Journal of Nursing Administration publishes pilot studies with negative results and also larger sample sizes.
Fink et al. ( 2008 ) mixed method/sequential exploratory 434 graduate nurse residents in the University HealthSystem Consortium/AACN nurse residency program at 12 academic hospital sites. Gender and ethnicity of participants was not specified. Purpose: To evaluate if qualitative responses to Casey-Fink Graduate Nurse Experience Survey could be analyzed quantitatively to easily analyze new nurses' experiences during a post BSN nurses residency program. Aims: 1. to analyze the qualitative voices of the resident respondents to determine if comments could further enrich the quantitative data and to determine if analysis of the themes mined from the qualitative data could be used to convert the open-ended questions on the Casey-Fink Graduate Nurse Experience Survey into quantitative questions for ease of test administration and analytic procedures.Variables: DVs: role changes, lack of confidence, workload, fears, orientation issues. IV: residency program within the first year of hire.Instruments: Casey-Fink Graduate Nurse Experience Survey. Qualitative data outcomes were gathered via open ended questions from the author. “The results of this qualitative analysis permitted further revisions of the Casey-Fink Graduate Nurse Experience Survey. Themes identified from data analysis of the 3 top skills difficult to master at each period, and the 5 open-ended questions asked on the original survey, were of sufficient strength to convert these items to multiple-choice format. The one open-ended item that the authors retained was the final survey question that asked residents to comment on their experiences” (p.347). New nurse stressors were issues with skills over a period of time, they were not getting easier. This was attributed to constant preceptor assistance and lack of being able to perform skills independently during complex patient cases. Work/life balance was a major stressor and impacted the ability to function at the job. Being able to communicate with MDs (a protective factor of resiliency) and organize their workload were barriers to transitioning into their new role which reflected Kramer et al. ( 2013 ) and Halfer and Graf's ( 2006 ) results. Communication from management and the desire to be a part of the unit's culture were pointed out to be a much-needed support. The top 3 most satisfying aspects of graduate nurse residents' work environment included as follows: support, camaraderie, and caring for patients. “There is not enough socialization in the residency program. Becoming a new nurse in a new environment is difficult” (p.347). ++ ⊕⊕○○ Methodical limitations: Detected. The design and execution of the study was to use a quantitative tool to gather qualitative data and revision of the tool was suggested.Relevance: The body of evidence from primary studies supported review findings that is applicable to the context specified in the review questions.Coherence: There is a clear fit between the data from primary studies and the review findings, yet the sample is homogeneous, downgraded 1 point.Adequacy of data: There is a good amount of qualitative data to represent the homogeneity sample.Publication bias: Not detected. The Journal of Nursing Administration publishes pilot studies with negative results and also larger sample sizes. Quality increased by 1 point due to all plausible residual confounding factors demonstrated an effect.
Gill et al. ( 2010 ) cohort study using mixed methods/sequential exploratory 7 participants/inpatient care areas at Level 1 trauma center. 7.7% participants were male. The ethnicity of participants was not specified. Purpose: to investigate the expectations, perceptions, and satisfaction of graduate nurses after 6 and 12 months of employment.Aims: to describe new graduates during the first year of practice.Variables: DV: perceptions regarding the first year of practice such as social support, stress, professional valuesInstruments: 10-item abbreviated version of the National Database of Nursing Quality Indicators (NDNQI) revised survey for RNs which is a series of statements relating to the nurses' perceptions of their work. It has been shown to be both reliable. “At the completion of the final interview, graduate nurses were asked to complete a brief three-item survey on intent to leave. Individuals were asked to indicate how often they contemplated leaving their unit, the organization, or the profession of nursing on a 5-point Likert scale” (p. E13). New graduates are fairly satisfied. Two themes emerged: establishing relationships and learning the job. Strong tie to primary studies that states group cohesion (a protective factor of resiliency) and satisfaction can increase the ability to stay at one's job and in nursing. At the end of the 12-month study, many graduates considered leaving their until and the organization, but few participants thought of leaving the profession entirely. ++ ⊕⊕⊕○ Methodical limitations: Not detected as the primary studies are reflected in the review findings. Relevance: The study was relevant. The body of evidence from primary studies supported the review finding and is applicable to the context of new nurse graduates and the aims of the study. Coherence: The study was coherent, and the findings were a fit between the primary studies and the review finding. Adequacy of data: There was adequate data supporting the review finding but the sample was very small. Publication bias: There is no detection of publication bias as results revealed perceptions and were not deemed as positive or negative.
Hodges et al. ( 2008 ) qualitative: phenomenological model/exploratory 11 new nurses/southeastern US and had experience between 12 and 18 months. 9% of participants were male. The ethnicity of participants was not specified. Purpose: To explore the nature of professional resilience in new BSN nurses in the acute care setting and to extrapolate pedagogical strategies that can be developed to support resilience and career longevity. Aims: to explore the existence and social structure of professional resilience among practicing nurses to evolve a middle range theory to explain the relationships of constructs within the concept. Variables: DV: experiences of social support of new nurses.Instruments: open-ended questions New nurses spend a significant amount of time learning their place in the social structure and need positive experiences to feel they are a part of the work environment. Resilience is needed to ensure new nurse self-protection, risk taking, and moving forward with reflective knowledge of self. Themes that emerged were learning the milieu (developing confidence and skills), discerning fit (accepted by the culture), and moving through (recovering from stress and identifying those they can trust in order to develop protective factors against work-life issues). Participants noted significant amount of adapting that must take place to be accepted socially and also the disparity between academics and practice. This distressed new nurses as they actualized the discrepancies. New nurses' emotional energy is consumed by cognitive work; resilience is necessary for such work in order to grow from adversity. Construction of a new nurse's social identity was found to be important to create their professional identity. ++ ⊕⊕○○ Methodical limitations: Not detected as primary studies revealed similar findings.Relevance: the study is relevant due to its context to the aim which explored professional resilience and as a protective factor, social support.Coherence: it is clear that social support is needed to be professionally resilient, yet it was not coherent regarding how to garner social support to ensure the development of resiliency, downgraded a point.Adequacy of data: There is an adequate amount of data but is from a small sample yet does reflect current findings regarding the phenomenon of new nurse resilience.Publication bias: There is no detection of publication bias as results revealed perceptions and were not deemed as positive or negative.
Hodges et al. ( 2010 ) qualitative: grounded theory/descriptive 19 new and experienced BSN nurses working in direct patient care (9 participants were 11 to 18 months in practice)/southeast US-multiple levels of med centers and hospitals. No gender or ethnicity of participants were specified. Purpose: to explain how BSN acute care nurses understand, adapt to, and negotiate challenge and change in acute care settings in the context of social and structural features and career persistence. Aims: to understand career persistence in BSN acute care nurses and create a middle range theory to place into practice to encourage career resilience.Variables: nurses spanning 11 months – over 5 years.Instruments: open-ended questions The central theme was building professional resilience, was noted to be the central social process. Verifying fit: participants stated incongruent personal principles and values regarding nursing practice and incompatibility with the environment (the environment does not match their strengths). Stage setting: how to protect one's self and form relationships in order to feel secure and supported (protective factors of resiliency). Optimizing the environment: seeking activities that help one attain professional goals. The key to understanding professionalism of nurses is to understand one's social group. ++ ⊕○○○ Methodical limitations: Detected as the studied was composed of new nurses (within 11–18 months of practice to those with 5 or more years). That is a large breath of experience to find out about nurse's resilience as the stress of a new job tests one's resilience and those that have overcome adversity are known as resilient. Downgraded one point.Relevance: Good relevance as the concept of an ever-changing health care arena is obvious, career resilience is a characteristic one needs to stay in the career. Coherence: The data aligns to the primary studies. Adequacy of data: The data is coming from a small population of different ages and time frames within their careers (18 months to over 5 years), downgraded one point.Publication bias: Most likely this study was published because of its “sensibility” regarding recommendations to help nurses stay engaged with their work life and work environment, downgraded one point.
Kramer et al. (2012) qualitative: grounded theory/exploratory 82 participant interviews were done. At the time of interviewing, 71% (n = 236) of the 330 NLNs were between 9 and 12 months post hire/local Magnet hospitals. Gender and ethnicity of participants were not specified. Purpose: to elicit from new nurses and experienced nurses on clinical units with very healthy work environments, the components and strategies of nurse residency programs and effective in new nurse integration into professional practice. Aims: What NRP components and strategies do NLNs and clinical nurses practicing on clinical units with Very Healthy Work Environments (VHWE) identify as effective in NLN transitioning and integrating into professional practice? Variables: DVs: delegation, prioritization, conflict resolution were used to construct the interview schedule and as the basis for selection of participant observations.Instruments: open-ended questions First theme was about delegation. Second theme was about prioritization. Third theme was about getting work done. Fourth theme clinical autonomy and how to make the right decisions. Text messages to MDs to relay info and data was citing as an effective communication technique in hospitals. Fifth theme: constructive conflict resolution. Sixth: feedback to restore self-confidence (a protective factor of resiliency). Results of this study support the recommendation that development of two-stage, Transition plus Integration, NRPs are no longer an option but a necessity. These NRPs need to have clearly differentiated goals, components, expected role performance, and rites of passage. ++ ⊕⊕⊕○ Methodical limitations: Detected. Interviews were conducted with 2 or 4 new nurses and experienced nurses (contamination possible as responses may not have been as genuine if nurses were alone) in each of the units and were interviewed by various hospital unit educators. Decreased one point. Relevance: Very relevant as learning about what creates a healthy work environment can help prepare a strong workforce and good transition experience is very desirable for organizations.Coherence: Some hospitals had clinical coaches and others did not, this may have affected participants' responses and experiences limiting generalizability yet since all programs were enrolled at hospitals with residency programs greater than 3 years, and since not every hospital has coaches, the sample size was large enough to represent the population of those in residency programs.Adequacy of data: There is adequate data to support the finding that residency programs are preferred when transitioning to first year of practice.Publication bias: findings were not positive or negative, therefore none detected.
Li et al. ( 2014 ) quantitative, correlational/descriptive, predictive A convenience sample of 251 nurse residents (0–3 months of working on a pediatric unit in Los Angeles, CA). 7.9% of participants were male. Percentage of Caucasian participants 30.3%, Black 0.8%, Latino 2.4%, and other ethnicities were not reported. Purpose: The purpose of the study examined protective factors that may decrease burnout and increase job satisfaction in a nurse residency program over 3 months. Group cohesion optimizes practice whereas organizational commitment helps to create an intention to stay at current job (p. 96). Aim: to determine whether factors such as group cohesion and organizational commitment would be protective and moderate the association between stress exposure and posttraumatic stress symptoms and other negative nurse outcomes which would create positive ones. Variables: DVs: stress, compassion, satisfaction, group cohesion, and organization commitment.Instruments: Life Events Checklist good reliability, PTSD Checklist Civilian Version, Compassion Satisfaction and Fatigue Test, Nurse Job Satisfaction Scale, Group Cohesion Scale, and Organizational Commitment Scale “Organizational commitment was not found to protect nurse residents from negative nurse outcomes, it did play an important role in promoting job satisfaction” (p. 95). “Results confirmed previous findings that stress exposure and PTSD symptoms have serious implications for a range of affective outcomes for new resident nurses” (p. 95). Information was provided about the relationships that group cohesion and negative nurse outcomes have and that establishing a relationship in a group can serve as a protective factor in helping bounce back from negative nurse outcomes like burnout and compassion fatigue. ** Social support could also impact how nurses respond to stress (p. 97). ++ ⊕⊕○○ Risk of bias: sample bias due to convenience sampling and collection of information was not reliable and only at one hospital, one type of floor. Inconsistency: findings were consistent with other findings within the context of group social support decreases the adverse effects of stress.Indirectness: Findings were applicable to the context of the study.Imprecision: relevant only to one hospital on one floor, downgraded one point. Publication bias: not likely as findings were neither positive or negative.
Martin & Wilson ( 2011 ) qualitative/interpretive phenomenology, descriptive 7 new nurses within the first year of practice who participated in an intensive transition program designed as a component of an orientation program to ease new graduates into nursing practice on various medical/surgical units/purposive convenience sample. 14% of participants were male. Percentage of Caucasian participants was 85.7%, Black 14%, there were no other ethnicities reported. (purposive: the researcher deliberately selects subjects most knowledgeable about the issue under study.) Purpose: to examine the lived experience of newly licensed RNs in their first year of practice in a hospital setting. Aims: to extract the meaning and understand from the human experience, new nurses, during their first year of hire. Variables: DV: experiences of new nurses during their first year of hire. Instruments: interview questions Themes: real nurse work, guidance, transitional processes, institutional context, and interpersonal dynamics. “The cumulative effects of socialization, skill acquisition, and stress on new nurses indicate that research is needed to answer questions regarding recruitment, retention, and job satisfaction” (p. 21). Caring of the profession vs non-caring within the profession is posed as an argument for a new orientation objective – possibly the formation of a “caring group” (better known as support group). “Professional acculturation is a complex process that requires time to navigate. The success of the process is often dependent upon the degree of perceived support the newly licensed RN receives” (p.22). Relationships are required to adapt to the stress of starting nursing. Collegial relationships with all nursing staff and MDs, and ancillary staff matters to new nurses. ++ ⊕⊕⊕○ Methodical limitations: somewhat detected as convenience sample was used to recruit sample yet framework for the study matched the purpose and aims for this study.Relevance: the findings are very applicable to the context of new nurse experiences. Coherence: good coherence with previous studies of professional acculturation and struggle to create a professional identity while transitioning to practice which is deems extremely stressful. Adequacy of data: findings aligned with Kramer's seminal work (1974), Reality Shock , and reconfirmed via Duchscher's work on Transition Shock Theory . Publication bias: none detected as the study did not report positive or negative findings.
McCalla-Graham & De Gagne ( 2015 ) qualitative: phenomenological/exploratory 10 participants, using a purposive, snowball sampling/southwest Florida, most were experiencing their second career. Gender and ethnicity were not specified. Purpose: to explore the lived experiences of new graduate nurses employed in an acute care setting.Aims: to best understand new graduate nurses' experiences in the acute settingVariables: DV: acute care setting in the first year of hire.Instruments: 11 open-ended questions Participants stated that nursing school did not prepare them for current roles or responsibilities and that the goal of nursing school was only to assist the new grad in passing the NCLEX. “The findings suggest that the graduate nurses thought that if they developed good coping skills, the acute care clinical setting might be less stressful for them” (p. 125). Participants also stated they were very overwhelmed by the workload and that positive reinforcement helped mitigate this stress. ++ ⊕⊕⊕○ Methodical limitations: none detected as the findings reflected similar findings as primary studies, there were very little issues, other the sampling method, in the way the study was designed/conducted. Relevance: the findings were relevant and the extent of the body of evidence from the primary studies supported and is applicable to the context of the new nurse shortage phenomenon occurring within the first year of practice. Coherence: The researchers discussed a clear fit between the data from primary studies and the review findings.Adequacy of data: there was rich data and the amount to support the findings were adequate.Publication bias: none detected as the results are neither positive or negative influencing the preference to publish.
Olson ( 2009 ) qualitative/exploratory, interpretive, phenomenological, longitudinal 12 participants/purposive sample of 2 groups of new graduates: 6 BSN and 6 ADN nurses – full time staff nurses at the time of data collection. 16.6% of participants were male. Ethnicity of participants not specified. Purpose: to understand the experience of newly licensed nurses from their perspective. Aims: to understand millennial, novice nurses' experiences throughout the first year of practice Variables: DV: new nurse experiencesInstruments: open ended interviews at 3, 6, and 12 months Themes that emerged: being in unfamiliar surroundings which seemed confusing and overwhelming because they had spent limited time in acute care as students. After a year, participants expressed fear about being oriented to a different place. The second theme, “out of the blue,” which are the “never to be forgotten” experiences – so chaotic and the difficulty of trying to keep up – this was relayed to researchers as feelings of helplessness, guilt, and extreme sadness as novices coped with death or a medical error for the first time. The third theme: finding my voice, this was a description of novices' relationships with preceptors, MDs, and other staff members. Feeling welcomed and confronting incivility with other nurses were crucial to feeling successful in the transition. The fourth theme was “am I ok?” Obtaining feedback, trust with knowing someone would tell them they were doing something wrong was very important to participants as they expressed great anxiety regarding making mistakes. The acute setting is very unfamiliar, and socialization can assist with the stressful adjustment which makes it difficult to grow and continue to learn. Millennials want nurturing, attention, and continuous feedback which places an extensive value on social support (a protective factor of resiliency). ++ ⊕⊕⊕○ Methodical limitations: limitation regarding small sample yet findings were analyzed well, and researcher demonstrated a good ability to reflect on participants' experiences to create common themes that are applicable to the phenomenon of new graduate experiences.Relevance: Primary studies support the findings and it is applicable to millennial, novice nurses' and their intentions to do everything really well regardless of how foreign something is and the need for immediate attention and feedback to continually grow and learn. Coherence: there is a good fit between the primary studies and the findings in this study. Adequacy of data: the quantity and degree of richness in primary studies support the review findings.Publication bias: Doubtful due to neither positive or negative results were shared, only reported experiences of a sample of new nurses.
Pellico et al. ( 2009 ) qualitative: case study model/descriptive 612 participants in 12–18 months of practice/stratified sampling in metropolitan midsize areas in the US working inpatient. Ethnicity and gender of participants not specified. Purpose: “The purpose of this article was to explore the perceptions of 612 NLNs' nascent experiences as reflected in their comments provided in a national survey that sought to gain a better understanding of the work life of NLNs” (p. 194).Aims: to understand NLN's work-life experiences.Variables: multiple areas across the US Instruments: 16-page survey with 207 items. “5 themes were discovered. “Colliding expectations” describes conflicts between nurses' personal view of nursing and their lived experience. “The need for speed” describes the pressure related to a variety of temporal issues. “You want too much” expresses the pressure and stress NLNs feel personally and professionally. “How dare you” describes unacceptable communication patterns between providers. “Change is on the horizon” suggests optimism for the future as NLNs speak of transforming the systems where care is provided (a protective factor of resiliency). This content analysis reveals that the working environment where NLNs begin their career is in need of reform” (p. 194). ++ ⊕⊕⊕○ Methodical limitations: this was secondary findings from a parent study and there were no limitations in the design of the findings of the primary studies.Relevance: the findings are applicable to the context specified to explore perceptions of new nurses' work life.Coherence: There is a good fit between the data from the primary studies and the findings yet primary studies did not reveal any mention of wanting to change new nurses' experiences as stated in the review of findings in this study.Adequacy of data: the data underlying a review finding are rich and come from different numbers of participants per study.Publication bias: doubtful as the results were neither positive or negative but reported the experiences of participants.

Tools Used in Studies to Determine NLN Resiliency or Protective Factors of Resiliency

Study Tool NLN Outcomes Reflecting NLN Resiliency
Anderson, Linden, Allen, & Gibbs ( 2009 ) The Halfer-Graf Survey (validity/reliability not reported) ( Halfer & Graf, 2006 ) and open-ended questions Compared job satisfaction and employee engagement after completed 2-day interactive residency modules which assisted NLNs to perform job, identify resources, and job expectations. Most valuable strategy to satisfy NLNs was email communication as a form of support, followed by positive patient outcomes and teamwork.
Bontrager, Hart, & Mareno ( 2016 ) Preceptor Role Effectiveness Scale (reliability coefficient = .75) ( Rauen, 1974 ); Group Cohesion Scale (reliability coefficient = .81) ( Hinshaw & Atwood, 1983 ); Nurse Job Satisfaction Scale (overall internal consistency reliability coefficient = .88) ( Hinshaw & Atwood, 1983 ); and Intent to Stay Scale (reliability coefficient = .85) ( Kim, Price, Mueller, & Watson, 1996 ) Preceptors, job satisfaction, and group cohesion were found to be importantto reduce transition shock and intention to leave.
Clark & Springer ( 2012 ) Open-ended questions Learning the work flow, feeling valued, preceptors, and coworkers enhanced satisfaction and commitment to the profession and the ability to work in a team.
Cline et al. ( 2017 ) Casey-Fink Graduate Nurse Experience Survey: the section on comfort and confidence (Cronbach α = .78). The next section consists of 5 factors, namely, support (α = .90), patient safety (α = .79), stress (α = .71), communication/leadership (α = .75), and professional satisfaction (α = .83) ( Casey, Fink, Krugman, & Propst, 2004 ) and institutional retention metrics A customized residency program may improve NLNs' experiences as they enter practice which increases confidence and may lead to intention to stay at current job.
Clipper & Cherry ( 2015 ) 16-item investigator developed survey assessing the attributes of transition shock to obtain NLN perceptions and effectiveness of their preceptors (Cronbach α = .954) ( Duchscher, 2009 ) NLNs were more positive regarding practices and a slightly better retention rate when a structured preceptor program was provided.
Fiedler, et al. ( 2014 ) McCloskey/Mueller Satisfaction Scale (Cronbach α = .94) ( Mueller & McCloskey, 1990 ) Residency programs can lowerturnover rates yet at 6 months, job dissatisfaction decreased yet at 12 months satisfaction increased.
Fink et al. ( 2008 ) Gill, Deagan & McNett ( 2010 ) Casey-Fink Graduate Nurse Experience Survey (Cronbach α = .89) ( Casey et al., 2004 )and open-ended questions 10-item abbreviated version ofthe National Database of Nursing Quality Indicators (reliability coefficient = .91) ( Taunton et al., 2004 ) and open-ended questions Constant preceptor assistance increased NLN satisfaction. Establishing relationships and learning the job positively affected NLN satisfaction. Despite positive results, some NLNs considered leaving the organization but few stated they thought of leaving the profession.
Hodges, Keeley, & Troyan ( 2008 ) open-ended questions Developing confidence by learning skills, being accepted by others, and recovering from stress because of the academic/practice disparity was found important for NLNs to build professional identities and a social connection in order to adapt and negotiate career stress.
Hodges, Troyan, & Keeley ( 2010 ) open-ended questions The practice environment does not match NLN strengths. Feeling supported is key and establishing a social group is necessary to develop career persistence.
Kramer et al. ( 2013 ) open-ended questions Delegation, prioritization, accomplishing work, clinical autonomy, effective clinical decision-making, constructive conflict resolution, and restoring self-confidence are important factors to promote NLN professional practice.
Li et al. ( 2014 ) Life Events Checklist (reliability κ > .50, test-retest reliability r = .82) ( Gray, Litz, Hsu, & Lombardo, 2004 ), PTSD Civilian Checklist (internal consistency α = .94, test-retest reliability r = .88) ( Weathers, Litz, Huska, & Keane, 1991 ), Compassion Satisfaction and Fatigue Test (test produces three subscales: compassion satisfaction, burnout, and CF/STS. Each scale showsgood internal consistency in this sample (α = .87, .90, and .87) ( Stamm, 2002 ), Nurse Job Satisfaction Scale (α = .90)( Mueller & McCloskey, 1990 ), Group Cohesion Scale (α = .89) ( Byrne & Nelson, 1965 ), and Organizational Commitment Scale (α = .89) ( Porter, Steers, Mowday, & Boulian, 1974 ) Relationships and social support can buffer stress and compassion fatigue.
Martin & Wilson ( 2011 ) open-ended questions Socialization, the ability to perform skills, and collegial relationships help to garner job satisfaction and retain NLNs.
McCalla-Graham & De Gagne ( 2015 ) open-ended questions NLNs reported more training needed for coping skills to deal with stress.
Olson ( 2009 ) open-ended questions The overwhelming work atmosphere confused NLNs as well as new experiencesnot encountered while in nursing school translated into feelings of helplessness. Inabilities to speak with MDs and not knowing who to trust verified extensive social support and continuous feedback are needed in millennial NLNs the first year of hire.
Pellico, Brewer, & Kovner ( 2009 ) open-ended questions Poorly understood NLN expectations, the expectations for NLNs to perform quickly, and incivility among clinicians informs organizations and leaders that the work environment needs reform.
Authors

Ms. Concilio is PhD Student, Dr. Lockhart is Professor and MSN Nursing Education Track Coordinator, Dr. Kronk is Associate Professor, and Dr. Schreiber is Professor of Epidemiology/Statistics, Duquesne University School of Nursing, Pittsburgh, Pennsylvania; and Dr. Oermann is Thelma M. Ingles Professor of Nursing, Duke University School of Nursing, Durham, North Carolina. Ms. Concilio is also Lecturer and Clinical Instructor, School of Nursing, San Diego State University, San Diego, California.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Dr. Jane Brannan, EdD, Professor of Nursing, Kennesaw State University, Kennesaw, Georgia, for her content expertise and support. The authors also thank David Nolfi, MLS, AHIP Head, Research Engagement, Health Sciences/STEM Initiatives, Assessment Coordinator Gumberg Library, Duquesne University, Pittsburgh, Pennsylvania, for ongoing support.

Address correspondence to Lisa Concilio, MSN-ED, RN, CCRN, Lecturer and Clinical Instructor, School of Nursing, San Diego State University, 10006 Maya Linda Rd. #5207, San Diego, CA 92126; e-mail: conciliol@duq.edu.

Received: August 13, 2018
Accepted: October 22, 2018

10.3928/00220124-20190319-05

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