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<ul><li><p>JONAVolume 38, Number 7/8, pp 341-348Copyright B 2008 Wolters Kluwer Health | Lippincott Williams &amp; Wilkins</p><p>T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N</p><p>The Graduate Nurse ExperienceQualitative Residency Program Outcomes</p><p>Regina Fink, PhD, RN, FAAN, AOCN</p><p>Mary Krugman, PhD, RN, FAAN</p><p>Kathy Casey, MS, RN</p><p>Colleen Goode, PhD, RN, FAAN</p><p>Graduate nurses experience role conflict and stressas they begin practice in work environments ofhigh complexity, nurse shortages, and expectationsto become competent rapidly. The authors reportoutcomes from a study that evaluated qualitativeresponses to the Casey-Fink Graduate Nurse Expe-rience Survey administered to graduate nurseresidents in the University HealthSystem Consor-tium/American Association of Colleges of Nursingpostbaccalaureate nurse residency program at 12academic hospital sites. Qualitative analysis pro-vided sufficient evidence to convert specific open-ended questions on the Casey-Fink Graduate NurseExperience Survey instrument to a quantitativeformat for ease of administration and analysis.</p><p>The transition of graduate nurses from an educa-tional program into the professional practice settingis a long-standing issue and is widely recognized as aperiod of stress, role adjustment, and reality shock.1-5</p><p>The turnover of graduate nurses as a result of thesetransitional stresses ranges from 20% to more than40%, resulting in a personal impact on the graduatenurse and a financial loss for acute care hospitalsestimated at $40,000 per graduate nurse who leavesin the first year of practice.6-9 In this period ofsignificant nursing shortages, developing structured</p><p>evidence-based residency programs to provide sus-tained developmental support to graduate nurses iscritical for the retention and satisfaction of nursesnew to the profession. The experiences of thegraduate nurse provide a window into the devel-opmental needs, with both quantitative and qual-itative data yielding insights into how graduatenurses perceive their competency, their confidence,and the factors that contribute in strengthening orundermining successful role functioning.</p><p>Background</p><p>One instrument designed to generate data on theexperiences of graduate nurses is the Casey-FinkGraduate Nurse Experience Survey. The originalresearch that tested this author-developed instrumentstudied 270 graduate nurses in 6 metropolitanDenver hospital sites at baseline, 3, 6, and 12months. It was discovered that graduate nursesexperienced high levels of stress during their first 6months of employment that later declined between 9and 12 months. These stressors included personaland financial issues; work environment frustrationsrelated primarily to workload; ambivalence asso-ciated with the desire to be independent yet still feelingshort of confidence in skills and critical thinking toachieve this; and inconsistent support from precep-tors, managers, and educators. Graduate nurses alsoidentified a lack of confidence in communicating withphysicians, managing and prioritizing patient careneeds, caring for dying patients, and delegating toancillary personnel. An overall lack of comfort andconfidence with specific procedures was prevalent andcontinued after a years experience.4</p><p>The Casey-Fink Graduate Nurse ExperienceSurvey was adopted as part of the program of</p><p>JONA Vol. 38, No. 7/8 July/August 2008 341</p><p>Authors Affiliation: Research Nurse Scientist (Dr Fink);Director, Professional Resources (Dr Krugman); Vice President,Patient Services, and Chief Nursing Officer (Dr Goode),University of Colorado Hospital, Aurora; Adjunct ClinicalInstructor, University of Colorado, College of Nursing (Ms Casey),Denver, Colorado.</p><p>Corresponding author: Dr Fink, Department of ProfessionalResources, University of Colorado Hospital, Leprino Bldg, 12401E 17th Ave, PO Box 6510, Mail Stop 901, Aurora, CO 80045(reginamfink@aol.com).</p><p>Funding Source: Qualitative data analysis for this study wasfunded by a Robert Wood Johnson grant awarded to theAmerican Association of Colleges of Nursing.</p><p>Copyright @ 2008 Lippincott Williams &amp; Wilkins. Unauthorized reproduction of this article is prohibited.</p></li><li><p>evaluation by the University HealthSystem Consor-tium (UHC)/American Association of Colleges ofNursing (AACN) postbaccalaureate graduate nurseresidency program,10-13 generating data since 2002.To date, more than 5,000 graduate nurses enrolledin the UHC/AACN residency program at 37 aca-demic hospital sites have taken the Casey-FinkGraduate Nurse Experience Survey, with docu-mented outcomes that consistently reflect those ofthe original study. The survey instruments Cron-bach coefficient ! is .89 after repeated measures(reliability of the instrument was based on responsesof sample respondents measured on several occa-sions; respondents were not independent of eachother). Whereas quantitative data outcomes havebeen reported,14 qualitative data have not beenanalyzed. This article will report on the qualitativedata outcomes from the instruments open-endedquestions using the first 2 cohort groups from theUHC/AACN postbaccalaureate residency program.</p><p>Purposes of the Study</p><p>There were 2 intents for this study:</p><p>1. to analyze the qualitative voices of theresident respondents to determine if theircomments could further enrich the quanti-tative data and</p><p>2. to determine if analysis of the themes minedfrom the qualitative data could be used toconvert the open-ended questions on theCasey-Fink Graduate Nurse Experience Sur-vey into quantitative questions for ease oftest administration and analytic procedures.</p><p>Methods</p><p>The investigators used data previously collected bysurvey methods from graduate nurse respondents ontheir answers to the questions in the Casey-FinkGraduate Nurse Experience Survey; they are resi-dents in the first 12 academic hospital sites in theUHC/AACN postbaccalaureate residency program.The participants took the survey over 3 timed dataperiods during the first year of transition into prac-tice: on hire, 6 months, and 12 months on completionof the 1-year program. The research was approved bythe appropriate institutional review boards. The sur-vey instrument consists of 5 sections: demographicinformation, skills/procedure performance (3 open-ended questions), comfort/confidence (25 Likert-typeitems), job satisfaction (9 Likert-type items), and aseries of 5 open-ended questions, which permittedthe graduate nurse residents to voice their personal</p><p>experiences about work environment and role tran-sition. The responses to these qualitative items werethe focus of this research.</p><p>Sample and Data Collection Procedures</p><p>The convenience sample consisted of 1,058 gradu-ate nurse residents hired between May 2002 andSeptember 2003 and had fully completed the oneyear residency program. Participants data for thisstudy were obtained through the UHCs online con-fidential residency program evaluation database.Participant anonymity is assured through coding;there is no access to individual resident responses.Graduate nurse residents at all sites were asked tovoluntarily complete multiple online surveys,including the Casey-Fink Graduate Nurse Experi-ence instrument. Of the 1,058 total respondents,434 completed the surveys for all 3 periods, for aresponse rate of 41%. One academic hospital sitewas eliminated from this data analysis because oflimited survey completion.</p><p>Qualitative Data Analysis Procedures</p><p>Qualitative data analysis increases the comprehen-siveness of a study by providing derived richness,detail in description, explanation, or a more completeunderstanding of a phenomenon, which is comple-mentary to the quantitative findings.15 Verbatimcomments of graduate nurse residents were catego-rized by site and period. Key words from respondentnarratives were independently identified by 2 inves-tigators (first author [R.F.] and research assistant[B.L.]). Each comment was coded, entered, andtallied into an Excel file by question. Some respon-dents had more than 1 comment; other respondentshad no comments at all. The investigators comparedfindings, identified cover terms and the commonthemes across institutions and periods, and validatedfindings with a team of independent investigators(coauthors M.K., K.C., C.G.). The total numberof separate qualitative comments analyzed over the3 timed data periods was 5,320.</p><p>Results</p><p>Demographics</p><p>The average respondent was a 26-year-old Caucasianwoman who held a bachelor of science in nursingdegree, as per requirement of the UHC/AACNresidency program. Of the resident sample, 90%held a grade point average of 3.0 or higher, and mosthad previous healthcare experience as unlicensedclinical providers such as nursing assistant. Graduate</p><p>342 JONA Vol. 38, No. 7/8 July/August 2008</p><p>Copyright @ 2008 Lippincott Williams &amp; Wilkins. Unauthorized reproduction of this article is prohibited.</p></li><li><p>nurse residents practiced in a wide variety of clinicalareas including critical care, medical/surgical, andspecialty services such as oncology, psychiatry,rehabilitation, and womens services. There were nostatistical differences in demographic outcomesrelated to numbers of preceptors, length of orienta-tion, working in the health field before becoming agraduate nurse resident, or area of clinical practice.</p><p>Skills/Procedure Performance</p><p>Residents were asked to self-identify (by writing)the top 3 skills and procedures that they wereuncomfortable of performing independently. Noneof the respondents believed that they were inde-pendent in all skills at baseline. Only 10% of thesample believed that they were independent inperforming all skills at 6 months, and only 7%answered the same at 12 months. Most respon-dents identified greater than 100 different skills/procedures that they were uncomfortable of per-forming at 12 months. The top 12 skills reported tobe most challenging over time are listed in Table 1.It is important to note that that even at 1 year ofpractice, many skills were repeatedly identified asproblematic over time, and others such as givingcode response, providing tracheostomy care, andcaring for patients at the end of life became morechallenging over time. One explanation for theseconcerns may be the graduate nurses reliance on</p><p>the preceptor for assistance with skills and proce-dures early in their orientation program. Asresidents move into an independent role, they facethe management of increasingly complex patientcare situations.</p><p>Stressors</p><p>The original research results indicated that graduatenurses experienced high personal stress during thefirst 6 months of transition into practice. In thisstudy, 24% of respondents reported being stressed atbaseline, 11% were stressed at 6 months, and 18%were stressed at 12 months. The 3 top stressorsduring the first 6 months of practice in order ofimportance included preparing and waiting for theresults of National Council Licensure Examination,moving away from home to a more independentlifestyle or out of state, and adjusting to theexpectations on the work environment and newregistered nurse (RN) role. During the second 6months of practice, having family responsibilities,becoming newly married and/or pregnant, acquiringa new house or apartment, and entering graduateschool were identified as most stressful. Althoughthese types of stressors are not unexpected, theiridentification gives the management insights intohow graduate nurse personal issues can add towork-related stressors, potentially impacting rolefunctioning.</p><p>Table 1. Top 12 Skills/Procedures That Cause Discomfort in Graduate Nurse Residents (N = 434)</p><p>Time 1 (Baseline) Time 2 (6 Mo) Time 3 (12 Mo)</p><p>Skill N Skill N Skill N</p><p>1. IV starts 156 1. IV starts 121 1. Code/emergency response 942. Blood draws/venipuncture 58 2. Code/emergency response 76 2. IV starts 823. Assessment skills 50 3. Arterial/venous/Swan-Ganz 50 3. Trach/suctioning care 574. Trach suctioning and care 49 4. Trach/suctioning care 46 4. Acting as charge 415. Dubhoff/NG tube placement 47 5. Dubhoff/NG placement 32 5. Venous/arterial/Swan-Ganz lines 406. Arterial/venous lines/Swan-Ganz 41 6. Catheter insertion 27 6. Death/dying/end-of-life care 386. Charting/documentation 41 7. Death/dying/end-of-life care 26 7. Dubhoff/NG tube placement 326. Code/emergency response 41 8. Assessment skills 25 8. EKG/telemonitoring and</p><p>interpretation25</p><p>7. Chest tube/pleurovac care 38 9. Chest tube/pleurovac care 24 9. IV drips/meds/insulin/heparin 258. Administering blood products 36 10. Care/assessment/unstable 19 10. Care of unstable, high-risk/</p><p>complex patient23</p><p>8. Prioritizing time management 36 10. EKG/telemetry interpretation 19 11. Vent care management 229. Catheter insertion/care 32 11. Administering blood products 17 12. External pacemakers,</p><p>ventricular assistive devices,pacing and epicardial</p><p>21</p><p>10. EKG/telemetry interpretation 31 11. Assisting with airwayprocedures/trach</p><p>11. Administering IV medications 28 11. Circulating in operatingroom/scrubbing in</p><p>12. IV drips (insulin/heparin) 26 12. Medication administration12. Physician communication 2612. Wound/dressing change 26</p><p>Abbreviations: EKG, electrocardiogram; IV, intravenous; NG, nasogastric.</p><p>JONA Vol. 38, No. 7/8 July/August 2008 343</p><p>Copyright @ 2008 Lippincott Williams &amp; Wilkins. Unauthorized reproduction of this article is prohibited.</p></li><li><p>Role Transition Difficulties</p><p>In response to the question on what difficulties, ifany, are you experiencing with the transition fromthe Fstudent role_ to the FRN role,_ 8% of therespondents reported no transition difficulties atbaseline, 28% had none at 6 months, and 58%reported none at 12 months. Therefore, 42% of thegraduate nurse sample still perceived having tran-sition difficulties at 1 year after being hired. Forthose graduate nurses who experienced transitiondifficulties, 5 overall themes were consistentlyidentified across all institutions and all periods.Figure 1 shows a list of these in order of re-spondent frequency, with the subcategories of rolechanges, lack of confidence, workload, fears, andorientation issues. Comments by residents includedconcerns about feeling alone and overwhelmedand being nervous about being the one who isultimately responsible for my patients. The grad-uate nurse residents desired to be respected bymore experienced nurses and found it difficult toask nursing assistants who I used to work with toperform tasks for me.</p><p>All of these role changes did improve as the firstyear progressed, but being placed in charge nurse orpreceptor roles prematurely added to their stress,particularly if this occurred between 6 and 12months of the residency program. Concerns relatedto communication skills surfaced, as shown by atypical comment as follows: I need to work on mycommunication and assertiveness with physicians.Many graduate nurse residents expressed feeling</p><p>overwhelmed with the workload and nurse topatient ratios. Those commenting verbalized thatthey felt a lack of organization and prioritizationskills, a key barrier to optimal performance in theirnew role. Graduates described having difficulty indeterminin...</p></li></ul>

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