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  • JONAVolume 38, Number 7/8, pp 341-348Copyright B 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

    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

    The Graduate Nurse ExperienceQualitative Residency Program Outcomes

    Regina Fink, PhD, RN, FAAN, AOCN

    Mary Krugman, PhD, RN, FAAN

    Kathy Casey, MS, RN

    Colleen Goode, PhD, RN, FAAN

    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.

    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

    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

    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.

    Background

    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

    The Casey-Fink Graduate Nurse ExperienceSurvey was adopted as part of the program of

    JONA Vol. 38, No. 7/8 July/August 2008 341

    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.

    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).

    Funding Source: Qualitative data analysis for this study wasfunded by a Robert Wood Johnson grant awarded to theAmerican Association of Colleges of Nursing.

    Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

  • 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.

    Purposes of the Study

    There were 2 intents for this study:

    1. to analyze the qualitative voices of theresident respondents to determine if theircomments could further enrich the quanti-tative data and

    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.

    Methods

    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

    experiences about work environment and role tran-sition. The responses to these qualitative items werethe focus of this research.

    Sample and Data Collection Procedures

    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.

    Qualitative Data Analysis Procedures

    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.

    Results

    Demographics

    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

    342 JONA Vol. 38, No. 7/8 July/August 2008

    Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

  • 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.

    Skills/Procedure Performance

    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