1

Integrative Review of the Literature

Alec Rich

Bon Secours Memorial College of Nursing

NUR 4322 – Nursing Research

Dr. Arlene Holowaychuk

04/23/2022

“I pledge… “
 2

Abstract

Purpose: The purpose of this integrative review is to examine if a nurse residency program

during the transition to practice period can have a positive effect on new graduate nurse

satisfaction and retention rates. Background: Nursing as a whole is suffering from a continuous

staffing shortage, and big part of that shortage is due to poor new graduate nurse retention rates.

With the implementation of a residency program, we can study the changes in nurse satisfaction

and study the reasons why new graduate nurse retention rates are low. Hopefully, this research

on transition to practice programs can lead to a new standard that can improve nurse retention

rates. This has a trickledown effect, because if we can improve staffing shortages, we will see

improvement reciprocated throughout the healthcare system. Design and Search Method: The

research design is an integrative review based on three research articles selected from PubMed,

and Ovid, and the eLibrary database. Results and Findings: New graduate nurse residency

programs are not a common practice in all healthcare settings. When implemented it can help

increase nurse satisfaction and retention rates. Implications for Practice: The results from this

review encourage the use of a nurse residency program during transition to practice and show

that it can directly affect nurse retention rates. Recommendations for Future Research: Further

research should be performed with larger sample sizes and different units to get a more

generalized look at the possible benefits of a nurse residency program.

 3

Integrative Review of the Literature

The purpose of this integrative review is to examine the use of a nurse residency program

on new graduate nurses and the affect it has on nurse satisfaction and retention rates. Nursing as

a whole has been suffering from a staffing shortage, and majority of the nurses that leave come

from the first two years of their practice. Many new graduate nurses suffer from poor leadership

during the transitional process, poor support, burnout, and stress on the job. Although this may

seem like issues that just come with the job, the use of a nurse residency program can provide

many benefits to help work around this. A nurse residency program offers proper mentorship,

close monitoring for stress levels and burnout, a cohesive unit that struggling new nurses can

confide in, and overall support on the job.

Without this assistance during the transition to practice period, nurses are showing to feel

less confident, less competent, less supported, and more stressed (Blegen et al., 2017; Failla et

al., 2021; Wildermuth et al., 2020). The biggest concern that we can see in nursing right now is a

continuous shortage in staffing. This concern aids the lack of use of nurse residency programs.

This integrative review aims to discuss and analyze the research studies related to the PICOT

question: “For new graduate nurses, what is the effect a residency program has on nurse retention

compared with new graduate nurses who have not undergone a residency program within the

first year of the transitional process?”

Design and Search Methods

The research design is an integrative review. The search for research criteria was

conducted utilizing the computer-based search engines PubMed and Ovid. Terms included in the

search consisted of, ‘nurse’, ‘new graduate’, ‘residency’, ‘retention’, ‘new nurse’, ‘transition’,

‘stress’, and ‘nurse residency program’. The search yielded 1,500 articles from Ovid, and 549
 4

from PubMed, indicating a plethora of literature on the topic. To provide information in

agreement with the issue, the search was limited to peer-reviewed, nursing research journal

articles, published in English, and written between the years 2016-2022. The search produced a

qualitative longitudinal study, a qualitative research design study, and a qualitative

phenomenological study.

The articles had to pertain to the researcher’s PICOT question, “For new graduate nurses,

what is the effect a residency program has on nurse retention compared with new graduate nurses

who have not undergone a residency program within the first year of the transitional process?”

The articles were then selected based on the following inclusion criteria: new graduate nurses,

retention rates after one to two years of practice, personal and hospital characteristics, qualitative

and quantitative research. The research articles were screened based on inclusion criteria and

PICOT question significance. Articles that did not match with the criteria were not used for this

review. The screening produced three new graduate nursing transition to practice research

articles.

Findings and Results

The findings and results of the three reviewed studies showed a positive effect of

implementing a nurse residency program during the transition to practice for new graduate

nurses as indicated by clinical measure outcomes. (Blegen et al., 2017; Failla et al., 2021;

Wildermuth et al., 2020). A synopsis of the compiled research articles is presented in Appendix

I. The researcher framed the review according to the following categories: new graduate nurse

retention rates and new graduate nurse satisfaction

New Graduate Nurse Retention Rates

 5

The three articles agreed on the idea that a new graduate nurse residency program worked

positively to benefit nurse retention rates and nurse satisfaction (Blegen et al., 2017; Failla et al.,

2021; Wildermuth et al., 2020). Nurse satisfaction being how happy the nurse is with the job, the

unit, and their patient outcomes. Nurse retention rates and nurse satisfaction in combination play

a large role in the reasons we are suffering a worldwide nursing shortage.

Blegen et al. (2017) created a quantitative longitudinal study that aimed to understand the

significance a nurse residency program can have on nurse retention rates through surveys at

baseline, six months, and nine months. The retention rates were collected at the end of the 1st

year and didn’t matter if you left the initial unit, but that you were still employed at the hiring

hospital. The random sample used 42 hospitals randomly assigned to implement the new TTP

(transition to practice) program, while 55 hospitals continued using their methods. The inclusion

factors were multisite, randomized trial of the effects of a newly designed TTP program. The

hospitals selected were located in Illinois, North Carolina, and Ohio. The study was approved by

the Institutional Review Board. The data was analyzed using the Bonferroni post hoc test which

helped determine which category differences were statistically significant when there were three

or more categories of the independent variable. A multivariate logistic regression test was used

to identify the most important characteristic predicting turnover. Results of the study found that

there was not much statistical significance between the control and study group when it came to

hospital and nurse characteristics. The retention rates were then tested between the hospitals

divided between the new evidence-based transition to practice program vs. those hospitals with

limited transition programs. The study showed a significant difference in retention rates with the

evidence-based transition to practice programs having a 13% higher retention rate at 88% vs.

75% (Blegen at al., 2017).

 6

A quantitative research design study by Failla et al. (2021), using a descriptive

comparative design measuring new graduate nurse retention was conducted over a 24 month

period. A sample of 117 new grade nurses part of a transition program from 5 hospitals within

the United States with ethnicity and race being representative of the community and most

respondents identifying as female and 14% identifying as male. Information on levels of care,

months in orientation and the degree held in nursing were also gathered from participants. A

descriptive comparative survey was completed by participants 3 times; one at baseline, one at 12

months and the final being completed at 24 months. Data collection was completed through the

Casey-Fink graduate nurses experience scale, the Gray-Toft and Anderson nursing stress scale,

Allen and Meyer Affective Commitment Scale (AMAC), Pearson Civility Norms (PCN) and

Helfer Graff Job Satisfaction Scale (GT-NSS). These surveys gathered information on the

participants’ perceptions of effective commitment, job satisfaction and job stress. For the AMAC

scale, significance showing a decline from baseline to 24 months was found with a p value of

0.000. This indicates that feelings of commitment to the health care organization declined over

the 24 month period. These perceptions of a decline in commitment were also found to be

significant using the previously mentioned scales with p values of 0.000. This shows that civility,

stress and job satisfaction are connected to NGNR’s commitment to the health organization.

The GT-NSS scale showed significantly different mean scores from baseline to 24

months (P = 0.000) which shows that NGNR stress increased over time. The PCN scale also

found a significant decrease in means from baseline to 24 months (p value 0.000), showing that

civility in the workplace is needed to increase commitment and a sense of job satisfaction to

reduce stress and intention of NGNR’s to leave the job. No statistical significance was found for

the Casey-Fink Graduate Nurses’ Experience Survey from baseline to 12 months. The
 7

Professional Satisfaction subscale found statistical significance (p = .010) with a decrease in hob

satisfaction from baseline to 12 months. The study finds that stress, civility, and job satisfactions

are related to affective commitment to the organization and increased retention rate. Including

the ideology that nurse leaders can have an impactful influence on new graduate retention rates.

Findings demonstrated a reduction in affective commitment and an increase in nursing stress

from baseline to 12 and 24 months of employment. The highest mean in intent to leave occurred

at 12 months, highlighting the vulnerability of the NGNR at that time. The results also show the

impact nurse leaders can have on new graduate nurse attitude and retention.

The qualitative phenomenological study by Wildermuth et al. (2020) was conducted at a

small Midwestern college of nursing where the experiences of a nursing student cohort was

looked into from their transition from student to new graduates using a nurse residency program.

These experiences were based off the framework of Meleis’ transition experience theory. A

convenience sample of 9 new graduate nurses was used with an inclusion criteria of participation

in clinical immersion experience and in orientation on the same unit. Data collection was done

through face to face interviews of the participants that lasted 45 to 90 minutes. The question

asked by the author of this study was: “What are your transition experiences as a student and a

new graduate in a collaborative nurse residency program?” Data analysis was completed with

interview transcripts that were highlighted for significant statements which were then grouped

into themes. These themes included what the participants experienced (textual description) and

how the experience happened (structural description). Both the textual and structural descriptions

were used to develop a composite description of the phenomenon. With this, the researchers

recognize the feelings of new graduate nurses, as well as, there experience during a nurse

residency. Major themes that came from the article were, feeling overwhelmed, feeling
 8

supported, and feeling confident. These themes follow previous literature in stating that

“transition can be facilitated or inhibited by personal, community, or societal conditions.”

New Graduate Nurse Satisfaction

Two of the studies provided data to support a nurse residency program aiding nurse

satisfaction (Failla et al., 2021; Wildermuth et al., 2020), while the third study concluded that

nurse characteristics didn’t have an impact on satisfaction or care (Blegen et al., 2017). Nurse

satisfaction is important in care because it describes how much they want to do their job, work

on their specific units, or even if they are confident in their practice. Nurses more satisfied on the

job will be more willing to work with others, provide cohesive care with their team members,

and overall benefit patient outcomes. This data further benefits the use of a nurse residency

program as a standard of practice.

Discussion and Implications for Practice

The research articles used for this integrative review offer the benefits of using a nursing

residency program in the transition to practice for new graduate nurses. The three research

studies incorporate data from nurse surveys and statistics on the implementation of a residency

program to aid in the transition to practice and improve retention rates (Blegen et al., 2017; Failla

et al., 2021; Wildermuth et al., 2020). All articles are in agreement that new graduate nurses can

benefit from some form of transition to practice residency program in regard to retention rate and

nurse satisfaction. The research studies explore beneficial information in relation to the PICOT

question, “For new graduate nurses, what is the effect a residency program has on nurse retention

compared with new graduate nurses who have not undergone a residency program within the

first year of the transitional process?”

 9

Each study supports the need for a nurse residency program during the transition to

practice evidenced by increased retention and nurse satisfaction. The research for the three

articles was collected in either an interview or survey form (Blegen et al., 2017; Failla et al.,

2021; Wildermuth et al., 2020). The new graduate nurses and nurse leaders were either

interviewed in person, or given a paper survey that was then analyzed.

The data collection methods for the three articles were similar, with two of the articles

using surveys (Blegen et al., 2017; Failla et al., 2021), while the third article used in person

interviews (Wildermuth et al., 2020). The population didn’t really differ between them, as it was

a study of new graduate nurses. There were no specific units studied during this research and

each article displayed information from multiple units.

The implications of these findings suggest improvement in nurse retention with the use of

a residency program. Applying a transition to practice program resulted in new graduate nurses

feeling more confident in their practice and more comfortable on their unit. With new graduate

nurses feeling more confident in their care and accepted on their units by nurse leaders, they

were more likely to stick around after their first year of work and increase retention rates (Failla

et al., 2021). This shows that new graduate nurse retention rates and satisfaction can be improved

with the implementation of a transition to practice program, which will in turn have a direct

effect on patient outcome.

Limitations

The articles used in this integrative review show limitations and suggest further research

should be done. Blegen et al. (2017) was limited in its study because it only lasted 1 year, when

previous work has shown that retention rates in the first job drops further in the second year of

practice. The sample also came from hospitals that volunteered to be a part of the NCSBN study
 10

and not necessarily representative of all US hospitals. Wildermuth et al. (2020) showed

limitations in their study being a very specific and small sample size, leading to data saturation

not being achieved. Due to the researcher also being a faculty member of the sample, a power

authority may have impacted the willingness of participants to share their true experiences. Failla

et al (2021) did not include how the sample size was obtained or where in the United States the

five hospitals were located. These limitations suggest that there is further research that can be

done around nurse residency programs and potentially understand its long-term effects better.

Value to Practice

In conclusion, the research obtained in this integrative review examined the

implementation of a nurse residency program for new graduate nurses. The research findings

suggestion the use of a residency program and its benefits to increase nurse satisfaction and

retention rates. Various analysis was done to collect data from the nurse’s perspective as well as

nursing leadership’s perspective before, during, and after the implementation of a nurse

residency program during the transition to practice. (Blegen et al., 2017; Failla et al., 2021;

Wildermuth et al., 2020). The research article findings support the PICOT question: “For new

graduate nurses, what is the effect a residency program has on nurse retention compared with

new graduate nurses who have not undergone a residency program within the first year of the

transitional process?” The results from the articles indicate the use of a nurse residency program

during transition to practice should be implemented into nursing practice to aid in new graduate

nurse satisfaction and improve new graduate nurse retention.

 11

References

Blegen, M. A., Spector, N., Lynn, M., Barnsteiner, J., & Ulrich, B. T. (2017). Newly Licensed

RN Retention: Hospital and Nurse Characteristics. Journal of Nursing Administration,

47, 508-514. https://doi.org/10.1097/NNA.0000000000000523

Failla, K. R., Ecoff, L., Stichler, J. F., & Pelletier, L. R. (2021). A 1-Year Accredited Nurse

Residency Program's Effect on Intent to Leave. The Journal of nursing

administration, 51(12), 606–613. https://doi.org/10.1097/NNA.0000000000001082

Wildermuth, M. M., Weltin, A., & Simmons, A. (2020). Transition experiences of nurses as

students and new graduate nurses in a collaborative nurse residency program. Journal of

Professional Nursing: official journal of the American Association of Colleges of

Nursing, 36(1), 69–75. https://doi.org/10.1016/j.profnurs.2019.06.006

 12

Appendix I: Summary of the Literature Table

APA Citation and Blegen, M. A., Spector, N., Lynn, M., Barnsteiner, J., & Ulrich, B.
Author Qualifications T. (2017). Newly Licensed RN Retention: Hospital and
Nurse Characteristics. Journal of Nursing Administration,
47, 508-514.
https://doi.org/10.1097/NNA.0000000000000523

Background/Problem With ever increasing numbers of older people and more inclusive
Statement health insurance coverage, the future of healthcare will include a
rising demand for nursing care, thereby worsening the current
nursing shortage. Although the number of newly educated nurses is
on the rise, the stability of the nursing workforce is uncertain. A
major concern is the low retention of newly licensed RNs (NLRNs).
Not only does the loss of a nurse affect the quality of care given, but
each nurse who leaves costs the institution up to 1.3 times their
salary to replace. To update the existing information about NLRN
retention, this study compared 1-year retention rates across
groupings created using personal and hospital characteristics and
determined which characteristics, if any, had the most influence on
the NLRN's decisions to stay.

Conceptual/theoretical None listed

Framework

Design/ Quantitative; Longitudinal Study

Method/Philosophical
Underpinnings

Sample/ 42 hospitals randomly assigned to implement the new TTP program

Setting/Ethical (study group), 55 hospitals continued using their methods (Control
Considerations group). Multisite, randomized trial of the effects of a newly
designed transition-to-practice (TTP) program.

Illinois, North Carolina, and Ohio.

Study was approved by IRB
Major Variables Independent Variable: Hospitals implementing the new TTP
Studied (and their program.
definition), if Dependent Variable: NLRN Retention rate
appropriate

Measurement The data used to create this study was collected from a study funded
Tool/Data Collection by the National Council of State Boards of Nursing. The data for the
Method nurse characteristics was collected from online surveys completed at
baseline, 6 months, and 9 months. The retention rates were collected
at the end of the 1st year (Does not matter if they were still on their
 13

initial unit, just that they were still employed at the hiring hospital).
Data Analysis Bonferroni post hoc tests were used to determine which category
differences were statistically significant when there were 3 or more
categories of the independent variable.
Multivariate logistic regression was used to identify the most
important characteristic predicting turnover.
Findings/Discussion The study showed that established evidence-based transition to
practice programs had a 13% higher retention rate. The study also
discovered that it’s not always personal characteristics that are
driving down retention rates, but also hospital characteristics (work
environment).

Appraisal/Worth to This study should interest current nurses and hospitals because, the
practice population directly effects the efficiency and quality of their
healthcare system. The evidence from this article has statistical
evidence that transition programs are beneficial to retention rate.
With further study, the transition to a residency program/transition
to practice program will be beneficial to overall nursing and
retention.
 14

APA Citation and Failla, K. R., Ecoff, L., Stichler, J. F., & Pelletier, L. R. (2021). A
Author Qualifications 1-Year Accredited Nurse Residency Program's Effect on Intent to
Leave. The Journal of nursing administration, 51(12), 606–613.
https://doi.org/10.1097/NNA.0000000000001082

Background/Problem Structured nurse residency programs support NGNR transition to

Statement the work environment and increase retention and organizational
commitment
Conceptual/theoretical No framework listed.
Framework

Design/ Quantitative;
Method/Philosophical The study used a descriptive, comparative design measuring
Underpinnings NGNR perceptions of affective commitment, job satisfaction, job
stress, and other variables over 3 times from baseline to 24
months
Sample/ Setting/Ethical The sample included 117 NGNRs across the 5 hospitals, with
Considerations attrition over time (baseline, n = 117; 12 months, n = 100; and 24
months, n = 97)

Major Variables Studied Independent: New graduate nurses studied in a transition program
(and their definition), if 3 times – baseline, 12, and 24 months.
appropriate Dependent: Nurse satisfaction, intent to leave, nurse stress levels.

Measurement Tool/Data Descriptive, comparative survery design over 3 times.

Collection Method Casey-Fink graduate nurses experience scale
Gray-Toft and Anderson nursing stress scale

Findings/Discussion The study finds that stress, civility, and job satisfactions are
related to affective commitment to the organization and increased
retention rate. Including the ideology that nurse leaders can have
an impactful influence on new graduate retention rates. Findings
demonstrated a reduction in affective commitment and an
increase in nursing stress from baseline to 12 and 24 months of
employment. The highest mean in intent to leave occurred at 12
months, highlighting the vulnerability of the NGNR at that time.
The results also show the impact nurse leaders can have on new
graduate nurse attitude and retention

Appraisal/Worth to The article states factors that contribute to stress (affects

practice retention) for new graduate nurses and also mentions the
influence that nursing leaders can have on retention rate.
 15

APA Citation and Wildermuth, M. M., Weltin, A., & Simmons, A. (2020). Transition
Author Qualifications experiences of nurses as students and new graduate nurses in a
collaborative nurse residency program. Journal of professional
nursing : official journal of the American Association of Colleges of
Nursing, 36(1), 69–75.
https://doi.org/10.1016/j.profnurs.2019.06.006

Background/Problem A small Midwestern college of nursing and an affiliate hospital

Statement partnered to design a nurse residency program where students are
extended pre-hire job offers in a practice area of their choice and are
then partnered with a preceptor who they will work with in a
clinical immersion experience during the last semester of their
nursing program and in their orientation period as new nurses.

Conceptual/theoretical Meleis’ transition experience theory

Framework

Design/ Qualitative; phenomenological study;

Method/Philosophical
Underpinnings

Sample/ 9 new graduate nurses. Convenience sample. Inclusion criteria

Setting/Ethical included participation in the clinical immersion experience and in
Considerations orientation on the same unit.

Major Variables Independent: New graduate nurses studied in a transition program.

Studied (and their Dependent: Lived experiences/Opinions from the interview that will
definition), if help develop strategies to support new nurses in transition.
appropriate

Measurement The researcher interviewed all of the subjects, lasting from 45 to 90

Tool/Data Collection minutes. All interviews were face to face in a private room. The
Method question asked was: “What are your transition experiences as a
student and a new graduate nurse in a collaborative nurse residency
program?”
Data Analysis Interview transcriptions were highlighted for significant statements,
which were then grouped into themes. What the participants
experienced (textual description) and how the experience happened
(structural description) were written. Finally, both the textual
description and structural description were used to develop a
composite description of the phenomenon.
Findings/Discussion The article recognizes the feelings of new graduate nurses, as well
as, there experience during a nurse residency. Major themes that
came from the article were, feeling overwhelmed, feeling supported,
 16

and feeling confident. Follows previous literature in stating that

“transition can be facilitated or inhibited by personal, community, or
societal conditions.”
Appraisal/Worth to These results help get an honest opinion of what new graduate
practice nurses are feeling first hand. The results of this research allow us to
further study how to improve new nurse graduate retention and
competence. If we can keep our nurses comfortable and happy with
their position, we can expect to see increased quality of care as a
reflection.