153The Journal of Continuing Education in Nursing

153The Journal of Continuing Education in Nursing · Vol 50, No 4, 2019

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; and James B. Schreiber, PhD

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 !rst time in the role as a professional nurse. NLN turnover has been reported in recent years to a”ect patient safety and com- pounds the global nursing shortage (Boamah & Las- chinger, 2015; Bradbury-Jones, 2015; Kovner, Brewer,

Fatehi, & Katigbak, 2014; Spence Laschinger, Zhu, & Read, 2016; #omas & Kellgren, 2017; World Health Organization, 2017). #e American population is liv- ing longer with chronic diseases and expanding disabili- ties; 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; Ghe- breyesus, 2018; National Academy of Medicine, 2017; Reinhard, 2014).

PROBLEM IDENTIFICATION AND SIGNIFICANCE #e 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)

abstract Background: Lack of resiliency contributes to grow-

ing dissatisfaction among newly licensed nurses (NLNs) and often leads to clinical errors and job resignations. Method: An integrative review synthesized current re- search investigating NLNs’ resiliency within their first year of hire and interventions that may affect their re- siliency. 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 pro- grams, 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 safe- ty. Resiliency should be measured using a resiliency scale rather than turnover rates. [J Contin Educ Nurs. 2019;50(4):153-161.]

Ms. Concilio is PhD Student, Dr. Lockhart is Professor and MSN Nurs- ing 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 !elma M. Ingles Professor of Nursing, Duke University School of Nursing, Dur- ham, North Carolina. Ms. Concilio is also Lecturer and Clinical Instructor, School of Nursing, San Diego State University, San Diego, California.

!e authors thank Dr. Jane Brannan, EdD, Professor of Nursing, Ken- nesaw State University, Kennesaw, Georgia, for her content expertise and support. !e authors also thank David Nol”, MLS, AHIP Head, Research Engagement, Health Sciences/STEM Initiatives, Assessment Coordinator Gumberg Library, Duquesne University, Pittsburgh, Pennsylvania, for on- going support.

!e authors have disclosed no potential con#icts of interest, “nancial or otherwise.

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

Received: August 13, 2018; Accepted: October 22, 2018 doi:10.3928/00220124-20190319-05

154 Copyright © SLACK Incorporated

reported that training one NLN may cost a health care system $60,000 to $96,000; therefore, increasing NLN resiliency is imperative to maintain patient safety and is a !nancial priority. NLNs experience immense stress, leading to a state of shock while transitioning to practice (Duchscher, 2009) and resulting in burnout and turn- over (Laschinger et al., 2016; Pfa”, Baxter, Jack, & Ploeg, 2014). Dyrbye et al. (2017) de!ned burnout as a syndrome characterized by emotional exhaustion that leads to poor performance and an attitude that is contrary to caring. Nurse burnout has led to sta$ng shortages and increased turnover rates, which has resulted in the use of physical re- straints, patient falls, and the formation of pressure ulcers (Aiken et al., 2014; Robert Wood Johnson Foundation [RWJF], 2012).

Resiliency has been identi!ed as a key factor in manag- ing the stress of nursing work–life, bu”ering burnout, and positively in%uencing NLNs’ intentions to stay their cur- rent 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. With- out resiliency or ways to cope with the emotional stressors and workplace adversities (Delgado et al., 2017), nurses (including NLNs) may develop inconsistent thoughts, be- liefs, 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). #is article describes an integrative review of the literature that examined NLNs’ resiliency within their !rst year of hire and interventions that a”ect their resiliency.


#e youngest generation of nurses are the most likely group of nurses to lack the protective factors of resilien- cy and leave the profession within the !rst 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 Col- leges 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 afore- mentioned stressors or bolstered nurses’ resilience (Insti-

tute 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 cor- rectly and in a timely manner) and cognitive-behavioral skills (cognitive re-framing, mindfulness, compassion, and emotional intelligence) in order to perform success- fully while stressed (Academy of Medical-Surgical Nurses, 2018; McAllister & Lowe, 2011). In this article, we pro- vide current knowledge on the concept of NLN resilience during the !rst 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 (Ga- briel, Diefendor”, & Erickson, 2011; Hart et al., 2014). #erefore, a need exists to understand NLN resilience during the !rst year of hire.

PURPOSE AND SPECIFIC AIMS #e purpose of this integrative review is to summarize

and synthesize NLN resiliency and interventions used to promote NLN resiliency within the !rst year of hire in an e”ort 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. #is integrative review explores the past literature to describe factors as- sociated with a lack of resiliency or its protective factors and to investigate approaches that increase NLN resil- iency. #e following speci!c aims guided this integrative review: t� What is the state of NLNs’ resiliency within their !rst

year of practice? t� What are the contributing factors that promote or hin-

der NLNs’ resilience? t� What are the outcomes associated with NLNs’ resil-

ience or lack of resiliency? t� 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?

t� 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 Kna%

(2005) guided this review of the literature. #is model included !ve stages (problem identi!cation, literature search, data evaluation, data analysis, and presentation) to enhance accuracy and ensure a thorough search.

155The Journal of Continuing Education in Nursing · Vol 50, No 4, 2019

Literature Search A systematic process was used to review the pri-

mary studies of qualitative and quantitative research designs (Whittemore & Kna%, 2005). #e process of conducting an integrative review is to provide an unbi- ased review of the literature. To retrieve relevant litera- ture, 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. #e following subject headings were used to retrieve articles that included descriptions about NLNs: newly licensed nurses, resiliency, and intention to leave. #e Boolean operators AND and OR were used to com- bine these terms with newly licensed nurse* and nurs* (Table A; available in the online version of this arti- cle). Inclusion criteria included (a) the topic addressed resilience or protective factors leading to resilience in NLNs; (b) study participants were NLNs within their !rst 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. #e review excluded nonresearch publications, gray literature, and publications that did not address the inclusion criteria.

A total of 789 articles were identi!ed from CINAHL and PubMed using the initial search terms; 56 duplicates were removed, resulting in 733 publications. As shown in the PRISMA %ow diagram (Figure 1), 570 articles were removed based on their abstracts, which did not meet the inclusion criteria. Next, 163 articles were re- trieved for full-text evaluation; 147 of these were exclud- ed as they did not meet the inclusion criteria, leaving 16 articles that comprised the !nal 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). #ere was no follow-up with authors to retrieve additional information.

Sample studies included qualitative (n = 8), quantita- tive (n = 5), and mixed-methods (n = 3) designs. Quali- tative studies used case study (n = 2), phenomenological (n = 3), and grounded theory analyses (n = 3). Quantita- tive 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 #e data evaluation stage used a methodological ap-

proach to appraise the quality of each publication (Whit- temore & Kna%, 2005). Each quantitative study was evaluated and categorized based on its quality of evidence and recommendation level for practice using the GRADE (Grading of Recommendations, Assessment, Develop- ment, and Evaluations) Guideline Criteria for Appraising Quality of Evidence (Schünemann, Ahmed, & Morgan, 2011); for qualitative studies, the GRADE-CERQual Con!dence in the Evidence from Review of Qualitative Research (Lewin et al., 2018) was used. Qualitative stud- ies were evaluated using GRADE-CERQual and catego- rized 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 !fth criterion. Elev-

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.

156 Copyright © SLACK Incorporated

en studies were rated as moderate to low quality (quali- tative, n = 8; mixed-methods, n = 3) and the remaining !ve 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, pub- lication 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).

Data Analysis During data analysis, primary studies were organized,

categorized, summarized, and integrated into a conclu- sion about the research problem of each study based on (a) NLNs’ resiliency within the !rst year of practice, (b) contributing factors of NLNs that promote or hinder re- silience, (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 us- ing a consistent, correlative method to identify patterns and relationships, create themes, draw conclusions, and provide a comprehensive summary (Whittemore & Kna%, 2005).

RESULTS Presentation of data is the !nal stage of an integrative

review, which exhibits detailed evidence from each sample study (Whittemore & Kna%, 2005). #e 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 di”erent journals, and more than one study was included in the Journal of Nursing Administration (n = 4), !e 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%. #e 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 rang- ing 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/eth- nicity. 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 hos- pitals 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. Insu$cient 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 & Wil- son, 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 re-

ported to enhance NLNs’ intentions to remain in their current jobs and the nursing profession. Residency pro- grams speci!cally designed to address the needs of NLNs positively a”ected NLN resiliency (Anderson et al., 2009; Cline et al., 2017; Fiedler et al., 2014). #e protective fac- tors 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; Clip- per & 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), organi- zational support (Fiedler et al., 2014; Fink et al., 2008; Olson, 2009), and plentiful clinical support (Fink et al., 2008).

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NLN resiliency decreased when NLNs experienced verbal abuse from physicians and incivility among other sta” nurses (Kramer et al., 2013; Martin & Wilson, 2011; Olson, 2009; Pellico et al., 2009). #eir inability to meet expectations of preceptors, unengaged preceptors, and de- creased support when making errors also hindered NLNs’ con!dence and job satisfaction which, in turn, negatively a”ected their resiliency (Gill et al., 2010; Li et al., 2014).

Outcomes Associated With NLN Resiliency Positive Outcomes. NLN resiliency, which has been in-

ferred 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 con!dence, adaptability, and im- proved 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. #e most common outcome as- sociated with poor NLN resiliency cited in the nurs- ing 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, sta”, 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; Mar- tin & Wilson, 2011; Pellico et al., 2009). Teamwork is the cornerstone of patient care delivery as clinicians col- laborate and use enhanced communication to bene!t patients to attain mutual goals (World Health Organiza- tion, 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 relation- ships, 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) de- scribed NLNs building comradery with others to negate feelings of inadequacy as method to protect themselves from the daily assault of stress and self-doubt. Addition- ally, 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 aca- demia to practice.

Measuring Resiliency and the Outcomes #is integrative review presents studies that correlated

resiliency using satisfaction surveys, evaluations of precep- tor e”ectiveness, and intention to leave surveys to best un- derstand 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 qual- ity by using the 10-item abbreviated version of the Na- tional Database of Nursing Quality Indicators (NDNQI) (reliability coe$cient = .91; Taunton et al., 2004). #e 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 satis!ed. #e same !nding was reported by Clark and Springer (2012), in which NLNs expressed intentions to leave their jobs despite being satis!ed with the care they delivered (n = 37).

DISCUSSION An iterative process of examining each sample study to

identify patterns, themes, noting intervening factors, and relationships between variability (Whittemore & Kna%, 2005) was done to clarify, summarize, and synthesize what is known about the phenomenon of resiliency in NLNs,

158 Copyright © SLACK Incorporated

within the !rst year of hire, in an e”ort to guide future research in this area.

First, the concept of NLN resiliency is not well un- derstood as NLN turnover has been interpreted to be an outcome of poor NLN resiliency. Second, the expec- tation 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 a”ects NLNs’ mental health. #ird, these feelings drain NLNs, which, in turn, can cause cognitive and emotional la- bility and a”ect clinical reasoning, a clear and present danger to patient welfare. Finally, resiliency should be measured using a resiliency scale, as the decision or in- tention to leave one’s job is not a surrogate to determine NLN resilience.

A growing body of research indicates NLNs’ attri- tion is increasing at an alarming rate, despite residency programs assisting in their transition to help them as- sume professional responsibilities for which they may be unprepared (Clark & Springer, 2012; Cline et al., 2017; RWJF, 2014). Nurse incivility among sta”, in- cluding NLNs, occurs due to the high-stakes climate and coworkers’ ine”ective communication skills (Las- chinger, Wong, Regan, Young-Ritchie, & Bushell, 2013). A paradox ensues as NLNs believe they would be cared for by caring professionals in a caring environ- ment (Hart et al., 2014; Hodges et al., 2008; Marine, Ruotsalainen, Serra, & Verbeek, 2006; Martin & Wil- son, 2011; Pariyo, Kiwanuka, Rutebemberwa, Okui, & Ssengooba, 2008).

Implications for Practice, Policy, and Research #e implications for this integrative review provide

information to hospital educators and administrators re- garding the trends and needs of NLNs and adds a new perspective on workforce readiness in an e”ort to pro- mote patient safety. Nursing research has used a positiv- ist 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 high- est attrition rate among any generation that has entered the nursing profession (RWJF, 2014). #erefore, 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). #is sociological lens may help researchers, managers, and educators evalu- ate NLN resilience as a truth created by their own per-

ceptions rather than through job satisfaction surveys or intention to leave scales. #e American Academy of Nurs- ing Policy agrees there is a need to build NLNs’ resilience (Goode, Glassman, Ponte, Krugman, & Peterman, 2018) to mitigate the negative e”ects of stress and encourage in- tention to stay at their !rst 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 !ndings not being applicable to each NLN’s experience during their !rst year of hire or to their abilities to build resiliency. For example, detailed information was not provided regarding sample char- acteristics 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 represen- tation of men in all sample studies, as well as a poor representation of ethnic/racial diversity. Various prac- tice settings among the studies limited generalizability of the !ndings as the settings included medical centers, hospitals, and specialty units (i.e., oncology). Each set- ting used di”erent ways to orient NLNs and participants faced varying types of experiences, which may not repre- sent all NLNs’ experiences when transitioning into their !rst jobs.

#e designs of the 16 sample studies were primar- ily 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 mea- sure participants’ resilience in any of the sample studies yet inferred that participants’ resilience was low if they intended to leave their jobs. #is ambiguity may have led to a lack of di”erentiation among the search terms, as turnover and intention to leave have been correlated with resilience. However, strategies that encourage group cohe- siveness, 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; Bon- trager 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 e”orts, NLN attrition rates continue to rise each year.

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CONCLUSION #is integrative review provides pertinent informa-

tion to researchers, managers, educators, and health care administrators about the concept of NLN resiliency. De- creased resiliency threatens patient safety. NLNs expressed di$culties feeling con!dent, which, in turn, a”ects profes- sional development—a factor that is crucial to preparing a competent workforce. A supportive sta” of nurses and physicians who are empathetic to the challenges NLNs face during the !rst year of hire is a proven facilitator of NLN resiliency; these supportive attributes increase NLN job engagement, con!dence, and enhances team building skills. Additionally, resilience may be an indicator of prac- tice readiness, a vital key to motivate and retain NLNs.

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Table A 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”))


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


Note. CINAHL = Cumulative Index to Nursing and Allied Health Literature.

“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]))

Total no. of citations including duplicates


T able B


m ary of F

indings from R

esearch Studies (N =

16) __________________________________________________________________________________________________________ A

uthor/year D

esign/M ethod

Sam ple population/ Purpose, A

im s, Findings A

ppraisal R ating/

Setting V ariables, and Q

uality of E vidence

Instrum ents using G



or G



-C E



_____________________________________________________________________________________ A

nderson et al. (2009)

m ixed m

ethods/ sequential exploratory

90 new graduate

nurses, gender and ethnicity not reported/interactive nurse residency

Purpose: to com pare

perceived job satisfaction and em

ployee engagem

ent of new

graduate nurses com

pleting an interactive nurse residency. A

im s: to m

easure job satisfaction and engagem

ents perceptions of new

nurses after com

pleting interactive residency m

odules and to test the environm

ent nursing satisfaction survey. V

ariables: change for nurse residency –

Q ualitative results

revealed 2 them es

(protective factors of resiliency em

erged): w hat

satisfied nurses (patients, patient outcom

es, and team

w ork) and w

hat did not satisfy nurses (staffing/scheduling, lack of team

w ork,


disrespect). Q

uantitative results: “A

fter the nurse residency sessions and 1 year later, the quantitative findings on the H

alfer-G raf

survey revealed that the nurse residents

+ +

⨁ ◯ ◯ ◯


isk of bias: T here

w ere lim

itations in detailed design as the outcom

e w as not

confidently determ

ined as the tool’s psychom

etrics w

ere not discussed. T

here w as no

discussion about the H

alfer-G raf Job/W

ork E

nvironm ent N

ursing Satisfaction Survey other than stating it w

as reliable and valid as previously stated in previous studies. M

ost inform ation w

as stated from

studies at

im plem

entation of a 2- day interactive nurse residency. Instrum

ents: H alfer-

G raf Job/W

ork E

nvironm ent N

ursing Satisfaction Survey (psychom

etrics not reported)

significantly perceived that they w

ere able to perform

their job, identify resources, understand perform

ance expectations, accom

plish w ork

tasks, and m anage

the dem ands of the

job effectively” (p. 168). A

n interactive learning environm

ent assists new

graduate nurses in job satisfaction and em

ployee engagem

ent. M ost

valuable strategy w

as em ail

com m

unication as a form

of support (a protective factor of resiliency).

low or unclear risk of

bias. T his denotes

serious risk of bias, dow

n grade one level (R

yan, 2016). Inconsistency: the sam

ple w as from

one cohort of new

graduate nurses and one period in tim

e. T

his denotes som e

inconsistency and a dow

ngrade of one point is recom

m ended

(R yan, 2016).

Indirectness: the author answ

ered the question of w

hether this particular cohort w

ere satisfied and engaged by using interactive residency m

odules. Im

precision: C

onfounding variables w

ere not discussed as to other reasons to the 4%

increase of new

graduate nurse retention w

hen com

pared to past years. T

here w as not

enough inform ation to

detect a precise estim

ate of the effect (interactive residency m

odules on new

graduate satisfaction and job engagem

ent). Publication bias: N

ot detected, Journal of N

ursing A

dm inistration has

various studies of size and design.

B ontrager et

al. (2016) quantitative/ descriptive, prospective, cross- sectional

84 new ly licensed

registered nurses enrolled in a residency program

. 5.8% of

participants w ere m

ale. 66.7%

participants w

ere C aucasian, 17.9%


ere black, 3.6%

L atino, and 7.1%



Purpose: to understand how

preceptor role effectiveness and group cohesion affect N


s’ satisfaction and intent to stay. A

im s: W

hat w ere the

relationships am ong

preceptor role effectiveness, group cohesion, and job satisfaction am

ong N


s? W hat w

ere the relationships am

ong preceptor role effectiveness, group cohesion, job satisfaction, and

H igh levels of

intention to stay at job w

as 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. G

roup cohesion w as

found to be vital to increase feelings of

+ +

⨁ ⨁ ◯ ◯


isk of bias: T ool

psychom etrics w

ere reported and C

ronbach D scores

show ed reliability and

validity. T he

tools/scales w ere

justly chosen to predict the outcom

e level. Inconsistency: the sam

ple w as not

discussed regarding units w

orked on or shift w

orked. T he

ability to exam ine

intent to stay am ong


N s?

V ariables: D

V :

preceptor role effectiveness, group cohesion, and job satisfaction Instrum

ents: Preceptor R

ole E

ffectiveness Scale, N

urse Job Satisfaction Scale, Intent to Stay Scale.

value, reduce burnout, stress and anxiety. G

roup cohesion is im

portant to reduce transition shock and intention to stay.

changes during the orientation period w

as not discussed. D

oubtful that there are large variations in the degree to w

hich the outcom

e is affected, no dow

ngrade if on the basis that it does not seem

to be an issue. Indirectness: T

here w

as evidence of indirectness as the outcom

e w as assessed

at only one period in tim

e w hich lim

ited the ability to exam

ine changes. T

he evidence that w

as found w

as m ore

restrictive than the review

question and m

ay not directly answ

er the review

question, “W hat w

ere the relationships am

ong preceptor role effectiveness, group cohesion, and job satisfaction am

ong N


s? W hat w

ere the

relationships am ong

preceptor role effectiveness, group cohesion, job satisfaction, and intent to stay am

ong N


s?” D ow

ngraded one point as som

e indirectness exists. Im

precision: good correlation w

ith prim

ary studies, no im

precision detected. Publication bias: N

ot detected, T

he Journal of C

ontinuing E

ducation in N ursing

has various studies of size and design.

C lark &

Springer (2012)

qualitative/ case study m


37 new graduate nurses

in a nurse residency program

across m any

specialty areas/ northw

estern U S

15.6% of participants

w ere m

ale. T he

ethnicity of participants w

as not reported.

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