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SDC#1
Title: New Graduate Nurse Transition Programs and Clinical Leadership Skills in Novice Registered Nurses
Authors: Kathy B. Chappell, PhD, RN; Kathy C. Richards, PhD, RN, FAAN; Scott D. Barnett, PhD
Authors’ Affiliations: Director, American Nurses Credentialing Center; University Professor and Assistant Dean
Doctoral Programs and Research Development, School of Nursing, College of Health and Human Services, George
Mason University; Statistician, James A Haley Veterans Hospital
Corresponding Author: Kathy B. Chappell, MSN, RN, Kathy.chappell@ana.org
Conflicts of Interest and Sources of Funding: Ms. Chappell received grants from George Mason University and
from the Association for Nursing Professional Development. Dr. Richards has received support from the National
Institutes of Health. Dr. Barnett has received support from the Department of Veterans Affairs and University of
South Florida.
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Abstract
Objective: Determine predictors of clinical leadership skill (CLS) for registered nurses (RN) with ≤ 24 months of
clinical experience.
Background: New graduate nurse transition programs (NGNTP) have been proposed as a strategy to increase CLS.
CLS is associated with positive patient outcomes.
Methods: Hierarchical regression modeling to evaluate predictors of CLS among individual characteristics of RNs
and characteristics of NGNTPs.
Results: Perceived overall quality of a NGNTP was the strongest predictor of CLS (R2 = .041, p < .01). Clinical
experience and NGNTP characteristics accounted for 6.9% of the variance in CLS; 12.6% of the variance among
RNs with assigned mentors (p < .01). RNs participating in NGNTPs > 24 weeks were 21 times more likely to
remain employed within the organization when compared to NGNTPs ≤ 12 weeks, a significant cost-benefit to the
organization.
Conclusions: Although perceived overall quality of a NGNTP was the strongest predictor of CLS, much of the
variance in CLS remains unexplained.
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The majority of literature on leadership and nursing focuses on nurses in formal leadership positions. Evaluating
leadership skill at the clinical level has been a recent focus. Bedside clinical nurses must utilize clinical leadership
skill (CLS) to ensure safe, high-quality patient care. Research supports the relationship between actions of bedside
clinical nurses and positive patient outcomes (1 – 3). CLS is defined as “staff nurse behaviours that provide direction
and support to clients and the healthcare team in the delivery of patient care.” (4; p. 450). Clinical leadership skill
has 5 defining characteristics: clinical expertise; effective communication; collaboration; coordination; and
interpersonal understanding (4). Increasing CLS in staff nurses improves their ability to identify clinical problems,
implement innovative change and evaluate outcomes (5). Increased CLS has been associated with leadership roles,
initiation of research studies, and publications/presentations at local and national levels (5 – 7).
New graduate nurse transition programs (NGNTP) are cited as 1 strategy to increase CLS, however much of the
outcome research on NGNTPs has focused on turnover and vacancy (8). Minimal research has explored the
relationship between individual characteristics of registered nurses (RNs) and CLS; or the relationship between
NGNTPs and CLS. The purpose of this study was to determine what individual characteristics of RNs and NGNTPs
subsequently predict increased CLS in RNs with ≤ 24 months of clinical experience. Characteristics of RNs
evaluated were: age; primary nursing degree; previous leadership or healthcare experience; and months of clinical
experience as an RN. Characteristics of NGNTPs evaluated were: NGNTP length; assigned mentor/quality of
mentor support; participation in/perceived improvement in professional development skill through participation in
supplemental courses to promote critical thinking ability, leadership, and/or delegation skills; and overall NGNTP
quality as perceived by RN participants (Figure 1).
Review of the Literature
We conducted a systematic review of the literature following the Preferred Reporting Items for Systematic Reviews
and Meta-Analysis (PRISMA) guidelines to evaluate the relationship between NGNs and CLS, and NGNTPs and
CLS (9). Electronic databases (CINAHL, Medline and Cochrane Library) were searched from January 2000 to
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January 2013. Search terms included “new nurse”, “new graduate”, “new graduate nurse”, “residency”,
“internship”, “orientation”, “transition” and “leadership.” A total of 93 articles were identified from the search, and
3 additional articles were identified through bibliography review. Outcomes from 17 studies meeting inclusion
requirements with data from more than 4000 NGNs were analyzed (9, 10 - 26). Studies were conducted in the
United States (n = 15), in Scotland (n = 1), and in New Zealand (n = 1). Study designs included repeated-measures
with (n = 3) and without (n = 2) a comparison group, pre/posttest with (n = 2) and without (n = 6) a comparison
group, case study (n = 1) or were classified as program evaluation (n = 3). The most common comparison group
was NGNs completing orientation prior to implementation of a NGNTP.
In the inclusion studies, NGNs were predominately female and < 35 years of age (8, 10 – 13, 15 - 18, 21, 24 - 26).
Evidence demonstrated that NGNs participating in NGNTPs ≥ 24 weeks had higher levels of CLS when compared
to NGNs not participating in a NGNTP (18 - 20). There was insufficient evidence to evaluate the effect of NGNTPs
< 24 weeks. There was some evidence that NGNTP curriculum impacted the magnitude of change in CLS from
baseline to post-program. There were large within-subjects effects on CLS for NGNs (n = 1334) participating in
NGNTPs using the University HealthSystem Consortium/American Association of Colleges of Nursing
(UHC/AACN) Nurse Residency™ program curriculum (Cohen’s d = 1.29) (9). Moderate to large within-subjects
effects were also found on CLS for NGNs (n = 75) participating in NGNTPs using the Versant New Graduate RN
Residency™ curriculum (Cohen’s d = .58) and on CLS for NGNs (n = 33) participating in NGNTPs developed by 1
organization (Cohen’s d = .57) (9). The majority of studies included only baccalaureate-prepared nurses or failed to
differentiate outcomes by academic preparation (9).
Evaluating impact of NGNTPs on CLS was limited by single group and historical control group designs. The
majority of studies used pre/post measures with no comparison group. Four of the studies used NGNs transitioning
into the clinical setting prior to implementation of the NGNTP as the comparison group, which limited ability to
control for confounding variables. There was lack of data on individual characteristics of NGNs such as age,
nursing degree, and previous leadership or healthcare experience and the outcomes of NGNTPs.
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Conceptual Model
The study variables and conceptual model were based on Bandura’s Self-Efficacy Theory and Benner’s Novice to
Expert framework (27 – 28). According to Bandura’s Self-Efficacy Theory, individuals who have had successful
experiences in 1 setting are more confident and may translate those experiences to different settings (27). The study
variables of previous leadership or healthcare experience associated with individual characteristics of RNs were
based on self-efficacy theory hypothesizing that there would be a relationship between previous experience and CLS
(27). Benner’s Novice to Expert framework describes the process by which new graduate nurses progress through
stages using experiential learning and draw from previous experiences as a reference for decision-making (28).
Study variables associated with NGNTP characteristics were based on Benner’s framework with the hypothesis that
NGNTPs are designed to help facilitate NGNs’ growth and developmental needs by providing a gradual increase in
clinical responsibility in a supportive environment. It was hypothesized that there would be a relationship between
components of a NGNTP and CLS. Therefore, NGNTP length, assigned mentor/quality of mentor support, and
participation in professional development classes/perceived improvement in professional development skill were
included in the study conceptual model. The number of months of experience as an RN was chosen as a control
variable and based on self-efficacy theory and Benner’s framework (27 – 28). Overall NGNTP quality as perceived
by RN participants was included as a variable (Figure 1).
Methods
Design, Sample, Setting
This research utilized a non-experimental, retrospective design to determine predictors of CLS in RNs with ≤ 24
months of clinical experience. Twenty-three United States hospitals representing Colorado, Hawaii, Kansas,
Illinois, Nevada, New York, Pennsylvania, Texas, Virginia, and Washington, DC participated. All but 2 hospitals
were part of a larger healthcare system. Criteria for participant selection included: currently employed in an acute
care hospital, ≤ 24 months of clinical experience as an RN, consent to participate, and fluent in English. For
hierarchical regression analyses with 9 predictors, Mertler and Vannatta (29) recommend using 15 subjects per
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independent variable to provide a reliable regression equation which required a sample size of 135 participants for
this study (29). A total of 306 participants were recruited which provided sufficient power for subsample analyses.
To test the hypothesis that individual characteristics of RNs and characteristics of NGNTPs were associated with
CLS, assuming alpha = .05, beta = .20, there was approximately 80% power to detect a statistically significant
difference using hierarchical regression modeling.
Data Collection
Instruments
Individual characteristics of RNs and NGNTPs were collected using a researcher-developed, self-report, on-line
questionnaire. CLS was measured using the Clinical Leadership (CL) Survey, an instrument with 5 subscales based
on the 5 leadership practices in Posner and Kouzes’ leadership model (4, 30 – 31) (SDC #1). The 5 leadership
practices of nurses in formal leadership positions as described in Posner and Kouzes’ model of leadership include:
challenging the process, inspiring a shared vision, enabling others to act, modeling the way, and encouraging the
heart (30, 31). The instrument subscales of the CL Survey that mapped to the leadership practices of Posner and
Kouzes’ model were: clinical expertise (challenging the process), effective communication (inspiring a shared
vision, enabling others to act, encouraging the heart), collaboration (inspiring a shared vision, enabling others to act,
modeling the way, encouraging the heart), coordination (modeling the way), and interpersonal understanding
(challenging the process, enabling others to act, modeling the way, encouraging the heart) (4). The original
instrument was modified following confirmatory factor analysis resulting in a final instrument of 15 items with 3
items measuring each clinical leadership construct. Responses were rated using a 5-point Likert scale ranging from
“almost never” to “almost always.” Mean CLS score was calculated by summing and averaging the 15 items.
Overall Cronbach’s alpha for the final instrument was 0.86. Two additional items (global clinical leadership (GCL)
scale, α = 0.78) were added to assess concurrent validity with the 15 item CL Survey instrument during instrument
development (4). For this research study, Cronbach’s alpha for the 15 item CL Survey and the GCL scale were .90
and .89. Subscales were not analyzed separately.
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Data Analysis
Data are presented as mean and standard deviation (SD) or frequency and percent, where appropriate. Preliminary
analysis assessed assumptions of normality, linearity and multicollinearity. With the exception of age, all
independent variables (Table 1) to be included in models met assumptions of normality with the exception of age.
As a result, age was evaluated for transformation using 2 separate modeling approaches; either with age inversely
transformed or untransformed. Given the similarity of results between both models and ease of interpretation, the
untransformed value of age was used. Intraclass correlation coefficients (ICC) (Table 2) were calculated to
determine the degree to which unique characteristics within each participating hospital contributed to the overall
analysis. Primary nursing degree, when coded into bivariate variables for the regression equation (Table 3), failed
assumptions for multicollinearity (tolerance and variance inflation factor). These variables were not predictors of
CLS and therefore were not re-coded.
Following evaluation of correlation, a series of hierarchical regression models were developed with all study
variables. In addition, effects of hospitals/healthcare systems on mean CLS scores were evaluated by the ICC. As
institutional variation accounted for less than 10% of the total variation, no analysis comparing institutions was
conducted. All analyses were conducted in PASW Statistics (ver. 18.0, Chicago, IL) and statistical significance was
considered for p ≤ 0.05, two-tailed.
Results
There were 4617 RNs within the 23 participating hospitals and/or healthcare systems meeting eligibility
requirements. Following data cleaning and removal of incomplete surveys, a total of 306 surveys (6.6%) were
analyzed (Figure 2).
Demographics
The mean age was 27.85 years (range 20 – 58), with 72% of respondents aged 20 – 29 years. The majority were
female (90.5%), non-Hispanic (91.9%), and Caucasian/white (74.2%). Over 75% of respondents were prepared at
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the baccalaureate level. The remaining respondents were prepared by associate degree (20.9%) and diploma or
master’s degree (1.3%) (Table 4).
Employment Characteristics
The mean length of experience as an RN was 10.91 months (range 1 – 24). Most were still employed in the same
organization (86.3%). The majority (58.2%) did not self-report previous leadership experience in a formal or
volunteer position defined as holding a role such as director, manager or similar position supervising others, but did
self-report previous formal or volunteer healthcare experience (74.8%) in roles such as nursing aide, nurse tech,
nurse intern/extern, clerical in medical setting, or emergency medicine technician/paramedic. Almost all were
currently employed in a staff nurse position (99.7%) (Table 4).
Characteristics of the NGNTP
The average NGNTP length was 22.6 weeks (range 4 – 52) (Table 4). Approximately half of all NGNTPs included
mentor support (49.7%) and almost all included classes to improve professional development skill (84.6%). Mean
value for overall quality of the NGNTP was 3.98 (SD .92) as self-reported on a 5-point Likert scale (1 – 5) (Table
4).
Comparison of Groups by Length of NGNTP
To explore differences in outcomes related to NGNTP length, four categories were created using quartiles, then regrouped to approximate program lengths typically used in the clinical setting (Table 4). RNs who participated in
shorter NGNTPs were significantly more likely to be older when compared with RNs who participated in longer
programs (p = .025). Longer NGNTPs were perceived to have higher overall quality when compared to NGNTPs
that were ≤ 12 weeks in length (p < .05). When compared to NGNTPs that were ≤ 12 weeks in length, odds ratio
calculation demonstrated that RNs participating in longer NGNTPs were significantly more likely to remain
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employed in the organization as originally hired (Table 5). RNs participating in NGNTPs > 24 weeks were 21 times
more likely to remain employed in the organization when compared to NGNTPs ≤ 12 weeks in length.
Predictors of CLS
The strongest predictors of CLS were overall quality of a NGNTP, NGNTP length, and months of clinical
experience as an RN (Table 3). Previous literature suggested that CLS improves over time regardless of any
intervention; therefore, regression modeling was conducted using months of clinical experience as a control variable
(9). Four hierarchical regression models were developed (Table 3). Months of clinical experience as an RN (Table
3; Model 1) accounted for only 1.1% of the variability in CLS (R2 = .014, R2adj = .011, F = 4.296, p = .039). When
NGNTP characteristics were added to the model (Table 3;Model 2), these variables accounted for 6.9% of the
variability in CLS (R2 = .084, R2adj = .069, F = 5.761, p = .000).
Additional Findings
Additional analyses were conducted using sublevel variables: quality of mentor support (n = 132) and perceived
improvement in professional development skill (n = 258) (Table 3). Both quality of mentor support (r = .278) and
perceived improvement in professional development skill (r = .201) correlated positively with CLS (p = .01).
Hierarchical regression modeling with months of clinical experience as an RN and NGNTP characteristics including
sublevel variables (quality of mentor support and perceived improvement in professional development skill) (n =
122) improved overall model prediction to 12.6% (R2 = .162, R2adj = .126, F = 5.203, p = .001) (Table 3).
Discussion
Based on study results, RNs with ≤ 24 months of clinical experience have higher levels of CLS when they
participate in NGNTPs that they perceive to be of high quality. It is unclear what specific NGNTP characteristics
result in the perception of high quality. NGNTP length correlated negatively with CLS (r = -.138, p = .05) and
comparison of scores demonstrated lower CLS associated with NGNTPs > 16 weeks when compared to NGNTPs ≤
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16 weeks, however the difference was not statistically significant. This is consistent with previous research findings
describing a pattern variation in CLS over the 1st post-graduate year with higher scores at baseline, dipping at 6
months, then increasing but not returning to baseline at 12 months (9). It may be that younger RNs in this study also
had longer NGNTPs, which is consistent with the higher number of traditional and 2 nd degree baccalaureate
prepared nurses in the cohort of NGNTPs > 24 weeks and eligibility criteria for the UHC/AACN Nurse Residency™
program. Lower CLS has also been correlated in the literature with baccalaureate prepared nurses when compared
to associate degree nursing (ADN) prepared nurses which may be an additional explanation. Months of clinical
experience as an RN correlated positively with CLS (r = .118, p = .05) and was a statistically significant predictor of
CLS (p = .039) which corresponds with previous research findings describing improvement in CLS over the 1st
post-graduate year.
In sublevel analysis, overall quality of a NGNTP remained the strongest predictor of CLS. Quality of mentor
support correlated positively with perceived overall NGNTP quality (r = .434, p = .000) and with CLS (r = .278, p =
.01) suggesting that mentors may play an important role in perception of quality and CLS. Evidence in the literature
supports the role that mentors play in supporting NGNs (17, 32 – 35). The need for mentor support may also differ
for nurses prepared differently by academic degree, or the need for mentor support may vary over time. These areas
were not explored in this study. The number of months of clinical experience and characteristics of NGNTPs
predicted only 6.9% of the variance in CLS for this study cohort. Among RNs with an assigned mentor, months of
clinical experience and characteristics of NGNTPs predicted only 12.6% of the variance in CLS for this study
cohort. Much of the variance in CLS, therefore, remains unexplained.
Results from this study cohort also support previous research findings that have demonstrated a relationship between
longer NGNTPs and increased NGN retention. When NGNs participated in NGNTPs that were > 24 weeks in
length, they were 21 times more likely to remain employed within the organization as compared to NGNs
participating in NGNTPs that were ≤ 12 weeks. The cost-benefit of retention is critically important for NGNs,
preceptors/mentors, nurse managers, nurse leaders, organizations, and the nursing profession. High turnover is
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costly from human resource and economic perspectives. Retaining 1 NGN in an organization has an estimated cost
savings of 1.2 – 1.3 times the average salary of an RN (36). The human resource costs on preceptors/mentors and
nurse managers to continually orient and support new employees are burdensome and can lead to burnout further
exacerbating the “revolving door” effect (36). Doubling the length of a NGNTP from 12 to 24 weeks can result in a
significant return in investment.
In summary, NGNs with ≤ 24 months of clinical experience develop significantly improved CLS when they
participate in NGNTPs that they perceive to be of high quality. They also are significantly more likely to remain
employed in the organization when they participate in NGNTPs that are > 12 weeks in length.
Strengths
A major strength of this study was a diverse sample from multiple facilities across the United States, including those
using standardized curricula developed by the UHC/AACN Residency™ and Versant Residency™ programs, as
well as those using curricula developed by individual organizations. This study was among the 1st to document
program characteristics and CLS for NGNTPs ≤ 22 weeks in length.
Limitations
Limitations included a study design limited to retrospective, self-report measures of NGNTPs. This limited the
ability to evaluate and control for specific characteristics of NGNTPs, such as curriculum, number and quality of
supplemental experiences, and hours of mentor support. There was risk that RNs failed to accurately recall data
including the total number of weeks of orientation, preceptorship, mentorship and supplemental experiences of the
NGNTP. It was also likely that RNs underestimated the total length as the majority of weeks recorded for NGNTPs
were ≤ 22 weeks even though the organizations reported that they provided a one year NGNTP. There was a lack of
detail regarding characteristics of the organization providing the NGNTP thereby limiting the opportunity to control
for variables such as individual hospital culture, quality of general orientation, shared governance, or Magnet®
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status. Finally, response rate (6.6%) was relatively low for this study as compared to average response rates of 10 –
20% to external email surveys as cited by 2 national survey companies (Constant Contact and SurveyGizmo). The
use of an electronic survey which required participants to go on-line, perhaps on their free time, and a small
incentive award may also have contributed to a low response rate.
Implications for Nurse Executives
There are a number of implications from this study for nurse executives. All NGNs benefit from participation in a
NGNTP regardless of individual characteristics or previous leadership or healthcare experience. NGNTPs using
standardized curriculum developed by the UHC/AACN Residency™ program resulted in the greatest change in CLS
from baseline to post-program, though all NGNs in these programs were baccalaureate prepared. New graduate
nurses participating in NGNTPs that are > 12 weeks in length are significantly more likely to remain employed
within the organization. Results from this study may be used by nurse leaders to evaluate which new graduate nurses
(NGN) might benefit from participating in a NGNTP, and characteristics of NGNTPs that contribute to increasing
CLS. Because NGNTPs often require significant organizational investment, these are critical factors that nurse
leaders should assess.
Future research
Recommendations for future research include comparative effectiveness studies to evaluate specific characteristics
of NGNTPs that impact CLS. In addition, evaluation of return on investment for NGNTPs will be important as
these programs require significant organizational investment. The validation of consistent curricula content and
levels of support to define a national model is indicated. Finally, it will be important to continue to explore the
relationship between CLS among novice bedside nurses and patient outcomes.
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