A Landscape of Evidence on RN Transition to Practice Programs

Abstract

Background:

First-year registered nurses (RNs) have the highest turnover rate of all hospital-based RNs, and often face various challenges during their transition to practice. RN transition-to-practice programs (RNTTPs) can potentially alleviate critical RN staffing shortages and support the development of the nursing workforce’s future.

Objectives:

To (1) capture and critically appraise the landscape of existing synthesis efforts on RNTTPs and (2) synthesize included reviews’ findings to assess the potential benefits of RNTTPs for organizational, nursing, and patient outcomes and descriptions of RNTTPs.

Research Design:

We conducted a systematic review of reviews to identify published evidence syntheses evaluating RNTTPs for newly graduated RNs.

Results:

Nineteen evidence reviews were included. Despite having similar scopes, there was little overlap in their included literature, and no single review included the majority of identified original research studies. Two reviews with high methodological rigor and high topical relevance emphasized the methodological issues in the available evidence, which used a mix of methodological approaches, and indicated a connection between RNTTPs and increased critical thinking, competency, and retention. Published reviews suggest program lengths between 6 and 12 months, but evidence for optimal program length was inconclusive or unsupported.

Conclusions:

RNTTPs that have been piloted and implemented in recent years deserve more rigorous evaluation to answer critical questions about their role in organizational, nurse, and patient outcomes. However, before best practices can be ascertained to support scaling and sustainment, their potential benefits must first be verified.

In 2025, a national survey of registered nurses (RNs) found that first-year hospital-based RNs had the highest turnover rate (31.9% for first-year RNs vs. 16.4% for all staff RNs) among all surveyed RNs.¹ New graduate RNs often express that they experience many stages of internal conflict at the start of their nursing careers. A national survey conducted in 2009 among newly licensed RNs indicated they often experienced significant stress and felt insufficiently supported during their first year in an acute care setting, a phenomenon referred to as “transition shock” or “reality shock”² that occurs when RNs transition from the role of student to graduate nurse, during which they may experience feelings of anxiety, insecurity, and inadequacy in response to the many challenges and expectations they face in clinical practice. This finding suggests that rigorous academic programs and extensive clinical experience may not necessarily prepare RNs for transitioning to clinical practice.³ Comprehensive transition-to-practice programs (RNTTPs) (also referred to as RNTTP residency programs) are intended to assist new graduate RNs with the “process of professional role socialization” and may help improve retention among new RNs.²

Comprehensive RNTTPs are different from more narrowly focused programs (eg, mentorships) or those of shorter duration (eg, traditional orientations, preceptorships). Through accreditation, RNTTPs have continued to improve and advance, emphasizing evidence-based practice, quality improvement, professional development, and competency-based evaluations. Although multiple accrediting bodies exist, such as the American Nursing Credentialing Center, the Commission on Collegiate Nursing Education, and the Accreditation Commission for Education in Nursing, there is variation in program characteristics, such as program length, and how RNTTPs are implemented.⁴ This variability has created uncertainty among nurse leaders and administrators about the best practices for training new graduate RNs.⁵

The Institute of Medicine (IOM) published The Future of Nursing: Leading Change, Advancing Health in 2011, in which it recommended that the federal government, state boards of nursing, accreditation bodies, and health care organizations implement and support RNTTPs, including funding these RNTTPs and evaluating them.⁶ The IOM specifically recommended evaluating “the effectiveness of the residency programs in improving the retention of nurses, expanding competencies, and improving patient outcomes.” Rigorously evaluating these outcomes would allow for comparisons between different RNTTP implementations, which would support nurse leaders and administrators to determine best practices.

Numerous reviews of RNTTPs have been conducted,^7–12 but often included a mix of RNTTPs, traditional orientations, and mentorship programs.^10–12 In addition, the ever-growing number of reviews that looked directly at residency and RNTTPs need to be summarized. The objectives of our systematic review of published evidence syntheses (a systematic review of reviews) on RNTTPs were to (1) capture and critically appraise the landscape of existing synthesis efforts on RNTTPs and (2) synthesize the findings of included reviews to assess the potential benefits of RNTTPs for organizational, nursing, and patient outcomes and descriptions of RNTTPs (eg, components, duration).

METHODS

We present this systematic review of reviews according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (Appendix A, Supplemental Digital Content 1, http://links.lww.com/MLR/D72). An a priori protocol was formally registered (PROSPERO CRD42023418830), and a full report was developed by the Veterans Affairs (VA) Evidence Synthesis Program.¹³ Here, we present an abridged version of the report results most relevant to the current, more focused scope, with additional discussion incorporated in the Discussion section.

Landscape of Existing Published Reviews

Literature Searches

To identify published evidence syntheses/reviews relevant to RNTTP, a research librarian conducted searches using a broad set of terms, including terms related to “transition to practice,” “new graduate nurse,” “transitional support,” and “Education, Nursing, Graduate,” with a systematic review delimiter in PubMed/MEDLINE and CINAHL Plus from 1/1/15 to 12/15/22 (Appendix B, Supplemental Digital Content 1, http://links.lww.com/MLR/D72 for the complete search strategy).

Literature Selection and Data Abstraction

The abstract and full text of each retrieved review were screened independently in duplicate by team members according to the inclusion criteria (Table 1).

TABLE 1.

Eligibility Criteria

Population	Newly graduated, entry-to-practice nurses (excluding nurse practitioners) in the first 12 months of employment following graduation and/or licensure for entry to practice.
Intervention	RNTTP or nurse residency programs specifically designed for newly graduated, entry-to-practice nurses to provide support or preceptorship during the first 12 months of employment following graduation and/or licensure for entry to practice. Programs must be 6 months or longer, or they were considered orientations rather than full RNTTPs. Programs must include some in-person component. Entirely remote or online/virtual programs were not included.
Comparator	Any comparator (eg, usual care, active comparator, historical controls) or no comparator.
Outcomes	Organizational outcomes (eg, retention/attrition, quality of care), nurse outcomes (eg, confidence, competence, practice-readiness, satisfaction), patient outcomes (eg, patient satisfaction, adverse events), components (eg, preceptorships, simulations), and implementation characteristics (eg, duration, recruitment strategies, settings, utilization, uptake, barriers/facilitators, and collaboration with academic partners).
Timing	Any
Setting	Any health care setting was eligible, as long as contents of the program were not so specialized to that setting that it resembled specialized training instead of a more general transition to practice program (eg, mental health-specific training in an exclusively mental health care setting); programs implemented in 2022 Organization for Economic Co-operation and Development member countries to approximate US health care delivery context.
Study Design	Syntheses, including systematic reviews, integrative reviews, scoping reviews, and other reviews using a formal review methodology were included in the systematic review of reviews.

Two reviewers (IML, PH) independently abstracted data from and assessed the quality of each included review. Any discrepancies in data abstraction were resolved by group discussion. The abstracted data included the review type (ie, systematic review, integrative review, or other review using a formal review methodology), review aim, whether the article described the context and factors contributing to the success or failure of the program (eg, setting, participants, components), excerpted relevant findings, the total number of studies included, and the search dates (Appendix C, Supplemental Digital Content 1, http://links.lww.com/MLR/D72).

Critical Appraisal of Included Reviews

Each published evidence synthesis was appraised for methodological rigor and relevance to our current objectives.¹⁴ Our appraisal of the methodological rigor was flexible to accommodate the range of methodological approaches identified,^14–20 and we generated summaries of critical methodological weaknesses that impacted our interpretations of the reviews’ findings, as well as any issues with review scope, including differences in population, interventions, or outcomes included. No reviews were excluded from our analysis based on our appraisal.

Reviews’ Coverage of the Primary Literature

During our analysis of the published reviews, we became aware of discrepancies in the literature included in identified reviews, signaling that they may not have fully incorporated all published original research in this area. To accurately quantify these discrepancies, we assessed the degree of overlap of included publications across the included reviews. The review team hand-searched reference lists of included reviews to identify included publications. We then constructed a crosswalk table that mapped each included publication to the reviews that had included it.

Next, the research librarian conducted a second search in PubMed/MEDLINE and CINAHL for original research studies published from 1/1/10 to 12/21/22 using the same search terms as the previous review search but without the systematic review delimiter. We limited the search to published and indexed articles available in the English language.

Two team members worked independently and in duplicate to screen and abstract data from each identified original research study. Eligibility criteria were identical to the review screening process, except for publication type. Original research studies of any design were included, and each novel, relevant original research study was added to the crosswalk table. Because these additional activities aimed to summarize the coverage of the reviews in the systematic review of reviews, we did not abstract study outcome data or evaluate studies for risks of bias.

Finally, we screened all publications included in prior reviews using the same process we used for the database search results and documented which publications included in prior reviews met our eligibility criteria.

We characterized the degree to which reviews’ coverage overlapped with each other and with our database search for original research studies and independent screening process.

Synthesis of Findings From Included Reviews

Main Synthesis Approach

We synthesized the findings of our systematic review of reviews using a narrative approach. We first described the landscape of existing published reviews, including the literature flow, key characteristics and categorization of included reviews, and the overlap of primary literature in existing reviews. We then narratively describe the reviews’ findings related to organizational, nurse, and patient outcomes, as well as RNTTP characteristics (eg, program components, duration of program).

RESULTS

Landscape of Existing Published Reviews

Overview of Included Reviews

The systematic review literature search identified 140 potentially relevant citations, 34 of which were included for abstract screening. Of the 34 citations, 9 citations were excluded for the following reasons: only focused on 1 component of an RNTTP (eg, mentorship only) (N = 5), no specific program described/evaluated (N = 2), nurse practitioners or other clinical professionals (N =1), and specific clinical settings (N = 1), which resulted in 25 citations to be included for the full-text screening. Six citations were excluded during the full-text screening for ineligible publication types, such as commentaries or editorials. Overall, 19 reviews were included in this review (Fig. 1). A full list of excluded reviews is provided in Appendix D, Supplemental Digital Content 1, http://links.lww.com/MLR/D72.

FIGURE 1.

Literature flow diagram.

Table 2 presents the details of included reviews and their key characteristics. We identified 7 integrative reviews, 6 systematic reviews, 3 scoping reviews, 1 rapid evidence assessment, and 2 other reviews without specified methodology.

TABLE 2.

Characteristics of Included Reviews

References	Type of review search dates included studies	Review aims methodological rigor and relevance to current scope	Excerpted relevant findings
Best fit reviews (N=2) High methodological rigor and direct relevance to our objectives
Brook et al8	Systematic review Search dates: January 2017-March 2017, repeated on April 2018 Included studies: 53	Aim: To evaluate the characteristics of successful interventions to promote retention and reduce turnover of early career nurses No methodological weaknesses, focused on specific outcome (retention/turnover), has strong analysis of included programs, which were a mix of interventions from different countries predominantly US. Delineated findings for RNTTPs specifically.	"A wide variety of interventions and components within those interventions were identified to improve nurse retention. Promising interventions appear to be either internship/residency programmes or orientation/transition to practice programmes, lasting between 27–52 weeks, with a teaching and preceptor and mentor component."
Rush et al7	Integrative review Search dates: Not reported Included studies: 76	Aim: To identify the best practices of formal new graduate nurse transition programs. No critical methodological weaknesses, scope most aligned with current scope focusing on RNTTPs, with findings reported for different components/program elements. Majority of studies from US.	"Most programs staggered education over time but the limited evidence showed no difference in new graduate nurse transition or satisfaction. New graduate nurse support was an important emphasis of all programs with preceptors the most common form of support and with beginning evidence showing quality vs quantity in preceptor support. Strengthening the quality of preceptor support was evident across studies with the bundling of concurrent strategies found to be helpful. Competency and confidence were found to increase over time for new graduate nurses in transition programs. Workplace environments influenced new graduate nurse transition and organizational commitment."
Ancillary reviews: retention (N=4) Reviews had methodological weaknesses and/or scope incompatibilities that resulted in limited use.
Ackerson and Stiles23	“Review” Search dates: 2006 through 5-9, 2016 Included studies: 26	Aim: To explore what the literature informs us regarding nurse residency programs implementation in acute care settings and their ability to retain nurses. Critical weaknesses include no identified review methodology/approach, no risk of bias assessment for determining issues affecting effectiveness interpretations, no clear selection criteria for inclusion. Scope focuses on RNTTPs within a specific setting (acute care) and outcome (retention). Country of included studies not reported.	"Established programs with at least a 12-month time frame were slightly more effective at retention. However, retention was not sustained at year two."
Asber22	Integrative review Search dates: conducted search Jan 2017 Included studies: 16	Aim: to examine the effects that nurse residency programs have on the retention of new graduates. Critical weaknesses include no detailed description of individual studies (e.g., evidence tables or risk of bias scores by study), single author with no mention of duplicate review of data, creating lack of transparency necessary for determining effectiveness. Scope focuses on RNTTPs with retention outcomes specifically. Country of included studies not reported.	"The 1-year retention was higher than the national average for new graduate nurses ranging from 74% to 100%."
Eckerson21	“evidence-based review” Search dates: 2012-2017 Included studies: 12	Aim: In newly hired BSN graduates, how would the use of a one-year nurse residency program compared to a traditional orientation affect turnover rates and reported satisfaction of the new nurse hires over a one-year period?” Critical weakenesses include no identified review methodology/approach, review authored by single individual with no affiliations identified, as well as additional non-critical weaknesses. Scope focuses on subset of our outcomes (retention and satisfaction) and subset of our population (BSN only), country of included studies not reported.	"Use of NRPs showed increased satisfaction and retention of new nurse graduates over a one-year period, leading to the conceptualization that this is a more effective method than traditional orientations for new nurse hires."
Van Camp and Chappy24	Systematic review Search dates: 2004-2016 Included studies: 22	Aim: To examine new graduate nurse residency programs, residents’ perceived satisfaction, and retention rates, and to make recommendations for implementation in perioperative settings. Critical weaknesses include inadequate discussion of methods, unclear and possible inappropriate use of risk of bias/quality assessment. Scope focuses on subset of outcomes (satisfaction and retention), majority US studies.	"Results indicate increased retention rates for new graduates participating in residency programs and that residency participants experienced greater satisfaction with their orientation than those not participating in residency programs. Residency participants also perceived the residency as beneficial."
Ancillary reviews: measurement (N=2) Reviews had methodological weaknesses and/or scope incompatibilities that resulted in limited use.
Aldosari et al25.	Scoping review Search dates: Not reported Included studies: 60	Aim: To identify newly qualified nurses/ experience during transition to professional practice, and explore their and other key stakeholders’ perceptions of nursing transition programmes. Focused on RNTTPs with scope and analysis not directly aligned with our aims, strong methods for their aims around identifying themes qualitatively from resident experiences, but challenging to directly interpret findings in the context of our aims, as their main focus did not align. Country of studies mixed.	"Evidence that nursing transition programmes positively impact the transition experience is inconclusive. Some studies suggest a positive impact on newly qualified nurses’ competency, level of confidence and attrition rates; others reported no impact. There was a general consensus that newly qualified nurses still encounter difficulties when transitioning into professional practice. Most articles found were quantitative in nature, focusing on measurable outcomes of nursing transition programmes. Few investigated the experiences and perceptions of newly qualified nurses, preceptors, and managers regarding the transition to professional practice."
Letourneau and Fater26	Integrative review Search dates: 2006-July 2013 Included studies: 25	Aim: Explore nurse residency programs described in the literature and evaluation the evidence supporting their use. Critical weaknesses include inadequate discussion of methods, no risk of bias assessment to assess robustness of claims of effectiveness/benefits, unclear selection criteria for inclusion of studies. Country of included studies not reported.	"Specifically, this review revealed an emphasis on organizational priorities pertaining to adjustment of the newly licensed nurse to the work environment and role. Consequently, the focus was on nurse retention, quality of nurse performance, and confidence. To date, no research has examined whether there is a link between participation in an NRP and patient outcomes that are determined to be nursing sensitive (eg, pressure ulcers, falls, intravenous infiltrations)."
Ancillary reviews: components/characteristics of RNTTPs (N=2) Reviews had methodological weaknesses and/or scope incompatibilities that resulted in limited use.
Bakon et al9	Integrative review Search dates: 2005-June 2016 Included studies: 30	Aim: To explore the various elements included in nursing graduate transition programs. Critical weakeness: incomplete description of individual studies (e.g., did not describe program elements, despite focus). Country of included studies mixed.	"There are numerous transition programmes available yet there remains a lack of transparency regarding their aims/objectives, course content, support timeframe and the type of support provided. This inconsistency has resulted in a lack of clarity regarding efficacy or superiority of any one programme over another. Innovative multifaceted programs may assist in supporting the graduate registered nurse to transition effectively into the clinical environment."
Chant and Westendorf27	Integrative review Search dates: 2007-? Included studies: 18	Aim: To identify commonalities among nurse residency programs deployed for greater than 3 years, showing improved job retention and satisfaction. Weaknesses include lack of transparency and justification for selection of included studies, details missing from methods (e.g., date search conducted). Only studies from US and Canada included.	"Successful, sustainable nurse residency programs have a strong foundation with committed leadership to support transition; a structured program with defined outcomes to promote clinical competence, safe patient care, and professional development; and an evaluation process to guide continual improvement and meet organizational needs."
Populated crosswalk only (N=9) Reviews had serious methodological weaknesses and/or scope incompatibilities, included some relevant studies and incorporated into crosswalk.
Ke et al28	Systematic review Search dates: Through June 2015 Included studies: 6	Aim: To determinte the effects of nursing preceptorship on the competence, job satisfaction, professional socialization and retention of new nurses. Multiple minor weaknesses including no protocol for systematic review, no excluded studies list. Scope incompatibility: different intervention (preceptorships) named, but included mix of interventions, including RNTTP-type studies.	"The most adopted preceptorship was a fixed preceptor/preceptee model and one-on-one for 1–3-month duration. It showed that new nurses’ overall competence increased significantly due to preceptorship. Only a few studies explored the effects of preceptorship on the job satisfaction and professional socialization of new nurses."
Alshawush et al29	Scoping review Search dates: Not reported Included studies: 19	Aim: To identify whether transition programmes support new graduate nurses and nursing students in terms of dealing with workplace violence, bullying, and stress and enhance new graduate nurses’ resilience during the transition from education to clinical practice. Scope incompatibilities: included students and new graduate nurses, mix of interventions.	“This review found that most transition programmes provide support for new graduate nurses when dealing with workplace violence, bullying and stress. Transition programmes varied in length, content and implementation. Preceptors' support, educational sessions and safe work environments are the most beneficial elements of transition programmes for supporting new graduate nurses. Education sessions about resilience provide new graduate nurses with knowledge about how to deal and cope with stressful situations in the work environment. We found no studies that focused on nursing students.”
Hampton et al10	Integrative review Search dates: Not reported Included studies: 7	Aim: Examined quantitative studies that evaluated the outcomes of interventions implemented to ease the transition from student to professional nurse. Unclear selection process/criteria. Scope includes broader array of interventions, including internships, orientations, etc.	"Despite the significance of the studies' results that indicate interventions to ease the transition-to-practice experience are beneficial and can have a positive impact on areas such as job satisfaction and retention, overall findings from this integrative review suggest the need for greater standardization of concepts that should be evaluated and the instruments used to determine if new nurses are successfully transitioning into professional nursing."
Wray et al11	Rapid evidence assessment Search dates: February 2018 Included studies: Unclear which includes mention residency	Aim: To undertake a rapid evidence assessment of approaches used to enhange nurse transition and retention for newly qualified nurses and to evaluate the strength of evidence for specific approaches to nurse transition and retention. Scope includes broader array of interventions, no results separate for RNTTPs.	"Orientation and creating supportive environments were frequently reported as being effective in enhancing transition across a range of studies."
Aparicio and Nicholson30	Other Search dates: Unclear Included studies: 6	Aim: To review the literature to find out whether there is evidence to support preceptorship and clinical supervision programs in retaining nurses, and particularly newly qualified nurses, in clinical practice. Scope incompatibility: different intervention (preceptorships), but included mix of interventions, including RNTTP-type studies.	"Training (preceptorship and clinical supervision programmes) is effective in retaining NQNs, increasing satisfaction, improving skills and competency and staff engagement; however, more support for both preceptors/supervisors and NQNs is needed to maximise the success of these programmes in the future."
Cochran31	Systematic review Search dates: Jan 2011-Sept 2014 Included studies: 15	Aim: Determine effectiveness of NRPs in reducing attrition of new nurses; if NRPs are effective, identify best practice in supporting newly licensed nurses during the transition to professional practice in acute care settings. Critical weaknesses: unclear search, no risk of bias assessment and inadequate interpretation of how study bias affects findings, inadequate reporting of details from original studies.	"NRPs are a cost-effective method proven to reduce attrition rates of new nurses. The most effective programs are 12 months in duration and focus on mentor/preceptor support with structured didactic content to assist newly licensed registered nurses to develop successfully in their professional role."
Hoover et al21	Scoping review Search dates: Sep 2019 Included studies: 69	Aim: To identify and synthesize research on in-service nurse mentoring programs. Scope incompatibility: different intervention (mentorship), but included mix of interventions, including RNTTP-type studies.	"Of the articles with sufficient data, they typically described small programs implemented in one facility (n = 23), with up to ten mentors (n = 13), with less than 50 mentees (n = 25), meeting at least once a month (n = 27), and lasting at least a year (n = 24). While over half of the studies (n = 36) described programs focused almost exclusively on clinical skills acquisition, many (n = 33) specified non-clinical professional development activities. Reflective practice featured to a varying extent in many articles (n = 29). Very few (n = 6) explicitly identified the theoretical basis of their programs."
Kenny et al.12	Systematic review Search dates: Not reported (included studies from January 1990 to April 2020) Included studies: 130	Aim: to: i) document the interventions that support and facilitate graduate nurse transition… and ii) to identify outcomes from graduate nurse transition interventions for the graduate, patient or client, and health service. Critical weaknesses include: cannot identify all included studies, inadequate reporting of details from included studies, no risk of bias assessment and inadequate interpretation of how study bias affects findings.	"The majority of authors reported outcomes for the graduate or the graduate and service, with only one reporting outcomes for the patient or client."
Tyndall et al33	Integrative review Search dates: 2010-June 2017 Included studies: 20	Aim: to critically analyze published research on the relationship between new graduate nurse transition programs and patient safety outcomes. Scope incompatibility: different interventions included (e.g., short orientation-type programs), but included mix of interventions, including RNTTP-type studies.	"This integrated review affirms the lack of empirical evidence linking participation in transition programs with positive patient outcomes and increased patient safety. Self-reported competency improvement by NGNs is the most common variable used in studies asserting that transition programs improve patient safety."

We identified 2 “best fit” reviews that had both high methodological rigor and direct relevance to our objectives, and integrative review with nearly identical aims to ours⁷ and a systematic review focused on retention and turnover.⁸ These reviews both reported studies conducted in a mix of countries, predominantly conducted in the United States. We identified 8 “ancillary” reviews that had methodological weaknesses and/or scope incompatibilities that limited their use. Of these ancillary reviews, 4 were specific to retention outcomes only,^21–24 2 had relevant findings related to measurement,^25,26 and 2 had findings relevant to RNTTP characteristics.^9,27 Nine reviews were precluded from further discussion due to a combination of methodological issues and scope incompatibilities,^{10–12,28–33} such as reporting findings that combined RNTTPs with mentorships, preceptorships, and/or orientations. Because these 9 reviews had included relevant studies, we included them in the crosswalk analysis.

Overlap of Included Reviews

While many of the 19 identified reviews had similar objectives, the degree of overlap in primary literature was minimal (see the full report for crosswalk).¹³ Of the 336 cumulative citations included in the 19 reviews, about two-thirds appeared only once, in a single review (N = 217, 65%). No study was included in every review; the most overlap for any single citation was inclusion in 10 reviews, which occurred twice.^34,35 Coverage across the 336 studies was low for all included reviews. The Rush and colleagues’ 2019 integrative review⁷ included roughly a quarter of identified studies (24%, 79/336 studies), while other reviews included less than 20% of the total identified literature from reviews.

Even when limiting to the reviews within a specific shared outcome, such as the 5 reviews specifically focused on retention,^8,21–24 the overlap did not improve. In this case, of the 91 primary studies included by at least one review, only 1 was included in all 5 reviews, while 70 studies were included in a single review.

Additional Findings From Independent Searches

Given the indicators that no individual review consistently and fully represented the existing evidence base of original research studies, we conducted our own literature search, which identified 25 additional relevant original research studies that were not included in any of the prior syntheses. We also screened all 336 studies identified by the reviews, and the majority did not meet our own inclusion criteria (N = 272, 81%). Because many reviews did not provide information about their screening and selection methodologies, it was unclear how these studies were included, or in what ways their inclusion process differed from our own. By our criteria, the 2 most common exclusion reasons were that studies only discussed a single-component program (N = 98), or studies did not present data or analysis of outcomes from a specific program (N = 73).

Summary of Coverage

There was no seminal study or set of studies that all review authors included, and most of the literature identified by reviews was only included by a single review. No single review served as a reliable compilation of the evidence base, and all reviews included studies we would consider to be excludes by our eligibility criteria.

Synthesis of Findings From Included Reviews

Reviews’ Coverage of Organizational, Nurse, and Patient Outcomes and Measurement

The identified reviews discussed critical organizational-level outcomes and some nurse-level outcomes; however, patient-level outcomes were absent. We prioritized reporting on the findings from the 2 “best fit” reviews,^7,8 which we supplement, when relevant, with findings from the 8 “ancillary” reviews.^9,21–27

The Rush and colleagues’ 2019 integrative review,⁷ which aimed “to identify the best practices of formal new graduate nurse transition programs,” was exceptionally aligned with the scope of our review of reviews. The authors included the most comprehensive overlap of original research studies; however, they included single-component programs, which fell outside our definition of multicomponent RNTTPs, and thus had other studies we did not include. They found that the quality of evidence, which was low to moderate overall, limited best-practice recommendations. They focused on 4 main categories of outcomes—competency and critical thinking, confidence, job satisfaction, and retention and turnover—while also describing data that were related to cost-benefit analyses. They found that the best quality evidence, which used a mix of methodological approaches, consistently connected RNTTPs with increased critical thinking, competency, and retention.

The systematic review by Brook and colleagues,⁸ also published in 2019 in the International Journal of Nursing Studies, included 53 studies. It aimed “to evaluate the characteristics of successful interventions to promote retention and reduce turnover of early career nurses.” Given its focus on quantitative analyses of retention and turnover, Brook and colleagues’ findings aligned with those of Rush and colleagues, stating that methodological issues limited the conclusions they could draw. They found indications that RNTTPs were associated with improved retention, but the composition of the program and its components also had some bearing on these improvements. The authors identified future research areas, including most notably, standardizing outcome measures across studies and increasing rigorous evaluations of RNTTPs’ cost-effectiveness, which is in alignment with our assessment.

Four ancillary reviews, either published in 2019 or earlier, had similar scopes that primarily focused on retention.^21–24 These reviews also reached similar conclusions, but with fewer included studies and more methodological issues than those found in the Rush and Brook reviews.^7,8

An additional 2 ancillary reviews^25,26 included measurement-related findings that contributed to the discussion points raised by Brook and colleagues.⁸ A review published in 2021 concurred, stating that there was a lack of agreement on the significance of various outcomes and that several studies used poorly validated measures.²⁵ A review published in 2015 detailed measures in its analysis,²⁶ which highlighted the Casey-Fink Graduate Nurse Experience Survey among a list of 6 other job satisfaction, performance, stress, and organizational commitment instruments. However, given the methodological issues and the 2015 publication date, this list was probably incomplete.

Descriptions of RNTTP Characteristics

The 2 best-fit reviews also discussed characteristics of RNTTPs,^7,8 while 2 ancillary reviews also contributed to insights related to RNTTP characteristics.^9,27 The first of these, an integrative review, developed a model of RNTTP key components for sustainability that aligned well with the 2 best-fit reviews in terms of the components they described (Fig. 2).²⁷ The 3 “common features” identified by Rush and colleagues⁷ included a defined resource person (eg, mentor, clinical coach, navigator), mentorship, and peer support opportunities. Brook and colleagues⁸ identified 5 unique program components, including preceptor, mentor, teaching/training, assessment (ie, evaluation of the program), and incentives components. In addition, each review had separate sections dedicated to education and workplace environment. The second ancillary integrative review included a list of 17 suggested elements for graduate transition programs, which overlapped with the model’s themes as well.⁹

FIGURE 2.

Chant and colleagues model of nurse residency programs key components for sustainability.

All 4 reviews,^7–9,27 in addition to other reviews mentioned,^21–26 discussed program length to some degree. However, given the methodological issues of many of the reviews as well as their included literature, any signal about ideal program length was not grounded in empirical comparisons between programs of different lengths, and as such we were unable to rely on their interpretations beyond the findings reached by Rush and Brook and their colleagues.

Rush concluded that bundled programs (ie, programs with multiple components) can be helpful but the evidence for program length was inconclusive. However, orientations longer than 4 months, and ideally up to 9 months were suggested.⁷ Brook and colleagues agreed on both findings, suggesting that programs lasting 27–52 weeks (∼6–12 mo) with teaching, preceptor, and mentoring components appeared most promising.⁸

DISCUSSION

In this systematic review of reviews, we identified 19 published evidence syntheses, many of which were integrative reviews (n=7) or systematic reviews (n=6), and nearly 50% were appraised as having rigor and/or relevance issues that required limiting their interpretation or use (n=8). Two best-fit reviews were the most informative for our study objectives.

A critical challenge for this systematic review of reviews was the lack of overlap between the identified original research within the reviews, with nearly all reviews missing more than half of the literature we identified in our crosswalk, as well as the potential missing coverage across original research studies not included in any reviews. While this may be appropriate given the varying scopes of the reviews to some extent, we did not see this when we reviewed the 5 reviews on retention; overlap was still low.

While the reviews we identified in our systematic review of reviews did discuss critical organizational-level outcomes and some nurse-level outcomes, patient-level outcomes were absent from the identified reviews. Both best-fit reviews emphasized the methodological issues in the available evidence, which limited best-practice recommendations and conclusions.^7,8 They found that the best quality evidence, which used a mix of methodological approaches, indicates a connection between RNTTPs and more critical thinking, competency, and retention, but that more rigorous evaluations are necessary to establish estimates of effect size with an acceptable strength of evidence.

Regarding program characteristics, multicomponent (ie, bundled) RNTTPs may be helpful,⁷ but the specific arrangement of components and how to choose components to match specific contexts remains unclear. There appeared to be a set of key components that were represented in the published evidence syntheses, including a defined resource person (eg, mentor, clinical coach, navigator, preceptor), mentorship, peer support opportunities, education/training, assessment, and workplace environment. Many of the evidence syntheses discussed program length to some degree. However, because of a dearth of strong comparative studies or methodologically rigorous evaluations, the evidence for program length was inconclusive, with published evidence synthesis reviews suggesting similar lengths around 6–12 months. Similarly, how components and program length relate to program success is unclear.

Limitations

Our systematic review of reviews aimed to orient nurse leaders and other readers to the large volume of published reviews and original research literature related to RNTTP programs. Most of the reviews we identified and the original research studies they included had substantial limitations. At the review level, the low methodological quality of most of the included reviews limited our confidence in their findings. Compounding the methodological quality issues of the reviews were the underlying methodological limitations of the original research studies, including small sample sizes, lack of comparison groups, and other critical issues increasing the potential risk of bias.

Aside from the limitations in the included literature, our review had 2 main limitations that deserve mention. The first limitation, inherent in all systematic reviews of reviews and umbrella reviews, is a reliance on prior synthesis efforts as the basis of our analysis. This was especially concerning given the critical methodological issues we observed in many of the identified reviews. While synthesizing data from original research studies would have been a more direct approach, this was not feasible given the scope of our systematic review of reviews and the volume of original research studies on this topic. Having now both conducted a systematic review of reviews and recognized the lack of overlap of original research studies across reviews, the preliminary groundwork for a deeper analysis of original research studies has been accomplished. The second limitation is publication bias. Given the common use of RNTTPs in a variety of health care settings, the published literature in this space may not accurately reflect the total experiences with RNTTPs at large. The RNTTPs captured in published evaluations or research projects may be qualitatively different from those that remain unpublished.

Recommendations for Future Research

Both new original research and additional evidence synthesis work may bolster or solidify our understanding of the effectiveness of RNTTPs. Future work for evidence synthesis could maximize the utility of the large volume of existing work by quantitatively analyzing comparable data from original research studies to pool smaller studies across key outcomes, while rigorously appraising risk of bias and applying certainty of evidence to resulting conclusions. In addition, systematically gathering data when available in published literature about program components, such as program length, instruments and measures used, size/scale of program implementation beyond single versus multisite, and other key characteristics, would be critical for developing optimal RNTTPs.

Considering the widescale methodological limitations of the existing original research evidence base, there are a few critical ways new research on RNTTPs could fill gaps. These recommendations consider the conclusions and suggestions of many of the included reviews, as well as key developments in the field, like the second IOM report The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity,³⁶ and the incorporation of health equity into the Quintuple Aim.³⁷ Specifically, the second IOM report³⁶ calls for nursing employers and others to implement “structures, systems, and evidence-based interventions to promote nurses’ health and well-being, especially as they take on new roles to advance health equity.” To work towards progress across these potential areas, we recommend improving outcome measurement and increasing the rigor of evaluation designs. Accrediting organizations, in addition to nursing employers, are in a uniquely powerful position to support rigorous outcome measurement and evaluation design, and to promulgate the ensuing best practices.

Future evaluations should improve outcome measurement…

• At the organizational level by increasing the duration of retention beyond a year, which in some cases is the length of the RNTTP and considering essential outcomes like access and health equity.

• At the nurse level by employing standardized outcome measurement for assessing typical outcomes including readiness, confidence, satisfaction, etc.

• At the patient level by being more inclusive of this patient outcomes in evaluations in general. Recommendations for patient outcomes include patient satisfaction and those sensitive to nursing-sensitive indicators.³⁸

Future evaluations can increase the rigor of design by…

• Incorporating comparator groups, longitudinal designs, adaptive designs, and/or multiple sites.

• Assessing organizational context.

• Testing adaptations to RNTTPs and components.

• Evaluating program sustainability and implementation outcomes.³⁹

• Employing a broader range of mixed methods and economic evaluation approaches.

The Learning Health System Approach and the Veterans Health Administration

As the largest employer of nurses in the United States,⁴⁰ the Veterans Health Administration (VHA) is well-positioned to support further work on RNTTPs. With up to 25% of future VHA RNs being anticipated as new graduates,⁴¹ understanding RNTTPs and their potential to improve organizational, nurse, and patient outcomes is essential.

The VHA Office of Nursing Services (ONS)⁴² has a long-standing RNTTP Residency Program with over 100 facilities running active RNTTPs and more than 3000 new graduate RN participants between 2019 and 2023.⁴¹ Recent evaluation efforts, led by the Nursing Innovations Center for Evaluation (NICE)/VA Collaborative Evaluation Center (VACE) found the ONS RNTTP Residency Program had retention rates of 89%, 84%, and 79% for 1 year, 2 year, and 3 years, respectively. In 2023, there was a 29% growth in new graduate hires. In addition, NICE coordinated the development and published findings on an item pool for a publicly available, psychometrically tested tool to measure new graduate RN competencies.⁴³ Planned evaluations should contribute to a better understanding of individual and organizational factors related to VHA’s RNTTP Residency Program success, and how it can be replicated in other contexts.

Through the Learning Health System⁴⁴ approach and specifically the Translation-to-Policy Learning Cycle,⁴⁵ this review, which was nominated by ONS nurse leaders of VHA’s RNTTP Residency Program, supports VHA in applying data to knowledge (eg, the consideration of external evidence) to improve future performance. In addition, to support future research on nursing, the VHA hosted a “Nursing State of the Art Conference” in November of 2023, and the research agenda that followed highlights several key areas^46,47 that align with findings and recommendations from this systematic review of reviews. For example, the recommendation from the Nursing Conference to increase research around the nurse work environment and organizational interventions to improve the environment—like RNTTPs—can potentially support a pipeline of competent, confident nurses.

Another Nursing Conference recommendation related to understanding nurse staffing needs is also in alignment with this review. To have a successful RNTTP program, staffing is a key area to be considered, as these programs require prospective planning around staffing to ensure there are resources needed to train new nurses safely. For example, most reviews assessed in our review agreed that some level of preceptor or mentor support is needed. For this to be possible, a new graduate nurse must be matched with an experienced nurse who is motivated to mentor on a consistent basis. Another consideration for staffing is the educational activities that pull new graduate nurses off the unit to receive additional training on interventions such as rapid responses/codes, wound care, and chest tube management, among other clinical domains. These training activities are important in giving new graduate nurses the chance to improve critical thinking and refine competencies learned in nursing school through more intensive simulation; yet, units must account for this in staffing needs. The upfront investment required to staff these RNTTP programs is hypothesized to improve staffing stability through improved retention of new nurses, but future research accounting for the aforementioned outcome measurement needs and evaluation designs is needed to be more definitive.

CONCLUSIONS

Since the IOM reports’ calls to action, RNTTPs have been piloted, implemented, and sustained in health care systems across the country. The need for better and more consistent measures in primary research as well as truly comprehensive, well-executed, and clearly documented syntheses of existing literature lays the groundwork for future work. These programs deserve rigorous evaluation using sophisticated methodology to answer critical questions about their key features and corresponding impacts in critical organizational, nurse, and patient outcomes. Because RNTTPs have the potential to alleviate grave nurse staffing shortages and support developing the future of the nursing workforce, these programs’ benefits should be verified and documented, and then best practices ascertained so that they can be scaled and sustained.