Impact of transition programmes for students and new graduate nurses on workplace bullying, violence, stress and resilience: a scoping review protocol

Abstract

Introduction

The shortage of nurses is projected to grow, and the number of new graduate nurses (NGNs) who are predicted to replace expert nurses has increased. Meanwhile, those NGNs leaving their job within the first year, give various reasons for leaving, including workplace bullying and violence. In response, some hospitals and universities have developed nurse transition programmes such as nurse residency programmes and nurse internship programmes to attract NGNs and to assist in their changing status from education to practice. Although these programmes have been successful in decreasing the turnover rate for new nurses and are cost-effective, their impact on workplace bullying and violence has not been systematically reviewed and is yet to be determined. A scoping review will be conducted to address this gap. The aim is to identify current knowledge regarding the content of transition programmes and their impact in supporting NGNs dealing with workplace violence, bullying and stress.

Methods and analysis

Arksey and O’Malley’s scoping framework and the Joanna Briggs Institute scoping review guidance will guide the methodology process of the review. Published studies, with no date limit, will be identified through the electronic databases (CINAHL, Scopus, MEDLINE, Web of Science, ASSIA, PsycINFO, Embase, PROSPERO and ProQuest Dissertation) and reference lists. Primary key terms will be ‘novice nurse’, ‘new graduate nurses’ and ‘transition programmes’. Two reviewers, guided by standardised procedures, will perform the study selection process independently. Data from the selected studies will be extracted using a data extraction form. Thematic analysis (for qualitative papers) and descriptive summary of the results (for quantitative papers) will be performed.

Ethics and dissemination

Ethical approval is not required for this review. Findings will be used to inform future study designs to evaluate the transition programmes and disseminated via peer-reviewed journals and conferences.

Strengths and limitations of this study.

• This is the first scoping review to explore whether transition programmes support new graduate nurses in dealing with workplace violence and bullying.

• A valid methodological framework will guide this review. A comprehensive search will be conducted and thematic analysis and descriptive approaches will be used to report the results.

• Only studies published in English will be included.

• Evaluation of the quality of the evidence will not be performed in this scoping review.

Introduction

As healthcare evolves, settings become more complex, resulting in a higher rate of turnover among healthcare workers.^{1 2} Moreover, global nursing shortages are well-documented and expected to rise. It is predicted that by 2025, over a million expert registered nurses will retire.^{3 4} As a result, these vacancies may be filled by new graduate nurses (NGNs) instead.^{3 5} Despite the need for NGNs to resolve this shortage, the turnover rate for them continues to be an issue worldwide.⁶ According to the Royal College of Nursing,⁷ NGNs are those who have between 0 and 24 months of work/clinical experience. This indicates that during the transition to clinical practice, NGNs are equipped with the required knowledge, cognitive abilities and skills to provide safer care for patients and keep up with the practice environment.⁸

NGNs tend to experience difficulties while adapting to their new jobs and transitioning to practice in a stressful and complex work environment.^{8 9} This can be due to their lack of clinical knowledge and self-confidence, as well as having to deal with issues such as high patient numbers, nursing shortages and complex patient care, and the lack of sufficient support.^10–12 These issues raise concerns among healthcare organisations about the ability of NGNs to deliver high quality care for their patients.¹³ The lack of support from colleagues, managers and preceptors can also result in stress and job dissatisfaction, leading to NGNs leaving within the first year of employment and an overall increase in turnover rate of NGNs.^{11 13 14} The cost of turnover internationally ranges from $10 000 to $88 000 per NGN depending on factors such as clinical speciality and geography.¹⁵

Research indicates that there is an international gap in how universities prepare student nurses for transitioning from the education system to practice.^{8 16 17} NGNs and nursing managers have regularly reported that their education did not fully provide them with the skills required for their transition.^18–20 The Institute of Medicine²¹ in the USA seeks to address the need for the establishment of transition programmes such as nurse residency programmes (NRPs) and internship programmes (INPs) to close this gap.^{22 23} Transitions programmes are used globally, for example, in Australia,²⁴ the UK²⁵ and Sweden.²⁶ They have various names but all serve the same purpose of closing the gap between theory and practice. Thus NRPs and INPs are important in nursing.

INPs and NRPs are orientation programmes, with preceptors, involving intensive lessons and practice relating to clinical skills, patient safety, evidence-based practice and leadership.^{21 27 28} These programmes were developed to facilitate the transition of NGNs into the workplace by supporting them and developing their clinical and leadership skills to improve NGNs retention rates.^29–31 However, there is a lack of a clear structure and a breadth of theories that underpin such programmes.⁶ Currently, the theories only include the transition theory,³² Watson’s³³ theory of human caring and the transition to practice model developed by the National Council of State Boards of Nursing.³⁴ The duration and names of these programmes are also varied.¹⁷

Despite the differences in theories used, framework, structure, length and title, the purpose of these programmes is the same: to bridge the gap between academic preparation and the demands of clinical practice.¹⁶ These programmes have been effective in supporting NGNs and students to develop their clinical, leadership and communication skills, improve patient safety and increase the retention rate for NGNs.^{6 35 36} They are also cost-effective for hospitals, as they reduce the turnover rate for the first-year novice nurses.15 27 37–40 Nevertheless, their impact on workplace bullying, violence and stress has not been reviewed and is yet to be determined.

Nursing has the highest rate of bullying and violence compared with other professions.⁴¹ Furthermore, evidence suggests that NGNs are more vulnerable to experience bullying and violence within nursing professions.⁴² NGNs might expect, but do not regularly receive support during their transition and can experience bullying and violence worldwide.10 13 36 43 44 Aggressive or abusive behaviour can be classified as workplace violence.^{31 45} Bullying usually refers to persistent exposure to interpersonal aggression and mistreatment from colleagues, superiors or subordinates,⁴⁶ where a staff member experiences adverse behaviour, such as threats.^{47 48} There is substantial variation in the definitions of bullying and violence, but these words are often used interchangeably.⁴¹ Other synonyms include incivility, verbal abuse, threats and hostility.^{49 50} Even though INPs and NRPs are designed to prepare less experienced nurses for the realities of clinical practice, there is a lack of research evidence on the impact of INPs and NRPs on preparing NGNs for bullying and violence at the workplace, particularly from the perspectives of NGNs. However, there are a few studies that have measured the impact of work violence and bullying on NGNs who are not enrolled in NRPs.10 43 49 51

A comprehensive mixed-methods systematic review of experiences of violence in the nursing profession shows that there is a widespread presence of workplace violence and bullying experienced by NGNs.⁴² There is evidence that prelicensure education for nurses, such as sessions covering the topic of workplace violence and simulations, are beneficial to NGNs.^{51 52} INPs and NRPs include both these sessions and simulations. However, it is unknown if these sessions effectively support NGNs during their transition to practice in terms of dealing with workplace violence and bullying. Additionally, there is evidence that medical residency programmes increased the resident’s awareness of how to deal with workplace bullying and violence.⁵³ Transition programmes appear to support the transition of NGNs and increase their retention and confidence. However, there is a paucity of quantitative and qualitative research that investigate and describe the relationship between the programmes and these issues among NGNs and student nurses, and whether they enable NGNs to deal with and overcome workplace violence and bullying. Furthermore, there is no systematic review or scoping review to date that explores the effectiveness of these programmes on such issues. Therefore, this scoping review aims to fill a gap in the evidence and identify whether the transition programmes support NGNs in terms of dealing with workplace violence, bullying and stress, and enhance the resilience of NGNs. The scoping review approach was chosen over other review methods, such as systematic review, to gain a broad understanding of the research on this topic, to initiate an academic discussion about the topic and review the methodology used in the research in this topic to inform future study designs.

Methods and analysis

In order to conduct a transparent scoping review, Arksey and O’Malley’s scoping review framework⁵⁴ and the Joanna Briggs Institute (JBI) scoping review guidelines⁵⁵ will be used to guide this scoping review. The Arksey and O’Malley’s scoping review framework involves¹ identifying the research question,² identifying relevant studies,³ selecting studies,⁴ charting the data and⁵ collating, summarising and reporting results.⁵⁴ This scoping review is expected to be completed by the end of November 2020.

Patient and public involvement

In formulating this scoping review protocol, no patient or public were involved. Furthermore, they will not be involved when conducting this scoping review. However, it is anticipated that the findings from this scoping review will be disseminated to the knowledge users, such as healthcare policymakers and administrators, managers and nurse preceptors.

Identifying the research question

In this scoping review, the review question is:

How do transition programmes impact on NGNs’ ability to manage violent, bullying and stressful situations, and enhance their resilience to such situations?

This scoping review aims to provide a summary of the extant literature and identify the gaps in transition programmes’ support concerning NGNs and workplace bullying, violence and stress globally. In publishing this review protocol, the reviewers aim to ensure transparency of the process and to prevent unnecessary duplicate work.

Eligibility criteria

This search will be limited to studies published in English due to the financial constraint, and no date limits will be set to ensure the most relevant studies are included. The inclusion criteria are detailed in table 1.

Table 1.

Inclusion criteria

PICo	Inclusion criteria	Exclusion criteria
Population	NGNs (BSN or diploma licensed) with 0 to 24 months of work experience in any healthcare settings (academic or community) and student nurses in the last semester of their nursing programmes or have finished their programmes and are enrolled in any type of transition programme, regardless of the name, duration or content of that programme	Studies that include nurses (expert) other than NGNs will be excluded.
Intervention	Transition programmes developed for NGNs and/or student nurses in colleges, universities and healthcare settings (academic or community) All programmes that have been established to ease the transition of NGNs and student nurses into practice (eg, internship, mentorship, preceptorship, residency and transition externship programmes)	General hospital orientation programmes that encompass all newly employed nurses who have been hired in hospitals, whether they are NGNs or not will be excluded
Outcomes	The outcomes for the studies to be included in this review should be related to the transition of NGNs and student nurses as well as their experience with bullying, violence, incivility, hostility, stress, conflicts, microaggressions and resilience during the enrolment into transition programmes	Studies that include/ compare NGNs with expert nurses or with other professions will be excluded

BSN, Bachelor of Science in Nursing; NGN, new graduate nurses; PICo, Population, Intervention/ Phenomena of interest, Comparison, outcomes.

Identifying relevant studies

The search strategy will involve three stages, as suggested by the JBI guidance:⁵⁶

Stage one

To identify extant research and relevant keywords for the search strategy, a preliminary search will be conducted in MEDLINE and CINAHL databases and using keywords from the review question: ‘nurse residency programme’, ‘transition programme’, ‘new graduate nurse’, ‘student nurses’, ‘workplace bullying’, ‘violence’, ‘stress’ and ‘resilience’. Any further keywords identified will be searched across all databases.

Stage two

With the support of a librarian, the following electronic databases will be used to perform a comprehensive literature review using all identified keywords: CINAHL, Scopus, MEDLINE, Web of Science, ASSIA, PsycINFO, Embase, PROSPERO and ProQuest Dissertation using the Boolean operators OR/AND. These databases have been chosen as they are the highly recommended in the field of nursing and allied health.⁵⁷ See the draft search in the online supplemental file 1.

Stage three

A back-chaining technique will be performed to ensure consistency in the manual reference lists searches.⁵⁶ A citation search will identify any related studies and ensure all papers are located. The search strategy may be modified if needed.

Selecting studies

The preferred reporting items for systematic reviews and meta-analyses for scoping reviews (PRISMA-ScR)⁵⁸ guidelines will be used, as they can improve reporting and intervention evaluation. Duplication of studies will be checked and removed initially. The titles of the papers will be screened. Papers that are not relevant to the inclusion criteria and do not answer the review question will be excluded. Abstracts will be screened for relevance according to the inclusion criteria. Finally, the full text will be examined by two independent reviewers, and studies that meet the inclusion criteria will be used for data extraction. In a scoping review, rigour is maintained by having a minimum of two reviewers selecting the papers.⁵⁹ On completion, the decisions of both reviewers will be compared, and any discrepancies will be discussed to reach a consensus; alternatively, a third reviewer will be consulted, thereby enhancing the reliability of the scoping review.⁵⁹

Charting the data

To minimise the risk of errors and to ensure data consistency from each study, a standardised extraction form will be used.⁶⁰ The JBI form will be used as its flexible design is suitable for both quantitative and qualitative studies, making it appropriate for this review.⁵⁵ JBI asserts that data charting needs to be piloted with two or three papers at the very least to ensure the right information is being extracted, to maintain consistency, as well as to determine if the form requires any amendments.⁵⁶ Any amendment to the form will be reported in the final manuscript. Study characteristics (author, year and country), design (aim, method, sample and participants) and results will be extracted in the extraction form. Further information that will be extracted from the included studies are transition programmes characteristics, NGNs reporting workplace bullying and violence during the transition programmes, and strategies of the transition programmes in supporting NGNs dealing with this issues.

Collating, summarising and reporting results

This scoping review will use the three steps for reporting data developed by Levac et al:⁶¹ analysing data, reporting results and applying meaning to the results. In the analysis process, a preliminary synthesis and an exploration of the relationships between the papers will be conducted as suggested by Popay et al.⁶² This to describe specific techniques and tools to facilitate and guide the synthesis process.

Step one: analysing the data

Findings from the data extraction form will be discussed and this will be supported with tables presenting a numerical summary and themes for the qualitative data. Popay et al⁶² recommended the grouping of findings to aid the processes of the analysis; therefore, the pattern in the reported factors of the intervention will be identified.

Step two: reporting results

For clarity and consistency, JBI recommends that when reviewing effectiveness, the reporting should be based on the protocol’s outcomes; this is a common method for demonstrating the results in a clear and structured way. Therefore, the results for the descriptive themes (workplace bullying, violence and resilience) will be reported along with the tabulation method between the findings. Thematic analysis will be used to present the data.⁶³ Based on the volume of the generated data, the computer software-facilitated coding, NVivo, may be used.⁶⁴

This scoping review aims to enhance the understanding of the relationships between these transition programmes and how they may support NGNs in overcoming workplace violence, bullying and stress. NGNs and student nurses are vulnerable to workplace violence and bullying. Internship and residency programmes have been developed to ease the transition, and it is evident that they are effective in supporting NGNs and decreasing turnover rates. However, the effectiveness of these programmes in supporting NGNs to overcome workplace violence and bullying is unknown. It is hoped that this scoping review will identify the effect of transition programmes on workplace bullying and violence, all of which are considered to be stressful for NGNs. Knowing such effects of the transition programmes may help support NGNs by providing insights into the best strategies during their transition, leading to improved resilience and reduced retention among them. Additionally, universities, nursing colleges and healthcare organisations may use the review findings as a guide when they initiate and evaluate nurse transition programmes.

Ethics and dissemination

Dissemination and translation will be guided by the PRISMA-ScR checklist to enhance the transparency of the finding. Results will be presented descriptively and thematically. Implications of the findings for educators, clinical practitioners, managers and nurse preceptors will be discussed. The results will be shared with different knowledge users nationally and internationally through conference posters, presentations and publication in academic journals.