Write an original scholarly paper on this article attached.

Qualitative Description of New Graduate Nurses’ Experiences in a Nurse Residency Program Susan B. Fowler, PhD, RN, CNRN, FAHA ƒ Samantha Chuffo Lind, BSN, RN, CCRN, TCRN ƒ Pamela R. Johnson, MSN, RN, PCCN ƒ Judy Lewis, BSN, RN-BC Nurse residents were asked to write a targeted story at the end of the 12-month program. Qualitative content analysis by two reviewers yielded five themes: team and teamwork, gratitude, asking questions, the art of nursing, and change.

Findings are supported from previous research and add new information to the body of knowledge about the experience of nurse residents. The nursing professional development practitioner can apply this knowledge in supporting and strengthening residency programs.

N urse residency programs are typically 12-month programs for newly licensed registered nurse (RN) graduates that provide a structured first work experience, support through mentoring relation- ships, clinical educational experiences, and individualized professional growth and commitment (Rosenfield, Smith, Iervolino, & Bowar-Ferres, 2004). Nurse residents were askedtowriteandshareatargetedstoryattheendof one organization’s program. The primary objective of this study was to determine common themes from written re- flections of experiences submit tedbyRNsatthecompletion of the program.

BACKGROUND This project took place at a large teaching hospital sys- tem in Central Florida. The nurse residency program has been in existence there since early 2000. The program consists of orientation, preceptorship, and classroom education and gatherings. The newly licensed RN is enrolled into the RN Residency Program during their first week as a new team member within our organization. The program begins with corpo- rate clinical orientation where the new nurse also learns about the RN Residency Program. Corporate clinical orien- tation is followed by unit-based orientation where the new nurse works with a preceptor. The program also includes core courses that support clinical competence in the nurse’s specialty area and five RN residency workdays, spread throughout their first year. The RN resident returns every 3 months for the workdays until program completion at the end of their first year. Educational content for the workdays includes profes- sional and leadership skills such as critical thinking, time management, and autonomous decision-making (see Table 1 for sample workday agenda). Content is delivered through various teaching methods such as didactic, simu- lation, group activities, and reflective discussions. All courses within the program are facilitated by the clinical learning team in collaboration with content or subject matter experts. Numerous studies have been conducted on nurse resi- dency programs using quantitative measures and limited qualitative methods. Findings from previous research dem- onstrate (a) the need and appreciation of support and camaraderie and (2) confidence, increased clinical compe- tency, and control over practice for new nurses participating in residency programs. Fink, Krugman, Casey, and Goode (2008) studied 434 nurse residents from 12 hospitals that took part in the University Health System Consortium/American Associa- tion of Colleges of Nursing postbaccalaureate residency program at the beginning of their program, 6 months into the program, and at program conclusion (12 months).

Nurse residents felt supported, appreciated a consistent preceptor, and desired to feel part of the unit culture.

Satisfiers included support, camaraderie, and caring for pa- tients. Rosenfield et al. (2004) evaluated 5 years of a nurse residency program and found, through use of two open- ended questions, the importance of the mentor for nurse residents. Confidence, increased clinical competency, and control over practice as a result of enhanced knowledge and skill res- onated in research findings from investigations of nurse Susan B. Fowler, PhD, RN, CNRN, FAHA, is Nurse Scientist, Center for Nursing Research at Orlando Health, Florida.

Samantha Chuffo Lind, BSN, RN, CCRN, TCRN, is Clinical Nurse II, Trauma Intensive Care Unit, Orlando Regional Medical Center, Florida.

Pamela R. Johnson, MSN, RN, PCCN, is Learning Consultant YOnboarding Te a m YRN Residence Program, Orlando Hea lth Institute of Learning, Florida. Judy Lewis, BSN, RN-BC, is Learning Consultant YOnboarding Team YRN Residence Program, Orlando Health Institute of Learning, Florida.

ADDRESS FOR CORRESPONDENCE: Susan B. Fowler, Center for Nursing Research at Orlando Health, 1100 Delaney Ave. F201, Orlando, FL 32806(e-mail: Susan.Fowler @Orlandohealth.com). The authors declare no conflicts of interest.

DOI: 10.1097/NND.0000000000000496 Journal for Nurses in Professional Development www.jnpdonline.com 319 JNPD Journal for Nurses in Professional Development &Volume 34, Number 6, 319 Y324 &Copyright B2018 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. residents. Olson-Sitke, Wendler, and Forbes (2012) studied 31 nurse residents at 6 and 12 months and found increased confidence over time,t(28) = 4.31,pG.001. Findings indi- cated that patient care, learning, resources, engagement, peer communication support, and relationship building were identified as major satisfiers. Williams, Goode, Krsek, Bednash, and Lynn (2007) studied nurse residency pro- gram outcomes in 679 RNs across 12 sites. At 12 months, nurses felt increased control over their practice and job sat- isfaction. They acknowledged increased ability to organize and prioritize and to communicate and lead. Stress and professional satisfaction decreased from entry into the pro- gram. Kowalski and Cross (2010) found that nurses (N=55) engaged in a nurse residency program reported increased clinical competency, decreasedsense of threat, and increased communication and leadership skills. Peer support and the opportunity to share were valued by nurses. High stressors included challenging patient assignments, patient status, time management, and communication. Bratt and Felzer (2011) reported that, after a 12-month Wisconsin Nurse ResidencyProgram, increases were noted in job satisfaction, clinical decision-making ability, quality of nurse performance, and organizational communication. Stress decreased over time. Investigators note that the time period from 6 to 12 months is the most difficult time for adjustment to the role and profession. Finally, Goode, Lynn, McElroy, Bednash, and Murray (2013) used the CaseyYFink Graduate Nurse Experience Survey, which addresses entry into the work- place and transition to the role of professional nurse to evaluate RNs engaged in nurse residency programs from 2002 to 2012. Total scores increased steadily from baseline to 6 and 12 months as did skills in organizing and prioritiz- ing and communication leadership.

In summary, findings from previous investigations on nurse residents demonstrate the importance of support and increases in confidence, clinical knowledge, and skill.

But most of the reviewed studies used quantitative mea- sures in a repeated measures design over time (baseline, 6 months, and 12 months) with limited open-ended ques- tions. Near the end of the program, nurse residents at our facility are asked to reflect on the past year and write openly about their experience. They considered the following:

nHow has your first year shaped your perception of the nurse?

nHas the profession met your expectations? Why or why not?

nWhat have you learned that you look forward to sharing with others?

nHow will you use your experiences to impact future new nurses on your unit?

nWhat has been the best/worst part of your experience as a new nurse?

nShare a patient interaction that will change the way you practice nursing in the future.

Themes from these written reflections based on open- ended questions may confirm findings from previous in- vestigations as well as contribute new understanding and direction to 12-month nurse residency programs. METHODOLOGY AND DATA ANALYSIS This qualitative study, approved by the organization’s in- stitutional review board, used qualitative description to explore reflections of experiences written by new RNs completing a 1-year nurse residency program. Written stories from a 2-year time period were reviewed until data were deemed saturated with the recurring themes. One clinical and one research nurse independently reviewed and identified themes and patterns. This approach to data review is termed qualitative content analysis (Polit & Beck, 2017). Qualitative content analysis involved breaking down data into smaller units, coding and naming the units, and clustering them based on similarities. Themes were finalized when the two nurses identified similar themes and reached consensus. TABLE 1 Samples of Workday Agendas 0730Y0740 Introductions and RN Residency Graduate Nurse Program Welcome 0740Y0900 Nurse/Physician Communication 0900Y0915 Break 0915Y1045 Understanding Radiology Procedures 1045Y1115 Reflective Discussions Group 1115Y1215 Lunch 1215Y1345 Principles of Deescalation and Communication 1345Y1400 Break 1400Y1530 Making Sense of Shift Report 1530Y1630 Time Management 0730Y0740 Introductions and RN Residency Program Welcome 0740Y0915 Wound & Ostomy Care 0915Y0930 Break 0930Y1030 Corporate Integrity/Compliance and Ethics 1030Y1130 Reflective Discussion 1130Y1230 Lunch 1230Y1330 Regulatory Jeopardy!

1330Y1530 Critical Thinking 1530Y1545 Wrap Up/Check Out CaseyYFink Survey 320 www.jnpdonline.comNovember/December 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. FINDINGS Five themes were identified and supported with quotes from 90 nurse stories (see Figure 1).

Theme 1: Team and Teamwork A team and teamwork is reflective of support and a sup- portive environment. According to the residents, the result of teamwork is that it makes the delivery of patient care eas- ier and nursing more enjoyable. It also makes it easier for one to get through a difficult shift. Support involves collab- oration, especially in times of crisis, as voiced by the residents:

n‘‘Being able to rely on one another creates a safety net that protects both yourself and the patients.’’ n‘‘Ibeing able to manage a crashing patient [sic] because coworkers step in to help, even if it means just passing meds to your other patient.’’ Teamwork and the support it provides has a positive influence on patient and nurse safety. One nurse used the analogy of being on a balance beam. Team members were ‘‘spotters’’ providing a safety net.

Support is also about camaraderie. Camaraderie in- volves colleagues who have everyone’s best interests in mind and work together to protect patients. As one resident stated: ‘‘I love the comradery on the unit. We can always be ourselves and encourage each other to do whatever it takes to advocate for our patients.’’ In other words, ‘‘The team is invested in my successI.’’Another resident explained that ‘‘The best part during my first year as a nurse is that I met several co-workers that were willing to assist, educate, and encourage me to be- come a good nurse.’’ Teamwork makes a lasting impression on nurse resi- dents. This may not be surprising considering that during this first year of practice learninghowto be a nurse within a specific setting requires collaboration among nurse educa- tors, preceptors, and other team members. The following statements demonstrate the strength of teamwork during this year of residency:

n‘‘One thing that has also stood out to me is the value of teamwork.’’ n‘‘Teamwork has proved to be one of the most im- portant things.’’ n‘‘The concept of teamwork has since been the ban- ner that I carry with meI.’’ Theme 2: Gratitude Gratitude from patients and families is more than just the words ‘‘thank you’’ and may include behaviors or gifts.

Thanks may or may not be expected but is appreciated when received, generating a sense of pride. In addition, gratitude validates the resident as an RN. A resident commented that ‘‘Once in a while there is a grateful mother that makes me happy and proud to be a nurse.’’ Gratitude also provides substance anchoring the resi- dents so they can move forward beyond difficult situations.

‘‘What keeps me going even through the very difficult times is the gratitude my patients have for myself and other nurses’’ explained a nurse resident.

Nurse residents recognized that gratitude does not necessarily result from ‘‘big’’ actions, but rather simple gestures and spending time with patients and families.

n‘‘The best patient experiences for me is always when parents thank me for taking time to sit with them and answer their questionsI.’’ n‘‘Seeing how grateful they are for a warm bed or cup of coffee while hospitalized, has me realize how a small act of kindness can make a difference to someone else.’’ Gratitude is a two-way street. Patients and families give gratitude, but nurse residents give gratitude to others. Inter- estingly, gratitude for colleagues and the opportunity for employment are also reflective in the previous theme of team and teamwork.

n‘‘My preceptor shaped me into the nurse I am today and I don’t think I could ever repay her.’’ n‘‘Thank you to all the nurses on the floor who have answered some of my questions when I have come across certain issues I just do not know how to handle.’’ Theme 3: Asking Questions Nurse residents asked questions of their colleagues, which was welcomed and maybe even expected. It is OK to ask FIGURE 1Themes.

Journal for Nurses in Professional Development www.jnpdonline.com 321 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. questions and not be afraid, as described by one resident who explained ‘‘Iit is OK to ask for help and that it doesn’t mean that I am weaker for doing it or incapable of doing my job.’’ Hearing experienced nurses ask questions reso- nated with nurse residents, confirming comfort in clinical inquiry. A nurse resident talked about a preceptor noting that ‘‘She was full of information and welcomed my con- stant stream of questions. The best part is, she wasn’t afraid to ask questions herself!...never be afraid to askIa question if you aren’t sure about something.’’ The idea that not asking questions can lead to stress was supported by the following comment: ‘‘I learned early on that my day will become more stressful if I never asked for help from my co-workers.’’ Asking questions and getting answers resulted in new knowledge and skills. As the year progressed, the nurse residents asked fewer questions, perhaps indicating in- creased confidence.

The experience of asking questions and getting answers that contributed to their professional growth inspired nurse residents to want to unselfishly share their learning with others. Nurse residents remembered the feelings that come with being a student or a brand new nurse having those experiences.

n‘‘I will always be available to help anyone that needs it if I can or at least point them in the right direction. We cannot know everythingI.’’ nWhen I have students who follow meIIpayattention to teaching them in way that they will be able to not only understand how to do something but why they are doing itI.’’ Theme 4: The Art of Nursing Nurse residents found that nursing is more than manag- ing machines or completing tasks such as medication administration.

n‘‘I don’t just pass meds. I have learned that I need to take care of my patients as a whole, such as listening to their problems, being there, and make them feel at ease.’’ n‘‘I have learned through this experience to pay more attention to my patients and not view them as a task to complete.’’ Nurses use all of their senses during application of the nursing process. They use their eyes to see, ears to listen, and hands to feel. Using one’s senses takes thought and demonstrates empathy for patients.

n‘‘I’ve learned to step back and listen.’’ n‘‘I will always place myself in the hands, eyes, and place of the patient to further give the best care possible.’’ Nurse residents appreciate the personhood of patients, considering more than their physical health. People suffer and need healing. Nurse residents recognized this chal- lenge, especially because it often involves emotions.n‘‘Caring and treating patients is not only about pass- ing medications and reporting abnormalities, it also entails providing comfort and other qualities that are immeasurable but paramount to the healing process.’’ n‘‘Helping those patients to stay comfortable in their last hours is one of the most caring things I have done as a nurse.’’ n‘‘Not only do they (nurses) have to manage the med- ical aspect of things, but they have to manage the emotional aspect of things, and most importantly, we must do so, so that both of these intertwine with a perfect balance.’’ n‘‘I have cried, laughed, danced with my patients to keep them with good spirits about their health care situation.’’ The science of nursing may encompass knowledge, skills, and critical thinking, but the art of nursing involves ‘‘compassion, kindness, helpfulness, and advocating.’’ One resident commented that this ‘‘is really what I be- lieve a nurse does.’’ As nurses, we take care of more than just the patient.

We take care of their families, significant others, groups, and the community. But, taking care of the family and others also requires knowledge. Residents recognized this aspect of holistic nursing care.

n‘‘Being a RN requires more than just having knowl- edge about caring for a patient, but also knowledge in caring for the entire family.’’ Theme 5: Change The yearlong nurse residency program changed the res- idents’ perceptions about nursing. They acknowledged that preceding perceptions about being a nurse were dif- ferent from what they currently do in practice. The demands of nursing warranted a change in ‘‘the way we(I) nurse’’ because it can be ‘‘physically and mentally exhausting at times.’’ One of the nurses’ biggest changes was in confidence as a result of their experience and increased knowledge.

Confidence resulted in comfort in ‘‘judgment and ability to advocate’’ for patients. Yet, not always, because ‘‘Some days they (I) felt like super RN, and other days they(I) felt like they(I) wanted to run away.’’ Nurse residents reflected on past and future fears that have changed. Regarding the past, they remembered that ‘‘When I first started I would pray in my car every dayIasking God to please not let me mess up that dayIFast forward to a year later, having those types of fears seem ridiculous.’’ Looking to the future with optimism, they recommend that graduating nurse residents should ‘‘Agree to take on tasks that challenge you and may even frighten you. You will not always know what you will excel at until you try it.’’ Confidence is not stagnant but rather dynamic and looks ahead to the future of professional growth and develop- ment. The following quotes support a positive outlook. 322 www.jnpdonline.comNovember/December 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. n‘‘I am much more confident now than a year ago and know that I will continue to build on that con- fidence as I further my career.’’ n‘‘I will always seek out opportunities to learn and grow.’’ n‘‘Continue learning something new on an everyday basisIcontinue to grow.’’ Nurse residents conjured images of the dynamic nature of their yearlong residency program and constant changes.

Some described it like walking on a balance beam. Others wrote about the wild nature of residency stating the following:

n‘‘My first year has been a wild ride.’’ n‘‘This first year was a whirlwind.’’ The inherent nature of a roller coaster includes ups and downs, similar to descriptions of the past year by nurse residents.

n‘‘My first year as a nurse was a roller coaster ride.’’ n‘‘Nothing during nursing school can prepare one for the roller coaster of ups and downs that is your first year as a nurse.’’ DISCUSSION Support from a team of nurse colleagues at all levels, but especially peers (Kowalski & Cross, 2010), resonated in most of the nurse resident stories. This finding was also noted by Fink et al. (2008) in terms of camaraderie. Nurse residents seemed to expect nursing to be a team effort, pos- sibly learned during clinical rotations in nursing school.

Gratitude was not a theme identified in previous re- search investigations. Gratitude from patients and families feeds the soul of the nurse resident, validating their role and skill, during a time of newness and uncertainty. Positive feedback is needed from all team members with the patient and family included as part of the team.

Asking questions was a key to learning and decreasing fear. A sense of team facilitates comfort with asking ques- tions. Nurse residents, having learned the importance of asking questions, began to provide answers to others, en- couraging more questions. This learning process comes full circle for nurse residents. Asking questions is part of communication, a skill identified by other investigators that increases throughout the residency program (Bratt & Felzer, 2011; Kowalski & Cross, 2010; Williams et al., 2007).

The holistic nature of nursing is evident in the fourth theme exemplifying the art of our profession. Through empathy, nurse residents gained a deeper understanding and appreciation of both the patient and family. These behaviors have the potential to positively impact the pa- tient experience.

Change was a constant during engagement in the year- long residency program. Nurse residents grew in their confidence with skills and knowledge, allowing them to be more independent, which is similar to findings by Rosenfield et al., (2004), Kowalski and Cross (2010), Bratt and Felzer (2011), and Olson-Sitki et al. (2012). Positivechange in oneself decreases stress and fear of threats (Bratt & Felzer, 2011; Kowalski & Cross, 2010). But with any change, there are dynamics of paradoxes, such as loving the ‘‘work’’ of nursing yet recognizing that it is ‘‘hard work.’’ The changes after 1 year in nurse residents do not stop, as they seek to continue to grow and learn. IMPLICATIONS FOR PRACTICE The transition of newly licensed nurses from the academic to the practice environment can be facilitated through a for- mal RN Residency Program. The five themes identified in this study indicate that new nurses desire an environment that supports their professional and personal growth. The nursing professional development (NPD) practitioner may support the transition to practice experience by contribut- ing to a healthy work environment and ‘‘fostering a sense of belonging’’ for the new nurse (Buckner & Di Leonardi, 2017). The National Council of State Boards of Nursing (n.d.; Cosme, & Pokorny, 2017) suggest that the RN Resi- dency Program curriculum should include content such as communication and teamwork. For example, discussions on time management need to highlight reaching out to team mem- bers for help. The concept of ‘‘cohorts’’ used in our residency program is an example of support for peer-to-peer relation- ships established among nurses in their first year of practice.

Study results demonstrated that new nurses felt validated by patients and families who were grateful for the care they rendered. New nurses were encouraged by even small ges- tures of patient and familyappreciation. In addition, gratitude from team members at the unit level was encour- aging for the newly licensed nurses. NPD practitioners may use this connection reported by newly licensed nurses with patients, families, and fellow teammates to promote the role of collaboration in providing compassionate care. Preceptor education and development should also stress the important benefits of providing positive comments, congratulations, and gratitude. The NPD practitioner plays a key role in ed- ucating both the newly licensed nurse and preceptor about building collaborative partnerships based on mutual re- spect and appreciation.

New nurse transition into practice is supported and de- veloped by preceptors who assist them in seeking answers to clinical and ethical questions posed during orientation.

Most importantly, though, new nurses need to feel empowered to ask questions without fear. Preceptors and NPD practitioners play a tremendous role in encultu- rating new nurses to an organization. Experienced nurses provide invaluable input into learning that shapes the percep- tion of the nursing profession by new nurses. Findings from the study indicated that new nurses, over a yearlong resi- dency program, concluded that nursing is more than the performance of tasks. Nurses take care of the person, not just ‘‘the patient’’ and act as their advocate during hospital- ization. This description of the nursing profession may be Journal for Nurses in Professional Development www.jnpdonline.com 323 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. taught, but it is not actualized until one is immersed in the practice of nursing.

A residency program that includes verbal and written storytelling provides rich opportunities for reflection.

Stories are powerful, especially when shared among nurse residents. Nurse residents realize that others share similar experiences, and together, they grow in their skill of empathy. Qualitative data adds complementary infor- mation to quantitative data collected during a nurse residency program. After graduation from the nurse res- idency program, nurses may be encouraged to keep a reflective journal during their second year of practice, allowing them the opportunity to continue to reflect and grow, personally and professionally.

CONCLUSION Written stories by nurse residents can provide opportunity for reflection and subsequent personal and professional growth. Findings from this study identified five major themes of teamwork, gratitude, asking questions, the art of nursing, and change, which complimented previous quantitative research and generated new knowledge about experiences in yearlong residency programs. Nurses who guide and/or educate new nurses can incorporate these themes into curriculum and teaching.

ReferencesBratt, M. M., & Felzer, H. M. (2011). Perceptions of professional practice and work environment of new graduates in a nurseresidence program.Journal of Continuing Education in Nursing, 42,559Y568.

Buckner, M., & Di Leonardi, B. C. (2017). Onboarding/orientation.

In Dicherson, P. S. (Ed.),Core curriculum for nursing professional development(5th ed., pp. 283Y284). Chicago, IL:

Association for Nursing Professional Development.

Cosme, S., & Pokorny, M. (2017). Partner for practice transitions. In Dickerson, P. S. (Ed.),Core curriculum for nursing professional development(5th ed., pp. 302Y303). Chicago, IL: Association for Nursing Professional Development.

Fink, R., Krugman, M., Casey, K., & Goode, C. (2008). The graduate nurse experience: Qualitative residency program outcomes.The Journal of Nursing Administration,38,341Y348.

Goode, C. J., Lynn, M. R., McElroy, D., Bednash, G. D., & Murray, B.

(2013). Lessons learned from 10 years of research on a post- baccalaureate nurse residency program.The Journal of Nursing Administration,43,73Y79.

Kowalski, S., & Cross, C. L. (2010). Preliminary outcomes of a local residence program for new graduate registered nurses.Journal of Nursing Management,18,96Y104.

National Council of State Boards of Nursing (n.d.)Transition to practice, Retrieved from https://www.ncsbn.org/2013_TransitiontoPractice_ Modules.pdf.

Olson-Sitki, K., Wendler, M. C., & Forbes, G. (2012). Evaluating the impact of a new residency program for newly graduated registered nurses.Journal for Nurses inStaff Development,28, 156Y162.

Polit, D. F., & Beck, C. T. (2017).Nursing research: Generating and assessing evidence for nursing practice(10th ed.). Philadelphia, PA: Wolters Kluwer.

Rosenfield, P., Smith, M. O., Iervolino, L., & Bowar-Ferres, S.

(2004). Nurse residency programVA 5-year evaluation from the participant’s perspective.The Journal of Nursing Administration,34, 188Y194.

Williams, C. A., Goode, C. J., Krsek, C., Bednash, G. D., & Lynn, M. R.

(2007). Post-baccalaureate nurse residency 1-year outcomes.The Journal of Nursing Administration,37,357Y363.