Effect of Transition Training Program on Novice Nurses' Working at University Hospitals

Introduction

Today’s health care environment is complex and creates demands requiring the professional nurse to be an astute critical thinker, confident and competent when caring for patients and families in multiple health care settings. However, since organizations are faced with increasing demands on resource utilization and simultaneous cost reductions, adequate attention to ensuring successful transition for the newly licensed nurse may be not be appropriately designed, managed, supported or evaluated (Hinkle & Cheever, 2018).

In recent years, many countries have faced serious nursing staff shortage. Currently, nursing staff shortage is a major healthcare challenge worldwide. Many factors such as hospital managerial style, working in long shifts, nurses’ heavy workload, and ineffective coping with transitions contribute to this crisis (Azimian et al., 2014).

Transition is defined as the process of moving from a state to another one which is usually associated with significant changes in goals, roles, and responsibilities (Abel & Carter-Templeton, 2020). Studies have shown that during transition, different problems such as anxiety, tension, fear, panic, and burnout endanger and undermine nurses’ physical and mental health. These problems accelerate staff turnover rate and result in the replacement of experienced nurses by novice ones who do not have enough knowledge, experience, and confidence for working in clinical settings. Given the direct relationship between nurses’ quality of working life and the quality of care provided by them, the final outcome of ineffective coping with transition would be inferior quality of nursing care and negative patient outcomes (Mohammadi et al., 2011).

A period of transition occurs when any nurse or midwife commences in a new clinical area. There is no specific time period in which transition occurs – it is an individual process. For nurses or midwives undertaking transition to professional practice as well as a new context, additional support will be focused on the first three to six months of practice (Villanueva et al., 2015).

A high level of additional support assists in a soft and positive transition to the practice setting as well as to the new role. Several strategies can be helpful in easing and speeding the process of role transition. These strategies include: strengthening internal resources, assessing the organization`s resources, culture, and group dynamics, negotiating the role, growing with a mentor and developing management knowledge and skills (Lalonde & McGillis Hall,  2017).

Research indicates that there is an international gap in how universities prepare student nurses for transitioning from the education system to practice (Wise,  2019).  New Graduate Nurses (NGNs) and nursing managers have regularly reported that their education did not fully provide them with the skills required for their transition (Little et al., 2013).The Institute of Medicine 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 (Crimlisk et al., 2017).Transitions programmes are used globally, for example, in Australia,  the UK and Sweden. 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 (Alshawush et al., 2020).

So new graduate nurses are novice practitioners, placed in an environment requiring competent clinical, critical thinking and decision-making skills. New graduate nurses develop these skills during transition to practice programs. In order to provide safe, quality patient care and optimize patient outcomes (AL-Dossary et al., 2013). Transition into practice programs help the new graduate nurse develops confidence and competencies including advanced problem solving, decision-making and critical thinking. The National Council of State Boards of Nursing (NCSBN) and the Institute of Medicine (IOM) have examined training and retention of new graduate nurses and the impact insufficient training may have. New graduate nurses who cannot properly transition to the RN role are at risk for increased job stress, leading to practice errors and putting patient safety at risk (Anderson et al., 2012).

Significance of the Study

 Health care Organizations are always short-staffed, and new nurses must be able to act as a nurse and provide patient care in a short period of time. (Barnett et al., 2014).These nurses are entering the healthcare field, receiving an abbreviated orientation, and then expected to take on a full patient assignment. This experience is setting them up for failure. These unprepared novice nurses become frustrated and eventually leave the facility.

More than 40% of new graduate nurse’s report making medication errors, and 50% they would not recognize life-threatening complications that require intervention, according to data collected by the National Council of State Boards of Nursing. The council also found average turnover rates for nurses in their first year on the job range from 35% to 60 %. So that, the transition training program for new nurses an essential need to become competent, confident, accountable and professional. In addition, they are able to coping with reality shock, improve retention and enhance the nurses' organizational citizenship behaviors (The National Counsil of State Board of Nursing, 2013).

Aim of the study

This research aims to investigate Effect of Transition Training Program on Novice Bachlors' degree Nurses' Working  at Minia University Hospitals.

Research questions:

The present study was carrying out to answer the following questions: -

1. What are the effects of transition training program on new nurses' working at Minia University Hospitals?

1. Is there the transition training program meet the needs of the novice nurses?

Subject and Methods

Research design

Quasi-experimental research design was utilized in this study.

Setting

The study was conducting at Minia University Hospitals. The Minia University Hospitals includes four hospitals as follow (Minia University Hospital, Gynecology, Obstetric and Pediatric Minia University Hospital, Urology Hospital, and Cardiothoracic Hospital) 

Subjects

The study subjects were including all novice nurses (bachelor's degree) in Minia University Hospitals. They are working in the field of nursing practice less than one year. Sample size (no=110), classified as follows (Minia University Hospital 35 nurse; Obstetric& Pediatric Hospitals 33 nurse; Urology Hospital 32 nurse; and Cardiothoracic Hospital 10 nurse) .

Inclusion criteria

• Nurses graduated from Faculty of Nursing
• Nurses have one year of experience

Exclusion criteria

• Nurses graduated from technical institute of nursing and school of nursing
• Nurses have more than one year of experience
•  Nurses refuse to participate in this study

Tools of data collection:

Two tools were used in this study as follows: nurse's transition knowledge questionnaire and the Casey-Fink graduate nurse experience Survey.

Tool I: Nurses Transition Knowledge Questionnaire, this tool was included two parts as follows:

1^st part was including: Personal characteristics data sheet for studied nurses.  It was including; (age, gender, marital status, hospital name, and attendance of any workshops bout communication, documentation critical thinking, and evidence-based practice).

2^nd  part: Nurses Transition Knowledge Questionnaire was developed by the researchers based on related literature (Anderson   et al., 2012; AL-Dossary et al., 2013;Zuriguel Perez et al., 2015; Alkouri et al., 2016; Carter et al 2016;& Amoah et al., 2018) to assess studied nurses level of knowledge regarding communication, documentation, critical thinking, and evidence based practice during different periods of measurement, (before program, immediately after program, and after three months of program implementation).The questions were related to: communication, documentation, critical thinking, and evidence based practice. This questionnaire composed of 40 questions (24 multiple choice questions and 16 questions true and false). The questions were scored as two for the correct answer and one for the incorrect answer. The scoring system of this tool was divided as follows

• Unsatisfactory knowledge (<60%).
• Satisfactory knowledge (>60%).

Low scoring means studied nurses had unsatisfactory knowledge and high scoring means studied nurses had satisfactory knowledge.

Tool II: The Casey-Fink Graduate Nurse Experience Survey:

This tool was developed by Casey et al., (1999)and revised by Altier, (2002) and again by Keller, (2006). The tool contains three sections: comfort/confidence; job satisfaction; and role transition to measure the role of transition during different periods of measurement, (before program, immediately after program, three months of program implementation). Twenty-four of the tool questions utilized a 5-point Likert scale ranging as (Strongly agree=5, Agree=4, Not sure=3, Disagree=2, Strongly disagree=1) and score was reversed for negative items to measure confidence and nine job satisfaction items utilized a 5-point Likert scale ranging as (Very satisfied =5, Moderately satisfied =4, Neither Satisfied nor Dissatisfied =3, Dissatisfied =2, Very dissatisfied =1). The remaining items consisted of four multiple-choice questions for role transition.

Scoring system:

The scoring system of the part of confidence was classified into 3 levels as a follow: Low level of confidence (24-56), Moderate level of confidence (57-88) and High level of confidence (89-120)

The scoring system of the part of job satisfaction was classified into 3 levels as a follow: Low level of job satisfaction (9-21), Moderate level of job satisfaction (22-33) and High level of job satisfaction (34-45).

Validity of the tool:

 Tools were tested for the face validity by a jury of five experts in Nursing Administration. The jury was consisted from one professor, one assistant professor of Nursing Administration Department – Faculty of Nursing – Minia University and three professors of Nursing Administration Department – Faculty of Nursing – Assuit University.

Tools face validity was done to identify the degree to which tools supposed to be measured. The tools were examined for content coverage, sequence of items, clarity, relevance, applicability, wording, length, format, and overall appearance. Based on experts` comments and recommendations; minor modifications had been made such as rephrasing and rearrangements of some sentences.  

Reliability:

Internal consistency of interview questionnaire was assessed with the Cronbach's alpha coefficient. Cronbach's alpha coefficient of 0.00 indicates no reliability and a coefficient of 1.00 indicates perfect reliability. However, a reliability coefficient of 0.70 is acceptable. Cronbach’s alpha for reliability testing was performed for each tool and the results was as represented s following (    1^st tool knowledge questionnaire was 0.891, and 2nd tool The Casey-Fink Graduate Nurse Experience Survey was 0.898).

Pilot Study

The pilot study for the questionnaires was conducted on (10%) as 11 nurse which were included in the study subjects. They were selected randomly from the different hospitals department in order to check and ensure the clarity and applicability of the tools; as well as to identify obstacles and problems that may be encountered during data collection and estimate the time needed to fill the questionnaires. In the light of the findings of the pilot study, no modification was done in the tools and the tools were put in their final form; so, the pilot study was included in the actual study.

Procedure

The study was conducted through the following phases: Assessment and planning phase, implementation phase, and evaluation phase.

Assessment and planning phase

• An official permission obtained from Dean of the Faculty of Nursing, the Directors of Minia University Hospitals.
• The tool of knowledge developed by the researchers based on related literature through three months from the beginning of June 2019 to the end of August 2019 
• Pre-test was done from participants; and the researchers collected data in three months from the beginning of September 2019 to the end of November 2019 by used two tools survey and knowledge test was taking for each from 25 to 30 minutes.
• A review of the related literature which covering various aspects of the problem was done. The review of literature developed in seven months from beginning of February 2020 to end of August 2020.
• The researchers were prepared the timetable of the program.
• The researchers were prepared the learning environment in which the study was conducted, and all needed resources as (conference room in the hospitals and data show).

Implementing phase (implement of the training program):

• The study subjects of studied nurses were divided into 2 subgroups in each hospital, each subgroup contained from 15 to 17 nurse on three hospitals but the hospital of cardiothoracic the subgroup contain 5 nurses, and the researchers applied the program for each subgroup on separate time.
• All sessions were implemented according to the working time of the participants; and it was done in teaching rooms of the hospital’s education building. Each session takes about 2 hours.
• The researchers explained objectives of the educational program to the studied nurses; content and time table
• At the beginning of each session, the objectives of the session were explained. The feedback before each session was obtained about the previous session and at the end of each session there were summary about the current session.
• The training program was implemented in two months from the beginning of September 2019 to the end October 2019.

Evaluation phase:

Evaluating of the immediateeffect of training program on studied nurses to assess knowledge about the topics of the program was done using the two tools. It was filled in end of October 2019.

The follow up was conducted after three months of the program implementation to assess knowledge about the topics of the program was done using the two tools. It was filled in the end of January 2020.

Ethical considerations

• Official permission was granted approval by the Ethical Committee of the Faculty of Nursing, Minia University
• The studied nurses were informed that their participation in the study was completely voluntary and there was no harm if they not participated in the study.
• The studied nurses were informed about the withdrawal procedures if they decided to leave the study at any time before, during or after the completion of data collection,
• Oral consent was obtained from studied nurses after explaining the nature and benefits of the study.
• Confidentiality of data, privacy, identity, voluntary participation and right to refuse to participate in the study was emphasized to subjects.

Statistical Analysis

Clean data by performing a series of comprehensive checks, making corrections whenever possible.  Raw collected data were coded and scored and a coding instruction manual was prepared. Data were fed to the computer and statistical analysis was performed using Statistical Package for Social Sciences (SPSS version 25). Significance of the obtained results was judged at the 5 % level of significance. Probability (p-value) less than 0.05 was considered significant and less than 0.001 was considered highly significant.

Results

Table (1): Personal characteristics data of the studied nurses at Minia University Hospitals (N=110).

Table (1) shows regarding, that the majority of the studied nurses (83.6%) are in age group ranged between 22-23 years; (71.8%) of them are females; also, the majority (81.8%) of them are single.

As regards to figure (1), nearly one third of the studied nurses working at Minia University Hospital, Obstetric &Pediatric Hospital, and Urology Hospital as (31.8%, 30%& 29.1%) respectively. Moreover figure (2) shows that, about three quarters (74.5%) of the sample don't attended any workshops.

Table (2) Mean scores of studied nurses’ knowledge during different times of testing (N =110)  

Table (2) Indicates that there is an increase in studied nurses' knowledge about communication mean score from (12.2±2.38) pre-program implementation to be immediately after the program (18.3±1.82); and (18.1±2.59) after three months of program implementation with high statistic difference (P = 0.001). While studied nurses are knowledge about documentation mean score from (12.1±2.17) pre-program implementation to be immediately after the program (18.6±1.84); and (18.05±2.59) after three months of program implementation with high statistical difference (P = 0.001).

Moreover, from table (2) it is noted that there is an increase in studied nurses' knowledge about critical thinking  mean score from (11.5±1.56) pre-program implementation to be immediately after the program (18.5±1.82); and decreased to be (18.0±2.59) after three months of program implementation with high statistic difference(P = 0.001), also  studied nurses' knowledge about evidence based practice mean score from (11.4±1.51) pre-program implementation to be immediately after the program (18.6±1.84); and (18.1±2.59) after three months of program implementation with high statistic difference(P = 0.001).

P₁= pre and immediately post the program implementation P₂ = pre and after three months of program implementation

* p≤0.05 (significant)

Figure (3): Percentage distribution of studied nurse’s perception regarding to total comfort/ confidence level during different times of testing (No =110)

Figure (3) summarizes that none (0%) of studied nurses have high level of confidence before program implementation compare with (85.5%) immediately post program implementation, as well as (82.8%) after three months of program implementation, with statistically significant differences(p=0.001)between pretest and different times of testing) pretest with immediately posttest, and pretest with after three months of posttest).

Figure(4) Percentage  distribution of studied nurse’s perception regarding   total of how satisfied are staff with the following aspects of their job during different times of testing (No =110)

Figure (4) illustrates that the majority (90.9%) of the sample have moderate satisfied about the aspects of their job before program implementation compare with (99.1% & 99.1%) immediate after program implementation and after three months of program implementation

Table (3) Percentage distribution of studied nurse’s perception regarding role of transition  (N=110)

Table (3) illustrates that, all of the studied nurses (100%) response the most difficult fromthe "student" role to the "RN" role are  lack of confidence (e.g. communication skills, delegation, knowledge deficit, critical thinking)  and fears (e.g. patient safety); while the response toward the most things  that help to  integrated in the unit are improved orientation (e.g. preceptor support and consistency, orientation extension, unit specific skills practice) and unit socialization (e.g. being introduced to staff and MDs, opportunities for staff socialization), also (50%) of them response toward the most  aspect which satisfied in their work environment are  peer support (e.g. belonging, team approach, helpful and friendly staff). While all of the studied nurses (100%) of sample response toward the least aspect which satisfied in their work environment are the orientation (inconsistent preceptors, lack of feedback) before program implementation.

More over immediate after the program implementation, about two thirds of the sample (66.7%) response the most difficult fromthe "student" role to the "RN" role are  fears (e.g. patient safety); while (63.6%) of the sample response toward the most things  that help to  integrated in the unit are increased support (e.g. manager, RN, and educator feedback and support, mentorship(, and improved work environment (e.g. gradual ratio changes, more assistance from unlicensed personnel, involvement in schedule and committee work), also (62.7%) of them response toward the most  aspect which satisfied in their work environment are patients and families (e.g. making a difference, positive feedback, patient satisfaction, patient interaction). While (63.6%) of sample response toward the least aspect which satisfied in their work environment are System (e.g., outdated facilities and equipment, small workspace, charting, paperwork) immediate after program implementation.

Table (4): Correlation between studied nurses knowledge confidence/ comfort level, job satisfaction during different times of testing (No =110)

                                * p≤0.05 (significant)

Table (4) shows that there is positive correlation between studied nurses’ total knowledge and confidence during different times of testing (P = 0.001).